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In the first few months of life, a notch may be seen on radiographs of the superolateral margin of the infant hip. It may be associated with a steeply inclined acetabular roof and may be an indicator of persistent neonatal instability or displacement of the femoral head.
After late reduction of the hip in children with developmental dysplasia the acetabular contour slowly improves and it is difficult to know if and when acetabular reconstruction is required. We studied the radiographs of 19 patients with unilateral dislocated or subluxated hips which had been reduced between the ages of one and two years. Preoperatively, all the affected hips showed acetabular dysplasia. After reduction they steadily improved for three years by which time none was dysplastic as measured by the acetabular index. After the age of ten years, when assessed by the more sensitive centre-edge angle, two were found to be dysplastic. It was not possible to predict these from early radiographs. We conclude that the decision to reconstruct an acetabulum should not be taken until three years after reduction, and that a few hips which appear to be developing satisfactorily at that time will, nevertheless, become dysplastic.
We measured the range of rotation in both hips of 397 normal children and in the unaffected hip of 135 children with unilateral congenital dislocation of the hip. Both groups were assessed for generalised joint laxity. Joint laxity was more common in normal children with an internally centred arc of hip rotation than in normal children with a neutral or an externally rotated arc. The children with congenitally dislocated hips had significantly more joint laxity than did the control group and significantly more of them had an internally centred arc of hip rotation. We suggest that the lax joint capsule fails to mould away the neonatal anteversion of the femoral neck during the first few months of life.
Hip dysplasia complicating the hereditary motor and sensory neuropathies is not widely recognised. We describe four patients in whom the neuropathy affected the proximal muscles and we suggest that hereditary motor and sensory neuropathies may be responsible for the failure of the initial treatment of some neonatal dislocated hips.
We studied the ossific nuclei on radiographs of the feet of three stillborn infants, two with club feet, relating the size, position and alignment of each nucleus to the cartilaginous talus or calcaneum in which it lay. Anteroposterior projections of the nucleus of the talus show deformity of that bone as well as subtalar malalignment. Lateral projections of the calcaneal nucleus may underestimate the degree of hindfoot equinus.
We treated 63 club feet in 44 patients by a defined programme of strapping from birth followed by one of two operations performed at six weeks, either a simple calcaneal tendon lengthening or a subtalar realignment, and reviewed them prospectively. The decision as to which operation to perform was taken at four weeks after radiographic measurement of the talocalcaneal angle. All but eight patients (ten feet) were followed for a mean of 8.7 years. The overall results after calcaneal tendon lengthening were satisfactory. The re-operation rate after subtalar realignment was high (39%) due to over or undercorrection of the deformity.
One-hundred newborn children at high risk of hip instability were prospectively assessed clinically and by ultrasound. The decision to treat was based only on the clinical examination. At the age of three months all the children were evaluated clinically and with an anteroposterior radiograph of the pelvis. None of the standard ultrasound measurements of acetabular depth and femoral head cover correlated with the outcome at three months. Dynamic assessment of stability was the only ultrasound technique that had a significant relation with outcome.
We reviewed the cases of 38 children with 45 congenitally dislocated hips who presented for primary treatment after the age of three years. Of these, 34 hips were managed by the 'direct approach' of Somerville and Scott (1957); 14 of these required secondary operations for subluxation, often with a poor outcome. Eleven hips were treated by combined pelvic and femoral osteotomy which, in general, gave good results. At a mean follow-up of 16.7 years, 80% of the whole series had a good or excellent clinical result and 51% were good or excellent radiologically. Simultaneous correction both above and below the hip is considered to be the best treatment for the older child with congenital hip dislocation.
The Oxford Knee, a resurfacing prosthesis with a meniscal bearing, can be used for either bicompartmental or unicompartmental arthritis. The first 103 unicompartmental cases are presented at a mean time since operation of 36 months (range 21 to 56 months). In those cases with surviving arthroplasties, pain was relieved in 96%. The full range of pre-operative flexion was maintained and flexion deformity was improved from a mean of 6.7 to 5.4 degrees. Stability and alignment were restored to normal in nearly all the knees. Absence of the anterior cruciate ligament was associated with a significantly greater incidence of failure. Six failures occurred in 37 knees lacking a normal anterior cruciate ligament (16.2%); three occurred in 63 knees with a normal anterior cruciate ligament (4.8%) (p less than 0.02). Criteria for the future selection of patients have been deduced from our experience. The operation is recommended for knees with severe unicompartmental osteoarthritis in which all the ligaments are still intact.
We describe 95 patients with previously treated congenital dislocation of the hip who underwent femoral osteotomy after the age of five years. The commonest indication for surgery was progressive uncovering and subluxation of the femoral head; other reasons were coxa vara, long leg dysplasia and persistent anteversion. Femoral osteotomy for uncovering of the femoral head (Severin Grade III) in this age group gave good results at maturity only when the acetabular angle was less than 25 degrees before operation. Femoral osteotomy alone was inadequate for true subluxation of the hip (Severin Grade IV).
A case of bilateral congenital pseudarthrosis of the olecranon is described. The clinical features, radiological appearance and prognosis are distinct from the type of congenital pseudarthrosis of the forearm reported previously. The lesion appeared to be a localised failure of ossification within the proximal ulnar metaphysis. Excision, stabilisation and bone grafting led to rapid fusion.
Two-hundred and fifteen children with 288 unstable hips have been treated by splintage during the first nine months of life. A simple treatment protocol was followed and the aim was to test the safety and reliability of this protocol as well as of the Von Rosen splint and the Pavlik harness. A vascular necrosis occurred in 3.8% of the splinted hips. Despite splintage, a proportion of children needed operation at a later date.
In 1957 Somerville and Scott described their "direct approach" to the management of established congenital dislocation of the hip; arthrography after a period of traction served to distinguish the dislocated from the subluxated hip. We review the long-term outcome of hips which, using their criteria, were subluxated; 72 hips have been reviewed at periods ranging from 15 to 37 years after treatment by traction, closed reduction and femoral osteotomy. The results have been classified clinically and radiologically according to Severin's criteria. There was progressive deterioration with age in both clinical function and radiographic appearance: 48.5% of hips showed evidence of dysplasia or subluxation at review. The results are similar to those found in a series treated by open reduction and limbectomy, differing only in the much lower incidence of degenerative changes after closed reduction.
There are many operations for hallux valgus and hallux rigidus, but Keller's operation remains one of the most popular, particularly for the older patient. A prospective trial was carried out to compare the results of Keller's operation modified by Kirschner-wire distraction with those of the standard operation. The results suggest that there is no advantage in using temporary Kirschner-wire distraction; indeed, degenerative changes in the interphalangeal joint and a subjectively worse result may result from its use.
In 1957 Somerville and Scott presented their principles of management for the older child with congenital hip dislocation. They advocated preliminary traction followed, in those hips which remained dislocated, by excision of the limbus and subsequent derotation varus osteotomy of the femur. As alternative regimes are advocated it becomes increasingly important to subject each method to detailed long-term review. One hundred and forty-seven hips in 121 patients aged between 12 months and three years and treated by the standard Somerville and Scott regime have been reviewed. The age at review ranged from 16 to 31 years. The recall rate was 91 per cent. Each patient was seen regularly in a special clinic where detailed notes, radiographs and records were available. The results have been assessed clinically and radiographically by modifications of Severin's criteria to enable comparisons to be made with other published series. Attention has been focused on the good and the bad prognostic factors and on the long-term complications. The most worrying feature has been the premature onset of degenerative arthritis even in hips which seemed to have been satisfactorily reduced.
