Association between the ossific nucleus and osteonecrosis in treating developmental dysplasia of the Hip: updated meta-analysis.

BACKGROUND: A meta-analysis concluded that there was no effect of the femoral head ossification and the incidence of osteonecrosis in the treatment of developmental dysplasia of the hip (DDH), unless only osteonecrosis grades II-IV were considered. The meta-analysis, limited due to the small number of studies available at that time, identified a need for an update as further research emerges. We observed a trend in recent years towards delaying treatment of DDH in the absence of an ossified nucleus. Numerous new publications on this topic encouraged us to update the 2009 meta-analysis. METHODS: We performed a systematic review of the literature from 1967 to 2016 and included studies that reported on the treatment of DDH, the ossific nucleus and osteonecrosis. Two independent reviewers evaluated all articles. We performed a meta-analysis with the main outcome defined as the development of osteonecrosis of the femoral head at least two years after closed or open reduction. RESULTS: Of four prospective and ten retrospective studies included in the systematic review, 11 studies (1,021 hips) met the inclusion criteria for the meta-analysis. There was no significant effect of the ossific nucleus on the development of all grades of osteonecrosis (relative risk, 0.88; 95% confidence interval, 0.56-1.41) or osteonecrosis grades II-IV (0.67; 0.41-1.08). In closed reductions, the ossific nucleus halved the risk for developing osteonecrosis grades II-IV (0.50; 0.26-0.94). CONCLUSIONS: Based on current evidence there does not appear to be a protective effect of the ossific nucleus on the development of osteonecrosis. In contrast to the previous meta-analysis, this update demonstrates that this remains the case irrespective of the grade of osteonecrosis considered relevant. This updated meta-analysis is based on twice as many studies with a higher quality of evidence

Congenital growth hormone deficiency associated with hip dysplasia and Legg-Calve-Perthes disease

Objective: Growth hormone deficiency (GHD) is usually treated with recombinant human GH (rhGH), and this has been rarely associated with hip disorders. We analysed the clinical data of patients with congenital GHD receiving rhGH who had associated hip dysplasia or Legg‐Calve‐Perthes disease (LCPD), with a view to determining whether the hip dysplasia was associated with the underlying disease or with rhGH treatment. / Design: We performed a retrospective analysis of paediatric and adolescent patients seen between 1992–2018 with congenital GHD and hip disorders. Data were collected through a review of the patients’ medical records and included demographics, clinical and imaging data, and the time frame between the onset of the symptoms related to the hip disorders and the onset of GH treatment. / Results: Of the 13 patients with hip disorders, hip dysplasia was present in ten patients and LCPD in three. Hip dysplasia was diagnosed before rhGH was initiated in 50% of cases. These patients had bilateral hip dysplasia and isolated GHD. LCPD was diagnosed in one patient before rhGH was commenced and did not progress. In two patients, LCPD was diagnosed after rhGH was started and did temporarily progress in one of them, but rhGH was not discontinued because LCPD did not seem to be related to rhGH treatment. / Conclusions: This study suggests that hip dysplasia could be a manifestation of an underlying GHD. Additionally, rhGH treatment may not necessarily be causative of LCPD

The most relevant diagnostic criteria for developmental dysplasia of the hip: a study of British specialists.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. Despite this considerable variation in practice exists. The aim of this study was to determine the clinical relevance and a ranking order for the diagnostic criteria in DDH amongst paediatric orthopaedic surgeons practicing in the UK. METHOD: One hundred members of the British Society of Children's Orthopaedic Surgery (BSCOS) were asked to rate the importance of 37 criteria useful in the diagnosis of DDH in newborns, using a 10 cm visual analogue scale. We determined the consistency among specialists in rating the criteria with the intraclass correlation coefficient (ICC) and compared the results to a group of international peers. RESULTS: Ortolani/Barlow tests, asymmetry in abduction ≥20° and a first-degree relative treated for DDH ranked among the top ten. Participants demonstrated poor consistency in rating the 37 criteria (ICC 0.39; 95% CI 0.29, 0.52), but for clinical examination criteria alone their consistency improved (ICC 0.52; 0.35, 0.75). The importance ratings of members of BSCOS and members of the European Paediatric Orthopaedic Society differed for 15/37 (41%) criteria (p <0.05). CONCLUSIONS: Members of BSCOS had a preference for criteria relating to clinical examination and ultrasound

Research priorities in children requiring elective surgery for conditions affecting the lower limbs: a James Lind Alliance Priority Setting Partnership

Objective: To identify and prioritise research questions concerning the elective surgical management of children with conditions affecting the lower limb by engaging patients, carers and healthcare professionals. Design: A modified nominal group technique. Setting: UK. Participants: 388 individuals (29 patients, 155 parents/carers, 204 healthcare professionals) were recruited through hospital clinics, patient charities and professional organisations and participated in the initial prioritisation survey; 234 individuals took part in the interim prioritisation survey. 33 individuals (3 patients, 9 parents/carers, 11 healthcare professionals, 7 individuals representing the project’s steering group and 3 James Lind Alliance (JLA) facilitators) attended the final face-to-face workshop to rank the top 10 research priorities. Interventions: Surveys were distributed using various media resources such as newsletters, internet messaging boards and the ‘Paediatric Lower Limb Surgery Priority Setting Partnership (PSP) website. Printed copies of the questionnaire were also made available to families in outpatient clinics. Outcome measures: Survey results, top 10 and top 26 priority rankings Results: The process took 18 months to complete (July 2017–January 2019); 388 people generated 1023 questions; a total of 801 research questions were classified as true uncertainties. Following the JLA methodology, 75 uncertainties were developed from the initial 801 questions. Twenty six of those were selected through a second survey and were taken to the final face-to-face workshop where the top 10 research priorities were selected. The top10 priorities included questions on cerebral palsy, common hip conditions (ie, Perthes’ disease and developmental dysplasia of the hip) as well as rehabilitation techniques and methods to improve shared decision-making between clinicians and patients/families. Conclusions: This is the first JLA PSP in children’s orthopaedic surgery, a particularly under-researched and underfunded area. We have identified important research topics which will guide researchers and funders and direct their efforts in future research

A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom

Aims: High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics. / Methods: A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children’s Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland. / Results: A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes’ disease (4.5) and bone infection (4.5). / Conclusion: This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children’s orthopaedic surgery and encourage the development of multicentre clinical trials

Management of slipped capital femoral epiphysis: results of a survey of the members of the European Paediatric Orthopaedic Society

AIM: To determine current practice recommendations for the treatment of slipped capital femoral epiphysis (SCFE) among members of the European Paediatric Orthopaedic Society (EPOS). MATERIALS AND METHODS: A questionnaire with 4 case vignettes of a 12-year-old boy presenting with a stable and unstable SCFE. Each, stable and unstable slips, was of mild (20° epiphyseal-shaft angle) and of severe (60° epiphyseal-shaft angle) degree was sent to all members of EPOS in 2009 in order to ascertain their views on the best management of SCFE. Specifically, respondents were asked about the role of reduction, methods of fixation, prophylactic fixation of the non-affected hip, postoperative management and their view on the anticipated need for secondary surgery. RESULTS: The response rate was 25% (72/287). The participating surgeons' average workload was 76% in paediatric orthopaedics, with mean 16 years of experience. Surgeons were most consistent in their advice for stable slips, where around 90% of the respondents did not recommend a reduction of the slip regardless of severity of slip. Seventy per cent of the respondents recommended the use of only one screw for fixation of a stable slip and for mild unstable slips. For severe unstable slips, 46% of surgeons recommended reduction only by positioning of the hip on the fracture table, 35% by manipulation and 11% advised open reduction. Responders were less consistent in their advice on the anticipated need for secondary osteotomies (in mild slips about 40% and about 60% in severe slips would advise an osteotomy) and on treatment of the contralateral hip (with 32% of surgeons recommending prophylactic fixation of the contralateral hip). CONCLUSION: Within members of EPOS, there is controversy on several aspects of the management of SCFE particularly on aspects of the treatment of unstable SCFE. SIGNIFICANCE: Members of EPOS predominantly use traditional means of treatment for patients with SCFE. In contrast, the more modern treatment concepts, such as open reduction via surgical dislocation, are rarely used

Study protocol for evaluation of aid to diagnosis for developmental dysplasia of the hip in general practice: controlled trial randomised by practice

Introduction: In the UK, a compulsory ‘6-week hip check’ is performed in primary care for the detection of developmental dysplasia of the hip (DDH). However, missed diagnoses and infants incorrectly labelled with DDH remain a problem, potentially leading to adverse consequences for infants, their families and the National Health Service. National policy states that infants should be referred to hospital if the 6-week check suggests DDH, though there is no available tool to aid examination or offer guidelines for referral. We developed standardised diagnostic criteria for DDH, based on international Delphi consensus, and a 9-item checklist that has the potential to enable non-experts to diagnose DDH in a manner approaching that of experts. / Methods and analysis: We will conduct a controlled trial randomised by practice that will compare a diagnostic aid against standard care for the hip check. The primary objective is to determine whether an aid to the diagnosis of DDH reduces the number of clinically insignificant referrals from primary care to hospital and the number of late diagnosed DDH. The trial will include a qualitative process evaluation, an assessment of professional behavioural change and a full health economic evaluation. We will recruit 152 general practitioner practices in England. These will be randomised to conduct the hip checks with use of the study diagnostic aid and/or as per usual practice. The total number of infants seen during a 15-month recruitment period will be 110 per practice. Two years after the 6-week hip check, we will measure the number of referred infants that are (1) clinically insignificant for DDH and (2) those that constitute appropriate referrals. / Ethics and dissemination: This study has approval from the Health Research Authority (16/1/2020) and the Confidentiality Advisory Group (18/2/2020). Results will be published in peer-reviewed academic journals, disseminated to patient organisations and the media. / Trial registration number: NCT04101903; Pre-results

Feeling the clunk: Managing and attributing uncertainty in screening for developmental dysplasia of the hip in infancy

This is the final version. Available on open access from Elsevier via the DOI in this recordThe management of uncertainty in clinical practice has been an enduring topic of sociological scholarship. However, little of this addresses how uncertainty and non-knowledge are attributed to the self and other actors. We take the example of checking for developmental dysplasia of the hip (DDH), part of infant screening in UK primary care, to examine the ‘double contingency’ of attributions of uncertainty and ignorance. Our data come from interviews with parents and General Practitioners (GPs), and observations of the six-week check conducted as part of a study to develop a checklist to aid GPs' diagnostic and referral decisions. Parents' pervasive uncertainties about managing with a new-born infant place them in a trusting relation to biomedicine, in which knowledge about infant hips is delegated to the clinical team: most described themselves as not-knowing about DDH. GPs focus on the uncertainties of applying sensory and experiential knowledge of infant bodies, in a consultation with more diffuse aims than screening for DDH. A prototype checklist, developed by orthopaedic specialists, was an explicit attempt to reduce uncertainty around thresholds for referral. However, using the checklist surfaced multiple logics of uncertainty. It also surfaced attributions of uncertainty and non-knowledge to other actors: orthopaedic specialists' assumptions about GPs' uncertain technical knowledge; GPs' assumptions about orthopaedic specialists' ignorance of the primary care setting; and clinicians' assumptions about the role of parental ignorance. This ‘double contingency’ of attributions of other actors' non-knowledge is a salient additional dimension to the uncertainty that infuses biomedical practice.Wellcome TrustNational Institute for Health Research (NIHR