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 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

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

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

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

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

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

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

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem. Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known. At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others. Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients

Aim. This study aims to determine the value of MRI in children with hip pain which remained unexplained following routine investigations including ultrasound examination. Materials and methods. Retrospective review of clinical notes and MRI findings in all children who received and MRI scan for undiagnosed hip pain over three years. Results. Fifty five children underwent an MRI scan of their hips for unexplained hip pain. 29 were male and 26 were female. The mean age was 10.9 years. The MR study provided a diagnosis in 22 children (40%), and was normal in 33 children (60%). Five cases were considered to be due to transient synovitis. Three children were diagnosed as osteoid osteoma. Two children were were found to have trochanteric bursitis. Two children were shown to have muscle trauma (one child with adductor trauma and one child with piriformis trauma). Two children were diagnosed with non-specific bone oedema. The remaining eight children were diagnosed with Perthes' disease, haemarthrosis, sacro-iliac infection, synovitis secondary to juvenile idiopathic arthritis, ischio-pubic osteochondrosis, acetabular dysplasia, Klippel-Trenaunay syndrome and resolution of an eosinophilic granuloma. None of the children discharged following a normal scan has subsequently presented with hip disease. Conclusions. It is concluded that MRI is useful in the diagnosis of hip pain in children in whom routine investigation has not yielded an answer

Background. Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children. Aim. The main objective of this study was to confirm whether bilateral 8-plates achieve an epiphysiodesis or not?. Methods and results. This is a prospective study of 27 patients who were treated with 8-plate epiphysiodesis for limb length discrepancy with a mean follow up of 28 months. Perthes disease was the most common underlying pathology for the LLD. The average preoperative LLD was 25.9 mm (15–49 mm). 17 patients successfully corrected to < 15 mm LLD, 5 patients corrected to between 15–20 mm and 5 patients did not correct to with in 15 mm LLD (22.2%). In those patients whom have corrected, the average correction length was 25.6 months with an average correction rate of 1.52 mm per month. There was a trend for insufficient equalisation if the procedure was performed < 1.5 years prior to skeletal maturity. The was also a trend for insufficient equalisation if performed at single physis only (femur or tibia). Complications included one superficial infection and one deep infection following plate removal at the end of treatment. Screw breakage was noticed in one patient. No long term complications were reported. No angular deformity was reported. Conclusion. This study has confirmed that bilateral 8 plates produce an epiphysiodesis. Failures are mainly due to late insertion or single physis usage. Future application depends on demonstrating reversibility when applied to younger children

Purpose. The hip region is the second most common site for tuberculosis following the spine in children. The aim is to describe the variable radiological patterns of presentation and their resemblance to pyogenic infection, tumours and other benign conditions of bone in children. Methods. The clinical and radiological records of 29 children aged 10 months–13 years with confirmed tuberculosis of the hip region seen between 1990 and 2011 were reviewed retrospectively. Clinical features were pain, limp and flexion, adduction contractures. Abscesses and sinuses were seen in 4 children. The ESR ranged between 7–110 mm/hr. Mantoux was positive in 20 children. All cases were histologically confirmed. Treatment involved biopsy, currettage of bone defects, limited synovectomy and adductor tenotomy. Patients were immobilised for 4 weeks on a spica cast or traction. Antituberculous treatment was administered for 9–12 months. Results. Radiologically 9 lesions were extra-articular and 20 involved the joint synovium and articular surface. Extra-articular lesions were seen in the pubis, greater and lesser trochanter, ilium, proximal femur and peri-acetabular regions. Intra-articular lesions were seen in the femoral head, neck and acetabulum. Dislocations and subluxations occurred in 8 patients; various lesions mimicked pyogenic arthritis, idiopathic chondrolysis, chondrobastoma, Perthes disease, eosinophilic granuloma and osteoid osteoma. Follow up ranged between 8 months and 5 years. Good range of movement was seen in 20 children. Nine children had flexion adduction contractures, four of these had ankylosed hips and five required abduction extension osteotomies. Other changes seen were coxa vara (2) coxa magna (1) and avascular necrosis (3). Conclusion. The variable radiological picture of tuberculosis of the hip region can mimic various osteoarticular conditions in children. Biopsy is essential and should be taken from the bony lesion and not the synovium alone. NO DISCLOSURES

Introduction. Through the paediatric LCP Hip plating system, the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to paediatrics. The purpose of this study was to review the outcome of the paediatric LCP Hip plate use in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications. Materials and methods. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Hip Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Results. Forty-three Paediatric LCP hip plates were used in forty patients for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, DDH, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of SUFE. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p = 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. There were no implant related complications. Conclusion. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric hip conditions in children with and without neuromuscular disease

Introduction. Patients who are symptomatic with concurrent acetabular dysplasia and proximal femoral deformity may have Perthes disease. Osteotomies to correct both the acetabular and proximal femur deformities may optimise biomechanics and improve pain and function. In this study, we assessed the long-term results for such a combined procedure. Methods. We included patients who underwent concurrent pelvic and proximal femoral osteotomies by the senior surgeon (JNOH) with a minimum follow-up of 5 years. A modified triple pelvic interlocking osteotomy was performed to correct acetabular inclination and/or version with a concurrent proximal femoral osteotomy to correct valgus/varus and/or rotational alignment. We assessed functional scores, radiological paramenters, arthroplasty conversion rate, time interval before conversion to arthroplasty and other associated complications. Results. We identified 63 patients (64 hips) with a mean age of 29.2 years (range 14.3–51) at a mean follow-up of 10.1 years (range 5.1–18.5). The mean sourcil inclination postoperatively was 4.9. O. (range 1–12) compared to 24. O. (range 14.5–33) preoperatively. The mean Tonnis grade postoperatively was 2.2 (1–3) compared to 1.8 (range 1–2) preoperatively. At the last follow-up assessment, the mean Oxford Hip Score was 56 (range 60–47), Non-arthritic Hip Score was 71 (range 59–80) and UCLA activity score was 8 (range 5–10). There were 12 (18.8%) conversions to arthroplasty at a mean of 7.9 years (range 2.2–12.2) after surgery. Other associated complications include 1 sciatic nerve injury, 1 deep infection and 5 non-unions that required refixation. Discussion. Symptomatic acetabular dysplasia with concurrent proximal femoral deformity is difficult to treat. The use of combined pelvic and femoral osteotomies can optimise acetabular and femoral head alignment to improve pain and function with more than 4 out of 5 hips preserved at 10 years

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

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

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