Aims

The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

Aims

Dislocation of the hip remains a major complication after periacetabular tumour resection and endoprosthetic reconstruction. The position of the acetabular component is an important modifiable factor for surgeons in determining the risk of postoperative dislocation. We investigated the significance of horizontal, vertical, and sagittal displacement of the hip centre of rotation (COR) on postoperative dislocation using a CT-based 3D model, as well as other potential risk factors for dislocation.

Low energy hip dislocation in children is an uncommon injury (0.335% of injuries ) which represents a true orthopaedic emergency. Case 1 ; A 6 year old girl attended hospital non-weightbearing with right thigh pain after slipping whilst attempting to kick a football. The leg was shortened and internally rotated with no neurovascular deficit. Radiographs revealed a posterior dislocation of the right hip. A closed reduction was undertaken in theatre within four hours. She was immobilised in a hip spica for 6 weeks. At six month review she was pain free and back to full activities. Radiographs showed no abnormality. Case 2 ; A 5 year old boy attended A+E non-weight-bearing with right lower leg and knee pain having done the splits playing football. Examination of knee and lower leg showed pain but nil else. Radiographs of the knee were normal. He was discharged with a diagnosis of possible ACL rupture. He re-attended 2 days later with immobility and increasing pain. Examination showed a 2cm leg length discrepancy. Radiographs revealed a posterior hip dislocation. He underwent a closed reduction in theatre. He progressed well under regular review until 5 months post-injury. He had increasing pain and decreasing range of movement. Radiographs showed trans-epiphyseal avascular necrosis. He therefore underwent a varus de-rotation osteotomy. One year on he has returned to full activities. He has a mild decreased range of movement. Radiographs show a flattened epiphysis and a united osteotomy. Hip dislocation requires less trauma in children due to ligamentous laxity and a soft pliable acetabulum. Overall 64% are low energy and 80% are posterior dislocations. Complications include AVN, arthritis, nerve palsy and recurrent dislocation. AVN is 20 times more common if reduction is after 6 hours. This report highlights the importance of thorough examination, accurate diagnosis and early treatment of paediatric hip dislocation

Children with cerebral palsy (CP) have an increased risk of progressive hip displacement. While the cause of hip displacement remains unclear, spasticity and muscle imbalance around the hip are felt to be a major factor. There is strong evidence demonstrating that a selective dorsal rhizotomy (SDR) reduces spasticity. However, the impact of this decreased spasticity on hip displacement is unknown. Past studies, which are small and lack long-term follow-up, do not provide a clear indication of the effect of SDR on hip displacement. The purpose of this study was to determine the influence of SDR on hip displacement in children with CP a minimum of five years post-SDR. A retrospective chart review was completed. Participants were selected from a consecutive series of children who had an SDR before January 1, 2013 at one tertiary care facility to ensure a minimum five year follow-up. Pre-operative and minimum five year post-SDR AP pelvis radiographs were required for inclusion. Hip displacement was evaluated using change in MP between radiographs completed pre-SDR and minimum five years post-SDR, or until orthopaedic hip surgery. In total, 77 participants (45 males, 32 females) at GMFCS levels of I (1), II (11), III (22), IV (35) and V (8) were included in the review. Mean age at time of SDR was 5 years (2.8– 11.6yrs). Pre-SDR mean MP of the 154 hips was 29% (0–100%). Post-SDR, 67 (43.5%) hips in 35 children had soft tissue, reconstructive, or salvage hip procedures at an average of 4.9 years (0.5–13.8yrs) post-SDR and an average MP of 46% (11–100%). In addition, seven hips (5%) had a MP ≥ 40% (40–100%) at most recent radiographic review that averaged 11 years (5.6–18.6yrs). Overall, the total number of subjects with hip displacement measuring MP >40% or who had a surgical hip intervention, by GMFCS level, was: 0 (0%) at level I, 0 (0%) at level II, 20 (45%) at level III, 22 (59%) at level IV, and 5 (81%) at level V. The incidence of hip displacement in children with CP post-SDR did not substantially differ from the overall incidence reported in the literature when evaluated by GMFCS level. This study is the largest long-term follow-up study investigating the effect of hip displacement post-SDR. Results suggest that SDR does not impact hip displacement in CP, however, further prospective study will be required to strengthen the evidence in this regard

Hip displacement, defined in this study as a migration percentage (MP) of more than 40%, is a common, debilitating complication of cerebral palsy (CP). In this prospective study we analysed the risk of developing hip displacement within five years of the first pelvic radiograph. . All children with CP in southern and western Sweden are invited to register in the hip surveillance programme CPUP. Inclusion criteria for the two groups in this study were children from the CPUP database born between 1994 and 2009 with Gross Motor Function Classification System (GMFCS) III to V. Group 1 included children who developed hip displacement, group 2 included children who did not develop hip displacement over a minimum follow-up of five years. A total of 145 children were included with a mean age at their initial pelvic radiograph of 3.5 years (0.6 to 9.7). The odds ratio for hip displacement was calculated for GMFCS-level, age and initial MP and head-shaft angle. A risk score was constructed with these variables using multiple logistic regression analysis. The predictive ability of the risk score was evaluated using the area under the receiver operating characteristics curve (AUC). . All variables had a significant effect on the risk of a MP > 40%. The discriminatory accuracy of the CPUP hip score is high (AUC = 0.87), indicating a high ability to differentiate between high- and low-risk individuals for hip displacement. The CPUP hip score may be useful in deciding on further follow-up and treatment in children with CP. Cite this article: Bone Joint J 2015;97-B:1441–4

Total Hip Arthroplasty (THA) and Hip Hemiarthroplasties (HA) are successful, cost-effective procedures that improve quality of life. Dislocation is a well recognised complication with a significant health and economic burden. We aim to establish the current management practices across the United Kingdom (UK) for Prosthetic Hip Dislocations (PHD). Our definition of a PHD includes; THA, HA and revision THA. This national study builds on our regional pilot study and records one of the largest datasets of Prosthetic Hip Dislocation management within the UK. A trainee-led collaborative; the North West Orthopaedic Research Collaborative (NWORC). Conducted a retrospective audit, registered as Quality Improvement (QI) projects, collected data from 38 hospital trusts across the UK. Data was collected on patient-related factors, inpatient management, and outpatient follow up of each PHD episode between January and July 2019. Primary outcome measured definitive management, in the form of revision surgery or the consideration for this through a referral pathway. A total of 673 (THA 504, Revision THA 141, HA 28) patients were included with a total of 740 dislocation episodes. Mean age was 75.6 years with female to male ratio 2:1. The majority of PHDs were a result of a low energy mechanism (98.7%) and presented over 6 months post index procedure (80.5%). Over half (53.8%) attended with a first or second time dislocation. Only 29.9% patients received onward revision referral; whereas 70.1% followed diverse management patterns, including local non-arthroplasty and primary arthroplasty surgeon follow-ups. Revision THAs had higher rates of referral for revision (p<0.001) compared to primary THA and HA dislocations. A high number of PHDs present across the UK, with under a third receiving definitive management plans. This variation increases the economical burden to the National Health Service, highlighting the need for national guidance to manage these complex patients

To estimate the clinical and economic burden of primary total hip arthroplasty (THA) dislocation in England. Retrospective propensity score-matched evaluation of patients with and without dislocation following primary THA using the UK Clinical Practice Research Datalink linked and Hospital Episode Statistics datasets with a 2-year follow-up. 13,044 patients with total hip replacements met the inclusion criteria (mean age 69.2, 60.9% female) of which 154 (1.18%) suffered at least one postoperative hip dislocation. The mean number of dislocations per patient was 1.44 with a maximum of 4. Approximately one-third of the patients with dislocation (32.5%) had more than one dislocation. Among patients with a hip dislocation 148 patients (96.7%) had at least one closed reduction and 20 patients (13.1%) had revision surgery. Two-year median direct medical costs were £14,748 (95% confidence interval [CI] £12,028 to £20,638) higher with vs. without dislocation (+227%). On average, patients with a dislocation had significantly greater healthcare resource utilization and significantly less improvement in EuroQol-5D (EQ-5D) index (0.24 vs. 0.45; p<0.001) and Visual Analogue Scale (VAS) (1.58 vs. 11.23; p=0.010) scores and Oxford Hip Scores (13.02 vs. 21.98; p<0.001). This is the first study to estimate the economic burden of dislocation in the UK throughout the entire patient pathway. Dislocation following total hip replacement is a costly complication, both in terms of economic costs and to the functional quality of life of the patient. Efforts to reduce the risks of dislocation should remain at the forefront of hip research

Total Hip Replacements (THR) and Hip Hemiarthroplasties (HA) are both successful and common orthopaedic procedures. Dislocation is a well-recognised complication carrying significant morbidity and, in some cases, increased mortality risks. We define prosthetic hip dislocations (PHDs) to include both THRs and HAs. Prosthetic Hip Dislocations (PHDs) are a common acute admission yet there are no published guidelines or consensus on management following reduction. A retrospective audit was undertaken by the North West Orthopaedic Research Collaborative (NWORC) between January 2019 and July 2019. A questionnaire was used to capture the management of each dislocation episode presenting to 11 Hospital trusts. The study was registered as a Quality Improvement (QI) project at each site. Data regarding the surgical management physiotherapy input, ongoing care and further management plans were recorded. A total of 183 patients with 229 dislocations were submitted for initial analysis (171 THRs, 10 HAs, 2 PFRs). Female to male ratio was 2:1 with mean age of 76.7 years. Average time to first dislocation was 8.1 years. 61.1% were first or second time dislocators and 38.9% presented with 3 or more dislocations. Initial reductions were predominantly attempted in theatre (96.5%, n=221) with only 3.5% (n=8) attempted in the emergency department. In theatre 89% (n=201) were reduced closed. There was no plan for revision surgery in 70.6% cases with no difference seen between patients with >=3 dislocations and <=2 dislocations. Of the patients with a revision plan, 71% of these were performed or planned locally. The high number of patients with 3 or more dislocations and the lack of plans for definitive interventions in the majority of cases highlights the significant variation in the management of this complex group of patients. This variation in the quality of care increases the burden on the National Health Service through repeat hospital episodes. We aim to roll out this study nationally to assess regional variations and ultimately make the case for national guidance on the management of prosthetic hip dislocations

Aims. The purpose of this study was to compare the prevalence of hip displacement and dislocation in a total population of children with cerebral palsy (CP) in Scotland before and after the initiation of a hip surveillance programme. Patients. A total of 2,155 children with CP are registered in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme, which began in 2013. Physical examination and hip radiological data are collected according to nationally agreed protocols. Methods. Age, Gross Motor Function Classification System (GMFCS) level, subtype of CP, migration percentage (MP), and details of hip surgery were analyzed for all children aged between two and 16 years taken from a time of census in March 2019 and compared to the same data from the initial registration of children in the CPIPS. Displacement of the hip was defined as a MP of between 40% and 99%, and dislocation as a MP of 100%. Results. A total of 1,646 children were available for analysis at the time of the census and 1,171 at their first registration in CPIPS. The distribution of age, sex, and GMFCS levels were similar in the two groups. The prevalence of displacement and dislocation of the hip before surveillance began were 10% (117/1,171) and 2.5% (29/1,171) respectively, and at the time of the census were 4.5% (74/1,646) and 1.3% (21/1,646), respectively. Dislocation was only seen in GMFCS levels IV and V and displacement seen in 90.5% (67/74) of these levels and 9.5% (7/74) in levels I to III. In total, 138 children had undergone hip surgery during the study period. The hip redisplaced after the initial surgery in 15 children; seven of these had undergone a second procedure and at the time of the census the hips in all seven had a MP < 40. Conclusion. Hip surveillance appears to be effective and has reduced the prevalence of hip displacement by over half and dislocation almost by half in these children. Cite this article: Bone Joint J 2020;102-B(3):383–387

The October 2023 Children’s orthopaedics Roundup. 360. looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast

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

Objective. To define the common pathology of the hips with irreducible posterior dislocation combined with femoral head fracture and the outcome of surgical treatment using surgical hip dislocation technique. Design: retrospective observational clinical study. Setting: Level III referral trauma center. Patients/Participants: from January 2011till February 2014 five patients with irreducible posterior hip dislocation and femoral head fracture who underwent operation were included and they followed for at least 18 months. Intervention. Open reduction and internal fixation of fractured femoral head and labral repair by suture anchors using surgical hip dislocation through trochanteric flip osteotomy approach. Main Outcome Measures: Clinical and radiographical findings of the irreducible posterior hip dislocation, intraoperative findings, clinical outcomes using Merle d'Aubigné & Postel and Thompson & Epstein scores, and radiological outcome. Results. All patients presented clinically with a shortened lower limb in neutral or external rotation of the hip (not in Internal rotation). All were Pipkin type II fracture of femoral head with the intact part of the head buttonholed on the posterior wall of the acetabulum through a capsule-labral flap. Postoperative computed tomography revealed perfect reduction except one case with severe comminution with good reduction. Only one patient with delayed operative management developed avascular necrosis and underwent total hip arthroplasty. Conclusion. Irreducible femoral head fracture-dislocation is rare injury with different clinical presentation that shows neutral or externally rotated limb and optimal surgical management is not clear. Surgical hip dislocation gives full access to the femoral head for reconstruction and opportunity to direct repair of the labral tears

Traumatic hip dislocation is a rare injury in orthopaedic practice and typically occures in high energy trauma. The goal of this study was to analyze hip morphology in patients with low energy traumatic hip dislocations and to compare it with a control group. We performed a retrospective comparative study. The study group included 45 patients with 45 traumatic posterior hip dislocation. Inclusion criteria were traumatic hip dislocation with simple acetabular rim or Pipkin I or II fracture. Traumatic dislocations combined with other acetabular or femoral fractures were excluded. The control group consisted of 90 patients (180 hips) that underwent radiographic examination for urogenital indication and had no history of hip pain. Hip morphology was assessed on antero-posterior and axial views. The study group showed significantly increased incidence (p<0.001) of positive cross-over sign (82% vs. 27%) with a increased retroversion index (26 ± 17 [0–56] vs. 6 ± 12 [0–53]), positive ischial spine sign (70% vs. 34%), and positive posterior wall sign (79% vs. 21). Hips that underwent an low energy posterior traumatic hip dislocation show significanly more radiographic signs for acetabular retroversion compared to a control group. Therefore, acetabular retroversion seems to be a contributing factor for posterior traumatic hip dislocation

To investigate the clinical results of capsular arthroplasty in the treatment of young patients with unilateral hip dislocation. We retrospectively evaluated all patients who had the capsular arthroplasty from June 2012 to September 2016 in our department. Hips were evaluated using hip Harris score (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The Tonnis osteoarthritis grade and Severin classification were used to access the radiographic outcomes. Fifty-nine patients (10 males and 49 females) with an average of 16.8y (range: 8–26y) were followed by a mean of 32.1 months (range: 12.5–66.0 months). The mean HHS was 83.4 (range: 31.2–99) and WOMAC score was 12.3 (range: 0–49) at the final follow up. Multivariate analysis revealed that the poor capsular quality (OR=8.29) was associated with the poor result. The thicker capsule (OR=0.83) and bigger femoral head (OR=0.73) were associated with the good result. There were 15 patients (25.4%) identified as Tonnis grade 0, 21 patients (35.6%) as grade 1, 18 patients (30.5%) as grade 2 and 5 patients (8.5%) as grade 3. According to Severin classification, 28 patients (47.6%) were regarded as class I, 22 patients (37.3%) as II, 7 patients (11.9%) as III and 2 patients (3.4%) as IV. One patient underwent THA after 41.5 months. The joint stiffness was the most common complication (10.2%). We confirmed the efficacy of the capsular arthroplasty in the treatment of young patients with unilateral hip dislocation. The capsular quality and the size of femoral head were associated with the clinical results

Background. Dislocation is a common complication following total hip arthroplasty (THA), and accounts for a high percentage of subsequent revisions. The purpose of this study was to develop a convolutional neural network (CNN) model to identify patients at high risk for dislocation based on postoperative anteroposterior (AP) pelvis radiographs. Methods. We retrospectively evaluated radiographs for a cohort of 13,970 primary THAs with 374 dislocations over 5 years of follow-up. Overall, 1,490 radiographs from dislocated and 91,094 from non-dislocated THAs were included in the analysis. A CNN object detection model (YOLO-V3) was trained to crop the images by centering on the femoral head. A ResNet18 classifier was trained to predict subsequent hip dislocation from the cropped imaging. The ResNet18 classifier was initialized with ImageNet weights and trained using FastAI (V1.0) running on PyTorch. The training was run for 15 epochs using ten-fold cross validation, data oversampling and augmentation. Results. The hip dislocation prediction classifier achieved the following mean performance: accuracy= 49.5(±4.1)%, sensitivity= 89.0(±2.2)%, specificity= 48.8(±4.2)%, positive predictive value= 3.3(±0.3)%, negative predictive value= 99.5(±0.1)%, and area under the receiver operating characteristic curve= 76.7(±3.6)%. Saliency maps demonstrated that the model placed the greatest emphasis on the femoral head and acetabular component. Conclusions. Existing prediction methods fail to identify patients at high risk of dislocation following THA. Our prediction model has high sensitivity and negative predictive value. Therefore, it can be helpful in rapid assessment of risk for dislocation following THA. The model further suggests radiographic locations which may be important in understanding the etiology of prosthesis dislocation

We investigated the preliminary results of femoral head necrosis treated by modified femoral neck osteotomy through surgical hip dislocation in young adults. 33 patients with femoral head osteonecrosis received modified femoral neck osteotomy through surgical hip dislocation from March 2015. 14 patients who had minimal 12 months of follow-up were reviewed radiographically and clinically (mean follow-up:16 months, 12–36 months). The mean age of the patients 32 years at the time of surgery (ranged from 16 to 42years). There were 6 women and 8 men. The cause of the osteonecrosis was steroid administration in 6, alcohol abuse in 4, trauma in 3, and no apparent risk factor in 1. According to the Ficat staging system, 1 hips was stage II, 9 hips III, and 4 hips stage IV. The posterior or anterior rotational angle was 90–180° with a mean of 143°. Clinical evaluation was performed in terms of pain, walk and range of motion on the basis of Merle d'Aubigné hip scores: 17–18 points are excellent, 15–16 are good, 13–14 are fair, 12 or less are poor. Recollapse of the final follow-up anteroposterior radiograph was prevented in 13 hips. One patient got 1 mm recollapse 18 months after surgery. No patient got progressive joint space narrowing. The Merle d'Aubigné score was excellent in 7 hips, good in 5, fair in 2. The preliminary results suggest that modified femoral neck osteotomy through surgical hip dislocation is in favor of young patients. But longer term follow-up is necessary

Purpose. This study re-examined the influence of the head shaft angle (HSA) on hip dislocation in a large cohort of children with cerebral palsy (CP). Method. The radiographs of GMFCS Level III – V children from a surveillance programme database were analysed and migration percentage (MP) and HSA measured. The first radiograph of each patient was taken to remove the effect of the surveillance programme. The most displaced hip in each child, by MP, was used for analysis and the corresponding HSA measured. Hip displacement was defined as MP > 40% and logistic regression was used to adjust for HSA, GMFCS, age and sex. Results. 640 children were eligible (271 female (42.3% ), 369 male (57.7% ), mean age 8.2 years, GMFCS III: 160 (25% ), GMFCS IV: 184 (28.75% ), GMFCS V: 296 (46.25% ). 118 children (18.44% ) had a MP > 40% and mean HSA was 160° (range 111 – 180°). Statistical analysis showed that an increasing HSA was associated with hip displacement (odds ratio of 1.02 for a 1° change). A 10° difference in HSA between two patients of the same age, sex and GMFCS gave odds of 1.26 of the patient with the higher HSA having hip displacement. Age and sex had no influence in this model, while a high GMFCS-level was a strong risk factor. Conclusion. Chougule et al found no correlation between HSA and hip migration in children with CP using linear regression analysis. However, the relationship between these variables is not linear. The present study independently confirms an earlier study that HSA is a risk factor for hip displacement in GMFCS III-V children

Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP. This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire. Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2]. In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP

Introduction & Objective. Labral refixation has established as a standard in open or arthroscopic treatment for femoroacetabular impingement (FAI). The rationale for this refixation is to maintain the important suction seal in the hip. To date, only few short-term results are available which indicate a superior result in FAI hips with labral refixation compared to labral resection. Scientific evidence of a beneficial effect of labral refixation in the long-term follow-up is lacking. Aim of this study was to evaluate if labral refixation can improve the cumulative 10-year survivorship in hips undergoing surgical hip dislocation for FAI compared to labral resection. Methods. We performed a retrospective comparative study of 59 patients treated with surgical hip dislocation for symptomatic FAI between December 1998 and January 2003. We analyzed two matched groups: The ‘resection’ group consisted of 25 hips that were treated consistently by excision of the damaged labrum. The ‘refixation’ group consisted of 34 hips that were treated with labral reattachment. Correction of the osseous deformity (rim trimming/femoral osteochondroplasty) did not differ between the two groups. We then evaluated the clinical (Merle d'Aubigné score) and radiographical results (according to Tönnis) at a follow-up of ten years. We calculated a cumulative Kaplan-Meier survivorship curve with the following factors as endpoints: conversion to total hip arthroplasty (THA), radiographic evidence of osteoarthritis progression, or a poor clinical result (defined as Merle d'Aubigné score of less than 15). The two curves were compared using the Log-rank test. Results. Hips with labral refixation had a significantly higher survivorship (78%, 95% confidence interval [CI] 64–92%) at ten years compared to labral resection (46%, 95% CI 26–66, p=0.008). 7 (20.6%) patients in the refixation group reached an endpoint: 2 with THA; 5 with a poor clinical result, and 5 with progression of OA. 15 (60.0%) patients in the resection group reached an endpoint: 3 with THA; 12 with a poor clinical result, and 4 with progression of OA. Conclusion. This is the first study proving that labral refixation leads to significantly better results in patients 10 years after open surgical hip dislocation for FAI. It seems advisable to preserve the labrum in this patient population whenever possible

Aim: This study was performed to review the early results of the use of a semi-constrained acetabular component in the treatment of recurrent hip dislocation at Palmerston North Hospital. Method: A retrospective case study of patients who underwent acetabular component revision with a semi-constrained cup for recurrent dislocation of the hip was performed. Results: Between April 1999 and July 2000, 10 patients with an average age of 75 years underwent acetabulum revision with a semi-constrained cup. There was an average of four dislocations before revision surgery, per patient. At follow-up between three and 18 months after the revision, there had been no dislocations. Aggressive post-operative rehabilitation was permitted, allowing discharge at an average of seven days postoperatively. Conclusion: The use of a semi-constrained acetabular cup was successful as a means of treatment for recurrent hip dislocation. This is an early review of the use of the implant. There are no published data on long term survival of this implant. The semi-constrained cup provides a simple yet effective option for dealing with the elderly recurrent hip dislocation

Aim. To assess the risk of hip dislocations in children with cerebral palsy (CP) attending special schools, and the effects of preventative soft tissue surgery (psoas and adductor tenotomy). Method. 110 children were reviewed from 1985-2000. Severity of CP was graded according to the Gross Motor Function Classification System (GMFCS). Hemiplegics - grade 1, Diplegics grades 2 & 3, Quadriplegics grades 4 & 5. Patients were grouped into age groups 5, 10 and 15 years and the number of hip dislocations in each group were noted. Numbers of patients who had preventative soft tissue surgery was also noted. Indication for surgery, >35% femoral head uncovering. Results. Percentage of dislocations increased with CP severity. At 15 years, no dislocations in GMFCS 2, 6% GMFCS 3, 19% GMFCS 4 and 40% in GMFCS 5. The number of patients with at least 1 hip dislocation increased with age at all age groups. GMFCS 4 (age 5 yrs 9%, age 10 yrs 20% and 15 yrs 30%). GMFCS 5 (age5 yrs 22%, age 10 yrs 48% and age 15 yrs 50%). By 15 years, 54 hips in GMFCS 2 & 3 (diplegics), preventative soft tissue surgery had not reduced chances of hip dislocation; only 1 dislocated (2%). In GMFCS 4 & 5 (quadriplegics), dislocations reduced from 40% in those without surgery to 26% in those who had preventive soft tissue surgery. This was particularly so in GMFCS 5 where there was a reduction from 83% dislocation without surgery to 33% with soft tissue preventive surgery. Conclusions. Preventive soft tissue surgery was effective in reducing the rate of hip dislocation in quadriplegic CP especially GMFCS 5

Objective: The presentation of mid-term results of porous tantalum TMT cup in congenital high hip dislocation. Materials and Methods: Between November 1997 and December 2000, we performed 27 total hip replacements in 22 women patiens suffering from high congenital hip dislocation according Xartofilakidis classification. The acetabular component was implanted at the true acetabular bed with restoration of the centre of hip rotation. Clinical and radiological observation took place in regular intervals for an average time of 10.2 years (8.5–12 years). Results: The average Harris Hip Score improved from 48.3 preoperatively (range 15–65) to 89.5 at the latest follow-up (56–100). Oxford hip score declined from 49.5 preoperatively to 21.2 at the first year and to 15.2 at five years examination. The absolute acetabular component’s migration was evaluated by EBRA method in the first 2 years and was at average 0.85 mm at the first year and 1.05 mm at the second year. An incident of gross initial migration was observed. No acetabular revision was performed and there was no case of mechanical loosening. Conclusion: The acetabular TMT component is highly adhesive and porous with a modulus of elasticity close to subchondral bone. It promotes initial stability, induces bone penetration and integration and offers a more “physiologig” load transfer. It also offers adequate polyethylene thickness, even in the smallest sizes, due to its manufacturing. The recent results from its use in high hip dislocation are excellent and justify the further study of longevity and probably the superiority of this material

Two cases of assymptomatic hip dislocation discovered incidentally are presented. Case 1- A 63-year old lady had an uncemented primary total hip replacement of the left hip for painful osteoarthritis in July 1993. She made an uneventful recovery post-operatively. This lady had no neurological abnormality and was mobilising independently. In April 2001,8 years later she was admitted as an emergency for suspected diverticulitis of the colon. Plain radiographs performed showed dislocated hip prosthesis. Case 2- This 75-year old lady, an active farmer, had right hip arthroplasty in July 1990 for painful osteoarthritis and made an uneventful recovery subsequently. She also did not have any neurological abnormality and was mobilising independently too. Dislocated prosthesis was discovered radiologically in December 2001 during a pre-operative work-up for the left hip (the other hip) arthroplasty. Discussion: Late dislocation is more common than was thought previously. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. It can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurological abnormality, trauma or polyethylene wear), or it can occur in association with combination of these factors. Both these patients were mobilising independently and did not suffer from any neurological abnormality. Both these patients had asked to be discharged after an initial 2-year follow-up. They had not experienced any problem with the hip replacement. These dislocated prosthesis were discovered incidentally. Revision arthroplasty was carried out successfully in both these patients. These cases emphasise the need for long-term clinical and radiological follow-up in hip arthroplasty patients as hip dislocations can be assymptomatic and not detected by clinical examination. Radiological review alongside evaluation using scoring systems is recommended

Introduction. Magnetic resonance imaging with intraarticular contrast (arthro-MRI) and radial cuts is the gold standard to quantify labral and chondral lesions in the setting of femoroacetabular impingement. To date, no study exists that has evaluated these findings as potential predictors of outcome for the long term follow-up after surgical treatment of FAI. Objectives. The purpose of this study was to detect potential predictors for failure after surgical hip dislocation for FAI based on specific preoperative arthro-MRI of the hip at a minimum follow-up of 10 years. Methods. Retrospective case series of 97 hips (75 patients) undergoing surgical hip dislocation for FAI between July 2001 and March 2003. Minimum follow-up was 10 years. Twelve radiographic factors were preoperatively evaluated on specific arthro-MRIs with radial cuts of the hips. Patients were then evaluated clinically and radiographically at latest follow-up (mean followup of 11 years, range 10–13 years). The following endpoints were chosen: conversion to total hip arthroplasty (THA), radiographic evidence of progression of osteoarthritis (OA), and/or a Merle d'Aubigné-Postel score of less than 15 indicating a poor clinical result. Univariate and multivariate Cox-regression analysis were performed with these endpoints as failures. Results. Hips with failure at 10-year follow up after surgical hip dislocation where more likely to show typical signs like decentration of the femoral head (52.9% compared to 17% in hips with good long term outcome; p = 0.007) in preoperative arthro-MRI evaluation. The strongest arthro-MRI based predictors of failure at the 10 year follow-up were a ‘double fond’ (hazard ratio with 95% confidence interval, 3.4 [3.2–3.7], p = 0.001), decentration of the femoral head (3.0 [2.8–3.3], p = 0.004) and posterior-inferior femoral osteophytes (3.3 [3.1–3.6], p = 0.002). Conclusions. Factors like double fond, decentration of the femoral head and postero-inferior femoral osteophytes in preoperative arthro-MRI predict inferior long term outcome after surgical hip dislocation for FAI. Therefore we recommend preoperative evaluation with arthro-MRI in addition to conventional radiography

The purpose of the study was to assess the accuracy of prereduction and postreduction obturator oblique radiographic views in the diagnosis of simple posterior hip dislocation, and to ascertain whether, in differentiating simple posterior hip dislocations from fracture dislocation, obturator oblique views are a safe diagnostic tool in the hands of junior registrars, trauma officers and community service doctors. A sample group of prereduction and postreduction radiographs of patients who had sustained posterior hip dislocations (Thompson and Epstein type I to III) was collected. All patients then had CT scans of the hip to confirm the plain radiographic findings. Shown only the radiographs, all junior doctors involved in the study correctly differentiated between simple posterior hip dislocations and fracture dislocations. This has implications for savings in both time and money. If CT scans are unnecessary in simple posterior hip dislocation, the need for transfer and tertiary level hospitalisation is obviated

Introduction:. A surgical hip dislocation provides circumferential access to the femoral head and is essential in the treatment pediatric and adult hip disease. Iatrogenic injury to the femoral head blood supply during a surgical may result in the osteonecrosis of the femoral head. In order to reduce vessel injury and incidence of AVN, the Greater Trochanteric Osteotomy (GTO) was developed and popularized by Ganz. The downside of this approach is the increased morbidity associated with the GTO including non-union in 8% and painful hardware requiring removal in 20% of patients. (reference) Recent studies performed at our institution have mapped the extra-osseous course of the medial femoral circumflex artery and provide surgical guidelines for a vessel preserving posterolateral approach. In this cadaveric model using Gadolinium enhanced MRI, we investigate whether standardized alterations in the postero-lateral surgical approach may reliably preserve femoral head vascularity during a posterior surgical hip dislocation. Methods:. In 8 cadaveric specimens the senior author (ES) performed a surgical hip dislocation through the posterolateral approach with surgical modifications designed to protect the superior and inferior retinacular arteries. In every specimen the same surgical alterations were made using a ruler: the Quadratus Femoris myotomy occurred 2.5 cm off its trochanteric insertion, the piriformis tenotomy occurred at its insertion and extended obliquely leaving a 2 cm cuff of conjoin tendon (inferior gemellus), and the Obturator Externus (OE) was myotomized 2 cm off its trochanteric insertion. (Figure 1) For the capsulotomy, the incision started on the posterior femoral neck directly beneath the cut obturator externus tendon and extending posteriorly to the acetabulum. Superior and inferior extensions of the capsulotomy ran parallel to the acetabular rim creating a T-shaped capsulotomy. After the surgical dislocation was complete, the medial femoral circumflex artery (MFCA) was cannulated and Gadolinium-enhanced MRI performed in order to assess intra-osseous femoral head perfusion and compared to the gadolinium femoral head perfusion of the contra-lateral hip as a non-operative control. Gross-dissection after polyurethane latex injection in the cannulated MFCA was performed to validate MRI findings and to assess for vessel integrity after the surgical dislocation. Results:. In 8 cadaveric specimens MRI quantification of femoral head perfusion was 94.3% and femoral head-neck junction perfusion was 93.5% compared to the non-operative control. (Figure 2) Gross dissection after latex injection into the MFCA demonstrated intact superior and inferior retinacular arteries in all 8 specimens. (Figure 3). Discussion and Conclusions:. In this study, perfusion to the femoral head and head-neck junction is preserved following posterior surgical dislocation through the postero-lateral approach. These preliminary findings suggest that specific surgical modifications can protect and reliably maintain vascularity to the femoral head after surgical hip dislocation. This approach may benefit hip resurfacing and potentially decease risk of femoral neck fracture secondary to osteonecrosis. In addition this may allow a vascular preserving surgical hip dislocation to be performed without the need for a GTO

Purpose: The prognosis of congenital hip displacement basically depends on the time of diagnosis and treatment. Recognising high-risk hips early remains a number one priority. We conducted a prospective study over a 20-year period from 1992 to 2002 to analyse the epidemiology of congenital hip displacement. Material and methods: The series included 1056 children with congenital hip disease (1491 hips). Epidemiological data, ultrasound and x-ray findings were recorded over 20 years. The objective was to identify risk factors and evaluate the impact of prevention measures. Results: The sex ratio showed female predominance, 6:1. The left hip was involved 1.8 times more often, with 41% bilateral involvement. Risk factors were major: family history (31%), breech presentation (25%), postural syndrome (12%); or minor: primiparity (54.4%), birth weight > 4 kg (9.2%). One or more major risk factors were found in 60.5% of the children and 30% had at least one minor risk factor. No risk factor was found in 40%. Screening efficacy improved with a rate of diagnosis before 4 months of 59% in 1983 and 96% in 2002. The number of hips discovered after the age of one year was 15% in 1983 and 6% in 2002. Discussion: The severity of the hip displacement is not influenced by risk factors nor bilateral involvement. Screening has enabled earlier diagnosis with a 37% increase in the rate of identification before the age of four months. This has been made possible by a systematic examination at birth and ultrasonography introduced in 1989. Conclusion: A regional map showing the paediatrician : maternity : general practitioner distributions is an important tool for screening campaigns. Despite adequate screening 40% of these children do not have any risk factor. Repeated examinations, communication and information exchange between healthcare professionals are the keys to success

Aims

The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study.

Introduction In an attempt to decrease the incidence of posterior hip dislocation following a posterior approach, a simple capsulorrhaphy was utilized in 255 consecutive primary total hip arthroplasties performed by one surgeon. Methods All patients were reviewed at a minimum of two years post-operatively and no patient was lost to follow-up. One patient sustained a posterior hip dislocation, while there were no anterior hip dislocations. The dislocation rate of 0.39 is equal to or less than the rates of dislocation reported in the literature using a direct lateral approach. Conclusions We postulate that this capsular repair creates not only a static restraint but also a capsule and gluteus medius mediated proprioceptive feedback to guard against extremes of internal rotation of the hip

Purpose. Surgical dislocation is useful for assessing and treating proximal femoral hip deformities. Legg-Calv Perthes disease (LCPD) causes proximal femoral growth deformity, resulting in reduced femoral head-neck offset and femoracetabular incongruity. The purpose of this study was to demonstrate the efficacy and report the short-term results of surgical hip dislocation for the treatment of adolescents with healed LCPD. Method. This retrospective review included 29 adolescents [19 males and 10 females, age 17 (range nine-35)] with LCPD, who underwent surgical hip dislocation between January 2001 and December 2009. All subjects had a clear diagnosis of LCPD, pre and postoperative WOMAC scores and at least one year of clinical and radiographic follow up. In addition to surgical dislocation, all patients underwent femoral head-neck osteoplasty, 21 underwent relative femoral neck lengthening and trochanteric transfer, 12 underwent intertrochanteric osteotomy and seven had labral debridement. The average follow-up was three years from the time of surgical intervention. Results. Postoperative WOMAC scores improved globally for pain, stiffness and function (p<0.0001, p<0.0004 and p<0.0009 respectively). Eight patients required additional surgical procedures after surgical dislocation (one periacetabular osteotomy, one flexion intertrochanteric osteotomy, one arthrotomy, five arthroscopies with labral/cartilage debridement. Three patients underwent total hip arthroplasties during the follow-up period and were considered failures. Two of the 29 patients experienced superficial wound complications. Conclusion. Surgical dislocation is an effective technique for the treatment of proximal femur deformity associated with LCPD. In the short-term, patients experience improved symptoms and function from this procedure

Heterotopic ossification is a recognised complication of surgery on the hip joint that can adversely affect the outcome. The aim of this study was to determine the incidence of heterotopic ossification following surgical hip dislocation and debridement for femoro-acetabular impingement using Ganz trochanteric flip osteotomy approach. We also compared the incidence of heterotopic ossification between two subgroups of patients; in the first group, a shaver burr was used to reshape the femoral head and in the second group, an osteotome was used. Methods: We reviewed postoperative radiographs of all patients who underwent surgical hip dislocation and debridement during the period between March 2003 and July 2007. We excluded patients with radiographic follow-up of less than one year. Brooker classification was used to grade heterotopic ossifications. Results: Ninety eight patients (mean age 35 years, range 12–65 years) were included with a mean radiological follow-up of 23 months (range 12–61 months). The overall incidence of heterotopic ossification was 31%. None of the patients developed Brooker grade III or IV heterotopic ossifications. The incidence of heterotopic ossifications in the shaver burr group (n=57) and in the osteotome group (n=41) was 30% and 32%, respectively. Conclusions: Heterotopic ossification of minor grade is a common complication of surgical hip dislocation using trochanteric flip osteotomy approach. The use of a shaver burr did not result in higher rates of heterotopic ossifications despite the formation of large amounts bone debris

Management of the young adult hip pathologies is a special entity in orthopaedic surgical practice that needs special emphasis and consideration. A wide range of pathological and traumatic conditions occur in the young adult hip that lead to functional disability and the development of premature osteoarthritis. Proper surgical interference when the hip is still in the pre-arthritic stage restores function to the young hip and protects it from early degenerative changes, and hence the anticipated need for future joint replacement surgery is prevented. Accurate estimation of the biomechanical error combined with careful understanding of the hip joint biology is the cornerstone of success of any hip preservation surgery ever performed to save the young adult hip. Safe surgical hip dislocation approach was adopted as one of the tools in the hands of the hip preservation surgeon to treat a broad spectrum of intra-articular hip pathologies like Perthes disease and severe forms of slipped capital femoral epiphysis (SCFE). Osteo-chondroplasty at the head-neck junction with relative femoral neck lengthening for Perthes disease, and Subcapital re-orientation of severe SCFE based on its retinacular vascular pedicle are often performed via the surgical hip dislocation approach. The approach is also useful with certain types of acetabular fractures that enables fixation of dual-column fractures via single approach with intra-articular visualization for the accuracy of reduction and hardware placement. The 4 cm mini-open direct anterior approach is ideal for the surgical treatment of cases with cam and/or pincer types of femoro-acetabular impingement. Peri-articular osteotomies performed either on the acetabular or the femoral sides of the hip joint are extremely useful in the correction of the biomechanical error that led to an existing hip pathology. Periacetabular osteotomies are commonly performed to treat dysplasia of the young hip. Proximal femoral osteotomies are commonly performed to treat a wide range of hip pathologies including non-unions of femoral neck fractures in the young adult. Correction of the biomechanical error at the proper timing ensures normalization of the hip joint loading conditions and range of motion that leads to reversal of the pathologic process and prevention of osteoarthritis. A hip joint replacement would have an unknown but certainly a finite life, whereas a young hip that has healed after hip preservation surgery would definitely last for a lifetime

Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis. In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient. The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up. In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising

Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure

Background. Acetabular fractures occur as a result of high-velocity trauma and are often associated with other life threatening injuries. Approximately one-third of these fractures are associated with dislocation of the femoral head but there are only few studies documenting the long term outcomes of this group of acetabular fracture. Methods. This was undertaken at the Royal Infirmary of Edinburgh which provides the definitive orthopaedic treatment for all major trauma including all acetabular fractures for the South East of Scotland. We retrospectively reviewed patients who sustained an acetabular fracture associated with a posterior hip dislocation from a prospectively gathered trauma database between 1990 to 2010. Patient characteristics, complications and the requirement for further surgery were recorded. Patient outcomes were measured using the Oxford Hip score and Short Form SF-12 health survey. Results. A total of 99 patients were treated over a 24 year period. The mean age was 41.3 years. The majority were male (75%). Road traffic accidents were the most common mechanism of injury (47%). The most common Letournal & Judet classification was a posterior wall fracture. Complications such as Sciatic Nerve Palsy was 12.1%, DVT 3%, Infection 5%, Heterotopic ossification 6.1%, Avascular necrosis at 11.1% and 19.2% went on to have a total hip replacement. The mean Oxford Score for Native hip was 34.7 and 31.8 for those who converted to hip replacement. SF12 Physical score was was 40.3 and 39 for the native hips and converted hips respectively. And the SF12 Mental score was 45.5 and 44.9 for the native hips and converted hips respectively. Conclusions. This is the first study to present the long term outcomes following an acetabular fracture dislocation. Our study suggests there is considerable disability in this group of patients and the requirement for subsequent THR has inferior patient reported outcomes. Level of Evidence. Cohort study, Level 2B

Introduction: Total hip arthroplasty is problematical in the case of high hip dislocation. To reposition the hip, a femoral shortening osteotomy is necessary in order to prevent damage to the neurovascular structures. This paper describes the implantation of a small threaded cup and a cementless straight stem using a simple technique with a simultaneous, derotating and shortening osteotomy for the femur. Materials and Methods: In this study, 30 cementless primary total hip arthroplasties were performed in 27 patients with high hip dislocation, and clinically assessed at a mean follow-up of 5.1 years. Acetabular reconstruction was done with a cementless threaded cup, whereby the cup was medialized to ensure that at least one thread was anchored in the bone in order to achieve good primary stability. All radiographs were analyzed retrospectively. Results: A femoral shortening osteotomy was performed in all cases. The average duration of surgery was 116 minutes. One cup loosening and one stem loosening was observed. Kaplan-Meier survivorship analysis, with aseptic radiological loosening as the endpoint, predicted a survival rate of 96,6% at 5.1 years for the acetabular component and 96.6% for the stem. The mean Harris hip score for the unrevised hips improved from 28.7 points preoperatively to 81.2 points postoperatively. Femur fractures, pseudoarthroses, paresis and deep infections were not found. Conclusion: The surgical technique described enables the initial stable fixation of a threaded cup in the small acetabulum and of a standard prosthesis without additional osteosynthesis for the performed osteotomy. Additional advantages include a shorter duration of surgery, a lower complication rate and a more rapid consolidation of the osteotomy in comparison to other techniques. Despite a patient group with a low average age and comparatively high daily activity, hip reconstruction with a cementless, threaded cup and the use of a cementless, straight stem without additional osteosyn-thesis has produced a good mid-term outcome

The coronal plane lower limb alignment plays an important role in the occurrence and progression in knee osteoarthritis. There have been reports of the valgus knee in patients with unilateral developmental hip dislocation (UDHD) with the relatively small sample size. Besides, few studies have analyzed the lower limb alignment of the contralateral side. The purpose of our study was to identify the coronal plane alignment of both the ipsilateral and the contralateral lower limb in patients with UDHD and find out the difference between patients with Hartofilakidis type II and III. The radiographic data of all UDHD patients who met the inclusion criteria from March 2011 to February 2017 were retrospectively reviewed, including the hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), anatomical lateral distal femoral angle (aLDFA), mechanical proximal tibial angle (MPTA) and the lateral distal tibial angle (LDTA). Besides, the femoral torsion angle was measured on the images of CT scan. The average HKA was 3.42°(range: −4.3–12.8°) on the affected side, and −2.11°(range: −11.4–5.4°) on the contralateral side (P?0.0001). The valgus lower limb alignment on ipsilateral side was most frequently seen in both Hartofilakidis type II (20cases, 51.3%) and type III groups (25cases, 67.6%), whereas for the contralateral side, the neutral alignment in type II group (27 cases, 69.2%) and varus alignment in type III group (19 cases, 51.4%) were most commonly observed. Both the mLDFA (P?0.001) and aLDFA (P?0.001) of ipsilateral side were significantly smaller than those of contralateral side. The average femoral torsion angle was 37.9°(range: 10.4–64.4°) on the affected side, and 27.1°(range: 9.7–45.5°) on the contralateral side (P?0.001). In conclusion, UDHD patients may present with lower limb malalignment on both sides. The valgus lower limb alignment is the most common deformity on ipsilateral side, which is caused by increased femoral torsion angle as well as the decreased aLDFA. The patients with Hartofilakidis type III UDHD may be more prone to present varus alignment deformity than those with Hartofilakidis type II on the contralateral side. The lower limb malalignment and deformity of ipsilateral distal femur should be considered during any surgery involving hip, knee or femur

Total hip joint replacement (THJR) for high riding congenital hip dislocation (CDH) is often performed in young patients, and presents unique problems with acetabular cup placement and leg length inequality. A database and the NZ Joint Registry were used to identify 76 hips in 57 patients with a diagnosis of CDH who underwent THJR in the Wellington region between 1994 and 2015. Records and radiographs of 46 hips in 36 patients classified pre-operatively as Crowe II, III or IV were reviewed. Surgical technique used a direct lateral approach, the uncemented acetabular component was located in the anatomic hip center and a primary femoral stem was used in all but one hip. Whether a step-cut sub-trochanteric femoral osteotomy was performed depended on degree of correction, tension on the sciatic nerve, and restoration of leg length. For the 36 patients classified as Crowe II or higher, the average age at operation was 44 years (26 – 66), female:male ratio was 4.5:1 and follow-up averaged 10 years (2 – 22.3). Of the 15 hips classified as Crowe IV, 10 required a step-cut sub-trochanteric femoral osteotomy to shorten the femur, but 5 were lengthened without undo tension on the sciatic nerve. Nine Crowe IV hips received a conventional proximally coated tapered primary femoral component. Oxford hip scores for 76% of patients was excellent (> 41/48), and 24% had good scores (34 – 41). All femoral osteotomies healed. Five hips have been revised, one at 2 years for femoral loosening, one at 5 years for dislocation, two at 12 years for liner exchanges, and one at 21 years for femoral loosening. THJR using primary prostheses for CDH can provide durable long-term results

Introduction: Little data are available about the incidence and the management of hip dislocation following the implantation of megaprosthesis of the proximal femur, which is one of the main complications following this procedure. Material and Methods: 190 patients, who received a proximal femur KMFTR/GMRS at our institution between 1982 and 2007, were retrospectively reviewed with regard to the incidence of hip dislocation as well as the success rate of the subsequent surgical/non-surgical treatment. A proximal femur tumor endoprosthesis was used in 148 patients following the resection of a malignant tumor and in 43 patients in severe revision cases following total hip arthroplasty. The average age at the time of surgery was 48 [6a to 83a] in the tumor group and 57.3 [45a to 78a] in the revision group. All of the revision cases and 12 patients from the tumor group had additional revision cups, such as the Schoellner pedestal cup. Results: 12.3 % (18/147) of the tumor patients and 13.9% (6/43) of the revision cases dislocated at least once. 66.7% (12/18) of the first dislocations from the tumor and 50 % (3/6) of the revision group were treated with closed reduction, the rest required surgery. All patients received an abduction cast for at least 8 weeks. 38% (7/18) of the dislocated hips of tumor group (4.8% [7/147] total) and 67% (4/6) of the revision group (9.3% [4/43] total) experienced a second dislocation. 57% (4/7) of the dislocations from the tumor and 100 % (4/4) of the revision group were treated with closed reduction. Three patients from the tumor group (2% [3/147] total) experienced a total of three dislocations and one patient four dislocations (< 1% [1/147] total). The first dislocation occurred in 88% of the cases within 5 months following surgery during activities of daily living. 82% of the second dislocations and all third dislocations occurred within 4 months of the previous dislocation. Interestingly, no significant difference was found in the rate of re-dislocation between surgical and non-surgical treatment in either group. Discussion: Dislocation of a proximal femur tumor endoprosthesis is an early complication following surgery and continues to be a challenging condition to treat, especially in cases with extensive soft-tissue defects. Since 2000, a polyester ligament is successfully used in our institution as a reinforcement to reduce the risk of hip dislocation in proximal femur tumor endoprosthesis. Surgical and non-surgical methods to reduce the risk of hip dislocation are discussed

Background. Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21. We describe long-term outcomes following precise use of the femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation. Methods. All individuals with Trisomy 21, who had hip surgery at Toronto's Hospital for Sick Children between 1998 and 2008, were searched using the hospital databases. 16 hips in 9 children aged less than 10 years, were identified. All had a femoral varus derotation osteotomy (VDRO) with a target femoral neck shaft angle (NSA) of 105° and less than 20° external rotation. All were performed by the senior author JHW. The clinical notes and radiographs were reviewed from presentation to final follow up. Continuous variables were assessed for normality with the d'Agostino Pearson test. Normally distributed variables are presented as means with 95% confidence intervals. Pre and postoperative means were compared using the student's t-test for paired samples. Results. Mean age at first known hip dislocation was 4.56 years (3.98, 5.15), mean age at surgery 6.07 years (5.15, 7.0) and mean follow-up 5.4 years (3.75, 7.06). Mean femoral neck shaft angle (NSA) fell from 166.7° (162.2°, 171.1°) to 106.0° (103.1°, 110.2°). In 2 hips, significant intraoperative instability persisted and periacetabular osteotomies with capsulorraphies were required. All patients developed an asymptomatic waddling gait postoperatively. 14 hips developed peritrochanteric varus deformities, mean 20.7° (15.96°, 25.4°)2 (12.5%) sustained periprosthetic fractures 4 and 8 years postoperatively. 1 hip (6.2%) developed painful arthritis. None re-dislocated at latest follow up. Conclusion. Prevention of long term disabling pain from habitually dislocating or recurrently subluxed hips, in patients with Trisomy 21, requires surgical intervention to increase hip containment. We believe surgical management of habitually subluxed or dislocated Trisomy 21 hips allows for a predictable result. We recommend a varus producing proximal femoral osteotomy to correct the NSA to 105° with less than 20° of external rotation. This technique was successful at restoring and maintaining hip stability in 16 hips with a mean follow-up of 5.4 years, whilst maintaining the patient's ability to remain community ambulators. It should be performed before aged 8 or signs of a widened or V-shape teardrop develops. In our experience this has been effective in maintaining hip stability. However, little is known about the natural history of habitual hip dislocation in these children. Patients with Trisomy 21 are living longer with hips that are at continuous risk. Thought should be given to the potential benefits of periodic screening of this treatable hip condition

Purpose: The purpose of this study was to examine the arthroscopy findings in the hips of patient with persistent pain after surgical hip dislocation for femoroacetabular impingement syndrome. Type of study: Retrospective, consecutive series of patients. Patients and Methods: Sixteen consecutive patients (6 male/10 female; average age 33,5 years 19–60y) with persistent pain after surgical hip dislocation for the treatment of femoroacetabular impingement were included. At the index surgery, all patients had an osteo-chondroplasty of the head neck junction and a resection of the acetabular rim with reattachment of the labrum in 9 cases. All patients had a preoperative arthro-MRI and were treated with arthroscopy of the hip. Results: At arthroscopy all reattached labra were stable. In the cases without preservation of the labrum, the joint capsule was attached level with the acetabular rim and had important synovitis. All patients had adhesions between the neck of the femur and joint capsule or between labrum and capsule. In 3 patients the arthroscopic procedure was technically limited by massive thickening of the capsule. Overall 75% (12 of 16) patients showed less pain or were pain free. MDA improved from preoperatively 13 to 16 points at last follow up. Conclusions: Persistent pain after surgical dislocation of the hip could result from intraarticular adhesions that can be shown in the MRI. Hip arthroscopy after previous surgery can be demanding due to scarring. If the adhesions can be released good results can be achieved. Hip arthroscopy is a save therapeutical tool to treat patients with intraarticulary adhesions after surgical dislocation of the hip for femoroacetabular impingement

This study reports on the natural history of acetabular fracture dislocations. We retrospectively reviewed patients who sustained an acetabular fracture associated with a posterior hip dislocation from a prospective database. Patient characteristics, complications and the requirement for further surgery were recorded. Patient outcomes were measured using the Oxford Hip score and Short Form SF-12 health survey. A total of 99 patients were treated over a 24 year period. The mean age was 41 years. Open reduction and internal fixation was performed in the majority (n=87), 10 were managed conservatively following closed reduction and two underwent primary total hip replacement (THR). At a median follow up of 12.4 years (range 4–24 years) patient outcomes were available for 53 patients. 12 patients had died. 19 patients went onto have a THR as a secondary procedure, of which 11 had confirmed avascular necrosis. Median time to THR was 2 years (range 1–17 years). The mean Oxford hip score was 35 (range 2–48), SF-12 physical component score (PCS) was 40 and a third of the patients used a walking aid. In THR group the mean Oxford score was 32 (range 3–46), SF-12 PCS was 39 and almost all required a walking aid. This is the first study to present the long term outcomes following an acetabular fracture dislocation. Our study suggests there is considerable disability in this group of patients and the requirement for subsequent THR has inferior patient reported outcomes

Literature surrounding artificial intelligence (AI)-related applications for hip and knee arthroplasty has proliferated. However, meaningful advances that fundamentally transform the practice and delivery of joint arthroplasty are yet to be realized, despite the broad range of applications as we continue to search for meaningful and appropriate use of AI. AI literature in hip and knee arthroplasty between 2018 and 2021 regarding image-based analyses, value-based care, remote patient monitoring, and augmented reality was reviewed. Concerns surrounding meaningful use and appropriate methodological approaches of AI in joint arthroplasty research are summarized. Of the 233 AI-related orthopaedics articles published, 178 (76%) constituted original research, while the rest consisted of editorials or reviews. A total of 52% of original AI-related research concerns hip and knee arthroplasty (n = 92), and a narrative review is described. Three studies were externally validated. Pitfalls surrounding present-day research include conflating vernacular (“AI/machine learning”), repackaging limited registry data, prematurely releasing internally validated prediction models, appraising model architecture instead of inputted data, withholding code, and evaluating studies using antiquated regression-based guidelines. While AI has been applied to a variety of hip and knee arthroplasty applications with limited clinical impact, the future remains promising if the question is meaningful, the methodology is rigorous and transparent, the data are rich, and the model is externally validated. Simple checkpoints for meaningful AI adoption include ensuring applications focus on: administrative support over clinical evaluation and management; necessity of the advanced model; and the novelty of the question being answered.

Cite this article: Bone Joint J 2022;104-B(12):1292–1303.

This study evaluates outcomes of hip adductor surgery in children with cerebral palsy in preventing hip displacement. This review is from the perspective of an extended follow-up (beyond 3 years in contrast to currently available literature) and the Gross Motor Function Classification System (GMFCS). A retrospective audit was performed of children with cerebral palsy aged 2 to 10 years who had primary adductor surgery at the Royal Children’s Hospital Melbourne between January 1994 and December 2004. These children had hip migration percentages (MP) greater than 30% and been followed up for a minimum 12 months post-operatively

Aims

In elderly patients with osteoarthritis and protrusio who require arthroplasty, dislocation of the hip is difficult due to migration of the femoral head. Traditionally, neck osteotomy is performed in situ, so this is not always achieved. Therefore, the purpose of this study is to describe a partial resection of the posterior wall in severe protrusio.

Introduction: The open treatment of hip impingement is now a well-recognised technique with numerous publications about pathogenesis and surgical technique. There are very few publications of very small series discussing surgical results. We present the results of 148 hips at a mean follow-up of 20 months (range 4 – 55). Methods: This is a two surgeon series of sequential patients including the early learning curve. Patients were treated for impingement through a Ganz trochanteric osteotomy and open surgical hip dislocation. Patient data, operative findings and methods, complication and clinical follow up were recorded as a prospective audit and include Oxford and McCarthy Non Arthritic Hip scores. Results: The patient demographics are as follows:. 141 patients, 148 hips. Average age 35, range 10–65 years. Ratio Male to Female 73:75. All patients underwent femoral osteochondroplasty. 60% of cases had the labrum detached, acetabular rim recession and labral repair with bone anchors. 3 patients had the labrum reconstructed with the ligamentum teres autograft. We have had 9 failures (6%) as defined by revision to arthroplasty. 2 hips underwent successful revision open surgery for inadequately treated posterior impingement. 3 patients required arthroscopy after open surgery (2 of whom are now pain free). 7 further patients have persistent groin pain but not required further intervention. We have had the following complications: 4 trochanteric non unions requiring revision fixation, 2 deep vein thrombosis, 2 haematomas, 1 superficial infection, no deep Infections. Life table survival curve with revision to arthroplasty defined as failure. Discussion: The early to midterm results of this innovative procedure are encouraging even when including the decision making and surgical technique learning curves. We will present the hip scores and discuss the failures in detail to warn others embarking on this surgery which cases are more likely to lead to unsatisfactory outcomes

We treated 133 traumatic posterior dislocations surgically between July 1994 and March 2001. In 16 patients, labral tears had occurred. Operating on posterior hip dislocations, initially we fixated the posterior wall with screws and/or buttress plate, depending on the size of the fragment, and did suture the torn labrum, relying rather on the buttress plate or intact posterior wall for stability. We began repairing the torn labrum when we realised that any small fragments still attached to the labrum simply pull out from under the buttress plate, allowing the hip to redislocate. Once the wall has been reconstructed, interrupted sutures are passed through the labrum, with the hip internally rotated to prevent shortening of the capsule when sutures are tied. A one-third tubular plate is placed over the sutures lying on the posterior wall and fixed with screws. The sutures are then tied individually over the plate. Postoperatively the patient is kept in bed for six weeks, with the hip abducted and knee extended. Seven patients in whom the labrum was not repaired experienced redislocation. We performed second operations on two of them, repositioning the plates and reconstructing the posterior wall, but redislocation again occurred. The redislocated femoral heads were damaged because they rubbed against the plate and screws. In the other nine patients, we sutured the labrum, and in a 3 month to 2.5 year follow-up, no redislocation has occurred. . Labral repair restores stability, and tying interrupted sutures over a buttress plate is an easy and effective method of repair

Background. A consecutive series of 76 patients (101 hips) underwent primary open reduction, capsulorrhaphy and innominate osteotomy for late presenting developmental hip dislocation. They were aged 1.5 to 5 years at the time of surgery between 1958 and 1965. This study was designed to review their outcome into middle age. Methods. We located and reviewed 60 patients (80 hips) using a public records search. This represents a 79% rate of follow-up at 40-48 years post-operatively. 19 patients (24 hips) had undergone total hip replacement and 3 had died. The remaining 38 patients (53 surviving hips) were assessed by the WOMAC. ¯. and Oxford hip outcome questionnaires, physical examination and standing pelvic radiograph. The radiographs were analysed for minimum joint space width and the Kellgren and Lawrence score. Accepted indices of hip dysplasia were measured. Results. Kaplan-Meier survival analysis is presented using the end point of total hip replacement. Survival rates at 30, 40 and 45 years post-reduction are 99% (95% CI +/−2.4), 86% (+/− 6.9) and 54% (+/−16.4) respectively. Average Oxford and WOMAC. ¯. scores for surviving hips were 16.8 (range 0-82) and 16.7 (range 0-71) respectively. Of 51 surviving hip radiographs, 38 had a minimum joint space width in excess of 2.0mm, 13 had definite osteoarthritis (OA) on this criterion. 29 were Kellgren and Lawrence grade 0/1(no or doubtful signs of OA), 7 grade 2 (mild OA), 15 grade 3 or 4 (moderate or severe OA). The average centre-edge and acetabular angles were 40° (range 0-61°) and 32° (20-43°) respectively. There was no significant association between outcome and the modifiable risk factors of body mass or age at surgery. Conclusion. This method of treatment achieves a 54% rate of hip survival at 45 years. Two thirds of surviving hips have an excellent prognosis at this stage

Purpose: To determine the effect of the ossific nucleus on avascular necrosis (AVN) of the hip in the treatment of hip dislocation. Methods: A systematic review was performed in MED-LINE, EMBASE, DARE, and Cochrane Library. Two independent reviewers evaluated all articles. Interrater agreement was determined by the kappa statistic. Quality of evidence was evaluated by the GRADE statement. A meta-analysis was performed on the main outcome, AVN 2 years after reduction. Results: 6 observational studies met the inclusion criteria. Inconsistency was found in that half of the studies reported a protective effect of the ossific nucleus, whereas half of the studies did not. A meta-analysis of all studies (415 patients) showed no statistical significant effect of the ossific nucleus on the development of AVN, with 42 (17%) cases of AVN in infants with the ossific nucleus present at reduction compared with 47 (28%) in the group without a ossific nucleus (RR 0.60, 95% CI 0.28 to 1.27). If only radiographic changes of grade ≥II were considered AVN, a significant difference in the prevalence of AVN was found, with 15 (6%) cases of AVN in infants with the ossific nucleus compared with 28 (20%) without the ossific nucleus (0.34, 0.17 to 0.67). Subgroup analysis showed that the presence of the ossific nucleus reduced the probability of AVN by 70% (0.30, 0.14 to 0.62) in case of a closed reduction, but no significant effect was found for open reduction (0.87, 0.50 to 1.54). All studies demonstrated methodological weaknesses compromising the quality of evidence. Conclusion: We could not demonstrate a significant effect of the ossific nucleus on the development of AVN. The meta-analysis suggested that the ossific nucleus might have a protective effect against the development of more severe forms of AVN

Aims

To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases.

Aims

There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

BACKGROUD/PURPOSE. Recently, the use of a large diameter femoral head has been discussed as a means to reduce the risk of hip dislocation after total hip arthroplasty (THA). Although it has been clear that increasing the head size increases the oscillation angle and hip stability, a consensus on the usefulness of a larger head size has not been reached due to an increased propensity for bone impingement. We studied the effect of the range of motion (ROM) and bone impingement caused by increasing the femoral head size using a 3D simulation system. PATIENTS AND METHODS. All patients who had undergone a primary THA in our hospital from October 2010 were selected, and we excluded those with severe osteoarthritis, severe dysplasia (Crowe group), or excessive femoral neck anteversion (35°). This resulted in 60 patients (16 men and 44 women), with a mean age of 66.6 years (range, 47–83 years). The diagnoses were osteoarthritis in 42 hips, osteonecrosis in 11 hips, rheumatoid arthritis in four hips, and femoral neck fracture in three hips. A virtual hip model was generated from the preoperative CT scan and a component was virtually implanted via computer simulation software (Zed Hip, LEXI, Japan). The acetabular cup was implanted with an inclination of 45°, anteversion of 20°, and the femoral stem was implanted into the femur recreating the same head height with an anteversion of 25°. We defined three leg positions: (A) maximum flexion (B) internal rotation with hip in 90°of flexion and 20°of adduction as posterior dislocation, and (C) external rotation with hip in 0°of extension as anterior dislocation. In each leg position, range of motion up to the impingement and the type of impingement (implant or bone) was assessed with 22-, 26-, 28-, 32-, and 36 mm femoral head sizes. RESULTS. We found a significant increase in ROM between the 22 mm and 26-, 28-, 32-, and 36 mm femoral heads, and between the 26 mm and 36 mm femoral head in each leg position, but no significant difference was found in femoral heads more than 28 mm. Bone impingement preceding implant impingement was increased with larger head sizes more than 50% of the 28 mm head size in each leg position. The 36 mm head size corresponded to (A) 87%, (B) 85%, and (C) 70%, respectively. CONCLUSIONS. We concluded that increasing the head size increased bone impingement, which led to restricting improvement in ROM. There was no significant increase in ROM for femoral heads more than 28 mm; therefore, excessively large head sizes may result in restrictive ROM due to an increased oscillation angle

In 2000, Reinhold Ganz developed a surgical technique for treating slipped capital femoral epiphysis using his surgical hip dislocation approach to facilitate anatomical reconstruction of the slipped epiphysis—reportedly, without risk of avascular necrosis. This technique is now being adopted cautiously in paediatric orthopaedic centres internationally. The technique will be described and early results presented. Complications and their treatments will also be discussed. Early experience suggests morbidity following the procedure is not insignificant and until more corroborating safety data is available, the author suggests this technically demanding surgery should only be offered to children whose significant deformity would otherwise result in childhood disability

Premature fusion of the triradiate cartilage was obtained surgically in 10 three-week-old rabbits, and compared with isolated fusion of the ilio-ischial and of the ilio-pubic limbs of the triradiate cartilage in two further groups of 10 rabbits. Complete fusion caused acetabular dysplasia five weeks after operation in all animals and hip dislocation at nine weeks in half of them; ilio-ischial fusion had a comparable effect. Ilio-pubic fusion had only a minimal effect on acetabular development. The posterior position of the ilio-ischial limb in the acetabulum and its predominance in the formation of the triradiate cartilage in quadrupeds may have contributed to its decisive effect on acetabular development

Purpose: Implantation of a prosthesis on a remodelled femur can cause technical difficulties affecting the outcome of the arthroplasty. We performed a tridimensional study of the femoral anatomy before prosthesis implantation for sequelar congenital hip dislocation. Material and method: The series included 312 hips in 262 patients. The same radiography and computed tomography work-up was perfomred in all patients. There were 288 women and 84 men, men age 56 years. Mean weight was 66 kg and mean height was 163 cm. The crowe classification was 195 dysplasia, 123 dislocations (41% class I, 27% class II, 13% class III, 19% class IV). Telemetric measurements were: femoral isthma, the centre of the lesser trochanter, limb length discrepancy, the cephalo-cervico-diaphyseal angle. Computed tomographic measurements were: anterio-posterior and mediolateral dimensions and femur funneling, helitorsion between the bichondylar plane and the upper femur, anteroposterior diameter of the acetabulum. Results: The mean mediolateral and anteroposterior diameters of the femoral canal at the isthma were 9.8 and 13.1 cm respectively in dysplasia and 9.3 and 12.6 cm, 9.4 and 12.7, and 9.7 and 13.6 cm in I, II, and III–IV congenital dislocations respectively. The femoral funneling index varied from 1.9 to 7.6 in dysplasia and from 2.6 to 7.9, 2.1 to 8.4 and 2.1 to 8.7 in I, II, and III–IV congenital dislocations respectively. The mean cephalo-cervico-diaphyseal angle was 129.3°, 131.9°, 136.8°, and 127.4° respectively. Maximal leg length discrepancy was 45, 57, 71, and 82 cm respectively. Mean helitorsion was 22.9° (1°–52°), 36.4° (8°–86°), 43.2° (2°–82°- and 38.4° (6°–68°) respectively. The mean anteroposterior diameter of the acetabulum was 52, 51.2, 53.1; and 49.6 cm respectively. Discussion and conclusion: The dysplastic or dislocated femur is narrower than the normal femur with wide variations in funneling and cephalo-cervico-diphyseal angle. The mean difference in leg length increases gradually with helitorsion but with wide individual variability, irrespective of the grade. These tridimensional anatomic data can be useful for predicting difficulties in prosthetic treatment of these patients

The aims of this study were to report functional outcomes of salvage procedures for patients with cerebral palsy (CP) who have chronic dislocation of the hip using validated scoring systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the time of surgery was 12.2 years (8 to 22) and the mean follow-up was 56 months (24 to 114). Patients were divided into three groups: 14 who underwent proximal femoral resection arthroplasty (PFRA group 1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2), and 13 who underwent subtrochanteric valgus osteotomy with resection of the femoral head (SVO with FHR group 3). All patients were evaluated using the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory (PedsQL). Significant improvements occurred in most CPCHILD and PedsQL subsection scores following surgery in all patients, without significant differences between the groups. There were 12 post-operative complications. Less severe complications were seen in group 1 than in groups 2 and 3. Salvage surgery appears to provide pain relief in patients with CP who have painful chronic dislocation of the hip. The three salvage procedures produced similar results, however, we recommend the use of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients with CP with chronic painful hip dislocation, but should be limited to selected patients considering complications. Cite this article: Bone Joint J 2016;98-B:137–43

Introduction: High developmental hip dislocation is the most severe anatomic constitution type in developmental dysplasia of the hip (DDH). After the age of 30–40 years the pseudo-articulation often becomes painful and requires advanced treatments. To restore limb length dislocation must be reduced by soft tissue release. If the reduction overreaches 40 mm the risk for nerve-damage increases dramatically. Reducing the dislocation, one-step soft tissue releases and slow release by continuous iliofemoral distraction were invented. In this study we report a combination of a one-step soft tissue release and slow continuous iliofemoral distraction in patients requiring over 40 mm distraction for uncemented THA. Material and Methods: Between 1998 and 2007 20 procedures in 19 patients with an age of 42.5 years (18–69 years) and a leg-length discrepancy of > 4 cm were performed. For 5.6 years (1–12 years) patients were followed-up clinically and radiographically. The treatment consisted of a two-step procedure. 1st operation: Soft tissue releases combined with the implantation of the THA components and placement of the external distraction apparatus. In the interval period slow iliofemoral distraction of 1mm–1.5 mm per day was conducted. Neurovascular signs and distraction was regularly monitored until the desired length was achieved. 2nd operation: the external fixation device was removed before applying the acetabular PE-inlay and the femoral head. Subsequent reduction was easy in most cases. Results: A distraction of 51 mm (41 mm–75 mm) in 61 days (32–94 days) with an indicated speed of 1–1.5 mm/d and an effective speed of 0.8 mm (0.4 mm/d–1.8 mm/d) was achieved. Treatment time was 86 days (50–210 days). Patients had to maintain 132 days (40–300 days) restricted weight bearing. 2.6 (2–6) interventions were performed until final reduction. Harris Hip Score increased by 43 points [44 (22–65) to 83 points (66–98)]. The patients showed satisfying increases in all dimensions of the SF-36 health score. In the course of treatment pin-instability was seen in 6 cases, 3 minor intraoperative femoral fractures, 3 infections and 3 nerve damages occurred. Discussion: The experiences of this study state the difficulties in the treatment of high DDH. The complication rate was high, but patients seemed to be satisfied finally. However, final scores were lower than in patients undergoing hip arthroplasties for degenerative osteoarthritis. Results of this treatment can be improved by avoiding certain pitfalls like insufficient soft tissue release, trans-cortical placement of the iliac screws or fast distraction. Nevertheless, soft tissue release and continuous iliofemoral distraction is the only option to restore limb-length and to preserve neurologic structures in cases with a dislocation over 40 mm

We present the 2 year results for the first 54 patients after Selective Dorsal Rhizotomy (SDR) delivered in Bristol, concentrating on change in Reimers' migration index.

Eligible patients are selected at the SDR multidisciplinary meeting. Physiotherapy assessment is performed pre-operatively and at 6, 12 and 24 months post-surgery. Data collected includes GMFCS, Gross Motor Function Measure (GMFM) 88 and Modified Ashworth score for spasticity for major lower limb muscle groups, amongst other data. Pelvic radiographs are taken pre-operatively and at 2 years post-operatively. Reimers' migration index was measured using the hospital picture archiving and communication system (PACS).

The mean age was 7.2 (3.9–17.5) at the time of surgery. Pre- and post-operative pelvic radiographs were available for 30 patients (60 hips). 57% (n=34) hips showed an increase in migration percentage (mean 5.4%, range 0.1–17.5%) and 43% (n=26) hips showed a decrease (mean 4.0%, range 0–15.5%). Overall no significant difference was found in Reimers' migration index at 2 year follow up (mean increase 1.3% (95% CI −0.3–3.0), p=0.12).

There was an improvement in GMFCS category (by 1 grade) for 9 patients and a worsening for 1 patient at 2 year follow up. The Modified Ashworth score for spasticity improved in all patients. There was a mean improvement of 1.7 in the hip adductors and 2.4 in the ankle plantar flexors.

There was a statistically significant improvement in the GMFM 88 D and E domains of 14.7 (95% CI 11.3–18.1), p<0.0001 and 11.4 (95% CI 7.4–15.7), p<0.0001 respectively.

We found no evidence that SDR leads to worsening hip subluxation at 2 year follow up. All patients had improvement in lower limb spasticity. Overall there was a statistically significant improvement in function, as shown by GMFM 88 domains for standing, walking, running and jumping.

Anatomic reduction (subcapital re-alignment osteotomy) via surgical hip dislocation – increasingly popular. While the reported AVN rates are very low, experiences seem to differ greatly between centres. We present our early experience with the first 29 primary cases and a modified fixation technique. We modified the fixation from threaded Steinman pins to cannulated 6.5mm fully-threaded screws: retrograde guidewire placement before reduction of the head ensured an even spread in the femoral neck and head. The mean PSA (posterior slip angle) at presentation (between 12/2008 and 01/2011) was overall 68° (45–90°). 59% (17/29) were stable slips (mean PSA 68°), and 41% (12/29) were unstable slips unable to mobilise (mean PSA 67°). The vascularity of the femoral head was assessed postoperatively with a bone scan including tomography. The slip angle was corrected to a mean PSA of 5.8° (7° anteversion to 25° PSA). We encountered no complications related to our modified fixation technique. All cases with a well vascularised femoral head on the post-operative bone scan (15/17 stable slips and 8/12 unstable slips) healed with excellent short term results. Both stable slips with decreased vascularity on bone scan (2/17, 12%) had been longstanding severe slips with retrospectively suspected partial closure of the physis, which has been described as a factor for increased risk of avascular necrosis (AVN). One of these cases was complicated by a posterior redislocation due to acetabular deficiency. In the unstable group, 4/12 cases (33%) had avascular heads intra-operatively and cold postoperative bone scans, 3 have progressed to AVN and collapse. Anatomic reduction while sparing the blood supply of the femoral head is a promising concept with excellent short term results in most stable and many unstable SCFE cases. Extra vigilance for closed/closing physes in longstanding severe cases seems advisable. Regardless of treatment, some unstable cases inevitably go on to AVN

Introduction

Wear-related osteolysis continues to be a concern in the long-term outcome and survivorship of total hip arthroplasty (THA) and there continues to be an emphasis on bearing materials that exhibit improved wear profiles. Oxidized zirconium metal (Oxinium®, Smith & Nephew) was developed to reduce the amount of polyethylene wear as compared to cobalt chromium femoral heads, without the risk of brittle fracture seen with older generation ceramics. There are a limited number of retrieval studies evaluating the performance of Oxinium in THA. The aims of this study were 1) to visually assess damage on the surface of a large number of retrieved Oxinium femoral heads, 2) to measure surface roughness of scratches on the surfaces of Oxinium femoral heads, and 3) to use scanning electron microscopy (SEM) to assess the integrity of the oxidized zirconium surface in damaged areas. BIOLOX delta (CeramTec), a ceramic alternative to Oxinium, was included in this study for comparison.

Between November 1997 and December 2000 we performed 27 total hip replacements in 22 patients with high congenital dislocation of the hip using porous tantalum monoblock acetabular components implanted in the true acetabular bed. Clinical and radiological evaluation was performed at regular intervals for a mean of 10.2 years (8.5 to 12). The mean Harris Hip Score improved from 48.3 (15 to 65) pre-operatively to 89.5 (56 to 100) at the final follow-up. The mean Oxford Hip Score was 49.5 (35 to 59) pre-operatively and decreased to 21.2 (12 to 48) at one year and 15.2 (10 to 28) at final follow-up. Migration of the acetabular component was assessed with the EBRA software system. There was a mean migration of 0.68 mm (0.49 to 0.8) in the first year and a mean 0.89 mm (0.6 to 0.98) in the second year, after excluding one initial excessive migration. No revision was necessary for any reason, no acetabular component became loose, and no radiolucent lines were observed at the final follow-up.

The porous tantalum monoblock acetabular component is an implant offering adequate initial stability in conjunction with a modulus of elasticity and porosity close to that of cancellous bone. It favours bone ingrowth, leading to good mid-term results.

Aims

We report a prospective cohort study of the midterm results of surgical dislocation of the hip (according to Ganz) to perform resection of osteochondromas involving the femoral neck in patients with multiple hereditary exostoses (MHE).

Introduction

Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short term outcomes, longer term outcomes are more sparsely reported. We aim to assess survivorship and functional outcome at ten years, in patients who have undergone open hip debridement.

Avascular necrosis is an iatrogenic complication of the treatment of congenital dislocation of the hip. In order to assess the incidence of this and other complications, we have reviewed a consecutive series of 211 children treated at some stage with the modified Denis Browne splint used in Adelaide. In 173 children treated with this splint alone for 238 subluxed or dislocated hips which were stable when reduced, six hips (2.5%) developed radiographic avascular necrosis, though there was progressive growth deformity in only one. There was a much higher incidence among cases treated for unstable reduction by tenotomy, plaster spica and then the splint, 20 of 33 hips (60.6%) showing radiographic signs, though only one led to progressive abnormality. Of seven patients treated by adductor tenotomy and the splint no case of avascular necrosis was encountered. In the whole series the incidence of significant long-term growth disturbance in children treated in this splint was 0.7%. The great majority of our cases of avascular necrosis were attributable to manipulation and plaster, not to the subsequent use of a splint.

Purpose: To analyse middle-term outcomes of treatment of patients with congenital luxation of hip using modified overhead traction.

Material and Methods: During the years 1991–2001, a total of 116 patients (138 hip joints) were treated. The group comprised 99 girls and 17 boys with the average age 4.7 months (ranging from 1.5–11 months). Patients were divided into two subgroups: patients who have been treated at our department from the determination of the diagnosis and those referred to our department from other facilities after unsuccessful conservative therapy. Only those patients were evaluated in whom the traction therapy was completed at least 2 years ago, the mean follow-up period was 4.5 years (2–10). After the initial preparatory horizontal traction, we moved to a 4-week overhead regimen wherein we increased the abduction by 10 degrees every five days. After completing the dystraction, every hip joint was examined using arthrography and where the reposition was possible, the therapy continued with the fixation in plaster spike for 6 weeks. Pavlik harnes were used for the final phase of the treatment.

Results: In the group of primarily treated patients, reposition was successful in 78 out of 91 hip joints (85.7%). In another 4 hip joints (4.4%), reluxation occurred after an average period of 3.5 weeks after the removal of the spike. Nine hip joints (9.9%), 7 of type IV and 2 of type IIIB, were non-repositionable. Much worse results were achieved in the group of patients who received previous treatment. Only 12 hip joints (25.5%) were maintained permanently repositionable but neither of them was of type IV. Reluxation within two weeks after the removal of the fixation occurred in another 5 hip joints (10.6%). A total of 30 hip joints (63.9%) could not be reposed due to arthrographic findings of reposition obstacles. All these patients were admitted for treatment after the 6th month of age. We have observed no case of avascular head necrosis in the group of 90 patients who received conservative treatment.

Conclusion: Traction therapy is a safe and mild method of treatment for congenital luxation of the hip joint. The rate of success of the therapy depends on the sonographic findings and age of patients at the beginning of therapy. Considerably worse results are achieved in the group of patients who have already received unsuccessful inadequate treatment.

Introduction

Recurrent dislocation after hip arthroplasty is a difficult problem. The purpose of the present study was to evaluate the results with the use of a constrained cup for treatment for instability after hip arthroplasty.

We have studied the natural history of spontaneous dislocation of the hip in cerebral palsy, with particular reference to the pattern of neurological involvement. In patients with bilateral hemiplegia and severe involvement of the upper limbs the incidence of dislocation was very high (59%), while in those with diplegia and little involvement of the upper limbs, only 6.5% were affected. There was no evidence of dysplasia or instability of the hip in any of the patients with unilateral hemiplegia. A strong correlation was found between the stability of the hip and the patients' ability to walk. These findings have a bearing on clinical surveillance and also on the indications for prophylactic surgery.

A six-year-old girl with congenital sensory neuropathy with anhidrosis (CSNA) presented with bilateral hip dysplasia and subluxation on the right side.

Conservative treatment of the hips by closed reduction and a plaster cast was unsuccessful. When aged seven years the patient had an intertrochanteric varus rotation osteotomy on the right side, but subluxation was again evident after five months. A Salter-type pelvic osteotomy was carried out followed by immobilisation, but one year later subluxation was present in the right hip and dislocation in the left. At the age of nine years, the right femoral head resembled a Charcot joint, although walking ability was preserved.

In patients with CSNA, surgery may not always be advisable.

Arthrogryposis multiplex congenita (AMC) is a rare disease with multiple joint contractures. It is widely believed that bilaterally dislocated hips should not be reduced since movement is satisfactory and open reduction has had poor results. Since 1977 we have performed a new method of open reduction using an extensive anterolateral approach on ten hips in five children with AMC. The mean age at surgery was 31.5 months (17 to 64) and the mean follow-up was 11.8 years (3.8 to 19.5).

At the final follow-up all children walked without crutches or canes. Two managed independently, one required a long leg brace and two had short leg braces because of knee and/or foot problems. The clinical results were good in eight hips and fair in two and on the Severin classification seven hips were rated as good (group I or group II).

We recommend the extensive anterolateral approach for unilateral or bilateral dislocation of the hip in children with arthrogryposis or developmental dislocation of the hip.

We report on a radiographic screening programme at four months of age for infants who were clinically normal at neonatal examination but were considered to be 'at risk' for congenital dislocation of the hip because of their family history, breech presentation, or a persistent click. From a total population of 13,662 live births over a two-year period, 357 (2.6%) infants at risk were identified. Of these 46 had abnormal radiographs (six subluxations, 40 acetabular dysplasia). In 12 infants treatment resulted in a normal hip; 34 required no treatment but were followed up until their radiographs were normal and walking had begun. Of the 311 infants with normal radiographs, 256 (82%) were examined after 15 months of age; none had any detectable abnormality. We suggest that radiography of the hip at four months is a valuable adjunct to neonatal screening for infants at increased risk of congenital dislocation of the hip.

Introduction and aim: prosthesis displacement while attempting closed reduction of a dislocated total hip or during dislocation itself is a rare but significant complication. We have come across three cases and there are at least six case reports in the literature. The aim of our study is to conduct an in vitro biomechanical study to assess, whether application of bone cement over the shoulder of the stem confers any additional advantage in the pull out strength of the implant.

Materials and Methods: We used fourteen saw bones and cemented seven bones with a standard cementing technique and another seven bones with additional cement over the shoulder of the implant. A tensile testing machine was used to assess the pull out force needed in both groups. A comparision was done between both groups.

Results: The mean pull out force in the routine cementing technique was 2066N(S.D. 256.65) and for the group with the cement on the shoulder was 3220N(S.D. 312.22). The mean difference was 1154N. The results were analysed with two-tailed t- test, unequal variance and the difference was statistically significant with p value of 0.00045.

Conclusion: Our experiment confirms that application of the bone cement over the shoulder of the implant does give additional axial stability and should be practised routinely to reduce this complication.

Purpose of the study: The natural history of congenital hip dysplasia with weight-bearing usually progresses towards degenerative joint disease. The anatomic type of the dislocation, whether treated or not, was well classified by Crowe who described four types.

Material and methods: Since 1989, we have used an ABG hydroxyapatite (HA) coated prosthesis for the treatment of congenital hip dysplasia. The hemispheric acetabular implant is coated with hydroxyapatite and the femoral implant, which is inserted in an anatomic position with anteversion, antetorsion and anteflexion, has a HA-coated stem. Forty-three Crowe type 3 or 4 hips (high position) were treated with this technique:

implantation of the cup in the paleoacetabulum;

Results: Cup implantation in the paleoacetabulum was achieved in all patients except two. A screwed autograft was inserted in 75% and remained stable over time for the larger grafts but tended to resorb for smaller grafts. For femoral anteverions, an ABG implant was used in 34 cases: 21 ABG1 stems, 11 ABF2 stems, and one ABG revision stem. The ABG stem enabled satisfactory anatomic restoration in 20 hips but with postoperative stiffness. For 14 hips, due to the important femoral anteversion related to the dysplasia, a reversed ABG-HA implant was used: eight left implants for right hips and six right implants for left hips. This «reversed» curvature gained 24° in the femoral anteversion plane. The outcome was excellent in these 14 cases, particularly with a clear improvement in postoperative external rotation. At close to 15 years follow-up we have had no case of femoral loosening, nor of femoral shaft osetolysis, with this type of implant.

Discussion: Certain authors propose using a custom-made implant for sequelar congenital hip dysplasia, but we prefer the proposed technique which provides very satisfactory results and limits the need for custom-made material.

Total Hip Replacement (THR) in proximal, posterior iliac dislocation of the hip often represents a problematic issue. Reviewing their selected cases (70 patients between 3700 THR from 1986 to 2001), authors focalized some key points for this demanding surgery. The most important steps are acetabular positioning, implant decisioning and surgical approach (exposure and release).

Acetabular cup positioning. The natural site (Paleoacetabulum), the ideal place to restore biomechanical and dynamic properties of the joint, many times gives few chances to achieve primary stability. So one site, at least the nearest possible to the natural site must be reached. A CT or MRI study is necessary to assess preoperative planning for cup positioning. We used two different cups, the Zweymuller and the Wagner cup, with good primary stability. A Conus stem (Wagner) or an Alloclassic stem (in less displastic femoral shape) was used.

We always performed this surgery as a one step procedure. No preventing traction or release surgery was performed. An anatomic and wide (medial and lateral) exposure of the joint must be performed. We used the Smith-Petersen approach modified by Wagner. A meticulous periarticular release of soft tissue was performed. In same cases a shortening femoral osteotomy was performed to allow refractory reduction. Possible complications are discussed. Good clinical outcomes at more than ten years are shown.

Objectives: We evaluated the results of a femoral shortening z-osteotomy in patients who underwent THA due to high dislocation of the hip.

Methods: From 8/1997 until 11/2003 we performed THA in combination with a z-shaped subtrochanteric shortening osteotomy in 6 patients (4 females, 2 males) with high dislocation of the hip. In all cases for the reconstruction of the acetabulum a cementless press fit component was implanted, in 5 cases in combination with an acetabular roof reconstruction by autograft. For the femoral component we used standard titanium cementless stems in 5 cases, in one case a revision model. The z-shaped shortening osteotomy was fixed by titanium cerclages in all cases.

Results: Postoperative complications (nerve lesions, THA dislocations, non union) could not be observed in the clinical and radiological follow up examinations 6 to 72 months postoperatively. In all cases femoral union at the area of the shortening osteotomy could be observed 3 months postoperatively.

Conclusion: Femoral shortening z-osteotomy in THR is a safe technique in patients with high total dislocation of the hip, leading to satisfactory postoperative results.

INTRODUCTION

Femoral head diameter has a major influence on stability and dislocation resistance after Total Hip Arthroplasty (THA). Although routine use of large heads is common, several recent studies have shown that contemporary large head prostheses can directly impinge against native soft tissues, particularly the iliopsoas which wraps around the femoral head, leading to refractory anterior hip pain. To address this, we developed a novel Anatomically Contoured large diameter femoral Head (ACH). We hypothesized that anatomical contouring of the ACH implant for soft tissue relief would not compromise dislocation resistance, and the ACH implant would provide increased stability compared to small heads.

In this prospective study of 18 hips we compared the efficacy of ultrasound with CT in determining the position of the femoral head in a spica cast after closed or open reduction in children with developmental dysplasia of the hip. Ultrasound was performed through the perineal opening of the cast. With a transinguinal approach, the superior ramus of the pubis, the acetabulum, the femoral head and the femoral neck can be depicted in one plane. The CT and ultrasound images were blinded and reviewed by two of the authors. Ultrasound was inconclusive in the first two reductions since the perineal opening was too small to see all the landmarks in one plane. In the following 16 reductions the landmarks were well defined and interpretation of the CT and ultrasound was similar. The perineal opening in the spica cast should be made in such a way that the ultrasound probe can be positioned in the groin so that the landmarks can be shown in one plane.

Aims. Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP. Methods. We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement. Results. A total of 108 patients were enrolled. The mean preoperative MP was 58.3% (SD 31.7%), which improved to 9.1% (SD 15.6%) at the last follow-up. NSA and MHR improved from 156.5° (SD 11.5°) and 82.3% (SD 8.6%) to 126.0° (SD 18.5°) and 89.1% (SD 9.0%), respectively. Factors affecting the postoperative MHR were preoperative MP (p = 0.005), immediate postoperative MP (p = 0.032), and history of Dega osteotomy (p = 0.046). Conclusion. We found that hip sphericity improves with HRS. Preoperative MP, reduction quality, and acetabular coverage influence femoral head remodelling. We recommend that surgeons should consider intervention early before hip displacement progresses and that during HRS, definite reduction and coverage of the femoral head should be obtained. Cite this article: Bone Joint J 2021;103-B(1):198–203

The February 2024 Children’s orthopaedics Roundup. 360. looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures

Aims. Pelvic tilt is believed to affect the symptomology of osteoarthritis (OA) of the hip by alterations in joint movement, dysplasia of the hip by modification of acetabular cover, and femoroacetabular impingement by influencing the impingement-free range of motion. While the apparent role of pelvic tilt in hip pathology has been reported, the exact effects of many forms of treatment on pelvic tilt are unknown. The primary aim of this study was to investigate the effects of surgery on pelvic tilt in these three groups of patients. Methods. The demographic, radiological, and outcome data for all patients operated on by the senior author between October 2016 and January 2020 were identified from a prospective registry, and all those who underwent surgery with a primary diagnosis of OA, dysplasia, or femoroacetabular impingement were considered for inclusion. Pelvic tilt was assessed on anteroposterior (AP) standing radiographs using the pre- and postoperative pubic symphysis to sacroiliac joint (PS-SI) distance, and the outcomes were assessed with the Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and Harris Hip Score (HHS). Results. The linear regression model revealed a significant negative predictive association between the standing pre- and postoperative PS-SI distances for all three groups of patients (all p < 0.001). There was a significant improvement in all three outcome measures between the pre- and postoperative values (p < 0.05). Conclusion. There is a statistically significant decrease in pelvic tilt after surgery in patients with OA of the hip, dysplasia, and femoroacetabular impingement. These results confirm that surgery significantly alters the pelvic orientation. Pelvic tilt significantly decreased after total hip arthroplasty, periacetabular osteotomy, and arthroscopy/surgical hip dislocation. The impact of surgery on pelvic tilt should be considered within the therapeutic plan in order to optimize pelvic orientation in these patients. Cite this article: Bone Joint J 2022;104-B(9):1025–1031

Aims. Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). Methods. A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability. Results. All HS app measurements (from 5 raters at week 0 and week 2 and PACS rater) showed highly significant correlation with the PACS measurements (p < 0.001). Pearson’s correlation coefficient (r) was constantly over 0.9, suggesting high validity. Correlation of all HS app measures from different raters to each other was significant with r > 0.874 and p < 0.001, which also confirms high validity. Both inter- and intra-rater reliability were excellent with ICC > 0.9. In a 95% confidence interval for repeated measurements, the deviation of each specific measurement was less than 4% MP for single measurer and 5% for different measurers. Conclusion. The HS app provides a valid method to measure hip MP in CP, with excellent inter- and intra-rater reliability across different medical and allied health specialties. This can be used in hip surveillance programmes by interdisciplinary measurers. Cite this article: Bone Jt Open 2023;4(5):363–369

The August 2023 Children’s orthopaedics Roundup. 360. looks at: DDH: What can patients expect after open reduction?; Femoral head deformity associated with hip displacement in non-ambulatory cerebral palsy; Bony hip reconstruction for displaced hips in patients with cerebral palsy: is postoperative immobilization indicated?; Opioid re-prescriptions after ACL reconstruction in adolescents are associated with subsequent opioid use disorder; Normative femoral and tibial lengths in a modern population of USA children; Retrospective analysis of associated anomalies in 636 patients with operatively treated congenital scoliosis; Radiological hip shape and patient-reported outcome measures in healed Perthes’ disease; Significantly displaced adolescent posterior sternoclavicular joint injuries

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

Aims. The purpose of this study was to evaluate the mid-term outcomes of autologous matrix-induced chondrogenesis (AMIC) for the treatment of larger cartilage lesions and deformity correction in hips suffering from symptomatic femoroacetabular impingement (FAI). Methods. This single-centre study focused on a cohort of 24 patients with cam- or pincer-type FAI, full-thickness femoral or acetabular chondral lesions, or osteochondral lesions ≥ 2 cm. 2. , who underwent surgical hip dislocation for FAI correction in combination with AMIC between March 2009 and February 2016. Baseline data were retrospectively obtained from patient files. Mid-term outcomes were prospectively collected at a follow-up in 2020: cartilage repair tissue quality was evaluated by MRI using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Patient-reported outcome measures (PROMs) included the Oxford Hip Score (OHS) and Core Outcome Measure Index (COMI). Clinical examination included range of motion, impingement tests, and pain. Results. A total of 12 hips from 11 patients were included (ten males, one female, mean age 26.8 years (SD 5.0), mean follow-up 6.2 years (SD 5.2 months)). The mean postoperative MOCART score was 66.3 (SD 16.3). None of the patients required conversion to total hip arthroplasty. Two patients had anterior impingement. External hip rotation was moderately limited in four patients. There was a correlation between MOCART and follow-up time (r. s. = -0.61; p = 0.035), but not with initial cartilage damage, age, BMI, or imaging time delay before surgery. PROMs improved significantly: OHS from 37.4 to 42.7 (p = 0.014) and COMI from 4.1 to 1.6 (p = 0.025). There was no correlation between MOCART and PROMs. Conclusion. Based on the reported mid-term results, we consider AMIC as an encouraging treatment option for large cartilage lesions of the hip. Nonetheless, the clinical evidence of AMIC in FAI patients remains to be determined, ideally in the context of randomized controlled trials. Cite this article: Bone Joint J 2024;106-B(5 Supple B):32–39

Hip instability is one of the most common causes for total hip arthroplasty (THA) revision surgery. Studies have indicated that lumbar fusion (LF) surgery is a risk factor for hip dislocation. Instrumented spine fusion surgery decreases pelvic tilt, which might lead to an increase in hip motion to accommodate this postural change. To the best of our knowledge, spine-pelvis-hip kinematics during a dynamic activity in patients that previously had both a THA and LF have not been investigated. Furthermore, patients with a combined THA and LF tend to have greater disability. The purpose was to examine spine-pelvis-hip kinematics during a sit to stand task in patients that have had both THA and LF surgeries and compare it to a group of patients that had a THA with no history of spine surgery. The secondary purpose was to compare pain, physical function, and disability between these patients. This cross-sectional study recruited participants that had a combined THA and LF (n=10; 6 females, mean age 73 y) or had a THA only (n=11; 6 females, mean age 72 y). Spine, pelvis, and hip angles were measured using a TrakSTAR motion capture system sampled at 200 Hz. Sensors were mounted over the lateral thighs, base of the sacrum, and the spinous process of the third lumbar,12th thoracic, and ninth thoracic vertebrae. Participants completed 10 trials of a standardized sit-to-stand-to-sit task. Hip, pelvis, lower lumbar, upper lumbar, and lower thoracic sagittal joint angle range of motion (ROM) were calculated over the entire task. In addition, pain, physical function, and disability were measured with clinical outcomes: Hip Disability Osteoarthritis Outcome Score (pain and physical function), Oswestry Low Back Disability Questionnaire (disability), and Harris Hip Score (pain, physical function, motion). Physical function performance was measured using 6-Minute Walk Test, Stair Climb Test, and 30s Chair Test. Angle ROMs during the sit-to-stand-to-sit task and clinical outcomes were compared between THA+LF and THA groups using independent t-tests and effect sizes (d). The difference in hip ROM was approaching statistical significance (p=0.07). Specifically, the THA+LF group had less hip ROM during the sit-to-stand-to-sit task than the THA only group (mean difference=11.17, 95% confidence interval=-1.13 to 23.47), which represented a large effect size (d=0.83). There were no differences in ROM for pelvis (p=0.54, d=0.28) or spinal (p=0.14 to 0.97; d=0.02 to 0.65) angles between groups. The THA+LF group had worse clinical outcomes for all measures of pain, physical function, and disability (p=0.01 to 0.06), representing large effect sizes (d=0.89 to 2.70). Hip ROM was not greater in the THA+LF group, and thus this is unlikely a risk factor for hip dislocation during this specific sit-to-stand-to-sit task. Other functional tasks that demand greater excursions in the joints should be investigated. Furthermore, the lack of differences in spinal and pelvis ROM were likely due to the task and the THA+LF group had spinal fusions at different levels. Combined THA+LF results in worse clinical outcomes and additional rehabilitation is required for these patients

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures

Hip instability is one of the most common complications after total hip arthroplasty (THA). Among the possible techniques to treat and prevent hip dislocation, the use of constrained liners is a well-established option. However, there is concern regarding the longevity of these devices due to higher mechanical stress caused by limited hip motion. The primary aim of this paper is to analyze the failure rate of a specific constrained liner in a series of consecutive cases. This study is a retrospective consecutive case series of THA and revision hip arthroplasty (RHA), in which a constrained polyethylene insert was used to treat or prevent hip instability. Patients were divided in 3 different groups (THA for hip fracture, THA for osteoarthrosis, and RHA). Survival analysis was performed for failure, defined as at least one episode of hip dislocation or radiographical signs of acetabular loosening. Logistical regression was used to investigate risk factors for failure. A total of 103 patients were included in the study. Fourteen patients (13,6%) were THA for osteoarthrosis, 60 (58,3%) were THA for hip fracture, and 29(28,2%) were RHA. The median follow-up was 28 months (ranging 12 − 173 months). Failure occurred in 4 cases (3,9%) comprehending 2 dislocations (1,9%) and 2 early acetabular loosening (1,9%). Amongst the groups, there were no cases of failures in the THA due to osteoarthrosis, in the THA for hip fracture there were 3 cases (5%) and in the RHA one case (3,4%). Failure-free survival was not statistically different between groups. There were no risk factors statistically related to failure. The use of constrained acetabular insert to prevent or treat instability achieved an adequate survival time with a low rate of complications. Further studies are necessary to corroborate our findings

Objectives. The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE). Methods. The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies. Results. Fifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (. sd). 7.02°), 41.45° (. sd. 10.5°) and 6.0° (. sd. 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively. Conclusion. In the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety. Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1

Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program

Although the incidence of total hip dislocation has decreased, it still remains a major problem particularly if recurrent. The actual incidence is around 1–2% but it has been documented as the leading cause for hip revision in the United States. In patients with recurrent hip dislocation, technical issues of leg length inequality, incorrect offset, and poor implant position should be addressed surgically and the abnormality corrected. In patients with recurrent hip dislocation, the articulation is preferably converted to a more stable articulation, with constrained sockets and dual mobility being the choices. In my experience, dual mobility articulations remain an excellent option for recurrent hip dislocation and its use is increasing significantly. It provides improved hip stability and data have demonstrated good success with recurrent hip dislocation. However, with use of the modular variety of dual mobility which is needed for acetabular cup fixation with screw augmentation, dissimilar metals are placed in contact (titanium socket and cobalt chrome liner insert) which potentially can pose a fretting or corrosion problem in longer term outcomes. Constrained sockets of the tripolar configuration provide another option which is useful in those patients with severe abductor dysfunction or insufficiency. Constrained sockets can also be cemented into the existing shell in cases where there is a well-fixed cup and cup removal may lead to significant bone loss and a need for complex acetabular reconstruction. It is important to remember that there are two types of constrained sockets, tripolar and focal constraint. Results with the tripolar constrained socket have been significantly better than the focal constraint variety which adds a polyethylene rim piece to the liner. In a mid-term follow up (2–9 years) of 116 constrained tripolar sockets, recurrent dislocation was only 3.3%. In papers reporting on focal constrained sockets, recurrent dislocation was in the 9–29% range. There continues to be a role for constrained sockets and selection of implant type has made a difference in ultimate outcome

Ideally the hip arthroplasty should not be subject to bony or prosthetic impingement, in order to minimise complications and optimise outcomes. Modern 3d planning permits pre-operative simulation of the movements of the planned hip arthroplasty to check for such impingement. For this to be meaningful, however, it is necessary to know the range of movement (ROM) that should be simulated. Arbitrary “normal” values for hip ROM are of limited value in such simulations: it is well known that hip ROM is individualised for each patient. We have therefore developed a method to determine this individualised ROM using CT scans. CT scans were performed on 14 cadaveric hips, and the images were segmented to create 3d virtual models. Using Matlab software, each virtual hip was moved in all potential directions to the point of bony impingement, thus defining an individualised impingement-free 3d ROM envelope. This was then compared with the actual ROM as directly measured from each cadaver using a high-resolution motion capture system. For each hip, the ROM envelope free of bony impingement could be described from the CT and represented as a 3d shape. As expected, the directly measured ROM from the cadaver study for each hip was smaller than the CT-based prediction, owing to the presence of constraining soft tissues. However, for movements associated with hip dislocation (such as flexion with internal rotation), the cadaver measurements matched the CT prediction, to within 10°. It is possible to determine an individual's range of clinically important hip movements from a CT scan. This method could therefore be used to create truly personalised movement simulation as part of pre-operative 3d surgical planning

Femoroacetabular impingement is a prearthritic deformity frequently associated with early chondral damage. Several techniques exist for restoring larger cartilage defects. While AMIC proved to be an effective treatment in knee and ankle, there are only short-term data available in hip. This study aimed to investigate the mid-term clinical outcome of patients with chondral lesions treated by AMIC and evaluate the quality of repair tissue via MRI. This retrospective, single center study includes 18 patients undergoing surgical hip dislocation for FAI between 2013 and 2016. Inclusion criteria were: cam or pincer-type FAI, femoral or acetabular chondral lesions > 1 cm. 2. , (IRCS III-IV). Due to exclusion criteria and loss-to-follow-up 9 patients (10 hips) could be included. Patient reported outcome measures included Oxford Hip Score (OHS) & Core Outcome Measure Index (COMI)). MRIs were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. None of the patients underwent revision surgery except screw removals from the greater trochanter. Followup data indicate a satisfactory to good hip function at 5 years: PROMS improved from pre- to postop at 5 years: OHS from 38.1 to 43.4, COMI from to 1.8 and UCLA from 4 to 8.1 respectively. MOCART score was 67.5 postoperatively. Subgrouping showed slightly better results for acetabular defects (Ø 69.4) compared femoral defects (Ø 60). Based on the reported mid-term results, we consider AMIC as a valuable treatment option for larger chondral defects of the hip

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Abstract. OBJECTIVES. Hip dislocations remain one of the most common complications of total-hip-arthroplasty (Zahar et al.,2013). There is contradicting evidence whether the surgical approach affects dislocation rates (Sheth et al., 2015; Maratt, 2018). The aim of this study was to develop instrumentation to measure hip forces during simulated range-of-motion tests where the hip was forced to dislocate in cadaveric specimen. METHODS. A total-hip-replacement was completed on both hips of a single cadaveric specimen by a trained orthopaedic surgeon during a lab initiated by DePuy. A direct-anterior surgical approach was performed on the right leg and a posterior approach was performed on the left. Before final implantation of the femoral component, a trial reduction with a femoral neck trial was performed. The neck trial was modified with strain gauges placed around the shaft which were designed to measure resultant hip forces throughout the range-of-motion assessment. A force-calibration was performed using a calibration-block to convert strain to force values. RESULTS. The developed method was able to measure joint forces. Initially the leg was flexed which led to a decrease of joint force for the load component in direction of the neck-axis which was the predominant force during hip dislocation. The leg was subsequently rotated internally which led to a sharp increase with maximum forces of 150N for the direct-anterior approach and 130N for posterior approach. The average absolute calibration error was 6.7%. CONCLUSIONS. The peak force in neck direction was slightly higher for the direct-anterior approach compared to the posterior approach which indicates that the soft tissue tension was potentially higher. Limitations of this study were potentially lower soft tissue tension of cadaveric specimens, the sample size and low calibration accuracy. Component position was not assessed, which is another significant contributor to joint stability. However, the data will be useful for enhanced understanding of dislocation mechanisms. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Acetabulum fractures caused by civilian firearms represent a unique challenge for orthopaedic surgeons. Treatment strategies should include the assessment of infection risk due to frequently associated abdominal injuries and maintenance of joint function. Still, internationally accepted treatment algorithms are not available. The aim of the study was to increase knowledge about civilian gunshot fractures of the acetabulum by describing their characteristics and management at a high-volume tertiary hospital. All adult patients admitted to our hospital between January 2009 and December 2022 with civilian gunshot fractures of the acetabulum were included in this descriptive retrospective study. In total our institution treated 301 patients with civilian gunshot fractures of the hip joint and pelvis during the observation period, of which 54 involved the acetabulum. Most patients were young males (88,9%) with a mean age of 29 years. Thirty patients (55,6%) had associated intraabdominal or urological injuries. Fracture patterns were mostly stable fractures with minor joint destruction amenable to conservative fracture treatment (n=48, 88,9%). Orthopaedic surgical interventions were performed in 21 patients (38,9%) with removal of bullets in contact with the hip joint via arthrotomy or surgical hip dislocation as most frequent procedures. Most patients received antibiotics on admission (n=49, 90,7%). Fracture related infections of the acetabulum were noted in six patients (11,1%) while the mortality in the study population was low with one demised patient (1,9%) due to the trauma burden. Most civilian acetabulum gunshot fractures are associated with intraabdominal or urological injuries. In comparison to the literature on extremity gunshot fractures, there is an increased risk of infection in our study population. The decision for surgical wash-out and bullet removal should be based on contamination and anticipated joint destruction, while osteosynthesis or primary arthroplasty are rarely necessary for these injuries

The recognition of hips at risk of displacement in children with cerebral palsy (CP) is a difficult problem for the orthopaedic surgeon. The Gross Motor Function Classification System (GMFCS) and head–shaft angle (HSA) are prognostic factors for hip displacement. However, reference values for HSA are lacking. This study describes and compares the development of HSA in normal hips and children with CP. . We selected 33 children from a retrospective cohort with unilateral developmental dysplasia of the hip (DDH) (five boys, 28 girls) and 50 children (35 boys, 15 girls) with CP with GMFCS levels II to V. HSA of normal developing hips was measured at the contralateral hip of unilateral DDH children (33 hips) and HSA of CP children was measured in both hips (100 hips). Measurements were taken from the radiographs of the children at age two, four and seven years. The normal hip HSA decreased by 2° per year (p < 0.001). In children with CP with GMFCS levels II and III HSA decreased by 0.6° (p = 0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did not alter significantly in GMFCS levels IV and V. . Between the ages of two and eight years, the HSA decreases in normal hips and CP children with GMFCS level, II to III but does not change in GMFCS levels IV to V. As HSA has a prognostic value for hip displacement, these reference values may help the orthopaedic surgeon to predict future hip displacement in children with CP. Cite this article: Bone Joint J 2015;97-B:1291–5

Aim. Aim of this monocentric, prospective study was to evaluate the safety, efficacy, clinical and radiographical results at 24-month follow-up (N = 6 patients) undergoing hip revision surgery with severe acetabular bone defects (Paprosky 2C-3A-3B) using a combination of a novel phase-pure betatricalciumphosphate - collagen 3D matrix with allograft bone chips. Method. Prospective follow-up of 6 consecutive patients, who underwent revision surgery of the acetabular component in presence of massive bone defects between April 2018 and July 2019. Indications for revision included mechanical loosening in 4 cases and history of hip infection in 2 cases. Acetabular deficiencies were evaluated radiographically and CT and classified according to the Paprosky classification. Initial diagnosis of the patients included osteoarthritis (N = 4), a traumatic fracture and a congenital hip dislocation. 5 patients underwent first revision surgery, 1 patient underwent a second revision surgery. Results. All patients were followed-up radiographically with a mean of 25,8 months. No complications were observed direct postoperatively. HHS improved significantly from 23.9 preoperatively to 81.5 at the last follow-up. 5 patients achieved a defined good result, and one patient achieved a fair result. No periprosthetic joint infection, no dislocations, no deep vein thrombosis, no vessel damage, and no complaint about limbs length discrepancy could be observed. Postoperative dysmetria was found to be + 0.2cm (0cm/+1.0cm) compared to the preoperative dysmetria of − 2.4 cm (+0.3cm/−5.7cm). Conclusions. Although used in severe acetabular bone defects, the novel phase-pure betatricalciumphosphate - collagen 3D matrixshowed complete resorption and replacement by newly formed bone, leading to a full implant integration at 24 months follow-up and thus represents a promising method with excellent bone regeneration capacities for complex cases, where synthetic bone grafting material is used in addition to autografts