Purpose: Adolescents and adults with decentered hip joints in DDH frequently suffer from moderate to severe pain frequently or exclusively during daily physical activity or sports activity. Especially power walking, running, walking downhill provoke pain in the thigh area.

Materials and Methods: Since 1993 we perform a triple pelvic osteotomy according to Tönnis in patients with typical DDH - related clinical findings and overlook 138 operated patients. The operation is not performed in hips with moderate or severe degenerative changes. Depending on the hip joint geometry in some cases of a decentered hip joint an osteotomy of the proximal femur is performed additionally. Concise patient questionnaires, special clinical tests and different types of radiographic examinations lead to the correct indication.

Results: In this special report we present the pre- and postoperative clinical findings, conventional x-rays, CT scans and MRI specific findings of 12 dysplastic, decentered hip joints from our patient collective of 110 patients. All six patients were female, the mean age at the time of the procedure was 33 years. At time of the last follow up examination all patients were satisfied with the postoperative result and no hip had to be converted to a total hip arthroplasty. The retrospective examination shows that in patients with a typical case history, distinct clinical findings and DDH signs in conventional x-rays the mentioned procedure can be correctly indicated by plain x-ray studies. In complex cases (e. g.: decentered hip joints, reduced acetabular antever-sion or reduced femoral antetorsion, tears of the labrum acetabulare) additional studies such as CT-Scans, MRI Scans or MR Arthrographies need to be performed. In suspected deformities of the proximal femur standard conventional x-rays to evaluate the femoral antetorsion (“Rippstein”) or axial projections (“Lauenstein”) to identify “bump” osteophytes have to be performed.

Conclusion: The classification of DDH-related symptoms is correctly done by an exact clinical examination in combination with the above mentioned conventional x-rays, CT-Scans (eventually combined with a 3D reconstruction), MRI-Scans and MRI-arthrographies. In this presented small patient collective no hip had to be converted to a total hip arthroplasty in spite of the fact that all hips were decentered.

Aims: A polyethylene free, metal on metal acetabular system (Hofer-Imhof cup; Lubrimet metal on metal articulation made of CoCr-forge alloy) was designed in an effort to improve total hip arthroplasty longevity. This study was undertaken to review the clinical performance of this implant and to determine if acetabular loosening or revision and wear and osteolysis were prevalent.

The long term results (mean follow up period 110 months) are presented in this study.

Methods: In this prospective, randomized study a minimum of 90 months follow up results involving the first 100 implanted metal liner total hip arthroplasties are presented. The mean follow up was 110 months. Between April 1995 and November 1996 ninety-eight patients (100 hips) had a total hip replacement consisting of a titanium cementless self reaming, parabolic cup, a cementless titanium stem and the Lubrimet® metal on metal articulation.

Two acetabular and one femoral component had to be revised due to aseptic loosening without showing macroscopic evidence of metallosis and no histological evidence of excessive metal wear. One patient hat to be revised by a complete change of the total hip (acetabular component and stem) showing histologic evidence of a metal induced hyperergic immunologic reaction. One patient presented with a broken neck of the stem and had to be revised by stem exchange.

As a none device related orthopedic complication one acetabular component required revision surgery due to a periprosthetic fracture.

Conclusions: The long term results of the Hofer-Imhof Lubrimet®Metal-on-metal articulation are satisfying and so the system represented a viable alternative for total hip arthroplasty in younger higher demand patients in the past. Due to the possible development of a hyperergic immunologic reaction to the metal on metal articulation and the availibility of a ceramic on ceramic articulation we do not implant this liner anymore.

Objectives: We evaluated the results of a femoral shortening z-osteotomy in patients who underwent THA due to high dislocation of the hip.

Methods: From 8/1997 until 11/2003 we performed THA in combination with a z-shaped subtrochanteric shortening osteotomy in 6 patients (4 females, 2 males) with high dislocation of the hip. In all cases for the reconstruction of the acetabulum a cementless press fit component was implanted, in 5 cases in combination with an acetabular roof reconstruction by autograft. For the femoral component we used standard titanium cementless stems in 5 cases, in one case a revision model. The z-shaped shortening osteotomy was fixed by titanium cerclages in all cases.

Results: Postoperative complications (nerve lesions, THA dislocations, non union) could not be observed in the clinical and radiological follow up examinations 6 to 72 months postoperatively. In all cases femoral union at the area of the shortening osteotomy could be observed 3 months postoperatively.

Conclusion: Femoral shortening z-osteotomy in THR is a safe technique in patients with high total dislocation of the hip, leading to satisfactory postoperative results.

Introduction: Pressure relief is essential in treating plantar neuropathic ulcers in the diabetic foot. This can be achieved in an excellent way by total contact casting, therefore especially the longstanding, problematic ulcer-nonresponding to common methods (such as insoles, special shoeware etc,) is adressed by this method.A second indication for total contact casting is presented by the acute stage of neuroosteoarthropathy (Charcot’s foot) with or without ulceration. Methods: 19 patients with diabetes type II were treated by total contact casting. The mean age was 55 (46–75) years. Only 4 out of 19 patients were women We found plantar ulcers 12 of the 19 cases, 7 cases had no ulcer, but a Charcot’s foot stage I was present. Most ulcerations were classified as Wagner stage II and III without any sign of infection. The mean duration of casting was 8 (1–22) weeks. All patients were treated in an outpatient-clinc, no admission to the hospital was needed. The method of casting is exactly presented. Results: Complications were seen in only one of the cases due to skin problems.8 of the 12 ulcers healed completely under casting, 4 healed by a mean of 4 weeks later due to further treatment after casting. All the cases of osteoathropathy could be treated until reaching stage II without any progression of the foot-deformity. Conclusions: The total contact cast gives us the possibility to treat patients with plantar neuropathic ulceration and/or Charcot’s foot stage I with the advantage of good plantar pressure reduction and upkeeping the patient’s full mobility at the same time.

Aims: A polyethylene free, metal on metal acetabular system (Hofer-Imhof cup; Lubrimet¨ metal on metal articulation made of CoCr-forge alloy) was designed in an effort to improve total hip arthroplasty longevity. This study was undertaken to review the clinical performance of this implant and to determine if early ace-tabular loosening or revision and wear and osteolysis were prevalent. The mid term results (mean follow up period 62,7 months) are presented in this study. Methods: In this prospective, randomized study a minimum of 55 months follow up results involving the þrst 100 implanted metal liner total hip arthroplasties are presented. The mean follow up was 62,7 months. Between April 1995 and November 1996 ninety-eight patients (100 hips) had a total hip replacement consisting of a titanium cementless self reaming, parabolic cup, a cementless titanium stem and the Lubrimet¨ metal on metal articulation. 98 patients (100 hips) had complete clinical and radiographic data 55 to 89 months after the operation. One acetabular and one femoral component had to be revised due to aseptic loosening without showing macroscopic evidence of metallosis and no histological evidence of excessive metal wear. As a none device related orthopedic complication one acetabular component required revision surgery due to a peri-prosthetic fracture. Conclusions: The mid-term results of the Hofer-Imhof Lubrimet¨Metal-on-metal articulation are encouraging and so the system may represent a viable alternative for total hip arthroplasty in younger higher demand patients.

Aims: To describe a new, simple method of classiþcation for ossiþcations after total hip arthroplasty situated in the anterior, intertrochanteric area. (ÒAIOÒ). Methods: Axial (ÒLauensteinÒ) radiographs of 209 patients after THA using the transgluteal approach were retrospectively analysed regarding the occurrence AIO. These formations are situated in the anterior intertrochanteric region, therefore the major part of these ossiþcations cannot be identiþed by the well known and accepted methods of e.g. Brooker which rely on one anterior-posterior radiograph. By dividing the anterior intertrochanteric region in zones a simple method of classiþcation was developed. According to our method AIO can be classiþed by their appearance and their extent: Grade I describes bony islands without connection to the femoral bone, Grade II ossiþcations are clip or shield like formations without connection to the femoral bone, Grade III ossiþcations appear as solid exostoses in contact with the femoral bone. Results: 97 of 209 patients developed an AIO (48,4%), 12 ossiþcations were classiþed as Grade I (12,4%),3 ossiþcations were classiþed as grade II (3,1%), 82 out of 209 patients developed an AIO Grade III. 27 (13%) of the patients developed solid ossiþcations situated strictly in the anterior intertrochanteric region, thus solely veriþable by an axial radiograph. Conclusions: In our patient collective 13% developed a solid ossiþcation only veriþable by an axial radiograph due to a strictly anterior intertrochanteric location. By using the well accepted methods of classiþcation relying only on one single ap radiograph (Brooker, Arcq, deLee) these formations would not have showed up in our study. Our method of classiþcation is simple and can be easily combined with the classiþcations mentioned above.

Aims: Evaluation of the potential of blood salvage in osteotomy of the pelvis after T…NNIS, using a special anaesthetic technique (Adrenalin Augmented Hypotensive Epidural Anaesthesia, AAHEA). Methods: From 1997 to 2002 thirtynine patients had surgery. 25 patients (4 men, 21 women; average age 33 yrs) had AAHEA and 14 (3 men, 11 women; average age 32 yrs) had standard anaesthesia. Autologous blood donation, intra-operative and postoperative cell saving was evaluated. The haemoglobine proþle, evidence of haematoma and the time needed for the operation were noted. In both groups 2 patients had additional surgery with intertro-chanteric osteotomy. Results: In this series haemoglobine was statistically signiþcant higher with AAHEA (p< 0,05) after a period of 7–10 days, and lower total usage of blood donation (p< 0,05) was evident. Amount of blood, collected with the cell saver intraoperatively: In the group with AAHEA 179 ml (± 155) versus standard-anaesthesia 935 ml (± 749); autologous blood donation: AAHEA-group 64% versus standard-group 77%. Conclusions: AAHEA is able to lower perioperative blood loss in major orthopaedic bone and joint surgery. This method leads to a remarkable reduction of the intra-operative blood loss and perioperative need of blood donation, autologous and homologous, further to a minimized risk of associated complications and lower costs.

DDH with or without previous treatment is the most frequent source of early hip OA in adolescents. Others are hip joint deformation following Legg-Calve-Perthes disease, slipped capital epiphysis or trauma. Secondary OA after rheumatoid arthritis, bacterial infection or as result of an hemophilic hip joint are relatively infrequent.

The choice of treatment depends on the type of the deformity and the severity of osteoarthritic changes. Osteotomies are favorably performed in adolescents. Arthrodesis is rarely accepted in this age group. In selected individuals THR is the matter of choice.

Pain, limping gait, restricted joint motion and sometimes clicking phemomena are the usual complains. Pain is usually aggravated by running and other sports activities.

Residual dysplasia of the hip with a spherical femoral head is best treated by a triple periacetabular osteotomy. The Bernese ostetomy of Ganz (3) and the triple osteotomy of Tönnis (9) are popular procedures. They mobilise an acetabular fragment, then reorient and stabilise the fragment in an optimal position. Internal fixation with screws provides stability and allows early mobilisation with partial weight bearing.

Chiari’s osteotomy is a supracetabular rotatory displacement osteotomy. Femoral head and joint capsule are medialised and covered by the osteomised iliac bone. The joint capsule in the weight bearing zone is transformed into fibrous cartilage by time. Congruent remodelling of the acetabular roof and fibrous tissue transformation into cartilage are biased by inproper height and orientation of the osteotomy (5). There is still an indication in severe DDH with subluxation of the femoral head and those with a severely deformed femoral head.

In pathomorphologies with aspherical femoral heads femoral osteotomies, usually valgus osteotomies, are required additionally in order to optimize the joint congruency

A dysplastic hip in a high dislocation and moderate to severe OA are contraindications.

Radiographic work up includes pelvic ap view and faux profil view. Assessment of the anterior and posterior acetabular rim indicate orientation of the acetabulum in terms of anteversion / retroversion. Orientation of the subchondral sclerosis over the femoral head is an indicator of femoral head coverage as CE-angle and AC-angle. 20°–30° abduction view in neutral rotation mimikes the postoperative acetabulum / femoral head relation. From CT-scans acetabular orientation ( ante-version / retroversion ), degenerative bone cysts, posteroinferior joint space and femoral head deformities and femoral neck osteophytes are depicted. Labrum pathology is dedectable by MRT and MRT-arthrography.

After treatment of DDH deformation of the femoral head and neck due to ischaemic necrosis develop in an incidence up to 20 %, depending on the method. Premature closure of the epiphyseal plate can also follow trauma, septic arthritis and Legg-Calve-Perthes disease. Most often an combination of acetabular dysplasia and coxa magna with short femoral neck and a high-standing greater trochanter are typical deformities. Specchiulli’s classification (8) is very helpful for deformations after avascular necrosis in DDH. Limping gait due to femoral shortening and insufficient strength of the abductor muscels are the major complains of adolescents. Symptoms exacerbate during walking of longer distances and restrict sports activities. Valgus osteotomy, Y-osteotomy, transfer of the greater trochanter alone or in combination with valgus osteotomy are appropiate methods to restore a better function and improve alignment of the mechanical axis to the knee joint. Femoral neck lengthening osteotomies (1,4) with distal-lateral transfer of the greater trochanter are advocated by several authors. Restoration of almost normal anatomy muscle function of the hip joint are realistic aims of these methods.

If the abductor muscel deficit is dominant and only a minor leg length discrepancy is in slight deformities, e.g. some Specchiulli’s type B2, we do not always need such complex procedures. Isolated transfer of the greater trochanter also improves the lever arm of the abductor muscles and therefore joint function, but does not influence leg length discrepancy. Disappearance of the Tren-delenburg-type gait is the most visible improvement of this procedure (7).

Total hip replacement (=THR) is rarely indicated in adolescents, but sometimes necessary for restoration of a almost normal quality of life. Especially in severe symptomatic OA after septic arthritis or trauma in some individuals remain only two options : arthrodesis or arthroplasty. Arthrodesis is a permanent solution for many years or even life time. Gait function is compromised remarkable (6) and specific compensatory mechanisms are adopted when walking. Excessive motion in the lumbar spine and ipsilateral knee provokes back and knee pain as well as osteoarthritic changes on the long run.

THR in young patients includes the risk of several revisions over life time , due to wear problems particularly in physically active individuals. A deficient acetabular bone stock as usual in severe acetabular dysplasia or poor bone quality after trauma or septic arthritis may compromize primary stability and secondary osteointegration. Nevertheless functional results and outcome (2) in terms of life quality are superior compared with various non-substituting procedures.