Purpose: Treatment of femoral epiphysiolysis with major displacement remains a controversial subject. Open repositioning of the epiphysis via a lateral approach as proposed by Dunn allows nearly anatomic restitution but with a high rate of complications. We report our experience with open repositions via an anterior approach which has been more reliable in our hands.

Material and methods: During the last decade, we operated nine hips for epiphysiolysis with major displacement, using the anterior approach to spare the medial circumflex artery. External reduction was not attempted. Preoperative and residual displacement were evaluated using the Southwick technique and according to the position of the femoral head in relation to the Klein line. Early after surgery, a bone scintigram was obtained for all hips. We followed these patients to bone maturity, with a mean follow-up of four years.

Results: The early postoperative scintigrams did not reveal any case of insufficient uptake in the femoral head. Mean correction was 43° on the lateral view, with a mean preoperative displacement of 72°. Mean residual displacement after surgery was 23°. After repositioning, position of the epiphysis in relation to the Klein line was not significantly different from the position observed on the healthy side. Postoperatively, leg length discrepancy was 1 cm. At last follow-up, there have been no signs of osteonecrosis, chondrolysis or osteoarthritic degeneration. At mean 44 months follow-up, all of the patients have unlimited activities, including sports. Only one patient complained of mild climate-related pain.

Discussion: Compared with the lateral approach with trochanterotomy as proposed by Dunn, we have found the anterior approach technically easier and more reliable in terms of protecting the epiphyseal blood supply. The correction obtained, voluntarily preserving a certain degree of under-correction, associated with resection of a portion of the neck enables repositioning without risking vessel stress. Use of a stable internal fixation which allows early mobilisation would be an explanation of the absence of postoperative chondrolysis.

Conclusion: These results appear to be sufficiently encouraging to advocate this technique previously described by PH Martin in 1948.

Purpose: Twenty-one total hip arthroplasties after ace-tabular fracture were reviewed at a minimum two-year follow-up. The purpose of this analysis was to study operative difficulties and complications in implanting a total hip arthroplasty on a sequelar acetabulum.

Material and methods: Ten acetabula had been treated surgically and eleven orthopaedically. Mean time interval between the initial trauma and the arthroplasty was 14 years (range 2 – 36). The posteriolateral approach was used in thirteen cases and the anterolateral approach in eight. Osteosynthesis material was totally removed in two patients and partially in three. Arthrolysis was performed in one patient who had grade IV heterotopic ossifications. Most of the cups were hydroxyapatite coated uncemented cups; two cups were cemented in a Postel Kerboul ring.

Results: An autologous graft was required for nine of the eleven orthopaedically treated fractures versus two of the ten surgically treated fractures (p < 0 .05). Mean operative time was 136 minutes and mean blood loss was 1200cc. Postoperative complications included one superficial phlebitis, one infraperitoneal bladder wound, one superficial haematoma, one incomplete popliteal palsy, one dislocation and two heterotopic ossiications (1 Brooker I and 1 Brooker IV). At review, the mean Postel Merle d’Aubigné score was 16.5. Radiologically there was no evidence of loosening or defective fixation.

Discussion: The operative difficulty was basically encountered in the group of orthopaedically treated acetabular fractures due to the callus (protrusion of the femroal head into the ovalised acetabulum. For these cases, an autologous graft was indispensable for reconstruction or defect filling (82% of the cases) to avoid excessive medialisation of the cup. For the fractures treated surgically, the osteo-synthesis material was only removed when it prevented proper cup position. An autologous graft was used to fill defects (18%) (wall or roof necrosis). Cup insertion without cement is the rule for first-intention treatment in these young patients, the supporting ring being used when required for second-intention treatment.

Purpose: Among 80 surgical treatments for acetabular fracture, the Dana Mears approach was used in 15. The purpose of this study was to analyse functional and radiological outcome of these fractures at a mean follow-up of 41 months.

Material and methods: The AO classification was used for fractures of the acetabulum : 12 class B (80%) with five B1a2 five B2a1 and two B1a1, and three class C (20%). There was one deformed callus (B1a2) at 120 days Two patients had associated pelvic injuries, eight a hip dislocation, and two an initial sciatic palsy. There were also two osteochondral fractures of the femoral head. The Dana Mears approach was modified slightly in the anterior part passing in front of the tensor muscle to preserve innervation. The gluteal muscles were raised by trochanterotomy. The displacement, the head/ roof congruency and the head/acetabulum congruency were assessed according to the 1981 SOFCOT criteria on the initial x-rays (AP pelvis, oblique ala and obturator) and computed tomographies. The quality of the reduction was assessed with the Matta and Duquesnoy-Senegas criteria. Clinical results were assessed with the Postel Merle d’Aubigné (PMA) score.

Results: Radiographically, there was an anatomic reduction in 73.3% of the cases and perfect head/roof congruency in 80%. Functional outcome was excellent or good in 80% of the patients. Postoperative complications included 11 ossifications, and one transient sciatic paralysis. There was one late aseptic osteonecrosis of the femoral head.

Discussion: The functional prognosis of these fractures is significantly correlated with the quality of reduction (p < 0.05). The advantage of this approach is the direct access to the roof without disinsertion of the gluteal muscles from the iliac crest, allowing more rapid recovery (seven to eight months) of medius gluteus function. In principal drawback is the very high rate of ossifications (one patient required revision for arthrolysis).

Conclusion: The Dana Mears triradiate approach is an integral part of the surgical treatment of acetabular fractures, particularly for B1a2 and B2a1 fractures, but also for B1a1 transtectal fractures. Conversely, this approach is insufficient for reduction of type C fractures requiring and extensive access to the iliac wing and for surgery of deformed calluses where an endopelvic approach is indispensable to control the vessels.