Introduction. Bulk bone grafting is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it is a technically demanding surgery with several critical issues, including graft resorption, graft collapse, and cup loosening. The purpose of this study is to describe our new bone grafting technique and review the radiographic and clinical results. Patients and Methods. We retrospectively reviewed 105 hips in 89 patients who had undergone covered bone grafting (CBG) in total hip arthroplasty for developmental dysplasia. We excluded patients who had any previous surgeries or underwent THA with a femoral shortening osteotomy. According to the Crowe classification, 6 hips were classified as group I, 39 as group II, 40 as group III, and 20 as group IV. Follow-up was at a mean of 4.1 (1 ∼ 6.9) years. The surgery was performed using the direct anterior approach. The acetabulum was reamed as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After pressfit fixation of the cup was achieved, several screws were used to reinforce the fixation. Indicating factor for using CBG was a large defect where the acetabular roof angle was more than 45 degrees and the uncovered cup was more than 2 cm (Fig.1). The superior defect of the acetabulum was packed with a sufficient amount of morselized bone using bone dust from the acetabular reamers. Then, the grafted morselized bone was covered with a bone plate from the femoral head. The bone plate was fixed with one screw to compact the morselized bone graft. The patient was allowed to walk bearing full weight immediately after surgery. We measured the height of the hip center from the teardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15 % of the pelvic height, which was nearly equal to 30 mm, because the mean pelvic height was 210 mm. Results. The mean height of the hip center was 9.8 (4.1∼18.0) % of the pelvic height and the 101 (96.2%) cups were placed within the anatomical hip center. Radiographically, in all patients, the host-graft interface became distinct and the new cortical bone in the lateral part of the plate bone appeared within 1 year after surgery (Fig.2, 3). We observed no absorption of the plate bone graft and no migration of the cup at the last follow-up. Conclusion. CBG technique is simple, because the bone graft is always performed after the pressfit of the cup is achieved. Moreover, patients require no partial weight bearing postoperatively, because the cup is supported by the host bone with the pressfit and additional screws. The CBG technique would be an excellent option for the reconstruction of the acetabulum in patients with severe dysplasia to avoid a high hip center and bulky bone grafting

Introduction. Bulk bone grafting of the cup is commonly used in total hip arthroplasty (THA) for developmental dysplasia. However, it carries a risk of the graft collapse in the mid-term or long-term results. The purpose of this study is to describe our new bulk bone grafting technique and review the radiographic and clinical results. Patients and Methods. We retrospectively reviewed 85 hips in 74 patients who had undergone bulk bone grafting in total hip arthroplasty for developmental dysplasia between 2008 and 2013. We excluded patients who had any previous surgeries or performed THA with the femoral shortening osteotomy. According to the Crowe classification, 4 hips were classified as Type 1, 28 as Type 2, 35 as Type 3, and 18 as Type 4. Follow-up was at a mean of 4.0 years (1 to 6.1). The surgery was performed using the direct anterior approach on a standard surgical table. The acetabulum was reamed for as close to the original acetabulum as possible. The pressfit cementless cup was impacted into the original acetabulum. After the pressfit fixation of the cup was achieved, two or three screws were used to reinforce the fixation. The superior defect of the acetabulum was packed with sufficient amount of morselized bone graft. Then, the bulk bone was placed on the morselized bone graft and fixed with one screw. Post-operatively, there were no restrictions to movement or position. On the first day after surgery, the patient was allowed to walk with full weight-bearing. We measured the height of the hip center from the interteardrop line and the pelvic height on anteroposterior roentgenograms of the pelvis and calculated the ratio of the hip center to the pelvic height. We defined the anatomical hip center as the height of the center less than 15% of the pelvic height. Results. The mean height of the hip center was 10.2 (4.1∼18.0)% of the pelvic height and the 81 (95.2%) cups were placed within the anatomical hip center. We observed no collapsed grafts, no severe absorption of the grafts, and no migration of the cup at the last follow-up. Conclusion. In our technique, there is no concern of the bulk bone graft collapse even in the long-term results, because the cup is not supported by the bulk bone graft but by the host bone with the pressfit and additional screws. Moreover, 95.2% of all cups were placed within the anatomical hip center. In conclusion, our new bulk bone graft technique would be simple to perform and an excellent option for the reconstruction of the acetabulum in patients with severe dysplasia

There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring. This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective. One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable. We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely

Background. In total hip arthroplasty (THA), the importance of preserving muscle is widely recognized. It is important to preserve the short external rotator muscles because they contribute to joint stability and prevent postoperative dislocation. However, despite careful capsular release and femoral rasping, damage to the short external rotator muscles may occur. The Optymis Shot Stem preserves more bone and surrounding tissue than does a traditional primary stem. We investigated the usefulness of the stem in terms of the extent of preservation of the tendon attachment on the greater trochanter. Method. In this study, we enrolled 31 consecutive patients (39 hips; 6 males, 25 females) who underwent THA. Simultaneous bilateral THA was performed in 8 patients. The patients’ mean age was 56.1 years. Diagnoses included developmental dysplasia in 35 hips (Crowe group 1: 31 hips, group 2: 4 hips), and sequel of Perthes disease in 4 hips. All THAs were performed via the direct anterior approach without traction tables. The femoral procedure was performed with the hip hyperextended, and posterior capsular release was performed if the femoral procedure became technically difficult. We compared the following among patients: the operative time, intraoperative blood loss, length of hospital stay, rate of posterior capsular release, postoperative radiographic findings, WOMAC score before and after surgery, and any complications. Results. The mean operative time was 42.0 ± 8.9 min, the mean intraoperative blood loss was 308 ± 196 g, and the mean hospital stay was 6.7 ± 1.3 days. Posterior capsular release was performed in 17 hips [44%; 10 hips (32%) in Crowe group 1, 8 hips (88%) for other diagnoses]. The total WOMAC score improved significantly from 42.4 points preoperatively to 11.2 points at 3 months preoperatively. A postoperative stem subsidence ≥3 mm was observed in 1 hip (2.6%), whereas postoperative dislocation, intra- and postoperative periprosthetic fracture, and thigh pain were not observed. Conclusions. The Optymis Short Stem could be placed without performing posterior capsular release in 68% of patients with Crowe group 1 developmental dysplasia. We therefore consider the stem as useful for preserving the tendon attachment on the greater trochanter

There are a growing number of younger patients with developmental dysplasia of hip, proximal femoral deformity and osteonecrosis seeking surgical intervention to restore quality of life, and the advent of ISTCs has resulted in a greater proportion of such cases being referred to existing NHS departments. Bone-saving hip athroplasty is often advocated for younger active patients, as they are potential candidates for subsequent revision arthroplasty. If resurfacing is contraindicated, short bone-conserving stems may be an option. The rationale for short stems in cementless total hip arthroplasty is proximal load transfer and absence of distal fixation, resulting in preserved femoral bone stock and avoidance of thigh pain. We have carried out 17 short stem hip replacements (Mini-hip, Corin Medical, Cirencester, UK) using ceramic bearings in 16 patients since June 2010. There were 14 females and 2 males, with a mean age of 50.1 years (range 35–63 years) at the time of the surgery. The etiology was osteoarthritis in 11, developmental dysplasia in 4, and osteonecrosis of the femoral head in one patient. All operations were performed through a conservative anterolateral (Bauer) approach. These patients are being followed and evaluated clinically with the Harris and Oxford hip scores, with follow-up at 6 weeks, 3 months, and annually thereafter. Initital results have been encouraging in terms of pain relief, restoration of leg length (one of the objectives in cases of shortening) and rage of movement. Radiological assessment has shown restoration of hip biomechanics. Specific techniques are required to address varus, valgus and femoral deformity with leg length inequality. There are two main groups of short stems, those that are neck-preserving and those that do not preserve the femoral neck. The latter group requires traditional techniques for revision. Another feature that differentiates them is the availability of modularity. The device we employed is neck-preserving and available with different neck lengths and offsets, which help in restoration of hip biomechanics. The advantage of such short stems may be preservation of proximal femoral bone stock, decreased stress shielding and the ease of potential revision. Such devices may be a consideration for patients with malformations of the proximal femur. Long-term follow-up will be of value in determining if perceived benefits are realised in practice

Incidence of Congenital talipes equino varus [CTEV] is 1 to 2 per 1000 birth, Out of all cases 20% cases are Non-idiopathic. The management of non-idiopathic CTEV, however, continues to be challenging due to Rigidity, Poor skin condition, Bony changes, Vascularity and Associated congenital abnormalities. In recent literature, short term results of Ponseti method for correction of non-idiopathic CTEV have been encouraging. As Ponseti method decreases the severity of deformity and hence decreases the need for extensive surgery. The aim of current study is to evaluate the results of Ponseti method in Non-idiopathic CTEV. Total 7 children below the age of one year with Non idiopathic clubfoot presented to us in the duration of 2013 to 2015 who were treated by us. The cases included are Streeters Dysplasia with congenital constriction rings 3, Arthrogryposis multiplex congenita with Developmental dysplasia of hip 2, Arthrogryposis multiple congenita spina Bifida 1, Pierre Robinson Syndrome with Ichthiosis 1. Initially all the patients treated with Ponseti casting technique and scoring was done using modified pirani scoring. At an average we could correct the foot from Pirani 7 to 2.5 with a relapse in 4 patients. 2 patients were treated again by Ponseti's method with success while treatment was discontinued in 2 feet. We recommended Ponseti's technique in Syndromic clubfoot as an non-surgical initial modality with good results given. The final outcome may depend more on the underlying condition than the CTEV

Revision total hip arthroplasty (THA) is a challenging scenario following complex primary THA for developmental dysplasia of hip (DDH). Our study envisages the long-term outcomes of revision DDH and the role of lateral structural support in socket fixation in these young patients who may require multiple revisions in their life-time. Hundred and eighteen consecutive cemented revision THAs with minimum follow up of 5 years following primary diagnosis of DDH operated between January 1974 and December 2012 were analysed for their clinical and radiological outcomes. The mean follow-up of 118 patients was 11.0 years (5.1–39.6 years). The Kaplan Mier survivorship at 11 years with end point as revision for any reason was 89.8% (CI 81.1–98.4). Of 118 revisions, 88 acetabular revisions were for aseptic loosening. Out of the acetabular revisions, 21 had pre-existing structural bone grafts from primary surgery, of which only 3 needed structural re-grafting during revision. Amongst the remaining 18 hips, the lateral support from the previous graft facilitated revision with no requirement of additional structural graft. Sixty-three hips did not have any form of grafting during primary operation. Amongst them, 35 had bone grafting in revision surgery (18 structural grafting). This study reports the largest number of revision THAs with primary diagnosis of DDH with the longest follow up. In our experience, the lateral support from the structural graft done in primary operation appears to have provided benefit in subsequent revision socket fixation

Objectives. For patients with Developmental Dysplasia of the Hip (DDH) who progress to needing total joint arthroplasty it is important to understand the morphology of the femur when planning for and undertaking the surgery, as the surgery is often technically more challenging in patients with DDH on both the femoral and acetabular parts of the procedure. 1. The largest number of male DDH patients with degenerative joint disease previously assessed in a morphological study was 12. 2. In this computed tomography (CT) based morphological study we aimed to assess whether there were any differences in femoral morphology between male and female patients with developmental dysplasia undergoing total hip arthroplasty (THA) in a cohort of 49 male patients, matched to 49 female patients. Methods. This was a retrospective study of the pre-operative CT scans of all male patients with DDH who underwent THA at two hospitals in Japan between 2006–2017. Propensity score matching was used to match these patients with female patients in our database who had undergone THA during the same period, resulting in 49 male and 49 female patients being matched on age and Crowe classification. The femoral length, anteversion, neck-shaft angle, offset, canal-calcar ratio, canal flare index, lateral centre-edge angle, alpha angle and pelvic incidence were measured for each patient on their pre-operative CT scans. Results. Significant differences were found in femoral anteversion with a mean male anteversion of 22 ˚ (±14.2), compared to 30˚ (±15.5), in females (p=0.02, Confidence Interval (C.I.) 1.6 to 14.9, Figure 1), offset, with a mean male offset of 31 mm (±6.2), compared to 29 mm (±6.1) in females, (p=0.04, C.I: 0.2 to 4.8), and femoral length with a mean femoral length of 434 mm in males (±22.2), compared to 407 mm in females (±23.9), (p<0.001, C.I: 19.2 to 34.3, Figure 2). No significant differences between male and female patients were found for the other measurements. Discussion. This was the first study of this size assessing femoral morphology in male patients with DDH undergoing THA. Significant differences were found between male and female patients in femoral anteversion, length and offset. This should be taken into account when planning and performing THA in these patients. Based on the findings from this study, a more anteverted femoral neck can be expected at the time of surgery in a female patient with DDH undergoing total hip arthroplasty, compared to a male patient

The use of short femoral components in primary total hip arthroplasty (THA) represents an attractive option. Advocates tout bone preservation and ease of use in less invasive surgical approaches. In 2006 we adopted the concept and have had experience with over 5,700 short, tapered, titanium, porous plasma-sprayed stems in patients undergoing primary THA. The plasma-sprayed portion of this stem is similar to the longer, standard length TaperLoc stem, with shortening resulting from a 3 cm reduction in length of the distal portion of the implant. However, the proximal aspect maintains the same flat, tapered wedge proximal geometry as the standard stem. During insertion in some femurs it was noted that distal canal fill occurred preferentially to proximal canal fill. This required distal broaching in order to accommodate a larger stem. In an effort to avoid this clinical situation and to improve the gradual off-loading that is the goal of a tapered geometry, the design was modified in 2011 to reduce the profile of the component. Other modifications include a lower caput-collum-diaphyseal (CCD) angle to enhance horizontal offset restoration without increasing leg length, width sizing from 5–18 mm in 1 mm increments, and polished neck flats to increase range of motion. Undoubtedly, porous plasma sprayed tapered titanium stems are successful in primary THA. Short stems can better accommodate proximal-distal femoral mismatch, particularly in hips with a large metaphysis and a narrow diaphysis, hips with an excessively bowed femur, and hips with severe deformity such as that encountered with developmental dysplasia and post-traumatic arthritis. Short stems violate less femoral bone stock, allowing for more favorable conditions should revision surgery become necessary. The concept of a short stem is appealing to patients, who perceive it as less invasive. In addition, short stems facilitate shorter incision surgery and operative approaches such as the muscle-sparing anterior supine intermuscular. Increased canal fill has been associated with distal cortical hypertrophy. Reducing the distal portion of the stem has reduced the incidence of distal canal fill, and allows for placement of a slightly larger implant

Introduction. Since its first description in 1988, periacetabular osteotomy has become the gold-standard worldwide in surgical treatment of developmental dysplasia of the hip. Several long-term studies have proven the efficacy of this procedure. In this study, we evaluated the mean 30-years results of this procedure of the first 63 patients (75 hips) operated at the institution where this procedure had been developed. Objectives. We determined the (1) cumulative 30-year survivorship of symptomatic patients treated with this procedure, determined the (2) clinical and (3) radiographic outcomes of the surviving hips, and (4) identified factors predicting the need for total hip arthroplasty (THA). Methods. We retrospectively evaluated the first 63 patients (75 hips) who underwent periacetabular osteotomy between 1984–1989. The mean age of the patients at surgery was 29 years (range, 13–56 years), and preoperatively 24% presented with advanced grades of osteoarthritis (Tönnis ³ Grade 1). 31% had previous operations to attempt sufficient coverage. All patients were invited for a regular clinical and radiographical follow-up 30 years after surgery. (1) We calculated the cumulative survivorship of the hip according to Kaplan-Meier with conversion to THA as the only endpoint. In addition, we assessed the (1) Merle d'Aubigné and the Harris Hip Score and assessed (3) radiographic progression of osteoarthritis according to Tönnis in the surviving hips. (4) A Cox-regression model was used to calculate predictors for failure and a prognostic model. Results. (1) The cumulative survivorship of the hip at 30-years was 32% (95% confidence interval 17–42%). 40 hips (53%) had subsequently undergone THA (2) The mean Merle d'Aubigné score of the surviving hips was 16 (SD 2, range, 12–18), which was significantly higher compared to the 10 years, and 20-years results and even to the preoperative value. (3) The minority of the preserved hips presented with radiographic progression of osteoarthritis. (4) The following predictors for failure were identified: age (hazard ratio [HR] 1.05), decreased preoperative internal rotation (HR 1.03), decreased preoperative external rotation (HR 1.03), preoperative limb (HR 1.57), positive preoperative impingement sign (HR 4.7), preoperative radiographic osteoarthritis (HR 2.8). Conclusion. Thirty years postoperatively, almost one third of hips undergoing PAO for DDH can be preserved. Periacetabular osteotomy is an effective technique for treating symptomatic developmental dysplasia

Between October 2001 and December 2010, 143 patients with developmental dysplasia underwent hip replacement surgery using a conical stem with modular necks (MODULUS) and titanium (Delta PF) and trabecular titanium cups system (Delta TT primary cups) (Lima Corporate, Villanova di San Daniele del Friuli, Italy), with ZTA/ZTA bearing (Ceramtec, Germany). 30 (21.0%) patients had both hips replaced, for a total of 173 implants. Mean age at the time of surgery was 55 years (range 22–81 years). Dysplasia evaluation was based on the Crowe score (6): 66 (38.1%) hips were classified as 1, 50 (28.9%) as 2, 33 (19.1%) as 3 and 24 (13.9%) as 4. Mean follow-up was 87 months (range 36–146 months); average Harris Hip Score increased from 42 (range 23–65) preoperatively to 92 (range 76–100) at the last follow-up. Stem revision was required in two cases. Cup revision was necessary in one case, for failed osteointegration. A postero-lateral approach was used in all cases, with patients lying in a lateral decubitus position. Shortening femoral osteotomy was performed in 5 (2.9%) cases for implant reduction due to excessive tension: oblique osteotomy was employed in 3 cases, using the stem as a fixation device, while subtraction Z-osteotomy with two Dall-Miles cables was used in the other 2 cases. Supra-acetabular bone grafting was performed in 3 cases. In all cases, the cup was implanted at the level of the paleo-acetabulum or in the area between the paleo- and neo-acetabulum. Head diameters were 28 mm in 54 (31.2%) cases, 32mm in 84 (48.6%) cases and 36mm in 35 (20.2%) cases. The association of Modulus stem and Delta TT cups showed good long-term clinical and radiographic results, with a Kaplan-Meier survivorship of 98.8% at 12 years (95% CI, 97.1%-100%)

The modern era of hip resurfacing was initiated over two decades ago to address the poor results of existing hip replacement devices in young patients. High failure rates have been reported with certain resurfacings. This is a 1 to 17-year review of a single surgeon series of resurfacings in patients under the age of 50 years. Between July 1997 and June 2014, 3627 hip resurfacing arthroplasties were implanted at our Centre in 2878 patients using a posterior approach. Of these 863 patients (1063 hips, 754 in men and 309 in women) were under the age of 50 years at the time of operation. They were followed up with postal questionnaires for up to 10 years through independent Outcomes Centres initially and are currently followed up by our own Centre. 18 patients (24 hips) died 5.9 (0.02 – 11) years after surgery due to unrelated causes, including one patient (1 hip) who was revised and died 5 years after revision. Mean follow-up is 11.9 years (0.8 to 17.8 years). There were 22 revisions altogether (2.1%) at a mean of 6.2 years (0.01 to 14.6 years) including one malpositioned cup in a female patient with developmental dysplasia who dislocated post-operatively and had to be repositioned. 9 hips failed from collapse of the femoral-head and 3 hips from femoral-neck fractures, giving rise to 12 femoral failures in all. There were six deep infections and three bearing-related failures including one pseudotumour, one for osteolysis and one for unexplained pain with neither metallosis nor pseudotumour. With revision for any reason as the end-point Kaplan-Meier survival analysis showed 98.9%, 98.6% and 97.2% implant survival at 5, 10 and 17 years. Men had better survival (99.1% and 98.1% at 10 and 17 years respectively) than women (97.3% and 95.3%). 17-year cumulative revision rates were higher in patients with a pre-operative diagnosis of dysplasia (6.1%) and AVN (7.6%) compared to all other diagnoses combined (1.5%). Patients with osteoarthritis had the best results (99.5%, 99.3%, 98.4% at 5, 10 and 17 years respectively). Our study shows that resurfacing arthroplasty is a viable option for hip arthritis in the young with a low incidence of wear-related failures in the long-term

Over the past 15 years metal on metal hip resurfacing (MOMHR) has seen a spectacular resurgence in utilization followed by near abandonment of the procedure. A select group of surgeons still offer the procedure to a select group of patients suggesting that there are benefits of MOMHR over total hip arthroplasty (THA). This is problematic for the following reasons:. 1). MOMHR does not lead to increased survivorship. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the England and Wales National Joint Registry, from countries with high rates of utilization of MOMHR, both report significantly worse survivorship with MOMHR compared to all types of conventional THA. Risk factors for revision of resurfacing were older patients, females, smaller femoral head size, patients with developmental dysplasia, and certain implant designs. 2). MOMHR is associated with the generation of metal ions that can have devastating effects in some patients. Cobalt and chromium ions generated from MOMHR can result in adverse local tissues reactions around the hip, sometimes with catastrophic consequences, as well as neurological deficits, skin rashes, and cardiomyopathy. It is unclear as to which patients are at risk for the generation of high ion levels and less clear with respect to the host response to these ions. The discriminative and predictive values of ion testing are still being determined. MOMHR subsequently require careful follow-up with limited tools to assess risk and pending problems. 3). MOMHR is not less invasive. In order to deliver the femoral head for safe preparation and to access the acetabulum with the femoral head and neck in situ, significant dissection and retraction are required. The exposure issue is compounded as the procedure is most often performed in younger, larger males. Difficulty with exposure has been associated with an insult to the femoral head's blood supply that may lead to fracture and/or neck narrowing. 4). Preservation of the femoral canal with MOMHR does not improve outcomes of revision. The perceived advantage of preserved femoral head and neck implies that a conversion of a MOMHR to total hip should convey survivorship similar to primary THA. However, this is not the case as confirmed by data from the AOANJRR demonstrating worse survivorship of revised resurfacings when compared to a primary total hip arthroplasty. 5). MOMHR does not result in superior functional outcomes. Advocates for MOMHR often claim that the large femoral head and intact femoral neck in resurfacing results in a better functional outcome and therefore, a better quality of life and satisfaction when compared to a conventional THA. This, however, was not the case when gait speed, postural balance evaluations and functional tests were used in a randomised study of 48 patients, which failed to show an advantage of MOMHR over THA. In conclusion, it is relatively straightforward to oppose and argue against the use of hip resurfacings as they have worse outcomes in all National Joint Registries, produce metal ions with significant clinical consequences, are more invasive, are difficult to revise with subsequent inferior outcomes when compared to a conventional primary THA, and do not provide better function. These adverse features come with a premium price when compared to a conventional THA

The childhood hip conditions of Developmental Dysplasia, Legg-Calve-Perthes Disease and Slipped Capital Femoral Epiphysis have a wide spectrum of anatomical outcomes following childhood treatment; ranging from morphologies, which result in normal hip function throughout life, to severely deranged morphologies, which result in pain and disability during childhood and adolescence. Some of these outcomes are as a result of well-intentioned interventions that result in catastrophic complications. In 2003, after years of working with impingement complicating periacetabular osteotomies and building on the work of William Harris, Reinhold Ganz published his concepts of ‘cam’ and ‘pincer’ hip impingement, and how these anatomical morphologies resulted in hip arthritis in adulthood. These concepts of impingement were added to his previous published work on hip instability to provide a comprehensive theory describing how hip arthritis develops on the basis of anatomical abnormalities. Surgical techniques have been developed to address each of these morphological pathologies. Ganz's concepts of hip impingement and instability may be applied to severe paediatric hip deformities to direct reconstructive joint preserving surgery to both the femur and the acetabulum. Ganz's surgical approaches have also been refined for use in paediatric hip surgery to allow radical reshaping salvage osteotomies to be performed on the developing femoral head with minimal risk of the devastating consequence of vascular Necrosis

Introduction. Total hip arthroplasty (THA) is becoming a common procedure because it dramatically relieves the patient's pain. Accordingly, young patients who hope to take THAs are also increasing. The results of THAs in the young patients have historically shown relatively poor survivorship. However several improvements of components may promise good long term results in active young patients. There was no consensus about the appropriate time for performing THA. The purpose of this study is to review the results of THAs younger than 40 years. Material and methods. A retrospective review of 14 primary THAs in 12 patients was conducted. The mean age was 27.0 (range 17–30). Ten were female (83%) and 2 were male (17%). The average follow –up period was 38.3 months (range 18–64). All operations were performed using direct anterior approach (DAA). All patients were allowed full weight bearing as tolerated in the immediate postoperative periods. All were cementless THA and the articulation bearing were ceramic/ceramic in 5 hips (33.3%), metal/highly cross linked polyethylene in 8 hips (53.3%), and ceramic/ highly cross linked polyethylene in 2 hips (13.3%). All patients were followed clinically and radiographically. Patients were evaluated at 4,6,12 weeks and each year postoperatively. Patients were allowed sports at 3 months postoperatively without limitations. Results. The underlying etiology was steroid-induced osteonecrosis in 5 patients, alcohol-induced osteonecrosis in 2 patients, developmental dysplasia in 2 patients (1 post osteotomy and 2 conservative therapy), infection in 1 patients, ankylosing spondylitis in 1 patients, and epiphyseal dysplasia in 1 patients. All patients failed conservative treatment. Two patients had prior osteotomy surgeries. Preoperative average JOA score, which is 100 points in full score, was 45 points. Those scores improved to 99 points post operatively. All patients became to walk without any assistive devices. There were no infections and dislocations. Their radiographs showed no loosening, subsidence, and osteolysis. All of their radiographs showed well fixed osseous integrations. Discussion and conclusion. Although our patients were very small numbers and follow up periods were not long, all of our patients showed good clinical and radiological results. When conservative treatments failed to relieve their pain, surgical treatments are required to restore their highly active lives. The modern THA has been showed numerous good results in older generations. With modern implants and surgical technique, we can also expect promising results in young patients under the condition with careful and long term follow-up

INTRODUCTION:. Management of developmental dysplasia of hip in adult is challenging and needs more to be understood in terms of ideal implant, position of acetabulum and operative technique. Patient may present very late, usually when osteoarthritic changes develop followed by pain. Operative management is difficult because of hypoplastic femoral medullary canal and shallow acetabulum filled with soft tissues. Altered anatomy of neurovascular structures also pose a risk of being injured during surgery. AIMS:. The goal of this study was to evaluate late results of total hip arthroplasty in adults after a minimum of 5 years follow-up. MATERIAL:. 45 Total hip arthroplasties in 40 patients were performed for painful hip dysplasia between 2003 and 2012. These 45 procedures were performed in 40 patients mean aged 32 +/− 14 years [17–56]. 29 patients (32 hips) were males and 11 patients (13 hips) were females. Non cemented total hip arthroplasty was done in all cases with mean follow up of 6 years. Of the 45 hips, 6 were neglected, dislocated hips with proximal migration of femoral head. In such patients sub-trochanteric osteotomy was done to bring the femoral head up to the level of Acetabulum. 5 patients (5 hips) were lost to follow up; consequently, the functional results were evaluated for 40 hips (35 patients). Harris hip score was used to evaluate the functional and clinical results. RESULTS and CONCLUSION:. Harris hip score improved in all patients. We concluded from this series that total hip replacement should be considered in all patients with painful dysplastic hip. Key words: Developmental Dyplasia Hip, Total Hip Arthroplasty

Introduction. Although total hip replacement (THR) has been described as the operation of the century, there is still room for improvement. There is therefore continued effort for advanced implants and bearing surfaces, moreover so, for the younger patient with a longer life expectancy and increased needs. Objectives. This prospective case-series study aims to present the preliminary, minimum three-years, results of a novel uncemeted stem, the Leader StemÒ (Vadin Implants Ltd, London, U.K.). The Leader StemÒ is a titanium, tapered stem for immediate three-point fixation. There is a metaphyseal porous-coating with titanium microspheres for bone in-growth. It has anti-rotational ribs in the metaphyseal - diaphyseal junction to promote initial stability and a grit blasted diaphyseal region for bone on-growth. The distal tip is polished and shortened to minimize thigh pain, while the whole design and concept is one to eradicate stress shielding. Methods. Between June 2010 and May 2012 we operated on 20 males and 29 female patients (53 THRs, mean age 66±13 years). The diagnosis was osteoarthritis in 39 patients (41 THRs), developmental dysplasia in six patients (eight THRs), avascular necrosis in two patients (two THRs) and chondrolysis in two patients (two THRs). Operations were performed by the posterior approach by two hip surgeons. The bearing surface was ceramic on ceramic in six patients (eight THRs), metal on polyethylene in 22 patients (22 THRs) and ceramic on polyethylene in 21 patients (23 THRs). Patients' demographic data, Harris Hip Scores (HHS) and Oxford Hip Scores (OHS) were collected prospectively, preoperatively, postoperatively, and at six months intervals thereafter. Radiographic evaluation was performed on standard anteroposterior and lateral X-rays at the same time intervals. Results. At last follow-up, mean 50 months after surgery, no revision for any reason has been reported. Six patients were lost to follow-up and one deceased three years post-operatively from an unrelated reason with a stable and untroubled prosthesis. There was one periprosthetic fracture two years after the initial operation but with a stable prosthesis, which was treated with open reduction – internal fixation. Three patients had complained of thigh pain, which had resolved at last follow up. At the most recent follow-up, the average HHS improved from 33.9±13.6 preoperatively to 89.35±12.72 and OHS from 12.7±5.6 to 41.6±7.2. No clinical score was significantly correlated to any demographic index, but the latest HHS was well correlated to the pre-operative score (R=0.41, p=0.007). Radiographically, no radiolucent lines in any of the Gruen zones and no stem subsidence were observed at any time interval, while cortical hypertrophy was observed at the diaphyseal zone in two patients. Conclusions. This study showed that this new press-fit stem design had excellent short-term clinical and radiological results in all followed-up patients, irrespective of their age, gender, and body mass index. Longer follow-up is needed to evaluate its long-term survival and effectiveness

Aim. The aim of this study is to assess the effectiveness of clinic based ultrasound screening by Orthopaedic surgeon for early diagnosis and treatment of developmental dysplasia of hip (DDH) in one stop clinic. Methods. This prospective study included 395 infants (185 male and 210 female) (5.2% of study population) who were referred for screening on the basis of abnormal findings or the presence of risk factors for DDH. Average age was 12.5 weeks (1 day to 15 months). All infants were assessed for risk factors of DDH. Clinical examinations were performed by the senior author followed by ultrasonography of both of the infant's hips, using the Graf's technique. Alpha and beta angles were calculated and hips were classified according to Graf's classification system. Results. Out of 790 hips examined 670 (84.8%) were labelled as normal. 120 (15.1%) hips in 84 patients were diagnosed as dysplastic or dislocated. Clinical examination only detected 39 patients out of 84, sensitivity of 46%. Average age of diagnosis was 12 weeks (3days-11 months). 79 patients were successfully treated with pavlic harness, 2 required traction and 3 were referred for surgical treatment. There were 14 cases of late diagnosis during one year period (> 4 months of age) (1.8/1000). Conclusion. Selective ultrasound screening is effective in early diagnosis of DDH and significantly reduces the duration of non operative treatment as well as the need for surgical intervention but does not completely eliminate late diagnosis of DDH. We find the concept of one stop DDH clinic highly effective and recommend that ultrasound training should be a part of orthopaedic curriculum

Background and aim. Since the market withdrawal of the ASR hip resurfacing in August 2010 because of a higher than expected revision rate as reported in the Australian Joint Replacement Registry (AOAJRR), metal-on-metal hip resurfacing arthroplasty (MoMHRA) has become a controversial procedure for hip replacement. Failures related to destructive adverse local tissue reactions to metal wear debris have further discredited MoMHRA. Longer term series from experienced resurfacing specialists however, demonstrated good outcomes with excellent 10-to-15-year survivorship in young and active men. These results have recently been confirmed for some MoMHRA designs in the AOAJRR. Besides, all hip replacement registries report significantly worse survivorship of total hip arthroplasty (THA) in patients under 50 compared to older ages. The aim of this study was to review MoMHRA survivorship from the national registries reporting on hip resurfacing and determine the risk factors for revision in the different registries. Methods. The latest annual reports from the AOAJRR, the National Joint Registry of England and Wales (NJR), the Swedish Hip Registry (SHR), the Finnish Arthroplasty Registry, the New Zealand Joint Registry and the Arthroplasty Registry of the Emilia-Romagna Region in Italy (RIPO) were reviewed for 10-year survivorship of MoMHRA in general and specific designs in particular. Other registries did not have enough hip resurfacing data or long term data yet. The survivorship data were compared to conventional THA in comparable age groups and determinants for success/failure such as gender, age, diagnosis, implant design and size and surgical experience were reviewed. Results. All registries showed a significant decline of the use of MoMHRA. The AOAJRR reported a cumulative revision rate of 9.5% (95%CI: 8.9–10.1%) at 10 years for all hip resurfacings. Female gender, developmental dysplasia and femoral head sizes <49mm were significant risk factors with revision rates twice as high for head sizes <49mm compared to >55mm. In males, cumulative revision rate for all MoMHRA was 6.6% at 10 years and 7.8% at 13years with no difference in the age groups. ASR had significantly higher revision rates (23.9% at 7 years) compared to other designs. The Adept and the Mitch had the lowest revision rates at 7 years (3.6%). Cumulative revision rates for 10,750 BHR (males and females pooled) were 5.0% at 7 years, 6.9% at 10years and 8.4% at 13 years. Cumulative revision rates of THA in patients <55 years was 6.0% at 10 years and 9.4% at 13 years. Similar survivorship results were found in the Finnish, Swedish, New Zealand and RIPO registry. In the SHR, 10-year survivorship of THA in patients <50 was only around 87%. In the NJR, cumulative revision rates for all MoMHRA pooled were much less favourable (13% at 10 years – 22% in patients<50) but the revision probability of ASR was 30.4% compared to 9.0% for BHR. Surgical experience was also identified as an important determinant of success/failure. Discussion. Registries are now confirming good 10-year survivorship of certain MoMHRA designs with excellent results in males. Risk factors for revision are female gender, small head size, dysplasia and certain implant designs

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention. There were no implant related complications. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions