Preoperative Gallows traction as an adjunct to hip open reduction surgery: Is it safe and is it effective?

Background: Traction is used at our hospital before open reduction in infants with developmental dysplasia of the hip. Theoretically, it reduces soft-tissue tension, allowing an easier surgical reduction and therefore lower surgical complications. Owing to extended hospital stays, potential complications, and lack of evidence, the use of traction has decreased. This study aims to quantify whether traction is safe and whether it has any demonstrable effect. Methods: The perioperative course of 80 patients undergoing preoperative traction and hip open reduction were reviewed. The height of hip dislocation was classified using the International Hip Dysplasia Institute classification system on both radiographs taken before and after traction. Any complications related to traction were recorded, along with the requirement for femoral shortening osteotomies, incidence of re-dislocation, and longer-term rate of avascular necrosis. Results: Traction lowered the resting position of the majority of hips, with the median International Hip Dysplasia Institute grade before traction improving from 4 to 3, a statistically significant improvement (p < 0.00001). There were no neurovascular complications. Two babies were complicated with broken skin sores; however, surgery still progressed uneventfully. Zero hips in the cohort required femoral shortening osteotomies to achieve a tension-free reduction, and the re-dislocation rate was 0%. However, 96% of hips were Severin 1 or 2 at 6-year follow-up. Conclusion: Notably, 1 week of preoperative traction significantly improves the resting position of the hip in high dislocations. It is safe when used in infants weighing <12 kg, and subsequent surgical outcomes are excellent, thus supporting its use ahead of developmental dysplasia of the hip open reduction surgery. Level of evidence: Level IV.

Fibular Grafting: A Worthwhile skill to Master for Difficult neck of Femur Fractures - A Case Series.

Introduction: Neck of femur fractures (NOF) in younger adults are often treated by head-preserving fixation procedures. Non-union is an infrequent but troublesome complication following internal fixation, especially in atypical presentations. Vascularized (VFG) and non-VFG (NVFG) fibular grafting and realignment procedures have been described as an adjunct to internal fixation. Reports are rare regarding the versatility of fibular grafts, their use, and their outcomes in the United Kingdom. Case Report: We present three complex NOF cases performed in the United Kingdom. One case is a 29-year-old Asian female treated with NVFG for a pathological transverse NOF fracture secondary to fibrous dysplasia. One case is a non-union following failed surgical management and revised using NVFG and dynamic hip screws. The last case is a VFG in a complex non-union intra-capsular fracture following conservative management in a 17-year-old male. Certain patient characteristics are described which make joint preserving surgery more attractive. All fractures united with no revisions at the time of final follow-up. Distinctions between the use of VFG and NVFG grafts are discussed. Conclusion: This case series demonstrates the important versatility of fibular grafting and how its properties are used in different cases. Fibular grafting is an effective technique in pathological, non-union, and late-presenting NOF. Both types of grafts introduce additional biology for difficult cases where neck resorption and adequate fixation are an issue, with NVFG grafts much easier to perform.