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As the world continues to adjust to life with COVID-19, one topic that requires further thought and discussion is whether elective international medical volunteerism can continue, and, if so, what challenges will need to be addressed. During a pandemic, the medical community is attentive to controlling the disease outbreak, and most of the literature regarding physician involvement during a pandemic focuses primarily on physicians traveling to areas of need to help treat the disease. As a result, little has been written about medical volunteerism that focuses on medical treatment unrelated to the disease outbreak. In a world-wide pandemic, many factors are to be considered in determining whether, and when, a physician should travel to another region to provide care and training for medical issues not directly related to the pandemic. Leaders of humanitarian committees of orthopaedic surgery subspecialties engaged with one another and host orthopaedic surgeons and a sponsoring organization to provide thoughtful insight and expert opinion on the challenges faced and possible pathways to provide continued orthopaedic support around the globe. Although this discussion focuses on international orthopaedic care, these suggestions may have a much broader application to the international medical community as a whole.

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BACKGROUND: Neglected traumatic hip dislocation in children is uncommon and there is no consensus on appropriate management. Previous studies report varied operative management with high rates of avascular necrosis and postoperative subluxation/dislocation. We report a series of 7 consecutive cases who underwent operative reduction after neglected hip dislocation and describe our technique for treatment. METHODS: All 7 children sustained posterior dislocations and had no treatment before presentation at our institution. An associated marginal acetabular fracture was present in 2 cases. One additional patient was excluded from the study due to complete loss of articular cartilage that precluded open reduction. The mean time before surgical intervention was 13.1 months (4 to 36 mo) with a mean age of 7 years (5.3 to 10.8 y). All children underwent preoperative skeletal traction for 10 to 14 days. A postero-lateral approach was used in all cases. The acetabulum was cleared of scar tissue and a femoral shortening performed as required (5 cases). Minor erosion of the articular cartilage of the posterior aspect of the femoral head was noted in 3/6 cases. After reduction, a posterior capsulorrhaphy was performed and the patient immobilized in a hip spica for 6 to 12 weeks. RESULTS: The mean follow-up was 44 months (33 to 56 mo). The majority of children (86%) could walk and run without a limp, could squat, and had no pain. One child had mild pain and a limp. Mean Harris Hip Score was 98.9. No hip subluxed or dislocated postoperatively. The radiographs at latest follow-up showed no evidence of growth disturbance in 29% of cases, coxa magna in 57%, and partial femoral head collapse in 1 case (14%). Of note, those patients managed within 8 months of injury had none or minimal evidence of growth disturbance. CONCLUSIONS: At medium-term follow-up, open reduction with a postero-lateral approach, posterior capsulorrhaphy, and femoral shortening (as required) produces a satisfactory outcome with a stable, congruent reduction. Good clinical function can be expected with a low incidence of avascular necrosis. LEVEL OF EVIDENCE: Level IV.

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INTRODUCTION: Avascular necrosis (AVN) is a serious complication of treatment for developmental dysplasia of the hip. There is ongoing controversy regarding AVN and its influence on hip development following medial open reduction (MOR). PURPOSE: The aim of our study was to (1) determine the long-term prevalence of AVN following MOR, (2) evaluate hip development after MOR, and (3) identify predictors of AVN and radiographic outcome at skeletal maturity after MOR. METHODS: A retrospective cohort analysis of 60 patients (70 hips) who underwent MOR with a mean follow-up of 10.83 years (5.23-16.74) was conducted. AVN was recorded according to Bucholz and Ogden classification and radiographic outcome based on Severin grading. AVN and hip morphology related to length of follow-up were evaluated. Chi-squared and t-tests were used to identify relationships between AVN and other variables. Logistic regression was used to assess predictors of AVN and Severin outcome. RESULTS: The rate of clinically significant AVN (types 2-4) following MOR was 32.9 % with type 2 accounting for 82.6 % of these cases. While early acetabular development was satisfactory, long-term outcome was unsatisfactory in 26 % of cases with AVN (vs 8.7 % of cases without AVN). A higher rate of AVN was identified when hips were immobilized in ≥60° of abduction postoperatively. A higher rate of poor Severin outcome was identified in hips with AVN. CONCLUSIONS: Our findings suggest that there is a high rate of AVN and unsatisfactory long-term outcome following MOR. AVN remains a significant concern following MOR surgery for developmental dysplasia of the hip that may not be apparent until long-term evaluation.

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STUDY DESIGN: Retrospective longitudinal cohort. OBJECTIVE: To evaluate the different patterns of stenosis with lateral subluxation in degenerative lumbar scoliosis (DLS). SUMMARY OF BACKGROUND DATA: Lateral subluxation of the vertebra is commonly seen in DLS. Different patterns of subluxation occur at different levels of the spine and are often associated with neurological compression that can be symptomatic requiring treatment. The pattern and location of the stenosis are variable in DLS. No study to date has evaluated the site of stenosis seen on magnetic resonance imaging with respect to the different patterns or locations of lateral subluxation. METHODS: The standing radiographs and supine magnetic resonance imaging scans of 35 consecutive patients with DLS were analyzed and demonstrated lateral listhesis on standing radiographs (average age, 70.2 years). Subluxation level, amount of listhesis, subluxation angle, axial rotation, and pattern or location of spinal stenosis were noted. RESULTS: There were 60 subluxations in 35 patients. Open subluxations resulted in predominantly contralateral lateral recess and foraminal stenosis (71%; 17 of 24 patients). Closed dislocations demonstrated an ipsilateral pattern of stenosis (82%; 14 of 17 patients). Open subluxations were most commonly present at L3-4 toward the convex apex, whereas closed subluxations were identified on the concavity of the curve, with L1-2 most frequently involved (53%; 9 of 17 patients). An association was identified with open dislocations involving the mid-lumbar spine and closed subluxations at L1-2 (p < .001). CONCLUSIONS: Open and closed subluxations in DLS result in different patterns of spinal stenosis. The presence of unilateral stenosis should alert the clinician to the possibility of spinal deformity and lateral subluxation. After careful review of the anteroposterior standing radiograph, any lateral subluxation and its type can be determined. This may assist decision making in how to treat the stenosis when deformity is present.

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Congenital midline cervical clefts (CMCC) are rare. There have been approximately 50 reports in the international literature with the majority found in Caucasian females. They consist of a skin tag, mucosal surface and a caudal sinus in the ventral midline of the neck. The embryological cause is disputed, as is the best course of treatment. A case of a 4-month-old Indian boy with a congenital midline cervical cleft is reported. The appropriate investigations are described as well as a new method of correcting the lesion. In addition, the most likely aetiological basis for the condition are discussed.

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