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[Remodeling of the acetabulum after experimental hip joint dislocation--an animal experiment study of the rabbit].

PURPOSE: Little is known about the remodeling potential of the acetabulum after dislocation and relocation of the hip joint. Most clinical data rely on radiographic measurements in a clinical setting, with only few singular reports on histologic changes at the time of surgery. This study was undertaken to examine the remodeling potential of the rabbit acetabulum after different length of hip dislocation and to gain insight into the histology of the remodeling process involved. METHOD: The right knee joint was immobilized in 28 matched New Zealand white rabbits, causing dislocation of the associated hip joint. Assessment of the joint status was made by serial X-rays in a reproducible standardized way, allowing measurement of the Acetabular Index (AI). The untreated left hip joints served as controls in the histologic sections and also allowed to develop an age matched scale of normal acetabular development for radiographic assessment. Dislocation was unsuccessful in 2 rabbits, 9 animals were sacrificed with the joint dislocated, and in 13 animals a closed reduction was performed and maintained in a Petrie type position for 10 days. Reduction was unsuccessful in 4 cases. The reduced group was sacrificed after 4 to 12 weeks, the point of harvesting being determined by no further change in the serial standardized radiographic measurements of the AI. All surgical procedures were done under the supervision of a veterinary surgeon and followed an approved protocol. RESULTS: In the time observed, the normal values of the Acetabular Index drop from 30 degrees to 20 degrees over a time of 3 months. In animals with a dislocated hip the AI increased to 40 degrees, which was completely reversible and reached normal values in 4 weeks, if reposition was done at this time (group A). Later reposition did improve the AI, but compared to normal age matched values, the AI remained elevated (> 30 degrees), demonstrating a residual dysplasia (group B). The histologic sections of the control left joints showed normal hyaline cartilage with physiologic vertical stacking of the cartilage zones. In the dislocated group the vertical stacking was lost, with chondrocytes demonstrating a fibro-cartilaginous metaplasia. There was hypocellularity with loss of nuclear staining. These changes were completely reversed in the group A, but remained in group B. CONCLUSIONS: This study demonstrates that an early reduction will not only allow for a normalisation of the radiographic values, but that the histologic changes as they develop during dislocation can completely be reversed. Long standing dislocation will lead to a permanent tissue metaplasia similar to the one seen in compression testing of joint cartilage, therefore loosing the potential for remodeling. Similar processes may occur in the human situation and the findings here underline the necessity for early reduction to allow for a complete remodeling of the hip joint.

Acetabulum↗
PubMed2004

Increased risk of dislocation after primary total hip arthroplasty in inflammatory arthritis: a prospective observational study of 410 hips.

BACKGROUND: It is unclear whether patients with inflammatory arthritis have a higher risk of dislocation after hip replacement. PATIENTS AND MATERIAL: We carried out a prospective study assessing the incidence of dislocation within 2 years after surgery for patients diagnosed with inflammatory arthritis (IA) and osteoarthrosis (OA). One single type of prosthesis was implanted using a lateral approach. Both diagnostic groups were compared by univariate analysis with respect to dislocation, sex, age, diagnosis, prior hip surgery, experience of the surgeon and malposition of the acetabular component. In a multivariate logistic regression approach, the difference in dislocation incidence was assessed after adjusting for the effect of the potential confounders given above. Between 1996 and 1999, 410 THA were performed: 70 in IA and 340 in OA. After 2 years no patients were lost to follow-up, but 12 patients had died, and 5 revisions were carried out for reasons other than dislocation. RESULTS: The dislocation rate in patients with IA was higher than in patients with OA: 10% (7 hips) in the IA group and 3% (10 hips) in the OA group (p = 0.006). No significant differences were found among the risk factors for dislocation between the two groups. Multivariate logistic regression analysis showed that IA is an independent risk factor for dislocation (odds ratio (OR) 3.7, 95% CI 1.3-11), together with malposition of the cup in more than 55 degrees abduction (OR 7.7, CI 2.3-26) and increased anteversion (OR 7.6, CI 1.4-42.4). INTERPRETATION: Our findings clearly suggest that inflammatory arthritis has to be considered as an independent risk factor for dislocation after primary THA.

Adult↗
PubMed2000

Radiographic evaluation of anterior dislocation of the shoulder.

PURPOSE: To establish radiographic criteria to choose the most appropriate technique of reduction for each type of anterior glenohumeral dislocation, and to determine the type of dislocation which requires general anesthesia. MATERIAL AND METHODS: Radiography in two different projections was performed in 67 patients with antero-inferior shoulder dislocations before a reduction attempt. The method proposed by BOss-HOLZACH-MATTER was used as the primary technique for all shoulder dislocations. RESULTS: Most subcoracoid dislocations (84.4%) could be reduced by the BOss-HOLZACH-MATTER method while only a few subglenoid dislocations (15.8%) were reducible by this technique. Displaced associated fractures significantly reduced the success rate of the reduction attempts. CONCLUSION: Anterior dislocations of the shoulder require different methods of reduction depending upon the type (sub-group) of dislocation. Reduction of subglenoid dislocations with associated greater tuberosity fracture should be performed under general anesthesia to avoid head-splitting fracture.

Adolescent↗
PubMed2001

Congenital dislocation of the patella.

Congenital dislocation of the patella may occur as a persistent lateral dislocation of the patella that presents with a knee flexion contracture and the patella tethered lateral to the femoral condyles or as an intermittent dislocation of the patella. In the latter syndrome, the patella dislocates completely with each flexion and extension cycle of the knee and is best termed obligatory dislocation of the patella, because the patient has no control over the patella dislocating as he or she moves the knee. The first type of congenital dislocation, which is fixed, often is associated with syndromes such as arthrogryposis and should be corrected surgically by lateral release and realignment of the patella. Obligatory dislocation of the patella tends to be an isolated dysplastic anomaly and may be relatively well tolerated. Rebalancing of the patella usually is done at a later age because of less interference with function. The current author describes the natural history of patella femoral dysplasia, detailing the pathologic changes that are present, and recommends surgical techniques for correcting both types of congenital dislocation of the patella.

Child↗
PubMed2001

In vitro genesis of subaxial cervical unilateral facet dislocations through sequential soft tissue ablation.

STUDY DESIGN: In vitro anatomic study investigating the degree of soft tissue disruption required to produce a subaxial cervical unilateral facet dislocation. OBJECTIVES: To develop an understanding of the relative contributions to stability of the subaxial cervical soft tissues and to define an anatomic threshold of injury necessary to produce a unilateral cervical facet dislocation. SUMMARY OF BACKGROUND DATA: The literature at this time is unclear regarding the precise pathomechanics of a cervical unilateral facet dislocation and the required threshold of soft tissue injury necessary for its genesis. Published clinical reports do not make any specific reference to these factors or are unclear in their objectivity. METHODS: Two adjacent vertebra at a time in 10 fresh-frozen subaxial cervical spine specimens (C2-C3 to C6-C7) were transfixed in the coronal plane with 3.5-mm Schanz screws. A steady unilateral vertical distraction force resulting in lateral cervical flexion was applied to these screws as the surrounding cervical soft tissue structures were sequentially ablated. Four experimental models were developed, varying the order of soft tissue disruption. RESULTS: The physiologic coupling of subaxial cervical unilateral distraction and rotation, because of the spatial orientation or inclination of the cervical facet joints, allowed the creation of a unilateral facet dislocation without an additional flexion moment. Disruption of the ipsilateral articular capsule, ligamentum flavum, and more than half of the anulus fibrosus was necessary for the genesis of a unilateral facet dislocation. Disruption of the supraspinous and interspinous ligaments was not necessary but appeared to facilitate or lessen the force required to dislocate a unilateral facet. Disruption of the anterior and posterior longitudinal ligaments and intertransverse ligaments was not necessary to create a unilateral facet dislocation. CONCLUSION: This anatomic study further supports the theory that discontinuity of the anterior and posterior longitudinal ligaments is not necessary for a unilateral facet dislocation to occur. The ipsilateral facet capsule, anulus fibrosus, and ligamentum flavum appear to be the physical soft tissue restraints that need to be disrupted to produce a unilateral facet dislocation.

Adolescent↗
PubMed2006

Dislocation of primary total hip arthroplasty with 36 and 40-mm femoral heads.

Some authors suggest the use of larger (36 and 40 mm) femoral heads against highly cross-linked polyethylene acetabular liners will reduce the prevalence of early dislocation after primary total hip arthroplasty (THA). We prospectively followed 61 consecutive patients at high risk for dislocation to determine the prevalence of early dislocation after primary THA with 36 and 40 mm femoral heads. We established specific indications for the use of these larger heads in primary arthroplasty. There were 65 hips in 61 patients with a minimum followup of 1 year (mean 2 years, range 1-4 years). There were 55 36 mm heads and 10 40 mm heads. All arthroplasties were performed by the posterior approach with capsular repair. The prevalence of early dislocation was 4.6% (3 of 65). There was one patient with an anterior dislocation and two with posterior dislocation. No patient underwent reoperation for dislocation. There was no dislocation in the 10 hips that had a 40 mm head. We identified no complications related to the larger femoral heads. The use of larger femoral heads did not notably reduce the prevalence of early dislocation after primary THA in high risk patients compared to historical controls.

Aged↗
PubMed2005

Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report.

STUDY DESIGN: A case report of acute quadriplegia resulting from closed traction reduction of traumatic bilateral cervical facet dislocation in a 54-year-old male with concomitant ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To report an unusual presentation of a spinal cord injury, examine the approach to reversal of the injury, and review the treatment and management controversies of acute cervical facet dislocations in specific patient subgroups. SUMMARY OF BACKGROUND DATA: The treatment of acute cervical facet dislocations is an area of ongoing controversy, especially regarding the question of the necessity of advanced imaging studies before closed traction reduction of the dislocated cervical spine. The safety of an immediate closed, traction reduction of the cervical spine in awake, alert, cooperative, and appropriately select patients has been reported in several studies. To date, there have been no permanent neurologic deficits resulting from awake, closed reduction reported in the literature. A case of temporary, acute quadriplegia with complete neurologic recovery following successful closed traction reduction of a bilateral cervical facet dislocation in the setting of OPLL is presented. METHODS: The clinical neurologic examination, radiographic, and advanced imaging studies before and after closed, traction reduction of a cervical facet dislocation are evaluated and discussed. A review of the literature regarding the treatment of acute cervical facet dislocations is presented. RESULTS: Radiographs showed approximately 50% subluxation of the fifth on the sixth cervical vertebrae, along with computerized tomography revealing extensive discontinuous OPLL. The cervical facet dislocation was successfully reduced with an awake, closed traction reduction, before magnetic resonance imaging (MRI) evaluation. The patient subsequently had acute quadriplegia develop, with the ensuing MRI study illustrating severe spinal stenosis at the C5, C6 level as a result of OPLL or a large extruded disc herniation. Following an immediate anterior decompression and a posterior stabilization procedure, the patient regained full motor and sensory function. CONCLUSIONS: This case report highlights the advantages and shows some safety concerns regarding immediate, closed traction reduction of cervical facet dislocation with real-time neural monitoring in an awake, alert, oriented, and appropriately select patient before MRI studies in the setting of preexisting central stenosis from OPLL.

Acute Disease↗
PubMed2005

Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment.

PURPOSE OF REVIEW: The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation. Recurrent instability is a common complication after traumatic shoulder dislocation in young people, with rates as high as 100% in skeletally immature patients and 96% in for adolescents. Treatment for shoulder dislocation has traditionally involved immobilization followed by a rehabilitation program. Recent studies have reported decreased rates of recurrent instability and improved outcomes in patients treated with surgical stabilization of acute, traumatic shoulder dislocation. The purpose of this review is to review recent publications concerning the treatment of traumatic shoulder dislocations in adolescents. RECENT FINDINGS: Lawton et al. retrospectively reviewed 70 shoulders in 66 patients 16 years old or younger treated for shoulder instability with follow-up more than 2 years. Forty-two shoulders were successfully treated with physical therapy, whereas 28 eventually required surgery. Subsequently, Deitch et al. retrospectively identified 32 patients between 11 and 18 years of age with radiographically documented traumatic anterior shoulder dislocation. Instability recurred in 75% of patients and 50% eventually required surgical stabilization. Bottoni et al. reported results of a prospective randomized trial comparing arthroscopic stabilization to nonoperative treatment of acute, traumatic shoulder dislocations in patients aged 18 to 26 years. Recurrent instability developed in 75% of patients treated conservatively versus 11% in those treated with surgery. DeBerardino et al. prospectively evaluated arthroscopic stabilization of acute shoulder dislocations in 48 young athletes with an average follow-up of 37 months and reported a 12% rate of recurrent instability. All patients with stable shoulders were able to return to their previous levels of activity. SUMMARY: Conservative management of traumatic shoulder dislocations in young patients is associated with high rates of recurrent instability. Recent studies have demonstrated improved results and significant reduction in recurrent instability in patients treated with surgical stabilization when compared with nonoperative treatment.

Adolescent↗
PubMed1984

Vertical dislocation of the C1 and C2 vertebrae in rheumatoid arthritis.

In a retrospective analysis of 450 patients with rheumatoid arthritis the cervical films were reviewed to detect vertical dislocation of the C1 and C2 vertebrae. A frequency of 10 per cent was found among all patients and of 24 per cent among those with cervical arthritis. The authors' method of measuring vertical dislocation at conventional radiography turned out to be superior to the method of McGregor , especially in cases with severe dislocation. The vertical dislocation was shown to be preceded by a horizontal dislocation and the appearance of vertical dislocation diminished or abolished the horizontal dislocation. Progression occurred in many cases and was combined with erosions of the atlas and axis. In more than half of the patients there was also contemporaneously a subaxial dislocation. Neurologic symptoms were more often occurring in patients with a severe vertical dislocation and in patients with spinal stenosis at the C1 level.

Adult↗
PubMed2003

Anterior shoulder dislocation: quantification of glenoid bone loss with CT.

OBJECTIVE: In recurrent anterior shoulder dislocation, glenoid bone loss may predispose the patient to further dislocation and failure of a Bankart repair. This study investigates the quantification of glenoid bone loss in anterior shoulder dislocation using CT. SUBJECTS AND METHODS: CT examinations were performed on 40 patients (average age, 31 years; range, 13-82 years), comprising 46 shoulders with anterior dislocation and 34 contralateral normal shoulders. Twenty shoulders in 10 healthy subjects were also examined. Both shoulders were examined simultaneously. Image reconstruction included oblique sagittal reformatted images en face to the glenoid fossa. Seven aspects of glenoid fossa shape and size were measured, including the cross-sectional area, maximum width, maximum height, and flattening of the anterior glenoid curvature. RESULTS: Variable flattening of the anterior glenoid curvature was a feature in 42 (91%) of 46 dislocated shoulders although it was seen in only two (4%) of 54 normal shoulders. Anterior glenoid flattening increased exponentially with an increasing number of dislocations. Anterior glenoid flattening, decreased maximum glenoid width, and decreased maximum width-to-length ratio were the most useful measures of bone loss. Maximum glenoid width was smaller than on the contralateral side in 79% of patients with unilateral dislocation by an average of 3.0 mm (range, 0.1-10 mm) or 10.8% (range, 0.4-32%). Glenoid cross-sectional area was a less useful measure of glenoid bone loss. CONCLUSION: Flattening of the anterior glenoid curvature is shown in most patients with anterior dislocation. In unilateral dislocation, a comparison of maximum glenoid width with that on the contralateral side was the best discriminator of moderate to severe glenoid bone loss.

Adolescent↗
PubMed2003

[Peri-lunate wrist dislocation: long-term outcome].

PURPOSE OF THE STUDY: We report our experience with 25 peri-lunate posterior wrist dislocations and compare outcome with data in the literature searching for prognostic factors. MATERIAL AND METHODS: Our series included 24 men and one woman, mean age 36 years. Twenty-three patient were less than 50 years old at the time of the accident. Diagnosis was established late in five patients. All patients were reviewed clinically and radiologically with a mean follow-up of 57 months. We differentiated pure dislocations (n=16) from trans-scapho-lunate dislocations (n=9). The pure dislocations included six type 1 and ten type 2 in the Witvoët and Allieu classification. We also distinguished groups by open or closed treatment, with or without pinning, and with or without suture of the scapho-lunate ligament. Screw fixation was used in case of scaphoid fracture. Post-operative cast immobilization was 45 days on the average, followed by three months of rehabilitation exercises. RESULTS: Residual pain of variable intensity was reported by 22 patients but subjectively, 21 patients considered outcome to be good or very good. Wrist movement was greatly impaired in eight patient with a 60 degrees flexion-extension arc. All patients had a 20% reduction in force compared with the healthy side. According to the Green and O'Brian functional score, outcome was poor in four wrists. The scapholunate space and the sapholunate angles were abnormal in seven wrists. Reduction was insufficient in only one case with the scapholunate space measuring 5 mm after trans-scapho-lunate dislocation. In most of the cases, these poor functional and/or radiographic results coincided with carpal instability which developed early or late after trauma. The most bothersome element in other cases was wrist stiffness. The trans-scapho-lunate dislocations appeared to evolve more favorably than the pure dislocations, but could also cause carpal instability. DISCUSSION: There is a real functional impairment after posterior peri-lunate dislocation. The differences in outcome we observed were not statistically correlated with type of treatment, probably because of the small number of patients, but did reveal certain tendencies. Closed reduction did not always avoid the development of carpal instability and gave only average results. Percutaneous pinning or open reduction did not improve outcome in pure dislocations. It might be good to use scapho-lunate suture more often to obtain better healing and reduce the risk of carpal instability, as has been suggested by certain teams.

Adult↗
PubMed1992

Recognition of arterial injury in elbow dislocation.

The clinical presentation of patients with elbow dislocations was reviewed to identify those factors indicating an increased risk for arterial injury. Sixty-two patients were treated for 63 elbow dislocations between January 1981 and July 1991. Eight patients (13%) sustained a concomitant arterial injury involving the brachial (7) and radial (1) arteries. Three clinical findings, absence of a radial pulse, open dislocation, and presence of systemic injuries, were correlated with arterial injury. A palpable radial pulse was absent in six (75%) patients with an arterial injury but in only two (4%) with normal vessels (p less than 0.0001, chi square). Five (33%) open dislocations had an associated arterial injury, whereas three (6%) arterial injuries occurred in closed dislocations (p less than 0.006, chi square). Systemic injury occurred in five dislocations (63%) with arterial injuries and 14 dislocations (25%) without arterial injury (p less than 0.04, chi square). Multivariate analysis showed that absence of a radial pulse was the only factor that significantly predicted arterial injury (p less than 0.0001). Although most elbow dislocations are not associated with arterial injury, absence of a radial pulse or presence of an open dislocation or both should alert the clinician to the increased possibility of an associated vascular injury.

Adult↗
PubMed2005

Traumatic lateral lumbosacral dislocation: one case and review of literature.

OBJECTIVE: Lateral traumatic lumbosacral dislocation is a rare and severe lesion of the lumbosacral junction. Only one case has been reported in the literature. We report a new case of pure lateral lumbosacral dislocation. METHODS: A 27-year-old man had an isolated pure lateral traumatic dislocation of the lumbosacral junction after a motorcycle accident. The diagnosis and the therapeutic course are analyzed and discussed. RESULTS: Traumatic lumbosacral dislocation usually occurs in patient with multiple traumas. Generally, in the case of complete fracture-dislocation, on lateral radiographs one can observe the L5 vertebra slippage over the sacrum, resulting from an associated severe disc disruption. This feature was not seen in our patient. Surgical treatment consisted of an open reduction of the dislocation, stabilization with posterior instrumentation, and a lumbosacral arthrodesis by posterolateral grafting. In cases of pure lateral dislocation, short instrumentation can be recommended, extending from L5 to S1. Addition of an interbody fusion should be considered when the L5-S1 disc is disrupted, which is responsible for the anterior slippage of L5 over S1. Disc disruption can be evoked on preoperative magnetic resonance imaging (MRI) and intraoperatively by exploring the spinal canal. CONCLUSIONS: Pure lumbosacral dislocation with a lateral translation seemed to have no disc disruption as observed in complete fracture dislocation. Nevertheless, we recommend looking for an L5-S1 disc disruption either on preoperative MRI or during surgical exploration.

Adult↗
PubMed2005

The epidemiology of shoulder dislocation in a state-hospital: a review of 106 cases.

This retrospective study was conducted in a state hospital set-up and aimed at identifying the magnitude of shoulder dislocations and their demographic data, characteristics of the injury, mechanism and predisposing factors, and the instituted treatment. Patients with radiographic evidence of shoulder dislocation admitted to the hospital from January 1999 to December 2002 were included. Data were recorded from the case notes. There were 105 shoulder dislocations with male predomination in 77% cases and age ranged between 11 and 90 years (average 30.9 years). The right shoulder was affected in 68% of the cases. The contributing events were fall in 37% of cases, road traffic accident 23%, sports 17% and pathological conditions 13%. Anterior dislocation occurred in 96.2% of the cases. Posterior and inferior dislocations encountered in two patients for each type. Twelve dislocations were associated fracture of the greater tuberosity, two each with humeral neck fracture and cerebral injuries. First time dislocation occurred in 73.6% of the cases. The recurrences ranged between 2 to 6 times (average 3.4 times). Closed manipulative reduction and strapping was the definitive treatment in 92.4% of the cases and the remaining needed surgical reconstruction. Four patients had open reduction and internal fixation of the associated fractures while another four had arthroscopic Bankart's repair. In conclusion, shoulder dislocation represents the most common shoulder problems. It afflicted young adults of reproductive age (21-40 years) and participation in sports was a risk factor in men. Women over 40 years and fall were at risk to develop shoulder dislocation.

Adolescent↗
PubMed1984

[Development of habitual shoulder dislocation].

The starting point of the retrospective analysis of 177 primary dislocations was the question of frequency of habitual dislocations, the correlation between habitual dislocation and time of early immobilisation, as well as the search for additional statements which would result in a differentiated therapy. 18.1% habitual dislocations were seen to develop, mostly after immobilisation for less than three weeks. It is an interesting fact that the technique of immobilisation made no difference. We found that after the first even there was generally no loss in function, whereas 14.5% of the men and 34.3% of the women complained of severe subjective symptoms. The 12 patients who underwent an operation because of habitual dislocation suffered neither from dysfunction nor from painful movement, and no dislocation was found. The rate of habitual dislocation in our patients showed a lower rate of dislocation of the shoulder joint. We found 18.1% dislocations, whereas the literature showed an average quota of 30%. To improve the results we recommend a special X-ray technique following the first reposition. In the age group between 20 and 30 years, which is most susceptible, we also recommend arthrography and arthroscopy of the shoulder joint. To improve typical lesions, such as osseous rupture of the capsule or what is known as Hill-Sachs lesions, primary operation is discussed as an alternative treatment.

Adolescent↗
PubMed1983

Dislocation arthropathy of the shoulder.

Seventy-four shoulders in seventy patients with a history of single or multiple dislocations of the shoulder demonstrated radiographic evidence of glenohumeral arthropathy. In every patient radiographs of the contralateral shoulder failed to reveal any abnormality (except, of course, in patients with bilateral dislocation). There were sixty-two anterior and eleven posterior dislocations, and one multidirectional dislocation. Shoulders with a posterior dislocation had a much higher incidence of moderate and severe arthrosis than those that had an anterior dislocation. This seemed to be related to delay in diagnosis. The number of recurrent dislocations or the presence of defects of either the glenoid rim or the humeral head, or both, was not related to the severity of the arthrosis. Operations in which internal fixation devices intruded on joint cartilage frequently resulted in moderate to severe arthrosis. Ten of the fifteen shoulders with severe arthrosis and six of the fourteen with moderate arthrosis had had no operation for the dislocation. Six of these sixteen shoulders had had a posterior dislocation for which reduction had been delayed.

Adolescent↗
PubMed1996

Avascular necrosis of the proximal femur in developmental dislocation of the hip. Incidence, risk factors, sequelae and MR imaging for diagnosis and prognosis.

Avascular necrosis of the proximal femur still remains the major complication of the treatment for developmental dislocation of the hip. In a three part study I reviewed this problem. Part I analyzed incidence, causes, and risk factors of avascular necrosis. In 105 children with 113 hips who developed avascular necrosis out of 636 consecutive patients with 823 hips treated nonoperatively for developmental dislocation of the hip in the years 1972-1976 the risk factors of avascular necrosis were determined. A method of treatment in most cases was Frejka pillow. Conventional radiographs obtained in AP views during the course of treatment and follow-up were analyzed. Avascular necrosis was found in 14 percent of the hips, classified as mild (49%), moderate (14%), and severe (37%). The differences between mild and severe cases were significant as regards age at the onset of treatment (p 0.006); with higher average age in mild forms, and degree of dislocation (p 0.01) with higher values in severe forms. The older the child was at the onset of treatment, the greater the risk of necrosis, notably if treatment was begun after 6 months of age. However, the incidence of the more severe cases was higher in the group up to 6 month of age. In general, avascular necrosis was more likely to occur in cases with high degree of initial dislocation and the differences between groups with low and high degree of dislocation were significant. In the group with highest initial dislocation the number of both mild and severe forms was high. Part II evaluated the growth and remodeling of the hip joint with avascular necrosis after nonoperative treatment of developmental dislocation on the basis of conventional radiography. An attempt was also made to determine the correlation between the severity of necrosis as seen in conventional radiography and the clinical and radiographic appearance of the hip after completion of growth. Finally the prognostic value of conventional radiography in prediction of deformities of the proximal femur due to necrosis was estimated. 68 patients with 98 involved hips treated exclusively nonoperatively for developmental dislocation of the hip in whom avascular necrosis developed were selected for the study. The average age at the time when the final radiograph was made was 25 (18-36) years and the average follow-up period was 23 (18-35) years. 16 patients (27 hips) were examined twice after completion of growth with the time interval of 10 years, the second examination being at an average age of 30 (26-36) years. In this group also progress of signs and symptoms of degenerative changes in clinical and radiographic examination was noted. To achieve sufficient data necessary to establish indications for further operative treatment in 2 patients also CT examinations with three-dimensional surface reconstruction were performed after physeal closure. Physical examinations were performed in all patients after completion of growth. Radiographs made before the onset of treatment for developmental dislocation of the hip, during treatment, at the child's age of 4-6 years, all obtained until the cessation of growth, and at final assessment, were studied. By physical evaluation 77 hips were rated as excellent or good, being pain free or with only occasional mild pain after walking long distances, with a good range of hip motion and negative Trendelenburg sign. The reasons for 21 fair or poor clinical end-results were pain, mostly with activity, and limp due to pain and abductor weakness. By radiographic evaluation in this group there were 50 hips rated as excellent or good, and 48 hips rated as fair or poor. In 29 hips excellent or good clinical findings at final review contrasted with fair or poor radiographic scores. In no case fair or poor clinical end-result coexisted with excellent radiographic ones. In the group examined twice after completion of growth with the time interval of 10 years no difference in clinical score was found in

Adolescent↗
PubMed1997

[Treatment of congenital hip dislocation using Pavlik's harness. Long term results].

PURPOSE OF THE STUDY: After many years using Pavlik harness for treatment of congenital hips dislocation, it is important to evaluate long-term results, failure causes and factors responsible for avascular necrosis. MATERIAL: One hundred and forty one children were treated by this mean (159 dislocated hips, 30 acetabular dysplasia). The follow up was 74 months (12-175). METHODS: In this study, the severity of the dislocation was evaluated by antero-posterior radiographs of the pelvis. The importance of proximal dislocation was measured by the distance from the top of the proximal femoral metaphysis to the Y line and the lateralization by the distance from the medial border of the proximal femoral metaphysis to the ischium. Results were appreciated using Severin classification modified by Kasser and Mose's circles. Several factors as age at the beginning of treatment, sex, previous treatment, passive abduction of the hip, amount of dislocation were statistically evaluated (chi 2 and P test). RESULTS: Of 159 dislocated hips, 10 (6.3 per cent) were not reduced by the harness. Temporary growth modifications and avascular necrosis were observed in 24 (16.1 per cent) of 149 reduced hips. We shall add to these, 3 avascular necrosis in 10 hips which were not reduced in the pavlik harness and 2 avascular necrosis which occurred in normal hips. This complication was not encountered in dysplasic hips without dislocation. Using Severin classification, there was 61 excellent, 33 good and 5 fair results in the group of 99 hips followed for more than 72 months. Of all growth anomalies and avascular necrosis, only half of them keep sequelae at the last follow-up. DISCUSSION: Some factors as age, sex, previous treatment have no incidence in the number of failures and avascular necrosis. On the contrary, passive abduction of the hip, severity of the dislocation were responsible for most of these complications. Pavlik harness must be used with circonspection. It can be used only where passive abduction is superior to 30 degrees and distance H superior to 4 mm. In other cases, it is preferable to use progressive traction. CONCLUSION: Pavlik harness is widely used for treatment of congenital hip dislocation. Reduction can be obtained as stabilisation and correction of acetabular dysplasia. The risk for avascular remains relatively high. The use of the harness needs a rigourous choice of indications.

Age Factors↗