The April 2023 Children’s orthopaedics Roundup. 360. looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Aims. To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child. Methods. A follow-up investigation was undertaken on a cohort of 28 children previously reported at a mean of 4.8 years. The present study looked at 26 patients who had an arthrodesis of the hip as a child at a mean follow-up of 20 years (15 to 29). Results. The mean Harris Hip Score (HHS) increased from 39.60 (SD 11.06) preoperatively to 81.02 (SD 8.86; p = 0.041) at final review. At latest follow-up, the HHS was found to be excellent in four patients (15%), good in 11 (42%), and fair in 11 (42%). A total of 16 patients (62%) reported mild low back pain, five (19%) had moderate pain, and five (19%) patients had no back pain. Mild ipsilateral knee pain was reported by 19 (73%), moderate pain by one (4%), and no pain by six (23%) patients. Mild contralateral hip pain was reported by ten patients (38%), and no pain by 16 (62%). The 36-Item Short Form Health Survey scores were very good in four patients (15%), good in 18 (70%), and poor in four (15%), with a mean score of 70.92 (SD 12.65). Of 13 female patients who had given birth, 12 did so with uncomplicated vaginal delivery. All patients had to modify their posture for toileting, putting on lower body clothes, foot care, and putting on shoes. Conclusion. Our results show that with hip arthrodesis, most patients have relatively good function at long-term follow-up, although some pain is experienced in adjacent joints, and modification in some activities of daily living is common. Cite this article: Bone Joint J 2022;104-B(9):1089–1094

Aims

Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients.

Patients with longstanding hip fusion are predisposed to symptomatic degenerative changes of the lumbar spine, ipsilateral knee and contralateral hip. 1. In such patients, conversion of hip arthrodesis to hip replacement can provide relief of such symptoms. 2 – 4. However, this is a technically demanding procedure associated with higher complication and failure rates than routine total hip replacement. The aim of this study was to determine the functional results and complications in patients undergoing hip fusion conversion to total hip replacement, performed or supervised by a single surgeon. Twenty-eight hip fusions were converted between 1996 and 2016. Mean follow up was 7 years (3 to 18 years). The reasons for arthrodesis were trauma 11, septic arthritis 10, and dysplasia 7. The mean age at conversion was 52.4 years (26 to 77). A trochanteric osteotomy was performed in all hips. Uncemented components were used. A constrained liner was used in 7 hips. Heterotopic ossification prophylaxis was not used in this series. HHS improved a mean of 27 points (37.4 pre-op to 64.3 post-op). A cane was used in 30% of patients before conversion and 80% after. Heterotopic ossification occurred in 12 (42.9%) hips. There was 2 peroneal nerve injuries, 1 dislocation, 1 GT non-union and 1 infection. There have been 5 revisions; 2 for aseptic loosening, 1 for infection, 1 for recurrent dislocation and 1 for leg length discrepancy. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

Aims

Appropriate acetabular component placement has been proposed for prevention of postoperative dislocation in total hip arthroplasty (THA). Manual placements often cause outliers in spite of attempts to insert the component within the intended safe zone; therefore, some surgeons routinely evaluate intraoperative pelvic radiographs to exclude excessive acetabular component malposition. However, their evaluation is often ambiguous in case of the tilted or rotated pelvic position. The purpose of this study was to develop the computational analysis to digitalize the acetabular component orientation regardless of the pelvic tilt or rotation.

Aims

This study aimed to explore whether intraoperative nerve monitoring can identify risk factors and reduce the incidence of nerve injury in patients with high-riding developmental dysplasia.

The main challenges in hip arthrodesis takedown include the decision to perform fusion takedown and the technical difficulties of doing so. In addition to the functional disadvantages of hip fusion, the long-term effects of hip arthrodesis include low back pain and in some cases ipsilateral knee pain. Indications for fusion conversion to THA include arthrodesis malposition, pseudoarthrosis, and ipsilateral knee, low back, contralateral hip problems, and functional disadvantages of ipsilateral hip fusion. When deciding whether or not to take down fusion, consider the severity of the current problem, risks of takedown and likely benefits of takedown. Best results of fusion takedown occur if abductor function is likely to be present. If the abductors are not likely to function well, dearthrodesis may still help, but the patient will have a profound Trendelenburg or Duchenne gait and risk of hip instability will be higher. Abductor assessment can be performed by determining if the abductors contract on physical exam and determining if the previous form of fusion spared the abductors and greater trochanter. EMG and MRI also can be performed to assess the abductors, but value in this setting is unproven. Before dearthrodesis establish realistic expectations: most patients will gain hip motion—but not normal motion, most will see improvement in back/knee pain, but many will become cane-dependent for life. The main technical issues to overcome involve exposure, femoral neck osteotomy, acetabular preparation, and femoral fixation. Exposure can be conventional posterior, anterolateral or direct anterior with an in-situ femoral neck cut. In complex cases, a transtrochanteric approach is often helpful. The in-situ neck cut is facilitated by fluoroscopy or intraoperative radiograph to make sure the cut is at the correct level and at the correct angle. Be careful not to angle into the pelvis with the cut. Acetabular preparation is more complex because anatomic landmarks often are absent or distorted. Try to find landmarks including ischium, ilium, teardrop, and fovea. Confirm location with fluoroscopy as reaming commences and during reaming. Depth of reaming can be improved by using the fovea (if present) and teardrop on fluoroscopy. Cup fixation is usually an uncemented cup, fixed with multiple screws because bone quality typically is compromised. Femoral fixation is at the surgeon's discretion, recognizing the proximal bone may be distorted in some cases. Postoperative management includes protected weight bearing as needed and heterotopic bone prophylaxis in selected patients

Aims

The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE.

The modified Dunn procedure has the potential to restore the anatomy in hips with slipped capital femoral epiphyses (SCFE) while protecting the blood supply to the femoral head. However, there is controversy about the risks associated with the procedure especially in the most severe capital slips. Therefore, we report on (1) clinical outcome, (2) the cumulative survivorship with endpoints AVN and/or OA progression and (3) radiographic anatomy of the proximal femur at followup in patients treated with a modified Dunn procedure for severe SCFE. We performed a retrospective analysis involving 46 hips of 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle >60°) between 1999 and 2016. Followup averaged 8 years, (range 1–17) with 2 patients lost to followup after one year. The mean age was 13 years (range 9–19 years). Mean preoperative slip angle was 64° (range 60–90) and 14 out of 46 hips (30%) presented with unstable slips. Clinical scores and PROMs were evaluated and the hips were followed standard x-rays. Cumulative survivorship (Kaplan-Meier) with three defined endpoints: (1) AVN; (2) progression by at least one OA grade according to Tönnis; (3) non-preserved hip joint. (1)Mean Harris Hip score (HHS) was 93 points (66–100) and mean Hip Disability and Osteoarthritis Outcome Score (HOOS) was 90 points (67–100) at last followup. (2)Cumulative survivorship was 93% at 10-year followup. Three hips reached an endpoint. Two hips (4%) had AVN, one of them underwent hip arthrodesis. One hip had OA progression. (3)Postoperative slip angle was 7° (1–16). Alpha angle on axial radiograph was 39° (26–71) at followup. 41/44 hips (93%) had no OA (Tönnis 0). The modified Dunn procedure largely corrected slip deformities with low apparent risk of progression to avascular necrosis or osteoarthritis at mean 8-years followup. The AVN rate in severe and unstable (30%) capital slip was 4% (2 hips) with this procedure

Aims

The aim of this study was to compare the rate of mortality and causes of death in Korean patients who undergo surgery for a fracture of the hip, up to 11 years after the injury, with a control group from the general population.

The main challenges in hip arthrodesis takedown include the decision to perform fusion takedown and the technical difficulties of doing so. In addition to the functional disadvantages of hip fusion, the long-term effects of hip arthrodesis include low back pain and in some cases ipsilateral knee pain. Indications for fusion conversion to THA include arthrodesis malposition, pseudoarthrosis, and ipsilateral knee, low back, contralateral hip problems, and functional disadvantages of ipsilateral hip fusion. When deciding whether or not to take down a fusion, consider the severity of the current problem, risks of takedown and likely benefits of takedown. Best results of fusion takedown occur if abductor function is likely to be present. If the abductors are not likely to function well, dearthrodesis may still help, but the patient will have a profound Trendelenburg or Duchenne gait and risk of hip instability will be higher. Abductor assessment can be performed by determining if the abductors contract on physical exam and determining if the previous form of fusion spared the abductors and greater trochanter. EMG and MRI also can be performed to assess the abductors, but value in this setting is unproven. Before dearthrodesis establish realistic expectations: most patients will gain hip motion—but not normal motion, most will see improvement in back/knee pain, but many will become cane-dependent for life. The main technical issues to overcome involve exposure, femoral neck osteotomy, acetabular preparation, and femoral fixation. Exposure can be conventional posterior, anterolateral or direct anterior with an in situ femoral neck cut. In complex cases, a transtrochanteric approach is often helpful. The in situ neck cut is facilitated by fluoroscopy or intra-operative radiograph to make sure the cut is at the correct level and at the correct angle. Be careful not to angle into the pelvis with the cut. Acetabular preparation is more complex because anatomic landmarks often are absent or distorted. Try to find landmarks including ischium, ilium, teardrop, and fovea. Confirm location with fluoroscopy as reaming commences and during reaming. Depth of reaming can be improved by using the fovea (if present) and teardrop on fluoroscopy. Cup fixation is usually an uncemented cup, fixed with multiple screws because bone quality typically is compromised. Femoral fixation is at the surgeon's discretion, recognizing the proximal bone may be distorted in some cases. Post-operative management includes protected weight bearing as needed and heterotopic bone prophylaxis in selected patients

Aims

To determine the effect of a change in design of a cementless ceramic acetabular component in fixation and clinical outcome after total hip arthroplasty

Patients with longstanding hip fusion are predisposed to symptomatic degenerative changes of the lumbar spine, ipsilateral knee and contralateral hip. In such patients, conversion of hip arthrodesis to hip replacement can provide relief of such symptoms. However, this is a technically demanding procedure associated with higher complication and failure rates than routine total hip replacement. The aim of this study was to determine the early functional results and complications in patients undergoing hip fusion conversion to total hip replacement, performed or supervised by a single surgeon, using a standardised approach and uncemented implants. We hypothesised that a satisfactory functional improvement can be achieved in following conversion of hip fusion to hip replacement. Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in 3 hips. Mean follow up was 5 years (2 to 15 years). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in 7 (39%) hips, in one case resulting in joint ankylosis. No hips dislocated. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotopic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

Some DEFINITIONS are necessary: “STEMS” refers to “intramedullary stem extensions”, which may be of a variety of lengths and diameters, fixed with cement, porous coating or press fit alone and which may be modular or an inherent part of the prosthesis. The standard extension keel on the tibia does not qualify as a “stem (extension)”. COMPLEX implies multiple variables acting on the end result of the arthroplasty with the capability of inducing failure, as well as necessary variations to the standard surgical technique. A lesser degree of predictability is implied. More specifically, the elements usually found in an arthritic knee and used for the arthroplasty are missing, so that cases of COMPLEX primary TKA include: Soft tissue coverage-(not relevant here), Extensor mechanism deficiency-patellectomy, Severe deformity, Extra-articular deformity, Instability: Varus valgus, Instability: Plane of motion, Instability: Old PCL rupture, Dislocated patella, Stiffness, Medical conditions: Neuromuscular disorder, Ipsilateral arthroplasty, Prior incisions, Fixation hardware, Osteopenia, Ipsilateral hip arthrodesis, Ipsilateral below knee amputation, etc. Complexity includes MORE than large deformity, i.e., success with large deformity does NOT mean success with constrained implants regardless of indication. In addition, the degree of constraint must be specified to be meaningful. NECESSARY presumably this means: “necessary to ensure durable fixation in the face of poor bone quality or more mechanically constrained” and SUFFICIENT suggests that stems, by themselves or in some shape of form, by themselves “will ensure success (specifically here) of fixation”. If we can start with the second proposal, that STEMS are SUFFICIENT for success the answer is: “NO”, many more aspects of surgical technique and implant design are required. Even if all other aspects of the technique are exemplary, some types of stems or techniques are inadequate, e.g., completely uncemented, short stem extensions. The answer to the first proposal is: “YES, in many cases”. The problem will be to determine which cases. There are philosophical analogies to this question that we already know the answer to. ANALOGY: Is a life-raft necessary on a boat? Yes, you may not use it, but it is considered necessary. Is a life-raft “sufficient” on a boat? No, other problems may occur. Are seat belts necessary? Are child seats necessary? The AAOS already has a position on child restraints, an analogous situation, where a party who cannot control their situation (anesthetised patient/ child) functions in the care of a responsible party. The objection may be argued in terms of cost saving by NOT using increased fixation. A useful analogy, (that would of course require specific analysis), is that of patellar resurfacing: universal resurfacing is cost-effective when considering the expense of even a small number of secondary resurfacings. Of course a complex arthroplasty that requires a revision procedure is far more expensive than secondary patellar resurfacing and so universal use of the enhanced fixation in the face of increased constraint makes sense. The human cost of revision surgery tips the balance irrefutably. DANGER-We must avoid the glib conclusion, often based on poor quality data, that constrained implants do not need additional intramedullary fixation (with stem extensions). When “complexity” is involved, complex analysis is appropriate to select the best course

Degenerative problems of the hip in patients with childhood and adult onset neuromuscular disorders can be challenging to treat. Many orthopaedic surgeons are reluctant to recommend total hip replacement (THR) for patients with underlying neuromuscular disorders due to the perceived increased risks of dislocation, implant loosening, and lack of information about the functional outcomes and potential benefits of these procedures in these patients. Modular femoral components and alternative bearings which facilitate the use of large femoral heads, constrained acetabular components and perhaps more importantly, a better understanding about the complications and outcomes of THR in the patient with neuromuscular disorders, make this option viable. This paper will review the current literature and our experience with THR in the more frequently encountered neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):27–31.

Introduction. Management of the sequelae of arthritis of the hip joint has changed over time. Total joint replacement has gained popularity due to retained mobility and stability. In the high demand paediatric and adolescent population problems are encountered with longevity of the procedure. Hip arthrodesis is a useful alternative procedure that sacrifices mobility of the joint to achieve pain relief and restores function. Several surgical techniques have been described to achieve hip fusion. We describe a technique that achieves concentric bone surfaces with hip resurfacing reamers. Maximum bone is preserved to maintain leg length. Trans-articular compression is achieved with cannulated screw fixation. Subtrochanteric de-functioning osteotomy completes the procedure to protect the fusion site and control the position of the limb. Our optimal position of fusion was 30 degrees of flexion, neutral to 5 degrees of abduction and neutral to 10 degrees of external rotation. Methods. Fourteen patients (8 female) treated by hip arthrodesis over a two-year period are reviewed in terms of clinical and radiological outcome in the short term. Their mean age at hip fusion was 11 years (6–18). The etiology included TB (6 cases), staphylococcal infection (2), non-specific arthritis (3), Perthe's (1), chondrolysis (1) and avascular necrosis following trauma (1). Results. Fusion was achieved in 12/14 patients. All patients in whom fusion was achieved had relief of pain and returned to their normal activities. Conclusion. We believe hip arthrodesis performed in the correct patient is a good procedure to preserve function and relieve pain. The procedure is technically demanding and careful follow-up to ensure optimal positioning and solid fusion is essential to ensure good results. NO DISCLOSURES

We report an intertrochanteric fracture in a patient who had undergone hip arthrodesis 30 years previously. A 53-year-old man was injured in a head-on car crash and was referred to our hospital for treatment. Plain radiographs showed an intertrochanteric fracture of the right proximal femur and deformity of the right hip joint. He had undergone hip arthrodesis surgery 30 years previously at another hospital. Computed tomography scan showed marked atrophy of the gluteus and iliopsoas muscles. He preferred undergoing total hip arthroplasty (THA) to internal fixation. THA was performed using the anterolateral approach with the patient in the supine position as he had undergone hip arthrodesis through the Smith–Petersen approach, and we were concerned about damaging the gluteus muscle and dislocation if we took the posterolateral approach. The femoral head was removed using curved chisels under fluoroscopy. A cementless THA (J Taper stem, Aquala polyethylene liner; Kyocera Medical Corporation, Osaka, Japan) was inserted and fixed appropriately. Full weight-bearing using a walking frame was allowed 2 weeks after the surgery. Six months after the operation, he was able to walk independently and had good range of movement of the hip joint but continued to have weakness in the abductor muscles. Very few cases of proximal femur fracture in a previously arthrodesed hip have been reported. Manzotti et al. reported a similar case but they performed open reduction and internal fixation. No previous reports in the literature describe THA for intertrochanteric fracture in an arthrodesed hip. The conversion of an arthrodesed hip to THA is technically challenging. It has a high risk of complications such as nerve injuries and hip instability. We were able to treat the patient successfully, but surgeons should carefully decide the treatment method depending on the case

A total of 219 hips in 192 patients aged between 18 and 65 years were randomised to 28-mm metal-on-metal uncemented total hip replacements (THRs, 107 hips) or hybrid hip resurfacing (HR, 112 hips). At a mean follow-up of eight years (6.6 to 9.3) there was no significant difference between the THR and HR groups regarding rate of revision (4.0% (4 of 99) vs 5.8% (6 of 104), p = 0.569) or re-operation rates without revision (5.1% (5 of 99) vs 2.9% (3 of 104), p = 0.428). In the THR group one recurrent dislocation, two late deep infections and one peri-prosthetic fracture required revision, whereas in the HR group five patients underwent revision for femoral head loosening and one for adverse reaction to metal debris. The mean University of California, Los Angeles activity scores were significantly higher in HR (7.5 (sd 1.7) vs 6.9 (sd 1.7), p = 0.035), but similar mean Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained (5.8 (sd 9.5) in HR vs 5.1 (sd 8.9) in THR, p = 0.615) at the last follow-up. Osteolysis was found in 30 of 81 THR patients (37.4%), mostly in the proximal femur, compared with two of 83 HR patients (2.4%) (p < 0.001). At five years the mean metal ion levels were < 2.5 μg/l for cobalt and chromium in both groups; only titanium was significantly higher in the HR group (p = 0.001). Although revision rates and functional scores were similar in both groups at mid-term, long-term survival analysis is necessary to determine whether one procedure is more advantageous than the other.

Cite this article: Bone Joint J 2013;95-B:1464–73.

Hip arthrodesis remains a viable surgical technique in well selected patients, typically the young manual labourer with isolated unilateral hip disease. Despite this, its popularity with patients and surgeons has decreased due to the evolution of hip replacement, and is seldom chosen by young adult patients today. The surgeon is more likely to encounter a patient who requests conversion to total hip replacement (THR). The most common indications are a painful pseudarthrosis, back pain, ipsilateral knee pain or contralateral hip pain. Occasionally the patient will request conversion because of difficulty with activities of daily living, body image and perceived cosmesis. The technique of conversion and a discussion of the results are presented. Cite this article: Bone Joint J 2013;95-B, Supple A:114–19