Terje Terjesen

Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants.

The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia.

Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients

The torsion of both femora was evaluated in 110 patients who had been treated by intramedullary nailing for unilateral femoral shaft fractures. The anteversion (AV) angle was measured by ultrasound, using a tilted-transducer technique. True torsional deformity, defined as an AV difference of 15 degrees or more between sides was found in 21 patients, but only eight had complaints related to the deformity. Three patients had reoperations for troublesome external torsional deformities. Of 26 patients with AV differences of 10 degrees to 14 degrees, defined as possible torsional deformity, three had complaints, but none had serious problems. AV differences of up to 29 degrees were observed in symptom-free patients, and no patients with AV differences below 10 degrees had complaints. Static and dynamic nailing showed almost equal tendencies to lead to torsional deformity. We conclude that torsional deformities are usually established during the operation. Many patients tolerate abnormal torsion, but efforts should be made to reduce and stabilise the femoral shaft fracture with an AV difference of less than 15 degrees.

Femoral anteversion in normal adults: Ultrasound measurements in 50 men and 50 women

The femoral anteversion (AV) angles were measured by ultrasound in a normal group of 100 adult subjects to find the normal range of anteversion, to determine the normal left/right difference, to assess the interobserver variation, and to find the correlation between AV angle and clinical hip rotation. All the ultrasound measurements were performed independently by 2 observers. The mean AV angle was 18 degrees in the women and 14 degrees in the men. The mean left/right difference in AV was 3.8 degrees, and the upper normal limit of side difference (mean +/- 2 SD) was 9.8 degrees. The mean (SD) interobserver variation was only 1.9 degrees (1.3 degrees). The correlations between AV angles and internal and external hip rotation were significant, but not very high (r = 0.49 and -0.49, respectively). We conclude that ultrasound is appropriate for measurement of femoral anteversion. Our results could be used as a basis when evaluating patients with clinically suspected rotational disorders of the femur.

Acetabular angles and femoral anteversion in dysplastic hips in adults: CT investigation.

Transpelvic CT was used to quantify the relationship between the acetabulum and proximal femur in 21 adult patients (33 hips) with congenital hip dysplasia (defined by a center edge angle of less than 20 degrees). The anterior and posterior acetabular sector angles (AASA and PASA) were measured, as well as the degree of acetabular and femoral anteversion. The results demonstrated deficient anterior acetabular support (i.e., decreased AASA) in approximately two-thirds of the dysplastic hips and reduced posterior support (i.e., decreased PASA) in one-third. The acetabular anteversion was normal. The femoral anteversion. however, was greater than normal in most hip. As important additional information is obtained by CT compared with conventional radiography, CT is recommended when operative procedures aimed at preventing or postponing osteoarthrosis are considered.

Computed tomography measurements of the acetabulum in adult dysplastic hips: which level is appropriate?

A study has been performed to evaluate whether one or several levels are needed with computed tomography (CT) study to provide sufficient information regarding anteversion and acetabular support to the femoral head. A total of 23 hips in 14 adults with uni- or bilateral congenital hip dysplasia (center-edge angle less than 20°) were assessed by obtaining 5-mm contiguous CT slices and performing acetabular measurements at four levels. Both anterior and posterior acetabular supports as quantified by the anterior and posterior acetabular sector angles were significantly lower than normal at all levels. The sector angles increased in the proximal cuts, whereas the acetabular anteversion increased caudally. Because no important additional information was gained by measuring at different levels, we conclude that CT study at one level is sufficient for acetabular measurements and suggest that the slice through the center of the femoral head is the most appropriate one.

Hip motion related to age and sex

In a selected population 4 years old to adult age, 1,522 hips in 761 healthy subjects of both sexes were studied. Arcs of passive motion of the hip were measured by the technique recommended by the American Academy of Orthopaedic Surgeons. The lower and upper limits of normal range of hip motion in all the planes were established for both sexes in the different age groups. We found that the amplitude of most hip motions decreased with age. Females had higher ranges of total hip motion, total rotation, internal rotation, and abduction compared with males.

Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients.

Background There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning. Method Before gait analysis, 60 ambulatory children aged 10 (4–18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis. Results Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%). Interpretation Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.

The natural history of hip development in cerebral palsy.

Aim  The purpose of this study was to evaluate a population‐based radiographic hip surveillance programme for children with cerebral palsy (CP) and to assess the natural history of hip displacement.

Ultrasound screening for hip dysplasia in newborns

We evaluated risk factors for neonatal hip instability (NHI) at birth using ultrasonography and assessed the reliability of our ultrasound method by means of an interobserver study. The hips of 4,459 newborns were examined by ultrasound from 1988 to 1990. The ultrasound evaluation was based mainly on measurement of femoral head coverage (FHC) by the bony acetabular roof. The mean FHC was 56% in boys and 54% in girls (a significant difference). Fifty-five newborns with unstable hips had a mean FHC of 37%, which was significantly lower than that of the normal hips. Known risk factors for NHI were confirmed (breech position, family history of hip dysplasia, increased birth weight), but no new risk factors were detected. The interobserver study included 200 hips. The 95% confidence limit for interobserver variation in FHC (±2 SD) was ±8%. Because of this moderate interobserver variation, and because the incidence of late-detected hip dysplasia was low (0.2 per 1,000), we conclude that our method for ultrasound examination is sufficiently reliable for screening of hips in newborns.

Regression of femoral anteversion. A prospective study of intoeing children.

To study the spontaneous regression of femoral anteversion, 30 children referred to the outpatient clinic for intoeing were followed until at least 15 years of age. The mean observation time was 9 (7-12) years, and all the children were examined three times during the growth period. The mean radiographic angle at the first examination was 42 degrees, at the second examination 36 degrees, and at the last examination 28 degrees. The mean decrease of the AV angle per year was 1.5 degrees, with a considerable range (0.2-3.1 degrees). The mean internal rotation of the hip decreased from 74 degrees to 53 degrees during the observation period, and the external rotation increased from 19 degrees to 37 degrees. While all 30 children had an intoeing gait at the first examination, this disappeared in all but 5 children.