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BACKGROUND: Traditional management of moderate to severe stable slipped capital femoral epiphysis (SCFE) has been in situ fixation followed by reconstructive surgery if symptoms arise. This delayed approach may lead to irreversible intra-articular damage of the hip over time. The purpose of this study was to compare radiographic and clinical outcomes of the modified Dunn procedure (MDP) versus in situ fixation followed by delayed Imhauser osteotomy (DIO). METHODS: This was a retrospective study from a single institution between 2001 and 2021. Among 250 patients diagnosed with SCFE, a total of 18 (18 hips) treated with MDP and 16 (18 hips) treated with DIO for moderate to severe stable SCFE were included. Most patients who underwent DIO either had concomitant (11/18 hips) or subsequent (2/18 hips) open osteochondroplasty. Mean follow up was 4.7 years (range: 1 to 12.8 y). Radiographs were reviewed to measure Southwick angle, anteroposterior and lateral alpha (α) angles, and femoral head-neck offset ratio preoperatively and at latest follow up. Charts were reviewed for demographics, subsequent surgeries, complications, and Heyman-Herndon clinical outcomes. RESULTS: The amount of deformity correction was greater in the MDP than DIO group based on anteroposterior α angles (mean: 22.3 vs. 11.9 degrees, P=0.046) and femoral head-neck offset ratios (mean: 0.26 vs. 0.12, P=0.001). There was no significant difference in Heyman-Herndon scores (both 16/18, 88.9% good to excellent outcomes, P>0.999). Less reoperations were performed in the MDP than DIO group (2/18, 11.1% vs. 9/18, 50%; P=0.004). AVN occurred in 2/18 hips (11.1%) in the MDP group with both surgeries performed early in the series and underwent prior in situ screw fixation compared with 0/18 hips (0%) in the DIO group (P=0.486). One patient in the DIO group was later diagnosed with osteoarthritis. CONCLUSIONS: MDP resulted in more anatomic coronal and sagittal plane deformity correction, less reoperations, and similar Heyman-Herndon clinical outcomes compared with DIO. AVN occurred in the MDP group whereas osteoarthritis occurred in the DIO group. These complications must be weighed against improved long-term clinical results for patients who would otherwise be at risk for premature degenerative joint disease due to residual proximal femoral deformity. LEVEL OF EVIDENCE: Level III-retrospective comparative study.
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INTRODUCTION: An initial screening ultrasound is essential for patients at higher risk of developmental dysplasia of the hip (DDH) due to breech presentation or a family history of DDH. The American Academy of Pediatrics recommends screening ultrasounds to be performed after 6 weeks of age to reduce the rate of false positives. However, there is limited evidence regarding whether these screening ultrasounds need to be adjusted for gestational age in prematurity. The purpose of this study was to evaluate the influence of moderate preterm and near-term births on screening hip ultrasounds for high-risk DDH populations. METHODS: We identified all prospectively enrolled patients in a single-center database referred for screening hip ultrasound for DDH. We included those hips referred for risk factors of DDH, including breech presentation, family history of DDH, or hip click, and excluded those with known dysplasia or referral for hip instability. Each ultrasound was measured by a pediatric radiologist to determine the alpha angle and femoral head coverage. Patients were classified as "premature" if born at <37 weeks gestation or "full term" if born at ≥37 weeks gestation. All patients underwent screening hip ultrasound between 5 and 8 weeks of age. Sonographic markers of dysplasia and the incidences of abnormal ultrasound and Pavlik harness treatment were compared between cohorts. Significance was set at P <0.05. RESULTS: A total of 244 hips in 122 patients were included, 58 hips in the premature cohort and 186 hips in the full-term cohort. The premature cohort had a significantly decreased gestational age compared with the full-term cohort (35.4 ± 1.1 vs 38.5 ± 1.1 wk, respectively, P < 0.001). However, there was no difference between premature and full-term cohorts in sex distribution (69% vs 75%, females, P = 0.39), unadjusted age at the time of ultrasound (6.6 ± 0.7 vs 6.8±0.7 wk, respectively, P = 0.07), or referral reason ( P = 0.14). On hip ultrasound, there was no difference between premature and full-term cohorts with respect to alpha angle (62.6 ± 3.3 vs 62.2 ± 5.3 degrees, P = 0.41), femoral head coverage (54.9 ± 6.3 vs 55.1 ± 10.6, P = 0.19), rate of abnormal ultrasound (18.3% vs 20.7%, respectively, P = 0.68), or the rate of Pavlik harness treatment (0% vs 5.3%, respectively, P = 0.12). DISCUSSION: There was no significant difference in alpha angle or femoral head coverage between premature and full-term patients at 5 to 8 weeks of unadjusted age. This preliminary data suggests that screening ultrasounds can be performed without adjusting for prematurity. LEVEL OF EVIDENCE: Level II, prognostic study.
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Apresentação Pélvica , Displasia do Desenvolvimento do Quadril , Luxação Congênita de Quadril , Recém-Nascido , Lactente , Gravidez , Feminino , Humanos , Criança , Masculino , Estudos Prospectivos , Quadril , Luxação Congênita de Quadril/diagnóstico por imagem , Luxação Congênita de Quadril/terapia , Luxação Congênita de Quadril/epidemiologia , Ultrassonografia/métodosRESUMO
BACKGROUND: Cord blood (CB) is a cell source for hematopoietic stem cell transplantation. In 2019, the percentage of births with CB collected for banking was only 3% nationally and 0.05% in our state. To increase CB donations, we need to understand pregnant women's awareness and knowledge of, plus barriers and facilitators to, CB banking (CBB). STUDY DESIGN AND METHODS: We recruited 289 women in their third trimester from an academic obstetric clinic between October 2020 and May 2021. Women attending this clinic come from all parts of the state in addition to local city residents. After agreeing to participate, participants completed a survey using Research Electronic Data Capture (REDCap). Data were analyzed using SAS version 9.4. RESULTS: Exactly 58.9% of participants had heard of CBB, but only 26.53% understood its purpose; 10.03% indicated someone had discussed CBB with them, and 61.3% were undecided about it. The preferred source of information was the clinic provider (82.1%), followed by CB bank staff (36.8%). The requested mode for receiving information was face-to-face with their provider, including written materials. Income, education, and marital status did not have a significant influence on information preferences. DISCUSSION: Lack of knowledge continues to be a major barrier to CBB. Developing educational interventions based on womens' preferences may increase understanding of CBB. Study participants preferred that the healthcare provider deliver this information. This study was done in a primarily rural, southern state, while previous studies were in larger metropolitan areas, yet results are comparable.
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Transplante de Células-Tronco Hematopoéticas , Gestantes , Feminino , Gravidez , Humanos , Armazenamento de Sangue , Universidades , Bancos de Sangue , Sangue FetalRESUMO
BACKGROUND: Abduction bracing is commonly used following open reduction and spica casting of developmental dysplasia of the hip. However, there is little evidence to support or refute this practice that carries associated cost and burden for families. The purpose of this study was to determine the efficacy of abduction bracing after open reduction in improving the acetabular dysplasia and reducing the rate of secondary surgery for residual dysplasia. METHODS: This is a retrospective study of patients treated with open reduction at a single tertiary referral center. Demographic data, severity of dislocation [International Hip Dysplasia Institute (IHDI) class], age at reduction, and casting duration were obtained. Patients were prescribed no bracing, part-time (≤18 h/d), or full-time (≥20 h/d) brace wear based on surgeon preference. Acetabular index (AI) measurements were obtained at cast removal and at 2- and 4-year follow-up. RESULTS: A total of 146 hips underwent open reduction with 61% (89/146) of hips treated with abduction bracing. There was no difference between braced and nonbraced cohorts with regards to sex, age at time of reduction, dislocation severity, cast duration, immediate postcasting AI, or incidence of medial open reduction. There was no difference in hips treated with or without brace following open reduction with regards to AI at 2 years postreduction (31.8±6.7 vs. 30.4±6.1 degrees, P =0.27) or at 4 years postreduction (24.9±6.5 vs. 24.7±6.5 degrees, P =0.97). However, further analysis showed lower mean AI at 2-year follow-up for braced versus nonbraced patients following medial open reduction (30.0±5.7 vs. 34.5±7.0 degrees, P =0.02). This difference was no longer present at 4-year follow-up (26.6±6.8 vs. 24.2±6.6 degrees, P =0.44). However, 4/19 (21%) nonbraced hips underwent secondary surgery for residual dysplasia and were consequently excluded from the AI measurement at 4 years postreduction (compared with 4/39 [10%] braced hips within the same time period). There was no difference in the rate of secondary surgery between braced and nonbraced hips (30% vs. 33%, respectively, P =0.70). Multivariate analysis demonstrated that neither IHDI classification, bracing, nor age at reduction predicted residual dysplasia. CONCLUSIONS: Abduction bracing following anterior open reduction for developmental dysplasia of the hip is not associated with decreased residual dysplasia at 2/4 years postreduction or with decreased secondary surgery. These results suggest that abduction bracing following anterior open reduction may not provide clinical benefit. However, abduction bracing may be beneficial following medial open reduction. A prospective study is necessary to provide more definitive recommendations. LEVEL OF EVIDENCE: Level III-therapeutic study.
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BACKGROUND: The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click. METHODS: We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation. RESULTS: Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity. CONCLUSIONS: Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click. LEVEL OF EVIDENCE: Level II-prospective prognostic study.
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Luxação Congênita de Quadril , Lactente , Gravidez , Feminino , Criança , Humanos , Pré-Escolar , Estudos Prospectivos , Luxação Congênita de Quadril/diagnóstico por imagem , Luxação Congênita de Quadril/terapia , Quadril , Articulação do Quadril/diagnóstico por imagem , Fatores de Risco , UltrassonografiaRESUMO
BACKGROUND: There is significant controversy in the literature over rates of late-developing dysplasia following normal screening ultrasound in breech babies, with reported rates varying from 7% to 29%. The purpose of this study is to investigate the rates of radiographic dysplasia in breech babies after a normal ultrasound with a minimum of 1 year of radiographic follow-up. METHODS: This study was an institutional review board-approved prospective study of all patients referred by their pediatrician for concern for developmental dysplasia of the hip between July 2008 and August 2014. We identified all subjects with breech presentation and excluded those with an abnormal initial examination/ultrasound or with <12 months of radiographic follow-up. Anterior-posterior pelvis films were obtained after >12 months and acetabular indices (AIs) were measured and compared with contemporary normative data. Dysplasia was diagnosed as >2 SDs above the mean. RESULTS: A total of 654 patients were referred with a history of a breech presentation, and 150 (22.9%) were found to have clinical instability or sonographic evidence of dysplasia on initial presentation and were observed with serial imaging or treated. Of the remaining 504 subjects with a normal clinical examination and screening ultrasound, 133 (26.4%; 74.4% females, 25.6% males) were followed until at least 12 months of age. Of those presenting at age 12 to 14 months, the mean AI was 0.42±0.83 SD above the mean with a skew towards elevated AIs. At the final follow-up (mean: 20.7±6.7 mo), the mean AI was 0.05±0.92 SD above the mean, and only 3/133 (2.2%) patients had a dysplastic hip. No patients underwent treatment other than an observation during the study period. CONCLUSIONS: One in 5 breech babies have dysplasia at presentation, but late dysplasia following normal screening ultrasound may be less common than previously reported and may be due to our prolonged follow-up period. We recommend surveillance of breech babies with follow-up visits after 12 months of age since earlier visits may offer limited benefits. LEVEL OF EVIDENCE: Level II-prospective prognostic study.
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Apresentação Pélvica , Displasia do Desenvolvimento do Quadril/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Exame Físico , Gravidez , Estudos Prospectivos , Radiografia , UltrassonografiaRESUMO
Aims: Abduction bracing is commonly used to treat developmental dysplasia of the hip (DDH) following closed reduction and spica casting, with little evidence to support or refute this practice. The purpose of this study was to determine the efficacy of abduction bracing after closed reduction in improving acetabular index (AI) and reducing secondary surgery for residual hip dysplasia. Methods: We performed a retrospective review of patients treated with closed reduction for DDH at a single tertiary referral centre. Demographic data were obtained including severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification, age at reduction, and casting duration. Patients were prescribed no abduction bracing, part-time, or full-time wear post-reduction and casting. AI measurements were obtained immediately upon cast removal and from two- and four-year follow-up radiographs. Results: A total of 243 hips underwent closed reduction and 82% (199/243) were treated with abduction bracing. There was no difference between those treated with or without bracing with regard to sex, age at reduction, severity of dislocation, spica duration, or immediate post-casting AI (all p > 0.05). There was no difference in hips treated with or without abduction brace with regard to AI at two years post-reduction (32.4° (SD 5.3°) vs 30.9° (SD 4.6°), respectively; p = 0.099) or at four years post-reduction (26.4° (SD 5.2°) vs 25.4° (SD 5.1°), respectively; p = 0.231). Multivariate analysis revealed only IHDI grade predicted AI at two years post-reduction (p = 0.004). There was no difference in overall rate of secondary surgery for residual dysplasia between hips treated with or without bracing (32% vs 39%, respectively; p = 0.372). However, there was an increased risk of early secondary surgery (< two years post-reduction) in the non-braced group (11.4% vs 2.5%; p = 0.019). Conclusion: Abduction bracing following closed reduction for DDH treatment is not associated with decreased residual dysplasia at two or four years post-reduction but may reduce rates of early secondary surgery. A prospective study is indicated to provide more definitive recommendations.