Aims. The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis. Patients and Methods. A total of 59 young adults with spastic cerebral palsy, with a mean age of 26 years (. sd.  3), were enrolled into the study in which their gait was compared with an evaluation that had taken place a mean of 12 years (. sd.  2) previously. At their visits during adolescence, the children walked with excessive flexion of the knee at initial contact and surgical or therapeutic interventions were not controlled between visits. Results. Based on the change in flexed-knee gait over approximately ten years, improvements were seen in increased Gait Deviation Index (p < 0.001) and decreased flexion of the knee at initial contact (p < 0.001). Greater popliteal angle (p < 0.001), reduced Gross Motor Function Measure section D (p = 0.006), and reduced speed of gait (p = 0.007) suggested a mild decline in function. Quality-of-life measures showed that these patients fell within normal limits compared with typical young adults in areas other than physical function. Conclusion. While some small significant changes were noted, little clinically significant change was seen in function and gait, with gross motor function maintained between adolescence and young adulthood. Cite this article: Bone Joint J 2018;100-B:549–56

We report the radiological outcomes, and short-term clinical results, of 47 periacetabular osteotomies undertaken through both the traditional bikini incision, and a minimally invasive approach. 47 periacetabular osteotomies have been undertaken in 45 patients, by the senior author, between 2005 and 2013. There were 10 male and 35 female patients. The mean age at operation was 28.2 years. Since 2010 surgery has been performed through a 7-cm skin incision (31 hips), an incision coined as minimally invasive by Søballe et al when they described their trans-sartorial approach for acetabular surgery. Clinical data was collected prospectively; primary outcome measures included the young adult hip score and the hip disability and osteoarthritis outcome score. Pre- and post-operative radiographs were analysed for achieved acetabular reorientation. At the time of follow-up the median young adult hip score had improved significantly from pre-operative values. Mean scores were 35.4 pre-operatively, and 64.25 post-operatively. Improvement in the anterior and lateral centre-edge angle was 32 and 32.9 degrees respectively through a traditional incision, and 27.1 and 30 degrees through the minimally invasive approach (p>0.05). No major complications occurred in any patient. Four patients complained of lateral cutaneous nerve hypoaesthesia, in two patients there was delayed union of the pubic osteotomy and in one non-union. Two patients have gone on to total hip replacement. The minimally invasive approach is safe and allows for accurate reorientation of the acetabulum whilst minimizing tissue damage. The scar is cosmetically appealing to patients, especially the predominantly female group treated with this condition. We did not see the evidence of reduced surgical stay that has been reported by other groups utilizing a minimally invasive approach. Level of evidence: II

Purpose. To determine (i) the relationship between osteonecrosis and hip function, physical function and quality of life in adolescents and young adults treated for DDH; and (ii) how affected children change over 10 years. Methods. We included 109 patients (mean age 19.2 ± 3.8 years) with osteonecrosis and 30 age-matched patients without osteonecrosis following DDH treatment between 1992–2005. All completed valid patient-reported outcome measures to quantify their hip function (maximum score 100); physical function (maximum score 100); and quality of life (maximum score 1). Of these, 39 patients had been followed prospectively since 2006, allowing quantification of within-person changes over time. We graded all radiographs for severity of osteonecrosis, residual dysplasia, subluxation and osteoarthritis. We determined the association between patient-reported outcomes and radiographic severity of osteonecrosis using mixed-effects regression analysis; and repeated-measures analysis of variance to quantify person changes over time. We adjusted for age, prior operations and acetabular dysplasia. Results. In 135 patients (168 hips) with and without osteonecrosis, mean differences (95% confidence interval) in hip function, physical function and quality of life were 0.75 (−6.67, 8.17), −1.97 (−17.58, 13.60) and −0.05 (−0.91, 0.36), respectively. Adjusted analysis showed no difference in these outcomes based on radiographic severity of osteonecrosis (p> 0.05). Of 39 patients followed over 10 years, 4 had undergone hip arthroplasty. For the remainder, mean changes (95% confidence interval) in hip function, physical function and quality of life from baseline to current assessment were 7.18 (−2.11, 12.26), −2.11 (−15.47, 11.25), −0.03 (−0.11, 0.05), respectively. Radiographic severity of osteonecrosis was not correlated with changes in patient-reported outcomes over time. Conclusion. Osteonecrosis secondary to DDH remains relatively benign even in young adulthood. Overall, patients demonstrated good hip function, physical function and normal quality of life. Equally, children maintained such high levels over the course of 10 years if their hip survived

Aims

This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes’ disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system.

Purpose of study. This study is to determine the survival and outcomes of the Birmingham Interlocking Triple Pelvic Osteotomy. A dysplastic hip predisposes to early arthritis. The Triple Pelvic Osteotomy (TPO) is a joint-preserving option for the treatment of young adults with hip dysplasia. The long term success of the procedure is not known. Patients and methods. The senior author has been performing Birmingham Interlocking Triple Pelvic Osteotomies for 18 years. The outcomes of the first 100 patients (117 TPOs) were reviewed using postal questionnaires, telephone interviews and radiograph review. The primary outcome measure of the study was the Kaplan—Meier survival curve for the TPO. Hip replacement or resurfacing were taken as failure points. The Oxford Hip Score (OHS) and University of California, Los Angeles (UCLA) score were used as secondary outcome measures for the surviving osteotomies. The pre-and post-operative acetabular index and centre-edge angles were measured from surviving radiographs. Results. Follow-up was 93% for survivorship. The mean age at operation was 31 years (range of 7 to 57 years). The mean pre- and post-operative centre-edge angles were 19°and 50° and acetabular indices were 23° and 2°. The Kaplan-Meier survival curve demonstrates that the 10, 15 and 18-year survival rates are 76%, 57% and 50% respectively. Survival was 89% if the osteotomy was performed before 20 years of age. The median UCLA score was five (inter-quartile range three to seven). Median OHS was 41 (inter-quartile range 24 to 46). The UCLA and OHSs show that those with surviving osteotomies tend to have good hip function. Conclusions. The Birmingham Interlocking Pelvic Osteotomy provides a valuable tool to preserve dysplastic hip function and delay arthroplasty surgery, particularly in the younger patient. It is best performed early before arthritis sets in

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-lateralising oblique 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 minimally invasively 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 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-centre-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 were no cases of avascular necrosis. 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

The atlas of Greulich and Pyle for skeletal maturity and epiphyseal closure is widely used in many countries to assess skeletal age and to plan orthopaedic surgery. The data used to compile the atlas were collected from institutionalised American children in the 1950s. In order to determine whether the atlas was relevant to subSaharan Africa, we compared skeletal age, according to the atlas, with chronological age in 139 skeletally immature Malawian children and young adults with an age range from 1 year 11 months to 28 years 5 months. The height and weight of each patient were also measured in order to calculate the body mass index. The skeletal age of 119 patients (85.6%) was lower than the chronological age. The mean difference was 20.0 ± 24.1 months (t-test, p = 0.0049), and the greatest difference 100 months. The atlas is thus inaccurate for this group of children. The body mass index in 131 patients was below the normal range of 20 to 25 kg/m. 2. . The reasons for the low skeletal age in this group of children are discussed. Poor nutrition and chronic diseases such as malaria and diarrhoea which are endemic in Malawi are likely to be contributing factors. We did not find any correlation between the reduction in body mass index in our patients and the degree of retardation of skeletal age

Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

Aims

We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up.

Aims

The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis.

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels.

The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services.

The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery.

Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients.

The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity.

The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

Cite this article: Bone Joint J 2015;97-B:1435–40.

In 1994 a cerebral palsy (CP) register and healthcare programme was established in southern Sweden with the primary aim of preventing dislocation of the hip in these children.

The results from the first ten years were published in 2005 and showed a decrease in the incidence of dislocation of the hip, from 8% in a historical control group of 103 children born between 1990 and 1991 to 0.5% in a group of 258 children born between 1992 and 1997. These two cohorts have now been re-evaluated and an additional group of 431 children born between 1998 and 2007 has been added.

By 1 January 2014, nine children in the control group, two in the first study group and none in the second study group had developed a dislocated hip (p < 0.001). The two children in the first study group who developed a dislocated hip were too unwell to undergo preventive surgery. Every child with a dislocated hip reported severe pain, at least periodically, and four underwent salvage surgery. Of the 689 children in the study groups, 91 (13%) underwent preventive surgery.

A population-based hip surveillance programme enables the early identification and preventive treatment, which can result in a significantly lower incidence of dislocation of the hip in children with CP.

Cite this article: Bone Joint J 2014; 96-B:1546–52.

Proximal femoral resection (PFR) is a proven pain-relieving procedure for the management of patients with severe cerebral palsy and a painful displaced hip. Previous authors have recommended post-operative traction or immobilisation to prevent a recurrence of pain due to proximal migration of the femoral stump. We present a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35 male, 28 female), none of whom had post-operative traction or immobilisation.

A total of 71 hips (89.6%) were reported to be pain free or to have mild pain following surgery. Four children underwent further resection for persistent pain; of these, three had successful resolution of pain and one had no benefit. A total of 16 hips (20.2%) showed radiographic evidence of heterotopic ossification, all of which had formed within one year of surgery. Four patients had a wound infection, one of which needed debridement; all recovered fully. A total of 59 patients (94%) reported improvements in seating and hygiene.

The results are as good as or better than the historical results of using traction or immobilisation. We recommend that following PFR, children can be managed without traction or immobilisation, and can be discharged earlier and with fewer complications. However, care should be taken with severely dystonic patients, in whom more extensive femoral resection should be considered in combination with management of the increased tone.

Cite this article: Bone Joint J 2014; 96-B:701–6.

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Cite this article: Bone Joint J 2013;95-B:271–8.

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Cite this article: Bone Joint J 2013;95-B:135-41.

In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most.

The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p < 0.0001). The mean changes in centre edge angle and Sharp’s angle were 72° (56° to 87°; p < 0.0001) and 12.3° (9° to 15.6°; p < 0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

We have investigated whether early anatomical open reduction and internal fixation (ORIF) reduces the incidence of complications of fracture of the femoral neck in children, including avascular necrosis, compared with closed reduction and internal fixation (CRIF). We retrospectively reviewed 27 such fractures (15 type-II and 12 type-III displaced fractures) in children younger than 16 years of age seen in our hospital between February 1989 and March 2007. We divided the patients into three groups according to the quality of the reduction (anatomical, acceptable, and unacceptable) and the clinical results into two groups (satisfactory and unsatisfactory). Of the 15 fractures treated by ORIF, 14 (93.3%) had anatomical reduction and reduction was acceptable in one. Of the 12 treated by CRIF, three (25.0%) had anatomical reduction, eight had acceptable reduction (66.7%), and one (8.3%) unacceptable reduction. Of the 15 fractures treated by ORIF, 14 (93.3%) had a good result and one a fair result. Of the 12 treated by CRIF, seven (58.3%) had a good result, two (16.7%) a fair result and three (25.0%) a poor result. There were seven complications in five patients.

ORIF gives better reduction with fewer complications, including avascular necrosis, than does CRIF in fractures of the femoral neck in children.