Introduction: This study evaluated the clinical and radiological outcomes of Chiari osteotomy for severe coxa irregularis and subluxation of the femoral head.

Materials and Methods: The study group included patients with late Legg-Calvé-Perthes disease (6 patients), posttraumatic avascular necrosis (1 patient), and multiple epiphyseal dysplasia (1 patient). The mean age at surgery was 11.4 years (range, 6.8 to 14.7). The clinical parameters evaluated included changes in pain, limp, and range of motion of the hip. Radiographic measurements were made to determine the width of the medial and superior joint spaces, acetabular coverage, lateral epiphyseal extrusion, and the Stulberg classification.

Results: At a mean follow-up of 5 years (range, 1.1 to 11.0 years), pain disappeared completely in 5 patients or markedly decreased, enough to complete normal daily physical activities, in the remaining 3 patients. Limping gait disappeared completely in 2 patients, but the remaining 6 patients had minimal limps. All the components of the range of hip motion increased significantly. Acetabular coverage averaged 55% (range, 33 to 87%) before operation and 88% (range, 79 to 97%) at the final follow-up. Lateral epiphyseal extrusion was 49% (range, 39 to 83%) before operation, and 18% (range, 8 to 40%) at the final follow-up. Joint spaces were not changed significantly after surgery.

Discussion: In conclusion, Chiari osteotomy has its own indications, as a salvage procedure, for older children and adolescents with subluxated, severe coxa irregularis. The current study confirms the efficacy of the operation in terms of the functional and radiological improvements.

Introduction: The authors introduce a modified technique of iliac splitting and expanding shelf (ISES) arthroplasty for severe LCPD, and report on the intermediate outcomes.

Materials and Methods: This new procedure is a modification of the previously reported tectoplasty of Saito (1986) and the shelf arthroplasty of Catterall (1992). Only the sartorius muscle and the indirect head of the rectus femoris muscle are detached, leaving the abductors intact. A superiorly hinged bony flap was raised from the lateral iliac wall just above the hip joint capsule. A corticocancellous bone plate was harvested from the inner table of the iliac wing, and was placed between the lateral hip joint capsule and the bony flap. The triangular space between the split iliac wall and the bone plate was packed with autogenous cancellous bone chips and Osteoset® (Wright-Medical, Arlington, Tennessee, USA). The repaired indirect head of the rectus femoris muscle gave stability to the shelf. After 4 weeks in a Petrie cast, the hip was mobilized, and partial weight bearing was started postoperative at 6 weeks. Twenty one hips in 21 children older than 8 years presenting with early (18 hips) and late (reossification) (3 hips) LCPD were treated by ISES arthroplasty. All patients were followed up for more than 2 years (range, 2 to 8.5 years).

Results: There were significant functional and radiological improvements after operation. One patient needed a secondary varus osteotomy to solve persistent subluxation. The poorest result occurred in a very obese child, presenting with early stage of Catterall IV involvement at age 11.5 years.

Discussion: Our modified technique of the shelf arthroplasty, sparing the abductor mechanism, appears to be a reliable and effective method to augment the superolateral coverage of the femoral head in severe LCPD.

Introduction: In severe Legg-Calve-Perthes (LCPD) disease with subluxated femoral head, the acetabulum sometimes takes a bicompartmental appearance. This study analyzed acetabular pathoanatomy using a 3-D CT program.

Materials and Methods: A 3-D CT software program that affords the section of 2-D image in any plane was used to analyze the acetabular pathoanatomy, with specific reference to the morphology of the inner surface of the acetabulum. Thirteen children with the bicompartmental acetabulae (12 LCPD and 1 AVN subsequent to septic hip arthritis) were evaluated.

Results: The anterior half of the acetabulum was concentric. The contour of the acetabular margin in the posterior half of the acetabulum consisted of two different arcs – an arc of the iliac acetabulum (superior) and the other arc of the acetabular fossa of the ischium (medial). The junction of these two arcs was located at the triradiate cartilage, which was increased in mediolateral thickness at this point. The osteochondral articular margin of the ischium posterior to the non-articular acetabular fossa was thickened forming a ridge. The mediolateral thickness of the non-articular acetabular fossa was thinner than that of the normal contralateral side. The combination of these focal morphologic changes of the acetabular fossa rendered the bicompartmental appearance on plain AP radiograph of the pelvis.

Discussion: The authors conclude that bicompartmentalization of the acetabulum apparently reflects the altered biomechanics of the hip joint due to the subluxated femoral head. The abnormal osteocartilaginous hypertrophy appears to be caused by synovial irritation and an eccentric molding effect of the subluxated femoral head.

The purpose of this study was to investigate the efficacy of oral alendronate for the older children with osteogenesis imperfecta. Eight boys and 6 girls with average age of 9.7 years were given oral alendronate, 10mg everyday for those > 35kg, 10mg every other day for those 20 – 35 kg, and 10mg every three days for those < 20 kg. Treatment period averaged 3.3 years (range, 2.1 to 3.6). The number of fractures decreased by 39% in the lower extremity, although not statistically significant. Ten patients or their parents reported improved well-being during the treatment period. Z score for bone mineral density improved from −3.75 to −1.18 in the lumbar spine, and from −3.84 to −2.74 in the femur neck. Restoration of the collapsed vertebral bodies was observed, and the metaphyseal bands appeared on the simple radiographs. Urinary excretion of calcium and N-telopeptide of type I collagen were decreased by 64% and 47%, respectively. Abdominal discomfort was reported in five patients, one of which needed temporary switch to intravenous protocol. Iliac crest biopsy including the physis showed expanded primary spongiosa area with numeric multi-nucleated cells, which had heterogenous immunoreactivity for osteoclast markers.

This study revealed beneficial effects of oral alendronate in osteogenesis imperfecta patients, supported by radiological, biochemical and histological findings. We believe that oral alendronate is a more convenient method of bisphosphonate treatment for osteogenesis imperfecta, especially in older children.

We evaluated growth and remodeling of the 21 hips after valgus osteotomy with rotational and sagittal components for hinge abduction in 21 patients (mean, 9.7 years) with Legg-Calvé-Perthes disease (LCPD) both clinically and radiologically. The type of osteotomy was determined by assessing the hinge movement three-dimensionally using preoperative gait assessment, 2-dimensional/3-dimensional computed tomography (2D/3D-CT), and intraoperative dynamic arthrography. The Iowa hip score averaged 66 (34 to 76) before operation and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiographic measurements revealed favorable remodeling of the femoral head and improved hip joint mechanics. Valgus osteotomy with rotational and sagittal components results in sustained improvement in symptoms and functions and beneficially influences remodeling of the hip.

Preoperative gait assessment, 2D/3D-CT, and intra-operative dynamic arthrography are helpful for assessing the spatial features of the femoral capital hump and for determining the optimal congruent position of the hip.