Comparing the Pemberton osteotomy and modified San Diego acetabuloplasty in developmental dysplasia of the hip.

PURPOSE: Patients with developmental dysplasia of the hip (DDH) may require a pelvic osteotomy to treat acetabular dysplasia. The Pemberton osteotomy and modified San Diego acetabuloplasty are two options available when surgically treating DDH. The purpose of this study was to compare outcomes following the Pemberton and modified San Diego when treating patients with acetabular dysplasia in typical DDH. METHODS: We included 45 hips in the modified San Diego group and 38 hips in the Pemberton group. Hips with less than two years follow-up and patients with a neuromuscular diagnosis were excluded. Clinical outcomes were rated using the modified McKay criteria with radiographic outcomes graded using the Severin score. Avascular necrosis (AVN) was assessed using the Kalamchi and MacEwen criteria. RESULTS: Mean follow-up was 4.9 years (2.1 to 11.2). Both procedures produced similar decreases in the acetabular index (modified San Diego: 17.0˚ versus Pemberton: 15.2˚; p = 0.846). Most hips had good/excellent results using the modified McKay criteria (modified San Diego: 78%, Pemberton: 94%; p = 0.055). Most hips were rated as good/excellent on the Severin scale (modified San Diego: 100%, Pemberton: 97%, p = 0.485). The proportion of hips with AVN grade 2 or higher were similar between groups (modified San Diego: 0%, Pemberton: 3%; p = 0.458). CONCLUSION: The modified San Diego acetabuloplasty is a safe and effective alternative to treat acetabular dysplasia in patients with typical DDH. By maintaining an intact medial cortex, acetabular reshaping can be customized to address each patient's specific acetabular deficiency. LEVEL OF EVIDENCE: Level III retrospective comparison.

Should paediatricians initiate orthopaedic hip dysplasia referrals for infants with isolated asymmetric skin folds?

PURPOSE: Asymmetric skin folds (ASFs) have been linked to developmental dysplasia of the hip (DDH) in select studies, leading to their inclusion in paediatric practice guidelines regarding orthopaedic referral for hip evaluation. The purpose of this study was to investigate the utility of isolated ASFs as a screening tool for DDH in a series of patient referrals evaluated at a single institution. METHODS: We performed a retrospective review of consecutive patients between 0 and 12 months of age referred to orthopaedic clinics for isolated ASFs. We recorded radiographic findings (acetabular inclination or alpha angle), diagnosis rendered and treatment administered. RESULTS: A total of 66 patients were included (mean age 6.4 months; 2.47 to 10.76). All patients received pelvic radiographs or ultrasound. In all, 36 patients (55%) were considered normal by their treating physician and 25 (38%) were considered dysplastic and underwent brace treatment. One hip with an isolated ASF was found to have a dislocated hip on radiograph prior to their initial orthopaedic visit. None of the patients in this study have required surgery to date. CONCLUSION: Using ASFs as a reason for referral led to increased diagnosis of mild dysplasia resulting in orthotic treatment. Thus, in our particular clinical environment, isolated ASFs can be an indicator of mild dysplasia and warrant further workup or referral. Because treatment philosophies regarding recognition and treatment of mild dysplasia vary amongst centres, the value of screening with ASFs likewise depends on the treating orthopaedic surgeon's threshold for treatment of mild dysplasia. LEVEL OF EVIDENCE: Level IV- Retrospective.

Patient-specific 3D models aid planning for triplane proximal femoral osteotomy in slipped capital femoral epiphysis.

PURPOSE: Slipped capital femoral epiphysis (SCFE) can result in a complex three-dimensional (3D) deformity of the proximal femur. A three-plane proximal femoral osteotomy (TPFO) has been described to improve hip mechanics. The purpose of this study was to evaluate the benefits of using 3D print technology to aid in surgical planning. PATIENTS AND METHODS: Fifteen children treated with TPFO for symptomatic proximal femoral deformity due to SCFE were included in this study. Ten patients were treated by a single surgeon with (model group, n = 5) or without (no-model group, n = 5) a 3D model for pre-operative planning, and compared with patients treated by two senior partners without the use of a model (senior group, n = 5) to evaluate for a learning curve. Peri-operative data including patient body mass index (BMI), surgical time and fluoroscopy time were recorded. RESULTS: Children in all three groups had similar BMIs at the time of the TPFO. Post-operative radiographic parameters were equally improved in all three groups. On average, surgical time decreased by 45 minutes and 38 minutes, and fluoroscopy time decreased by 50% and 25%, in the model group compared with the no-model and senior groups, respectively. CONCLUSIONS: Patient-specific 3D models aid in surgical planning for complex 3D orthopaedic deformities by enabling practice of osteotomies. Results suggest that 3D models may decrease surgical time and fluoroscopy time while allowing for similar deformity correction. These models may be especially useful to overcome steep learning curves for complex procedures or in trainee education through mock surgical procedures.

Protrusio acetabuli: diagnosis and treatment.

Idiopathic protrusio acetabuli is an uncommon disease process with both primary idiopathic and secondary forms. It is important to consider all etiologic possibilities before evaluating treatment options. Diagnosis is made on the basis of an anteroposterior radiograph of the pelvis that demonstrates a center-edge angle greater than 40 degrees and medialization of the medial wall of the acetabulum past the ilioischial line. For the skeletally immature patient, triradiate fusion (occasionally combined with intertrochanteric osteotomy) provides good results. For the young adult, valgus intertrochanteric proximal femoral osteotomy is recommended. In the older adult, this procedure may provide an acceptable result if there is minimal arthritis. For patients with more advanced arthritis, total hip arthroplasty with lateralization of the cup to a normal position provides a predictable long-term solution.

Congenital coxa vara: computed tomographic analysis of femoral retroversion and the triangular metaphyseal fragment.

Three patients with congenital coxa vara studied with two- and three-dimensional computed tomographic (2DCT and 3DCT) methods are reported. In all cases, the femoral retroversion was documented and subsequently corrected by proximal femoral osteotomy. In two patients with isolated coxa vara, the physeal-femoral neck angle was decreased as seen in slipped capital femoral epiphysis in adolescents. Our studies suggest that the triangular metaphyseal fragment reflects a Salter-Harris type II separation pattern through the defective femoral neck. The epiphysis and attached triangular fragment slip from the normal superoanterior portion of the neck in an inferior-posterior direction. The treating surgeon should be aware of the often marked femoral retroversion component present in severe congenital coxa vara. This knowledge allows surgical planning for corrective osteotomies that will better normalize hip mechanics. A combination of marked valgus and flexion with internal rotation of the distal fragment are required to fully correct the deformity.

One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips.

Ninety-two patients with cerebral palsy underwent a special type of pericapsular acetabuloplasty designed to correct the hip dysplasia that occurs in cerebral palsy. The osteotomy was performed as part of a combined procedure (including femoral osteotomy and soft-tissue releases). Retrospective analysis was performed on 75 of the children (104 hips from 1982 through 1995) with a mean follow-up of 6.9 years. Ninety-nine (95%) of the 104 hips remained well reduced at follow-up. There were no redislocations. If the preoperative migration percentage was >70% (severe subluxation), improved results were noted in hips that had an open reduction with capsulorrhaphy. There were 13 complications including intraarticular extension of the acetabuloplasty (one) and avascular necrosis of the femoral head (eight hips, 8%). Indications for addition of a pericapsular acetabuloplasty include an open triradiate cartilage, acetabular dysplasia (acetabular index >25 degrees), and subluxation or dislocation with a migration percentage of >40%. Even hips with relative incongruity and some deformity of the femoral head can be successfully treated with this combined approach.

Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia.

Traditional methods of analysis and surgical techniques for hip dysplasia concentrate on frontal-plane analysis of the hip. More recent studies on imaging and operative correction of hip dysplasia recommend three-dimensional (3D) analysis, and some have mentioned but not emphasized the importance of transverse-plane acetabular anatomy (anteversion/retroversion). In this study we found that failure to analyze and understand transverse-plane acetabular anatomy can contribute to complications after triple innominate osteotomy (TIO). A subset of seven patients (eight hips) who were treated with TIO for deficient acetabular coverage resulting from hip dysplasia or Legg-Calvé-Perthes disease had both pre- and postoperative 3D computed tomography (CT) studies. Most of the postoperative studies were obtained to analyze complications (external limb rotation, nonunion). Analysis of the 3D CT studies showed a change in the position of the acetabular fragment after osteotomy into greater adduction, anterior rotation (extension), and external rotation, improving femoral head coverage. All of the hips had increased external rotation of the acetabulum after TIO. Excessive external rotation (>10 degrees) was noted in five hips, and these included two hips with pubic osteotomy nonunion, two with ischial nonunion, and one with marked external rotation of the lower limb. External rotation of the acetabular fragment during redirectional pelvic osteotomy can result in (a) excessive external rotation of the lower limb, (b) decreased posterior coverage, (c) increased gaps at the pubic and/or ischial osteotomy sites with resultant higher rates of nonunion, and (d) lateralization of the joint center. The surgical technique for TIO should be designed to avoid excessive external rotation of the acetabular fragment.

The effect of valproic acid on blood loss in patients with cerebral palsy.

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Early surgical correction of residual hip dysplasia: the San Diego Children's Hospital approach.

Studies of the etiology of premature osteoarthritis of the hip show that the most common cause is residual childhood hip dysplasia. Hip dysplasia is often asymptomatic in childhood, making detection difficult and creating complex treatment decisions (major surgery in the asymptomatic child). Symptoms do not develop typically until the teenage or early adult years, and surgical correction at this age is often incomplete and complicated. In contrast, if the dysplasia is recognized early, surgical correction can be performed using simpler osteotomies with more predictable results. Our experience with children, adolescents and adults with residual hip dysplasia has led us to adopt a philosophy of early surgical correction which seeks to normalize hip joint morphology by age 5 or 6 years. The reasoning, methods and early results of this approach are reviewed in this paper.

Pelvic osteotomies for the treatment of hip dysplasia in children and young adults.

Persistent acetabular dysplasia is a well-known cause of premature hip osteoarthritis. In the dysplastic hip, point loading occurs at the edge of the steep, shallow acetabulum. Pelvic osteotomies reduce this load by increasing the contact area, relaxing the capsule and muscles about the hip, improving the moment arm of the hip, and normalizing the forces of weight bearing. The orthopaedic surgeon can choose from among a variety of pelvic osteotomies (e.g., redirectional, reshaping, and salvage) for the purpose of restoring normal anatomy and biomechanical forces across the hip joint. Treatment of residual dysplasia is based on the patient's age and the presence or absence of congruent hip reduction. A Salter or Pemberton procedure is generally appropriate for a child between the ages of 2 and 10. A triple innominate osteotomy can be considered for the older child or adolescent in whom the triradiate cartilage remains open. After triradiate closure, the Ganz periacetabular osteotomy can be considered in addition to the triple innominate osteotomy.

Anteversion of the acetabulum in developmental dysplasia of the hip: analysis with computed tomography.

Acetabular anteversion was measured by using two-dimensional (2-D) computed tomography (CT) scans in 39 dysplastic and 27 normal hips (patient age range, 3-33 years), and averaged 19.7 degrees in the dysplastic hips and 18.1 degrees in the normal hips. There was no statistically significant difference between the two groups, with a wide range of acetabular anteversion values noted in both groups (8-32 degrees ). Although acetabular anteversion may be increased in some patients with developmental dysplasia of the hip (DDH), it is not a universal finding. We believe that assessment and understanding of acetabular anteversion is needed before performing corrective osteotomies for hip dysplasia to optimize results and avoid the complications of acetabular retroversion.

Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children.

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20 degrees, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.

Congenital dislocation of the knee.

Between February 1988 and June 1995, 24 congenital dislocations of the knee joints (17 patients) were reduced with closed methods including immediate reduction, serial casting, or traction in patients from 10 min to 26 days old. At an average follow-up of 4 years and 10 months, an excellent or good result was achieved if there were no associated anomalies. Fair or poor results were the result of delayed treatment or associated musculoskeletal anomalies including arthrogryposis multiplex congenita or Larsen's syndrome. Routine check of the hip dislocation is suggested. Diagnosis with manual testing was difficult, and other methods such as radiography or sonography were suggested in combination to detect hip dysplasia. The dislocated knee should be reduced before treating the hip dislocation. Concomitant treatment of the congenital dislocation of the knee and the hip with Pavlik harness provided satisfactory results. When late, progressive, genu valgus deformity occurred because of global instability of the knee and asymmetric physeal growth, reconstruction of the medial structures of the knee and prolonged bracing provided good results.

Scoliosis in total-body-involvement cerebral palsy. Analysis of surgical treatment and patient and caregiver satisfaction.

STUDY DESIGN: A nonrandomized descriptive case series. OBJECTIVES: To analyze the results of spinal fusion in patients with total-body-involvement cerebral palsy to determine early and late outcomes, including caregiver satisfaction. METHODS: Data from 79 to 100 patients with total-body-involvement spastic cerebral palsy who underwent posterior Luque instrumentation, or anterior spinal fusion, or both, were adequate to be included in the study. Functional status was evaluated by physical examination, and a personal interview was conducted with the patient, parents, and primary caregiver. RESULTS: Median follow-up was 4 years (range, 2-14 years). Late progression of scoliosis (> 10 degrees), pelvic obliquity (> 5 degrees), and decompensation (> 4cm ) were noted in more than 30% of the patients. More than 75% of patients with late progression were skeletally immature at the time of surgery and underwent a posterior procedure only. Twenty-one percent of the patients required a revision procedure because of disease progression. Progression was not noted in any patient who underwent anterior fusion (with or without anterior instrumentation) plus posterior instrumentation from the upper thoracic spine to the pelvis. Eighty-five percent of parents or caregivers were very satisfied with the results of surgery and noted a beneficial impact of the patient's sitting ability, physical appearance, ease of care, and comfort. CONCLUSIONS: To avoid late progression of trunk deformity in skeletally immature patients, anterior spinal release and fusion combined with posterior segmental spinal instrumentation and fusion from the upper thoracic spine to the pelvis are recommended. Skeletally mature patients with good curve flexibility can be treated with posterior instrumentation and fusion only. Skeletally mature patients with large fixed curves benefit from an anterior-posterior procedure for better correction of the scoliosis and pelvis obliquity. Despite the surgical complexity and expected complications, the overall good surgical results and high patient and caregiver satisfaction confirm that corrective spinal surgery is indicated and is beneficial for most patients with total-body-involvement cerebral palsy and scoliosis.

Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases.

Despite a tendency for rotational abnormalities of the lower leg in children to improve spontaneously over time, some fail to correct and require corrective derotation osteotomy. In this retrospective study, we report the technique and results of the distal transverse tibial and fibular derotation osteotomy with Kirschner-wire fixation performed in 63 limbs of children with cerebral palsy, clubfoot, idiopathic tibial torsion, and myelomeningocele, as well as other less common conditions. There were no significant infections, neurologic complications, delayed or nonunions, or compartment syndromes as a result of the osteotomy. There were three (4.8%) complications, including late fracture (one), cross-union (one), and distal physeal closure (one). We conclude that transverse, same-level, distal tibial and fibular osteotomy fixated with crossed Kirschner wires is a safe, efficient, and effective surgical approach to the treatment of children with tibial torsion in a variety of clinical conditions.

Anterior release and fusion in pediatric spinal deformity. A comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches.

STUDY DESIGN: A consecutive series of patients undergoing thoracoscopic anterior spinal release and fusion for scoliosis or kyphosis was compared with a consecutive series of patients treated with an open thoracotomy approach. OBJECTIVES: To compare the early clinical results, costs, and charges of performing an anterior thoracic spinal release and fusion with the two approaches. SUMMARY OF BACKGROUND DATA: The thoracoscopic approach to the spine is gaining acceptance, yet there are little data comparing the technique with standard open methods for the treatment of spinal deformity. METHODS: The first 14 thoracoscopic cases performed at the authors' hospital were compared with 18 open thoracotomy cases treated during the previous 12-month period. In each case the discs were excised and bone grafted before performing a posterior fusion. The early clinical outcomes and the hospital charges/costs were analyzed. RESULTS: The percent curve correction was similar between the thoracoscopic and open methods: scoliosis 56% and 60%, respectively; kyphosis, 88% and 94%, respectively. The blood loss and complication rates were similar between the two groups; however, the chest tube output was greater in the thoracoscopic group. The length of hospital stay was not reduced, and the cost of the open procedure is 29% less than the thoracoscopic approach. The minimally invasive thoracoscopic approach avoids cutting the chest/shoulder musculature, greatly decreasing the morbidity of anterior spinal surgery. CONCLUSIONS: The thoracoscopic technique is a safe and effective alternative to open thoracotomy in the approach to the anterior thoracic spine for the treatment of pediatric and adolescent spinal deformity.

Intramalleolar triplane fractures of the distal tibial epiphysis.

The intramalleolar triplane fracture of the distal tibial epiphysis is a relatively rare injury in children. We studied five children with intramalleolar triplane fractures. Four of the five children were competitive athletes. Each child underwent computerized tomography with three-dimensional reconstruction. Delineation of the intramalleolar fracture pattern with computerized tomography with three-dimensional reconstruction demonstrated three distinct types of intramalleolar triplane fractures: I. intraarticular and within the weight-bearing zone, II. intraarticular and outside the weight-bearing zone, and III. extraarticular. Computerized tomography with three-dimensional reconstruction delineated the fracture pattern and allowed selection of the optimal treatment method. A classification scheme of the three types of intramalleolar triplane fracture is proposed.

Location of acetabular deficiency and associated hip dislocation in neuromuscular hip dysplasia: three-dimensional computed tomographic analysis.

Forty-one hips in 24 patients with neuromuscular disease (NMD) were studied using three-dimensional computed tomography (3DCT). The location of the acetabular deficiency was posterior (37%), anterior (29%), midsuperior (15%), and mixed (19%) (anterosuperior, posterosuperior, and global). Although subtle morphologic changes occurred in the entire acetabulum, the major acetabular deficiency coincided with the direction of the subluxation or dislocation. The location of the acetabular deficiency that develops in cerebral palsy is not always posterosuperior, as suggested by other authors. The pattern of spasticity that results in muscle imbalance around the hip joint and changes in proximal femur architecture causes hip subluxation or dislocation, which may be either, posterior, anterior, or midsuperior. 3DCT studies are required to analyze accurately and understand acetabular deficiency in childhood NMD. These image data also allow more accurate planning for surgery in neuromuscular hip dysplasia.