Aims.
Aims. This study analysed the clinical and radiological outcome of
anatomical reduction of a moderate or severe stable slipped capital
femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified
Dunn osteotomy) through the surgical approach described by
We present our experience of the modified Dunn
procedure in combination with a
Aims. We report a prospective cohort study of the midterm results of
surgical dislocation of the hip (according to Ganz) to perform resection
of osteochondromas involving the femoral neck in patients with multiple
hereditary exostoses (MHE). . Methods. Hip range of movement (ROM) was assessed pre- and post-operatively.
Patients’ judgment of post-operative reduction of pain, symptoms,
the Rand 36-item Health Survey (RAND-36) and complications were
analysed. . Results. Symptomatic osteochondromas of the femoral neck were removed
in 20 hips (17 patients) between 2007 and 2012. There were nine
men and eight women with a mean age at the time of surgery of 29
years (11 to 47). Mean follow-up was 46 months (26 to 73). At latest
follow-up, mean ROM was significantly increased in all directions.
Post-operatively the pain associated with the lesion was either
significantly decreased or non-existent. There was a significant
improvement in seven RAND-36 sub-domains. Encountered complications
in four patients were pseudoarthrosis of the trochanteric osteotomy,
traumatic separation of the trochanteric osteotomy, a pertrochanteric
femoral fracture and avasvular necrosis. Histological analysis revealed
osteochondromas in all hips. . Discussion. This study confirms the
Aims. The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union. Methods. We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union. Results. A total of 331 patients underwent PAO during the study period with 56 (15.4%) stress fractures: 46 fractures of the retroacetabular posterior column, five cases of ischiopubic stress fracture, and five cases of concurrent ischiopubic and retroacetabular stress fractures. Overall, 86% (48/56) healed without intervention. Univariate analysis revealed that stress fractures occurred more frequently in females (p = 0.040), older patients (mean age 27.6 years (SD 8.4) vs 23.8 (SD 9.0); p = 0.003), and most often with the use of the broad Mast chisel (28.5%; p < 0.001). Multivariable analysis revealed that increasing age (odds ratio (OR) 1.04; 95% CI 1.01 to 1.07; p = 0.028) and use of the broad Mast chisel (OR 5.1 (95% CI 1.3 to 19.0) compared to narrow
The use of joint-preserving surgery of the hip
has been largely abandoned since the introduction of total hip replacement.
However, with the modification of such techniques as pelvic osteotomy,
and the introduction of intracapsular procedures such as surgical
hip dislocation and arthroscopy, previously unexpected options for
the surgical treatment of sequelae of childhood conditions, including
developmental dysplasia of the hip, slipped upper femoral epiphysis
and Perthes’ disease, have become available. Moreover, femoroacetabular
impingement has been identified as a significant aetiological factor
in the development of osteoarthritis in many hips previously considered to
suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognised
earlier in the disease process, these techniques may be used to
decelerate or even prevent progression to osteoarthritis. We review
the recent development of these concepts and the associated surgical
techniques. Cite this article:
Several studies have reported the safety and efficacy of subcapital
re-alignment for patients with slipped capital femoral epiphysis
(SCFE) using surgical dislocation of the hip and an extended retinacular
flap. Instability of the hip and dislocation as a consequence of
this surgery has only recently gained attention. We discuss this
problem with some illustrative cases. We explored the literature on the possible pathophysiological
causes and surgical steps associated with the risk of post-operative
instability and articular damage. In addition, we describe supplementary
steps that could be used to avoid these problems.Aims
Materials and Methods
The primary source for the blood supply of the head of the femur is the deep branch of the medial femoral circumflex artery (MFCA). In posterior approaches to the hip and pelvis the short external rotators are often divided. This can damage the deep branch and interfere with perfusion of the head. We describe the anatomy of the MFCA and its branches based on dissections of 24 cadaver hips after injection of neoprene-latex into the femoral or internal iliac arteries. The course of the deep branch of the MFCA was constant in its extracapsular segment. In all cases there was a trochanteric branch at the proximal border of quadratus femoris spreading on to the lateral aspect of the greater trochanter. This branch marks the level of the tendon of obturator externus, which is crossed posteriorly by the deep branch of the MFCA. As the deep branch travels superiorly, it crosses anterior to the conjoint tendon of gemellus inferior, obturator internus and gemellus superior. It then perforates the joint capsule at the level of gemellus superior. In its intracapsular segment it runs along the posterosuperior aspect of the neck of the femur dividing into two to four subsynovial retinacular vessels. We demonstrated that obturator externus protected the deep branch of the MFCA from being disrupted or stretched during dislocation of the hip in any direction after serial release of all other soft-tissue attachments of the proximal femur, including a complete circumferential capsulotomy. Precise knowledge of the extracapsular anatomy of the MFCA and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posterior approach.
Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH. Patients were divided into four groups: A, adolescents who had not undergone surgery for DDH in childhood (25 hips); B, adolescents who had undergone surgery for DDH in childhood (20 hips); C, adults with DDH who had not undergone previous surgery (80 hips); and D, a control group of patients with healthy hips (70 hips). The radiological evaluation of digital anteroposterior views of hips included the Wiberg angle (centre-edge angle (CEA)), femoral head cover (FHC), medialization, distalization, and the ilioischial angle. Clinical assessment involved the Harris Hip Score (HHS) and gluteal muscle performance assessment.Aims
Methods
Anterior and posterior drawer tests of the shoulder are described. Their purpose is to detect anterior and posterior shoulder instability and thereby to eliminate some of the failures of operative treatment. Their value in assessing unidirectional and multidirectional instability both before and after operation is discussed.
Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a ‘trochanteric flip’ osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.
This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology.Aims
Methods
Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve. The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time.Aims
Methods
The modified Smith–Petersen and Kocher–Langenbeck
approaches were used to expose the lateral cutaneous nerve of the
thigh and the femoral, obturator and sciatic nerves in order to
study the risk of injury to these structures during the dissection,
osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular
osteotomy. Injury of the lateral cutaneous nerve of thigh was less likely
to occur if an osteotomy of the anterior superior iliac spine had
been carried out before exposing the hip. The obturator nerve was likely to be injured during unprotected
osteotomy of the pubis if the far cortex was penetrated by >
5 mm.
This could be avoided by inclining the osteotome 45° medially and
performing the osteotomy at least 2 cm medial to the iliopectineal
eminence. The sciatic nerve could be injured during the first and last
stages of the osteotomy if the osteotome perforated the lateral
cortex of ischium and the ilio-ischial junction by >
10 mm. The femoral nerve could be stretched or entrapped during osteotomy
of the pubis if there was significant rotational or linear displacement
of the acetabulum. Anterior or medial displacement of <
2 cm
and lateral tilt (retroversion) of <
30° were safe margins. The
combination of retroversion and anterior displacement could increase tension
on the nerve. Strict observation of anatomical details, proper handling of
the osteotomes and careful manipulation of the acetabular fragment
reduce the neurological complications of Bernese peri-acetabular
osteotomy. Cite this article:
Osteonecrosis of the femoral head can be caused by a variety of disorders and affects the relatively young patient. Most studies have concentrated on the femoral changes; the sites of early lesions of the labrum and acetabular cartilage have not been recorded. We studied 17 hips with osteonecrosis and a wide congruent joint space on radiographs and by direct inspection of the femoral head, labrum and acetabular cartilage during surgery. All of the femoral heads had some anterosuperior flattening which reduced the head-neck ratio in this area. A consistent pattern of damage to the labrum and the acetabular cartilage was seen in all hips. Intraoperatively, impingement and the cam-effect with its spatial correlation with lesions of the labrum and acetabular cartilage were observed. These findings could be helpful when undertaking conservative surgery for osteonecrosis, since the recognition of early radiologically undetectable acetabular lesions may require modification of the surgical technique.
We carried out the Bernese periacetabular osteotomy for the treatment of 13 dysplastic hips in 11 skeletally mature patients with an underlying neurological diagnosis. Seven hips had flaccid paralysis and six were spastic. The mean age at the time of surgery was 23 years and the mean length of follow-up was 6.4 years. Preoperatively, 11 hips had pain and two had progressive subluxation. Before operation the mean Tönnis angle was 33°, the mean centre-edge angle was −10°, and the mean extrusion index was 53%. Postoperatively, they were 8°, 25° and 15%, respectively. Pain was eliminated in 7 patients and reduced in four in those who had preoperative pain. One patient developed pain secondary to anterior impingement from excessive retroversion of the acetabulum. Four required a varus proximal femoral osteotomy at the time of the pelvic procedure and one a late varus proximal femoral osteotomy for progressive subluxation. Before operation no patient had arthritis. At the most recent follow-up one had early arthritis of the hip (Tönnis grade I) and one had advanced arthritis (Tönnis grade III). Our results suggest that the Bernese periacetabular osteotomy can be used successfully to treat neurogenic acetabular dysplasia in skeletally mature patients.
The acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or 'os acetabuli' as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.
In the Trillat procedure for recurrent anterior instability of the shoulder the coracoid process is osteotomised and tilted downward to act as a bone block, and a screw is used to fix it and the Bankart lesion to the anterior scapular neck. We reviewed 52 cases after a mean follow-up of 69 months. Results in 73% of shoulders were excellent, 10% were good, 7% fair and 10% poor. Dislocation recurred in 4%, but a positive apprehension sign was present in 10 other shoulders. Some degenerative changes were seen in 62% of shoulders, a complication known to be associated with bone-block procedures. The most important reason for loss of lateral rotation was iatrogenic impingement of the coracoid. This frequent and potentially serious complication can also cause posterior subluxation of the humeral head and osteoarthritis.
Symptomatic impingement of the rotator cuff between the humeral head and the coracoid process has been studied and three varieties recognised: idiopathic, iatrogenic and traumatic. In all three the clinical findings consisted of pain in front of the shoulder, referred to the upper arm and forearm, and especially felt during forward flexion and medial rotation; the pain could be reproduced by medial rotation with the arm in 90 degrees of abduction, or by adduction with the shoulder flexed to 90 degrees. Patients were relieved of their symptoms by restoring adequate subcoracoid clearance.