Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure.

OBJECTIVE: The Pavlik harness (PH) has been widely used as the standard treatment for infants with developmental dysplasia of the hip (DDH). When the initial application of the PH fails, alternative treatments, such as closed reduction, open reduction, and reapplication of the PH will be considered. Compared with other treatments, reapplication of the PH offers certain advantages, including simplicity and reduced physical, and psychological stress, on both infants and caregivers. This study aims to investigate the effectiveness of reapplying the PH in patients with DDH. METHODS: This study included patients with DDH (complete dislocation) who were treated by reapplication of PH between 1988 and 2012. Patients who were able to follow-up for more than 5 years were included. We examined the reduction rate and several factors to identify indicators associated with successful reduction during reapplication, including age, sex, side of hip dislocation, and the presence of the Ortolani sign. At the final follow-up, hip development was assessed using the Severin classification, whereas avascular necrosis (AVN) was evaluated using the Kalamchi classification and the Salter criteria. RESULTS: A total of 56 patients (48 females and 8 males) and 57 hips were included in this study. The mean age at first and second application of PH was 4.2 months old (range: 0.12 to 6.4), and 5.8 months old (3.0 to 11.4), respectively. The reduction rate was 49% (28 out of 57 hips). Among the successfully reduced hips, the AVN rate was 3.6% (1 out of 28 hips). The Severin classification revealed 27 hips in class I and 1 hip in class III. Statistical analysis indicated a significantly higher proportion of left hip involvement in the reduction group (85% vs 41%, χ 2 test, P < 0.001). Although not statistically significant, the rate of positive Ortolani sign tended to be higher in the reduction group (61% vs 38%, χ 2 test, P = 0.06). CONCLUSION: The reapplication method demonstrated a 49% reduction rate and a low AVN rate of 3.6% in our study. It is worth considering for patients who fail the initial PH treatment, particularly in cases of left-side dislocation and a positive Ortolani sign during the initial application.

Radiologic Changes After 10 Years Postreduction in Developmental Dysplasia of the Hip Treated With Different Reduction Methods and Risk Factors for Osteoarthritis.

BACKGROUND: This study examined how radiologic indices at 10 years postreduction change over time and influence the final outcome through a comparative study of 3 reduction methods for developmental dysplasia of the hip, including the Pavlik harness, closed reduction, and open reduction (OR). METHODS: Patients treated from 1990 to 2000 for dysplasia of the hip and followed up for >20 years were included in this study. Radiologic indices at 10 years postreduction and final follow-up (average 24 years postreduction) were measured in the 3 groups. The relative joint space of <66% compared with the healthy side was defined as positive osteoarthritis (OA) at the final follow-up. The relationship between OA and factors such as age, sex, method of reduction, radiologic indices, and Severin and Kalamchi classifications at 10 years postreduction were examined. Clinical evaluation was performed using the modified Harris Hip Score; a score of ≥80 was defined as good performance at the final follow-up. RESULTS: Sixty-five patients (totaling 74 hips) were included. There were no significant differences in radiologic indices between the 10-year postreduction time and final follow-up. Excluding 9 bilateral patients, based on the relative joint space, 21% of the patients (13/56 hips), were positive for OA. Univariate analysis showed that the incidence of positive OA was significantly associated with OR and Kalamchi grade 4 at 10 years postreduction. The modified Harris Hip Score was 80 or higher in 90% of the cases at the final follow-up. CONCLUSIONS: No significant changes in hip morphology were observed at 10 years postreduction. The Kalamchi classification at 10 years postreduction and OR were significantly associated with the incidence of OA at the final follow-up. Therefore, patients who undergo OR and/or display Kalamchi grade 4 have a high risk of developing OA and would require individual instructions for their daily lives to prevent further progression of OA and longer follow-up. LEVEL OF EVIDENCE: Level Ⅲ-case-control study.

Radiological results of Shelf acetabuloplasty in adolescent hip dysplasia with aspherical femoral head: how to get an ideal placement of the Shelf graft.

Shelf acetabuloplasty continues to be effective in the prevention or delay of osteoarthritis in adolescent dysplastic hips. We aimed to evaluate the efficacy and to determine the correct level of the bone graft objectively. We retrospectively analyzed 16 hips underwent Shelf acetabuloplasty originated by Spitzy. The mean age at surgery was 15.3 years old with the mean caput index at 39.7%. The average follow-up was 11 years. The radiological evaluation was based on acetabular-head index (AHI) at preoperative and latest radiographs, acetabular-Shelf distance (ASD) and Shelf-head ratio at immediate postoperative and latest radiographs. The cutoff value for the ideal ASD was determined by receiver operating characteristic (ROC) and the Pearson correlation test used in statistical analysis to assess the relationship between ASD and Shelf graft resorption. Clinical evaluation was performed using Harris Hip Score (HHS) at the latest follow-up. The AHI was improved in all cases, from mean 56.9 to 91.0% (P < 0.001). The mean of ASD was 7 mm. In nine of the 16 cases, the Shelf graft was well united at the same level of the existing acetabulum with good continuity. The ROC curve showed the cutoff value for the ideal ASD was 6 mm. The Pearson correlation test also showed a positive relationship between ASD and Shelf graft resorption (P = 0.001). The average of HHS scores was 98.1 points. Both radiological and clinical results were acceptable. The ideal placement that keeps the shelf sufficient to bear the mechanical stress without bone resorption over time was at the level of 6 mm from the joint space. Level III - therapeutic study.

Single Versus Combined Procedures for Severely Involved Legg-Calvé-Perthes Disease.

BACKGROUND: The concept of containment as an effective approach to reduce the risk of femoral head deformity has been questioned because modest results have been achieved after nonoperative and operative treatments for severely involved Legg-Calvé-Perthes disease. Several reports have shown the limited effectiveness of some conventional single procedures. However, there is limited data on the effectiveness of combined procedures. METHODS: The surgical group comprised 77 patients (mean age 8.3 y) and involved 79 hips. The average follow-up term was 9.5 years. Sixty-five patients were unilaterally involved and 12 patients were bilaterally involved (although 10 of the latter patients only received surgery on 1 hip). Among patients, 28 hips were classified as Herring class B/C border (>8 y old) and 51 hips were Herring class C. The 79 hips were divided into 2 treatment groups for further analysis: group 1, single procedures (femoral varus osteotomy) (n=47); group 2, combined procedures [femoral varus osteotomy+Dega (Pemberton) osteotomy] (n=32). RESULTS: Using Stulberg classification I and II (acceptable outcome), the final outcome was statistically significant for group 2 (21 hips, 65.6%) compared with group 1 (18 hips, 38.3%) (P=0.031). The average remodeling efficacy, defined as the change in caput index between preoperation and postoperation, was better in group 2 (12.7%) than in group 1 (3.9%) (P=0.005). The acetabulum-head index and α-angle were also statistically significant in group 2 than in group 1 at the last follow-up. Clinical evaluations were statistically significant in group 2 compared with group 1. CONCLUSIONS: Both clinically and radiologically, the combined procedure group demonstrated significantly better outcomes with accelerated remodeling in both the severely affected femoral heads and the acetabula compared with the single procedure group. With this procedure, we anticipate the increased likelihood of preventing or delaying coxarthroses in adulthood. LEVEL OF EVIDENCE: Level III-therapeutic study.

Outcome of patients with Legg-Calvé-Perthes onset before 6 years of age.

BACKGROUND: The prognosis of Legg-Calvé-Perthes disease (LCPD) in young patients has been accepted as favorable. The purpose of this study was to clarify the outcome of LCPD patients with onset before 6 years of age. METHODS: From 1989 to 2007, of 332 LCPD patients, 114 hips (in 100 patients) were diagnosed before 6 years of age (mean age, 4.5 y old) with subsequent repair of the epiphysis in all cases. Waldenström classification at presentation was initial stage in 76 hips and fragmentation stage in 38 hips. Lateral pillar classification was group A in 17 hips, group B in 22 hips, group B/C in 24 hips, and group C in 51 hips. Treatment methods were observation with restriction of activity alone in 42 hips and several containment treatments in 72 hips. RESULTS: At the mean age of 14, Stulberg classification was class I in 26 hips, II in 46 hips, III in 28 hips, and IV in 14 hips. These data show an acceptable outcome in 72 of 114 hips (63%). Logistic regression analysis revealed that lateral pillar classification (odds ratio, 3.6) and good range of abduction without treatment (odds ratio, 4.0) were prognostic factors. CONCLUSIONS: Poor outcome was observed even in patients before 6 years of age with large necrotic area. Lateral pillar classification and good range of abduction were prognostic factors. LEVEL OF EVIDENCE: Level IV. Therapeutic studies-investigating the results of treatment. Case series.

Lateral insertion is a good prognostic factor after in situ fixation in slipped capital femoral epiphysis.

BACKGROUND: In situ fixation (ISF) is standard treatment for slipped capital femoral epiphysis (SCFE) to stabilize the epiphysis and to prevent further slip. The aim of this study was to clarify the incidence of slip progression after ISF and its prognostic factors. METHODS: We retrospectively reviewed 53 hips in 49 consecutive SCFE patients who underwent single screw ISF and were followed until physeal closure. Clinical and radiographic findings were viewed to assess progression of the posterior tilting angle (PTA). RESULTS: Mean PTA was 33.4 degrees (range, 18 to 75 degrees) at ISF and 35.9 degrees (range, 18 to 75 degrees) at physeal closure with progression of PTA of 2.5 degrees (range, -2 to 19 degrees). Slip progression occurred in 28 of 53 hips (53%), and more than five degrees of progression occurred in 14 hips (26%). Multiple regression analysis revealed that point of screw insertion (one point for lateral and two points for medial) was a significant prognostic factor for progression of the slip by the following formula: (progression of PTA) = -1.523 + 2.701 × (point of screw insertion), R(2) = 0.148, p = 0.005. CONCLUSIONS: The current study showed that a screw inserted from the lateral side to the intertrochanteric line prevented postoperative slip progression.

Postoperative improvement of femoroacetabular impingement after intertrochanteric flexion osteotomy for SCFE.

BACKGROUND: Patients with slipped capital femoral epiphysis (SCFE) may develop cam-type femoroacetabular impingement (FAI). Early management of FAI has been advocated for patients with symptomatic FAI. The various treatment options, including reorientation surgeries, realignment procedures, and osteoplasty, remain controversial. QUESTIONS/PURPOSES: We asked whether an intertrochanteric flexion osteotomy improved the clinical symptoms of FAI in patients with SCFE and confirmed whether the radiographic signs were compatible with the clinical signs of FAI. METHODS: We retrospectively reviewed 32 symptomatic patients who underwent 32 intertrochanteric flexion osteotomies for severe SCFE. FAI was diagnosed clinically with a positive impingement sign. The osteotomies were designed preoperatively using CT. Cam-type FAI was evaluated with the modified α angle (ß angle) on a Lauenstein view, measured between the proximal femoral shaft axis and the line from the center of the femoral head to the anterior point where the distance of the head center exceeded the femoral head radius. The minimum followup was 2 years (mean, 5 years; range, 2-9 years). RESULTS: At last followup, only two patients complained of pain or inconvenience in daily life; the impingement sign was negative in 24 hips (75%). The ß angles at last followup were reduced on average by 39°. The postoperative ß angle was higher in hips with positive clinical signs of FAI than in those with negative signs. CONCLUSIONS: Intertrochanteric flexion osteotomy for SCFE improved the clinical and radiographic signs of FAI. The ß angle and clinical findings showed compatible improvement. We believe our intertrochanteric flexion osteotomy is a viable option for treating severe SCFE. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Remodeling of angulation deformities in diaphyseal femoral fracture in children.

BACKGROUND: The purpose of this study was to reconsider the factors influencing the remodeling effects in diaphyseal femoral fractures in children based on radiological results. PATIENTS AND METHOD: We reviewed 39 patients with more than a 5° residual angulation deformity at the fracture site on anteroposterior and/or lateral views at the primary healing stage. The average follow-up period was 30.4 months. Angulation deformity was measured on plain radiographs both at the primary healing stage and the final follow-up. The correction rate (A - B/A × 100, A angulation deformities at the primary healing, B the angulation at the final follow-up) between at the primary healing stage and final follow-up was analyzed in terms of age at injury (0-5, 6-9, and ≥10 years), fracture site (proximal one third, middle one third, and distal one third) and direction of the deformities (coronal and sagittal planes). RESULT: The remodeling effect significantly appeared on the coronal plane (correction rate 66.7 %) rather than on the sagittal plane (correction rate 31.6 %) in the 0- to 5-year age group (P < 0.05). There was a statistically significant difference in the correction rate between the 0- to 5-year age group (66.7 %) and the 6- to 9-year group (30.6 %) on the coronal plane (P < 0.05), with no significance between any other two groups on both planes. No statistical difference of remodeling effect appeared among the three fracture sites. The average leg-length discrepancy was 4.7 mm longer. CONCLUSION: We suggest that a patient ≤5 years at injury could expect more sufficient remodeling on the coronal plane compared with the other age groups on both planes. However, a patient >5 years at injury should be encouraged to undergo the maximum possible correction of the angulation deformity at the initial treatment. Surgical intervention might be considered for that purpose.

Evaluation of behavior and neuropeptide markers of pain in a simple, sciatic nerve-pinch pain model in rats.

Pathomechanisms of injured-nerve pain have not been fully elucidated. Radicular pain and chronic constriction injury models have been established; however, producing these models is complicated. A sciatic nerve-pinch injury is easy to produce but the reliability of this model for evaluating pain behavior has not been examined. The current study evaluated pain-related behavior and change in pain markers in the dorsal root ganglion (DRG) of rats in a simple, sciatic nerve-pinch injury model. In the model, the sciatic nerve was pinched for 2 s using forceps (n = 20), but not injured in sham-operated animals (n = 20). Mechanical and thermal hyperalgesia were measured every second day for 2 weeks using von Frey filaments and a Hargreaves device. Calcitonin gene-related peptide (CGRP), activating transcription factor-3 (ATF-3), phosphorylated p38 mitogen activated protein (Map) kinase (p-p38), and nuclear factor-kappa B (NF-κB; p65) expression in L5 DRGs were examined at 4 and 7 days after surgery using immunohistochemistry. The proportion of neurons immunoreactive for these markers was compared between the two groups. Mechanical (during 8 days) and thermal hyperalgesia (during 6 days) were found in the pinch group rats, but not in the sham-operated animals (p < 0.05); however, hyperalgesia was not significant from days 10 to 14. CGRP, ATF-3, p-p38, and NF-κB expression in L5 DRGs was upregulated in the nerve-injured rats compared with the sham-operated rats (p < 0.01). Our results indicate that a simple sciatic nerve pinch produced pain-related behavior. Upregulation of the pain-marker expression in the nerve-injury model suggested it could be used as a model of pain. However, it was not considered as suitable for long-term studies.

A case of spontaneous hemoarthrosis after a total knee arthroplasty.

A 63-year-old woman with osteoarthritis had undergone right total knee arthroplasty. Nineteen months later, the patient presented with a recurrent hemoarthrosis. Open arthrotomy revealed hypertrophic synovium with small clots in the suprapatellar pouch, but entrapment of synovial tissues could not be observed. Histological examination of the extirpated specimen showed fibrous hypertrophy of synovium. The patient has no symptoms 51 months after surgery.