Introduction. Legg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively. Methodology. This is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of:. Age – Patient must be part of the Paediatric Service, i.e., under the age of 16. Diagnosis – Patient must have a diagnosis of Perthes Disease with a Herring Classification documented. Application of a Hip Distractor Frame formed part of the patient's surgical management. Surgery was completed by Mr Connor Green. Surgery was completed between January 2021 and December 2022. Patient were required to have their external hip distractor frame removed by December 2022. Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results. Results. From analysing the data, the following results were identified:. 80% of the sample cohort had a length of stay of 5 days following surgery. There were two outliers due to infection who had a length of stay of 14 days. 90% of the sample received a pre-operative Physiotherapy and Occupational Therapy assessment. This assessment included information gathering regarding the child's home and social environment; their functional baseline and anticipated post-operative needs. Standardised and non-standardised assessments were used. 88.89% of those who completed a pre-operative assessment required referral to community Occupational Therapy teams for equipment provision (wheelchair, transfer aids) to allow for timely discharge. On average, each patient in the sample required 17 physiotherapy outpatient sessions prior to handover to the community teams. 100% of our sample required post operation onward referral for MDT input in the community (Occupational Therapy and Physiotherapy). Conclusions. The importance of a multi-disciplinary approach towards family and children was highlighted in this study. A comprehensive pre-operative therapy assessment optimizes care for this cohort by preparing them in terms of equipment provisions, local team input and expectations for therapy. The data suggests future Limb Reconstruction team should include Physiotherapy and Occupational Therapy as part of the multi-disciplinary team, in the treatment of children with Perthe's Disease. We suggest an MDT pre-assessment is completed to optimize patient care, reduce length of stay and improve patient satisfaction in the acute hospital setting

Perthes disease is a childhood disorder often resulting in femoral head deformity. Categorical/dichotomous outcomes of deformity are typical clinically, however quantitative, continuous measures, such as Sphericity Deviation Score (SDS), are critical for studying interventions. SDS uses radiographs in two planes to quantify femoral head deformity. Limitations of SDS may include non-orthogonal planes and lost details due to projections. We applied this method in 3D, with specific objectives to: 1. Develop SDS-like sphericity measures from 3D data 2. Obtain 2D and 3D sphericity for normal and Perthes hips 3. Compare slice-based (3D) and projection-based (2D) sphericity CT images of 16 normal (8 subjects) and 5 Perthes hips (4 subjects) were segmented to create 3D hip models. Ethics board approval was obtained for this study. SDS consists of roundness error (RE) in two planes and ellipsoid deformation (ED) between planes. We implemented a modified SDS which was applied to (a) orthogonal projections simulating radiographs (sagittal/coronal; 2D-mSDS), and (b) largest radii slices (sagittal/coronal; 3D-mSDS). Mean 2D-mSDS was higher for Perthes (27.2 (SD 11.4)) than normal (11.9 (SD 4.1)). Mean 3D-mSDS showed similar trends, but was higher than 2D (Perthes 33.6 (SD 5.3), normals 17.0 (SD 3.1)). Unlike 2D-mSDS, 3D-mSDS showed no overlap between groups. For Perthes hips, 2D-mSDS was consistent with SDS. For normal hips, 2D-mSDS was higher than expected (similar to Stulberg II). Projection-based (2D) measures may produce lower mSDS due to spatial averaging. Slice-based (3D) measures may better distinguish between normal and Perthes shapes, which may better differentiate effectiveness of treatments

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

Perthes disease often leaves young adults with hip joint incongruency due to femoral head asphericity, (extra-articular extrusion and superior flattening). This causes femoro-acetabular impingement, a reduced range of movement and early degenerative change. We report a novel method for restoration of femoral head sphericity and femoro-acetabular congruency. Two males (aged 21 and 22 years) presented with groin pain and severe hip stiffness after childhood Perthes disease. Imaging confirmed characteristic saddle shaped deformities of the femoral head, with cartilage loss overlying a central depression in the superior section of the head. A new method of treatment was proposed. Both cases were treated in the same manner. A surgical dislocation was performed with a trochanteric flip osteotomy. The extra-articular bump was removed with osteotomes and a burr to reduce femoro- acetabular impingement. The sphericity of the femoral head was restored using a HemiCap partial re-surfacing (Arthrosurface, MA, USA). The radius of the implant was selected to match that of the acetabulum. Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. Both patients recovered without incident and were mobilised with crutches, restricted to touch weight-bearing for six weeks to protect union of the trochanteric osteotomy. At a minimum of three year follow-up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage. We conclude that this novel treatment functions well in the short term. Further surveillance is on-going to confirm that this treatment results in improved long term durability of the natural hip joint after Perthes disease

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

Opinions about the treatment of Perthes' disease vary widely. However there is no disagreement about the need for containment during fragmentation stage to create an optimum biomechanical environment for remodelling of femoral head. Types of containment may vary. Younger children do well irrespective of the method of containment. Older children usually require surgical containment. The present study was aimed at evaluating the results of different methods of surgical containment in different age group and identifying specific factors that alter the final outcome and prognosis. 107 cases were reviewed retrospectively. 21 cases were excluded due to lack of records. 86 hips were available for clinical and radiological evaluation. 31 patients were under 7 years and required Varus osteotomy (VO). 55 patients were above 7 years. VO was performed in 30 hips and Shelf containment was done in 25. Case notes were reviewed for demographic details, surgical details and clinic letters. Radiographs were reviewed for Herring's grading, Stulberg staging, containment indices, centre edge angle, lateral pillar height, Mose index, neck shaft angle and shelf width. In all patients, there was an improvement in pre-operative symptoms and summated range of motion, especially abduction. Good functional and radiological outcome was seen in age group < 7 years. In older children, outcome was good to satisfactory with Herring grade B. Stulberg grading worsened with advancing age and Herring grade C, irrespective of the method of containment. Persistence of varus neck shaft angle and trochanteric overgrowth were significant problems with VO. Although all containment indices improved with Shelf group, Stulberg grading remained poor in most patients. The lateral pillar classification and age strongly correlate with final outcome. Herring group C had the least favourable result. Stulberg staging remained poor in older children irrespective of the method of containment

Sixty-two children with unilateral Perthes disease who underwent trochanteric epiphyseodesis combined with varus osteotomy of the femur during the active stage of the disease, (mean age at surgery: 8.4 years) and twenty controls were followed up untill skeletal maturity. The following measurements were taken on radiographs taken at skeletal maturity: the articulo-trochanteric distance (ATD), the center-trochanteric distance (CTD), the length of the abductor lever arm, the neck-shaft angle, the radius of the femoral head and the Reimer's migration index of normal and affected hips. The shape of the femoral head was assessed according to the criteria of Mose. The range of hip motion, the strength of hip abduction and limb lengths were measured and the Trendelenburg sign was elicited. The mean values of ATD and CTD were greater and the frequency of a positive Trendelenburg sign was less in children who had undergone trochanteric epiphyseodesis in 60% of operated children. The procedure was not effective in 30% and there was over-correction in in 10% of children. Logistic regression analysis showed that the size of the femoral head and the age at surgery were variables that significantly influenced the effectiveness of trochanteric growth arrest. At skeletal maturity, the mean shortening of the affected limb in operated children was 0.44 cm (SD 0.68 cm), while that of non-operated children was 0.86 cm (SD 0.78 cm) (p: 0.023). The range of motion of the hip was excellent and there were no significant differences in the range of motion between children with optimal correction, under-correction and over-correction. A probability curve plotted on the basis of the of a logistic regression model suggests that effective trochanteric arrest may be achieved in a high proportion of children operated at, or before, 8.5 years of age, and in half the children operated between the age of 8.5 years and 10 years

Introduction. Hip arthrodiastasis for paediatric hip conditions such as Perthes disease is growing in popularity. Intended merits include halting the collapse of the femoral head and maintaining sphericity by minimising the joint reaction force. This can also be applied to protecting hip reconstruction following treatment of hip dysplasia. Our aim was to assess functional outcomes and complications in a cohort of paediatric patients. Materials and Methods. A retrospective single-surgeon cohort study was performed in a University teaching hospital from 2018–2021. Follow-up was performed via telephone interview and review of patient records. Complications, time in frame and functional scores using the WOMAC hip score were recorded. Results. Following review, 26 procedures were identified in 24 patients. Indications included 16 cases of Perthes disease, 4 following slipper upper femoral epiphysis, 3 avascular necrosis, and single cases following infection, dysplasia and a bone cyst. Pre-treatment WOMAC scores averaged 53.9, improving to 88.5 post-removal. Pin site infections were encountered in 11 patients, all treated with oral antibiotics. Two patients required early removal of frame due to pin loosening. Average time in frame was 3.9 months. Conclusions. This series displays how hip arthrodiastasis can be used to manage paediatric hip conditions. Complex reconstructions may be required in patients with severe deformity following perthes disease, DDH or SUFE. The use of arthrodiastasis in these patients aims to protect the reconstruction and potentially improve outcomes. A dedicated team of specialist nurses, physiotherapists and psychologists are crucial to the treatment program

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed

Introduction. Torsional deformities are increasingly recognized as an additional factor in young patients with hip pain resulting from pincer- and cam-deformities. For example decreased femoral torsion can worsen an anterior Femoroacetabular impingement (FAI) conflict while an increased torsion can be beneficial with the same configuration. It is unknown how often torsional deformities are present in young patients presenting with hip pain that are eligible for joint preserving surgery. We questioned (1) what is the prevalence of a pathological femoral torsion in hips with FAI or hip dysplasia? (2) which hip disorders are associated with an abnormal torsion?. Methods. An IRB-approved retrospective study of 463 consecutive symptomatic FAI patients (538 hips) and a MRI or CT scan on which femoral torsion could be measured was performed (‘study group'). Out of 915 MRI we excluded 377 hips. The study group was divided into 11 groups: Dysplasia (< 22° LCE), retroversion, anteverted hips, overcoverage (LCE angle 36–39°), severe overcoverage (LCE>39°), cam (>50° alpha angle), mixed FAI, varus- (<125° CCD angle), valgus- (>139° CCD), Perthes-hips and hips with no obvious pathology. The ‘control group' of normal hips consisted of 35 patients (35 hips) without radiographic signs of osteoarthritis or hip pain wich was used for a previous study. Femoral antetorsion was measured according to Tönnis et al. as the angle between the axis of the femoral neck and the posterior axis of the femoral condyles. Normal femoral torsion was defined by Tönnis et al. as angles 10–25° while decreased resp. increased torsion was defined as <5° and >25°. Statistical analysis was performed using analysis of variances (ANOVA). Results. (1) Fifty-one percent of the patients of the study group presented with abnormal values for femoral torsion. Torsional deformities (<10° or >25°) were measured in 52% of all 538 hips eligible for joint preserving surgery. (2) Torsional deformities were present in 86% of Perthes hips, in 61 % of dysplastic hips, 52.3 % of hips with overcoverage, in 51% of mixed FAI, in 50% of varus hips, in 45% of valgus hips, in 45% of retroverted hips, in 47% of anteverted hips, in 43% of cam FAI, 35% of hips with severe overcoverage. No torsional deformity was present in the control group. Analysis of Variances (ANOVA) revealed significant differences (p<0.001) of torsion between normal hips (mean 17°) and hips with dysplasia (26°), valgus hips (27°), hips with no obvious pathology (30°) and Perthes hips (32°). Mean femoral torsion was in the normal range in the other groups. Conclusion. More than half of the patients wich are eligible for joint preserving surgery of the hip present with abnormal femoral torsion. In particular dysplastic-, valgus-, Perthes hips and hips with no obvious pathology had a significantly altered femoral torsion compared to normal hips. Femoral antetorsion should be measured in every patient eligible for hip-preserving surgery

Surgical treatment options for Femoroacetabular impingement (FAI) includes both surgical dislocation and hip arthroscopy techniques. The primary aim of this study was to evaluate and compare the survivorship of arthroscopies (scope) and surgical dislocations (SD) at minimum 5-year follow-up. The secondary aim was to describe differences in functional outcomes between the 2 groups. This was a retrospective, single surgeon, consecutive, case-series from a large tertiary care centre. We evaluated all surgeries that were performed between 2005 and 2011. Our institutional database was queried for any patient undergoing surgery for FAI (pincer (n=23), cam (n=306), or mixed (n=103) types). Patients with childhood pathologies i.e. Legg Calve Perthes and slipped capital femoral epiphysis were excluded. This resulted in 221 hips (169 males, 52 females) who underwent either SD (94, 42.5%) or scope (127, 57.5%). A manual chart review was completed to identify patients who sustained a complication, underwent revision surgery or progressed to a total hip arthroplasty (THA). In addition, we reviewed prospectively collected patient reported outcome measure (PROMs) using (SF12, HOOS, and UCLA). Survivorship outcome was described for the whole cohort and compared between the 2 surgical groups. PROMs between groups were compared using The Mann-Whitney U test and the survival between groups was assessed using the Kaplan-Meier Analysis and the Log-Rank Mantel Cox test. All analyses were performed in SPSS (IBM, v. 26.0). The cohort included 110 SDs and 320 arthroscopies. The mean age of the whole cohort was 34±10; patients in the SD group (32±9) were younger compared to the arthroscopy group (39±10) (p<0.0001). There were 16 post-operative complications (similar between groups) and 77 re-operations (more common in the SD group (n=49) due to symptomatic metal work (n=34)). The overall 10-year survival was 91±3%. Survivorship was superior in the arthroscopy group at both 5- (96% (95%CI: 93 – 100)) and 8- years 94% (95%CI: 90 – 99%) compared to the SD Group (5-yr: 90% (95%CI: 83 – 98); 8-yr: 84% (95%CI:75 – 93)) (p=0.003) (Figure 1). On average HOOS improved from 54±19 to 68±22 and WOMAC from 65±22 to 75±22. The improvement in PROMs were similar between the 2 groups. We report very good long-term joint preservation for the treatment of FAI, which is similar to those reported in hip dysplasia. In addition, we report satisfactory improvement in function following such treatment. The differences reported in joint survival likely reflect selection biases from the treating surgeon; more complex cases and those associated with more complex anatomy were more likely to have been offered a SD in order to address the pathology with greater ease and hence the inferior joint preservation identified in this group. For any figures or tables, please contact the authors directly

Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz. A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed. There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure. This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE

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

Purpose. Leg length discrepancy after total hip arthroplasty (THA) sometimes causes significant patient dissatisfaction. In consideration of the leg length after THA, leg length discrepancy is often measured using anteroposterior (AP) pelvic radiography. However, some cases have discrepancies in femoral and tibial lengths, and we believe that in some cases, true leg length differences should be taken into consideration in total leg length measurement. We report the lengths of the lower limb, femur, and tibia measured using the preoperative standing AP full-leg radiographs of the patients who underwent THA. Materials and methods. From August 2013 to February 2017, 282 patients underwent standing AP full-leg radiography before THA. Of the patients, 33 were male and 249 were female. The mean age of the patients was 65.7±9.4 years. We measured the distances between the center of the tibial plafond and lesser trochanter apex (A-L), between the femoral intercondylar notch and lesser trochanter (K-L), and between the centers of the tibial plafond and intercondylar spine of the tibia (A-K) on standing AP full-leg radiographs before THA operation. We examined the differences in leg length and the causes of these discrepancies after guiding the difference between them. Results. The mean A-L was 674±44 mm on the right and 677±43 mm on the left. The mean difference between the left and the right was 6.2±7 mm. The differences of ≥5 and ≥10 mm between the left and right were confirmed in 131 (46%) and 39 cases (14%), respectively. The mean K-L was 343±23 mm on the right and 343±23 mm on the left, with a mean difference of 4.4±4 mm. The lateral differences of ≥5 and ≥10 mm were confirmed in 88 (31%) and 22 (8%), respectively. The mean A-K was 325±22 mm on the right and 327±22 mm on the left, with a mean difference of 4±4.5 mm. The differences of ≥5 and ≥10 mm between the left and right were confirmed in 24 (9%) and 67 cases (%), respectively. Discussion. Considering the total length of the lower limbs beyond the little trochanter and the leg length after THA, we confirmed that 46% of the leg length differences of ≥5 mm were admitted to 14%. Thus, THA appeared effective. Perthes head, Crowe classifications 3 and 4, history of childhood paralysis, and so on may be factors for leg length differences beyond the lesser trochanter. Conclusion. We think that it would be preferable to prepare a preoperative plan to measure leg length after THA by measuring the total length of the lower extremity before surgery and determining the difference between the left and right sides

Sugioka trans-trochanteric valgus osteotomy (TVO) has originally been described for advanced osteoarthritis of hip. This has many advantages over conventional subtrochanteric osteotomies such as early union with simple fixation and preserving proximal femoral geometry to enable standard femoral components for a future hip replacement. Lateral displacement and distalisation of the greater trochanter increases the lever arm and improves abductor limp. The use of TVO has never been reported in children. We report our experience of TVO for hinge abduction in children (mostly in Perthes' disease). Twenty four patients of mean age 10.2 years at surgery, (range 7- 17 years) underwent TVO between 1998 and 2007. The diagnosis was Perthes' disease in 19 and avascular necrosis from other causes in the remaining five. Average follow-up was 4.4 years (18 months to 11 years). All patients had pre-operative confirmation of hinge abduction by arthrogram. Osteotomies were performed at inter-trochanteric level and fixed with screws and wire. The neck shaft angle increased by mean 11.75 degrees (range 6 to 23). Migration index increased by mean 3.88% (-14% to + 29%). Average limb length discrepancy at final follow-up was 10.8 mm (range -30 to +10mm). Final articulo-trochanteric distance was 4.5mm (range -15 to +21 mm) less than the opposite side. Functional assessment was carried out using the Modified IOWA hip scores. The mean hip score was 75.1 (range 38.8 to 97.6). Complications were one case of trochanteric non-union requiring further surgery, one case of stiffness which responded to manipulation under anaesthesia. Our results indicate that Sugioka TVO is a successful procedure for hinge abduction of the hip

Metal on metal hip resurfacing is increasing in popularity for the young, active patient. We present the results of a consecutive series from a single surgeon over a ten year period; 295 hip resurfacings (McMinn and Cormet; Corin, Cirencester, UK) with a minimum follow up of 2 years and a mean follow up of 4 years. There were 173 males with a mean age of 53.4 years and 121 females with a mean age of 50.3 years. Forty-six patients underwent bilateral resurfacings. All resurfacings were performed through a posterior approach. The aetiology in this group was primary OA in 75.9%, inflammatory arthritis in 6.1%, DDH in 6.1%, AVN in 4.7%, trauma in 4.7%, Perthes in 1.7% and SUFE in 0.7%. Patients were reviewed clinically and radiographically on an annual basis. Follow-up was available on 93% of patients. 94.2% of hips have survived and the mean Harris Hip Score is 87.5. Females had a higher failure rate (10.7%) than males (2.3%). There was no clear trend between patient age and failure rate. The highest failure rate (33.3%) was seen in patients with DDH whilst only 4.5% of patients with OA failed. One patient with AVN failed but no failures occurred in patients with inflammatory arthritis, trauma, Perthes or SUFE. Failures occurred due to cup loosening (2.0%), neck fractures (1.7%), head loosening (1.0%), head collapse (0.3%), infection (0.3%) and pain (0.3%). The five patients who suffered neck fractures were symptomatic within 3 months of surgery. We remain cautiously optimistic about the medium term results of hip resurfacing. Careful patient selection is important and caution should be taken in females and patients with DDH

Bone preserving hip arthroplasty devices are appealingfor use in young patients because their high-demand activities and extended lifetimes makes the prospect of multiple revisions a reality. Therefore prostheses which ensure a straightforward revision with a low complication rate and good clinical outcome are favourable for young and active patients. Modern hip resurfacing serves these conditions and shows very good mid-term and now longer term (10 and 13 years) results especially in osteoarthritis. With other diagnoses like avascular necrosis, deformities of the femoral head in m. Perthes or slipped femoral epiphysis (SUFE), or in large bone cysts and erosive arthritis the bone stock of the femoral head gives insufficient support to the femoral component. In these conditions the alternative to a resurfacing procedure had been a stemmed total hip arthroplasty (THA). The Birmingham Mid Head Resection device (BMHR; Smith&Nephew Orthopaedics) is an alternative to resurfacing and to a stemmed THA. The BMHR device consists of an uncemented short stem made of titanium alloy and a large diameter cobalt-chrome head. The stem does not enter the femoral canal thus facilitating future revisions. The metal-on-metal bearing is the same as in resurfacing. The instrumentation allows switching from a planned BHR to the BMHR. The BMHR uses the unique anatomy of the head neck junction to prepare internally a cone that matches the frustoconical section of the BMHR stem. Thus a cement free press fit can be achieved. This maintains anatomical load transmission and avoids osteopenia of the proximal fenur. Since 2006 we have performed 662 BMHR implantations. The indications were osteoarthritis in about 70%, dysplasia in 20%, AVN 5,5%, posttraumatic OA in 3%, SUFE and m. Perthes in 1%. Complications occured in 3,2%. Fractures of the femoral neck occured in 8 patients, 4 of them caused by technical errors in the beginning, 3 because of higher risk indication. All revisions were performed successfully and the cup was retained. Low grade infections in 2 cases with one stage revision and 3 unstable cups needed to be reinserted. All revisions were successful. One early dislocation was treated by closed reduction, another remained unstable and was treated by THA. In conclusion we continue to use the BMHR to bridge the gap between resurfacing and stemmed THA because the complications we experienced are not inevitable and had become very rare with our growing experience

Over the past fifteen years hip preservation surgery has rapidly evolved. Improved understanding of the pathomechanics and associated intra-articular degeneration of both hip instability and femoroacetabular impingement have led to improved surgical indications, refined surgical techniques and more effective joint preservation surgical procedures. The periacetabular osteotomy (PAO) was initially introduced by Ganz and colleagues and has become the preferred treatment in North America for pre-arthritic, symptomatic acetabular dysplasia. Both hip arthroscopy and safe surgical dislocation of the hip have been popularised for the treatment of symptomatic femoroacetabular impingement disorders. Hip arthroscopy is effective for focal and\or accessible impingement lesions while the surgical dislocation approach is reserved for nonfocal disease patterns as seen in complex FAI, and residual Perthes and SCFE deformities. Femoroacetabular impingement from major acetabular retroversion can be managed with the PAO if there is coexistent posterosuperior acetabular insufficiency. Short- to mid-term results of these procedures are generally good to excellent for most patients and the complication rates associated with these procedures are very acceptable. Long-term outcomes are best known for the PAO. Several recent studies have documented survivorship rates of 65–90% at 10–20-year follow-up. Certain factors are associated with long-term success including minimal pre-operative radiographic OA, early symptoms, accurate acetabular correction, and younger age. These data strongly suggest that the PAO can defer THA to an older age for most patients while completely avoiding arthroplasty may only be possible in select patients with excellent congruency, no secondary OA and an ideal surgical correction

There is an increased incidence of dislocation, dysplasia, slipped epiphysis, Perthes’ disease, and avascular necrosis leading to degenerative arthritis which occurs in up to 28% of Down's syndrome patients. As the life expectancy for patients with Down's syndrome has increased, so has the presence of hip disease. Hip replacement has been shown to have good results in this population. Special considerations include a high risk of postoperative dislocation and leg length inequality which often require large head THR or dual mobility type reconstruction to reduce these risks. Numerous spine deformities including scoliosis and C1-2 subluxation need to be taken into account-anesthesia consult

Direct anterior approach (DAA) is one of the best way to the hip joint for prevention of post-operative dislocation. We have applied this method as minimum invasive surgery (MIS) to more than two hundred developmental dysplastic hip of Japanese patients in total hip arthroplasty (THA) and there is no post-operative dislocation within three years of last observation carried forward (LOCF). The reason of this benefit is derived from the accuracy of cup positioning and keeping good muscle balance. But the learning curve is very important and some technical pitfalls are there in this approach. We have chosen thirty four patients that the duration of operating time more than one and half hours and loss of blood more than five hundred gram in hour series. The most important factors of the difficulties are the combinations of shortening of femoral neck, especially Perthes like deformity of developmental deformities of the hip joint (DDH) and widening of pelvic bone for the reason of insufficiency working spaces and the difficulties of broaching insertion (8/34). The second factor is the contracture of hip and knee joints combinations for the difficulties of lift up the proximal femur as broaching stem (3/34). The obesity, Body Mass Index (BMI) above thirty is not the reason of difficulties of women in our series. DAA can be extended to Smith-Petersen approach and very useful technique for primary THA in Japanese dysplastic hip patients