Femoral remodelling after subtrochanteric osteotomy for developmental dysplasia of the hip

Children who present late with hip dislocation may require femoral osteotomy after reduction, to correct valgus and anteversion deformity of the femoral neck. After these procedures proximal femoral growth is unpredictable. We have studied proximal femoral growth in 40 children who had been treated by femoral osteotomy. Preoperatively, the mean femoral neck-shaft angle was 5 degrees greater on the affected side than on the contralateral side. Postoperatively, it was 28 degrees less. There was progressive recorrection; after five years the angle was not significantly different from that on the contralateral side. In our series 70% of the capital epiphyses became abnormally shaped, taking the appearance of a 'jockey's cap'. All the growth plates became angulated but this corrected with time. Correction of the neck-shaft angle probably results from the more normal mechanical environment provided by reduction. The abnormal radiographic appearance of the epiphysis and growth plate is probably due to the rotation produced by the osteotomy.     

The intertrochanteric osteotomy in the treatment of congenital dysplasia of the hip

The dysplastic acetabulum develops to normal shape only if the head of the femur is in central position in the articualr cavity correct according to biomechanics of the hip joint. Anterior rotation of the neck of the femur should be reduced operatively to neutral position as soon as possible if joint congruity cannot be achieved by conservative treatment. The indication for an intertrochanteric derotation osteotomy is made in cases demonstrating a roof inclination less than 30 degrees in children age 1 1/2 to three. After the third year of age, the mutual growth-stimulating effect of the articular bodies is not important enough to be useful in treatment of dysplasia. The femoral osteotomy has to be performed intertrochanterically. If articular congruity cannot be achieved by intertrochanteric osteotomy only, an additional innominate osteotomy of the pelvis is indicated at the same stage. The results of 435 cases demonstrated a good development of the acetabular roof if the intervention was performed early, according to correctly specified indications. In cases with insufficient growth potential of the acetabular roof, resulting in an increased inclination, an additional reconstruction of the acetabular cavity is required.     

Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24-84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.     

Intertrochanteric femoral osteotomy with concentric reduction of the femoral head in treatment of residual congenital acetabular dysplasia

A method of classification based upon increase of the anteversion and valgus deformity of the upper femur associated with a dysplastic acetabulum and subluxation of the femoral head demonstrates 4 main groups: I or II in patients 1 to 3 years of age; III, patients approximately 2 years of age; IV, patients with absolute contraindication for surgical intervention. The Monticelli technique employs a Kirschner wire for the internal fixation and incorporates it in a hip spica. The results of the surgical treatment are very gratifying when classification and specified indications are correct. In follow-up observations ranging from 3 to 11 years, with an average of 7 years, there were practically no complications other than a few superficial skin infections.     

Evaluation of treatment of hip subluxation in myelomeningocele by intertrochanteric varus derotation femoral osteotomy

A retrospective study of 27 subluxed hips was carried out in 18 patients with myelomeningocele treated by varus derotation intertrochanteric osteotomy. Twenty-three of the 27 hips were stable at follow-up review. The causes of failure were related to the presence of pelvic obliquity secondary to scoliosis or to a dysplastic acetabulum (acetabular index above 25 to 30 degrees). Transfer of the iliopsoas tendon was not found to be necessary in order to achieve stable reduction.     

Intracapsular hip pressure after femoral neck fracture

A consecutive series of 34 patients with femoral neck fractures was included in a prospective study aimed at evaluating preoperative variations in intracapsular pressure after changes in hip position, hip traction, and aspiration of hemarthrosis and their influence on the development of femoral head necrosis. Patients were observed for 7 years after surgery. Before aspiration, the mean intracapsular pressure in the antalgic physiologic position was 44.4 mm Hg. There were no differences between displaced and undisplaced fractures. The pressure was a maximum (mean value, 124.8 mm Hg) with the hip in extension and inward rotation, this pressure being greater than the blood systolic pressure in most cases. Hip traction of 3 kg in the antalgic physiologic position was found to be highly effective in preventing any bone flow tamponade effect in displaced and undisplaced femoral neck fractures: the mean intracapsular pressure decreased to 28.5 mm Hg. Aspiration of the hemarthrosis induced a significant decrease in intracapsular pressure only in cases with impaired vascularity of the femoral head as measured by scintigraphy using 99mTc labeled methyldiphosphonate. Aspiration of the hemarthrosis therefore is indicated only in the above cases, although it is less effective than hip traction in the antalgic position. There was no significant correlation between intracapsular pressure and the scintigraphy ratio. Avascular necrosis of the femoral head was detected in six cases. Among these, five patients had an intracapsular pressure below their diastolic blood pressure. This could indicate that vascular damage related to the fracture could be an important cause of bone necrosis despite that blood supply can be decreased by a tamponade effect.     

Evaluation of isokinetic hip strength after rotational acetabular osteotomy

Fifty-four patients with dysplastic hip and secondary degenerative arthrosis (58 hips) underwent rotational acetabular osteotomy (RAO) using a conventional anterior-posterior method or a new technique involving detachment of the greater trochanter. Pre- and postoperative hip abductor strength (HAS) and knee extensor strength (KES) were evaluated using an isokinetic dynamometer. Postoperative HAS in patients treated by detachment of the greater trochanter reached preoperative levels 16 weeks postoperatively. Comparison of the postoperative HAS based on the two different surgical approaches showed that RAO by detachment of the greater trochanter was superior to the conventional method. Pre- and postoperative HAS showed a good correlation. Postoperative improvements in HAS over presurgical values were not significant in patients with advanced-stage arthrosis and severely dysplastic hips. Preoperative HAS should serve as an index for determining whether RAO is undertaken using detachment of the greater trochanter.     

Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip

In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1-4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2-13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin's criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old.     

Outcome of Perthes'' disease in unselected patients after femoral varus osteotomy and splintage

PURPOSE: To study the incidence, cause, recovery time, and prevention of diplopia following subcutaneous injection of botulinum A toxin for the treatment of facial spasms. METHODS: Patients who experienced diplopia after botulinum A toxin injections had their deviations examined in detail. When the muscle that caused diplopia was identifiable, the injection closest to that muscle was omitted in the next treatment in an attempt to prevent diplopia. RESULTS: Of 250 patients receiving about 1500 sets of injections, 25 (1.7%) incidents of diplopia occurred in 10 patients. Excluding two patients who declined further treatment after having diplopia on their first botulinum A toxin treatment, seven of the remaining eight patients had multiple incidents of diplopia. The most common pattern of diplopia was "uncertain diagnosis." The most common identifiable cause of diplopia was paresis of the inferior oblique muscle. Omission of the injection into the central portion of the lower eyelids in the next treatment prevented recurrence of diplopia in only one of the four patients. No significant correlation between botulinum A toxin doses injected and times to recovery was noted. CONCLUSIONS: Diplopia following botulinum A toxin treatment is uncommon. Seven patients (3% of patients studied) had 22 episodes of diplopia (88% of episodes). When diplopia occurs, it tends to recur on reinjection, sometimes with a prolonged recovery time. This response may not be dose dependent. The extraocular muscles of some patients may be more susceptible to chemodenervation than others, or botulinum A toxin may diffuse to extraocular muscles more easily in some patients than in others.     

Implant stability in revision total hip arthroplasty: allograft bone packing following extended proximal femoral osteotomy

One method of revising the femoral component in revision total hip arthroplasty in the presence of compromised femoral bone stock is to pack the upper femur with particulate allograft and then to cement the femoral component into the allograft bed. This technique is being used clinically with encouraging results. Additionally, surgical exposure of the femoral canal during revision total hip arthroplasty can be greatly improved with an extended trochanteric osteotomy, which is subsequently repaired with wires or cables. To assess the feasibility of performing the allograft bone packing technique following an extended trochanteric osteotomy, the stability of this construct in a cadaver model was measured, using micromotion sensing instruments and loads applied on a materials testing machine. The stability of the cemented allograft impaction construct following extended trochanteric osteotomy was comparable to the stability of the control construct, which consisted of a similar impacted allograft construct without osteotomy. The stability of the osteotomized side was comparable to that of the control side. It is concluded that the initial in vitro stability of the allograft impaction technique following extended proximal femoral osteotomy is adequate to justify experimental in vivo use.     

Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip

We report the results of proximal femoral osteotomy that was performed to treat osteoarthrosis in twenty-three consecutive young adults (twenty-five hips) who had a mean age of thirty-eight years (range, eighteen to fifty-three years). The mean duration of follow-up was seven years (range, two to twelve years). With conversion to a total hip replacement as the end point, the rate of survival at twelve years was 67 per cent (95 per cent confidence interval, 37 to 88 per cent). Four hips (16 per cent) were converted to a total hip replacement at a mean of eight years after the osteotomy. For the patients who did not have conversion to a total hip replacement, the mean score for pain, according to the system of Merle d'Aubigné and Postel as modified by Charnley, improved from 3.4 points preoperatively to 5.1 points postoperatively, the mean score for walking ability improved from 3.9 to 4.7 points, and the mean score for range of motion improved from 3.2 to 4.2 points. These results compare favorably with those following other forms of operative treatment of osteoarthrosis of the hip in young adults. In addition, the osteotomy does not preclude subsequent replacement arthroplasty if one is necessary.     

Acetabular and femoral fixation 15 years after cemented total hip surgery

Total hip arthroplasty in patients younger than 51 years of age remains controversial. The authors report results in 47 hips in 40 patients at an average followup of 15 years. Second generation femoral cementing techniques were used. Special attention was given to studying the differences between the outcome of acetabular versus femoral fixation. The patient group included 11 in whom custom components were used and 13 who had structural autografts for severe acetabular dysplasia. One femoral component and 10 acetabular components were revised for aseptic loosening. After 15 years, improved cementing techniques produced a marked reduction in the rate of femoral aseptic loosening. Loss of fixation of cemented acetabular components was common.     

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

Traumatic rupture of Dupuytren's contracture is rare. It has been reported only twice in recent times and only on four previous occasions over the last millenium. These cases are reported and the forces involved in rupturing Dupuytren's contracture are discussed.     

Surgical techniques in canine hip dysplasia

Based on retrospective studies, the surgical techniques most commonly used in treating canine hip dysplasia are discussed. Total hip replacement provides the best functional results. Material fatigue is not a problem.     

Treatment of developmental dysplasia of the hip after failed open reduction

It is difficult to obtain a good result by secondary open reduction if a primary open reduction for developmental dysplasia of the hip (DDH) fails. Complications such as avascular necrosis of the femoral head and subluxation of the hip are common. In this study, we retrospectively reviewed the causes of failure of primary open reduction and the final clinical and radiographic outcomes of 32 patients (34 hips) with DDH who underwent repeat open reduction and other procedures from January 1982 to December 1995. The ages of the patients at the time of the secondary operation ranged from 1.5 to 16.5 years (mean, 5.9 yr). The interval from the primary open reduction to the secondary procedure ranged from 3 days to 10 years (mean, 8.9 mo). In most cases (30 hips), the position of the redislocated femoral head was T?nnis grade 3 or 4. Avascular necrosis of the femoral head was evident in about half of the hips before the secondary open reduction. The most common cause of failure of the primary operation was a tight inferior capsule and transverse acetabular ligament, which blocked complete reduction. At a mean follow-up period of 42 months (range, 24-147 mo) after the secondary operation, the radiographic classification was Severin class 1 or 2 in 15 of the 34 hips, and Severin class 3 or worse in the remaining 19 hips. Clinically, according to the modified McKay criteria, 18 of the 32 patients (18 hips) had excellent or good results, and three patients (four hips) had poor results. In conclusion, the main cause of failure of the primary open reduction of DDH was technical error. We believe that detailed preoperative evaluation is critical for the success of primary open reduction of DDH.     

Closed intramedullary femoral osteotomy. Shortening and derotation procedures

Closed osteotomy and nailing were performed on 37 patients for leg-length inequality or rotational deformities. Shortening operations were performed in 31 patients, derotation in six. Preoperatively, the leg-length discrepancy ranged from 2 to 6.6 cm. All femoral shortenings resulted in correction to less than 1 cm. Preoperatively, rotational deformities averaged 58 degrees; all were corrected to within 5 degrees of normal. Follow-up observation averaged 3.3 years. There were no nonunions or infections. All patients regained preoperative joint range of motion (ROM). Thirteen patients were Cybex tested one year or more postoperatively; all had quadriceps and hamstring strength equal to or greater than the contralateral leg, except for two patients who had suffered additional trauma to the shortened femur. Closed femoral osteotomy is an effective, safe, and reproducible means to obtain lower limb length correction in patients with leg-length inequality or rotational abnormality.     

Magnetic resonance tomography in congenital hip dysplasia and dislocation

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