Outcomes following medial open reduction in infants aged ≤6 months with developmental dysplasia of the hip.

Aim: To evaluate mid-long term radiological outcomes following early medial approach open reduction (MAOR) performed for developmental dysplasia of the hip (DDH) in infants aged ≤6 months old at time of surgery, specifically incidence of clinically significant avascular necrosis (AVN), Severin outcomes and rates of further surgery. Methods: This is a single centre retrospective study of patients treated from 1999 to 2017. Only infants aged ≤6 months old at time of MAOR, and aged at least 6 years old at latest follow-up were included (minimum 5.5 years follow-up). Data was collected from electronic healthcare records and serial radiographs reviewed to assess outcomes. AVN was classified according to Kalamchi and MacEwen, with types 2-4 considered clinically significant. Severin classes I (excellent) and II (good) were considered satisfactory outcomes, and classes III + considered unsatisfactory. Results: MAOR was performed on 48 hips in 44 patients. Mean age at time of surgery was 4 months (SD 1.4, range 2-6), with mean follow-up of 9.8 years (SD 2.7, range 6.2-16.2). Clinically significant AVN developed in 9/48 hips (19 %), all of which were type 2. Only 1/48 hips (2 %) required a subsequent pelvic osteotomy due to residual dysplasia with subluxation at 2 years post MAOR. At final follow-up, 81 % of patients had excellent or good radiological outcomes (Severin I/II). No statistically significant predictors for developing AVN, including age and presence of ossific nucleus, were identified. Conclusion: Early MAOR in infants aged ≤6 months was associated with a very low rate of significant residual dysplasia requiring further surgery, yet was not associated with unacceptable rates or severe forms of AVN. We therefore recommend MAOR is performed early to optimise acetabular remodelling potential and minimise the need for concurrent or subsequent bony procedures.

Adverse Outcomes in Infantile Bilateral Developmental Dysplasia of the Hip.

BACKGROUND: It is believed that bilateral developmental dysplasia of the hip (DDH) has poorer outcomes with higher rates of avascular necrosis (AVN) and reintervention, compared with unilateral DDH. However, there is limited evidence in the literature, with few studies looking specifically at bilateral cases. METHODS: A retrospective review of 36 patients (72 hips) with >4 years of follow-up. Patient population included surgically treated DDH including late presentations and failures of conservative treatment. The dislocated hips underwent either simultaneous closed or 1 open and 1 closed, or sequential open reduction. AVN and secondary procedures were used as endpoints for analysis as well as clinical and radiologic outcomes. RESULTS: At the last follow-up, 33% of hips had radiologic signs of AVN. Those hips that had no ossific nucleus (ON) at the time of surgery had an odds ratio of developing AVN of 3.05 and a statistically significant association between the 2 variables, whereas open/closed or simultaneous/sequential reduction did not increase the risk for AVN. In addition, 45.8% of those hips required further surgery. The estimated odds ratio of needing additional surgery after simultaneous reduction was 4.04. Clinically, 79.2% of the hips were graded as McKay I, whereas radiologically only 38.8% were Severin I. CONCLUSIONS: The AVN rate in bilateral DDH treated surgically is greater than the rate noted in unilateral cases from the same institution undergoing identical protocols. There was no difference in AVN rates between simultaneous and sequential or between the first and second hip to be sequentially reduced. Presence of ON decreases the risk for AVN, suggesting that in bilateral cases, awaiting the appearance of the ON is an important tool to reduce the incidence of AVN. LEVEL OF EVIDENCE: IV.

Shelf acetabuloplasty for containment in the early stages of Legg-Calve-Perthes disease.

BACKGROUND: To evaluate the effectiveness of shelf acetabuloplasty in the containment of extruded hips without hinge abduction in early stages of Legg-Calve-Perthes disease, we present a retrospective series of 44 patients (45 hips) treated between August 1999 and February 2010, which included 34 boys and 10 girls with a mean age at diagnosis of 7.4 years (range, 3.9 to 15.3). METHODS: All patients presented with sclerosis or early fragmentation stages. The average time from diagnosis to surgery was 2.1 months (range, 0 to 8.2) and the mean time to heal was 40.4 months (range, 20 to 82.2). The Reimer migration and the deformity indices were measured on initial, preoperative, postoperative, and healed x-rays. The average deformity index at 3 of those 4 timepoints was significantly related to their final Stulberg classification. CE angles increased and Sharp angles decreased significantly as a result of treatment. RESULTS: At the healed stage and consistent with other published series, 84.4% of patients were Stulberg III or less, denying any pain, and with full range of movement, whereas 15.6% were classified as Stulberg IV. CONCLUSIONS: We defend that shelf acetabuloplasty should be performed early in the disease and, uniquely, we propose that the indication for treatment should be guided by the deformity and the Reimer migration indices. LEVEL OF EVIDENCE: IV.

Incomplete periacetabular acetabuloplasty.

BACKGROUND: Residual acetabular dysplasia is one of the most common complications after treatment for developmental dysplasia of the hip. The acetabular growth response after reduction of a dislocated hip varies. The options are to wait and add a redirectional osteotomy as a secondary procedure at an older age, or to perform a primary acetabuloplasty at the time of the open reduction to stimulate acetabular development. We present the early results of such a procedure-open reduction and an incomplete periacetabular acetabuloplasty-as a one-stop procedure for developmental dysplasia of the hip. PATIENTS AND METHODS: We retrospectively reviewed the results obtained with 55 hips (in 48 patients, 43 of them girls) treated between September 2004 and February 2011. This cohort included late presentations and failures of nonoperative treatment and excluded unsuccessful previous surgical treatment (including closed reductions), neuromuscular disease, and other teratological conditions. Patients were treated once the ossific nucleus was present or when they reached one year of age. 31 cases were late presentations while 17 represented failures of nonoperative treatment. The mean age of the patients at surgery was 1.3 (0.6-2.6) years. The mean follow-up period was 4 (2-8) years. According to the IHDI classification, 1 was grade I, 9 were grade II, 13 were grade III, and 32 were grade IV. Results The mean acetabular index fell from 38 (23-49) preoperatively to 21 (10-27) at the last follow-up. There were no infections, nerve palsies, or graft extrusions. None of the cases required secondary surgery for residual acetabular dysplasia. 8 patients developed avascular necrosis (AVN) of grade II or more. The incidence of AVN was significantly associated with previous, failed nonoperative treatment. 1 patient developed coxa magna requiring shelf arthroplasty 4 years after the index procedure and 1 patient with lateral growth arrest required medial screw epiphysiodesis. INTERPRETATION: This incomplete periacetabular acetabuloplasty is a reliable adjunct to open reductions, and it is followed by a rapid acetabular growth response that avoids secondary pelvic procedures. It is a one-stop surgery with predictable outcome that can be performed in 0.5- to 2.5-year-old children.

Cryoprotectant permeation through human articular cartilage.

OBJECTIVE: The cryopreservation of intact articular cartilage is constrained by minimal chondrocyte survival. It was the aim of the present study to gain an insight into the permeation kinetics of cryoprotectants through cartilage. This knowledge is essential for achieving adequate tissue permeation prior to cooling. DESIGN: The diffusion coefficients and penetration rates through human articular cartilage of dimethyl sulfoxide (Me(2)SO) and glycerol at different temperatures (4 degrees C, 17 degrees C, 27 degrees C and 37 degrees C) and at two concentrations [10% (v/v) and absolute state] were measured using diffusion nuclear magnetic imaging. Deuterated water (D(2)O) was used as a control substance. RESULTS: Glycerol penetrated faster than Me(2)SO at all temperatures and at rates that were comparable to those for D(2)O. The penetration rate of each agent increased with increasing temperature. The diffusion coefficients for glycerol and Me(2)SO increased with increasing temperature and decreased at the higher concentration, but the differences between each agent were not significant. CONCLUSIONS: The classical cryopreservation protocols expose cartilage samples to Me(2)SO at a too low temperature and/or for an insufficient time period for optimal cell survival. When considering the penetration rate, glycerol appears to be a more efficient cryoprotective agent than Me(2)SO. The present study demonstrates the power of nuclear magnetic resonance technology to elucidate key physiological factors in cryobiology.

Longitudinal growth after nonphyseal forearm fractures.

The overgrowth phenomenon after fracture has been considered rare in the upper extremity. This study analyzes 119 patients with forearm fractures treated conservatively. All patients had scanograms of both forearms 5 years later. A difference in length more than 2 mm was considered a discrepancy. Positive values of discrepancy were called overgrowth. A radial length discrepancy was observed in 80 patients (67.2%) and overgrowth in 38 (26.8%); ulnar values were 65 (54.6%) and 29 (24.3%), respectively. Radial overgrowth and ulnar overgrowth were related to the location of the radial fracture and handedness but not to the type of fracture, age or sex of the patient, or the presence or absence of an associated ulnar fracture. Discrepancy did not show a significant relationship to any of these variables. Surprisingly, fractures in the proximal and middle thirds often presented with overgrowth, whereas those closer to the distal physis did not.

Primary osteosarcoma in adults older than 40 years.

The aim of the current study was to determine the prognostic factors of primary osteosarcoma in adults. This is a review of 47 patients older than 40 years (27 men and 20 women) who were treated between 1977 and 1998 at the authors' institution. Tumors involved the lower limbs in 26 patients and the axial skeleton in 18 patients (38.3%). Eight patients (17%) had synchronous pulmonary metastasis and seven had a pathologic fracture before the definitive surgery. At review, 33 patients had died and 13 were alive. Twenty-one patients (44.7%) did not receive any form of systemic treatment. Tumors were treated surgically in 42 patients (89%). Local recurrence was documented in seven patients (17%). Metastasis after diagnosis appeared in 29 patients (61.7%). The 5-year disease-free survival and overall survival rates were 32.54% and 41.64%, respectively. Adult patients (> 19 years) with primary osteosarcoma had a poor clinical outcome. Metastatic disease at presentation or later, a pathologic fracture, large tumor volumes, and inadequate margins at the time of surgery were associated with significantly lower survival. The high number of adults presenting with advanced stage lesions and more tumors in the axial location might explain the high rate of recurrences. Aggressive multiagent regimens are needed to improve survival.