Objectives. There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments. Methods. A long-term follow-up beyond the age of hip-joint maturity was performed for 115 hips in 103 patients who underwent open reduction using Ludloff’s medial approach in our hospital. The mean age at surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3 years (15 to 28). The radiological condition at full growth of the hip joint was evaluated by Severin’s classification. Results. All 115 hips successfully attained reduction after surgery; however, 74 hips (64.3%) required corrective surgery at a mean age of 2.6 years (one to six). According to Severin’s classification, 69 hips (60.0%) were classified as group I or II, which were considered to represent acceptable results. A total of 39 hips (33.9%) were group III and the remaining seven hips (6.1%) group IV. As to re-operation, 20 of 21 patients who underwent surgical reduction after 12 months of age required additional corrective surgeries during the growth period as the hip joint tended to subluxate gradually. Conclusion. Open reduction using Ludloff’s medial approach accomplished successful joint reduction for persistent CDH or DDH, but this surgical treatment was only appropriate before the ambulating stage. Cite this article: Bone Joint Res 2014;3:1–6

We reviewed 91 patients (103 feet) who underwent a Ludloff osteotomy combined with additional procedures. According to the combined procedures performed, patients were divided into Group I (31 feet; first web space release), Group II (35 feet; Akin osteotomy and trans-articular release), or Group III (37 feet; Akin osteotomy, supplementary axial Kirschner (K-) wire fixation, and trans-articular release). Each group was then further subdivided into severe and moderate deformities. The mean hallux valgus angle correction of Group II was significantly greater than that of Group I (p = 0.001). The mean intermetatarsal angle correction of Group III was significantly greater than that of Group II (p < 0.001). In severe deformities, post-operative incongruity of the first metatarsophalangeal joint was least common in Group I (p = 0.026). Akin osteotomy significantly increased correction of the hallux valgus angle, while a supplementary K-wire significantly reduced the later loss of intermetatarsal angle correction. First web space release can be recommended for severe deformity. Additionally, K-wire fixation (odds ratio (OR) 5.05 (95% confidence interval (CI) 1.21 to 24.39); p = 0.032) and the pre-operative hallux valgus angle (OR 2.20 (95% CI 1.11 to 4.73); p = 0.001) were shown to be factors affecting recurrence of hallux valgus after Ludloff osteotomy. Cite this article: Bone Joint J 2013;95-B:803–8

Aims: The aim of this prospective study was to analyse the Ludloff osteotomy for its potential of correcting hallux valgus deformity. Methods: Between September 1998 and October 1999 84 consecutive patients who underwent a Ludloff osteotomy were included in this prospective study. All patients were examined preoper-atively and at a minimum follow up of 2 years according a standardized questionnaire based on the HMIS of the American Foot and Ankle Society. X-rays were taken preoperatively, at 6 weeks and at þnal follow up. Results: 75 patients were available for an average follow up of 33 months (24 to 41). The average preoperative HMIS was 52 points and at follow up 87 points. 78% of the patients rated the outcome as excellent and good. 82% of patients were painfree at follow up. Radiological evaluation revealed a preoperative average hallux valgus angle (HV) of 36û and a preoperative average intermetatarsal angle (IM) of 17û This was corrected by surgery to an average HV of 14û and an average IM of 8û. Preoperatively sesamoidposition Grade III was present I 71%, Garde II in 29%. At follow up Grade 0 was present in 60%m Grade 1 in 37% and Grade2 in 3%. There was no Grade 3 sesamoid position at follow up. Conclusions: The ludloff osteotomy is a good alternative for the correction of severe hallux valgus deformity. In elderly patients and osteoporotic bone early weight-bearing should not be allowed because of poor bone quality

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff’s medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff’s medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations

Query: In the past few years, chevron osteotomy has become more widespread in the treatment of mild Hallux valgus deformities thanks to its low rate of complications and excellent results. The results in moderate to severe deformities are not as convincing, depending on the surgical procedure used. The objective of this study was to examine the influence which the choice of surgical procedure and thus the osteotomy has on the clinical, radiological and pedobarographic results in the forefoot. Method: In a prospective study, we examined the surgical results of 140 feet treated between August 2004 and March 2005 in our clinic for moderate Hallux-Valgus deformity. In 70 patients, Ludloff osteotomy and in 70 the Scarf osteotomy was selected as the method. The patients underwent pre- and postoperative clinical, radiological and pedobarographic examination. In addition, patient satisfaction was determined using the Kitaoko Forefoot Score. Indication for performance of the osteotomy was a Hallux-Valgus deformity up to an intermetatarsal angle (IMA) of 17°. Results: The mean preoperative IMA was 14.5 °, the Hallux-Valgus angle (HVA) 31.3°. The IMA could be improved by Scarf osteomy on average by 7.6°, by Ludloff osteotomy by 8.1°. With suitable plantarisation of the 1st metatarsal head, better and more even pressure distribution in the forefoot could be achieved with both surgical procedures and the load peaks reduced overall. The complication rate was somewhat lower overall in the Scarf osteomy. Conclusion: Both the Scarf osteotomy, and the Ludloff ostetomy enable achieving of good results in moderate deformity. The extent to which one procedure should be preferred over the other could not be determined. Both procedures have advantages as well as disadvantages. Further attention to this area of Hallux-valgus surgery is definitely needed to meet the higher demands of the patients

Background: This study compares two diaphyseal osteotomies (scarf and Ludloff) which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at twelve months. Materials and Methods: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed. Results: There was no stastically significant difference between the two groups at 6 and 12 months in subjective satisfaction, AOFAS score, improvement in functional activities and range of movements. The improvement in pain (at best) and transfer lesions at 12 months was significantly better in the scarf group (p< 0.05). The radiological results at 6 and 12 months including intermetatrsal angle (p< 0.001), hallux valgus angle (p< 0.01), distal metatarsal articular angle and seasmoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were three cases (5%) of delayed union in the Ludloff group. Two of these healed with dorsiflexion malunion. One patient in the Ludloff osteotomy group developed a complex regional pain syndrome. There were two wound complications in the scarf group. Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months

Introduction: This study compares two diaphyseal osteotomies (scarf and Ludloff), which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at six and twelve months. Material and methods: Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed. Results: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. There was no statistically significant difference in the two groups at 6 and 12 months in subjective satisfaction, AOFAS forefoot score, improvement in functional activities and range of movements. The improvement in pain (at best) and plantar callosities at 12 months was significantly better in the scarf group (p< 0.001). The radiological results at 6 and 12 months including intermetatarsal angle (p< 0.001), hallux valgus angle and shortening of the first ray (p< 0.01), distal metatarsal articular angle and sesamoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were six complications in the Ludloff group with three delayed unions, two dorsiflexion malunions and one complex regional pain syndrome. There were two wound complications in the scarf group. Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis.

Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured.

The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups.

Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

Cite this article: Bone Joint J 2014;96-B:406–13.

Background: Deformity of the femoral head after open reduction for developmental dislocation of the hip (DDH) influences the outcome of pelvic osteotomy as a final correction for residual dysplasia to prevent secondary osteoarthritis. The purpose of this study was to review long-term outcomes after open reduction using a medial approach for DDH. The correlation between age at the time of operation and femoral head deformity at skeletal maturity was specifically evaluated.

Methods: Forty-two hips in 40 patients with more than 10 years of follow-up were assessed radiologically. The mean age at the time of surgery was 14.3 (range, 6–31) months, and the postoperative follow-up period ranged from 10 to 27 (mean, 15.8) years. The round and enlargement indices of the femoral head were measured on follow-up radiographs to evaluate deformity and enlargement of the femoral head at skeletal maturity.

Results: Severin classification was I and II in 16 hips; III, IV, and V in 23; and II at the final follow-up in the 3 hips treated by osteotomy less than 10 years after open reduction. Mean round index at follow-up was 58.3 ± 8.3 (range, 47–79); it showed correlation with age at the time of operation (r = 0.68, p < 0.001). Mean enlargement index at follow-up was 113.4 ± 11.8 (range, 93–137) and showed no correlation with age at the time of operation (r = 0.009, p = 0.96).

Conclusions: At more than 10 years’ follow-up, the occurrence of deformity of the femoral head correlated with increased age at the time of operation. Indications for use of a medial approach in the correction of DDH in older patients must take into account the risk of subsequent femoral head deformity at skeletal maturity.

Aims. Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach. Patients and Methods. Children with a dislocated hip, younger than one year of age at the time of surgery, who were treated using a medial approach were eligible for the study. Radiographs were evaluated for the degree of dislocation and the presence of an ossific nucleus preoperatively, and for the degree of AVN and residual dysplasia at one and five years and at a mean of 12.7 years (4.6 to 20.8) postoperatively. Radiographic outcome was assessed using the Severin classification, after five years of age. Further surgical procedures were recorded. Functional outcome was assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) or the Hip Disability and Osteoarthritis Outcome Score (HOOS), depending on the patient’s age. Results. A total of 52 children (58 hips) were included. At the latest follow-up, 11 hips (19%) showed signs of AVN. Further surgery was undertaken in 13 hips (22%). A total of 13 hips had a poor radiological outcome with Severin type III or higher. Of these, the age at the time of surgery was significantly higher (p < 0.05) than in those with a good Severin type (I or II). The patient-reported outcomes were significantly worse (p < 0.05) in children with a poor Severin classification. Conclusion. This retrospective long-term follow-up study shows that one in five children with DDH who undergo open reduction using a medial surgical approach has poor clinical and/or radiological outcome. The poor outcome is not related to the presence of AVN (19%), but due to residual dysplasia. Cite this article: Bone Joint J 2018;100-B:822–7

Aims

Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up.

Background:. The Chevron osteotomy is straightforward, requires less dissection and allows earlier rehabilitation than some other osteotomies. However it is generally perceived as unsuitable for severe deformities even though a 2012 meta-analysis and an earlier RCT failed to show any advantage of the scarf over the chevron. We aim to assess the correctability of severe HV comparing the correction, the clinical outcomes and complications of the Chevron osteotomy with other techniques employed in a consecutive series. Methodology:. We reviewed a series of 92 cases of severe hallux valgus (IMA >17° regardless of the HVA). The follow-up period varied from 1 to 4 years. Pre-operative x-rays and final post-operative weight-bearing x-rays were performed. Outcome scores (MOXFQ and AOFAS), IMA, HVA and foot width were collected. Complications were monitored. Results:. There were 97 cases of severe hallux valgus performed during the study period, 55 were treated with a large-shift modified Chevron osteotomy, 42 with a number of other techniques that included Ludloff, Basal or Scarf osteotomy and also fusion in the form of a Lapidus or 1. st. MTP. The average pre-operative measurements were IMA of 19.1°, HVA of 40°, osseous forefoot width of 93.2 mm and the forefoot: hindfoot ratio was 3.11. Post-operatively the measurements were IMA of 9.2 and HVA of 9.76, the osseous forefoot width was 82.8 mm and the forefoot: hindfoot ratio was 2.57. Radiological outcomes for the Chevrons were similar to the alternative techniques though the rate of recovery was better. There is an increase in the rate of screw removal after a large shift Chevron osteotomy, reasons for this are discussed. Conclusion:. The Chevron osteotomy is successful in the management of severe hallux valgus. It has the advantage of being a stable osteotomy that permits immediate weight-bearing and movement of the MTP joint

Purpose of the study. This study aims to evaluate the use of closed reduction of hips with developmental dysplasia of the hip (DDH) and medial open reduction of these hips as a subsection of closed reduced hips. Methods. The study was a retrospective analysis of treatment of 30 children with developmental dysplasia of the hip (DDH). These children were taken from a consecutive series of children treated over a period from June 2000 to 2011 with closed reduction by a single surgeon. The ages at the time of diagnosis were between 1 day and 13 months (mean 5.25 weeks). Included in this series are 7 patients treated with medial open reduction, all done with the Ludloff approach. Follow up of these patients was from 8 months to 12 years (mean 5 years). All patients needing secondary procedures were noted. The X- rays were evaluated for percentage acetabulum cover in patients over the age of 8 and improvement of the acetabular index in all these patients. Results. 4 children needed secondary procedures. 1 child of the closed reduction group developed avascular necrosis of the femoral head that was treated with a Salter osteotomy and a further 2 needed secondary open reductions after redislocation following initial closed reduction. One child with bilateral open medial reductions had a Salter osteotomy 6 years after the initial treatment was done. 26 of the children had good outcomes with improvement of the acetabular angles, percentage acetabular cover and pain free independent ambulation. The average acetabular index improved from 37.5° to 23.3°. Conclusion. Closed reduction of DDH hips is a good treatment modality. Early treatment allows for acetabular and femoral development. There are minimal secondary procedures necessary after closed reduction, and open medial reduction does not increase the complication rate. NO DISCLOSURES

Failed Hallux Valgus Surgery Aim. We aim to explore the reasons behind long term failure of hallux valgus surgery. Patients & Methods. A series of patients with problems following failed hallux valgus surgery presenting to a tertiary referral unit is presented. There were 47 patients with 55 problematic feet, 45 were female. The mean age was 59 years (Range 25–79). The failed bunions were compared to a prospectively collected series of 80 patients with successful 1st metatarsal osteotomies, 40 ludloff and 40 scarf osteotomies. Before the index surgery, all the patients in the failed group, the predominant symptom was pain. Only 53% admitted deformity was an issue. A wide spectrum of procedures were performed, 13 Wilson's, 11 Keller's, 8 Chevron, 3 Bunionectomy, 2 Scarf, 1 Basal and 1 Mitchell's. In 16 patients the original procedure was unknown. The mean time to developing problems was 9.4 years (Range 0–45) with mean time to presentation 13.6 years. (Range 0–47) Radiographs revealed 2/3 of patients had relative shortening of the first metatarsal. Over 80% of x-rays demonstrated evidence of degenerative change. The mean AOFAS score deteriorated with increased shortening. The failed bunions had statistically significantly different AOFAS pain scores (15.1 vs 31.9 p < 0.05), function scores (25.02 vs 31.9 p < 0.05). Additionally, the hallux valgus angle was significantly higher (24 vs 11.7 p < 0.05) although there was no change in DMMA between the two groups (13 vs 7.6 p > 0.05). There was a significantly higher incidence of first ray shortening (12% vs 0% p < 0.05). Discussion. This represents an unusual series, with nothing similar in the literature. Problems following hallux valgus surgery do not present for over 10 years. Functional Scores deteriorate with increasing shortening. MTPJ degeneration is common and from our data we are unable to explain why

Ludloff’s medial approach has never been used for other hip surgeries especially not for THR. 47 patients (26 men/21 women) provided informed consent to participate in the study. The inclusion criterion for the study was the diagnosis of osteoarthritis of the hip joint. The average age at operation was 53.7±10.4years. All patients were provided with a CUT. ®. prosthesis. All patients were examined clinically and X-rayed preoperatively as well as postoperatively at three days, two weeks, six weeks and six months. The functional hip scores according to Harris and the Oxford hip score were obtained preoperatively and at the defined intervals postoperatively. The surgical duration and the intraop-erative as well as the postoperative blood loss were measured for each patient. Abductor muscle function and the number of steps a patient was able to walk without walking aids on a treadmill at a velocity of 5km/h (a maximum of 100steps was measured) were assessed. Multifactorial analyses of variance and Chi-square tests were performed. Based on the numbers available there were no significant differences between the two groups in the distribution of patient age (p=0.604), gender (p=0.654), weight (p=0.180) and height (p=0.295). No significant differences in the calculated Harris score (p=0.723) were found pre-operatively. The amount of steps the patient was able to walk was not different between the approach groups (p=0.636). The total amount of blood loss (intra- + post-OP) was even significantly lower in the medial approach group (p=0.009). Three days post-operatively the leg lengths were assessed. The difference was not statistically significant based on the numbers available (p=0.926). The overall correlation between Harris and Oxford score was significant (r. 2. =0.63, p< 0.001). Three days post-operatively a slight, but significant better Harris (p< 0.001) and Oxford scores (p=0.001) could be observed in the medial approach group. The number of steps the patient was able to walk without help or crutches was significantly higher in the medial approach group (p=0.001). The Trendelenburg sign (p< 0.001) and the limping criterion (p< 0.001) were significantly less in the medial approach group. Two weeks post-operatively the Harris (p=0.001) and the Oxford (p=0.046) scores were significantly better for the medial approach group. The number of steps the patient was able to walk without help or crutches was significantly higher in the medial approach group (p< 0,001). The medial approach is clinically feasible to perform the implantation of a femoral neck prosthesis. The accuracy of the stem implantation reflected in both the leg lengths and the postoperative X-ray alignment was not different between the groups. After six months there was no significant difference between the conventional anterolateral approach and the medial approach in the presented study

Proximal Metatarsal osteotomies are used for larger deformities, generally those with an intermetatarsal angle greater than 15°. These osteotomies usually are combined with a Distal Soft Tissue Release, which is necessary to correct metatarsophalangeal (MTP) sub-luxation with a Hallux Valgus Angle greater than 35°. Many types of osteotomies have been described. These include a medial opening wedge, a lateral closing wedge, proximal chevron, and a crescentic. Additional osteotomies include the Scarf, Ludloff, and Mao osteotomies. Presently, the proximal chevon and crescentic osteotomies are widely used. In our study we used the proximal chevon osteotomy combined with Distal Soft Tissue Release and approximation of the 1. st. and 2. nd. metatarsus using a string to further decrease the intermetatarsal angle. From January 2000 to June 2005 the basal chevon osteotomy was selected in 44 patients (37 female and seven male patients, ages 14 to 80, mean: 54.97 years) total of 49 feet with moderate metatarsus primus varus (IMA 13 to 20 degrees) and hallux valgus deformities (less than 50 degrees). The AOFAS Hallux Metatarsopha-langeal-Interphalangeal Scale and patient satisfaction were monitored prior to surgery, and postoperatively. Changes in the IMA and HV angle were measured in the conventional method and documented. All patients were treated in a Darco Post operative splint. Results: Multiple complications were encountered. The most common is transfer metatarsalgia. This occurred in 10 patients (20%). Other complications include delayed union (4%), increase in the height of the first metatarsus (10%), floating toe (6%), superficial infection (15%), local parenthesis and early recurrence of deformity in 3%. 38 patients were available for follow-up. The hallux valgus angle improved significantly more than 20 degrees on average postoperatively. The intermeta-tarsal angle also improved significantly (more than 10 degrees on average) postoperatively. The position of the sesamoids was realigned to beneath the first metatarsal head and the metatarsal length remained essentially unchanged. The AOFAS score preoperatively was a mean of 75.64 with respect to pain, deformity, motion, disability, and cosmetic. The AOFAS score postoperatively was a mean of 94.55. The mean improvement was 18.91. About 95.45 percent (42/44) were satisfied and would recommend the surgery to a friend. Conclusions: The basal chevron osteotomy combined with Distal Soft Tissue Release and realignment using a string is a technically demanding procedure and has multiple potential complications but provdes a reliable method with respect to stability, technical ease and satisfactory surgical outcome for correction of moderate and severe bunion deformity, both as a primary and revision procedure

The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years’ follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60°of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

Cite this article: Bone Joint J 2014;96-B:279–86.