Periacetabular osteotomy with concomitant hip arthroscopy: a case series with 24 months minimum follow-up

PURPOSE To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. METHODS Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. RESULTS A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. CONCLUSION To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

Medición radiográfica del ángulo acetabular para el diagnóstico temprano de la displasia del desarrollo de la cadera / Radiographic measurement of the acetabular angle for early diagnosis of hip development dysplasia

Resumen: Antecedentes: Para evitar secuelas en la displasia del desarrollo de la cadera el tratamiento debe ser temprano; el ángulo acetabular corresponde a la inclinación del techo del acetábulo. Stanisavljevic indica que para medir adecuadamente el ángulo acetabular se deben colocar las caderas en abducción. Pregunta: ¿cuál es la magnitud de la diferencia de la medición radiográfica del ángulo acetabular entre las proyecciones anteroposterior de pelvis en posición neutra y con abducción de caderas? Métodos: Se tomaron 916 mediciones radiográficas comparando las de posición neutra contra las de abducción de caderas, de pacientes atendidos en consulta externa entre el 1 de Abril de 2010 y el 31 de Marzo de 2013. Resultados: Se realizaron pruebas t para medias de dos muestras emparejadas y se obtuvo una diferencia hipotética de las medias de 0.0000 y el coeficiente de correlación de Pearson para cadera derecha fue 0.74427531 y para la izquierda 0.73779866. Usando una Tabla propuesta de normalidad del ángulo acetabular según edad, se obtuvo el área bajo la curva en una distribución tgl457 = 0.650 con p = 0.516. El índice acetabular en posición neutra y con abducción de caderas es similar con alta significancia estadística, según el análisis de correlación de Pearson. Con base en la curva ROC, el índice acetabular en posición de rana tiene una alta sensibilidad y especificidad. Por tanto, la medición del índice acetabular en posición con abducción de caderas, tiene alta confiabilidad de lograr un diagnóstico correcto.

Abstract: Background: In order to avoid sequelae in the development dysplasia of the hip the treatment should be early; The acetabular angle corresponds to the inclination of the roof of the acetabulum. Stanisvljevic indicates that to properly measure the acetabular angle, the hips should be placed in abduction. Question: What is the magnitude of the difference in radiographic measurement of the acetabular angle between the anteroposterior projections of pelvis in neutral position and with abduction of hips? Methods: 916 radiographic measurements were taken by contrasting the neutral position against those of hip abduction, of patients in our clinic attended between April 1, 2010 and March 31, 2013. Results: T tests were performed for means of two matched samples and a hypothetical difference of the mean of 0.0000 was obtained and the Pearson correlation coefficient for right hip was 0.74427531 and for the left 0.73779866. Using a proposed Table of normality of the Acetabular angle according to age, the area was obtained under the curve in a distribution Tgl457 = 0.650 with P = 0.516. The index acetabular in neutral position and with abduction of hips is similar with high statistical significance, according to the analysis of correlation of Pearson. Based on the ROC curve, the acetabular index in frog position has a high sensitivity and specificity. Discussion: Therefore, the measurement of the acetabular index in position with hip abduction, has high reliability to achieve a correct diagnosis.

Utilidad de la artrografía en la decisión terapéutica en niños con displasia del desarrollo de cadera de tres meses a tres años de edad / Usefulness of the arthrogram in the decision therapy in children with developmental dysplasia of the hip from 3 months to 3 years of age

Resumen: Objetivo: Evaluar la utilidad de la artrografía como herramienta en la decisión terapéutica de pacientes con displasia del desarrollo de cadera (DDC). Material y métodos: 19 niños con diagnóstico de DDC habitual de edad entre tres meses y tres años, sin antecedentes quirúrgicos, Tonis II o III y expediente radiográfico completo. Para cada caso se registró la decisión terapéutica radiográfica y artrográfica por tres observadores independientemente, en el análisis estadístico el estándar fue la cirugía realizada necesaria para lograr una reducción concéntrica y cobertura acetabular adecuada. Resultados: 20 casos, 19 pacientes, de los cuales 18 fueron unilateral y uno bilateral. Fueron 17 niñas (89%) y dos niños (11%). Edad promedio: un año tres meses (de cuatro meses a dos años 11 meses), 11 Tonis II (55%) y nueve Tonis III (45%). El coeficiente de correlación intraclase (CCI) en relación con la decisión terapéutica radiográfica fue de 0.8933 y para la artrografía fue de 0.7205. El CCI de la decisión terapéutica radiográfica en relación con el estándar fue de 0.7933 y para la artrográfica fue de 0.6219. Se confirmó que en los 20 casos revisados la utilidad de la artrografía (CCI 0.6219) es menor que la de las radiografías (CCI 0.7933). La utilidad de la artrografía fue mayor en los pacientes con Tonis II con una edad entre nueve meses y dos años.

Abstract: Objective: To evaluate the utility of arthrography as a tool in therapeutic decision in developmental dysplasia of hip (DDH). Material and methods: 19 children with true DDH with age between three months and three years, without previous surgical treatment, with Tonis II or III, and complete X-rays. For each case; therapeutic decision was registered for X-rays and arthrography by three independent observers, we took like standard, surgery in each patient necessary to obtain a concentric reduction and good acetabular coverage. Results: 20 cases, 19 patients. 18 unilateral, 1 bilateral. They were 17 girls (89%) and 2 children (11%). Average Age: 1 year 3 months (4 months to 2 years 11 months). 11 Tonis II (55%) and 9 Tonis III (45%). The intraclass coefficient of correlation (ICC) in relation to the decision therapeutic radiographic was of 0.8933 and for the arthrography of 0.7205. And ICC of the decision therapeutic radiographic in connection with the standard was of 0.7933 and for the arthrography it was of 0.6219. We confirm that in our 20 cases, the utility of the arthrography (ICC 0.6219), is smaller to the X-rays (ICC 0.7933). The utility of the arthrography was bigger in the patients with Tonis II, and an age between nine months and two years.

Detección temprana clínica y radiológica básica de la displasia congénita de cadera en unidades médicas del primer nivel de atención / Early clinical and radiological basic detection of congenital hip dysplasia at primary health care units

Resumen: Hay un aumento en el número de casos de displasia de cadera congénita tardía, secuelas, discapacidad y falta de diagnóstico temprano. La problemática observada es que difieren la sensibilidad y exploración clínica y los conocimientos del tema en médicos son deficientes. Se evaluó la calidad de la capacitación en displasia congénita de cadera al personal del primer nivel de la atención médica. Se realizó un estudio de cohorte prospectiva estudiando a 228 médicos por tres años; se les aplicó un examen pre- y postcurso, se dio un taller. Posteriormente, se inició la toma de radiografías de pelvis en menores de seis meses, se evaluó la referencia y la medición radiográfica. El análisis estadístico valoró el cambio de calificación obtenida en las mediciones antes y después del taller, tanto en el grupo que lo recibió como en el que no lo llevó. Se utilizaron promedios, desviación estándar, mínimo y máximo para describir las calificaciones, así como para las diferencias de puntajes. Para probar la significancia en las diferencias, se utilizó "t" de Student, con n-1 grados de libertad. Se detectaron 31 caderas patológicas en menores de seis meses de vida con el taller. Discusión: El grupo capacitado reflejó que el curso podría tener impacto positivo al mejorar significativamente la calificación (p < 0.0001) posterior al curso tanto teórico como práctico y la medición radiográfica. Se evidenció un bajo conocimiento. La capacitación con el taller sensibilizó al personal médico y se observó un número progresivo de pacientes menores de seis meses con una detección oportuna.

Abstract: The number of cases of late congenital hip dysplasia has increased, together with its sequelae, disability and absence of early diagnosis. The problem is that there is a difference between the sensitivity and the clinical exam, and the physicians' knowledge of this topic is poor. We evaluated the quality of the training provided to the primary health care staff on congenital hip dysplasia. A prospective cohort study was undertaken to study 228 physicians for 3 years. A workshop was delivered and the physicians took a pre-workshop and a post-workshop exam. Then pelvic X-rays of infants under 6 months of age were taken and the X-ray references and measurements were assessed. The statistical analysis assesses the change in the pre-workshop and post-workshop grades in both the group that participated in the workshop and the group that did not. The statistical variables used included means, standard deviation, minimum and maximum grades, and the score differences. Student's t test was used to prove the statistical significance of the differences, with n-1 degrees of freedom. Thirty-one pathological hips were detected in infants under 6 months of age in the group that took the workshop. Discussion: The group that received the training shows that the latter may have a positive impact since an improvement in the grades (p < 0.0001) was seen after the theoretical and practical course and after the X-ray measurements. A low knowledge level was observed. The training raised the awareness of the health care staff and a progressive increase was seen in the number of infants under 6 months of age who received a timely detection.

Comparison of clinical and sonographic prevalence of developmental dysplasia of the hip

Developmental dysplasia of the hip [DDK] is one of the most widely discussed abnormalities in neonates. The advantages of sonographic examination are well known, but its main disadvantage is that it might lead to over diagnosis, which might cause over treatment. Variations in the incidence of developmental dysplasia of the hip are well known. During six months study since September 2006 all 1300 neonates [2600 hips] were born in our hospital examined clinically and sonographically [587 hips] in the first 48 hours of life. Sonography was performed according to Grafs method, which considers mild hip sonographic abnormalities as type II a. Type IIb Graf were considered pathologic. Sonography screening of 587 hips detected 36 instances of deviation from normal indicating a sonographic DDH incidence of 12.5%. However, only 8 neonates remained abnormal and required treatment, indicating a true DDH incidence of 6 per 1000 live birth. Risk of diagnosis clinically and sonographicaly were 2.5 and 4.5 percent respectively and was significant [P<0.00001, x[2]=l 170]. In order to avoid over diagnosis in first days examination, repeated clinical and sonographic examination is required

The Correlations of the Radiological Parameters of Hip Dysplasia and Proximal Femoral Deformity in Clinically Normal Hips of a Korean Population

BACKGROUND: The aim of this study was to answer the following two questions: 1) Do the radiological parameters of dysplasia have significant correlations between themselves or with the parameters of the proximal femoral deformity and vice versa? 2) Do the physical parameters have a significant correlation with the radiological parameters of hip dysplasia and proximal femoral deformity? METHODS: Four hundred and twenty eight consecutive patients with no clinical evidence of hip osteoarthritis and who underwent pelvic radiography in the supine position for hip contusion or a routine health check were analyzed for the relationships between the center-edge (CE) angle, acetabular depth, acetabular angle, the head-neck ratio and the neck-shaft angle as well as the relationships of the above-mentioned variables with age, gender, body height and the body mass index. RESULTS: The CE angle, acetabular depth and acetabular angle showed a strong correlation with each other. The neck-shaft angle and the head-neck ratio showed no correlation with each other or with the CE angle, acetabular depth and acetabular angle. Age was positively associated with the CE angle, and inversely associated with the acetabular depth or acetabular angle. Male gender was significantly associated with the increased neck-shaft angle, and inversely associated with the head-neck ratio. CONCLUSIONS: The radiological parameters of hip dysplasia are all strongly, if not perfectly, inter-correlated. Age was associated with the radiological parameters of hip dysplasia whereas gender was associated with the radiological parameters of a proximal femoral deformity.

Frequency of developmental dysplasia of hip detected by graf's ultrasonographic method in icteric newborns: a preliminary study

Limping is a debilitating problem that can be prevented by screening at risk newborns. Jaundice is a problem that brings approximately one fifth of newborns to hospital in early infancy. The aim of this study was to find out whether the newborns with physiologic jaundice are at an increased risk of developing developmental dislocation of hip and whether it is logical to screen these newborns with Graf's ultrasonographic method. Throughout a year, 320 icteric newborns [640 hips] that referred to Nemazee Hospital Neonatal Emergency Room for checking their bilirubin were screened by Graf's ultrasonographic method for developmental dislocation of hip [DDH]. Any newborn with other problems such as congenital anomalies were excluded form this study. Of the 640 hips, 21 newborns [3.28%] had a dysplastic hip [Class IIa] that needed follow up and 12 from them came back for follow up of hip ultrasongraphy, all of whom became normal [Class Ia] without treatment. Only 1 hip did have severe dysplasia [Class IIc] [.16%] that needed treatment at the time of discovery. The rate of DDH seems not to increase in the newborns with physiologic jaundice. It seems not to be logical to screen newborns with physiologic jaundice with Graf's ultrasonographic method, if screening is not cost-effective

Ultrasonographic findings in developmental dysplasia of the hip in Iraqi infants

Ultrasound [U/S] is valuable modality for evaluating the hip in infants because it enables direct imaging of the cartilaginous portion of the hip that cannot be seen on plain radiographs. Furthermore, U/S examination enables dynamic study of the hip with stress maneuvering. U/S is the preferred imaging modality which used to study the hip disorders like developmental dysplasia of hip [DDH], because it is sensitive indicator of malposition, instability and lack of acetabular development. U/S accomplishes all of these without exposing the infant to ionizing radiation, not expensive, non-invasive and available. The aim of our study is to determine the effectiveness and sensitivity of ultrasound examination of neonates to confirm the early clinical diagnosis of developmental dysplasia of hip [DDH] especially in the high risk groups of neonates and young infants. We conducted a retrospective review of ultrasonographic imaging in 60 neonates and young infants [36 females and 24 males; age range, 1-9 months, median age, 4 months]. U/S examination of the hip joint were evaluated for, percent bony coverage [PBC], which indicates the percentage of the femoral head that covered by the bony acetabulum, normally, 50% or over of the femoral head should be covered by bony acetabulum. And evaluated for Graf angles, alpha angle which defines the bony acetabulum and normally it is more than 60 degree and beta angle which indicates the cartilaginous development and it is normally less than 55 degree. Also evaluate the femoral head flattening which usually associated with delayed ossification, shortening and anteverting of the femoral neck .DDH is more common in the female patients [F:M = 3:1] Instability and dislocation is usually unilateral, this is seen in 30 patients [50%], [unilateral :bilateral = 3:1]. Left hip is more commonly affected, this is seen in 24 patients [40%],[L:R = 4:1]. Children born by caesarian section are more likely to have associated instability or dislocation of the hip, 10 patients [25%]. First born baby are more affected, 4 patients [10%] and usually these children are more likely to have been breech presentation during their gestation, 14 patients [35%]. Family history of DDH is seen in 6 patients [15%]. The U/S is the preferred modality for evaluating the hip in infants who are younger than 6 months. U/S of infant's hip can be used in the diagnosis of DDH and also in monitoring of treatment or follow-up the improvement in the acetabular maturity and morphology, as well as the location of femoral head can be documented to assist in the guidance of therapy plan

Clinical and radiological aspects of closed reduction in developmental dysplasia of the hip treated in the first six months

To evaluate the success rate and subsequent restoration of normal acetabular angle [AC], and associated growth changes secondary to avascular necrosis of the proximal femur in cases of developmental dysplasia of the hip [DDH] treated during the first six months of life. Retrospective study from 1998 to 2006. Department of Pediatric Orthopedics, Altona Children Hospital, Hamburg, Germany. Twenty six patients with twenty nine dysplastic hips were evaluated regarding grade of hip dysplasia. The success rate of closed reduction, postoperative restoration of normal acetabular coverage [AC angle] and associated complication were noted. Closed reduction of DDH with intraoperative arthrogram followed by spica cast. Success rate of closed reduction and restoration of normal acetabular index. Closed reduction could be achieved in twenty two hips [76%]. Out of those twenty two hips fifteen [68%] developed normal acetabular index, six [27%] showed persistent acetabular dysplasia and one [5%] had border -line measurement. Closed reduction was not successful in seven hips. Those seven hips were treated by open reduction and capsulorrhaphy. Closed reduction of DDH in the first six months of life was achieved in [76%] of dislocated hips, and did not show any significant growth changes in the proximal femur. The early changes in the ossific nucleus of capital femoral epiphysis [CFE] alone were found to be of very little value in predicting the nature of development of the hip

[Application of ultrasound in musculo skeletal pathologies in pediatrics]

Osteoarticular ultrasound, a well established technique in adults, appears to be very useful also in children because of the non ossification of cartilaginous structures, the possibility to avoid sedation and irradiation, and hence the use of scanner and MRI will be reduced. This is a review of the clinical applications of musculoskeletal ultrasound in the pediatric population. Pictorial examples of cases collected between January 2003 and December 2006 of different pathologies encountered in Lebanon are displayed with a discussion of congenital malformations, traumatic lesions, inflammatory and infectious lesions, bone dystrophy and dysplasia, metabolic and tumoral lesions

Utrasonic evaluation of neonatal hip dysplasia

Ultrasound imaging of the neonatal hip [less than five months] is crucial for the early diagnosis and management of the developmental dysplasia of the hip [DDH] and for avoiding hip morbidity. The objective of this study was to evaluate and compare the different sonographic techniques adopted for the assessment of DDH and to verify the value of routine neonatal hip sonography. For the early detection of DDH, the study included 1200 hips [600 neonates], being examined by the routine standard and stress dynamic ultrasound hip techniques. The results of this study showed the importance of performing combined standard and dynamic hip sonography for all cases

Proximal femoral focal deficiency (PFFD).

A 1-year-old child with proximal femoral focal deficiency (PFFD) is presented. The clinical spectrum and associated abnormalities is described and the diagnosis and management of this entity is discussed.

Clinical, radiological and ultrasound study of clicky hips in neonates

32 full term newly born Saudi babies, 25 females and 7 males. The study comprised 15 cases as control. 17 cases were referred to the orthopaedic department due to clicky hips; 7 of the latter were bilateral. Barlows and Ortolain tests were used for examination of the hips. Radiological: Plain X-rays of the pelvis and hips were done in all cases. Ultrasound: Coronal section was obtained for each hip joint, alpha and beta angles were measured as well as the femoral head diameter, containment of the femoral head, cartilage covering, labrum and ligamentum teres and also shape of promontory. t-student test, F ratio, chi square and r test were used. Monthly clinical and ultrasound follow up examinations were performed. showed that the ultrasound examination of the hips proved valuable and superior to the other methods and is considered a sensitive tool in detecting any changes in the neonatal hips