We performed Kawamura's dome osteotomy of the pelvis, with simultaneous distal transfer of the greater trochanter on 101 hips in 91 patients with osteoarthritis secondary to hip dysplasia. The mean age at operation was 30 years (15 to 55), and follow-up was for a mean of 8.3 years (5 to 14). Clinical evaluation using the Merle d'Aubigne score showed 92% excellent or good results. Radiologically, 91 hips had good acetabular remodelling and showed no signs of progression of osteoarthritis. In ten hips the osteoarthritic process progressed despite the osteotomy and six of these eventually underwent total hip replacement. Factors which were significantly associated with a poor outcome included an advanced stage of osteoarthritis, valgus deformity of the proximal femur, old age at the time of operation and postoperative persistence of abductor insufficiency

We used the stainless steel cable grip system described by Dall and Miles in 1983 to fix trochanters in 40 hips after total arthroplasty with trochanteric osteotomy. The cable broke in 32.5% of the hips; the trochanter failed to unite in 37.5%. Significantly more cables broke when placed inside the femoral canal than when the cable was placed round the femoral shaft (58% as against 9.5%, difference p less than 0.01). The high incidence of breakage may have resulted from contact between the stainless steel cable and the titanium prosthesis, from the acute angulation, or because of the lower fatigue strength of stainless steel. Better results have been obtained using cables with a higher fatigue strength, passed outside the proximal femur

Hereditary multiple exostoses is an autosomal dominant disorder characterised by multiple osteochondromata, most commonly affecting the forearm, knee and ankle. Osteochondromata of the proximal femur have been reported to occur in 30% to 90% of affected patients with coxa valga in 25%. Acetabular dysplasia is rare but has been described. This is the first report of a patient requiring surgical intervention. A girl was seen at the age of nine with hereditary multiple exostoses and when 12 developed bilateral pain in the groin. Radiographs showed severely dysplastic acetabula with less than 50% coverage of the femoral heads and widening of the medial joint space. Large sessile osteochondromata were present along the medial side of the femoral neck proximal to the lesser trochanter, with associated coxa valga. The case illustrates the importance of obtaining initial skeletal surveys in children with hereditary multiple exostoses to identify potential problems such as acetabular dysplasia and subluxation of the hip

Three cases are reported in which an osteosarcoma developed in relation to an enchondroma in a long bone. Two of the cases were in the proximal femur whilst one occurred in the proximal humerus, both recognised sites for old calcified enchondromas or "cartilage rests". The ages of the patients at presentation were 55, 63 and 84 years and all were women. Two patients died with pulmonary metastases within six months of the onset of clinical symptoms. Despite their intimate relationship to the enchondromas, none of the osteosarcomas could be shown histologically to have arisen from tumour cartilage. It appears probable that these are cases in which independently arising tumours have merged to form a so-called "collision" tumour, but the possibility that they could have been derived by dedifferentiation of a previously benign neoplasm cannot be discounted

We have divided Severin group-V severely dysplastic hips with a false into three subtypes, based on the height and shape of the socket. We performed rotational acetabular osteotomy (RAO) in 19 hips in 17 young adults with a type-1 ‘low’ false acetabulum which had direct contact with the true acetabulum. This is a periacetabular osteotomy which gives acetabular coverage with articular cartilage and produces a nearly normal position of the head. Concomitant osteotomies of the proximal femur were carried out in 11 hips. We reviewed the patients clinically and radiologically at a mean of ten years (6 to 18) after operation. Of the 19 hips, 15 showed very good or good results. This operation is indicated in young adults with a dysplastic hip and a type-1 low false acetabulum. Subclassification of Severin group V is a convenient way of defining those patients who would benefit from the procedure

Postoperative deep-vein thrombosis (DVT) is believed to be rare in Asians. We studied 88 consecutive patients in Malaysia who had operations for fracture of the proximal femur or for total hip or knee replacement. No patient had prophylaxis against DVT; bilateral ascending venography was performed between six and ten days after operation. A total of 55 patients (62.5%) showed venographic evidence of DVT. The prevalence was greatest after total knee replacement (76.5%), less after total hip replacement (64.3%) and smallest in the fracture group (50%). One patient developed symptomatic pulmonary embolism. In contrast to other reports from Asia, we found an incidence of postoperative DVT which is similar to that reported in Western populations. This suggests that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedures should be reconsidered

Treatment with corticosteroids is a risk factor for non-traumatic avascular necrosis of the femoral head, but the pathological mechanism is poorly understood. Short-term treatment with high doses of methylprednisolone is used in severe neurotrauma and after kidney and heart transplantation. We investigated the effect of such treatment on the pattern of perfusion of the femoral head and of bone in general in the pig. We allocated 15 immature pigs to treatment with high-dose methylprednisolone (20 mg/kg per day intramuscularly for three days, followed by 10 mg/kg intramuscularly for a further 11 days) and 15 to a control group. Perfusion of the systematically subdivided femoral head, proximal femur, acetabulum, humerus, and soft tissues was determined by the microsphere technique. Blood flow in bone was severely reduced in the steroid-treated group. The reduction of flow affected all the segments and the entire epiphysis of the femoral head. No changes in flow were found in non-osseous tissue. Short-term treatment with high-dose methylprednisolone causes reduction of osseous blood flow which may be the pathogenetic factor in the early stage of steroid-induced osteonecrosis

We randomised 24 patients before they had a cemented hemiarthroplasty for hip fracture to receive either thorough or minimal saline lavage of the femoral canal. We then determined the effect in each group on the thromboembolic and cardiopulmonary responses to the pressurised insertion of cement, using transoesophageal echocardiography to show the echogenic embolic response. We found a statistically significant reduction in both the duration of the response and the number of large emboli in patients who had had thorough lavage as compared with the control group with minimal lavage. There was also less disturbance of pulmonary function, as assessed by the change in end-tidal CO2 levels and oxygen saturation, in patients who had thorough lavage. Three patients had a significant fall in blood pressure during cement insertion; all had only minimal lavage. We consider that thorough lavage should be an essential part of the preparation of the proximal femur before cement insertion

We describe six patients with aggressive granulomatous lesions around cementless total hip prostheses. Two patients previously had a cemented prosthesis in the same hip. The Lord prosthesis was used in five patients, the PCA in one. Both prostheses were made of chrome-cobalt alloy. Pain on weight-bearing occurred on average 3.2 years after the cementless arthroplasty, and at that time radiography revealed aggressive granulomatosis around the proximal femoral stem and the acetabular component in five of the patients; one had a large solitary granuloma in the proximal femur. Revision was performed on average 4.8 years after the cementless arthroplasty. At that time all granulomas had grown large in size; while waiting for revision operation, two femoral stem components fractured. All the granulomas showed a uniform histopathology, which included histiocytosis; the cause for these lesions was thought to be plastic debris from the acetabular socket

The prevalence and onset of pressure sores was studied in 283 patients admitted to a general hospital with either fracture of the proximal femur or for elective hip surgery. Ninety patients developed pressure sores, of which 60 are reported in detail. Most were in women aged 70 or more who had been admitted with hip fractures. The majority of pressure sores started soon after admission, particularly on the day of operation, after which the numbers of new cases decreased. Half the patients had more than one pressure sore and the commonest sites were the sacrum, heels, and buttocks. The mortality in patients with pressure sores was 27% and their mean length of stay in hospital far exceeded that of other patients. The prevention of pressure sores in elderly patients requires more skill and attention than the nurse alone can offer; it demands the help of the whole orthopaedic team

Aims

There is an increased risk of dislocation of the hip after the resection of a periacetabular tumour and endoprosthetic reconstruction of the defect in the hemipelvis. The aim of this study was to determine the rate and timing of dislocation and to identify its risk factors.

We describe 100 consecutive patients with osteoid osteoma. Of the 97 who had operations, 89 were treated by intralesional excision and eight by wide resection. The three remaining patients were not operated on because the osteoid osteoma was almost painless, or was found in the pedicle of the 12th thoracic vertebra at the site of entrance of the artery of Adamkjewicz. The diagnosis was confirmed histologically in all specimens. No local recurrences were observed at a minimum follow-up of one year. All except one patient were mobilised two to four days after surgery. A precise preoperative diagnosis of the lesion is mandatory, based on clinical findings, standard radiographs, thin-section CT and a bone scan. We compared our operative technique with 247 cases in which the percutaneous technique of removal or coagulation of the nidus had been performed. The latter procedure has a less constant rate of primary cure (83% v 100%). Its principal indication appears to be for osteoid osteomas in the proximal femur and the pelvis

Children with congenital focal deficiency of the proximal femur present many problems that are but rarely encountered by the individual surgeon who is thus unable to accumulate a wide experience. This paper reviews the literature and analyses the treatment of twenty-three cases at the Royal Children's Hospital, Melbourne, with the object of producing a rational plan of treatment. The management of instability of the hip, malrotation, inadequate proximal musculature and leg length inequality are separately considered for five grades of deficiency. Milder forms are amenable to subtrochanteric osteotomy to correct varus deformity. Exploration and grafting of the pseudarthrosis is indicated where progressive deformity develops. In the more severe deficiency, conservative management of the proximal bony defect provides a better result with an operation only rarely indicated. The gross leg length inequality may be most successfully overcome by Syme's amputation with subsequent fusion of the knee to create an above-knee amputee with an end-bearing stump allowing ready fitting of a prosthesis

Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

Aims

Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification.

Aims

Fibrinolysis plays a key transition step from haematoma formation to angiogenesis and fracture healing. Low-magnitude high-frequency vibration (LMHFV) is a non-invasive biophysical modality proven to enhance fibrinolytic factors. This study investigates the effect of LMHFV on fibrinolysis in a clinically relevant animal model to accelerate osteoporotic fracture healing.

Aims

To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA).

The results and complications of the use of Bailey-Dubow extensible rods in 28 lower limb bones of 10 patients suffering from osteogenesis imperfecta are reviewed. Twenty-eight operations were for the primary insertion of the rods into the femur or tibia; a further nine operations were needed for the treatment of complications. These complications included 10 instances of proximal migration of the distal end of the rod, one of incorrect placement in the proximal femur, four instances of loosening of a T-piece and three of infection about a rod, two of these being in one child. Most complications arose from technical faults at insertion. The details of technique which have evolved from experience are described. Only one fracture has occurred in a bone after correct placement of a rod. Of the 10 patients, seven of whom had never walked before, seven were able to walk and two others had achieved walking, but were under treatment for complications at the time of review. There was no evidence of damage to growth epiphyses. The greater technical complexity of insertion of Bailey-Dubow rods is well justified by the results obtained when they are correctly applied

Over the 10-year period 1969 to 1978, 271 consecutive cases of congenital dislocation of the hip were diagnosed at birth. Standard anteroposterior radiographs of the pelvis were obtained routinely and were analysed retrospectively. The medial gap, a measure of the separation between the proximal femur and the pelvic wall, was found to be significantly increased in cases with unilateral or bilateral dislocation when compared to normal. A medial greater than five millimetres is indicative of femoral head displacement and is of value where the clinical diagnosis is uncertain. The rate of missed dislocation at birth was 0.6 cases per thousand. Treatment with the Malmo splint was the normal routine. The Pavlik harness was applied if splintage was poorly tolerated by the infant, or in the rare instance of limited hip abduction. Failure to maintain reduction by splintage occurred in 3.3 per cent. The incidence of pressure deformities of the femoral head was 2.95 per cent and there was a residual deformity in later childhood of 1.1 per cent. It is presumed that this lesion can be attributed to the effect of splintage and it was notably avoided in the later period of the review when greater mobility of the abducted hips was encouraged