An Eastern Europe and Middle East multinational expert Delphi consensus study on the prevention, diagnosis, and treatment of developmental dysplasia of the hip before walking age.

PURPOSE: The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age. METHODS: Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age. RESULTS: Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head. CONCLUSION: The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided.

Corticosteroid-Associated Avascular Necrosis of the Femoral Head in Patients with Severe COVID-19: A Single-Center Study.

BACKGROUND Avascular necrosis (AVN) of the femoral head can result from high-dose corticosteroid therapy. Given that severe COVID-19 pneumonia patients respond positively to corticosteroids, this study aimed to explore the incidence of femoral head AVN associated with corticosteroid therapy in 24 patients diagnosed with severe COVID-19 at a single center. MATERIAL AND METHODS The study included 24 patients who were diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through real-time reverse transcription polymerase chain reaction test (rRT-PCR) and with COVID-19 pneumonia via high-resolution computed tomography (HRCT). Moderate cases received 2×4 mg Dexamethasone while severe cases were also administered with 3×40 mg Methylprednisolone. Diagnosis of femoral head AVN was confirmed with magnetic resonance imaging (MRI) and radiographs, which was subsequently treated by a total hip arthroplasty (THA) or a core decompression surgery (CDS) in line with the Ficat and Arlet classifications RESULTS Among the patients, 8 had a moderate infection course, while 16 were severe. The mean corticosteroid duration was 15±5 days for Dexamethasone and 30 days for Methylprednisolone. Severe patients presented with higher grade femoral head AVN and greater pain levels compared to moderate cases (p<0.05). Four patients developed bilateral AVN. The treatment resulted in 23 THAs and 5 CDSs CONCLUSIONS The data from this study corroborate earlier studies and case reports, suggesting an increased occurrence of AVN of the femoral head during the COVID-19 pandemic due to the high-dose corticosteroid therapy employed for patients hospitalized with severe COVID-19 pneumonia.

Free-gliding screw fixation in slipped capital femoral epiphysis: potentially growing im-plants for symptomatic and prophylactic pinning.

INTRODUCTION: In situ fixation is the gold standard for mild and moderate slipped capital femoral epiphysis (SCFE) cases. The condition is associated with a low percentage of avascular necrosis and chondrolysis.[1] The present study examines the postoperative femoral neck remodelling and implant elongation in cases of therapeutic and prophylactic in situ fixation using the free-gliding screw system. AIM: The aim of our study was to assess the postoperative femoral neck growth and evaluate the biomechanical evolution and complication's rate for 19 therapeutic and 11 prophylactic in situ fixations with a free-gliding screw. MATERIALS AND METHODS: We measured the preoperative and postoperative articulo-trochanteric distance (ATD), alpha angle (α angle) and screw elongation in symptomatic hips and in contralateral hips with prophylactic fixation. We compared the radiographic param-eters of 30 hips. RESULTS: ATD remains approximately the same for symptomatic cases, whereas it increases for prophylactic fixated hip. Screw elongates in both group with statistically higher value for the prophylactic group. The alpha angle remains pathological in these cases with a mean value of 67.12±4.62°, but decreases for group II. Screw elongates by a mean value of 3.14±2.74 mm for group I and 6.78±8.81 mm for group II. CONCLUSIONS: Prophylactic in situ fixation with free-gliding screws does not affect the proximal femoral growth (ATD), and does not decrease the alpha angle significantly. Screw elongates statistically in both groups, but more significantly for group II. For symptomatic hips, the in situ fixation allows the femoral neck to grow with ATD preserved, but significantly less than in group II. The alpha angle decreases but remains pathological.

Periostin and IFN-γ levels in serum and nasopharyngeal aspirate in infants with viral-induced wheezing - 2 year follow-up.

BACKGROUND: The present study assesses the immune response in children with viral-induced wheezing by examining the two factors-interferon-gamma (IFN-γ) and periostin in serum and nasopharyngeal aspirate (NPA). The aim was to find a pattern with the severity and frequency of wheezing episodes. METHODS: Sixty-nine infants (40 boys and 29 girls), with a mean age of 11.4±6 (2 - 23) months, hospitalized with a first or recurrent episode of bronchial obstruction were enrolled in this study. The serum and NPA concentrations of IFN-γ and periostin were assessed by ELISA methodology. Fifty of the children (72%) were followed for 2 years. RESULTS: We detected lower NPA IFN-γ production in boys, infants with atopic status, family history of asthma, and respiratory syncytial virus infection. Recurrent wheezing in children was associated with a twice lower concentration of IFN-γ in NPA compared to those with the first episode (7.1 vs. 14.8 pg/ml, p=0.05). Higher serum periostin level was established in children over 12 mo in the group of recurrent wheezers with persistent manifestations compared to those without symptoms during the follow-up (410.5 vs. 269.7 ng/ml, p = 0.03). Multivariate logistical regression model assessed high level of serum periostin, male gender, atopy, family history of asthma, and severity of the attack as significant risk factors for persistent compared to intermittent wheezing (r < sup > 2 < /sup > = 0.87, p = 0.04). CONCLUSIONS: Our results demonstrated that recurrent viral-induced wheezing is associated with decreased IFN-γ production and increased periostin response and their correlation with severity and persistence of symptoms were the main outcome measures.

Case report of LCP pediatric hip osteosynthesis of a proximal femoral fracture in a child with marble bone disease.

We present a case report demonstrating the experience of the department of pediatric orthopaedics of the University Orthopedic Hospital at Sofia Medical University in the treatment of an intertrochanteric proximal femoral fracture in a child with osteopetrosis. We performed open fracture reduction with stable 120° LCP (Locking Compression Plate) Pediatric hip osteosynthesis. Fracture consolidation and ability to walk without crutches was achieved in a half a year. The presented case is the first for Bulgaria. There are still no publications in the world literature on application of such osteosynthesis in marble bone disease.

Residual dysplasia after successful Pavlik harness treatment: early ultrasound predictors.

The purpose of this study was to evaluate a group of children treated with Pavlik harness for developmental dysplasia of the hip (DDH) to determine early ultrasound characteristics that predict poor acetabular development after walking age. From a group of 487 infants with DDH, 55 met inclusion criteria of (1) ultrasound documentation of major neonatal hip instability, (2) treatment with Pavlik harness, and (3) a minimum of 4 years of follow-up. These 55 infants had 100 abnormal hips. Harness treatment alone was successful in treating 87 of 100 hips. Persistent or late acetabular dysplasia was defined from serial radiographs. At a mean follow-up of 5.3 years, 5 of the 87 (6%) were found to have sequelae (late acetabular dysplasia, avascular necrosis of the femoral head, or both). Three sonographic findings present on the initial ultrasound predicted late sequelae: (1) dynamic coverage index of 22% or less, (2) alpha angle less than 43 degrees, and (3) abnormal echogenicity of the cartilaginous roof on initial ultrasound. Abnormal echogenicity was the most specific single predictor of residual dysplasia (sensitivity 100% and specificity 88%). The structurally normal cartilaginous roof is non-echogenic except for a short triangular fibrous tip (the labrum). Pathologic cartilage becomes echogenic beyond the tip as hyaline cartilage becomes fibrous and deformed. In unstable hips that respond well to Pavlik harness treatment, it would appear that midterm acetabular development can be affected when early transformation of roof cartilage accompanies displacement and instability.