Osman Yüksel Yavuz

Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip.

Although hip ultrasonography is gaining acceptance as the most effective method for the early diagnosis of developmental dysplasia of the hip, there is still some controversy regarding the use of ultrasonography as a screening method. The purpose of this study was to investigate prospectively the capacity of clinical examination findings and associated risk factors to detect developmental dysplasia of the hip defined ultrasonographically in infants. A total of 3,541 infants underwent clinical examination and hip ultrasonography. Measured against ultrasonography as a standard, the sensitivity and specificity of clinical examination were 97% and 13.68%, respectively. Graf type IIb or more severe developmental dysplasia was found in 167 infants (208 hips), at an overall frequency of 4.71%. Graf type IIa physiological immaturity was encountered in 838 hips, and of these, 15 hips (1.78%) developed Graf type IIb dysplasia and underwent treatment. Patient characteristics that were found to be significant risk factors were swaddling use, female gender, breech delivery and positive family history. Given its low specificity, our findings suggest that clinical examination does not reliably detect ultrasonographically defined developmental dysplasia of the hip in infants being screened for this disease.RésuméSi l’échographie est une méthode efficace pour le diagnostic précoce des dysplasie ou des luxations de hanches, son utilisation comme méthode de dépistage est controversée. Le propos de cette étude est de réaliser une étude prospective de cet examen à partir de patients présentant des facteurs de risques et d’un examen clinique (3,541 enfants). La sensibilité et la spécificité de l’examen clinique a été respectivement de 97% et 13.68%. Cent soixante-sept enfants (208 hanches) présentaient soit un type IIb de Graf ou une atteinte plus sévère soit 4.71%. Une hanche immature avec un type IIa de Graf a été présente dans 838 hanches, 15 d’entre-elles (1.78%) évoluant vers le type IIb et nécessitant un traitement. Les facteurs de risques utilisés ont été les suivants : sexe féminin, antécédent, siège. Du fait de cette spécificité basse de l’examen, nous pensons que l’examen clinique ne permet pas de mettre en évidence de façon certaine les stades de dysphonies détectés à l’échographie de la hanche chez les enfants ainsi dépistés.

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.

Value of anatomic landmarks in carpal tunnel surgery

This study investigated which anatomic landmarks were most useful for correct and safe incision placement in carpal tunnel surgery. Kirschner wires were attached to the hands to mark previously defined landmarks. The bony attachments of the transverse carpal ligament, which were identified previously, were drawn on an anteroposterior digital x-ray of the hand, with the thumb in full abduction. The relationship between anatomic landmarks and these bony attachments were examined. In all hands, either the line along the third web space or the crease between the thenar and the hypothenar regions, or both, were on the ulnar half of the transverse carpal ligament. During incision placement, we recommend selecting the most ulnar choice between the line drawn along the third web space and the crease between the thenar and hypothenar regions in order to be at safe distance from the recurrent motor branch of the median nerve.

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).

Which modality is the best choice in distal radius fractures treated with two different Kirschner wire fixation and immobilization techniques

BACKGROUND The aim of the study was to investigate whether the number and position of Kirschner (K)-wires, and the manner and duration of immobilization influence radiologic and functional outcomes of distal radius fractures treated with percutaneous K-wire fixation. METHODS Ninety-two patients were included into the study with a mean follow-up period of 19.84±5.22 months (range, 13-34 months). In Group I, forty-five patients were treated with 3 K-wires and supported with a volar semi-circular cast for the first 3 weeks followed by a removable splint for a further 3 weeks. In Group II, forty-seven patients were treated with 2 K-wires and supported with a below-elbow circular cast for 6 weeks postoperatively. RESULTS No significant difference in grip strength and DASH scores was found between the two groups. In clinical examination, significantly better functional results were determined in patients supported with a removable volar splint. At 6 weeks postoperatively, volar tilt, radial inclination, and radial length were significantly better in Group I compared to Group II (all p values). CONCLUSION Tripod technique with 3 K-wires is a safe and reliable procedure to achieve stability and good radiological results. The use of a removable splint also improves the functional outcomes in the treatment of both intra- and extra-articular distal radius fractures.

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.

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.