Rates and risk factors for failure of reduction in closed reduction in developmental dysplasia of the hip: a systematic review and meta-analysis.

Objective: In developmental dysplasia of the hip (DDH), concentric reduction of dislocated hips cannot be achieved by closed reduction in many cases, and open reduction is required ('failure of reduction'). The incidence of cases requiring open reduction and the significance of risk factors for unsuccessful reduction remain unclear. We investigated the overall rate and the risk factors for failed closed reduction in DDH. Methods: We followed the Cochrane recommendations in our systematic review and meta-analysis. We performed a systematic search in three medical databases to identify all studies reporting on pediatric patients with hip dislocation in DDH on 2 July 2022. Eligible studies reported on the rate of failure in children younger than 36 months. We calculated odds ratios (ORs) with 95% CIs from two-by-two tables (event rate in risk group, event rate in non-risk group). Results: We identified 13 316 studies and included 62 studies (5281 hips) for failure rate and 34 studies (3810 hips) for risk factor analysis. The overall rate of failure in closed reduction was 20%. The risk of failure of reduction increased with the grade of dislocation and was significantly higher for high dislocations (group 0-24: IHDI 4 vs IHDI 2 OR: 17.45, CI: 9.26-32.92; Tönnis 4 vs Tönnis 2 OR: 14.67, CI: 1.21-177.37; Graf IV vs Graf III OR: 3.4, CI: 2.27-5.09). Male gender was also a significant risk factor (OR: 2.27, CI: 1.13-4.56) in group 0-36. Conclusion: Higher grade dislocations and male gender are significant risk factors for failure of reduction in closed reduction in hip dislocation in DDH.

Epiphysis preserving resection of malignant proximal tibial tumours.

PURPOSE: The purpose of the study was to evaluate the treatment of five patients with proximal tibial epiphysis preserving resection for malignant tumours of the tibia. METHOD: Three patients suffered from Ewing sarcoma, two had osteosarcoma. The proximal level of the resection was in the line of the growth plate in four patients, and 2 cm below of the growth plate in one patient. The distal resection level was in the diaphysis, depending on the tumour border. The resected part of the tibia was substituted by both the ipsilateral and contralateral fibulas. The two fibulas were proximally built into the epiphysis, the contralateral, freely transplanted fibula was placed distally into the tibial diaphysis. The leg was fixed in an Ilizarov frame. RESULTS: The follow-up period was 4.9 years on average (range, 3.5-8 years). Neither local recurrence nor metastasis was noticed in patients with tibia tumour resection during the observation time. Proper fixation of the transplanted fibula with all of the patients, both proximal to the tibia epiphysis and distal to diaphysis, was experienced. The range of motion of the knee was 122° on the average. Two patients can walk without support and three can walk with an orthosis fully weight bearing. The limb shortening of the affected side was 2.6 cm on average (range,1.5-4.5 cm). In three patients the transplanted opposite side fibula has broken. In one patient, chronic osteomyelitis developed at the distal part of the transplanted fibula. CONCLUSIONS: The difficulties of intercalary segment supplementation were present to a greater extent because of the small size of proximal epiphysis, but the preserved knee joint can produce better function for the patient in this limb-saving surgery.

Obesity and Ankle Prosthesis Revision: A Systematic Review and Meta-analysis.

BACKGROUND: The increasing number of total ankle arthroplasties (TAAs) has led to growing evidence on the risk factors for complications after surgery. However, the role of obesity in this patient group has been the subject of much debate. Therefore, this systematic review aimed to investigate the evidence for untoward effects of obesity following TAA. METHODS: We conducted a comprehensive search on April 28, 2023, in MEDLINE (via PubMed), Embase, and CENTRAL. Eligible observational studies reported on the short- and long-term outcomes of primary TAA, comparing patients with and without obesity (defined as body mass index > 30). Using a random effects model, we calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) from 2 by 2 tables (event and nonevent in the obese and nonobese primary TAA groups). RESULTS: Nine studies with 10 388 patients were eligible for inclusion in the meta-analysis. We found significantly higher odds of revision in the obese group compared to the nonobese group (OR = 1.68, CI: 1.44-1.95). However, the odds of overall perioperative complications (OR = 1.55, CI: 0.50-4.80) and wound complications (OR = 1.34, CI: 0.29-6.20) were nonsignificantly higher in the obese group. CONCLUSION: Based on our results, obesity may have affected long-term outcomes following TAA and may have negatively affected the prosthesis's survival.

[Hungarian adaptation of the Caregiver Priorities and Child Health Index of Life with Disabilities questionnaire]. / Cerebralis paresisben szenvedo gyermekek egészségindexe.

INTRODUCTION: Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire is a measurement tool for assessing health status and wellbeing of disabled children, which evaluates children's quality of life from the caregiver point of view. OBJECTIVE: The aim of our work was the Hungarian translation and cultural adaptation of the questionnaire and also validation of the CPCHILD on Hungarian cerebral palsy patients. Further aim was to test the eligibility of the questionnaire for superficial assessment of caregiver's psychological attitudes. METHOD: Translation of the questionnaire was carried out according to the Beaton's guidelines. Test-retest, interrater reliability (ICC) and also internal consistency (Cronbach-alpha) were calculated for reliability. The importance of the questions was assessed for face validity and known group validity test was done to measure construct validity. For examining parental attitudes, the patients were divided into ambulatory and non-ambulatory groups and the 36 quality of life questions of the 7th domain were used to find relations. RESULTS: During test-retest reliability measurements, the ICC was 0.96 (95% CI: 0.88-0.98), and Cronbach-alpha exceeded the minimal expected value of 0.7 (0.74-0.97) except in the 5th domain (0.67), while measuring interrater reliability the ICC was 0.87 (95% CI 0.70-0.94). Face validity was above the 2.0 threshold in every question (2.6-4.5; mean: 3.4 ± 1.34) and the known group validity calculations showed significant differences between the CPCHILD scores of ambulatory and non-ambulatory groups. Examining parental attitudes, a significant difference was also shown among the parents of ambulatory and non-ambulatory children in assessing the importance of sitting in the quality of life of their children (2.89 ± 1.28 vs. 3.51 ± 0.82; p<0.01). CONCLUSION: The final outcome of our study is that CPCHILD questionnaire has become widely accessible in Hungarian language. Our result, that the answers referring to the sitting abilities and the activities should be carried out in sitting position, was significantly different among the caregivers of the ambulatory and non-ambulatory children, showing that the parents of the GMFCS IV and V category children evaluate the importance of sitting ability higher compared to those parents who care for GMFCS I, II and III category children. Furthermore, the results draw attention to the wellbeing and health of the children measurable with CPCHILD as well as that parental caregiver attitudes can be recognized which may give further help in finding the balance between expectations and possibilities during the rehabilitation of cerebral palsy children. Orv Hetil. 2023; 164(16): 610-617.

A rabbit model for studying degeneration and regeneration properties of young striated muscle at different distraction rates.

The present study evaluated the histological changes in the muscle tissue after limb lengthening in skeletally immature rabbits and assessed the effect of different lengthening rates on the regeneration and degeneration properties of striated muscle. Thirteen different lengthening protocols were applied on a total of 16 male domestic white rabbits divided into four groups. The histopathological changes were analysed by a semiquantitative method according to the scoring system of Lee et al. (1993). After evaluation of the five main degenerative parameters (muscle atrophy, internalisation of muscle nuclei, degeneration of the muscle fibre, perimysial and endomysial fibrosis, haematomas), it is evident that rabbits subjected to limb lengthening at a rate of 3.2 mm/day showed more degenerative changes than those limb-lengthened at 0.8 or 1.6 mm/day. Our study showed that the regenerative mechanisms were not endless. If the daily lengthening rate reached the 3.2 mm/day limit, the regenerating ability of the muscle decreased, and signs of degeneration increased significantly.

Possible mistakes in prediction of bone maturation in fibular hemimelia by Moseley chart.

The purpose of this study was to establish a nomogram in order to predict limb length discrepancies in children with unilateral fibular hemimelia more accurately. In 31 children with unilateral fibular hemimelia the femoral-tibial length and skeletal age were determined an average of seven times per case by sequential radiographs during growth. From the data, a skeletal age nomogram was developed which shows a steeply declining mean skeletal age pattern in unilateral fibular hemimelia (the slope in girls was -0.59 and in boys -0.64). This nomogram crosses the normal mean skeletal age line of the Moseley straight-line graph at 10.5 years in girls and at 12 years in boys, and continues to decline until maturity. The results demonstrate an abnormal skeletal maturation process in patients with unilateral fibular hemimelia. The consistently declining steep skeletal age nomogram in unilateral fibular hemimelia makes prediction of skeletal maturity and limb length discrepancy inaccurate by the standard predictive methods particularly when using early skeletal ages. The skeletal age nomogram from our data determines skeletal maturation in children with unilateral fibular hemimelia more accurately, and allows a correct prediction of limb length discrepancy.

A Novel Three-Dimensional Computational Method to Assess Rod Contour Deformation and to Map Bony Fusion in a Lumbopelvic Reconstruction After En-Bloc Sacrectomy.

Introduction: En-bloc resection of a primary malignant sacral tumor with wide oncological margins impacts the biomechanics of the spinopelvic complex, deteriorating postoperative function. The closed-loop technique (CLT) for spinopelvic fixation (SPF) uses a single U-shaped rod to restore the spinopelvic biomechanical integrity. The CLT method was designed to provide a non-rigid fixation, however this hypothesis has not been previously tested. Here, we establish a computational method to measure the deformation of the implant and characterize the bony fusion process based on the 6-year follow-up (FU) data. Materials and Methods: Post-operative CT scans were collected of a male patient who underwent total sacrectomy at the age of 42 due to a chordoma. CLT was used to reconstruct the spinopelvic junction. We defined the 3D geometry of the implant construct. Using rigid registration algorithms, a common coordinate system was created for the CLT to measure and visualize the deformation of the construct during the FU. In order to demonstrate the cyclical loading of the construct, the patient underwent gait analysis at the 6th year FU. First, a region of interest (ROI) was selected at the proximal level of the construct, then the deformation was determined during the follow-up period. In order to investigate the fusion process, a single axial slice-based voxel finite element (FE) mesh was created. The Hounsfield values (HU) were determined, then using an empirical linear equation, bone mineral density (BMD) values were assigned for every mesh element, out of 10 color-coded categories (1st category = 0 g/cm3, 10th category 1.12 g/cm3). Results: Significant correlation was found between the number of days postoperatively and deformation in the sagittal plane, resulting in a forward bending tendency of the construct. Volume distributions were determined and visualized over time for the different BMD categories and it was found that the total volume of the elements in the highest BMD category in the first postoperative CT was 0.04 cm3, at the 2nd year, FU was 0.98 cm3, and after 6 years, it was 2.30 cm3. Conclusion: The CLT provides a non-rigid fixation. The quantification of implant deformation and bony fusion may help understate the complex lumbopelvic biomechanics after sacrectomy.

Structural changes in the lengthened rabbit muscle.

This study evaluated the histological changes in muscle tissue after limb lengthening in skeletally mature and immature rabbits and assessed the most vulnerable level of striated muscle. Twenty-three male domestic white rabbits, divided into six groups, were operated on and different lengthening protocols were used in the mature and immature rabbits. The histopathological changes were analysed by a semi-quantitative method according to the scoring system of Lee et al. (Acta Orthop Scand 64(6):688-692, 1993). After the evaluation of the five main degenerative parameters (muscle atrophy, muscle nuclei internalisation, degeneration of the muscle fibre, perimysial and endomysial fibrosis, haematomas), it is evident that the adults lengthened at a rate of 1.6 mm/day showed more degenerative changes than those lengthened at 0.8 mm/day. The adult 1.6 mm/day lengthened group presented significantly higher damage in the muscle and lower regenerative signs compared with the young 1.6 mm/day lengthened group, according to the summarised degenerative scores.

[Botulinum toxin treatment in children with cerebral palsy]. / Botulinumtoxin-kezelés infantilis cerebralis paresisben.

Introduction: Botulinum toxin is used for decreasing spasticity, improving gait pattern and preventing secondary deformities and orthopedic surgeries in children with cerebral palsy. Despite its wide use, there is no evidence for the long-term beneficial effect of the toxin. Aim: The authors focused on the short-term effects of the toxin and on the subjective evaluation done by the parents about the botox treatment. Method: First, the calf muscle of 18 children was treated and casting was also performed. In our second patient group, multilevel lower limb injection was done in 12 cases. Joints' range of motion, muscle tone and spasticity were assessed before and 4-6 weeks after treatment. In ambulatory children, gait analysis was done. Side effects were recorded and parental opinion about the treatment was requested. Results: Increased ankle range of motion and decreased muscle tone and spasticity were seen in our first patient group. In the second group, hip flexion contracture became milder and hip abduction and the popliteal angle improved. However, gait analysis results only slightly changed after botox treatment. Occasional mild and transient adverse effects were observed during the pharmacologically active period of the toxin. Associate beneficial effects were also reported such as better comfort, easier movements, improving function of the non-injected upper limb, decreasing dysarthria and dysphagia. Conclusion: Our study strengthens the observation that botox treatment of the spastic calf muscle together with plaster casting can result in improved ankle dorsiflexion. Multilevel botox treatment can improve lower limb joints range of motion, however, gait pattern remains unchanged. The administration of botulinum toxin with respect to the guidelines has no major adverse effects. Further studies are needed to clarify the observed beneficial associate effects of the toxin. Orv Hetil. 2019; 160(28): 1105-1111.

[Kinesiological examination in AIS]. / Kineziológiai vizsgálatok adolescens idiopathiás scoliosisban.

AIM: To define the shape of the scoliotic spine by the CMS-system, to analyze the changes of the scoliotic spine as compared to that of non-scoliotic patients and to study the effect of loading on the deformed spine in AIS. The aim of the authors was to find a connection between the progression of scoliosis and the changes of movements of the deformed spine. They also analyse the effect of loading on the deformed spine and reach conclusions with regard to the progression of the spine deformity. PATIENTS AND METHOD: In a prospective study 25 scoliotic patients with type King 1-2-3 scoliosis were examined. Mean Cobb grades were dorsal 27 degrees (min. 15, max. 42), lumbal 25 degrees (min. 14, max. 43). RESULTS: The significant increase of extension seems to be in connection with increased lordosis in scoliosis. The significant increase of right rotation in AIS emphasizes that very often the first sign is the increased rotation on the thoracic spine, which could be larger than the right curve on the spine itself. However, the significant decrease of left and right bending is not in correlation with the severity of the spine deformities. Up to 30 degrees Cobb grades the pp angle is in significant correlation with the Cobb grade, but over 30 Cobb grade this correlation is weak. CONCLUSION: During the clinical examination of the patient's spine only the "processus spinosus angle" may be observed, not the so-called Cobb angle, that is why we cannot leave out of consideration the X-ray analysis during the follow-up of the patients. The loading has a great influence on the degree of the gibbus and the severity of the thoracic curve.

[Kinesiological examinations and cutaneous EMG with integrated 3D UH system in adolescent idiopathic scoliosis (type: King 1-13)]. / Kineziológiai vizsgálatok és cutan elektromiográfia integrált háiromdimenziós ultrahangos klinikai vizsgálórendszerrel adolescens idiopathiás King 1-3 típusú scoliosisban.

UNLABELLED: The origin of idiopathic scoliosis is unknown however there are many hypothesis. One of them is the biomechanic theory. The cause of spreading the cutaneous EMG is: noninvasive, and can be used during movements. AIM: Authors find by CMS system in their earlier examination, that range of right rotation (of idiopathic scoliotic spine King 1-3 type) increased. They supposed that the change of spine motion cause change in muscle functions also. To verify this hypothesis above: they made examinations by cutaneous EMG parallel to the kinesiological examinations.(CMS system, 3D ultrasound movement analyse). METHOD: Kinesiological examinations on 25 girls with idiopathic scoliosis (King 1-3) were performed parallel to examining cutaneous bilateral EMG on eight spinal close muscles. RESULT AND CONCLUSION: They established that beside functional movements there were a so called non-functional movement however this component were small. Analysing the results, they used phase and amplitude analysis. In the course of phase- and amplitude analysis, they took only those changes into consideration which were significantly different of the two side compared with to healty groups. In the course of phase- and amplitude analysis, they found: that muscle erector spine was weakened in strength and decreased in movement range. They intend to make clear the etiology part in idiopathic scoliosis.

The humerus is the best place for bone lengthening.

The aim of this study was to examine the effectiveness of lengthening the humerus in children and young adults. Between 1984 and 2005, the Orthopaedic Department of Semmelweis University elongated 11 humeri (ten patients) for reasons of congenital hypoplasia (four cases), osteomyelitis (three cases), epiphyseolysis, growth plate closure after irradiation and obstetrical paralysis (one case each). The study cohort consisted of five females and five males, with an average age at the time of surgery of 17.8 years (range: 12-31 years). In every case, the lengthening was performed with a unilateral Wagner fixator. The lengthening protocol was 1 mm distraction daily (callotasis) after a 7-day latency period. The fixator was removed after total bone healing. Plate fixation or bone transplantation was not used. The average rate of lengthening was 6.2 cm (4.5-10.5 cm), and the achieved lengthening was 27% (range: 16-44%). The average healing index was 32 day/cm. One patient who suffered from temporary radial paresis, and temporary flexion contracture of the elbow was regarded as a complication following placement of the fixator. Based on our results, humeral shortening can effectively be treated with the unilateral Wagner fixator. The main difference between the original Wagner method and our approach is that we were able to leave the fixator in the humerus until total bony reconstruction so there was no need for plate fixation or bone transplantation.

Dysplasia epiphysealis hemimelica (Trevor's disease): 7 of our own cases and a review of the literature.

BACKGROUND AND PURPOSE: Dysplasia epiphysealis hemimelica is characterized by irregular overgrowth of cartilage in the epiphysis, usually affecting the knee and ankle. We treated 7 children by surgery between 1980 and 2005. After reporting one child case, we summarize our cases and the cases described in the literature. METHOD: We discuss the diagnosis of this dysplasia, especially the role of radiography. We describe the suggested treatment, which could be surgical or non-surgical depending on the location and the symptoms. RESULTS: After reviewing 57 cases, we found that this dysplasia occurs twice as often in males as in females. The medial side of the epiphysis is affected twice as often as the lateral side. In two-thirds of the cases, more than one epiphysis was affected. If the location of the exostosis suggests that it might lead to joint deformity, early surgical excision is recommended. INTERPRETATION: Since there is often involvement of more than one epiphysis, we emphasize the importance of a skeletal survey once this dysplasia is diagnosed.

The incidence of avascular necrosis of the healthy, contralateral femoral head at the end of the use of Pavlik harness in unilateral hip dysplasia.

We examined the incidence of avascular necrosis (AVN) of the healthy femoral head in unilateral hip dysplasia at the end of the use of the Pavlik harness. The evaluation of AVN was done with the help of standardised roentgenograms. Between 1974 and 1982, 1,064 dysplastic hips (869 children) were treated with the Pavlik harness at the Orthopaedic Department of Semmelweis University. Of these, 674 children who had unilateral hip dysplasia were chosen for this study. In the period of our investigation, ultrasonography was not yet used routinely, so in some cases the hip was mistakenly diagnosed as dysplastic. The average patient age was 3.2 months, and the average length of treatment was 4.9 months. We found no correlation between the appearance of AVN in the healthy hips at the end of treatment with the Pavlik harness and the age of the child at the start of treatment. On the other hand, there was a strong significant correlation between the appearance of AVN and the length of treatment.

Open adductor tenotomy in the prevention of hip subluxation in cerebral palsy.

We reviewed radiographs of 76 hips in 41 patients with cerebral palsy treated with open adductor tenotomy because of hip subluxation. The majority of patients suffered from spastic diplegia. The aim of our study was to evaluate the effect of adductor release on hip subluxation. We measured the centre-edge angle and migration percentage pre-operatively and 1 and 3 years post-operatively. We considered the results according to patients' age at time of surgery (younger or older than 4 years of age) and ability to walk. Children younger than 4 years of age had better results than children older than 4 years of age. In children without walking ability, more than half of the hips had further radiological subluxation. In children with walking ability, we observed stabilisation or improvement of femoral-head subluxation in more than three quarters of the cases.

Intraarticular osteoid osteoma: clinical features, imaging results, and comparison with extraarticular localization.

OBJECTIVE: Intraarticular osteoid osteoma is uncommon and presents diagnostic difficulties, which are important for both rheumatologists and orthopedic surgeons. Clinical symptoms, imaging procedures, differential diagnostic problems, and treatment results of intraarticular as compared with extraarticular osteoma are analyzed in this retrospective study. METHODS: Nineteen patients with intraarticular osteoid osteomas (Group A), with a mean followup period of 34 months, are compared with 15 others with extraarticular lesions (Group B). RESULTS: Nine intraarticular tumors were located in the hip, 3 in the elbow, 6 in the ankle, and one in the first metatarsal head. The nonspecific symptoms in Group A, such as chronic synovitis, decreased range of motion, joint effusion, contractures, and lack of the intense perifocal sclerotic margin on radiographs, led to significant delay in diagnosis (on average 26.6 mo in Group A, 8.5 mo in Group B). The extreme variety of previous diagnoses at referral reflect the problems of differential diagnosis. A detectable nidus is often absent on conventional radiograph. Bone scintigraphy is unspecific and often fails to visualize the nidus. Computed tomography scans were accurate in two-thirds of the intraarticular and in 90% of extraarticular cases. Magnetic resonance image findings, although sometimes controversial, provided essential additional information for the correct diagnosis and therapy. CONCLUSION: Clinical symptoms and imaging signs of intraarticular osteoid osteomas were significantly different from the classical hallmarks of extraarticular lesions. The 10% intraarticular occurrence of osteoid osteomas in this series is not as rare as some investigators suggest. The radiological and clinical findings are uncharacteristic and misleading, and the lesions are difficult to identify. Careful search for history data, such as nocturnal pain and positive salicylate test, in addition to extensive imaging procedures, led to the correct diagnosis prior to surgery in two-thirds of our patients with intraarticular osteoid osteomas.