This retrospective study was to investigate radiographic and clinical outcomes in treatment of hip instability in children and young adults undergoing periacetabular osteotomy (PAO) with or without femoral osteotomy. 19 patients (21 hips) with CP were treated with PAO with or without femoral osteotomy The mean age was 16.2 years old (7 to 28 years). Five patients (5 hips) received PAO, Six patients (7 hips) PAO with femoral derotation osteotomy, Eight patients (9 hips) PAO with varus derotational osteotomy (VDRO). Anteroposterior pelvic radiographs and CT were taken to assess the migration percentage (MP), lateral center-edge angle (LCEA), Sharp angle, femoral neck anteversion, neck-shaft angle. Gross Motor Function Classification System (GMFCS) was assessed pre- and post-surgery. Complications were recorded. The mean follow-up time was 41.2 months (range, 24 to 86 months). All hips but one were pain free at final visit. The GMFCS improved by one level in 10 of 19 patients. MP improved from a mean of 76.6% to 18.6% at the final follow-up(p<0.001). The mean pre-operative LCEA and Sharp angle were −33.5 ? and 35 ? respectively, improved to 21.5 ? and 11.8 ? at the final follow-up (p < 0.001). There were six patients (7 hips) had re-subluxation at latest follow-up. Nervus cutaneus femoris lateralis was impaired in four patients after surgery. There was no re-dislocation, AVN, or infections in this group. Satisfactory clinical and radiologic results can be obtained by PAO with or without femoral osteotomy minor complications

Aims. Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods. Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results. Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion. These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients. Cite this article: Bone Joint Res 2023;12(10):657–666

Objective. In total knee arthroplasty, three-dimensional “criss-cross” line locate femoral osteotomy and conventional osteotomy were used. By comparing the two methods osteotomy in patients before and after surgery and imaging-related information data, to evaluate the recent post operative efficacy, at the same time to find out if there has clinical evidence that three-dimensional “criss-cross” line locate femoral osteotomy can be used in total knee arthroplasty. Methods. From July 2012 to July 2014, 64 patients who undertook the artificial total knee arthroplasty were divided into 2 groups: conventional osteotomy group(group A)and three-dimensional “criss-cross” line locate femoral osteotomy group(group B). In the X-ray of the two groups, it was measured that the hip-knee-ankle angle and the joint gap symmetry of 90°flexion degree. It was also measured that the two group joints range of motion. Those data were statistically analyzed. The KSS score of the two groups were compared. Results. In Group B the excellent and good rate was 93.8%, and Group A was 81.3%. The postoperative results of Group A were relatively better than Group B in limb alignment and joint mobility. There were significant differences between the prosthesis placement of the two group patients. Conclusion. The Short-term results of the three-dimensional “criss-cross” line locate femoral osteotomy group was better than the conventional osteotomy group. The reference osteotomy method of three-dimensional “criss-cross” line is very helpful to have a good result in TKA

Purpose. Proximal femoral osteotomy is an attractive joint preservation procedure for osteonecrosis of the femoral head. The purpose of this study was to investigate the cause of failure of proximal femoral osteotomy in patients with osteonecrosis of the femoral head. Patients and Methods. Between 2008 and 2014, proximal femoral osteotomy was performed by one surgeon in 13 symptomatic hips. Ten trans-trochanteric rotational osteotomies (anterior: 7, posterior: 3) and 3 intertrochanteric curved varus osteotomy were performed. Of the patients, 9 were male and 1 was female, with a mean age at surgery of 36.9 years (range, 25–55 years). The mean postoperative follow-up period was 38 months (range, 12–72 months). Three patients (4 hips) had steroid-induced osteonecrosis, and 7 (9 hips) had alcohol-associated osteonecrosis. At 6 postoperative weeks, partial weight bearing was permitted with the assistance of 2 crutches. At more than 6 postoperative months, full weight bearing was permitted. Patients who had the potential to achieve acetabular coverage of more than one-third of the intact articular surface on preoperative hip radiography, computed tomography, and magnetic resonance imaging were considered suitable for this operation. A clinical evaluation using the Japanese Orthopaedic Association (JOA) scoring system and a radiologic evaluation were performed. Clinical failure was defined as conversion to total hip arthroplasty (THA) or progression to head collapse and osteoarthritis. The 13 hips were divided into two groups, namely the failure and success groups. Results. The mean preoperative JOA score was 59 points. The score in the success group (7 hips) improved to 89 points at the time of final follow-up. In the failure group (6 hips), 5 hips were converted to THA because of progression to secondary collapse or osteoarthritis in a mean postoperative period of 35 months (range, 24–51 months). After converting to THA, good clinical and radiographic results were achieved, except in 1 patient who had incomprehensible severe pain around the affected hip. Advanced osteoarthritis was observed in 1 hip awaiting THA. Various factors cause failure of proximal femoral osteotomy, such as difficulty in controlling the underlying disease with less than 10 mg of steroid (Fig. 1), overuse of the affected hip within 6 postoperative months without the physician's consent, vascular occlusion after total necrosis of the femoral head as a result of damage to the nutritional vessel during or after the operation, and incorrect judgement of the indication of the operation and the extent of the intact load-bearing area. Conclusion. We think that full weight bearing should be permitted postoperatively only after more than 6 months, and heavy work and sport, only after more than 1 year. Efforts should be made to improve surgeons' skill in proximal femoral osteotomy and accurate judgement of imaging data. For steroid-induced osteonecrosis of the femoral head, proximal femoral osteotomy is an acceptable procedure for relieving pain if the underlying disease can be controlled with not more than 5 mg of steroid

The purpose of this study was to evaluate the effect of previous femoral osteotomy on the outcome of total hip replacement performed for degenerative arthritis secondary to developmental dysplasia of the hip. Eighty three primary total hip arthroplasties were performed in sixty-nine patients with osteoarthritis secondary to developmental hip dysplasia (DDH) with a minimum three year follow up. Twenty six hips had undergone previous femoral osteotomy (eleven hips, femoral osteotomy alone (FO); fifteen hips, combined femoral and pelvic osteotomy and fifty-seven hips, no previous surgery. The non operative patients with DDH served as an age and sex matched control group (control). Cementless arthroplasty was performed in seventy-eight hips. The mean duration from femoral osteotomy to primary THA was 22.9 years. The mean follow up was 7.6 years (FO) and 7.2 years (control). The overall revision rate was 15.4 % (FO) and 21.1 % in the Control group (p> 0.05). Twenty-one hips had one or more complications during or after surgery. The FO group had a higher femoral fracture rate (23.1%) compared to controls (10.5%) (p< 0.05). At latest mean follow-up (7.4 yrs (range, two to sixteen)), the mean Harris hip score was eighty-five (FO) and eighty-five (control group) (p> 0.05). The function and pain scores in the femoral osteotomy group were similar to the controls (p> 0.05). The requirement for bone grafting was similar and operative time significantly greater (FO) compared to controls. The frequency of radiolucent lines around the femoral component in the FO group (36%) was significantly higher than the control group (12.2%) (p< 0.05). Survival analysis was performed with the Kaplan-Meier method. At ten years, the survival of the acetabular component was 84.6%/73.6% and for the femoral component 92.2%/96% in the FO/control group. Patients with a prior femoral osteotomy have no significant difference in functional outcome, overall complication rate or revision rate compared to controls. However, there is a significant increase in femoral fracture and operative time. Previous femoral osteotomy does not compromise the functional outcome of subsequent total hip arthroplasty

We describe 95 patients with previously treated congenital dislocation of the hip who underwent femoral osteotomy after the age of five years. The commonest indication for surgery was progressive uncovering and subluxation of the femoral head; other reasons were coxa vara, long leg dysplasia and persistent anteversion. Femoral osteotomy for uncovering of the femoral head (Severin Grade III) in this age group gave good results at maturity only when the acetabular angle was less than 25 degrees before operation. Femoral osteotomy alone was inadequate for true subluxation of the hip (Severin Grade IV)

1. One hundred and forty-two cases of extra-articular arthrodesis of quiescent tuberculous hips with fibrous ankylosis have been reviewed. 2. The methods used were the ilio-femoral graft with and without osteotomy, and the ischio-femoral graft by the Brittain or Foley technique. 3. Success occurs more frequently when the grafting operation is combined with or followed by a femoral osteotomy. 4. It is suggested that this success is due largely to the increased immobilisation afforded by the osteotomy. 5. It appears that equally good results can be obtained with either an ilio-femoral or an ischio-femoral graft in these cases provided that an upper femoral osteotomy is also carried out, preferably at or soon after the grafting operation. 6. An upper femoral osteotomy will frequently convert an unsuccessful extra-articular hip graft into a successful one without further grafting

Introduction: We describe the successful treatment of advanced Perthes’ disease in 5 patients using a combined pelvic and femoral osteotomy. To our knowledge, there are no reports in orthopaedic literature describing simultaneous pelvic and femoral osteotomy as treatment for healed Perthes disease. Method: There were 4 males and 1 female, age range 10 years to 18 years (mean 13 years). All five patients were rated as Stulberg IV. We used a Tonnis pelvic osteotomy and a 20° valgus femoral osteotomy. Clinical parameters, measured pre and post operatively, included range of movement, Harris hip and pain scores (patient and parent perception of pain on an analogue scoring system). Results: The mean improvement in Harris hip score was 30 points and the mean reduction in pain score was 6. Range of movement was not affected. Complications included one case of non-union of the femoral osteotomy, successfully treated by open reduction and internal fixation with bone graft. Conclusions: Simultaneous pelvic and femoral osteotomy may improve symptoms and function in symptomatic patients with healed Stulberg IV Perthes disease

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

Aim: To study the complications of an extended lateral femoral osteotomy (after Paprosky) of the femur utilised for exposure in revision total hip replacement. Method: A retrospective audit was performed of the senior author’s revision hip patients who had, at the time of surgery, an extended lateral femoral osteotomy for both deformity correction and to facilitate cement removal. No attempt was made to correlate the use of an osteotomy and operating time or overall results as no unbiased control group was available. The time to radiological union and complications of the procedure was reviewed to assess the safety of an osteotomy in one surgeon’s practice. Results: Thirty patients with 31 osteotomies were reviewed, all with long-stem fully porous coated femoral stems. It was the senior author’s anecdotal opinion that osteotomy facilitated cement removal without canal perforation and was necessary for varus deformity correction in many patients. All osteotomies united without further procedures after an average of 22 weeks (range: 12 to 38 weeks). There was one fatigue fracture of the osteotomised fragment, one non-union of the greater trochanter and two cable failures; all without significant sequelae. There was one fracture of the medial proximal femur that required a period of four weeks of bed-rest; otherwise all patients were mobilised full weight bearing as tolerated. One patient had deep infection and a loose femoral component. Two patients had instability of the hip in the post-operative period. Conclusion: We have shown that the osteotomy reliably united and was safe even with early full weight bearing, with few complications. Extended femoral osteotomy for deformity correction and cement removal in revision hip replacement is a safe and easy technique that reliably facilitates revision

Purpose: Total hip arthroplasty after failure of femoral osteotomy raises high risk of complications. Outcome has been controversial. The purpose of this retrospective analysis was to evaluate the difficulties and results. Material and methods: Between March 1974 and January 1995, 68 patients (82 hips), 51 women and 17 men, mean age 59±11.5 years (32–84) underwent surgery. Initial indications were mainly acetabular and/or femoral dysplasia (n=47 hips) or congenital dislocation (n=21 hips). Mean time between osteotomy and arthroplasty was 13.8±8.4 years (10 months-45 years). We used cemented titanium femoral stems (Ceraver Ostal) with an alumina (n=66) or polyethylene (n=16) cup. An alumina-alumina bearing was used in 67 hips (81%). Functional outcome was assessed with the Postel-Merle-d’Aubligné score. Radiological analysis searched for lucent lines and signs of wear. The actuarial survival was determined. Results: One patient (1 hip) was lost to follow-up. Thirteen patients (14 hips) died of intercurrent causes. Six hips required revision for aseptic loosening (isolated cup loosening in five and bipolar loosening in one) at 8.5 years on average (4.5–12). There were 22 intraoperative complications (27%) including 18 fractures or femoral stem misalignments and four cases of damage to the acetabular fundus. Other complications included one postoperative dislocation, two sciatic nerve palsies with partial recovery, and one non-union of the greater trochanter. There were no infections. At maximum follow-up (11.8±4.7 years, ragne 5.4–20), the mean functional score was 16.5 (15–18) versus 9.9 (6–14) preoperatively (p< 0.05). There were no femoral lucent lines. A complete lucent line around the cup was observed in eleven hips including six with a massive cemented alumina cup. Considering revision for aseptic loosening as failure, cumulative survival at 12 years was 82% (95%IC 67–96%) for the cup and 98% (92–99.7%) for the femoral stem. Discussion: These results confirm the high risk of intraoperative complications of total hip arthroplasty performed for failure of femoral osteotomy. Architectural changes expose these patients to technical problems. The survival of the implants appears to be relatively unaffected by the prior procedure but the functional results are slightly less satisfactory then for primary arthroplasties

Upper femoral osteotomy is a recognised treatment for selected patients with Perthes' disease. The results of this procedure were investigated at skeletal maturity in 44 patients (48 hips). The indication for operation was Catterall group II, III, and IV hips with 'head-at-risk' signs. Harris and Iowa scores were calculated clinically, and each hip was assigned radiographically to one of the five Stulberg classes, its initial Catterall grading checked and other relevant indices measured. Results showed excellent clinical function. Shortening was present in 14 hips (29%) and a positive Trendelenburg's sign was seen in 12 (25%). On radiographic assessment 58% of hips were Stulberg class I or II, with a good prognosis. The results of femoral osteotomy were better than those for conservatively treated hips in all age groups except those under five years

We compared 74 total hip arthroplasties (THAs) carried out after previous proximal femoral osteotomy with a diagnosis-matched control group of 74 primary procedures performed during the same period. We report the perioperative results and the clinical and radiological outcome at five to ten years. We anticipated a higher rate of complications in the group with previous osteotomy, but found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates. There was a trend towards improved survival in the group without previous osteotomy (90% v 82%), but this difference was not statistically significant. The only significant differences were a higher rate of trochanteric osteotomy (88% v 14%) and a longer operating time in the osteotomy group. Our study indicates that THA after previous osteotomy is technically more demanding but not necessarily associated with a higher rate of complications. Furthermore, proximal femoral osteotomy does not jeopardise the clinical and radiological outcome of future THA enough to exclude the use of osteotomy as a therapeutic alternative in younger patients

Aim: To study the adequacy of reduction of DDH postoperatively using MRI. Method: Ten consecutive children with DDH who underwent open reduction and femoral osteotomy using Coventry stainless steel implants were scanned postoperatively. Results: MRI gave reliable diagnostic information in all cases. The position of the femoral head in the acetabulum was clearly seen, despite artefact due to the metal. The mean scanning time was 3 minutes 45 seconds (range: 2 minutes 20 seconds – 5 minutes 30 seconds) and the total time in the MRI suite was between 7 and 10 minutes. No child required sedation. Conclusions: The use of MRI scanning has been described after closed and open reduction of the hip in DDH to check hip position but has not previously been reported after open reduction with femoral osteotomy and the use of metalwork. Satisfactory images, comparable time and cost to CT scanning and the lack of exposure to ionising radiation make MRI an appealing method of imaging. We recommend it as the investigation of choice in this patient group

We compared 63 hips (Catterall Groups 3 and 4) contained by femoral osteotomy with 85 untreated hips and found that 50.7 per cent of treated patients developed congruous spherical femoral heads in contrast to 14.1 per cent of those untreated. We have also considered certain other features relevant to the outcome. We suggest that the indications should not be modified on the grounds of early age of onset. Relief from weight-bearing does not appear to improve the results of containment. We have assessed the shortening which follows femoral osteotomy and conclude that this is only significant when there is growth disturbance at the capital epiphysis. These changes are at least as frequent in untreated patients

Patients with dislocation, severe subluxation of the hip joints were treated with cementless THA combined with subtrochanteric shortening femoral osteotomy. Total hip arthroplasty (THA) requiring subtrochanteric osteot-omy has been considered to lead to several complications. The aim of this paper is to assess the clinical results and complications of this procedure. An acetabular component was placed into position at the site of the true acetabulum. After femoral corrective shortening osteotomy for dislocation or severe sub-luxation of the hip joints, an AML cementless stem was tightly inserted into the femoral canal to achieve bony union and osteointegration with the implant. Twenty-one patients (23 hips; 2 men, 19 women) treated with cementless THA combined with subtro-chanteric femoral shortening osteotomy were enrolled in this study. The mean age was 55 years and the mean follow-up period was 4.5 years. The average elongation of the limb was 48 mm after subtrochanteric shortening femoral osteotomy. Solid union of the osteotomy was obtained within an average of 5.5 months after surgery. None of these patients developed sciatic nerve palsy. There were 4 cases of non-union of the osteotomy site and 3 of aseptic loosening of the femoral component related to intraoperative femoral fracture. Upward migration of the proximal part of the femur was related to poor preoperative bone quality. In order to diminish these complications, careful patient selection, accurate femoral reaming and suitable methods of bone cutting and augmentation of the oste-otomy site are necessary

Purpose: Background: Treatment of Legg-Perthes disease in older children with greater involvement of the femoral head remains uncertain. Innominate or combined innominate and femoral osteotomies are generally performed to better contain and provide more coverage of the femoral head by the acetabulum and thus achieve a more spherical head and a congruent joint. The purpose of the study was to show the results of both surgeries. Methods: We carried out a retrospective review of 43 hips in 41 patients (36 males, 5 females), with lateral pillar classifications of B (25 hips), B/C (12), and C (6), who had not responded to non-surgical treatment and all treated by one surgeon. They underwent Salter innominate (23 hips) or combined innominate and femoral osteotomies (20 hips). Mean age of the former group at surgery was 7 years, 11 months and of the latter, 10 years, 7 months. Combined osteotomy was performed in older children with more head involvement and stiff hips that did not respond to other treatments. Patients were evaluated with a mean follow-up of 9 years, 4 months using the Stulberg radiographic assessment. Results: Results: Stulberg I or II (SI-SII) results were attained by 57% of the innominate osteotomy group and 30% of the combined. Eleven of 14 LPB hips in the innominate group and 5 of 11 in the combined became SI-II in contrast to 2 of 5 and 1 of 7 LPB/C hips, respectively. All 6 LPC hips were classified Stulberg III or IV (SIII-IV). Children younger than 8 years in the innominate group had better results than the older children (65% vs 33%) and those younger than 10 in the combined group did better than the older (43% vs 0%). Conclusions: Conclusions: The LPB and LPB/C groups treated by innominate osteotomy had better results (more spherical heads) than those undergoing combined osteotomy, age proving a stronger prognostic factor than disease stage. The LPC led to aspherical congruent hips with either type of surgery, regardless of patient’s age. The outcome was better in LPB in children younger than 8 years of age and in LPB/C in those older than 8 years. Age of onset still remains the primary determinant of outcome in LCPD

We developed a custom-made template for corrective femoral osteotomy during THA in a patient with a previous Schanz osteotomy. A seventy-year-old woman presented to our clinic with a chief complaint of right hip, left knee and left ankle pain with marked limp. She had undergone Schanz osteotomy of the left femur because of high dislocation of the left hip when she was 20 years old. After right THA was performed, we decided to perform left THA with corrective femoral osteotomy. A custom-made osteotomy template was designed and manufactured with use of CT data. During surgery, we placed the template on the bone surface, cut the bone through a slit on the template, and corrected the deformity as preoperatively simulated. Two years after surgery, she had no pain in any joints, could walk more than one hour without limp. Japanese Orthopedic Association hip score were 100 points for both hips. THA in patients with previous Schanz osteotomy was reported to be technically demanding and the rate of complications was high. In 2008, Murase T et al. developed a system, including a 3D computer simulation program and a custom-made template to corrective osteotomy of malunited fractures of the upper extremity. We applied the system to corrective femoral osteotomy during THA in a patient with a previous Schanz osteotomy. The surgical procedure was technically easy and accurate osteotomy brought the patient to acquire good alignment of lower extremities with good clinical results

Revision arthroplasty poses many challenges including extensile exposure and difficulty in safe removal of cemented/uncemented femoral component and/or distal cement particularly from a poor bone stock. Extended trochanteric osteotomies are associated with complications including non-union, proximal migration of the trochanter or osteotomised segment, wire breakage and difficulties associated with reattachment of the fragment. We present a technique of trochanter sparing extended anterior femoral osteotomy (AFO) through a modified Hardinge approach in reducing the difficulties associated in conventional and ETO. We assessed the performance of this technique in 23 patients with a maximum follow-up of 10 years. No trochanteric escape or fractures seen in any cases. No proximal migration, subsidence or failure of femoral component seen. Union was seen in all cases. Mean time for union was 3 months. 1 patient developed recurrent dislocations that required constrained liner. Improvement in Harris Hip scores was noted from 13 (pain) and 9 (function) pre-operatively to 39 (pain) and 22 (function) (p<0.05). Extended trochanter sparing AFO allows extensive exposure similar to traditional ETO. It heals reliably without the use of vertical wires, trochanteric plates or grips. The avoidance of abductor mechanism and osteotomy through weakest anterior non weight bearing area of the proximal femur may be a significant advantage

Introduction. Perthes' disease is associated with coxa breva, plana and magna, and a high riding prominent greater trochanter causing abductor shortening and weakness, leg shortening and extra-articular impingement. A trochanteric advancement with an infero-lateralising oblique sliding osteotomy of the proximal femur would lengthen femoral neck, improve abductor length and strength, relieve impingement and improve leg length. We assessed the mid-term outcomes for this procedure. Method. We included patients who underwent the operation by the senior author (JNOH) with more than 2 years follow-up. The osteotomies were performed minimally invasively under image intensifier guidance and fixed with blade plate or locking plates. We assessed functional scores, radiological changes in neck length, Tonnis grading for arthritis and evidence of femoral head avascular necrosis, time interval for conversion to hip arthroplasty and associated complications. Results. Twenty four patients (25 hips) underwent the procedure at mean age of 18.7 years (range:9.3–38.8) with a mean follow-up of 5 years (range:2–13.8). At the last assessment, the mean Oxford Hip Score was 41.6 (range:58–27), Non-Arthritic Hip Score was 53.4 (range:25–77) and UCLA activity score was 4.2 (range:2–6). For changes in neck length, the mean “Head-centre-to-Greater-trochanteric-tip-distance” was 60 mm (range:43–78) compared to 39 mm (range:30–48) pre-operatively and the mean “Head-centre-to-Lesser-trochanteric-tip-distance” was 54 mm (range:47–64) compared to 37 mm (range:31–41) pre-operatively. The mean Tonnis grade was 1.5 (range:1–3) compared to 1.3 (range:1–2) pre-operatively. Two patients underwent arthroplasty conversion at 2 and 13.8 years later. One patient needed head-neck debridement for impingement and 2 patients underwent trochanteric refixation for non-union. There were no cases of avascular necrosis. Discussion. Symptomatic Perthes' hip deformity in adolescents and young adults is difficult to treat with joint preserving surgery. The mid-term clinical, functional and radiological results for double proximal femur osteotomy are encouraging

Introduction. Perthes disease is associated with coxa breva, plana and magna, and a high riding prominent greater trochanter causing abductor shortening and weakness, leg shortening and extra-articular impingement. A trochanteric advancement with an infero-lateralizing sliding osteotomy of the proximal femur would lengthen femoral neck, improve abductor length and strength, relieve impingement and improve leg length. We assessed the mid-term outcomes for this procedure. Method. We included patients who underwent the operation by the senior author (JNOH) with more than 2 years follow-up. The osteotomies were performed under image intensifier guidance and fixed with blade plate or locking plates. We assessed functional scores, radiological changes in neck length, Tonnis grading for arthritis and evidence of progression in femoral head avascular necrosis, time interval for conversion to hip arthroplasty and associated complications. Results. Twenty four patients (25 hips) underwent the procedure at mean age of 18.7 years (range:9.3–38.8) with a mean follow-up of 5 years (range:2–13.8). At the last assessment, the mean Oxford Hip Score was 41.6 (range:58–27), Non-Arthritic Hip Score was 53.4 (range:25–77) and UCLA activity score was 4.2 (range:2–6). For changes in neck length, the mean “Head-centre-to-Greater-trochanteric-tip-distance” was 60 mm (range:43–78) compared to 39 mm (range:30–48) pre-operatively and the mean “Head-center-to-Lesser-trochanteric-tip-distance” was 54 mm (range:47–64) compared to 37 mm (range:31–41) pre-operatively. The mean Tonnis grade was 1.5 (range:1–3) compared to 1.3 (range:1–2) pre-operatively. Two patients underwent arthroplasty conversion at 2 and 13.8 years later. One patient needed head-neck debridement for impingement and 2 patients underwent trochanteric refixation for non-union. There was no progression in avascular necrosis of femoral head. Discussion. Symptomatic Perthes hip deformity in adolescents and young adults is difficult to treat with joint preserving surgery. The mid-term clinical, functional and radiological results for double proximal femur osteotomy are encouraging

We studied, clinically and radiologically, the growth and remodelling of 21 hips after valgus femoral osteotomy with both rotational and sagittal correction for hinge abduction in 21 patients (mean age, 9.7 years) with Perthes’ disease. The exact type of osteotomy performed was based on the pre-operative clinical and radiological assessment and the results of intra-operative dynamic arthrography. The mean IOWA hip score was 66 (34 to 76) before surgery and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiological measurements revealed favourable remodelling of the femoral head and improved hip joint mechanics. Valgus osteotomy, with both rotational and sagittal correction, can improve symptoms, function and remodelling of the hip in patients with Perthes’ disease

Introduction Growth of femoral neck can be stunted due to early fusion of capital femoral epiphysis and can occur in DDH, LCPD and Septic Arthritis of Hip, while the greater trochanter (GT) continues to grow normally. This results in a high riding greater trochanter with altered abductor function and shortening of the involved limb. Management of patients with such deformities in adolescence is challenging, more so in planning to conserve the hip joint. Methods and Results We wish to present our experience in the management of such deformed proximal femur with double femoral osteotomy in 15 patients (6 male, 9 female), mean age 22 (11–36) years with an average follow-up of five years. Average distalisation of GT was 2.2 cms and limb-length gained was 2.8 cms. Fracture of GT with displacement was the only complication encountered that required further surgery. Discussion Primarily the procedure was performed to distalise the greater trochanter thereby improving abduction function, increasing the offset at the hip joint, and creating a more anatomical neck; so facilitating any subsequent joint-sacrificing procedure. Although the secondary benefit of the procedure was to gain limb length, this was what the patients appreciated was the greatest benefit. The technique demands detailed preoperative planning, detailed execution of the plan but produces consistently good results

We treated 31 hips in 30 patients with advanced osteoarthritis of the hip secondary to acetabular dysplasia, by valgus-extension femoral osteotomy. The mean follow-up was 12.7 years (10 to 17). Acetabuloplasty was added in ten severely dysplastic hips. In 28 hips, radiological widening of the joint space was seen three years after operation, but in 12 had narrowed again by ten years. Survivorship analysis showed that the rate of survival was 82% using the pain score as the index of failure, and 72% based on radiological findings at ten years. Better long-term results were obtained in hips which had an acetabular head index greater than 70% or a roof osteophyte more than 5 mm in length three years after operation. Acetabuloplasty should be added for the hip which is severely dysplastic and with a poorly developed roof osteophyte

Hypothesis. Successful total hip arthroplasty (THA) in the presence of developmental dysplasia of the hip (DDH) depends on restoration of the anatomic centre of hip rotation and may require simultaneous femoral osteotomy. Techniques using uncemented components are widely reported. In osteopenic bone an all-cemented technique may be more appropriate; however, the outcome following this procedure is not known. We present the results of a series of thirty-five cemented THA with simultaneous subtrochanteric osteotomy. Methods and analysis. 28 patients with DDH (35 hips) who underwent this procedure at a mean age of 47.3 years were retrospectively reviewed. Two patients (two hips) died within 12 months of surgery. The clinical notes and radiographs of the remaining patients were reviewed with a minimum follow-up of 2 years (mean, 5.6 years; range, 2-14 years). Complications were noted. SF-12 and Oxford hip scores (OHS) were recorded for 18 patients pre-operatively and after 6 and 12 months. Results. Union occurred in 32 of 33 femora (97%); one patient had an infected nonunion. The overall revision rate was 19% at 5.6 years (8% femoral revision rate). There were three dislocations, two of which required further surgery. Two patients had a transient neuropraxia. The mean SF-12 physical component score increased from 32 to 52 and mean SF-12 mental component score increased from 48 to 51. The mean OHS decreased from 40 to 27. Conclusion. Combined subtrochanteric osteotomy and cemented THA is technically demanding with a higher complication rate than routine THA. The rate of union, complications, implant survivorship, and early OHS were comparable to those for similar techniques using cementless components

We have considered the reasons for securing containment of the femoral head in Perthes' disease and have reviewed briefly the methods used. The present investigation describes the outcome in a controlled series of forty-eight hips treated by containment by femoral varus-rotation osteotomy in selected patients. In assessing the results we have emphasised that controls are essential, and for this purpose we have used two comparable groups, one untreated and the other treated by methods other than containment. The same factors were considered in assessment--namely age, duration, group, and the presence or absence of "at risk" signs. The results were graded similarly as good, fair and poor in all groups. We have concluded that containment by femoral osteotomy is the treatment of choice in patients with "at risk" signs provided that severe deformity has not already occurred. There is no evidence that treatment of any kind favourably influences the course of the disorder in the remainder. Although this is predominantly a radiological study some clinical features are discussed

The use of MRI scanning has been described after open reduction of the hip in DDH to check hip position but has not previously been reported after open reduction with femoral osteotomy and the use of metalwork. We performed a prospective study utilising MRI to document the adequacy of reduction. An MRI scan was performed on the second postoperative day in order to confirm the satisfactory reduction of the hip following surgery. Previously a CT scan was performed. 10 consecutive cases were scanned and all gave diagnostic information of satisfactory reduction. Sedation was not required. The mean scanning time was 3 minute 45 seconds and the total time in the MRI suite ranged from 7 to 10 minutes. Satisfactory images, the lack of need of sedation, comparable time and cost to CT scanning and most importantly the lack of exposure of the child to ionising radiation make MRI a most appealing method of imaging. We therefore recommend it as the investigation of choice in this patient group. Demographic data reviewed included gender, MP at time of primary surgery, GMFCS level, age at time of surgery, type of adductor release procedure performed, and experience of surgeon. Outcome variables assessed were type of subsequent failure, time of failure after primary procedure, and length of follow-up. Three hundred and thirty children underwent hip adductor surgery. The number of children per GMFCS Level was 33 Level II, 55 level III, 103 level IV, and 139 level V. The average age at time of primary surgery was 4.19 years, mean MP at time of primary surgery 43.16%, and mean length of post-operative follow-up was 7.10 years. Eighty two children had adductor longus and gracilis lengthening alone, 97 also had an iliopsoas release, 97 had psoas tenotomy and phenolisation of the obturator nerve, and 54 had a psoas tenotomy and neurectomy of the anterior branch of the obturator nerve (in addition to longus & gracilis lengthening). At time of audit 106 children did not require further surgery (‘surgery success’ of 32%). Thirty one were in children of GMFCS level II (94%), 27 level III (49%), 28 level IV (27%), and 20 level V (14%). A Cox proportional hazards survivorship analysis was constructed to chart the time course of progression to further surgery over time to reveal statistically significant ‘surgery success’ rates according to GMFCS. Differences in the success rates according to GMFCS become more apparent beyond 3 years post-surgery. The most important determinant for predicting the success of hip adductor surgery in preventing hip displacement is GMFCS at the time of primary surgery. Current treatment strategies need to be re-evaluated with the context of undertaking long-term post-operative follow up, particularly for children GMFCS levels VI and V

Purpose: Patients with sickle-cell anaemia tolerate surgery poorly. They are susceptible to infections and results of orthopaedic treatment are uncertain. Mechanical and infectious complications of total hip arthroplasty encountered in adults have led us to conduct systematic screening and early conservative surgical treatment for osteonecrosis of the femoral head (ONFH). Two surgical techniques have been retained in sickle-cell anaemia patients: simple drilling and femoral osteotomy. Material and methods: Between 1993 and 1999, among 248 sickle-cell anaemia patients examined in our study, 69 had active or quiescent ONFH: stage I=1, stage II=42, stage III=16, stage IV=10. We retained for analysis 16 patients (7 SS and 8 SC, 1 S-betathal), seven men and nine women, age range 15–44 years. These patients had 24 hips with active disease. Simple drilling-biopsy was indicated for osteochondrosis of the hip joint (n=1), stage I ONFH (n=1), stage II ONFH (n=13, early stage III ONFH (n=3) and advanced stage III ONFH (n=3). These three patients with advanced stage III disease underwent drilling for two particular indications: poor general status and disabling pain. Flexion femoral osteotomy was performed for the last three patients with stage III ONFH with localised polar weakening. In all, we performed three femoral osteotomies and 21 simple drilling procedures. Mean postoperative follow-up was six years (2–10). Results: Clinical results were assessed with the Postel-Merle-d’Aubligné score. Among the 24 hips, 20 had a favourable outcome (83%). Discussion: ONFH in sickle-cell anaemia patients requires surgical cure when the femoral heads display recent changes of the bony network (osteolysis, defects) and associated cephalic remodelling with or without pain. After drilling and osteotomy, the disease course shows that the femoral head’s spherical shape is preserved when the lesions are treated early by drilling in stage I, II, and III disease. Bipolar weakening remains an indication for femoral osteotomy. This conservative approach can prevent osteoarthritic degradation. It has enabled us to postpone total hip arthroplasty in young subjects with sickle-cell anaemia

Purpose. To evaluate the clinical and radiologic midterm results of rotational acetabular osteotomy (RAO) in incongruent hip joints. Material and Methods. A consecutive series of 15 hips in 14 patients who underwent RAO in incongruent hip joint were evaluated at an average follow-up of 52.3 months (range from 36 to 101 months). The average age at operation was 27 years (range from 12 to 38 years) old. The preoperative diagnoses were developmental dysplasia in 4 hips, sequelae of Legg-Calvé-Perthes disease in 8 hips, and multiple epiphyseal dysplasia in 3 hips. The RAO procedures were combined with a femoral valgus oseotomy in 10 hips, advance osteotomy of greater trochanter in 4 hips, derotational osteotomy in 2 hips. Clinically, Harris hip score, range of motion, leg length discrepancy(LLD) and hip joint pain were evaluated. Radiological changes of anterior and lateral center-edge(CE) angle, acetabular roof angle, acetabular head index(AHI), ratio of body weight moment arm to abductor moment arm, and a progression of osteoarthritis were analyzed. Results. The Harris hip score ha been improved from average from 67.5 points preoperatively to 97.6 points postoperatively. There have been no significant changes in the range of motion. The anterior CE angle increased from an average of 9.0°(-19.7□18.6°) to 32.5°(22.6□39.1°), the lateral CE angle from 7.6°(-12.1□14.1)° to 31.7°(26.5□37.8°) and the AHI from 61%(33□73%) to 86%(65□100%). The average ratio of body weight moment arm to abductor moment arm was changed 1.88 to 1.49. There was no case showing progression of osteoarthritis. None of the patients experienced revision surgery. Conclusion. The conventional salvage operation, such as Chiari osteotomy, has been recommended in incongruent hip. However, if we can expect to have a congruency after RAO with/without any femoral osteotomies, it would be a hopeful procedure for the incongruent joints by enhancing acetabular coverage, taking joint surface with normal articular cartilage, increasing abductor moment arm with additional improvement in LLD

The Author presents results 2–4 years following treatment of seven patients with complicated hip impingements with this new combination of operations. Seven patients, aged 15–35yrs were treated by contemporaneous surgical dislocation and debridement of the hip with contemporaneous corrective subtrochanteric femoral osteotomy.. The dislocation and dedridement were performed in the usual way, but the seating chisel for a 95deg blade plate was introduced(to correct varus/valgus) before the trochanter was osteotomised. After debridement, the blade plate was used to transfix the trochanter in position. A separate subtrochanteric osteotomy was then performed at the upper end of the gluteus maximus insertion to provide correction of version and/or valgus/varus where indicated. The plate was removed six to twelve months later. There were no perioperative complications. Weight-bearing was restricted until bone healing was complete [8–13wks]. Thereafter patients mobilised normally.. At review, all patients were pleased with the outcome. Pre-operative HHS was 62–70: at review it was 90– 96. There were no complications in the medium-term. All patients experienced an improvement in range of movement and exercise tolerance. Avascular necrosis has not occurred overtly and the six patients who had post-operative MRI scans showed no evidence of it. This new combination of established operations combines the joint conserving benefits of debridement with realignment of the femur in patients with complicated impingements of the hip. The report is preliminary, but the combination of operations appears to be safe in terms of the absence of AVN and effective in its relief of symptoms

We report 16 patients (18 hips) treated between 1997 and 1999. The average age was 5 years and 3 months (range, 2–9 years). Of all the hips evaluated, 13 (72%) corresponded to diplegic patients and 5 (28%) to tetra-plegic patients. The surgical plan consisted on femoral osteotomy combined with Dega pericetabular osteotomy coupled with adductor and psoas tenotomy using as a variable the reduction of the hip by the anterior approach depending on each case. We used the following criteria to evaluate results: 1 – pain, 2 – abduction range, 3 – Reimmers index, 4 – acetabular index. Diplegic patients had good (78%), fair (12%) and poor (12%) results. Tetraplegic patients had good (25%), fair (50%) and poor (25%) results in this short follow up. On analyzing the cases, we observed an adequate development of the neurologic hips when using the acetabuloplasty with the Dega technique because it minimized the risk of coverage loss, as commonly seen in these kind of patients due to the progressive valgus during the postoperative period

The aim was to assess the effect of caudal block on patients who have had proximal femoral &/or pelvic osteotomy compared to patients who have had epidural anaesthesia with regards to pain relief and hospital stay. We looked at two patient cohorts; epidural & caudal pain relief in aforementioned procedures. Interrogation of our clinical database (WinDip, BlueSpeir&clinical notes) identified 57 patients: 33 proximal femoral osteotomy, 13 pelvic osteotomy and 11 combined(25 Males 32 Females), aged 1–18 years-old between 2012–2014, in two institutions. A database of demographics, operative indications, associated procedures, analgesia and type of anaesthesia was constructed in relation to daily pain score and length of hospital stay. 39 patients had epidural anaesthesia, and 18 had caudal block. Cerebral palsy with unstable hips was the commonest indication(21), followed by dysplastic hip(10), Perthes disease(8) and other causes(18). The Face, Legs, Activity, Cry, Consolability(FLACC) scale was used to assess pain. Length of hospital stay in caudal block patients was 3.1 days(1–9), in epidural anaesthesia patients stay was 4.46 days(2–13). Paediatrics high dependency unit after an epidural was needed in 20(Average stay 3.4 days) compared to 1 who received caudal block. Caudal block FLACC pain score in the first 36 hours was 1.23(0–4) compared to 0.18(0–2) in patients who had an epidural. Caudal block is associated with less hospital stay and fewer admissions to the high dependency unit, it also provides adequate pain relief post osteotomies when compared to epidural, therefore could be performed at units lacking epidural facilities. A change in related practice however should be cautious and supported by further studies

Purpose of the study: Generally, hip prosthesis implantation for congenital hip dysplasia is a routine procedure. Material and methods: We compared preliminary results between two surgical techniques. On one hand, hip prostheses were implanted via trochanterotomy with femoral shortening osteotomy for cemented insertion and trochanteroplasty. On the other, access was achieved via a triple infratrochanteric osteotomy for shortening, correction of valgum and derotation followed by implantation of a press-fit prosthesis without osteosynthesis. Results:. Between 1993 and 2001, 61 patients underwent surgery for Crowe III or Eftekhar grade C hips (n=45) and Crowe IV or Eftekhar grade D hips (n=16). Mean patient age was 42 years. Prostheses inserted via the trans-trochanteric approach with femoral shortening osteotomy and cementing developed complications related to the trochanteroplasty: nonunion of the greater trochanter (n=6), functional impairment (n=2), infection after bursitis on suture and secondary necrosis (n=1). Because of these complications we adopted the triple femoral osteotomy technique for shortening, derotation and press-fit femoral implants. Between 2001 and 2005, eight Eftekhar D hips were treated with this technique. Locked non-cemented femoral prostheses were inserted. Pre- and postoperative clinical assessment was based on the Postel-Merle-d’Aubigné score. For the cup, the technique remained unchanged, with cemented implants. The lengthening obtaine varied from 3.5 to 5.5 cm with no cases of sciatic palsy. There has been no case of prosthesis dislocation. Conclusion: These preliminary results concern non-cemented femoral prosthesis with insufficient follow-up. We nevertheless have found this an attractive technique free of femoral complications

Dynamization of fracture fixation is used clinically to improve the bone healing process. This study evaluated the effect of late dynamization on callus stiffness and size in a rat diaphyseal femoral osteotomy. The external unilateral fixator was dynamized by removal of the inner fixator bar, at three weeks (D3-group: n=8) or four weeks (D4-group: n=9) post-operation. Published data of a five week rigid (R-group: n=8) and flexible fixation group (F-group: n=8) were included for comparison. Preoperative and postoperative movements of the rats were measured using a motion detection system. After 5 weeks the rats were sacrificed and healing was evaluated by biomechanical and densitometric methods. By 34 days post-operation, rats from the four fixation groups had similar activity levels. There was no significant difference in flexural rigidity, callus volume or callus mineral density between the D3 and D4-groups. Both the D3-group and D4-group had significantly greater flexural rigidity (p< 0.01) and significantly lower callus total volume (p< 0.03) and callus bone volume (p< 0.03) compared to the F-group. There was no significant difference in flexural rigidity or callus mineral density between the dynamized groups compared to the R-group. However, the D3-group had less callus bone volume (p=0.06) compared to the R-group. The D4-group had significantly less callus bone volume (p=0.02) and less callus total volume (p=0.05) compared to the R-group. Late dynamization led to a stiffer callus with a smaller callus volume compared to continuously flexible fixation. The late dynamized groups had less callus volume than the continuously rigid group, but the stiffness and calcification and of the callus were similar. The late dynamized groups had undergone resorption processes, indicative of more advanced healing. Late dynamization enhanced fracture healing compared to the continuously rigid or flexible fixation

An extra articular correction may be necessary in osteoarthritis with an important post traumatic or congenital deformity. In the last 5 years we performed 11 TKR associated with a tibial (9 cases) or a femoral Osteotomy (2 cases), in one time surgery. The average intra osseous deformity was 14°. The technical problems are different in varus and valgus knees. 1- Which type of osteotomy ? In varus knees with a tibial deformity (6 cases) we use a hight tibial valgus osteotomy with opening wedge. Pre operative planning with long standing X rays allows precise determination of the amount of correction needed. A rigide wire, driven up to the fibular head, is placed. A provisional wedge of the desired size (degree of correction) is maintened temporarily by a staple, which will be removed later. Once the correction has been performed and maintened, the standard instrumentation to implant the prosthesis is used. In valgus knees with a tibial deformity (2 cases) a hight tibial closing wedge osteotomy, and in valgus knees with a femoral deformity (2 cases), a low femoral closing wedge osteotomy, are used. In all cases a medial approach without any release and without fibular osteotomy is performed. 2- Which kind of prosthesis?. Two degrees of constraint are possible in fonction of particular needs. Most of the time, a non-constrained PS articular implants will be used and when more constraint will be needed (in lateral instability), CCK-type articular surfaces will be choised. In all cases, a stem will have to be, associated with the osteotomy (tibial or femoral). Different diameters will allow a good press-fit and if necessary, an offset stem will be used. 3- Associated osteosynthesis or not? Stability provided by the press-fit stem may allow not to use an osteosynthesis in most than 50% of cases. If a doubt remains about stability, a small plate can bee added on the medial tibial side of the tibia. 4- Which immediate post-op follow-up?. Full weight bearing will be immediate. A splint will be used only for walking during six weeks. A standard rehabilitation protocole will be followed. In our 11 patients with a short follow up (1 to 5 years) complications consisted in one hematom and one phlebitis. Post-operative alpha angle was 96° and beta angle 91°. TKR with an associated osteotomy seems to be a possible alternative when osteoarthritis is associated with an important extra articular deformity

Introduction: Dynamization is used to improve the healing process. The optimal time for dynamization however remains unknown. In this study we proved the hypothesis that an early dynamization will improve the fracture healing. Material and Methods: Twenty-four rats underwent a diaphyseal femoral osteotomy, with a 1mm gap. The osteotomy was stabilized by either rigid (R-group; n=8) or flexible (F-group; n=8) external fixation. The dynamized group (D-group: n=8) had a rigid fixation for 1 week, and then a flexible fixation for the remaining 4 weeks. The flexible fixation design resulted in an axial stiffness of 10N/mm and the rigid fixation in 74N/mm. After 5 weeks, healing was evaluated by biomechanical, densitometric, and histological methods. Results: The flexural rigidity was 47% higher in the R-group than in the F-group (p< 0.01). Also, the flexural rigidity was 45% higher in the R-group than in the D-group (p< 0.01) (Table 1). Mineralized callus tissue volume was 37% lower in the R-group than the D-group (p=0.002). Conclusion: The hypothesis could not be supported, in that early dynamization did not improve healing compared to rigid or flexible fixation. The rigid fixation had a stiffer callus with smaller callus volume, and more calcified tissue in the whole callus. The rigid fixation had bridging in the gap more often, which explains the increased flexural rigidity measured. Dynamization utilized in previous studies allowed closure of the fracture gap and thereby enhanced the rate of healing, which was not the case in the present investigation

We report on a case of bilateral medial patellar dislocation, studied with hip/knee/ankle TC for evaluation of torsional defects and treated four times with distal derotative femoral osteotomy and cuneiform subtractive osteotomy of the lateral part of the femoral trochlea. The patient, a woman 18 years of age at the beginning of treatment, presented with femoral neck anteversion of 30° dx and 25° sx referred to the plane passing posteriorly to the distal femoral condyles; the trochlear angle was 140° dx and 144° sx with medial inclination of trochlea due to medial hypoplasia. The patellae were facing medially, and clinically the patient had suffered medial dislocation of the patella several times. The treatment lasted 4 years: the femoral derotation of 10° was executed by Orthofix monoassial external fixator; the lateral bone wedge removed from the trochlea was about 10 mm and we used reabsorbable nails for fixation. Current values are 17° of femoral neck anteversion bilaterally, and the trochlear angle is 151° dx and 150° sx. The patient, now 26 years old, has not had any more dislocations and her knees have complete mobility with no pain. The good result demonstrates the importance of femoral neck anteversion in the genesis of knee disorders. In this case the absence of specific abnormalities of the extensor mechanism (valgus knee, lateralisation of tibial apophyisis) probably caused the hypoplasia of the medial part of the trochlea and the resulting, rare medial patellar dislocation

1. Osteotomy for osteoarthritis of the hip induces a fibrin layer over the exposed bone which forms the basis of a fibrocellular protective mantle that can differentiate towards cartilage.

2. The process is accompanied by bone remodelling, which reduces sclerosis, resolves osteolytic foci and, in company with bone formation in the fibrous mantle, restores the subchondral plate.

3. Many important aspects of the pathogenesis of osteoarthritis and of its partial repair by osteotomy remain to be elucidated.

Because of post traumatic mal union or constitutionnal intraosseous femoral or tibial deviation, an extra articular deformity may be present in patients requiring TKR. In those cases, recreation of the mechanical axis will affect the orientation of femoral or tibial bone cuts and soft tissue balance. In those important deformities, an extra articular correction may be necessary. Between 1998 and 2013 we performed 31 TKR associated with femoral (6 cases) or tibial (25 cases) osteotomy in one time surgery. This study was prospective and the patients were examinated at 1, 2, 5, 10 and 15 years for the first patients. There were 17 males (one bilateral case) and 13 females with a 63 years average age (from 29 to 79). The deformity was constitutionnal in 14 cases, post trauma in 9 cases, post osteotomy in 8 cases. The extra articular deformity was between 10° and 35°: 15 in varus, 11 in valgus, 2 multidirectionnal, 1 intraosseous flessum, 1 important translation and 1 rotational deformity. In all the cases we used a long stem implant in the osteotomized bone: an osteosynthesis was performed in 26 cases (7 plates, 19 stapples). A posterostabilised prosthesis was used in 28 patients, a CCK implant in 3. We studied pre and post operatively with a 3 to 17 years follow up, IKS scoring, knee motion, knee stability and radiologicaly, HKA, tibial and femoral mechanical angle. In the knees with a varus deformity the average HKA was 158° before surgery and 181 after osteotomy combinated with TKR. In the valgus cases, the average HKA was 198° pre and 179° post operatively. Complications consisted in 1 peroperative fracture, 1 extension lag of 15° and 1 hematoma.

TKR associated with osteotomy seems to be a possible alternative in patients with severe constitutional or post traumatic extra articular deformities after discussion of the other solutions: osteotomy and TKR in two times surgery (particulaly in young patients) or constraint TKR (rotating hinged implants) in patients over 80 years of age.

Introduction and Aims: The authors present their results following treatment of 15 patients with complex hip deformities by this new combination of operations.

Method: Fifteen patients aged 14 to 36 years (one male) were treated by contemporaneous metal-on-metal hip resurfacing and rotation osteotomy of the femur to nor-malise anteversion over a five-year period (1996–2001). The resufacing was performed in the usual way; anteversion was corrected at the end of the operation where limited internal or external rotation (< 20deg) was felt likely to interfere with the foot progression angle. The plate was removed about one year later.

Results: There were no peri-operative complications. Weightbearing was restricted until bone healing was complete (8–13 weeks). Thereafter patients mobilised normally. One patient had her plate removed at six months, as there was sleep disturbance due to local tenderness. At review, all patients were pleased with the outcome. Pre-operative HHS was 65–72: at review it was 89–96. There were no complications in the medium term. All patients had an abnormal foot progression angle pre-operatively (14 had fixed internal rotation, one external rotation). At review, in extension all fell within the physiological range IR50/ER50.

Conclusion: This new combination of established operations facilitates the bone conserving benefits of the metal-on-metal resurfacing with corrective rotational osteotomy in patients with complex hip deformity. We have avoided the use of expensive custom protheses and have allowed patients the benefits of a prosthesis minimising bone resection and retaining the physiological modulus of elasticity

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

The purpose of the study was to assess the usefulness of this combination of operations in this challenging patient group.

18 patients (19 hips) with cerebral palsy and painful subluxed or dislocated hips underwent hip resurfacing with shortening and rotation osteotomy of the femur between 1999 and 2005. The mean age was 25 (range 14–59) and follow-up averaged 47 months. Eleven patients were quadriplegic, five were diplegic and two were hemiplegic.

There were no infections. There were two plate cut-outs and two dislocations. All stabilised following necessary treatment. Four plates were removed after about one year. All quadriplegic and four of the diplegic patients were chair-bound pre-operatively. Their carers all felt that their comfort sitting had improved. Seventeen patients (eighteen hips) were pain-free at latest follow-up. One patient, whose plate had not been removed had some lateral tenderness on transferring, but no apparent pain on sitting. Three of the previously chairbound diplegic patients were able to stand and one was able to walk.

As all eighteen of the carers were very satisfied with the outcome, this approach to the treatment of these challenging patients has proved promising

We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity.

Purpose of the study: Implantation of a total hip arthroplasty (THA) for major misalignment is a difficult procedure and few results have been published. In the 1950s to 1970s, supra-trochanteric osteotomy was proposed for sequelar osteoarthritis of congenital hip dislocation. Subsequent degradation 20 to 30 years later can lead to neo-osteoarthritis of the joint with an effect on hip alignment and overall balance between the knee and the spine. We present a prospective consecutive series of 60 THA performed from 1991 to 2003on hips with Milch and Schanz osteotomies.

Material and methods: The objective was to reconstruct an anatomic hip joint by femoral re-alignment de-osteotomy, inferior displacement of the hip joint to enable insertion of an implant with a correctly position center of rotation and normal muscle lever arms. The technique was novel because of the direct approach to the subtrochanteric angle. The step by step procedure enabled insertion of the prosthesis without trochanterotomy. Overall recovery was long, often 12 to 18 months. There were 47 patients 60 hips) with at least 18 months follow-up. None of the patients were lost to follow-up.

Results: Results were available for 54 hips (three deaths, six hips). Mean follow-up was eight years. Outcome was good (patient satisfaction, normal x-ray) for 77%. Twelve hips presented poor clinical and radiological results due to loosening and mobilization of the femoral implant with or without nonunion of the deosteotomy. Ten hips were revised at mean five years via a femoral access for insertion of a press-fit distally locked prosthesis with graft of the nonunion (with acetabular replacement in one hip). The outcome was good at last follow-up for nine of these hips. One repeated revision gave satisfactory results.

Discussion: The only factors of risk of failure were related to femoral re-alignment and absence of trochanterotomy. A lesser risk of nonunion was related to the technique used for osteotomy, osteosynthesis and grafting. The use of a non-cemented implant with a solid primary stability and in certain cases a custom-made implant can be discussed for selected patients.

Angular proximal femoral deformities increase the technical complexity of primary total hip arthroplasties (THAs). The goals were to determine the long-term implant survivorship, risk factors, complications, and clinical outcomes of contemporary primary THAs in this difficult cohort. Our institutional total joint registry was used to identify 119 primary THAs performed in 109 patients with an angular proximal femoral deformity between 1997 and 2017. The deformity was related to previous femoral osteotomy in 85%, and developmental or metabolic disorders in 15%. 53% had a predominantly varus angular deformity. The mean age was 44 years, mean BMI was 29 kg/m. 2. , and 59% were female. An uncemented metaphyseal fixation stem was used in 30%, an uncemented diaphyseal fixation stem in 28%, an uncemented modular body stem with metaphyseal fixation sleeve in 24%, and a cemented stem in 18%. Simultaneous corrective femoral osteotomy was performed in 18%. Kaplan-Meier survivorships and Harris hip scores were reported. Mean follow-up was 8 years. The 10-year survivorships free of femoral loosening, aseptic femoral revision, any revision, and any reoperation were 95%, 93%, 90% and 88%, respectively. Revisions occurred in 13 hips for: aseptic femoral component loosening (3), stem fracture (2), dislocation (2), aseptic acetabular loosening (2), polyethylene liner exchange (2), and infection (2). Preoperative varus angular deformities were associated with a higher risk of any revision (HR 10, p=0.03), and simultaneous osteotomies with a higher risk of any reoperation (HR 3.6, p=0.02). Mean Harris hip scores improved from 52 preoperatively to 82 at 10 years (p<0.001). In the largest series to date of primary THAs in patients with angular proximal femoral deformities, we found a good 10-year survivorship free from any revision. Varus angular deformities, particularly those treated with a simultaneous osteotomy due to the magnitude or location of the deformity, had a higher reoperation rate. Keywords: Proximal femoral deformity; dysplasia; femoral osteotomy; survivorship; revision. Level of evidence: Level III, comparative retrospective cohort

Aims. To evaluate how abnormal proximal femoral anatomy affects different femoral version measurements in young patients with hip pain. Methods. First, femoral version was measured in 50 hips of symptomatic consecutively selected patients with hip pain (mean age 20 years (SD 6), 60% (n = 25) females) on preoperative CT scans using different measurement methods: Lee et al, Reikerås et al, Tomczak et al, and Murphy et al. Neck-shaft angle (NSA) and α angle were measured on coronal and radial CT images. Second, CT scans from three patients with femoral retroversion, normal femoral version, and anteversion were used to create 3D femur models, which were manipulated to generate models with different NSAs and different cam lesions, resulting in eight models per patient. Femoral version measurements were repeated on manipulated femora. Results. Comparing the different measurement methods for femoral version resulted in a maximum mean difference of 18° (95% CI 16 to 20) between the most proximal (Lee et al) and most distal (Murphy et al) methods. Higher differences in proximal and distal femoral version measurement techniques were seen in femora with greater femoral version (r > 0.46; p < 0.001) and greater NSA (r > 0.37; p = 0.008) between all measurement methods. In the parametric 3D manipulation analysis, differences in femoral version increased 11° and 9° in patients with high and normal femoral version, respectively, with increasing NSA (110° to 150°). Conclusion. Measurement of femoral version angles differ depending on the method used to almost 20°, which is in the range of the aimed surgical correction in derotational femoral osteotomy and thus can be considered clinically relevant. Differences between proximal and distal measurement methods further increase by increasing femoral version and NSA. Measurement methods that take the entire proximal femur into account by using distal landmarks may produce more sensitive measurements of these differences. Cite this article: Bone Jt Open 2022;3(10):759–766

Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique. 89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months. All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies. Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity