The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

Aim

The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups.

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the ‘5 moments of hand hygiene’ in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively.

We recommend caution in the universal adoption of the WHO ‘5 moments of hand hygiene’ by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes.

This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.

The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital.

Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy.

The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.

Carpal Tunnel Syndrome is the most common entrapment neuropathy encountered in clinical practice. Previous studies have suggested that the disease has a higher prevalence in the elderly(Stevens JC etal, Neurology 1988;) and that this sub group also tends to have a higher prevalence of severe CTS.(Seror P, Ann Hand Surg 1991; Bland etal, J Neurol Neurosurg Psychiatry). Surgical decompression of the median nerve is the treatment of choice with a reported success rate of between 53 and 97 %.(Katz et al, J Hand Surg 1998).

There has been some controversy regarding the effectiveness of surgery in elderly patients. The aim of our study was to evaluate the results of carpal tunnel release in patients over the age of 75 years at the time of surgery. A literature search revealed few studies carried out in elderly patients–Weber etal-(mean age 75 years), Porter etal (mean age 59.8 years) and Leit et al (mean age 79 years). The average age of our patient group (80.4 years) is the highest reported in literature so far.

We posted questionnaires to all patients who were over 75 years at the time of their surgery. There were a total of 49 patients (65 hands) operated over the last 10 years who belonged to this age group. We used the Brigham And Women’s Hospital Questionnaire devised by Levine et al. (1993). In addition, we added some questions to assess patient satisfaction with the procedure. 65% of the patients were females. The average age was 80.4 years.

The completed questionnaires were used to calculate the Pre and Post operative scores. The mean pre operative score was found to be 3.18, which improved post operatively to 1.8. (Scale of 1 to 5, with 1 being the best and 5 the worst). Importantly, although all symptoms improved, some such as pain and numbness showed a much greater improvement than grasping power. On the Visual Analogue Scale, pain scores improved from 6.4 to 2.3 post surgery. 82 % of patients had no scar tenderness, 12 % had mild to moderate tenderness, while 6 % reported severe scar tenderness. Overall 79% of patients showed improvement, 15 % felt that the surgery had made no difference, while 6% reported worsening of their symptoms after surgery.

Our study showed that 8 out of 10 elderly patients will improve after carpal tunnel release, though all symptoms are unlikely to improve. The symptom least likely to improve is weakness of the hand. The results of this study are important to counsel this sub group of elderly patients, so that they may take an informed decision on whether to proceed with the surgery.

Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal fractures with the clinical outcome. Methods: Between March 1994 and August 2001, at two centres, The Womenñs and Childrenñs Hospital, Adelaide, Australia and The Royal London Hospital, London UK 60 children were surgically treated for diaphyseal forearm fractures using Elastic Stable Intramedullary Nails (ESIN) or 2.5mm Kirschner wires. Having established no difference in the clinical outcome or subjective disability of either technique we compared the implant cost directly. Results: The two treatments both resulted in an excellent outcome with all fractures leading to union with no subjective disability. The Kirscner wires cost £3.00 per wire while the ESI Nails cost between £57.50 and £ 113.30 per wire, depending on the dimensions. Conclusions: We were not able to demonstrate any difference in outcome between ESIN and K-Wiring, although the nails do offer theoretical advantages. The cost implications of using the special implant are twenty fold or more, and as the pressures of cost cutting grow, we wonder if theoretical advantage is Òvalue for moneyÒ.

Introduction: The majority of forearm fractures in children can be managed with a plaster cast alone and manipulation under anaesthetic as required. A small number of cases however require surgical intervention. A variety of methods are available but the use of elastic intramedullary nails is becoming the technique of choice.

Method: We present a two-centre study assessing the outcome of either Elastic StabJe Intramedullary Nails (ESIN) or Kirschner wires as the method of fracture stabilisation in diaphyseal forearm fractures of the radius and ulna.

Results: ESIN group: 24 children underwent ESIN fixation. There were 22 boys and 2 girls, mean age 9.4 years (1.4–15.2 years, p=O.ll). Indications for stabilisation included 21 cases for fracture instability (immediate or delayed,) 2 irreducible fractures and 1 open fracture. 14 children underwent surgery on the day they sustained their fracture. The remainder were operated on an average 6.5 days following injury (1–14 days). In the K wire group: 36 children underwent K-wires fixation with 2.5mrn wires. There were 21 boys and 15 girls, mean age 10.6 years (2.2–15.5 years). Indication for stabilisation included 22 cases for fracture instability , 6 irreducible fractures and 8 open fractures. 32 children underwent surgery on the day they sustained their fracture. The remaining 4 patients were operated on the following day.

Conclusions: All fractures united with no resultant subjective disability. The complication rate following K-wires was 16% and that following nail fixation 9%. Loss of forearm rotation was documented in 4 children in the K-wire group and 3 children stabilised with nails. These results confirm an excellent outcome following intramedullary fixation. We have demonstrated no difference in outcome between K-wires and ESIN, although the elastic nails do offer some theoretical advantages.