İsmail Uraş

Indicators of successful use of the Pavlik harness in infants with developmental dysplasia of the hip

This study examined the outcomes of ultrasound-monitored Pavlik harness treatment in 25 infants (2 boys and 23 girls) representing a total of 31 cases of developmental dysplasia of the hip of Graf type IIc or more severe. For all infants, Pavlik harness treatment started after ultrasonographic diagnosis in our clinic. If there was no improvement by the third week of follow-up, the harness treatment was discontinued. Of the 25 patients (31 hips), 16 patients (18 hips) were successfully treated with the Pavlik harness. The effects of age at start of treatment, gender, side of pathology, first clinical evaluation findings, bilaterality, and Graf type on Pavlik harness treatment success were analysed. We found that the outcome of treatment with the Pavlik harness was related to Graf type, age at start of treatment, and bilaterality.RésuméEtude du traitement par harnais de Pavlik, avec contrôle par ultra-sons, de 31 dysplasies de hanche de type IIc ou plus selon Graf, chez 25 enfants (2 garçons et 23 filles). Dans tous les cas le traitement a débuté après un diagnostic ultrasonographique. En cas d’absence d’amélioration à la troisième semaine le traitement était arrêté. Sur les 25 patients, 16 (18 hanches) avaient un succés. Le rôle de l’âge au traitement, du sexe, du côté, de la première évaluation clinique, de la bilatéralité et du type selon Graf étaient étudiés. Nous avons constaté que l’efficacité du traitement par harnais de Pavlik dépend du type selon Graf, de l’âge au début du traitement et de la bilatéralité.

Correlation of femoral head coverage and Graf α angle in infants being screened for developmental dysplasia of the hip

Ultrasonography has become accepted as a useful imaging modality in the early detection of developmental dysplasia of the hip (DDH). The purpose of this study was to investigate the extent to which ultrasonographic measurements of femoral head coverage correspond to the categories of hip maturity defined by Graf’s angle α. The infants in this study (1,037 infants, 2,034 hips) were examined as part of an ultrasound screening program for detecting DDH. We found that femoral head coverage is positively correlated with α angle, and we also found upper and lower threshold values of femoral head coverage (51% and 39%), such that all hips having these values or beyond had mature or pathological development, respectively. For the detection of hips having mature development, this provided a specificity of 100% (by definition) and a sensitivity of 82.6%. For hips having pathological development, specificity was 100% and sensitivity was 79.2%.RésuméL’échographie est une méthode permettant l’analyse et le dépistage des dysplasies de hanches (DDH). Le propos de cette étude est d’analyser la couverture de la tête fémorale, de déterminer si cette couverture permet de définir différentes catégories de maturité des hanches selon l’angle a de Graf. 1037 enfants (2034 hanches) ont été examinés par échographie dans un programme de dépistage de la luxation de hanche (DDH). Nous avons trouvé que la couverture de la tête fémorale était corrélée avec l’angle a de Graf. Nous avons pu déterminer des valeurs repères hautes et basses de couverture de la tête (51% et 39%), de telle sorte que les hanches qui sont soit dans ses valeurs soit en dehors de ces valeurs, ont un développement mature ou pathologique. La spécificité de ce dépistage est de 100% et la sensitivité de 82,6%. Pour les hanches pathologiques la spécificité est de 100% et la sensitivité de 79,2%.

Percutaneous release of trigger thumb: do we really need steroid?

We would like to comment on the article by Cebesoy et al. entitled “Percutaneous release of the trigger thumb: is it safe, cheap and effective?” [2]. First, we would like to congratulate the authors for their contribution to the relevant literature. We know that percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and conservative treatment of the trigger digit. However, most hand surgeons are hesitant to release the A1 pulley of thumb percutaneously due to the close proximity to the digital nerve. That is why most surgeons choose open surgery or steroid injection alone for the trigger thumb. In the authors’ study, 84% of trigger thumbs (21 of 25) were cured by percutaneous release of the A1 pulley with steroid injection [2]. In a recent valuable study, authors found that a percutaneous trigger digit release resulted in high percentage of successful releases of A1 with no steroid injection [1, 3, 4]. In another study, steroids are found to be a highly effective treatment of trigger digits [5]. In the authors’ study, was this high success rate related more to percutaneous release or more related with steroid injection? And what is the contribution of steroid injection to this procedure? The authors’ study is extremely valuable, but if they had an isolated control group consisting of patients treated by percutaneous release of A1 pulley or by steroid injection group, then the comparison and distinction would be much easier. We agree with the authors: percutaneous release is a safe and effective technique which provides significant cost savings. But do we need to increase this cost by using steroids?

The efficacy of semirigid hip orthosis in the delayed treatment of developmental dysplasia of the hip.

This study assessed the use of semirigid hip orthosis to stabilize the femoral head into the acetabulum in the delayed treatment of developmental dysplasia of the hip (DDH; Graf type IIb or more severe) under the age of 6 months. Ninety-eight hips from 75 patients (four boys, 71 girls) were evaluated retrospectively. The mean age at treatment initiation was 3.2±1.3 months (1–6 months). As the dysplastic hip matured into a type I hip, we applied the weaning regimen for 1 month. Seventy-two patients (96%) were treated successfully in 4.2±1.1 months (2–8 months). All of the failures were type IV hips. We did not detect any acetabular or femoral head pathology in the later follow-up. Semirigid hip orthosis is safe and effective as the first-line treatment method for delayed DDH except in type IV hips in patients under 6 months of age. Level of Evidence: Level IV. Case series.

A new measurement method in Graf technique: prediction of future acetabular development is possible in physiologically immature hips.

Background: Universal ultrasound screening has led to overtreatment and higher follow-up rates than are found with clinical examination alone because of high incidence of physiologically immature hips (type IIa) in the first weeks of life. The ability to predict future acetabular development in physiologically immature hips (type IIa) would therefore help to reduce overtreatment and unnecessary follow-up. Methods: We described the &ggr;-angle to assess the femoral head coverage by the acetabular roof, which is measured between the baseline defined by Graf and the cartilaginous edge line connecting the inferior point of the iliac bone (lower limb) to the medial corner of the acetabular labrum. We retrospectively analyzed ultrasonographic findings of infants with developmental dysplasia of the hip diagnosed in our hospital and infants with normal hips screened in our hospital. Group 1 (35 hips) consists of type IIa hips at initial examination and went on to develop into dysplastic hips at follow-up. Group 2 (279 hips) consists of type IIa hips at initial examination and went on to develop into normal hips (type I) at follow-up. Results: The &ggr;-angles of type IIa hips that developed into type I hip at follow-up ranged between 77 and 82. The &ggr;-angles of type IIa hips that developed into hip dysplasia ranged between 72 and 78. All type IIa hips that had &ggr;-angles >78 degrees developed into normal hips. We also observed that all type IIa hips that had &ggr;-angles <77 degrees developed into dysplasia. Conclusions: The amount of cartilage mass covering the femoral head, which is a part of the acetabular roof, can therefore provide information about future acetabular development. This paper describes a new method of measurement (the &ggr;-angle) that assesses the extent of the cartilage coverage of the femoral head, which can predict acetabular development. Its use would decrease the rates of unnecessary follow-up and treatment. Level of Evidence: Level II (development of diagnostic criteria on the basis of consecutive patients).

Bilateral Transverse (Bowdler) Fibular Spurs with Hypophosphatasia in an Adolescent Girl

Hypophosphatasia is a clinically heterogeneous inheritable disorder characterized by defective bone mineralization and the deficiency of serum and tissue liver/bone/kidney alkaline phosphatase activities. Due to the mineralization defect of the bones, various skeletal findings can be radiologically observed in hypophosphatasia. Bowing and Bowdler spurs of long bones are the characteristic findings. The Bowdler spurs reported on in the previous pertinent literature were observed in the perinatal aged patients and these lesions have rarely involved adolescents. We herein report on a 14-year-old girl with fibular Bowdler spurs.

Challenging question: Which bone-sparing prosthesis should be used in a young patient with avascular necrosis of the hip?

Sir, As new treatment options emerge for old diseases and survival is lengthened, we face new complications. Avascular necrosis (AVN) is one of them. Although it can be idiopathic, it also can be due to long-term complications of metabolic diseases (like chronic renal insufficiency, diabetes), treatments (steroid use, renal transplantation or cancer chemotherapy) and dietary habits (alcohol intake) [1]. For an unsalvageable hip, we have to replace the joint, but especially for young patients here is the challenge: which prosthesis should we use? The most widely reported prosthetic options are femoral head resurfacing, thrust plate prosthesis (TPP), cemented and non-cemented total hip prosthesis. The former two are advocated for their preservation of the femoral bone stock for possible future revisions. The latter two have the advantage of being studied in a vast number of patients with long-term follow-up and great success rates. Choosing a bone-preserving method for especially young patients is logical, but there are important considerations. The first question should be about patient selection. Which types of AVN should be the primary indication? Apparently, there are studies which report that renal transplantation patients [1], steroid-induced AVN [2] and the extension of necrosis into the femoral neck [1] are contraindications to TPP. Some others reported that sickle cell anemia and immunosuppressive treatment increase the likelihood of septic loosening in TPP and resurfaced femoral heads [2]. These patients should instead undergo a classic cemented/non-cemented total hip replacement surgery. The second issue is revision. This is an area which must be studied. Regarding the TPP, as there are screw holes in the metaphyseal region with possible accompanying osteolysis under the plate [3], revision should either be done by a cemented prosthesis or by a distally engaging cementless prosthesis. If proximally engaged stems are going to be used, then cerclage wiring systems should be ready in the operating theatre. When comparing short-term to mid-term results, unpredictability has been noted for the hip-resurfacing prosthesis with failure rates as high as 34% with a relatively short time to revision (3 months to 2.5 years) [4]. High failure rates and patient satisfaction as low as 61% have been reported for this prosthesis in other studies as well [5, 6, 7]. In comparison, the TPP is a better studied prosthesis with more clinical experience. It also has a higher incidence of clinical success in terms of hip scores and a lower implant failure rate ranging between 2.7% and 9.7% [1, 2, 8, 9]. This result is very similar to the results of conventional total hip replacements [10, 11]. In conclusion, one should be aware of the fact that performing a hip arthroplasty in a patient with AVN of the hip is very different from applying the same procedure to a patient with primary coxarthrosis. The cause of the AVN should influence the choice of implant. For carefully selected young patients, the first line of hip replacement can be done with a TPP hip prosthesis with the advantage of bone stock preservation and near physiological bone loading. There is still a need for studies into the long-term follow-up and especially the revision of these prostheses. This Letter to the Editor refers to the article at http://dx.doi.org/ 10.1007/s00402–004–0652-y. A Reply to this Letter is available at http://dx.doi.org/10.1007/s00402–004–0787-x.

Functional Evaluation of Partial Hip Arthroplasty in Patients with Hip Fractures

A total of 82 of 130 patients who were operated with partial hip arthroplasty for hip fractures reached Fatih University Hospital (new name of Turgut Özal University). The mean follow-up time was 37.76 months and the mean age of the 82 patients was 78.99. Of the total number of patients, 25 were men and 57 were women. A total of 49 patients were alive and 33 were dead. The mean postoperative survival of these patients was 31.1 months. The mean total score of the Oxford hip score was 50.17. There was no effect of operation age, sex, hypertension, diabetes mellitus, renal diseases, dementia, and chronic obstructive lung disease on the Oxford hip score. Survival was not affected by the result of the Oxford hip score. The total Oxford hip score was less in patients who had heart disease, but it was not significant statistically. Embolus affected the hip score negatively.