The natural history of hip abnormalities detected by ultrasound in clinically normal newborns: a 6-8 year radiographic follow-up study of 93 children

Ultrasound screening for hip dysplasia or dislocation has revealed a group of children with clinically normal hips, but with abnormal or suspicious ultrasound. During the 3-year period 1988-90, we found 170 children with this combination. We evaluated the natural history of these hips. 93 children were examined clinically and with standard radiography 6-8 years after birth. The center edge (CE) angle of Wiberg and migration percentage (MP) were measured on the radiographs. 87 children had not undergone any treatment, whereas treatment with an abduction orthosis had been initiated at approximately 4 months of age because of persisting dysplasia in 6 cases. All hips were radiographically normal at this follow-up. The mean CE value was 24 degrees (SD 6.5) and the mean MP was 13% (SD 5.2). 73 children had no complaints in their lower extremities, whereas 12 had intoeing gait, 1 had outtoeing gait, 2 had hip or knee pain, and 5 had other complaints not relevant to hip dysplasia. We conclude that infants with sonographically abnormal or suspicious hips, but with normal clinical findings, do not need immediate treatment because spontaneous resolution occurs in most of them. Postponement of treatment in the few with persistent dysplasia does not seem to affect the outcome.     

Natural history of ultrasound hip abnormalities in clinically normal newborns.

One hundred one clinically normal newborn hips showed varying degrees of sonographic hip dysplasia according to the classification of Graf. None were treated, and after +/- 6 months, radiographs showed that only four had definite dysplasia. Of these, three had had risk factors such as breech delivery or familial predisposition. Forty-three other clinically normal newborn hips showed ultrasonic instability, which spontaneously corrected. The severity of ultrasound dysplasia at birth was not related to ultimate development of the hip. Our results indicate that ultrasound should not be performed as a general screening procedure in clinically normal newborns.     

The value of a new ultrasound stress test in assessment and treatment of clinically detected hip instability

Fifty patients with clinical suspicion of hip dislocation were investigated prospectively with a dynamic ultrasound stress test. A posterior force was applied to hips in flexion and any movement between the femoral head and the acetabulum was measured. The results of this test showed that posterior movement ranged from 0 to 13.0 mm. Hips that were clinically normal had a mean movement of 1.4 mm, hips with minor clinical instability had a mean movement of 0.6 mm, hips with moderate instability had a mean movement of 4.5 mm, and those with major instability had a mean movement of 5.1 mm. This was statistically significant to a 1% confidence interval. We propose two groups of ultrasound-detected movement: group A less than 5.0 mm representing physiologic laxity, and group B greater than or equal to 5.0 mm being pathological and requiring treatment.     

The natural history of small abdominal aortic aneurysms: an ultrasound study

A retrospective study was undertaken to assess whether, using serial ultrasound examinations, the behaviour of small abdominal aortic aneurysms could be predicted. The average increase in size was found to be 0.3 cm/year. The pattern of increase in size was not affected by age, sex or the presence of hypertension. A proposed course of management of patients with small aneurysms is suggested, particularly if they have other significant medical problems.     

The stanmore total hip arthroplasty: A 15- to 20-year follow-up study

An ongoing study was made of 804 primary Stanmore total hip prostheses implanted in 839 patients between 1973 and 1991. The earliest surviving implants were brought back for radiologic and clinical review in 1995 at an average of 17 years after surgery. The remainder of the patients still living were sent a questionnaire to assess their current status. Survivorship was 95% at 10 years, 85% at 15 years, and 73% at 20 years. The average Merle d'Aubigné—Postel score was excellent up until 14 years. Patient satisfaction remained high until 22 years. Overall, 10% of the prostheses had failed. The results of this study suggest that the Stanmore prosthesis is capable of producing satisfactory long-term results that compare favorably with those of other cemented prostheses.     

Prospective study of 100 consecutive Harris-Galante porous total hip arthroplasties: 4- to 8-year follow-up study

This prospective study evaluates 100 consecutive Harris-Galante Porous (Zimmer, Warsaw, IN) noncemented femoral prostheses 4 to 8 years after surgery. Two femoral components were revised for aseptic loosening. The mean Harris hip score was 56 before surgery and 92 at final follow-up evaluation, with moderate thigh pain seen in 6%. Ingrowth was classified as bony (89%), stable fibrous (8%), and unstable (3%). A pedestal formed in 18%, measurable subsidence occurred in 22%, and endosteal erosion occurred in 12%. Patients with pedestal formation had a higher incidence of unstable growth pattern (P < .05). Patients with bony ingrowth had a lower mean subsidence (0.38 mm) than those with fibrous stable ingrowth (3 mm) and unstable ingrowth (7.5 mm) (P < .05). Thigh pain correlated with the type of ingrowth, and endosteal erosion with the linear polyethylene wear. Survival analysis was 97.5% at 8 years.     

Good results after treatment with the Frejka pillow for hip dysplasia in newborns: a 3-year to 6-year follow-up study

Because there is no consensus with regard to the efficiency of the Frejka pillow in the treatment of hip joint dysplasia in newborns, the aim of the present study was to evaluate our results with this device. During the 3-year period 1988 to 1990, the Frejka pillow was used in 108 newborns with clinically unstable hips verified by ultrasonography. There were three treatment failures (2.8%), defined as infants who needed additional treatment with an abduction splint or hip-spica cast. Avascular necrosis of the femoral head occurred in one patient (0.9%). At an age of 3 years to 6 years, 85 of the children attended a follow-up examination. An intoeing gait was observed in 17% and slightly reduced hip mobility in 20% of the patients. Compared with normal children, the patients had somewhat lower coverage of the femoral head by radiography, indicated by a lower centre-edge angle and a higher migration percentage, but the coverage was within the normal range in all cases. The mean anteversion angle was larger than that of normal children but only three patients had abnormally high anteversion angles. In conclusion, the results with the Frejka pillow were good, with few treatment failures and complications, and it is the most simple abduction device for the parents to handle. More rigid devices like the von Rosen splint seem to involve a slightly lower failure rate, but a higher risk of avascular necrosis. Therefore, we recommend the Frejka pillow when treatment is started within a few days of birth.     

Development of the hip joints in unoperated children with cerebral palsy: A radiographic study of 76 patients

Background?The aims of the present study were to assess the development of hip dysplasia in children with bilateral spastic cerebral palsy and to evaluate the factors that influence the progression.

Patients and methods?76 children, 42 with spastic quadriplegia and 34 with diplegia, were included in the study. Their mean age at the first radiographic examination was 3.5 (1–11) years. The patients were followed up until operative treatment (54 subjects) or until the most recent radiograph in those who did not undergo hip surgery. The mean length of follow-up was 4.8 (1–13) years. On the initial and most recent radiographs, the migration percentage (MP) was measured, which is the percentage of the femoral head lateral to the acetabular rim.

Results?The mean MP of the side with the largest displacement was 25% (-18–66) at the initial radiographic examination and 51% (9–100) at the last follow-up. The mean increase in MP was 7% (-2–33) per year. Linear multiple regression revealed that gait function and age were the most important variables that influenced the rate of MP progression. Children who could not walk had significantly greater MP progression per year (12%) than those who walked with or without support (2%). In the quadriplegics, the maximal yearly increase in MP was 13% under 5 years of age and 7% in older children. This difference was statistically significant, whereas no significant difference in relation to patient age was seen in the diplegics.

Interpretation?There is a pronounced trend towards displacement of the hips in quadriplegic CP patients who are under 5 years of age and cannot walk. Because hip dislocation may lead to severe problems, close follow-up is important in finding the appropriate time for hip surgery in order to avoid progression towards dislocation. The risk of severe hip dysplasia is considerably less in spastic diplegia.??     

Migration of uncemented, long-stem femoral components in revision hip arthroplasty:A 2-8 year clinical follow-up of 45 cases and radiostereometric analysis of 13 cases

We reviewed after 48 (24-90) months the clinical results in 45 cases of revision hip arthroplasties where an uncemented, long-stem femoral prosthesis (BIAS®, Zimmer) had been used. A subgroup of 13 cases was followed with radiostereometric analysis (RSA) for 2 years. 3/45 cases had been re-revised, another 12 had unsatisfactory pain scores. The median Harris score was 69 (26-99). 12/13 stems migrated; 11 subsided 4.1 (0.4-7.9) mm, and 8 migrated posteriorly 2.9 (1.9-9.6) mm.

The poor clinical results and large migrations speak against the use of this prosthesis in revision hip arthroplasty.     

The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness. A prospective,longitudinal follow-up

Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 +/- 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values. The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <20 degrees) and 0.2% persistent severe late dysplasia (CEA <15 degrees). All could be identified by an abnormal CEA (<20 degrees) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice.     

The natural history of subarachnoid haemorrhage with negative angiography: a prospective study and 3-year follow-up

One hundred and forty-eight patients with negative cerebral angiography after subarachnoid haemorrhage are reported. Good grade, normotension and normal CT are associated with a favourable outcome. In 89 patients with negative four-vessel angiography the overall annual risks of rebleeding and fatal rebleeding were 1.5% and 0.4% respectively. In 52 patients undergoing appropriate limited angiography corresponding risks were 2.5% and 1.9%. No fatal rebleeds occurred after 6 months. Initial CT scanning in 104 patients was abnormal in 34. Of these, 14 had SAH alone, in whom no episodes of rebleeding occurred, although SAH on CT was associated with an increased chance of a poor outcome. Twenty had other abnormalities, three of whom rebled, two (both with ICH on CT) being fatal. The annual risks of rebleeding and fatal rebleeding in patients with these CT abnormalities were 5.0% and 3.33% respectively. Fifty-two patients were hypertensive, of whom six rebled, four fatally. Two of the 89 normotensive patients rebled, neither fatally.     

Acetabulum-head index in children with normal hips: a radiographic study of 154 hips.

The acetabulum-head index (AHI), which is used to assess femoral head coverage on plain radiographs, was measured in 77 children (154 hips) with normal hips aged 2 to 14 years. The mean AHI value was 94 (range, 79-114). Both the intraobserver and the interobserver reproducibility of the measurements was high. The AHI values tended to decrease with increasing age. The mean AHI minus 2 standard deviations, which was used to define the border value for subluxation of the femoral head, was 80. The authors propose that an AHI < or = 80 can be used as a guideline to reveal abnormal lateral displacement of the femoral head in children.     

Metal ion levels in large-diameter total hip and resurfacing hip arthroplasty - Preliminary results of a prospective five year study after two years of follow-up

ABSTRACT: BACKGROUND: Metal-on-metal hip resurfacing is an alternative to metal-on-metal total hip arthroplasty, especially for young and physically active patients. However, wear which might be detected by increased serum ion levels is a matter of concern. METHODS: The aims of this preliminary study were to determine the raise of metal ion levels at 2-years follow-up in a prospective setting and to evaluate differences between patients with either resurfacing or total hip arthroplasty. Furthermore we investigated if the inclination of the acetabular component and the arc of cover would influence these findings. Therefore, 36 patients were followed prospectively. RESULTS: The results showed increments for Co and Cr in both implant groups. Patients treated with large-diameter total hip arthroplasty showed fourfold and threefold, respectively, higher levels for Co and Cr compared to the resurfacing group (Co: p<0,001 and Cr: p=0,005). Nevertheless, we observed no significant correlation between serum ion levels, inclination and arc of cover. CONCLUSION: In order to clarify the biologic effects of ion dissemination and to identify risks concerning long-term toxicity of metals, the exposure should be monitored carefully. Therefore, long-term studies have to be done to determine adverse effects of Co and Cr following metal-on-metal hip replacement.     

Modified Hauser operation for patellar instability: Immediate mobilization of 35 knees, a 5-8 year follow-up study

We performed a follow-up examination of 35 knees with chronic patellar instability treated by a modified Hauser operation: medialization and distalization of the tibial tubercle without dorsal transfer, and fixation of the tubercle rigidly with 2 cortical screws. Cast immobilization was not used and the patients were allowed to mobilize the knee immediately. the follow-up period was 6 (5-8) years. 27 of 35 knees were excellent or good at follow-up, while 8 patients were more or less dissatisfied with the result. 5 knees had arthrosis at follow-up. No severe complications occurred, nor did the rate of minor complications differ from earlier reports.     

Fixation of cementless acetabular cups: A radiographic 4-8-year study of 102 porous-coated components

We studied fixation changes over time in 113 porous-coated Howmedica (PCA) cementless acetabular cups inserted in 90 patients 1984-1988. The mean follow-up was 5 years. Radiographic fixation was classified as stable, fibrous-stable, or unstable. 9 cups, 3 in neutral position and 6 vertical, were revised. At follow-up, 40/75 neutral cups were stable versus 7/27 vertical cups. Most stable cups and two thirds of the unstable cups were clinically good. After the first 2 years, 28/75 neutral cups and 10/27 vertical cups changed their fixation: 12 had improved fixation and 26 had a worse one.     

The radiographic joint space width in clinically normal hips: effects of age,gender and physical parameters

OBJECTIVE: The aim of the study was to assess the relationship of the radiographic joint space width (JSW) in the hip with age and a variety of physical parameters in a clinically non-arthritic population in order to identify potential age-related changes. DESIGN: One hundred and eighteen patients (58F/60M, age range 20-79 years) who underwent supine abdominal radiography for non-rheumatological indications and had no hip pain were evaluated. Height, weight and leg lengths were measured. JSW was quantified manually by a dial caliper, and femoral head diameters were determined for each hip. RESULTS: Overall, JSW was 3.61mm+/-0.58 (mean+/-SD) in the right (R) and 3.63mm+/-0.59 in the left (L) hip (range 2.34-6.1mm). There was no age-related decline in the JSW, either by decade (P=0.5 and 0.6, for R and L hips, respectively), or by individual age (Spearman's rho=-0.108 and 0.057, P=0.3 and 0.5 for R and L hips, respectively); similarly, no age-related changes were observed when each gender was analyzed separately. Women had significantly narrower hip JSW than men (P=0.001 and 0.01, R and L hips, respectively). However, gender was no longer significant after height was taken into account (P=0.26 and 0.45, for R and L hips, respectively). JSW correlated significantly with height, weight (which also correlated with height) (r=0.31/0.27 and 0.29/0.28 for height and weight R/L, respectively, P<0.004 for each), but not with body mass index (P=0.62 and 0.57, R and L, respectively). Hip JSW significantly correlated also with femoral head diameter and leg length (r=0.38/0.29 and 0.25/0.19 for femoral head and leg length, R/L, respectively). CONCLUSIONS: No effect of aging was detected on the radiographic JSW of the hip among normal individuals even at advanced ages. In contrast, height, femoral head diameter and leg length were directly related to JSW.     

A 15- to 25- year follow-up study of primary Charnley low-friction arthroplasty: a single surgeon series

Long term outcome studies are essential to determine the effectiveness and durability of a procedure. We report our 15 to 25 year clinical and radiographic follow-up with the Charnley low-friction hip arthroplasty. Four hundred and forty-seven primary Charnley hip arthroplasties were performed by a single surgeon. Ninety-eight of the 447 hips from 75 patients were available for follow up at average of 18.9 years (range 15.3 to 25.4 years). Seventy-two hips (73.5%) survived clinically. Of these 72, seventy-one stems (98.6%) and 60 sockets (83.3%) survived radiographically. Kaplan-Meier survival analysis on all 447 hips using revision as an endpoint revealed 66.2% +/- 5.7% survival at 20 years. Twenty-six hips were revised. The main reason for revision was failure of the socket. Complications included dislocation (3 of 98 hips), heterotopic ossification (7 of 98 hips), trochanteric wire breakage (6 of 98 hips), and trochanteric non-union (1 of 98 hips). Charnley low-friction hip arthroplasty is an effectiveand durable procedure. Key words: hip, arthroplasty, charnley, follow-up.     

The natural history of undiagnosed wrist pain in young women. A long-term follow-up.

43 young women with undiagnosed wrist pain were followed up for a median of 13 years (range 3 to 19). 26% were now free of pain and 35% had improved; 30% were unchanged and 9% were worse. Overall, 40% were still significantly troubled. There was no evidence that those patients suffered or had suffered from emotional or psychiatric disturbance which might have been responsible for the pain. Only three patients had developed ganglia.