An Eastern Europe and Middle East multinational expert Delphi consensus study on the prevention, diagnosis, and treatment of developmental dysplasia of the hip before walking age

PURPOSE

The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age.

METHODS

Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age.

RESULTS

Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head.

CONCLUSION

The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided.

Developmental disorders of the hip treated at the Clinic for Orthopaedic Diseases – in a period of 10 years (2009-2018)

Developmental hip dysplasia includes a wide range of conditions such as subluxation, dislocation, hip instability, and teratological hip. The diagnosis  was confirmed by clinical examination, ultrasound  examination and anterior-posterior view radiograph  (AP). Treatment  varied  depending on the patient's age and the degree of dysplasia: Pavlik harness, closed reduction, open reduction  and corrective osteotomies. In this  study 242 patients were included, of whom  198 were female  patients and 44 male. All of the patients were treated with conservative treatment- closed reducation and spica casting. Left-sided dislocations were  more common than right sided dislocations with predominance in the female patients. The main treatment in follow-up patients was closed reduction with or without adductor muscle tenotomy   (m. add. longus). In cases with  unsuccessful attempt  of closed reduction, open reduction  was performed with or without adductor muscle tenotomy. Depending on the residual dysplasia, patients were additionally treated with pelvic osteotomies    (Salter 's inominate  osteotomy), varus derotation osteotomy, valgus osteotomy, proximal femoral resection, and  trochanter major  transposition. 167 patients were treated with closed reduction  and 3 with open reduction. The remaining patients were treated with closed reduction and additional surgery or with open reduction and additional surgery. Out of all treated patients, only 10 patients had recurrent dislocation of the hip, 7 female and 3 male patients. Closed reduction was performed again on two patients, and open reduction of the hip was performed on one patient. The average  age  of  patients was  21.5 months. By presenting the cases in a period of 10 years, it was conclud  that most  cases were  diagnosed later. Also, the standard closed reduction treatment  was successful even after the first year in said  patients. Depending on the residual dysplasia of the hip, in order to achieve better congruence of the joint, additional surgeries were  performed.

Closed Reduction in Developmental Dysplasia of the Hip in Patients Older than One Year

INTRODUCTION

Besides an effective screening method for developmental dysplasia of the hip, there is certain number of children in whom the condition has been overseen or they have never been screened and the parents have noticed the odd walking pattern in their toddler. Treatment of such patients is controversial. One of the recommended treatment methods because of the short-term hospitalization, but often considered unsuccessful is closed reduction of the hip followed by cast immobilization.

HYPOTHESIS

Closed hip reduction in late diagnosed developmental dysplasia of the hip gives good results.

AIM

Our aim in this retrospective study was evaluation of the success of the treatment with closed reduction of hip dislocation in children older than 12 months.

PATIENTS AND METHODS

In the study, we included 20 patients treated at our clinic from June 2004 to May 2017. Of these 20 patients, 8 had bilateral involvement, 12 had unilateral, in a total of 28 hips. In all patients we noted preoperatively the range of movement, the presence of limp, any limb inequality, and hip pain. We used clinical and radiological parameters for evaluation. Clinically, we examined the range of movement, limb inequality as well as limb function and we classified it according to the modified McKay's criteria. Same examinations were done at 1, 3, and 5 years after closed reduction.

RESULTS

At the last follow-up examination, using McKey's criteria for clinical evaluation we rated the hips in two patients (7%) as grade III, i.e. fair grade, 10 hips (36%) were grade II - rated good, and 16 hips (57%) were evaluated as grade I. In four hips, there were signs of avascular necrosis of the hip, while in one patient the avascular necrosis developed after the closed reduction. Radiographic assessment (Figs 3, 4) using Severin's scoring system showed no hips with types V and VI, type IV was observed in 7%, type III in 21%, type II in 29%, while most of the hips (12, 43%) were type I.

CONCLUSION

We concluded that the procedure was justified. An advantage of this method is that it is inexpensive; it entails no direct operative changes of the bone structures and gives good results.

Severe digital malformations in a rare variant of fibrodysplasia ossificans progressiva

A 16-year-old girl with a history of nontraumatic swelling of both forearms, osteochondromas of the knees, heterotopic ossification of the neck and back, severe malformations of all digits with hypoplastic or absent nails, alopecia partialis of the scalp, and moderate cognitive impairment was seen for diagnostic evaluation. Whole exome sequencing identified an activating mutation of ACVR1 (c.983G > A; p.Gly328Glu) which confirmed a suspected FOP variant. The delayed diagnosis of an FOP variant in this patient could have been avoided if the significance of severe digital malformations had been recognized, especially in the setting of progressive heterotopic ossification.

The Influence of Anterior Cruciate Ligament Remnant on Postoperative Clinical Results in Patients with Remnant Preserving Anterior Cruciate Ligament Reconstruction

BACKGROUND:

Anterior Cruciate Ligament (ACL) remnants have important biomechanical, vascular and proprioceptive function.

AIM:

To determine the influence of the ACL residual remnants after partial and complete ACL ruptures on postoperative clinical results in patients with remnant preserving ACL reconstruction.

PATIENTS AND METHODS:

The study included 66 patients divided into two groups. In patients from the investigation group remnant preserving ACL reconstruction was performed, in patients from the control group single bundle ACL reconstruction was performed. The results were assessed by Rolimeter measurements, Lysholm and Tegner scores and proprioception evaluation.

RESULTS:

The mean side-to-side difference of anterior tibia displacement (mm) was improved from 4.4 ± 1.06 to 0.4 ± 0.7 in the investigation group, and from 4.6 ± 0.68 to 1.9 ± 0.64 in the control group (p < 0.001). Difference in the angles in which the knee was placed by the device and the patient has improved from 1.5 ± 0.96° to 0.5 ± 0.53° in the investigation group and from 1.8 ± 0.78° to 1.3 ± 0.97° in the control group (p < 0.05). Tegner and Lysholm scores showed no difference between the groups.

CONCLUSION:

Preservation of the ACL residual bundle provides a better knee stability and proprioceptive function.

Operative treatment of the knee contractures in cerebral palsy patients

Introduction:

Knee flexion is one of the main problems of the lower extremities in cerebral palsy patients. Many operative procedures are recommended for contractures of the knee in cerebral palsy patients. We performed simple operation and analyzed the results after operative treatment with nine years follow up.

Method:

85 patients with spastic cerebral palsy were treated in period 2001 – 2010. 40 were ambulatory and 45 non ambulatory with ability to stand with support. All of them underwent same surgical procedure with distal hamstrings lengthening. Tenotomies were performed on m. semitendinosus, m. semimembranosus, m. gracillis and biceps femoris. Only m. semitendinosus was tenotomized completely, other muscles were tenotomized only on tendinous part. The patients had a plaster immobilization for five days after the surgery with the knee extended.

Results:

All 85 patients had improvement of the popliteal angle pre and post operative respectively. Improvement in the crouch gait was noticed in the period of rehabilitation. We had no complication with the wound. Three of the patients had overcorrection and achieved recurvatum of the knees.

Conclusion:

We consider this procedure very simple with satisfying improvement of standing, walking and sitting abilities in children with spastic cerebral palsy.

Operative treatment of the knee contractures in cerebral palsy patients

INTRODUCTION

Knee flexion is one of the main problems of the lower extremities in cerebral palsy patients. Many operative procedures are recommended for contractures of the knee in cerebral palsy patients. We performed simple operation and analyzed the results after operative treatment with nine years follow up.

METHOD

85 patients with spastic cerebral palsy were treated in period 2001-2010. 40 were ambulatory and 45 non ambulatory with ability to stand with support. All of them underwent same surgical procedure with distal hamstrings lengthening. Tenotomies were performed on m. semitendinosus, m. semimembranosus, m. gracillis and biceps femoris. Only m. semitendinosus was tenotomized completely, other muscles were tenotomized only on tendinous part. The patients had a plaster immobilization for five days after the surgery with the knee extended.

RESULTS

All 85 patients had improvement of the popliteal angle pre and post operative respectively. Improvement in the crouch gait was noticed in the period of rehabilitation. We had no complication with the wound. Three of the patients had overcorrection and achieved recurvatum of the knees.

CONCLUSION

We consider this procedure very simple with satisfying improvement of standing, walking and sitting abilities in children with spastic cerebral palsy.

Hip reduction in cerebral palsy with soft tissue operative procedures

Hip reduction in cerebral palsy patients with a soft tissue procedure was analysed during operative procedure. Eleven patients with unilateral dislocation of the hip and a quadriplegic form of cerebral palsy underwent soft tissue operation on the hips. Tenotomy of the adductor and flexor muscles of the hip was performed. The contralateral hip sustained only tenotomy of the adductor muscles. The average age of the patient study group was 8.5 and the follow-up period was 4 years. In all patients, repositionings of the hip were achieved and stabilization was maintained postoperatively at the regular outpatient follow-up. The range of extension and abduction motion were increased postoperatively compared to the preoperative range of motion. Retention of the hip was maintained within 20 degrees of abduction. Tenotomy of the adductor and flexor muscles enables hip reduction without opening the joint capsule in quadriplegic cerebral palsy patients. The hip became painless and the improvement in the hygiene was evident.

Soft tissue surgical procedures in the prevention of hip dislocation in patients with spastic cerebral palsy

Hip dislocation in the spastic form of cerebral palsy is mainly unilateral, leading to pelvic deformities, appearance of scoliosis, difficult positioning when seated, as well as pain experienced during walking and standing. Tenotomies of adductor muscles were performed in 22 patients (44 hips), 14 male and 8 female. In 12 patients decrease in migration percentage was noted, the average patient age being 5,4 years. In 10 patients no changes in migration percentage were detected, compared to preoperative values. Mean age of the latter group was 7,2 years. The results of the operative procedures were considered good, since the regular follow-up radiographies (done every 6 months) showed decrease in migration percentage. Adductor muscle tenotomies should be performed in incipient hip dislocations with migration index not overcoming 30%, preferably at younger age.