Comparing ultrasound measurements of neonatal hips using the methods of Graf and Terjesen

In a prospective study, 232 neonates were examined sonographically using the methods of Graf and Terjesen. In order to determine the reproducibility of the methods, 50 hips were evaluated by two skilled examiners. In an inter-observer study, five physicians and five medical students evaluated 24 images, which were evaluated on ten occasions at two-weekly intervals by one of the authors. Statistical evaluation used the Bland-Altman approach.The neonates (110 females, 122 males) were less than four days old. The mean alpha angle was 62.4 degrees and mean femoral head cover was 55.4%. According to Graf's method, 1.3% of hips were pathological, compared with 4.1% according to Terjesen. Spearman's correlation coefficient between femoral head cover and alpha angles was 0.552. The Bland-Altman approach shows greater variation for femoral head cover than for alpha, if measured by experienced examiners. The Bland-Altman approach shows almost equal reproducibility for alpha and femoral head cover in the inter-observer test, but better repeatability for alpha in the intra-observer test.The Graf results relate better than Terjesen's to the well-known frequency of 1% to 2% hip dysplasia in the European population. Kappa statistics indicate a fair agreement between the two methods. Inter-observer evaluation shows an equal reproducibility of both methods, whereas intra-observer tests reveal better repeatability with Graf's method.     

Assessment of variations in the measurement of hip ultrasonography by the Graf method in developmental dysplasia of the hip

The purpose of this study was to assess the variations in the measurement of hip ultrasonography using the Graf method in developmental hip dysplasia. Twenty-two observers independently analyzed 20 hip ultrasonograms on two occasions. Intraobserver and interobserver agreement ratios on the exact Graf classification were 65% and 51%, respectively. Intraobserver and interobserver agreement ratios on the treatment method according to the hip type were 76% and 64%, respectively. Average intraobserver and interobserver differences were 4.0 degrees and 5.1 degrees for the alpha angle, and 5.9 degrees and 10.1 degrees for the beta angle, respectively. It was concluded that having a basic knowledge of the Graf method was the key point, and the observer's previous number of examinations had no effect on the results.     

Ultrasound measurements in the management of unstable hips treated with the pavlik harness: reliability and correlation with outcome

The purposes of this study were to determine the interobserver and intraobserver reliability of ultrasound measurements in unstable neonatal hips treated with the Pavlik harness and to determine whether ultrasound measurements correlate with radiological outcome at 6 months. Sixty-four babies treated from birth with the Pavlik harness for neonatal hip instability were scanned at 2 and 6 weeks. The alpha and beta angles of Graf, the combined (H) angle of Hosny, and the femoral head coverage (FHC) were measured by 3 observers and remeasured by each observer on a minimum of 50 scans. From 248 scans, 792 sets of measurements were made. Hips were categorized as normal, abnormal, or borderline for each parameter; and interobserver and intraobserver repeatability coefficients and Kappa values were calculated. The alpha angle had the smallest interobserver range (17 degrees), the H angle range was 21 degrees, and the beta angle 28 degrees. Kappa values were best for the FHC and beta angle (0.66-0.8). The mean acetabular index (AI) of all hips at 6 months was 26 degrees (SD, 4.9). The AI was 30 degrees or greater in 24 hips (18 babies) despite prolonged splintage in 9 hips (6 babies). A stepwise linear regression analysis showed that the FHC at 6 weeks was predictive of AI at 6 months (regression coefficient -0.27; 95% confidence interval -0.42 to -0.12; P<0.001). We recommend the FHC as being reproducible, useful, and predictive of outcome in neonatal hips treated for instability.     

External Fixation for Redislocated Colles' Fractures

Rereduction was carried out in 5% of all treated Colles' fractures and they were externally fixated with a one-bar Hoffmann apparatus. The results of 57 of the first 69 patients treated with a follow-up time of at least 1 year are presented. Using Frykman's criteria, 18 patients were judged as “excellent”, 25 as “good” and 14 patients were judged as “unsatisfactory”. The anatomical analysis showed no increase of deformity during the fixation. The final mean results were a 3.0 mm radial shortening and the articular plane of the radius at a right angle to the long axis. Among the first patients, five cases of pin-loosening were seen, but there were no adverse effects in the final result. There were no pin-tract infections. The results justify using the method as a routine when a redislocated Colles' fracture is rere-duced.     

Prediction of mechanical properties of the human calcaneus by broadband ultrasonic attenuation

Broadband ultrasonic attenuation (dB MHz cm⁻¹, nBUA) was determined for specimens from 20 human calcanei, along with apparent density, elasticity (Young's modulus), and compressive strength. The calcanei were modified to provide “whole” (only soft tissue removed), “core” (mediolateral cores corresponding to in vivo measurement region), “can” (cortical end plates removed from core), and “der” (core defatted) samples. The nBUA values for the various modifications were highly correlated. The presence of the cortical endplates creates a significant nBUA, probably due to complex phase interactions. nBUA_can was a good predictor of elasticity (R² = 75.7%) and strength (R² = 73.6%). Apparent density was a better predictor of the mechanical variables than nBUA, with R² values of 88.5% for elasticity and 87.6% for strength. The morphological anisotropy defined by “fabric” for the specimens was extremely uniform. The coefficient of variation in nBUA (40.5%) and compressive strength (64.4%) was significantly greater than for apparent density (23.5%) and fabric (6.7%). It is well known that a power law relationship exists between apparent density and elasticity or strength in cancellous bone. An interesting finding in this work is that there also appears to be a power law relationship between nBUA and apparent density, with an exponent of approximately 2, which, in the light of clinical implications, warrants further investigation.     

Meta-analysis of COL1A1 Sp1 polymorphism in relation to bone mineral density and osteoporotic fracture

Genetic factors play an important role in the pathogenesis of osteoporosis and several candidate gene polymorphisms have been implicated in the regulation of this process. One of the most widely studied is the Sp1 binding site polymorphism in the COL1A1 gene. This polymorphism has been associated with BMD and osteoporotic fracture in several studies, but the data from different studies have been conflicting. Here we have attempted to clarify the association between COL1A1 Sp1 alleles, BMD, and osteoporotic fracture by conducting a meta-analysis of 26 published studies including 7849 participants. Under a fixed effects model, BMD values at the lumbar spine (6800 subjects) were significantly lower in the “Ss” genotype group when compared with “SS” homozygotes (standardized mean DIFFERENCE = 0.131 [95% CI, 0.06,0.16], P = 0.00005) but the difference was not significant for the “ss” comparison (0.09 [−0.03,0.21], P = 0.13). At the femoral neck (6750 subjects) BMD values were lower in the “Ss” genotype (0.14 [0.08,0.19], P < 0.00001) and lower still in the “ss” genotype group (0.19 [0.07,0.31], P = 0.001). Similar results were found when the data were analyzed under a random effects model. Analysis of fracture data (6961 subjects) showed an increased odds ratio for any fracture in “Ss” subjects (1.26 [95% CI 1.09,1.46], P = 0.002) and an even greater increase in “ss” subjects (1.78 [1.30,2.43], P = 0.0003). Subgroup analysis showed that increased risk was largely attributable to vertebral fracture where the odds ratio was 1.37 [1.15,1.64] for “Ss” (P = 0.0004) and 2.48 [1.69,3.65] for “ss” (P < 0.00001). The risk of nonvertebral fracture was not increased in relation to the COL1A1 genotype, although power to detect an effect was limited by the fact that fewer studies had analyzed nonvertebral fracture. We conclude that the COL1A1 Sp1 alleles are associated with a modest reduction in BMD and a significant increase in risk of osteoporotic fracture, particularly vertebral fracture.     

Significant Assessment Discrepancies Occur Between the Examiners Having and Not Having Further Special Hands-on Course Trainings in Infantile Hip Ultrasonography by the Graf Method

Purpose of the StudyThe purpose of this retrospective diagnostic study was to investigate whether or not assessment variabilities occurred in hip ultrasonography (US) by the Graf method between the examiners having (CC) and not having (NoCC) additional special hands-on course trainings by the authorized trainers.MethodologyRandomly selected 270 hip sonograms of 135 babies were independently assessed by CC and NoCC according to the Graf method.ResultsAn inconsistency between CC and NoCC regarding the US diagnosis was seen in 128 hips (47%). This was mainly due to the fact that CC considered 120 of 128 sonograms unusable according to the checklist of the Graf’s examination technique. Probe tilting errors followed by non-visualization of lower limb of os ilium as well as of chondroosseous junction were the most noticed technical problems by CC. There was a significant difference between CC and NoCC concerning the measurement of beta angle. This was mainly due to discordance between the groups about identifying the “bony rim” point.ConclusionSignificant hip US image assessment variabilities exist between the examiners having further trainings by the authorized trainers in special hands-on courses and the examiners having no further trainings in special hands-on courses in the Graf method. The findings of this study may emphasize the importance of training the hip US practitioners in the special hands-on courses for providing a standard clinical practice as well as for avoiding the assessment variabilities between the examiners in the Graf method.     

Longitudinal study of normal hip development by ultrasound

In the management of a newborn's hips, ultrasonography has proven to be useful. The progression of measurements at different ages in normal hips has not been thoroughly investigated. The purpose of this prospective study was to assess the longitudinal development of clinically stable hips. Forty newborns (80 hips) were assessed by ultrasonography at birth and at 6 and 12 weeks of age. Femoral head coverage (FHC), alpha angles, and beta angles were measured. The results showed a significant change in values between the three points in time for all measurements (P < 0.001). The mean FHC progressed from 58.4% to 65.6% to 69.3%, the mean alpha angle from 70.2 degrees to 76.8 degrees to 80.3 degrees , and the mean beta angle from 52.1 degrees to 45.7 degrees to 42.9 degrees . In clinically stable hips, the FHC and alpha and beta angles change significantly over time; therefore, it is important to consider the child's age when interpreting ultrasound images.     

Sonographic assessment of stable hip reposition in newborns and infants with congenital hip dysplasia treated conservatively]

The paper presents a sonographic assessment of dysplastic hip morphology with clinically diagnosed instability after achieving stable reposition. The analysed group comprised 42 dysplastic unstable hips. They were classified according to the Graf classification as type D, III and IV. The analysed group was divided into 2 subgroups according to the child's age at the time treatment was began. Group I comprised children in whom treatment was began at age 2-6 weeks. Group II included children who were 7-12 weeks old at the time treatment was began. The morphology of the dysplastic hip was assessed basing on angle alpha and beta measurements. Stable repositioning of the hip was achieved on average 5 weeks after conservative treatment was started. The average alpha angle was 50 degrees in group I and 48 degrees in group II; accordingly, angle beta was on average 60 degrees and 69 degrees.     

The deviation of the mechanical leg axis correlates with an increased hip alpha angle and could be a predictor of femoroacetabular impingement

Purpose

This study was designed to evaluate whether the mechanical axis deviation (MAD) of the leg correlates with an increased hip alpha angle as described by Nötzli, which is associated with femoroacetabular impingement (FAI).

Methods

In a retrospective analysis, standing full-length anteroposterior radiographs were analysed in patients who suffered from symptomatic leg alignment. The study included 85 radiographs of 80 patients with an average age of 43.11 years (range 18–60 years). Five patients underwent a bilateral long-leg X-ray examination. All radiographs were transferred as Digital Imaging and Communications in Medicine data files from the Picture Archiving and Communications System into the OrthoPlanner software version 2.3.2. The radiographs were measured by one orthopaedic surgeon and one independent radiologist.

Results

The mean value of the alpha angle of Nötzli was 61.43° (49.07–74.04°). A total of 57 (67 %) radiographs showed a varus deviation, 25 (29.5 %) had a valgus malalignment and three (3.5 %) a straight leg axis. Of 82 radiographs, 40 (48.8 %) had a moderate axis deviation with a MAD <15 or > − 15 mm and a mean alpha angle of 57.81°, and 42 (51.2 %) with extended axis deviation of a MAD > 15 or < − 15 mm had a mean alpha angle of 62.93°; 40 (95.2 %) of these 42 showed an alpha angle > 55°. The alpha angle was significantly increased in extended axis deviation compared to moderate axis deviation (P = 0.001).

Conclusions

This study confirmed that increased alpha angles were found significantly at higher degrees of axis deviation on the full-length radiograph. In cases of a MAD >15 or < − 15 mm and symptomatic coxalgia, diagnostic tests must be pursued for FAI.     

Is it worthwhile to screen the hip in infants born with clubfeet?

Purpose

There is some disagreement about whether idiopathic congenital talipes equinovarus (CTEV) increases the risk of neonatal developmental dysplasia of the hip (DDH). This study aimed to investigate the incidence of DDH in our infants with idiopathic CTEV.

Methods

We conducted an observational cohort study over a three-year period to assess the relationship between idiopathic CTEV and DDH. All neonates younger than six weeks with idiopathic CTEV who were treated in our medical centre were admitted to this study. Each subject underwent hip ultrasound examination using the Graf method at the age of six weeks. DDH was diagnosed when a hip was type IIa(−) or worse according to the Graf classification of sonographic hip type.

Results

A total of 184 patients were diagnosed with idiopathic CTEV and underwent hip sonography. In total, seven hips of five individuals underwent treatment (four girls and one boy). The results indicated that 2.7 % of babies (five of 184) with idiopathic CTEV had DDH. However, we did not find any statistically significant difference (p = 0.5776) in the Pirani scores between the DDH group and group with normal hips.

Conclusions

This study revealed that the idiopathic CTEV group had a greater incidence of DDH in comparison with the general population. It is recommended that hip sonography be undertaken particularly in patients with idiopathic CTEV.     

Subeschar clysis in deep burns

Six hundred thirteen patients with deep burn of up to 50% total body surface area (TBSA) were treated with 0.25% povidone iodine subeschar clysis (PVP-SEC) in addition to surface application of povidone iodine + Neosporin in the form of “crust”. The results were compared with those of 595 age, sex and percentage of burn, matched patients treated only by “crust application”. The quantitative bacterial count showed significantly less incidence of infection on the 7th and 8th days post treatment (P<0.001). The organisms identified were predominately Staphylcocous aureus and Pseudomonas aeroginosa. Significantly more number of patients, with burns up to 50% TBSA, could be grafted within 20 days in the SEC group. The graft acceptance rate in this group was 90%.     

Subclinical hypervitaminosis A causes fragile bones in rats

Excessive intake of vitamin A has been associated with an increased risk of hip fracture in humans. This finding has raised the question of whether long-term intake of relatively moderate doses (“subclinical” hypervitaminosis A) contributes to fracture risk. Although it has been known for more than half a century that toxic doses of vitamin A lead to spontaneous fractures in rats, the lowest intake that induces adverse effects is not known, and the result of exposure to excessive doses that do not cause general toxicity has been rarely investigated. In this study, mature female rats were fed a standard diet with 12 IU vitamin A/g pellet (control, C), or standard diet supplemented with either 120 IU (“10 × C”) or 600 IU (“50 × C”) vitamin A/g pellet for 12 weeks. Fifteen animals were included in each group. The supplemented diets correspond to a vitamin A intake of approximately 1800 IU/day and 9000 IU/day, respectively. The latter dose is about one third of that previously reported to cause skeletal lesions. At the end of the study, serum retinyl esters were elevated 4- (p < 0.01) and 20-fold (p < 0.001) and the total amount of liver retinoid had increased 3- (p < 0.001) and 7-fold (p < 0.001) in the 10 × C and 50 × C group, respectively. The animals showed no clinical signs of general toxicity, and there were no significant bone changes in the 10 × C group. However, in the 50 × C group, a characteristic thinning of the cortex (cortical area −6.5% [p < 0.001]) and reduction of the diameter of the long bones were evident (bone cross-sectional area −7.2% [p < 0.01] at the midshaft and −11.0% [p < 0.01] at the metaphysis), as measured by peripheral quantitative computed tomography. In agreement with these data and a decreased polar strength strain index (−14.0%, p < 0.01), the three-point bending breaking force of the femur was reduced by 10.3% (p < 0.01) in the 50 × C group. These data indicate that the negative skeletal effects appear at a subchronic vitamin A intake of somewhere between 10 and 50 times the standard diet. This level is considerably lower than previously reported. Our results suggest that long-term ingestion of modest excesses of vitamin A may contribute to fracture risk.     

A case of Moyamoya disease with progressive involvement from unilateral to bilateral

A case of Moyamoya disease in a child starting with unilateral lesion and developing into bilateral involvement is reported. Angiographic findings at onset showed unilateral involvement, hence, it was filed as a “probable” case according to the diagnostic criteria of the Japanese Cooperative Research Committee. The carotid angiograms on the other side were totally normal. Three years later the occlusive lesion became bilateral, to meet the criteria as a “definite” case. Clinical manifestations, angiograms, electroencephalograms, and position emission tomograms in this case are presented, and the relation between the probable and definite cases is discussed.     

Ultrasound screening of the infant's hip: introduction of a new combined angle

This study evaluates the most widely used sonographic measurements for judging an infant's hip morphology. The alpha and beta angles of Graf, the bony coverage percentage of Morin and a new combined angle were analysed. This latter angle records the direction of the whole acetabulum (cartilagenous and bony) as one unit. One-hundred sonograms were examined independently by two observers to calculate the interobserver and intraobserver limits of agreement. The new combined angle proved to be the most reproducible measurement. Graf's alpha angle was the second most reliable measurement followed by the bone coverage percentage. The relationship between the combined angle and alpha angle was statistically significant with a correlation coefficient of 0.70 (P<0.001).     

Catastrophic failure of an uncemented acetabular component due to high wear and osteolysis

Background The purposes of this study were (1) to evaluate the wear pattern of the hydroxyapatite-coated “Dual Radius” Omnifit cup, (2) to investigate whether wear is correlated to any demographic or prosthesis-related factors, and (3) to describe micromotion of both the cup and the stem.

Patients and methods 154 hips were implanted between 1990 and 1996 and followed for an average of 6 years. Wear was measured according to the “Charnley-duo” method and, in 79 hips, with radiostereometry (RSA). RSA was also used to evaluate micromotion. We analyzed the femoral heads using scanning electron microscopy, energy dispersive X-ray spectroscopy and an atomic force microscope.

Result 66 cups were revised and had a mean annual wear of 0.32 mm compared to 0.12 mm in hips not revised. Osteolytic processes were observed in 35 hips but at revision osteolysis was present in 51 cases. 43/66 sockets were loose. Micromotion evaluated by RSA, weight, age, side, size of cup, screws, polyethylene thickness or shelf-life of the polyethylene did not correlate to wear, whereas male gender did.

Interpretation It is still unclear why about half of our cases had an abnormal wear rate. Annual wear exceeding 0.2 mm is prognostic of late failure and should be considered a warning sign.     

The response of rat tibiae to incremental bouts of mechanical loading: A quantum concept for bone formation

To investigate the minimum number of loading bouts necessary to produce new lamellar or woven bone formation, and the time required for its initiation, bone formation was measured in 32 retired breeder female Sprague-Dawley rats following one, two, three, or five bouts of applied loading. Bending forces of 54 N were applied to right tibiae using a four-point loading apparatus, and left tibiae served as contralateral controls. Loading was applied as a sine wave with a frequency of 2 Hz for 18 s (36 cycles) per loading bout. Rats were injected with alizarin on day 1 and calcein on days 5 and 12, and were killed on day 19. One bout of loading was sufficient to increase the periosteal woven bone surface (Wb.Pm/B.Pm) from 0% to 40% (p < 0.01), and to 80% after five bouts of loading (p < 0.01), with a dose-response relationship for increases in Wb.Pm/B.Pm (p < 0.0001), mineral apposition rate (Wb.AR; p = 0.002), and bone formation rate (Wb.BFR/BS; p = 0.0001). In the first labeling period (days 1–5), the endocortical lamellar bone forming surface (BS_f/BS) was increased slightly (p < 0.05), but no significant differences were shown for BFR/BS or MAR. From days 5 to 19, right tibiae showed a dose-response increase in BFR/BS (p = 0.002) and BS_f/BS (p = 0.008), but not MAR. These results are consistent with a “quantum” model of bone formation such that a “quantum” of bone cells is activated in response to the loading bout and the strain magnitude dictate the size or microstructural organization of a given packet of new bone. Conversely, the distributed nature of loading may define the recruitment, rather than size, of new packets of bone.     

Risk of hip/femur fractures in patients using antipsychotics

The objective of our study was to investigate whether use of antipsychotics is associated with hip/femur fractures and whether pharmacological differences between antipsychotics are related to the occurrence of fractures.

A case-control study was conducted, in which cases were defined as patients with a hip/femur fracture. Each patient was matched to one control patient. The association between use of antipsychotics and the occurrence of hip/femur fractures was evaluated using conditional logistic regression.

The study included 44,500 patients from 683 general practices from different geographical areas in the UK, registered within the General Practice Research Database (GPRD). Exposure to antipsychotics was categorized as “no use”, “current use” and “prior use”.

Both current and prior use of antipsychotics were associated with an approximately two-fold increased risk of fractures. After adjustment for possible confounders, a small significant effect remained (Odds Ratios (OR) of 1.3). We did not find an association between dose of antipsychotics, or between the degree of blockade of the alpha-1 adrenoceptor or histamine-1 receptor and risk of fractures. The total number of days of antipsychotic use was significantly associated with an increased risk of hip/femur fractures.

We conclude that there is a small increased risk of hip/femur fractures associated with the use of antipsychotics. This risk increases with long-term use.     

Strategies to improve compliance with evidence-based clinical management guidelines

Background: Clinical management guidelines (CMGs) have been developed to standardize physician practices and ensure safe and cost-effective patient care. In June 1996, evidence-based CMGs were initiated at our urban Level I trauma center. This study compares physician compliance with two such CMGs before (PRE) and after (POST) the institution of continuous surveillance by a clinical resource manager.

Study Design: For 2 months PRE resource manager surveillance hospital records were reviewed retrospectively for compliance with two CMGs. POST data were collected prospectively for 2 months by the resource manager, who alerted practitioners to deviance from CMGs to justify or document therapy alternatives. The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis. “Under” or “over” therapy described that which fell short of or exceeded guidelines. Data were analyzed by chi-square; p < 0.05 defined statistical significance.

Results: Compliance with the CMGs was 48% PRE and 74% POST (p = 0.001). All noncompliant instances POST (and none PRE) were altered or justified. Deep venous thrombosis and ulcer “over” therapy was significantly higher PRE (19% versus 2%, p = 0.003; 49% versus 19%, p = 0.001), resulting in $22,760.35 in costs. There was no difference in pulmonary embolism or gastrointestinal bleed rate (1%) PRE to POST.

Conclusions: The use of a clinical resource manager empowered to monitor and coordinate physician behavior improves compliance with CMGs. Further study is warranted to validate resultant outcomes benefit, specifically cost-effectiveness and duration of the need for such a program.