Executing an extended retinacular flap containing the blood supply for the femoral head, reduction osteotomy (FHO) can be performed, increasing the potential of correction of complex hip morphologies. The aim of this study was to analyse the safety of the procedure and report the clinical and radiographic results in skeletally mature patients with a minimum follow up of two years. Twelve symptomatic patients (12 hips) with a mean age of 17 years underwent FHO using surgical hip dislocation and an extended soft tissue flap. Radiographs and magnetic resonance imaging producing radial cuts (MRI) were obtained before surgery and radiographs after surgery to evaluate articular congruency, cartilage damage and morphologic parameters. Clinical functional evaluation was done using the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). After surgery, at the latest follow-up no symptomatic avascular necrosis was observed and all osteotomies healed without complications. Femoral head size index improved from 120 ± 10% to 100 ± 10% (p<0,05). Femoral head sphericity index improved from 71 ± 10% before surgery to 91 ± 7% after surgery (p<0,05). Femoral head extrusion index improved from 37 ± 17% to 5 ± 6% (p< 0,05). Twenty five percent of patients had an intact Shenton line before surgery. After surgery this percentage was 75% (p<0,05). The NAHS score improved from a mean of 41 ± 18 to 69 ± 9 points after surgery (p< 0,05). The HOS score improve from 56 ± 24 to 83 ± 17 points after surgery (p< 0,05) and the mHHS score improved from 46 ± 15 before surgery to 76 ± 13 points after surgery (p< 0,05). In this series, femoral head osteotomy could be considered as safe procedure with considerable potential to correct hip deformities and improve patients reported outcome measures (PROMS). Level of evidence - Level IV, therapeutic study. Keywords - Femoral head osteotomy, Perthes disease, acetabular dysplasia, coxa plana

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

Aims

Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO.

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Background: Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are thought to predispose patients to degenerative joint changes. However, the natural history of these malformations is not clearly delineated. Methods: Seven-hundred twenty-two patients ≤55 years that received unilateral primary total hip arthroplasty (THA) from 1980–1989 were identified. Pre-operative radiographs were reviewed on the contralateral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radiographic follow-up were included. Radiographic metrics in conjunction with the review of two experienced arthroplasty surgeons determined structural hip diagnosis as DDH, FAI, or normal morphology. Every available follow-up AP radiograph was reviewed to determine progression from Tönnis Grade 0–3 until the time of last follow-up or operative intervention with THA. Survivorship was analyzed by Kaplan-Meier methodology, hazard ratios, and multi-state modeling. Results: One-hundred sixty-two patients met all eligibility criteria with the following structural diagnoses: 48 DDH, 74 FAI, and 40 normal. Mean age at the time of study inclusion was 47 years (range 18–55), with 56% females. Mean follow-up was 20 years (range 10 – 35 years). Thirty-five patients eventually required THA: 16 (33.3%) DDH, 13 (17.6%) FAI, 6 (15.0%) normal. Kaplan-Meier analysis demonstrated that patients with DDH progressed most rapidly, followed by FAI, with normal hips progressing the slowest. The mean number of years spent in each Tönnis stage by structural morphology was as follows: Tönnis 0: DDH = 17.0 years, FAI = 14.8 years, normal = 22.9 years; Tönnis 1: DDH = 12.2 years, FAI = 13.3 years, normal = 17.5 years; Tönnis 2: DDH = 6.0 years, FAI = 9.7 years, normal = 8.6 years; Tönnis 3: DDH = 1.6 years, FAI = 2.6 years, normal = 0.2 years. Analysis of degenerative risk for categorical variables showed that patients with femoral head lateralization >10 mm, femoral head extrusion indices >0.25, acetabular depth-to-width index <0.38, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all had a greater risk of progression from Tönnis 0 to Tönnis 3 or THA. Among patients with FAI morphology, femoral head extrusion indices >0.25, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all increased the risk of early radiographic progression. Analysis of degenerative risk for continuous variables using smoothing splines showed that risk was increased for the following: femoral head lateralization >8 mm, femoral head extrusion index >0.20, acetabular depth-to-width index <0.30, lateral center-edge angle <25 degrees, and Tönnis angle >8 degrees. Conclusions: This study defines the long-term natural history of DDH and FAI in comparison to structurally normal young hips with a presumably similar initial prognostic risk (Tönnis Grade 0 degenerative change and contralateral primary THA). In general, the fastest rates of degenerative change were observed in patients with DDH. Furthermore, risk of progression based on morphology and current Tönnis stage were defined, creating a new prognostic guide for surgeons. Lastly, radiographic parameters were identified that predicted more rapid degenerative change, both in continuous and categorical fashions, subclassified by hip morphology

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure.

A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment.

The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (sd) 0.9) vs 1.5 L (sd 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group.

The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE.

Cite this article: Bone Joint J 2015;97-B:1604–7.

In Norway total joint replacement after hip dysplasia is reported more commonly than in neighbouring countries, implying a higher prevalence of the condition. We report on the prevalence of radiological features associated with hip dysplasia in a population of 2081 19-year-old Norwegians. The radiological measurements used to define hip dysplasia were Wiberg’s centre-edge (CE) angle at thresholds of < 20° and < 25°, femoral head extrusion index <  75%, Sharp’s angle > 45°, an acetabular depth to width ratio < 250 and the sourcil shape assessed subjectively. The whole cohort underwent clinical examination of their range of hip movement, body mass index (BMI), and Beighton hypermobility score, and were asked to complete the EuroQol (EQ-5D) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The prevalence of hip dysplasia in the cohort varied from 1.7% to 20% depending on the radiological marker used. A Wiberg’s CE angle <  20° was seen in 3.3% of the cohort: 4.3% in women and 2.4% in men. We found no association between subjects with multiple radiological signs indicative of dysplasia and BMI, Beighton score, EQ-5D or WOMAC. Although there appears to be a high prevalence of hip dysplasia among 19-year-old Norwegians, this is dependent on the radiological parameters applied.

Cite this article: Bone Joint J 2013;95-B:279–85.

We present the results of Chiari pelvic osteotomy in the treatment of adolescent hip incongruence, with special interest in identifying possibilities, limitations and complications. In a series of 86 patients treated by Chiari pelvic osteotomy (13 operated bilateraly) at the Institute for Orthopaedic Surgery “Banjica” with a follow-up period more than 48 months, we analyzed the relation of Chiari-specific parameters collected from postoperative radiograms (osteotomy angle and heigth, and displacement index) to various preoperative and postoperative parameters (Sharp acetabular angle, Wiberg CE angle, Heyman and Herndon femoral head extrusion index (FHEI), Acetabular depth ratio (ADR), Shenton-Menard arch integrity, limb length discrepancy, gait quality) and functional result according to HHS and McKay scoring systems. We found highly significant improvements of Sharp angle (from 47.2±6.1° preoperatively to 38.6±7.8° finally, p<0.01), Wiberg CE angle (from 10.2±16.8° to 38.9±14.6°, p<0.01) and FHEI (from from 53.4±21% to 1.9±70.7%, p<0.01). In adition, HHS was also improved from 76±15.1 to final 87.9±9.4, p<0.01). We also assessed the satisfaction of both patients (index 4.2 out of 5) and surgeons (index 3.7 out of 5). Chiari pelvic osteotomy is useful surgical procedure in the selected cases of adolescent hip incongruence with disturbance of hip centering and coverage

We report the use of a 15° face-changing cementless acetabular component in patients undergoing total hip replacement for osteoarthritis secondary to developmental dysplasia of the hip. The rationale behind its design and the surgical technique used for its implantation are described. It is distinctly different from a standard cementless hemispherical component as it is designed to position the bearing surface at the optimal angle of inclination, that is, < 45°, while maximising the cover of the component by host bone.

In order to evaluate the relationship between acetabular and proximal femoral alignment in the initiation and evolution of osteoarthritis of the dysplastic hip, the acetabular and femoral angles were calculated geometrically from radiographs of 62 patients with pre-arthrosis and early osteoarthritis. The sum of the lateral opening angle of the acetabulum and the neck-shaft angle was defined as the lateral instability index (LII), and the sum of the anterior opening angle of the acetabulum and the anteversion angle of the femoral neck as the anterior instability index (AII). These two indices were compared in dysplastic and unaffected hips. A total of 22 unilateral hips with pre-arthrosis were followed for at least 15 years to determine whether the two indices were associated with the progression of osteoarthritis.

The LII of the affected hips (197.4 (sd 6.0)) was significantly greater than that of the unaffected hips (1830 (sd 6.9)). A follow-up study of 22 hips with pre-arthrosis showed that only the LII was associated with progression of the disease, and an LII of 196 was the threshold value for this progression.

We present a new CT-based method which measures cover of the femoral head in both normal and dysplastic hips and allows assessment of acetabular inclination and anteversion. A clear topographical image of the head with its covered area is generated.

We studied 36 normal and 39 dysplastic hips. In the normal hips the mean cover was 73% (66% to 81%), whereas in the dysplastic group it was 51% (38% to 64%). The significant advantage of this technique is that it allows the measurements to be standardised with reference to a specific anatomical plane. When this is applied to assessing cover in surgery for dysplasia of the hip it gives a clearer understanding of where the corrected hip stands in relation to normal and allows accurate assessment of inclination and anteversion.

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

To investigate the proportion of dysplastic hips which are retroverted. We studied the radiographs of over seven hundred patients with dysplastic hips who had had a periacetabular osteotomy in the period 1984–1998. We excluded patients with neuromuscular dysplasia, Perthes’ disease of the hip, post-traumatic dysplasia and proximal focal femoral deficiency. We selected 232 radiographs of patients with congenital acetabular dysplasia. A number of parameters were measured including lateral centre-edge angle, anterior centre-edge angle, acetabular index of weight-bearing surface, femoral head extrusion index and acetabular index of depth to width. Also recorded were acetabular version and congruency between femoral head and acetabulum. The lateral centre-edge angle of Wiberg had a mean value of 6.4° (SD 8.9°), the mean anterior centre-edge angle was 1.3° (SD 13.5°) and the acetabular index of weight-bearing surface of the acetabulum had a mean value of 24.5° (SD 9.7°). The majority (192, 82.8%) of acetabula were anteverted as might be expected. However, a significant minority (40, 17.2%) were retroverted. The mean anterior centre-edge angle in retroverted hips was 6.7° (SD 9.4°) compared with 0.4° (SD 13.3°) in anteverted hips. The authors have shown that, in a typical group of patients with congenital acetabular dysplasia significant enough to warrant periacetabular osteotomy, the majority of hips as expected have anteverted acetabula. However, a significant minority are retroverted. This finding has an important bearing on the performance of the osteotomy. We have also found that most if not all the information required prior to and following periac-etabular osteotomy can be obtained from an orthograde view of the pelvis

Femoroacetabular cam impingement is thought to be a cause of premature osteoarthritis of the hip.

The presence of cam malformation was determined in 2803 standardised anteroposterior (AP) pelvic radiographs from the Copenhagen Osteoarthritis Study by measuring the alpha (α) angle and the triangular index, a new measure of asphericity of the femoral head. In addition, the α-angle and the triangular index were assessed on the AP and lateral hip radiographs of 82 men and 82 women randomly selected from patients scheduled for total hip replacement (THR). The influence of varying femoral rotation on the α angle and the triangular index was also determined in femoral specimens under experimental conditions.

From the 2803 radiographs the mean AP α-angle was 55° (30° to 100°) in men and 45° (34° to 108°) in women. Approximately 6% of men and 2% of women had cam malformation. The α-angle and triangular index were highly inter-related. Of those patients scheduled for THR, 36 men (44%) and 28 women (35%) had cam malformation identifiable on the AP radiographs. The triangular index proved to be more reliable in detecting cam malformation when the hip was held in varying degrees of rotation.

The combination of the α-angle and the triangular index will allow examination of historical radiographs for epidemiological purposes in following the natural history of the cam deformity.

In a longitudinal case-control study, we followed 81 subjects with dysplasia of the hip and 136 control subjects without dysplasia for ten years assessing radiological evidence of degeneration of the hip at admission and follow-up. There were no cases of subluxation in the group with dysplasia. Neither subjects with dysplasia nor controls had radiological signs of ongoing degenerative disease at admission. The primary radiological discriminator of degeneration of the hip was a change in the minimum joint space width over time. There were no significant differences between these with dysplasia and controls in regard to age, body mass index or occupational exposure to daily repeated lifting at admission.

We found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip. The association of subluxation and/or associated acetabular labral tears with dysplasia of the hip may be a conditional factor for the development of premature osteoarthritis in mildly to moderately dysplastic hips.

Introduction: Peri-acetabular rotational osteotomy is recognized as the non-arthroplastic treatment for Developmental Dysplasia of the Hip (DDH). This procedure has increased in popularity during the last decade. It aims to restore the acetabular cover over the femoral head and thus delay secondary osteoarthritic changes in the hip. Materials and methods: We reviewed 16 patients who underwent peri-acetabular rotational surgery at our hospital. The indication for surgery was DDH in all cases. Reinert’s approach was used for surgical exposure. Two patients underwent a valgus femoral osteotomy at the same time. Mean age was 40 years (range 15–49). The mean follow-up was 46.5 months (range 4–108). The results of the surgery were assessed with radiological indices and a patient satisfaction survey. The radiological indices recorded were Wiberg’s angle, acetabular inclination angle, femoral head extrusion index and Tonnis osteoarthritis grading. Results: The intervention failed to benefit two patients who subsequently required a total hip arthroplasty. Both patients had Tonnis grade 3 osteoarthritis. One patient developed a necrotic skin flap requiring skin grafting. The mean pre-operative Wiberg’s angle was 11 degrees (range −7 to 25) which was corrected to 35 degrees (range 17 to 58). Mean pre-operative acetabular index was 25 degrees (range 14 to 40) which was corrected to 11 degrees (range of 2 to 21). Mean pre-operative femoral head extrusion index was 37 degrees (range 18–50) which was reduced to 14 degrees (range 0–32). In all but the two patients in whom the surgery had failed, patients reported reduction in hip pain. Conclusions: Peri-acetabular rotational osteotomy is a challenging but worthwhile procedure for young patients with DDH. The early results from the procedure are encouraging providing patient selection is appropriate. We would like to initiate a debate to identify the ideal patient for this procedure

It is generally agreed that in acetabular dysplasia the acetabulum lies excessively anteverted. Although this is true for the majority of hips, we have found that in some patients with dysplastic hips, the acetabulum lies unexpectedly in retroversion. Aim: To investigate the proportion of dysplastic hips which are retroverted. Method: We studied the radiographs of over seven hundred patients with dysplastic hips and who had had a periacetabular osteotomy in the period 1984–1998. We excluded patients with neuromuscular dysplasia, Perthes disease of the hip, post-traumatic dysplasia and proximal focal femoral deficiency. We selected 232 radiographs of patients with congenital acetabular dysplasia. A number of parameters were measured including, lateral centre edge angle, anterior centre-edge angle, acetabular index of weight bearing surface, femoral head extrusion index and acetabular index of depth to width. Also recorded was acetabular version and congruency between femoral head and acetabulum. Results: The lateral centre-edge angle of Wiberg had a mean value of 6.4° (SD 8.9°), the mean anterior centre-edge angle was 1.3° (SD 13.5°) and the acetabular index of weight bearing surface of the acetabulum had a mean value of 24.5° (SD 9.7°). The majority (192, 82.8%) of acetabula were anteverted as might be expected. However, a significant minority (40,17.2%) were retroverted. The mean anterior centre-edge angle in retroverted hips was 6.7° (SD 9.4°) compared with 0.4° (SD 13.3°) in anteverted hips. Conclusion: The authors have shown that in a typical group of patients with congenital acetabular dysplasia, significant enough to warrant periacetabular osteotomy, the majority of hips as expected have anteverted acetabula. However, a significant minority are retroverted. This finding has an important bearing in the performance of the osteotomy