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Purpose The aim of this article is to review the current concepts in the indications, results and failure causes of the treatment of developmental dysplasia of the hip (DDH) with the Pavlik harness. Methods: The reported variables influencing the outcome in the Pavlik harness treatment were analyzed. Results Significant discrepancies about the clinical and radiological outcomes, the rates of failure and complications as well as the variables influencing the treatment outcome occur in the published studies due to the heterogeneity of the data and the differences in the methods used. The overall short-, mid- or long-term success rate of the treatment ranges from 45% to 100% and it is commonly over 75%. The rate of osteonecrosis of the femoral head ranges from 1% to 30%. Age, gender, laterality, radiological or clinical severity of the initial hip pathology and parents' compliance are the commonly reported determinants of failure of the treatment. Conclusion The failure in treatment with the Pavlik harness is multifactorial, initial type of hip dysplasia being the most prominent followed by the treatment initiation age. This type of treatment cannot be considered as the best option in Graf IV hips (hip ultrasonography) or highly dislocated hips (plain radiography) and in infants older than three months of age, as the risk of failure and development of complications including osteonecrosis and femoral nerve palsy seem to increase in such circumstances. Large-scale, comparative studies including homogenous data are needed to answer the unsolved questions concerning indications. [ABSTRACT FROM AUTHOR]

This study aims to assess whether or not the nationwide newborn ultrasonographic hip screening program has influenced the rate of different types of surgical interventions performed in developmental dysplasia of the hip (DDH) in children in Turkey. A retrospective analysis of the nationwide data obtained from the National Registry System between January 1, 2015, and December 31, 2020, was carried out. The rate of minor and major surgical interventions was calculated by dividing the total number of primary closed/open reductions with or without tenotomies and the total number of primary pelvic or periacetabular osteotomies with or without femoral osteotomies by the total number of live births in the country per year, respectively. The rates of primary minor surgical interventions were found to be 0.47/1000 in 2015, 0.71/1000 in 2016, 1.07/1000 in 2017, 1.00/1000 in 2018, 1.06/1000 in 2019, and 0.89/1000 in 2020. The rates of primary major surgical intervention were found to be 0.74/1000 in 2015, 0.40/1000 in 2016, 0.33/1000 in 2017, 0.31/1000 in 2018, 0.32/1000 in 2019, and 0.21/1000 in 2020. The introduction of the nationwide newborn hip screening program has significantly changed the surgical treatment modalities in children with DDH. A nearly twofold increase in the rate of primary closed/open reduction and hip spica casting and nearly three quarters decrease in the rate of primary bony procedures were observed within 6 years., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age., Methods: Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age., Results: Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head., Conclusion: The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: This study aimed to evaluate the diagnosis and treatment preferences of orthopedic surgeons in developmental dysplasia of the hip (DDH) cases under the age of 1 in Türkiye with a higher incidence of DDH, estimated to be around 5-15 per 1000 live births., Methods: This was a nationwide cross-sectional survey. A link for the online survey, including 16 multiple-choice questions, was sent to the email group of the National Orthopedic Society., Results: Among 233 filled-out surveys, 211 met the inclusion criteria. Half of the participants had experience of <10 years as orthopedic surgeons, managed <25% of pediatric patients in daily practice, and treated <25 DDH cases per year before walking age. Ninety-seven percent used more than one method, hip ultrasound the most common, for exact diagnosis of DDH under 6 months. Pavlik harness was the most commonly preferred brace, but the use of Tübingen orthosis increased among experienced surgeons. The uppermost age limit for bracing was higher in surgeons dealing with more pediatric patients and treating more DDH cases. Dislocated hips and hips requiring closed/open reduction were more commonly referred to other surgeons by less experienced surgeons in terms of years, number of pediatric patients, and treated DDH cases per year. The lowest age limit for intervention under general anesthesia was lower in surgeons treating >25 DDH cases per year. Over one-third used both anterior and medial approach open reduction, but a trend to anterior open reduction alone was more evident in surgeons treating >50 DDH cases per year. More experienced surgeons were more prone to check the intraoperative reduction with postoperative computed tomography or magnetic resonance imaging. Diagnosis and treatment ages of DDH cases did not significantly change during the coronavirus disease 2019 pandemic., Conclusion: Management preferences of orthopedic surgeons in DDH before walking age primarily depend on the rate of pediatric patients in daily practice and the number of treated DDH cases per year.

Purpose: The aim of this expert consensus study was to establish consensus on the treatment of different types of slipped capital femoral epiphysis and on the use of prophylactic screw fixation of the contralateral unaffected side., Methods: In this study, a four-round Delphi method was used. Questionnaires including all possible theoretical slip scenarios were sent online to 14 participants, experienced in the field of children's orthopedics and in the treatment of hip disorders in children., Results: In-situ fixation was considered to be the first treatment choice in all types of mild slip scenarios and in moderate, stable ones. Performing in-situ fixation was not favored in moderate, unstable, and in all severe slip scenarios. In moderate to severe, unstable slip scenarios, there was consensus on the use of gentle closed or open reduction and internal fixation. Any consensus was not established in the optimal treatment of severe, stable slips. There was also consensus on the use of prophylactic screw fixation of the contralateral side in case of co-existing endocrine disorder and younger age., Conclusions: The establishment of consensus on the treatment of all types of slipped capital femoral epiphysis even among the experienced surgeons does not seem to be possible. The severity of the slip and stability of the slip are the primary and secondary determinants of the surgeons' treatment choices, respectively. In-situ fixation is still the preferred treatment option in several slip types. Gentle capital realignment by closed or open means is recommended in displaced, unstable slips. Prophylactic screw fixation of the contralateral side is indicated under certain circumstances., Level of Evidence: level V., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Objective: This study aimed to assess the treatment trends and the factors influencing the treatment methods of Orthopaedic Surgeons in closed, isolated, middle-third diaphyseal long bone fractures without any neurovascular injury in children., Methods: This was a cross-sectional electronic survey of Turkish Orthopaedic Surgeons who were active members of the Turkish Society of Children's Orthopaedics (TSCO) and still managing the children's fractures in their daily clinical practice. An initial e-mail including the electronic survey followed by three reminder e-mails was sent to 110 members, and then reminder telephone calls were made., Results: The survey response rate was 66/110 (60%). In recent years, a definitive trend to surgical treatment was not seen 98%, 77%, 39%, and 88% of the responders in the closed humerus, forearm, femur, and tibia mid-shaft fractures, respectively. Neither the years of expertise nor the intensity of daily pediatric patients of the participants did not affect the treatment trend in any fracture scenarios. The patient's age was the most cited factor influencing the responders' decisions on whether conservative or surgical treatment would be performed in each fracture scenario. The most cited lowest age limits for surgical treatment inclosed mid-shaft fractures of the humerus, forearm, femur, and tibia, were the adolescent age group, 10-12 years, six years, and ten years, respectively., Conclusion: This is the first study assessing the daily clinical practice of members of TSCO in the management of closed, isolated, non- complicated middle-third diaphyseal long bone fractures in children just before the covid-19 pandemic started. A marked tendency toward surgical treatment is seen in femur mid-shaft fractures, followed by forearm mid-shaft fractures up to a certain level. The patient's age is the main determinant of the responders' decisions on the type of treatment in closed, isolated, non-complicated middle-third diaphyseal long bone fractures in children.

Purpose of the Study: The purpose of this retrospective diagnostic study was to investigate whether or not assessment variabilities occurred in hip ultrasonography (US) by the Graf method between the examiners having (CC) and not having (NoCC) additional special hands-on course trainings by the authorized trainers., Methodology: Randomly selected 270 hip sonograms of 135 babies were independently assessed by CC and NoCC according to the Graf method., Results: An inconsistency between CC and NoCC regarding the US diagnosis was seen in 128 hips (47%). This was mainly due to the fact that CC considered 120 of 128 sonograms unusable according to the checklist of the Graf's examination technique. Probe tilting errors followed by non-visualization of lower limb of os ilium as well as of chondroosseous junction were the most noticed technical problems by CC. There was a significant difference between CC and NoCC concerning the measurement of beta angle. This was mainly due to discordance between the groups about identifying the "bony rim" point., Conclusion: Significant hip US image assessment variabilities exist between the examiners having further trainings by the authorized trainers in special hands-on courses and the examiners having no further trainings in special hands-on courses in the Graf method. The findings of this study may emphasize the importance of training the hip US practitioners in the special hands-on courses for providing a standard clinical practice as well as for avoiding the assessment variabilities between the examiners in the Graf method., Competing Interests: Conflict of interestThe author declares no conflicts of interest., (© Indian Orthopaedics Association 2021.)

Background: No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip., Methods: This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips., Results: SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P<0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P<0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively., Conclusions: ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered hip(s). This study shows that, ASC can be introduced as a risk factor in selected newborn hip screening programs., Level of Evidence: Level II-diagnostic study.

Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children's fractures.The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children's fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children. Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012., Competing Interests: ICMJE Conflict of interest statement: HO reports employment by TOBB University of Economics and Technology, outside the submitted work. MCN reports employment by Hospital CUF Descobertas, outside the submitted work., (© 2020 The author(s).)

Objectives: This study aims to evaluate the clinical outcomes of children with spastic type cerebral palsy (CP) treated with botulinum toxin type A (BoNT-A) injection for lower limb contracture and the influence of age, gender, functional level and degree of initial contracture on treatment outcomes., Patients and Methods: Clinical records at pre-BoNT-A injection and post-BoNT-A injections of 153 sessions of a total of 118 consecutive children (67 boys, 51 girls; mean age 5.9±2.6 years; range, 2.5-16 years) were retrospectively evaluated. Degrees of pre- and post-injection contracture were evaluated. Post-injection supplemental casting for 10 days was recorded in all cases. Less than 20° of hip flexion contracture, more than 30° of hip abduction, a negative prone Ely test, less than 50° of popliteal angle and at least 5° of ankle dorsiflexion values at post-injection were accepted as sufficient clinical improvement., Results: Sufficient post-injection range of motion (ROM) was observed in 80% of cases with hip flexion contracture, in 45% of cases with hip adduction contracture, in 84% of cases with knee flexion contracture and in 77% of cases with ankle equinus contracture. Prone Ely test that was positive in 60% of cases with knee extension contracture was negative at post-injection. Improvement in contractures were prominent in children with lesser degree initial contractures., Conclusion: Botulinum toxin type A injection increases ROM in hip, knee and ankle joint contractures in CP. Although age, gender and functional level may influence the clinical outcomes, pre-treatment level of contracture is the main determinant in improvement in ROM at post-injection.

This review aims to summarize the basic treatment principles of fractures according to their types and general management principles of special conditions including physeal fractures, multiple fractures, open fractures, and pathologic fractures in children. Definition of the fracture is needed for better understanding the injury mechanism, planning a proper treatment strategy, and estimating the prognosis. As the healing process is less complicated, remodeling capacity is higher and non-union is rare, the fractures in children are commonly treated by non-surgical methods. Surgical treatment is preferred in children with multiple injuries, in open fractures, in some pathologic fractures, in fractures with coexisting vascular injuries, in fractures which have a history of failed initial conservative treatment and in fractures in which the conservative treatment has no/little value such as femur neck fractures, some physeal fractures, displaced extension and flexion type humerus supracondylar fractures, displaced humerus lateral condyle fractures, femur, tibia and forearm shaft fractures in older children and adolescents and unstable pelvis and acetabulum fractures. Most of the fractures in children can successfully be treated by non-surgical methods.

Background: To investigate the outcomes of patients undergoing open reduction and internal fixation with olecranon osteotomy due to AO type13C fractures of the distal humerus., Methods: Data of 39 patients (mean age, 44.7 years; males, 56.4%) undergoing surgery with the diagnosis of AO type 13C distal humeral fractures were retrospectively evaluated. Patients' demographic characteristics, medical history, and radiological and functional outcomes were recorded. The patients were evaluated at the final follow-up according to the Mayo Elbow Performance Index (MEPI)., Results: The mean degrees of flexion and extension loss were 102.2 degrees (range, 60-120 degrees) and 11.4 degrees (range, 0-25 degrees), respectively, at the final follow-up. According to the MEPI score, outcomes were excellent in seven, good in 12, fair in 13, and poor in seven patients. All patients achieved a radiological union of the fracture site within the first postoperative six months. It was found that the loss of extension was more severe, the range of flexion was decreased, and the mean MEPI score was lower in the patients with type C3 fractures than in those with type C1 and type C2 fractures. No significant difference was determined between fixation techniques (tension band vs. cannulated screw) regarding the functional outcomes., Conclusion: Our results revealed better prognosis in AO type C1 and type C2 fractures than in AO type C3 fractures and no different effects of two fixation techniques in olecranon osteotomy on the outcomes.

Objectives: This study aims to assess the experience gained in a single institution in the treatment of mixed type femoroacetabular impingement (FAI) using safe surgical hip dislocation (SSHD) technique., Patients and Methods: In this study, 22 hips of 21 patients (7 males, 14 females; mean age 33.8±10.6 years; range 19-52 years) treated by SSHD technique in our clinic between October 2009 and October 2014 were retrospectively evaluated. Preoperative and final Harris hip scores (HHS) and alpha angles were compared. Age, gender, laterality, impingement tests, preoperative HHS, cam and pincer type FAI radiographic indicators and intraoperative articular findings were assessed in terms of their influence to the final functional outcomes., Results: Mean duration of the symptoms was 29.5 months. Groin pain, activated by flexion and internal rotation of the hip, was the main symptom. A radiographic diagnosis of "mixed type FAI" was made in all hips. Mean follow-up duration of 22 hips was 48 months. The difference between the mean preoperative and latest HHS was statistically significant (60.0 vs. 87.6 points, p<0.001). The treatment was considered satisfactory in 17 of 22 hips (77%) having a mean HHS of 95.0 points. Hips having a preoperative HHS of less than 60 points were more prone to unsatisfactory outcome. Among the investigated patient-dependent, clinical, radiographic variables and intraoperative articular findings, coxa profunda sign in a plain radiograph was found correlated with a higher rate of unsatisfactory outcome (p=0.040)., Conclusion: Safe surgical hip dislocation procedure has a success rate of 77% after a mean follow-up of four years. Coxa profunda sign is associated with the unsatisfactory clinical outcome. Preoperative HHS of less than 60 points seems to be a negative predictive variable on the clinical outcome.

Background: Treatment of developmental dysplasia of the hip (DDH) using the Pavlik harness has been a widely used method in patients between 0 and 6 months of age for many years. However, the factors influencing the success rate of this treatment modality have still not exactly been determined as a result of the limited number of clinical studies with higher level of evidence., Questions/purposes: We, therefore, asked whether (1) patient-related variables such as age, gender, and laterality; coexisting risk factors including family history, breech presentation, intrauterine packing, first-born girl, oligohydroamnios, and swaddling; and (2) the severity of hip dysplasia, defined by ultrasonography, are associated with differences in the success rate of Pavlik harness treatment in infants with DDH., Methods: Between 2012 and 2014, we treated 153 children (≤ 6 months of age) with DDH using the Pavlik harness. Hip dysplasia apart from coexisting neuromuscular disorders, congenital abnormalities, or syndromes was our inclusion criteria. Of patients thus treated, 130 (85%) were available for the evaluation of patient- and hip-related variables against the success of Pavlik harness treatment. Mean age of these patients on day of diagnosis and initiation of treatment was 108 days. The diagnostic and followup examinations of the hips were made by ultrasonography using Graf's method. Pavlik harness treatment was initiated in Graf Type IIa- and worse hips and treatment was considered "successful" when a Graf Type I hip was achieved. Pavlik harness treatment was successful in 92 (71%) patients (130 of 181 hips [72%])., Results: Age was the only patient-related variable influencing the success rate of the treatment; the mean age of children in whom Pavlik harness treatment succeeded (97 ± 38 days; 95% confidence interval [CI], 90-112) was lower than the age of those who failed (135 ± 37 days; 95% CI, 123-147; p < 0.001). The highest success rate was obtained in children younger than age 3 months (37 of 40 [93%]) and the lowest one older than age 5 months (nine of 24 [37%]) (p < 0.001). The threshold age value related to an increased risk of failure was found to be 4 months and older, which had a sensitivity of 66% and a specificity of 77% (p < 0.001). A higher initial α angle was observed in the hips in which the treatment succeeded (53° ± 6°; 95% CI, 51°-53°) than in those that failed (47° ± 7°; 95% CI, 45°-50°; p < 0.001). The threshold α angle value related to an increased risk of treatment failure was 46° and less, which had a sensitivity of 47% and a specificity of 86% (p < 0.001). Dislocated hips (Graf Type III and IV hips) had the lowest rate of treatment success (five of 19 [26%] and two of four [50%], respectively), whereas Graf Type IIa- hips had the highest (27 of 29 [93%]) (p < 0.001)., Conclusions: We conclude that Pavlik harness treatment is less effective in children at and over the age of 4 months at the time the harness is first applied as well as in hips with complete dislocations and hips with severely deficient acetabular bony roofs. In such older patients and worse hip types, the use of initial Pavlik harness treatment needs to be revisited. Future studies, comparing the outcomes of the Pavlik harness treatment and other types of interventions in such patients and hip types, are needed., Level of Evidence: Level III, therapeutic study.

The aim of this case series was to assess the data of 66 children (mean age 28 months) with a diagnosis of pulled elbow. The most common time interval of injury was 12-6 p.m. and spring was the peak season. Children younger than 2 years of age had a higher rate of atypical injury history. A successful reduction by supination and flexion maneuver was achieved at the first attempt in 57 of 66 patients. The patients admitted to the hospital within the first 2 h following the injury had a higher rate of successful reduction at the first attempt. The rate of radiographic examination was considerably high and a well-defined algorithm to avoid the complicacy in ordering a plain radiograph in such cases was suggested. All patients achieved full clinical recovery after a mean follow-up of 2 years, and recurrence was observed in 16 of 66 children.

Objectives: This study aims to define a quantitative measurement method for acetabular version in a standard anteroposterior hip radiograph, assess the intraobserver and interobserver agreements of this method, and compare it with the gold standard computed tomography (CT)., Patients and Methods: Anteroposterior standard hip radiographs and simultaneously taken transverse acetabular CT sections of 78 hips of 39 patients (10 males, 29 females; mean age 60 years; range 40 to 81 years) were used in the study. In standard anteroposterior hip radiographs, "acetabular anterior wall line" was identified as the line between the most lateral edge of the acetabulum and the inferolateral edge of the teardrop. "Acetabular posterior wall line" was identified as the line between the most lateral edge of the subchondral sclerosis and the outmost point of acetabulum posterior lunate surface sclerosis. To assess the reliability of this technique, mentioned angles in 78 hips were measured by two authors independently two weeks apart. Direct radiographic values were compared with the acetabular version measurement values in CT examination., Results: Mean acetabular version angles of 78 hips in plain radiographs and CT were 18.0° (9-25°) and 17.2° (12-25°), respectively. Mean intraobserver measurement differences were 1.3° (0-5°) and 1.5° (0-6°). Mean interobserver measurement difference was 1.4° (0-5°). The mean difference between plain radiography measurements and CT measurements was 2.5° (0-6°). A significant correlation was detected between plain radiographic measurements and CT measurements., Conclusion: By this quantitative method, acetabular morphology may be measured less invasively, easily, quickly and reliably in plain radiograph in transverse plane.

Purpose: The aim of this case series was to assess the effect of two common causes of inherited thrombophilia, factor V Leiden (FVL) and prothrombin mutation (PTM) on the development of osteonecrosis of the femoral head (ONFH) following the treatment of developmental dysplasia of the hip (DDH)., Methods: FVL and PTM analysis of 58 patients (45 females and 13 males; mean age 12.2 years) with ONFH due to DDH treatment was done., Results: Rate of inherited thrombophilia (FVL plus PTM) was 15.5 %. Inherited thrombophilia was nearly four times higher in male patients than in female patients and this difference was mainly due to FVL (P < 0.05). This finding was against the common belief that, coagulation abnormalities were equally distributed across the sexes in normal population. Rates of overall inherited thrombophilia, FVL and PTM were not correlated with the type of ONFH (P > 0.05)., Conclusion: Hereditary thrombophilia, especially FVL, may be one of the causative factors for the development of ONFH following DDH treatment in male patients. Further prospective, controlled studies are needed to undoubtedly enlighten this issue.