The infants who have mature hip on ultrasonography but have risk factors of developmental dysplasia of the hip are required radiographic examination.

OBJECTIVES: This study aims to evaluate the short-term results of infants who were radiologically diagnosed with developmental dysplasia of the hip (DDH), but in whom hip development was normal ultrasonographically. PATIENTS AND METHODS: Between January 2018 and September 2020, a total of 15 infants (2 males, 13 females; median age: 5 months; range, 4 to 6 months) who were diagnosed with DDH radiologically and treated were retrospectively analyzed. Hip ultrasonography was used for early diagnosis, treatment, and for follow-up in infants up to six months of age. While the ultrasonographic findings were normal, radiography was performed in infants between four to six months of age who were at risk for DDH. RESULTS: Fifteen patients (22 hips) were diagnosed with DDH radiologically and treated. Radiologic dysplasia continued in seven hips of five patients during short-term follow-up. CONCLUSION: These results suggest that ultrasonographic hip maturation may not be consistent with normal hip development in infants, particularly in those who are at risk for DDH. In infants with DDH which is confirmed by radiography (less than 6 months of age), the diagnosis may be missed on ultrasonographic examination.

Is Stage 2 idiopathic osteonecrosis of the hip joint associated with version angles on imaging methods?

OBJECTIVES: In this study, we aimed to investigate whether anatomical variations of acetabulum were associated to idiopathic osteonecrosis (ON) of the femoral head. PATIENTS AND METHODS: Between January 2014 and March 2020, a total of 46 patients (32 males, 14 females; mean age: 43 years; range, 18 to 66 years) who were diagnosed with unilateral or bilateral ON of the hip joint and 44 healthy age- and sex-matched controls (30 males, 14 females; mean age: 46 years; range, 18 to 79 years) with no signs of ON of the hip joint were retrospectively analyzed. For both groups, measurements were taken of the anatomic parameters, including the acetabular version angle (VA), the sharp angle (SA), and the center-edge angle (CEA) on anteroposterior pelvic radiographs and magnetic resonance imaging (MRI) scans. RESULTS: The mean VA of both hips was found to be significantly smaller in Group 1 than in Group 2 on both MRI and X-ray (14.9±4.1 and 14.4±3.1 vs. 17.3±3.9 and 18.0±3.7, respectively; p=0.004, p<0.001). The mean SA of both hips was found to be significantly smaller in Group 1 than in Group 2 on both MRI and X-ray (39.0±2.9 and 38.9±2.8 vs. 41.6±3.9 and 40.8±4.9, respectively; p=0.001, p=0.036). The mean CEA of both hips was found to be significantly larger in ON group than in control group on both MRI and X-ray (36.7±6.1 and 36.9±7.0 vs. 32.0±6.0 and 31.5±7.5, respectively; p<0.001, p=0.001). CONCLUSION: Version angles were found to be smaller in patients with ON and more acetabular coverage was observed. Greater coverage of the acetabulum may indicate early collapses of the femoral head even in Stage 2 ON patients. The smaller version angles may be associated with ON.

Discrepancy between ultrasonographic and radiographic findings in patients treated for developmental dysplasia of the hip; hip maturation on ultrasonography may not be consistent with radiographic hip maturation.

Currently, hip sonography is used for early diagnosis and for monitoring developmental dysplasia of the hip (DDH) treatment in many countries. An early pioneer of ultrasonography for early diagnosis of DDH was Graf. Based on the Graf approach, hip ultrasonography is more sensitive and specific than radiography for the diagnosis of DDH, because of its capability to show cartilaginous structures of the hip joint. The aim of this study was to compare radiographic and ultrasonographic findings in patients treated for DDH. This study included 88 infants (98hips) treated for DDH. Radiography was simultaneously used for treatment and follow-up evaluation in addition to ultrasonography after six months of age. A retrospective evaluation was made of the ultrasonographs and radiographs of these infants. Of the total 98 hips, 28 were normal both ultrasonographically and radiographically, and a pathologic hip was demonstrated in 32 hips both sonographically and radiographically. Hip ultrasonography showed abnormal development in 32 hips, while radiography showed abnormal development in 70 hips. In 38 hips, the findings were normal according to ultrasonography but pathological according to radiography. There were no hips that were normal radiographically but pathological sonographically. When radiography is accepted as the standard imaging method in our study patients, the sensitivity and specificity of hip ultrasonography were determined as 45.7% [95% confidence interval (CI): 41.5-45.7] and 100% (95% CI: 89.4-100), respectively. These findings suggest that hip maturation apparent on ultrasonography may not be consistent with radiographic hip development in infants treated for DDH.

Can a Hip Diagnosed as Graf Type 1According to Graf Checklist Deteriorate Over Time? A Case Series and Evaluation of the Graf Method.

INTRODUCTION: According to the Graf method, mature Type 1 hips will not worsen overtime. However, some cases have been reported in literature of hips which were initially Graf Type 1 hips and then worsened later. Our aim is to show the mistakes of the hip sonograms, which had been diagnosed as a mature Graf Type 1 hips. CASE REPORT: A review of literature revealed four studies initially diagnosed as Graf Type 1 hips and which then worsened overtime. Professor Graf has previously stated that measurements from inappropriate sonograms may result in an incorrect diagnosis. In this paper, the four aforementioned studies and their sonograms reported in literature were evaluated according to the Graf technique. In the light of the findings, it was discussed whether a mature hip could worsen overtime. In the reported cases, some of the deficiencies according to the Graf checklist were determined. CONCLUSION: From this examination, it can be concluded that Type 1 mature hips which worsened overtime, except for special circumstances as previously mentioned by Professor Graf, are related to an initial wrong diagnosis. As a result, if a Graf Type 1 hip was determined appropriately according to Graf checklist, it will never worsen later in normal circumstances.

Reduction of the dislocated hips with the Tübingen hip flexion splint in infants.

PURPOSE: Early detection and conservative treatment are essential for a successful outcome in developmental dysplasia of the hip (DDH). The aim of this study was to evaluate the efficacy of Tübingen hip flexion splint treatment on dislocated hips of type D, 3, and 4 according to the Graf classification. METHODS: A total of 104 dislocated hips in 92 patients were treated with Tübingen splints. Splint treatment was applied to patients with dislocated hips as diagnosed under ultrasonographic evaluation. After four to six weeks of treatment, the hips were re-evaluated according to the Graf classification under ultrasonography. The success of Tübingen splinting was determined as follows: hips initially diagnosed as Graf type 3 and 4 were upgraded to type 2c, 2b, or 1 after treatment, and hips initially diagnosed as Graf type D were upgraded to type 2b or 1 after treatment. RESULTS: The mean age at treatment initiation was 11.91 ± 5.16 (range, 4-32) weeks. There were no statistically significant relationships between success rates and sex, bilateral hip involvement, or initial physical examination findings (p > 0.05). The age at the start of treatment was found to be statistically significant in terms of the success of the splint (p = 0.03). CONCLUSIONS: For successful treatment with Tübingen splints, the cut-off point of starting initial treatment was defined as the 15th week, with sensitivity of 84.62% and specificity of 62.50%. The success rate was 75% with a successful outcome in 78 hips. In view of these results, Graf type D, 3, and 4 dislocated hips can be successfully treated with Tübingen splints.

Sagittal plane tilting deformity of the patellofemoral joint: a new concept in patients with chondromalacia patella.

PURPOSE: The aims of this study were to evaluate sagittal plane alignment in patients with chondromalacia patella via magnetic resonance imaging (MRI), analyse the relationships between the location of the patellar cartilaginous lesions and sagittal alignment and finally investigate the relationships between the sagittal plane malalignment and patellofemoral loadings using by finite element analysis. METHODS: Fifty-one patients who were diagnosed with isolated modified Outerbridge grade 3-4 patellar chondromalacia based on MRI evaluation and 51 control subjects were evaluated. Chondromalacia patella patients were divided into three subgroups according to the chondral lesion location as superior, middle and inferior. The patella-patellar tendon angle (P-PT) was used for evaluation of sagittal alignment of patellofemoral joint. Each subgroup was compared with control group by using P-PT angle. To investigate the biomechanical effects of sagittal plane malpositioning on patellofemoral joint, bone models were created at 30°, 60° and 90° knee flexion by using mean P-PT angles, which obtained from patients with chondromalacia patellae and control subjects. The total loading and contact area values of the patellofemoral joints were investigated by finite element analysis. RESULTS: The mean age of all participants was 52.9 ± 8.2 years. The mean P-PT angle was significantly lower in chondromalacia group (142.1° ± 3.6°) compared to control group (144.5° ± 5.3°) (p = 0.008). Chondral lesions were located in superior, middle and inferior zones in 16, 20 and 15 patients, respectively. The mean P-PT angles in patients with superior (141.8 ± 2.7) and inferior subgroups (139.2 ± 2.3) were significantly lower than the values in the control group (p < 0.05). The contact area values were detected higher in models with chondromalacia than in the control models at the same flexion degrees. There were increased loadings at 30° and 90° flexions in the sagittal patellar tilt models. CONCLUSION: This study revealed that sagittal plain malpositioning of the patellofemoral joint might be related to chondromalacia, especially in the presence of lesions in the upper and lower part of the patella. This condition leads to supraphysiological loadings on the patellofemoral joint. Sagittal patellar tilt should be considered in the evaluation and management of patellar cartilage defects. Taking sagittal plane malalignment into consideration in patellofemoral joint evaluation will enable us to design new physical and surgical modalities. LEVEL OF EVIDENCE: IV.

Maternal Height and Infant Body Mass Index Are Possible Risk Factors for Developmental Dysplasia of the Hip in Female Infants.

Developmental dysplasia of the hip (DDH) is a wide-spectrum disease with a multifactorial etiology and, despite its prevalence, no definitive etiology has yet been established. The aim of this study was to investigate new risk factors for DDH by evaluating newly defined potential risk factors. A total of 71 infants were separated into 2 groups:Group I, 28 female first-born infants diagnosed with DDH and their mothers;and Group II, 43 healthy female first-born infants and their mothers. The maternal height and weight before pregnancy, infant height and weight at birth, and body mass index (BMI) of both mother and infant were determined. Calculations were made of the ratios between these parameters. Of the examined risk factors, only maternal height and the ratio of maternal height to infant BMI (MH/I-BMI) were found to be significant for DDH in infants. In conclusion, the results of this study show that a short maternal height and a low MH/I-BMI increase the risk of DDH. Further studies with a larger series are necessary to confirm these results.

A rarely seen multilevel thoracic vertebral fracture after a nocturnal hypoglycemic convulsion attack.

A 49-year-old male presented with acute midthoracic severe back pain following a witnessed nocturnal convulsion attack. There was no history of trauma and the patient had a 23-year history of Type I diabetes mellitus. MRI scans of the thoracic spine revealed compression fractures at T5, T6, T7, and T8 vertebrae. The patient was treated conservatively. At 17 months after the initial diagnosis, the complaints of back pain had been resolved and the patient was able to easily undertake daily living activities. Hypoglycaemia is a common problem in diabetic patients treated with insulin. Convulsions may occur as a consequence of insulin-induced hypoglycemia. Nontraumatic compression fractures of the thoracic spine following seizures are a rare injury. Contractions of strong paraspinal muscles can lead to compression fracture of the midthoracic spine. Unrecognized hypoglycaemia should be considered to be a possible cause of convulsions in insulin-dependent diabetic patients. The aim of this report is to point out a case of rarely seen multilevel consecutive vertebrae fractures in a diabetic patient after a nocturnal hypoglycaemic convulsion attack.

Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques?

BACKGROUND: The aim of the study was to investigate whether the number and position of Kirschner (K)-wires, and the manner and duration of immobilization influence radiologic and functional outcomes of distal radius fractures treated with percutaneous K-wire fixation. METHODS: Ninety-two patients were included into the study with a mean follow-up period of 19.84±5.22 months (range, 13-34 months). In Group I, forty-five patients were treated with 3 K-wires and supported with a volar semi-circular cast for the first 3 weeks followed by a removable splint for a further 3 weeks. In Group II, forty-seven patients were treated with 2 K-wires and supported with a below-elbow circular cast for 6 weeks postoperatively. RESULTS: No significant difference in grip strength and DASH scores was found between the two groups. In clinical examination, significantly better functional results were determined in patients supported with a removable volar splint. At 6 weeks postoperatively, volar tilt, radial inclination, and radial length were significantly better in Group I compared to Group II (all p values). CONCLUSION: Tripod technique with 3 K-wires is a safe and reliable procedure to achieve stability and good radiological results. The use of a removable splint also improves the functional outcomes in the treatment of both intra- and extra-articular distal radius fractures.

An unusual presentation of charcot arthropathy caused by syringomyelia mimicking a soft tissue tumor.

Charcot arthropathy is a chronic, degenerative condition and is associated with decreased sensorial innervation. Numerous causes of this arthropathy have been described. Here we report a case of neuropathic arthropathy secondary to syringomyelia which was misdiagnosed as a soft tissue tumor and treated surgically and additionally with radiotherapy at another institution. The patient had clinical and radiological signs of syringomyelia, associated with a limited range of motion, swelling, and pain in the affected joint. Neuropathic arthropathy, although less common, should be considered in cases of unexplained joint swelling, pain, and limited range of motion of the affected joint.

Does the wedge wing in the neck screw prevent cut-out failure in Ota/AO 31-A2 trochanteric fractures in elderly patients?

The purpose of this retrospective study was to evaluate the effects of Dyna Locking Trochanteric (DLT) nail (U & I Corporation 529-1, Yonghyun-dong, Uijungbu Kyunggi-Do, Korea 480-050) in 31-A1 and 31-A2 intertrochanteric femur fractures. Eighty-seven patients (63 female and 24 male, mean age 77 years) were treated. The mean duration of followup was 16.6 +/- 3.1 months (range, 12-24 months). There were 36 cases of 31-A1 and 51 cases of 31-A2 fractures. The duration of surgery, fluoroscopy screening time, the blood loss, the hospital stay, the tip-apex distance were significantly less in the 31-A1 fracture group compared with the 31-A2 fracture group (p < 0.001). Cut-out was observed in 13 patients (14.9%) above 80 years old with 31-A2 fractures. Especially in elderly patients with unstable 31-A2 fractures, the wedge wing on the neck screw does not work properly. Therefore further biomechanical investigations and also prospective clinical studies with larger series are needed to improve the device.

Functional treatment of developmental hip dysplasia with the Tübingen hip flexion splint.

OBJECTIVE: Developmental dysplasia of the hip (DDH) is a deformity that may cause to serious disability. Early diagnosis and early treatment are very important. Our aim is to report the outcomes of infants with DDH who were treated with the Tübingen hip flexion splint. MATERIALS AND METHODS: Retrospectively, 49 patients (45 female, four male; 60 hips) diagnosed with DDH were included in the study. For diagnosis, all patients underwent ultrasonography of the hip performed according to the Graf method. Infants whose hips were Graf type 2b or worse underwent orthotic treatment. Treatment success was defined as development into a mature hip (Graf type 1 on ultrasonography and no acetabular dysplasia apparent on the latest radiograph). RESULTS: Overall median age at the start of treatment was 18 weeks (14-25). Median total treatment time (from initial application of the splint to the end of weaning) was 17 weeks (14-20). Median duration of follow up was 13.5 months (8.5-31.5). Treatment was successful in 56/60 hips (93.3%). Of the 56 successfully treated patients, acetabular dysplasia was present early in follow up but later resolved in 4 patients. No complications were encountered in any patients in the study. CONCLUSION: The Tübingen splint provides abduction, but due to its different design it offers the advantages of preventing hip adduction and leaving the knee and ankle joints free. Our findings suggest that in infants with DDH, the Tübingen hip flexion splint is an effective form of treatment.

An Unusual Disengagement of the Humeral Head Component after Hemiarthroplasty: A Case Report Presentation.

INTRODUCTION: Proximal humeral fractures account for 4% to 5% of all fractures. Complex proximal humeral fractures with displaced three- and four-part fragments, humeral head splits and fracture-dislocations are more difficult to treat. In older patients, because of poor bone quality, hemiarthroplasty is often the indicated treatment. CASE REPORT: One such case of a 73-year-old woman is presented here. The patient presented with a four-part fracture of the proximal humerus, with displacement of the humeral head. Hemiarthroplasty was done in the right shoulder. At postoperative 20 days, during physical therapy, the humeral head component of the prosthesis disengaged and a second operation was necessary. A deltopectoral approach was repeated using the previous incision. The humeral stem was seen to be well-fixed into the bone so the humeral head was changed for a new one of the same size. At two years, the dominant right side had active, painless ROM. CONCLUSION: The management and two-year follow-up of this case is reported here, which was the first to occur at our institution.

Abnormal Development of the Femoral Head Epiphysis in an Infant with no Developmental Dysplasia of the Hip Apparent on Ultrasonography.

INTRODUCTION: In the investigation of hip development in newborns and infants, ultrasonography and radiography are widely used, but their optimal roles in this setting remain controversial. CASE REPORT: Here we describe an 8.5-month-old infant who had undergone hip radiography at a primary care facility and was referred to our hospital to be evaluated for developmental dysplasia of the hip. Ultrasonography showed no developmental dysplasia of the hip according to standard criteria, but developmental retardation of the femoral head was apparent on the radiograph. CONCLUSION: This patient's findings demonstrate that abnormalities in femoral head epiphysis development can go undetected during routine ultrasonographic evaluations for developmental dysplasia of the hip.

A comparison of ultrasonography and radiography in the management of infants with suspected developmental dysplasia of the hip.

The aim of this study was to determine the sensitivity and specificity of plain radiography in the detection of developmental dysplasia of the hip, using hip ultrasonography as a reference standard. A retrospective review was made in 44 infants ranging in age from 4 weeks to 50 weeks (mean age: 21.7 weeks). Both radiographic and ultrasonographic images were obtained for 86 hips. Radiography and ultrasonography were found to be significantly correlated in terms of classification of developmental dysplasia of the hip presence or absence (p < 0.0001, Fisher's exact test). With ultrasonography accepted as the standard for the diagnosis of developmental dysplasia of the hip, radiography had a sensitivity of 61% and a specificity of 87%. The results of this study suggest that the two imaging methods give similar overall results, but that low grade dysplasia detected on ultrasonography may go undetected on radiography.

Surgical management of grade I chondrosarcoma of the long bones.

The aim of this study was to compare the rates of local recurrence according to surgical treatment options in low-grade chondrosarcomas of the long bones. A retrospective review was made of 30 consecutive patients (12 male, 18 female) with a mean age of 40.7 years (range: 16-69 years) with intramedullary low-grade chondrosarcoma of the long bones treated either by intralesional curettage or wide resection at our institution between 1995 and 2011. The mean overall follow-up was 74 months (range : 24-186 months). There was no difference in local recurrence rates between patients treated with intralesional resection or wide resection (p = 0.98). Intralesional curettage seems to be feasible in selected cases to reduce the patient's postoperative morbidity in Grade I chondrosarcoma cases.

Biceps tenodesis with interference screw: cyclic testing of different techniques.

Different surgical techniques exist for biceps tenodesis. The most secure fixation technique is with interference screws. The purpose of the study was to compare the biomechanical performance of three different interference screw biceps tenodesis fixation methods, which involve different tunnel preparation methods. Using a sheep shoulder model and metal interference screws, a bone wedge technique was compared to serial tunnel dilation and a control group. After a preload, all repairs were cyclically loaded (20-60 N) for 100 cycles followed by destructive testing. Biceps tenodesis using an interference screw--bone wedge technique showed statistically lower cyclic displacement (8.1 ± 6.4 mm) than serial dilatation with an interference screw (21.3 ± 8.4 mm) or interference screw fixation alone (18.3 ± 8.3 mm) (P = 0.02). There were no statistically significant differences in ultimate failure strength for any of the interference screw biceps tenodesis techniques tested. The tunnel preparation method chosen for interference screw fixed biceps tenodesis can have a positive effect on tenodesis performance. Using the bone wedge technique may allow a more rapid rehabilitation program applicable for the traumatic biceps tendon rupture seen in young, athletic patients with high demands.

Spinal osteochondroma: a report on six patients and a review of the literature.

INTRODUCTION: Osteochondromas are the most common benign tumour of the bone. They occur in two forms as solitary and hereditary multiple form. Osteochondromas are generally located on the metaphysis of the long bones. From 1 to 4% of osteochondromas occur in the spine. Spinal osteochondromas can cause cord and root compression and also be asymptomatic. In the diagnosis of osteochondromas, radiological methods are very important. PURPOSE OF STUDY: Because spinal osteochondroma is very rare, other benign and malign tumours should be kept in mind during differential diagnosis. In this paper, six patients with spinal osteochondral lesions were evaluated at our orthopaedic oncology department. PATIENTS: Between 1986 and 2009, six patients, four males, two females with an average age of 31.2 (9-65) were diagnosed with spinal osteochondroma at our clinic. Although one patient was diagnosed following another complaint, five patients were suffering from pain. In addition, four patients had swelling and one patient had neurological symptoms. Five patients were treated surgically, and the sixth one was followed conservatively. DISCUSSION: The patients with spinal osteochondral lesions applied with mostly pain and swelling at the dorsal of the vertebrae. Because neurological symptoms are rarely seen, radiological examination is of great importance in diagnosis. CONCLUSIONS: Patients suffering from spinal osteochondroma, due to the risk of secondary chondrosarcoma, must be closely evaluated both clinically and radiologically. If necessary, the patient must be treated surgically following histopathological diagnosis.

Stress fracture of the femoral neck as a complication of revision arthroplasty of the knee: a case report.

Stress fracture of the femoral neck is a rare complication of total knee arthroplasty. We report a case of femoral neck fracture following revision arthroplasty of the ipsilateral knee. Contributing factors may have been the patient's osteoporosis and a period of immobilisation before the revision arthroplasty. The patient was treated successfully with hemiarthroplasty of the hip. In patients who have undergone total knee arthroplasty, complaints of groin pain that radiates to the involved knee should alert to the possibility of a stress fracture of the femoral neck.