Return to sport after forearm fractures in children: A scoping review and survey.

Purpose: A common question faced by clinicians is when a child may return to sport after treatment for a pediatric forearm fracture. There are few published recommendations and fewer supported by evidence. The aims of this study were to summarize existing published recommendation for return to sport after pediatric forearm fractures and to conduct a survey to determine usual clinical recommendations. Methods: A scoping review was performed on Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar in accordance with the Joanna Briggs Institute guidelines. In addition, 64 orthopedic surgeons were anonymously surveyed asking for recommendations regarding return to sport after pediatric forearm fractures. Participants were to assume children were 9 years old and played a sport with an average risk of forearm injury. Results: Twenty-two publications for return to sport were retrieved. Children with distal radius buckle fractures safely commonly returned to sport by 4 weeks after initial injury, while survey respondents recommended over 6 weeks. Survey respondents valued fracture stability the highest when making return to sport recommendations. Children with simple, metaphyseal, single-bone fractures were usually allowed to return to sport at 8-10 weeks post-injury. Diaphyseal and complete fractures were prescribed longer return to sport intervals. Australian respondents also prescribed longer return to sport intervals. Conclusion: Children with distal radius buckle fractures may return to sport by 4 weeks after initial injury, sooner than recommended. Published recommendations remain limited for other fractures. However, our survey suggests children with simple, metaphyseal, single-bone fractures may return to sport at 8-10 weeks. Children with diaphyseal and complete fractures should abstain from sport for longer than metaphyseal and greenstick fractures, respectively. Level of evidence: level V.

Persistently Raised Serum Titanium Levels After Spinal Instrumentation in Children.

STUDY DESIGN: Prospective study of patients undergoing elective spinal deformity surgery with repeated testing for circulating metal ions including preoperative levels acting as controls. OBJECTIVE: The aim was to determine if levels of particular circulating metal ions are maintained to two years postsurgery including different implant systems and rods. SUMMARY OF BACKGROUND DATA: Adults having hip replacements, especially metal-on-metal bearings, may develop high metal ion levels. Pediatric spinal implants are known to cause circulating metal ions, notably titanium, chromium, cobalt, and nickel. MATERIALS AND METHODS: Fifty-six children having spinal deformity surgery were studied with repeated testing for circulating metal ions, using high-resolution inductively coupled plasma mass spectrometry. Linear mixed-effects models adjusting for repeated measurements over time were used to analyze levels of titanium, cobalt, chromium, and nickel. RESULTS: Titanium levels showed a rapid increase by seven days and a peak at 30 days that was essentially maintained at the two-year assay. At two years, titanium levels were 5.14 times greater compared with the presurgery control level (P<0.0001). Cobalt levels were shown to gradually rise to a peak at 30 days and then slowly decline but remained 1.74 times above mean baseline level at two years (P=0.0004), with a declining trajectory. Chromium and nickel levels rose immediately postoperatively and then steadily declined to baseline by six months and remained at baseline at two years. The five implant systems tested had generally equivalent results. CONCLUSION: The persistent and rising levels of titanium, in a predominantly female population, is concerning. Titanium is known to cross the placental barrier and enter the circulation of the fetus in rodents and humans, and to accumulate in solid organs especially the liver, spleen, heart, and lymph nodes in humans. This potentially exposes the offspring of mothers with spinal implants to titanium, with potential teratogenic effects.

Interobserver and Intraobserver Reliability in the Salter Classification of Avascular Necrosis of the Femoral Head in Developmental Dysplasia of the Hip.

BACKGROUND: Avascular necrosis (AVN) of the femoral head is a concerning complication that can result from treatments for developmental dysplasia of the hip (DDH). AVN can lead to degenerative osteoarthritis, persistent acetabular dysplasia, reduced function, and continuing hip pain. The incidence of AVN reported in the DDH literature is widely varied (0% to 73%). This variability may arise from lack of consensus on what constitutes true AVN in this patient population, and lack of clear criteria provided in studies reporting incidence rates. METHODS: A multicentre, prospective database of infants diagnosed with DDH between 2010 and 2014 from 0 to 18 months of age was analyzed for patients treated by closed reduction (CR). Twelve pediatric orthopaedic surgeons completed 2 rounds of AVN assessments. Deidentified anteroposterior radiographs at most recent follow-up were provided to surgeons along with patient age at radiographic assessment, length of follow-up, ands affected hip. Ten of 12 surgeons completed a third round of assessments where they were provided with 1 to 2 additional radiographs within the follow-up period. Radiographic criteria for total AVN described by Salter and colleagues were used. Surgeons rated the presence of AVN as "yes" or "no" and kappa values were calculated within and between rounds. RESULTS: A total of 69 hips in 60 patients were assessed for AVN a median of 22 months (range: 12 to 36) post-CR. Interobserver kappa values for rounds 1, 2, and 3 were 0.52 (range: 0.11 to 0.90), 0.61 (range: 0.21 to 0.90), and 0.53 (range: 0.10 to 0.79), respectively. Intraobserver agreement for AVN diagnosis was an average of 0.72 (range: 0.31 to 0.96). CONCLUSIONS: Despite using the most commonly referenced diagnostic criteria, radiographic diagnosis of AVN following CR in DDH patients demonstrated only moderate agreement across surgeons. The addition of sequential radiographs did not improve cross-observer reliability, and while substantial agreement was seen within observers, the range of intraobserver kappa values was large. LEVEL OF EVIDENCE: Level I-diagnostic study.

Local Bone Grafting Is Sufficient for Instrumented Adolescent Idiopathic Scoliosis Surgery: A Preliminary Study.

BACKGROUND: Several options for grafting exist; iliac crest bone grafting, allografts, and bone substitutes. Local bone graft (LBG) offers high-quality bone graft and no commercial cost. The aim of this study was to assess the clinical and radiologic results of adolescent idiopathic scoliosis (AIS) surgery with posterior instrumentation and fusion (PIF) in patients using only LBG and to measure the quantities harvested. METHODS: A total of 218 AIS patients who underwent pedicle screw PIF surgery using only LBG with a minimum 1-year follow-up were reviewed. Bone was harvested during surgery from the excised facet joints, spinous processes (not from the end instrumented vertebrae) and decortication of laminae and transverse processes in the operative field. The harvested bone graft weight of 127 patients was recorded prospectively and then computed to graft weight per kilogram body weight (GWPK) and graft weight per motion segment (GWPMS). RESULTS: The median follow-up time was 24.7 months (12.1 to 133 mo) with 128 of the 218 patients having over 2 years follow-up. A total of 280 curves were fused. One hundred fifty-six of the patients had single curve instrumentation and 62 had double curve surgery. The median preoperative primary Cobb angle was 57.0 (31 to 100) degrees and postoperatively was 20.0 (0 to 66) degrees, indicating a median correction of 65.3% (17.5% to 100%). The median graft weight was 30 g (14 to 62 g), GWPK was 0.54 g/kg (0.24 to 1.29 g/kg) and GWPMS was 3.3 g/motion segments (2.3 to 10.0 g/kg). Twelve of 218 patients (5.5%) required subsequent surgery. Only 2 patients developed pseudarthrosis (0.91%), noting that modern segmental instrumentation warrants longer follow-up for increased confidence of complete fusion. CONCLUSIONS: LBG achieved successful fusion in over 99% of patients undergoing PIF for AIS. The described terms GWPK and GWPMS can be insightful for future studies. LBG offers a safe and low-cost solution for bone grafting in AIS surgery. LEVEL OF EVIDENCE: Level IV.

The coronal aorto-mesenteric orientation theory for post-operative nausea and vomiting following scoliosis surgery in children: a pilot study.

BACKGROUND: Post-operative nausea and vomiting (PONV) is often encountered following corrective scoliosis surgery in children, frequently attributed to high-dose opiate administration. PONV is a frequent cause of prolonged hospital stay. Mechanisms related to transient partial duodenal compression by narrow angulation of the superior mesenteric artery (SMA) and aorta following scoliosis surgery are poorly understood and might be implicated in PONV. This study investigates relationships between biomechanical anatomic variations of the SMA and aorta, and its relationship with clinically significant PONV following scoliosis surgery in children. METHODS: Children undergoing elective spinal arthrodesis for adolescent idiopathic scoliosis were assessed by preoperative abdominal ultrasound and spinal X-ray prior to surgery. Post-operative assessment of clinically significant PONV is compared to preoperative imaging and clinical variables. RESULTS: Thirteen patients (11 female and two male), with a mean age of 14 years and 1 month were included. Five patients (38.5%) developed clinically significant PONV. A significant association was observed between the coronal aorto-mesenteric orientation and PONV (P = 0.035). Of the five patients who developed PONV, two had direct coronal angulation of the SMA, one had left angulation and two had right angulation. Patients with significant PONV had narrower aorto-mesenteric distances which approached significance (P = 0.06). No other preoperative variable reached significance. CONCLUSION: Patients with coronal aorto-mesenteric orientation preoperatively appear at greater risk of developing significant PONV following scoliosis surgery, independent of opiate requirements, prompting consideration of transient partial duodenal obstruction as an important factor in the mechanisms of PONV. A coronal aorto-mesenteric orientation theory (CAMOT) is proposed to explain this biomechanical vascular 'scissor'.

Disruption of paediatric orthopaedic hospital services due to the COVID-19 pandemic in a region with minimal COVID-19 illness.

PURPOSE: This study was designed to evaluate the impact of the COVID-19 pandemic on paediatric orthopaedic services in a paediatric tertiary hospital in South Australia. METHODS: A retrospective audit was conducted of orthopaedic activity at a major paediatric tertiary hospital with a Level 1 paediatric trauma centre, where no patients were admitted with COVID-19 illness. Orthopaedic Emergency Department (ED) presentations, outpatient clinics and hospital admissions for the period between 16 March 2020 to 26 April 2020 were studied and compared with the same period in 2019 (18 March 2019 to 28 April 2019). Chi-square tests were performed with p < 0.05 indicating statistical significance. RESULTS: In total, 621 patients presented to the ED with orthopaedic complaints during the pandemic (versus 997 in 2019). However, there was minimal change in the number of ED presentations requiring admission (110 in 2020 versus 116 in 2019). Among patients discharged directly from ED, 27.3% received hospital outpatient referral (versus 39.1% in 2019), with the remaining patients referred to community health services or discharged directly.There was a 509.8% increase in telehealth (video and phone) outpatient consultations compared to 2019 and a 60.6% decline in face-to-face appointments. There was a total of 144 orthopaedic admissions (elective and emergency) compared to 184 in 2019. Admissions for children under seven remained unchanged (32.5% reduction in children aged seven and above). CONCLUSION: Despite an overall decline in all paediatric orthopaedic hospital activity, the number of emergency admissions for musculoskeletal conditions did not change. Elective surgery numbers for children aged under seven were also unchanged. Appropriate planning and hospital resources allocation are necessary to meet this service requirement in future pandemics.Level of evidence IV.

Clubfoot deformity in the Solomon Islands: Melanesian versus Polynesian ethnicity, a retrospective cohort study.

PURPOSE: Congenital talipes equinovarus (CTEV) has a high incidence in the South Pacific, with New Zealand Maori and Polynesian rates of up to seven per 1000 live births, at least five times higher than the Caucasian population. A genetic component is suggested to explain this, however, there is little information regarding the difference of incidence between Polynesian and Melanesian ethnicity in the South Pacific. Our aim was to investigate the effects of ethnicity on the incidence of CTEV in the Solomon Islands, specifically comparing Melanesian and Polynesian ethnicity. METHODS: Between 2011 and 2017, data was collected in the Solomon Islands from over 40 clinics upon introduction of the Ponseti programme for treatment of CTEV. Records were kept using the validated Global Clubfoot Initiative data form. Ethnicity was documented, including family history. RESULTS: In total, 138 children presented during this period, with 215 affected feet reviewed and treated. In all, 74% of children had solely Melanesian parents and 6% Polynesian. Using the general population ethnic breakdown of 95.3% Melanesian and 3.1% Polynesian, the odds of CTEV in children of Melanesian parents were 0.41 times lower compared with the odds in children of Polynesian parents. CONCLUSION: The results indicate that in the Solomon Islands, CTEV in Melanesian children was less than half as likely to occur in Polynesian children. Our findings also support the theories of minimal Polynesian genetic material persisting in the Solomon Islands and a different genetic risk of CTEV between Polynesians and Melanesians. LEVEL OF EVIDENCE: III.

Chromium Metal Ion Release During Instrumented Spinal Surgery in Children: The Effects of Electrosurgery.

STUDY DESIGN: Prospective 2-year study with operative sampling and in-vitro analysis of chromium ions following spinal surgery in children. OBJECTIVES: To measure metal ion levels at preoperative, intraoperative, and postoperative times to determine patterns of metal ion release during instrumented spinal surgery. SUMMARY OF BACKGROUND DATA: Raised serum metal ion levels are reported following instrumented spinal fusion in adolescent idiopathic scoliosis. The authors noted raised chromium levels in patients receiving implants that did not contain chromium. This prompted further work to establish the source. The electrosurgery tips used were discovered to contain 17% chromium. METHODS: Chromium, cobalt, and titanium levels were measured before, during, and after surgery in serum and local intraoperative fluid samples in 11 children undergoing posterior instrumentation for scoliosis. Administered drugs, cell-saver fluids, and intraoperative fluids, both local and intravenous, were investigated to exclude these as sources of chromium ions. An in-vitro study was also performed to elucidate sources of intraoperative chromium ions. RESULTS: High chromium levels were detected in all samples from the wound irrigation fluid prior to insertion of metal implants. Immediate postoperative chromium serum ion levels were also elevated and returned to baseline by day 30. In-vitro sampling of fluids from test models using electrosurgery revealed high levels of chromium ions CONCLUSION.: This finding of high chromium metal ion concentrations in intraoperative and early postoperative samples provides evidence of chromium release during the dissection phase of spinal surgery. This challenges existing beliefs that metal ion release occurs solely due to implants and now implicates the electrosurgery electrode tips as a source of raised chromium ion levels. Thorough irrigation of the operative site after the dissection phase of surgery to both dilute and reduce the intraoperative chromium ion load is suggested. Alternative electrosurgery electrode tips or other methods to coagulate during surgery could be considered. LEVEL OF EVIDENCE: 2.

Do Children With Spinal Deformity Who Have Metal Implants and Frequent Exposure to X-Rays Increase Their Risk of Cancer?

STUDY DESIGN: Spinal surgery cohort. OBJECTIVE: The authors assess the risk of cancer in children who have undergone frequent radiographs and have metal implants for the treatment of spinal deformity. SUMMARY OF BACKGROUND DATA: Concerns have been raised regarding the cancer risk to children exposed to repeated radiological examinations as part of routine surveillance to monitor progression of spinal deformity. Additionally, there are reports of increased cancer risk in adults having joint replacement with metal implants causing raised metal ion levels in the blood. METHODS: A large number of consecutive children undergoing instrumented spinal surgery since 1979 were examined for their development of malignancy. High quality data on all invasive cancers from the South Australian Cancer Registry and deaths were linked to the spinal surgery cohort with the calculation of standardized incidence ratios (SIRs) using the Quinquinquennium method. RESULTS: The study cohort was formed by 865 children. The average follow-up time from date of surgery to either death or censoring date was 18 years with a maximum of 36 years. A total of 15,921 person years were examined. There was no increased rate of cancer in these patients. For the total cohort, the SIR was 1.00 (95% confidence interval [CI] 0.50-1.79). For females the SIR was 0.83 (95% CI 0.33-1.70) and for males the SIR was 1.33 (95% CI 0.36-3.40). The male SIR reflected an expected cancer incidence of three cases, when four cases were observed, and was not statistically significant. CONCLUSION: This study has found that radiation exposure and possible exposure to circulating metal ions as a result of routine instrumented spine surgery in children since 1979 is not associated with an increased risk of cancer in up to 36 years of follow up. LEVEL OF EVIDENCE: 2.

Children bouncing to the emergency department: Changes in trampoline injury patterns.

AIM: To compare trampoline injuries and injury costs sustained at a commercial trampoline park versus private homes presenting to a major Australian children's hospital over a 12-month period. METHODS: Children presenting with a trampoline injury to the paediatric emergency department in 2015 were identified using a keyword search of triage information. A comparison of injuries sustained at a commercial trampoline park and private homes was performed. RESULTS: A total of 392 children presented with injuries, and the majority of injuries (68.9%) occurred at a private home; 19.4% were from a commercial trampoline park. Significant differences were seen between patients from a private home and commercial park for median age (5.6 vs. 12.8 years; P < 0.001), gender (48.2 vs. 61.8% female; P = 0.03) and season of injury. Of the injuries, 27.3% occurred when children fell off the trampoline, and fractures (39.5%) were the most common injury; 17.4% required hospital admission, and 12.8% required surgical intervention. Commercial park injuries had a significantly longer median length of stay (37.4 vs. 22.8 h; P = 0.03). The estimated total acute cost for these trampoline injuries in 1 year was $546 786. Commercial trampoline park injuries accounted for 21.7% of the estimated cost and private homes for 68.2%. CONCLUSIONS: Paediatric trampoline injuries remain a common source of hospital presentation and admission, despite the introduction of a Voluntary Australian Standard. Paediatric trampoline injuries usually occur in private homes; however, the increasing popularity of commercial trampoline parks contributes to a change in the profile of trampoline injuries. Commercial park injuries were more expensive to treat.

Evaluating the role of prereduction hip traction in the management of infants and children with developmental dysplasia of the hip (DDH): protocol for a systematic review and planned meta-analysis.

INTRODUCTION: Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries. Effective treatment to realign the hip is necessary to avoid long-term morbidities and maximise functional outcome. Treatment options depend on patient age but typically involve hip bracing and/or reduction under general anaesthetic. Some centres also employ prereduction hip traction. Historical papers suggest traction reduces risk of avascular necrosis (AVN) femoral head and reduces requirement for open reduction. However, several studies including a large retrospective cohort study, dispute this. We propose to perform the first systematic review and meta-analysis to clarify the value of prereduction hip traction in the management of DDH in children under the age of 3 years by identifying whether it impacts on the rate of successful closed reduction (CR) and risk of AVN. METHODS AND ANALYSIS: We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify potentially relevant studies. Studies reporting on incidence of successful CR, AVN femoral head and complications associated with prereduction hip traction in children of less than 3 years with DDH will be eligible for inclusion. Only randomised controlled trials, prospective and retrospective case-control and comparative cohort studies will be included in quantitative review. There will be no study design restrictions for inclusion in qualitative review. Following study selection, full-text paper retrieval, data extraction and synthesis, studies will be assessed for risk of bias and heterogeneity. If the included studies are sufficiently homogeneous, then we will perform meta-analysis. A narrative synthesis of the systematic review's results will also be presented. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary patient data will not be collected. The systematic review's results will be disseminated through a peer-reviewed publication. TRIAL REGISTRATION NUMBER: CRD42017064254; Pre-results.

Surgical Management of Thoracolumbar Kyphosis in Patients With Mucopolysaccharidosis: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To determine the indications and outcomes for surgical treatment of thoracolumbar kyphosis in patients with mucopolysaccharidoses (MPS) to define future studies. SUMMARY OF BACKGROUND DATA: Improvements in the medical treatment of MPS have increased lifespan and improved quality of life for many patients, but with no effect on thoracolumbar kyphosis. A greater number of these challenging patients may now be considered spinal surgical candidates. METHODS: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a PubMed database search was conducted using relevant keywords to identify articles describing MPS patients with thoracolumbar kyphosis treated surgically. Information was collected regarding demographics, indications for surgery, surgical details and outcomes. RESULTS: Sixteen articles describing 58 patients were included for review. The median age at surgery was 7 years (range 2.4-65 years) and median follow up was 3.7 years (range 7 weeks-10.3 years). The most commonly reported surgical indication was progression of deformity in 39/58 patients (67%). Preoperative neurological compromise was reported in 7/58 (12%) patients and resolved completely postoperatively in all pediatric patients. Three pediatric patients had died before final follow up. Postoperative paraplegia was reported in 2/51 patients who were neurologically intact preoperatively. Additional significant perioperative medical complications were reported in nine patients. CONCLUSION: Thoracolumbar spinal surgery is most commonly performed in MPS I. Preoperative neurological compromise associated with thoracolumbar kyphosis was reported only in MPS IV and VI, where it was associated with factors other than the degree of kyphosis. Perioperative complications are common, may be catastrophic and relate to the complexity of the MPS condition. The indications for thoracolumbar kyphosis surgery in other conditions of short stature cannot be extrapolated to MPS patients. LEVEL OF EVIDENCE: 4.

Mini C-arm: faster, cheaper, safer?

BACKGROUND: Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. METHODS: A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. RESULTS: There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm2 , P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than the comparison II. Consultants had a 14% lower dose-area product (0.012 versus 0.014 Gy.cm2 , P < 0.001) and 18% shorter screening time (8 versus 9.8 s, P < 0.001) than registrars. CONCLUSION: The Fluoroscan mini C-arm II does not demonstrate a radiation saving during closed reductions of paediatric forearm fractures but allows shorter procedures and theatre time with similar re-displacement rates. The purchase price is lower than a traditional II. We noted that operator experience reduces radiation dose.

Fixation methods for acute injuries of the ankle syndesmosis: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to compare the effectiveness of three fixation methods for acute injuries of the ankle syndesmosis - metal screw fixation, bioabsorbable screw fixation and suture button fixation.The reviewers seek to critically evaluate the available evidence to provide an evidence-based appraisal of the comparative safety and efficacy of the treatment strategies.

Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure.

BACKGROUND: The use of a brace has been shown to be an effective treatment for hip dislocation in infants; however, previous studies of such treatment have been single-center or retrospective. The purpose of the current study was to evaluate the success rate for brace use in the treatment of infant hip dislocation in an international, multicenter, prospective cohort, and to identify the variables associated with brace failure. METHODS: All dislocations were verified with use of ultrasound or radiography prior to the initiation of treatment, and patients were followed prospectively for a minimum of 18 months. Successful treatment was defined as the use of a brace that resulted in a clinically and radiographically reduced hip, without surgical intervention. The Mann-Whitney test, chi-square analysis, and Fisher exact test were used to identify risk factors for brace failure. A multivariate logistic regression model was used to determine the probability of brace failure according to the risk factors identified. RESULTS: Brace treatment was successful in 162 (79%) of the 204 dislocated hips in this series. Six variables were found to be significant risk factors for failure: developing femoral nerve palsy during brace treatment (p = 0.001), treatment with a static brace (p < 0.001), an initially irreducible hip (p < 0.001), treatment initiated after the age of 7 weeks (p = 0.005), a right hip dislocation (p = 0.006), and a Graf-IV hip (p = 0.02). Hips with no risk factors had a 3% probability of failure, whereas hips with 4 or 5 risk factors had a 100% probability of failure. CONCLUSIONS: These data provide valuable information for patient families and their providers regarding the important variables that influence successful brace treatment for dislocated hips in infants. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Increase in late diagnosed developmental dysplasia of the hip in South Australia: risk factors, proposed solutions.

OBJECTIVES: To review evidence for the increased incidence of late diagnosed developmental dysplasia of the hip (DDH) in South Australia; to identify perinatal risk factors associated with late DDH in babies born between 2003 and 2009 in SA. DESIGN: Linkage study of data collected prospectively by the South Australian Birth Defects Register (SABDR) and the Pregnancy Outcome Statistics Unit (SA Department of Health), supplemented by medical records review. PARTICIPANTS: All children born 2003-2009 in whom DDH was diagnosed between 3 months and 5 years of age and notified to the SABDR (data inclusion range, 2003-2014). Children with teratological hip dislocations and other major congenital abnormalities were excluded. MAIN OUTCOME MEASURES: Uni- and multivariable analyses were performed to identify perinatal risk factors for late diagnosed DDH. RESULTS: The incidence of late diagnosed DDH in babies born 2003-2009 was 0.77 per 1000 live births, contrasting with the figure of 0.22 per 1000 live births during 1988-2003. Significant perinatal risk factors were birth in a rural hospital (v metropolitan public hospital: odds ratio [OR], 2.47; CI, 1.37-4.46; P = 0.003), and being the second child (v being the first-born: OR, 1.69; CI, 1.08-2.66; P = 0.023). Breech presentation was highly significant as a protective factor when compared with cephalic presentation (OR, 0.25; CI, 0.12-0.54; P < 0.001). CONCLUSIONS: The incidence of late DDH has increased in SA despite an ongoing clinical screening program. Increased awareness, education, and avoidance of inappropriate lower limb swaddling are necessary to reverse this trend.

What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants?

BACKGROUND: Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition. QUESTIONS/PURPOSES: Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation. METHODS: A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%. RESULTS: A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002). CONCLUSIONS: Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time. LEVEL OF EVIDENCE: Level III, retrospective study.