Subtrochanteric Femoral Osteotomy Research Articles

Is Subcapital Realignment for Slipped Capital Femoral Epiphysis a Reproducible Technique? Midterm Results.

The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique. (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery? Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons. At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years. In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis. Level IV, therapeutic study.

Is There a Difference in Femur Length Between Neglected Developmental Dysplasia of The Hip (DDH) And Contralateral Normal Hip-Femur Length?: A Radiographic Study

Background and Aim: There are several anatomical problems with the hip joint that are associated with developmental dysplasia (DDH), such as the femoral head being out of place in relation to the acetabulum. First-born status, female sex, a positive family history, breech presentation, and oligohydramnios are all risk factors for preterm labor and birth. DDH severity has been graded using a variety of classification systems, including the Crowe classification, the Hartofilakidis classification, and the Eftekhar and Kerboul classification. The purpose of this study was to determine whether there is a difference in femur length between patients with neglected developmental dysplasia of the hip (DDH) and the normal femur. Materials And Methods: This is a case series study of 14 patients with Unilateral DDH who did not have surgery. Between January 2017 and December 2020, data were retrieved and obtained from our hospital’s picture archiving and communication system (P.A.C.S). A Pelvis x-ray and a Full-Length Femur x-ray were taken for those patients. As a radiological landmark, a fulllength film from the tip of the greater trochanter to the intercondylar space was used in this study. The following were the inclusion criteria: 1. The patient must be an adult who is at least 18 years old. 2. The deformity should only occur on one side (Unilateral DDH). 3. They had never had surgery before. 4. Crowe types III and IV Results: The mean age of the patients was 34 (SD 12.4) years, with females outnumbering males (71.4 % vs 28.6 %). Additionally, the mean length of the affected femur was 41.6 (SD 3.88) and the mean length of the normal femur was 42.2. (SD 4.08). When we compared the baseline characteristics of patients by age group (35 years vs 35 years), we discovered that the BMI of the older age group (35 years) was statistically significantly higher than the younger age group (35 years) (P-value =0.028) Conclusion: As a result of our study, we found an approximately 1 to 2 cm difference in femur length between patients with unilateral DDH and normal hip, which was correlated with age and body mass index (BMI). Preoperative considerations for unilateral DDH include taking a long film of both femurs to determine their relative length differences. This will assist in determining the amount of subtrochanteric femoral osteotomy to perform.

The Clinical and Radiological Outcomes of Subtrochanteric Osteotomy in Crowe Type IV Hip Dysplasia: A Comparison of Three Different Stem Designs.

The purpose of this study was to determine whether there are differences in clinical and radiographic outcomes among three different stem designs for subtrochanteric osteotomy in Crowe type IV developmental dysplasia of the hip (DDH). A retrospective analysis of prospectively collected data was undertaken from a consecutive series of 37 Crowe type IV DDHs treatment of noncemented total hip arthroplasty with chevron subtrochanteric osteotomy in 30 patients. Patients are divided into three groups, including Ribbed group (using Link Ribbed stem; n = 14), Synergy group (using Synergy stem; n = 9), and Link Classic Uncemented (LCU) group (using LCU stem; n = 14), according to the design of the stem. The clinical and radiographic outcomes were evaluated. All patients were followed for 36 months. The time of bone union of the LCU stem was significantly longer than that of the Synergy stem (P = 0.02) and the Ribbed stem (P > 0.05); the time of bone union of the Ribbed stem was longer than that of the Synergy stem (P > 0.05). The length of stem in the distal femur of the Ribbed stem (P = 0.000) and the Synergy stem (P = 0.001) is significantly longer than that of the LCU stem. There were three hips with malunion, stem loosening, and varus alignment, which were observed in the LCU stem. None of these were observed in Ribbed and Synergy stems. In total hip arthroplasty with a noncemented stem combined with subtrochanteric femoral osteotomy for Crowe IV DDH, 89.2% hips (33/37) can achieve good and excellent clinical outcomes. There were three hips (1 hip in the Ribbed stem and two in the LCU stem) with fair clinical outcomes and one hip (LCU stem) with poor clinical outcomes. Although Ribbed, Synergy, and LCU stems have similar clinical outcomes, the LCU stem has a tendency to a varus position, longer union time, malunion, and stem loosening, when compared with the Ribbed and Synergy stems. We recommend against adoption of the LCU stem for Crowe IV DDH with subtrochanteric femoral osteotomy. Level III, therapeutic study.

Step-Cut Subtrochanteric Osteotomy Combined with Total Hip Arthroplasty for Neglected Traumatic Hip Dislocations.

BackgroundTotal Hip Arthroplasty remains the standard treatment protocol for patients with neglected traumatic dislocations of the hip with arthritis. A total hip arthroplasty needs to be frequently combined with a subtrochanteric shortening femoral osteotomy to aid in the reduction of the hip joint in such cases. Still long-term stable implant fixation, rigid construct, and favorable functional outcome remain a challenge. In respect to subtrochanteric shortening osteotomy, various techniques have been described in the literature, including the step-cut, double chevron, transverse, and oblique osteotomies. Out of these types, a subtrochanteric step-cut osteotomy provides a better rotational stability and a larger surface of contact to aid in union. As there is a paucity in the literature regarding the step-cut osteotomy for traumatic dislocations of the hip, we designed this study to evaluate the outcomes of this procedure.MethodsWe prospectively evaluated 24 patients with neglected traumatic dislocations of the hip, who underwent total hip arthroplasty with a step-cut subtrochanteric shortening osteotomy using a long modular stem within a span of 4 years. The indications were severe pain and difficulty in walking and performing activities of daily living. Patients fulfilling the inclusion criteria were evaluated in terms of Harris Hip Score, leg length discrepancy, neurological status, union of the osteotomy, and implant stability.ResultsThe mean Harris Hip Score significantly improved from 33.4 preoperatively to 89.2 postoperatively at the latest follow-up. At the final follow-up, all patients showed union at the osteotomy site and there were no cases of implant loosening or instability. No neurological complications were reported.ConclusionsTotal hip arthroplasty combined with a step-cut subtrochanteric femoral shortening osteotomy in patients with neglected dislocations of the hip was associated with good functional outcome and higher success rates in terms of stable implant fixation and union at the site of osteotomy.

Total hip arthroplasty without subtrochanteric femoral osteotomy is possible in patients with Crowe III/IV developmental dysplasia: total hip arthroplasty without femoral osteotomy.

We aimed to present our THA technique without femoral shortening osteotomy that we perform for the treatment of coxarthrosis on Crowe type III/IV developmental dysplasia of the hip and to present the early clinical outcomes of our patients. 77 patients with Crowe type III/IV developmental dysplasia of the hip, who had admitted to our clinic between 2013 and 2017, and had undergone cementless THA without femoral shortening by a single surgeon, were retrospectively evaluated. Patients were called for a final evaluation and assessed by Harris Hip Score. Trendelenburg sign was observed. For radiological evaluation, routine anteroposterior and lateral hip radiography and orthoroentgenogram was used. Mean duration of follow-up was 38.2 (22-52) months. Pre-operative mean Harris Hip Score was 53.9 (49-62) and post-operative mean value was 82.7 (76-95). Mean duration of operation was 44.9 (39-57)min. In post-operative final evaluation only three patients (3.8%) had positive Trendelenburg sign. 3 patients (3.8%) had early dislocation. No sciatic palsy was observed in any of the patients. Revision with acetabular cage was performed for one (1.2%) patient due to protrusion development in the acetabular cup. The mean prosthesis survival rate was 98.8%. Total hip arthroplasty without femoral osteotomy can be considered as a successful method in selected patients with Crowe III/IV coxarthrosis. It provides good clinical outcomes in the early period, reduces surgery duration, has acceptable complication rates, has high prosthesis survival rates.

Total hip arthroplasty with rectangular stems and subtrochanteric transverse shortening osteotomy in Crowe type IV hips: a retrospective study

BackgroundThe complexity of femoral and acetabular anatomy and restoring anatomic center of hip rotation in Crowe type IV developmental dysplasia of the hip (DDH) complicates standard reconstruction. The aim of this study is to evaluate surgical techniques and clinical outcomes of subtrochanteric transverse shortening osteotomy with the use of cementless rectangular cross-section femoral implants in Crowe IV dysplastic hips.MethodsA total of 26 hips of 25 consecutive patients with Crowe type IV DDH who underwent cementless total hip arthroplasty with subtrochanteric femoral transverse shortening osteotomy were retrospectively analyzed. The Harris Hip Score, Visual Analog Scale-pain, leg length discrepancy, and vertical and lateral migration of hip rotation center were recorded.ResultsMean age, follow-up, and time of union were 41 ± 9.7 years, 7.1 ± 1.2 years, and 3.7 ± 1.1 months, respectively. Mean Harris Hip Score significantly improved from 38 ± 5.7 to 86 ± 6.1 points postoperatively (P < .01). Mean leg length discrepancy and Visual Analog Scale significantly decreased from 4.3 ± 1.3 to 1.2 ± 0.6 cm, and 6.4 ± 1.2 to 1.8 ± 0.8 points, respectively (P < .01). One female patient had a dislocation due to acetabular liner wear, which was managed by liner and head change. One patient had Sudeck’s atrophy, while another had pain on the lateral thigh, both of which were resolved with conservative management.ConclusionsCombined transverse subtrochanteric femoral osteotomy and cementless total hip arthroplasty with rectangular cross-section femoral implants is technically demanding, effective, and safe in femoral shortening for treatment of Crowe type IV DDH.

Total hip arthroplasty performed in secondary hip osteoarthritis caused by hartofilakidis type 2 and type 3 developmental dysplasia of the hip; evaluation of outcomes and comparison of clinical scores of these two types

The aim of this study was to evaluate the outcomes of Total hip arthroplasty (THA) performed for hip osteoarthritis caused by Hartofilakidis type 2 and 3 developmental dysplasia of the hip (DDH) and to compare these two types in terms of clinical scores. Thirty-six hips of thirty patients who suffered from hip osteoarthritis caused by DDH and who underwent THA operations from January 2005 to May 2010 were included in the study. In the case of insufficient coverage of the acetabular cup, roof reconstruction was performed using femoral head autografts. Subtrochanteric transverse femoral osteotomy was performed when required. Clinical evaluations were performed using Harris Hip Score (HHS). 3 male and 27 female patients were included in this study. Mean age was 57.2 (25-76) years. Mean follow up time was 34.3 (12–65) months. 24 hips were classified as Hartofiladikis type 2, and 12 as type 3. HHS was 43.2 (38-54) points and 90.1 (76-96) points at the preoperative and postoperative last control visits, respectively (p

Total hip arthroplasty with step-cut subtrochanteric femoral shortening osteotomy in high riding hip dislocated patients with previous femoral osteotomy

To evaluate the long-term clinical and radiological outcomes of cementless total hip arthroplasty (THA) in high riding hip dislocated patients with previous proximal femoral osteotomy. Twenty-one consecutive patients with a mean age forty-two years were treated with cementless THA Step-cut subtrochanteric femoral osteotomy was performed in all twenty-eight hips. Metal on polyethylene (MoP) and ceramic on ceramic (CoC) bearings were used in two different consecutive time periods. The mean follow-up time was twelve years. Harris hip score, limb length discrepancy, complications, union status of the osteotomy, survivorship of constructs were the criteria for evaluation. The mean Harris hip score improved from 39.5 to 88.7 points. The mean limb length discrepancy in unilateral cases decreased from 54.5mm to 12.3mm. The mean amount of femoral shortening was 37mm. The mean union time was 3.5 months and there were no delayed union and non-union. There were three cup and two femoral revisions due to osteolysis in patients who had MoP. There was only one femoral revision in patients who had CoC. The Kaplan Meier survivorship with an end point of any revision of the stem and the acetabular component was 94% (95% CI, 75%-98%) and 92% (95% CI, 74%-99%) at ten years respectively. Total hip arthroplasty with subtrochanteric step-cut femoral shortening is a successful technique to improve the hip functions and reconstruct limb length discrepancy in young patients with proximal femoral deformities.

Cementless Total Hip Replacement for the Management of Severe Developmental Dysplasia of the Hip in the Middle Eastern Population: A Prospective Analysis.

In the Middle East, severe developmental dysplasia of the hip with subsequent high dislocation is often seen. We assessed the efficiency of total hip replacement (THR) with subtrochanteric shortening femoral osteotomy and trochanteric advancement in this population. This prospective study assessed 25 female patients with symptomatic and severe (Crowe IV). Pre- and postoperative Harris hip score (HHS) and Oxford hip score (OHS) were performed alongside assessment of leg length discrepancy (LLD) and the ability to sit in a cross-legged position. The mean HHS and OHS improved pre-operatively at 1 and 10 years, respectively (p-value < 0.001). The mean postoperative LLD was 3 mm (0-8 mm). Functionally, 22/25 patients were able to sit cross-legged. None of the 25 hips underwent revision during this period. Total hip replacement with subtrochanteric shortening osteotomy in combination with trochanteric advancement is sufficient for the management of Crowe type IV hips in this population.

Total hip arthroplasty with femoral subtrochanteric osteotomy after Schanz osteotomy.

Schanz osteotomy is one of the options for the management of hip instability caused by congenital or septic arthritis. Following Schanz osteotomy, there is risk of hip pain secondary to hip arthritis. It may be necessary to perform subtrochanteric femoral osteotomy in conjunction with total hip arthroplasty (THA). This study evaluates the outcomes and complications associated with THA. We performed 36 THA after Schanz osteotomy. Patients were divided into three groups: (1) successful Schanz osteotomy, (2) highly dislocated hip with contact between the femoral head and pelvis, and (3) completely dislocated hip without contact between the femur and pelvis. Clinical and radiological evaluations were completed for each group. In all three groups, hip function improved significantly (p<0.01). There were four types of complications: transient paralysis, femoral fracture, dislocation, and non-union. Complications occurred frequently in the completely dislocated hip group. Our study shows that acceptable results may be obtained from THA with subtrochanteric femoral osteotomy after Schanz osteotomy. However, this procedure is a technically demanding treatment option, and there were characteristic complications intra and after surgery. Therefore, surgeons should treat hip osteoarthritis after Schanz operation with utmost care, especially completely dislocated hip.

Total Hip Arthroplasty With a Non-Modular Conical Stem and Transverse Subtrochanteric Osteotomy in Treatment of High Dislocated Hips

Conventional stems may be unsuitable for hypoplastic femurs associated with severe dysplasia, meanwhile, custom-made or modular stems in total hip arthroplasty are often complex and expensive. This series included 21 Crowe type IV dysplastic hips in which a non-modular cementless conical stem was implanted with transverse subtrochanteric femoral osteotomy. Follow up averaged 40months. Twenty hips survived with mean Harris hip score improved from 52 to 90. One hip failed for stem loosening. The average leg lengthening was 3.8cm with transient sciatic nerve palsy occurring in three hips. Femoral offset averaged 3.3cm postoperatively. The non-modular conical stem not only obviated the complexities, high medical cost and potential risk at the neck-stem interface associated with stem modularity, but also simplified surgical technique.

Total hip arthroplasty with subtrochanteric osteotomy in neglected dysplastic hip.

Total hip arthroplasty (THA) in the presence of developmental dysplasia of the hip (DDH) presents many challenges to the reconstructive surgeon. The complexity of femoral and acetabular anatomy in these cases makes standard reconstruction technically challenging. Restoring the anatomic centre of hip rotation may require femoral osteotomy. The aim of this study was to determine the rate of union, complications and functional results in a series of patients with Crowe IV dysplastic hips who underwent cementless THA and simultaneous subtrochanteric oblique osteotomy. A retrospective study was designed in a series of 13 patients (14 hips) with Crowe IV DDH who underwent cementless THA and simultaneous subtrochanteric oblique osteotomy at a mean age of 37 years. Patients were reviewed clinically and radiographically with a minimum follow-up of two years. Complications were noted. Harris Hip Score (HHS) was recorded pre-operatively and at six and 12 months postoperatively. Union occurred in 14 of 14 femora (100%). The overall revision rate was 14% (7% femoral, 7% acetabular). No dislocations necessitated further surgery. No patient had intraoperative femoral fracture, sciatic nerve injury, infection or deep venous thrombosis. Mean HHS improved from 42 preoperatively to 79 at 6 months and 86 at 12 months. Combined subtrochanteric femoral osteotomy and cementless THA is technically demanding and proved to be safe and effective in femoral shortening for treatment of Crowe IV DDH.

Artroplastia total em quadris displásicos luxados com reconstrução acetabular e encurtamento femoral

To describe a new procedure of total hip replacement in patient with severe developmental dysplasia of the left hip, using technique of acetabular reconstruction with autogenous bone grafts and subtrochanteric shortening femoral osteotomy. Total hip replacement done in January of 2003. The Eftekhar's classification was used and included type D, neglected dislocations. Bone graft incorporated in acetabular shelf and femoral osteotomy. Our contribution is the use of an Allis plate to better fix acetabular grafts, avoiding loosening, and cerclage around bone graft in femoral osteotomy site, which diminish pseudoarthrosis risk. This technique shows efficiency, allowing immediately resolution for this case with pain and range of motion of hip improvement. It also allows the acetabular dysplasia reconstruction, equalization of the limb length (without elevated risk of neurovascular lesion) and repairs the normal hip biomechanics due to the correction of the hip's center of rotation.

Predicting Leg-Length Change after Total Hip Arthroplasty by Measuring Preoperative Hip Flexion under General Anaesthesia

To measure preoperative hip flexion under general anaesthesia in patients with developmental dysplasia of the hip and analyse its correlation with leg-length change. 79 women and 6 men aged 27 to 82 (mean, 59) years underwent 92 total hip arthroplasties for severe developmental dysplasia of the hip of Crowe types II (n=60), III (n=17), and IV (n=15). All such patients had severe pain and/or considerable difficulty in walking and performing daily activities. 16 of the hips were treated with transverse subtrochanteric shortening osteotomy, whereas the remaining 76 had no femoral osteotomy. Preoperative passive hip flexion was measured under general anaesthesia with a goniometer by a single investigator. Its mean value in patients with Crowe type-III deformity was 60.3º. Therefore, >60º of flexion was defined as high. Postoperative leg-length change was measured radiographically. The distraction of the greater trochanter was equal to the leg-length change in patients treated without femoral osteotomy, whereas leg-length change was calculated by subtracting the amount of resection of the femur from the distraction of the greater trochanter in patients treated with femoral osteotomy. Of the 16 hips treated with a transverse subtrochanteric shortening femoral osteotomy, 2, 2, and 12 were Crowe types II, III, and IV, respectively. In these 16 hips, hip flexion was high in 10 (mean, 86º) and low in 6 (mean, 36º). Leg-length change was significantly greater in the high than low flexion groups (31 vs. 13 mm, p<0.01). In the 76 hips without osteotomy, hip flexion was high in 54 (mean, 85º) and low in 22 (mean, 40º). Leg-length change was significantly greater in the high than low flexion groups (25 vs. 19 mm, p=0.016). Preoperative hip flexion under general anaesthesia correlated with leg-length change in hips with osteotomy (r=0.850, p=0.0002) and without osteotomy (r=0.267, p=0.019). Preoperative hip flexion measured under general anaesthesia may predict leg-length change after THA.

Subtrochanteric valgus osteotomy in developmental coxa vara

Background:Valgus subtrochanteric osteotomy is the gold standard surgical treatment of developmental coxa vara. Nevertheless, there has been no consensus on the method of fixation and osteotomy details. In the literature, there are few reports on employing rigid internal fixation methods that preclude the need of postoperative immobilization. We present early radiologic and clinical outcome of a modified Y shaped subtrochanteric valgus osteotomy fixed with precontoured DCP.Patients and Methods:Ten patients with 10 hips of developmental coxa vara were subjected to a corrective Y-shaped subtrochanteric valgus femoral osteotomy. All the cases were fixed by a precontoured small dynamic compression plate (DCP). There were six males and four females. The right hip was affected in four patients and the left hip in six. The average age at the presentation time was 5.1 years (range 4–9 years). Clinical evaluation was done by IOWA hip score.Results:Clinically, the IOWA hip score improved postoperatively significantly (P<.05). The average preoperative head shaft angle was 94° (range 85°-100°) and the average post-operative head shaft angle was 120° (range 115°-125°). Postoperatively, the average epiphyseal-Hilgenreiner angle and the head-shaft angle fell into the normal values. No recurrence of deformity was reported.Conclusion:The Y-shaped subtrochanteric valgus osteotomy with rigid internal fixation precludes the use of external immobilization attained satisfactory clinical and radiologic results with no evidence of deformity recurrence on the short-term follow-up.

Femoral Shortening in Total Hip Arthroplasty for High Developmental Dysplasia of the Hip

When reconstructing a hip with developmental dysplasia with a high dislocation, placing the acetabular component in the anatomic position can result in a prosthetic hip that is difficult to reduce. Subtrochanteric femoral osteotomy and shortening makes reduction easier but can be associated with complications (eg, limp, sciatic nerve injury, nonunion of the osteotomy) or compromise long-term stem survival. We therefore evaluated (1) the short-term complication rate, (2) functional scores, and (3) survivorship of prostheses in patients with high developmental dysplasia of the hip reconstructed with femoral shortening. We prospectively followed 46 patients (65 hips) operated on from 1990 to 2000. There were 34 females and 12 males with a mean age of 48 years (range, 16-79 years). Before surgery, all patients had a positive Trendelenburg test. The minimum followup was 8 years (mean, 13 years; range, 8-18 years). One patient experienced recurrent dislocation and two peroneal nerve palsies, one of which partially recovered and one of which was permanent. In one patient, the stem subsided and after 8 months was replaced by a larger stem that stabilized. One patient had a nonunion but was functioning well and did not have additional surgery. At followup, 12 of the 65 hips (18%) had a positive Trendelenburg test. The mean muscle strength of the abductors was 4 (range, 3-5). The mean Harris hip score was 87 (range, 59-100) and the mean visual analog scale pain score 81 (range, 35-100). At followup, all stems were well fixed with no obvious signs of radiographic loosening. Ten cups were revised because of aseptic loosening. Our data suggest femoral osteotomy and shortening at the subtrochanteric level predictably allows a stable reduction in patients with high developmental dysplasia of the hip and does not lead to any reduction in long-term survival. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Successful ambulation by surgical conversion in a complex form of epigastric heteropagus

A female neonate with a complex form of epigastric heteropagus and with three legs was referred to us. The left leg appeared normal, the central one was hypoplastic and resected 1 month after birth, and the right one projected in the cranial direction with knee flexion contracture. Three bones of the parasite were sandwiched between the right ilium and the ischiopubic bones of the autosite. At the age of 4, we performed the subtrochanteric femoral osteotomy with 90 degrees of varization and rotation, along with knee disarticulation. Ambulation was successfully achieved with the prosthesis with a multiaxis knee unit.

Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip

Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation. After placement of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy. The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (-9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed. Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length.

Subluxación primaria recidivante medial de rótulas: Revisión a largo plazo de un caso asociado a síndrome de desalineación torsional severa

We present a long-term review of a girl aged 11 years and 4 months with medial primary recurrent subluxation of both patellae of several months evolution associated with miserably malalignment syndrome. Not one case of medial recurrent dislocation of the patellae has been described previously. Three years previously following a jump she had suffered a right patellar luxation - self-reduced and not immobilised - followed by 10 subsequent episodes of subluxation and three more medial luxations. She could hardly walk autonomously due to persistent or habitual subluxation and patellofemoral pain, mainly in the right knee. Physical examination revealed habitual medial subluxation of both patellae, with clear medial patellar displacement, quadriceps amyotrophy and medial instability. The medial subluxation suppression test was positive. She showed excessive femoral anteversion of the hips (IR: 90 degrees, ER: 30 degrees), genu varum, neutral tibial torsion, patella alta, dysplastic trochlear grooves with medial condyle hipoplasia and both patellae were dysplastic (Wiberg type III). We performed a derotation subtrochanteric femoral osteotomy and bilateral proximal patellar realignment. Following surgery, bilateral stability of both sides permitted normal walking and running, as well as apprehension and the Smillie test (-), with a hip mobility of 65 degrees ER and 50 degrees IR. Fifteen years after the surgery the patient complains of antero-external knee pain in the right knee during prolonged walking, in getting up and down stairs and when in a prolonged sitting position, diagnosed as excessive lateral pressure syndrome.

Subtrochanteric Valgus Osteotomy for Chronically Dislocated, Painful Spastic Hips

Many treatments have been proposed for a painful chronically dislocated hip in a child with spasticity who is unable to walk. The valgus subtrochanteric femoral osteotomy was originally described as a treatment for a missed congenital hip dislocation in a young adult who was able to walk. The purpose of this study was to investigate the outcomes of a modified Hass subtrochanteric valgus osteotomy for the treatment of symptomatic chronic hip dislocations in patients with spasticity due to neuromuscular disorders. Patients were identified by surgical codes. Medical records were reviewed for surgical indications, complications, and results. Preoperative and postoperative radiographs were assessed. Caregivers were contacted and asked to complete a brief survey detailing the pain that the patient experienced with daily activities before and after surgery as well as other information. Thirty-one Hass osteotomies in twenty-four consecutive patients were performed by one surgeon between 1995 and 2005. Although fifteen patients (63%) had at least one complication (including urinary tract infection, pneumonia, hardware failure, and heterotopic bone formation), the majority of the patients were doing well at an average of forty-four months postoperatively. The duration for which the patient could sit, ease of transfers, and ease of diaper changes had all improved according to the caregivers. Fourteen of fifteen caregivers who replied to the question stated that they were satisfied with the operative results and would have the procedure done again if they had the decision to make. The modified Hass osteotomy provides children who have symptomatic hip dislocations due to neuromuscular disorders with reproducible pain relief and improves ease of positioning by their caregivers. The complication rate, although high, was comparable with that of similar surgical procedures in this patient population. Concurrent femoral head resection at the time of the proximal femoral osteotomy was not necessary in this group of patients.