Aims. The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV. Methods. The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children’s Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. Results. The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached ‘consensus in’, no statements reached ‘consensus out’, and 18 reached ‘no consensus’. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached ‘consensus in’, no statements reached ‘consensus out’, and three reached ‘no consensus’ and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. Conclusion. We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758–764

Introduction: Cases of developmental dislocation of the hip occur after walking age because of late or missed diagnosis and failed conservative or operative treatment. Up to now there is no consensus on the treatment of DDH after walking age. The purpose of this retrospective study was to evaluate the results of operative treatment in DDH after walking age in our patient population and to describe the treatment strategies and operative techniques used. Material and Methods: Forty-two patients presenting 54 cases of DDH after walking age were operated on in our clinic between 1985 and 1997. There were 34 female and 8 male patients, with an average age at the time of operation of 47 months (range: 14 – 151 months). The parameters studied were the type of DDH according to Ts, the preoperative AC- angle, the postoperative AC- and CE- angles as well as the radiological outcome using the Severin classification. Results: Based on the Ts classification we found 18 cases of type II, 22 cases of type III and 14 cases of type IV dislocations. Each hip had an average of 1.4 operations. The average preoperative AC- angle was 38.2 degrees (range: 22–50) whereas the average AC- angle in the last radiographic follow up was 22.2 degrees (range:5–10). The statistical analysis showed that the AC angle at the last follow up was significantly (p< 0,001) smaller than in the preoperative radiographs. The classification according to Severin showed class I in 28 cases, class II in 15 cases, class III in 8 cases and class V in 3 cases. Conclusion: Although our study presents the results after a mid-term follow up the radiological results favor our clinical experience that a single stage combined procedure consisting of open reduction, pelvic osteotomy as well as a corrective osteotomy within the proximal femur with subsequent shortening should be recommended

Objective: The Ponseti method for the treatment of club foot has been shown to be effective in children up to one year of age. However, it is not known whether it is successful in older children. In this prospective study, we used Ponseti method in club foot after walking age; that are neglected or undergone an insufficient previous treatment. Materials and Methods: From 2003 to 2005 we treated and followed-up 37 feet of 30 patients. All the club foot deformities corrected by the method described by Ponseti, with minor modifications. The mean age at presentation was 21 months (12–72 months) and the mean follow-up was 26 months (16–32 months). 21 feet had previous conservative and surgical treatments. The mean applied cast count that used for this method was 5.4 (4 – 8 cast). After cast treatment we performed achilotomyfor 15 feet, achiloplasty for 20 feet and achiloplasty and posterior capsulotomy for 2 feet. All the patients evaluated before and after treatment by the Dimeglio classification. Results: Before treatment 35 feet were grade 3 and 2 feet were grade 4, and after the treatment 11 feet were grade 0, 26 feet were grade 1. All the patients deformities were corrected and the treatment results were statically significant (p=0.0001). Patients distincted in two groups according to their age at the beginning of the treatment. 20 feet were younger than 20 months and 17 feet were older than 20 months. All the patients younger than 20 months had grade 3 deformity before treatment and 19 feet improved grade 1 and 1 foot improved to grade 2 after this method. In patients older than 20 months 15 feet were grade 3 and 2 feet were grade 4. and after this treatment method in this group 13 feet were improved to grade 1 and 4 feet were improved to grade 2. Patients older than 20 months had worse results for the components of varus, medial rotation of calcanopedal block and adductus thant the other group. And difference in these groups were significant. (p> 0.005). Conclusion: We conclude that the Ponseti method is a safe, effective and low-cost treatment for idiopathic club foot presenting after walking age

Aim To find out how does the late surgical treatment of DDH after walking age affects quality of life at adulthood. Patients and Methods 157 adults with 220 dysplastic hips were evaluated by physical examination, short-form 36 health questionnaire, WOMAC, Harris Hip Scoring, X-rays, computed tomography (CT) and magnetic resonance imaging (MRI). Additional hip scores were applied. Data analyzed by using SPSS 11.0. Results 39 hips of 24 patients were treated with open reduction (OR) (n=6), OR+femoral osteotomy (n=4), OR+iliac osteotomy (n=6), OR+femoral+iliac osteotomy (n=23) at a mean age of 7 years. 181 hips in 133 patients received no treatment for DDH. Mean age at evaluation was 38±13,6 years. No difference was found between treated and untreated groups in respect to SF-36 and WOMAC responses. Mean Total Harris Hip Score was slightly lower in untreated group (63 vs. 70, p=0,049). 74% of all cases have low back pain (LBP). LBP rate was not different for treated and untreated groups (80% vs. 73%, p=0,505). Interestingly, LBP was found to begin at an earlier age in treated group (23 vs. 32 years, p=0,000). Conclusion This study failed to show that surgical treatment of DDH after walking age improves adulthood quality of life. Treatment for DDH should be performed before walking age to prevent progressive degenerations at many different joints, like; sacroiliac, lumbosacral and intervertebral joints besides the hips and knees

Late presentation of DDH continues to remain a major problem particularly in the developing countries. Femoro-Acetabular Zones (FAZ) system is created to find a relation between acetabular maturity and severity of dislocation, in one hand, and the success of closed reduction, on the other hand. We hypnosis that the lower the acetabular index and the closer the femoral head to the acetabulum, the more likely the success of treatment. Thus, a retrospective study was performed on late diagnosed DDH hips that underwent closed treatment at a particular hospital in the Middle East. FAZ are drawn on the AP view of the pelvic x-ray and is based on a perpendicular from the acetabular index at the lateral margin of the superior acetabular rim then another perpendicular to Perkin's line is drawn. This gives three zones, graded I-III. The center of femoral metaphysis is identified denoting the position of the femoral head in relation to the zone classification. FAZ system was applied on 65 pelvic radiographs; mean patient age was 24 months (range: 12 to 36 months) with a minimum follow up of 3 years. Overall, 37 of 65 hips (57%) achieved a satisfactory outcome (Severin I&II), while 22 hips (33%) were found to be unsatisfactory (Severin III). 6 hips (10%) needed an open reduction (p-value 0.001). FAZ could perfectly predict the successful cases. FAZ system is a simple and novel classification and if employed, could reasonably predict the outcome of non-surgical treatment of DDH after walking age

Thanks to neonatal screening, idiopathic congenital dislocation of the hip (CDH) is generally diagnosed and treated at an early age. Despite this measure, late diagnosis of CDH still occurs. The goal of this article is to analyse the results of Petit-Morel’s closed reduction (CR) technique in the treatment of CDH diagnosed between 1 and 5 years old. We reviewed 72 hips in 60 patients. The treatment method was the same for all patients, beginning by bilateral longitudinal traction to achieve ‘presentation’ of the hip. It was followed by ‘penetration’ in a hip spica cast made under general anesthesia. The third step was an almost systematic surgical treatment of the remaining acetabular dysplasia. Results were evaluated using the radiological Severin score. Average follow-up was 11.9 years. The failure of CR occurs only twice. In this two cases, open reduction showed intraarticular obstacles to reduction. The only case of avascular necrosis (AVN) occured in one of this two failures of CR. At last follow-up, 95.8% of hips were rated as normal, or midly deformed. Young age at treatment significantly influenced the prognosis in our series. Neither the gender nor the height of the dislocation did appear to have any influence on the result. The patients which did not undergo a periacetabular osteotomy were significantly younger than the other one in the series. Pelvic osteotomy is an integral part of the method, as after 18 months many hips have lost their capacity to correct the remaining dysplasia. However, we only perform this osteotomy if the hip shows no sufficient correction during the semesters following the reduction od the dislocation. Considering Severin score, it is impossible to privilege closed or open reduction, as the results of both methods are close. However, in case of failure of reduction, which occurs in both methods, a second open reduction is much more difficult to achieve than and open reduction in a hip first treated by closed reduction. The results of this second surgery on the hip are poorer, with higher rates of AVN. Moreover, long-term functional and radiological deterioration of the hip is higher after open reduction than closed reduction. Lowest rates of AVN are reported after traction followed by closed reduction compared with exteporaneous reduction or open reduction, thanks to progressive reduction of the hip. Finally, mention should be made of the cost of the treatment. Petit-Morel’s protocole is expensive, both because of the duration of stay in the hospital, and by indirect costs as parent adaptation of its work during the treatment. The cost of open reduction is lower. However, considering the prooved better results of the closed method, requiring lower rates of further surgical procedure, we think that this method is the one to be promoted for treatment of CDH in children between 1 and 5 years old.

Aims. To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot. Methods. A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper. Results. In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function. Conclusions. There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step. Cite this article: Bone Joint Open 2020;1-8:457–464

Purpose and Background. Both overall spine shape and the size and shape of individual vertebrae undergo rapid growth and development during early childhood. Motor development milestones such as age of walking influence spine development, with delayed ambulation linked with spinal conditions including spondylolysis. However, it is unclear whether associations between motor development and spine morphology persist into older age. Therefore, these associations were examined using data from the MRC National Survey of Health and Development, a large nationally-representative British cohort, followed up since birth in 1946. Methods and Results. Statistical shape modelling was used to characterise spinal shape (L5-T10) and identify modes of variation in shape (SM) from dual energy x-ray absorptiometry images of the spine taken at age 60–64 years (N=1327 individuals; 51.8% female). Associations between walking age in months (reported by mothers at 2 years) and SMs were examined with adjustment for sex, birthweight, socioeconomic position, height, lean mass and fat mass. Later onset of independent walking was weakly associated with greater lordosis (SM1; P=0.05) and more uniform antero-posterior vertebral size along the spine (SM6, P=0.07). Later walking age was also associated with smaller relative anterior-posterior vertebral dimensions (SM3) among women whereas the opposite was found for men (P <0.01 for sex interaction). Conclusions. Spinal morphology in early old age was associated with the age that individuals began walking independently in childhood, potentially due to altered mechanical loading. This suggests that motor development may have a persisting effect on clinically-relevant features of spine morphology throughout life. Conflict of interest: None. Funded by the UK Medical Research Council (Grant MR/L010399/1) which supported FRS, SGM and AVP

Actually conservative treatment and/or minimal invasive surgical approach is considered the gold standard in the treatment of CF all around the world. Two main italian pediatric hospitals (Bambino Gesù in Rome and Meyer in Florence) will present own series in order to realize how the two methods (Ponseti in Rome and Seringe in Florence) can be used, the right indications for each method and sharp limits as well. The aim of this study is to compare two methods for evaluating their effectiveness and their applicability. Patients, Methods and Results. Rome series: from 1998 to 2009 pediatric hospital Bambino Gesù in Rome had treated 1350 patients with the Ponseti method (1980 feet). All feet had been scored according to Pirani classification. At age of 3–4 months, the 72% of feet treated had minimal surgery consisted in transversal tenotomy of achille's tendon. Casting for further 3 weeks and Denis-Brown splint wore full time until walking age and during the night only for 3 years after walking age. Surgery had been performed in 72% of case and surgery has been directly related to CF severity. Florence series: the Unit of Pediatric Orthopaedics Meyer Children's Hospital of Florence was born in January 2004 and therefore the series includes patients from January 2004 to December 2009. 173 patients (239 feet) were treated. Dimeglio's classification was used. At the age of 4–5 months were treated with tenotomy of Achille's tendon 51,9% of patients, mainly stage 3, and immobilization in long leg cast was used only for three weeks after surgery. Discussion. Minimally invasive treatment for CF is universally considered one of the best way to correct the deformity without using the extensive surgery that often causes stiffness, pain and shoes discomfort in adulthood. The long-term results of two series are similar and this enhance our mind that not invasive method for CF treatment is effective, low-cost, with very low rate of recurrence, only if applied following strictly the protocol. In our series in fact the highest rate of recurrence concerns the missing of Denis-Brown device or early dismission of Denis-Brown as well. The adherence to the protocol is chiefly recommended by the authors when surgery is not performed and therefore the risk of recurrence is higher. The French method especially needs a skill panel of physical therapist that are in confidence with the bandage manoeuvres. Only medical operators in confidence with the methods are able to guarantee good results and a low rate of recurrence as well. For this reason the method recommended by Dr. Seringe is easy exported in geographic areas where health service and health support are well represented

Aim: Patients treated with one-stage combined operations after walking age for developmental dysplasia of the hip (DDH), and whose follow-up revealed both clinical and radiological complete healing underwent flexor and extensor isokinetic muscle strength (IMS) measurements of the hip and results were evaluated in comparison with the contralateral hips. Methods: A total of 22 patients with unilateral DDH and treated with one-stage combined operations after walking age were included in the study. All patients were operated by the same surgeon. In their last follow-up visit, all patients were functionally excellent in accordance with the Barrett’s Modified McKay Criteria and according to the Severin’s Classification for radiological grading of the hip all cases were type I. IMS of hip flexors and extensors were tested by Biodex 3 Pro isokinetic test device at 120º/sc and 240º/sc. In all patients, peak torque (PT), peak torque angle (PTA), total work (TW), and average power (AP) values of operated and non-operated hips were measured at both angular velocities and recorded separately for flexors and extensors. For comparative evaluation, values of the operated and non-operated hips were used for determining the differences in IMS (DIMS), total work (DTW), and average power (DAP). In statistical assessment; Student’s t test, paired t test, and Spearman’s Rank correlation analysis were used. Results: The mean age of patients were 12,8±2,9 (9–18) years old. At the last control visit, the mean value of follow-up periods were 112,6±32,0 (68–159) months. Parameters like age, age at the time of operation, and the length of postoperative follow-up period showed no statistical relation with IMS measurements (p> 0,05). For flexors, TW was lower at the operated hip when compared with the non-operated hip at 120º/sc and 240º/sc (p=0,001 and p=0,002, respectively). AP was lower at the operated hip at 120º/sc and 240º/sc (p=0,011 and p=0,003, respectively). PT was lower at the operated hip (22,5±11,3) when compared with the non-operated hip (27,1±12,1) only at 120º/sc (p=0,001). For extensor muscles, PT, TW, AP, and PTA showed no statistically significant difference (p> 0,05). For flexors, the DIMS between operated and non-operated hips at 120º/sc and 240º/sc were measured as −15,3±22,2% (median;-14,4) and −8,0±21,4% (median;−2,5), respectively. Conclusions: In operated DDH patients with a mean follow-up period of around 10 years, IMS measurements revealed that the flexor muscle strength of the operated hip was still weaker than the non-operated hip. At 120º/sc, which represented evaluation against higher resistance, DIMS, DWF, and DAP were higher when compared with 240º/sc. This finding shows that hip flexors of these patients may remain weak in activities like sports, which require more resistance

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.

Between 1980 and 2003, 600 patients with idiopathic clubfoot attended our clinic. Until 1989, we manipulated the feet according to the Robert Jones method. After that we changed to the Ponseti method. Depending on the residual deformity at age 3 months, patients underwent either percutaneous Achilles tenotomy or full posteromedial release, as described by McKay, and were supplied with a thermoplastic splint until walking age. Minor changes to the surgical technique were made over the years. At follow-up, a minimum of 2 years postoperatively, the feet were evaluated both according to the McKay scoring method and by a simpler method that correlated well with it. Although our results compare unfavourably with those of Ponseti (80% non-surgical correction), we had excellent overall outcomes, with low revision and complication rates

Background. Several risk factors for the development of osteonecrosis following treatment of developmental dislocated hip have been reported. The need for further research with a large-enough sample size including statistical adjustment of confounders was demanded. The purpose of the present study was to find reliable predictors of osteonecrosis in patients managed for developmental dislocation of the hip. Methods. A retrospective cohort study of children, who have been hospitalized at our department between January 1998 and February 2007 with a developmental dislocation of the hip, was completed. Sixty-four patients satisfied the criteria for inclusion. Three groups according to age and treatment were identified. Group A and B included patients treated with closed or open reductions aged less than twelve months. Patients of group C were past walking age at the time of reduction and were treated by open reduction combined with concomitant pelvic and femoral osteotomies. The average duration of follow-up for all patients was 6.8 years. Logistic regression analysis was conducted to identify predictors for the development of osteonecrosis. Results. The overall rate of osteonecrosis in group A and B was 27.4% compared to 88.2% in patients of group C. After pooling of all data, no protective effect of the ossific nucleus of the femoral head on the development of osteonecrosis was found (p = 0.14). Additionally, an increase of surgical procedures in children of group C could not be demonstrated (p = 0.17). By using logistic regression analysis the type of reduction and secondary reconstructive procedure due to residual acetabular dysplasia could be identified as predictors for the development of osteonecrosis. Conclusions. Open reduction combined with concomitant osteotomies and secondary reconstructive interventions due to residual acetabular dysplasia increase the risk for osteonecrosis in the treatment of the developmental dislocated hip. Therefore, we advocate early reduction of the dislocated hip in the first year of life to avoid the need for concomitant osteotomies combined with open reduction. Level of Evidence. Prognostic study, level II-1 (retrospective study)

Aim: To compare acetabular development and hip stability over time in patients treated for developmental dysplasia of the hip (DDH) by open reduction combined with either varusderotation (VDRO) or innominate (IO) osteotomies. Method: Patients who underwent open reduction for DDH, combined with either VDRO (38 patients) or IO (33 patients), between 15 months and 4 years of age were reviewed. Both groups comprised a single surgeon consecutive series, differing only in the type of osteotomy performed. A total of 490 postoperative radiographs over a maximum follow-up period of 13.6 years were analyzed. We used repeated measures analysis of variance to compare the change in acetabular index (AI) as well as several other radiographic indices of acetabular development and hip stability over time. Results: After osteotomy, the AI decreased in both groups but the magnitude of the decrease was significantly different between groups over time (p< 0.0001). The AI of patients undergoing VDRO never decreased as much as that of patients undergoing IO, with a mean difference of 10.4 degrees after 4 years (p< 0.0001). Similarly the IO group demonstrated more favourable acetabular architecture and hip stability over time compared to the VDRO group, as quantified by change in the acetabular floor thickness (p< 0.03), lateral centring ratio (p< 0.0001) and superior centring ratio (p < 0.0001). Conclusions: Acetabular remodelling after IO was more effective at reversing acetabular dysplasia and maintaining hip stability than VDRO. Long-term follow-up of VDRO will be necessary to determine if late improvement occurs. IO may be preferable over VDRO in the treatment of hip dislocation after walking age

Purpose. To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH). Methods. Case-note review of 22 children (44 hips) with idiopathic bilateral hip dislocation referred to a tertiary centre before walking age. The management protocol was as follows: . Examination under general anaesthesia, arthrogram, closed reduction and appropriate soft tissue release (adductors/psoas), application of a ‘frog’ cast. CT scan at 2 weeks to confirm reduction. Change of cast and arthrogram at 6 weeks to confirm improving position and stability. Cast removal at 12 weeks, and application of an abduction brace for 6 weeks. Treatment failure could occur on day 1 (failure of reduction), at week 2 (failure to maintain reduction), at week 6, or after cast removal. Results. Median age at presentation was 3.8m (2w-7.5m). 19/22 were girls. 7 had a caesarean section for breech presentation, 16/22 had had prior Pavlik harness treatment. All hips were Tonnis 2 or more. Mean age at surgery was 7 months (range 3-12m). 9/44 hips failed on day 1. 13/44 hips failed at 2 weeks. 1/44 hip failed at 6 weeks. 8/22 patients had bilateral failure. 7/22 patients maintained a unilateral hip reduction and 7/22 patients maintained a bilateral reduction after treatment. Mean follow-up was 25m (range 6-71m). 1 patient has bilateral AVN. Successful results were not associated with presentation, previous treatment given, the level of dislocation (Tonnis) or patient age at time of treatment. Conclusion. Following a successful initial reduction, this protocol failed to maintain reduction in 13/35 (40%) hips at 2 weeks: significantly worse than our presented results for unilateral dislocation. Significance. With our current protocol, the percentage chance of reducing at least one of bilateral idiopathic dislocated hips is 64% (14/22) but parents should be told that there is only a 1:3 chance of a successful outcome for both hips following closed reduction

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Aim: Complete tenotomy was performed on the most important flexor hip muscle; namely the iliopsoas during open reduction in patients with developmental dysplasia of the hip (DDH). The iliopsoas and other flexor-extensor muscles in operated and contralateral hips were evaluated comparatively by magnetic resonance imaging (MRI). Methods: A total of 22 patients with unilateral DDH after the walking age and treated with one-stage combined surgery were analyzed. All patients were operated by the same surgeon with complete tenotomy of iliopsoas muscle hindering open reduction. All patients had functionally excellent results in accordance with the Barrett’s Modified McKay Criteria in their last follow-up visits and according to Severin’s classification all cases were type 1. The imaging was performed by 1,5 T GE Excite MRI device at the supine position, without contrast material and sedation. The sagittal sections for iliopsoas muscle and T2-W FSE axial images for flexor and extensor muscle groups were used. The operated and contralateral sides were compared. Student’s t test, paired t test, and Spearman’s Rank correlation analysis were used for statistical assessment. Results: The mean age was 12,8±2,9 (9–18) years old. The mean postoperative follow-up period was 112,6 ± 32,0 (68–159) months. The reattachment of the iliopsoas to trochanter minor was observed in 7 patients, with no significance in terms of age, postoperative follow-up period, and the duration of postoperative period (p> 0,05). The atrophy in the operated side was significant in the length of iliopsoas muscle section area (p=0,0001); and the section areas of rectus femoris (p=0,002), tensor fascia lata (p=0,0001), and gluteus maximus (p=0,0001). No significance was detected in sartorius muscle section area (p=0,886). However, unlike other muscles; the ratio of operated versus contralateral side mean muscle section areas was above 1 (1,1± 0,3) for the sartorius muscle. Iliopsoas muscle reattachment was not significant for ratios of the other muscles’ operated versus contralateral side muscle section areas (p> 0,05). The atrophy was significant for the second (p=0,03) and the third (p=0,022) section’s diameter ratios in the non-reattachment versus reattachment group for the iliopsoas muscle. Conclusion: The reattachment of the iliopsoas muscle to trochanter minor after complete tenotomy was observed in 32% of patients. Following complete iliopsoas tenotomy, the expected compensatory hypertrophy in other flexor hip muscles was not detected. At the operated side, all evaluated muscles were atrophic except for the sartorius muscle. The atrophy of iliopsoas muscle was significant for the operated hip with non-reattachment to insertion site versus reattachment group

Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus. Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8). Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9). Results:. AVN scores. Closed Reduction (n=34) : Grade 1 : 5. Open Reduction (n= 11) : Grade 1: 2, Grade 2: 1, Grade 3: 1. Open, with shortening (n=24): Grade 1: 5, Grade 2: 1. Severin Scores:. Closed I: 22 II:3 III:8 IV:0. Open I:6 II:1 III:2 IV:2. Shortening I: 8 II:8 III:3 IV:2. Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results. Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued

A less invasive surgical treatment of clubfoot is increasingly considered, it aims to limit extensive exposure, to improve the functional and cosmetic outcome and to lower the risk of stiffness and recurrence of the deformity. The Ponseti method consists in an original casting technique followed, only in the most resistant clubfeet, by a percutaneous Achilles tenotomy. Critical decision is the selection of the clubfeet which needs tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision. MATERIAL AND Methods: 98 newborns with 122 congenital clubfeet were treated by the Ponseti casting technique from mid-2000 to June 2006. According to Manes classification, there were 20 mild, 47 moderate and 55 severe clubfeet. After 3 to 8 weeks of casting, clubfeet candidate to surgery underwent sonographic assessment according to the original technique previously published by the authors. On the sagittal posterior plane the R.O.M. of the ankle and subtalar joints was stated both in neutral position and under manipulation. No surgery was performed in clubfeet with normal sonographic dorsiflexion, percutaneous tenotomy was done in clubfeet with mild limited sonographic dorsiflexion and more extensive posterior release (tendon Z-lengthening and posterior cut of ankle and subtalar joint) was performed in clubfeet with most evident sonographic persistent equinus and anterior dislodgment of the talus in the ankle mortise. The R.O.M. was checked again by ultrasound at the end of treatment. According to Ponseti method a Denis Browne bar, with clubfoot 60° externally rotated, was worn full time until the walking age. Results: 35/122 clubfeet (28,6%) were treated conservatively (all the 20 mild and 15/47 of moderate deformities), 87/122 (71,4%) surgically (32/47 of moderate deformities and all the 55 severe deformities). On the basis of the dynamic ultrasound evaluation 38 clubfeet underwent simple tenotomy and 49 ones underwent extensive posterior release. At the end of the casting normal dorsiflexion was documented by ultrasound in 72 (82,7%) of the operated feet. Conclusions: The need of surgery in the Ponseti casting technique shows a great variability in Literature. These controversial data are probably due not only to the different confidence in the Ponseti method, but also to the different criteria used in evaluating the correction obtained by casting. Ultrasound assessment of the deformity gives objective qualitative and quantitative information about the restoration of the physiological dorsiflexion and articular biomechanics. On the basis of this simple, non invasive and widely available procedure the surgeon can evaluate the effectiveness of the serial casting and may be able to establish and graduate the need of corrective surgery

The term “skeletal skew” recognises the oblique positioning or slanting of two similar halves of the body. It is preferred to asymmetry which describes a disproportion between two quantities with no common measure. In 1982 69 babies with skeletal skew were described in relation to the abduction contracture which affects the hip and leg on which the body lies in persistent sidelying. The skeletal skew was evident at birth in 24 cases, but only became obvious at 4–6 months of age in the remaining 45 cases. The adducted, uppermost hip looks spuriously dysplastic but the proximal femoral ossification centre is usually equal to the opposite side and the ultrasound scan is within normal limits. Associated skewing affects the skull (plagiocephaly) the neck (torticollis), thorax, pelvis and feet in a proportion of these squint babies. When the pelvic radiograph is assessed confusion is avoided if the ischial lower border is set horizontally; this corrects the apparent, increased acetabular inclination (angle) on the adducted side. The concomitant rotational artefact can be appreciated by reviewing differences in the widths of the iliac wings and obturator foramina, sacral-symphysial alignment and femoropelvic overlap. Of the 45 cases with pronounced skeletal skew manifesting at 3–4 months of age, the oblique positioning corrected during early walking age, as shown by calculating the difference between the abduction arcs of the two hips. The plagiocephaly, with flattening of the brow on the upper side, may persist until skeletal maturity. Follow up at 18 years was achieved in 41 of the 45 cases. There was one case of mild bilateral hip dysplasia and one case of a leg length discrepancy of 1.5 cm. In 40 cases the hips were normal clinically and radiographically although 5 had persistence of increased femoral anteversion. No splintage or stretching of the adducted hip had been undertaken during infancy and hence the great majority of cases with skeletal skew correct. Ultrasound assessment is advised in borderline cases for this relatively common condition which results in a referral rate of 5.3 per 1000 live births, compared to the Edinburgh neonatal splintage rate for hip instability of 3.8 per 1000 live births