Sagittal alignment in patients with flexion contracture of the hip before and after total hip arthroplasty.

INTRODUCTION: In hip osteoarthritis, hip flexion contracture can severely alter the patient's alignment, and, therefore, affect the patient's quality of life (QOL). Hip contracture is not well-studied, partly because of the difficulties of its diagnosis. The aim of this study was to propose a quantitative definition of hip flexion contracture, and to analyse sagittal alignment in these patients compared to non-contracture ones, before and 12 months after total hip arthroplasty (THA). MATERIALS AND METHODS: Consecutive patients with hip arthrosis and an indication for THA were included (N = 123). Sagittal full-body radiographs were acquired in free standing position and in extension. QOL questionnaires were administered before and after surgery. Spinopelvic parameters were measured, including the pelvic-femur angle (PFA). Patients with low pelvic incidence (< 45°) were included in the hip contracture group if PFA > 5°, or PFA > -5° when pelvic incidence ≥ 45°. RESULTS: 29% of patients were in the hip flexion contracture group, and they showed lower pelvic tilt than the no-contracture group (p < 0.001), larger lumbar lordosis (LL) and smaller PI-LL (p < 0.001), as well as a forward position of the head. 16% of patients still had hip contracture 12-months postop. Contracture patients showed higher QOL scores after surgery. CONCLUSIONS: The proposed method to diagnose hip contracture group allowed to define a group of patients who showed a specific pattern of sagittal spinopelvic alignment. These patients improved their alignment and quality of life postoperatively, but their hip mobility was not always restored. Diagnosing these patients is a first step toward the development of more specific surgical approaches, aiming to improve their surgical outcome.

Two-Stage Treatment for Ankylosing Spondylitis With Severe Hip Contracture.

Ankylosing spondylitis is a progressive inflammatory disease that often involves the hip, causing deformities and dysfunction. Total hip arthroplasty (THA) may be used, but contracture of the hip joint in ankylosing spondylitis makes THA technically difficult and leads to poor efficacy. This retrospective study describes a novel 2-stage surgical treatment for ankylosing spondylitis of the hip and evaluates its efficacy relative to THA alone. Patients with ankylosing spondylitis and severe hip flexion contracture treated between 2011 and 2017 were assigned to either an experimental group or an age-matched control group (n=12 each) based on receiving, respectively, soft tissue release of the hip joint, femoral osteotomy, and supracondylar bone traction (stage I) and THA (stage II) or THA only. Clinical and radiological data included preoperative, postoperative, and follow-up Harris Hip Score and visual analog scale score, hip range of motion, femoral nerve injury, and heterotopic ossification. Both groups had significant corrections after surgery. At the final follow-up, the experimental group had significantly higher Harris Hip Scores and range of motion in extension compared with the control group, significantly more reduction in visual analog scale score, and no femoral nerve injury. The novel 2-stage surgery for patients with ankylosing spondylitis and severe hip flexion contracture is effective for restoring hip function and improving patients' quality of life, having fewer complications than traditional THA alone. [Orthopedics. 2019; 42(6):e502-e506.].

Gluteal Fibrosis and Its Surgical Treatment.

BACKGROUND: The objective of this study was to analyze the literature regarding the diagnosis, pathogenesis, and prevalence of gluteal fibrosis (GF) and the outcomes of treatment. METHODS: We searched PubMed, Embase, and Cochrane literature databases, from database inception to December 15, 2016. We used the following search terms including variants: "contracture," "fibrosis," "injections," "injections, adverse reactions,' "gluteal," and "hip." All titles and abstracts of potentially relevant studies were scanned to determine whether the subject matter was potentially related to GF, using predefined inclusion and exclusion criteria. If the abstract had subject matter involving GF, the paper was selected for review if full text was available. Only papers including ≥10 subjects who underwent surgical treatment were included in the systematic analysis. Data abstracted included the number of patients, patient age and sex, the type of surgical treatment, the method of outcome measurement, and outcomes and complications. RESULTS: The literature search yielded 2,512 titles. Of these, 82 had a focus on GF, with 50 papers meeting the inclusion criteria. Of the 50 papers reviewed, 18 addressed surgical outcomes. The surgical techniques in these papers included open, minimally invasive, and arthroscopic release and radiofrequency ablation. Of 3,733 operatively treated patients in 6 reports who were evaluated on the basis of the criteria of Liu et al., 83% were found to have excellent results. Few papers focused on the incidence, prevalence, and natural history of GF, precluding quantitative synthesis of the evidence in these domains. CONCLUSIONS: This study provided a systematic review of surgical outcomes and a summary of what has been reported on the prevalence, diagnosis, prognosis, and pathogenesis of GF. Although GF has been reported throughout the world, it requires further study to determine the exact etiology, pathogenesis, and appropriate treatment. Surgical outcomes appear satisfactory. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty in Ankylosing Spondylitis With Extension Contracture of Hips.

BACKGROUND: Despite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied. METHODS: We retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded. RESULTS: Between July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays. CONCLUSION: Extension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients.

Cirugía de la anquilosis de cadera por osificación heterotópica secundaria a lesión medular / Surgical treatment of hip ankylosis due to heterotopic ossification secondary to spinal cord injury

Objetivo: Exponer nuestra experiencia en el diagnóstico y tratamiento quirúrgico de la anquilosis de cadera secundaria a osificación heterotópica periarticular. Material y métodos: Estudio descriptivo, longitudinal, de cohortes, retrospectivo, de 20 pacientes consecutivos (30 caderas) afectos de osificación heterotópica periarticular secundaria a lesión medular en los últimos 10 años, con un seguimiento mínimo de un año. Se realizó una revisión de las historias clínicas y pruebas de imagen, se valoró el tipo y localización de la osificación heterotópica periarticular, la movilidad pre- y postoperatoria, tipo, nivel y causa de la lesión medular según escala ASIA, tiempo desde la lesión medular hasta la cirugía, existencia de hábito tabáquico, abordaje quirúrgico utilizado y complicaciones asociadas a la cirugía. Resultados: Se evaluaron un total de 20 pacientes (30 caderas): 16 pacientes presentaron un lesión medular completa ASIA A y 4, ASIA B. Todos los pacientes presentaban una anquilosis completa de la cadera que limitaba la sedestación en silla de ruedas, la higiene y los cambios posturales. La movilidad posquirúrgica media fue de 90° de flexión, 20° de rotación interna y 40° de rotación externa. En todos los pacientes se realizó fisioterapia intensiva en la articulación intervenida en el postoperatorio inmediato así como la administración de 200 mg de celecoxib cada 24h durante un mes con el fin de prevenir la recidiva de la osificación. En ningún caso de la serie tuvimos recidivas de la osificación. Conclusiones: El tratamiento quirúrgico mediante exéresis de la osificación hasta conseguir un rango de movilidad adecuado es el tratamiento de elección para los pacientes con anquilosis de cadera

Objectives: To expose our experience in the diagnostic and surgical treatment of neurogenic heterotopic ossification of the hip. Material and methods: We designed an observational retrospective descriptive study including 20 patients (30 hips) with neurogenic heterotopic ossification of the hip secondary to spinal cord injury attended in our institution in the last 10 years, with a minimum of one year follow-up. Medical files and imaging studies were reviewed. The study variables analyzed were: type and localization of neurogenic heterotopic ossification, pre-post excision range of motion, level and aetiology of spinal cord injury, ASIA score, smoking history, surgical approach and complications associated with surgery. Results: A total of 20 patients were treated with resection of heterotopic ossification in 30 hips. 16 patients presented ASIA A spinal cord injury and 4 ASIA B spinal cord injury. Preoperatively all the patients had severe ankylosis in the hip that made sitting in a wheel chair and activities such as repositioning and hygiene difficult. The average postoperative motion at the follow-up evaluation was 90° in flexion, 20° of internal rotation and 40° of external rotation. Immediately after surgery all the patients followed a specific intensive physiotherapy regime for the hip and celecoxib 200 mg was administrated daily orally for a month to prevent recurrence of heterotopic bone formation. None of the patients reviewed suffered a recurrence of heterotopic bone formation. Conclusions: Surgical excision of hip ossification in order to achieve functional ROM of the hip is the best treatment for patients with neurogenic heterotopic ossification of the hip

Shear-wave elastography assessment of gluteal muscle contracture: Three case reports.

RATIONALE: Gluteal muscle contracture (GMC) is a clinical syndrome characterized by limited hip joint function due to fibrosis and contracture of the gluteal muscle and fascia fiber. Imaging examination is significant for its diagnosis and guidance of surgical treatment. PATIENT CONCERNS: This report presents 3 cases of GMC with bilateral involvement and summarizes the literature on the imaging findings of this disease. The clinical symptoms and presentations of the 3 cases well-matched the clinical diagnosis of GMC. Preoperative ultrasonography including elastography was performed. To our knowledge, studies based on the elastography findings of the disease are limited. DIAGNOSES: The diagnosis of GMC was finally confirmed by postoperative pathologic examination. INTERVENTIONS: All 3 patients then have a surgical therapy which cut off the contracture tract. OUTCOME: Symptoms of abnormal gait and limited hip joint function were greatly improved after surgical treatment. LESSONS: The elasticity of the GMC zone in patients with GMC is higher than that of the muscles in the corresponding sites of healthy people.

Prone Position-Induced Quadriceps Transcranial Motor Evoked Potentials Signal Loss-A Case Report.

BACKGROUND: Transcranial motor evoked potential (TcMEP) is widely used intraoperatively to monitor spinal cord and nerve root function. To our knowledge, there is no report regarding TcMEP signal loss purely caused by patient positioning during the spinal procedure. PURPOSE: The objective of this article is to report an intraoperative TcMEP signal loss of a patient with fixed sagittal imbalance posture along with mild hip contractures. STUDY DESIGN: A retrospective case report. METHODS: A 57-year-old man had fixed sagittal imbalance and flexed hip contractures. For a reconstruction surgery of T10 to the sacrum/ilium and L5 pedicle subtraction osteotomy (PSO), he was put in a prone position on a Jackson table. In order to accommodate his fixed hip flexion contracture, thigh pads were not used and pillows were placed under his bilateral thighs for cushioning. TcMEPs were used to assess lumbar nerve root function. Ten minutes after incision, bilateral vastus medialis TcMEPs were lost during spine exposure whereas all other data remained normal at baseline. The bilateral lower extremities were repositioned, with the knees flexed into a sling position to increase hip flexion. Five minutes after repositioning, the bilateral vastus medialis TcMEPs gradually improved and maintained baseline amplitude during the remainder of the surgery. RESULTS: No muscle weakness was detected immediately after surgery. The patient was discharged day 6 postoperatively with markedly improved posture and alignment. CONCLUSION: Insufficient hip flexion in patients with fixed sagittal imbalance and hip flexion contractures may cause TcMEP signal changes in the quadriceps response. TcMEP monitoring of bilateral lower extremities is highly recommended for patients with sagittal imbalance and hip contractures, with consideration for lower extremity repositioning when data degradation does not correlate with the actual spinal procedure being performed.

Slow correction of severe spastic hyperlordosis in an adult by means of magnetically expandable rods.

BACKGROUND: We describe a case of severe and progressive lumbar hyperlordosis (160°) in a 28-year-old female university student with cerebral palsy. Her main complaints were abdominal wall pain and increasing inability to sit in her custom wheelchair. METHOD: When deciding on our opinion about the most promising treatment strategy, we contemplated slow continued correction by means of percutaneously expandable magnetic rods (MAGEC) after the index surgery as a key component of a satisfactory correction in this severe and rigid curve. After an initial radical release and partial correction, a release and correction procedure was required for the bilateral hip flexion contracture. A final in situ posterior fusion was performed as a second spinal procedure, once the desired final correction at 66° of lumbar lordosis was achieved. RESULT: Three years after the completion of surgery, the patient has a stable clinical and radiological result as well as a solid posterior fusion on CT. CONCLUSION: This is the first case published in which percutaneous magnetic distraction was successfully used in an adult patient.

Treatment of the Lower Extremity Contracture/Deformities.

Lower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient's greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.

Clinical outcomes of arthroscopic surgery for external snapping hip.

BACKGROUND: Studies have reported on the arthroscopic technique for release of external snapping hip syndrome. However, no study with large sample size has been reported for arthroscopic surgery. METHODS: Patients with 229 bilateral and 19 unilateral external snapping hips were treated from January 2012 to June 2013. After locating the contracture position, arthroscopic surgery was performed accordingly. Preoperative and postoperative angles were compared. RESULTS: Comparing range of motion, all patients obtained higher adduction and flexion angles. At postoperative follow-up of 24 months, the adduction angle was improved from -14.4 ± 5.14 to 35.7 ± 4.21 for type I, from -31.2 ± 5.22 to 31.7 ± 2.84 for type II, from -49.0 ± 3.47 to 21.6 ± 3.43 for type III, and from -64.5 ± 4.65 to 18.3 ± 3.10 for type IV (P < 0.001). Similarly, the flexion angle was also significantly improved for all the four types (P < 0.001). Excellent ratio and satisfaction rate were good in types I and II. All the clinical features were cured after arthroscopic surgery. CONCLUSIONS: Arthroscopic surgery could be an effective procedure for external snapping hip, due to less operating time, small scar, fast postoperative recovery, and complete contracture release.

Reorientational Proximal Femoral Osteotomies for Arthrogrypotic Hip Contractures.

BACKGROUND: Severe hip contractures in arthrogrypsosis are multiplanar, which can preclude or can greatly complicate sitting and ambulation. The reorientational osteotomy at the intertrochanteric level preserves preoperative hip motion but moves it to a more functional domain. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure. METHODS: Since 2008, 65 patients with arthrogryposis had 119 reorientational proximal femoral osteotomies with a minimum follow-up of 2 years. The mean patient age at the time of the surgical procedure was 48 months. An intertrochanteric wedge osteotomy aligned the femoral shaft with the body axis, leaving the hip joint in its preexisting position. A cannulated hip blade plate was used for fixation. Hip motions were recorded preoperatively, at implant removal, and at the time of the latest follow-up, as was ambulatory ability. RESULTS: Eighty-one hips had a mean flexion contracture of 52° preoperatively, which improved by 35°; 84 hips with a mean preoperative adduction of -20° improved by 42°; 101 hips with a mean preoperative internal rotation of -16° improved by 35° (p < 0.0001 for all). The flexion-extension total arc of motion for the 119 hips improved by 13° (p < 0.0001). Only 11 of 94 hips that preoperatively flexed ≥90° did not do so postoperatively, but none of the patients reported seating difficulties and one of the patients had already regained hip flexion of >90° by a soft-tissue release. At a mean follow-up of 40 months, 36 patients were independently ambulatory and 20 patients were walker-dependent. CONCLUSIONS: Children with arthrogryposis often have the potential for ambulation if the limb positioning can be optimized. The reorientational hip osteotomy corrects the hip contractures by altering the range of motion but not the total arc of motion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gluteal muscle fibrosis with abduction contracture of the hip.

PURPOSE: Gluteal muscle fibrosis with hip contracture is a rare condition and causes major disability; literature reports are sparse. The aim of this study is to present, for the first time in Iraq and the region, a case series of gluteal fibrosis and the results of surgical treatment. METHODS: Seven children--six boys and one girl--diagnosed as having gluteal muscle fibrosis with hip contracture, were investigated and treated by open surgical release of fibrotic bands and physiotherapy. RESULTS: All patients improved dramatically over the subsequent weeks, and were able to sit and squat in the normal position. CONCLUSIONS: Gluteal muscle fibrosis with hip contracture is present in Iraq and more awareness is needed for early diagnosis. Surgical treatment provided excellent results. More studies are needed to delineate the aetiology of the condition.

Corrections of lower limb deformities in patients with diastrophic dysplasia.

OBJECTIVE: Accurate understanding of the cause of the underlying pathology in children with diastrophic dysplasia would help in designing targeted management of their locomotion. METHODS: Diastrophic dysplasia was diagnosed in twelve patients (nine girls and three boys; age range 1-14 years), all of whom presented with small stature and apparent short extremities. Club foot (mostly talipes equinovarus) was the most frequent and consistent abnormality. Concomitant abnormalities such as hip flexion contracture, flexion contractures of the knees with excessive valgus deformity and lateral patellar subluxation, were also encountered. Muscle ultrasound and muscle magnetic resonance imaging imaging showed no myopathic changes and muscle biopsies and the respiratory chain were normal. Serum choline kinase and plasma lactate concentrations were normal. RESULTS: Surgical correction of the foot and ankle in patients with diastrophic dysplasia is extremely difficult because of the markedly distorted anatomy. In all of these children, plantigrade foot was achieved along with the improved function of the locomotor system. Mutations of the diastrophic dysplasia sulfate transporter (also known as solute carrier family 26 member 2) were encountered. CONCLUSION: Arthrogryposis multiplex is the usual terminology used to describe the abnormality in infants with multiple contractures. Diligent orthopaedic care should be provided based on an accurate understanding of the associated syndromes in such children.

Percutaneous Adductor Release in Nonambulant Children with Cerebral Palsy.

INTRODUCTION: Adductor spasticity at hips is the main barrier in functional activities and rehabilitation of spastic cerebral palsy patients. The aim of this study is to evaluate the results of percutaneous adductor release under general anaesthesia. METHODS: From July 2005 to July 2010, 64 hips in 32 patients (19 males and 13 females) were recruited from outpatient department having adductor contracture at hips in cerebral palsy children. All children were operated under general anaesthesia. All children were followed for twenty-four months. The clinical results were evaluated radiologically, including measurement of CE- angle, AC-index and femoral head coverage and in terms of activity level of children. RESULTS: Of the thirty-two children, twenty-eight showed marked and immediate improvement. None of our children was functionally worse at follow-up. The CE-angle and femoral head coverage did not change significantly. The AC-index improved significantly (P = 0.01).The results were excellent in 12.5% children, good in 50%, fair in 25% and poor in 12.5%. CONCLUSIONS: Bilateral mini-invasive adductor release can be an effective treatment for children suffering from adductor contracture refractory to nonoperative management and early adductor release can prevent subluxation and possibly the need for future bony procedure on the proximal femur and pelvis.

[Clinical classification of gluteal muscle contracture under arthroscopy].

OBJECTIVE: To explore clinical effects of gluteal muscle contracture and minimum invasive surgery under the arthroscopy. METHODS: Totally 358 patients with gluteus contracture were treated,which included 175 males and 183 females with an average age of (19.7 +/- 6.8) years old (ranged, 14 to 41). All patients have a history of repetitive intramuscular injection of penicillin with benzyl alcohol solvent. According to clinical characteristics and intraoperative situation, patients were classified into four groups:cable strip (118 cases), fanshaped (107 cases), mixed (87 cases), tensor fasciae latae contracture(46 cases). The curative effects were evaluated according to postoperative function evaluation standard of gluteus contracture. RESULTS: All patients were followed up and 37 cases withdrew. The following up time ranged from 1.5 to 8 years with an average of 3.5 years. According to evaluation standard of gluteus contracture, 303 cases got excellent results, 13 cases good,and 5 cases fair at the final follow-up. No recurrence, infection and neurovascular injury occurred. CONCLUSION: The classification of gluteal muscle contracture is beneficial for choose surgical strategy and improve curative effect. The advantage of plasma knife minimally invasive solution in treating gluteal muscle contracture with radiofrequency under arthroscopy is minimally invasive, safe, and benefit for early functional exercises.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor.

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober's test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

Predicting the outcome of intramuscular psoas lengthening in children with cerebral palsy using preoperative gait data and the random forest algorithm.

This study used the random forest algorithm to predict outcomes of intramuscular psoas lengthening as part of a single event multi-level surgery in patients with cerebral palsy. Data related to preoperative medical history, physical exam, and instrumented three-dimensional gait analysis were extracted from a historic database in a motion analysis center. Data from 800 limbs of patients with diplegic cerebral palsy were analyzed. An index quantifying the overall deviation in pelvic tilt and hip flexion was used to define outcome categories. The random forest algorithm was used to derive criteria that predicted the outcome of a limb. The criteria were applied to limbs that underwent psoas lengthening with outstanding results (accuracy=.78, sensitivity=.82, specificity=.73). The criteria were then validated using an extended retrospective case-control design. Case limbs met the criteria and underwent psoas lengthening. Control limbs met the criteria, but did not undergo psoas lengthening. Over-treated limbs failed the criteria and underwent psoas lengthening. Other-treated limbs failed the criteria and did not undergo psoas lengthening. The rate of good outcomes among Cases exceeded that observed among controls (82% vs. 60%, relative risk=1.37), and far exceeded that observed in Over-treated limbs (27%). Other-treated limbs had good outcomes 52% of the time. Application of the criteria in the future is estimated to increase the overall rate of good pelvis-hip outcomes from 58% to 72% among children with diplegia who undergo single-event multi-level surgery (SEMLS).

New minimally invasive option for the treatment of gluteal muscle contracture.

Gluteal muscle contracture is a clinical syndrome that involves contracture and distortion of the gluteal muscles and fascia fibers due to multiple causes. Physical examination demonstrates a characteristic gait due to hip adduction and internal thigh rotation. This study introduces a new minimally invasive method for surgical release of gluteal muscle contracture. Patients with gluteal muscle contracture were assigned to 4 categories: type A, contracture occurred mainly in the iliotibial tract; type B, contracture occurred in the Iliotibial tract and gluteus maximus; type C1, movement of the contraction band was palpable and a snapping sound was audible during squatting; and type C2, movement of the contraction band was not palpable or almost absent and a snapping sound was audible during squatting. This classification method allowed prediction of the anatomic location of these pathological contractures and determination of the type of surgery required. Four critical points were used to define the operative field and served as points to mark a surgical incision smaller than 4 mm. The contracture was easily released in this carefully marked operative field without causing significant neurovascular damage. Over a period of 5 years, between March 2003 and June 2008, the authors treated 1059 patients with this method and achieved excellent outcomes. Most patients were fully active within 12 weeks, with the assistance of an early postoperative rehabilitation program. The most significant complication was a postoperative periarticular hematoma, which occurred in 3 patients within 10 days postoperatively and required surgical ligation of the bleeding vessel.

Management of hip contractures and dislocations in arthrogryposis.

Arthrogryposis represents a group of heterogeneous disorders, characterized by contractures of multiple joints at birth. Involvement of the hip is very common (55-90% of patients) ranging from soft tissue contractures to subluxation and dislocation. Isolated contracture of the hip can usually be managed conservatively: compensative mechanisms and contractures of other joints should be evaluated before planning surgery. For unilateral dislocations, open reduction is indicated to provide a level pelvis, even though the risk of stiffness, avascular necrosis and redislocation is significant. Indications for surgical reduction of bilateral dislocations are more controversial: an adequate evaluation of ambulatory potential of the child (muscular weakness, involvement of upper extremities, etc.) and of stiffness of the hips is suggested. An extensive and long-lasting programme of bracing, physiotherapy and multiple surgery may lead to some measure of functional ambulation in most cases, but high need for surgery and considerable risk of complications must be considered. This paper summarizes problems and principles of treatment for hip contractures and dislocations in arthrogryposis and provides a review of the current literature.

Total hip replacement fifteen years after pelvic support osteotomy (PSO): a case report and review of the literature.

Treatment of chronic hip instability in children and young adults is challenging. Proximal femoral osteotomy had been suggested to provide pelvic stability and improved abductor function. Total hip replacement after pelvic support osteotomy can be challenging due to altered anatomy due to angulation of the proximal femur in both frontal and sagittal planes. This is a 29-year-old woman who had total hip replacement after pelvic support osteotomy. The patient had pelvic support at the age of 14 years. Pelvic support osteotomy delayed the need for total hip replacement for 15 years. Preoperative planning for total hip replacement with model was used for proper understanding of the anatomy of the proximal femur. Revision of femoral component was necessary due to penetration of the proximal femur. In conclusion, total hip replacement after pelvic support osteotomy is a technically demanding procedure, and careful attention to surgical details is necessary for successful outcome.