"Video Technique on Clinical Tests for DDH": New-Born to Walking Age.

INTRODUCTION: The early diagnosis of developmental Dysplasia of Hip (DDH) remains elusive. In the absence of symptoms, early signs need heightened awareness and an astute clinical examination. CLINICAL TESTS: Every newborn child must be examined for hip instability by the Barlow and Ortolani tests. Periodic examination of the lower limbs for limb length discrepancy, restricted hip abduction, thigh or gluteal crease asymmetry must alert the examiner to rule out hip dysplasia. In a walking child with unilateral DDH the limp is obvious, and the Trendelenburg sign is positive. In bilateral DDH, limitation of hip abduction and waddling gait with increased lumbar lordosis are the only early discernible signs. Often the care-giver or parents notice the subtle changes of limb asymmetry and bring to the notice of the primary care doctors. These early signs must not be ignored to prevent late presenting DDH. CONCLUSION: This article highlights the signs of DDH that every clinician dealing with children must be well-versed. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00528-w.

The Difference between Computed Tomography and Magnetic Resonance Imaging Measurements of Tibial Tubercle-Trochlear Groove Distance for Patients with or without Patellofemoral Instability: A Systematic Review and Meta-analysis.

The tibial tubercle-trochlear groove (TT-TG) distance was originally described for computed tomography (CT) but has recently been used on magnetic resonance imaging (MRI) without sufficient evidence demonstrating its validity on MRI. The current review aims to evaluate (1) whether there is a difference in the TT-TG distances measured using CT and MRI, (2) whether both the TT-TG distances measured using CT and MRI could be used to differentiate between patients with or without patellofemoral instability, and (3) whether the same threshold of 15 to 20 mm can be applied for both TT-TG distances measured using CT and MRI. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRSIMA) guidelines. All studies that compared TT-TG distances either (1) between CT and MRI or (2) between patients with and without patellofemoral instability were included. A total of 23 publications were included in the review. These included a total of 3,040 patients. All publications reported the TT-TG distance to be greater in patients with patellofemoral instability as compared to those without patellofemoral instability. This difference was noted for both TT-TG distances measured on CT and on MRI. All publications also reported the TT-TG distance measured on CT to be greater than that measured on MRI (mean difference [MD] = 1.79 mm; 95% confidence interval [CI]: 0.91-2.68). Pooling of the studies revealed that the mean TT-TG distance for the control group was 12.85 mm (95% CI: 11.71-14.01) while the mean TT-TG distance for patients with patellofemoral instability was 18.33 mm (95% CI: 17.04-19.62) when measured on CT. When measured on MRI, the mean TT-TG distance for the control group was 9.83 mm (95% CI: 9.11-10.54), while the mean TT-TG distance for patients with patellofemoral instability was 15.33 mm (95% CI: 14.24-16.42). Both the TTTG distances measured on CT and MRI could be used to differentiate between patients with and without patellofemoral instability. Patients with patellofemoral instability had significantly greater TT-TG distances than those without. However, the TT-TG distances measured on CT were significantly greater than that measured on MRI. Different cut-off values should, therefore, be used for TT-TG distances measured on CT and on MRI in the determination of normal versus abnormal values. Pooling of all the patients included in the review then suggest for 15.5 ± 1.5 mm to be used as the cut off for TT-TG distance measured on CT, and for 12.5 ± 2 mm to be used as the cut-off for TT-TG distance measured on MRI. The Level of evidence for this study is IV.

The Difference between Cartilaginous and Bony Sulcus Angles for Patients with or without Patellofemoral Instability: A Systematic Review and Meta-Analysis.

The cartilaginous sulcus angle and bony sulcus angle have been widely used to evaluate trochlea dysplasia. The current review aims to evaluate (1) whether there is a difference in measurement for cartilaginous and bony sulcus angles, (2) whether both the cartilaginous and bony sulcus angles could be used to differentiate between patients with or without trochlear dysplasia, and (3) whether the same cut-off of 145 degrees, originally used for radiographs, can be applied for the cartilaginous and bony sulcus angles measured on CT and MRI. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. A total of 11 publications with 1204 patients were included. All publications reported the sulcus angle to be greater in patients with patellofemoral instability. All publications reported the cartilaginous sulcus angle to be greater than the bony sulcus angle (MD 7.27 degrees; 95% CI: 5.67 - 8.87). The mean cartilaginous sulcus angle for the control group was 141.83 degrees (95% CI: 139.90 - 143.76) while the mean cartilaginous sulcus angle for patients with patellofemoral instability was 156.24 degrees (95% CI: 153.71 - 158.77). The mean bony sulcus angle for the control group was noted to be 133.69 degrees (95% CI: 131.23 - 136.15) while the mean bony sulcus angle for patients with patellofemoral instability was 148.42 (95% CI: 144.02 - 152.82). Both the cartilaginous and bony sulcus angles measured on CT and MRI could therefore be used to differentiate between patients with and without trochlear dysplasia. However, the cartilaginous sulcus angles are significantly higher than that of bony sulcus angles. Different cut off values should therefore be used.

The Outcomes of Distal Femoral Varus Osteotomy in Patellofemoral Instability: A Systematic Review and Meta-Analysis.

Distal femoral varus osteotomies have been novelly described in the recent years to be successful in the management of patellofemoral instability with genu valgum. However, these publications are limited to case reports and small case series and no published literature have attempted to analyze them in totality. The current review aims to pool together these small case series to evaluate the outcomes and complications of distal varus femoral osteotomies when performed for patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. All studies that reported the outcomes of distal femoral varus osteotomy for patellofemoral instability were included. A total of five publications were included in the review, which included a total of 73 patients. All of the studies reported improvement in the radiological outcomes for genu valgum correction and patellofemoral instability. One study using opening wedge osteotomy reported a decrease in Caton-Deschamps index postoperatively, while another study using closing wedge osteotomy reported maintenance of the Caton-Deschamps index postoperatively. Second look arthroscopy showed an improvement in the status of the chondral lesions of the medial facet of the patellar undersurface, the lateral facet of the patellar undersurface and the trochlear groove 2 years postoperatively. All studies also reported a decrease in the risk of recurrence of patellofemoral instability, reduction in pain, and an improvement in all the clinical outcomes knee scores. Distal femoral varus osteotomy is promising and useful in the management of patellofemoral instability with genu valgum. The procedure can allow for radiological correction of the genu valgum and patellofemoral instability, reduction in the risk of recurrence of patellofemoral instability, reduction in pain, improvement in clinical knee outcome scores, and improvement in the status of the chondral lesions in the patellofemoral joint. It is highly versatile and could accommodate varying degrees of correction. These improvements in radiological and clinical outcomes can be seen in studies for both closing wedge and opening wedge distal femoral osteotomies. However, opening wedge osteotomies appear to decrease the patellar height as compared with closing wedge osteotomies which maintain the patellar height; therefore, the patellar height should be assessed preoperatively prior to deciding whether to perform an opening wedge or closing wedge distal femoral varus osteotomy. The Level of Evidence for this study is IV.

The Outcomes of Isolated Distal Realignment Procedures in Patellofemoral Instability: A Systematic Review and Meta-analysis.

Distal realignment procedures are now commonly performed routinely with proximal realignment procedures. Despite so, only a limited number of publications exist that have looked into the efficacy of isolated distal realignment procedures, and whether there is indeed a need for routine proximal realignment procedures to be added to the distal realignment procedures. The current systematic review and meta-analysis aims to evaluate the outcomes of isolated distal realignment procedures in the management of patellofemoral instability. The review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRSIMA) guidelines. All studies that reported the outcomes of isolated distal realignment procedures for patellofemoral instability were included. A total of six publications were included, with 347 knees. All studies consistently reported a decrease in the rates of patellofemoral instability or maltracking (odds ratio [OR]: < 0.01; 95% confidence interval [CI]: < 0.01-0.01) and an increase in the odds of having a good outcome (OR: 0.01; 95% CI: < 0.01-0.02) after distal realignment procedures. A total of 24 out of 306 patients (7.8%) had postoperative instability or maltracking, and a total of 220 out of 303 patients (72.6%) were rated to have good or excellent outcomes postoperatively. Isolated distal realignment procedures can lead to good outcomes when used in the management of patellofemoral instability. These include a significantly decreased rate of patellofemoral instability or maltracking and a significantly increased number of patients with excellent or good outcomes postoperatively. Comparisons between patients with and without additional proximal realignment procedures suggest that additional proximal realignment procedures do not definitely improve the outcomes of distal realignment procedures and, therefore, should not be routinely performed in all patients undergoing distal realignment procedures. The Level of Evidence for this study is IV.

The Outcomes of Isolated Lateral Release in Patellofemoral Instability: A Systematic Review and Meta-Analysis.

There have been conflicting reports regarding the outcomes of lateral release when used in the management of patellofemoral instability. This systematic review and meta-analysis therefore aims to evaluate the outcomes of isolated lateral release in the management of patellofemoral instability. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies that reported the outcomes of isolated lateral release for recurrent patellofemoral dislocations were included. A total of 10 publications were included, with 204 knees. All studies consistently reported a decrease in the rates of patellofemoral dislocation (odds ratio [OR] < 0.01; 95% confidence interval [CI]: <0.01-0.01) and an increase in the odds of having a good outcome (OR 0.01; 95% CI: <0.01-0.02) after lateral release. All studies also consistently reported a similar number of patients participating in sports postoperatively as compared with preinjury (OR 2.78; 95% CI: 0.53-14.68). A total of 28 (14.1%) out of 198 patients had postoperative dislocation. Of these patients, 15 required a secondary procedure for patellofemoral realignment; however, all patients who had their eventual outcomes reported still had a good outcome postoperatively. Isolated lateral release can lead to good short- to middle-term outcomes when used in the management of recurrent patellofemoral dislocations. The procedure can lead to a significantly decreased rate of recurrence of patellofemoral dislocations, a significantly increased rate of good outcomes, and a similar number of patients being able to participate in sports as compared with the number of patients participating in sports prior to having patellofemoral dislocations. An isolated lateral release could therefore potentially serve as a simple and relatively low-risk procedure that could be performed as a first-line surgical management in selected patients with patellofemoral instability, allowing them to possibly avoid a more complex and major operation. This is a Level IV study.

Treatment of Proximal Humerus Fractures using PHILOS Plate.

INTRODUCTION: Treatment of proximal humerus fractures always holds a dilemma for the treating surgeon. AIM: To assess the functional outcome of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating. MATERIAL AND METHODS: Fifty three consecutive patients were treated with PHILOS plating between August 2013 and August 2014. The inclusion criteria were skeletally matured patients with closed fracture proximal humerus with displacement >1 cm and varus angulation of >450. Severely comminuted fractures, open fractures and valgus impacted fractures were excluded from the study. The outcome was assessed using Neer's scoring system. RESULTS: The average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes. CONCLUSION: PHILOS plating has a good functional outcome. However, proper patient selection, thorough knowledge of the anatomy and biomechanical principles are the pre-requisites for a successful surgery.