[Natural course of coxarthrosis in dysplastic hips]

We tried to determine the natural history of the hip and select the optimal treatment in 64 patients (94 hips with subluxation or dysplastic hips followed for more than ten years). Patients were classified into advanced and non-advanced groups according to radiographic analysis of the stage of the disease. Fourteen out of 43 hips (33%) developed early osteoarthritis (early OA) from pre-osteoarthritis (pre-OA) within an average of 9.4 years, while 34 out of 50 hips (68%) developed advanced-stage OA from early OA within an average of 7.7 years. In pre-OA, the CE angle, slope of the acetabular roof, acetabular head index, acetabular depth ratio and Japanese Orthopaedic Association (JOA) hip score were significant predictors, while in early OA, a broken Shenton's line, cranial joint space and JOA score were significant.

Spongy metal Lübeck hip prostheses for osteoarthritis secondary to hip dysplasia. A 2-6-year follow-up study

Between May 1987 and December 1990, 66 hips in 59 patients with osteoarthritis secondary to hip dysplasia underwent cementless total hip arthroplasty with a spongy metal Lübeck hip prosthesis (S+G Implants, Lübeck, Germany) that had a fully porous-surfaced short stem made of cased cobalt-chrome-molybdenum alloy. Sixty-five hips in 58 patients were prospectively followed for 2-6 years (mean, 43 months). Patient age at operation ranged from 29 to 63 years (mean, 51 years). The Merle d'Aubigné hip score improved from 7.8 before surgery to 16.9 at the final follow-up evaluation. All hips were rated as either excellent (63%) or good (37%). Mild thigh pain was recognized in only three hips (5%) at 6 months after surgery, but it disappeared within 2 years. Serial roentgenograms showed stable fixation with bone ingrowth in all hips, that is, bone densification in contact with the implant and trabecular connection to the endosteal surface. The authors found no migration of the implant or circumferential radiolucency. Moderate osteopenia, presumably due to stress shielding, was seen in only four hips (6%). Acetabular bone-grafting performed in 31 hips gave successful support to the socket. Cancellous bone chips grafted to small defects showed excellent remodeling. The authors conclude that the spongy metal Lübeck hip prosthesis contributed to lower rates of thigh pain and migration than cementless prostheses.

Cure of the limp in children with congenital dislocation of the hip and ischaemic necrosis. Fifteen cases treated by trochanteric transfer and contralateral epiphysiodesis

Fifteen patients who limped and had early fatigue on walking caused by ischaemic necrosis after treatment for congenital dislocation of the hip had distal and lateral transfer of the greater trochanter. Nine of them in whom the predicted leg-length discrepancy was more than 3 cm also had epiphysiodesis of the contralateral leg. At skeletal maturity the limp was eliminated and walking distance was significantly improved in them all. In those who had epiphysiodesis the average leg-length discrepancy was 0.7 cm at maturity. Two of those not treated by epiphysiodesis used a heel raise of 1.5 cm. In seven cases the two operations were performed simultaneously without serious complications. This procedure is recommended at about the age of 12 years.

[Femoral head dysplasia and its relationship to femoral head necrosis (Perthes' disease)]

Fifty-five patients totaling 98 hips afflicted by Dysplasia Capitis Femoris (DFC), monitored between 1960 and 1983, were analyzed. Mean follow-up: 8 years and 4 months (minimum 2 years, maximum 22 years and 2 months). Forty-three (78%) patients were males; fourteen (25%) were females. Non displayed any alteration in other osteoarticular segments. In 24 of the 98 affected hips it was possible to determine the exact radiological age appearance of the Epiphyseal Nucleus. Thirty-seven of the 55 patients had moderate signs and symptoms which were of short evolution. According to presence or absence of necrotic signs of the femoral epiphysis, two types of lesions were classified: Type 1: Pure Dysplasia Capitis Femoris (88 hips). Type 2: Dysplasia Capitis Femoris with unequivocal signs of necrosis (10 hips). Upon review of the 98 diseased hips, 80 (81.63%) had been fully repaired, while 18 (18.37%) were in reparatory stage. From the 80 fully healed hips, 56 were normal; 18 exhibited a Spherical Coxa Magna and 6 had a non-spherical epiphysis. As treatment concerns, patients with D.C.F. Type 1-A or Type 1-B only require observation and periodical control in addition to moderate restrictions in physical activities upon presence of symptomatic pain that is transitional. Patients with D.C.F. Type 2 must be treated as a classic case of Perthes Disease. Finally, a hypothesis of their etiopathogenis and its relationship to Perthes Disease is brought forth.

[Indication for Chiari's pelvic osteotomy]

The results of 61 Chiari's pelvic osteotomies carried out during a 10 years period are reported. Present role of the operation in the correction of acetabular dysplasia in comparison to Pemberton's acetabuloplasty, to triple pelvic osteotomies and to the prosthetic replacement of the hip joint is discussed. In conclusion the operation is still indicated in special cases. Depending on the age of the patients pain can be observed already after 3-5 years however a great part of the patients is completely free of complaints even 10 years postoperatively.

Comparison of inpatient and outpatient traction in developmental dislocation of the hip

We studied 83 hips in 72 children being treated for developmental hip dislocation to assess the influence of home traction upon the incidence and severity of avascular necrosis (AVN). We compared two types of traction prior to closed or open reduction: inpatient Bryant's skin traction (40 hips), and outpatient (home) Bryant's skin traction (43 hips). No routine in-traction radiographs were taken in either group. After traction, a stable closed reduction was achieved in 55 hips (66%). Open reduction was performed on 28 hips (34%). The rate of severe AVN involving growth disturbance and resultant deformity (Bucholz types II, III, and IV) was low in both traction groups (inpatient, three out of 40, outpatient, one out of 43). These results demonstrate that an outpatient traction program without attention to radiographic hip station is as safe as identically instituted inpatient programs, as well as those that emphasize achievement of a traction reduction or a predetermined hip station.

Cementless total hip arthroplasty for congenitally dislocated or dysplastic hips. Technique for replacement with a straight femoral component

A new straight cementless stem was used for replacement of 67 dislocated or severely dysplastic hips. There were 45 hips with complete dislocation, 27 of which were cases after Schanz osteotomy. Technical solutions for various deformities are presented here. The acetabular component was placed at the level of the original cotyloid cavity or some lower position. In hips after total dislocation a metaphyseal shortening osteotomy was combined with distal advancement of the greater trochanter with intact attachment of the abductor muscles. This method was appropriate also for the femora, where high-seated Schanz osteotomy was previously performed. If the diaphysis was too narrow for the stem, it was split about 10 cm both anteriorly and posteriorly. In cases with unilateral total dislocation where Schanz osteotomy had been seated low, metaphyseal segmental shortening with angular correction was performed and the stem was used as an intramedullary nail. Special attention was paid to achieve sufficient abduction strength to balance the pelvis and abolish Trendelenburg limp and to restore leg length. The clinical and radiographic results of the consecutive series were assessed three to five years after the arthroplasty. Pain relief and the functional results including improvement of gait were generally good, primary complications were few, but the loosening and revision rate of the smooth-threaded acetabular component was unacceptably high. There were no problems with the press-fit cups. In general the outcomes were good even when reoperation was required.

[The effect of ultrasonography screening of hips in newborn infants on femur head necrosis and the rate of surgical interventions]

We compared two similarly sized groups of sonographically unstable or decentered hips with comparable initial findings, both treated by standardized conservative primary treatment. The results show that an early definite diagnosis improves the prognosis. If built on a secure initial diagnosis rationally grounded and efficient conservative therapy can be initiated and followed through on. Since the treatment is started extremely early, the hip can benefit from the considerably greater potential for spontaneous development present in the first three months of life. In this way we can shorten the treatment time considerably and also complete it at a younger age. Finally, early treatment also reduces the risk of the complication of necrosis of the femoral head and significantly decreases the rate of surgical procedures. Only a sufficiently well executed and comprehensively organized sonographic neonatal screening program can produce a definite very early diagnosis and with it almost 100% successful early treatment of all grades of disturbances of hip maturity. Sonographic screening of the newborn is a very important piece in the jigsaw of prophylaxis and primary prevention in our public health care program.

Open reduction through a medial approach for congenital dislocation of the hip. A critical review of the Ludloff approach in sixty-six hips

We reviewed the results of open reduction through the medial approach of Ludloff, done for congenital dislocation in sixty-six hips (sixty-three children). The mean age at the time of the operation was twelve months (range, two to sixty-three months), and the mean duration of follow-up was six years (range, two to thirteen years). Avascular necrosis was evident preoperatively in two hips (3 per cent) and was noted postoperatively in another seven hips (11 per cent). There was a correlation between the age of the patient at the time of the operation and postoperative avascular necrosis, with an increased prevalence of the complication in patients who had been managed with the open reduction after the age of twenty-four months. One redislocation and two subluxations were noted at the time of the first changing of the cast, four weeks postoperatively. Although the acetabular index decreased from a mean of 38 degrees preoperatively to a mean of 16 degrees at the time of follow-up, acetabular dysplasia did not resolve in 33 per cent of the hips and pelvic osteotomy was performed. We consider the Ludloff approach to be a safe and effective method for the treatment of congenital dislocation of the hip in infants who are less than the age of twenty-four months and in whom a concentric reduction with less than 60 degrees of abduction was not achieved following closed reduction. The advantages of this approach include direct access to the iliopsoas, the transverse acetabular ligament, and the constricted capsule; minimum loss of blood; and a cosmetically acceptable scar.

Arthrodiastasis for stiff hips in young patients

Joint distraction (arthrodiastasis) with a unilateral fixator was used to treat 9 patients with stiffness of the hip which had followed Perthes' disease (3), epiphysiolysis (2), congenital dysplasia (2), tuberculosis (1) and idiopathic chondrolysis (1). Their average age was 14 years, and they all had pain, limp and shortening of the leg. Distraction of 0.5 to 1 cm was maintained for an average of 94 days. The average range of movement subsequently was 65 degrees compared with 20 degrees before. The articular space was widened by an average of 2.8 mm, and only 3 patients had pain on follow up.

Congenital pseudoarthrosis of the radius. A case report and review of the literature

Congenital pseudoarthrosis of the radius (CPR) is rare. Only ten cases seem to have been found in the literature. Congenital pseudoarthrosis of the radius usually is associated with neurofibromatosis or fibrous dysplasia. This is a report of a congenital pseudoarthrosis of the left radius associated with congenital dislocation of the left hip in a five-month-old girl. Apart from the pseudoarthrosis, there were no visible abnormalities. This patient was treated successfully with excision of the pseudoarthrosis, shortening osteotomy of the ulna, grafting, and intramedullary fixation of both the radius and the ulna. Review of the literature disclosed the extreme difficulties in treating this condition. It was also found that vascularized fibular graft has been used successfully.

Pemberton osteotomy for residual acetabular dysplasia in children who have congenital dislocation of the hip

We reviewed the results for fifty-two hips in forty-two patients who had had a Pemberton pericapsular osteotomy between 1968 and 1984 as treatment for residual acetabular dysplasia of the hip. The average age of the patients at the time of the osteotomy was four years. The average duration of follow-up was ten years. At the time of the most recent follow-up, forty-two of the fifty-two hips had a rating of Severin class IA, an essentially normally developed hip. The results of the Pemberton osteotomy were unpredictable if there had been necrosis of the femoral head (without infection) preoperatively. We believe that the Pemberton osteotomy is a safe, effective procedure for the treatment of acetabular dysplasia in patients who have congenital dislocation of the hip.

The pathogenesis of femoral head deformity in congenital dislocation of the hip. Experimental study of the effects of articular interpositions in pigs

An experimental study was conducted based on the hypothesis that articular interpositions such as inverted limbi are major factors influencing deformities of the femoral head and neck that complicate treatment of congenital dislocation of the hip. In 24 neonatal pigs, the hip was fixed in a cast for one to three hours in the frog-leg position after insertion of an allogeneic meniscus into the hip joint. No macroscopic changes were observed immediately and one day after the above procedure, but electron microscopy showed degeneration of the cells in the physis. After 29-39 days, varus deformity and flattening of the femoral head were observed in all animals. After five months, marked deformity of the femoral head and replacement of the physis by fibrous tissue were noted. Angiograms obtained during cast fixation and 30 minutes after removal of the cast showed no circulatory occlusion. A short period of immobilization in the frog-leg position combined with articular interposition plays a major role in degeneration of the physis and predisposes to deformities of the femoral head and neck.

Dome osteotomy of the pelvis for osteoarthritis secondary to hip dysplasia. An over five-year follow-up study

We performed Kawamura's dome osteotomy of the pelvis, with simultaneous distal transfer of the greater trochanter on 101 hips in 91 patients with osteoarthritis secondary to hip dysplasia. The mean age at operation was 30 years (15 to 55), and follow-up was for a mean of 8.3 years (5 to 14). Clinical evaluation using the Merle d'Aubigné score showed 92% excellent or good results. Radiologically, 91 hips had good acetabular remodelling and showed no signs of progression of osteoarthritis. In ten hips the osteoarthritic process progressed despite the osteotomy and six of these eventually underwent total hip replacement. Factors which were significantly associated with a poor outcome included an advanced stage of osteoarthritis, valgus deformity of the proximal femur, old age at the time of operation and postoperative persistence of abductor insufficiency.

[The correction of the manifestations of the pathological alterations to the hip joints after the reduction of congenital hip dislocation in children]

The paper outlines mechanisms underlying the development and predetermining the forms of hip joint disorders consequent to setting of congenital hip dislocation, the results of a 3-8-year follow-up of relevant 75 cases in children. Individual treatment regimens combined appropriate exercise, biomechanical correction, physiotherapy, acupuncture, manual therapy.

Screening of children with hemihypertrophy, aniridia, and Beckwith-Wiedemann syndrome in patients with Wilms tumor: a report from the National Wilms Tumor Study

To evaluate the usefulness of regular radiographic screening to detect an asymptomatic intraabdominal tumor in patients with an increased risk of developing Wilms tumor, we reviewed the files of patients with hemihypertrophy, aniridia, or Beckwith-Wiedemann syndrome who were registered on the National Wilms Tumor Studies. Screening was employed infrequently in the management of children with hemihypertrophy, with only 25% (6/24) of those whose hemihypertrophy was identified more than 30 days prior to the diagnosis of Wilms tumor undergoing such examinations. Most patients with aniridia were evaluated regularly for the occurrence of Wilms tumor. There were more stage 1 tumors identified in patients whose tumor was detected only through radiographic evaluation. The role of routine radiographic screening needs to be carefully evaluated in a homogeneous group of patients such as those with aniridia using a prospective study design to determine if such screening improves the survival rate of children with this rapidly growing, but readily treatable form of childhood cancer.

Arthroplasty in the sequelae of congenital hip dysplasia

The authors report their experience in the surgical treatment of the sequelae of congenital hip dysplasia, more specifically, 125 arthroplasties performed in 116 patients, with specific reference to the technical difficulties encountered and the various surgical methods used. This review suggests that prosthetization yields a high percentage of good results (77%) and constant remission of pain. Nonetheless, joint function, particularly when motion was severely compromised before surgery, or when dislocation was very severe (Crowe grades III and IV), is not always restored.

Inferior (obturator) dislocation of the hip in neonates. A complication of treatment by the Pavlik harness

Two neonates, treated by the Pavlik harness for congenital dislocation of the hip, developed inferior dislocation due to excessive hip flexion. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip in both patients.

Early and late loosening of the acetabular cup after low-friction arthroplasty

Between 1971 and 1979, 680 low-friction arthroplasties of the hip were performed in 598 patients. The average duration of follow-up was twelve years and eight months. Sixty-one acetabular cups had loosening as seen on roentgenograms eighteen years postoperatively, resulting in a total cumulative probability of loosening of 19 per cent, according to survivorship analysis. In twenty-nine cups, the loosening appeared within ten years after the operation (early loosening) and in thirty-two, more than ten years after the operation (late loosening). Early loosening was associated with deficient structure of the bone of the acetabulum, a previous congenital dislocation of the hip, acetabular fracture, or acetabular protrusion in all instances (p < 0.01). Late loosening was associated with the depth of acetabular wear. Of the thirty-two cups that had more than two millimeters of wear, eighteen (56 per cent) had loosening on the roentgenograms (p < 0.001). In hips that had early loosening, migration was the most frequent finding, and its rate of progression was higher than in hips that had late loosening (p < 0.001). In late loosening, a complete bone-cement radiolucency of more than two millimeters was the most frequent finding. Clinical failure was seen in twenty-two (76 per cent) of the twenty-nine cups that loosened early and in nine (28 per cent) of the thirty-two cups that loosened late. The probability of extensive resorption of bone necessitates close observation of patients who have early loosening, while a reasonable period of observation is possible for those who have late loosening.

Cause and prevention of osteochondritis in congenital dislocation of the hip

All treatment modalities of congenital displacement of the hip (CDH) bear the risk of ischemic necrosis at the proximal femoral epiphysis. The causes of ischemic necrosis were investigated in a review of the literature and personal experience with CDH patients during the past 30 years. Compression of articular cartilage, caused by an increase in intraarticular pressure, has been implicated as the mechanism of osteochondritis. Muscle spasm, pressure on posterior circumflex vessels, and compromised pericephalic microcirculation in the newborn have been demonstrated to increase intraarticular pressure. The most dangerous causative factors include forced reduction under general anesthesia, spica cast immobilization of the hips in the Lorenz or Lange position, insufficient continuous prereduction traction, and splints or braces that are either too rigid or that force the hip into an extreme position. An intertrochanteric varus osteotomy can also lead to ischemic necrosis when performed at the time of reduction. Preventive measures include sufficient continuous traction, casting in a moderate position, and bracing that allows active movement. None of these measures constitute a guarantee against necrosis, but they will lessen the incidence and severity of involvement.

Congenital hip dislocation. Long-range problems, residual signs, and symptoms after successful treatment

In the treatment of congenital dislocation of the hip, reduction must be obtained and maintained to provide the proper stimulus for resumption of normal hip joint growth and development. Subluxation and avascular necrosis must be avoided, as degenerative joint disease is certain to occur. Acetabular dysplasia leads to degenerative joint disease with time, although no roentgenographic parameters are predictive. "Normal" hip joint anatomy may fail to develop, depending on the age of the patient at reduction and the growth potential of the acetabular cartilage. However, as normal anatomy as can be achieved should be restored at the age of maturity. This should provide the best possible mechanical environment to avoid exceeding the pressure tolerance level of the hip joint articular cartilage, thereby avoiding degenerative joint disease.

Manifestations of ischemic necrosis complicating developmental hip dysplasia

Ischemic or avascular necrosis of the hip is a serious complication of the treatment of developmental hip dysplasia. The degree of ischemic insult can be classified based on an understanding of the vascularity of the proximal femur. Physeal involvement and subsequent growth disturbance, producing late deformity of the proximal femur, can compromise long-term results. Early recognition of ischemic necrosis patterns can be helpful in planning further treatment.

The Spitzy shelf operation for the dysplastic hip. Retrospective 10 (5-25) year study of 124 cases

Since 1961 we have used the Spitzy shelf operation combined with a vertical flap osteotomy of the outer cortex of the ilium for early arthrosis secondary to acetabular dysplasia, subluxation, and dislocation. In 124 hips, followed for 10 (5-25) years, clinical improvement was maintained in 67/85 of patients who were operated on under the age of 30 and in 22/39 of patients treated after 30. However, less than half of the hips in the younger group and only one out of ten in the older group were symptom-free.

Current concepts in the management of pediatric hip disease

A wide variety of disorders affects the pediatric hip. The most common of these are developmental dysplasia of the hip, Legg-Calvé-Perthes disease, and slipped capital femoral epiphysis. Magnetic resonance imaging and ultrasound improve the imaging of these diseases, but the ultimate impact of this technology on treatment is unknown. Complications of treatment for these and other pediatric hip diseases can be devastating; so much recent research concentrates on the etiology, prevention, and effects of these complications. Finally, these diseases occur in skeletally immature individuals, and long-term follow-up is essential for accurate evaluation of results.