The incidence of avascular necrosis of the healthy, contralateral femoral head at the end of the use of Pavlik harness in unilateral hip dysplasia

We examined the incidence of avascular necrosis (AVN) of the healthy femoral head in unilateral hip dysplasia at the end of the use of the Pavlik harness. The evaluation of AVN was done with the help of standardised roentgenograms. Between 1974 and 1982, 1,064 dysplastic hips (869 children) were treated with the Pavlik harness at the Orthopaedic Department of Semmelweis University. Of these, 674 children who had unilateral hip dysplasia were chosen for this study. In the period of our investigation, ultrasonography was not yet used routinely, so in some cases the hip was mistakenly diagnosed as dysplastic. The average patient age was 3.2 months, and the average length of treatment was 4.9 months. We found no correlation between the appearance of AVN in the healthy hips at the end of treatment with the Pavlik harness and the age of the child at the start of treatment. On the other hand, there was a strong significant correlation between the appearance of AVN and the length of treatment.

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Résumé Nous avons examiné l’incidence de la nécrose avasculaire de la tête fémorale dans les dysplasies unilatérales de hanches à la fin du traitement utilisant le harnais de Pavlik. L’évaluation de cette nécrose avasculaire a été déterminée à l’aide des radiographies standards. Entre 1974 et 1982, 1064 hanches dysplasiques (869 enfants) ont été traitées par harnais de Plavik au Département de l’Université Semmelweis. Parmi cette population, 674 enfants, présentant une lésion unilatérale de la hanche ont été choisis pour cette étude. Au moment de cette étude l’écho doppler de la hanche n’était pas utilisé en routine, ainsi certaines hanches ont été, à tort, diagnostiquées comme dysplasiques. L’age moyen des patients était de 3,2 mois et la durée moyenne du traitement a été de 4,9 mois. Nous n’avons pas trouvé de corrélation entre l’aspect de la nécrose avasculaire de la hanche à la fin du traitement de l’harnais de Pavlik et de l’age de l’enfant au moment du début du traitement. Par contre, il existe une corrélation significative entre l’existence de la nécrose avasculaire et la durée du traitement.

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An erratum to this article can be found at     

Development of hip dysplasia in a child with perinatal contralateral high above-knee amputation

The development of acetabular dysplasia in the growing child has been postulated to be due to abnormal forces on the acetabular rim, such as when the hip is in an adducted position. In this case report we document the development of acetabular dysplasia, as measured radiographically, in a child with a perinatal contralateral high above-knee amputation.     

Delphian lymph node metastasis predicts occult contralateral carcinoma for unilateral papillary thyroid carcinoma patients with contralateral benign nodules

BackgroundFor unilateral PTC patients with benign nodules in the contralateral lobe evaluated preoperatively, the necessity of total thyroidectomy remains controversial. This study aimed to investigate the predictive factors for occult contralateral carcinoma and whether DLN metastasis could predict it.MethodsA total of 148 patients with unilateral PTC and contralateral benign nodules who were treated with a near-total thyroidectomy or TT at a single institution between August 2018 and April 2020 were enrolled. Clinicopathological features such as age, sex, TgAb or TPOAb level, primary tumor location, nodule number in contralateral lobe, carcinoma number in primary lobe, tumor size, capsular invasion, central lymph node metastasis, DLN metastasis were analyzed to investigate the rate and predictive factors of occult contralateral carcinoma.Results44.6% patients were diagnosed with occult contralateral thyroid carcinoma. Univariate analysis showed that sex (P = 0.008), mulifocality of primary carcinoma (P < 0.001), tumor size (P = 0.033), capsular invasion (P = 0.042), CLN metastasis (P = 0.004), DLN metastasis (P = 0.001) were associated with occult contralateral carcinoma. Multivariate analysis showed that multifocality of primary carcinoma (p = 0.000, OR = 9.729), DLN metastasis (p = 0.042, OR = 4.701), capsular invasion (p = 0.022, OR = 2.909), and male patients (p = 0.006, OR = 3.926) were all independent predictive factors.ConclusionFor unilateral PTC patients with benign nodules in the contralateral lobe evaluated preoperatively, multifocality of primary carcinoma, DLN metastasis, capsular invasion, and male patients are independent predictors of occult contralateral carcinoma. We suggest separate excision and frozen section of DLN intraoperatively, if DLNs were confirmed metastasized, a TT was highly recommended.     

Seasonal variation in children with developmental dysplasia of the hip

Background

It has been postulated that developmental dysplasia of the hip (DDH) is more frequent in infants born in the winter months. It was the purpose of this study to ascertain if there was any seasonal variation in DDH at the author’s institution and compare/contrast our results with those in the literature using rigorous mathematical fitting.

Methods

All children with DDH treated at the author’s institution from 1993 to 2012 were identified. The month of birth was recorded and temporal variation was analyzed using cosinor analysis. Similar data from the literature was analyzed.

Results

There were 424 children (363 girls, 61 boys). An additional 22,936 children were added from the literature for a total of 23,360. Pearson’s Chi-square test demonstrated a non-uniform distribution in the month of birth for both our 424 children as well as the combined literature series in both the Northern and Southern hemispheres. Cosinor analysis of the 424 children demonstrated double peaks in mid-March and mid-October. For the entire 23,360 children, no seasonal variation was observed in 2,205 (9.4 %), a single winter peak in 16,425 (70.3 %), a single summer peak in 1,280 (5.5 %), and double peaks in the spring and autumn in 3,450 (14.8 %).

Conclusions

This study partly supports the hypothesis of tight clothing/cold temperature as one factor in the etiology of DDH with the tighter clothing/swaddling increasing the risk of DDH. However ~20 % of the DDH births demonstrated a non-winter peak. The single summer and double spring/autumn peaks, as well as in those series where no seasonal variation was noted, refutes the cold winter clothing hypothesis. Perhaps these different patterns in seasonal variation represent the heterogeneity of the genetic factors in DDH interacting with external factors (temperature and clothing) and internal factors (metabolic). Further study will be required to understand these different patterns in DDH seasonal variation.

Level of evidence

IV—case series.     

Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia

ObjectiveThe aim of this study was to investigate whether being the parents of children with developmental hip dysplasia (DDH) is a risk factor for asymptomatic dysplasia.MethodsAsymptomatic parents of children who were diagnosed with DDH were assessed for presence of dysplasia by examining their anteroposterior pelvis radiographs at the neutral position. Eighty-six hips of 43 participants were included in the study group and 98 hips of 49 participants were included in the control group. Presence of hip dysplasia over the anteroposterior pelvis radiographs was analyzed for Wiberg's angle, acetabular index of the weight-bearing zone (the Tönnis angle), acetabular depth/width index, femoral head coverage ratio (FHCR) and femoral neck/shaft angle.ResultsThe mean acetabular depth/width ratio was 44.3% in the study group and 53.5% in the control group. And, the mean FHCR was 80% in the study group and 82% in the control group. There was a statistically significant difference between the two groups in terms of mean acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05). In addition, 21 participants in the study group and 2 in the control group had a pathological acetabular depth/width ratio. And, the number of participants with a pathological FHCR was 22 in the study group and 13 in the control group. A statistically significant difference was found between the two groups regarding the number of pathological measurements of acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05).ConclusionHaving a parent with DDH is a definitive risk factor for the development of hip dysplasia in childhood. In addition, being a parent of a child with DDH is a risk factor for asymptomatic dysplasia. These parents should be screened by roentgenogram.Level of EvidenceLevel III, Diagnostic Study.     

Natural course of the minimally symptomatic nonoperated hip in patients with bilateral hip dysplasia treated with contralateral rotational acetabular osteotomy

Background The purpose of this study was to investigate the natural course of the minimally symptomatic nonoperated hip in patients with preosteoarthritis or early osteoarthritis in bilaterally dysplastic hips. Methods The material consisted of 61 patients with bilaterally dysplastic hips who underwent rotational acetabular osteotomy in their symptomatic hip and nonoperative treatment in their asymptomatic or minimally symptomatic hip. The average follow-up was 10.1 years (range 7.0–15.6 years), and the average age at the time of surgery was 38.2 years (range 20–58 years). All patients were divided into two groups by joint congruity of the nonoperated hip at surgery with rotational acetabular osteotomy. Results On radiographic assessment, 1 of the 35 preosteoarthritis hips had developed early osteoarthritis, and 6 of the 26 early osteoarthritis hips had progressed to advanced osteoarthritis. The Kaplan-Meier survivorship analysis for the whole group of nonoperated hips, with radiographic progression of osteoarthritis as the endpoint, predicted a 10-year survival rate of 83.7% (95% confidence interval 70%–98%). Significant differences were observed in the radiographic stage (pre- and early osteoarthritis group, P = 0.015) and joint congruity (good and fair group, P = 0.005). Conclusions If the contralateral nonoperated hip has good joint congruity, minimal symptoms, and no or little radiographic change in patients with pre- or early osteoarthritis and bilateral acetabular dysplasia, the probability of radiographic progression is low.     

Prevalence of developmental dysplasia of the hip in children with clubfoot

Purpose

The relationship between congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH) remains uncertain. The role of routine hip screening in children with CTEV is debated. A recent study has found a high incidence of DDH in patients with CTEV. The aim of our study was to determine the true prevalence of radiographic hip dysplasia and identify the need for routine hip screening in patients treated for CTEV.

Methods

From a single centre database of 165 children consisting of 260 CTEV, a prospective radiological prevalence study of 101 children was performed over a period of 3 months. A single anterior-posterior pelvic radiograph was performed at a minimum age of 5 months. The DDH was determined by a single senior investigator based on the age-adjusted acetabular index (AI) as described by Tonnis.

Results

There were no dislocations or subluxations. According to the age-adjusted AI, 16 children had ‘light’ dysplasia and one child had ‘severe’ dysplasia. The child with severe dysplasia was known to have DDH and had already undergone treatment. The 16 children with light dysplasia did not require any form of treatment.

Conclusion

Out of one hundred and one children with CTEV, only one had DDH requiring treatment. This is consistent with the majority of the literature supporting the premise that there is no true association between CTEV and DDH. We, therefore, feel that routine hip screening for children with CTEV is not supported by current evidence and cannot be recommended.     

Spontaneous ankylosis of the contralateral hip after unilateral adductor tenotomy in cerebral palsy

This is the case report of a 15-year-old black male with spastic quadriplegia cerebral palsy who developed heterotopic ossification and spontaneous ankylosis of his contralateral nonoperative hip after unilateral adductor tenotomy. To the authors' knowledge, this is the only reported case of such an occurrence. The mechanism and possible risk factors are discussed as well as management of this complication.     

Magnetic resonance arthrography in children with developmental hip dysplasia

Conventional and gadolinium enhanced magnetic resonance arthrograms were done on 14 hips in 10 children ages 7 to 24 months. The contralateral normal hips in those with unilateral disease were studied with unenhanced magnetic resonance imaging for comparison. By conventional arthrography, there were no well visualized structures. Visualized structures seen as filling defects were the labrum, ligamentum teres, and transverse acetabular ligament. By magnetic resonance arthrography, well visualized structures were the labrum, ligamentum teres, transverse acetabular ligament, and pulvinar. By unenhanced magnetic resonance imaging, well visualized structures were the labrum, ligamentum teres, and transverse acetabular ligament. The difference in visualization by magnetic resonance arthrography versus conventional arthrography was statistically significant with respect to all five structures: labrum, ligamentum teres, transverse acetabular ligament, pulvinar, and psoas tendon. The difference in visualization by magnetic resonance arthrography versus unenhanced magnetic resonance imaging was statistically significant with respect to the labrum and pulvinar. Magnetic resonance arthrography is indicated for assessing complete concentric reduction when it does not appear to be achieved by conventional arthrography, for confirming closed reduction immediately after manipulation, and potentially for preoperative planning for an open reduction.     

Sciatic nerve course in adult patients with unilateral developmental dysplasia of the hip: implications for hip surgery

Background

Sciatic nerve injury is a disastrous adverse complication of surgery and can cause debilitating pain, functional impairment and poor quality of life. Patients with developmental dysplasia of the hip (DDH) have a high incidence of sciatic nerve injury after total hip arthroplasty (THA). A better understanding of the course of the sciatic nerve in patients with DDH may help minimise the risk of sciatic nerve injury after THA.

Methods

A total of 35 adult patients with unilateral DDH were enrolled in this retrospective study. We reviewed the patients’ computed tomography (CT) scans, which included the area from the iliac crest to below the lesser trochanter. The distance between the sciatic nerve and regional anatomic landmarks in four different sections on CT scans was measured to identify the course of the sciatic nerve.

Results

The distance from the sciatic nerve to the spine’s midline was shorter on the affected side than on the healthy side (p < 0.05); the same difference was also detected in the distance to the ilium/ischium outside the true pelvis (p < 0.05). The distance to the greater trochanter was longer on the affected side (p < 0.05). However, the two sides showed no significant difference in the distance from the sciatic nerve to the lesser trochanter (p > 0.05).

Conclusions

For patients with unilateral DDH, the sciatic nerve was located near the ischium and ilium but relatively far from the femur of the affected hip joint, compared to its location on the healthy side. These findings reveal that sciatic nerve becomes shorter in the affected low-limb and is relatively unlikely to be directly injuried using the posterolateral approach in patients with unilateral DDH.     

Imaging methods used for children with hip dysplasia

Ultrasound has been used to examine the infant hip for more than 20 years. The Thornbury model for assessing the clinical efficacy of a diagnostic imaging procedure has been used in this review to determine what has been achieved and what remains to be learned. To accomplish the effective and efficient treatment of patients with developmental dysplasia of the hip, orthopaedic, radiologic, and pediatric organizations must collaborate in writing and revising standards of care and guidelines for treatment as our knowledge base grows.     

Bilateral incidence and severity of acetabular dysplasia of the hip

BACKGROUND: Most Japanese patients have secondary osteoarthritis, mainly due to developmental dislocation of the hip (DDH) or acetabular dysplasia (AD). However, the precise pathomechanism of AD remains unknown. The purpose of this study was to investigate the frequency of bilateral AD and determine the correlation of the severity of AD between the right and left hips. METHODS: A total of 206 patients with prearthritis or early-stage osteoarthritis caused by AD were examined radiographically, and their history of treatment for DDH during infancy was reviewed. There were 187 women and 19 men included in the study, and the mean age at examination was 37.6 years (range 20-49 years). RESULTS: A total of 174 patients (84%) had bilateral AD. In all, 72 (35%) of the 206 patients had a history of treatment for DDH (DDH group), and the remaining 134 (65%) had no history of DDH (non-DDH group). Bilateral AD was observed in 55 patients (76%) in the DDH group and 119 patients (89%) in the non-DDH group; the difference was significant. The center-edge angle, acetabular head index, acetabular angle, and acetabular roof angle showed positive correlations between the right and left sides in the non-DDH group. There was no correlation of the acetabular roof angle between the two sides in the DDH group. CONCLUSIONS: A high rate of bilateral AD and a positive correlation of the severity of AD between the right and left hips were observed, especially in patients with no history of DDH. Our data suggest that in many patients AD occurred as a result of bone malformation involving bilateral hip joints. More research from a genetic standpoint is needed to elucidate the pathomechanism of this disease.     

Good long-term outcome of the untreated contralateral hip in unilateral slipped capital femoral epiphysis

Purpose

There is no consensus regarding prophylactic fixation of the contralateral hip in slipped capital femoral epiphysis (SCFE). In order to further study this question, we evaluated the long-term natural history of untreated contralateral hips.

Methods

Forty patients treated for unilateral SCFE without evidence of subsequent contralateral slip during adolescence were reviewed with a mean follow-up of 36 years (range 21–50 years). The deformity after SCFE may demonstrate radiographic signs of cam-type femoroacetabular impingement. We, therefore, measured α-angles in the contralateral hips on anteroposterior (AP) and frog-leg lateral radiographs. The angles were compared with those of a control group of adults without SCFE. Five years after the radiographic examination, with a mean follow-up of 41 years, all patients were evaluated by telephone interview. As range of motion and deformity could not be examined, a modified Harris hip score (HHS) (maximum score of 91 points) was used. A modified HHS <76 points and/or radiographic osteoarthritis (OA) was classified as a poor long-term outcome.

Results

The mean value of the AP α-angle was significantly higher in the contralateral hips in SCFE patients than in the control group (55° vs. 46°), while the mean value of the lateral α-angle was not. Abnormally high values for one or both α-angles were found in 16 contralateral hips (40 %), of which five patients had abnormal values for both α-angles and were considered to have had an asymptomatic contralateral slip. Five patients (13 %) had a poor outcome in the contralateral hip, of which three patients (8 %) had OA. There was a significant association between hips with both α-angles that were abnormal and poor outcome.

Conclusions

Since the natural history showed good long-term radiographic and clinical outcome in 35 of 40 patients and only three had OA, we conclude that routine prophylactic fixation of the contralateral hip is not indicated.     

腹腔镜下小儿腹股沟隐匿性疝的临床特点分析

目的:分析小儿单侧腹股沟斜疝合并对侧隐匿性疝的临床特点。方法:回顾分析2007年12月至2015年5月为4 232例患儿行腹腔镜疝囊高位结扎术的临床资料。结果:4 232例患儿中男3 776例,女456例,3 919例行单侧腹股沟斜疝手术,1 868例(47.7%)合并对侧隐匿性疝,其中左侧斜疝合并对侧隐匿性疝的比例为50.7%,右侧斜疝合并对侧隐匿性疝的比例为45.9%,差异有统计学意义(χ~2=8.4951,P=0.0036)。结论:对侧隐匿性疝发生率与性别、年龄无关。儿童单侧腹股沟斜疝合并对侧隐匿性疝比例较高,且不随年龄增长而降低。腹腔镜手术可同时探查双侧腹股沟,利于预防性处理对侧隐匿性疝,具有一定的临床优势。     

Prevention of hip dysplasia in children and adults

Klisic and Pajic summarized the history of early diagnosis and treatment of hip dysplasia when they wrote, Devising the preventive approach to developmental dysplasia of the hip (DDH) required much time.... Despite the 2400-year-old suggestion made by Hippocrates that children's hip dislocations are curable if treatment is started very early, the preventive approach was proposed by Roser only in 1879 [who] described early diagnosis in newborns and performed reduction by abduction... He also advocated early treatment by fixing babies' hips in abduction. However, surgeons did not readily accept these proposals, despite the good results shown by Froelich in 1906 and Le Damany in 1911. In 1927, Putti succeeded in interesting some orthopedic surgeons in the procedure by showing the results of early treatment. But the practical problem remained: ie, how to detect the DDH in patients at an early age. The turning point came in 1935 when pediatrician Ortolani introduced early detection of DDH by “early clinical search” shortly after a child's birth, instructing obstetricians, pediatricians, and midwives to perform the search. Rediscovering the diagnostic “segno della scatto,” ie, reducible displacement, he popularized the prophylactic approach to DDH by early detection and treatment. Fifteen years later, another pediatrician, Palmen, organized systematic screening in nurseries by pediatricians. Since Klisic and Pajic wrote this in 1993, the use of ultrasound, albeit still controversial in some ways, has influenced the treatment and prevention of DDH. Klisic's attempts to universally prevent the disease may still be able to be incorporated into further efforts at disease prevention through education and the systematic trials of hip abduction pillows or braces similar to his wide-diaper diapering technique. The goal of prevention is to eradicate a disease so that it does not present to the physician. For DDH, this goal may be tenable.     

Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip

Four hundred and eight siblings, parents, and grandparents of seventy-eight children from the New England area who had congenital dysplasia of the hip were evaluated, by clinical examination and by measurements of the acetabulum on pelvic radiographs, for the signs and sequelae of congenital dysplasia of the hip. Six siblings and four mothers (representing seven of seventy-eight families) had been diagnosed with congenital dysplasia of the hip during childhood. The other ninety-one siblings were asymptomatic and had no radiographic evidence of dysplasia of the hip. In the adults in these families, acetabular coverage (as measured by the center-edge angle of Wiberg) was no different from that in the control subjects. There was no difference between the study group and the control subjects in the prevalence of osteoarthrosis of the hip or of osteoarthrosis that could be considered secondary to congenital dysplasia of the hip. The results indicate that children born to families that have a history of congenital dysplasia of the hip have a greater prevalence of this problem compared with the general population, but also that examinations of the hip in newborns are effective in detecting congenital dysplasia of the hip in such families. The greater prevalence of congenital disease of the hip among the siblings and mothers in these families is consistent with a multifactorial inheritance. The fact that acetabular development in the family members who did not have congenital dysplasia of the hip was no different from that in the control subjects suggests that acetabular dysplasia, rather than being an inherited abnormality, is secondary to subluxation or dislocation.