Surgical treatment of late developmental displacement of the hip. Results after 33 years.

The outcome of displaced hips treated by Somerville and Scott's method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change. The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

Reliability of the Severin classification in the assessment of developmental dysplasia of the hip.

This study was undertaken to investigate the reliability of Severin's classification at various ages, and to determine whether the reliability is improved by careful measurement rather than subjective assessment. The radiographs taken at ages 6, 10 and 16 years of 20 randomly selected patients treated for developmental dysplasia of the hip were graded by six observers on two separate occasions using parameters measured according to Severin's criteria. In addition, four of these observers regraded the same radiographs using subjective assessment without measurements being made on two other separate occasions. Agreements between and within observers were evaluated using the weighted Cohen's kappa statistic for each age group. Intraobserver reliability was good, there being a close association between the measured and the subjectively observed ratings. This accords with the subjective nature of this classification. The interobserver reliability was found to be poor although it improved when direct measurements were made. Overall agreement between observers improves as patient age increases. It is concluded that comparisons between different observers using the Severin classification system are not reliable. However, a single investigator comparing treatment modalities in the same study allowing for individual bias in assessing deformity and subluxation would produce reliable results.

Acetabular dysplasia and failure of development of the ischiopubic synchondrosis: a report of three related cases.

Three cases of acetabular dysplasia associated with failed ossification of the ischiopubic synchondrosis are presented. The patients are second-degree relatives and all skeletally mature with no evidence of other pathological process to delay ossification. A summary of the development of the inferior pubic ramus is presented and the literature of this unusual condition is reviewed.

The reliability of measurements of pelvic radiographs in infants.

We have evaluated the reliability of the measurement of radiological indicators in developmental dysplasia of the hip. Three observers each independently assessed 60 pelvic radiographs from infants aged from 3 to 36 months. Errors from the true value of a single measurement made by a single observer (E1), of the average of two measurements by a single observer (E2), and of the average of two single measurements by two different observers (E3) were established for the acetabular index of Hilgenreiner, for the assessment of superior and lateral femoral displacement and for indicators of pelvic alignment. The errors for the assessment of the acetabular index were E1 +/- 5 degrees, E2 +/- 5 degrees, and E3 +/- 3.5 degrees. There was a significant correlation between the presence of an acetabular notch on the radiograph and an increased error in measurement (p = 0.01). Yamamuro's measurement of lateral femoral displacement was more reliable than the Hilgenreiner distance. The errors of indicators of pelvic alignment showed a correlation with the age of the infant; the quotient of pelvic rotation was more reliable after seven months of age (p < 0.0001). The errors of the measurement of the symphysis os-ischium angle tended to increase with age and those of the measurement of the index of pelvic tilt decreased with skeletal maturation (p = 0.002).

Unreamed nailing of tibial shaft fractures in multiply injured patients.

In a prospective study, 63 tibial shaft fractures were managed by intramedullary nailing with a solid nail inserted without reaming. The patients were followed to union or a definitive outcome (non-union or death). Three patients died early in the post operative course as a result of other injuries. This left 60 nails in the series for complete follow up. Eighty-two per cent of the fractures were the result of motor vehicle accidents, 44 nails were inserted within 72 h of injury. Fifty-six fractures united (93%) at a mean of 21.1 weeks (8-52). There were 4 non-unions among this population of multiply injured patients. All closed fractures united at a mean of 19.5 weeks. Those nailed acutely united at a mean of 16.8 weeks. The open fracture group (classified according to Gustilo and Anderson) included the 4 non-unions (2 type II, 1 type IIIa and 1 type IIIb). A union rate of 86.2% was achieved in these fractures. All type I fractures united. One deep infection occurred in the series. The major complication identified in the current series was failure of the distal cross bolts.