Intraoperative 3D Fluoroscopy During Open Reduction for DDH: An Effective Alternative to Postoperative CT/MRI.

BACKGROUND: Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI. METHODS: This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated. RESULTS: Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery (P<0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery (P=0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI (P=0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention (P=0.51), and at cast removal, there were 3 subluxations in each group (P=0.69) and 1 redislocation in the 3D group (P=1.00). CONCLUSIONS: Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH. LEVEL OF EVIDENCE: Diagnostic Study, level II.

The impact of public health lockdown measures during the COVID-19 pandemic on the epidemiology of children's orthopedic injuries requiring operative intervention.

BACKGROUND: In March 2020, Ontario instituted a lockdown to reduce spread of the SARS-CoV-2 virus. Schools, recreational facilities, and nonessential businesses were closed. Restrictions were eased through 3 distinct stages over a 6-month period (March to September 2020). We aimed to determine the impact of each stage of the COVID-19 public health lockdown on the epidemiology of operative pediatric orthopedic trauma. METHODS: A retrospective cohort study was performed comparing emergency department (ED) visits for orthopedic injuries and operatively treated orthopedic injuries at a level 1 pediatric trauma centre during each lockdown stage of the pandemic with caseloads during the same date ranges in 2019 (prepandemic). Further analyses were based on patients' demographic characteristics, injury severity, mechanism of injury, and anatomic location of injury. RESULTS: Compared with the prepandemic period, ED visits decreased by 20% (1356 v. 1698, p < 0.001) and operative cases by 29% (262 v. 371, p < 0.001). There was a significant decrease in the number of operative cases per day in stage 1 of the lockdown (1.3 v. 2.0, p < 0.001) and in stage 2 (1.7 v. 3.0; p < 0.001), but there was no significant difference in stage 3 (2.4 v. 2.2, p = 0.35). A significant reduction in the number of playground injuries was seen in stage 1 (1 v. 62, p < 0.001) and stage 2 (6 v. 35, p < 0.001), and there was an increase in the number of self-propelled transit injuries (31 v. 10, p = 0.002) during stage 1. In stage 3, all patient demographic characteristics and all characteristics of operatively treated injuries resumed their prepandemic distributions. CONCLUSION: Provincial lockdown measures designed to limit the spread of SARS-CoV-2 significantly altered the volume and demographic characteristics of pediatric orthopedic injuries that required operative management. The findings from this study will serve to inform health system planning for future emergency lockdowns.

Prolonged Brace Treatment Does Not Result in Improved Acetabular Indices in Infantile Dislocated Hips.

BACKGROUND: The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. However, significant variability exists in the duration of brace treatment after successful reduction of the dislocated hip. The purpose of this study was to evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database. METHODS: We retrospectively studied prospectively enrolled infants with at least 1 dislocated hip that were initially treated with a PH and had a recorded AI at 2-year follow-up. Subjects were treated at 1 of 2 institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured shorter brace treatment protocol. Hip dislocation was defined as <30% femoral head coverage at rest on the pretreatment ultrasound or International Hip Dysplasia Institute (IHDI) grade III or IV on the pretreatment radiograph. RESULTS: Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace ×3 longer than hips from institution 2 (adjusted mean 8.9±1.3 vs. 2.6±0.2 mo) (P<0.001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (P=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9 degrees) compared with Institution 2 (adjusted mean 23.5±0.8 degrees) (P=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age-matched and sex-matched AI normal data (P=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia (more than 2 SD from the mean), compared with a 22% (6/27) from Institution 2 (P=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (P=0.071). CONCLUSIONS: The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Femoral Lengthening in Children: A Comparison of Motorized Intramedullary Nailing Versus External Fixation Techniques.

BACKGROUND: Femoral lengthening is associated with high complication rates often related to the type of surgical device used to perform the lengthening. The advent of intramedullary lengthening devices has promised a reduction in complications when compared with external fixation systems. The purpose of this study was to compare the clinical outcomes of femoral lengthening in children using a motorized intramedullary nail (Precice) versus an external fixation system (Taylor Spatial Frame-TSF; or Monolateral Rail System-MRS) at a single institution, single surgeon practice. METHODS: This study is a retrospective comparison of pediatric patients who had previously undergone femoral lengthening (±deformity correction). Patients ages 8 to 18 years of age were included and grouped based on whether they had undergone Precice nailing or external fixation (TSF or MRS) between 2010 and 2019. RESULTS: Twenty-seven patients (32 femurs) were included. Thirteen patients (15 femurs) had undergone Precice nailing and 14 patients (17 femurs) had undergone external fixation. The Precice group had significantly fewer problems, obstacles, and complications than the external fixation group, Precice 6.6%, 0%, 0%, respectively, and external fixation 47.1%, 29.4%, 0% respectively (P<0.01). Unplanned return to the operating room occurred in 4 cases, solely in the external fixation group. There were no differences in percentage of goal length achieved, Precice (mean 93.6%, range: 66.7% to 114.3%), external fixation (mean 96%, range: 76.9% to 117.5%) P=0.31 and total length achieved, Precice (mean: 44 mm, range: 20 to 80 mm), external fixation (mean: 46 mm, range: 10 to 70 mm) P=0.72. There was no difference in consolidation index, Precice (24.1 d/cm), external fixation (28.5 d/cm) P=0.36. The Precice group had a significantly shorter length of stay (mean: 2.2 d, range: 1 to 4 d), compared with the external fixation group (mean: 3.7 d, range: 2 to 8), P=0.01. CONCLUSIONS: Femoral lengthening in children using a motorized intramedullary nail was associated with a markedly reduced rate of complications and shorter length of stay compared with external fixation. LEVEL OF EVIDENCE: Level III.

Interobserver and Intraobserver Reliability in the Salter Classification of Avascular Necrosis of the Femoral Head in Developmental Dysplasia of the Hip.

BACKGROUND: Avascular necrosis (AVN) of the femoral head is a concerning complication that can result from treatments for developmental dysplasia of the hip (DDH). AVN can lead to degenerative osteoarthritis, persistent acetabular dysplasia, reduced function, and continuing hip pain. The incidence of AVN reported in the DDH literature is widely varied (0% to 73%). This variability may arise from lack of consensus on what constitutes true AVN in this patient population, and lack of clear criteria provided in studies reporting incidence rates. METHODS: A multicentre, prospective database of infants diagnosed with DDH between 2010 and 2014 from 0 to 18 months of age was analyzed for patients treated by closed reduction (CR). Twelve pediatric orthopaedic surgeons completed 2 rounds of AVN assessments. Deidentified anteroposterior radiographs at most recent follow-up were provided to surgeons along with patient age at radiographic assessment, length of follow-up, ands affected hip. Ten of 12 surgeons completed a third round of assessments where they were provided with 1 to 2 additional radiographs within the follow-up period. Radiographic criteria for total AVN described by Salter and colleagues were used. Surgeons rated the presence of AVN as "yes" or "no" and kappa values were calculated within and between rounds. RESULTS: A total of 69 hips in 60 patients were assessed for AVN a median of 22 months (range: 12 to 36) post-CR. Interobserver kappa values for rounds 1, 2, and 3 were 0.52 (range: 0.11 to 0.90), 0.61 (range: 0.21 to 0.90), and 0.53 (range: 0.10 to 0.79), respectively. Intraobserver agreement for AVN diagnosis was an average of 0.72 (range: 0.31 to 0.96). CONCLUSIONS: Despite using the most commonly referenced diagnostic criteria, radiographic diagnosis of AVN following CR in DDH patients demonstrated only moderate agreement across surgeons. The addition of sequential radiographs did not improve cross-observer reliability, and while substantial agreement was seen within observers, the range of intraobserver kappa values was large. LEVEL OF EVIDENCE: Level I-diagnostic study.

The Gait Outcomes Assessment List for Children With Lower Limb Difference (GOAL-LD): Assessment of Reliability and Validity.

BACKGROUND: The Gait Outcomes Assessment List for children with Lower Limb Difference (GOAL-LD) is a patient and parent-reported outcome measure that incorporates the framework of the International Classification of Functioning, Disability, and Health. This prospective multicenter cohort study evaluates the validity and reliability of the GOAL-LD and the differences between parent and adolescent report. METHOD: One hundred thirty-seven pediatric patients aged over 5 years attending limb reconstruction clinics at the participating sites were assessed at baseline, and a self-selected cohort also completed an assessment 2 to 6 weeks later. Construct and criterion validity were assessed by comparing GOAL-LD scores with a measure of limb deformity complexity (LLRS-AIM) and the Pediatric Outcomes Data Collection Instrument, using Spearman correlation coefficients. Face and content validity were determined through ratings of item importance. Test-retest reliability was reported as an intraclass correlation coefficient and internal consistency using Cronbach α. Adolescent reports were compared with their parents using paired t tests. RESULTS: The GOAL-LD demonstrated a moderate negative correlation with the LLRS-AIM (r=-0.40, P<0.001) and was able to discriminate between deformity complexity groups as defined by the LLRS-AIM (χ2=11.43, P=0.022). Internal consistency was high across all domains (α≥0.68 to 0.97). Like domains of the Pediatric Outcomes Data Collection Instrument and the GOAL-LD were well correlated. Parents reported a lower total GOAL-LD score when compared with adolescents (mean difference 3.04; SE 1.06; 95% confidence interval, 0.92-5.16; P<0.01); however this difference was only significant for body image and self-esteem (Domain F) and gait appearance (Domain D). Test-retest reliability remained high over the study period (intraclass correlation coefficient 0.85; SE 0.03; 95% confidence interval, 0.77-0.91). CONCLUSIONS: The GOAL-LD is a valid and reliable self and parent-reported outcome measure for children with lower limb difference. Parents report a lower level of function and attribute a higher importance to items when compared with their children. The GOAL-LD helps to communicate parent and child perspectives on their function and priorities and therefore has the capacity to facilitate family centered treatment planning and care. LEVEL OF EVIDENCE: Level II-diagnostic. Prospective cross-sectional and a longitudinal cohort design.

Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort.

BACKGROUND: Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR. METHODS: Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed. RESULTS: A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia. CONCLUSIONS: Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip. LEVEL OF EVIDENCE: Level II-prospective observational cohort.

Ischiofemoral Impingement in Children: Imaging With Clinical Correlation.

OBJECTIVE: The purpose of this study is to correlate the MRI finding of quadratus femoris edema in children with established measures of ischiofemoral impingement in adults and to determine their clinical significance. MATERIALS AND METHODS: A case-control retrospective review was performed of MR images of 12 hips of nine children (mean age, 10 years) that showed abnormal signal intensity in the quadratus femoris muscle. The findings were compared with those for 13 hips in 13 control subjects (mean age, 9.8 years). Two musculoskeletal radiologists independently measured the ischiofemoral space, quadratus femoris space, inclination angle, and hamstring tendon area. Quadratus femoris muscle edema, tears, or fatty replacement were assessed visually. Statistical analysis determined inter- and intraobserver variability and statistical differences between the two subject groups. RESULTS: Subjects with abnormal signal in the quadratus femoris muscle had a statistically significantly narrower ischiofemoral space (mean, 11.5 vs 20.7 mm; p < 0.05) and quadratus femoris space (mean, 7.2 vs 14.3 mm, p < 0.05) compared with control subjects. Inclination angles were statistically significantly larger in affected subjects (145.5° vs 138.7°; p < 0.05). No statistically significant difference was found in hamstring tendon area. Four of 12 patient hips had no symptoms or symptoms unrelated to the abnormality. Inter- and intraobserver variability scores were strong for all continuous variables. CONCLUSION: Ischiofemoral impingement is a cause of hip pain in children and should be considered with the combination of quadratus femoris muscle edema and narrowing of ischiofemoral space and quadratus femoris space. Coxa valga may contribute to narrowing of these parameters and predispose to ischiofemoral impingement. The MRI features of ischiofemoral impingement, however, are nonspecific and may be seen in patients with pain localized to that hip or in patients with symptoms unrelated to the abnormality.

What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

BACKGROUND: Little information exists concerning the variability of presentation and differences in treatment methods for developmental dysplasia of the hip (DDH) in children < 18 months. The inherent advantages of prospective multicenter studies are well documented, but data from different centers may differ in terms of important variables such as patient demographics, diagnoses, and treatment or management decisions. The purpose of this study was to determine whether there is a difference in baseline data among the nine centers in five countries affiliated with the International Hip Dysplasia Institute to establish the need to consider the center as a key variable in multicenter studies. QUESTIONS/PURPOSES: (1) How do patient demographics differ across participating centers at presentation? (2) How do patient diagnoses (severity and laterality) differ across centers? (3) How do initial treatment approaches differ across participating centers? METHODS: A multicenter prospective hip dysplasia study database was analyzed from 2010 to April 2015. Patients younger than 6 months of age at diagnosis were included if at least one hip was completely dislocated, whereas patients between 6 and 18 months of age at diagnosis were included with any form of DDH. Participating centers (academic, urban, tertiary care hospitals) span five countries across three continents. Baseline data (patient demographics, diagnosis, swaddling history, baseline International Hip Dysplasia Institute classification, and initial treatment) were compared among all nine centers. A total of 496 patients were enrolled with site enrolment ranging from 10 to 117. The proportion of eligible patients who were enrolled and followed at the nine participating centers was 98%. Patient enrollment rates were similar across all sites, and data collection/completeness for relevant variables at initial presentation was comparable. RESULTS: In total, 83% of all patients were female (410 of 496), and the median age at presentation was 2.2 months (range, 0-18 months). Breech presentation occurred more often in younger (< 6 months) than in older (6-18 months at diagnosis) patients (30% [96 of 318] versus 9% [15 of 161]; odds ratio [OR], 4.2; 95% confidence interval [CI], 2.3-7.5; p < 0.001). The Australia site was underrepresented in breech presentation in comparison to the other centers (8% [five of 66] versus 23% [111 of 479]; OR, 0.3, 95% CI, 0.1-0.7; p = 0.034). The largest diagnostic category was < 6 months, dislocated reducible (51% [253 of 496 patients]); however, the Australia and Boston sites had more irreducible dislocations compared with the other sites (ORs, 2.1 and 1.9; 95% CIs, 1.2-3.6 and 1.1-3.4; p = 0.02 and 0.015, respectively). Bilaterality was seen less often in older compared with younger patients (8% [seven of 93] versus 26% [85 of 328]; p < 0.001). The most common diagnostic group was Grade 3 (by International Hip Dysplasia Institute classification), which included 58% (51 of 88) of all classified dislocated hips. Splintage was the primary initial treatment of choice at 80% (395 of 496), but was far more likely in younger compared with older patients (94% [309 of 328] versus 18% [17 of 93]; p < 0.001). CONCLUSIONS: With the lack of strong prognostic indicators for DDH identified to date, the center is an important variable to include as a potential predictor of treatment success or failure.

A Reliable and Valid Objective Structured Assessment of Technical Skill for the Application of a Pavlik Harness Based on International Expert Consensus.

BACKGROUND: The use of competency-based training is increasing in medical education as it offers individualized learning opportunities to master required skills. Inherent to this method of teaching is the need for standardized and objective assessments of skill mastery. In orthopaedic surgery, educational programs have focused on surgical skills with lesser emphasis on nonoperative techniques. Accordingly, formal evaluation tools specific to Pavlik Harness application do not exist, despite its widespread use and potential complications from inappropriate application. This study sought to develop a reliable and valid evaluation tool based on international expert consensus to standardize and evaluate Pavlik Harness application for developmental dysplasia of the hip. METHODS: Consensus was sought from 10 content experts using Delphi methodology. Resulting items formed the Objective Structured Assessment of Technical Skill (OSATS). Thirty-five participants were selected into 3 a priori groups (expert, intermediate and novice) based on Pavlik Harness experience. On 2 occasions, 3 content experts assessed randomized and deidentified videotapes of each participant applying a Pavlik Harness to an infant model using the OSATS and global rating scales (GRS). The reliability and validity of the OSATS was determined with intraclass (ICC) and Pearson correlations and analysis of variance (ANOVA). RESULTS: Consensus was obtained after 2 rounds of structured surveying and resulted in a 25-item OSATS. The reliability of the OSATS was excellent with an ICC of 0.96 for interrater and 0.98 for test-retest reliability. Construct validity was excellent with high correlations between OSATS and GRS (>0.90). In addition, the OSATS discriminated between expert, intermediate, and novice users. CONCLUSIONS: We have developed a competency-based evaluation tool for Pavlik Harness application based on consensus from international experts. The OSATS has been shown to be a reliable and valid method for assessing Pavlik Harness application that can discriminate between expert, intermediate, and novice users. LEVEL OF EVIDENCE: Level II.

Intraoperative assessment of closed reduction for developmental dislocation of the hip using 3-dimensional fluoroscopy.

BACKGROUND: Postoperative imaging for operatively treated developmental dislocation of the hip typically uses computed tomography or a magnetic resonance imaging (MRI). Neither imaging modality offers the ability to intervene intraoperatively. The 3-dimensional (3D) C-arm provides an attractive alternative providing immediate intraoperative feedback on the quality of a hip reduction. Our primary research question was to determine whether 3D fluoroscopy could assess hip position after closed reduction and spica casting. Secondary questions included whether reduction was maintained postoperatively when compared with postoperative MRI, and to determine the radiation dose received by the infant. METHODS: We retrospectively identified 16 patients from 2010 to 2013 who underwent closed reduction and spica casting for a developmentally dislocated hip who underwent both intraoperative 3D fluoroscopy and postoperative MRI imaging. Scans were retrieved and assessed by a blinded pediatric orthopaedic fellow. Assessment of hip reduction was graded based on the modified Shenton line of the pelvis in axial plane images. Effective radiation doses between imaging modalities were compared using an anthropomorphic phantom. RESULTS: All hips were reduced on 3D fluoroscopic images. Comparing the intraoperative 3D scans with the postoperative MRI images all 16 hips were in the same position. At 12 weeks all hips were reduced and no signs of subluxation were identified on the plain anteroposterior radiograph. 3D fluoroscopy achieved the lowest effective dose of radiation per study measuring 0.3 mSv compared with 0.5 mSv for low-dose CT and 0.48 mSv for 60 seconds of live fluoroscopy. CONCLUSIONS: Accurate assessment of the quality of hip reduction is possible in the axial plane using 3D fluoroscopy with no significant loss of reduction in the early postoperative period. When comparing the effective radiation exposure to limited-cut computed tomography protocols, 3D fluoroscopy offers a low-dose alternative that may facilitate cost savings and early discharge. LEVEL OF EVIDENCE: Diagnostic studies-investigating a diagnostic test; study of nonconsecutive patients with consistently applied gold standard; level III.

Resolving residual acetabular dysplasia following successful brace treatment for developmental dysplasia of the hip in infants.

Aims: Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods: This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years' mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results: Of 202 infants who completed the protocol, 181 (90%) had two and five years' follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years' follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion: The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years' follow-up.

Management of hip instability in trisomy 21.

The unstable hip in Trisomy 21 presents with a spectrum of hip instability with different problems at different ages. What links this multiphase problem, in many patients, is the final common pathway of untreated instability, that of a stiff, dislocated, and often-painful hip, leading to significant functional disability. Historically, the results of treating hip instability in Trisomy 21 were variable with a notable frequency of poor results. With an improved understanding of the Trisomy 21 hip in terms of its pathoanatomy and a more contemporary surgical approach to hip reconstruction, much improved results can be expected and indeed have recently been shown. The mainstay of treatment for the habitual dislocation group presenting before 8 years of age is the femoral varus derotation osteotomy. The older group presenting with painful subluxation often show signs of secondary acetabular dysplasia and thus are best treated with redirectional acetabular osteotomy with or without the use of femoral varus derotation osteotomy. The presence of radiographic features of degenerative arthritis in the fixed dislocation group precludes the use of joint-preserving techniques for hip reconstruction, and these patients can achieve excellent results with total joint arthroplasty. The natural history, historical results, assessment, treatment, and management of complications of hip instability in Trisomy 21 are addressed in this paper.

The true pelvic volume change with various corrective osteotomy techniques for exstrophy-epispadias complex spectrum: the value of computer-assisted virtual surgery.

Pelvic osteotomies are essential to approximate widened symphysis pubis in the exstrophy-epispadias complex, yet it is unknown which osteotomy type has the greatest effect on pelvic volume. We therefore used virtual surgery to study pelvic volume change with anterior, oblique, and posterior iliac osteotomies. Preoperative CT scans of two cloacal and one classic bladder exstrophy patients were used. Simulations were free-hand or constrained to keep minimal strain in the sacrospinous SSL and sacrotuberous STL ligaments. Changes in inter-pubic distance, pelvic volume, SSL and STL strains were measured. Mean pelvic volume decreased by 10% with free hand compared to 23% with constrained simulations (P = 0.171) and decreased by 7% with posterior, 17% with diagonal and 26% with horizontal osteotomies (P = 0.193). SSL and STL were strained by 20% and 26%, respectively, with free-hand simulations. A statistically significant moderate positive correlation was found between the decrease in inter-pubic distance and reduction in pelvic volume (r = 0.6, P = 0.004). Mean pelvic volume decreased 0.05, 0.37 and 0.62% for each mm of pubic symphysis approximation with posterior, diagonal and horizontal osteotomies, respectively. Differences in effect on pelvic volume were identified between the osteotomies using virtual surgery which predicted residual diastasis in actual cloacal exstrophy surgical reconstructions. Oblique osteotomies are a compromise, avoiding difficulties with posterior osteotomies and excessive pelvic volume reduction with horizontal osteotomies. Understanding how osteotomy type affects pelvic morphology with virtual surgery may be an effective adjunct to pre-operative planning in exstrophy spectrum.

A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants.

Aims: Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment. Methods: This was a single-centre, prospective, longitudinal cohort study of a consecutive series of infants with ultrasound-confirmed DDH who underwent a comprehensive nonoperative brace management protocol in a unified multidisciplinary clinic between January 2012 and December 2016 with five-year follow-up radiographs. The radiological outcomes were acetabular index-lateral edge (AI-L), acetabular index-sourcil (AI-S), centre-edge angle (CEA), acetabular depth ratio (ADR), International Hip Dysplasia Institute (IHDI) grade, and evidence of avascular necrosis (AVN). At five years, each hip was classified as normal (< 1 SD), borderline dysplastic (1 to 2 SDs), or dysplastic (> 2 SDs) based on validated radiological norm-referenced values. Results: Of 993 infants assessed clinically and sonographically, 21% (212 infants, 354 abnormal hips) had DDH and were included. Of these, 95% (202 infants, 335 hips) successfully completed bracing, and 5% (ten infants, 19 hips) failed bracing due to irreducible hip(s). The success rate of bracing for unilateral dislocations was 88% (45/51 infants) and for bilateral dislocations 83% (20/24 infants). The femoral nerve palsy rate was 1% (2/212 infants). At five-year follow-up (mean 63 months (SD 5.9; 49 to 83)) the prevalence of residual dysplasia after successful brace treatment was 1.6% (5/312 hips). All hips were IHDI grade I and none had AVN. Four children (4/186; 2%) subsequently underwent surgery for residual dysplasia. Conclusion: Our comprehensive protocol for nonoperative treatment of infant DDH has shown high rates of success and extremely low rates of residual dysplasia at a mean age of five years.

Testing of an Ultrasound-Limited Imaging Protocol for Pavlik harness Supervision (TULIPPS) in developmental dysplasia of the hip: a randomized controlled trial.

AIMS: There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring. METHODS: This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs. RESULTS: Overall, 100 patients were included; 42 patients completed the standard protocol (SP) and 40 completed the limited protocol (LP). There was no significant difference in mean right α angle at the end of treatment (SP 70.0° (SD 3.2°) ; LP 68.7° (SD 2.9°); p = 0.033), nor on the left (SP 69.0° (SD 3.5°); LP 68.1° (SD 3.3°); p = 0.128). There was no significant difference in mean right acetabular index at follow-up (SP 23.1° (SD 4.3°); LP 22.0° (SD 4.1°); p = 0.129), nor on the left (SP 23.3° (SD 4.2°); LP 22.8° (SD 3.9°); p = 0.284). All hips had femoral head coverage of > 50% at end of treatment, and all were IHDI grade 1 at follow-up. In addition, the LP group underwent a 60% reduction in US use once stable. CONCLUSION: Our study supports reducing the frequency of US assessment during PH treatment of DDH once a hip is reduced and centred.Cite this article: Bone Joint J 2022;104-B(9):1081-1088.

The levels of evidence in pediatric orthopaedic journals: where are we now?

BACKGROUND: In recent years, it has become common to publish a level of evidence grading for orthopaedic journal publications. Our primary research question is: is there an improvement in levels of evidence of articles published in pediatric orthopaedic journals over time? In addition, what is the current status of levels of evidence in pediatric orthopaedic journals? METHODS: All articles in Journal of Pediatric Orthopaedics-A (JPO-A) and Journal of Pediatric Orthopaedics-B (JPO-B) for 2001, 2002, 2007, and 2008 and those in Journal of Children's Orthopaedics (JCO) for 2007 and 2008, were collected by an independent reviewer. Of the 1,039 articles identified, animal, cadaveric and basic science studies, expert opinion and review articles were excluded. Seven hundred fifty remaining articles were blinded and randomized with respect to journal, title, publication date, author, and institution. According to the currently accepted grading system, study type and level of evidence was assigned to each article. Interobserver and intraobserver reliability were investigated. Statistical analysis was carried out using SPSS software. RESULTS: There were no statistically significant differences in study type or levels of evidence in articles published before and after 2003. Of articles published during 2007/2008, 3.0% were graded as level I, 5.0% as level II, 24.1% as level III, and 58.0% as level IV. Analysis of the separate journals for all 4 years revealed that JPO-A published 2.6% (13 of 503) level I studies, whereas JPO-B published 4.3% (7 of 163) and JCO published 1.2% (1 of 84). The intraobserver reliability was high for study type (κ, 0.842) and substantial for level of evidence (κ, 0.613). The interobserver reliability for study type and level of evidence was high (κ 0.921 and 0.860, respectively). CONCLUSIONS: Since the introduction of levels of evidence to orthopaedic journals in 2003, there has been minimal change in the quality of evidence in pediatric orthopaedic publications. We note a modest increase in level III articles and a corresponding decrease in level IV articles. Articles can be reliably graded by nonepidemiologically trained individuals. LEVEL OF EVIDENCE: Not applicable.

The Boltysh impact structure: An early Danian impact event during recovery from the K-Pg mass extinction.

Both the Chicxulub and Boltysh impact events are associated with the K-Pg boundary. While Chicxulub is firmly linked to the end-Cretaceous mass extinction, the temporal relationship of the ~24-km-diameter Boltysh impact to these events is uncertain, although it is thought to have occurred 2 to 5 ka before the mass extinction. Here, we conduct the first direct geochronological comparison of Boltysh to the K-Pg boundary. Our 40Ar/39Ar age of 65.39 ± 0.14/0.16 Ma shows that the impact occurred ~0.65 Ma after the mass extinction. At that time, the climate was recovering from the effects of the Chicxulub impact and Deccan trap flood volcanism. This age shows that Boltysh has a close temporal association with the Lower C29n hyperthermal recorded by global sediment archives and in the Boltysh crater lake sediments. The temporal coincidence raises the possibility that even a small impact event could disrupt recovery of the Earth system from catastrophic events.

Levels of evidence at the Pediatric Orthopaedic Society of North America annual meetings.

BACKGROUND: Since 2003, levels of evidence have been used in the orthopaedic literature to inform the reader of the study quality and its relative significance. Our primary research question was to identify if, since their introduction, there has been an improvement in the levels of evidence of the scientific papers presented at Pediatric Orthopaedic Society of North America (POSNA) meetings. METHODS: The abstract of every paper presented orally at the POSNA annual meeting were identified for the years 2001, 2002 (pre-2003) and 2007, 2008 (post-2003). In all, 364 abstracts were identified by an independent reviewer who then excluded cadaver, animal, and basic science studies. The 307 included abstracts were then independently blinded and randomized. Two nonepidemiologically trained pediatric orthopaedic fellows independently assigned a study type and level of evidence to each abstract based on the primary research question. The first reviewer reanalyzed 50 randomly selected abstracts. Disagreement was resolved by consensus opinion with an epidemiologically trained pediatric orthopaedic surgeon. The interobserver and intraobserver reliability was calculated for the assignment of study type and levels of evidence. Changes in the study types and levels of evidence were analyzed to compare papers presented pre-2003 and post-2003. RESULTS: For study type and levels of evidence the interobserver reliability between the authors showed substantial agreement (kappa 0.755 and 0.647, respectively). The intraobserver reliability also showed substantial agreement (kappa 0.806 and 0.789, respectively). Comparing pre-2003 and post-2003 studies there were no significant differences between the types of study presented. An increase in the number of level III studies was identified. A decrease in level I and level IV studies was identified. CONCLUSIONS: There has been no significant improvement in the scientific quality of studies presented at POSNA Annual Meetings as measured by levels of evidence since their introduction. We have shown substantial agreement between nonepidemiologically trained orthopaedic surgeons when categorizing abstracts using this system. Study types and levels of evidence can be difficult to assign from the current abstract format due to their brevity and structure. LEVEL OF EVIDENCE: Not applicable.

The lateral edge and sourcil acetabular indices for surgical decision-making in developmental dysplasia of the hip.

PURPOSE: The acetabular index (AI) is a radiographic measure that guides surgical decision-making in developmental dysplasia of the hip (DDH). Two AI measurement methods are described; to the lateral edge of the acetabulum (AI-L) and to the lateral edge of the sourcil (AI-S). The purpose of this study was to determine the level of agreement between AI-L and AI-S on the diagnosis and degree of acetabular dysplasia in DDH. METHODS: A total of 35 patients treated for DDH with Pavlik harness were identified. The AI-L and AI-S were measured on radiographs (70 hips) at two and five years of age. AI-L and AI-S were then transformed relative to published normative data (tAI-L and tAI-S). Bland-Altman plots, linear regression and heat mapping were used to evaluate the agreement between tAI-L and tAI-S. RESULTS: There was poor agreement between tAI-S and tAI-L on the Bland-Altman plots with wide limits of agreement and no proportional bias. The two AI measurements were in agreement as to the presence and severity of dysplasia in only 63% of hips at two years of age and 81% at five years of age, leaving the remaining hips classified as various combinations of normal, mildly and severely dysplastic. CONCLUSION: AI-L and AI-S have poor agreement on the presence or degree of acetabular dysplasia in DDH and cannot be used interchangeably. Clinicians are cautioned to prudently evaluate both measures of AI in surgical decision-making. LEVEL OF EVIDENCE: I.