BACKGROUND: The prevalence of developmental dysplasia of the hip (DDH) has been considered to be low in East Asia, but this may be incorrect because of inconsistent diagnostic definitions and testing criteria. In 2015, the AAOS released guidelines for systematic screening for DDH in newborns. We implemented these guidelines and compared DDH incidence and outcomes before and after their implementation.
METHODS: We used a historic comparison cohort of newborns with DDH between July 2015 and May 2017 before guideline implementation (the preguideline group); their data were retrieved using electronic medical records. In this group, the newborns received general hip screening without systemic follow-up. The postguideline group included newborns who were screened for hip dysplasia and followed up per the AAOS guidelines between July 2017 and May 2019. Their data were prospectively collected. The primary outcome in the postguideline group was DDH incidence. Other outcomes included rates of referral, surgery, and complications, and DDH prognosis.
RESULTS: The preguideline and postguideline groups included 3534 and 2663 newborns, respectively, of whom 49 (1.1%) and 225 (8.4%), respectively, were referred to the pediatric orthopaedic clinic enrolled. In the postguideline group, 35 patients were diagnosed as having DDH (incidence: 1.3%, 95% CI: 0.8%-1.9%). Both the incidence and referral rates were significantly higher in the postguideline group than in the preguideline group. Furthermore, the mean age at referral was 6.7±10.06 months and 0.9±0.25 months in the preguideline and postguideline groups, respectively, indicating a potential for early treatment in the postguideline group. Finally, the female sex was identified as a risk factor for residual hip dysplasia at 6 months of age.
CONCLUSIONS: DDH incidence in East Asia seems comparable to that in Western countries. Implementing the AAOS guidelines increased the diagnosis rate and opportunity for early treatment initiation, thus potentially avoiding surgical intervention. Nevertheless, residual DDH may be detected in some patients at 6 months of age, particularly in female infants.
METHODS: Level IV.

Variation in the diagnostic interpretation of radiographs is a well-recognised problem in human and veterinary medicine. One common solution is to create a \'consensus\' score based on a majority or unanimous decision from multiple observers. While consensus approaches are generally assumed to improve diagnostic repeatability, the extent to which consensus scores are themselves repeatable has rarely been examined. Here we use repeated assessments by three radiologists of 196 hip radiographs from 98 cats within a health-screening programme to examine intra-observer, inter-observer, majority-consensus and unanimous-consensus repeatability scores for feline hip dysplasia. In line with other studies, intra-observer and inter-observer repeatability was moderate (63-71%), and related to the reference assessment and time taken to reach a decision. Consensus scores did show reduced variation between assessments compared to individuals, but consensus repeatability was far from perfect. Only 75% of majority consensus scores were in agreement between assessments, and based on Bayesian multinomial modelling we estimate that unanimous consensus scores can have repeatabilities as low as 83%. These results clearly show that consensus scores in radiology can have large uncertainties, and that future studies in both human and veterinary medicine need to include consensus-uncertainty estimates if we are to properly interpret radiological diagnoses and the extent to which consensus scores improve diagnostic accuracy.

Optimum management of hip displacement in children with cerebral palsy (CP) is facilitated by an approach that focuses on anticipatory and preventive measures. Hip surveillance programs for children with CP were developed at the beginning of the new millennium, with the purpose of identifying hip displacement sufficiently early to permit a choice of effective management options. In the early years, hip surveillance was guided by epidemiological analysis of population-based studies of prevalence. In Australia, a National Hip Surveillance in CP Working Group was first convened in 2005. This resulted in a 2008 Consensus Statement of recommendations published and endorsed by Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM). The group undertook that the recommendations should be reviewed every 5 years to ensure currency and congruency with the emerging evidence base. As new evidence became available, hip surveillance guidelines developed, with the most recent 2020 Australian Hip Surveillance Guidelines endorsed by the AusACPDM. Implementing comprehensive hip surveillance programs has now been shown to improve the natural history of hip dislocations and improve quality of life. Standardised hip surveillance programs can also facilitate planning for multicentre research through harmonisation of data collection. This, in turn, can help with the identification of robust new evidence that is based on large cohort or population studies. Here a review of evidence informing the updated 2020 Hip Surveillance Guidelines is presented.

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

BACKGROUND: The positive predictive value of clinical hip examinations performed by generalist health professionals in screening for developmental dysplasia of the hip (DDH) is low and declining.
OBJECTIVE: To assess the self-reported recognition of nationally recommended clinical hip examinations in the screening programme for DDH in Denmark among midwives, GPs, and GPs in training.
METHODS: A cross-sectional, web-based open survey study among Danish midwives, GPs, and GPs in training.
METHODS: Responders were asked to identify which of six written statements of clinical hip examinations were featured in the national Danish guidelines on DDH screening. Three statements were the official statements of the Ortolani, Galeazzi, and hip abduction examinations from the national guidelines, and three statements were false and constructed by the author group. Participants were asked to select up to six statements.
RESULTS: A total of 178 (58 GPs, 97 midwives, and 23 GPs in training) responses were included. Overall, 89% of responders correctly identified the Ortolani manoeuvre and 92% correctly identified one of the constructed descriptions as being false. The remaining four descriptions had significantly lower correct answer percentages ranging from 41%-58%, with significantly lower correct answer percentages of midwives for three out of all six descriptions when compared with GPs.
CONCLUSIONS: The recognition of two out of three recommended clinical hip examinations in the Danish screening programme for DDH is low overall among current screeners. Efforts should be made to heighten the knowledge level by further education of screeners.

Hip displacement is a common orthopedic problem in children with cerebral palsy (CP) that can result in significant morbidity. Hip surveillance has been shown to reduce the incidence of hip dislocations in children with CP and to reduce the need for salvage hip surgeries. Guidelines for hip surveillance have been developed and can be adapted to meet local needs. Implementation of surveillance guidelines for a population of children is complex and highly dependent upon the region, province/state, or country\'s system of care for children with CP. Recognizing that implementation of the evidence on hip surveillance was necessary in British Columbia, a Canadian province spanning 1 million square kilometers, a comprehensive, coordinated approach to hip surveillance was developed collaboratively by provincial stakeholders. Surveillance guidelines and a desired implementation plan were established based on the best available research evidence, current international practice, and service delivery in British Columbia. Staged implementation preceded full provincial roll out. Implementation was supported by detailed communication, knowledge translation, and evaluation plans. This province-wide hip surveillance program is the first of its kind in North America.

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group \"Clinical Tissue Regeneration\" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm2. Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary.
Hintergrund Symptomatisch präarthrotische Deformitäten wie das femoroazetabuläre Impingement (FAI) oder die Hüftdysplasie führen häufig zu lokalisierten Knorpeldefekten und nachfolgend zur Entstehung einer Koxarthrose. In der vorliegenden Arbeit werden die derzeitigen Methoden und Erkenntnisse zur Diagnose und operativen Behandlung von Knorpelläsionen dargestellt, um hieraus geeignete Therapieempfehlungen für das Hüftgelenk abzuleiten. Material und Methoden Übersichtsarbeit zur Ätiologie und Therapie von Knorpelschäden am Hüftgelenk unter Berücksichtigung der aktuellen Literatur mit Darstellung der Studienlage und der Diskussion von Vor- und Nachteilen verschiedener operativer Verfahren zum Gelenkerhalt. Ergebnisse In den meisten der bisher publizierten Studien zur operativen Behandlung von Knorpelschäden des Hüftgelenks wurden Defekte behandelt, die am Azetabulum durch ein FAI vom Cam-Typ ausgelöst werden. Ihre Entstehung kann durch rechtzeitige Beseitigung der pathologisch relevanten Deformitäten verhindert werden. Für die Therapie bereits bestehender vollschichtiger Knorpelläsionen werden derzeit fast ausschließlich knochenmarkstimulierende Techniken und die matrixgekoppelte autologe Knorpelzelltransplantation (MACT) eingesetzt. Für die Hüfte existieren zu diesen Verfahren bisher nur Studien auf geringem Evidenzniveau, was vor allem in der noch jungen Historie der Knorpelchirurgie in diesem Gelenk begründet ist. Allerdings ist schon jetzt zu erkennen, dass sich einige Erfahrungen mit den genannten Methoden vom Knie auf die Hüfte übertragen lassen. Schlussfolgerung Bei umschriebenen und vollschichtigen Knorpelschäden ab 1,5 – 2 cm2 stellt die MACT das zu bevorzugende Therapieverfahren dar, sofern keine wesentliche Gelenkdegeneration besteht. Ähnlich wie im Knie kann keine gesicherte obere Altersgrenze für einen gelenkerhaltenden Eingriff oder eine MACT im Hüftgelenk festgelegt werden, da das numerische nicht zwangsläufig mit dem biologischen Patientenalter bzw. Gelenkzustand korreliert. Wie für andere Gelenke auch, sind Langzeitbeobachtungen und die Durchführung prospektiv randomisierter Studien anzuraten.

OBJECTIVE: To ensure hip surveillance guidelines reflect current evidence of factors influencing hip displacement in children with cerebral palsy (CP).
METHODS: A three-step review process was undertaken: (1) systematic literature review, (2) analysis of hip surveillance databases, and (3) national survey of orthopaedic surgeons managing hip displacement in children with CP.
RESULTS: Fifteen articles were included in the systematic review. Quantitative analysis was not possible. Qualitative review indicated hip surveillance programmes have decreased the incidence of hip dislocation in populations with CP. The Gross Motor Function Classification System was confirmed as the best indicator of risk for displacement, and evidence was found of hip displacement occurring at younger ages and in young adulthood. Femoral geometry, pelvic obliquity, and scoliosis were linked to progression of hip displacement. A combined data pool of 3366 children from Australian hip surveillance databases supported the effectiveness of the 2008 Consensus Statement to identify hip displacement early. The survey of orthopaedic surgeons supported findings of the systematic review and database analyses.
CONCLUSIONS: This review rationalized changes to the revised and renamed Australian Hip Surveillance Guidelines for Children with Cerebral Palsy 2014, informing frequency of radiographic examination in lower risk groups and continuation of surveillance into adulthood for adolescents with identified risk factors.

BACKGROUND: Mucopolysaccharidosis type I (MPS-I) is a lysosomal storage disorder characterized by progressive multi-organ disease. The standard of care for patients with the severe phenotype (Hurler syndrome, MPS I-H) is early hematopoietic stem cell transplantation (HSCT). However, skeletal disease, including hip dysplasia, is almost invariably present in MPS I-H, and appears to be particularly unresponsive to HSCT. Hip dysplasia may lead to pain and loss of ambulation, at least in a subset of patients, if left untreated. However, there is a lack of evidence to guide the development of clinical guidelines for the follow-up and treatment of hip dysplasia in patients with MPS I-H. Therefore, an international Delphi consensus procedure was initiated to construct consensus-based clinical practice guidelines in the absence of available evidence.
METHODS: A literature review was conducted, and publications were graded according to their level of evidence. For the development of consensus guidelines, eight metabolic pediatricians and nine orthopedic surgeons with experience in the care of MPS I patients were invited to participate. Eleven case histories were assessed in two written rounds. For each case, the experts were asked if they would perform surgery, and they were asked to provide information on the aspects deemed essential or complicating in the decision-making process. In a subsequent face-to-face meeting, the results were presented and discussed. Draft consensus statements were discussed and adjusted until consensus was reached.
RESULTS: Consensus was reached on seven statements. The panel concluded that early corrective surgery for MPS I-H patients with hip dysplasia should be considered. However, there was no full consensus as to whether such a procedure should be offered to all patients with hip dysplasia to prevent complications or whether a more conservative approach with surgical intervention only in those patients who develop clinically relevant symptoms due to the hip dysplasia is warranted.
CONCLUSIONS: This international consensus procedure led to the construction of clinical practice guidelines for hip dysplasia in transplanted MPS I-H patients. Early corrective surgery should be considered, but further research is needed to establish its efficacy and role in the treatment of hip dysplasia as seen in MPS I.

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