Hip Displacement in Cerebral Palsy: The Role of Surveillance

IntroductionHip displacement is common in cerebral palsy (CP) and is related to the severity of neurological and functional impairment. It is a silent, but progressive disease, and can result in significant morbidity and decreased quality of life, if left untreated. The pathophysiology of hip displacement in CP is a combination of hip flexor-adductor muscle spasticity, abductor muscle weakness, and delayed weight-bearing, resulting in proximal femoral deformities and progressive acetabular dysplasia. Due to a lack of symptoms in the early stages of hip displacement, the diagnosis is easily missed. Awareness of this condition and regular surveillance by clinical examination and serial radiographs of the hips are the key to early diagnosis and treatment.Hip surveillance programmesSeveral population-based studies from around the world have demonstrated that universal hip surveillance in children with CP allows early detection of hip displacement and appropriate early intervention, with a resultant decrease in painful dislocations. Global hip surveillance models are based upon the patients’ age, functional level determined by the Gross Motor Function Classification system (GMFCS), gait classification, standardized clinical exam, and radiographic indices such as the migration percentage (MP), as critical indicators of progressive hip displacement.ConclusionDespite 25 years of evidence showing the efficacy of established hip surveillance programmes, there is poor awareness among healthcare professionals in India about the importance of regular hip surveillance in children with CP. There is a need for professional organizations to develop evidence-based guidelines for hip surveillance which are relevant to the Indian context.     

坐骨重叠征与发育性髋关节脱位手术后再脱位的相关性分析

目的提出坐骨重叠征(ischium overlap sign,IOS)的概念,并分析其与发育性髋关节脱位(developmental dysplasia of the hip,DDH)手术后再脱位的关系。方法回顾性分析2013年9月至2017年5月山东大学附属省立医院治疗的88例(105髋)DDH患儿病例资料,其中男童16例、女童72例;平均年龄12(5~24)个月,平均随访时间34(15~59)个月;双侧17例,左侧63髋,右侧42髋;1髋为髋臼发育不良,11髋半脱位,93髋全脱位。术中行髋关节造影检查,按照Bowen标准选择闭合或切开复位石膏固定术。IOS是指在人类位髋关节造影平片上股骨头软骨内缘与坐骨外缘的重叠关系,二者重叠为Ⅰ度,相接为Ⅱ度,分离为Ⅲ度。将93髋全脱位按照IOS分度进行分组,比较组间再脱位发生率。结果 1髋髋臼发育不良和11髋半脱位者IOS均为Ⅰ度。93髋全脱位中IOSⅠ度14髋,Ⅱ度39髋,此两组均行闭合复位石膏固定,无再脱位病例;Ⅲ度40髋中,闭合复位石膏固定17髋,6髋再脱位;切开复位石膏固定23髋,1髋再脱位。本研究发现Ⅲ度组的再脱位发生率(7/40,17.5%)高于其他两组(P=0.006)。IOS为Ⅲ度的40髋中,闭合复位的再脱位发生率(6/17,35.3%)高于切开复位(1/23,4.4%),差异有统计学意义(X^2=4.518,P=0.034)。结论 IOS与DDH术后再脱位有一定的关系,IOS为Ⅲ度的髋关节如行闭合复位,再脱位的风险较高。     

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.     

Intra-articular Hymovis injection for managing hip OA in active sportsmen. A 24-month observational retrospective clinical investigation

BackgroundHip Osteoarthitis (OA) risk is sport-specific and depends on frequency, intensity, and type of mechanic stress the hip is subjected to. This retrospective observational study aims to investigate the safety and performance of Hymovis (HYADD-4) injection, a hexadecyl (C-16) HA-derivative, when used to manage symptomatic hip OA in active middle-aged sportsmen over a 24-month observation period.MethodsThe retrospective analysis included clinical records of active sportsmen, aged between 40 and 65 years, and suffering from symptomatic Kellgren-Lawrence grade II to III hip OA, treated with two (24 mg/3 ml) Hymovis injections, two weeks apart, every 3–4 months, for two years. When available, data on MRI examination were included in the analysis as well as Heidelberg Sports Activity Score (HAS) and Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaires.ResultsThirty patients (56.4 ± 7.3 years) were included in the study, sixteen cyclists and 14 tennis players. For all patients, HAS and most HAGOS scores improved significantly (p < 0.05) at the first control visit (4 months) and further improved over time. For all other scores an important clinical benefit was experienced by more than 50% of participants. No adverse events were recorded.ConclusionTreatment of hip OA in active sportsmen with Hymovis seems a safe and effective approach for the management of OA symptoms, by potentially protecting cartilage and subchondral bone from further damage.     

The effects of increased forward trunk lean during stair ascent on hip adduction and internal rotation in asymptomatic females

BackgroundIncreased hip adduction and internal rotation can lead to excessive patellofemoral joint stress and contribute to patellofemoral pain development. The gluteus maximus acts as a hip extensor, abductor, and external rotator. Improving hip extensor use by increasing one’s forward trunk lean in the sagittal plane may improve frontal and transverse plane hip kinematics during stair ascent.Research questionDoes increasing forward trunk lean during stair ascent affect peak hip adduction and internal rotation?MethodsTwenty asymptomatic females performed five stair ascent trials (96 steps/min) on an instrumented stair using their self-selected and forward trunk lean postures. Three-dimensional kinematics (200 Hz) and kinetics (2000 Hz) were recorded during the stance phase of stair ascent. Biomechanical dependent variables were calculated during the stance phase of stair ascent and included peak forward trunk lean, hip flexion, hip adduction, hip internal rotation angles, and the average hip extensor moment.ResultsDuring the forward trunk lean condition, decreases were observed for peak hip adduction (MD = 2.8˚; 95% CI = 1.9, 3.8; p < 0.001) and peak hip internal rotation (MD = 1.1˚; 95% CI = 0.1, 2.2; p = 0.04). In contrast, increases were observed during the forward trunk lean condition for the peak forward trunk lean angle (MD = −34.7˚; 95% CI = −39.1, −30.3; p < 0.001), average hip extensor moment (MD = −0.5 N·m/kg; 95% CI = −0.5, −0.4; p < 0.001), and stance time duration (MD = −0.02 s; 95% CI = −0.04, 0.00; p = 0.017).SignificanceIncreasing forward trunk lean and hip extensor use during stair ascent decreased peak hip adduction and internal rotation in asymptomatic females. Future studies should examine the effects of increasing forward trunk lean on hip kinematics, self-reported pain, and function in individuals with patellofemoral pain.     

Effect of contralateral cane use on hip moment impulse in the frontal plane during the stance phase

BackgroundRecent reports have shown that the daily cumulative moment in the frontal plane (i.e., product of hip moment impulse in the frontal plane during the stance phase and mean steps per day) is a risk factor for hip osteoarthritis. This study aimed to clarify the effect of contralateral cane use on hip moment impulse in the frontal plane of the stance limb.MethodsThis study included 15 healthy subjects who walked under four experimental conditions: (1) without a cane and (2–4) contralateral cane use with 10%, 15%, and 20% body weight support (BWS), respectively. To maintain the same walking speed in all conditions, the cadence was set to 80 steps/min, and the step length was fixed. The hip moment impulses in the frontal plane (i.e., area under the hip ab-adduction moment waveform) and peak hip adduction moments in all conditions were calculated.ResultsContralateral cane use significantly decreased the hip moment impulse in the frontal plane and peak hip adduction moment compared to non-cane use. Moreover, the hip moment impulse in the frontal plane and peak hip adduction moment decreased significantly with increased cane BWS. There were no significant differences in walking speed, cadence, and step length between the four conditions.ConclusionContralateral cane use decreases the hip moment impulse in the frontal plane and peak hip adduction moment in the stance limb. These findings may help clarify how to delay the progression of hip osteoarthritis.