The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants

Aims

Abduction bracing is commonly used to treat developmental dysplasia of the hip (DDH) following closed reduction and spica casting, with little evidence to support or refute this practice. The purpose of this study was to determine the efficacy of abduction bracing after closed reduction in improving acetabular index (AI) and reducing secondary surgery for residual hip dysplasia.

Introduction. Femoral-shortening osteotomy for the treatment of leg length discrepancy is demanding technique. Many surgical technique and orthopaedic devises have been suggested to perform this procedure. Herein, we describe modified femoral shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique. Materials and Methods. We operated on six patients with LLD. Mean femoral shortening was 4.2 cm. Osteotomy was performed using a multiple drill-hole technique, and bone was stabilized using an intramedullary nail. Post-operative clinical and radiological data were reported. Results. Shortening was achieved, with a final LLD of < 1 cm in all patients. All patients considered the lengths of the lower limbs to be equal. No special surgical skills or instrumentation were needed. Intraoperative and post-operative complications were not recorded. Conclusions. Percutaneous femoral-shortening osteotomy over a nail using multiple drill-hole osteotomy technique was effective and safe in treating LLD

Aims

Perthes’ disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths.

Aims. Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. Methods. In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). Results. The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. Conclusion. THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. Level of evidence IV. Femoral shortening useful in conditions other than DDH and septic sequelae. Restoration of hip centre combined with offset to be planned and ensured

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Introduction. The anatomic abnormalities are observed in developmental dysplasia of the hip (DDH) and it is challenging to perform the total hip arthroplasty (THA) for some DDH patients. If acetabular cup was placed at the original acetabular position in patients with high hip dislocation, it may be difficult to perform reduction of hip prosthesis because of soft tissue contracture. The procedures resolving this problem were to use femoral shortening osteotomy, or to place the acetabular cup at a higher cup position than the original hip center. Femoral shortening osteotomy has some concerns about its complicated procedure, time consuming, and risk of non-union. Conversely, implantation of the acetabular cup at the higher cup position may eliminate these shortcomings and this procedure is considered to be preferred if possible. However, the criteria of cases without femoral shortening osteotomy are not clear. In this study, we retrospectively analysed the clinical outcomes of patients performed THAs for high hip dislocation, and clarified the adaptation of THA with or without femoral shortening osteotomy. Methods. We included a total of 65 hip joints from 57 patients who underwent primary THA using Modulus stem for high hip dislocation from November 2007 to December 2015 at our institution. The mean follow up period was 5.2 years (2 – 10 years). The mean age at surgery was 65.4 years (Table 1). Thirty seven hips were classified as Crowe III, and twenty eight hips as Crowe IV based on Crowe classification. We classified patients into two groups based on the use of femoral osteotomy. Then, we compared the surgical time, blood loss, Japanese Orthopaedic Association (JOA) Score as clinical outcomes, preoperative position of the greater trochanter, the cup position, and complications between two groups. The position of the greater trochanter was measured the height of the tip of greater trochanter from the inter teardrop line. The cup center position was assessed by measuring the distance between the cup center and ipsilateral tear drop. Receiver operating characteristic (ROC) curves were plotted for deciding the cut-off value for the height of the greater trochanter. The cut-off value presented the maximum sensitivity and specificity was determined. Results and Discussion. Fifty three THAs were operated without femoral shortening osteotomy, and twelve THAs were performed with femoral shortening osteotomy. The surgical time was significantly longer in the osteotomy group than the non-osteotomy group. The mean height of the tip of the greater trochanter were 53.2±11.4mm in the non-osteotomy group and 92.2±19.7 mm in the osteotomy group (Table 2). The cut-off value of the height of greater trochanter evaluated from the ROC curve analysis was 69.5mm (Fig.1). There were no significant differences in clinical score between two groups. More ratio of revisions and fractures were observed in the osteotomy group with significant differences. Conclusion. There were significant differences in postoperative complications in osteotomy group compare to non-osteotomy group. In cases with a greater trochanter tip height of 69.5 mm or less, it may be considered to avoid femoral shortening osteotomy

Objectives

The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower-limb lengthening and to assess macroscopical and microscopical changes to the implants and evaluate differences following design modification, with the aim of identifying potential surgical, implant, and patient risk factors.

Aims

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator.

Introduction. Limb length discrepancy (LLD) is one of the major reasons of dissatisfaction after total hip arthroplasty(THR) and limb equalization after THR in unilateral developmental dysplasia of the hip (DDH) is very important. study designed to measure the difference of adult femoral length between normal and dislocated hip in unilateral DDH. Method. Sixty patients with unilateral high riding DDH (crow type 3,4) who were underwent THR included. All the cases had digital lower limb scanograms. Exclusion criteria was any previous hip or femur surgery, any rheumatoid disease, history of any disease that affect the growth. All the scanograms measured by one fellowship of adult reconstruction and one radiologist specialized in musculoskeletal imaging. Each one repeated the measurements two months later blindly and inter observer and intra observer reliability checked. Each one measured femoral length in both sides from greater trochanter(GT), to the distal surface of the femoral condyles. Results. 59 female and one males included. Average age was 27.5 years (19–50 years). Inter observer reliability index were excellent (ICC 98%). Only 6 cases (10%) had exactly equal femoral length, 31(52%) cases were longer on the dislocated side and 23 (38%) cases were shorter. Average overgrowth was 6.1 mm (Range: 1–22) and average undergrowth was 10.7 (Range 1–21). 35 cases (58.3%) cases had 5 mm or more differences and 30% had 5–10 mm .17 cases (28.3%) had at least 10 mm difference that 8 cases (13%) had shorter and 9 cases (15%) had longer femur on dislocated side. Maximum difference was 22 mm over length on dislocated side. Conclusions. More than half of patients with unilateral high riding DDH have longer femur on the dislocated side and 15% of them are longer than 10 mm. we recommend to get the scanograms in all the unilateral DDH cases to avoid post-operative limb discrepancy and detecting the amount of shortening in cases that need femoral shortening

Aims

There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication.

Introduction. The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator. Method. 9 patients underwent the ‘rail and nail’ technique for the management of femoral non-union. Distraction osteogenesis was commenced on the 6. th. post-operative day. Proximal locking of the nail and removal of the external fixator was performed approximately one month after length had been restored. Full weight bearing and joint rehabilitation was encouraged throughout. Consolidation was defined by the appearance of 3 from 4 cortices of regenerate on radiographs. Results. 7 males and 2 females of adult age underwent treatment between 2009 and 2016. The mean lengthening was 6.6cm (3–10cm). The external fixator was removed at a mean 123 days (57–220), with an external fixation index of 20 days/cm. The regenerate healing index was 28 days/cm. There were no deep infections. Significant complications were seen in 4 patients including knee stiffness, a foot drop, delayed union of the non-union osteotomy (requiring exchange nailing and bone grafting) and revision nailing due to a prominent proximal tip. Conclusion. The combined over-sized intramedullary nail and external fixator enables compression of the femoral osteotomy, alignment of the bone and controlled lengthening. Once the length has been restored, removal of the external fixator and proximal locking of the nail reduces the risk of complications associated with the fixator and stabilises the femur with the maximum working length of the nail. This small retrospective study demonstrates encouraging results for this complex clinical scenario

Aims

The aim of this study was to evaluate the long-term clinical and radiographic outcomes of the Birmingham Interlocking Pelvic Osteotomy (BIPO).

Aims

To present our experience of using a combination of intra-articular osteotomy and external fixation to treat different deformities of the knee.

The treatment of developmental dysplasia of the hip (DDH) in children remains controversial, we describe the clinical and radiological outcomes of 47 hips in 43 children treated with open surgery by one surgeon between 2004 and 2008 for DDH. The mean age at operation was 25 months (5 to 113) with a mean follow up of 89 months (22 to 169). 46 hips had an anterior open reduction, 1 had a medial approach performed and 16 had anterior open reductions only. 5 of the primary operations also had a pelvic osteotomy, 7 had a femoral osteotomy and 18 had a combined femoral and pelvic osteotomy. 7 (15%) of the hips required a second operation for dislocation, subluxation or dysplasia. At the latest follow up 40 of the 45 hips where Severin grades were recordable (89%) were graded as excellent or good, Severin class I or II. Clinically significant AVN (grade II to III according to the Kalamchi and MacEwen classification) was seen in 5 (11%) of the hips. We found a pelvic osteotomy to be a risk factor for AVN (p 0.02) and age at operation to be a risk factor for poor morphology at final follow up (p 0.03). We proceed to open surgery in patients over 12 months old or those with failed closed reduction. Over 18 months old a pelvic osteotomy should be performed in selective cases depending on intra-operative stability, but we will now consider doing this as a staged procedure and delaying the osteotomy for a period of time after open reduction to reduce the risk of AVN. We will also have a much lower threshold for performing a femoral shortening osteotomy in these patients as open reduction with Salters osteotomy alone tended to have a poorer outcome