Usefulness of Measuring Acetabular Anterior Coverage Using a Tomosynthesis Imaging System

2017 ◽  
Vol 27 (1) ◽  
pp. 87-91
Author(s):  
Tadahiko Ohtsuru ◽  
Yasuyuki Morita ◽  
Yuhei Horiuchi ◽  
Yasuaki Murata ◽  
Shuji Shimamoto ◽  
...  
Keyword(s):  
Anterior Margin ◽  
Sagittal Plane ◽  
Imaging System ◽  
Early Stage ◽  
Intraclass Correlation ◽  
Standing Position ◽  
Developmental Dysplasia ◽  
Strong Positive Correlation ◽  
Effective Doses ◽  
Dysplasia Of The Hip

Purpose The purpose of this study was to compare the usefulness of measuring acetabular anterior coverage by tomosynthesis and false profile (FP) radiography. Methods 70 hips in 35 patients who were diagnosed with early stage osteoarthritis of the hip, and 60 hips from 30 healthy volunteers were analysed. Plain FP radiographs were taken, and vertical-centre-anterior margin (FP-VCA) angles were measured. Acetabular anterior coverage was measured in the natural standing position using a tomosynthesis imaging system in the sagittal plane. As with FP radiography, we measured vertical-centre-anterior margin (TS-VCA) angles. Results The median values of the FP-VCA angle, and TS-VCA angle were 43.8°, 54.4°, respectively. The TS-VCA angle was significantly larger than the FP-VCA angle. For FP radiographs, the intraobserver intraclass correlation coefficient (ICC) was 0.68, and the interobserver ICC was 0.79. For tomosynthesis sagittal images, the intraobserver ICC was 0.85, and the interobserver ICC was 0.92. There was a strong positive correlation between the TS-VCA angle and the FP-VCA angle. When the FP-VCA angle was 25°, the TS-VCA angle was 35° in regression analysis. Conclusions Measuring acetabular anterior coverage using sagittal plane tomosynthesis correlates well with FP radiography. Regardless of the presence of acetabular deformities, tomosynthesis demonstrated high reproducibility, simple posture setting, low effective doses, and high versatility. A cut-off value of 35° was useful for the detection of developmental dysplasia of the hip joint using the TS-VCA angle.

scholarly journals Accuracy of New Deep Learning Model-Based Segmentation and Key-Point Multi-Detection Method for Ultrasonographic Developmental Dysplasia of the Hip (DDH) Screening

Diagnostics ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. 1174
Author(s):  
Si-Wook Lee ◽  
Hee-Uk Ye ◽  
Kyung-Jae Lee ◽  
Woo-Young Jang ◽  
Jong-Ha Lee ◽  
...  
Keyword(s):  
Deep Learning ◽  
Intraclass Correlation ◽  
Alpha Angle ◽  
Learning Model ◽  
Developmental Dysplasia ◽  
Human Observer ◽  
Intraobserver Variability ◽  
Cad System ◽  
Deep Learning Model ◽  
Dysplasia Of The Hip

Hip joint ultrasonographic (US) imaging is the golden standard for developmental dysplasia of the hip (DDH) screening. However, the effectiveness of this technique is subject to interoperator and intraobserver variability. Thus, a multi-detection deep learning artificial intelligence (AI)-based computer-aided diagnosis (CAD) system was developed and evaluated. The deep learning model used a two-stage training process to segment the four key anatomical structures and extract their respective key points. In addition, the check angle of the ilium body balancing level was set to evaluate the system’s cognitive ability. Hence, only images with visible key anatomical points and a check angle within ±5° were used in the analysis. Of the original 921 images, 320 (34.7%) were deemed appropriate for screening by both the system and human observer. Moderate agreement (80.9%) was seen in the check angles of the appropriate group (Cohen’s κ = 0.525). Similarly, there was excellent agreement in the intraclass correlation coefficient (ICC) value between the measurers of the alpha angle (ICC = 0.764) and a good agreement in beta angle (ICC = 0.743). The developed system performed similarly to experienced medical experts; thus, it could further aid the effectiveness and speed of DDH diagnosis.

scholarly journals Effect of altered proximal femoral geometry on predicting femoral stem anteversion in patients with developmental dysplasia of the hip

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Chenhui Huang ◽  
Haitao Tan ◽  
Willem Alexander Kernkamp ◽  
Rongshan Cheng ◽  
Junjie Liang ◽  
...  
Keyword(s):  
Femoral Stem ◽  
Femoral Anteversion ◽  
Developmental Dysplasia ◽  
Prediction Errors ◽  
Strong Positive Correlation ◽  
Positive Correlation ◽  
Press Fit ◽  
Preoperative Ct ◽  
Dysplasia Of The Hip ◽  
Anatomical Parameters

Abstract Background The deformity of the proximal femur and acetabular in patients with developmental dysplasia of the hip (DDH) renders an intraoperative decision for ideal component placement challenging. We hypothesized that the altered morphology of calcar femorale (CF) in DDH patients changed the fixation mechanism of the cementless metaphyseal-filling stem and aimed to predict stem anteversion using proximal femoral anatomical parameters from preoperative CT. Methods Preoperative and postoperative CT scans of 34 DDHs with a metaphyseal-filling stem in THA were retrospectively analyzed. Proximal femoral anatomical parameters, including the femoral anteversion (FA) and the CF angles at the low femoral neck (LFN) and the center of the lesser trochanter (CLT) levels (FA-LFN, FA-CLT, CF-LFN, and CF-CLT) were measured. The dysplastic hips were divided into the CF group (n = 21) and the non-CF group (n = 13) according to the presence of the CF-LFN. The association between the anatomical parameters and the postoperative stem anteversion was statistically analyzed, and the predicted stem anteversion was compared with postoperative stem anteversion. Results In the CF group, the combination of the CF-LFN and FA-CLT exhibited a strong positive correlation (R = 0.870, p < 0.001) with the postoperative stem anteversion. In the non-CF group, only the FA-LFN had a strong positive correlation (R = 0.864, p < 0.001). Average prediction errors were 5.9° and 6.4° in the CF and non-CF groups. Conclusions The presence of CF-LFN is related to the press-fit mechanism of the metaphyseal-filling stem, and the preoperative measurements from CT images can be employed as a tool to predict postoperative stem anteversion in DDH patients.

scholarly journals Prediction of time to prosthesis implantation as a function of joint anatomy in patients with developmental dysplasia of the hip

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Michael Müller ◽  
Anasthasia Rakow ◽  
Georgi I. Wassilew ◽  
Tobias Winkler ◽  
Carsten Perka
Keyword(s):  
Early Stage ◽  
Treatment Options ◽  
Developmental Dysplasia ◽  
Prosthesis Implantation ◽  
Secondary Osteoarthritis ◽  
Time Of Surgery ◽  
Hip Anatomy ◽  
The Mean ◽  
The Relationship ◽  
Dysplasia Of The Hip

Abstract Background Developmental dysplasia of the hip (DDH) can lead to pain and premature secondary osteoarthritis at an early stage. Joint-preserving osteotomy is an established solution to this problem. In contrast, a conservative approach would result in pain persistence, ultimately raising the patients question for a possible date of expected prosthesis implantation. The aim of the study was to identify the relationship between the dysplastic hip anatomy and the time of prosthesis implantation in order to enable prognostic predictions in younger patients with symptomatic DDH. Materials and methods Data from 129 hips who received THA due to secondary DDH osteoarthritis were evaluated. The preoperative hip anatomy was evaluated for AI and LCE angle. Multiple linear regression analyses were then used to correlate the influence of these parameters with the patient’s age at the time of surgery. In addition, a graphical relationship was derived by the method of power least squares curve fitting with second-degree polynomials. Results The mean age for THA was 54.3 ± 11 years. The time of surgery correlated significantly with LCE (0.37) and AI (− 0.3) (p < 0.001). The mean age of patients with LCE angle ≤ 10° was 41.9 ± 14.0 years, for LCE 11–20° 52.7 ± 9.5 years, and for LCE 21–30° 57.0 ± 10.3 years. The following formula could then be determined for the calculation of the potential patient age at the time of THA as a function of LCE angle: age pTHA = 40.2 + 0.8 × LCE angle − 0.01 × (LCE angle)2. Conclusion A significant correlation between the extent of dysplasia and the time of prosthesis implantation was identified. In particular, the LCE and the AI correlated strongly with the time of implantation. The more dysplastic the angles were, the sooner the THA was necessary. Using the calculations presented in this study, the probable age of prosthesis implantation can be prognosticated and included in a counseling session about treatment options for DDH.

scholarly journals Association of the Anatomical Sacral Slope With Lumbar Lordosis and Pelvic Incidence in Female Patients With Developmental Hip Dysplasia: A Retrospective Cross-sectional Study

2020 ◽  
Author(s):  
Norio Imai ◽  
Hayato Suzuki ◽  
Atsushi Sakagami ◽  
Yuki Hirano ◽  
Naoto Endo
Keyword(s):  
Correlation Coefficient ◽  
Healthy Subjects ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Strong Association ◽  
Intraclass Correlation ◽  
Correlation Coefficients ◽  
Developmental Dysplasia ◽  
Sacral Slope ◽  
Dysplasia Of The Hip

Abstract Background:The anatomical sacral slope, considered an anatomical pelvic parameter independent of femoral head centers for measurement, was previously described to strongly correlate withpelvic incidenceon two-dimensional examination of normal healthy subjects. However, the associationbetween anatomical sacral slope and pelvic incidence was unclear in patients withdevelopmental dysplasia of the hip. Thecurrent study aimed to examine the association between anatomical sacral slope and other spinopelvic parameters on plain radiographs in female patients with developmental dysplasia of the hip. Methods:Eighty-four women with developmental dysplasia of the hip were examined. Lumbar lordosis, thoracic kyphosis, pelvic incidence, sacral slope, and anatomical sacral slope, which was deemedthe angle formed by the straight line of the S1 superior endplate and a line at a right angle to the anterior pelvic plane, were determined by plain radiographs. The correlations were examined by Pearson correlation coefficients, and intra- and interrater intraclass correlation coefficients were evaluated forreliability.Results:A strong association was observed between pelvic incidence and anatomical sacral slope (r=0.725, p<0.001). In addition, the association between anatomical sacral slope and lumbar lordosis wassimilar to that between pelvic incidence and lumbar lordosis (r=0.661, p<0.001 and r=0.554, p<0.001, respectively). The intraraterintraclass correlation coefficient values were 0.869 for anatomical sacral slope and 0.824 for pelvic incidence. Furthermore, the interraterintraclass correlation coefficient values were 0.83 for anatomical sacral slope and 0.685 for pelvic incidence. Conclusions:We found that the strong association between anatomical sacral slope and pelvic incidence wasequal to that in normal,healthy subjects. The associationbetweenanatomical sacral slope and lumbar lordosis was equal to that between pelvic incidence and lumbar lordosis. Additionally, the intraclass correlation coefficient value foranatomical sacral slope was slightlyhigher than that forpelvic incidence. We thusconclude that anatomical sacral slope can be considered a helpful anatomical pelvic parameter that isasubstitute for pelvic incidence not only in normal subjectsbut also in patients with developmental dysplasia of the hip.

scholarly journals The severity of developmental dysplasia of the hip does not correlate with the abnormality in pelvic incidence

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Rongshan Cheng ◽  
Muyin Huang ◽  
Willem Alexander Kernkamp ◽  
Huiwu Li ◽  
Zhenan Zhu ◽  
...  
Keyword(s):  
Pelvic Incidence ◽  
Sagittal Plane ◽  
Three Dimensional ◽  
Developmental Dysplasia ◽  
Control Group ◽  
Type I ◽  
Type Ii ◽  
Computed Tomography Images ◽  
Significant Difference ◽  
Dysplasia Of The Hip

Abstract Background The purpose of this study was to investigate the association between the severity of Developmental dysplasia of the hip (DDH) and the abnormality in pelvic incidence (PI). Methods This was a retrospective study analyzing 53 DDH patients and 53 non-DDH age-matched controls. Computed tomography images were used to construct three-dimensional pelvic model. The Crowe classification was used to classify the severity of DDH. The midpoint of the femoral head centers and sacral endplates were projected to the sagittal plane of the pelvis. The PI was defined as the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting this point to the axis of the femoral heads. Independent sample t-tests were used to compare the differences between the PI of DDH group and the non-DDH controls group. Kendall’s coefficient of concordance was used to determine the correlation between the severity of DDH and PI. Results Patients with DDH had a significantly (p = 0.041) higher PI than the non-DDH controls (DDH 47.6 ± 8.2°, normal 44.2 ± 8.8°). Crowe type I patients had a significantly (p = 0.038) higher PI (48.2 ± 7.6°) than the non-DDH controls. No significant difference between the PI in Crowe type II or III patients and the PI in non-DDH controls were found (Crowe type II, 50.2 ± 9.6°, p = 0.073; Crowe type III, 43.8 ± 7.2°, p = 0.930). No correlation was found between the severity of DDH and the PI (r = 0.091, p = 0.222). Conclusions No correlation was found between the severity of DDH and the PI. The study confirmed that the PI in DDH (Crowe type I) group was higher than that of the non-DDH control group, while the PI does not correlate with the severity of DDH.

scholarly journals Atraumatic Anterior Dislocation of the Hip Joint

2015 ◽  
Vol 2015 ◽  
pp. 1-5
Author(s):  
Tadahiko Ohtsuru ◽  
Yasuyuki Morita ◽  
Yasuaki Murata ◽  
Junya Itou ◽  
Yuji Morita ◽  
...  
Keyword(s):  
Hip Joint ◽  
Traffic Accidents ◽  
Road Traffic ◽  
Sagittal Plane ◽  
Imaging System ◽  
High Energy ◽  
Developmental Dysplasia ◽  
Anterior Dislocation ◽  
Dislocation Mechanism ◽  
Dislocation Of The Hip

Dislocation of the hip joint in adults is usually caused by high-energy trauma such as road traffic accidents or falls from heights. Posterior dislocation is observed in most cases. However, atraumatic anterior dislocation of the hip joint is extremely rare. We present a case of atraumatic anterior dislocation of the hip joint that was induced by an activity of daily living. The possible causes of this dislocation were anterior capsule insufficiency due to developmental dysplasia of the hip, posterior pelvic tilt following thoracolumbar kyphosis due to vertebral fracture, and acetabular anterior coverage changes by postural factor. Acetabular anterior coverage changes in the sagittal plane were measured using a tomosynthesis imaging system. This system was useful for elucidation of the dislocation mechanism in the present case.

scholarly journals Development of an electronic navigation system for elimination of examiner-dependent factors in the ultrasound screening for developmental dysplasia of the hip in newborns

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Alexander Kolb ◽  
Catharina Chiari ◽  
Markus Schreiner ◽  
Stephan Heisinger ◽  
Madeleine Willegger ◽  
...  
Keyword(s):  
Navigation System ◽  
Sagittal Plane ◽  
Ultrasound Image ◽  
Frontal Plane ◽  
Developmental Dysplasia ◽  
Axial Plane ◽  
Conventional Group ◽  
Ultrasound Screening ◽  
The Impact ◽  
Dysplasia Of The Hip

Abstract To develop an electronic navigation system to increase reliability and comparability in the ultrasound screening of developmental dysplasia of the hip (DDH). The impact of the navigation system on transducer positioning and on sonographic measurements according to Graf was analyzed. Twenty hips in newborns were examined sonographically using a new navigation system capable of detecting the transducer and pelvis position in order to calculate the relative tilt in the frontal, axial, and sagittal-plane. In each newborn an ultrasound image was obtained conventionally according to Graf and a second image using the sonographic navigation system. Relative roll and pitch angles and sonographic measurements were analyzed using paired T-tests and Levene-tests. Relative tilt angles in the conventional group ranged from − 8.9° to 14.3° (frontal-plane) and − 23.8° to 14.2° (axial-plane). In the navigation-assisted group ranges from − 3.0° to 3.5° and − 2.8° to 4.5° were observed. Variances were significantly lower in the navigation-assisted group (p < 0.001 and p = 0.004 respectively). The navigation system allowed for a significant reduction of relative tilt angles between the transducer and the newborn pelvis, thus supporting an optimal transducer positioning. This is a promising approach to improve reproducibility and reliability in the ultrasound screening for DDH.

scholarly journals DISPLASIA PERKEMBANGAN PANGGUL AWAL (LAHIR HINGGA USIA 4 BULAN)

2015 ◽  
Vol 7 (1) ◽  
Author(s):  
Vivi Sumarna ◽  
Engeline Angliadi
Keyword(s):  
Early Stage ◽  
Hip Dislocation ◽  
Breech Presentation ◽  
Developmental Dysplasia ◽  
Older Children ◽  
Keywords Hip ◽  
Hip Abduction ◽  
Gait Abnormalities ◽  
Dysplasia Of The Hip

Abstract: Developmental dysplasia of the hip refers to a continuum of abnormalities of the immature hip that can range from subtle dysplasia to dislocation. The identification of risk factors, including breech presentation and family history, should heighten a physician’s suspicion of this condition. The diagnosis is based on physical examination. Palpable hip instability, unequal leg lengths, and asymmetric thigh skinfolds may be present in newborns with a hip dislocation, whereas gait abnormalities and limited hip abduction are more common in older children. The role of ultrasonography is controversial, but it is generally used to confirm the diagnosis and to assess hip development once the treatment is initiated. Bracing is the first-line treatment in children aged less than six months. Surgery is an option for children with unsuccessful non-operative treatment and in children who are diagnosed after six months of age. It is important to confirm the diagnosis of the developmental dysplasia of the hip in the early stage to improve the result of treatment and to decrease the risks of complications. Keywords: hip, developmental dysplasia, immature, instability, bracing   Abstrak: Displasia perkembangan panggul mengacu pada serangkaian abnormalitas pada panggul imatur yang mencakup displasia ringan hingga dislokasi. Identifikasi faktor-faktor risiko yang meliputi letak sungsang dan riwayat keluarga, harus menigkatkan kecurigaan dokter akan displasia perkembangan panggul. Diagnosis ditegakkan melalui pemeriksaan fisik. Instabilitas panggul yang dapat dipalpasi, panjang tungkai yang tidak sama, dan lipatan kulit paha yang asimetris dapat ditemukan pada bayi baru lahir dengan dislokasi panggul, sedangkan abnormalitas gait dan keterbatasan abduksi panggul lebih umum pada anak-anak yang lebih tua. Peran ultrasonografi masih kontroversial tetapi secara umum untuk mengonfirmasi diagnosis dan menilai perkembangan panggul sejak dimulainya perawatan. Penggunaan brace merupakan perawatan lini pertama pada anak-anak berusia kurang dari enam bulan. Pembedahan merupakan pilihan bagi anak-anak dengan perawatan nonoperatif yang gagal dan pada anak-anak yang didiagnosis setelah berusia enam bulan. Displasia perkembangan panggul sangat penting ditegakkan sejak dini untuk meningkatkan hasil perawatan dan mengurangi risiko komplikasi. Kata kunci: panggul, displasia perkembangan, imatur, instabilitas, brace

scholarly journals Correlation of the anatomical sacral slope with pelvic incidence in female patients with developmental hip dysplasia: A retrospective cross-sectional study

2020 ◽  
Author(s):  
Norio Imai ◽  
Hayato Suzuki ◽  
Atsushi Sakagami ◽  
Yuki Hirano ◽  
Naoto Endo
Keyword(s):  
Correlation Coefficient ◽  
Intraclass Correlation Coefficient ◽  
Healthy Subjects ◽  
Lumbar Lordosis ◽  
Pelvic Incidence ◽  
Intraclass Correlation ◽  
Correlation Coefficients ◽  
Developmental Dysplasia ◽  
Sacral Slope ◽  
Dysplasia Of The Hip

Abstract Background: The anatomical sacral slope is considered as an anatomical pelvic parameter independent of femoral head centers for measurement of anatomical sacral slope and was previously described to strongly correlate with pelvic incidence on a two-dimensional examination of healthy subjects. However, the correlation between anatomical sacral slope and pelvic incidence was unclear in patients with developmental dysplasia of the hip. This study aimed to examine the correlation between anatomical sacral slope and other spinopelvic parameters by analyzing plain radiographs of female patients with developmental dysplasia of the hip. Methods: Eighty-four women with developmental dysplasia of the hip were examined. Lumbar lordosis, thoracic kyphosis, pelvic incidence, sacral slope, and anatomical sacral slope (the angle formed by the straight line of the S1 superior endplate and a line at a right angle to the anterior pelvic plane), were determined by analyzing plain radiographs. The correlations were examined by Pearson correlation coefficients, and intra- and inter-rater intraclass correlation coefficients were evaluated for reliability. Results: A strong correlation was observed between pelvic incidence and anatomical sacral slope (r=0.725, p<0.001). In addition, the correlation between anatomical sacral slope and lumbar lordosis was similar to that between pelvic incidence and lumbar lordosis (r=0.661, p<0.001 and r=0.554, p<0.001, respectively). The intra-rater intraclass correlation coefficient values were 0.869 and 0.824 for anatomical sacral slope and pelvic incidence, respectively. Furthermore, the inter-rater intraclass correlation coefficient values were 0.83 and 0.685 for anatomical sacral slope and pelvic incidence, respectively. Conclusions: We observed that the strong correlation between anatomical sacral slope and pelvic incidence in patients with developmental dysplasia of the hip was equal to that in normal healthy subjects. The correlation between anatomical sacral slope and lumbar lordosis was equal to that between pelvic incidence and lumbar lordosis. Additionally, the intraclass correlation coefficient values for the anatomical sacral slope were slightly higher than those for pelvic incidence. Thus, we conclude that anatomical sacral slope can be considered as a helpful anatomical pelvic parameter that is a substitute for pelvic incidence not only in normal healthy subjects, but also in patients with developmental dysplasia of the hip.

Assessment of pelvic morphology using 3D imaging and analysis in unilateral Crowe-IV developmental dysplasia of the hip

2020 ◽  
Vol 102-B (10) ◽  
pp. 1311-1318
Author(s):  
Yi-Fan Huang ◽  
Yu-Hang Gao ◽  
Ye-Ran Li ◽  
Lu Ding ◽  
Jian-Guo Liu ◽  
...  
Keyword(s):  
Acetabular Component ◽  
3D Imaging ◽  
Sagittal Plane ◽  
Morphological Changes ◽  
Imaging Techniques ◽  
Developmental Dysplasia ◽  
Affected Side ◽  
Healthy Side ◽  
Hip Rotation ◽  
Dysplasia Of The Hip

Aims Morphological abnormalities are present in patients with developmental dysplasia of the hip (DDH). We studied and compared the pelvic anatomy and morphology between the affected hemipelvis with the unaffected side in patients with unilateral Crowe type IV DDH using 3D imaging and analysis. Methods A total of 20 patients with unilateral Crowe-IV DDH were included in the study. The contralateral side was considered normal in all patients. A coordinate system based on the sacral base (SB) in a reconstructed pelvic model was established. The pelvic orientations (tilt, rotation, and obliquity) of the affected side were assessed by establishing a virtual anterior pelvic plane (APP). The bilateral coordinates of the anterior superior iliac spine (ASIS) and the centres of hip rotation were established, and parameters concerning size and volume were compared for both sides of the pelvis. Results The ASIS on the dislocated side was located inferiorly and anteriorly compared to the healthy side (coordinates on the y-axis and z-axis; p = 0.001; p = 0.031). The centre of hip rotation on the dislocated side was located inferiorly and medially compared to the healthy side (coordinates on the x-axis and the y-axis; p < 0.001; p = 0.003). The affected hemipelvis tilted anteriorly in the sagittal plane (mean 8.05° (SD 3.57°)), anteriorly rotated in the transverse plane (mean 3.31° (SD 1.41°)), and tilted obliquely and caudally in the coronal plane (mean 2.04° (SD 0.81°)) relative to the healthy hemipelvis. The affected hemipelvis was significantly smaller in the length, width, height, and volume than the healthy counterpart. (p = 0.014; p = 0.009; p = 0.035; p = 0.002). Conclusion Asymmetric abnormalities were identified on the affected hemipelvis in patients with the unilateral Crowe-IV DDH using 3D imaging techniques. Improved understanding of the morphological changes may influence the positioning of the acetabular component at THA. Acetabular component malpositioning errors caused by anterior tilt of the affected hemi pelvis and the abnormal position of the affected side centre of rotation should be considered by orthopaedic surgeons when undertaking THA in patients with Crowe-IV DDH. Cite this article: Bone Joint J 2020;102-B(10):1311–1318.

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