Nawaz, Haq

umer, masood

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eCommons@AKUDepartment of Surgery Department of SurgeryJanuary 2008Developmental dysplasia of Hip--where do westand?masood umerAga Khan University, masood.umer@aku.eduHaq NawazAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Orthopedics CommonsRecommended Citationumer, m., Nawaz, H. (2008). Developmental dysplasia of Hip--where do we stand?. JPMA: Journal of the Pakistan Medical Association,58(1), 2-4.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/237days after the onset of illness and may remain in positive for3-6 months.  A negative initial  test does not exclude thediagnosis in an appropriate clinical setting.  Dengue IgGantibody becomes positive in 7-10 days and remains so forlife. In secondary infections levels of IgG antibody may riserapidly in the acute phase, whereas IgM antibody levelsmay remain low or absent.19There is no specific treatment for this self limitingdisease. Supportive care should be provided. Patientsshould be well hydrated and those who cannot maintain anadequate intake orally must be given intravenous fluids.Platelets and fresh frozen plasma are only indicated in theevent of serious bleeding. Platelet infusions are usually onlyrequired when the platelet count falls below 20,000/Cmm.Aspirin , NSAIDS and antibiotics should be avoided. A high index of suspicion, clinical vigilance, dailymonitoring for haematocrit rise, falling  platelet count ,DIC, coagulopathy and institution  of prompt supportivecare are life saving. In centres experienced in handling thesecases mortality has been reduced to 0.2% with the promptinstitution of appropriate supportive measures.6 Preventionlies in vector control by  all possible means, primarily  bymeasures which eliminate  breeding areas for Aedesaegypti. Dengue patients should  be protected from furthermosquito bites to contain spread of infection. Protectivevaccine is elusive at present, but live attenuated, tetravalentdengue vaccines have been shown to be immunogenic  andsafe and are undergoing further trials.20References1. Peterson LR, Gulber DJ. Flaviviruses.  In : Warrel DA, Cox TM, Firth JD, eds.Oxford Textbook of Medicine: New York: Oxford University Press, 2005: pp382-5.2. Guha-Sapir D, Schimmer B. Dengue Fever: new paradigms for a changingepidemiology. Emerg Themes Epidemiol 2005; 2:1. 3. Guzman MG, Kouri G. Dengue: an update. Lancet Infect Dis 2002;2:33-42. 4. Gubler DJ, Clark GG. Dengue/dengue hemorrhagic fever: the emergence of aglobal health  problem. Emerg Infect Dis 1995;1:55-57. 5. Gubler DJ. The global emergencies/resurgence of arboviral diseases as publichealth problems. Arch Med Res 2002; 33:330-42. 6. Gibbons RV, Vaughn DW. Dengue: an escalating problem. BMJ 2002;324:1563-6.7. Halstead SB, O'Rourke EJ. Dengue viruses and mononuclear phagocytes.I.Infection enhancement by non-neutralizing  antibody. J Exp Med1977;146:201-17.8. Halstead SB. In vivo enhancement  of dengue virus infection in rhesusmonkeys by passively transferred antibody. J Infect Dis 1979; 140:527-33.9. Halstead SB. Immune enhancement of viral infection. Prog Allergy1982;31:301-64.10. Setiati TE, Mairuhu AT, Koraka P, Supriatna M, Mac Gillavry MR, BrandjesDP et al . Dengue disease severity in Indonesian children: an evaluation of theWorld Health Organization  classification system . BMC Infect Dis 2007; 7: 22.11. World Health Organization: Dengue Haemorrhagic Fever: diagnosis,treatment, prevention and control 2nd ed. Geneva: WHO 1997. 12. George R. Problems in diagnosis and classification of dengue virus infection.Malays J Pathol 1993; 15:25-7. 13. Murgue B, Deparis X, Chungue E, Cassar O, Roche C. Dengue: an evaluationof dengue severity in French Polynesia based on an analysis of 403 laboratory-confirmed cases . Trop Med Int Health 1999; 4:765-73.14. Phuong CX, Nhan NT, Kneen R, Thuy PT, van Thien C, Nga NT et al. Clinicaldiagnosis and assessment of severity of confirmed dengue infections inVietnamese children: is the world health organization classification systemhelpful ? Am J trop Med Hyg 2004; 70: 172-9. 15. Rigau-Perez JG, Bonilla GL. An evaluation of modified case definitions forthe detection of dengue hemorrhagic fever. Puerto Rico Association ofEpidemiologists. P R Health Sci J 1999; 18:347-52. 16. Vaughn DW, Green S. Dengue and dengue hemorrhagic fever. In: StricklandGT, ed. Hunter's tropical medicine and emerging infectious disease:Philadelphia: Saunders, 2000:240-1.17. Wilder-Smith A, Earnest A, Paton NI . Use of simple laboratory features todistinguish the early stage of severe acute respiratory syndrome from denguefever. Clin Infect Dis 2004; 39:1818-23. 18. Watt G, Jongsakul K, Chouriyagune C, Paris R. Differentiating dengue virusinfection from scrub typhus in Thai adults with fever. Am J Trop Med Hyg2003; 68:536-8.19. Wilder-Smith A, Schwartz E. Dengue in Travelers. N Engl J Med 2005 ; 353:924-32.20. Barrett AD. Current status of Flavivirus vaccines. Ann N Y Acad Sci 2001;951:262-71.2 J Pak Med AssocEditorialDevelopmental Dysplasia of Hip - Where do we stand?Masood Umer, Haq NawazDepartment of Surgery, Aga University, Stadium Road, Karachi.Developmental Dysplasia of the Hip (DDH) is aclinical condition requiring specialized and dedicatedpeople for its treatment. The treating surgeon shouldhave a sound knowledge of the factors responsible fornormal growth, patho-anatomy, obstacles to reduction,natural history of the disease and reasons for failure oftreatment before daring into treating DDH. The treatmentbecomes more complex and challenging with increasingage of the child.1As the day and age of sub- and super-specializationis dawning, the results of its treatment, especially in theolder children (walking age group) in the developed worldhave improved considerably.2 Unfortunately, we, inPakistan do not have many fellowship trained dedicatedpaediatric orthopaedic surgeons; hence most patients end upbeing treated by 'general orthopedic surgeons' who have avariable experience in treating this condition. Most of themhave learned to treat DDH by default and hardly any byVol. 58, No. 1, January 2008 3their choice. Personally, I have witnessed even some of thesenior graduating residents being unable to put on a pavlikharness or a Von Rosen splint on to a neonate for dislocatedhip. Proper use of these devices within the first few monthsof life and meticulous monitoring ensures excellentresults3,4 with success rates as high as 95% in expert hands.There is thus an imminent need for a focus on this aspect inthe regular orthopaedic postgraduate curriculum. The recentefforts by Pakistan Orthopaedic Association to create sub-specialty forums is a step in the right direction. A workshopon applying the DDH splints was also held in thisconnection by the paediatric orthopaedics forum last year.Such brilliant efforts need to be continued on a regularbasis. As realization about this deficiency in residencytraining grows, more and more students will be interested toattend such workshops.   Parents of children with DDH are usually unaware ofthe training level and expertise of a particular surgeon whenthey approach an orthopaedic surgeon for the treatment oftheir child. The treatment results are thus very variable andmost are never reported. Patients ending up withcomplications are labeled under 'God's will' and the primarysurgeon occasionally has no idea of what went wrongduring the procedure; the challenge of offering a revisionprocedure can only be undertaken once the pitfalls of theprimary surgery are identified. A similar example is to orderx-ray for evaluation of newborn with suspected DDH whichis not indicated in this age-group.5 Parents of children withDDH should therefore be educated to approach aspecialized orthopaedic surgeon for the treatment of theirchild's condition or one who has considerable experience intreating DDH. Parental counseling is also invaluable duringthe entire treatment process and can play a key role insuccessful treatment especially with the harness.Based on personal clinical experience, it is commonknowledge that DDH has a lower incidence rate than othercommon conditions like septic hip arthritis or acuteproximal femoral osteomyelitis. No formal studies reportingthe incidence of DDH in Pakistan have been reported so far.In the west, it is around 5 in 1000 hips and risk factorsinclude first born, female sex, positive family history,breech presentation and oligohydramnios.6 Other associatedfactors include ethnic background (e.g. Native American),torticollis and lower limb deformity.5 Epidemiologicalstudies are desperately needed in our part of the world toisolate families and ethnic groups who are suffering fromthis problem. Preventive strategies can then be targetedtowards them. A common observation is the absence ofDDH in communities where mothers carry neonates on theirbacks with hips abducted apart. One can hypothesize thatcarrying and maintaining a neonate in a 'pangoora' by thebedside with both legs tightly adducted may have anopposite effect. This is routine in some segments of oursociety and we need to study the rates of DDH in thesefamilies.    Routine screening of the newborn should includeboth the Ortolani test and the Barlow maneuver. Allorthopaedic and especially paediatric medicine residentsneed to master the techniques of these two tests. Paediatricmedicine residents are the first ones examining allnewborns. It is their high index of suspicion that will raisealarms and calls for orthopaedic consultation. Anopportunity of diagnosis missed at birth is usually paid veryheavily by the child and his/her parents in later years asdelayed treatment becomes more complicated andchallenging. The use of ultrasound for routine screening hashuge financial implications and should be restricted only tohigh risk categories mentioned above.7 It is one of the bestimaging modality to show real-time pictures of the hip jointin a neonate.8 Dedicated paediatric orthopaedic surgeonsneed to master its technique and have a machine in theirclinic to facilitate regular monitoring.      Surgical treatment of DDH is reserved for childrenin the walking age group.4 The goals are to create normalanatomy of the proximal femur and acetabulum andmaintain that anatomy to allow normal development of hipfunction. With experience and greater understanding of theoutcomes, surgical recommendations have also changed.Pre-operative traction has been replaced by femoralshortening.9 A simultaneous open reduction, femoralshortening, de-rotation, and acetabuloplasty, all togetherknown as the triple procedure, are now the currentrecommendations in an older child.10,11 This is acomplicated surgery, and the outcome has a directcorrelation with experience. The need for early referral to aspecialized care centre is again emphasized. The value of objectively evaluating one's results istremendous. Several universally accepted evaluationcriteria such as the Severin's scoring system12 and the Iowahip score13 for evaluating hip function are available. Theyserve as the basis for objective analysis and presentation ofresults. Young surgeons entering into this specialized fieldare encouraged to maximize the use of these internationallyaccepted systems in their routine pre- and post-opevaluations. Hardly a couple of studies documenting theresults of treatment of DDH could be found in the localliterature.14 This is despite the fact that DDH is beingtreated in every major public and private teaching hospitalof the country. The objective of writing a manuscript canonly be achieved once proper documentation and objectiveevaluation are incorporated from the very beginning andbecome part of routine practice. Production of qualityscientific papers on their surgical work is probably the bestreflection of any good residency program in the country. In general, paediatricians and family practitionersshould refer a child with DDH for specialist care as early aspossible. The outcome of treatment during the first sixmonths of life is much better and predictable than in late-diagnosed DDH. Dedicated surgeons sub-specializing inpaediatric orthopaedics is the need of the day. References1.  Danielsson L. Late-diagnosed DDH: A Prospective 11-year follow-up of 71consecutive patients (75 hips). Acta Orthop Scand 2000;71:232-42.2.  Vallemshetla VR, Mughal E, O'Hara JN. Congenital dislocation of the hip. Are-appraisal of the upper age limit for treatment. J Bone Joint Surg Br2006;88:1076-81.3.  Weinstein SL, Mubarak SJ, Wenger DR. Developmental Hip Dysplasia andDislocation: Part I. Instr Course Lect 2004; 53: 523-30.4. Weinstein SL, Mubarak SJ, Wenger DR. Developmental Hip Dysplasia andDislocation: Part II. Instr Course Lect 2004; 53: 531-42.5.  Weinstein SL. Developmental hip dysplasia and dislocation. In: Morrissy RT,Weinstein SL, eds. Lovell and Winter's pediatric orthopaedics. 5th ed.Philadelphia: Lippincott Williams and Wilkins 2001; p 905-56.6. Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmentaldysplasia of the hip: a new approach to incidence. Pediatrics 1999 103:93-9. 7. US Preventive Services Task Force. Screening for developmental dysplasia ofthe hip: recommendation statement. Pediatrics 2006;117:898-902.8.  Harding MG, Harcke HT, Bowen JR, Guille JT, Glutting J. Management ofdislocated hips with Pavlik harness treatment and ultrasound monitoring. JPediatr Orthop 1997;17:189-98.9.  Schoenecker PL, Strecker WB. Congenital dislocation of hip in the children.Comparison of the effects of femoral shortening and of skeletal traction in thetreatment. J Bone Joint Surg Am 1984;66:21-7. 10.  Karakas ES, Baktir A, Argun M, Tuwrk CY. One-stage treatment of congenitaldislocation of the hip in older children. J Pediatr Orthop. 1995;15:330-611.  Klisic P, Jankovic L, Basara V. Long-term results of combined operativereduction of the hip in older children. J Pediatr Orthop 1988;8:532-4.12.  Severin E. Contribution to the knowledge of congenital dislocation of the hipjoint. Late results of closed reduction and arthrographic studies of recentcases. Acta Chir. Scandinavica, Supplementum 1941; 63.13. Larson CB. Rating scale for hip disabilities. Clin Orthop. 1963; 31:85-93.14 Bhatti A, Majid A, Mehboob G, Raja MA, Ahmed S. One stage correction ofcongenital dislocation of the hip in older children. JCPSP 1997 7:113-7.4 J Pak Med AssocOriginal ArticleDengue fever outbreak in Karachi 2006 - A study of profile and outcome ofchildren under 15 years of ageSaba Ahmed1, Fehmina Arif2, Yousuf Yahya3, Arshaloos Rehman4, Kashif Abbas5, Sohail Ashraf6, Dure Samin Akram7Civil Hospital and Dow University of Health Sciences1-3,7, Liaquat National Hospital4-6, Karachi.AbstractObjective: To evaluate children with serologically confirmed Dengue fever in order to identify common clinicalfeatures, progress of disease, grades of severity and outcome of cases during the outbreak in 2006.Methods: A cross-sectional, descriptive study was conducted on serologically positive children with Denguefever (DF) admitted in Civil Hospital Karachi and Liaquat National Hospital between October and November2006. Various clinical features and laboratory parameters were analyzed for frequencies. Data was alsoevaluated to identify the common clinical types and grades of infection as classified by WHO.Results:A total of 35 children were evaluated in the study. Mean age of children was 8.3 ± 3.5 years and majoritywas male (54%). Sixty five percent were under 10 ± 3.5 years of age. Frequent clinical features included fever(97%), vomiting (68%), abdominal pain (68%) and rashes (65%). Gastrointestinal bleeding (61%) and epistaxis(26%) were commonest haemorrhagic manifestations. Thrombocytopenia (86%), anaemia (57%) andLeucopenia (43%) were common laboratory findings. Leukocyte count improved in 2 to 7 days and Platelet countin 2 to 8 days. Dengue haemorrhagic fever (DHF) was seen in 22 children (62%). Majority had Grade-II severity.Mortality was 1 (3%) out of 35 patients.Conclusion: 2006 outbreak of Dengue infection in Karachi showed slight difference in clinical features andcourse of disease compared to epidemics in other regions, thereby, indicating the need for continuous sero-epidemeological surveillance (JPMA 58:4;2008).IntroductionDengue is an important mosquito borne viralinfection. It occurred sporadically till the 19th century.Recent years have seen epidemics of this arthropod borneviral disease and presently it is endemic in 112 countriesaround the world.1,2 Dengue virus is an RNA virus offlaviridae family, with four serotypes, transmitted by thebite of Aedes aegypti mosquito. It manifests in three ways,a mild atypical form, classic Dengue and Denguehaemorrhagic fever3 which may evolve into Dengue shocksyndrome. Mortality can occur in Dengue shock syndromeunless prompt and adequate management with fluidreplacement is provided.

Developmental dysplasia of Hip--where do we stand?

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Developmental dysplasia of Hip--where do we stand?

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