Cakirgil method in the surgical treatment of older children with developmental dysplasia of the hip: Mid-term follow-up results of 17 hips and literature review.

OBJECTIVES: This study aimed to evaluate the results of the Cakirgil method in patients with advanced developmental dysplasia of the hip (DDH). PATIENTS AND METHODS: Patients who underwent surgical treatment with the Cakirgil method between January 2011 and December 2022 with a diagnosis of DDH were retrospectively scanned. Thirteen patients (7 females, 6 males; 8.0±2.7 years; range, 5 to 12 years) with severe DDH were included in the study. The results of the Cakirgil method, including adductor tenotomy, open reduction, femoral shortening, varus and derotation osteotomy, and Dega acetabuloplasty, were retrospectively evaluated in 17 hips of these 13 patients. Clinical and radiological evaluation was performed according to the acetabular index, center edge angle, Severin score, and McKay criteria. RESULTS: Five patients had comorbidities. The mean follow-up period was 78.3±28.9 (range, 12 to 135) months. The acetabular index decreased from 35.24° to 22.06° and center edge angle improved from -34.71° to 26.59°. The Severin score decreased from 4.82 to 2.29 and the McKay criteria from 3.47 to 1.88. All changes were statistically significant (p<0.001). Redislocation was observed in only one hip. CONCLUSION: Surgical treatment of the older patients with neglected DDH is technically difficult, and the results are prone to complications. The technique outlined by Prof. Dr. Güngör Sami Cakirgil, a renowned specialist in DDH surgeries in Türkiye who has made notable contributions to the relevant research, yields satisfactory outcomes when employed under suitable circumstances.

Total hip arthroplasty in patients with coxarthrosis due to developmental dysplasia of the hip: Is fixation of the subtrochanteric osteotomy necessary?

OBJECTIVES: This study aims to analyze the clinical, functional, and radiographic results of patients with Crowe type IV developmental dysplasia of the hip (DDH) sequelae undergoing cementless total hip arthroplasty (THA) with transverse subtrochanteric shortening osteotomy without fixation at the osteotomy site. PATIENTS AND METHODS: Between March 2013 and February 2020, a total of 42 hips of 34 patients (8 males, 26 females; mean age: 50.7±11.7 years; range, 27 to 76 years) with Crowe type IV DDH treated with subtrochanteric shortening osteotomy combined with primary cementless THA were retrospectively analyzed. Each case was evaluated to the Harris Hip Score (HHS). Crowe classification, location of the rotation center of hip, loosening of the implants, and union at the osteotomy line were evaluated radiologically. RESULTS: The mean follow-up was 57.9±31.5 (range, 24 to 192) months. The mean interval to complete bone union in 40 hips (95%) after surgery was 3.5±0.9 (range, 2 to 6) months. The mean preoperative HHS scores of the patients was 35.6±6.86, while the scores increased to 91.53±5.41 at the final follow-up (p<0.001). CONCLUSION: Our study results suggest that excellent clinical and radiological results can be obtained in Crowe type IV dysplastic hips in patients undergoing THA with the rectangular femoral component and transverse shortening osteotomy technique, without fixation at the osteotomy site.

The Diagnosis of Developmental Dysplasia of the Hip From Hip Ultrasonography Images With Deep Learning Methods.

BACKGROUND: Hip ultrasonography is very important in the early diagnosis of developmental dysplasia of the hip. The application of deep learning-based medical image analysis to computer-aided diagnosis has the potential to provide decision-making support to clinicians and improve the accuracy and efficiency of various diagnostic and treatment processes. This has encouraged new research and development efforts in computer-aided diagnosis. The aim of this study was to evaluate hip sonograms using computer-assisted deep-learning methods. METHODS: The study included 376 sonograms evaluated as normal according to the Graf method, 541 images with dysplasia and 365 images with incorrect probe position. To classify the developmental hip dysplasia ultrasound images, transfer learning was applied with pretrained VGG-16, ResNet-101, MobileNetV2 and GoogLeNet networks. The performances of the networks were evaluated with the performance parameters of accuracy, sensitivity, specificity, precision, F1 score, and AUC (area under the ROC curve). RESULTS: The accuracy, sensitivity, specificity, precision, F1 score, and AUC results obtained by testing the VGG-16, ResNet-101, MobileNetV2, and GoogLeNet models showed performance >80%. With the pretrained VGG-19 model, 93%, 93.5%, 96.7%, 92.3%, 92.6%, and 0.99 accuracy, sensitivity, specificity, precision, F1 score, and AUC results were obtained, respectively. CONCLUSION: In this study, in addition to the ultrasonography images of dysplastic and healthy hips, images were also included of probe malpositioning, and these images were able to be successfully evaluated with deep learning methods. On the sonograms, which provided criteria appropriate for evaluation, successful differentiation could be made of healthy hips and dysplastic hips. LEVEL OF EVIDENCE: Level-IV; diagnostic studies.

The infants who have mature hip on ultrasonography but have risk factors of developmental dysplasia of the hip are required radiographic examination.

OBJECTIVES: This study aims to evaluate the short-term results of infants who were radiologically diagnosed with developmental dysplasia of the hip (DDH), but in whom hip development was normal ultrasonographically. PATIENTS AND METHODS: Between January 2018 and September 2020, a total of 15 infants (2 males, 13 females; median age: 5 months; range, 4 to 6 months) who were diagnosed with DDH radiologically and treated were retrospectively analyzed. Hip ultrasonography was used for early diagnosis, treatment, and for follow-up in infants up to six months of age. While the ultrasonographic findings were normal, radiography was performed in infants between four to six months of age who were at risk for DDH. RESULTS: Fifteen patients (22 hips) were diagnosed with DDH radiologically and treated. Radiologic dysplasia continued in seven hips of five patients during short-term follow-up. CONCLUSION: These results suggest that ultrasonographic hip maturation may not be consistent with normal hip development in infants, particularly in those who are at risk for DDH. In infants with DDH which is confirmed by radiography (less than 6 months of age), the diagnosis may be missed on ultrasonographic examination.

Discrepancy between ultrasonographic and radiographic findings in patients treated for developmental dysplasia of the hip; hip maturation on ultrasonography may not be consistent with radiographic hip maturation.

Currently, hip sonography is used for early diagnosis and for monitoring developmental dysplasia of the hip (DDH) treatment in many countries. An early pioneer of ultrasonography for early diagnosis of DDH was Graf. Based on the Graf approach, hip ultrasonography is more sensitive and specific than radiography for the diagnosis of DDH, because of its capability to show cartilaginous structures of the hip joint. The aim of this study was to compare radiographic and ultrasonographic findings in patients treated for DDH. This study included 88 infants (98hips) treated for DDH. Radiography was simultaneously used for treatment and follow-up evaluation in addition to ultrasonography after six months of age. A retrospective evaluation was made of the ultrasonographs and radiographs of these infants. Of the total 98 hips, 28 were normal both ultrasonographically and radiographically, and a pathologic hip was demonstrated in 32 hips both sonographically and radiographically. Hip ultrasonography showed abnormal development in 32 hips, while radiography showed abnormal development in 70 hips. In 38 hips, the findings were normal according to ultrasonography but pathological according to radiography. There were no hips that were normal radiographically but pathological sonographically. When radiography is accepted as the standard imaging method in our study patients, the sensitivity and specificity of hip ultrasonography were determined as 45.7% [95% confidence interval (CI): 41.5-45.7] and 100% (95% CI: 89.4-100), respectively. These findings suggest that hip maturation apparent on ultrasonography may not be consistent with radiographic hip development in infants treated for DDH.

Can a Hip Diagnosed as Graf Type 1According to Graf Checklist Deteriorate Over Time? A Case Series and Evaluation of the Graf Method.

INTRODUCTION: According to the Graf method, mature Type 1 hips will not worsen overtime. However, some cases have been reported in literature of hips which were initially Graf Type 1 hips and then worsened later. Our aim is to show the mistakes of the hip sonograms, which had been diagnosed as a mature Graf Type 1 hips. CASE REPORT: A review of literature revealed four studies initially diagnosed as Graf Type 1 hips and which then worsened overtime. Professor Graf has previously stated that measurements from inappropriate sonograms may result in an incorrect diagnosis. In this paper, the four aforementioned studies and their sonograms reported in literature were evaluated according to the Graf technique. In the light of the findings, it was discussed whether a mature hip could worsen overtime. In the reported cases, some of the deficiencies according to the Graf checklist were determined. CONCLUSION: From this examination, it can be concluded that Type 1 mature hips which worsened overtime, except for special circumstances as previously mentioned by Professor Graf, are related to an initial wrong diagnosis. As a result, if a Graf Type 1 hip was determined appropriately according to Graf checklist, it will never worsen later in normal circumstances.

Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia.

OBJECTIVE: The aim of this study was to investigate whether being the parents of children with developmental hip dysplasia (DDH) is a risk factor for asymptomatic dysplasia. METHODS: Asymptomatic parents of children who were diagnosed with DDH were assessed for presence of dysplasia by examining their anteroposterior pelvis radiographs at the neutral position. Eighty-six hips of 43 participants were included in the study group and 98 hips of 49 participants were included in the control group. Presence of hip dysplasia over the anteroposterior pelvis radiographs was analyzed for Wiberg's angle, acetabular index of the weight-bearing zone (the Tönnis angle), acetabular depth/width index, femoral head coverage ratio (FHCR) and femoral neck/shaft angle. RESULTS: The mean acetabular depth/width ratio was 44.3% in the study group and 53.5% in the control group. And, the mean FHCR was 80% in the study group and 82% in the control group. There was a statistically significant difference between the two groups in terms of mean acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05). In addition, 21 participants in the study group and 2 in the control group had a pathological acetabular depth/width ratio. And, the number of participants with a pathological FHCR was 22 in the study group and 13 in the control group. A statistically significant difference was found between the two groups regarding the number of pathological measurements of acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05). CONCLUSION: Having a parent with DDH is a definitive risk factor for the development of hip dysplasia in childhood. In addition, being a parent of a child with DDH is a risk factor for asymptomatic dysplasia. These parents should be screened by roentgenogram. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

The role of ADAMTS genes in the end stage of hip osteoarthritis.

PURPOSE: The aim of this study is to investigate which ADAMTS genes play a major role in the development of primary hip osteoarthritis, by comparing the tissue and blood samples in patients with hip osteoarthritis and a control group. MATERIAL AND METHODS: Human articular cartilage was obtained from femoral heads of 15 patients with end stage osteoarthritis undergoing total hip replacement. As the control group, the cartilages was obtained from femoral heads of 15 patients, who did not have osteoarthritis or degenerative changes in hip joint, undergoing hip replacement following the fracture of the femoral neck. After the cartilage samples were taken from the resection materials, the DNA polymorphisms in the patients' cartilage samples were tested by Polymerase Chain Reaction (PCR), the serum levels of aggrecanase genes were analyzed with Enzyme-Linked ImmunoSorbent Assay (ELISA). RESULTS: The level of ADAMTS5 and ADAMTS9 genes were found significantly lower as a result of ELISA analysis degenerative arthritis group than the control group (p < 0,05). ADAMTS 1, 4, 8, 15 were similar between the two groups in ELISA analysis (p > 0,05). As a result of quantitative real time RT-PCR analysis, the level of ADAMTS8 mRNA increased 3.5 fold in hip degenerative arthritis group when compared with femoral neck fractures group. ADAMTS1, ADAMTS4 and ADAMTS5 expression levels in hip degenerative arthritis group were decreased 2.5, 2 and 2.5 fold, respectively. ADAMTS9, 15 were found to be similar between two groups. CONCLUSON: As a result of this study on hip osteoarthritis, the ADAMTS8 levels was found to be significantly higher in the end stage of hip osteoarthritis. Unlike similar studies on knee osteoarthritis, ADAMTS1,4,5 levels were found to be lower.

Reduction of the dislocated hips with the Tübingen hip flexion splint in infants.

PURPOSE: Early detection and conservative treatment are essential for a successful outcome in developmental dysplasia of the hip (DDH). The aim of this study was to evaluate the efficacy of Tübingen hip flexion splint treatment on dislocated hips of type D, 3, and 4 according to the Graf classification. METHODS: A total of 104 dislocated hips in 92 patients were treated with Tübingen splints. Splint treatment was applied to patients with dislocated hips as diagnosed under ultrasonographic evaluation. After four to six weeks of treatment, the hips were re-evaluated according to the Graf classification under ultrasonography. The success of Tübingen splinting was determined as follows: hips initially diagnosed as Graf type 3 and 4 were upgraded to type 2c, 2b, or 1 after treatment, and hips initially diagnosed as Graf type D were upgraded to type 2b or 1 after treatment. RESULTS: The mean age at treatment initiation was 11.91 ± 5.16 (range, 4-32) weeks. There were no statistically significant relationships between success rates and sex, bilateral hip involvement, or initial physical examination findings (p > 0.05). The age at the start of treatment was found to be statistically significant in terms of the success of the splint (p = 0.03). CONCLUSIONS: For successful treatment with Tübingen splints, the cut-off point of starting initial treatment was defined as the 15th week, with sensitivity of 84.62% and specificity of 62.50%. The success rate was 75% with a successful outcome in 78 hips. In view of these results, Graf type D, 3, and 4 dislocated hips can be successfully treated with Tübingen splints.

Sutureless approach with vein grafts and mesenchymal stem cells in primary nerve repair: Functional and immunohistological results.

PURPOSE: The aim of this study was to define a sutureless peripheral nerve repair technique with a vein graft and bone marrow-derived stem cells (BMSC) and compare it to epineural repair. MATERIALS AND METHODS: Thirty Wistar Albino rats were divided into five groups evenly. In the control group (C), epineural repair was performed. In the SV (suture + vein) and MSV (BMSC + suture + vein) groups, epineural repair was wrapped with a vein graft. In the V (vein) and MV (vein + BMSC) groups, sutureless repair using a vein graft was performed by taking sutures away from the regeneration site. Rats were evaluated with pinprick, toe spread tests and sciatic nerve index (SFI) at 4th, 8th, and 12th weeks. They were sacrificed at 12th week, repair sites were harvested and evaluated immunohistochemically. RESULTS: There was no difference in pinprick and toe spread tests between the groups at 12th week. The mean SFI was -76.5 ± 3.7, -65.2 ± 11.7, -46.2 ± 19.4, -68.8 ± 9.8, -56 ± 8.8 in the C, SV, MSV, V, MV groups, respectively. The MSV group showed significantly the best SFI results (P < .05). NF-H immunostaining scores were as C; 1 ± 0.18, SV; 2.5 ± 0.36, MSV; 4 ± 0.49, V; 1.56 ± 0.54, MV; 3 ± 0.39, whereas GAP-43 scores were as C; 1 ± 0.31, SV; 2.66 ± 0.56, MSV; 4.50 ± 0.23, V; 2 ± 0.23, MV; 3 ± 0.6. The best nerve regeneration according to immunostaining results was observed in the MSV group (P < .05). The mean fibrosis area was 221.5 ± 25.9, 101.6 ± 7.1, 121.3 ± 18.8, 150.3 ± 12.1, 152.4 ± 11.8 µm2 in the above groups, respectively. SV and MSV groups showed the significantly less fibrosis area (P < .05). CONCLUSION: Epineural suture repair combined with vein wrapping and BMSCs (MSV) showed the best SFI, GAP-43, and NF-H immunostaining results.

One patient, one bone, and two different tumoral lesions.

In this article, we report a 67-year-old female patient who has two different tumoral lesions located in left humerus with clinical and radiological findings. Previously, the patient was diagnosed as impingement syndrome in shoulder, but, tumoral lesions were detected on the radiograms incidentally during evaluation.

Maternal Height and Infant Body Mass Index Are Possible Risk Factors for Developmental Dysplasia of the Hip in Female Infants.

Developmental dysplasia of the hip (DDH) is a wide-spectrum disease with a multifactorial etiology and, despite its prevalence, no definitive etiology has yet been established. The aim of this study was to investigate new risk factors for DDH by evaluating newly defined potential risk factors. A total of 71 infants were separated into 2 groups:Group I, 28 female first-born infants diagnosed with DDH and their mothers;and Group II, 43 healthy female first-born infants and their mothers. The maternal height and weight before pregnancy, infant height and weight at birth, and body mass index (BMI) of both mother and infant were determined. Calculations were made of the ratios between these parameters. Of the examined risk factors, only maternal height and the ratio of maternal height to infant BMI (MH/I-BMI) were found to be significant for DDH in infants. In conclusion, the results of this study show that a short maternal height and a low MH/I-BMI increase the risk of DDH. Further studies with a larger series are necessary to confirm these results.

[Is intraarticular administration of tranexamic acid efficient and safe as systemic administration in total knee arthroplasty? Single center, randomized, controlled trial]. / Total diz artroplastisinde eklem içi tranekzamik asit uygulamasi sistemik uygulama kadar etkin ve güvenilir midir? Tek merkez, randomize, kontrollü çalisma.

OBJECTIVES: This study aims to compare the efficiency and safety of intraarticular and intravenous tranexamic acid administration in patients who were performed primary total knee arthroplasty. PATIENTS AND METHODS: This single center, randomized, controlled trial included 60 patients (8 males, 52 females; mean age 67.8 years; range 53 to 87 years) who were performed primary total knee arthroplasty by three surgeons due to a diagnosis of primary osteoarthritis between January 2015 and June 2015. Patients were separated into three groups. Patients in group 1 and group 2 were administered 2 g intravenous tranexamic acid and 2 g intraarticular tranexamic acid, respectively. Patients in group 3 were not administered tranexamic acid. Pre- and postoperative hemoglobin difference, volume of blood collected in drains, and transfusion rate were analyzed. RESULTS: Compared with the control group, there was no significant difference between group 1 and group 2 in terms of total blood loss from the drain, pre- and postoperative hemoglobin difference, and the need for blood transfusion. CONCLUSION: Both intraarticular and intravenous administrations reduce blood loss and need for transfusion and there is no significant difference between the two techniques in terms of safety.

A rarely seen multilevel thoracic vertebral fracture after a nocturnal hypoglycemic convulsion attack.

A 49-year-old male presented with acute midthoracic severe back pain following a witnessed nocturnal convulsion attack. There was no history of trauma and the patient had a 23-year history of Type I diabetes mellitus. MRI scans of the thoracic spine revealed compression fractures at T5, T6, T7, and T8 vertebrae. The patient was treated conservatively. At 17 months after the initial diagnosis, the complaints of back pain had been resolved and the patient was able to easily undertake daily living activities. Hypoglycaemia is a common problem in diabetic patients treated with insulin. Convulsions may occur as a consequence of insulin-induced hypoglycemia. Nontraumatic compression fractures of the thoracic spine following seizures are a rare injury. Contractions of strong paraspinal muscles can lead to compression fracture of the midthoracic spine. Unrecognized hypoglycaemia should be considered to be a possible cause of convulsions in insulin-dependent diabetic patients. The aim of this report is to point out a case of rarely seen multilevel consecutive vertebrae fractures in a diabetic patient after a nocturnal hypoglycaemic convulsion attack.

Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques?

BACKGROUND: The aim of the study was to investigate whether the number and position of Kirschner (K)-wires, and the manner and duration of immobilization influence radiologic and functional outcomes of distal radius fractures treated with percutaneous K-wire fixation. METHODS: Ninety-two patients were included into the study with a mean follow-up period of 19.84±5.22 months (range, 13-34 months). In Group I, forty-five patients were treated with 3 K-wires and supported with a volar semi-circular cast for the first 3 weeks followed by a removable splint for a further 3 weeks. In Group II, forty-seven patients were treated with 2 K-wires and supported with a below-elbow circular cast for 6 weeks postoperatively. RESULTS: No significant difference in grip strength and DASH scores was found between the two groups. In clinical examination, significantly better functional results were determined in patients supported with a removable volar splint. At 6 weeks postoperatively, volar tilt, radial inclination, and radial length were significantly better in Group I compared to Group II (all p values). CONCLUSION: Tripod technique with 3 K-wires is a safe and reliable procedure to achieve stability and good radiological results. The use of a removable splint also improves the functional outcomes in the treatment of both intra- and extra-articular distal radius fractures.

[Situs inversus of the fibula: medialized fibula]. / Fibulanin situs inversusu: Medialize fibula.

Congenital extremity anomalies are caused by pathological changes during the development process of the embryo. Exposure to toxins during 4-12 weeks of pregnancy may lead to extremity anomalies. In this article, we present a girl patient born as one of triplets at the 31st week and fifth day of pregnancy with meningomyelocele, Arnold-Chiari type 2 malformation, developmental dysplasia of the right hip, hypothyroidism, and lower extremity anomaly. Mother had a history of antenatal usage of sodium valproate. Radiographic examination of the lower extremity showed medial location of the fibula.

A proven case of cutaneous rhizopus infection presenting with severe limb pain very soon after induction treatment in a patient with acute lymphoblastic leukemia.

Objective and Importance. Invasive mucormycosis may complicate the course of patients with hematologic malignancies and has a very high mortality rate. Early diagnosis and aggressive approach combined with surgical and medical treatment have paramount importance for cure. Clinical Presentation. We report here a case of a patient with acute lymphoblastic leukemia presenting with a subcutaneous mass lesion which was sampled by an ultrasound guided needle biopsy. The pathology showed microorganisms with aseptate hyphae with wide, irregular walls and more or less branching with highly vertical angles which suggested a mold infection. The specimen was also cultured where Rhizopus spp. grew. Conclusion. Posaconazole 200 mg QID was commenced. She recovered from neutropenia and pain on day 20 of treatment. After 4 courses of hyper-CVAD chemotherapy, the remaining soft tissue mass was removed surgically and she underwent allogeneic HSCT from a full matched sibling donor under secondary prophylaxis.