Watchful waiting for the undisplaced hip dysplasia when undergoing contralateral hip reconstruction.

PURPOSE: Patients undergoing surgical reduction of the dislocated hip secondary to developmental dysplasia may have a contralateral undisplaced dysplastic hip. This study aimed to compare the observation of the contralateral undisplaced dysplastic hip with the treatment by acetabuloplasty in terms of persistent dysplasia to determine the need for bilateral surgery. METHODS: Acetabular dysplasia was defined by an acetabular index (AI) of more than 30 degrees plus a center edge angle (CEA) of less than 20 degrees. A surgical database was queried retrospectively for a cohort between 2008 and 2016. Inclusion criteria were aged between 1 and 6 years, unilateral developmental dysplasia (international hip dysplasia institute grade 1) with contralateral dislocation, no previous treatment and a minimum follow-up of 1 year. RESULTS: Fifty-seven patients were included, 40 in the observation group and 17 in the acetabuloplasty group. The mean age (interquartile range) was 20 (17-23) months, and the mean follow-up was 42 (22-62) months. The baseline values were similar for both groups. At the final follow-up, no hip had dysplasia, as specified a priori in either group, but the final AI and CEA were corrected more in the acetabuloplasty group (p < 0.001). Based on the adjusted analysis, both acetabuloplasty and follow-up without treatment were associated with improved acetabular coverage. CONCLUSION: Watchful expectancy of undisplaced hip dysplasia presenting in patients undergoing contralateral hip reconstruction during years of acetabular growth is safe as the risk of persistent dysplasia and additional surgery is low. LEVEL OF EVIDENCE: III.

Correction of the acetabular index is more crucial than the type of acetabuloplasty in developmental dysplasia.

BACKGROUND: Acetabular remodeling may not be predictable after open reduction in developmental dysplasia of the hip (DDH) in older children. Several acetabuloplasties have been developed, and all are aimed at correcting the dysplastic acetabulum. The goal of this study is to evaluate if the type of pelvic acetabuloplasty and the corrected (postoperative) acetabular index (AI) affect early follow-up femoral head coverage. METHODS: A retrospective review of single-surgeon consecutive acetabuloplasties (Dega or Pemberton) from December 2012 to December 2015 was conducted. The inclusion criteria were a diagnosis of DDH, undergoing simultaneous primary open reduction, and follow-up of at least 18 months. Univariable analysis was based on the type of acetabuloplasty. The correlation between AI and final center edge angle (CEA) was tested. Multiple regression was performed. RESULTS: Of the total 58 hips in 39 patients included, 41 underwent Dega acetabuloplasty, and 17 had Pemberton acetabuloplasty. The median follow-up was 40.50 months (interquartile range 27.25-57). Pemberton acetabuloplasty produced a lower corrected AI, but the difference was not significant in follow-up measurements. Corrected AI was significantly correlated with final CEA (R = - 0.31, P = 0.018). In the multiple regression, only corrected AI was independently associated with final CEA (B = - 0.29, SE = 0.15, P = 0.06), whereas the type of acetabuloplasty, age, and preoperative severity of the dislocation were not. CONCLUSION: The correction obtained during acetabuloplasty affects early follow-up femoral head coverage. Ensuring proper sizing and placement of the grafted bone is probably more important than the type of acetabuloplasty chosen. LEVEL OF EVIDENCE: Level III.

Treatment of developmental dysplasia of the hip (DDH) between the age of 18 and 24 months.

BACKGROUND: Treatment of developmental dysplasia of the hip between the age of 6 and 18 months starts with closed reduction (CR). If CR is not attainable, open reduction is performed. Open reduction and pelvic osteotomy (ORPO) is usually done directly after the age of two. The aim of this study is to evaluate CR compared to ORPO with respect to early radiographic outcome in patients aged 18 to 24 months at reduction. METHODS: A single-surgeon cohort was reviewed. Inclusion criteria were age between 18 and 24 months, no prior treatment and minimal follow-up of 2 years. Hips that were not displaced or had a nonidiopathic cause were excluded. Residual dysplasia was defined as a center edge angle (CEA) of less than 15° or CEA less than 20° with an acetabular index (AI) of more than 30°. Multiple regression was used, the outcome was follow-up CEA, and the explanatory variables were age, sex, type of surgery, international hip dysplasia grade and preoperative AI. Values of preoperative AI in the CR group and follow-up CEA were plotted. RESULTS: Eighty-two hips in fifty patients were included. Residual dysplasia was identified in 16 hips (20%), 12 (27%) after CR, and 4 (11%) after ORPO (p = 0.10). Recurrence and avascular necrosis rates were not statistically different. Preoperative AI and type of surgery independently affected CEA. CR patients with a preoperative AI of more the 40° had a 50% (10/20) risk of residual dysplasia. CONCLUSION: CR is an important option to consider in selected patients between the age of 18 and 24 months and the selection should not be based on intraoperative assessment only, but also on preoperative measurement of AI. LEVEL OF EVIDENCE: Level III.

Single-leg spica provides adequate stability after open reduction in developmental dysplasia of the hip.

INTRODUCTION: The late detection of developmental dysplasia of the hip (DDH) will remain a major concern in some parts of the world until effective screening programs become available. With late diagnosis comes the need for open surgical reduction. Surgery is invariably followed by a period of immobilisation in a spica cast to prevent postoperative displacement. The goal of this study is to evaluate the effect of double-leg spica as compared to single-leg spica, on the risk of displacement after unilateral open reduction of the hip. MATERIALS AND METHODS: This was a retrospective review of DDH patients from 2012 to 2016 and younger than 4 years of age, who had unilateral anterior open reduction. Patients who had one of the following were excluded: neuromuscular diagnosis, the addition of K-wire, and simultaneous bilateral open reductions. Demographic data were collected along with related clinical and radiographic variables. A total of 128 patients (162 hips) met the inclusion criteria; 93 were in the double-leg spica group, and 69 were in the single-leg spica group. RESULTS: The mean age was 25.4 ± 8.1 months and the mean follow-up was 18.6 ± 11.6 months. Baseline characteristics were balanced between the two groups. There were three events of redislocation in the double-leg spica group as compared to one redislocation in the single-leg spica group. The difference did not reach statistical significance (p = 0.637, risk ratio 1.317, CI 0.736-2.356). The difference in subsequent disruption of Shenton's line and hip migration of more than 29% was (p = 0.395, risk ratio 1.411, CI 0.892-2.234) and (p = 0.087, risk ratio 0.67, CI 0.417-1.078), respectively. Three patients had a greenstick distal femur fracture after double-leg spica and one after single-leg spica. CONCLUSION: These data suggest that including the contralateral hip in the cast after open reduction is not essential as it does not seem to improve stability.

Principles of rotationplasty.

Rotationplasty is a reconstructive, limb-sparing option for management of lower extremity bone deficiency. This technique involves an intercalary resection, followed by 180° rotation of the distal limb to allow the ankle to function as a knee joint when it is fitted with a modified below-knee prosthesis. Gait analysis and functional outcome studies have reported favorable results with rotationplasty compared with those of above-knee amputation. Moreover, patient satisfaction with rotationplasty is higher than with other limb salvage procedures. The primary drawback of this procedure is patient acceptance of the limb's appearance.

Casting in infantile idiopathic scoliosis as a temporising measure: A systematic review and meta-analysis.

OBJECTIVE: Treatment of infantile idiopathic scoliosis remains vague. Because implantation of temporary telescopic devices carries a high risk of complications, interest in the older technique of serial casting is growing as a temporising measure before invasive procedures. The goal of this review was to meta-analyse studies examining the effect and safety of casting in infantile idiopathic scoliosis. METHODS: Two reviewers independently searched for relevant studies in PubMed and Embase databases through November 2018. The studies included were limited to infantile idiopathic scoliosis patients who underwent casting, had a mean Cobb angle of 20 or more and written in English. The methodological quality of the chosen studies was assessed. The primary outcome was the difference in Cobb angle means from before and after casting. The secondary outcome was adverse events of casting. Heterogeneity was explored and a funnel plot was drawn. RESULTS: Of the 366 studies screened, 10 studies were included in the meta-analysis (243 subjects) and all were non-randomised. The casting was consistently associated with a reduction in the mean Cobb angle. The pooled mean difference was 24.85° (95% confidence interval: 19.25 to 30.46, p < 0.001). A number of reversible adverse events were reported, most commonly skin irritation and transient pulmonary symptoms. Heterogeneity between studies was high. In the meta-regression analysis, the starting Cobb angle did not influence Cobb angle change, but there was an inverse correlation between the mean difference in Cobb angle and mean age. CONCLUSION: Casting seems to be effective and safe in decreasing Cobb angle even in high curve magnitudes. In older patients, casting showed less Cobb angle correction.

Development of a prediction model for allogenic blood transfusion in children undergoing surgery for developmental dysplasia of the hip.

BACKGROUND: Blood transfusion is a common practice, but it is not without cost and risk. A model that predicts the risk of blood transfusion could guide informed preoperative blood ordering and use of blood loss preventive measures. OBJECTIVE: This study aimed to develop a prediction model of blood transfusion in children with developmental dysplasia of the hip (DDH) undergoing surgery. METHODS: A retrospective cohort of DDH patients from 2008 to 2017. The included patients were between 1 to 9 years old, underwent anterior open reduction and/or acetabular osteotomy with and without femoral shortening. The unit of analysis was undergoing such an operation. The outcome was allogenic blood transfusion. Potential predictors were age, sex, body mass index (BMI), international hip dysplasia institute grade, type of surgery, intervention bilaterally during the same operative session, primary versus reoperation surgery, the addition of regional anaesthesia, preoperative haemoglobin and hematocrit. RESULTS: A total of 524 patients who met the inclusion criteria underwent 721 operative sessions. The median age (interquartile range) at operation was 23 (20-33) months. The blood transfusion rate was 11.8%. Independent predictors were lower preoperative haemoglobin, reduced BMI, simultaneous bilateral surgery and the extent of surgical treatment. CONCLUSIONS: The developed prognostic model allows prediction for blood transfusion in DDH patients undergoing surgery.

Prediction of the requirement of open reduction for developmental dysplasia of the hip.

Objective Closed reduction (CR) is a noninvasive treatment for developmental dysplasia of the hip (DDH), and this treatment is confirmed intraoperatively. This study aimed to develop a preoperative estimation model of the probability of requiring open reduction (OR) for DDH. Methods The study design was cross-sectional by screening all patients younger than 2 years who had attempted CR between October 2012 and July 2016 by a single surgeon. Potential diagnostic determinants were sex, age, side, bilaterality, International Hip Dysplasia Institute (IHDI) grade, and acetabular index (AI). An intraoperative arthrogram was the reference standard. A logistic regression equation was built from a reduced model. Bootstrapping was performed for internal validity. Results A total of 164 hips in 104 patients who met the inclusion criteria were analysed. The prevalence of CR was 72.2%. Independent factors for OR were older age, higher IHDI grade, and lower AI. The probability of OR = 1/[1 + exp - (-2.753 + 0.112 × age (months) + 1.965 × IHDI grade III (0 or 1) + 3.515 × IHDI grade IV (0 or 1) - 0.058 × AI (degrees)]. The area under the curve was 0.79. Conclusion This equation is an objective tool that can be used to estimate the requirement for OR.

Predictors of femoral shortening for pediatric developmental hip dysplasia surgery: an observational study in 435 patients.

BACKGROUND: Open reduction of the congenitally dislocated hip may not be possible without femoral shortening. The goal of this study is to develop a prognostic prediction model for the need of femoral shortening in children undergoing anterior open reduction for the treatment of developmental dysplasia of the hip (DDH). The secondary objective was to determine if femoral shortening influences the risk of adverse events. METHODS: A cohort from February 1, 2008 thru July 31, 2017 was studied retrospectively at a single centre. Patients between the age of 1 and 8 years, having international hip dysplasia institute (IHDI) grade 3 and 4, undergoing primary anterior open reduction for DDH were included in the study. The outcome of interest was femoral shortening, and the potential predictors were age, sex, side, body mass index and IHDI grade. Logistic regression was employed to identify the independent predictors and was followed by internal validation using bootstrapping. In addition, complications encountered were recorded and analysed. RESULTS: A total of 548 hips in 435 patients were included. Median follow-up (interquartile range) was 27 (13-48.25) months. Femoral shortening was needed on 119 hips. Factors that increased the probability of femoral shortening in the reduced model were age, male gender, and IHDI grade 4. Adjusting for IHDI and the addition of pelvic osteotomy, the probability of recurrence was lower when femoral shortening is included and higher with increased patient age. There were more deep infections when femoral shortening is added. Femoral shortening did not affect the occurrence of avascular necrosis. CONCLUSION: In addition to age and superior displacement of the femoral head, male gender is considered to be an independent predictor for needing femoral shortening. Studying the probability of femoral shortening in DDH surgery may optimize family education, operating room preparation, and operative time utilization. Moreover, there appears to be less risk of recurrence when femoral shortening is performed at the cost of higher probability of deep surgical site infection.

Acute presentation of Sinding-Larsen-Johansson disease simulating patella sleeve fracture: A case report.

OBJECTIVES: Diagnosis of Sinding-Larsen-Johansson disease may not be an easy task. Several sport-related conditions affect the distal pole of the patella in the adolescent, and treatment varies considerably. The article describes a patient that had radiographic features of Sinding-Larsen-Johansson disease associated with an atypical acute presentation. METHODS: Case report and literature review. RESULTS: A 10-year-old boy presented with a sudden pain after a noncontact soccer injury. He had tenderness and swelling over the patella. Radiographs showed minimally displaced distal patellar ossicle. Magnetic resonance imaging excluded sleeve cartilaginous injury and documented Sinding-Larsen-Johansson disease. The knee was immobilized briefly. There was complete healing of the injury in 4-week follow-up radiographs. CONCLUSION: Emergency physicians, radiologists, and orthopedic surgeons should be aware of the acute presentation of Sinding-Larsen-Johansson disease after knee injuries.

Treatment of chronic bilateral facet dislocation in a 6-year-old: A case report.

OBJECTIVES: Spine injuries seldom affect the subaxial spine in children less than 9 years of age. We describe the management of a chronic paediatric bilateral facet dislocation. METHODS: Case report and literature review. A 6-year-old boy presented 10 weeks after a motor vehicle collision with bilateral C4-C5 malunited facet dislocation. He had an incomplete spinal cord injury; right brown sequard hemiplegia, Frankel grade D. RESULTS: Surgical management was through posterior-anterior-posterior approach without preoperative skull traction. Two years postoperatively, the child was asymptomatic, ambulating and functioning well. The injury had healed in radiographs. CONCLUSION: A combined approach for chronic bilateral facet dislocation applies to the paediatric age group to realign the spine.

Combined pelvic and femoral reconstruction in children with cerebral palsy.

Objective The primary aim of this study was to determine the effect of age, femoral head migration, and ambulatory status on radiographic outcomes after combined pelvic and femoral reconstruction in children with cerebral palsy. The secondary aim was to evaluate the fate of the opposite hip after unilateral reconstruction. Methods A retrospective cohort study design of consecutive patients from 1995-2009 was used. The records were screened for patients who underwent varus derotational osteotomy and modified Dega osteotomy. Results Eighty-five hips in 71 patients were included. The mean age was 8.4 ± 3.2 years and the mean follow-up was 6.6 ± 3.1 years. The final measures were a mean migration index of 20% ± 15.58%, centre edge angle of 28.45° ± 15.98°, and Sharp's angle of 40.75° ± 8.5°. Those values were not correlated with age and the initial migration index. Nonambulatory status did not negatively affect hip stability. Final measurements of the contralateral hips were similar to the reconstructed hips, and the cumulative incidence for later reconstruction was 5.67%. Conclusions Regardless of age, preoperative displacement, and ambulation, the combined procedure provides durable radiographic improvement. In unilateral cases, there is a low risk of later deterioration of the opposite side.

The Added Value of Postoperative Axial Imaging in Developmental Dysplasia of the Hip.

BACKGROUND: Redislocation is a dreaded complication after reduction of developmental dysplasia of the hip (DDH) in young children. While early detection facilitates urgent reoperation, delayed revisions are more complicated. Despite the weak evidence, an axial postoperative imaging tool is recommended. This study's goal is to compare the effectiveness of conventional pelvic radiography alone and axial imaging. METHODS: Data were collected retrospectively between 2012 and 2016. One study group comprised consecutive patients who had operative reduction followed by routine low-dose computed tomography (CT). Hips that had anteroposterior pelvic radiographs as the only confirmatory tool were used as a reference group. RESULTS: We identified 241 patients (339 hips). The mean age and follow up were 19.6 months ± 9.3, and 15.5 months ± 11.1, respectively. There were 147 hips in the radiography group and 192 in the CT group. Radiography detected only three out of nine redislocations during the same admission; in contrast, 2/2 redislocations in the routine CT group were addressed before hospital discharge (p<0.01). There was no significant delay in hospital discharge when CT was used (p= 0.28). CONCLUSION: Conventional radiography is not as effective as axial imaging in preventing late detection of redislocation. LEVEL OF EVIDENCE: level III, Diagnostic Study.

Salvage of mangled upper extremity using the Masquelet technique in a child: A case report.

AIM: To report our experience with the Masquelet concept in a pediatric upper extremity following an open injury to the elbow. METHODS: A case report and literature review. RESULTS: An 11-year-old boy was transferred to our institution after a motor vehicle collision. There was a primary loss of the ulnohumeral articulation and the surrounding soft tissues as well as the ulnar nerve. Reconstruction used the Masquelet-induced membrane technique and a soft tissue flap. At the 30-month follow-up, the extremity was pain free and functional. CONCLUSION: This case highlights the value of the Masquelet technique in pediatric extremity injuries, where there is a loss of a major articular segment, as well as significant soft tissue compromise.