1st International Medical Conference: Advances in Pediatric Care

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    The Value of the Salter Osteotomy as a Routine Adjunct to Open Reduction of Developmental Dislocation of the Hip
    (2008-11-16) Dr. AlaaEldin Azmi Ahmad

    Introduction: Despite the widespread use of screening programs to detect hip dysplasia in the
    newborn, children are still seen later in childhood with established dislocation. We retrospectively evaluated the radiographs of 59 cases of open reduction, with and without Salter osteotomy, both to evaluate the long-term effects of the Salter osteotomy on the quality of the hips and to decide if it should be a routine adjunct to open reduction. We also compared the hips with the Salter osteotomy done at the time of primary open reduction with those in which it was done later as a secondary procedure to determine if the procedure actually affects the development and modeling of the acetabulum. This series is distinguished by the long follow-up to, or almost to, skeletal maturity.

    Methods: We reviewed the records and x-rays of sixty two (59) hips with DDH with no associated congenital or neuromuscular disorders who underwent open reduction as primary surgical treatment after the age of 1.5 years. All patients had their primary treatment in our hospital between 1975 and 1992 with a minimum follow-up of 9.6 years. There were 36 hips that had only open reduction as a primary procedure (Group R) and 26 hips that also had a Salter osteotomy (Group RS). In Group R there were 4 hips that had a subsequent secondary Salter osteotomy (Group R/S, the slash representing an interval of time). 15 First International Faculty ofMedicine Conference 2008 We evaluated radiographs done preoperatively, postoperatively and at the time of the most recent follow up visit. We measured the acetabular index (AI), center edge (CE) angles, and the sphericity of the femoral head by the Mose technique. The hips were assessed for avascular necrosis by the method of Kalamchi and MacEwen and the overall outcome graded according to Severin.

    Results: For Group R and Group RS, the mean ages at first operation were 4.9 years and 3.6 years respectively, and the mean radiological follow-ups were 11.3 years and 9.6 years. The pre-operative acetabular indices were 35.0º and 35.2º indicating that the severities of dysplasia were similar. 57.5% of Group R went on to have subsequent surgery compared to 23% of group RS. In groups R & RS respectively, assessment of outcome at final follow-up revealed CE angles of 26.5º and 30.1º, mean Mose circle indices of 3.8º and 2.4º, avascular necrosis presence in 57.5% and 31%, and good (grades 1 & 2) Severin results in 63% and 81%. In groups R/S & RS the pre-operative acetabular indices were 31º and 37.6º indicating that the hips in group R/S were less dysplastic to start. Assessment of outcome at final follow-up revealed, in groups R/S and RS respectively, CE angles of 34.0º and 29.8º, mean Mose circle indices of 2.5º and 2.1º, avascular necrosis presence in 50% and 31%, and good (grades 1 & 2) Severin results in 75% and 85%.

    Conclusions: Our results show that routinely performing a Salter osteotomy at the time of primary open reduction of the hip improves the long-term outcome of the hip. The femoral head is a better shape as evaluated by both the Mose and Severin methods and the acetabulum provides better coverage as indicated by the center-edge angle. In addition, fewer subsequent surgical procedures were required and evidence of avascular necrosis was less.
    It might be argued that the only effect of the Salter osteotomy is a fixed geometrical change, that it should not matter in the long run whether that change is introduced early or later, and that the Salter osteotomy could be omitted from the primary procedure and performed later only for persistent dysplasia. Having only 4 cases in our R/S group prevents us from reaching reliable conclusions but the fact that group RS was more dysplastic at the start, and arguably better at the end suggests that there is an advantage in doing the Salter osteotomy early.

    Significance: These results should cause those surgeons who do not routinely include the Salter osteotomy in the primary surgical treatment of the dislocated hip to reconsider their strategy in terms of including the Salter osteotomy in their primary surgical treatment of the dislocated hip over 1.5 years of age.

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    Masculinizing Genitoplasty in Intersex Patients (Severe Hypospadias)
    (2008-11-16) Dr. Jehad M. Abu Daia

    Purpose: Perineal & scrotal forms are the most severe, uncommon and challenging variants in the spectrum of hypospadias These forms are often associated with extreme chordee, penoscrotaltransposition and bifid or absent scrotum We reviewed cosmetic and functional outcome of masculinizing genitoplasty (MGP) in intersex patients assigned as a male performed in our service in the last 6 years.

    Materials and Methods: A total of55 patients underwent MPG by one surgeon during 6 year period. Patient age ranged from 6 months to 16 years .The presenting disease was severe hypospadias or intersex, scrotal hypospadias in 30 cases , and perineal hypospadias in 25 .Some patients were evaluated for gender, chromosomal and biochemical data by pediatric endocrinologists. Most of our patients had idiopathic male pseudohermaphroditism.. MGP was performed using Augmented Koyanagi Nonomura one-stage surgical techniques in the first 2 years,then we used extended unilateral parameatal flape with minimal mobilization technique in the next 4 years, dorsal plication needed in7 patients.Scrotoplasty and orchiopexy was performed in the same operation. 21 First International Faculty of Medicine Conference 2008

    Results: Followup was 1 to 6 years. Satisfactory cosmetic and functional results in terms of good urinary stream and straight phallus in ( 72%) of cases . Complications requiring reoperation occurred in (28%). complications presented are various degrees of failure of the urethroplasty or cosmetic appearance.95% of patients have satisfactory result after the second operation.

    Conclusions: Male pseudohermaphroditism better to be managed by single stage male genitoplasty, a second operation may be needed only in about 25% of cases ( patients with complications from the first operation) . In order to achieve a longer new urethra we recommend our modified technique – the extended parameatal-based flap with minimal moblization urethroplasty.

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    Vesicoureteric Reflux
    (2008-11-16) Dr. Eyad Z. Al-Aqqad
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    One stage feminizing genitoplasty: 4 years of experience with 29 cases
    (2008-11-16) Dr. Jehad M. Abu Daia

    Purpose: We retrospectively evaluated the results of one-stag feminizing genitoplasty in children with congenital adrenal hyperplasia (CAH).

    Patients And Methods: Twenty nine patients with 46XX CVAH (congenital verilized adrenal hyperplasia )patients were referred following complete evaluation of gender, chromosomal and biochemical data by pediatric endocrinologists in 6 year period between 2001 and 2007- at European Gaza Hospitan –Gaza ; 28 patient( new cases 26 + Redo 2)were managed by one-stage feminizing genitoplasty (vaginoplasty-valvoplasty and clitroplasty ),age 3monthes to 12 years.We used the Passerini-Glazel technique, and in 5 patients we mobilize the urogenital sinus en bloc , one female patient underwent gender reversal and was raised as males.

    Results: Follow up was 3 monthsto 6 years. Preoperative ultrasound plus or minus genitogram
    and endoscopy provide the correct data regarding the vaginal and internal genital anatomy in all cases, Operating time ranged between 90 and 180 minutes, average hospitalization period was 4 to 9 days Complications consisted of intraoperative uretheral injury in 1 case wound infection in 2 and stenosis at the suture line in 2 patients -corrected by introitoplasty . All patients have had successful cosmetic results except one need redo clitroplasty for residual clitoromegalia.

    Conclusion: Most patients with 46XX CVAH are preferably raised as females and require a feminizing genitoplasty . Preoperative investigations and surgical managment of every case on its own merits gives satisfactory primary results , some revision at puberty should be anticipated in some cases.