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.

Sonoelastographic Findings in Clubfeet.

PURPOSE: One of the main features of congenital idiopathic clubfoot is the increased stiffness of soft tissues. With the growing popularity and availability of sonoelastography as a method to assess the stiffness of different tissues, we considered applying it to congenital clubfeet in order to to determine whether sonoelastography can be a useful imaging method for the evaluation of clubfeet, to assess whether there are any differences in stiffness of specific tendons between clubfeet and normal contralateral feet and to observe which treatment methods have an impact on the aspect of these structures on the elastograms. PATIENTS AND METHODS: A case-control study was performed involving 10 adolescent patients with unilateral idiopathic congenital clubfeet who were treated either with the Ponseti method or surgically with posteromedial release (PMR) during early infancy. Using compression sonoelastography, we obtained semi-quantitative data expressed as fat to tendon ratios in treated clubfeet and normal contralateral feet. The tendons of the following muscles were examined: tibialis anterior, tibialis posterior, flexor hallucis longus, peroneus longus and Achilles tendon at three levels (calcaneal insertion, lengthened zone and musculotendinous junction). RESULTS: The only statistically significant difference in the strain ratio (p = 0.023) between clubfeet and normal feet was at the level of the calcaneal insertion of the Achilles tendon, which was stiffer in clubfeet. Although other differences were not statistically significant, they may reflect some of the pathological modifications of clubfeet. CONCLUSION: Overall, sonoelastography may be a useful examination tool in the quantitative and qualitative assessment of soft tissue stiffness in clubfeet, but further research is necessary.

Posteromedial Release versus Ponseti Treatment of Congenital Idiopathic Clubfoot: A Long-Term Retrospective Follow-Up Study into Adolescence.

PURPOSE: Although many short-term studies have shown the superiority of Ponseti treatment to surgical treatment, studies with long-term follow-up of patients into adolescence are lacking. The aim of this study was to compare the morphological, functional and radiological results of the two methods into and during adolescent age, when both soft tissue and bony procedures can be performed to correct residual deformities. PATIENTS AND METHODS: We retrospectively evaluated two groups of patients diagnosed with congenital idiopathic clubfoot and treated with either the Ponseti method (34 clubfeet) and surgery in the form of posteromedial release (31 clubfeet). All included clubfeet were clinically fully corrected after initial treatment and final plaster removal. Evaluation was performed with the International Clubfoot Study Group (ICFSG) score. RESULTS: The age at follow-up was 12.8±1.6 years in the Ponseti group and 13.5±1.7 years in the surgical group. Excellent or good results were obtained in 26 feet (76%) of the Ponseti group and in 14 feet (45%) in the surgical group. The Ponseti treatment was significantly superior to posteromedial release in terms of the final score (10.58±6.49 versus 17.26±8.83, p<0.001), functional score (p<0.001) and radiological score (p<0.001). Residual deformities were clinically present in both groups but were less frequent and less severe in Ponseti-treated patients. Flat-top talus was found to be present in both groups, but the Ponseti method was more protective than surgical treatment against this outcome (relative risk=0.494, p=0.002). The overall foot and ankle mobility was significantly better in the Ponseti group (p<0.001). CONCLUSION: The Ponseti method was superior to surgery for treatment of clubfoot and achieved better long-term morphological, functional and radiological results. It preserves better mobility of the foot and ankle, and results in less frequent and less severe residual deformities than surgical treatment.

Cross-cultural adaptation and validation of the Romanian International Knee Documentation Committee-subjective knee form.

AIM: We aimed to translate and cross-culturally adapt the International Knee Documentation Committee-subjective knee form (IKDC) in Romanian. METHOD: The original (US) IKDC-subjective knee form was translated according to recommended guidelines. Validity was tested using Spearmans's correlation coefficient between score sand test-retest reproducibility. Reliability and internal consistency were determined using Cronbach's alpha coefficient and intraclass correlation coefficient (ICC). RESULTS: A total of 106 data sets were available for processing. The average age was 52 years and the male to female ratio was 40:66. Fifty-five subjects repeated the form after an average of 4 days. There were no floor or ceiling effects (range 3.4-74.7). There was a strong correlation between the first and repeated administration of the IKDC-subjective knee form (r = 0.816, n = 50) and moderate compared to Tegner-Lysholm knee rating scale (r = 0.506, n = 102), KOOSJR (Knee disability and Osteoarthritis Outcome Score for Joint Replacement, r =  - 0.622, n = 96), EuroqolEQ-5D-5L Index (r = 0.633, n = 100) and visual analogue scale VAS (r = 0.484, n = 99). Internal consistency was moderate with Cronbach's alpha 0.611 (n = 102) and ICC 0.611 for average measures (95% CI 0.493-0.713). CONCLUSION: The Romanian translation of the IKDC-subjective knee form is a valid, consistent and reproducible outcome measure in patients with knee pain and dysfunction.

Combined Anterolateral, Anterior, and Anteromedial Ankle Impingement in an Adolescent Soccer Player: A Case Report and Review of the Literature.

A unique case of combined anterolateral, anterior, and anteromedial ankle impingement in an adolescent soccer player is presented in this article. To the best of our knowledge, this is the only report of circumferential, massive, anterior ankle impingement in children described in the literature. The importance of proper diagnosis and treatment of such a lesion is illustrated in this case report. We also emphasize that clinical examination combined with 3D computed tomography scan reconstruction is an excellent and cost-effective imaging modality that can help with the diagnosis of anterior ankle impingement. Finally, open surgical treatment showed excellent results in an elite athlete.

Ultrasonography of borderline and asymmetric infant hips - a challenge in the management of developmental dysplasia of the hip.

BACKGROUND AND AIM: Developmental dysplasia of the hip (DDH) is a potentially disabling disease. There are many diagnostic approaches, Graf method ultrasonography being the most popular imaging method. Although considered as a healthy condition, the existence of hips at the 60 degree limit or the asymmetries higher than 4 degrees between left and right side may be a source of unfavorable evolution and consequently of late diagnosed dysplasia cases. METHODS: The retrospective study was conducted in the Radiology Department of the Emergency Clinical County Hospital Cluj-Napoca, by retrospective analysis of the database containing 3013 records of the subjects presented for DDH assessment between January 2008 and December 2014. The study focuses on investigating two possible sources of missed cases by clinical-ultrasound management of DDH: borderline and asymmetric hips. Two conditions were studied in patients considered healthy according to Graf method: borderline hips (those with α angle value of 60° and 61°) and asymmetric hips (left to right difference between the α angle values exceeds 4°). Three study groups were formed: healthy subjects, asymmetric/borderline subjects and patients with immature or mild dysplasia. The incidence of risk factors, clinical suspicion and the success of therapy were evaluated. RESULTS: There were no significant differences between the three groups regarding the role of the risk factors in DDH pathogenesis. Data reveal a high suspicion rate after the clinical examination, in groups II and III, compared to the healthy population. This means that from this point of view, Group II might be considered having at least a dysplastic prognosis. An increased correlation in the therapeutic results was observed between Group II patients and those from mild delayed maturation subgroups from Group III (IIa-, IIa+). CONCLUSIONS: Asymmetric and borderline hips should be approached similarly to immature hips, clinical suspicion and the therapeutic outcome being similar.

Joint hyperlaxity prevents relapses in clubfeet treated by Ponseti method-preliminary results.

PURPOSE: The aim of the study was to evaluate the role of joint hyperlaxity (by Beighton score) as a protective factor for clubfoot relapse. METHODS: Patients with idiopathic clubfoot treated with the Ponseti method between January 2004 and December 2012, without other congenital foot deformity, and not previously treated by open surgery were included in either the Relapse group (n = 23) if it was a clubfoot relapse or the Control group (n = 19) if no relapse was noted. Joint laxity was evaluated using the Beighton score at the latest follow-up against the Normal group (n = 22, children matched by sex and age without clubfoot deformity). RESULTS: We found a significantly higher joint laxity in the Control group (4.58, 95% confidence interval [CI]: 2.1-7.06) as compared to the Relapse (3.17, 95% CI: 1.53-4.81, p = 0.032) and Normal (3.14, 95% CI: 1.78-4.5, p = 0.03) groups. The univariate logistic regression showed a 5.28-times increase in the risk of relapse for a Beighton score lower than 4/9 points (odds ratio = 5.28; 95% CI = 1.29-21.5; p = 0.018). CONCLUSIONS: Joint hyperlaxity could be a protective factor for clubfoot relapse.

Aggressive development of an aneurysmal bone cyst of the proximal femur in a paediatric patient: a case report.

We report development of an aneurysmal bone cyst (ABC) that was located in the proximal region of the femur in an 11-year-old girl. Over a period of 30 weeks, the ABC showed fulminant local progression, with destruction of the bone, which led to an abrupt loss of function of the left hip. The standard tumour treatment protocol was followed. We performed embolisation of the tumour followed by a biopsy, which confirmed the diagnosis of ABC. The outcome was negative with total destruction of the proximal third of the femur, despite repeating the embolisation. Because of the unfavourable local progression, a second biopsy was performed and we reconfirmed the initial diagnosis. The final decision regarding the therapeutic approach was total hip arthroplasty with femoral reconstruction with a prosthesis. Following this treatment, the patient's outcome was favourable, with complete recovery of function and no local relapse.

Outcome of pinning in patients with slipped capital femoral epiphysis: risk factors associated with avascular necrosis, chondrolysis, and femoral impingement.

Objective This study aimed to assess the principal risk factors that could lead to the most common long-term complications of slipped capital femoral epiphysis, such as avascular necrosis, chondrolysis, and hip impingement. Methods We conducted a single-centre, retrospective study and evaluated patients (70 patients, 81 hips) who were treated for slipped capital femoral epiphysis from 2010 to 2015 and who underwent pinning. We measured the severity of displacement radiologically using the Southwick angle. Postoperative radiographs were evaluated for the most frequent long-term complications of avascular necrosis (AVN), chondrolysis, and femoral acetabular impingement (FAI). Results We found seven cases of AVN, 14 cases of chondrolysis, and 31 hips had an α angle of 60°. Sex, ambulation, and symptoms did not affect development of these complications. Patients with a normal weight were almost two times more likely to develop FAI. Patients with moderate and severe slips had a similar percentage of AVN. In severe slips, 85.7% of patients had an α angle higher than 60°. Conclusions This study shows that severe slips have a higher risk of developing AVN and hip impingement. Every patient who suffers from SCFE (even the mildest forms) should be regularly checked for FAI.

Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review.

Hip osteoarthritis is the most common joint disorder, and is represented by a degenerative process, resulting in pain and functional impairment. If conservative treatment for hip osteoarthritis fails, the only remaining option is hip arthroplasty. Despite good survival of implants, loosening of components is the most common complication. This leads to revision surgeries, which are technically demanding, expensive, and result in a low satisfaction rate. Uncemented hip replacements require proper osseointegration for increased survival. Physical characteristics of implants include biocompatibility, Young's modulus of elasticity, strength, and corrosion resistance, and each influence fixation of implants. Moreover, implant surface treatments, pore size, pore density, and femoral stem design should be appropriately selected. Patients' optimization of obesity, osteoporosis, cardiovascular disease, psychotic disorders, and smoking cessation are associated with a higher survival of implants. Surgical factors, such as approach, drilling and rasping, acetabular bone coverage, acetabular cup positioning, and implant size, also affect survival of implants. Avoiding drugs, which may impair osseointegration of implants, and having an appropriate rehabilitation protocol are important. Future directions include anabolic and anti-catabolic bone-acting drugs to enhance osseointegration of implants. Comprehensive knowledge of the factors mentioned above is important for preventing aseptic loosening, with important socioeconomic consequences.

Transitioning to the direct anterior approach in total hip arthroplasty. Is it a true muscle sparing approach when performed by a low volume hip replacement surgeon?

PURPOSE: We conducted this study to establish if the transition from a lateral approach (LA) to the direct anterior approach (DAA) for a low volume hip arthroplasty surgeon during the steep learning curve can be performed maintaining the muscle sparing approach of the DAA without increasing the complication rates. METHODS: In this controlled, prospective, randomized clinical study we investigated 70 patients (35 DAA, 35 LA) with similar demographics that underwent a total hip arthroplasty. Assessment of the two approaches consisted of determining the invasiveness through serum markers for muscle damage (i.e. myoglobin, creatine kinase and lactate dehydrogenase), the operative parameters such as post-operative pain and rescue medication consumption, the component positioning and complication rates. RESULTS: Post-operative myoglobin levels were higher (p < 0.001) in the LA group (326.42 ± 84.91 ng/mL) as compared to the DAA group (242.80 ± 71.03 ng/mL), but with no differences regarding other biomarkers for muscle damage. Pain levels were overall lower in the DAA group, with a statistical and clinical difference during surgery day (p < 0.001) associated with lower (p < 0.001) rescue medication consumption (median 1 (1; 3) mg morphine vs. 3 (2; 4) mg morphine). Most patients in the LA group reported chronic post-operative pain throughout all three evaluated months, while the majority of patients in the DAA group reported no pain after week six. Component positioning did not differ significantly between groups and neither did complication rates. CONCLUSION: The DAA can be transitioned from the LA safely, without higher complication rates while maintaining its muscle spearing advantages when performed by a low volume hip arthroplasty surgeon.

The modified Dunn procedure for slipped capital femoral epiphysis does not reduce the length of the femoral neck.

OBJECTIVE: The treatment of slipped capital femoral epiphysis (SCFE) is evolving, with the development of new surgical techniques. |We wanted to study if modified Dunn procedure restores the normal alignment of the proximal femur and the risk of avascular necrosis is increased. METHODS: This is a single centre, retrospective study, comparing the outcomes of in situ pinning and modified Dunn procedure. Between 2001 and 2014, 7 children (7 hips) underwent the modified Dunn procedure and 10 children (10 hips) pinning in situ for stable and unstable SCFE. Mean age of the patients was 12.7 years with a median follow-up of 18 months. RESULTS: The radiological parameters improved in the modified Dunn procedure group, while the length of the femoral neck didn't change significantly (p=0.09). Postoperative clinical outcomes were slightly better in the modified Dunn procedure group (6 hips out of 7 had good and excellent results) compared to the pinning in situ group (8 good and excellent results out of 10 hips) (p=0.04). No avascular necrosis was found and there were no cases of chondrolysis. CONCLUSION: Radiographic parameters of the proximal femur assessed in our study improved in all hips that underwent modified Dunn procedure, without the creation of secondary deformities.

A new sign in the standard hip ultrasound image of the Graf method.

AIM: The aim of the study was to assess the usefulness of obtaining a 900 angle between the plane of the osteochondral plate and the surface of the transducer during standard hip ultrasonography according to Graf method. MATERIAL AND METHODS: In this retrospective study 1078 patients (2156 hips) were included examined between 2008 and 2014 for developmental dysplasia of the hip (DDH) ultrasound screening. The patients were divided in two groups. Group I consisted of 402 patients examined between January 2008 and December 2011 using the standard Graf method. Group II consisted of 676 patients examined from January 2012 to December 2014 using the Graf method with an additional criterion: 900 angle between the plane of the osteochondral plate and the surface of the transducer. RESULTS: We found more dysplastic patients in group I comparing to group II: 55 (13.7%) and 38 (5.6%) respectively. The difference in the incidence of patients diagnosed with DDH was highly significant (p<0.001). The mean alpha angle value in group I was 65.310, respectively 67.520 for group II (p<0.001). CONCLUSION: The new osteochondral plate sign has the potential to reduce the overdiagnosis of DDH and provide a better tailored approach to borderline hips.

A Clinical Evaluation of the Pirani and Dimeglio Idiopathic Clubfoot Classifications.

The clubfoot classifications described by Pirani and by Dimeglio are in widespread use today in foot and ankle surgical practice and are used to differentiate between lesions and compare treatment results. The aim of the present study was to determine whether in an independent center, one or both classification systems can be implemented practically and in a reproducible manner. From January 2004 to January 2014, we conducted a prospective study concerning the classification systems for clubfoot. The study group included 280 children (411 feet). The mean Dimeglio score noted by the 2 examiners was 10.3 ± 0.69 and 10.6 ± 0.81 points for the 411 feet, respectively. The mean difference in the Dimeglio scoring system was 1.11 ± 0.43 points (95% confidence interval 1.5 points). The Pearson correlation coefficient was 0.85. The corresponding mean Pirani scores were 5.1 ± 0.23 and 5.3 ± 0.17 points for the 411 feet. The mean difference in the Pirani score was 0.65 points (95% confidence interval 0.45 points). The Pearson correlation coefficient was 0.89. The good correlation coefficient for the Dimeglio and Pirani systems recommends their simultaneous use in clubfoot examinations, because the aspects under investigation (reducibility and foot aspect) are both different and complementary.

Ponseti treatment for clubfoot in Romania: a 9-year single-centre experience.

Manipulation and casting according to the Ponseti method are the 'gold standard' for clubfoot treatment, and this method is endorsed by the American Association of Orthopaedic Surgeons. We conducted a retrospective study from January 2004 to December 2012 in our institution. All patients with idiopathic clubfoot were included, and a very strict analysis of the treatment outcomes, relapses and their treatment was carried out. A total of 382 children were included and followed up for a mean period of 6 years. The initial correction rate was 100%. At latest follow-up, the relapse rate was 19.03%, the initial correction being recovered by recasting, second or third percutaneous Achilles tenotomy or anterior tibial tendon lateral transfer. The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions, and the very good results are maintained through a 9 years follow-up period.

Elastic Stable Intramedullary Nailing for Fractures in Children - Principles, Indications, Surgical Technique.

Elastic stable intramedullary nailing (ESIN) is a minimally invasive technique. According to this technique, two elastic nails are introduced through the metaphysis into the medullary canal, advanced through the fracture site and impacted into the opposite metaphysis. These nails are preformed in a C-shaped manner, which allows for their precise orientation and the creation of an elastic system that resists deformation.

Elastic Stable Intramedullary Nailing for Fractures in Children - Specific Applications.

Elastic stable intramedullary nailing (ESIN) is a new minimally invasive technique for the treatment of pediatric fractures. It approximates the physiological healing process of bone, without opening the fracture site. Also, the operative stress is minimal because of the minimally invasive nature of the procedure, and the volume of implants is small, offering a very good stability without plaster cast immobilization.

Sonoelastography contribution in cerebral palsy spasticity treatment assessment, preliminary report: a systematic review of the literature apropos of seven patients.

This paper aims to present our experience of 7 cases of spastic children, using sonoelastography in assessing the muscle spasticity: the relaxed muscle structures appear mostly soft (green-yellow-red), while contracted or degenerated muscle fibers appear hard (blue). Using sonoelastographic findings we established the proper place for injecting the botulinum toxin (20 U/kg Dysport) into the affected muscle. The result was a precise, guided injection, with positive, therapeutic results. It is important consider several factors that can influence the evolution of the case: gray scale ultrasound appearance of the muscle, the patient age, the dosage and the fractionation of toxin.

Comparative results of the conservative treatment in clubfoot by two different protocols.

The current study aims at presenting the results of the two methods of conservative treatment in clubfoot: the Romanian traditional method and the Ponseti method. The study population included 103 children (148 clubfeet) treated in our department between 1998 and 2005. Between 1998 and 2003, the conservative treatment protocol was based upon the Romanian method. The Ponseti method has been used since 2004. The main criterion for the assessment of the efficiency of the two conservative methods in clubfoot is the number of feet requiring surgical treatment - posteromedial release at 18 months. This criterion is clearly in favor of the Ponseti method: four feet (5%) needed posteromedial release in Ponseti group patients versus 13 feet (18%) in Romanian group patients (P=0.0193). The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.