Arthrographically defined subchondral defects in Perthes' disease.

Since the original 1910 description of Perthes' disease, the aetiology and pathophysiology of this condition have remained elusive, and the treatment controversial. We found during arthrography that it has been possible to demonstrate a fluid-filled space between the ossified epiphysis of the femoral head and its overlying articular cartilage. This finding has not previously been documented in the literature, and we believe this mechanically vulnerable region may be subject to mechanical distortion, acting as a significant contributor to the evolving femoral head deformity seen in Perthes' disease. If this is so, treating this lesion could prevent further femoral head deformation.

The Salter innominate osteotomy: should it be combined with concurrent open reduction?

The timing of surgical realignment of the acetabulum after reduction of the dysplastic hip is controversial since a delay in correction may allow the joint to sublux again. The radiographic outcome after 188 Salter osteotomies was reviewed 5-25 years postoperatively using a comprehensive rating scale; 139 hips (69%) developed satisfactorily, 49 hips (26%) remained dysplastic but stable and nine hips (5%) were unsatisfactory. The best results occurred in children under the age of 30 months treated by combined open reduction and Salter osteotomy, when no further operation was required. The staged procedure yielded a slightly smaller proportion of satisfactory results, which were independent of the age of the child (and the incidence of redisplacement and avascular change was reduced). If the innominate osteotomy reduced the acetabular inclination by approximately 15 degrees the hip joint usually stabilized and a normal acetabular (Sharp) angle was present at maturity. When 132 patients were assessed clinically at maturity (between the ages of 16 and 35 years), clinical, functional and radiographic review revealed that 121 of 148 hips were graded in Severin groups I and II. The clinical outcome was determined by the degree to which the acetabular dysplasia was corrected.

Children with acute Perthes' disease have asymmetrical lower leg growth and abnormal collagen turnover.

BACKGROUND: Abnormalities in distal growth and low levels of insulin-like growth factor (IGF)-I have been reported in children with Perthes' disease. Our aim was to establish whether the acute phase of Perthes' disease is associated with abnormalities of growth, of bone or of collagen turnover. METHODS: We performed a cross-sectional study of 15 children (3-11 years of age, 13 boys) at acute presentation and a longitudinal cohort study of 9 children. We measured (1) the lengths of both lower legs (by knemometry) at weeks 1, 2, 6 and 12, (2) height and weight at presentation and at the second-year follow-up, and (3) levels of IGF-I, IGFBP-3, collagen markers and bone alkaline phosphatase at weeks 1 and 12, and in year 2. RESULTS: Height SD scores were normal at presentation but declined thereafter. Lower leg growth was not impaired at presentation but was asymmetrical, ceased during weeks 2-6, and then resumed symmetrically. Patients had persistently low IGF-I, low soft tissue collagen synthesis and enhanced collagen breakdown compared with age- and sex-related reference data. Markers of bone formation increased during follow-up. INTERPRETATION: Acute changes in lower leg growth reflected differential weight bearing, then immobilization and remobilization. Persistently low IGF-I may have contributed to low soft tissue collagen synthesis and growth. Changes in bone formation markers most likely reflected bone healing.

Tratamento da displasia do desenvolvimento do quadril pela técnica de Salter isolada ou associada à osteotomia do fêmur / Treatment of hip developmental dysplasia by isolated Salter's technique or associated to femoral osteotomy

Os resultados do tratamento da displasia do desenvolvimento do quadril (DDQ) por meio da redução aberta e osteotomia do ilíaco pela técnica de Salter foram analisados em 93 pacientes (103 quadris) com idade entre 18 meses e cinco anos. Em 59 quadris (57,28 por cento) foram associadas subseqüentemente osteotomia de rotação e varização do fêmur. A técnica de Salter foi precedida por período de tração percutânea em 84 quadris (81,55 por cento). Os quadris foram divididos em dois grupos: grupo A (44 quadris), tratados pela técnica de Salter, e grupo B (59 quadris), em que, além da técnica de Salter, foram adicionadas, subseqüentemente, osteotomia de rotação e varização do fêmur. Os resultados foram bons em 33 quadris (75,00 por cento) do grupo A e em 38 (64,40 por cento) do grupo B. Com relação à faixa etária, no grupo A houve 89,28 por cento de bons resultados nos pacientes operados entre 18 e 30 meses, em comparação com 50,00 por cento nos operados entre 31 e 60 meses de idade. No grupo B, houve 65,00 por cento de bons resultados nos operados entre 18 e 30 meses e 63,15 por cento nos com idade entre 31 e 60 meses. A análise comparativa entre os grupos sem e com osteotomia femoral revelou que, na faixa etária de 18 a 30 meses, 89,28 por cento tiveram bons resultados sem osteotomia femoral associada, ao passo que, naqueles em que foi adicionada osteotomia do fêmur, os resultados bons baixaram para 65,00 por cento. Nos pacientes operados entre 31 e 60 meses não foi observada diferença nos resultados entre os grupos sem e com osteotomia femoral. O grau de displasia, medido pelo índice acetabular (IA) pré-operatório, o grau de melhora do IA, obtido pela osteotomia do ilíaco, o uso de tração pré-operatória e o tipo de luxação não tiveram influência nos resultados de nenhum dos grupos. Melhores resultados foram obtidos nos quadris que não haviam sido submetidos a tratamento prévio.

Infantile skeletal skew: the use of ultrasound in management.

The term 'infantile skeletal skew' recognizes the prenatal or postnatal moulding of a small proportion of babies who develop characteristic changes including plagiocephaly, wry neck, scoliosis, pelvic obliquity and postural foot deformities. Pelvic obliquity may cause an abduction contracture of the hip on one side and an adduction contracture on the other, and radiographs may suggest a 'dysplasia' of the acetabulum on the adducted side, giving rise to concern that the hip is unstable. In these cases we have found that early ultrasound assessment of the adducted side will reassure the clinician that the hip is 'in joint' and the condition should be allowed to resolve itself over several months without any treatment. Eighteen infants with features of moulding in whom there was concern over the development of the hip on the adducted side, have been prospectively studied with the use of ultrasound until the age of 18 months when a final radiograph confirmed normal development of the hips.

Guidewire damage during cannulated screw fixation for slipped capital femoral epiphysis.

Cannulated screw fixation of slipped capital femoral epiphysis is a standard procedure for the mild to moderately displaced slip. We report six cases in which the guidewire was damaged by a cannulated drill. In five the wire broke off within the femur. The broken wire was retrieved in two of the cases but not in the remaining three. The progress of all six patients was unaffected by this complication.

Seasonal distribution of idiopathic congenital talipes equinovarus in Scotland.

Idiopathic congenital talipes equinovarus has a reported prevalence of between 0.64 and 2.5 per thousand live births in the Scottish population. A retrospective study of neonates (n=162), who presented with idiopathic congenital talipes equinovarus in Scotland over a 3 year period (1994-1996) revealed a seasonal increased incidence of the condition in neonates born in March and April. The probable aetiological factors for congenital talipes equinovarus are discussed.

Tratamento cirúrgico da displasia acetabular residual em portadores de luxaçäo congênita do quadril / Surgical treatment of residual acetabular dysplasia in congenital dislocation of the hip

Os resultados do tratamento cirúrgico da displasia acetabular residual são analisados em 60 pacientes (63 quadris) portadores de luxação congênita do quadril previamente tratados. A osteotomia do inominado foi indicada sempre que o acetábulo se apresentava insuficiente após o tratamento conservador ou cirúrgico inicial da luxação. Diversos fatores como idade, variação do índice acetabular, presença de alterações avasculares prévias, quepoderiam influenciar os resultados, foram analisados com o objetivo de identificar a situação mais propícia à indicação da osteotomia do inominado para tratamento da displasia acetabular residual. Em 28 quadris (44,5 por cento), foi realizado tratamento complementar no fêmur nas situações em que ocorreu menor correção pela osteotomia do inominado ou nos quadris que apresentavam anteversão ou valgismo excessivo do fêmur proximal.