An Eastern Europe and Middle East multinational expert Delphi consensus study on the prevention, diagnosis, and treatment of developmental dysplasia of the hip before walking age.

PURPOSE: The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age. METHODS: Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age. RESULTS: Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head. CONCLUSION: The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided.

Correction of Severe Knees Valgus Deformities in a Patient With Renal Osteodystrophy.

Renal osteodystrophy (ROD) is a complex and rare entity that refers to a large spectrum of abnormalities of skeletal homeostasis in patients suffering from chronic kidney disease. The goal of this study was to present the outcome of the very rare case of an adult with severe deformity of painful bilateral valgus knees due to ROD, requiring multilevel osteotomies above and below the knee. A 42-year-old male patient was admitted to our department with painful severe bilateral valgus knees deformity due to ROD. The patient underwent bilateral lateral opening-wedge osteotomy of distal femur and medial tibial closing-wedge osteotomy. The osteotomies site healed in 8 weeks without complications. The surgical treatment of lower limb valgus knee deformities secondary to ROD is a challenging and demanding procedure. In our patient, the femoral opening-wedge osteotomy with blade-plate fixation, and tibial closing-wedge osteotomy with plate fixation, restored almost normal knee congruency to prevent lateral unicompartmental degenerative deterioration of the knee.

Comparison of systemic inflammatory responses of proximal femoral nail versus dynamic hip screw after treatment of patients with pertrochanteric fractures: A prospective comparative study.

OBJECTIVE: The aim of this study was to investigate the differences between the induction of early postoperative inflammatory response and muscle tissue injury biomarkers after treatment of pertrochanteric fractures by dynamic hip screw (DHS) or proximal femoral nail (PFN). METHODS: In this prospective comparative study, 40 patients with AO-Müller/Orthopaedic Trauma Association (AO/OTA) 31. A1-31.A2 pertrochanteric fractures were enrolled and allocated one of the two groups based on the treatment type: group DHS, (n =20,mean age = 78.4 ± 6.9 years) and group PFN (n = 20, mean age = 77.75 ± 7.0 years). Operation time was recorded in both groups. In each patient, circulating levels of high sensitivity interleukin-6 (hs-IL-6), C-reactive protein (CRP), and creatine kinase (CK), and erythrocyte sedimentation rate (ESR)weremeasured fromblood samples collected 1 hour preoperatively and 24 hours postoperatively. RESULTS: The operation time was slightly shorter in group PFN than in group DHS (51.9 ± 21.1 and 38 ± 15.2 min, respectively; P = 0.02). DHS and PFN both increased hs-IL-6 (143.81 ± 89.12 and 94.13 ± 67.14, respectively), CRP (98.84 ± 31.81 and 104.4 ± 31.80, respectively), and CK (400.8 ± 31.81 and 250.7 ± 31.80, respectively) 24 hours postoperatively. However, PFN compared to DHS resulted in a lesser increase from baseline to 24 hours postoperatively only in hs IL-6 (58.91 ± 59.02 vs 113.30 ± 76.24, respectively; P = 0.0016) and CK (163.6 ± 123.3 vs 310.0 ± 198.3, respectively; P < 0.0001).Moreover, there was a positive correlation of CK levels' surgery time in DHS (r = 0.38, P = 0.0065) and PFN (r = 0.45, P = 0.0013). CONCLUSION: The results of this study have shown that PFN can induce a lower early postoperative inflammatory response and muscle tissue injury based on the assessment of hs-IL-6 and CK levels, compared to DHS in after the treatment patients pertrochanteric fractures. LEVEL OF EVIDENCE: Level II, Therapeutic Study.

Clubfeet and congenital constriction band syndrome.

BACKGROUND: Clubfeet and constriction band syndrome is a very rare non-idiopathic condition. Treatment is often difficult and the recurrence deformity rate is high. The purpose of this study was to assess the effectiveness of Ponseti method in the treatment of congenital constriction band syndrome accompanied by clubfoot deformity and lymphedema. CASE PRESENTATION: We are presenting an interesting case of bilateral clubfeet and congenital circumferential constriction band syndrome in the lower limb. Ponseti method of correcting the congenital clubfoot deformity was applied. Constriction band release is accomplished by two stages completely excising the fibrous band and multiple two-stage Z-plasties on the right calf. CONCLUSION: The results of this study indicate that the Ponseti method of gentle, systematic manipulation and weekly cast changes is an effective treatment of non-idiopathic clubfoot distal to congenital amniotic constriction band.

Corrective osteotomy of distal radius malunion after IIIB open fracture: Palmar approach - Case report.

BACKGROUND: Despite the fact that distal radius fractures are the most common, open fractures are relatively uncommon. The aim of this study is to present the case with severe malunion of extra-articular left distal radius after open fracture grade IIIB (Gustillo). The treatment was done with open correctuve osteotomy and ostosynthesis with volar low profile plate. CASE PRESENTATION: A 32-years old man was admitted to our departement because of severely malunited left distal radius extra-articular metaphyseal fracture after treatment of an open fracture. He was primary treated in a Regional Hospital with irrigation, debridement, antimicrobial cover, and immediate skeletal management through fixation with Kirschner's wires. No external fixator was used. He developed volar metaphyseal angulation after loss of primary reduction of K-wires fixation; therefore it required corrective surgical treatment. Because of malunion, open corrective osteotomy and bone grafting of distal radius with volar plating were done. Follow-up 20 months after surgery show deformity correction of radial volar inclination, height, and restitution of distal radioulnar joint. CONCLUSION: This case report offers an informative overview on this uncommon case of distal radius open fracture malunion treated successfully with volar approach corrective osteotomy. Corrective surgery is the primary therapy of choice in the this case. This method have shown to be safe and effective in treatment of distal radius malunion with volar angulation.

Management of Coxa Vara Septica and Pseudoarthrosis of the Femoral Neck: A Case Report.

BACKGROUND Coxa vara and pseudoarthrosis of the femoral neck after septic hip arthritis is a very rare disease. The aim of this study was to present a case with pseudoarthrosis of the femoral neck, with coxa vara after neonatal septic arthritis of the right hip, and treatment of the pseudarthrosis with proximal femoral valgus osteotomy. CASE REPORT A 12-month-old female, who had suffered neonatal septic arthritis with a five-day history of fever and painful right hip now demonstrated painless limping to the right hip, pelvic obliquity, Trendelenburg-Duchenne gait, limitation of hip abduction, lower-extremity length discrepancy with 3.0 cm of shortening of right femur, and walking on her tiptoes. In addition, a viable femoral head, coxa vara, and pseudoarthrosis of the femoral neck were observed. At the age of 26-months, the patient had a realignment valgus osteotomy of the proximal femur and adductor tenotomy was performed. At the last follow-up postoperative evaluation, at the age of four and a half years, the patient showed successful consolidation of pseudoarthrosis, correction of Trendelenburg gait, restored right lower extremity alignment, and corrected lower-extremity length discrepancy. CONCLUSIONS In the case of coxa vara and pseudoarthrosis of the femoral neck, realignment of the proximal femoral valgus osteotomy and bone grafting of the pseudoarthrosis resulted in ossification of the femoral neck as the epiphyseal plate was placed at right angle to the compressive forces.

Gait knee kinematics after ACL reconstruction: 3D assessment.

PURPOSE: While many studies about anterior-cruciate-ligament-deficient (ACLD) patients have demonstrated functional adaptations to protect the knee joint, an increasing number of patients undergo ACL reconstruction (ACLR) surgery in order to return to their desired level of activity. The purpose of this study was to compare 3D kinematic patterns between individuals having undergone ACLR with their healthy contralateral knee and a control group. METHODS: Three-dimensional kinematic data were obtained from 15 patients pre- and post-ACLR, 15 contralateral knees and 15 healthy controls. Data were recorded during treadmill walking at self-selected speed. Flexion/extension, external/internal tibial rotation, adduction/abduction and anterior/posterior tibial translation were compared between groups. RESULTS: ACLR knees showed a significantly higher knee-joint extension during the entire stance phase compared with ACLD knees. However, ACLR knees still showed a deficit of extension compared with healthy control knees. In the axial plane, there was no significant difference in pre- and postoperative kinematic data. Significant difference was achieved between ACLR knees and healthy control knees, specifically between 28 and 34 % and 44 and 54 % of the gait cycle. There was no significant difference in anterior-posterior translation or coronal plane between groups. CONLUSION: Following ACL reconstruction, patients have better clinical and kinematic parameters. Despite improvements, knee kinematics during gait in the ACLR group differed from the control group. These kinematic changes could lead to abnormal loading in the knee joint and initiate the process for future chondral degeneration.

Application of topical pharmacological agents at the site of peripheral nerve injury and methods used for evaluating the success of the regenerative process.

Traumatic injuries of the peripheral nerves are very common. Surgical repair of the damaged nerve is often complicated by scar tissue formation around the damaged nerve itself. The main objective of this study is to present the recent data from animal experimental studies where pharmacological topical agents are used at the site of peripheral nerve repair. Some of the most commonly topical agents used are tacrolimus (FK506), hyaluronic acid and its derivatives, and melatonin, whereas methylprednisolone and vitamin B12 have been used less. These studies have shown that the abovementioned substances have neuroprotective and neuroregenerative properties though different mechanisms. The successes of the regenerative process of the nerve repair in experimental research, using topical agents, can be evaluated using variety of methods such as morphological, electrophysiologic, and functional evaluation. However, most authors agree that despite good microsurgical repair and topical application of these substances, full regeneration and functional recovery of the nerve injured are almost never achieved.

The Pelvic Support Osteotomy After Type IVA Septic Arthritis of the Hip.

INTRODUCTION: A misdiagnose and inadequate treatment of neonatal septic arthritis of the hip has multiple sequelae and causes a severe disability. The aim of this study is evaluation of treatment of residual deformity after type IVA neonatal septic arthritis of the hip by Pelvic support osteotomy. CASE PRESENTATION: A 11-year-old, white girl, was treated surgically by pelvic support osteotomy. The patient underwent two surgical interventions. The first operation consists in lengthening of the left femur for 6 cm with monolateral lengthening external fixation device. The second operation consists in pelvic support osteotomy of the left femur and lengthening for 4 cm. The limb was well aligned after healing, with the axis aligned under the medial wall of the acetabulum. CONCLUSION: Pelvic support osteotomy can successfully correct a Trendelenburg-Duchenne gait and simultaneously restore knee alignment and correct lower-extremity length discrepancy.

Correlation between avascular necrosis and the presence of the ossific nucleus when treating developmental dysplasia of the hip.

PURPOSE: This study assessed whether avascular necrosis (AVN) is correlated with the presence or absence of the ossific nucleus (ON) at the initiation of conservative treatment for developmental dysplasia of the hip (DDH). To date, the correlation between the presence of the ON and AVN manifestations remains ambiguous. METHODS: The medical records of 148 patients with 234 dislocated hips who presented at our institution between January 2006 and December 2007 were reviewed. Based on ultrasound examination, the hips were classified according to Graf IIIa, IIIb, and IV criteria. Patients aged >6 months were simultaneously examined by standardized pelvis radiography. RESULTS: The ON was present in 84 hips (35.9 %) at the beginning of treatment. Treatment was begun at a mean age of 5 months, with overhead traction for 2 weeks followed by arthrography and a spica cast for 4 weeks. Afterwards, we used a Tübingen hip-flexion splint. The mean age at final follow-up was 87 months. Hips were radiographically evaluated at last follow-up according to the Ogden-Bucholz AVN classification scheme. There was no significant difference in AVN prevalence between ON(-) versus ON(+) hips in children aged ≤10 months (P = 0.681), whereas when all age groups were analyzed together, AVN was significantly increased in ON(+) hips (P = 0.002). Clinical examination revealed no differences in limping, leg length inequality, and range of motion of hips in the ON(-) versus ON(+) groups. CONCLUSION: We conclude that DDH treatment should be performed early without regard to the presence or absence of the ON. Reduction should not be delayed beyond >10 months of age because any delay in treatment increases the incidence of AVN.