Selective sonographic screening for developmental dysplasia of the hip - increasing trends in late diagnosis.

There are concerns that selective sonographic screening for developmental dysplasia of the hip (DDH) may be suboptimal. Our aim was to test this hypothesis by identifying trends in presentation and surgical treatment in patients with DDH. This is a retrospective review of children born between 1997-2018 who were treated surgically for DDH at our sub- regional paediatric orthopaedic unit. Demographic data, risk factors, age of diagnosis and surgical treatments were analysed. Late diagnosis was defined as greater than 4 months. 103 children (14 male, 89 female) underwent surgery. 93 hips were operated for dislocation and 21 for dysplasia. 13 patients presented with bilateral hip dislocations. The median age at diagnosis was 10 months (95% CI: 4-15). 62/103 (60.2%) were diagnosed late (after 4 months) and the median age for diagnosis in this group was 18.5 months (95% CI: 16-20.5). Significantly more patients were referred late (p=0.0077). The presence of risk factors (breech presentation or family history) was associated with early diagnosis. Over the duration of our study the operation rate per 1000 live births gradually increased, and on Poisson regression analysis there was a statistically significant increasing trend towards late diagnosis in recent years (p=0.0237), which necessitated more aggressive surgical management. In the UK, the current selective sonographic screening programme for DDH has shown a deterioration over the years of this study and this questions its current effectiveness. It appears that the majority of irreducible hip dislocations are diagnosed late, with an increased need for surgical management.

Actividades deportivas con soporte musical: ¿una nueva forma de aprender reanimación cardiopulmonar? / Sports Activities with Musical Support: A New Way to Learn Cardiopulmonary Resuscitation?

El objetivo del estudio fue analizar la viabilidad de enseñar RCP en actividades deportivas con apoyo musical y evaluar si este nuevo enfoque iguala los resultados de un curso tradicional de reanimación cardiopulmonar (RCP). Participaron 84 estudiantes universitarias sin conocimientos de RCP distribuidas en dos grupos de forma aleatoria. El primero recibió formación de RCP sólo manos integradas en una clase de aeróbic y el otro recibió un curso de RCP de manera convencional. Los resultados en la clase coreografiada comparados con el curso tradicional fueron: Profundidad media de compresiones (41,64 vs 42,92; p = 0,446), re-expansión correcta (65,47% vs 72,47%; p = 0,423), frecuencia de compresiones en un minuto (102,50 vs 138,53; p < 0,001), compresiones totales (202,50 vs 277,95; p < 0,001). Los dos métodos formativos alcanzaron resultados similares por lo que la introducción de la enseñanza de RCP en actividades deportivas puede ser un nuevo método formativo

The aim of the study was to analyse the feasibility of teaching CPR in sports activities with musical support in order to assess if this new methodology of CPR training is as effective as a traditional CPR course. 84 university students with no knowledge of CPR participated. They were distributed in two groups randomly. The first one received an experimental fitness dance class CPR course and the other was given a traditional training CPR course. The following parameters were obtained: fitness dance class group vs traditional CPR course: Average compression depth (41,64 vs 42,92; p = 0,446), Chest Recoil (65,47% vs 72,47%; p = 0,423), average compression rate (102.50 vs 138.53; p<0.001), total number of compressions (202.50 vs 277.95; p< 0.001). The two training methods achieved similar results, so CPR teaching in sports activities with musical support can be a new training method

Neonatal screening and selective sonographic imaging in the diagnosis of developmental dysplasia of the hip.

Aims: The aim of this prospective cohort study was to evaluate the effectiveness of the neonatal hip instability screening programme. Patients and Methods: The study involved a four-year observational assessment of a neonatal hip screening programme. All newborns were examined using the Barlow or Ortolani manoeuvre within 72 hours of birth; those with positive findings were referred to a 'one-stop' screening clinic for clinical and sonographic assessment of the hip. The results were compared with previous published studies from this unit. Results: A total of 124 newborns with a positive Barlow or Ortolani manoeuvre, clunk positive, or 'unstable' were referred. Five were found to have clinical instability of the hip. Sonographically, 92 newborns had Graf Type I hips, 12 had Graf Type II hips, and 20 had Graf Type IV hips. The positive predictive value (PPV) of clinical screening was 4.0% and the PPV of sonography was 16.1%. This has led to an increased rate of surgery for DDH. Conclusion: Compared with previously published ten-year and 15-year studies, there has been a marked deterioration in the PPV in those referred with potential instability of the hip. There appears to be a paradox, with rising referrals and a decreasing PPV combined with an increasing rate of surgery in newborns with developmental dysplasia of the hip. Cite this article: Bone Joint J 2018;100-B:806-10.

Efecto de 3 métodos de enseñanza en soporte vital básico en futuros maestros de Educación Primaria. Un diseño cuasiexperimental / Effect of 3 basic life support training programs in future primary school teachers. A quasi-experimental design

OBJETIVO: Evaluar el aprendizaje en soporte vital básico (SVB) en personal lego tras 3 experiencias formativas diferentes. Dise˜no: Se trata de un estudio cuasi experimental antes-después de muestreo no probabilístico, sin grupo control. Ámbito: Estudiantes de formación de profesorado de educación primaria de la Universidad de Santiago de Compostela. PARTICIPANTES: Un total de 124 estudiantes (68,8% mujeres y 31,2% hombres) de entre 20 y 39 años (M = 22,23; DE = 3,79), cuyo criterio de inclusión fue el no tener conocimientos previos sobre SVB. INTERVENCIONES: Se aplicaron 3 programas formativos sobre SVB a estudiantes universitarios: curso tradicional, métodos audiovisuales y dispositivos de retroalimentación. Variables de interés principales: En masaje continuo: profundidad media de la compresión, porcentaje de reexpansión correcta, ratio de compresiones por minuto, porcentaje de compresiones correctas. Con el desfibrilador externo semiautomático: tiempo empleado en aplicar una descarga antes y después de la formación. RESULTADOS: Existen diferencias significativas en los resultados obtenidos tras 2 min de masaje continuo en función de los programas formativos recibidos, favorables al método de retroalimentación: ratio de compresiones por minuto (p < 0,001), profundidad media de la compresión (p < 0,001), porcentaje de compresiones correctas (p < 0,001) y porcentaje de reexpansión correcta (p < 0,001). En cuanto al desfibrilador externo semiautomático, se encontraron diferencias estadísticamente significativas en el T después (p = 0,025). CONCLUSIONES: El programa de formación con dispositivos de retroalimentación obtuvo los mejores resultados de calidad de compresiones cardíacas, seguido del curso tradicional y del método audiovisual. Sus superiores resultados se manifestaron tanto en hombres como en mujeres. Los 3 métodos formativos lograron el objetivo de reducir los tiempos de desfibrilación

AIM: To evaluate the learning of basic life support (BLS) measures on the part of laypersons after 3 different teaching programs. DESIGN: A quasi-experimental before-after study involving a non-probabilistic sample without a control group was carried out. Scope: Primary school teacher students from the University of Santiago (Spain). PARTICIPANTS: A total of 124 students (68.8% women and 31.2% men) aged 20-39 years (M = 22.23; SD = 3.79), with no previous knowledge of BLS, were studied. INTERVENTIONS: Three teaching programs were used: a traditional course, an audio-visual approach and feedback devices. Main variables of interest: Chest compressions as sole cardiopulmonary resuscitation skill evaluation: average compression depth, compression rate, chest recoil percentage and percentage of correct compressions. Automated external defibrillator: time needed to apply a shock before and after the course. RESULTS: There were significant differences in the results obtained after 2 minutes of chest compressions, depending on the training program received, with feedback devices having a clear advantage referred to average compression depth (p < 0.001), compression rate (p < 0.001), chest recoil percentage (p < 0.001) and percentage of correct compressions (p < 0.001). Regarding automated external defibrillator, statistically significant differences were found in Tafter (p = 0.025). CONCLUSIONS: The teaching course using feedback devices obtained the best results in terms of the quality of chest compressions, followed by the traditional course and audio-visual approach. These favorable results were present in both men and women. All 3 teaching methods reached the goal of reducing defibrillation time

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip.

Aims: The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH). Patients and Methods: Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated. Results: A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%. Conclusion: Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

Effect of 3basic life support training programs in future primary school teachers. A quasi-experimental design. / Efecto de 3métodos de enseñanza en soporte vital básico en futuros maestros de Educación Primaria. Un diseño cuasiexperimental.

AIM: To evaluate the learning of basic life support (BLS) measures on the part of laypersons after 3different teaching programs. DESIGN: A quasi-experimental before-after study involving a non-probabilistic sample without a control group was carried out. SCOPE: Primary school teacher students from the University of Santiago (Spain). PARTICIPANTS: A total of 124 students (68.8% women and 31.2% men) aged 20-39 years (M=22.23; SD=3.79), with no previous knowledge of BLS, were studied. INTERVENTIONS: Three teaching programs were used: a traditional course, an audio-visual approach and feedback devices. MAIN VARIABLES OF INTEREST: Chest compressions as sole cardiopulmonary resuscitation skill evaluation: average compression depth, compression rate, chest recoil percentage and percentage of correct compressions. Automated external defibrillator: time needed to apply a shock before and after the course. RESULTS: There were significant differences in the results obtained after 2minutes of chest compressions, depending on the training program received, with feedback devices having a clear advantage referred to average compression depth (p<0.001), compression rate (p<0.001), chest recoil percentage (p<0.001) and percentage of correct compressions (p<0.001). Regarding automated external defibrillator, statistically significant differences were found in Tafter (p=0.025). CONCLUSIONS: The teaching course using feedback devices obtained the best results in terms of the quality of chest compressions, followed by the traditional course and audio-visual approach. These favorable results were present in both men and women. All 3teaching methods reached the goal of reducing defibrillation time.

Evaluación de la fiabilidad de los dispositivos acelerómetros de retroalimentación inmediata en función de la superficie en la que se realice la reanimación cardiopulmonar / Assessment of the reliability of the accelerometers feedback devices depending on the surface on which cardiopulmonary resuscitation is performed

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Clicky hip alone is not a true risk factor for developmental dysplasia of the hip.

AIMS: A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH. PATIENTS AND METHODS: A total of 362 infants from 1997 to 2016 were referred with clicky hips to our 'one-stop' paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips. RESULTS: The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001). CONCLUSION: Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations. Cite this article: Bone Joint J 2017;99-B:1533-6.

'The psychological problem is looking at you, are you looking for it?': psychological associations with symptomatic musculoskeletal referrals.

It is important that paediatric orthopaedic surgeons recognise that psychological conditions may present with musculoskeletal symptoms. Identification through careful and sensitive history taking is vital. There is a lack of training in this regard in paediatric orthopaedics. We present a series of cases initially referred for a musculoskeletal complaint. Further probing revealed an underlying psychological problem which was neither picked up by the referring physician nor volunteered by the patient. In our opinion, it is important that this training omission is addressed as such psychological problems may be devastating for these individuals and their families.

Late presentation of developmental dysplasia of the hip : a 15-year observational study.

AIMS: Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening. PATIENTS AND METHODS: Between 01 January 1997 to 31 December 2011, a prospective, longitudinal study was undertaken of a cohort of 64 670 live births. Late presenting dislocation was defined as presentation after three months of age. Diagnosis was confirmed by ultrasound and plain radiography. Patient demographics, referral type, reason for referral, risk factors (breech presentation/strong family history) and clinical and radiological findings were recorded. RESULTS: There were 31 infants with an irreducible dislocation of the hip, an incidence of 0.48 (95% confidence interval (CI) 0.34 to 0.68) per 1000 live births. Of these, 18 (0.28 (95% CI 0.17 to 0.44) per 1000 live births; 58%) presented late. All infants had a documented normal newborn clinical examination and no abnormality reported in the six to eight week check. Of the 18 late presenting cases 72% (n = 13) had no risk factors: 16 were referred by GPs and two were late due to administrative issues (missed appointments). The mean time to diagnosis was 62.4 weeks (19 to 84). CONCLUSION: Despite universal clinical neonatal and selective ultrasound screening, late cases of irreducible hip dislocation still occur. We recommend an update of the national screening programme for DDH, a review of training and education of healthcare professionals involved in the physical examination of neonates and infants, and the addition of a further assessment after the six to eight week check. Cite this article: Bone Joint J 2017;99-B:1250-5.

Evaluación del conocimiento y de las habilidades para el uso de un Desfibrilador Externo Automatizado (DEA) por estudiantes universitarios. Un diseño cuasiexperimental / Assessment of knowledge and skills in using an Automated External Defibrillator (AED) by university students. A quasi-experimental study

Objetivo: Evaluar la capacidad del personal lego (estudiantes universitarios) para usar un desfibrilador externo automatizado (DEA). Diseño: Estudio cuasiexperimental de medidas repetidas de muestreo no probabilístico con grupo control. Ámbito: Estudiantes de formación de profesorado de la Universidad de Santiago de Compostela. Participantes: La muestra estuvo compuesta por 129 sujetos, 69% mujeres y 31% hombres, de entre 19 y 47 años (media 23,2 ± 4,7), cuyo criterio de inclusión fue el no tener conocimientos previos sobre DEA. Intervenciones: Se tomaron los tiempos empleados en aplicar una descarga sobre un maniquí con DEA sin formación (T0); tras una explicación teórico-práctica inferior a 1 minuto (T1) y tras 6 meses del proceso formativo (T2). Variables de interés principales: La variable de resultado principal fue el tiempo empleado en aplicar una descarga. Se definió la variable «efecto de mejora» mediante la diferencia absoluta de tiempo entre T1 y T0, y la variable «efecto de grado de olvido» como la diferencia absoluta entre T1 y T2. Resultados: Las medias de tiempos fueron: T0 = 67,7 s; T1 = 44,2 s; T2 = 45,9 s. Se redujo el tiempo para realizar una descarga tras la explicación formativa (T1 < T0) (−23,4 s; p < 0,001). El T2 es inferior a T0 (−21,8 s; p < 0,001), pero mayor que T1 (1,6 s; p = 0,002). El efecto de mejora fue significativo (p < 0,001), al igual que el grado de olvido (p = 0,002). Conclusiones: Se demostró el fácil manejo del DEA, ya que personas sin formación fueron capaces de aplicar una descarga. El tiempo de administración de descarga se redujo tras una pequeña formación. Este tiempo apenas aumentó pasados 6 meses (AU)

Aim: To evaluate layperson (university student) ability to use an automated external defibrillator (AED). Design: A repeated measures quasi-experimental study with non-probabilistic sampling and a control group was carried out. Scope: Teacher training degree students at the University of Santiago de Compostela (Spain). Participants: The sample consisted of 129 subjects (69% women and 31% men), between 19-47 years of age (mean 23.2 ± 4.7 years). As inclusion criterion, the subjects were required to have no previous knowledge of AED. Interventions: Times to apply defibrillation with an AED to a mannequin were recorded untrained (T0), after a theoretical and practice explanation lasting less than one minute (T1), and 6 months after the training process (T2). Main variables of interest: The primary endpoint was the time taken to deliver a defibrillation discharge. The «improvement effect» variable was defined by the absolute time difference between T1 and T0, while the «degree of forgetfulness effect» variable was defined as the absolute difference between T1 and T2. Results: The mean times were T0 = 67.7 s; T1 = 44.2 s; T2 = 45.9 s. The time to apply defibrillation was reduced after explanation training (T1 < T0) (−23.4 s; P < .001). T2 proved shorter than T0 (−21.8 s; P < .001) but longer than T1 (1.6 s; P = .002). The improvement effect was significant (P < .001), in the same way as the degree of forgetfulness (P = .002). Conclusions: Easy handling of AED was demonstrated, since untrained people were able to deliver a discharge. Defibrillation time was reduced after brief training. This time barely increased after 6 months (AU)

Gastric and colon metastasis from breast cancer: case report, review of the literature, and possible underlying mechanisms.

Gastrointestinal metastases from breast cancer are not common. We present a 58-year-old female diagnosed with lobular breast cancer some years before whose relapses were gastric and colonic mucosal. Simultaneous metastases are extremely rare. To our knowledge, no cases of initial dual affectation have been reported. The patient also showed gastritis by Helicobacter pylori. Invasive lobular breast carcinoma is the most frequent special type of breast cancer and carries some specific molecular alterations such as loss of expression of E-cadherin. Although underlying mechanisms of metastasization are not entirely known, chemokines as well as inflammatory events seem to be implicated in this process. Interaction between chemokines and their receptors frequently induces cell migration. We hypothesize that H. pylori, inflammatory cells, and chemokines may create a favorable environment attracting tumor cells.

Assessment of knowledge and skills in using an Automated External Defibrillator (AED) by university students. A quasi-experimental study. / Evaluación del conocimiento y de las habilidades para el uso de un Desfibrilador Externo Automatizado (DEA) por estudiantes universitarios. Un diseño cuasiexperimental.

AIM: To evaluate layperson (university student) ability to use an automated external defibrillator (AED). DESIGN: A repeated measures quasi-experimental study with non-probabilistic sampling and a control group was carried out. SCOPE: Teacher training degree students at the University of Santiago de Compostela (Spain). PARTICIPANTS: The sample consisted of 129 subjects (69% women and 31% men), between 19-47 years of age (mean 23.2±4.7 years). As inclusion criterion, the subjects were required to have no previous knowledge of AED. INTERVENTIONS: Times to apply defibrillation with an AED to a mannequin were recorded untrained (T0), after a theoretical and practice explanation lasting less than one minute (T1), and 6 months after the training process (T2). MAIN VARIABLES OF INTEREST: The primary endpoint was the time taken to deliver a defibrillation discharge. The "improvement effect" variable was defined by the absolute time difference between T1 and T0, while the "degree of forgetfulness effect" variable was defined as the absolute difference between T1 and T2. RESULTS: The mean times were T0=67.7s; T1=44.2s; T2=45.9s. The time to apply defibrillation was reduced after explanation training (T1

Computational ligand design in enantio- and diastereoselective ynamide [5+2] cycloisomerization.

Transition metals can catalyse the stereoselective synthesis of cyclic organic molecules in a highly atom-efficient process called cycloisomerization. Many diastereoselective (substrate stereocontrol), and enantioselective (catalyst stereocontrol) cycloisomerizations have been developed. However, asymmetric cycloisomerizations where a chiral catalyst specifies the stereochemical outcome of the cyclization of a single enantiomer substrate--regardless of its inherent preference--are unknown. Here we show how a combined theoretical and experimental approach enables the design of a highly reactive rhodium catalyst for the stereoselective cycloisomerization of ynamide-vinylcyclopropanes to [5.3.0]-azabicycles. We first establish highly diastereoselective cycloisomerizations using an achiral catalyst, and then explore phosphoramidite-complexed rhodium catalysts in the enantioselective variant, where theoretical investigations uncover an unexpected reaction pathway in which the electronic structure of the phosphoramidite dramatically influences reaction rate and enantioselectivity. A marked enhancement of both is observed using the optimal theory-designed ligand, which enables double stereodifferentiating cycloisomerizations in both matched and mismatched catalyst-substrate settings.

Synthesis of malhamensilipin A exploiting iterative epoxidation/chlorination: experimental and computational analysis of epoxide-derived chloronium ions.

We report a 12-step catalytic enantioselective formal synthesis of malhamensilipin A (3) and diastereoisomeric analogues from (E)-2-undecenal. The convergent synthesis relied upon iterative epoxidation and phosphorus(v)-mediated deoxydichlorination reactions as well a titanium-mediated epoxide-opening to construct the C11-C16 stereohexad. The latter transformation occurred with very high levels of stereoretention regardless of the C13 configuration of the parent epoxide, implicating anchimeric assistance of either the γ- or δ-chlorine atoms, and the formation of chloretanium or chlorolanium ions, respectively. A computational analysis of the chloronium ion intermediates provided support for the involvement of chlorolanium ions, whereas the potential chloretanium ions were found to be less likely intermediates on the basis of their greater carbocationic character.

Neonatal clinical screening of the hip in the diagnosis of developmental dysplasia of the hip: a 15-year prospective longitudinal observational study.

Over a 15-year prospective period, 201 infants with a clinically unstable hip at neonatal screening were subsequently reviewed in a 'one stop' clinic where they were assessed clinically and sonographically. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage. Most clinically unstable hips referred to a specialist clinic are female and stabilise spontaneously. Most irreducible dislocations are not identified from this neonatal instability group. There may be a small subgroup of females with instability of the hip which may be at risk of progression to irreducibility despite early treatment in a Pavlik harness. A controlled study is required to assess the value of neonatal clinical screening programmes.

Is congenital talipes equinovarus a risk factor for pathological dysplasia of the hip? : a 21-year prospective, longitudinal observational study.

There is controversy whether congenital foot abnormalities are true risk factors for pathological dysplasia of the hip. Previous United Kingdom screening guidelines considered congenital talipes equinovarus (CTEV) to be a risk factor for hip dysplasia, but present guidelines do not. We assessed the potential relationship between pathological dysplasia of the hip and fixed idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational study. All fixed idiopathic CTEV cases were classified (Harrold and Walker Types 1 to 3) and the hips clinically and sonographically assessed. Sonographic Graf Type III, IV and radiological irreducible hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed idiopathic CTEV feet. Sonographically, there were 259 normal hips, 18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip. There were no cases of radiological or sonographic irreducible hip dislocation. Fixed idiopathic CTEV should not be considered as a significant risk factor for pathological hip dysplasia. This conclusion is in keeping with the current newborn and infant physical examination guidelines in which the only risk factors routinely screened are family history and breech presentation. Our findings suggest CTEV should not be considered a significant risk factor in pathological dysplasia of the hip.

Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip?

AIM: The relationship between the presence and severity of sonographically diagnosed developmental dysplasia of the hip (DDH) and the clinical abnormality of limitation of hip abduction (LHA) was investigated. METHODS: A prospective, longitudinal, selective 'at risk' and neonatal instability hip ultrasound programme between 1 January 1996 and 31 December 2005. 2876 neonates/infants were initially screened for DDH by clinical examination and by hip ultrasound imaging. Pathological sonographically evaluated DDH was considered to be Graf Type III, IV and irreducible hip dislocation. Inclusion criteria were cases of unilateral or bilateral limitation of hip abduction hip. EXCLUSION CRITERIA: syndromal, neuromuscular and skeletal dysplasia cases. RESULTS: 492 children presented with LHA (55 unilateral LHA). The mean age of neonates/infants with either unilateral or bilateral LHA was significantly higher than those without (p<0.001). In the sonographic diagnosis of Graf Type III and IV dysplasias, unilateral LHA had a PPV of 40% compared with only 0.3% for bilateral LHA. The sensitivity of unilateral LHA increased to 78.3% and a PPV 54.7% after the age of 8 weeks for Graf Types III, IV and irreducible hip dislocation. CONCLUSIONS: This study identifies a time-dependent association with unilateral LHA in the diagnosis of 'pathological' DDH after the age of 8 weeks. The presence of bilateral LHA in the young infant may be a normal variant and is an inaccurate clinical sign in the diagnosis of pathological DDH. LHA should be actively sought after 8 weeks of age and if present should be followed by a formal ultrasound or radiographic examination to confirm whether or not the hip is developing in a satisfactory manner.