RESUMEN
OBJECTIVES: Avascular necrosis (AVN) of the femoral head is a major complication following treatment for developmental dysplasia of the hip (DDH). It is caused by excessive pressure over the femoral head, which compromises its blood supply. The rate of AVN following DDH treatment ranges from 6% to 48%. This study aimed to analyze the rate of AVN in DDH patients following different standard surgical treatments. METHODS: A retrospective cohort study was performed on patients diagnosed with DDH between January 2007 and December 2013. All idiopathic DDH patients who underwent standard surgical treatments were included in the study. Neuromuscular and teratologic patients and patients with previous surgical treatment outside the institute were excluded from the study. RESULTS: Overall, 204 hips in 143 pediatric patients were included in the study. The majority (84.8%) of the patients were female. Most patients (82.2%) received single treatment. The most commonly used surgical treatment was open reduction with pelvic osteotomy (82.8%). Type 4 Tonnis classification of DDH was found in 62.3% of patients. AVN was found in 14.3% of our study population. The majority (57.1%) of diagnosed AVN patients showed Grade 1 (Kalamchi) AVN classification. Patients who underwent closed reduction and hip spica showed a significantly higher rate of AVN compared to other treatments (14.3%, P = 0.044). CONCLUSION: Close follow-up of patients treated with closed reduction is mandatory as these patients have the highest risk of AVN. We recommend the introduction of national screening programs targeting all newborn children and including systematic follow-up at well-baby clinics during the early years of life.
RESUMEN
Intraoperative neurophysiological monitoring (IONM) consists of a group of neurodiagnostic techniques that assess the nervous system's functional integrity during surgical operations. A retrospective analysis of a pediatric female patient was conducted who underwent 12 operations for the correction of scoliosis, tethered cord, and split spinal cord wherein IONM played an important role. From age 3 to 6, she underwent six procedures including a release of the tethered cord, resection of the filum terminale, removal of a T11-T12 bony spur, release of L3 adhesions, repair of subcutaneous meningocele, and correction of scoliosis with a vertical expandable prosthetic titanium rod (VEPTR) technique without the use of IONM. However, a multimodality IONM protocol with somatosensory evoked potentials, transcranial electrical motor evoked potentials (TCeMEP), and an electromyogram was utilized during the later procedures. At age 6 (the seventh procedure), a VEPTR expansion was performed, with loss and recovery of the lower extremity motor evoked potentials. The postoperative magnetic resonance imaging (MRI) showed a partial split cord malformation with retethering of the spinal cord. We repaired her split cord malformation and tethered cord while employing IONM. Using IONM for her operation was crucial because a sudden significant loss of TCeMEP resulted in a cancellation of the procedure; the MRI showed a thick remnant attached to the spinal cord. If the procedure was performed without IONM, we could have missed the underlying pathology, an error that may have resulted in paraplegia. We strongly recommend using IONM during high-risk surgical procedures to help significantly reduce the risk of permanent postoperative complications.
