[Prevention, care and screening of hips of newborn infants]. / Prévention, soins et surveillance des hanches de bébés.

The frequency of C.D.H. and the indications for surgical treatment have been considerably reduced. Since a 3-part prevention protocol has been initiated: screening of newborns, prophylactic triple-diapering in slight flexion-abduction, aided by the availability of the equipment, and repeated examinations of infants.

[Open reduction with pelvic osteotomy and femoral shortening]. / Réduction sanglante avec ostéotomie pelvienne et raccourcissement femoral.

The combined procedure of femoral shortening, reduction of the hip, iliac osteotomy, transfer of the iliopsoas muscle, and redirection of the femoral head, applied in 225 hips of children over the age of 7, gave good results in two-thirds of the cases, and poor in one-tenth. The quality of the outcome diminished with increasing age at surgery.

Long-term results of combined operative reduction of the hip in older children.

Long-term results of open reduction, combined with femoral shortening, iliac osteotomy, reorientation of the upper femur, and medial iliopsoas transfer, are analyzed in 144 hips, according to patients' answers to follow-up questionnaires. Age at surgery ranged from 7 to 15 years with a follow-up of 9-24 years (mean 13 years). Two-thirds of patients had good results, one-fourth had fair results, and one-tenth had poor results. This was in accordance with radiologic rating in 225 hips, with a mean follow-up of 5 years. Quality of results decreased with age at surgery. The combined procedure is not advised after the appearance of pubertal signs. Since radiologic results favored Chiari's iliac osteotomy and subjective results favored the Pemberton type, individual choice is advised, according to the severity of acetabular dysplasia and the age of the patient. Redislocations, when left alone, had better results than did hips that were operated on again.

Effects of triple prevention of CDH, stimulated by distribution of "baby packages".

Triple prevention of congenital dislocation of the hip (CDH) consists of screening and earliest treatment in newborns, universal wide diapering in all presumably healthy hips, and repeated screening and early treatment in infants. Preventive activity proved to be decisively stimulated by introduction of "baby packages," containing equipment for wide diapering, which are being distributed to every newborn free of charge. Since the introduction of baby packages, prevalence of CDH dropped from 1.3 to 0.7% despite incomplete distribution. Likewise, incidence of surgery for CDH decreased sevenfold.

Chiari's pelvic osteotomy in the treatment of Legg-Calvé-Perthes disease.

Results of Chiari's pelvic osteotomy in Legg-Calvé-Perthes disease were analyzed in 37 hips of 36 patients. The mean age at surgery was nine years. The results were assessed according to both the quality of sphericity and containment of the femoral head. The results were satisfactory in 26 hips (70%), acceptable in 10 hips (27%), and poor in only one hip (3%). In cases where preoperative arthrography revealed a saddle-shaped distortion of the protruding and flattened epiphysis, the results were less satisfactory. The authors conclude that Chiari's osteotomy is needed where other kinds of containment cannot be expected to be successful. The indications are smooth flattenings of severely protruding epiphyses in patients aged seven years or more, and severe epiphyseal protrusions without flattening in patients 10 years or older.

Triple prevention of congenital dislocation of the hip.

Triple prevention of congenital dislocation of the hip consists of (a) examining newborns so as to apply treatment as early as possible in symptomatic and suspected cases, (b) regular diapering in abduction of all presumably healthy hips by means of soft abduction pants so as to direct possible cases of dysplasia toward normal development, and (c) reexamination of these hips until the child can walk so as to discover missed cases. Primary treatment of diagnosed and suspected hip dislocations consists of immediate application of a Frejka splint and abduction exercises, followed by a radiograph at the age of 4 months. Persistence of any clinical symptom for 3 weeks requires intensification of treatment by use of the Pavlik harness.

Perthes' disease.

Perthes' disease may be regarded as a generalised disorder of cartilage development in which there is a particular predisposition for repeated episodes of infarction in the proximal femoral epiphysis. The resulting deformation of the head is due to collapse of the ossific nucleus and irregular growth of the cartilage. The shape of the epiphysis is determined by the pressure of the surrounding structures. The most ominous factors determining prognosis are onset in the older child, epiphysial protrusion, extensive involvement of the epiphysis and arrest of subcapital growth. The overall prognosis is determined by the quality of preservation of the sphericity of the head, with maldevelopment leading to osteoarthritis. The aim of treatment is to achieve sphericity by containing the epiphysis within the acetabulum. A uniform regime of management cannot be recommended for all patients. Prolonged weight relief in containment appears to be the most satisfactory method of treatment in those with a pour prognosis. Operation is necessary to provide containment in the presence of ephiphyseal protrusion, and may also shorten the length of treatment in some younger patients. In the majority of young children the use of abduction braces which permit walking is recommended. In children with a minor degree of involvement a short period of bedrest may be all that is required. Overtreatment of young children should be avoided, as should undertreatment in the older age groups.

Treatment of Perthes' disease in older children.

The results of treating 148 hips in 135 children (aged 7 to 16 at the onset of management) for Perthes' disease are analysed. Cases are classified according to the amount of epiphysial containment and the results assessed according to the degree of preserved sphericity. It is concluded that to obtain satisfactory results in this age group treatment should be prolonged until the restitution of the epiphysis so as to maintain the initially achieved containment throughout the reparative process. Containment should be secured initially as follows: by non-operative treatment, in children aged seven to nine years with contained and also with slightly subluxated epiphyses; by femoral osteotomy, in children aged seven to nine years with severely subluxated epiphyses and also in children aged 10 and more with slightly subluxated epiphyses; by Salter's osteotomy, in children aged 10 years and more with contained epiphyses; by Chiari's osteotomy, in all crushed but smooth epiphyses, and also in children aged 10 and more with severely subluxated epiphyses; and by cheilectomy, in all crushed and saddle-shaped epiphyses, but only during the regenerative stage of the disease.

Cylindrically modeled bone grafts.

A technique of autogenous grafting for repair of large defects in long bones is presented. Quadrangular grafts, taken from the external table of the posterior ilium, are modeled by bending them into cylindrical form, which has higher mechanical resistance as compared to flat struts. Cancellous chips are added. The original shape of the bone is immediately restored, and heavy internal fixation is avoided. combination of cortical and cancellous bone grafts provides both strength and rapid bone healing. There is no risk of fracture at the donor site. Of eight consecutive cases operated on, seven were successful. One failed because of relapsing infection. The procedure is suitable in children, adolescents, and young adults, for difficult cases of large defects in long bones left after resection of tumors and tumor-like conditions, as well as after diaphyseal distraction for leg lengthening.

Relocation of congenitally elevated scapula.

In the treatment of Sprengel's deformity, extraperiosteal greenstick fracture of the clavicle in conjunction with surgical release of all attachments between the scapula and the spine provides an easy, safe method of relocating the scapula to its normal level. The improved position is maintained by temporary fixation of the inferior border of the scapula to the eighth rib with slowly resorbable sutures. Section of the coracoclavicular ligaments, excision of the superior pole of the scapula, and suture fixation of the medial angle of the scapula to the spinous process of the fourth vertebra enables the procedure to be performed on patients until the age of puberty. This surgical technique has been performed in 28 consecutive patients with Sprengel's deformity, aged 4 to 19 years, without any neurovascular complications. A normal scapular position was achieved in 67% of cases, 1 to 2 cm elevation in 29%, and 5 cm in 4%.

Approach to treatment of Legg-Calvé-Perthes disease.

The essence of management of Legg-Calvé-Perthes disease (LCPD) should be the provision of containment and its maintenance during epiphyseal remodeling. Containment may be achieved by a variety of nonoperative and surgical methods. The choice for individual patients depends on the patients' age at onset and the degree of epiphyseal involvement. The specifics of treatment and its duration are presented in 2 tables for practical assistance in the proper choices. Comparative analysis has confirmed that improved results can be obtained when patients are treated by this approach.

[Wrapping in abduction of newborns in maternity wards]. / Siroko povijanje novorodencadi u porodilistu.

Triple prevention of the congenital dysplasia of the hip comprises detection in newborns, general wrapping in abduction, and detection in infants. It starts already in obstetric institutions and is legalized as an obligatory form of health protection of the population. Baby-packages for prophylactic wrapping with the thigh in abduction and flexion, are provided for each newborn free of change and distributed in the maternity wards. Already in prenatal consultations and later in the maternity ward mothers are taught how to apply wrapping in abduction to normal children and how to use therapeutic pants in children suspect of a pathologic hip.

Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children.

A one-stage, combined operative procedure for reduction of congenitally dislocated hips in older children consists of shortening of the femur; open reduction by an inferior approach to the joint; reconstruction of the acetabular roof; correction of anteversion of both the femoral neck and the neck-shaft angle; anterior transposition of the iliopsoas muscle. On 60 hips operated in children, ages 5 to 15 with a follow-up period, ranging from 5 to 9 years, the results were found to be excellent in 3 per cent, good in 60 per cent, fair in 30 per cent, and poor in 7 per cent. The procedure is indicated in children up to the time of early puberty. The primary indication is high bilateral dislocation. In unilateral dislocations some residual leg-length discrepancy frequently occurs. This procedure should be done only by orthopedic surgeons who have special training and experience in the treatment of congenital dislocation of the hip.