We have used a modified technique of cervical osteotomy to treat a consecutive series of 23 patients with chronic slip of the upper femoral epiphysis. It has been successful in correcting both moderate and severe deformities with a low incidence of avascular necrosis, comparable to that seen after subtrochanteric osteotomies. We describe the operative details and discuss the features which make cervical osteotomy technically superior to intertrochanteric and subtrochanteric procedures.
Of a consecutive series of 117 one-year-old infants with 130 established dislocations of the hip, 11% failed to respond to primary surgical treatment. Genetic and iatrogenic factors accounted for half the failures. There were no obvious causes in the remainder, though a few had the superficial stigmata of spinal dysraphism, and by two years of age, most of the group had developed a lateral rotation posture of the affected leg associated with a relatively smaller foot on that side. Radiologically, the femoral head had drifted and rotated laterally out of the surgically deepened acetabulum, causing persistent subluxation. Although there was no clinical evidence of sensory or motor denervation, sensory spinal evoked potential tests revealed the presence of neurological deficits in the majority of patients in this group.
Total hip replacement for adults with unreduced congenital dislocation presents a difficult problem because soft-tissue contractures usually prevent sitting at the normal anatomical level. Extensive soft-tissue division or a high-level acetabulum leads to reduced function and poor fixation of the components. We describe a new technique for hip replacement in such cases. The shortened abductors and flexors are released proximally and excision of the upper third of the ilium allows them to be repaired without tension, while providing bone graft to reconstruct the acetabular roof. We report 12 such replacements in 10 patients with good results and few early complications.
A series of 75 patients who had undergone anterior cervical fusion between 1965 and 1977 were reviewed. The patients were divided into two groups: those in Group A had had the level of fusion indicated by cine radiography, whereas in Group B the level had been determined by plain radiographs and clinical symptoms and signs. Results showed that cine radiography was the more accurate diagnostic technique. Accurate diagnosis of the level to be fused, the careful clinical selection of patients and sound bony union were found to be vital to the success of anterior cervical fusion. The incidence of pseudarthrosis was significant in single-level fusions and was even greater in double-level fusions and in patients with a history of trauma, especially whiplash injuries. It was rare to develop recurrence of symptoms in adjacent levels after fusion of a level localised by cine radiography.
A prospective study of allergic contact dermatitis after metal-on-plastic total hip replacement was undertaken in 69 patients, of whom 54 were available for review after operation. Before operation six patients were metal sensitive, but only one remained so afterwards; this patient had given a clear history of metal sensitivity and a titanium prosthesis had therefore been used. In all six patients the result of the operation was good and no case of loosening occurred. Sixty-three patients had negative patch tests before operation; in none of these was metal sensitivity detected after operation. Cutaneous sensitivity to various metals is well documented after the insertion of metal-on-metal prostheses and in failed prostheses. We have not found any such increased sensitivity after metal-on-plastic hip replacement. There is little evidence of a direct causal relationship between metal sensitivity and subsequent loosening. The cutaneous sensitivity may be the consequence of loosening rather than its cause. Our results suggest that, providing metal-on-plastic prostheses are used, routine patch testing before hip replacement is no longer required.
The features of congenital elevation of the scapula are described for a group of 16 children. Fibrous bands which tether the scapula and limit its movements were discovered in most children. Vertical displacement osteotomy of the medial border of the scapula and division of the fibrous attachments have provided a reliable and safe treatment for 12 children during the past 10 years.
Thirty-one patients have been reviewed four and a half to thirteen years after total excision of the patella for fracture. This operation did not give the uniformly excellent results previously reported by some authors. The type of incision used was unimportant in the long term. Immobilisation in plaster-of-Paris for any period between one and eight weeks after operation had no adverse effect on the long-term results. There was no correlation between the amount of calcification or ectopic bone formation found in the patellar tendon and the degree of function or discomfort in the joint. There was no evidence that osteoarthritis is an inevitable sequel to patellectomy in man. Maximal recovery of knee function may take up to three years after patellectomy. In this series 22% of patients had excellent results, 39% good results and 39% poor results, according to defined criteria. The implications of these findings are discussed.
1. General joint laxity affecting more than three joints was found in 7 per cent of normal schoolchildren. Similar laxity was found in fourteen of a random series of forty-eight girls, and in nineteen of twenty-six boys, with non-familial congenital dislocation of the hip. Such laxity was also found in four of seven girls and five of seven boys with familial (first degree relative affected) congenital dislocation of the hip. 2. It is concluded that persistent generalised joint laxity, which is often familial, is an important predisposing factor to congenital dislocation of the hip in boys. It is less important in girls, except perhaps in familial cases, as in girls there is an alternative temporary hormonal cause of joint laxity.
1. The histories of 149 patients, coming to the Hospital for Sick Children within the first three years of life with congenital dislocation of the hip (191 dislocated hips), and treated by conservative methods, have been reviewed. 2. The patients with unilateral dislocations (107) have been divided into three groups, according to the angle of slope of the opposite acetabulum. This angle was measured on the first radiograph and related to the mean value for age and sex. 3. The opposite hip was classed as "normal" if the acetabular angle was below or within one standard deviation above the mean for sex and age; as "moderately shallow" if it was between one and two standard deviations above the mean; and as "shallow" if it was over two standard deviations above the mean. This grouping was found to have a direct bearing on the results of conservative treatment in unilateral cases. 4. Most bilateral dislocations behaved as unilateral dislocations with shallow opposite hips. 5. Additional factors influencing the response to conservative treatment–sex, age at first attendance, family history, fragmentation of the femoral epiphysis and eccentric reduction–are discussed.
