Konservative Behandlung der Hüftreifungsstörung

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis

INTRODUCTION

Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques.

METHODS

Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models.

RESULTS

From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results.

CONCLUSIONS

Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.

Paediatric hip ultrasound: uncertainties in examination and choice of treatment

PURPOSE

In Germany, neonates undergo hip sonography examination using the Graf method during the routine U3 screening examination, performed by consultant physicians four to five weeks after birth, and are referred to specialized orthopaedic departments if there are any uncertainties. This study evaluated the quality of sonographic screening in the outpatient sector and the treatment requirements of referred children.

METHODS

We performed a retrospective analysis of the patient data of 384 neonates collected in consultations performed between April 2016 and April 2019.

RESULTS

In total, 74% (n = 284) of neonates presented a hip type Ia/b. Treatment (abduction brace or Fettweis cast) was required in 32% (n = 122) of cases. The treatment duration was significantly correlated with age at first presentation (Pearson's r = 0.678; p = 0.001). The treatment duration for patients aged > 200 days old at first presentation was twice as long as those aged 100 days at first presentation. Patients with public health insurance require referral by a consultant. Developmental dysplasia of the hip as referral diagnosis could not be confirmed in control examination in 64% (n = 132) of cases. Of the public health insured children, 97% (n = 200) were referred through a consultant paediatrician.

CONCLUSION

We identified deficits in performing and interpreting the Graf method of ultrasound examination. A total of 64% of referred pathological hips turned out to be physiological configurations in our control examination. The future goal should be to increase anatomical knowledge of the newborn hip and ensure the correct use of Graf ultrasound method. Advanced training courses are recommended and necessary.

LEVEL OF EVIDENCE

IV.

Residual hip dysplasia in children: osseous and cartilaginous acetabular angles to guide further treatment-a pilot study

PURPOSE

In case of residual hip dysplasia (RHD) in children, pelvic radiographs are sometimes insufficient to precisely evaluate the entire coverage of the femoral head, when trying to decide on the need for further reconstructive procedures.

METHODS

This study retrospectively compares the bony and the cartilaginous acetabular angle of Hilgenreiner (HTE) of 60 paediatric hips on pelvic MRI separated in two groups. Group 1 included 31 hips with RHD defined by a bony HTE > 20°. Group 2 included 27 hips with a HTE < 20°. They were compared by introducing a new ratio calculated from the square of cartilaginous HTE above the bony HTE on frontal MRI. The normal upper limit for this acetabular angle ratio was extrapolated from the published normal values of cartilaginous HTE and bony HTE in children.

RESULTS

The acetabular angle ratio was statistically significantly increased in the hips with RHD with a mean value of 7.1 ± 4.7 compared to the hips in the control group presenting a mean value of 2.1 ± 1.9 (p < 0.00001).

CONCLUSIONS

This newly introduced ratio seems to be a helpful tool to orientate the further treatment in children presenting borderline RHD.

Cellular and molecular changes to chondrocytes in an in vitro model of developmental dysplasia of the hip‑an experimental model of DDH with swaddling position

The aim of the present study was to assess the cellular and molecular changes to chondrocytes in a developmental dysplasia of the hip (DDH) model and to investigate the early metabolism of chondrocytes in DDH. Neonatal Wistar rats were used for the DDH model with swaddling position. Primary cultures of chondrocytes were prepared at serial interval stages (2, 4, 6 and 8 weeks) to investigate cellular proliferation. The expression of collagen II and aggrecan mRNA was detected to assess the anabolic ability of chondrocytes. The expression of matrix metallopeptidase (MMP)-13 and ADAM metallopeptidase with thrombospondin type 1 motif 5 (ADAMTS-5) mRNA was measured to investigate the degradation of collagen II and aggrecan, respectively. Morphological changes were observed in coronal dissection samples after the removal of fixation. Primary chondrocytes at serial intervals were assessed using a Cell Counting Kit-8 assay and the results revealed that DDH chondrocytes had more proliferative activity. The expression of collagen II mRNA was upregulated at 2 weeks and was more sensitive to mechanical loading compared with aggrecan. Similar changes occurred at 6 weeks. Furthermore, MMP-13 and ADAMTS-5 mRNA expression levels were upregulated at 2 weeks. It was also demonstrated that DDH chondrocytes exhibited high proliferative activity at the early stages and degeneration later.

[Paediatric hip sonography: current status at German university hospitals]

BACKGROUND

This study was conducted to evaluate the current status of pediatric hip sonography at German university hospitals.

MATERIAL AND METHODS

A questionnaire was sent to all heads of orthopedic departments in Germany. They were asked to give details of the technique and instrumentation used for hip ultrasound examination, local organization of consultation and options for advanced training of students and staff.

RESULTS

The return rate of the questionnaires was 93.9 %. Pediatric hip ultrasonography was performed at every university hospital by staff of the orthopedic and trauma departments (n = 31, 100 %). A well-established tradition of teaching both medical students and physicians on this topic was reported by many departments. Courses with a focus on pediatric hip sonography were organized in 25.8 % of the German university hospitals. In the majority of the responding orthopedic and trauma departments a 7.5 MHz linear transducer for ultrasound examination (93.5 %), a foot switch for rapid freezing of the ultrasound image (93.5 %) and a cradle for positioning the infant (100 %) were used. A guided probe device recommended by Graf was only used in 35.5 % of the departments. Evaluation of the sonograms was performed in 19 of the clinics (61.3 %) in the classical way on printed paper strips.

CONCLUSIONS

This survey documented the high importance of pediatric hip sonography in German university hospitals. Quality controls in the orthopedic departments are carried out internally. For this reason both the implementation of standardized training courses and the schooling of well-trained instructors are mandatory.

[Congenital dysplasia and dislocation of the hip: proven and new procedures in diagnostics and therapy]

BACKGROUND

As developmental dysplasia of the hip (DDH) is the most common congenital muskuloskeletal anomaly, it seems necessary to give an update on the normal growth, pathoanatomy, diagnostic and therapeutic procedures.

OBJECTIVES

Which investigations or procedures have withstood the test of time? What are new therapeutic strategies and considerations? What are the problems?

METHODS

Review of the current literature on DDH supplemented by several years experience in the treatment of this condition by the authors.

RESULTS

We have still a long way to achieve the goal of agreement on universal standardization of assessment and treatment methods based on age and staging regarding DDH, as in the Ponseti treatment procedure for clubfoot.

CONCLUSION

Our experiences, as well as the literature suggest the use of Graf's nomenclature for classification of DDH in the first year of life. If dynamic ultrasound (US) shows at least a partial relocation of a decentered hip in the first 6 weeks of life, splinting in human position is advocated. The treatment of a Graf type IV hip joint is very difficult and often need surgery. The established surgical procedures in the literature are still up to date. Radiological follow-up of the affected as well as the unaffected side until the end of the growth phase is mandatory due to the risk of residual dysplasia.

Early radiological outcome of ultrasound monitoring in infants with developmental dysplasia of the hips

The purpose of this study was to evaluate the early radiological outcome after ultrasound-monitored treatment of developmental dysplasia of the hip (DDH) and to examine whether there was a correlation between the initial severity of DDH, measured by ultrasound, and the severity of residual dysplasia on the radiograph at the first follow-up. At the beginning of ultrasound-monitored treatment, the sonographic findings of 90 children (72 girls, 18 boys, mean age 7.2 weeks) with DDH (29 unilateral, 61 bilateral) were staged according to the Graf classification and assigned to four categories. Treatment was continued until normal ultrasound findings were reached. At the time children started walking (mean age 14.8 months), an anteroposterior radiograph of the pelvis was performed. The acetabular index was measured and classified according to the normal values of the hip joint, as described by Tönnis. The ultrasound findings expressed by the Graf classification were compared with the acetabular index measured at radiographic follow-up. Although normal values in ultrasound were reached before abduction splinting was discontinued, at the time of radiological follow-up, 59 hips (32.8%) showed mild residual dysplasia and another 53 hips (29.4%) showed severe residual dysplasia according to the criteria of Tönnis. Statistically, there was no significant correlation between the Graf classification and the radiological outcome at follow-up. Even after successful ultrasound-monitored treatment, a risk for residual dysplasia remains. Therefore, radiological follow-up of every hip treated once is necessary. We found no correlation between the severity of DDH measured by ultrasound and the subsequent presence of residual dysplasia at radiological follow-up.