[The modified Dunn procedure to treat severe slipped capital femoral epiphysis]. / Die modifizierte Dunn-Operation zur Behandlung der schweren Epiphyseolysis capitis femoris.

The modified Dunn procedure enables restoration of the proximal femoral anatomy and normal hip function in patients with slipped capital femoral epiphysis (SCFE). Surgery is indicated in severe SCFE and in hips with a moderate slip angle and impaired function. To prevent further dislocation of the femoral head, the authors recommend non-weightbearing until surgery, since an accurate evaluation of slip stability is not possible in the clinical setting. Only a well-trained orthopedic surgeon with a high level of expertise in hip preservation surgery should perform this procedure. Precise knowledge of the vascular anatomy of the proximal femur is essential to perform successful surgery with low rates of complications such as avascular necrosis of the femoral head. Surgical hip dislocation with osteotomy of the greater trochanter is the approach used. After arthrotomy, stability of the physis is checked. To prevent rupture of the retinacular vessels in hips with an unstable physis, these heads are prophylactically pinned before dislocation out of the socket. Blood supply to the femoral head as well as intraarticular damage can be judged in the dislocated position of the femoral head. The retinacular flap preserves epiphyseal perfusion while the femoral head is dislocated from the femoral neck. Resection of posteromedial callous formation from the femoral neck as well as removal of the remaining physis from the femoral head prevent stress on the retinacular vessels after reduction of the femoral head (epiphysis) on the neck.

[Bernese periacetabular osteotomy. : Indications, technique and results 30 years after the first description]. / Periazetabuläre Osteotomie nach Ganz : Indikationen, Technik und Ergebnisse 30 Jahre nach Erstbeschreibung.

The Bernese periacetabular osteotomy (PAO) is a surgical technique for the treatment of (1) hip dysplasia and (2) femoroacetabular impingement due to acetabular retroversion. The aim of the surgery is to prevent secondary osteoarthritis by improvement of the hip biomechanics. In contrast to other pelvic osteotomies, the posterior column remains intact with this technique. This improves the inherent stability of the acetabular fragment and thereby facilitates postoperative rehabilitation. The birth canal remains unchanged. Through a shortened ilioinguinal incision, four osteotomies and one controlled fracture around the acetabulum are performed. The direction of acetabular reorientation differs for both indications while the sequence of the osteotomies remains the same. This surgical approach allows for a concomitant osteochondroplasty in the case of an aspherical femoral head-neck junction. The complication rate is relatively low despite the complexity of the procedure. The key point for a successful long term outcome is an optimal reorientation of the acetabulum for both indications. With an optimal reorientation and a spherical femoral head, the cumulative survivorship of the hip after 10 years is 80-90 %. For the very first 75 patients, the cumulative 20-year survivorship was 60 %. The preliminary evaluation of the same series at a 30-year follow-up still showed a survivorship of approximately 30 %. The PAO has become the standard procedure for the surgical therapy of hip dysplasia in adolescents and adults.

Size and shape of the lunate surface in different types of pincer impingement: theoretical implications for surgical therapy.

OBJECTIVE: Acetabular rim trimming is indicated in pincer hips with an oversized lunate surface but could result in a critically decreased size of the lunate surface in pincer hips with acetabular malorientation. There is a lack of detailed three-dimensional anatomy of lunate surface in pincer hips. Therefore, we questioned how does (1) size and (2) shape of the lunate surface differ among hips with different types of pincer impingement? METHOD: We retrospectively compared size and shape of the lunate surface between acetabular retroversion (48 hips), deep acetabulum (34 hips), protrusio acetabuli (seven hips), normal acetabuli (30 hips), and hip dysplasia (45 hips). Using magnetic resonance imaging (MRI) arthrography with radial slices we measured size in percentage of the femoral head coverage and shape using the outer (inner) center-edge angles and width of lunate surface. RESULTS: Hips with retroversion had a decreased size and deep hips had normal size of the lunate surface. Both had a normal shape of the outer acetabular rim. Protrusio hips had an increased size and a prominent outer acetabular rim. In all three types of pincer hips the acetabular fossa was increased. CONCLUSION: Size and shape of the lunate surface differs substantially among different types of pincer impingement. In contrast to hips with protrusio acetabuli, retroverted and deep hips do not have an increased size of the lunate surface. Acetabular rim trimming in retroverted and deep hips should be performed with caution. Based on our results, acetabular reorientation would theoretically be the treatment of choice in retroverted hips.

[Anterior approaches to the acetabulum]. / Anteriore Zugänge zum Acetabulum.

Since the 1960s the ilioinguinal approach by Letournel with the three anatomic windows has been successfully established for the treatment of acetabular fractures involving predominantly the anterior column. The previous standard approach, the iliofemoral approach by Smith-Petersen, is still used for the therapy of anterior wall or isolated femoral head fractures. The increase in acetabular fractures in the elderly with lateral compression fractures after lateral falls, characterized by medial displacement of the quadrilateral plate and superomedial dome impaction, led to the use of the intrapelvic modified Stoppa approach with or without the first window of the ilioinguinal approach in the 1990s. To combine the advantages of the second and third windows of the ilioinguinal approach and the medial view of the modified Stoppa approach the Berne research group recently introduced the pararectus approach in acetabular surgery, which can be used as a less invasive acetabular surgical (LIAS) technique especially in the elderly.

[Posterior approaches to the acetabulum]. / Posteriore Zugänge zum Acetabulum.

Posterior approaches to the hip joint were developed by Langenbeck and Kocher in the nineteenth century. Letournel created the term Kocher-Langenbeck approach which became one of the most important approaches to the hip joint. The further extension of this approach by digastric trochanteric osteotomy and subsequently by surgical hip dislocation enables visualization of the entire hip joint which allows complete evaluation of articular joint damage, quality of reduction and confirmation of extra-articular hardware. With the increasing incidence of acetabular fractures in the elderly there is a concomitant increase of complicating factors, such as multifragmentary posterior wall fractures, dome impaction, marginal impaction and femoral head damage. These factors are negative predictors and compromise a favorable outcome after acetabular surgery. With direct joint visualization these factors can be reliably recognized and corrected as adequately as possible. Surgical hip dislocation thus offers advantages in complex posterior wall, transverse and T-shaped fractures with or without posterior wall involvement. For these fracture types surgical hip dislocation represents a standard approach in our hands.

Evaluation of articular cartilage in patients with femoroacetabular impingement (FAI) using T2* mapping at different time points at 3.0 Tesla MRI: a feasibility study.

OBJECTIVES: To define the feasibility of utilizing T2* mapping for assessment of early cartilage degeneration prior to surgery in patients with symptomatic femoroacetabular impingement (FAI), we compared cartilage of the hip joint in patients with FAI and healthy volunteers using T2* mapping at 3.0 Tesla over time. MATERIALS AND METHODS: Twenty-two patients (13 females and 9 males; mean age 28.1 years) with clinical signs of FAI and Tönnis grade ≤ 1 on anterior-posterior x-ray and 35 healthy age-matched volunteers were examined at a 3 T MRI using a flexible body coil. T2* maps were calculated from sagittal- and coronal-oriented gradient-multi-echo sequences using six echoes (TR 125, TE 4.41/8.49/12.57/16.65/20.73/24.81, scan time 4.02 min), both measured at beginning and end of the scan (45 min time span between measurements). Region of interest analysis was manually performed on four consecutive slices for superior and anterior cartilage. Mean T2* values were compared among patients and volunteers, as well as over time using analysis of variance and Student's t-test. RESULTS: Whereas quantitative T2* values for the first measurement did not reveal significant differences between patients and volunteers, either for sagittal (p = 0.644) or coronal images (p = 0.987), at the first measurement, a highly significant difference (p ≤ 0.004) was found for both measurements with time after unloading of the joint. Over time we found decreasing mean T2* values for patients, in contrast to increasing mean T2* relaxation times in volunteers. CONCLUSION: The study proved the feasibility of utilizing T2* mapping for assessment of early cartilage degeneration in the hip joint in FAI patients at 3 Tesla to predict possible success of joint-preserving surgery. However, we suggest the time point for measuring T2* as an MR biomarker for cartilage and the changes in T2* over time to be of crucial importance for designing an MR protocol in patients with FAI.

Synovial sarcomas usually metastasize after >5 years: a multicenter retrospective analysis with minimum follow-up of 10 years for survivors.

BACKGROUND: Synovial sarcoma (SS) is a malignant soft tissue sarcoma with a poor prognosis because of late local recurrence and distant metastases. To our knowledge, no studies have minimum follow-up of 10 years that evaluate long-term outcomes for survivors. PATIENTS AND METHODS: Data on 62 patients who had been treated for SS from 1968 to 1999 were studied retrospectively in a multicenter study. Mean follow-up of living patients was 17.2 years and of dead patients 7.7 years. RESULTS: Mean age at diagnosis was 35.4 years (range 6-82 years). Overall survival was 38.7%. The 5-year survival was 74.2%; 10-year survival was 61.2%; and 15-year survival was 46.5%. Fifteen patients (24%) died of disease after 10 years of follow-up. Local recurrence occurred after a mean of 3.6 years (range 0.5-14.9 years) and metastases at a mean of 5.7 years (range 0.5-16.3 years). Only four patients were treated technically correctly with a planned biopsy followed by a wide resection or amputation. Factors associated with significantly worse prognosis included larger tumor size, metastases at the time of diagnosis, high-grade histology, trunk-related disease, and lack of wide resection as primary surgical treatment. CONCLUSIONS: In SS, metastases develop late with high mortality. Patients with SS should be followed for >10 years.

The iliocapsularis muscle: an important stabilizer in the dysplastic hip.

BACKGROUND: The iliocapsularis muscle is a little known muscle overlying the anterior hip capsule postulated to function as a stabilizer of dysplastic hips. Theoretically, this muscle would be hypertrophied in dysplastic hips and, conversely, atrophied in stable and well-constrained hips. However, these observations have not been confirmed and the true function of this muscle remains unknown. QUESTIONS/PURPOSES: We quantified the anatomic dimensions and degree of fatty infiltration of the iliocapsularis muscle and compared the results for 45 hips with deficient acetabular coverage (Group I) with 40 hips with excessive acetabular coverage (Group II). PATIENTS AND METHODS: We used MR arthrography to evaluate anatomic dimensions (thickness, width, circumference, cross-sectional area [CSA], and partial volume) and the amount of fatty infiltration. RESULTS: We observed increased thickness, width, circumference, CSA, and partial volume of the iliocapsularis muscle in Group I when compared with Group II. Additionally, hips in Group I had a lower prevalence of fatty infiltration compared with those in Group II. The iliocapsularis muscle typically was hypertrophied, and there was less fatty infiltration in dysplastic hips compared with hips with excessive acetabular coverage. CONCLUSION: These observations suggest the iliocapsularis muscle is important for stabilizing the femoral head in a deficient acetabulum. This muscle serves as an anatomic landmark when performing a periacetabular osteotomy. Additionally, preoperative evaluation of morphologic features of the muscle can be used as an adjunct for decision making when treating patients with borderline hip dysplasia or femoroacetabular impingement.

The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity.

BACKGROUND: The prevalence of a cam-type deformity in athletes and its association with vigorous sports activities during and after the growth period is unknown. QUESTIONS/PURPOSES: We therefore compared the prevalence and occurrence of a cam-type deformity by MRI in athletes during childhood and adolescence with an age-matched control group. PATIENTS AND METHODS: We retrospectively reviewed 72 hips in 37 male basketball players with a mean age of 17.6 years (range, 9-25 years) and 76 asymptomatic hips of 38 age-matched volunteers who had not participated in sporting activities at a high level. RESULTS: Eleven (15%) of the 72 hips in the athletes were painful and had positive anterior impingement tests on physical examination. Internal rotation of the hip averaged 30.1° (range, 15°-45°) in the control group compared with only 18.9° (range, 0°-45°) in the athletes. The maximum value of the alpha angle throughout the anterosuperior head segment was larger in the athletes (average, 60.5° ± 9°), compared with the control group (47.4° ± 4°). These differences became more pronounced after closure of the capital growth plate. Overall, the athletes had a 10-fold increased likelihood of having an alpha angle greater than 55° at least at one measurement position. CONCLUSIONS: Our observations suggest a high intensity of sports activity during adolescence is associated with a substantial increase in the risk of cam-type impingement. These patients also may be at increased risk of subsequent development of secondary coxarthrosis. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Long-term outcome after traumatic anterior dislocation of the hip.

INTRODUCTION: Traumatic anterior dislocation of the hip joint is rare. Additional injuries to the hip due to dislocation are even more infrequent. Outcome is limited by osteoarthritic joint degeneration or the occurrence of avascular necrosis of the femoral head. METHOD: Anterior hip dislocation occurred in ten of 100 patients with traumatic hip dislocations (8 men, mean age: 43, 22-62years) at two major trauma centres, between January 2001 and December 2008. Four patients had impaction fractures of the femoral head and three patients had fractures of the anterior acetabular wall. One patient presented with an open dislocation. In three of the ten patients surgical treatment was necessary. RESULTS: Nine patients were evaluated retrospectively at a follow-up of 4.8 ± 2.3 years (mean ± SD). The mean scores were 88 ± 19 (Harris Hip-Score), 15 ± 23 (WOMAC-Score), level 6 (UCLA-Score). Four cases presented with only fair clinical or radiological results according to Epstein. AVN with collapse of the femoral head was observed in one. CONCLUSION: Traumatic anterior hip dislocations presented in six of the ten cases with additional injuries to the hip. Surgical treatment in cases with deep impaction fractures of the femoral head or with large fragments of the acetabulum may improve the outcome.

Femoral cartilage damage occurs at the zone of femoral head necrosis and can be accurately detected on traction MR arthrography of the hip in patients undergoing joint preserving hip surgery.

The primary purpose was to answer the following question: What is the location and pattern of necrosis and associated chondrolabral lesions and can they be accurately detected on traction MR arthrography compared with intra-operative findings in patients undergoing hip preservation surgery for femoral head necrosis (FHN)? Retrospective, diagnostic case series on 23 patients (23 hips; mean age 29 ± 6 years) with diagnosis of FHN undergoing open/arthroscopic joint preserving surgery for FHN and pre-operative traction MR arthrography of the hip. A MR-compatible device for weight-adapted application of leg traction (15-23 kg) was used and coronal, sagittal and radial images were acquired. Location and pattern of necrosis and chondrolabral lesions was assessed by two readers and compared with intra-operative findings to calculate diagnostic accuracy of traction MR arthrography. On MRI all 23 (100%) hips showed central FHN, most frequently antero-superiorly (22/23, 96%) where a high prevalence of femoral cartilage damage was detected (18/23, 78%), with delamination being the most common (16/23, 70%) damage pattern. Intra-operative inspection showed central femoral head cartilage damage most frequently located antero-superiorly (18/23, 78%) with femoral cartilage delamination being most common (14/23, 61%). Traction MR arthrography enabled detection of femoral cartilage damage with a sensitivity/specificity of 95%/75% for reader 1 and 89%/75% for reader 2. To conclude, femoral cartilage damage occurs at the zone of necrosis and can be accurately detected using traction MR arthrography of the hip which may be helpful for surgical decision making in young patients with FHN.

VEGF incorporated into calcium phosphate ceramics promotes vascularisation and bone formation in vivo.

Bone formation and osseointegration of biomaterials are dependent on angiogenesis and vascularization. Angiogenic growth factors such as vascular endothelial growth factor (VEGF) were shown to promote biomaterial vascularization and enhance bone formation. However, high local concentrations of VEGF induce the formation of malformed, nonfunctional vessels. We hypothesized that a continuous delivery of low concentrations of VEGF from calcium phosphate ceramics may increase the efficacy of VEGF administration.VEGF was co-precipitated onto biphasic calcium phosphate (BCP) ceramics to achieve a sustained release of the growth factor. The co-precipitation efficacy and the release kinetics of the protein were investigated in vitro. For in vivo investigations BCP ceramics were implanted into critical size cranial defects in Balb/c mice. Angiogenesis and microvascularization were investigated over 28 days by means of intravital microscopy. The formation of new bone was determined histomorphometrically. Co-precipitation reduced the burst release of VEGF. Furthermore, a sustained, cell-mediated release of low concentrations of VEGF from BCP ceramics was mediated by resorbing osteoclasts. In vivo, sustained delivery of VEGF achieved by protein co-precipitation promoted biomaterial vascularization, osseointegration, and bone formation. Short-term release of VEGF following superficial adsorption resulted in a temporally restricted promotion of angiogenesis and did not enhance bone formation. The release kinetics of VEGF appears to be an important factor in the promotion of biomaterial vascularization and bone formation. Sustained release of VEGF increased the efficacy of VEGF delivery demonstrating that a prolonged bioavailability of low concentrations of VEGF is beneficial for bone regeneration.

Revision of a blade cut-out in PFN-A fixation: Blade exchange, cement augmentation and a cement plug as a successful salvage option.

A potential and feared complication of proximal femur nails with cephalomedullary fixation is migration of the cephalomedullary screw or blade (cut-out or cut-through). In patients not suitable (e.g. low demand, comorbidities) for conversion to total hip arthroplasty blade exchange with cement augmentation may be an option. This article describes the first successful clinical use of a salvage procedure of a previously published technique, which allows the surgeon to avoid intraarticular cement leakage by using a standard cement plug to close the defect in the femoral head.

Cartilage damage in femoroacetabular impingement (FAI): preliminary results on comparison of standard diagnostic vs delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC).

OBJECTIVES: To study the three-dimensional (3D) T1 patterns in different types of femoroacetabular impingement (FAI) by utilizing delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) and subsequent 3D T1 mapping. We used standard grading of OA by Tonnis grade on standard radiographs and morphological grading of cartilage in MRI for comparative analysis. METHODS: dGEMRIC was obtained from ten asymptomatic young-adult volunteers and 26 symptomatic FAI patients. MRI included the routine hip protocol and a dual-flip angle (FA) 3D gradient echo (GRE) sequence utilizing inline T1 measurement. Cartilage was morphologically classified from the radial images based on the extent of degeneration as: no degeneration, degeneration zone measuring <0.75 cm from the rim, >0.75 cm, or total loss. T1 findings were evaluated and correlated. RESULTS: All FAI types revealed remarkably lower T1 mean values in comparison to asymptomatic volunteers in all regions of interest. Distribution of the T1 dGEMRIC values was in accordance with the specific FAI damage pattern. In cam-types (n=6) there was a significant drop (P<0.05) of T1 in the anterior to superior location. In pincer-types (n=7), there was a generalized circumferential decrease noted. High inter-observer (intra-observer) reliability was noted for T1 assessment using intra-class correlation (ICC):intra-class coefficient=0.89 (0.95). CONCLUSIONS: We conclude that a pattern of zonal T1 variation does seem to exist that is unique for different sub-groups of FAI. The FA GRE approach to perform 3D T1 mapping has a promising role for further studies of standard MRI and dGEMRIC in the hip joint.

[Radiological diagnosis of femoroacetabular impingement]. / Radiologische Diagnose des femoroazetabulären Impingements.

Femoroacetabular impingements (FAI) are due to an anatomical disproportion between the proximal femur and the acetabulum which causes premature wear of the joint surfaces. An operation is often necessary in order to relieve symptoms such as limited movement and pain as well as to prevent or slow down the degenerative process. The result is dependent on the preoperative status of the joint with poor results for advanced arthritis of the hip joint. This explains the necessity for an accurate diagnosis in order to recognize early stages of damage to the joint. The diagnosis of FAI includes clinical examination, X-ray examination and magnetic resonance imaging (MRI). The standard X-radiological examination for FAI is carried out using two X-ray images, an anterior-posterior view of the pelvis and a lateral view of the proximal femur, such as the cross-table lateral or Lauenstein projections. It is necessary that positioning criteria are adhered to in order to avoid distortion artifacts. MRI permits an examination of the pelvis on three levels and should also include radial planned sequences for improved representation of peripheral structures, such as the labrum and peripheral cartilage. The use of contrast medium for a direct MR arthrogram has proved to be advantageous particularly for representation of labrum damage. The data with respect to cartilage imaging are still unclear. Further developments in technology, such as biochemical-sensitive MRI applications, will be able to improve the diagnosis of the pelvis in the near future.

Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up.

AIMS: The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE. PATIENTS AND METHODS: We performed a retrospective analysis involving 46 hips in 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips were available for clinical and radiological examination. Mean preoperative age was 13 years, and 14 hips (30%) presented with unstable slips. Mean preoperative slip angle was 64°. Kaplan-Meier survivorship was calculated. RESULTS: At the latest follow-up, the mean Merle d'Aubigné and Postel score was 17 points (14 to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean Hip Disability and Osteoarthritis Outcome Score was 91 points (67 to 100). Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression of osteoarthritis (OA). Two hips (5%) developed AVN of the femoral head and required further surgery. Three other hips (7%) underwent implant revision due to screw breakage or change of wires. Cumulative survivorship was 86% at ten-year follow-up. CONCLUSION: The modified Dunn procedure for severe SCFE resulted in a low rate of AVN, low risk of progression to OA, and high functional scores at long-term follow-up. The slip deformities were mainly corrected but secondary impingement deformities can develop in some hips and may require further surgical treatment. Cite this article: Bone Joint J 2019;101-B:403-414.

Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland.

OBJECTIVE: To analyse the epidemiological data, injury pattern, clinical features and mechanisms of severe spinal injuries related to alpine skiing and snowboarding. STUDY DESIGN: A six-year review of all adult patients with severe spinal injuries sustained from alpine skiing or snowboarding. SETTING: Tertiary trauma centre in Bern, Switzerland. PATIENTS AND METHODS: All adult patients (over 16 years of age) admitted to a tertiary trauma centre from 1 July 2000, through 30 June 2006, were reviewed using a computerised database. From these records, a total of 728 patients injured from snow sports were identified. Severe spinal injuries (defined as spinal fractures, subluxations, dislocations or concomitant spinal cord injuries) were found in 73 patients (17 female, 56 male). The clinical features of these patients were reviewed with respect to epidemiological factors, mechanism of injury, fracture pattern, and neurological status. RESULTS: The majority of severe spinal injuries (n = 63) were related to skiing. Fatal central-nervous injuries and transient or persistent neurological symptoms occurred in 28 patients (23 skiers, 5 snowboarders). None of the snowboarders suffered from persistent neurological sequelae. Snowboarders with severe spinal injuries (n = 10) were all male (p<0.05), and were significantly younger than skiers (p<0.001). The most commonly affected site was the lumbar spine. However, 39 patients (53.4%) suffered from injury pattern at two or more levels. CONCLUSIONS: With advances in technology and slope maintenance, skiers and snowboarders progress to higher skill levels and faster speeds more rapidly than ever before. Great efforts have been focused on reducing extremity injuries in snow sports, but until recently very little attention has been given to spinal injury prevention on the slopes. Suggestions for injury prevention include the use of spine protectors, participation on appropriate runs for ability level, proper fit and adjustment of equipment, and taking lessons with the goal of increasing ability and learning hill etiquette.

Hip2Norm: an object-oriented cross-platform program for 3D analysis of hip joint morphology using 2D pelvic radiographs.

We developed an object-oriented cross-platform program to perform three-dimensional (3D) analysis of hip joint morphology using two-dimensional (2D) anteroposterior (AP) pelvic radiographs. Landmarks extracted from 2D AP pelvic radiographs and optionally an additional lateral pelvic X-ray were combined with a cone beam projection model to reconstruct 3D hip joints. Since individual pelvic orientation can vary considerably, a method for standardizing pelvic orientation was implemented to determine the absolute tilt/rotation. The evaluation of anatomically morphologic differences was achieved by reconstructing the projected acetabular rim and the measured hip parameters as if obtained in a standardized neutral orientation. The program had been successfully used to interactively objectify acetabular version in hips with femoro-acetabular impingement or developmental dysplasia. Hip(2)Norm is written in object-oriented programming language C++ using cross-platform software Qt (TrollTech, Oslo, Norway) for graphical user interface (GUI) and is transportable to any platform.

The modified Dunn procedure for slipped capital femoral epiphysis: the Bernese experience.

PURPOSE: Based on previous investigations on the vascular blood supply to the femoral head, a technique for anatomical reduction after slipped capital femoral epiphysis was developed. This technique is a modification of the original technique by Dunn using a retinacular soft-tissue flap. This allows the visual control of the epiphyseal vascular blood supply. We report the experience at the inventor's institution with a critical discussion of the available literature. METHODS: Using a trochanteric osteotomy for surgical dislocation of the hip, a retinacular soft tissue flap is created containing the deep branch of the medial femoral circumflex artery, the external rotators and the capsule. The femoral epiphysis can be mobilised safely and reduced on the femoral neck after resection of the almost constantly present reactive metaphyseal callus. RESULTS: In our institution, the rate of avascular necrosis with 2% is comparably low to Dunn's original results. It is only present in cases where no bleeding was already evident before reduction of the epiphysis. The ten-year long-term results are favorable in these cases with a good functional result and only little progression of osteoarthritis. However, other authors have reported higher rates of avascular necrosis up to 24% in their initial experience. CONCLUSIONS: In experienced hands using the correct meticulous surgical technique, the results are favorable regarding the rates of avascular necrosis, the functional outcome and the development of radiographic osteoarthritis - even in acute and severe cases. Avascular necrosis is rare but can be observed if there is no evidence of intra-operative femoral head perfusion before and after reduction of the epiphysis.

Patients undergoing surgical hip dislocation for the treatment of acetabular fractures show favourable long-term outcome.

AIMS: The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome. PATIENTS AND METHODS: We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (sd) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (sd 3). RESULTS: Clinical grading was assessed using the modified Merle d'Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d'Aubigné score of < 15 and/or progression of osteoarthritis. CONCLUSION: The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508-15.