Study Design. Retrospective clinical and radiographic review of patients after Bernese periacetabular osteotomy for symptomatic congenital hip dysplasia. Introduction. The Bernese periacetabular osteotomy for the treatment of symptomatic congenital hip dysplasia is known to be a complex operative procedure. Several authors reported significant percentages of peri- and postoperative complications. Objective.The aim of our study was to reveal whether the incidence as well as the grade of complications affect the postoperative outcome which was determined by the short form (SF) 36 and the Western Ontario McMasters osteoarthritis (WOMAC) questionnaires. Methods. A consecutive series of 50 patients with 60 hips operated between 1988 and 2000 were investigated retrospectively with a mean follow up period of 32 months. Results. With an incidence of 30% a lesion of the lateral cutaneus nerve occurred. In 10% a peroneal nerve palsy was diagnosed immediate postoperatively, with 4% persistent neurological deficit presented at one year follow up. Several other minor and major complications occurred with an overall complication rate of 68%. According to the severity of complications two groups of patients were identified. Statistical analysis did not reveal any difference between the results of the SF-36 (p=0.2) and WOMAC (p=0.09) questionnaires. Radiological analysis revealed a deterioration of osteoarthritis in 32% of our patients. These patients predominantly judged their postoperative results poor to fair (r=0.71). 76% rated the operation as successful and 64% would have surgery again. The subjective estimation of patients health status postoperatively was significantly reduced compared to an age matched healthy reference group (p=0.0001). Conclusion. Despite the high incidence of complications 76% of the patients rated the operation as successful. 32% of the patients faced a deterioration of osteoarthritis. The postoperative results after Bernese periacetabular osteotomy are rather more influenced by the progression of osteoarthritis than by the occurrence of perioperative complications

Purpose of the study: Acetabular version is a most important parameter for repositioning the acetabular fragment during periacetabular osteotomy. Recently, a few studies have presented a significant number of dysplastic hips with acetabular retroversion. There have not however been any studies devoted specifically to the severity of bilateral acetabular retroversion. The purpose of this work was to determine the incidence of bilateral retroversion in patients undergoing periacetabular osteotomy for dysplasia in order to identify and validate a retroversion index which would be predictive of the degree of retroversion. This index could be added to congenital hip dysplasia classifications to include acetabular version. Material and methods: The Lequesne lateral view of the hip was obtained in 174 patients (348 hips, 137 women and 37 men, mean age 30 years) undergoing periacetabular osteotomy for symptomatic dysplasia. One hundred ninety-five hips (56%) were operated on and 153 (44%) were considered normal or non-symptomatic and were not operated. The following parameters were noted for each hip: VCE, VCA, HTE, femoral head extrusion, index of acetabular depth, crossing-over, retroversion index. The retroversion index was checked on a bone model of the pelvis which was x-rayed in the neutral position then turned progressively. Statistical data were analyzed with SAS. Results: Five percent of the operated hips presented neutral version, 53% anteversion and 42% retroversion. Twenty-four percent of the non-operated hips were normal, 22% presented pure retroversion and 54% were dysplastic. All of the measurements were significantly deviated towards dysplasia for operated hips, with the exception of the retroversion index and the VCA. Discussion: These data validated the retroversion index and confirmed that one out of three dysplastic hips displays retroversion. In addition, it would appear that for dysplastic hips with retroversion, the degree of lateral coverage or the HTE angle determines whether surgery is needed or not and not the degree of retroversion. But as pure retroversion can be symptomatic in itself, and since the majority of these version or cover anomalies can be treated by periacetabular osteotomy, we propose a classification of hip dysplasia included acetabular version. Conclusion: This classification is designed as an aid for the orthopedic surgeon for reorienting the acetabular fragment to obtain the optimal position

Purpose of the study: the Pavlik harness has been used for the treatment of congenital hip dislocation since it was designed by Arnold Pavlik in 1950. There remains however a certain debate concerning the best moment to start treatment and its duration. We advocate early use of the Pavlic harness for a short period.

Material and methods: Forty-five hips (34 infants) were treated. The diagnosis of dislocation was clinical. The Barlow and Ortolani maneuvers were used to search for clinical instability classed as «positive dislocation test» or «negative test but presence of piston movement». Different classifications of positive tests were used to search for an association with increasing severity of hip instability. Static and dynamic ultrasound was then used to confirm the diagnosis of hip dislocation. A Pavlik harness was installed immediately after diagnosis of congenital hip dislocation, on the day of birth if possible, according to the precepts proposed by the inventor.

Results: Among the 43 hips analyzed I the present series, reduction and stabilization was successfully achieved with the Pavlic harness in 40 used as early as possible for a short a period as possible. This 95.6% success rate (2 failures, 0 complications) was achieved within 3 o 8 weeks.

Discussion: Our results are comparable with other series reporting early use of the Mubarak method. The duration of treatment was shorter with our therapeutic method. We did not attempt to treat the dysplasia, spontaneous regression was monitored radiographically.

Conclusion: We consider congenital hip displasia to be a therapeutic emergency. Treatment should be undertaken as soon as the dislocating intrauterine constraints cease. Early use of the Pavlik harness on easily dislocated or dislocated reducible hips has given excellent results. The shorter treatment duration does not lead to any recurrence as long as clinical stability with formal radiographic confirmation at treatment end.

The aim of this paper is to present a new solution in treating osteoarthritis after congenital dysplasia. In the First Orthopaedic Clinic in Prague, we have obtained, by using oval-shaped cups, excellent results in the treatment of acetabular deficiency occurring in THA loosening. These positive results have also encouraged us to use the implants in THA for secondary coxarthrosis.

In severe acetabular defects, an endoprothesis is very difficult to implant. A whole range of methods has been described for fixing the acetabular component. We prefer not to use cemented implants with middle-aged patients. Methods using bulk bone grafts are being scaled down. Cup implantation to the neoacetabulum is disadvantageous because forces inherent to the hip joint are considerably higher in the superior lateral position. Cotyloplasty and controlled fracture impair the medial wall with the enhanced risk of implant protrusion to the pelvis. The implementation of an oval cup eliminates the above-mentioned disadvantages.

During the period of 1994 to 1998, we applied the LOR cup in treating secondary coxarthrosis eight times in six women (mean age: 54 years). 83% had already been operated for congenital hip dislocation. The stage of the dysplasia was classified as Crowe II in two hip joints, Crowe III in four, and Crowe IV in two. An average of four screws were used for a 52x64 cup. Mean follow-up was 4.8 years.

The mean Harris hip score at follow-up was 92 points. There were no infections, luxations, implant migrations, or screw failures. The radiograph evaluations revealed just one case of a translucent line 1 mm wide in the b,c zone. Osteointegration was perfect with the other implants.

Using the oval-shaped cup does not usually require implementation of bulk bone grafts. Implant shape and the option of implementing an eccentric inlay enables preservation of the rotational centre, which is advantageous in terms of biomechanics. Implantation of the cup is easy and fast. Because of the good results, we suggest introducing the oval-shaped cup as a standard method of THA primo-implantation with patients who have acetabular dysplasia. The LOR cup was designed as a revision implant, but a disadvantage is the insufficient size scale and the 32 insert. For widespread application, it is therefore necessary to design a smaller size 28 inlay cup. We are currently developing our own acetabular component with a more suitable size scale and a plasma-sprayed hydroxyapatite ceramic coating.

Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique. 89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months. All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies. Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity

Purpose of the study: The natural history of congenital hip dysplasia with weight-bearing usually progresses towards degenerative joint disease. The anatomic type of the dislocation, whether treated or not, was well classified by Crowe who described four types. Material and methods: Since 1989, we have used an ABG hydroxyapatite (HA) coated prosthesis for the treatment of congenital hip dysplasia. The hemispheric acetabular implant is coated with hydroxyapatite and the femoral implant, which is inserted in an anatomic position with anteversion, antetorsion and anteflexion, has a HA-coated stem. Forty-three Crowe type 3 or 4 hips (high position) were treated with this technique:. implantation of the cup in the paleoacetabulum;. screwed autograft harvested from the femoral head to fill the bony defect;. implantation of an anatomic stem, without cement but with HA-coated shaft. Results: Cup implantation in the paleoacetabulum was achieved in all patients except two. A screwed autograft was inserted in 75% and remained stable over time for the larger grafts but tended to resorb for smaller grafts. For femoral anteverions, an ABG implant was used in 34 cases: 21 ABG1 stems, 11 ABF2 stems, and one ABG revision stem. The ABG stem enabled satisfactory anatomic restoration in 20 hips but with postoperative stiffness. For 14 hips, due to the important femoral anteversion related to the dysplasia, a reversed ABG-HA implant was used: eight left implants for right hips and six right implants for left hips. This «reversed» curvature gained 24° in the femoral anteversion plane. The outcome was excellent in these 14 cases, particularly with a clear improvement in postoperative external rotation. At close to 15 years follow-up we have had no case of femoral loosening, nor of femoral shaft osetolysis, with this type of implant. Discussion: Certain authors propose using a custom-made implant for sequelar congenital hip dysplasia, but we prefer the proposed technique which provides very satisfactory results and limits the need for custom-made material

The endoprosthetic treatment of secondary osteoarthritis resulting from congenital hip dysplasia is difficult due to the small diameter of the acetabulum and the hypoplastic anterolateral bone stock. On the femoral side the increased femoral anteversion, insufficient femoral offset and proximal femoral deformities (mostly valgus deformities) as well as the small diameter and straight form of the intramedullary canal pose challenges. Careful preoperative planning is mandatory. The Crowe classification is usually used to describe these pathologies. In severe cases (Crowe 3 and especially Crowe 4) a shortening and derotating femoral osteotomy should be taken into account. Small acetabular components, acetabular augments, and modular femoral components must be available at all times. For acetabular fixation press-fit cups are preferred today, but excellent results were also described for threaded cups. The advantage of press-fit cups is the extensively documented and superior track record, but threaded cups allow for an easier reconstruction of the original hip center as well as slight medialization. As a result of medialization a reduction in polyethylene wear together with a low rate of loosening lead to very good long-term results in a younger patient population. Cementless straight stems are documented to be preferable for the small femoral diameter and the straight anatomic shape of the proximal femur. Nevertheless, the higher complication rate, especially the increased rate of nerve palsies, should be preoperatively discussed with the patient. The ideal bearing surface is currently unclear, ceramic-on-ceramic seems to be promising, although the longest data available support the use of metal-on-polyethylene

In the congenital hip dysplasia, patients treated with total hip replacement (THR) often report persistent disability and pain, with unsatisfactory function and quality of life. A major challenge is to restore the center of rotation of the hip and a satisfactory abduction function [1]. The position of the acetabular cup during THR might be crucial, as it affects abduction moment and motor function. Recently, several software systems have been developed for surgical planning of endoprostheses. Previously developed software called HipOp [2], which is routinely used in clinics, allows surgeons to properly position the prosthetic components into the 3D space of CT data. However, this software did not allow to simulate the articular range of motion and the condition of the abductor muscles. Our aim is to present HipOpCT, an advanced version of the software that includes 3D musculoskeletal planning, through the application to hip dysplasia patients to add knowledge in the diagnosis and treatment of such patients who need THR. 40 hip dysplasia patients received pre-operative CT scanning of pelvis and thighs and had their THR surgery planned using HipOpCT. The base planning includes import of CT data, positioning of prosthetic components interactively through multimodal display, as well as geometrical measurements of the implant and the host bone. The advanced planning additionally includes evaluation of femoro-acetabular impingement and calculation of leg lengths, abductor muscle lengths and lever arms through the automatic creation of a musculoskeletal model. The musculoskeletal parameters in all patients were calculated during the surgical planning, and the data were processed to evaluate pre- and post-operative differences in leg length discrepancy, length and lever arm of the abductor muscles, and how these parameters correlated. The surgical planning led to an increase in the operated leg length of 7.6 ± 5.7 mm. The variation in abductors lever arm was −0.9% ± 4.8% and significantly correlated with the variation in the operated leg length (r = −0.49), pre-operative leg length discrepancy (r = 0.32) and variation in abductors length (r = −0.32). The variation in abductors length was 6.6% ± 5.5%, and significantly correlated with the variation in the operated leg length (r = 0.92), post-operative leg length discrepancy (r = 0.37), pre-operative abductors length (r = −0.37) and variation in abductors lever arm (r = −0.32). The increase in the operated leg length was strongly correlated to the increase in abductor muscle length. Conversely, abductor lever arms slightly decreased on average, and were inversely correlated to leg length variation and abductors lengths. This interactive technology for surgical planning represent a powerful tool for orthopaedic surgeons to consider the best muscle reconstruction, and for rehabilitation specialists to achieve the best functional recovery based on biomechanical outcomes. In a parallel study, we are investigating how these advanced planning is reflected onto the function, pain and biomechanical outcome after a rehabilitation protocol is completed

Aim. This study presents the early results of a novel procedure, both in timing and surgical technique, aimed to treat those cases of congenital hip dysplasia that present late or fail conservative treatment. Methods. 48 patients and 55 hips treated over the period from December 2004 to February 2011 were retrospectively reviewed. All were treated with adductor and psoas tenotomy, open reduction, capsulorrhaphy and acetabuloplasty by the senior author. Results. Thirty-five of the cases (72.92%) were late presentations whilst 13 (27.08%) cases represented failure of conservative treatment with Pavlik harness. According to the IHDI classification, there was 1 (1.82%) grade I, 9(16.36%) grade II, 13 (23.64%) grade III, and 32 (58.18%) grade IV. The age of the patients at surgery averaged 16.01 months and the mean follow-up was 31.07 months (10.13–84.20 months). The average pre-operative AI was 37.97 ° (range 23 to 49). AI fell steadily over time reaching an average of 24.7° (range 14.7° to 30°) at 22 months post-acetabuloplasty. One of the earliest cases had some residual lateralisation requiring a Shelf acetabuloplasty 4 years after the index procedure. There were no infections, nerve palsies or graft displacement in the series. Seven cases (12.73%) developed AVN graded II or over (five grade II, one grade III, and one grade IV). The incidence of AVN significantly associated with previous failed conservative treatment (p<0.05) and was not related to pre-operative IHDI classification or AI (p=0.42 and p=0.31 respectively). Conclusion. This one-stop procedure seems to be safe whilst providing reliable outcomes; igniting the remodelling process that results in a concentric and stable hip. However, pelvic anatomy is not distorted and hence, additional pelvic osteotomies may be utilised if needed

Metal-on-metal hip resurfacing (MOMHR) is a good surgical indication for young active patients. However, it cannot be used in patients with severe CDH and in particular a too short head/neck. To address these cases, a new surgical technique consisting of augmentation of the femoral head with impacted morcellized bone grafts has been developed. 32 osteoarthritis patients following severe congenital insufficiency of the femoral head/neck were treated with MOMHR combined with femoral head augmentation. The required amount of augmentation was calculated on preoperative X-rays and confirmed during surgery. Using special instrumentation, bone chips produced while reaming the socket and trimming the head were impacted on the head to achieve the desired reconstruction and lengthening. Finally, the femoral component was cemented. Mean patient age was 49+ 9 years (18–66). Median head lengthening was 12+ 2 mm. Mean follow up is 4.2 years (3–6). Mean preoperative Harris hip score (HHS) was 58 and at follow-up 95 (p < 0.05). Mean leg lengthening was 2.2 cm (p = 0.001). In all Gruen zones, bone mineral density (BMD) decreased during the first 3 months. At 2 years in zone 1 mean BMD increased to 96.8% (p = 0.009) and in zone 7 to 102.1% (p = 0.05). A correlation was found between valgus positioning of the femoral components and increased BMD (p = 0.005). This impaction bone grafting technique expands the use of MOMHR to patients with severe congenital hip dysplasia leading to a more anatomical reconstruction with a full recovery of function and BMD

Purpose of the study: Generally, hip prosthesis implantation for congenital hip dysplasia is a routine procedure. Material and methods: We compared preliminary results between two surgical techniques. On one hand, hip prostheses were implanted via trochanterotomy with femoral shortening osteotomy for cemented insertion and trochanteroplasty. On the other, access was achieved via a triple infratrochanteric osteotomy for shortening, correction of valgum and derotation followed by implantation of a press-fit prosthesis without osteosynthesis. Results:. Between 1993 and 2001, 61 patients underwent surgery for Crowe III or Eftekhar grade C hips (n=45) and Crowe IV or Eftekhar grade D hips (n=16). Mean patient age was 42 years. Prostheses inserted via the trans-trochanteric approach with femoral shortening osteotomy and cementing developed complications related to the trochanteroplasty: nonunion of the greater trochanter (n=6), functional impairment (n=2), infection after bursitis on suture and secondary necrosis (n=1). Because of these complications we adopted the triple femoral osteotomy technique for shortening, derotation and press-fit femoral implants. Between 2001 and 2005, eight Eftekhar D hips were treated with this technique. Locked non-cemented femoral prostheses were inserted. Pre- and postoperative clinical assessment was based on the Postel-Merle-d’Aubigné score. For the cup, the technique remained unchanged, with cemented implants. The lengthening obtaine varied from 3.5 to 5.5 cm with no cases of sciatic palsy. There has been no case of prosthesis dislocation. Conclusion: These preliminary results concern non-cemented femoral prosthesis with insufficient follow-up. We nevertheless have found this an attractive technique free of femoral complications

The aim of the study was to determine the mid-term clinical result of the patient operated by Chiari pelvic osteotomy. A mid-term evaluation of the Chiari pelvic osteotomy performed on 65 hips in 58 patients is presented. Indications were: 1) congenital hip dysplasia in cases where conservative or other surgical treatment had failed, 2) deformed, laterally uncovered femoral head due to Legg-Calvé-Perthes disease, 3) age between 10–40 years, 4) no signs of advanced osteoarthritis. Patients were classified according to pain, limp, Trendelenburg sign, range of motion, abductor muscle strength, and radiographic appearance (Wiberg and Idelberger angles). A mean follow-up of five years revealed relief of pain and an increase of hip motion in many cases. However, limping and a positive Trendelenburg sign frequently persisted. The radiographic appearance showed that the Wiberg angle had increased from the preoperative average of 6 degrees to 30 degrees postoperatively. The Idelberger angle decreased from the preoperative average of 72 degrees to an average of 60 degrees postoperatively. The Chiari osteotomy is a technically exacting procedure which provides adequate femoral head coverage. This coverage facilitates pain relief and increased function. However, the results were less consistent in the cases of Perthes disease. Considering the indications and contra-indications, the Chiari pelvic osteotomy has good clinical results in the reduction of painful standing and walking of young adult patients with DDH

Aims

The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate.

To evaluate the osseointegration enhancement, a consecutive randomized series of 50 on a total of 483 cementless titanium prostheses were prospectically studied. The features of the stem were the following: tapered, straight, low-profile neck, metaphyseal and hystmic fit, proximal 1/3 hydroxyapatite coated (HA) and titanium porous coated (PC). The acetabular component was hemispherical, titanium porous coated. A zircornia or Co/Cr head (28mm) was used. Female were 53% and average age 65. The general diagnosis was ostheoarthritis, congenital hip dysplasia, fracture, aseptic loosening, osteonecrosis, previous femoral osteotomy, previous pelvic osteotomy. Clinical objective assessment was based on the HHS. A patient oriented evaluation (Womac and SF12) was obtained. Radiological assessment was based on the Engh’s method. The general and prospectical group results have been evaluated. In all the groups the HHS, Womac and SF12 questionnaires showed a statistically significant improvement in quality of life. Consistent evidence of proximal bone ingrowth were present in 100 % (HA) and 96 % (PC), stable proximal fibrous ingrowth in 4 % (PC). Cortical hypertrophy (50 % zone 3–5), stress shielding (56 % zone 1) and pedestal ( one case) were assessed. Nor osteolysis neither subsidence were identified. No significant general complications such as infections or periprosthetic fractures were observed. The use of HA seems to improve the mechanism of osseointegration and earlier clinical outcomes, even if this difference is not significant. Patient oriented evaluation and radiographic assessments confirmed the reliability of this cementless prosthesis. Less osteolysis could be predicted in the future, according to the reported results of other authors in the HA coated stems

Purpose of the study: Prenatal screening and search for risk factors has lead to early diagnosis of congenital hip dysplasia. The percent of excentration of the dysplastic hip can be quantified with ultrasonography. The purpose of this study was to evaluate the usefulness of ultrasound monitoring of confirmed hip dysplasia as a method for determining the appropriate time to discontinue treatment. Material and methods: We collected a series of patients presenting unstable hips one month after birth. Ultrasonographic examinations were performed to quantify the instability. Initial treatment was forced abduction. If the infant’s weight was greater than 5.6 kg, a Pavlik harness was used. Physical examination and control ultrasound examinations were performed at 4, 8 and 12 weeks. Forced abduction and ultrasound surveillance were discontinued when the percent of acetabular cover was greater than 50%. Long-term surveillance consisted in physical examination and plain ap view of the pelvis at four months and at onset of walking. Results: Ultrasound monitoring was instituted for 71 hips in 51 patients. Mean age at onset of the monitoring scheme was 37.7 days (range 38–74 days). Mean acetabular cover, as evaluated by ultrasound before treatment, was 35.5% (range 20–45%). After four weeks, mean cover for 42 hips was 54.7% (range 50–85%). For the other 29 hips, mean acetabular cover was 41.4% (range 36–47%) at four weeks. At eight weeks, 26 of these 29 hips had a mean cover of 60% (52–85%). Acetabular cover remained below 50% for three hips at twelve weeks. Mean HTE at four months was 20.7° (range 10–26°). At walking, all hips were centered and no irregularities were noted on the x-rays of the femoral nucleus. Discussion: The majority of infants with unstable hips diagnosed at birth achieve spontaneous cure without treatment. For others, cure can be achieved with forced abduction but with a risk of osteochondritis. In our study, ultrasound monitoring enabled a reliable assessment of the proper moment to interrupt treatment. Conclusion: Ultrasound examination of the hip joint is a satisfactory method for monitoring hip dysplasia in infants aged less than four months. It appears to be useful for determining the moment to interrupt treatment

Acetabular loosening is often dangerous because the patient is pain free for several years. The subsequent bone loss may represent the greatest challenge in revision surgery. The extension of the bone loss may be small or wide, but it could also be associated with several defects. Usually, the most affected district is the dome, especially because the cup leans to migrate proximally. The object of this study is to evaluate the use of an iliac stem cup (Link®) associated with impacted bone grafts in acetabular loosening and congenital hip dysplasia (CDH). The surgical technique requires a posterolateral approach, dedicated cannulated hardware tools to improve iliac stem positioning, intraoperative C-arm and bone grafts to enhance primary stability. We performed 21 implants in 18 cases of acetabular loosening (10 grade 2 and 8 grade 3 according to Paprosky) and three CDH: average age was 68 years old in 14 women and seven men. Mean follow-up was 21 months. We used bone grafts in 17 cases. In one case we cemented the McMinn cup because of poor initial stability with no complications at 18 months. We noted radiolucency lines < 2 mm in one case and bone resorption in two cases. Mean Harris Hip Score (HHS) was 60 preoperatively and 88 postoperatively. The complications were: malpositioning of the stem (1%), sacroiliac pain (4%), superficial infection (2%) and DVT (1%). The primary cementless stability is achieved by the aid of an iliac palpator checked by fluoroscopy: the palpator works as a guide for the iliac stem to avoid malpositiong or wrong inclination. In addition, the dedicated cup trials could also function as an impactor for chips bone grafts in the so-called “impaction grafting technique”. In conclusion, we confirm that the McMinn cup, despite a demanding surgical technique, represents a valid alternative to acetabular revision surgery because of the good initial stability and the respect of loading lines and it also allows the use of pressurised bone chips. Furthermore, the hip centre is restored in acetabular loosening and CDH

Purpose of the study: We reviewed 69 consecutive cases of total knee arthroplasty revisions to analyze the causes of failure. Material and methods: Sixty-nine total knee arthroplasty revisions were required between 1990 and 1997 for non-septic failure. Five categories of failures were identified: 30 loosenings including 11 with an initial malposition (varus position of the tibial component in 8 cases), 14 laxities (medial in 5, lateral in 5 and anteroposterior in 4), 11 stiff knees with no other clinical or radiological anomaly, 6 patellar failures (2 dislocations, 2 cases of excessive wear, 2 painful knees with a Freeman prosthesis), and 8 cases of painful knees with no other detectable anomaly. Results: A three-phase reconstruction procedure was used after removing the failing TKA:1) reconstruction of the tibia with replacement of lost bone, 2) reconstruction of the femur with balanced flexion determining the size of the implant, 3) balanced extension determining the distal/proximal position of the femoral component. A “simple” sliding prosthesis was used in 16 cases, a modular reconstruction prosthesis in 40 cases and a hinge prosthesis in 13 cases. Mean follow-up for functional and radiographic assessment after revision surgery was 37 months (59 cases) with a minimum follow-up of 1 year. The best outcome was observed in the “loosening”, “laxity”, and “stiffness” patients. Outcome was less favorable for the group “isolated pain” with IKS functional scores of 35.5 ± 16 and 52.5 ± 21. Discussion: In 36 p. 100 of cases, TKA failure was related to a technical mistake (component malposition, poor ligament alignment). In 33 p. 100, failure was patient related (multiple procedures, congenital hip dysplasia, rheumatoid arthritis...). Outcome after revision TKA was less favorable than after primary TKA, particularly in case of painful knees with no other detectable anomaly. Conclusion: Surgical revision of TKA must follow a rigorous procedure with a detailed preoperative work-up. The decision for revision must not be made unless a precise anomaly has been identified

Introduction and Objectives: This study reviews the results of osteoarticular ultrasound of the hip in infants using the Graf method between 1992 and 2002 for the diagnosis and treatment of congenital hip dysplasia (CHD) and congenital hip dislocation in the province of Santa Cruz de Tenerife, Canary Islands, Spain. The objective of this study is to evaluate the impact of early diagnosis and treatment of infant hip pathologies related to CHD using a non-invasive, reproducible, and relatively easy-to-use method of clinical evaluation. Materials and Methods: Between 1992 and 2002, 5,760 (18%) of a total 32,000 newborns in our province received an ultrasound examination using the Graf technique due to the presence of one or more risk factors. Graf methods and ultrasonographic criteria were used to conduct a systematic study with static ultrasonograms, dynamic studies, and/or stress studies of the hips. During the 10-year period, only 4 hips required surgical intervention after one year of age when orthopaedic treatment was not an option. This represents a significant reduction in the rate of surgery due to earlier treatment after ultrasonographic diagnosis. Results: Risk factors associated with the appearance of congenital hip deformities diagnosed by ultrasound in the infant population of Santa Cruz de Tenerife, in order of frequency, were as follows: female newborn, first pregnancy, first birth (36%), lax hip (30%), asymmetry (25%), positive Ortolani hip clunk (15%), family history (15%), reduced abduction (6%), associated osteoarticular pathology (5%), prematurity (3%), and others. Ultrasound made it possible to initiate early treatment and control. The wide pillow (including the Frejka abduction pillow) was used in 31.63% of cases, Pavlik harness in 10.87%, a DSS splint in one case, and the Kramer extension/repositioning technique requiring hospitalisation was used in 1.92% of cases. Average age to maturity of dysplastic hips (reaching type I) was 4 months. Discussion and Conclusions: There are no significant differences between the results obtained in our study and those reported in the literature of other populations on the use of ultrasonographic hip screening using the Graf technique

In congenital and acquired angular deformities of the coxofemoral joint, hip prosthesis presents considerable difficulties. The aim of this study is to analyse the different surgical solutions for this problem. In the geographical area of G. Pini Institute, where congenital hip dysplasia is endemic and where also historically the surgical outcome of various types of osteotomy (both acetabular and femoral) have been investigated, this problem has often been encountered. We have evaluated several parameters, also with respect to particular cases in which tailored prosthetic solutions were required, to establish which kind of prosthetic treatment is most reliable today. From 1994 to 2002 more than 6000 surgical hip prosthesis procedures were carried out at our institute: 750 in dysplastic hips and 112 after osteotomy. In our clinical division we also evaluate patientsin the pre-surgical phase with the DEXA, which gives qualitative and quantitative data about peri-prosthestc bone. After the first period of using standard, customised prostheses with no modular neck, we have progressively increased the use of a modular stem with press-fit cups that guarantee minimal bone sacrifice and a good recovery of articular biomechanics. In particular, with the use of modular components for the head and neck it is easy to reinstate the centre of rotation and achieve good offset and good lower limb length, without “escamotages” such as the use of a larger stem not perfectly inserted in the femoral diaphysis and the non-physiological cup position to avoid the risk of luxation. We have progressively abandoned the use of PE, which is the cause of debris and should be avoided in angular deformities: in patients under 65 years of age we use ceramic-on-ceramic bearing surfaces with monob-lock insert, whereas in patients over 65 we prefer to use metal-on-metal bearing surfaces (always monoblock). Deformities caused by the same pathological condition resulting in surgical osteotomy make implantation of standard prosthetic models impossible; our surgical experience suggests the use of different prosthetic models. The use of custom-made prostheses has progressively been reduced thanks to the development of suitable modular prostheses which suit these patients perfectly. In the past few years the use of cemented prostheses in these patients has decreased: according to our experience the use of cementless prostheses in relatively young subjects allows a good range of motion but above all it is useful to preserve bone in view of a possible future revision

Introduction: Cementless hydroxyapatite coated prosthesis are mainly selected for a relatively young and active patient population. Most clinical studies demonstrate excellent osseous integration of the HA coating and good outcome. The clinical follow-up reports of the ABG group suggest excellent results, however we observed an alarming rate of acetabular osteolysis and polyethylene wear which required revision surgery. Thus a comprehensive retrospective evaluation of all operated patients had been conducted. Patients and Methods: 162 ABG hips were replaced in 148 patients, of them 75 patients were studied and followed-up. Mean age was 56 (range 33–71). 48 patients were women and 27 were men. 8 patients had bilateral hip replacement. Etiology of hip disease varied and included primary osteoarthritis (27 patients – 36%), congenital hip dysplasia (24 patients – 32%), osteonecrosis (12 patients – 16%), ankylosing spondylitis (5 patients – 6.6%), post traumatic arthritis (5 patients – 6.6%) and post-infectious arthrosis (2 patients – 2.6%). Postoperative follow-up period averaged 4 years (range 15–80 months). Results: The mean postoperative Harris hip score was 89 (range 52–100). 23 patients (30%) reported of modified life activity after surgery, and the majority had resumed their previous occupations. Complications included 3 early and one late dislocations – one patient required an early cup revision, one patient suffered a fracture of the femur during stem insertion, and 3 patients (4%) had deep vein thrombosis. There was one case of a femoral vein injury and one resolving superficial infection. No deep infections were noted. 13 patients had undergone cup revision due to severe polyethylene wear and periacetabular osteolysis. Of them 5 were diagnosed during this retrospective study and 8 were referred for revision due to clinical symptoms. Thus the revision rate of the entire operated population is 13/162 = 8.0% and 13/75 = 17.3% of the studied patients. The true loosening rate should be between these 2 figures. In 2 patients the entire cups were removed and revised due to loosening. In 11 patients following the removal of the polyethylene inserts the metal back proved to be stable. In these cases the bone defects were filled-up with bone graft substitute, and a highly cross-linked polyethylene (22 mm head) were cemented into the metal shell. No stems needed revision. Conclusion: In spite of a relatively high Harris Hip Score and generally good long-term follow-up a high rate of acetbular lysis and polyethylene wear were observed. This observation warrants avoiding the use of the ABG cups until further investigation is performed. A continued clinical and radiographic analysis is required for the entire operated patients. In all cases of polyethylene wear or significant osteolysis revision is indicated