Treatment of Graf Type IIa Hip Dysplasia: A Cut-off Value for Decision Making

Background: The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases. Aims: To evaluate the natural course of type IIa hips using Graf's own perspective of physiological immaturity and maturational deficit. Study Design: A single center, retrospective cohort study. Methods: This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and ß angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and ß angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and ß angles for persistent dysplasia. Results: Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip). Conclusion: The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.

Factors affecting adherence with foot abduction orthosis following Ponseti method.

OBJECTIVE: The Ponseti method is an effective protocol for treatment of congenital idiopathic clubfoot. Foot abduction orthosis (FAO) is sometimes necessary to preserve the correction achieved with the serial casting and tenotomy. Patient and family adherence to brace use is a common problem, as nonadherence is directly related to relapse. The aim of this study was to investigate patient and parent characteristics related to relapse. METHODS: One hundred and fifty-three children who were treated with Ponseti method (mean age: 44.62 months; range: 16-104 months) and their parents were included in the study. Thirty-one patients experienced relapse at an average follow-up of 32 months (range: 6-84 months) since beginning orthosis use. At the time of follow-up visits, parents were questioned about brace use adherence. Satisfaction with Symptoms Scale in the American Academy of Orthopaedic Surgeons (AAOS) Pediatric Outcomes Data Collection Instrument (PODCI) was used. RESULTS: Difficulties with brace use were encountered in 122 children. Children of parents who were satisfied with the treatment had relapse at an average of 69.13±2.64 months, and those of parents who were not satisfied at 32.83±7.51 months. The most important variable was the child's adaptation to the orthosis treatment without an adverse reaction. Additionally, better compliance was found in children with higher-educated parents. CONCLUSION: Non-compliance with periods of intolerance is very common for children during orthosis treatment. Parents' coping strategies are very important to avoid relapses. It is important to develop strategies to guide parents.

Differences between the alpha angles measured manually and digitally from paediatric hip ultrasonograms.

The aim of this study was to reveal whether a meaningful difference is caused by measuring the alpha angle in hip ultrasonography manually or digitally to help the early diagnosis and treatment of DDH and observe the treatment implications of any such difference. All ultrasound images were obtained by same orthopaedist, and each hip was measured twice by two investigators with different levels of experience. Standard images were taken, and a printout of the standard images were obtained. The alpha angle was measured digitally by using the sonography device. The alpha angle was also measured by pencil, ruler and goniometer on the printout after 2 days. One hundred and two hips of 51 babies, at a mean age of 14 weeks, were assessed. The mean alpha angle measured manually with a goniometer was 64.4° (±1.6°), while that measured on the ultrasonography device was 65.3° (±0.9°). This difference was found to be statistically different (p = 0.016). Typology changes occurred in a total of 10 hips out of 102 as a result of manual and digital measurements. However, this study showed reduction in alpha angle variation and considerable advantages for manual alpha angle measurement with pencil and goniometer on a printout compared to computer-based measurement; future studies are needed to understand these differences caused by each measurement method.

Congenital agenesis of pubis and bilateral cryptorchidism: A case report.

INTRODUCTION: Agenesis of the pubic bone, as evidenced in the world literature, is a very rare clinical and congenital abnormality. Several disorders may occur with hypoplasia of the pubis. PRESENTATION OF CASE: Here, we report a rare longer follow-up case of the congenital unilateral agenesis of the superior ramus of pubic bone with bilateral undescended testes, osteoporosis, cranial malformations, acetabular dysplasia, unilateral shortening of the lower extremity and an abnormal gait pattern. DISCUSSION: Somatic mutations may responsible for developmental abnormalities of the mesoderm from which the pubic bones and urogenital structures develop. CONCLUSION: An isolated x-ray finding of ramus pubis agenesis may associate with cryptorchidism or several other urogenital malformations.

Idiopathic hypertonicity as a cause of stiffness after surgery for developmental dysplasia of the hip.

INTRODUCTION: There are various complications reported with surgical treatment of DDH. Most studied complication is avascular necrosis of the femoral head and hip stiffness. The purpose of this report was to describe a case with severe stiffness of the hip due to hypertonicity in periarticular muscles after it was treated for developmental dysplasia of the hip (DDH). PRESENTATION OF CASE: Three-year-old patient referred to our institution with bilateral DDH. Two hips were operated separately in one year with anterior open reduction, femoral shortening osteotomy. Third month after last surgery, limited right hip range of motion and limb length discrepency identified. Clinical examination revealed that patient had limited range of motion (ROM) in the right hip and compensated this with pelvis obliquity. Gluteus medius, sartorius and iliofemoral band release performed after examination under general anesthesia. Symptoms were persisted at 3rd week control and examination of the patient in general anesthesia revealed full ROM without increased tension. For the identified hypertonicity, ultrasound guided 100IU botulinum toxin A injection performed to abductor group and iliopsoas muscles. Fifth month later, no flexor or abductor tension observed, and there was no pelvic obliquity. DISCUSSION: Stiffness as a complication is rare and is usually resolved without treatment or simple physical therapy. Usually it is related with immobilization or surgery associated joint contracture, and spontaneous recovery reported. Presented case is diagnosed as hip stiffness due to underlying local hypertonicity. That is resolved with anesthesia and it was treated after using botulinum toxin A injection. CONCLUSION: Hypertonicity with hip stiffness after surgical treatment of DDH differ from spontaneous recovering hip range of motion limitation and treatment can only be achieved by reduction of the muscle hypertonicity by neuromuscular junction blockage.

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities.

INTRODUCTION: The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. PATIENTS AND METHODS: The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors' clinics. RESULTS: At a mean follow-up of 46 months (range 24-89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. CONCLUSION: Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.

[Treatment of congenital clubfoot with the Ponseti method]. / Dogustan çarpik ayagin Ponseti yöntemi ile tedavisi.

OBJECTIVES: This study aimed to present the author's early experience with the Ponseti technique in correcting clubfoot and to evaluate the need for aggressive surgery in the first year of life. METHODS: The study included 44 feet of 31 patients (25 boys, 6 girls; mean age 3 months; range 4 days to 8 months) with idiopathic clubfoot deformities of grade II, III, or IV. Twenty-seven feet (19 patients) had not received any treatment before. Twelve patients (17 feet) had had unsuccessful prior conservative treatment elsewhere. All patients had manipulation casting in accordance with the Ponseti technique, and percutaneous Achilles tenotomy was performed in the presence of persistent equinus. Maintenance of correction was obtained with the use of a foot abduction brace. The mean follow-up period was 18 months (range 6.5 to 40 months). RESULTS: Forty-two feet (95%, 29 patients) were treated successfully using the Ponseti method. In terms of compliance with the foot abduction brace, a significant difference was noted between patients without previous treatment and those with deformities considered resistant to prior conservative treatment. The latter manifested more compliance with brace application. CONCLUSION: Ponseti method proved efficient in correcting idiopathic congenital clubfoot deformities irrespective of initial deformity grades, provided that the details of the technique are strictly adhered to. The results also suggest the role of brace application in order to avoid relapses along with the importance of increasing patients' compliance through family education and experienced orthotists.