The purpose of this study was to assess whether the use of a joint-sparing technique such as curettage and grafting was successful in eradicating giant cell tumours of the proximal femur, or whether an alternative strategy was more appropriate.

Between 1974 and 2012, 24 patients with a giant cell tumour of the proximal femur were treated primarily at our hospital. Treatment was either joint sparing or joint replacing. Joint-sparing treatment was undertaken in ten patients by curettage with or without adjunctive bone graft. Joint replacement was by total hip replacement in nine patients and endoprosthetic replacement in five. All 11 patients who presented with a pathological fracture were treated by replacement.

Local recurrence occurred in five patients (21%): two were treated by hip replacement, three by curettage and none with an endoprosthesis. Of the ten patients treated initially by curettage, six had a successful outcome without local recurrence and required no further surgery. Three eventually needed a hip replacement for local recurrence and one an endoprosthetic replacement for mechanical failure. Thus 18 patients had the affected joint replaced and only six (25%) retained their native joint. Overall, 60% of patients without a pathological fracture who were treated with curettage had a successful outcome.

Cite this article: Bone Joint J 2014;96-B:127–31.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018).

This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

Cite this article: Bone Joint J 2015;97-B:405–11.

Intact abductors of the hip play a crucial role in preventing limping and are known to be damaged through the direct lateral approach. The extent of trauma to the abductors after revision total hip replacement (THR) is unknown. The aim of this prospective study was to compare the pre- and post-operative status of the gluteus medius muscle after revision THR. We prospectively compared changes in the muscle and limping in 30 patients who were awaiting aseptic revision THR and 15 patients undergoing primary THR. The direct lateral approach as described by Hardinge was used for all patients. MRI scans of the gluteus medius and functional analyses were recorded pre-operatively and six months post-operatively. The overall mean fatty degeneration of the gluteus medius increased from 35.8% (1.1 to 98.8) pre-operatively to 41% (1.5 to 99.8) after multiple revision THRs (p = 0.03). There was a similar pattern after primary THR, but with considerably less muscle damage (p = 0.001), indicating progressive muscle damage. Despite an increased incidence of a positive Trendelenburg sign following revision surgery (p = 0.03) there was no relationship between the cumulative fatty degeneration in the gluteus medius and a positive Trendelenburg sign (p = 0.26). The changes associated with other surgical approaches to the hip warrant investigation.

Cite this article: Bone Joint J 2014;96-B:1618–22.

Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation.

After placment of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy.

The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (−9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed.

Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length.

Total hip replacement for developmental hip dysplasia is challenging. The anatomical deformities on the acetabular and femoral sides are difficult to predict. The Crowe classification is usually used to describe these cases – however, it is not a very helpful tool for pre-operative planning. Small acetabular components, acetabular augments, and modular femoral components should be available for all cases. Regardless of the Crowe classification, the surgeon must be prepared to perform a femoral osteotomy for shortening, or to correct rotation, and/or angulation.

Cite this article: Bone Joint J 2013;95-B, Supple A:31–6.

Aims

To investigate the longevity of uncemented fixation of a femoral component in total hip arthroplasty (THA) in patients with Dorr type C proximal femoral morphology.

Cartilage defects of the hip cause significant pain and may lead to arthritic changes that necessitate hip replacement. We propose the use of fresh osteochondral allografts as an option for the treatment of such defects in young patients. Here we present the results of fresh osteochondral allografts for cartilage defects in 17 patients in a prospective study. The underlying diagnoses for the cartilage defects were osteochondritis dissecans in eight and avascular necrosis in six. Two had Legg-Calve-Perthes and one a femoral head fracture. Pre-operatively, an MRI was used to determine the size of the cartilage defect and the femoral head diameter. All patients underwent surgical hip dislocation with a trochanteric slide osteotomy for placement of the allograft. The mean age at surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months (3 to 74). The mean Harris hip score was significantly better after surgery (p < 0.01) and 13 patients had fair to good outcomes. One patient required a repeat allograft, one patient underwent hip replacement and two patients are awaiting hip replacement. Fresh osteochondral allograft is a reasonable treatment option for hip cartilage defects in young patients.

Cite this article: Bone Joint J 2014;96-B(11 Supple A):11–16.

We describe the clinical and radiological results of cementless primary total hip replacement (THR) in 25 patients (18 women and seven men; 30 THRs) with severe developmental dysplasia of the hip (DDH). Their mean age at surgery was 47 years (23 to 89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe type IV. Cementless acetabular components with standard polyethylene liners were introduced as close to the level of the true acetabulum as possible. The modular cementless S-ROM femoral component was used with a low resection of the femoral neck.

A total of 21 patients (25 THRs) were available for review at a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified Harris hip score improved from 46 points pre-operatively to 90 at final follow up (p < 0.001).

A total of 15 patients (17 THRs; 57%) underwent revision of the acetabular component at a mean of 14.6 years (7 to 20.8), all for osteolysis. Two patients (two THRs) had symptomatic loosening. No patient underwent femoral revision. Survival with revision of either component for any indication was 81% at 15 years (95% CI 60.1 to 92.3), with 21 patients at risk.

This technique may reduce the need for femoral osteotomy in severe DDH, while providing a good long-term functional result.

Cite this article: Bone Joint J 2014;96-B:1449–54.

When performing total hip replacement (THR) in high dislocated hips, the presence of soft-tissue contractures means that most surgeons prefer to use a femoral shortening osteotomy in order to avoid the risk of neurovascular damage. However, this technique will sacrifice femoral length and reduce the extent of any leg-length equalisation. We report our experience of 74 THRs performed between 2000 and 2008 in 65 patients with a high dislocated hip without a femoral shortening osteotomy. The mean age of the patients was 55 years (46 to 72) and the mean follow-up was 42 months (12 to 78). All implants were cementless except for one resurfacing hip implant. We attempted to place the acetabular component in the anatomical position in each hip. The mean Harris hip score improved from 53 points (34 to 74) pre-operatively to 86 points (78 to 95) at final follow-up. The mean radiologically determined leg lengthening was 42 mm (30 to 66), and the mean leg-length discrepancy decreased from 36 mm (5 to 56) pre-operatively to 8.5 mm (0 to 18) postoperatively. Although there were four (5%) post-operative femoral nerve palsies, three had fully resolved by six months after the operation. No loosening of the implant was observed, and no dislocations or infections were encountered.

Total hip replacement without a femoral shortening osteotomy proved to be a safe and effective surgical treatment for high dislocated hips.

We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature.

We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29).

All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p <  0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head.

Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement.

Cite this article: Bone Joint J 2014;96-B:1441–8.

It is becoming increasingly common for a patient to have ipsilateral hip and knee replacements. The inter-prosthetic (IP) distance, the distance between the tips of hip and knee prostheses, has been thought to be associated with an increased risk of IP fracture. Small gap distances are generally assumed to act as stress risers, although there is no real biomechanical evidence to support this.

The purpose of this study was to evaluate the influence of IP distance, cortical thickness and bone mineral density on the likelihood of an IP femoral fracture.

A total of 18 human femur specimens were randomised into three groups by bone density and cortical thickness. For each group, a defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing the appropriate lengths of component. The maximum fracture strength was determined using a four-point bending test.

The fracture force of all three groups was similar (p = 0.498). There was a highly significant correlation between the cortical area and the fracture strength (r = 0.804, p <  0.001), whereas bone density showed no influence.

This study suggests that the IP distance has little influence on fracture strength in IP femoral fractures: the thickness of the cortex seems to be the decisive factor.

Cite this article: Bone Joint J 2014;96-B:1378–84.

The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms.

Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches.

We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.

Aims

We report on the outcome of the Exeter Contemporary flanged cemented all-polyethylene acetabular component with a mean follow-up of 12 years (10 to 13.9). This study reviewed 203 hips in 194 patients. 129 hips in 122 patients are still in situ; 66 hips in 64 patients were in patients who died before ten years, and eight hips (eight patients) were revised. Clinical outcome scores were available for 108 hips (104 patients) and radiographs for 103 hips (100 patients).

Aims

The goals of this study were to define the risk factors, characteristics, and chronology of fractures in 5417 revision total hip arthroplasties (THAs).

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: Bone Joint J 2014;96-B:5–18.

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).

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three.

Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating.

An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone.

The December 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Vitamin E infusion helpful in polyethylene; Hip replacement in fracture and arthritis; Non-surgical treatment for arthritis; Cost and approach in hip surgery; Who does well in FAI surgery?; AAOS Thromboembolism guidelines; Thromboprophylaxis and periprosthetic joint infection; Fluid collections not limited to metal-on-metal THR

Excision of the proximal femur for tumour with prosthetic reconstruction using a bipolar femoral head places a considerable load on the unreplaced acetabulum.

We retrospectively reviewed the changes which occur around the affected hip joint by evaluating the post-operative radiographs of 65 consecutive patients who underwent proximal prosthetic arthroplasty of the femur, and in whom an acetabular component had not been used. There were 37 men and 28 women with a mean age of 57.3 years (17 to 93). Radiological assessment included the extent of degenerative change in the acetabulum, heterotopic ossification, and protrusio acetabuli.

The mean follow-up was 9.1 years (2 to 11.8). Degenerative changes in the acetabulum were seen in three patients (4.6%), Brooker grade 1 or 2 heterotopic ossification in 17 (26%) and protrusion of the prosthetic head in nine (13.8%).

A total of eight patients (12.3%) needed a revision. Five were revised to the same type of prosthesis and three (4.6%) were converted to a total hip arthroplasty.

We conclude that radiological evidence of degenerative change, heterotopic ossification and protrusion occur in a few patients who undergo prosthetic arthroplasty of the proximal femur for tumour. The limited extent of these changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in these patients.

Cite this article: Bone Joint J 2015;97-B:1704–9

Aims

We present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation.