We assessed the management of 11 neglected developmental dislocated hips in terms of shape of the acetabulum and femoral head pre-operatively and the level of the position of the reduction immediately post-operatively. We compared it with medium term clinical and radiological results.

The shape of the acetabulum and the femoral head can be determined in two planes doing CT or MR of the pelvis. The studies were done to determine the development of the acetabulum and the anatomical fit of the femoral head in the acetabulum. Radius of curvature in the axial and coronal planes was determined of the acetabulum and the femoral head. MR spin echo specification for visualization of the cartilage bone was used. Post-operative radiological namely CT when still in spika, and Shenton’s line and central location of the hip in the direction of the triradiate were subsequently assessed.

Radius of curvature was determined in 6 cases. It varied according to age, but for the older patients the acetabulum was 5mm smaller on average on the coronal views. Eight hips were treated with open reduction. Postoperatively one hip gradually subluxed and dislocated eventually. The hips that remained reduced were initially inferiorly located with an irregular Shenton’s line. Three were treated conservatively with pelvic support osteotomies and planned bone lengthening procedures.

Shape of the femoral head and acetabulum is the most important determining factor in open reduction of neglected DDH. Axial plane MR radius of curvature is not necessarily a true reflection of the shape of the acetabulum. MR coronal views with cartilage enhancement are necessary in assessing the shape of the acetabulum. The inferior position of the reduced hip can be ascribed to the conical shape of the acetabulum and is associated with a maintained reduction.

In an effort to determine if severe degrees of SCFE can be successfully treated with in situ pinning an anatomical study was undertaken to determine the relationship between severity of SCFE, the level of the metaphysis in relation to epiphysis on AP x-ray of the hip, the position of entry on the femoral neck and impaction/inclusion.

A dry bone specimen of a young adult without bony pathology was used to create a severe SCFE of varying degrees between 30 and 90 degrees. Standard x-rays AP pelvis and frog lateral were taken to determine the degree of SCFE. A titanium pin marker was inserted in the femoral neck to be centrally directed and placed in the femoral head for each degree of SCFE studied. The position of the pin was inspected as well as assessed with x-rays and CT. Computer model was then used to determine values for younger patients as well as the role that screw diameter will play.

Twelve degrees of SCFE were studied namely from 30 to 90 degrees. Varus and external rotation were simulated as well according to the tables of Rab. The results show that severe SCFE of more than 60 degrees pinning in situ as a method of management is associated with risk. SCFE of 70 degrees is pinned midway up the femoral neck. The screw penetrates the posterior neck and in younger children will penetrate in lesser degrees. Impaction is present in mild degrees of SCFE and demonstrated to contribute to failure of fixation.

The study illustrates that severe SCFE is difficult to pin in situ, associated with inclusion and impaction that will result in coxarthrosis and biomechanically not secure. If the level of the femoral neck metaphysis is proximal or at the same level as the epiphysis, the SCFE is of such a degree that the neck may be reconstructed given the limits of subtrochanteric and intertrochanteric osteotomies.

Statistics of the clinical activities of an academic training unit was compiled from 1 January 2005 until 31 December 2005. The statistical study had three purposes. Firstly to determine the pathological profile of the patient population and to determine the distribution of patients who needed acute management versus elective surgery. Secondly to determine the needed staff establishment especially with the future anticipated expanding role of the public health sector in the management of orthopaedic patients. The last aim was to create a model of the clinical activities of a junior orthopaedic surgeon during one year of orthopaedic trauma training.

Detailed statistics were compiled of all the clinical activities at the two hospitals. The one is a tertiary trauma centre, but also functions at a secondary trauma care level. The second hospital is a referral tertiary care orthopaedic hospital where elective surgery takes place. Furthermore the statistics were also compiled in such a way that detailed doctor activities could be processed from it.

There were 181 spinal admissions of which 77 were treated surgically. 106 were treated conservatively. Elective spinal surgery consisted of 20 cases who needed reconstructive surgery and we managed 56 spinal infections. 1263 cases were admitted for orthopaedic trauma management of which 259 had surgery for femur fractures. A total of 250 tibia fractures were treated surgically and a total of 216 radius and ulna fractures. 117 arthroscopic knee procedures were done. A total of 168 arthroplasty cases were treated of which 47 were problem cases.

Pathological profile was determined and gave guidance to clinical studies that should be undertaken. The numbers of some types of injuries that were managed are large. Staff establishment assessment can be done and the expansion of it can be motivated for. A model can be compiled for clinical activities of orthopaedic surgeons in training. Extracted from this statistical analysis an activity list was compiled for an orthopaedic surgeon in training. Amongst other minor cases and excluding Paediatric orthopaedic cases – Femur neck fractures 18, Femur fractures 29, Ankle fractures 53, Humerus fractures 12 and adult Supracondylar humerus fractures 9 and Radius Ulna fractures 34 were done.

A prospective study was done on 6 adolescent patients with severe unilateral chronic SCFE who underwent femoral neck cuneiform osteotomies with an antero lateral Ganz approach and subsequent anterior hip dislocation.

Patients with chronic SCFE, open growth plates and Southwick diaphyseal epiphyseal angle of more than 60 degrees were selected. In situ pinning was not possible in these cases due to the severity of the disease and keeping in consideration the concepts of impaction and inclusion as described by Rab. The surgical approach as described by Ganz for impingement syndromes in adults was used. A lateral approach with the patients lying on the side was followed by trochanteric osteotomy, anterior capsulotomy and anterior dislocation of the hip. Metaphyseal cuneiform osteotomies were done on all of the hips. Clinical and radiological assessment was done by the Southwick classification. Additional radiological assessment consisted of the evaluation of correction of anatomy on an AP pelvis. The hips were furthermore assessed for AVN by using bone scans.

This is a short term follow-up. Of the 6 patients 5 did excellently according to the Southwick result score. One patient had only a fair result due to the damage caused by the impingement prior to the corrective osteotomy. None developed AVN.

The management of severe chronic SCFE remains controversial. A single method of management namely pinning in situ can not be used in all degrees of SCFE. Intertrochanteric osteotomies and subtrochanteric osteotomies distort anatomy. It can not be performed for deformities of more than 50 and 70 degrees. Dislocation of the femoral head fascilitates femoral neck osteotomies and can be used safely without the complication of AVN if the Ganz surgical exposure is used.