Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

We evaluated growth and remodeling of the 21 hips after valgus osteotomy with rotational and sagittal components for hinge abduction in 21 patients (mean, 9.7 years) with Legg-Calvé-Perthes disease (LCPD) both clinically and radiologically. The type of osteotomy was determined by assessing the hinge movement three-dimensionally using preoperative gait assessment, 2-dimensional/3-dimensional computed tomography (2D/3D-CT), and intraoperative dynamic arthrography. The Iowa hip score averaged 66 (34 to 76) before operation and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiographic measurements revealed favorable remodeling of the femoral head and improved hip joint mechanics. Valgus osteotomy with rotational and sagittal components results in sustained improvement in symptoms and functions and beneficially influences remodeling of the hip. Preoperative gait assessment, 2D/3D-CT, and intra-operative dynamic arthrography are helpful for assessing the spatial features of the femoral capital hump and for determining the optimal congruent position of the hip

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.

Background

Femoral neck nonunion is a challenging problem. If it is not treated properly, it will be ended with a catastrophe because the victims are younger and active patients and missing hip joint will result in a handicapped like person. If the head is viable, the best treatment is valgus osteotomy. In the original technique, site of nonunion was not explored but in our technique, there is exploration and cleaning of nonunion site and after reduction of fragments, fixation and subtrochanteric osteotomy were done.

It is very difficult to perform total knee arthroplasty (TKA) for severe varus bowing deformity of femur. We performed simultaneous combined femoral supra-condyle valgus osteotomy and TKA for the case had bilateral varus knees with bowing deformity of femurs.

Introduction and Aims: This prospective study was conducted in our institution to evaluate the effect of valgus osteotomy in the treatment of neglected intracapsular fracture of neck of femur in younger patients and the time since injury was three or more than three weeks. There were 20 patients, age ranging from 17 to 50 years.

Method: All the osteotomies were fixed by 120-degree double-angled blade plate.

Results: Eighteen fractures united. The average time for union was 14.4 weeks. Two went in to non-union, in which one of them had intra-articular penetration of the implant. Fourteen patients had noticeable lengthening of the limb. All the patients with united fractures were able to sit cross-legged, squat and do one leg stance.

We conclude by stating that this procedure should be considered in neglected intracapsular fractures of neck of femur in young adults as the head preserving procedure.

Conclusion: Patients with vertical shear fractures represent the spectrum of high-energy pelvic disruption. The functional outcome is significantly better in patients with APC III and LC III fractures when compared to vertical shear and complex acetabular fractures thus reflecting the severity of the injury. Secondary osteoarthritis and neurologic injury appear to contribute to the poor outcome of acetabular fractures. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic floor trauma.

Eighteen children between the ages of 6 and 12 years with unilateral non-united femoral neck fractures were treated by valgus intertrochanteric osteotomy with bone grafting between January 1995 and December 2000. Twelve fractures were judged as Pauwel 3, and 6 as Pauwel 2, and 5 children had avascular necrosis in addition to non-union. The initial treatment included internal fixation in 14 fractures, conservative treatment in 2 fractures, and no treatment in 2. The average interval from injury to osteotomy was 10 months (8-14 months). In each case we used a 90° child or adolescent hip plate modified by making an angle of 120 0 between the blade and shaft portions to simulate an adult Osteotomy plate. All fractures healed after osteotomy and bone grafting; the average time to radiological union was 12 weeks (8-24 weeks). At an average follow-up of 3.5 years (2-6 years), 15 cases were rated good, 2 fair, and 1 poor based on Ratliff’s criteria. Valgus osteotomy with bone grafting provided successful results in treatment of non-united femoral neck fractures in children, even in the presence of avascular necrosis

Femoral head deformity with flattening and lateral protrusion can occur secondary to epiphyseal dysplasia or avascular necrosis of any aetiology in childhood. This causes painful impingement of the lateral femoral head on the acetabular lip, a phenomenon known as hinge abduction. We aimed to review our experience of valgus extension osteotomy in the treatment of hinge abduction in children and young adults with avascular necrosis. Twenty patients undergoing valgus osteotomy for hinge abduction performed by a single specialist were clinically and radiologically reviewed. The aetiology was Perthes disease in 16 patients and treatment of DDH in 4 patients. The indication for the procedure was pain and limited abduction. The mean follow-up was 4.5 years. Patients were assessed using modified Iowa hip scores at final follow-up. The procedure corrected some leg shortening and improved the abduction range of the affected hip. Overall 80 % of patients did well. The mean Iowa hip score in Perthes group was 84 at final follow-up. Four patients preoperatively had cysts/ defects in their femoral head. These were seen to fill up during their postoperative follow-up. Poorer outcome was associated with preoperative hip stiffness and surgery before stabilisation of the avascular process. Conclusion: Valgus osteotomy is an effective procedure for relieving hinge abduction with associated additional benefits including improvement of leg shortening and improvement in hip abduction. The procedure should be avoided in stiff hips

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Purpose: The current literature lacks a truly comprehensive examination of the use of a valgus osteotomy to treat osteonecrosis of the femoral head and Perthes disease in the pediatric and adolescent population. Owing to the severity of the pathology, a retrospective examination of the success of valgus osteotomies in treating avascular necrosis and Perthes disease in children and adolescents is warranted.

Method: Twenty-four patients with diagnosis of osteo-necrosis of the femoral head or Perthes disease treated between 1995 and 2007 with a proximal femoral valgus osteotomy were identified. The causes of avascular necrosis were Perthes (N=14, 60.9%), slipped capital femoral epiphyses, (N=4, 17.4%), femoral neck fracture (N=2, 8.7%), hip septic arthritis (N=2, 8.7%) and developmental delays and idiopathic osteonecrosis (N=1, 4.3%). The average age of receiving a femoral valgus osteotomy was 10± 3.6 years. The average age at follow-up was 12.2± 4 years, mean time of follow-up from the initial valgus osteotomy to last assessment was 23± 15.3 months.

Results: Postoperative pain improved significantly compared to preoperative pain (p=.002). Seventy five percent of patients (n=9) who had limitations in their daily activities preoperatively reported that they no longer experienced them after the treatment. External rotation (p=.005) and abduction (p=.003) improved significantly at follow up. Postoperative Ficat & Arlet classification was significantly better when compared to the classification before valgus osteotomy (p=0.007). Univariate analysis showed that sixty percent of patients (n=6) who had Perthes had improved in their Ficat & Arlet stage whereas one (14.3%) patient with a different diagnosis improved (p=.082). Complications from the surgery were reported in 5 of the 23 (21.7%) cases.

Conclusion: The results of this study suggest that proximal femoral valgus osteotomy is a safe and effective treatment method for osteonecrosis of the femoral head in the pediatric population. Perthes patients improved their femoral head shape more than all other etiologies; there was a trend toward statistical significance in this change. Proximal femoral valgus osteotomy may improve pain and activity limitations in children with osteonecrosis of the femoral head. It is also effective at improving range of motion and femoral head x-ray appearance of the femoral head for these children.

Introduction: The results of high tibial osteotomy tend to deteriorate over time. Consequently, a certain percentage of these patients will ultimately undergo TKR for the symptomatic treatment of the osteoarthritis of their knees. High tibial osteotomy, on the other hand, produces anatomic alterations around ipsilateral knee joint, that might bring about technical difficulties during the performance of TKR procedure. One of these difficulties has to do with the alteration of relationship between tibial anatomic axis and ipsilateral plateau.

Aim: The radiographic evaluation of the alteration of the relative position of the tibial medullary canal with respect to the ipsilateral plateau, after high tibial, closed-wedge osteotomy, with stable fixation.

Material – Method: For this aim, we studied 49 knees (in 45 patients), that had undergone high tibial valgus osteotomy, between 1990 and 1997, in our Department. The relative change of tibial anatomic axis was determined by calculating the index of “tibial condylar offset” in the AP view of each knee during three follow up examinations done at the direct post operative period, three months post operatively and at least one year post operatively.

Results: There was a definite tendency of medialization of the tibial anatomic axis post operatively (and, consequently, of the tibial medullary canal) with respect to the centre of the ipsilateral plateau. This was in direct proportion to the degree of valgus correction. The mean percentage of post operative alteration of “tibial condylar offset”, in comparison to its preoperative value, was 19%.

Conclusions: The insertion of a stemmed tibial implant, in a knee that has previously undergone high tibial osteotomy, through the centre of the tibial plateau runs a certain risk of abutment on the lateral cortex, due to the medialization of the tibial medullary canal with respect to the centre of tibial plateau. The above observations show the importance of a thorough pre-op plan of every TKR procedure that has been preceded by high tibial osteotomy

Valgus extension osteotomy (VGEO) is a salvage procedure for ‘hinge abduction’ in Perthes’ disease. The indications for its use are pain and fixed deformity. Our study shows the clinical results at maturity of VGEO carried out in 48 children (51 hips) and the factors which influence subsequent remodelling of the hip. After a mean follow-up of ten years, total hip replacement has been carried out in four patients and arthrodesis in one. The average Iowa Hip Score in the remainder was 86 (54 to 100). Favourable remodelling of the femoral head was seen in 12 hips. This was associated with three factors at surgery; younger age (p = 0.009), the phase of reossification (p = 0.05) and an open triradiate cartilage (p = 0.0007). Our study has shown that, in the short term, VGEO relieves pain and corrects deformity; as growth proceeds it may produce useful remodelling in this worst affected subgroup of children with Perthes’ disease

Introduction: We compared femoral head resection (FHR) and traction with femoral head resection and valgus osteotomy (the McHale procedure), in order to determine the effectiveness of these two procedures in the treatment of painful hip subluxation in severely involved individuals with cerebral palsy.

Methods: Retrieval of demographic patient information, operative technique, post-operative complications, and migration of the femoral shaft was obtained from a retrospective review of charts and radiographs. Caregivers were then contacted by telephone and queried regarding post-operative changes in pain, sitting tolerance, and hygiene as well as overall satisfaction with surgical intervention.

Results: 27 patients, 36 hips comprise the study cohort; 26 patients have quadriplegia, one has diplegia and is the only patient who is ambulatory. 16 patients underwent FHR, 11 patients underwent McHale procedures. The average age of surgery was 19 years, range from 8 to 42 years. Average follow-up was 3.4 years from time of surgery. The majority of patients (17) had not undergone reconstructive hip surgery because they were lost to orthopedic follow-up, and missed the opportunity to have the hip relocated before femur was significantly deformed. Six patients had painful hips despite previous attempts at surgery, three patients refused reconstructive surgery, and one patient was not deemed medically stable enough for reconstructive surgery.

Post-operative complications were numerous and included skin breakdown, wound dehiscense, hardware infection or failure, heterotopic ossification, and death. The complication rate was significantly higher in patients who had undergone FHR and traction (13/16) compared with the patients who had a McHale procedure (3/11). The average length of hospitalization was almost twice as long for the FHR group (7 days) as for the McHale group (4 days). Telephone surveys of caregiv-ers often demonstrated equivalent overall satisfaction with surgery in both groups with average scores of 8/10 for the FHR and 7.6/10 for the McHale group (on a scale from 1 to 10, 10 being the most satisfied). Only two of the respondents (one from the FHR group, one McHale) we contacted regretted having had surgery.

Caregivers felt that post-operatively pain relief was achieved in almost all patients. The average time to achieve a more pain-free state was three months. Sitting tolerance improved variably between individual patients, while few caregivers felt that hygiene improved after surgery, although they also felt that hygiene had not been a significant problem pre-operatively.

Purpose

To evaluate the clinical and radiologic midterm results of rotational acetabular osteotomy (RAO) in incongruent hip joints.

Purpose: It was demonstrated in 1986 that to obtain a good radioclinical result at 10–13 years after valgus tibial osteotomy for the treatment of medial femorotibial osteoarthritis that the frontal valgus at this follow-up had to be 3–6°. In 1995, it was demonstrated that the side of deterioration in knees initially aligned between 2° varus and 2° valgus or with genu valgum (≥ 3° valgus) depended on the tibiofemoral axis: a positive index (tibial torsion greater than femoral torsion) favouring medial femorotibial deterioration and progressive varisation, and a negative index favouring lateral femorotibial deterioration and progressive valgisation. Can the post-osteotomy valgus be modified by the tibiofemoral index and prevent obtaining ideal correction at 10–13 years?

Material and methods: Forty-five knees with femortibial deterioration of the medial compartment were treated between 1987 and 1990 by tibial medial opening osteotomy for valgisation. Functional outcome in the 45 knees was assessed at a mean follow-up of 11 years (range 10–13 years). Postoperative frontal axis after healing and frontal axis at last follow-up was measured by goniometry in the standing position for all knees. A scan in the torsion position was obtained for 36 knees to measure the tibiofemoral index.

Results: At maximum follow-up, outcome was good in 58% of the knees, fair in 24%, and poor in 18%, differences which were not statistically different. Frontal axis changed with time. Among the 36 knees which had been realigned correctly (3–6° valgus) after healing, four exhibited an increase in valgus beyond 6° and five lost valgus passing below 3°. But ideal valgus was achieved at last follow-up for three of five knees which had been undercorrected, Among the 38 knees for which a torsion scan was available, 33 were correctly realigned postoperatively and 22 were well aligned at last follow-up. There was no statistical difference between knees with good, fair, or poor outcome among the 33 knees well corrected postoperatively (3–6° valgus). There was however a statistical difference between the good (64%), fair (27%), and poor (9%) functional results among knees with ideal valgus at last follow-up (p = 0.03).

The variation between the postoperative and last follow-up goniometry data exhibited a statistical correlation with the tibiofemoral index (p = 0.0005). If the index was less than 13°, most of the knees showed an increase in valgus (13 out of 19 knees); if valgus was greater than or equal to 13°, valgus was lost (for 12 of 19 knees).

Conclusion: To have the best chance of obtaining a good functional result 10 to 13 years after tibial osteotomy for valgisation, the valgus at this follow-up must be between 3° and 6°. But to achieve this valgus, the postoperative valgus must be modulated in relation to the tibiofemoral index. For an index ≥ 13°, the postoperative valgus should be pushed towards 6°; for an index < 13°, valgisation should aim at achieving a 3° postoperative valgus or less.

Introduction. We assessed the role of four different High Tibial osteotomies (HTOs) for medial compartment osteoarthritis of knee (MCOA): Medial Opening Wedge High Tibial Osteotomy (MOWHTO), Focal Dome Osteotomy with Ilizarov Fixator (FDO-I), intra-articular, Tibial Condylar Valgus Osteotomy with plating (TCVO-P) and intra-articular plus extra-articular osteotomy with Ilizarov(TCVO-I); in correcting three deformity categories: primary coronal plane varus measured by Mechanical Axis deviation (MAD), secondary intra-articular deformities measured by Condylar Plateau Angle (CPA) and Joint Line Convergence Angle (JLCA), and tertiary sagittal, rotational and axial plane deformities in choosing them. Materials and Methods. We retrospectively studied HTOs in 141 knees (126 patients). There were 58, 40, 26, and 17 knees respectively in MOWHTO, FDO-I, TCVO-P and TCVO-I. We measured preoperative (bo) And postoperative (po) deformity parameters. Results. Average age was 56.1, average follow-up was 44.6 months. Mean bo-MAD in MOWHTO, FDO-I, TCVO-P, and TCVO-I were 8.8, −14.7, −11.5, −30.8% respectively. po-MAD was close to Fujisawa point in all except TCVO-P (45.2%). CPA corrected from −4.9° to −1.4° (p=0.02)and JLCA from 5.6° to 3.2° (p=0.001); CPA was better corrected by Intra-articular osteotomies (p=0.01). Conclusions. MOWHTO corrects isolated mild primary varus deformities (bo-MAD≥ 0%). Primary varus (bo-MAD= −25% −0%) with associated tertiary sagittal, rotational, or axial deformities, without secondary intra-articular deformities needed FDO-I. Primary varus (bo-MAD= −25% −0%) with secondary intra-articular deformities, without tertiary deformities, corrected well with TCVO-P. TCVO-I corrects severe primary varus (bo-MAD< −25%) with large deformities in secondary and tertiary categories

We studied, clinically and radiologically, the growth and remodelling of 21 hips after valgus femoral osteotomy with both rotational and sagittal correction for hinge abduction in 21 patients (mean age, 9.7 years) with Perthes’ disease. The exact type of osteotomy performed was based on the pre-operative clinical and radiological assessment and the results of intra-operative dynamic arthrography. The mean IOWA hip score was 66 (34 to 76) before surgery and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiological measurements revealed favourable remodelling of the femoral head and improved hip joint mechanics. Valgus osteotomy, with both rotational and sagittal correction, can improve symptoms, function and remodelling of the hip in patients with Perthes’ disease

Aims

Perthes' disease (PD) is a relatively rare syndrome of idiopathic osteonecrosis of the proximal femoral epiphysis. Treatment for Perthes' disease is controversial due to the many options available, with no clear superiority of one treatment over another. Despite having few evidence-based approaches, many patients with Perthes' disease are managed surgically. Positive outcome reporting, defined as reporting a study variable producing statistically significant positive (beneficial) results, is a phenomenon that can be considered a proxy for the strength of science. This study aims to conduct a systematic literature review with the hypothesis that positive outcome reporting is frequent in studies on the treatment of Perthes' disease.

Aims

The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.