The natural course of osteoarthritis of the hip due to subluxation or acetabular dysplasia

In 59 patients, 86 hips with subluxation or hip dysplasia were examined to determine the natural course of the condition and select suitable treatment. Thirty-three percent of the joints (13/39 hips) developed early osteoarthritis from pre-osteoarthritis within an average term of 9.2 years, while the remaining, sixty-six percent (31/47 hips) developed advanced-stage osteoarthritis from early osteoarthritis within an average term of 7.8 years. Patients were classified into advanced and non-advanced groups according to radiographic analysis of the advanced groups according to radiographic analysis of the advance of the disease and statistical analysis was performed. In pre-osteoarthritis, centre-edge 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 osteoarthritis, a broken Shenton's line, cranial joint space and JOA score were significant. On the basis of multiple parameters, formulas for predicting development in patients with pre-osteoarthritis, those with early osteoarthritis, and all patients together were established, with an accuracy of 87%, 71%, and 68%, respectively.

The relationship between the treatment of congenital dislocation of the hip and avascular necrosis

The most important complication following the treatment of congenital dislocation of the hip is avascular necrosis. The potential sequelae that may arise after the onset of avascular necrosis are worse than if the hip remained dislocated. We evaluated 38 hips in which avascular necrosis developed after reduction. The average patient age at the time of reduction was 4.3 years, with a follow up of 6 to 15 years. Twelve hips had closed reduction and 26 had open reduction. Following reduction, 8 hips had Type I, 6 had Type II, 9 had Type III, and 15 had Type IV avascular necrosis. In this article, we evaluate our cases and review current literature on the subject. Close follow up and timely interventions can reduce potential sequelae to a minimum.

Femoral head anteposition after surgery of congenital dislocation of the hip. A computerised tomography study of 22 hips suspected of anterior dislocation

A new term called "femoral head anteposition" to describe the clinical appearance of a hip operated on because of CDH and suspected of anterior dislocation, has been introduced. CT scans of both the horizontal and sagittal planes of 22 hips suspected of iatrogenic anterior dislocation were made from 22 children. These had been operated on because of CDH by the open reduction method with derotation varus osteotomy of the femur and transiliac osteotomy by Dega. An evaluation of the CT scans combined with clinical examination allowed the differentiation of the homogeneous clinical appearance from the "anteposition". It was then possible to establish one or several coexisting reasons to the situation. These were: anterior dislocation of the hip, coxa magna after avascular necrosis, gluteal muscle fibrosis or periarticular ossifications.

[Supratrochanteric osteotomy of the hip in adults with dysplastic coxarthrosis]

On the basis of complex assessment of the results of supratrochanteric osteotomy of pelvis (30 operations) and osteotomy of pelvis with the subsequent intertrochanteric osteotomy (24 observations) in patients with dysplastic coxarthrosis at mean terms of observation, equalling to 90 months, have been determined efficiency and indications for these operations. Indications for pelvic osteotomy are formed on the basis of roentgeno-anatomic interrelations in hip joint, where the decisive part is played by the angle of vertical inclination of the cotyloid cavity and degree of coating of the head of the femur. Intertrochanteric osteotomy following the pelvic osteotomy is indicated at preserved pain syndrome, resulting from coxarthrosis, subsequent to the muscular system restoration.

[Tendency of acetabular development of conservatively treated hip dislocation with femur head necrosis (1)]

The late results of 101 cases of avascular necrosis in congenital dislocation of the hip are reported, which occurred after closed reduction between 1954 and 1960. A good development of hips was observed in 24 cases (23,8%). A severe deformity took place in 33 hips (32.7%), which mostly had total femoral head necrosis. In the groups with partial necrosis a good development was occurred only in the half of all cases. Early treatment led to better results. Besides the necrosis the grade of luxation plays an important role for the development of the hips.

The frequency of occurrence of congenital dysplasia of the hip in Poland

In Poland, the number of newborn infants suffering from congenital dysplasia of the hip (CDH) is high. Its percentage has not changed during the past 30 years. The aim of this paper was (1) to find the frequency of occurrence of CDH based on the highest possible number of cases and to obtain the most objective data from examination performed by orthopedic surgeons; (2) to gather information about methods of treatment used; (3) to establish time of treatment (depending on how advanced the dysplastic process was); and (4) to determine the number of complications. The data are based on 17,094,000 inhabitants, or 46.2% of the Polish population. During the years 1980 to 1984, about 350,000 deliveries were annually registered. On the basis of the data, the following were concluded: (1) The frequency of CDH among children in Poland comes to 6.8%. (2) Cases of dysplasia with dislocation are 1.06%. (3) Almost half the number of children (46.2%) are being treated in outpatient departments run by orthopedic surgeons. The remainder are being cared by pediatric and general surgeons, or pediatricians. (4) Necrosis of the femoral head occurred in 10.4% of patients. (5) The most satisfactory therapeutic results (almost 100% cured) are obtained when treatment begins during the first week of the child's life.

[Evaluation of treatment of the hip in arthrogryposis multiplex congenita]

In a retrospective review of 77 patients with arthrogryposis multiplex congenita, 21 showed involvement of the hip (28%). The authors studied 18 cases with hip dislocation (11 bilateral and seven unilateral) and three with hip contracture. There were 12 female and nine male patients ranging their age from one month to 14 years. The follow-up in this series lasted from two to 23 years. The treatment was conservative or surgical. The contractures were treated by manipulation and abduction orthosis in one patient and surgically by multiple hip tenotomy in two. The dislocation was treated by abduction orthosis (two cases), closed reduction (two cases) and open reduction (one case) in the 11 cases with bilateral involvement; for the seven unilateral dislocations the treatment was: closed reduction and abduction orthosis (one case), closed reduction with abductor tenotomy and hip spica cast (four cases) and open reduction followed by hip spica and abduction orthosis (one case); one case remained without treatment of the hip involvement because of severity of deformities in knee and foot. Ten patients of this groups were not treated because they were confined to wheelchairs. The overall result was good in six patients, regular in four and poor in two in the dislocation group; for the three cases of hip contracture the result of treatment was good. In conclusion the authors recommend such treatment for the independent ambulatory patients and emphasize the necessity of treatment of patients with unilateral hip involvement.

Chiari osteotomy in the adult: a long-term follow-up study

For almost 20 years the Chiari pelvic displacement osteotomy has been used as a method of providing cover to the femoral head in cases of acetabular dysplasia. The osteotomy is one of a number of procedures that have been used in an attempt to prevent the early development of secondary osteo-arthritis and the need for total hip replacement. More recently, the operation has been undertaken in cases where there is already some arthritic change. This long-term review of 18 Chiari operations shows that the procedure was successful in cases of acetabular dysplasia where there was minimal subluxation of the femoral head (i.e. with Shenton's line still intact). In more advanced cases where there was significant subluxation (i.e. with Shenton's line broken by more than 1 mm) and even early arthritic changes, the results were poor. It is concluded that the operation may be of value as an almost 'prophylactic' procedure but that it is of no value as a so-called 'salvage' procedure.

[Correlations of congenital femoral dislocation and scoliosis]

In the article is analysed the state of spine and hip joints on the basis of comparative appreciation of orthospondylometric and coxometric data in accordance with the roentgenograms in anteroposterior projection. It has been revealed that the point in common between the congenital hip dislocation and scoliosis is the same dysplastic essence. Biomechanical changes, which take part in this community, determine the final formation of pathology of spine and hip joints. In the process of examination of children with congenital hip dislocation recommended detection and preventive treatment of the spine changes and in case of spine pathology the hip joint pathology should be looked for.

Behavior of the proximal femur during the treatment of congenital dysplasia of the hip: a clinical long-term study

The influence of the acetabular cover on the development of the proximal femur during the treatment of congenital dysplasia of the hip was studied in 47 children (58 hips) with a follow-up of 22 years. Varus osteotomy failed to correct hip dysplasia in 33 hips of 27 children. Chiari osteotomy was followed by a positive anti-Chiari effect (oval shaped acetabulum with proximal migration of the femoral head) in 15 children (20 hips). In five children (five hips) with coxa vara due to avascular necrosis, the anti-Chiari effect was negative. The combination of Chiari and varus osteotomy before the age of 8 years was followed by a positive anti-Chiari effect and recurrence of valgus deformity in seven of eight hips. The long-term failure of the varus and Chiari osteotomy, together with a review of clinical and experimental surveys, led us to prefer the acetabular redirectional osteotomy.

Trochanteric advancement for premature arrest of the femoral-head growth plate. 6-year review of 30 hips

Between 1971 and 1985, 30 children (35 hips) with premature closure of the subcapital growth plate were treated with trochanteric advancement. After 6 (3-8) years, 25 children (30 hips) were reviewed. Of the 30 hips, 27 had had one or more operations before the trochanteric advancement. All the trochanters fused without complication. Trendelenburg's sign was positive in 24 hips preoperatively and became negative postoperatively. The hip abduction was increased in 28 of the 30 hips reviewed.

Pelvic support osteotomy in an unusual congenital dislocation of the hip. A 52-year follow-up study

Structural changes in the anatomy of the soft tissues as a result of long-standing congenital dislocation of the hip (CDH) are seldom described in the literature. Similarly, the anatomy of a hip 52 years after a pelvic support osteotomy for CDH seems not to have been previously observed. A long-term follow-up autopsy study of bilateral pelvic support osteotomies performed in a 91-year-old autopsy subject showed unexpectedly flattened sciatic nerves.

Chiari pelvic osteotomy for osteoarthritis secondary to hip dysplasia. Indications and long-term results

Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage.

[Remarks concerning diagnostic principles and early treatment of congenital hip dislocation]

Principles of early diagnosis and treatment of congenital dislocation of the hip are presented. The clinical course, complications and results of treatment by Frejka pillow are reported. Indications for surgical treatment in cases of failure by conservative management, as well as in cases of deficient rebuilding of the hip are discussed.

[The mechanism of the development of residual deformation and complications after the reduction of congenital hip dislocation in children and their conservative treatment]

There is described the mechanism of development of hip joint instability of different types and associated secondary complications. Conservative biomechanical approach of treatment of residual instability and its complications: enchondral growth and ossification, delay, pathologic restructuring and coxarthrosis, is proposed.

Fiber density in congenital muscle fiber type disproportion. II. Congenital muscle hypotonia and hip dislocation

Our previous paper presenting electromyographic findings in patients with congenital fiber type disproportion myopathy, confirmed the myogenic character of the disease process. That group of patients was however fairly heterogenous regarding both the clinical features and the morphological changes in muscle fibers (e.g. cases with central cores). In the present study we have examined 13 children with hypotonia and muscle fiber type disproportion operated on in childhood for congenital hip dislocation. In all cases CNEMG and SFEMG with FD estimation was performed in biceps brachii and quadriceps femoris muscles. In all muscles examined either slight EMG changes indicative of myopathy or a normal EMG pattern was found. None of the patients demonstrated an evident increase in FD values. Normal FD and the recruitment pattern proportional to the force of contractures indicate that the normal number of motoneurons is preserved. Accordingly, our present findings confirm the conclusions of our previous paper.

Acetabular dysplasia in the adolescent and young adult

Hip dysplasia is a major cause of osteoarthrosis in adults. Early aggressive osteotomy has the potential of preventing the development of arthritis, but carries with it significant risks. The problem is further complicated because the surgeon has no means of quantifying the dysplastic deformity or of predicting what a particular combination of osteotomies would do to correct the deformity. This study describes methods of quantifying hip-joint geometry in three dimensions based on computed tomography and magnetic resonance studies, and of simulating pelvic osteotomy to correct the deformities. The study analyzes 49 normal hip joints and 20 dysplastic hip joints. The results show that the normal acetabulum is nearly a full hemisphere, which is anteverted 20 degrees and abducted 53 degrees. The normal lateral center-edge angle is 37 degrees. The dysplastic acetabulum is not anterolaterally maldirected, as has been assumed, but is globally dysplastic. Analysis of the individual dysplastic hip joints showed a wide variability. Some patients were deficient globally, some anterolaterally, and some posterolaterally. Methods of analyzing a patient's hip joint, quantifying abnormalities, simulating surgery, and predicting results are demonstrated in a case example.

The treatment of infantile coxa vara with the external circular fixator

Coxa vara worsens as it evolves, and is often accompanied by other femoral deformities, such as hypometria, axial knee deviations, and rotational deformity. Traditional surgical techniques, especially intracapsular femoral neck osteotomy, are difficult to execute and often cause joint stiffness while not sufficiently correcting the coxa vara or the other deformities, in particular hypometria. For these reasons this study used the external circular fixator to simultaneously correct these deformities. The results are presented after discussion of technical details.

Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip

Four hundred and eight siblings, parents, and grandparents of seventy-eight children from the New England area who had congenital dysplasia of the hip were evaluated, by clinical examination and by measurements of the acetabulum on pelvic radiographs, for the signs and sequelae of congenital dysplasia of the hip. Six siblings and four mothers (representing seven of seventy-eight families) had been diagnosed with congenital dysplasia of the hip during childhood. The other ninety-one siblings were asymptomatic and had no radiographic evidence of dysplasia of the hip. In the adults in these families, acetabular coverage (as measured by the center-edge angle of Wiberg) was no different from that in the control subjects. There was no difference between the study group and the control subjects in the prevalence of osteoarthrosis of the hip or of osteoarthrosis that could be considered secondary to congenital dysplasia of the hip. The results indicate that children born to families that have a history of congenital dysplasia of the hip have a greater prevalence of this problem compared with the general population, but also that examinations of the hip in newborns are effective in detecting congenital dysplasia of the hip in such families. The greater prevalence of congenital disease of the hip among the siblings and mothers in these families is consistent with a multifactorial inheritance. The fact that acetabular development in the family members who did not have congenital dysplasia of the hip was no different from that in the control subjects suggests that acetabular dysplasia, rather than being an inherited abnormality, is secondary to subluxation or dislocation.

Results of a 25-year screening programme for neonatal hip instability

From 1962 to 1986, 117,256 neonates were screened for congenital dislocation of the hip (CDH). When the primary physical examination was performed by the junior paediatric staff there was a persistent late diagnosis rate of 0.5 per 1000 live births. When the primary examination was undertaken by experienced orthopaedic personnel (1982 to 1984) the late diagnosis rate fell and fewer infants were splinted.

[Femoral head necrosis in hip dislocation and its prognosis (a literature review)]

In this article are discussed the classifications of avascular necrosis following treatment of congenital dislocation of the hip. The reported incidences of avascular necrosis according to the method of treatment are reviewed. The long-term follow-up and end results of conservative treatment of congenital dislocation of the hip with and without avascular necrosis have been analysed.