Aims. The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome. Methods. Overall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores. Results. Long-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%). Conclusion. Ulna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common. Cite this article: Bone Jt Open 2022;3(5):375–382

Twenty-Six total hip arthroplasties were performed in Crowe grade 3 or 4 hip dysplasia using subtrochanteric shortening osteotomy with 2-kinds of femoral stem(Primary monoblock and modular femoral stem). The average age was 46.2 years, and the average follow-up was 4.1 years. Acetabular reconstruction with structural autograft was used in 13 hips. Radiologically, hip centers were nearly normalized by vertical height of 10.6mm elevation and horizontal lengths of 1.7mm compared with uninvolved sites. Three of four osteotomy nonunions were managed with bone graft and other one wating for surgery. One acetabular revision was performed for migration. One postoperative dislocation was managed successfully with closed reduction and abduction brace. One patient (> 7cm) showed postoperative neurologic complications was noted. Harris hip score was improved from 35.6 to 81.7. A cementless modular distal fluted femoral stem is a useful device in these patients

Ulnar shortening osteotomy (USO) is a procedure performed to alleviate ulnar sided wrist pain caused by ulnar impaction syndrome (UIS) and/or triangular fibrocartilage complex (TFCC) injury. Presently, non-union rates for ulnar shortening osteotomy is quoted to be 0–18% in the literature. However, there is a dearth of literature on the effect of site of osteotomy and plate placement on the rate of complications like a delayed union, symptomatic hardware and need for second surgery for hardware removal. In this study, we performed a multi-centered institutional review of ulnar shortening osteotomies performed, focusing on plate placement (volar vs. dorsal) and osteotomy site (distal vs. proximal) and determining if it plays a role in reducing complications. This study was a multi-centered retrospective chart review. All radiographs and charts for patients that have received USO for UIS or TFCC injury between 2013 and 2017 from hand and wrist fellowship-trained surgeons in Calgary, Alberta and Winnipeg, Manitoba were examined. Basic patient demographics including age, sex, past medical history, and smoking history were recorded. Postoperative complications such as delayed union, non-union, infection, chronic regional pain syndrome, hardware irritation requiring removal were evaluated with a two-year follow-up period. Osteotomy sites were analyzed based on the location in relation to the entire length of the ulna on forearm radiographs. Surgical techniques including volar vs. dorsal plating, oblique vs. transverse osteotomy cuts, and plate type were documented. Continuous variables of interest were summarized as mean or medians with standard deviation or inter-quartile range as appropriate. Differences in baseline characteristics were determined by t-test or one-way ANOVA for continuous variables and chi-square or Fischer exact test for dichotomous variables. All analyses were conducted using SPSS V24.0 (Chicago, IL, USA). All statistical tests were considered significant if p < 0.05. Between 2013–2017 there were 117 ulnar shortening osteotomies performed. The average age of patients was 46.2 ± 16.2, with 62.4% being female. The mean pre-operative ulnar variance was +3.89 ± 2.17 mm and post-operative ulnar variance was −1.90 ± 1.80 mm. 84.6% of the plates were placed on the volar aspect of the ulna and 14.5% were placed on the dorsal aspect. An oblique osteotomy was made 99.1% of the time. In measuring osteotomy placement, the average placement was made in the distal 1/3 of the ulna. Overall, there was a 40% complication rate. Hardware irritation requiring removal encompassed 23%, non-union 14%, and wound infection covered 0.8%. When comparing dorsal vs volar plating, there was no statistically significant difference for non-union or hardware removal. Similarly, in evaluating osteotomy level, there was no statistical difference between proximal vs distal osteotomy for non-union and hardware removal. In this multi-centered retrospective review of ulnar shortening osteotomies, we found that there was an overall complication rate of 40%. There was no statistically significant difference in complication rates between dorsal vs volar plate placement or proximal vs distal osteotomy sites. Further studies examining other potential risk factors in lowering the complication rate would be beneficial

Introduction. Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods. We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results. The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion. The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure

Introduction. Limb Length discrepancy after total hip replacement has been reported to happen in 1–27% of cases with differences up to 70mm. Occasionally revision THR has been used to achieve limb length equalisation, especially when patients are symptomatic with hip/back pain, neurologic symptoms or instability. However, in presence of a well-functioning, pain free hip without hip symptoms, revision THR for shortening can lead to problems with decrease in offset or stability. An option in these cases would be a distal shortening osteotomy of femur. Materials and Methods. From 2005 to 2014 five shortening osteotomies were done for LLD with limb lengthening of ipsilateral side following THR. All patients had well-functioning THRs with and no complications as dislocations or nerve symptoms. A distal metaphyseal shortening osteotomy, fixed using a 95 degree blade plate, was chosen for better healing at this level and ease of surgery. Results. Cause of LLD – Patient 1 had ‘neck preserving’ Hip replacement and post-operative lengthening. Patient 2 had Bilateral DDH with B/L THR, but with sub-trochanteric shortening on one side and not the other. Patient 3 had Bilateral DDH treated with THR with high hip centre on one side and at site of native cup on the other. Further two patients had total hip replacements for DDH. The average lengthening was 28mm (25 – 32mm). No patients had neuro-vascular compromise. All achieved radiological and clinical union by 3 months. At one year all patients were weight bearing without pain or discomfort and had full range of movement at knee. One patient required removal of plate due to discomfort that resolved following plate removal. Conclusion. Our series of patients demonstrate that in cases with symptomatic limb lengthening in presence of an otherwise well-functioning THR, shortening osteotomy of distal metaphysis of femur is a viable option

Background: Patients with adolescent idiopathic scoliosis (AIS) exceeding fifty degrees or more at maturity are at risk for continuous progression. For curves in the thoracolumbar or lumbar region vertebral olisthesis, with severe low back pain with or without radicular pain, may result. Conventional techniques with anterior, posterior or combined approaches often fail to achieve a good alignment. The technique described by Bradford employing a shortening osteotomy at the apical segments can be used in very stiff curves with translations. Methods: Three women with AIS and successive curve deterioration were treated by means of shortening osteotomy at our institution. The mean age was 40 (48–35) years and the follow up was 26 (60–8) months. The resected vertebrae were L1 in two cases and L2 in one. The operations were staged, initially anterior discectomies were performed. A flap of the vertebral wall was then raised and a total resection of the vertebral body and the convex pedicle was undertaken. After protection of the dual sac with a Spongostan film, the harvested bone was impacted into the defect. One week later, the remnants of the vertebra were removed posteriorly following temporary stabilization. Correction was achieved by compression. Results: Two osteotomies united and the patients are pain free, in good balance and back at work. The other case had a temporary partial drop foot on one side, however radiographically is progressing well and she remains in rehabilitation. There have been no implant related complications. Conclusion: Shortening osteotomy appears to be a good technique when treating adult patients with late rigid, painful scoliotic deformities of the thoracolumbar region

Purpose: Total hip arthroplasty in high riding congenital dislocation of the hip is a challenging procedure. In order to position the cup in the true acetabulum, femoral shortening osteotomy is often needed. The purpose of our study was to evaluate the results of two different methods of femoral shortening osteotomy. Method: Thirty-one total hip arthroplasties were performed in 29 cases with high congenital hip dislocation. The acetabular cups were placed at true acetabulum and femoral shortening osteotomies of the femur were performed at proximal (14 hips, group 1) or distal femur (17 hips, group 2). After a mean follow up of 4.2 years, all 31 hips were evaluated with Harris Hip Scores and X-rays. Technical difficulties and complications were also reported. Results: The mean increase in Harris Hip Score was 51 in group one and 52 in group two. There was one peroneal nerve palsy and one early dislocation in group 1, while there was no such perioperative complications in group 2. One acetabular cup and femoral stem were revised in group 1. Non-union happened in two cases of group 2. Special shape (cylindrical, non-tapered and longer than standard) femoral stems were needed for most proximal osteotomy patients. Conclusion: Hip arthroplasty, with insertion of cup at true acetabulum and femoral shortening osteotomy in patients with high congenital dislocation, can produce good results. Either proximal or distal femoral shortening osteotomy could have advantages and disadvantages. Proximal shortening osteotomy is a more challenging procedure, may need special stem design, and could compromise stem fixation

Introduction: Ulnocarpale Impaction Syndrom is defined as a degenerative disease on the basis of a relative mis-proportion in lenghth ratio between ulnar and radius, caused either by posttraumatic degeneration or idiopathic history. This causes an unusual high load bearing in the ulnar carpale joint as well as in the distal radio – ulnar joint. All these factors lead to a degeneration of the triangular discus, secondary lunotriqutral instability and chondromalazia of ulna, lunate bone and the triquetral bone. Ulnocarpale Impaction Syndrom is diagnosed by clinical evaluation as well as typical radiologic findings. If non operative treatment leads to unsatisfactory results few operative options can be considered. Ulnar shortening osteotomy is one of them. Material and Methods: From 2003 until 2006, 10 Patients were treated. 3 female patients and 7 male patients, with an average age of 46 years and/or 42,7 years were operated on. We evaluated forearm rotation, power, DASH Score, Numeral Analogue scale and radiologic findings considering ulnar lenghth and bone consolidation. Results: Painfree forearm rotation increased significantly postoperatively. An increase in power was seen as well as a reduction of the DASH score of 51,6 points. Also the numeral analogue scale showed a reduction of 5 points. Postoperatively the ratio of ulnar to radial lenghth was nearly equal (average of ulnar -1mm) and all osteotomies showed normal bony healing. Conclussion: Surgical therapy of painful ulnar impaction syndrom using ulnar shortening osteotomy seems to be a very feasible and practical procedure. In comparison to resection arthroplasty and the wafer procedure, ulnar shortening osteotomy shows no significant increase of pressure in the sigmoid fossa. Therefor it is the treatment of joice in our departement

Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis. In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient. The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up. In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising

Background: We report on the surgical treatment of a case spinal neuroarthropathy, where surgical fusion of the pathological level was achieved by a shortening osteotomy and apposition of the adjacent vertebral bodies. Neuropathic (Charcot) arthropathy of the spine is relatively an uncommon problem. Spinal neuroarthropathy has been described to occur after traumatic paralysis as well as other causes of neuropathic arthropathy. Surgery has been recommended for the treatment of painful or unstable neuropathic joints of the spine. From the few cases that have been reported in the literature, surgical management included extensive debridement, bridging of the defect with autogenous graft as well as instrumentation to achieve an anterior and posterior fusion. To the knowledge of the authors, the technique of spine shortening and vertebral apposition was reported only once in the literature, however the patient had to be kept recumbent in a cast for six months. (. 1. ). Methods: Literature review and a case of spinal neuroarthropathy successfully treated by a shortening osteotomy and instrumented arthrodesis is presented. Results: Patient was allowed to mobilize in his wheelchair by the second week post operation with a support of a TLSO, which was used for five months. Roentgenograms and CT scan done at thirteen months showed good position of the spine and evidence of solid bone arthrodesis. This matched marked clinical improvement in the preoperative symptoms. Conclusion: Treatment of a Charcot affection of the spine should be directed toward vertebral stabilization to eliminate the pathological effects and complications secondary to instability. Sound arthrodesis in our case could be achieved with resection of the affected level(s), shortening of the spine and good apposition of fresh bleeding bone surfaces. Careful attention to the demanding surgical technique is required. Yet, any fusion procedure poses additional stresses to the adjacent levels. So long term monitoring of the rehabilitation is mandatory to detect the possibility of developing secondary levels of Charcot joints below a previously successful fusion

Background: the purpose of this paper is to evaluate the functional and clinical results of the developmental high dislocated hips after subtrochanteric transverse shortening osteotomy fixed axially and rotationally by cementless femoral stem and the asetabular component placed into the anatomical place. Methods: in a retrospective study, we evaluated the results and complications of twenty-four consecutive primary cementless total hip arthroplasty in eighteen patients (sixteen female and two male) all of whom had Crowe IV (Hartofilakidis type III) high dislocations. The arthroplasty was performed in combination with a subtrochanteric transverse shortening osteotomy and Zweymüller femoral stem(SL plus) without any fixation instruments for the osteotomy site and with placement of the acetabular component at the level of anatomic hip center. All of the patients were evaluated at a mean of 4 years postoperatively. Results: the mean Harris Hip score increased from 17.25 points preoperatively to 84.87 points at the time of final follow up (p< 0.01). Seven of the twenty four hips had an early or late complications and/or reoperations. None of the subtrochanteric osteotomies were followed by non-union and no other complications concerning the femoral site is seen. There was one instance of isolated loosening of asetabuler component. Two hips dislocated postoperatively which were treated by closed reduction and bracing for 12 weeks. One siatic neurapraxic injury was identified which resolved within 6 months’ time. Intraoperative femoral cracks were seen in three hips. One of them on the proximal part (trochanteric site) and the other two on the distal femur. All were fixed by cerclage and cables without any further pain and complications. Conclusions: subtrochanteric shortening osteotomy and cementless total hip arthoplasty for the treatment of developmental dysplasia and dislocations of the hip were associated with high rates of successful fixation of the femoral component and the asetabulum. The osteotomy site has a healing potential within the eight weeks’ time without any complications. The mean Harris hip score was 84.87 points. The complication rate is higher than that associated with primary total hip arthroplasty for the degenerative arthritis

Introduction Total hip arthroplasty in patients affected by major dysplasia poses great surgical difficulties due to insufficient primary acetabulum, small femoral canal, excessive anteversion of the femoral neck, traction on the neurovascular structures, muscular imbalance that is difficult to restore, and marked epiphyseal rising. In this study we present our experience in lowering and arthroplasty in major hip dysplasia, obtained by shortening osteotomy achieved in a single stage, using techniques designed to diminish possible risks. Materials and methods From 1989 to 2000 we treated 20 patients (27 operations, 7 bilateral) at our institute who were affected by the sequela (lowering of the prosthesis) of Eftekhar Grade-C (11 cases) or Grade-D (16 cases) congenital luxation of the hip. Mean follow-up was 63 months. Clinical results were assessed before and after surgery according to the Merle D’Aubigné method. We also evaluated the presence and degree of Trendelenburg position and the possible use of shoe lifts. The radiographic results of the hip prosthesis were assessed by the Gruen and Dee Lee methods for the stem and cup respectively. Results The mean preoperative clinical score according to the Merle D’Aubigné classification was 3 ± 1 for pain, 3 ± 1 for walking, and 4 ± 2 for movement. The preoperative Trendelemburg position was very marked in all patients. In 18 cases out of 27 a shoe lift was used with a mean height of 60 mm ± 10. We performed a “Z” osteotomy in 14 cases and an oblique osteotomy in 13 cases. The postoperative mean clinical score was 6 ± 1 for pain, 6 ± 1 for walking, and 5 ± 1 for movement. Postoperative Trendelemburg position was present in 19 cases, and 9 cases out of 27 still used a shoe lift with a mean height of 30 mm ± 10. Movement of the cup and stem was observed at 84 months and 112 months’ follow-up respectively, which required revision surgery. Conclusions The choice between oblique and Z osteotomy depends on two parameters: the surgeon’s experience and the extent of femoral resection. Z osteotomy may be more difficult to perform technically, but it enables better adaptation of the prosthesis to the femoral segments for resections over 35 mm. No significant differences in time to unite were observed between oblique and Z osteotomies

Background. Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Patients and Methods. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups. Results. The preoperative flexion of patients without iliofemoral osteoarthritis was significantly higher than for patients with iliofemoral osteoarthritis. All hips without iliofemoral OA had higher motion. The preoperative flexion in the higher motion group both with and without iliofemoral OA was significantly greater than in the lower group with iliofemoral OA (Figure 1). Leg length change in patients without iliofemoral osteoarthritis was significantly greater than with iliofemoral osteoarthritis (Figure 2), and the higher hip motion group had greater leg length change in THA than the lower motion group. No clinical evidence of postoperative neurologic injury was observed in patients with iliofemoral OA. Postoperative transient calf numbness in the distribution of the sciatic nerve was observed in 2 of 25 hips without iliofemoral OA (8.0%), however, no sensory and motor nerve deficit was observed. Discussion. The authors hypothesized that preoperative hip motion could affect soft tissue contractures, and our findings suggest that the soft tissues surrounding the hip joint with iliofemoral OA should be more contracted than the hip without OA. We also found leg length change in the higher motion group was greater than in the lower motion group. Previous studies reported limb lengthening in excess of 4 cm could increase the risk of nerve palsy. Transient calf numbness in the distribution of the sciatic nerve was observed in 2 hips without iliofemoral OA and their leg length change was not greater than 4 cm. Our findings suggest that hips without iliofemoral OA should be paid attention to protect the nerves from excessive elongation. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia

Aim. To assess the survivorship of a tapered fluted Titanium monoblock stem in conjunction with subtrochanteric shortening for patients with High Dislocation performed at 2 centres. Methods. This was a retrospective study of 84 hips in 52 patients between two centres. All patients had a high dislocation. Thirty five patients had bilateral dysplasia. All patients had total hip arthroplasty with a subtrochanteric shortening osteotomy. The acetabular component was placed at the level of the anatomic hip centre. The femoral component was the “Wagner Cone prosthesis” which is a monoblock Titnium Alloy stem, tapered and fluted. The acetabular component varied. All patients had a follow up examination with a Harris Hip Score and a plain radiograph. The radiographs were assessed for osteotomy complications, change in stem position, evidence of loosening, heterotopic ossification & stress shielding if any. Notes were reviewed for complications. Results. The mean age at operation was 55 yrs (range 20–83). The mean follow up was 9 years (range3–20). Eight patients were lost to follow up (16%). All the rest of the femoral components survived that were available for follow up −84% (worst case scenario). Six patients (7.8%) had an early complication that needed a reoperation. The Mean Harris Hip Score (HHS) improved from 42 points to 88 points. Conclusion. The success rate of patients undergoing Cementless Arthroplasty using the Wagner cone stem in conjunction with a subtrochanteric shortening osteotomy is very high. The complication rate is however larger than in the normal population

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy. We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management. She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved. This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray

Background. There are many difficulties during performing total hip replacement in high riding DDH. These difficulties include:. In Acetabular part: bony defect in antero lateral acetabular wall/finding true centre of rotation/shallowness of true acetabulum/hypertrophied and thick capsular obstacle between true and false acetabulum. In Femoral part: small diameter femoral shaft/excessive ante version/posterior placement of greater trochanter. anatomic changes in soft tissue & neurovascular around the hip including: adductor muscle contracture/shortening of abductor muscles/risk of sciatic nerve injury following lengthening of the limb after reduction in true acetabulum/vascular injury. The purpose of this lecture is how to manage above problems with using reinforcement ring (ARR) for reconstruction of true acetabulum and step cut L fashion proximal femoral neck shortening osteotomy in a single stage operation. Method. 23 surgeries in 19 patients, including 18 female and one male were performed by me from Jan. 1997 till Dec. 2009. Six patients had bilateral hip dislocation, but till now only four of them had bilateral stepped operation. Left hip was involved in 15 cases (65.2%). The average age was 40 years old. All hips were high riding DDH according to both hartofillokides and crowe classification. Reconstruction of true acetabulum was performed with aid of reinforcement ring and bone graft from femoral head in all cases. Trochantric osteotomy was done in all, followed by fixation with wire in 22 cases which needed two revisions due to symptomatic non union (9%). Hooked plate was use in one case for trochantric fixation. Due to high riding femur, it was necessary to performed femoral shortening in neck area as a step cut L fashion. In two patient, one with bilateral involvement, after excessive limb lengthening following trial reduction, it was necessary to performed concomitant supracondylar femoral shortening. (3 cases = 13%). 22 mm cup & miniature muller DDH stem were used in 18 cases (78.26%). In 5 cases, one bilaterally, non cemented stem and 28 mm cemented cup in ring were used. Primary adductor tenotomy was performed in 9 cases. Secondary adductor tenotomy needed in 2 cases (totally = 47.82%). Repair of iatrogenic femoral artery tear after traction injury with retractor, occurred in 2 cases (8.69%). All patients evaluate retrospectively. Average follow up month is 68.7. Results. One case of left acetabular component revision due to painful bony absorption in infero medial part of ring with poor inclination wad done, after 2 years of primary operation. Know after 13 years she has had early signs of stem loosening in the same side. Another acetabular component revision following traumatic dislodgment of cup and cement from ring was performed after 13 months from primary operation. Again she had poor implant inclination. So revision rate is 8.69%. (One case will need revision in near future, so the revision rate will increase to 13%) Radiological wires breakage which were used for greater trochanteric fixation, could be seen in 11 cases (47.82%), but only two of them with functional impairment needed to re-fixation with Menen plate(18.18% of trochanteric non union). Average limb lengthening after operation is 4.3 Cm (2-7 Cm). Only one case of transient Sciatic nerve paresis had happened for 2 months followed by complete recovery. Two case of secondary adductor tenotomy wre done, one after traumatic dislocation of prosthesis with pubic fracture, and the other one after restriction of hip abduction. The average Harris hip score from 23 pre -operatively has been increase to 85.38. (The pre op. scores were 12.625 – 40.775/The post op. scores were 64.92 – 96). No post operative infection was seen. Discussion. This is a midterm follow up survey, but 7 cases have more than 9 years follow up with only one stem loosening (11% long term loosening rate). It is a challenging procedure for performing joint replacement in high riding DDH, if so using reinforcement ring with graft for true acetabulum reconstruction and getting primary proximal femoral shortening in a step cut L fashion around the lesser trochanteric region would be a worthy procedure. In high riding DDH due to hypoplasia of lesser trochanter, there is not a significant difference in bone resistance and it is possible to get shortening in this area without fearing of deco promising bony stability. The average shortening is 3 Cm. In specific cases with more severe contracture for preventing neuro-vascular complication, concomitant shortening osteotomy in supracondylar area is recommended. Although greater trochanter fibrous union has produced less functional impairment, but a better technique should be considered. Distal and lateral advancement of osteotomised greater trochanter lead to better abductor muscle performance and less limp. Adductor tenotmy has a great importance in contracted soft tissue, so in any case with abduction limitation it should be performed

Introduction. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur. Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required. Purpose of the study is to verify surgical procedures and explore reconstruction options on severe hip dysplasia. Materials and methods. In last 25 years, 2308 arthroplasties were performed in dysplastic hips (565 cases had a previous femoral osteotomy). In 128 cases was required a correction of femoral side deformity: in 64 cases was performed a greater trochanter osteotomy (in 12 of these a proximal femoral shortening was associated), 55 cases were treated by a shortening subtrochanteric osteotomy (that allows corrections in any plane) and in 9 cases was performed a distal femur osteotomy. Discussion. Long-term results in these patients are steadily inferior to those obtained in general population (70% survival rate at 15 years). On femoral side early failures reflect learning curve and are due to insufficient fixation of osteotomies. Despite this, the more promising outcomes are concerning shortening sub-trochanteric osteotomy with uncemented stem but only early and mid-term data are available

Treating Crowe type 3 or 4 of hips tends to be technically difficult when performing total hip arthroplasty (THA) due to the severely dysplastic acetabulum and proximal femur in addition to a high dislocation of the hip. Since the socket is limited to being placed at the original hip center, a femoral shortening osteotomy is often required in order to prevent neurovascular problems. This osteotomy will need the stability of the femoral stem with both the proximal and the distal femoral bones. We used the modular S-ROM stem, which has a valuable proximal structure and a distal flute structure to stabilize the stem with the proximal and distal femoral fragments. The purpose of this study was to report the clinical and radiographic results of the primary THA with a shortening osteotomy while also using the S-ROM prosthesis. Between 1994 and 2004, primary THA using the S-ROM prosthesis was performed on 7 hips in 6 cases (1 male, 5 females). Crowe type 3 or 4 was observed in one and 6 hips, respectively. The mean age at operation was 56 years old (range 51~60). The mean follow-up period was 41 months (range 24~56 months). Four hips had previously undergone a subtrochanteric valgus osteotomy. All hips underwent a step-cut femoral osteotomy at the proximal metaphysis for the shortening and/or correction of angulations with on-lay chip bone grafts. All of the used stems were straight type. The clinical outcome was evaluated using the clinical scoring system of hip joints established by the Japanese Orthopaedic Association (JOA). According to a 100 point scale, pain was determined to be 40, ROM was 20, gait was 20 and ADL was 20. No hips had undergone any revision surgery as of the most recent follow-up. Union was achieved at the osteotomy site in all hips. Neither osteolysis nor a loosening of the implant was radiographically observed. The mean JOA score before THA and at the last follow-up was 41 (31–48) and 81 (62–91) points, respectively. The mean postoperative days to start full weight bearing was 53 days (range 49~70). In two cases (28%), a procedure using circular wiring was performed to treat a crack in the proximal femur. The S-ROM prosthesis was thus found to be useful for primary THA with a shortening metaphyseal femoral osteotomy for hips in patients with Crowe type 3 or 4 developmental dysplasia

Introduction

Second ray problems are common, especially chronic MTP joint dislocation, and intractable metatarsalgia caused by a relatively long second ray we describe a new extra-articular technique that allows considerable shortening

Introduction: Angular and torsional deviations of femur are usually combined with Congenital Dislocation of the Hip (CDH) and increase the complications of hip arthroplasty. The aim of this study is to evaluate surgical and reconstructive options for the treatment of CDH. Material and Methods: In this retrospective study, we evaluated the results and complications of 55 primary cementless total hip arthroplasties, all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 8,1 years postoperatively. Results: From 1984, more than 2000 cases of arthroplasty have been performed in dysplastic hip, 565 cases had a previous femoral osteotomy; 128 cases needed correction of femoral side deformity; 64 had a greater trochanteric osteotomy. In 9 cases rotational abnormality and shortening were controlled with plate and distal femur osteotomy. 55 cases were treated by a shortening subtrochanteric osteotomy. Only non-cemented stems were used. 4 failures occurred for the incorrect fixation of the metaphysis. The fixation can be obtained only by prosthetic press-fit, but it is preferable to use metal wires. There was no sciatic injury; indeed shortening osteotomy provides an easy control of deformity and lengthening, with a maximum of 4 cm. One case was reviewed for heterotopic calcification (grade 4). One infection of the soft tissue was medically cured. There were two revisions for polyethylene failure at 8 and 12 years postoperative. Discussion: The anatomic abnormalities associated with CDH and previous femoral osteotomy increase the complexity of hip arthroplasty. We had best results with the femoral shortening subtrochanteric osteotomy where a rapid consolidation was obtained. Moreover, the functional result was better for the management of the insertion of the muscle tendons in particular the mediogluteus and also for the relatively correct positioning in favour of the reciprocal relationship of the pelvic-trochanter. The detachment of the greater trochanter associated with a metaphyseal proximal shortening, remains an effective technique for the treatment of malformations that are difficult to treat, but there is a high risk of pseudarthrosis of greater trochanter. Conclusion: Femoral shortening subtrochanteric osteotomy preserves the proximal femoral anatomy, avoids the problems associated with reattachment of the greater trochanter, and facilitating a cementless femoral reconstruction in relatively young patients