The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years’ follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60°of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

Cite this article: Bone Joint J 2014;96-B:279–86.

Aim

To establish the incidence of clinically significant avascular necrosis (AVN) and the resultant influence on radiological outcome following medial open reduction for DDH.

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001).

Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis.

Introduction: Methicillin-sensitive staphylococcus aureus (MSSA) has been the predominant aetiological agent in acute osteomyelitis (AHO) in children. Recent studies from the United States have demonstrated an increase in community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, which have been linked to increased morbidity.

Aim: a) to compare the patterns of AHO including the incidence of CA-MRSA in two tertiary children’s hospitals in Canada (The Hospital for Sick Children) and the United Kingdom (Southampton General Hospital) respectively, b) to compare the clinical course of MSSA versus CA-MRSA AHO in children in these two institutions.

Method: A retrospective review was carried out of all children up to 16 years, who were diagnosed with AHO at both centres over a five-year period. Demographic information, diagnostics, aetiology, treatment and outcomes was collected for comparison across both institutions and between MSSA and CA-MRSA identified patients.

Results: 99 cases of AHO were identified in Toronto (HSC) and 82 cases in Southampton (SGH) over the given time frames. The male: female ratios were 1.5:1 at HSC and 1.7:1 at SGH. The most commonly identified organism at both sites was MSSA, representing 42% of cultures at HSC and 22% at SGH. 2 Cases of CA-MRSA were identified at HSC, while 1 case was identified in Southampton, confirmed to be PVL-positive. No cases of Haemophilus influenzae were identified at either site. There were no significant differences in the median lengths of stay, rates of operative intervention, or complications between the two institutions. CA-MRSA cases were on average younger (7.5 yrs vs 9 yrs) and were all girls, compared with 32% girls in the MSSA group. CA-MRSA patients had similar initial laboratory profiles with the MSSA patients, except for significantly higher C-Reactive Proteins (200 vs 64) (p < 0.05). CA-MRSA patients experienced a significantly longer hospital stay (23 vs 8 days); were more likely to undergo surgical intervention (2/3 vs 34/59); were treated with longer duration of IV antibiotics (34 days vs 10.5 days); and longer total duration of antibiotics (61 days vs 46 days). 1/3 CA-MRSA patients required admission to the ICU for sepsis

Conclusions: MSSA remains the predominant aetiological agent in AHO at two large children’s hospitals in Canada and the UK. The patterns of infection are similar at both sites. CA-MRSA AHO infections have been identified at both centres, and although these remain uncommon, they are associated with a more severe clinical course. One can expect the incidence of CA-MRSA strains to rise, necessitating increased vigilance.