Aims. The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. Methods. We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. Results. In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). Conclusion. Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636–1645

Aims. Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI. Methods. We reviewed 103 patients with DDH successfully treated by CR and spica casting in a single institution between January 2016 and December 2020. MRI was routinely performed immediately after CR and at the end of each cast. Using MRI, we described the labrum-acetabular cartilage complex (LACC) morphology, and measured the femoral head to triradiate cartilage distance (FTD) on the midcoronal section. A total of 13 hips with initial complete reduction (i.e. FTD < 1 mm) and ten hips with incomplete MRI follow-up were excluded. A total of 86 patients (92 hips) with a FTD > 1 mm were included in the analysis. Results. At the end of the first cast period, 73 hips (79.3%) had a FTD < 1 mm. Multiple regression analysis showed that FTD (p = 0.011) and immobilization duration (p = 0.028) were associated with complete reduction. At the end of the second cast period, all 92 hips achieved complete reduction. The LACC on initial MRI was inverted in 69 hips (75.0%), partly inverted in 16 hips (17.4%), and everted in seven hips (7.6%). The LACC became everted-congruent in 45 hips (48.9%) and 92 hips (100%) at the end of the first and second cast period, respectively. However, a residual inverted labrum was present in 50/85 hips (58.8%) with an initial inverted or partly inverted LACC. Conclusion. An eccentric reduction can become concentric after complete reduction and LACC remodelling following CR for DDH. Varying immobilization durations were required for achieving complete reduction. A residual inverted labrum was present in more than half of all hips after LACC remodelling. Cite this article: Bone Joint J 2023;105-B(2):140–147

Aims. This study aimed to evaluate the accuracy of implant placement with robotic-arm assisted total hip arthroplasty (THA) in patients with developmental dysplasia of the hip (DDH). Methods. The study analyzed a consecutive series of 69 patients who underwent robotic-arm assisted THA between September 2018 and December 2019. Of these, 30 patients had DDH and were classified according to the Crowe type. Acetabular component alignment and 3D positions were measured using pre- and postoperative CT data. The absolute differences of cup alignment and 3D position were compared between DDH and non-DDH patients. Moreover, these differences were analyzed in relation to the severity of DDH. The discrepancy of leg length and combined offset compared with contralateral hip were measured. Results. The mean values of absolute differences (postoperative CT-preoperative plan) were 1.7° (standard deviation (SD) 2.0) (inclination) and 2.5° (SD 2.1°) (anteversion) in DDH patients, and no significant differences were found between non-DDH and DDH patients. The mean absolute differences for 3D cup position were 1.1 mm (SD 1.0) (coronal plane) and 1.2 mm (SD 2.1) (axial plane) in DDH patients, and no significant differences were found between two groups. No significant difference was found either in cup alignment between postoperative CT and navigation record after cup screws or in the severity of DDH. Excellent restoration of leg length and combined offset were achieved in both groups. Conclusion. We demonstrated that robotic-assisted THA may achieve precise cup positioning in DDH patients, and may be useful in those with severe DDH. Cite this article: Bone Joint Res 2021;10(10):629–638

Aims. Developmental dysplasia of the hip (DDH) is a complex musculoskeletal disease that occurs mostly in children. This study aimed to investigate the molecular changes in the hip joint capsule of patients with DDH. Methods. High-throughput sequencing was used to identify genes that were differentially expressed in hip joint capsules between healthy controls and DDH patients. Biological assays including cell cycle, viability, apoptosis, immunofluorescence, reverse transcription polymerase chain reaction (RT-PCR), and western blotting were performed to determine the roles of the differentially expressed genes in DDH pathology. Results. More than 1,000 genes were differentially expressed in hip joint capsules between healthy controls and DDH. Both gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses revealed that extracellular matrix (ECM) modifications, muscle system processes, and cell proliferation were markedly influenced by the differentially expressed genes. Expression of Collagen Type I Alpha 1 Chain (COL1A1), COL3A1, matrix metalloproteinase-1 (MMP1), MMP3, MMP9, and MMP13 was downregulated in DDH, with the loss of collagen fibres in the joint capsule. Expression of transforming growth factor beta 1 (TGF-β1) was downregulated, while that of TGF-β2, Mothers against decapentaplegic homolog 3 (SMAD3), and WNT11 were upregulated in DDH, and alpha smooth muscle actin (αSMA), a key myofibroblast marker, showed marginal increase. In vitro studies showed that fibroblast proliferation was suppressed in DDH, which was associated with cell cycle arrest in G0/G1 and G2/M phases. Cell cycle regulators including Cyclin B1 (CCNB1), Cyclin E2 (CCNE2), Cyclin A2 (CCNA2), Cyclin-dependent kinase 1 (CDK1), E2F1, cell division cycle 6 (CDC6), and CDC7 were downregulated in DDH. Conclusion. DDH is associated with the loss of collagen fibres and fibroblasts, which may cause loose joint capsule formation. However, the degree of differentiation of fibroblasts to myofibroblasts needs further study. Cite this article: Bone Joint Res 2021;10(9):558–570

Aims. The aim of this study was to examine whether hips with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH) have significant asymmetry in femoral length, and to determine potential related factors. Patients and Methods. We enrolled 90 patients (82 female, eight male) with DDH showing unilateral OA changes, and 43 healthy volunteers (26 female, 17 male) as controls. The mean age was 61.8 years (39 to 93) for the DDH groups, and 71.2 years (57 to 84) for the control group. Using a CT-based coordinate measurement system, we evaluated the following vertical distances: top of the greater trochanter to the knee centre (femoral length GT), most medial prominence of the lesser trochanter to the knee centre (femoral length LT), and top of the greater trochanter to the medial prominence of the lesser trochanter (intertrochanteric distance), along with assessments of femoral neck anteversion and neck shaft angle. Results. The percentages of hips with an absolute difference of > 5 mm in femoral GT and LT lengths were significantly larger in the DDH group (24% for both) compared with those of the control group (2% and 7%, respectively). The femoral length GT of the affected femur was significantly shorter in Crowe I and longer in Crowe IV than that of the unaffected side. The affected-to-unaffected difference of the intertrochanteric distance showed positive correlation with that of the femoral length GT in Crowe I and Crowe II/III, and negative correlation with that of the femoral length LT in the Crowe I and Crowe IV groups. Conclusion. Hips with unilateral end-stage OA secondary to DDH show significant asymmetry in femoral length between both the greater and lesser trochanter and the knee compared with controls. The intertrochanteric distance was a morphological factor related to femoral-length asymmetry. When undertaking total hip arthroplasty (THA) in the presence of DDH, long leg radiographs or CT measurements should be used to assess true leg-length discrepancy. Cite this article: Bone Joint J 2019;101-B:297–302

Aims. To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia. Methods. We reviewed patients with severe hip dysplasia, defined as Severin IVb or V (lateral centre-edge angle (LCEA) < 0°), who underwent TOA with a structural bone allograft between 1998 and 2019. A medical chart review was conducted to extract demographic data, complications related to the osteotomy, and modified Harris Hip Score (mHHS). Radiological parameters of hip dysplasia were measured on pre- and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan–Meier product-limited method, and a multivariate Cox proportional hazard model was used to identify predictors for failure. Results. A total of 64 patients (76 hips) were included in this study. The median follow-up period was ten years (interquartile range (IQR) five to 14). The median mHHS improved from 67 (IQR 56 to 80) preoperatively to 96 (IQR 85 to 97) at the latest follow-up (p < 0.001). The radiological parameters improved postoperatively (p < 0.001), with the resulting parameters falling within the normal range in 42% to 95% of hips. The survival rate was 95% at ten years and 80% at 15 years. Preoperative Tönnis grade 2 was an independent risk factor for TOA failure. Conclusion. Our findings suggest that TOA with structural bone allografting is a viable surgical option for correcting severely dysplastic acetabulum in adolescents and young adults without advanced osteoarthritis, with favourable mid-term outcomes. Cite this article: Bone Joint J 2023;105-B(7):743–750

Aims. The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia. Methods. We reviewed patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia who underwent TOA between November 1998 and December 2019. Patient demographic details, osteotomy-related complications, and the modified Harris Hip Score (mHHS) were obtained via medical notes review. Radiological indicators of hip dysplasia were assessed using preoperative and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors of failure. Results. This study included 127 patients (137 hips). Median follow-up period was ten years (IQR 6 to 15). The median mHHS improved from 59 (IQR 52 to 70) preoperatively to 90 (IQR 73 to 96) at the latest follow-up (p < 0.001). The survival rate was 90% (95% CI 82 to 95) at ten years, decreasing to 21% (95% CI 7 to 48) at 20 years. Fair joint congruity on preoperative hip abduction radiographs and a decreased postoperative anterior wall index (AWI) were identified as independent risk factors for failure. The survival rate for the 42 hips with good preoperative joint congruity and a postoperative AWI ≥ 0.30 was 100% at ten years, and remained at 83% (95% CI 38 to 98) at 20 years. Conclusion. Although the overall clinical outcomes of TOA in patients with advanced osteoarthritis are suboptimal, favourable results can be achieved in selected cases with good preoperative joint congruity and adequate postoperative anterior acetabular coverage. Cite this article: Bone Joint J 2024;106-B(8):783–791

Objective. Hip arthroscopy in the setting of hip dysplasia is controversial in the orthopaedic community, as the outcome literature has been variable and inconclusive. We hypothesise that outcomes of hip arthroscopy may be diminished in the setting of hip dysplasia, but outcomes may be acceptable in milder or borderline cases of hip dysplasia. Methods. A systematic search was performed in duplicate for studies investigating the outcome of hip arthroscopy in the setting of hip dysplasia up to July 2015. Study parameters including sample size, definition of dysplasia, outcomes measures, and re-operation rates were obtained. Furthermore, the levels of evidence of studies were collected and quality assessment was performed. Results. The systematic review identified 18 studies investigating hip arthroscopy in the setting of hip dysplasia, with 889 included patients. Criteria used by the studies to diagnose hip dysplasia and borderline hip dysplasia included centre edge angle in 72% of studies but the range of angles were quite variable. Although 89% of studies reported improved post-operative outcome scores in the setting of hip dysplasia, revision rates were considerable (14.1%), with 9.6% requiring conversion to total hip arthroplasty. Conclusion. The available orthopaedic literature suggests that although improved outcomes are seen in hip arthroscopy in the setting of hip dysplasia, there is a high rate of re-operation and conversion to total hip arthroplasty. Furthermore, the criteria used to define hip dysplasia vary considerably among published studies. Cite this article: M. Yeung, M. Kowalczuk, N. Simunovic, O. R. Ayeni. Hip arthroscopy in the setting of hip dysplasia: A systematic review. Bone Joint Res 2016;5:225–231. DOI: 10.1302/2046-3758.56.2000533

To quantify the prevalence of Generalized Joint Hypermobility (GJH), aka Hypermobility Spectrum Disorder, in adult patients presenting with hip pain to a sub-specialty hip practice, this 4-year, prospective, observational study evaluated correlations with clinical, demographic, and baseline outcomes. 1,004 consecutive new hip patients (390 males, 614 females) were evaluated for GJH using the Beighton 9-point physical exam criteria and the Hakim-Grahame 5-item history questionnaire. Diagnosis, age, sex and race were tested as predictors of GJH. Patient reported outcomes from iHOT-12 and a modified Harris Hip Score (mHHS) were also assessed. There were 333 patients presenting with hip dysplasia over this period. Hip dysplasia (DDH) patients without osteoarthritis (OA) had a significantly elevated prevalence of GJH (77.9%) compared to non-dysplastic hip patients (32.8%, p<0.0001) or to patients with DDH+OA (35.7%, p<0.0001). The prevalence of GJH was significantly higher in females (OR=4.2, 95% CI: 3.2 to 5.5, p<0.0001) and inversely proportional to age. Hispanic patients presented with significantly lower prevalence of GJH compared with other races (p<0.05). GJH was not a predictor of patient-reported outcomes scores (p=0.51 for iHOT-12 and p=0.44 for mHHS). During the course of this study, we successfully performed our first PAO procedure on an outpatient basis (February 2019). That is currently our standard practice. With a strong correlation observed between hypermobility and developmental dysplasia of the hip (DDH), further research is warranted to explore the genetic basis and significance of this association

The gold standard treatment of hip dysplasia is a peri-acetabular osteotomy (PAO). Labral tears are seen in the majority of patients presenting with hip dysplasia and diagnosed using Magnetic Resonance Imaging (MRI). The goal was to (1) evaluate utility/value of MRI in patients undergoing hip arthroscopy at time of PAO, and (2) determine whether MRI findings of labral pathology can predict outcome. A prospective randomized controlled trial was conducted at tertiary institutions, comparing patients with hip dysplasia treated with isolated PAO versus PAO with adjunct hip arthroscopy. This study was a subgroup analysis on 74 patients allocated to PAO and adjunct hip arthroscopy (age 26±8 years; 89.2% females). All patients underwent radiographic and MRI assessment using a 1.5-Tesla with or 3-Tesla MRI without arthrography to detect labral or cartilage pathology. Clinical outcome was assessed using international Hip Outcome Tool-33 (iHOT). 74% of patients (55/74) were pre-operatively diagnosed with a labral tear on MRI. Among these, 41 underwent labral treatment (74%); whilst among those without a labral tear on MRI, 42% underwent labral treatment (8/19). MRI had a high sensitivity (84%), but a low specificity (56%) for labral pathology (p=0.053). There was no difference in pre-operative (31.3±16.0 vs. 37.3±14.9; p=0.123) and post-operative iHOT (77.7±22.2 vs. 75.2±23.5; p=0.676) between patients with and without labral pathology on MRI. Value of MRI in the diagnostic work-up of a patient with hip dysplasia is limited. MRI had a high sensitivity (84%), but low specificity (44%) to identify labral pathology in patients with hip dysplasia. Consequently, standard clinical MRI had little value as a predictor of outcome with no differences in PROM scores between patients with and without a labral tear on MRI. Treatment of labral pathology in patients with hip dysplasia remains controversial. The results of this subgroup analysis of a prospective, multi-centre RCT do not show improved outcome among patients with dysplasia treated with labral repair

Aims. The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS). Methods. Data from 686 patients (882 hips) with hip dysplasia who underwent transposition osteotomy of the acetabulum, a type of PAO, between 1998 and 2019 were reviewed. After screening the study included 442 patients (582 hips; response rate, 78%). Patients who completed a study questionnaire consisting of the visual analogue scale (VAS) for pain and satisfaction, FJS-12, and Hip disability and Osteoarthritis Outcome Score (HOOS) were included. The ceiling effects, internal consistency, convergent validity, and PASS thresholds of FJS-12 were investigated. Results. The median follow-up was 12 years (interquartile range 7 to 16). The ceiling effect of FJS-12 was 7.2%, the lowest of all the measures examined. FJS-12 correlated with all HOOS subscales (ρ = 0.72 to 0.77, p < 0.001) and pain and satisfaction-VAS (ρ = -0.63 and 0.56, p < 0.001), suggesting good convergent validity. Cronbach’s α was 0.95 for the FJS-12, which indicated excellent internal consistency. The median FJS-12 score for preoperative Tönnis grade 0 hips (60 points) was higher than that for grade 1 (51 points) or 2 (46 points). When PASS was defined as pain-VAS < 21 and satisfaction-VAS ≥ 77, the FJS-12 threshold that maximized the sensitivity and specificity for detecting PASS was 50 points (area under the curve (AUC) = 0.85). Conclusion. Our results suggest that FJS-12 is a valid and reliable assessment tool for patients undergoing PAO, and the threshold of 50 points may be useful to determine patient satisfaction following PAO in clinical settings. Further investigation of the factors influencing postoperative joint awareness may enable improved prediction of treatment efficacy and informed decision-making regarding the indication of PAO. Cite this article: Bone Joint J 2023;105-B(7):760–767

Aims. This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry. Methods. In total, 116 patients who underwent unilateral total hip arthroplasty were included in this study. Of these, 93 had DDH-OA and 23 had PHOA. Patients with DDH-OA were categorized into three groups: Crowe grade I, II/III, and IV. Anatomical femoral length, femoral length greater trochanter (GT), femoral length lesser trochanter (LT), tibial length, foot height, lower LL, and whole LL were evaluated using preoperative CT data of the whole leg in the supine position. Asymmetry was evaluated in the Crowe I, II/III, IV, and PHOA groups. Results. The incidences of whole and lower LL asymmetries were 40%, 62.5%, 66.7%, and 26.1%, and 21.7%, 20.8%, 55.6%, and 8.7% in the Crowe I, II/III, and IV, and PHOA groups, respectively. The incidence of tibial length asymmetry was significantly higher in the Crowe IV group (44.4%) than that in the PHOA group (4.4%). In all, 50% of patients with DDH-OA with femoral length GT and LT asymmetries had lower LL asymmetry, and 75% had whole LL asymmetry. The incidences of lower and whole LL asymmetries were 20% and 42.9%, respectively, even in the absence of femoral length GT and LT asymmetries. Conclusion. Overall, 43% of patients with unilateral DDH-OA without femoral length asymmetry had whole LL asymmetry of ≥ 5 mm. Thus, both the femur length and whole LL should be measured to accurately assess LL discrepancy in patients with unilateral DDH-OA. Cite this article: Bone Jt Open 2024;5(2):79–86

Aims. Hip dysplasia (HD) leads to premature osteoarthritis. Timely detection and correction of HD has been shown to improve pain, functional status, and hip longevity. Several time-consuming radiological measurements are currently used to confirm HD. An artificial intelligence (AI) software named HIPPO automatically locates anatomical landmarks on anteroposterior pelvis radiographs and performs the needed measurements. The primary aim of this study was to assess the reliability of this tool as compared to multi-reader evaluation in clinically proven cases of adult HD. The secondary aims were to assess the time savings achieved and evaluate inter-reader assessment. Methods. A consecutive preoperative sample of 130 HD patients (256 hips) was used. This cohort included 82.3% females (n = 107) and 17.7% males (n = 23) with median patient age of 28.6 years (interquartile range (IQR) 22.5 to 37.2). Three trained readers’ measurements were compared to AI outputs of lateral centre-edge angle (LCEA), caput-collum-diaphyseal (CCD) angle, pelvic obliquity, Tönnis angle, Sharp’s angle, and femoral head coverage. Intraclass correlation coefficients (ICC) and Bland-Altman analyses were obtained. Results. Among 256 hips with AI outputs, all six hip AI measurements were successfully obtained. The AI-reader correlations were generally good (ICC 0.60 to 0.74) to excellent (ICC > 0.75). There was lower agreement for CCD angle measurement. Most widely used measurements for HD diagnosis (LCEA and Tönnis angle) demonstrated good to excellent inter-method reliability (ICC 0.71 to 0.86 and 0.82 to 0.90, respectively). The median reading time for the three readers and AI was 212 (IQR 197 to 230), 131 (IQR 126 to 147), 734 (IQR 690 to 786), and 41 (IQR 38 to 44) seconds, respectively. Conclusion. This study showed that AI-based software demonstrated reliable radiological assessment of patients with HD with significant interpretation-related time savings. Cite this article: Bone Jt Open 2022;3(11):877–884

Aims. The aims of this study were to compare clinically relevant measurements of hip dysplasia on radiographs taken in the supine and standing position, and to compare Hip2Norm software and Picture Archiving and Communication System (PACS)-derived digital radiological measurements. Methods. Preoperative supine and standing radiographs of 36 consecutive patients (43 hips) who underwent periacetabular osteotomy surgery were retrospectively analyzed from a single-centre, two-surgeon cohort. Anterior coverage (AC), posterior coverage (PC), lateral centre-edge angle (LCEA), acetabular inclination (AI), sharp angle (SA), pelvic tilt (PT), retroversion index (RI), femoroepiphyseal acetabular roof (FEAR) index, femoroepiphyseal horizontal angle (FEHA), leg length discrepancy (LLD), and pelvic obliquity (PO) were analyzed using both Hip2Norm software and PACS-derived measurements where applicable. Results. Analysis of supine and standing radiographs resulted in significant variation for measurements of PT (p < 0.001) and AC (p = 0.005). The variation in PT correlated with the variation in AC in a limited number of patients (R. 2. = 0.378; p = 0.012). Conclusion. The significant variation in PT and AC between supine and standing radiographs suggests that it may benefit surgeons to have both radiographs when planning surgical correction of hip dysplasia. We also recommend using PACS-derived measurements of AI and SA due to the poor interobserver error on Hip2Norm. Cite this article: Bone Joint J 2021;103-B(11):1662–1668

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

Aims. The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version?. Methods. A retrospective, review board-approved, controlled study was performed including 120 hips in 86 consecutive patients with symptomatic FAI or hip dysplasia. Pelvic CT scans were reviewed to calculate parameters for sagittal balance (pelvic incidence (PI), PT, and sacral slope), anterior pelvic plane angle, pelvic inclination, and external rotation of the iliac wing and were compared to a control group (48 hips). The 120 hips were allocated to the following groups: AR (41 hips), hip dysplasia (47 hips) and cam FAI with normal acetabular morphology (32 hips). Subgroups of total AR (15 hips) and high acetabular anteversion (20 hips) were analyzed. Statistical analysis was performed using analysis of variance with Bonferroni correction. Results. PI and PT were significantly decreased comparing AR (PI 42° (SD 10°), PT 4° (SD 5°)) with dysplastic hips (PI 55° (SD 12°), PT 10° (SD 6°)) and with the control group (PI 51° (SD 9°) and PT 13° (SD 7°)) (p < 0.001). External rotation of the iliac wing was significantly increased comparing AR (29° (SD 4°)) with dysplastic hips (20°(SD 5°)) and with the control group (25° (SD 5°)) (p < 0.001). Correlation between external rotation of the iliac wing and acetabular version was significant and strong (r = 0.81; p < 0.001). Correlation between PT and acetabular version was significant and moderate (r = 0.58; p < 0.001). Conclusion. These findings could contribute to a better understanding of hip pain in a sitting position and extra-articular subspine FAI of patients with AR. These patients have increased iliac external rotation, a rotational abnormality of the iliac wing. This has implications for surgical therapy with hip arthroscopy and acetabular rim trimming or anteverting periacetabular osteotomy (PAO). Cite this article: Bone Jt Open 2021;2(10):813–824

Aims. Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH. Methods. Patients were divided into four groups: A, adolescents who had not undergone surgery for DDH in childhood (25 hips); B, adolescents who had undergone surgery for DDH in childhood (20 hips); C, adults with DDH who had not undergone previous surgery (80 hips); and D, a control group of patients with healthy hips (70 hips). The radiological evaluation of digital anteroposterior views of hips included the Wiberg angle (centre-edge angle (CEA)), femoral head cover (FHC), medialization, distalization, and the ilioischial angle. Clinical assessment involved the Harris Hip Score (HHS) and gluteal muscle performance assessment. Results. Significant improvements in radiological parameters were achieved in all measurements in all groups (p < 0.05). The greatest improvement was in CEA (mean of 19° (17.2° to 22.3°) in Group B), medialization (mean of 3 mm (0.9 to 5.2) in Group C), distalization (mean of 6 mm (3.5 to 8.2) in Group B), FHC (mean of 17% (12.7% to 21.2%) in Group B), and ilioischial angle (mean of 5° (2.3° to 8.1°) in Group B). There were significant improvements in the mean HHS and gluteal muscle performance scores postoperatively in all three groups. Conclusion. The greatest correction of radiological parameters and clinical outcomes was found in patients who had undergone hip surgery in childhood. Although the surgical treatment of DDH in childhood makes subsequent hip surgery more difficult due to scarring, adhesions, and altered anatomy, it requires less correction of the deformity and has a beneficial effect on the outcome of PAO in adolescence and early adulthood. Cite this article: Bone Joint J 2022;104-B(7):775–780

Literature data show varying rates of aseptic loosening of standard hemispherical cups after primary total hip arthroplasty (THA) in patients with Crowe IV developmental dysplasia of the hip (DDH). In order to improve the results regarding the frequency of aseptic loosening of the acetabular component, we decided to use custom-made acetabular implants (CMAI) in this category of patients. The aim of our study was to report outcomes after primary THA using CMAI in patients with Crowe IV DDH. We retrospectively analyzed the results of primary THA using the CMAI in 58 hips. The mean follow-up period was 5.2 years (range 4.2 – 6.3). Patients demonstrated improved functional outcomes according to the Oxford Hip Score: preoperatively 16.9 and postoperatively 38.5 (P < 0.05). Revisions were performed in 2 cases due to dislocations, in 1 case due to nonunion of the greater trochanter and in 1 case due to chronic pain syndrome caused by contact of the CMAI flange with the iliopsoas muscle. In a patient with chronic pain syndrome, during the revision, the pubic flange of the CMAI, which was in contact with the iliopsoas muscle, was removed. There were no radiological signs of loosening of the CMAI. The use of CMAI shows good results in patients with DDH. Extended capability for supplementary screw fixation is an excellent feature of such implants, allowing them to obtain reliable primary fixation. Further observation is required to assess CMAI in the long-term follow-up

In primary total hip arthroplasty (THA) for patients with Crowe II or higher classes developmental dysplasia of the hip (DDH) or rapidly destructive coxopathy (RDC), the placement of the cup can be challenging due to superior and lateral acetabular bone defects. Traditionally, bone grafts from resected femoral heads were used to fill these defects, but bulk graft poses a risk of collapse, especially in DDH with hypoplastic femoral heads or in RDC where good quality bone is scarce. Recently, porous metal augments have shown promising outcomes in revision surgeries, yet reports on their efficacy in primary THA are limited. This study retrospectively evaluated 27 patients (30 hips) who underwent primary THA using cementless cups and porous titanium acetabular augments for DDH or RDC, with follow-up periods ranging from 2 to 10 years (average 4.1 years). The cohort included 22 females (24 hips) and 5 males (6 hips), with an average age of 67 years at the time of surgery. The findings at the final follow-up showed no radiographic evidence of loosening or radiolucency around the cups and augments, indicating successful biological fixation in all cases. Clinically, there was a significant improvement in the WOMAC score from an average of 39.1±14.7 preoperatively to 5.1±6.4 postoperatively. These results suggest that the use of cementless cups and porous titanium acetabular augments in primary THA for DDH and RDC can lead to high levels of clinical improvement and reliable biological fixation, indicating their potential as a viable solution for managing challenging acetabular defects in these conditions

Developmental dysplasia of the hip can cause pain and premature osteoarthritis. However, the risk factors and timing for disease progression in young adults are not fully defined. This study identified the incidence and risk factors for contralateral hip pain and surgery after periacetabular osteotomy (PAO) on an index dysplastic hip. Patients followed for 2+ years after unilateral PAO were grouped by eventual contralateral pain or no-pain, based on modified Harris Hip Score, and surgery or no-surgery. Univariate analysis tested group differences in demographics, radiographic measures, and range-of-motion. Kaplan-Meier survival analysis assessed pain development and contralateral hip surgery over time. Multivariate regression identified pain and surgery risk factors. Pain and surgery predictors were further analyzed in Dysplastic, Borderline, and Non-dysplastic subcategories, and in five-degree increments of lateral center edge angle (LCEA) and acetabular inclination (AI). 184 patients were followed for 4.6±1.6 years, during which 51% (93/184) reported hip pain and 33% (60/184) underwent contralateral surgery. Kaplan-Meier analysis predicted 5-year survivorship of 49% for pain development and 66% for contralateral surgery. Painful hips exhibited more severe dysplasia than no-pain hips (LCEA 16.5º vs 20.3º, p<0.001; AI 13.2º vs 10.0º p<0.001). AI was the sole predictor of pain, with every 1° AI increase raising the risk by 11%. Surgical hips also had more severe dysplasia (LCEA 14.9º vs 20.0º, p<0.001; AI 14.7º vs 10.2º p<0.001) and were younger (21.6 vs 24.1 years, p=0.022). AI and a maximum alpha angle ≥55° predicted contralateral surgery. 5 years after index hip PAO, 51% of contralateral hips experience pain and 34% percent are expected to need surgery. More severe dysplasia, based on LCEA and AI, increases the risk of contralateral hip pain and surgery, with AI being a predictor of both outcomes. Knowing these risks can inform patient counseling and treatment planning