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Abstract Background Several aspects of slipped capital femoral epiphysis (SCFE) treatment remain controversial. Loder’s work has been instrumental in changing our understanding and approach to the management of the condition when he introduced the concept of “slip instability” and showed that avascular necrosis (AVN) developed in 47% of unstable slips but none of the stable slips. As the two types of SCFE behave differently in terms of presentation, progress and complications, we approached them as two different conditions to highlight these differences. This paper focuses on treatments of stable SCFE. Materials and methods An extensive literature search was carried out from multiple databases. One thousand six hundred and twenty-three citations were screened. Three hundred and sixteen full publications were obtained for further scrutiny. Fifty-eight studies (2262 hips) were included in the review. These studies evaluated 6 interventions. AVN was chosen as a surrogate for bad outcome. Secondary outcomes were chondrolysis (CL), femoro-acetabular impingement (FAI), osteoarthritis (OA) and patients’ reported outcomes. The latter were pooled when they met our predefined criteria. Results The type of surgical intervention was an important risk factor. Pinning in situ (PIS) was associated with the lowest AVN rate (1.4%). Moreover, the CL, FAI and OA rates were relatively low in patients who underwent PIS. These were not translated into high patient satisfaction rates among these patients, with only 47% reporting an “excellent” outcome. In contrast, 87% of patients who underwent Ganz surgical dislocation reported an “excellent” outcome. The Ganz surgical dislocation was associated with an AVN rate of 3.3%; double that observed in pinning in situ. Conclusion Pinning in situ is the best treatment for mild and moderate stable slip. Ganz surgical dislocation gives higher patient satisfaction for severe stable slip but the risk of AVN is doubled compared with pinning in situ. Devices that allow continued growth may be better than standard screws. Level of evidence Level III.

Background: The orthopedic department at Al Jalila Children's Specialty Hospital (AJCH) was opened in April 2018. A focused hip ultrasound training course was conducted in April 2019 to improve hip ultrasound imaging quality., Objectives: This study aims to evaluate the impact of focused training courses on predefined image quality criteria of infant hip ultrasound in the context of developmental hip dysplasia. It also seeks to measure the inter- and intra-rater agreement among various disciplines., Methods: A retrospective review of 120 hip ultrasound images (60 infants) was performed between April 2018 and April 2020. Based on internationally agreed criteria, 60 hip images obtained before the course were compared to another 60 hip images obtained after the course. Inter-rater and intra-rater agreements were also evaluated using intraclass correlation (ICC)., Results: The study evaluated the impact of a focused training course on the quality of infant hip ultrasound images for developmental dysplasia of the hip. Image quality significantly improved after the training, with optimal images increasing from 48% to 82% (P<0.001). Logistic regression confirmed the training's positive effect, highlighting its clinical and statistical significance. The study has also demonstrated excellent agreement among raters for alpha and beta angles, as reflected by ICC statistics. The agreement for alpha angles was notably higher than for beta angles (ICC 0.970 vs. 0.904; P<0.0001). However, inter-rater agreement for hip types, assessed using kappa statistics, was moderate (κ = 0.512) and targeted to address a limited shortfall or gaps in services., Conclusion: The study confirms the value of focused training in improving the quality of care. This training should be carefully planned and targeted to address limited shortfalls or gaps in services in other areas of service delivery., Level of Evidence: The study is a retrospective cohort with evidence level II., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. MBRU Institutional Review Board (MBRU-IRB) issued approval SRP-2018-069. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alawadhi et al.)

Acute osteomyelitis (OM) of the patella is an exceptionally rare condition in children. The rarity of this condition, coupled with its nonspecific symptoms and varied clinical presentations, makes early diagnosis challenging and often results in delayed treatment. Prompt identification and initiation of antibiotic therapy are essential for a full recovery and to prevent the disease from progressing to a chronic, more severe form. This case report discusses a previously healthy six-year-old boy who developed OM of the left patella following a fall from standing height after tripping three days prior to his presentation at the emergency department. Due to the unusual and infrequent nature of patellar OM, it is often overlooked as a potential cause of knee pain in pediatric patients. Clinicians must consider patellar OM in the differential diagnosis for children presenting with knee pain. Accurate and timely diagnosis relies on thorough clinical assessments, laboratory testing, and appropriate imagining techniques (i.e., X-ray and magnetic resonance imaging (MRI)). Early identification and appropriate treatment are critical in preventing the infection from spreading within the joint and ensuring a favorable outcome., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Abdelwahab et al.)

Patellar instability is a challenging orthopedic condition affecting both pediatric and adult populations. The diagnosis and treatment of this condition present challenges for surgeons because of the multitude of classifications and treatment options available in the literature, leading to potential confusion in treatment strategies. Nonoperative treatments often prove ineffective, with reported recurrence rates nearing. Consequently, numerous surgical interventions have been developed in pursuit of improved outcomes. However, the results of these early interventions have not been universally successful, resulting in over 100 surgical interventions being recommended for patellofemoral instability, and none of which have achieved universal success. This hesitancy among surgeons to recommend surgery can leave patients inadequately treated. This article aims to share our matrix approach to patellar instability, developed over the past decade. By providing insights into the condition, we hope to stimulate interest among aspiring surgeons and facilitate a comprehensive understanding of the diagnosis and management of patellofemoral instability., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Almessabi et al.)

Background: "Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy., Description: The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks., Alternatives: Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap 1-3 . Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication 4 , (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened 2,5-7 , and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened 8,9 ., Rationale: The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises., Expected Outcomes: Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase 1,3,8 . Reported complications with this technique were mainly superficial infection., Important Tips: Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field., Acronyms and Abbreviations: 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A439)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH., Methods: Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification., Results: The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis., Conclusions: Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Rare diseases collectively impose a significant burden on healthcare systems, especially in underserved regions, like the Middle East, which lack access to genomic diagnostic services and the associated personalized management plans., Methods: We established a clinical genomics and genetic counseling facility, within a multidisciplinary tertiary pediatric center, in the United Arab Emirates to locally diagnose and manage patients with rare diseases. Clinical genomic investigations included exome-based sequencing, chromosomal microarrays, and/or targeted testing. We assessed the diagnostic yield and implications for clinical management among this population. Variables were compared using the Fisher exact test. Tests were 2-tailed, and P < .05 was considered statistically significant., Results: We present data on 1000 patients with rare diseases (46.2% females; average age, 4.6 years) representing 47 countries primarily from the Arabian Peninsula, the Levant, Africa, and Asia. The cumulative diagnostic yield was 32.5% (95% CI, 29.7-35.5%) and was higher for genomic sequencing-based testing than chromosomal microarrays (37.9% versus 17.2%, P = 0.0001) across all indications, consistent with the higher burden of single gene disorders. Of the 221 Mendelian disorders identified in this cohort, the majority (N = 184) were encountered only once, and those with recessive inheritance accounted for ~ 62% of sequencing diagnoses. Of patients with positive genetic findings (N = 325), 67.7% were less than 5 years of age, and 60% were offered modified management and/or intervention plans. Interestingly, 24% of patients with positive genetic findings received delayed diagnoses (average age, 12.4 years; range 7-37 years), most likely due to a lack of access to genomic investigations in this region. One such genetic finding ended a 15-year-long diagnostic odyssey, leading to a life-threatening diagnosis in one patient, who was then successfully treated using an experimental allogenic bone marrow transplant. Finally, we present cases with candidate genes within regions of homozygosity, likely underlying novel recessive disorders., Conclusions: Early access to genomic diagnostics for patients with suspected rare disorders in the Middle East is likely to improve clinical outcomes while driving gene discovery in this genetically underrepresented population., (© 2023. The Author(s).)

The SARS-COV-2 pandemic has brought unparalleled challenges to healthcare provision. Being a newly discovered virus, there is a lack of previous experience and published evidence to guide healthcare providers on how to deliver services. We would like to share our approach to service delivery in a newly open children's hospital in the United Arab Emirates with a particular focus on paediatric orthopaedic services., (Copyright © 2021. Published by Elsevier Ltd.)

There has been a substantive change in our lifestyle over the last two decades. The widespread availability of entertaining digital devices created an unhealthy culture of a sedentary lifestyle, with our children hooked to their digital devices for countless hours. The mental and social consequences have been well explored in several studies. Leading a sedentary lifestyle has been shown to be associated with obesity, diabetes, cardiovascular diseases, and even early death. The adolescent-acquired flatfeet is another addition to the ever-growing list. The lack of physical activities among children nowadays has led to a pandemic of long muscles tightness in children, particularly during the growth spurt. The mismatch between the long bones and adjacent muscles growth caused relative muscles shortening, particularly the muscles that cross more than one growth center, such as the hamstring muscles and gastrocnemius muscles. As a result, it has become common to see children who cannot touch the floor on forward bending because of hamstring muscles tightness or inability to walk on their heels because of gastrocnemius muscles tightness. While muscles tightness is relatively benign, its consequences, such as adolescent-acquired flatfeet, are not. In this review, we have explored the condition, its prevention, and treatment to raise awareness among the public and professionals., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Al Ali et al.)

Bladder exstrophy (BE) is a rare congenital anomaly caused by an embryological defect in the closure of the abdominal wall. It comprises a spectrum of defects about severity, including epispadias in the mildest form and cloacal exstrophy in the worst. Surgical correction is required to achieve urinary continence, maintain normal renal function, achieve secured abdominal wall closure, and create cosmetically and functionally satisfactory genitalia. Iliac bone osteotomy is considered essential to achieve the above goals in most patients by reducing the tension of the closed abdominal wall layers, particularly when present late in infancy. Several types of pelvic iliac bone osteotomy have been described to aid bladder and cloacal exstrophy closure. They can be grouped into posterior iliac osteotomy, anterior iliac osteotomy, oblique (also called diagonal) iliac osteotomy, and a combination of posterior and anterior iliac osteotomy. We described here the Y-pelvic osteotomy, which was developed by the Manchester Orthopaedic Group in the United Kingdom. It has the advantage of anterior and posterior osteotomies but also has less risk to the neurovascular structures, less blood loss, and ease of surgical technique. The osteotomy was named the Y-pelvic osteotomy due to the morphological shape it resembles., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Alshryda et al.)

Background The use of circular frames in correcting lower limb deformity is well-established and has evolved dramatically over the years. Three new frames have been introduced recently, and this study is set to compare them in terms of accuracy and efficiency in correcting a similar long bone deformity. These frames are the Taylor Spatial Frame (TSF; Smith & Nephew, London, United Kingdom), the Truelok Hexapod System (TL-HEX; Orthofix, Lewisville, Texas), and Orthex (OrthoPediatrics, Warsaw, Indiana). Methods This is a biomechanical study comparing the above three types of circular frames to correct similar deformities in Sawbones models. The deformities that are compared were: (1) 30° valgus deformity of the distal femur; (2) 30° varus deformity of the proximal tibia. Each frame was applied to the deformed bone in the standard way that we apply to normal bone. X-rays were taken before and after the deformity correction. The frames' software was used to estimate the deformities. The variations between the software's estimations and the known bone deformities were compared. Residual deformity after initial correction and the number of re-programmings was compared among these three frames. The least residual deformity and re-programming is the favorable outcome. Results All the Sawbones models had a 30° actual coronal angulation. The Orthex software estimated the deformity at around 25.35° (SD 4.6), TSF 25.6° (SD 2), and TL-HEX 29.87° (SD 2.1). One-way analysis of variance (ANOVA) showed a significant difference in the findings (P-value 0.014). Accuracy was measured by comparing the residual deformity in angulation in the coronal plane after the first and second correction. The Orthex median residual deformity was 1°, TSF was 2.5°, and TL-HEX was 3° with a range of less than 5° for all of them. The independent samples Kruskal-Wallis test shows that there is no significant difference between the three groups (P=0.549). The frequency of strut changes required throughout the correction was not significant among the three frames using the Fisher exact test (P=0.336). TSF struts are not designed to be readjusted. Conclusion The three frames were comparable in terms of accurate correction of the two deformities, strut changes, and strut adjustments. The TL-HEX frame software was superior to other frames in terms of analyzing the deformity but the difference, although statistically significant clinically, was not., Competing Interests: The TL-HEX and TSF frames that are used in the study were recycled from previous clinical work. The Orthex frame was provided by OrthoPediatrics company free of charge. These did not influence our findings in any shape or form., (Copyright © 2022, Basha et al.)

Introduction: Developmental dysplasia of the hip (DDH) is a common paediatric orthopaedic condition that attracts a substantive amount of controversy. The treatments vary because of the wide spectrum of the condition and the age of children at presentation. Although conservative and surgical treatments exist; it is widely accepted that conservative treatment is the first line of treatment in the first 6 months of life. Several devices have been proposed as the treatment of choice; however, to the best of our knowledge these have not been critically appraised. Therefore, we conducted this review., Methods: A modified Cochrane method was followed with a preplanned detailed research protocol that was developed to guide all aspects of the review. Treatment failure of the devices was chosen as the primary outcome. Secondary outcomes included femoral nerve palsy (FNP), avascular necrosis of the femoral head (AVN), residual dysplasia, skin problems, failure of subsequent surgical treatment, compliance and tolerance issues. Results are reported according to the PRISMA guidelines., Results: A total of 30 studies were included in the review comparing 5 devices (The Pavlik harness, the Von Rosen splint, the Tubingen brace, the Frejka pillow, and the Aberdeen splint). The devices were compared in terms of success rate, AVN rate and residual dysplasia. The von Rosen splint has been shown to be superior to other devices in term of success rates and residual dysplasia (Χ 2 : P < 0.05)., Conclusion: The review findings should be interpreted with caution as there are substantive flaws in the literature and a randomized control trail is warranted to confirm the best device to treat DDH. This is feasible given the magnitude of the problem, the clear diagnostic criteria and the treatment options., (Copyright © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Bacillus Calmette-Guérin (BCG) vaccine is a live attenuated vaccine used globally since 1921, and in the United Arab Emirates (UAE), it is administered to all newborns within the first few days of life for well-established benefits. BCG osteomyelitis is a rare complication that should be considered while assessing osteomyelitis in children. This report describes three cases of BCG osteomyelitis involving proximal metaphysis of the humerus in 11 months and three months old immunocompetent male infants and the left proximal tibia in a two-year-old immunocompetent female. To the best of our knowledge, these are the first cases to be reported in the UAE. The report outlines in detail how to make a timely diagnosis by explaining the insidious clinical presentation of BCG osteomyelitis, including its radiologic, microbiologic, and histologic aspects. As well, it outlines the treatment course carried out for these three patients. As such, this report will aid physicians in staying vigilant for such rare complication and commencing early treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Ghoweba et al.)

Self-mutilation of fingers following nerve injuries is extremely rare, but it can lead to serious complications, including amputation if not treated timely. We report here what we believe to be the first English language reports of self-mutilation of fingers following median nerve injury caused by a supracondylar humeral fracture., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Binfadil et al.)

Avascular necrosis (AVN) of the femoral head following slipped capital femoral epiphysis (SCFE) is a serious complication that often leads to a permanent disability. Radiological findings of AVN may take up to two years to become apparent. This means painful waiting for children, parents, and treating teams. We would like to describe a new radiological sign that we noted in four patients. The sign has been named as the crescent moon sign or eid crescent sign. It may become visible as early as six weeks following surgery, and it carries a good prognosis that the femoral head is viable and will not develop AVN. Two out of the four patients were treated in our hospital by Ganz surgical dislocation. The other two patients had been featured in other publications, but the significance of the moon crescent signs, which were present, was not recognized or appreciated. All four patients did not develop AVN. A relatively similar radiological sign has been described in talus bone fractures (Hawkins' sign). Like SCFE, talus bone fractures have a high AVN rate. Both, the crescent moon sign and Hawkins' sign carry a good prognosis and indicate that the bone blood supply is restored., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Alshryda et al.)

Background: Allogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA)., Methods: A systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted., Results: We identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference -0.02, 95%, confidence interval CI -0.04 to -0.00, P = 0.01, Heterogeneity I 2  = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups., Conclusion: TXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs., (Copyright © 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. All rights reserved.)

Human factors and systems factors can affect surgical performance, including the operating room (OR) environment, teamwork and communication, technology and equipment, tasks and workload factors, and organizational variables. Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical errors that often lead to adverse healthcare events. We are highlighting a potential error and hazardous situation, which may occur due to the difficulty in reading the embossed letters of some ampoules because of the typeface of these ampoules. This problem is particularly important in the ORs, which require special sterile conditions. We are adding a simple step to help in the differentiation between plastic, embossed ampoules. This simple and easy-to-do step makes it possible for accurate and correct identification, without jeopardizing the safety of the patients and health care professionals., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Elgabaly et al.)

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Trisomy 21 is the most common chromosomal disorders in humans; it is caused by an extra copy of chromosome number 21. This extra chromosomal material causes widespread abnormalities involving nearly every part of human body. Hip disorders are the second most serious musculoskeletal disorder in patients with T21 with a reported incidence between 2 and 28%. The outcomes of these hip disorders in patients with T21 are much less favorable than similar hip diagnoses in normal patients and a substantive number of these patients develop severe osteoarthritis that require total hip arthroplasty (THA). The outcome of THA in this cohort of patient is not well studied., Methods: A modified Cochrane review methodology has been utilized in this review. An extended literature search was performed of the medical databases. A hierarchical approach was used to include relevant studies. Search, published papers and extracted data were checked by authors independently then jointly to ensure accuracy., Results: Nine studies (321 patients with Trisomy 21) who underwent total hip arthroplasty (THA) were included. The functional hip scores (Harris and WOMAC hip scores) improved substantively after hip arthroplasty. The 5-year cumulative revision rate was 7.5%; twice as high as age matched control. Medical and surgical complications were 3 times higher than matched controls., Conclusion: Total hip arthroplasty can be offered to patients with T21 and severe arthritis although the increased revision and complication rates must be appreciated by patients and care givers., (Copyright © 2018. Published by Elsevier Ltd.)

The management of slipped upper femoral epiphysis is controversial and evolving as insight into the condition develops. Loder introduced the concept of slip stability and demonstrated a strong association between poor outcome and instability. Almost half of patients with unstable slip developed femoral head osteonecrosis. This has been influential in surgeons' choice of treatments. Some surgeons have adopted a minimal intervention approach such as pinning in situ or gentle reduction and pinning whereas others advocated an urgent open reduction and stabilisation of slip using various surgical techniques. In this review we analysed the influence of various interventions, timing of surgery and severity of the slip on the outcome of unstable slip., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Tranexamic acid (TXA) has been successfully used to reduce bleeding in joint replacement. Recently local TXA has been advocated to reduce blood loss in total knee or hip replacement; however, this raised concerns about potential adverse effects of TXA upon the artificial joint replacement., Materials and Methods: In this biomechanical study we compared the effects of TXA and saline upon the following biomechanical properties of artificial joint materials-(1) tensile properties (ultimate strength, stiffness and Young's modulus), (2) the wear rate using a multi-directional pin-on-plate machine, and (3) the surface topography of pins and plates before and after wear rate testing., Results: There were no significant differences in tensile strength, wear rates or surface topography of either ultra-high-molecular-weight polyethylene pins or cobalt chromium molybdenum metal plates between specimens soaked in TXA and specimens soaked in saline., Conclusion: Biomechanical testing shows that there are no biomechanical adverse affects on the properties of common artificial joint materials from using topical TXA., Level of Evidence: V.

This is a retrospective study of 51 consecutive hip reconstructions in children with cerebral palsy performed between 2011 and 2013. Tranexamic acid (TXA) was used in 14 hip reconstructions only. Transfusion rate was higher, postoperative Hb was lower, and patients stayed longer in the TXA group. This did not reach a statistical significance (P = 0.75, 0.5, and 0.71, resp.). More than half of the patients who had TXA underwent bilateral hip reconstructions in comparison with 27% only in the non-TXA group. Bilateral hip reconstructions mean more surgery, more blood loss, and more blood transfusion. The patients who had TXA were significantly more disabled as evident by the higher proportions of patient with worse GMFCS levels. Although we have not been able to demonstrate the value of TXA in reducing blood loss and transfusion rate in children with CP who underwent hip reconstruction, it is hoped that an interest in exploring the value of TXA in paediatric orthopaedic surgery is generated. Ideally this should be explored further in an adequately powered, randomised controlled trial where risk of bias is minimized.

Purpose: Slipped upper femoral epiphysis (SUFE) is not common with a reported incidence of 10 per 100 000. The management of SUFE is controversial and evolving, with advancing surgical skills and expertise. The infrequency of cases, the various classifications in use, the various surgical treatments, and lack of robust evidence for outcomes, has resulted in the lack of clear, evidence-based recommendations for treatment. Although mild slip can be treated with pinning-in-situ (PIS) with predictably good outcome, moderate and severe slips present a challenge for the treating surgeons. It is logical to reduce the slip to near anatomical position; however, this desire has always been tempered by concerns about the potentially devastating complications of osteonecrosis and Chondrolysis, Methods: This is a single centre, retrospective study comparing (PIS) and Fish femoral neck osteotomy. Seventy four children presented with SUFE (90 hips). The mild and the moderate groups were treated with a single pining-in-situ (PIS). The severe group had either a surgical reduction by Fish femoral neck osteotomy or PIS. The study was approved by the regional and local ethic committee. Demographic data, clinical findings, radiographic features were collected., Results: Avascular necrosis of the femoral head (osteonecrosis) was the primary outcome. There were 11 cases of osteonecrosis (12.2%): 3/41(6.9%) in the stable group compared to 7/22 (31.8%) in the unstable group, statistically significant [P < 0.001]. In the severe slip group, the osteonecrosis rate was 33.3% in the PIS group and 26.6% in the Fish osteotomy (P = 0.539). This is not statistically significant, but the trend favours surgical reduction., Conclusions: Then reduction of the deformity is valuable. The majority of cases that do not suffer osteonecrosis will benefit by reduction of the deformity; those who are destined to develop osteonecrosis are still better off with the femoral head in a reduced position. The unstable slip is more likely to be severe and more likely therefore to receive surgical reduction than a stable and less severe hip. The implication here is that the osteotomy might not be the cause of the osteonecrosis; it is the vascular damage due to the instability of the slip that is responsible., (Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use., (©2014 The British Editorial Society of Bone & Joint Surgery.)

Background: Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid., Methods: A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions., Results: Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months., Conclusions: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects., Level of Evidence: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid., Methods: A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications., Results: Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p &lt; 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months., Conclusions: Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: The scaphoid fractures account for 50%-80% of all carpal bone fractures in young individuals. Non-union of the fracture occurs in approximately 5%-10% of undisplaced scaphoid fractures. Current management varies significantly among different places and surgeons., Objectives: The purpose of this review is to investigate the evidence of the effectiveness and safety of various treatments of acute scaphoid fractures., Methodology: Systematic review and metanalysis of all the randomised and quasi-randomised trials comparing different treatments of acute scaphoid fractures., Results: Thirteen RCTs (Published 18 times) have met our inclusion criteria. The followings have been investigated: 1. Colles cast versus scaphoid cast. 2. Above elbow versus below elbow scaphoid cast. 3. Colles cast with the wrist in flexion versus Colles cast with the wrist in extension. 5. Operative versus non-operative treatment. 6. Union rate versus time to union., Conclusion: Scaphoid fracture can be treated by Colles cast for up to 12 weeks. The wrist should not be in flexion. There is no advantage of an above elbow cast over a below elbow cast. Operative treatment for scaphoid does not provide a higher union rate in undisplaced fractures, but may do in displaced fracture. Open approach seems to be superior to percutaneous fixation., (Copyright © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

The absence of the hallucal sesamoid is a rare condition. Rarer still is the presentation of adolescent hallux valgus with the absence of both hallucal sesamoid. Seven cases of absence of the tibial sesamoid bone and 3 cases of absence of the fibular sesamoid bone have been found in the literature, and only a single case of bilateral absence of both sesamoid bones with hallux varus has been reported. We would like to present a unique case of bilateral absence of the hallucal sesamoid in an 18-year-old woman with severe adolescent hallux valgus but no other apparent congenital deformity., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effect of tranexamic acid (TXA) upon blood loss and transfusion in primary total knee replacement. The review used the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. A total of 19 trials were eligible: 18 used intravenous administration, one also evaluated oral dosing and one trial evaluated topical use. TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk ratio (RR) 2.56, 95% confidence interval (CI) 2.1 to 3.1, p < 0.001; heterogeneity I(2) = 75%; 14 trials, 824 patients). Using TXA also reduced total blood loss by a mean of 591 ml (95% CI 536 to 647, p < 0.001; I(2) = 78%; nine trials, 763 patients). The clinical interpretation of these findings is limited by substantial heterogeneity. However, subgroup analysis of high-dose (> 4 g) TXA showed a plausible consistent reduction in blood transfusion requirements (RR 5.33; 95% CI 2.44 to 11.65, p < 0.001; I(2) = 0%), a finding that should be confirmed by a further well-designed trial. The current evidence from trials does not support an increased risk of deep-vein thrombosis (13 trials, 801 patients) or pulmonary embolism (18 trials, 971 patients) due to TXA administration.

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) -164 to -44, p = 0.0006, heterogeneity I(2) 0%), postoperative blood loss by a mean of 172 ml (95% CI -263 to -81, p = 0.0002, heterogeneity I(2) 63%) and total blood loss by a mean of 289 ml (95% CI -440 to -138, p < 0.0002, heterogeneity I(2) 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference -0.20, 95% CI -0.29 to -0.11, p < 0.00001, I(2) 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.