Abraham Ganel

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations.

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3–5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3–18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.

Congenital muscular torticollis in infants : Ultrasound-assisted diagnosis and evaluation

Ultrasonography is considered the modality of choice for differentiating congenital muscular torticollis from other pathologies in the neck. The authors present their experience with ultrasound examination for the evaluation and management of congenital muscular torticollis. Twenty-six infants, 14 boys and 12 girls, age ranging from 1 to 16 weeks, with torticollis and a palpable mass were examined. Ultrasound showed a well-defined mass in the sternocleidomastoid muscle. The lesions ranged in size from 8 to 15.8 mm on maximal transverse diameter, with length ranging from 13.7 to 45.8 mm. Clinically the torticollis disappeared between 1 to 6 weeks, with complete clinical reduction of the palpated mass between 2 and 8.5 weeks. The ultrasonographic disappearance of the mass was delayed by an average of 2 weeks in comparison to the clinical disappearance of the mass. Ultrasound is advocated for the diagnosis and follow-up of congenital muscular torticollis because it noninvasively provides reliable and dynamic information without sedation.

DISTAL TRANSFER OF THE GREATER TROCHANTER IN COXA VARA

Seven patients (nine hips) who suffered from coxa vara were treated by distal transfer of the greater trochanter. The operation eliminated or markedly diminished the preoperative Trendelenburg sign, thus improving gait. In three patients (four hips) operated upon at the aged of 9 and 12 years, the initial coxa vara was converted into an almost normal valgus kemoral neck. There was one poor result due to technical failure.

Effect of Proximal Phalangeal Epiphysiodesis in the Treatment of Macrodactyly

The recommended treatment for macrodactyly of the foot will often include epiphysiodesis of the proximal phalanx in an attempt to halt further longitudinal growth of the toe. Nine patients who underwent open epiphysiodesis and debulking of the excess soft tissue involving 11 toes were reviewed to evaluate the effectiveness of this procedure. In 9 of 11 toes, overall length of the proximal phalanx did not change after surgery. Two toes demonstrated continued growth; one of these toes underwent a repeat epiphysiodesis of the phalanx, and the other foot underwent epiphysiodesis of the affected metatarsal. Overall, this surgical approach led to radiographic results that satisfied the surgical goals.

Titanium elastic nail--a useful instrument for the treatment of simple bone cyst.

A simple bone cyst is a common benign lytic lesion in the pediatric population. Successful methods of treatment include injections with bone marrow and curettage of the cyst and filling with bone graft or bone graft substitute. Opening the cyst walls and creating a connection with the medullary canal promote healing. We describe a simple method of opening the cyst walls without creating a large cortical defect, using the AO Titanium Elastic Nail. This flexible nail allows creation of connections to the medullary canal in several directions through one cortical hole.

Total Hip Arthroplasty After Childhood Septic Hip in Patients Younger Than 25 Years of Age

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14–25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

Subluxation of the Hip Joint During Femoral Lengthening

Three cases of subluxation of the hip joint occurred during femoral lengthening using the Wagner technique. This infrequent complication, which may result from a conflict of force vectors at the hip joint during lengthening, can, when left untreated, nullify the benefits of such a procedure. We suggest that increased awareness and closer monitoring can improve the prognosis for patients undergoing this course of therapy, especially where a previous hip operation has been performed.

Distal transfer of the greater trochanter revisited: long-term follow-up of nine hips

Seven female patients (nine hip joints) with avascular necrosis and functional coxa vara secondary to developmental dysplasia of the hip joint (DDH) were treated by distal transfer of the greater trochanter (DTT). A 5-year follow-up showed good results in 89% of the hip joints. We reviewed the patients again 12 years later using the Mayo Clinic hip score. Improvement of gait was maintained in the majority of the patients (71%), but the hip score was low in 67% of the patients because of the development of osteoarthritis. Two patients underwent a total hip arthroplasty, and a third is awaiting this operation. Distal transfer of the trochanter is beneficial in improvement of gait but may enhance the development of osteoarthritis.

Leg lengthening in achondroplastic children.

Bilateral simultaneous elongation of the lower limbs was performed in 3 achondroplastic children. A total of 10 bones were elongated with Wagners distraction apparatus, mainly by a modified Wagner technique. Maximal elongation of 34 to 44% of the original bone length resulted in relatively minor complications. Elongation of the lower limbs in achondroplastic children improves trunk-to-lower-limb proportions.

The value of hip aspiration in pediatric transient synovitis.

Introduction: Hip transient synovitis (TS) is a common pediatric orthopaedic problem. Although a self-limiting illness, it often makes the patient temporarily disabled and poses a diagnostic difficulty because of its similarity to septic arthritis in clinical manifestations. The aim of this study was to evaluate the use of a single ultrasound-guided hip aspiration as a treatment modality for TS. Methods: Between the years 1984 and 1989, 112 children with TS were treated through bed rest and using nonsteroidal anti-inflammatory drugs (group 1). Between the years 1990 and 1999, 119 children diagnosed with TS were treated using hip aspiration, bed rest, and nonsteroidal anti-inflammatory drugs (group 2). Recovery parameters were compared between these patient groups. Results: Twenty-four hours after admission, limping was noted in 92% and 10% of the patients in groups 1 and 2, respectively, (P<0.001). Refusal to bear weight was observed in 14% and 1% in groups 1 and 2, respectively, (P<0.001), and hip joint pain was reported in 81% and 6% in groups 1 and 2, respectively, (P<0.001). Larger joint effusions were found to be the reason behind the inability to bear weight. Conclusions: Pain due to TS may be because of capsule stretching owing to the accumulation of joint effusion. Ultrasound-guided hip aspiration relieves pain and limitation in movement and provides rapid differential diagnosis from septic arthritis of the hip joint.