Three-dimensional computerized tomographic analysis of the deformity of lateral growth disturbance of proximal femoral physis.

BACKGROUND: Lateral growth disturbance of the proximal femoral physis after treatment of developmental dysplasia of the hip, also known as type 2 avascular necrosis, has been described in a 2-dimensional (2D) plane with standard radiographs. It is not well described in the 3-dimensional plane using 3D computed tomography (CT) scan. The purpose of this study was to define the anatomy of the proximal femur after the lateral growth disturbance of the proximal femoral physis with 3D CT scans. METHODS: Ten patients (11 hips) with lateral growth disturbance of the proximal femoral physis after treatment for developmental dysplasia of the hip (9 hips) and extracorporeal membrane oxygenation (2 hips), were studied with 2D and 3D CT methods. CT was done at an average age of 12.5 years (range, 9.8 to 16.69). RESULTS: In addition to the typical valgus configuration in the coronal plane, increased antetorsion of the femur (10 of 11 hips) and increased anteversion of the femoral head (8 of 11 hips) were a common finding seen in the transverse plane. In 6 of 7 hips for which the CT scan was performed before the closure of the capital femoral epiphysis, the physeal bridge was seen to be located in the anterolateral (5 hips) or posterolateral (1 hip) area of the proximal femoral physis. The version of the femoral head was correlated to the location of the physeal bridge. Acetabular dysplasia was seen in 4 hips. In the 3D reconstruction view, flexion deformity of the femoral head was seen in 6 hips and lack of coverage at the anterolateral portion of the femoral head was observed in 6 hips. CONCLUSIONS: The treating surgeon should be aware of the often marked antetorsion and also anteversion of the femoral head and neck associated with lateral growth disturbance of the proximal femoral physis. This knowledge allows surgical planning to correct rotational and sagittal plane correction of the proximal femur, which will allow normalizing hip mechanics. Acetabular side correction also may be needed if acetabular dysplasia is present. LEVEL OF EVIDENCE: Level III, diagnostic study.

A radiological classification of lateral growth arrest of the proximal femoral physis after treatment for developmental dysplasia of the hip.

BACKGROUND: After treatment of developmental dysplasia of the hip, lateral growth arrest of the physis of the proximal femur resulting in disturbance of the growth of the capital femoral epiphysis is not uncommon. The changes are usually not apparent until approximately the age of 9 years. The residual deformity has a variable prognosis at skeletal maturity. The purpose of this study was to assess the long-term impact of these proximal femoral changes on the function of the hips. METHODS: We reviewed the natural history of 22 hips in 21 patients who had a lateral growth arrest of the physis of the proximal femur after treatment of developmental dysplasia of the hip. The average age at follow-up was 22 years. The radiographic changes in the proximal femur after the growth arrest were analyzed. Radiographic outcome was assessed using Severin criteria, with classes I and II being graded as satisfactory and classes III and IV being graded as unsatisfactory. The Iowa hip score was used to assess clinical outcome. RESULTS: The consistent radiographic findings were a shortened lateral neck length in comparison with the medial neck length and lateral tilting of the capital femoral epiphysis, both of which were evident by an average age of 9 years. Overall, 41% of hips had a satisfactory radiological outcome according to the Severin classification. Two types of changes were observed in the proximal femur: a varus configuration (pattern A, 12 hips) and a valgus configuration (pattern B, 10 hips). Pattern A hips (varus) had a satisfactory result in 75% of the hips compared with none in pattern B hips (valgus). CONCLUSIONS: Valgus orientation of the proximal femur (pattern B) leads to disruption of the Shenton line, progressive subluxation, and acetabular dysplasia which resulted in class III or class IV Severin grade hips leading to a poorer clinical and radiological outcome at long-term follow-up. LEVEL OF EVIDENCE: Level III-Diagnostic study.

The incidence of occult dysplasia of the contralateral hip in children with unilateral hip dysplasia.

BACKGROUND: The purpose of this study is to determine the incidence of contralateral hip dysplasia in children with unilateral hip dysplasia. METHODS: We reviewed all patients with developmental dysplasia of the hip (DDH) who were evaluated at our institution until skeletal maturity (at least age 13 years). In the contralateral ("normal") hip, radiographic measurements of the acetabular angle >46 degrees, center edge angle <20 degrees, and migration index >20% were considered abnormal. RESULTS: Of the 43 patients in the study, 18 (42%) were diagnosed with bilateral hip dysplasia as an infant or toddler; 8 on the initial visit, and 10 after repeated evaluations. Twenty-five patients had no evidence of contralateral hip dysplasia, even on repeated examinations. Of this group, 10 of 25 (40%) had mild acetabular dysplasia at maturity (mean center edge angle, 31 degrees; acetabular angle, 43 degrees; and migration index, 14%). No child in this group was diagnosed with significant hip dysplasia at skeletal maturity that required treatment to date. DISCUSSION: The results of this study indicated that mild acetabular dysplasia occurs at maturity in the contralateral hip in up to 40% of patients diagnosed with unilateral DDH, even when the contralateral hip was carefully evaluated as a child. The significance of mild acetabular dysplasia is not well defined, but intermittent evaluation of the contralateral hip in children with DDH would seem prudent. LEVEL OF EVIDENCE: IV.

Hip arthroscopy for the treatment of children with hip dysplasia: a preliminary report.

The use of arthroscopic techniques to diagnose and treat hip disorders in children provides the potential to limit the morbidity of current techniques.

Prader-Willi Syndrome: clinical concerns for the orthopaedic surgeon.

BACKGROUND: Prader-Willi Syndrome (PWS) is a chromosome 15 disorder characterized by hypotonia, hypogonadism, hyperphagia, and obesity. Musculoskeletal manifestations, including scoliosis, hip dysplasia, and lower limb alignment abnormalities, are well described in the orthopaedic literature. However, care of this patient population from the orthopaedic surgeon's perspective is complicated by other clinical manifestations of PWS. Osteopenia, psychiatric disorders, and diminished pain sensitivity are frequently noted in PWS but are not discussed in the orthopaedic literature. The authors present a clinical review of an 8-year experience of caring for 31 patients with PWS to highlight all clinical concerns that influence orthopaedic management. METHODS: Thirty-one institutionalized patients diagnosed with PWS were examined and all past medical records were reviewed. Patient demographics, genetic testing, musculoskeletal diagnoses, psychiatric diagnoses, and clinical behaviors were recorded. Radiological studies performed in the course of routine clinical care were evaluated. RESULTS: Twenty-three men and 8 women, with an average age of 22 years (range, 8-39 years), were studied. A chromosome 15q abnormality was confirmed in 18 patients. Scoliosis was clinically detected in 21 of 30 patients and confirmed by radiographs in 14 of these 24 patients (overall with scoliosis, 45%) with an average primary curve of 27 degrees; 3 were braced, and 2 underwent spinal fusion. Radiographs also revealed diminished cervical lordosis and increased cervicothoracic kyphosis in 16 patients, a previously undescribed finding. Hip radiographs of 26 patients revealed dysplasia in 2 patients (13%); no slipped capital femoral epiphysis were identified. Fourteen patients had sustained a total of 58 fractures, with 6 patients sustaining multiple fractures (range, 2-7). Six patients have undergone orthopaedic surgical procedures with one major complication (spinal infection). Fracture management was associated with frequent minor complications. Bone densitometry was performed on 14 patients; 8 patients had osteopenia, and 4 had osteoporosis based on lumbar spine z scores. Twenty-six patients had Axis I psychiatric diagnoses including impulse control disorder (7), organic personality disorder (6), oppositional defiant disorder (5), dysthymic disorder (4), depressive disorder not otherwise specified (3), attention-deficit/hyperactivity disorder (2), and obsessive-compulsive disorder (2). Nine patients exhibited self-mutilating behaviors. CONCLUSIONS: Osteopenia, poor impulse control and defiant behaviors, and diminished pain sensitivity are aspects of PWS that may complicate all facets of orthopaedic nonsurgical and surgical management in this patient population. The treating orthopaedic surgeon must plan carefully and proceed with caution when treating children and adults with PWS.

Operative treatment for type II avascular necrosis in developmental dysplasia of the hip.

Lateral growth disturbance of the proximal femur may occur after treatment of developmental dysplasia of the hip, although usually it is not recognized until the child is older. This resultant dysplasia is also known as Kalamchi and MacEwen Type II avascular necrosis. The valgus configuration of the proximal femur and associated acetabular dysplasia may need operative reconstruction. Our purpose in doing this study was to assess the results of reconstruction in these patients. We reviewed 24 patients (30 hips) with Type II avascular necrosis who had acetabular and/or proximal femoral osteotomy after treatment for developmental dysplasia of the hip. The results were assessed according to the timing and type of operation and were graded using the Severin classification (I and II satisfactory and III and IV unsatisfactory). All patients were followed up past skeletal maturity. At a mean followup of 22 years, 15 of 24 patients (17 of 30 hips) had a satisfactory result. The patients with hips that were reconstructed after the diagnosis of Type II avascular necrosis had more satisfactory results than those operated on before the diagnosis of (70% versus 50%) avascular necrosis. Patients with 10 of the 13 hips that had acetabular and femoral reconstruction had a satisfactory result.

Development of hip dysplasia in a child with perinatal contralateral high above-knee amputation.

The development of acetabular dysplasia in the growing child has been postulated to be due to abnormal forces on the acetabular rim, such as when the hip is in an adducted position. In this case report we document the development of acetabular dysplasia, as measured radiographically, in a child with a perinatal contralateral high above-knee amputation.

Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability.

This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement < or =3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.

Radiologic evaluation of juvenile tillaux fractures of the distal tibia.

This study evaluated the accuracy of plain radiographs and computerized tomography (CT) in assessing juvenile Tillaux fractures of the distal tibia. A simulated Tillaux fracture was made in four cadaver specimens and displaced 0, 1, 2, 3, and 5 mm. Plain radiographs and CT were performed on each specimen at each amount of displacement, and the results were compared with the actual amount of displacement present. Plain radiographs and CT were accurate within 1 mm in depicting the actual fracture displacement about 50% of the time. CT was more sensitive than plain radiographs in detecting fractures with >2 mm of displacement. Fracture displacement of >2 mm is generally considered an indication for fracture reduction. Because of its sensitivity in detecting fractures displaced >2 mm, CT is the preferred imaging modality in the assessment of juvenile Tillaux fractures.

Management of leg length inequality.

Leg length inequality is common. Treatment objectives include obtaining leg length equality, producing a level pelvis, and improving function. Clinical assessment should include determination of a level pelvis with the patient standing using a set of blocks of various heights to estimate the amount of leg length inequality. Radiographic measures include the teleroentgenogram, orthoradiograph, and computed tomography (CT). A prediction of the ultimate leg length inequality at skeletal maturity will be needed to determine treatment. Our guidelines for treatment of leg length inequality are as follows: <2 cm--no treatment or a lift in the shoe; 2 to 6 cm--an epiphysiodesis or shortening procedure is considered; 6 to 15 cm--a lengthening procedure is considered. A leg length inequality of 15 to 20 cm--may require a staged lengthening, lengthening combined with epiphysiodesis, or amputation. Numerous complications of limb lengthening procedures occur frequently, even in experienced hands.

Development dysplasia of the hip from birth to six months.

The term "developmental dysplasia or dislocation of the hip" (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term "congenital dysplasia or dislocation of the hip," DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treat- ment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddlerTs ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and soft- tissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.