An in-depth analysis of young adults with osteonecrosis secondary to developmental dysplasia of the hip who underwent total hip arthroplasty.

BACKGROUND: Patients with osteonecrosis of the femoral head secondary to DDH frequently require total hip arthroplasty (THA), but it is not well understood which factors necessitate this requirement. We determined the incidence of THA in patients who have osteonecrosis secondary to DDH and factors associated with need for THA. METHODS: We included patients who received closed or open reductions between 1995 and 2005 with subsequent development of osteonecrosis. We determined osteonecrosis according to Bucholz and Ogden; osteoarthritis severity (Kellgren-Lawrence), subluxation (Shenton's line); neck-shaft angle; and acetabular dysplasia (centre-edge and Sharp angles). We also recorded the number of operations of the hip in childhood and reviewed case notes of patients who received THA to describe clinical findings prior to THA. We assessed the association between radiographic variables and the need for THA using univariate logistic regression. RESULTS: Of 140 patients (169 hips), 22 patients received 24 THA (14%) at a mean age of 21.3 ± 3.7 years. Associated with the need for THA were grade III osteonecrosis (OR 4.25; 95% CI 1.70-10.77; p = 0.0019), grade IV osteoarthritis (21.8; 7.55-68.11; p < 0.0001) and subluxation (8.22; 2.91-29.53; p = 0.0003). All patients who required THA reported at least 2 of: severe pain including at night, stiffness, and reduced mobility. Acetabular dysplasia and number of previous operations were not associated with the need for THA. CONCLUSIONS: We identified a 14% incidence of THA by age 34 years in patients with osteonecrosis secondary to DDH. Grade III osteonecrosis (global involvement femoral head and neck) was strongly associated with THA, emphasising the importance to avoid osteonecrosis when treating DDH.

The Importance of Monitoring and Factors That May Influence Leg Length Difference in Developmental Dysplasia of the Hip.

In unilateral Developmental Dysplasia of the Hip (DDH), avascular necrosis (AVN), femoral or pelvic osteotomy, and residual dysplasia causing subluxation of the proximal femur may influence Leg Length Discrepancy (LLD). This can lead to gait compensation, pelvic obliquity, and spinal curvature. The aim of this study is to determine the prevalence of LLD, establish which limb segment contributes to the discrepancy, describe how AVN influences LLD, and ascertain variables that may influence the need for LLD corrective procedures. METHODOLOGY: This study assessed long-leg radiographs at skeletal maturity. Radiographs were assessed for the articulo-trochanteric distance (ATD) and femoral and tibial length. AVN was classified according to Kalamchi-MacEwen. RESULTS: 109 patients were included. The affected/DDH leg was longer in 72/109 (66%) patients. The length difference was mainly in the subtrochanteric segment of the femur. AVN negatively influenced leg length. Older (≥three years) patients with multiple procedures were more likely to have AVN. LLD interventions were performed in 30 (27.5%) patients. AVN grade or type of DDH surgery did not influence the odds of needing a procedure to correct LLD. CONCLUSIONS: Procedures to correct LLD were performed irrespective of previous DDH surgery or AVN grades. In most patients, the affected/DDH leg was longer, mainly in the subtrochanteric segment of the femur, largely influenced by femoral osteotomy in patients with multiple operative procedures for DDH. We recommend careful monitoring of LLD in DDH.

Tension-band Plating for Leg-length Discrepancy Correction.

Aim: Dual tension-band plates are used for temporary epiphysiodesis and longitudinal guided growth. The study aim was to assess rate of correction, to identify development of femoral and tibial intra-articular deformity during correction and to document resumption of growth after plate removal. Materials and methods: A retrospective study of 34 consecutive patients treated with dual tension-band plates between 2012 and 2020 was performed. Twenty-four patients had surgery at the distal femur, six at the proximal tibia and four at both. Twenty-five female patients were treated at a mean age of 11.6 (±1.4) years and nine male patients at 13.5 (±1.5) years. Measurements were performed on standardised long-leg radiographs and included leg-length discrepancy (LLD), joint line congruency angle (JLCA), tibial roof angle, femoral floor angle and notch-intercondylar distance. Measurements were taken pre-operatively, at the end of discrepancy correction and at skeletal maturity. Results: The LLD reduced by a mean of 12.9 mm (95% CI 10.2-15.5) with the mean residual difference 8.4 mm (95% CI 5.4-11.4). The mean correction rate for the proximal tibia was 0.40 (SD 0.33) mm/month and 0.68 (SD 0.36) mm/month for the distal femur. A significant mean change in residual LLD [-2.5 mm (95% CI -4.2 to -0.7)] was observed between plate removal and skeletal maturity at the femoral level only. After length discrepancy correction, the tibial roof angle showed a significant difference of 8.4° (95% CI 13.4-3.4) between legs. In femoral epiphysiodesis patients, no important differences were observed. Conclusion: A significant reduction in LLD can be achieved using dual tension-band plating. A change in intra-articular morphology was observed only in the proximal tibia and not in the distal femur. In the authors' opinion, tension-band plating is a useful tool for leg-length equalisation but should be reserved for younger patients or when residual growth is difficult to predict. It is one of the management strategies for limb-length difference prior to skeletal maturity. How to cite this article: Tolk JJ, Merchant R, Calder PR, et al. Tension-band Plating for Leg-length Discrepancy Correction. Strategies Trauma Limb Reconstr 2022;17(1):19-25.

Leg length discrepancy in patients with Perthes' disease : a note of caution for the arthroplasty surgeon.

AIMS: Perthes' disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths. METHODS: All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. RESULTS: Overall, 79 patients were included, of whom 21 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort, the mean LLD was 1.8 cm (95% confidence interval (CI) 1.5 to 2.0), mean ATD difference was 1.8 cm (95% CI -2.1 to -1.9), and mean subtrochanteric difference was -0.2 cm (95% CI -0.4 to 0.1). In the epiphysiodesis group, the mean LLD before epiphysiodesis was 2.7 cm (95% CI 1.3 to 3.4) and 1.3 cm (95% CI -0.5 to 3.8) at skeletal maturity. In the nonepiphysiodesis group the mean LLD was 2.0 cm (95% CI 0.5 to 5.1; p = 0.016). The subtrochanteric region on the PD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the nonepiphysiodesis group (-1.0 cm (95% CI -2.4 to 0.6) vs 0.1 cm (95% CI -1.0 to 2.1); p < 0.001). CONCLUSION: This study demonstrates that LLD after PD originates from the proximal segment only. In patients who had contralateral epiphysiodesis to balance leg length, this is achieved by creating a difference in subtrochanteric length. Arthroplasty surgeons need to be aware that shortening of the proximal femur segment in PD patients may be misleading, as the ipsilateral subtrochanteric length in these patients can be longer. Therefore, we strongly advise long-leg standing films for THA planning in PD patients in order to avoid inadvertently lengthening the limb. Cite this article: Bone Joint J 2021;103-B(11):1736-1741.

Patient-reported outcomes in young adults with osteonecrosis secondary to developmental dysplasia of the hip - a longitudinal and cross-sectional evaluation.

BACKGROUND: Osteonecrosis of the femoral head is a common complication in the treatment of developmental dysplasia of the hip (DDH). While functional outcomes of affected patients are good in childhood, it is not clear how they change during the transition to young adulthood. This study determined the relationship between osteonecrosis and hip function, physical function and health status in adolescents and young adults. METHODS: We performed a cross-sectional study of 169 patients with a mean age of 19.7 ± 3.8 years with and without osteonecrosis following an open or closed reduction (1995-2005). We also performed a separate longitudinal evaluation of an historical cohort of 54 patients with osteonecrosis, embedded in this sample. All completed patient-reported outcome measures in 2015/2016 to quantify hip function (maximum score 100); physical function (maximum score 100); and general health status (maximum score 1). We graded all radiographs for subtype of osteonecrosis (Bucholz-Ogden); acetabular dysplasia (centre-edge angle); subluxation (Shenton's line); and osteoarthritis (Kellgren-Lawrence). Analyses were adjusted for the number of previous surgical procedures on the hip and for the severity of residual hip dysplasia. RESULTS: In 149 patients (186 hips) with and without osteonecrosis, the mean differences (95% confidence interval) in hip function, physical function and quality of life were - 4.7 (- 10.26, 0.81), - 1.03 (- 9.29, 7.23) and 0.10 (- 1.15, 1.18), respectively. Adjusted analyses stratified across types of osteonecrosis showed that only patients with Bucholz-Odgen grade III had reduced hip function (p < 0.01) and physical function (p < 0.05) but no difference in health-related quality of life when compared to no osteonecrosis. CONCLUSION: Osteonecrosis secondary to DDH is a relatively benign disorder in adolescents and young adulthood. Affected patients demonstrated minimal physical disability, a normal quality of life but reduced hip function.

The Development of Leg Length Difference and Influence on Persistent Dysplasia in Patients with Developmental Dysplasia of the Hip.

INTRODUCTION: Leg-length difference (LLD) is common in patients with developmental dysplasia of the hip (DDH). LLD of > 1 cm at skeletal maturity is reported in > 40% of patients, with the majority related to ipsilateral overgrowth. A longer DDH leg might lead to excessive mechanical loading at the acetabular margin, resulting in compromised acetabular development. We hypothesised that the LLD would negatively influence acetabular development. If so, it would be advantageous to identify such patients early in the course of follow-up, and address this if necessary. METHODS: A retrospective study was conducted on a consecutive series of DDH patients managed surgically at the Royal National Orthopaedic Hospital, Stanmore, United Kingdom. We included patients with adequate long-leg radiographs at the age of 4-8 years (early-FU) and skeletal maturity (final-FU). Bilateral cases and those who underwent surgical procedures for hip dysplasia during the follow-up period were excluded. Measurements including leg length and centre-edge-angle (CE-angle) were obtained at the 2 time points. RESULTS: Twenty-seven patients were included, mean age at early-FU 5.7 (± 0.9) years, and 13.9 (± 1.0) years at final-FU. Mean LLD at early-FU was 9.5 (± 7.6) mm and 10.9 (± 9.4) mm at final-FU, p = 0.337. Correlation between early- and final-FU LLD was 0.68 (p < 0.001). The mean CE-angle at early follow-up was 14.6° (± 9.8), this improved to 23.2° (± 8.2) at skeletal maturity (p = 0.003, paired samples t-test). Linear regression analysis showed a non-significant trend towards less CE-angle improvement in patients with more initial residual dysplasia and more initial LLD. CONCLUSION: Most leg-length differences can be identified early in the follow-up period, nevertheless, considerable individual changes in LLD are observed on continued follow-up. Furthermore, a trend was observed towards impaired acetabular improvement in patients with more LLD. These findings justify careful clinical and radiological monitoring of LLD from an early stage in the follow-up period. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00492-5.

Early to medium-term outcomes of uncemented ceramic-bearing total hip arthroplasty in teenagers for paediatric hip conditions.

AIMS: Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients. METHODS: Surgery was performed by a single surgeon working in the paediatric orthopaedic unit of a tertiary referral hospital. Databases were interrogated from 2003 to 2017 for all teenage patients undergoing THA with a minimum 2.3 year follow-up. Data capture included patient demographics, the underlying hip pathology, number of previous surgeries, and THA prostheses used. Institutional ethical approval was granted to contact patients for prospective clinical outcomes and obtain up-to-date radiographs. In total, 60 primary hips were implanted in 51 patients (35 female, 16 male) with nine bilateral cases. The mean age was 16.7 years (12 to 19) and mean follow-up was 9.3 years (2.3 to 16.8). RESULTS: The most common indication for teenage hip arthroplasty was avascular necrosis secondary to slipped upper femoral epiphysis (31%; n = 16). Overall, 64% of patients (n = 33) had undergone multiple previous operations. The survival at follow-up was 97%; two patients required revision for aseptic loosening (one femoral stem, one acetabular component). Both patients had fused hips noted at the time of arthroplasty. A further two patients had radiolucent lines but were asymptomatic. At latest follow-up the mean Oxford Hip Score was 44 (31 to 48) and a Visual Analogue Scale measurement of 1.5, indicating satisfactory function. CONCLUSION: Operating on this cohort can be complicated by multiple previous surgeries and distorted anatomy, which in some cases require custom-made prostheses. We have demonstrated a good outcome with low revision rate in this complex group of patients. Cite this article: Bone Joint J 2020;102-B(11):1491-1496.

Surgical management of chronic pelvic instability following periacetabular osteotomy nonunion.

INTRODUCTION: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia in skeletally mature individuals without arthritis. Pelvic nonunion and associated stress fractures are under-reported. Nonunited stress fractures can cause continued buttock pain and pelvic instability. The aim of this study is to report on our experience managing patients with ongoing pain following nonunion of PAO. PATIENTS AND METHODS: 8 patients presented to a tertiary referral pelvic service with symptomatic PAO nonunion between 2015-2018. All patients underwent open reduction internal fixation of the superior pubic ramus nonunion, with ipsilateral iliac autograft, at an average of 48.1 (15-82) months following initial osteotomy. Demographic and perioperative data were recorded. Follow-up was on average to 9.9 months, once union was confirmed radiographically. RESULTS: All patients were female and average age was 31.8 (18-41) years. In 7/8 (87.5%) patients a modified Stoppa approach was successfully utilised. 1 patient required an ilioinguinal approach due to the amount of rotational correction. All patients went on to union at the superior pubic ramus and reported improvement in mechanical symptoms. 5/8 (62.5%) patients were noted to develop union of the posterior column or inferior pubic ramus stress fracture indirectly. 2/8 (25%) patients developed progression of intra-articular pain, despite restoration of pelvic stability. 1 patient required intraoperative transfusion due to femoral vein injury. There were no other complications seen in this series. CONCLUSIONS: To our knowledge, this is the largest case series of surgically managed PAO nonunion. Pelvic instability resulting from nonunion and stress fracture can be satisfactorily addressed by mobilising, grafting and plating the nonunion at the superior pubic ramus. The modified Stoppa approach is suitable in most cases, allowing excellent exposure whilst minimising the insult to soft tissues. The altered anatomy of the pelvis following PAO should be anticipated to reduce the risk to nearby neurovascular structures.

Bilateral Developmental Dysplasia of the Hip: Does Closed Reduction Have a Role in Management? Outcome of Closed and Open Reduction in 92 Hips.

BACKGROUND: Bilateral developmental dysplasia of the hip (DDH) is believed to have a worse outcome than unilateral DDH with the optimal treatment unclear. To define indications for treatment we report a retrospective series of 92 hips (46 patients) who underwent closed reduction (CR) and/or open reduction (OR). METHODS: A total of 58 hips in 29 patients underwent attempted CR using our standardized protocol. In the same 12 year time period, 54 hips in 27 patients underwent an OR. Outcome measures included resolution of acetabular dysplasia, need for further surgery, development of osteonecrosis (ON), and modified Severin Grade. RESULTS: CR was successful in 57% of hips; in this group secondary surgery was required in 15% and ON was seen in 12%. In the OR group, 11% failed to stabilize and required further early surgery: ON rate was 15% overall, and secondary surgery was required in 5%. In Tonnis 2/3 hips younger than 2 years, Severin grading was comparable following CR and OR, with 92% and 90% graded as Severin 1, respectively. The rate of significant ON was higher after CR in Tonnis 2/3 hips (12%) than after OR (0%). Overall, Tonnis 4 hips did badly: 94% failed CR and following OR, further surgery for redislocation/residual dysplasia was required in 21%. CONCLUSIONS: CR can be successful in Tonnis 2/3 bilateral hips, with acceptable rates of secondary surgery, ON, and Severin grading, the latter equivalent to open reduction. Importantly, persisting with casting of a unilateral dislocation, to allow the contra-lateral hip to stabilize, does not have an adverse effect. CR is not advised in Tonnis 4 bilateral hips. Parents should be counseled that the outcome of surgery for bilateral hips is not as good as for unilateral DDH, particularly for Tonnis 4 hips which are more difficult to stabilize and more likely to require supplementary surgery even after open reduction. LEVEL OF EVIDENCE: Level IV-Therapeutic Study.

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation.

PURPOSE: Proximal femoral excision is a salvage procedure for painful chronic hip dislocation in cerebral palsy (CP) patients. The primary objective of this article is to describe our experience of an amplified interposition myoplasty, with appropriate peri-operative pain and tone management strategies, in a cohort of non-ambulatory CP patients with painful chronic hip dislocation. Our secondary objective is to present the clinical outcomes of these patients. METHODS: We describe our experience in 20 CP patients (25 procedures) at mean 54-month (range 27-169) follow-up with a surgical technique that includes an augmented interposition myoplasty and tone management. The indications for surgery were pain (21 hips), poor sitting tolerance (11) and difficulty with perineal care (8). RESULTS: The mean age was 22 years (range 10-40) with 11 patients Gross Motor Function Classification Scale (GMFCS) IV and 9 patients GMFCS V. Mean length of stay was 13 days (3-35). One procedure required revision at 12 months. Mean pain score improved from 7.8 (5-10) pre-operatively to 2.8 (1-5) post-operatively (p < 0.001). Sitting tolerance improved in all patients and in 75 % (15) perineal care was easier. CONCLUSIONS: Our interposition myoplasty technique with individualised pain/tone management has good outcomes in this cohort of patients with multiple co-morbidities.

Genetic skeletal dysplasias: a guide to diagnosis and management.

The skeletal dysplasias are a large, heterogeneous group of genetic disorders characterised by abnormal growth, development and remodelling of the bones and cartilage that comprise the human skeleton. They typically present with disproportionate short stature in childhood, or premature osteoarthritis in adulthood. The latest classification lists 456 disorders under 40 group headings differentiated by specific clinical, radiographic and molecular criteria. Establishing an accurate diagnosis is important to predict final height, expected complications and treatment, and for specific genetic and psychological counselling. In addition to the skeletal disorder, individuals frequently demonstrate abnormalities of hearing, vision, neurological, pulmonary, renal or cardiac function that require multidisciplinary assessment. This review provides a guide to diagnosis and discusses management principles for the common limb and spinal abnormalities that affect quality of life for the majority.

Idiopathic chondrolysis of the hip: presentation, natural history and treatment options.

Idiopathic chondrolysis of the hip is a rare disorder characterized by pain, stiffness, limp and radiological loss of joint space of the affected hip. The clinical outcome varies from complete recovery to fibrous ankylosis. Management remains controversial. We aim to outline the natural history and pathology of the disease and treatment strategies.

Custom cementless THA in patients with Legg-Calve-Perthes Disease.

Legg-Calve-Perthes disease is characterized by osteonecrosis of the femoral head during childhood. Outcomes of total hip arthroplasty (THA) for these patients are less satisfactory than for those with primary osteoarthritis, often complicated by young patient age, multi-planar deformities and previous childhood surgery. To our knowledge no one has reported the long-term outcomes of cementless custom-made THA in patients with Legg-Calve-Perthes disease. We reviewed 15 THAs with an average follow-up of ten years. Survivorship rates of the femoral and acetabular components were 100% and 79% respectively. Mean Harris Hip Scores improved from 41 preoperatively to 80 at final follow-up. With excellent functional outcome, custom-made cementless prostheses should be considered as a treatment option for osteoarthritis secondary to Legg-Calve-Perthes disease in the presence of abnormal proximal femoral and acetabular anatomy.

Surveillance after treatment of children with developmental dysplasia of the hip: current UK practice and the proposed Stanmore protocol.

Monitoring of a patient with developmental dysplasia of the hip (DDH) is required after initial treatment to ensure early detection and correction of complications or poor progression. We established the current practice of surveillance in DDH in the UK. A protocol has been designed at this unit with the aim of identifying the stages in the progression of DDH when imaging of the hip is necessary to detect failure or possible complications of treatment. The outcomes and secondary procedure rates under the surveillance protocol used at this unit, for a UK population, have been reviewed with a minimum of 5 years of follow-up. Frequency of follow-up has been reported as yearly or more frequently until skeletal maturity by 70% of respondents. Ninety patients presenting with DDH were managed under the protocol developed at this unit, with equivalent outcomes as those in patients who reported yearly follow-up. Following our proposed protocol we believe it is possible to limit disruption to the patient's life, reduce costs and maintain compliance and ensure timely detection of any complications, without significant increase in secondary procedure rates.

The Bernese peri-acetabular osteotomy through a modified approach. A technical note.

INTRODUCTION: A modification of the technique for performing the Bernese periacetabular osteotomy is described. MATERIALS AND METHODS: A medial approach to the Ischium and a subtle re-orientation of the pubic osteotomy are detailed. CONCLUSION: Surgical morbidity is likely decreased with a concurrent cosmetic advantage without compromise to surgical correction or patient safety.

Resurfacing hip arthroplasty in neuromuscular hip disorders - A retrospective case series.

BACKGROUND: Management of the degenerate hip in patients with neuromuscular conditions should be aimed at improving quality of life and ease of nursing care. Arthroplasty poses a significant challenge with predisposition to dislocation and loosening due to anatomical abnormalities, soft tissue contractures and impaired muscle tone. METHODS: We present a series of 11 hips (9 patients) following total hip resurfacing arthroplasty for painful osteoarthritis in patients with differing neuromuscular conditions. Patients were assessed clinically and radiographically and also for satisfaction of their carers due to improved ability to provide nursing care. Mean patient age was 33.1 years (range 13-49 years) with mean follow up at publication 63.7 months (41-89 months). All patients were operated by a single surgeon (AHN) and received the required post operative care and physiotherapy. Soft tissue releases were performed when necessary. All hips were assessed clinically and radiographically at 6 weeks and 6 months and 1 year post-operatively. Six month follow-up also included a questionnaire with scoring of care-provider satisfaction. RESULTS: Ten hips had good clinical results with improvement in pain and function and radiologically showed no signs of loosening. One hip required revision to proximal femoral excision due to dislocation and loose acetabular component with severe pain. None of the other hips dislocated. Analysis of care provider satisfaction assessing ability to provide personal care, positioning and transferring, comfort, interaction and communication scored excellent to good in 10 patients and satisfactory in one. CONCLUSION: We believe hip resurfacing arthroplasty to be a viable option in the treatment of the complex problem of osteoarthritis in the hips of patients with neuromuscular disease. The improved biomechanics confer greater stability when compared to conventional total hip arthroplasty. Although technically demanding, a successful result has been shown to improve patient pain, function and ease of nursing care. LEVEL OF EVIDENCE: Level IV.

Total hip arthroplasty in teenagers: an alternative to hip arthrodesis.

Debilitating arthritis in teenage patients is a complex problem with limited surgical options. Hip arthrodesis is unpopular amongst patients, and contemporary total hip arthroplasty (THA) may be a promising alternative. We report on the outcomes of THA in patients less than 20 years of age. All consecutive teenage patients undergoing THA at a tertiary referral centre were reviewed. Mean follow-up was 3.4 years (range 0.6-6.8) and 9 patients had at least 5 years follow-up. There were 51 THAs in 43 patients with a mean age of 17 years (range 12-19). The commonest indication was osteonecrosis (35 cases), mostly secondary to slipped upper femoral epiphysis (15 cases). Forty-six were uncemented and 5 were reverse hybrid THAs of which 7 were computer assisted design/manufacture (CADCAM) components. The commonest bearing surface used was ceramic on ceramic (40 cases). The survival rate was 96% and there were 2 complications. At latest follow-up, the mean Harris hip score was 90 (range 68-99) and UCLA activity score was 6 (range 4-9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. We report good short to intermediate term survivorship and outcomes, and feel THA represents a valid alternative option to hip arthrodesis.