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ABSTRACT: BACKGROUND: Wide variation exists in reported prevalence estimates and management standards of developmental dysplasia of the hip (DDH). Discrepancies in diagnosticians' opinions may explain some of this variation. QUESTIONS/PURPOSES: We sought to determine (1) the consistency with which pediatric orthopaedic surgeons rate the importance of diagnostic criteria for DDH, and (2) whether there were geographic differences in how the diagnostic criteria were rated by surgeons. METHODS: One hundred ninety-seven of 220 members of the European Paediatric Orthopaedic Society and 100 of 148 members of the British Society of Children's Orthopaedic Surgery treating children with DDH participated in this cross-sectional study across 35 countries (15 regions). Each rated 37 items in four domains that specialists previously had identified as the most important features associated with DDH in early infancy. We determined consistency using the intraclass correlation coefficient (ICC; two-way random-effects model) interpreted as poor (0-0.40), acceptable (0.41-0.74), or good (≥ 0.75). RESULTS: Poor consistency among surgeons was found in rating the 37 diagnostic criteria (ICC, 0.33; 95% CI, 0.24-0.45). Consistency was poor for three domains (patient characteristics/history: ICC, 0.29; 95% CI, 0.16-0.58; ultrasound: ICC, 0.26; 95% CI, 0.14-0.52; radiography: ICC, 0.34; 95% CI, 0.12-0.95) and acceptable for one (clinical examination: ICC, 0.50; 95% CI, 0.33-0.73). Surgeons in particular regions appeared to have a concept of DDH diagnosis that distinguished them from specialists of other regions; consistency in eight regions was greater (ICC ≥ 0.40) than consistency among all 15 regions. CONCLUSIONS: The consistency of specialists in rating diagnostic criteria for DDH was lower than expected, and there was considerable geographic variation in terms of how specialists assigned importance ratings of the diagnostic criteria; these findings are somewhat counterintuitive, given the frequency with which this condition is diagnosed. These inconsistencies could explain, partly, the widely differing prevalence estimates and management standards of DDH.
Clinical Orthopaedics and Related Research 03/2013; · 2.53 Impact Factor
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ABSTRACT: BACKGROUND: Osteonecrosis is perhaps the most important serious complication after treatment of developmental dysplasia of the hip (DDH). The classification by Bucholz and Ogden has been used most frequently for grading osteonecrosis in this context, but its reliability is not established and unreliability could affect the validity of studies reporting the outcome of treatment. QUESTIONS/PURPOSE: We established the interrater and intrarater reliabilities of this classification and analyzed the frequency and nature of disagreements. METHODS: Three pediatric hip surgeons, a musculoskeletal pediatric radiologist, and three orthopaedic trainees graded 39 radiographs (hips) according to the Bucholz and Ogden classification, blinded to any clinical data. Ratings were repeated after 2 weeks. Interrater reliability and intrarater reliability were determined using the simple kappa statistic. Grading was compared among raters, the nature and frequency of disagreements established, and subgroup analyses performed. RESULTS: Interrater reliability was 0.34 (95% CI = 0.28, 0.40) for all raters, and 0.31 (0.20 to 0.43) for the three surgeons. The best interrater reliability was observed between the radiologist and a surgeon with a kappa of 0.51 (0.30, 0.72). Intrarater reliability estimates ranged from 0.44 to 0.69. Raters disagreed regarding the grade of osteonecrosis in 26 of 39 hips (67%), with seven of 26 disagreements (27%) involving confusion between Grades I and II. CONCLUSIONS: The interrater reliability was lower than expected, considering the raters' experience. Distinguishing between Grades I and II was the most frequently observed problem. We believe that the low reliability was a result of an ambiguous classification scheme rather than the variability among the raters. Outcome studies of DDH based on this classification should be interpreted with caution. We recommend the development of a new classification with better prognostic ability. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 08/2012; · 2.53 Impact Factor
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ABSTRACT: Osteonecrosis of the femoral head is a major potential complication following the treatment of developmental dysplasia of the hip. It remains unclear if the radiographic changes associated with osteonecrosis are clinically relevant.
In the present cross-sectional study, we determined the relationship between morphological changes on radiographs (classified with use of the Bucholz-Ogden system) and health-related quality of life (assessed with the Health Utilities Index Mark 3 [HUI3]; maximum score, 1), physical function (assessed with the Activities Scale for Kids [ASK]; maximum score, 100), and hip function (assessed with the Children's Hospital Oakland Hip Evaluation Scale [CHOHES]; maximum score, 100). The study group included seventy-two children (mean age, 14 ± 2.5 years) with a diagnosis of osteonecrosis of the hip secondary to the treatment of developmental dysplasia of the hip. Patient assessments were standardized (intraclass correlation coefficient, ≥0.93). Radiographs were graded by three experts according to consensus. Analyses were adjusted for the number of previous surgical procedures on the hip and for the severity of residual hip dysplasia.
The median ASK score was 97 (interquartile range, 93 to 100), the median CHOHES score was 86 (interquartile range, 77 to 96), and the median HUI3 score was 1 (interquartile range, 0.9 to 1). The ASK summary scores were nearly equal (median, >90) across all radiographic grades. Adjusted mean scores showed a downward shift with worse radiographic grades. The ASK scores (p = 0.004) and CHOHES scores (p = 0.006) differed across radiographic grades, with Bucholz-Ogden grade-I and II hips demonstrating significantly better scores than grade-III and IV hips.
Osteonecrosis secondary to the treatment of developmental dysplasia of the hip is a relatively benign condition in children and teenagers. While it was associated with limited hip function, it was not associated with physical disability. However, we speculate that this function will decline with increasing age. With regard to clinical outcome, Bucholz-Ogden grade-I hips are similar to grade-II hips and grade-III hips are similar to grade-IV hips.
The Journal of Bone and Joint Surgery 12/2011; 93(24):e145. · 3.27 Impact Factor
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ABSTRACT: Clinicians use various criteria to diagnose developmental dysplasia of the hip (DDH) in early infancy, but the importance of these various criteria for a definite diagnosis is controversial. The lack of uniform, widely agreed-on diagnostic criteria for DDH in patients in this age group may result in a delay in diagnosis of some patients.
Our purpose was to establish a consensus among pediatric orthopaedic surgeons worldwide regarding the most relevant criteria for diagnosis of DDH in infants younger than 9 weeks.
We identified 212 potential criteria relevant for diagnosing DDH in infants by surveying 467 professionals. We used the Delphi technique to reach a consensus regarding the most important criteria. We then sent the survey to 261 orthopaedic surgeons from 34 countries.
The response rate was 75%. Thirty-seven items were identified by surgeons as most relevant to diagnose DDH in patients in this age group. Of these, 10 of 37 (27%) related to patient characteristics and history, 13 of 37 (35%) to clinical examination, 11 of 37 (30%) to ultrasound, and three of 37 (8%) to radiography. A Cronbach alpha of 0.9 for both iterations suggested consensus among the panelists.
We established a consensus regarding the most relevant criteria for the diagnosis of DDH in early infancy and established their relative importance on an international basis. The highest ranked clinical criteria included the Ortolani/Barlow test, asymmetry in abduction of 20° or greater, breech presentation, leg-length discrepancy, and first-degree relative treated for DDH.
Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 09/2011; 469(12):3451-61. · 2.53 Impact Factor
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ABSTRACT: Osteonecrosis (ON) is a major complication after treatment of developmental dysplasia of the hip (DDH). Several studies have explored the absence of the femoral head ossific nucleus at the time of hip reduction as a risk factor for the development of ON, but findings have been inconsistent.
We therefore determined the incidence of ON in children who underwent reduction of a dislocated hip in the presence or absence of the ossific nucleus.
We retrospectively reviewed the radiographs of 105 hips in 89 patients treated for DDH at the age of 18 months or younger. Radiographs were graded for the presence of the ossific nucleus at the time of hip reduction and for the presence of ON, as graded by the Bucholz and Ogden classification, for patients at a mean age of 10 years. We used log-binomial regression to estimate if the presence of the ossific nucleus was associated with a lower incidence of ON.
We identified ON in 37 of the 105 hips (35%). The incidence of ON at 10 years was 40% in the absence of the ossific nucleus and 32% in the presence of the ossific nucleus (adjusted relative risk, 0.86; 95% confidence interval, 0.36-1.81). When only radiographic changes of Grade II and greater were considered ON, the risk was still not increased (relative risk, 1.26; 95% confidence interval, 0.62-2.56).
Patients with an ossific nucleus at the time of hip reduction showed a slight tendency toward better outcomes. The ossific nucleus did not protect for ON.
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 02/2011; 469(10):2838-45. · 2.53 Impact Factor
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ABSTRACT: Open reduction for the treatment of hip dislocation due to developmental dysplasia of the hip in children of walking age is frequently combined with either a femoral varus derotation osteotomy or an innominate osteotomy; however, it remains unclear which of these procedures is preferable in terms of subsequent hip development. The purpose of the present study was to compare acetabular development in patients managed for dislocation of the hip with open reduction combined with one of the two osteotomies.
Patients between fifteen months and four years of age with hip dislocations that were treated at two different centers were compared. At one center, open reduction combined with a femoral varus derotation osteotomy was performed (thirty-eight patients), and at the other, open reduction combined with an innominate osteotomy was performed (thirty-three patients). In each group, one surgeon performed all of the operations. A total of 490 postoperative radiographs that were made over a mean follow-up period of 6.2 years were analyzed. We compared the change in acetabular index as well as several other radiographic criteria of acetabular development and hip stability over time.
After osteotomy, the acetabular index improved in both groups; however, the acetabular index in patients who underwent a varus derotation osteotomy never improved as much as that in patients who underwent an innominate osteotomy, with a mean difference of 9.5 after four years (p < 0.0001). Similarly, the innominate osteotomy group demonstrated better acetabular architecture and hip stability over time as quantified by the change in the acetabular floor thickness (p = 0.03), lateral centering ratio (p < 0.0001), and superior centering ratio (p < 0.0001).
In the present series, acetabular remodeling after open hip reduction and innominate osteotomy was more effective for reversing acetabular dysplasia and maintaining hip stability than open reduction combined with a femoral varus derotation osteotomy was. Long-term follow-up is necessary to determine whether the more favorable hip development following innominate osteotomy is associated with a lower incidence of premature degenerative hip disease.
The Journal of Bone and Joint Surgery 11/2009; 91(11):2622-36. · 3.27 Impact Factor
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ABSTRACT: The aim of this study was to systematically review the quality of papers on the clinimetric properties of magnetic resonance imaging for the diagnosis of juvenile idiopathic arthritis in peripheral joints.
A review of Medline, EMBASE, the Database of Abstracts of Reviews of Effects, and the Cochrane Library was performed by using a systematic search strategy. Two independent reviewers evaluated selected articles by using Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tools. Items were reported independently for STARD and QUADAS.
Eighteen studies (validity, n = 18; reliability, n = 3; responsiveness, n = 3) were included. Their overall quality of reporting of methods was fair. Methodological problems with the STARD system included a lack of reporting of exclusion criteria (n = 14), partial or no information on operators' expertise (n = 14) or blinding (n = 18), and deficient information on study time frames (n = 12), treatments (n = 10), or indeterminate results (n = 18). The distribution of QUADAS scores was heterogeneous, with overall scores ranging between 3.5 (poor) and 16.5 (excellent) (maximum score, 17.5).
The quality of reporting of methods in studies on the magnetic resonance imaging assessment of juvenile idiopathic arthritis is heterogeneous and fair overall. Further methodological refinement of research design should be sought in future studies to provide stronger evidence for the value of novel techniques in clinical settings.
Academic radiology 07/2009; 16(6):739-57. · 2.09 Impact Factor
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ABSTRACT: The role of the presence of the femoral head ossific nucleus as a risk factor for the development of osteonecrosis of the femoral head in infants with developmental dysplasia of the hip has been investigated in several small studies, but the results have been inconsistent. The purpose of the present study was to determine the effect of the presence of the ossific nucleus on the development of osteonecrosis.
A systematic review of the medical literature from 1966 to 2007 was performed. Two independent reviewers evaluated all articles. Interrater agreement was determined, and the quality of evidence was evaluated. A meta-analysis was then performed with the main outcome defined as the development of osteonecrosis of the femoral head two years after reduction.
Six observational studies (five retrospective and one prospective) met the inclusion criteria. Inconsistency was found in that half of the studies demonstrated a protective effect of the ossific nucleus on the development of osteonecrosis whereas half of the studies did not. A meta-analysis (including 358 patients) showed no significant effect of the presence of the ossific nucleus on the development of grades-I through IV osteonecrosis, with forty-one cases of osteonecrosis (19%) found in infants in whom the ossific nucleus had been present at the time of hip reduction compared with thirty cases (22%) in the group without an ossific nucleus (relative risk=0.75, 95% confidence interval=0.46 to 1.21). When only radiographic changes of grade II or worse were considered to represent osteonecrosis, a significant difference in the prevalence of osteonecrosis was found, with fourteen cases of osteonecrosis (7%) in infants with an ossific nucleus compared with eighteen cases (16%) in those without an ossific nucleus (relative risk=0.43, 95% confidence interval=0.20 to 0.90). A subgroup analysis showed that the presence of the ossific nucleus reduced the probability of osteonecrosis by 60% (relative risk=0.41, 95% confidence interval=0.18 to 0.91) after closed reduction, but no significant effect was found in patients treated with open reduction (relative risk=1.14, 95% confidence interval=0.62 to 2.07). All studies demonstrated methodological weaknesses compromising the quality of evidence.
We did not find that the presence of the ossific nucleus had a significant effect on the development of osteonecrosis of any grade after hip reduction in infants with developmental dysplasia of the hip. The meta-analysis suggested that the presence of the ossific nucleus has a protective effect against the development of the more severe forms of femoral head osteonecrosis. However, the quality of evidence is moderate, and additional research is likely to have an important impact on the confidence in the estimate of the effect and may change this estimate.
The Journal of Bone and Joint Surgery 05/2009; 91(4):911-8. · 3.27 Impact Factor
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ABSTRACT: To determine the morphology and hemodynamic characteristics of the arterial vessels of the proximal femur according to specific anatomic regions in asymptomatic neonates in 2 pediatric-based health care institutions.
Forty-three neonates (29 female, 14 male; age range, 2 d-3 mo; median age, 3 d) were enrolled in the study. Thirty-two (37%) of 86 hips were classified as Graf type IIA joints (mean alpha angle, 56.0 degrees +/- 2.7 degrees ), and 54 (63%) were classified as type I joints (mean alpha angle, 65.0 degrees +/- 4.6 degrees ).
Colour and spectral Doppler imaging identified vessels running along the acetabular labrum, epiphyseal vessels, and femoral neck. We showed 4 different patterns of vascularity of the hips: radial, parallel, mixed radial-parallel, and indeterminate, however, they were not related to the hip maturity (P = .3, coronal plane; P = .62, transverse plane) or to the amount of colour pixels identified in each region (P = .35). The mean number of pixels in the ligamentum teres region was significantly higher than that in other regions of interest (P = .03). Except for the acetabular labrum arteries, Doppler spectrum waveforms of proximal femur arteries presented with low resistivity. There was a tendency towards females' acetabular arteries presenting with lower peak systolic velocities than males' acetabular arteries (P = .06).
Colour Doppler spectrum waveforms and intensity of vascularity in normal neonatal hips differ according to the anatomic region under evaluation. This observation deserves further investigation on its role on the physiopathogenesis of neonatal hip disorders.
Canadian Association of Radiologists Journal 05/2009; 60(2):79-87. · 0.69 Impact Factor
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ABSTRACT: To establish, in patients with subacromial impingement syndrome, (1) the relationship between pain and shoulder function, as determined by the Constant score, and morphological findings, as determined by radiographs and magnetic resonance imaging (MRI) and (2) the relationship between acromial shape and minimum acromiohumeral distance (AHD).
Cross-sectional study.
Tertiary care center.
Forty-seven patients (33 males and 14 females; mean age, 51.7 years) with unilateral subacromial impingement syndrome who had failed to respond to conservative therapy for at least 6 months.
The Constant score was determined preoperatively; acromial shape (type I, flat; type II, curved; and type III, hooked) was evaluated on preoperative outlet view radiographs and oblique sagittal T1-weighted MRIs; AHD was evaluated on preoperative anteroposterior radiographs and oblique coronal T1-weighted MRIs.
Correlation coefficients and the simple kappa statistic were calculated. Student t test and mean differences with 95% confidence limits were reported for group comparisons.
The Constant score was fairly correlated with AHD (r = 0.39, P < 0.01) but not with acromial shape. Patients with an AHD < or =7 mm on MRI scored significantly lower than those with an AHD >7 (mean difference, 18.5; P < 0.01). Acromial shape and AHD were not correlated, neither on radiographs nor on MRI.
AHD seems to better reflect the clinical status of patients with subacromial impingement, but without rotator cuff tears, than acromial shape. Acromial shape is not a good descriptor of subacromial space narrowing.
Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 04/2009; 19(2):83-9. · 1.50 Impact Factor
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Current Orthopaedic Practice 03/2009; 20(2):203–208.
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ABSTRACT: Great advances have been made in developing strategies to improve the quality of medical care in the past decade; these advances include better diagnostic technologies, such as ultrasonography (US), computed tomography, and magnetic resonance imaging. Although these tests provide new information on many conditions, such as developmental dysplasia of the hip (DDH), the differentiation of what is normal, what is abnormal, and what is disease is no longer intuitive. Historically, the diagnosis of DDH was straightforward. The diagnosis was based primarily on clinical findings, which were often confirmed with radiography. Abnormal hips were either subluxated or dislocated and, if left untreated, adverse consequences were certain in either situation. Since the introduction of hip US, however, increased diagnostic sophistication has led to uncertainty as to how to interpret the continuous spectrum of acetabular morphology. There is no consensus on the degree of acetabular dysplasia that does or does not require treatment. Because not every abnormal finding may require treatment, the terms abnormality and disease are not synonymous.
Radiology 03/2007; 242(2):355-9. · 5.73 Impact Factor
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ABSTRACT: To systematically review the quality of diagnostic accuracy reporting in studies on the use of ultrasonography (US) for the diagnosis of developmental dysplasia of the hip (DDH). MATERIALS AND METHOds: A systematic review of the MEDLINE, EMBASE, DARE, and Cochrane Library databases was performed by using a validated search strategy. Two independent reviewers evaluated articles by using the Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Studies of Diagnostic Accuracy included in Systematic Reviews (QUADAS) statements. Items were reported individually for STARD and QUADAS because these instruments do not incorporate a summary score. A simple kappa statistic with 95% confidence intervals was used to measure the level of agreement between the two reviewers.
Ten studies were included. In three studies, reliability was investigated, and in seven studies elements of both validity and reliability were investigated. In no study did the authors adequately report more than 40% of the STARD items. The quality of methods that were used in the studies was poor. Only one (14%) of seven studies provided information on more than 50% of the QUADAS items. All studies included a good description of image acquisition, but data analysis was imperfect and lacked estimates of diagnostic accuracy and precision. Authors tended to overinterpret their results.
Overall, there was imperfect reporting of diagnostic accuracy in studies on the use of US for diagnosis of DDH.
Radiology 01/2007; 241(3):854-60. · 5.73 Impact Factor
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ABSTRACT: Timing the reduction of a delayed presenting dislocated hip is controversial if the ossific nucleus of the proximal femoral epiphysis is absent. We formulated a decision model for management of 6- to 13-month-old infants based on two strategies: waiting for the ossific nucleus to appear before reducing the hip or immediate reduction. The model included the occurrence of long-term physical disability within a period of 20 years. A literature synthesis provided outcome probabilities. Outcome was measured by utilities derived by content experts. Waiting for the ossific nucleus was the preferred strategy with an expected value of 0.95 as opposed to 0.86 in the immediate reduction strategy. Sensitivity analyses showed the model was robust. Based on the results of decision analysis, reducing a dislocated hip in the presence of the ossific nucleus is likely to be the better strategy if avascular necrosis and long-term disability are considered. The difference between the two strategies is equivalent to one quality-adjusted life year, which is substantial. Level of Evidence: Economic and Decision Analyses, Level II-1. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 09/2006; 449:295-302. · 2.53 Impact Factor
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ABSTRACT: We sought to establish the levels of interrater reliability and intrarater reliability of the Graf classification among orthopaedic surgeons in their final training year and who learned the method by instructed teaching or self study. Using standard teaching material developed by Graf, two groups of senior orthopaedic residents at the same training level received structured teaching sessions (Group A, n = 2) or performed self study (Group B, n = 2). Interrater reliability and intrarater reliability were determined (Cohen's weighted kappa). Proportions of correctly rated sonograms were compared between groups, implications of misclassifications were analyzed, and sensitivity analyses were performed. Interrater reliability was 0.59 (95% CI = 0.32-0.85) for Group A, and 0.47 (95% CI = 0.14-0.79) for Group B. Intrarater reliability showed an overall kappa of 0.57 (95% CI = 0.35-0.78) in Group A, and 0.47 (95% CI = 0.19-0.75) in Group B. The proportion of correctly rated sonograms between groups was similar in the original dataset and in the sensitivity analysis. Misclassifications influencing treatment were infrequent; one patient would have received unwarranted treatment and three patients would not have received warranted treatment. The Graf classification showed moderate reliability. Using self study, it can be learned almost, but not quite as effectively as by a structured program.
Clinical Orthopaedics and Related Research 07/2006; 447:119-24. · 2.53 Impact Factor
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ABSTRACT: Standard innominate osteotomies that are recommended for treatment of the typical form of developmental dysplasia of the hip are not recommended for dysplasia associated with neuromuscular disorders. A periacetabular osteotomy that permitted accurate correction of the posterolateral acetabular deficiency was done on 40 patients (50 hips). The purpose of this study was to present the surgical technique, to evaluate whether it can improve acetablular dysplasia, and to provide stable hips. The patients had a mean age of 9.5 years at the time of surgery. The medial cortex of the ilium was left intact, whereas the supraacetabular and retroacetabular cancellous bone, and posterolateral cortical bone were cut. The posterior cut extended down to the triradiate cartilage, or through its former site, respectively. Forty-one hips were evaluated at a mean followup of 5.3 years (range, 2-11.7 years) after surgery. The mean acetabular index improved from 32 degrees preoperatively to 12 degrees at followup. The mean migration percentage improved from 77% to 13%. A redislocation or unstable hip occurred in two patients. According to caregivers, surgery improved personal care, positioning, and comfort. This osteotomy decreases the radius of the elongated acetabulum, provides coverage by articular cartilage particularly at the posterolateral aspect of the acetabulum, and preserves the entire medial wall of the ilium.
Clinical Orthopaedics and Related Research 03/2005; · 2.53 Impact Factor
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ABSTRACT: Our aim was to determine the value of different MRI planes independently and in combination for assessment of acromial shape.
Sixty-one patients with subacromial impingement syndrome who had undergone acromioplasty after failure to respond to conservative treatment were included in the study. Parasagittal T2-weighted MR images and outlet view radiographs of the affected shoulders were acquired preoperatively. Three-dimensional models of all acromions were constructed from the MR images, and the Bigliani type of acromion depicted by these models was determined. Results were compared with the acromial type assessed during acromioplasty. To provide a reliable reference for further processing and correlation, we used only those 56 acromions with agreement on acromial shape between intraoperative findings and 3D models. Then, acromial shape was determined for three MRI slice positions (S-1, lateral acromial edge; S-2, just lateral of acromioclavicular joint; and S-3, lateral portion of acromioclavicular joint), for a combination of S-1 and S-2, and for the radiographs.
Kappa coefficients were 0.36 (36%) for S-1, 0.41 (41%) for S-2, and -0.10 (-10%) for S-3. For the outlet view radiographs, the kappa coefficient was 0.55 (55%), showing better correlation than any single slice position. Best results, however, were achieved with a combination of S-1 and S-2, with a kappa coefficient of 0.66 (66%).
For determination of acromial shape, outlet view radiographs are superior to any single MRI slice position, but inferior to a combination of two MRI slices (S-1 and S-2). If a single MRI slice is being used, the slice position just lateral to the acromioclavicular joint is recommended.
American Journal of Roentgenology 03/2005; 184(2):671-5. · 2.78 Impact Factor
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ABSTRACT: Tibial lengthening over nails, using modified Ender nails, was performed in nine children whose mean age at surgery was 12.8 years. The prerequisite for using this technique was the absence of axial malalignment and an indication for tibial lengthening only. Lengthening was not performed in one case due to the development of a compartment syndrome after the tibial osteotomy. Breakage of one interlocking screw without loss of alignment or length was observed in one case. Superficial pin tract infections were observed in two cases. An average of 4.1 cm (range 3-4.5 cm) lengthening of the tibia was achieved in eight of the nine cases. The modified Ender nails used permitted locking at both ends after achieving the desired distraction and permitted early removal of the external fixator. The advantage of this technique is that it permits early removal of the fixator and thus decreases the incidence of fixator related problems and facilitates early rehabilitation.
Journal of Pediatric Orthopaedics B 12/2004; 13(6):383-8. · 0.47 Impact Factor
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ABSTRACT: Problems associated with common treatment modalities of bone cysts located in the proximal femur include a high blood loss, infection, lack of stability, donor-site morbidity, restriction to normal activity, and high recurrence rate.
Twelve patients with a simple bone cyst of the proximal femur were treated with retrograde flexible nailing. Six showed a pathological fracture. Mean age at surgery was 10.4 years, mean follow-up was 57 months. Radiographs were classified as healed, healed with residuals, recurred, or no response.
The mean healing period was 38.8 months. Two cysts healed completely, nine healed with residuals. There was no recurrence or non-responder. In a fractured cyst a perforation of a nail through the cyst occurred 4 months after nailing.
The method is less invasive and offers early stability to the bone without the need for cast immobilization.
Archives of Orthopaedic and Trauma Surgery 10/2004; 124(7):437-42. · 1.37 Impact Factor
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ABSTRACT: Brachmann-de Lange syndrome (BDLS) is a disorder of unknown cause that is recognized on the basis of characteristic facies in association with growth retardation, mental retardation and, in many cases, upper limb anomalies. Because of its association with skeletal anomalies, patients with the syndrome are often referred to the paediatric orthopaedic surgeon. Thirty-four patients with Brachmann-de Lange syndrome were evaluated for the prevalence and pattern of musculoskeletal involvement. The average age of the patients was 10.2 years (range, 1 month to 44 years). Both sexes were affected equally. The common orthopaedic manifestation affected the hand (100%), elbow (47%), and the heel cord (26%). Severe bony anomalies included complete absence of the hand in one case, and ulna hemimelia in two cases. In two patients bilateral Legg-Perthes-like changes were noted. Scoliosis presented in four cases, all before the age of 10 years. Surgery was performed in two patients with severe bilateral equinovarus feet. Despite the constellation of musculoskeletal findings, most of the patients did not have surgical intervention for their deformities.
Journal of Pediatric Orthopaedics B 04/2004; 13(2):118-22. · 0.47 Impact Factor
