Selective treatment program for developmental dysplasia of the hip in an epidemiologic prospective study

Over 1 year of ultrasound (US) mass screening, 4,568 newborns were examined consecutively at age 3-4 weeks using both clinical and ultrasonographic examination methods. The US examination involved both the static and dynamic scanning. In total, 25 babies were treated early (5.5 per 1,000), and 6 babies were given late treatment for postnatally developing acetabular dysplasia (1.3 per 1,000). Early treatment was instituted only for hips remarkably distorted anatomically, as could be seen from their shape on the static scan, and for those that were sonographically unstable with an apparent stress displacement. Clinical examination at age 3-4 weeks failed in more than half of all sonographically abnormal cases. In one case, the postnatal development of the hip joint was associated with the worsening of its formation and a developing subluxation despite its primary normal characteristics.

[Ultrasonography in legg-calvé-perthes disease]

Several last reports showed a very good utility of US visualisation in Legg-Calvé-Perthes disease especially in the assessment of the lateral extrusion of the femoral head and the subchondral fracture. Prospective analysis of 43 patients with 53 affected hip joints in this study showed that the hip joint effusion and synovitis have to be differentiated. Effusion occured only in the early stages of the disease. Sensitivity of US detection of the femoral head deformity was 87,3 % in this group compared with X-ray diagnosis. Assessment of the lateral extrusion seems to be rather inaccurate due to the high inter-observer error. A new approach which was suggested, posterior scanning of the flexed hip joint can be effective only if the femoral head is fragmented. US could replace classical X-ray, hopefully, only very partially. Key words: ultrasonography, Legg-Calvé-Perthes disease.

[Congenital posteromedial angulation of tibia and fibula.]

The author has based his article on all available literature dealing with a rare congenital clinical unit "congenital posteromedial angulation of tibia and fibula". Congenital kyphoscoliosis of tibia is a synonym for the same disease. In contrast to other angulations of the tibia and fibula the above mentioned clinical unit is characterized by a spontaneous remodeling of the bone deformity. Persisting is only the shortening of tibia. The author describes in the study his own follow-up of four cases. In one case it was necessary to correct valgus deformity of tibia in 8th month of age. Angulation in all four children spontaneously corrected itself before the 3rd year of age. Documentation is supplemented with a developmental series of x-rays in both projections. The medial component of angulation persists longer than the dorsal component. Discrepancy of the length of lower limbs in our cases where the growth has not finished yet ranges between 2-4 cm. Key words: congenital posteromedial angulation of tibia and fibula.

Ultrasound examination of neonate's hip joints

In a mass screening project, 872 neonates were examined clinically and by ultrasound. Hip joint stability was assessed in the ultrasound stress test showing a normal or physiologic instability, in the range of 0 to 2 mm. Along with the dynamic examination, a modified Graf's method was used. All obtained sonograms were submitted to careful assessment by one of authors, including regular measurement of alpha and beta angles. This relatively small group in the low-risk population served as a model of normality. White newborns compared with an black Caribbean group did not show the presence of apparent primary acetabular dysplasia. Both methods--dynamic ultrasound test and Graf's scanning--seemed to us to be valuable.

[Chronic recurrent multifocal osteomyelitis.]

The authors discuss the diagnostic and prognostic problem of chronic recurrent osteomyelitis (CRMO) described for the first time in 1972 by Giedione. This relatively rare disease of unknown origin is characterized by a slow onset with oedema and pain at several sites of the locomotor apparatus which occur concurrently or consecutively and are followed by relapses. The body temperature is normal or slightly elevated. CRMO is sometimes associated also with palmoplantar pustulosis. The authors evaluate six patients wih CRMO treated in 1988-1994 (4 boys and 2 girls), age 7-13 years at the onset of the disease. There were at least 2 and not more the 4 foci per patient. The clinical symptoms before the first orthopaedic examination persisted for 1-5 weeks. Concurrent skin disease was not observed. Relapses of symptoms were described in the patients at 8 sites with remissions lasting 4-16 weeks. The most frequent site in the investigated group is the distal metaphysis of the femur and proximal metaphysis of the tibia (11 times), the medial portion of the clavicle (twice) and the short bones of the toes (three times). Classical X-ray diagnosis revealed skeletal changes consistent with the appearance of acute or chronic haematogenic osteomyelitis. All-body scintigraphy 99mTc revealed an increased cumulation of the radiopharmaceutical preparation in the focus sooner than the classical X-ray picture. Bacteriological examination of specimens obtained from blood and material from the osseous foci does not identify the causal agent. FW and CRP examination gave elevated values and frequently also leucocytosis. Antibiotics administered for 4-32 weeks produced no detectable effect, non-steroid antiphlogistics mitigated subjective complaints. Sequestration was not observed in the investigated patients. Post-inflammatory premature closing of the growth zones on the short bones of the feet are found as a rule. Key words: chronic multifocal recurrent osteomyelitis, child age.

[Deformity of the forearm caused by benign bone tumours treated by external fixation.]

A developed deformity of the forearm is usually due to an osteochondroma and has a typical clinical and X-ray appearance. Patients suffering from this disease have a restricted function of the forearm due to shortening of the bones, usually both bones, and in particular girls are aware of the cosmetic and aesthetic loss. The X-ray symptomatology of the deformity is as follows: dislocation of the head of the radius, multiple tumours on both bones which dislocate the bones, ulnar angulation of the radius and ulna, shortening of the ulna, ulnar inclination of the articulation surface of the distal radius, ulnar subluxation of the wrist and shortening of the metacarpal bones. The therapeutic procedure used by the authors is stagewise and comprises the following operations: ablation of the osteochondromas, gradual extension of the ulna, reposition of the head of the radius and correction osteotomy of the distal radius. The objective of the submitted paper is long-term clinical and X-ray evaluation of the forearm deformity after operation. In the majority of patients after treatment radial duction in the wrist remains restricted but this is not important from the functional aspect. The X-ray finding of ulnar subluxation of the wrist frequently improves after extension of the ulna. Key words: osteochondromas, deformities of the forearm, gradual extension of the ulna.

[Legg-calvé-perthes disease.]

The author summarizes basic findings on the etiology and epidemiology of Legg-Calvé-Perthes disease (LCP). Attention is paid to its pathogenesis, and the relationship of transient synovitis to LCP is discussed. Attention is paid to pathological findings in LCP and the relationship of growth to the development of LCP. The author analyzes work devoted to clinical and radiological findings, arthrography and scintigraphy of the hip joints, incl. MR, CT and US examinations. He deals also with the differential diagnosis of LCP and prognostic factors which have an impact on therapeutic results. Therapy is discussed from the aspect of conservative treatment (Atlanta splints did not prove very effective in severe forms of LCP), as well as from the aspect of surgical treatment. Special attention is paid to varus osteotomy and osteotomy of the pelvis according to views of various authors, and on the other hand to valgusextension osteotomy in patients where so-called abduction on a hinge with excentric rotation of the head of the femur develops. Special attention is devoted to therapeutic possibilities in severe forms of LCP. The latest views on classification of so-called abduction on a hinge are given corresponding to the grade of lateral extrusion of the head, incl. possibilities of suitable treatment. Key words: Legg-Calvé-Perthes disease, diagnosis, treatment.

[Possibilities to Visualize the Non-ossified Patella by Ultrasound.]

The patella ossifies between the second and third year of life. Inborn dislocation of the patella must be, however, diagnosed as soon as possible. The basis is naturally clinical diagnosis, but the possibillity of imaging of the patellofemoral joint is welcome, as it provides graphic documentation. Apart from the financially and otherwise pretentious NMR examination, documentation can be obtained by ultrasound. The author demonstrates two cases of dislocation of the patella in Down's disease. Key words: congenital dislocation of the patella, ultrasound.

[Late results of conservative treatment of perthes disease.]

The objective of the submitted work was to assess the long-term prognosis of Perthes disease. From the originally invited 142 patients 72 attended the check-up examination, complete X-ray documentation was assembled only in 32 patients with 38 affected hip joints. The time interval which had elapsed since the onset of the disease was on average 17 years. The authors evaluated the clinical and X-ray picture of the hip joints and assessed retrospectively the affection of the head according to Catterall's method, incl. signs of a head associated with risk. Treatment provided during the sixties and beginning of the seventies did not meet the principles of modern "containment" therapy. It comprised bed rest, application of a plaster spike and aftertreatment with a Thomas splint. During late check-up examinations Wiberg's angle, the epiphyseal index, the index of overlapping of the head, the distance of the head from the floor of the acetabulum and the height of the peak of the greater trochanter above the centre of the head of the femur were assessed. In addition to assessment of these partial X-ray parameters the authors evaluated the spherical properties of the head by Mose's method and subjectively the X-ray picture, using a three grade scale (satisfactory, feasible, poor). In the majority of assessed parameters the authors found a statistically significant correlation with the retrospective classification of the original X-ray pictures classified according to Catterall. The clinical picture was satisfactory in the majority, the authors did not find painful restriction of movement, while almost half the patients reported occasional subjective complaints as regards the hip joint. On the X-ray changes in the overgrowth of the greater trochanter were more marked than changes of the spherical character of the head and the extent of decentering. The follow-up of the group will continue to obtain a longer time interval from the onset of the disease. Key words: Perthes disease, late results, Catterall's classification.

Local action transcutaneous flurbiprofen in the treatment of soft tissue rheumatism

The objective of the present study was to establish the efficacy and tolerability of local action transcutaneous flurbiprofen (flurbiprofen LAT) in the treatment of soft tissue lesions. A randomized, double-blind, parallel-group placebo-controlled study was carried out in two hospital outpatient rheumatology clinics. One hundred and four patients aged 18-75 yr were randomized to receive a non-woven polyester-backed patch supporting a formulation containing 40 mg flurbiprofen 12-hourly over 14 days; or a non-medicated (but otherwise identical) control. Statistically significant differences in favour of the active preparation were seen at both days 7 (P = 0.02) and 14 (P = 0.009) for the investigator's overall opinion of severity of the condition, and at day 7 for the investigator's assessment of pain severity (P = 0.04 intention-to-treat; P = 0.052 N.S. eligible data). The need for further treatment in the form of steroid injections after the trial was greater in the controls (29/44, 66%) than in the flurbiprofen LAT group (17/46, 37%) (chi 2 = 7.54 on 1 d.o.f., P = 0.006). Plasma flurbiprofen levels in 11 patients ranged from 13.4 to 338.7 ng/ml (mean 116; median 57.9). Eight out of 53 (15%) patients receiving flurbiprofen LAT reported a total of 10 adverse events, compared with three out of 51 (6%) reporting seven events among controls. Patients found the patch convenient and soothing. We conclude that flurbiprofen LAT is an effective and acceptable treatment for soft tissue lesions, and should be considered as an alternative therapy to local steroid injection.

[Cooperation between the pediatrician and orthopedist in the diagnosis of congenital hip dislocation]

The author summarizes the principles of clinical diagnosis, referring to experience assembled in an investigation comprising more than 35,000 neonates during past years. The submitted pattern could be a practical instruction for examination of the hip joints by paediatricians--neonatologists. The author emphasizes the fact that the diagnosis of complete dislocation unless irreponible is very easy, and being a clinically very obvious defect, it should not be missed. In other countries the trend predominates to ensure examination of the hip joints of neonates by paediatricians-neonatologists for whom this examination is a matter of routine. The author outline possibilities of ultrasonographic examination, static as well as dynamic. In large towns it proved useful to establish an ultrasonographic examination room where some 4000 infants aged 2-3 weeks are examined. The hitherto used classification of ultrasonic examination is not quite reliable in view of "over-diagnosis" and thus to unnecessary therapy which can lead--as any abduction therapy--to complications such as avascular necrosis. Paediatricians-neonatologists should master the clinical problem and be aware of the responsibility for early clinical diagnosis to enable orthopaedists to specify indication for early treatment based on ultrasonographic examination.

Early diagnosis of congenital dislocation of the hip

In this prospective study, 35,550 neonates were examined shortly after birth by a team of orthopaedic surgeons. They diagnosed 775 unstable or dislocated hips in 656 babies; there were two teratological dislocations. Treatment was first with a Frejka pillow and, if this failed to give a normal hip, a Pavlik harness at three months. Early clinical examination did not identify 21 infants who were found to have subluxation or dislocation of the hip at the three-month review. The number of missed cases declined during the study, however, reflecting the increasing experience of the examiners. One case of avascular necrosis occurred in the group treated from birth and one in the late-diagnosed group. Open reduction was necessary only in the two teratological dislocations. Experienced examiners are needed for accurate clinical diagnosis; and treatment should be started before the baby is discharged from the maternity ward.

[Early therapy of congenital hip dislocation and ultrasonic studies of clinically positive cases--results of a prospective epidemiological study in Brünn]

The early diagnosis of CDH in CSFR an in other countries is discussed from different views. To our opinion only the orthopaedic surgeons are able to ensure the high sensitivity and specificity of the clinical tests. In the Brno-prospective epidemiologic study we have examined 19,879 neonates. The frequency of dislocation and instability was 368 cases (18%). The early treatment with Frejka pillow or Pavlik harness has failed only in one case. The systematic second (6 weeks) and third examination (3 months) discovered 19 late diagnosed cases (0.95%). In the era of conventional diagnosis the usual frequency of CDH in CSFR was 20-30%. The ultrasonographic examination of all neonates is not yet possible in our country; we have examined only clinically positive cases.

[Neonatal osteomyelitis is still a reality]

The authors draw attention to the fact that it is essential to consider osteomyelitis of children under 1 year as a separate nosological unit with regard to the anatomical features of the vascular supply of epimetaphyses. The authors discuss the diagnostic difficulties. In addition to the basic examination they emphasize also the importance of whole-body scintigraphy and examination by ultrasound. They indicate surgery where clinical symptoms do not recede within 24-48 hours after the onset of antibiotic treatment and where on probatory puncture pus is revealed and if during establishment of the diagnosis the X-ray finding is already positive. As to antibiotics they use Oxacillin first. The authors evaluate the results of treatment of 25 neonates after a 2-10-year interval following the onset of the disease. The process was found most frequently in the proximal and distal metaphysis of the femur (56%) and in the proximal metaphysis of the tibia (24%). They operated 18 patients in the acute stage (72%). Staphylococcus aureus was cultivated in 60% from pus and in 50% from haemocultures. The authors found a satisfactory state in 17 patients (68%) and an unsatisfactory one in 8 patients (32%).

[Clinical and ultrasonic diagnosis of congenital hip dislocation (dynamics of changes in early therapy)]

The authors present part of their prospective epidemiological study of congenital dysplasia of hip joints within which newborns were examined by ultrasonogram prior to the beginning of the therapy. Apart from the standard examination in the frontal plane after Graf they examined on principle also the ultrasonographic stability by the dynamic test after Schuler as well as by the application of the probe anteriorly with the simultaneous provocation according to Palmén. The authors have processed pathological ultrasonographic findings in 53 newborns (64 hip joints). The technique of the examination by ultrasound from the anterior approach is explained in detail. The comparison of both dynamic tests has shown that the examination from the anterior approach is considerably more sensitive than Schuler's dynamic test and also fully correlates with the clinical finding. It is a fact that the shift of the head in the flexion dorsally represents the most important component of the movement in unstable hip joint during provocation, it is far more noticeable than the lateralization of the head or the shift in the cranial direction. After achieving ultrasonographic stability the classical Graf method is sufficient for the registration of residual changes on the acetabular rim. The follow-up of patients until their complete healing has shown a surprisingly rapid remodellation of hip joints. The whole complex of clinically unstable hip joints has been divided into subgroups according to Graf classification. In type IIc or IId on the basis of ultrasonographic examination from the anterior approach the stable joints from the ultrasonographic viewpoint have been distinguished from unstable ones. The follow-up carried out in short intervals has shown that of longest duration is the remodellation of total dislocation and, on the contrary, of shortest duration is the healing of joints in the IIc or IId type. An absolute majority of affected hip joints have become normal until 3rd month of the age. The complex does not include two patients with teratological dislocation, the incidence of which has been determined in our study by the ratio of 2 cases in 35,550 of timely examined newborns. The role of the factor of spontaneous stabilization cannot be in this part of the study completely discounted. However, herewith we present part of an accomplished epidemiological study where the number of timely diagnosed patients including late diagnoses corresponds to the number of dislocations and subluxations determined within the conventional late diagnosis.

[Generalized laxity of the ligaments in children]

Authors reviewed the literature about the nomenclature and classification of ligamentous laxity syndrome. They are using the term "Generalized ligamentous laxity". They prefer the methods, with total body points-system to the extensometry of the fingers. On the basis of 890 healthy children they determined the statistic characteristics of the score of the generalized ligamentous laxity in relation to age and sex. They suggest, on the basis of the obtained data, the way of clinical application.