Rechtstreeks verwijzen door de jeugdarts bij verdenking op heupdysplasie: het perspectief van ouders

Doel: Rechtstreeks verwijzen door de jeugdarts naar de tweede lijn lijkt zinvol bij verdenking op heupdysplasie. Screening op heupdysplasie vindt plaats door lichamelijk onderzoek en de identificatie van risicofactoren. Echografische screening blijkt medisch en economisch gezien te leiden tot betere uitkomsten. Als onderdeel van een studie naar de haalbaarheid van implementatie van echografische screening in Nederland is onderzocht hoe ouders het verwijstraject beoordelen afhankelijk van de manier waarop zij naar de orthopaedisch chirurg zijn verwezen - rechtstreeks of via de huisarts - bij verdenking op heupdysplasie. Methode: Een vragenlijst is ontwikkeld om de ervaring van ouders die verwezen zijn te meten. In totaal is de vragenlijst gestuurd naar 355 ouders van kinderen die verwezen zijn tussen januari 2008 en november 2008. Resultaten: De respons op de vragenlijst was 46,5%. Ouders waren meer tevreden wanneer zij door de jeugdarts rechtstreeks waren verwezen dan wanneer dat via de huisarts plaatsvond. De tijd tussen de verwijzing en de eerste afspraak bij de orthopaedisch chirurg was korter als kinderen rechtstreeks werden verwezen. Tot slot waren ouders meer tevreden als zij het verwijstraject als niet stressvol ervoeren en als het traject soepel verliep. Conclusie: Gebaseerd op de perceptie van ouders, geeft dit onderzoek een eerste indicatie dat, met inachtneming van een aantal belangrijke randvoorwaarden, rechtstreeks verwijzen in het geval van heupdysplasie wenselijk is

Visual Inspection for Lower Limb Malalignment Diagnosis Is Unreliable

Objective: Visual inspection of the lower limb is often part of standard clinical practice during a physical examination at the outpatient clinic. This study aims to investigate how reliable visual inspections are in terms of detecting lower limb malalignments without additional tools and physical examinations. Design: This study enrolled 50 patients. Each patient underwent a whole leg radiograph (WLR); in addition, a standardized digital photograph was taken of the lower limbs. Four persons (different experience levels) visually rated the digital photograph twice (unaware of the hip knee angle [HKA] on the WLR) and placed them in the category: severe valgus (>5°); moderate valgus (2°-5°); neutral, moderate varus (2°-5°); and severe varus (>5°). Visual ratings were compared with the measured HKA on WLRs for correlation using Spearman’s rho. Linear ordinal regression models with significance when P < 0.05 were used to test whether body mass index (BMI), age, gender, and HKA were possible risk factors for incorrect visual HKA assessment. Results: Spearman’s rho between the visual assessment and measured HKA on the WLR was moderate with 0.478 (P < 0.01). Women had an increased odds ratio of 3.7 (P = 0.001) for incorrect visual assessment. Higher HKA also increased the odds ratio for erroneous visual assessment with 1.4 (P = 0.003). BMI and age did not significantly increase the odds of erroneous visual leg axis assessments in this study. Conclusions: Visual assessment of the lower limb alignment does not provide clinically relevant information. Lower limb malalignment diagnoses cannot be performed using only a visual inspection. Physical examination tests and radiographical assessments are advised. Level of evidence: Diagnostic level II

Efficient cascaded V-net optimization for lower extremity CT segmentation validated using bone morphology assessment

Semantic segmentation of bone from lower extremity computerized tomography (CT) scans can improve and accelerate the visualization, diagnosis, and surgical planning in orthopaedics. However, the large field of view of these scans makes automatic segmentation using deep learning based methods challenging, slow and graphical processing unit (GPU) memory intensive. We investigated methods to more efficiently represent anatomical context for accurate and fast segmentation and compared these with state-of-the-art methodology. Six lower extremity bones from patients of two different datasets were manually segmented from CT scans, and used to train and optimize a cascaded deep learning approach. We varied the number of resolution levels, receptive fields, patch sizes, and number of V-net blocks. The best performing network used a multi-stage, cascaded V-net approach with 1283−643−323 voxel patches as input. The average Dice coefficient over all bones was 0.98 ± 0.01, the mean surface distance was 0.26 ± 0.12 mm and the 95th percentile Hausdorff distance 0.65 ± 0.28 mm. This was a significant improvement over the results of the state-of-the-art nnU-net, with only approximately 1/12th of training time, 1/3th of inference time and 1/4th of GPU memory required. Comparison of the morphometric measurements performed on automatic and manual segmentations showed good correlation (Intraclass Correlation Coefficient [ICC] >0.8) for the alpha angle and excellent correlation (ICC >0.95) for the hip-knee-ankle angle, femoral inclination, femoral version, acetabular version, Lateral Centre-Edge angle, acetabular coverage. The segmentations were generally of sufficient quality for the tested clinical applications and were performed accurately and quickly compared to state-of-the-art methodology from the literature

Acetabular rim extension using a personalized titanium implant for treatment of hip dysplasia in dogs: short-term results

Hip dysplasia (HD) is a common orthopedic problem in young dogs. To decrease the laxity of the hip joint related to HD, the surgical treatments are recommended to increase femoral head coverage. ACEtabular rim eXtension (ACE-X) using a personalized 3-dimensional printed titanium shelf implant is a new surgical treatment to increase femoral head coverage and decrease laxity of the dysplastic hip joint, however, the efficacy is less know. Client-owned dogs older than 6 months with clinical signs of coxofemoral joint subluxation and radiographic evidence of HD with no or mild osteoarthritis (OA) were included. The Norberg angle (NA), linear percentage of femoral head overlap (LFO), and percentage of femoral head coverage (PC) were investigated radiographically and with computed tomography (CT) before and after surgery. OA was graded (scores 0–3) according to the maximum osteophyte size measured on CT. In addition, joint laxity (Ortolani) test results, gait analysis, and the Helsinki chronic pain index (HCPI) questionnaire were obtained at preoperative, immediately postoperative and at 1.5- and 3-month evaluations. Acetabular rim extension was performed in 61 hips of 34 dogs; NA, LFO, and PC were significantly higher immediately postoperatively and at the 1.5- and 3-month follow-up examinations compared with preoperative values (p < 0.05). Osteophyte size gradually increased over time (p < 0.05). The OA score significantly increased between preoperatively and directly postoperatively, and between preoperatively and at 3-month follow-up (p < 0.05). The laxity test normalized in 59 out of 61 hips after surgery, and the HCPI questionnaire showed that the pain score decreased significantly at 1.5 and 3 months, postoperatively. The force plate showed no significant improvement during the 3 months follow-up. Although pain reduction by the implant was unclear in short-term results, a personalized shelf implant significantly increased femoral head coverage and eliminated subluxation of the dysplastic hip joint. Further studies are required to study the long-term efficacy of gait, chronic pain, and progression of osteoarthritis

Life span care for patients with skeletal dysplasia: A roadmap

Patients with skeletal dysplasias usually experience health related problems in different parts and systems of the body. Therefore, they face challenges in multiple domains of functioning and health. To address these different domains, interdisciplinary care should be the standard for these patients. The basic algorithm of interdisciplinary care can be similar for patients with different skeletal dysplasias, as many of the problems and needs are generic within different age groups. With increased age the domains in which patients with skeletal dysplasia face challenges will change and the focus and frequency of the interdisciplinary care should change accordingly. Thorough understanding of the specific characteristics of different skeletal dysplasias is required to create an individualized efficient interdisciplinary screening and care program. This paper presents the current structure and rationale of the interdisciplinary screening and care program of the skeletal dysplasia expert center of the University Medical Center Utrecht in the Netherlands. It is presented here, tailored to osteogenesis imperfecta, but the structure of the program is generic for all skeletal dysplasias

A tutorial on discrete-event simulation for health policy design and decision making: Optimizing pediatric ultrasound screening for hip dysplasia as an illustration

Background It is increasingly recognized that healthcare is a complex system with limited resources and many interacting sources of both positive and negative feedback. Discrete-event simulation (DES) is a tool that readily accommodates questions of capacity planning, throughput management and interacting resources. As a result the use of DES in informing healthcare decision making is increasing. However, understanding when and how to build a DES model and use it for policy making is not yet a common knowledge.Methods The steps in building a DES model will be demonstrated using a real-world example, i.e., pediatric ultrasound screening for hip dysplasia. The main components of a DES model such as entities, resources and queues will be introduced and we will examine questions such as referral schedule, number of ultrasound machines and type of screeners and how these entities interact. Finally a review of the statistical techniques appropriate to DES will be provided.Conclusion Discrete-event simulation is a valuable tool in the policymakers armentarium. It can be used effectively to analyze and understand complex healthcare systems and policy problems such as population screening.Discrete-event simulation Infant screening Operations research Regional health planning

Statistical Shape Modeling of US Images to Predict Hip Dysplasia Development in Infants

Background The current widely applied Graf classification used on US images for developmental dysplasia of the hip in infants does not enable prediction of the development and outcome of well-centered stable dysplastic hips (Graf type II). Purpose To use statistical shape modeling on US images to identify acetabular shape characteristics of Graf type II hips, which enable prediction of the development of Graf type II hips, and to identify which hips benefit from Pavlik harness treatment. Materials and Methods In this secondary analysis of a prospective multicenter randomized trial on treatment of 104 infants aged 3-4 months with Graf type IIb or IIc hip dysplasia conducted between 2009 and 2015, a statistical shape model was developed on baseline US images. With multivariable logistic regression adjusted for infant sex and treatment (Pavlik harness treatment vs active observation), shape modes were correlated with the outcomes of persistent hip dysplasia on US images (α angle <60°) after 12-week follow-up and residual hip dysplasia on pelvic radiographs (Tönnis classification: acetabular index greater than 2 standard deviations) around 1 year of age. An interaction term (treatment with mode) was used to investigate if this result depended on treatment. Results Baseline US images were available in 97 infants (mean age, 3.37 years ± 0.43 [standard deviation]; 89 [92%] girls; 90 cases of Graf type IIb hip dysplasia; 52 cases treated with Pavlik harness). Shape modes 2 and 3 of the statistical shape modeling were associated with persistent hip dysplasia on US images (odds ratio [OR] = 0.43; P = .007 and OR = 2.39; P = .02, respectively). Mode 2 was also associated with residual hip dysplasia on pelvic radiographs (OR = 0.09; P = .002). The interaction term remained significant after multivariable analysis, indicating that Pavlik harness treatment was beneficial in patients with negative mode 2 values (OR = 12.46; P = .01). Conclusion Statistical shape modeling of US images of infants with Graf type II dysplastic hips predicted which hips developed to normal or remained dysplastic and identified hips that benefited from Pavlik harness treatment. © RSNA, 2022