Varus Derotation Osteotomy Research Articles

Recurrence of hip instability after reconstructive surgery in patients with cerebral palsy.

Hip instability can cause major problems in children with cerebral palsy, although good outcomes of hip reconstructive surgery for hip instability have been reported. In the present study, we investigated the recurrence of hip instability after reconstructive surgery and the factors influencing this recurrence in patients with cerebral palsy. We examined consecutive patients with hip instability related to cerebral palsy who had undergone hip reconstructive surgery including femoral varus derotational osteotomy. The neck-shaft angle, head-shaft angle, and migration percentage were measured at each postoperative follow-up evaluation. For each Gross Motor Function Classification System (GMFCS) level, annual changes in radiographic indices were adjusted for multiple factors with use of a linear mixed model, with sex as the fixed effect and laterality and each subject as the random effects. A total of 144 hips (seventy-six patients) were included in this study, and 845 radiographs were evaluated. The GMFCS level was II or III for twelve patients, IV for thirty, and V for thirty-four. The neck-shaft angle showed no significant change in the patients with GMFCS level II or III (p = 0.425), IV (p = 0.106), or V (p = 0.972). The head-shaft angle showed a significant change in those with GMFCS level IV (p = 0.008) but not in those with level II or III (p = 0.201) or V (p = 0.591). The migration percentage did not change significantly in patients with GMFCS level II or III (p = 0.742), but it increased significantly by 2.0% per year (p < 0.001) in patients with GMFCS level IV and by 3.5% per year (p = 0.003) in those with level V. Periodic monitoring and follow-up for the recurrence of hip instability is important in patients with cerebral palsy and a GMFCS level of IV or V.

Radiological outcome of reconstructive hip surgery in children with gross motor function classification system IV and V cerebral palsy.

Hip subluxation is common in children with cerebral palsy (CP). The aim of this study was to describe the radiological outcome of reconstructive hip surgery in children with CP, gross motor function classification system (GMFCS) level IV and V, and determine whether the GMFCS level plays a predictive role in outcome. This was a retrospective cohort study conducted at a tertiary-level pediatric hospital with a CP hip surveillance program. Of 110 children with GMFCS IV and V CP registered for hip surveillance, 45 underwent reconstructive hip surgery between 1997 and 2009, defined as varus derotational proximal femoral osteotomy with or without additional pelvic osteotomy. Eleven children were excluded because of lack of 12-month follow-up (n=10) or missing clinical records (n=1). Thus, 21 GMFCS IV children (median age 6 years at surgery) and 13 GMFCS V children (median age 5 years at surgery), who underwent 58 index surgeries, were included in the study. Clinical records and radiology were reviewed. The two surgical groups were femoral osteotomy (varus derotational femoral osteotomy with an AO blade plate or femoral locking plate fixation), or femoral ostetotomy with additional pelvic osteotomy. Reimer's migration percentage (MP) was calculated from anteroposterior pelvis radiographs to determine the outcome for each hip independently. Failure was defined as MP of greater than 60% or further operation on the hip. Reconstructive surgeries were performed for 58 hips with a median preoperative MP of 55%. There were 15 failures at a median of 62 months, including nine failures in 35 GMFCS IV hips and six failures in 23 GMFCS V hips. Overall, GMFCS V hips tended to fail earlier, (hazard ratio 2.3) with a median time to failure of 78 and 39 months for GMFCS IV and V hips, respectively. Combined femoral and pelvic osteotomies had the lowest failure rates in both groups of patients. The GMFCS classification may have some predictive value for outcomes following reconstructive hip surgery, with surgery for GMFCS V hips tending to fail earlier.

One-stage hip reconstruction in children with cerebral palsy: long-term results at skeletal maturity.

PurposeHip subluxation is common in children with cerebral palsy (CP). Surgery is indicated in case of pain or progressive increase of Reimers index on radiographs. Peri-iliac osteotomy combined with femoral osteotomy is one of the numerous operative techniques available, but results at skeletal maturity remain unclear. The purpose of this radiological study was to report the long-term results of this procedure.Materials and methodsTwenty hips in 20 children were retrospectively evaluated at skeletal maturity. Mean age at surgery was 8.1 years and follow-up averaged 9.1 years. All patients underwent Dega acetabuloplasty, soft-tissue release and femoral-shortening varus derotation osteotomy without open reduction. Reimers index, acetabular angle (AA) and neck-shaft angle (NSA) were compared on preoperative, postoperative and latest follow-up radiographs.ResultsDega osteotomy significantly improved the AA and the correction remained stable at maturity. The NSA significantly decreased postoperatively (153°–115°), but recurrence of the valgus deformity (130°) of the proximal femur was observed at maturity. Consequently, Reimers index followed the same evolution. No case of osteonecrosis was reported but one hip dislocated and one subluxated during follow-up.ConclusionProgressive recurrence of the valgus deformity of the proximal femur, attributable to adductors spasticity and gluteus medius weakness, led to a significant increase in the Reimers index. However, hip coverage remained >70 % at maturity in 90 % of the hips. This one-stage procedure without hip dislocation efficaciously corrected acetabulum dysplasia and successfully treated neurological hips in CP patients.Level of evidenceIV: retrospective study.

Eighteen Year Follow-Up Results of Accessory Lower Limb Disarticulation and Pelvic Bone Reconstruction for Monocephalus Tripus Tribrachius

Monocephalus tripus tribrachius, a type of conjoined twins with one head and three upper and lower extremities, is a rare congenital disorder. To date, no long-term follow-up results of surgical procedures for this condition have been reported in Korean literature. We experienced a case of monocephalus tripus tribrachius, which had been surgically managed with an accessory lower limb disarticulation and pelvic bone reconstruction to manage this accessory limb and accompanying comorbidities in hip joint and pelvis. Subsequently, ipsilateral Syme amputation was done for intractable deformity of foot, and later, ipsilateral femoral varus derotational osteotomy was done for inadequate coverage of femoral head observed in follow-up. We report 18-year follow-up results of the procedures with a review of literatures.

Besonderheiten in der Behandlung des Hüftgelenks bei Kindern mit dem Down-Syndrom

The treatment of hip instability in patients with Down syndrome is challenging. We have performed different pelvic osteotomies and corrections at the proximal femur for this indication. This retrospective study was conducted to evaluate the clinical and radiological outcome of each intervention. All in all, 166 patients with Down syndrome were treated at our orthopaedic department in the observation period. Problems related to the hip joint were diagnosed in 63 of those patients. Only patients who underwent surgery were included in this study. The charts and X-rays of these 31 patients were evaluated with respect to the following parameters: incidence of the hip problem, concomitant diseases, temporal progress, kind of operation method and date, duration of stay in the hospital, after-care, follow-on surgery related to complications, AC angle, CE angle, ACM angle, CCD angle, index of migration according to Reimers, classification of Bauer and Kerschbauer and general morphology of the femoral head. The group was compared with an age-matched group of 21 patients with hip dysplasia. Those patients underwent the same sort of operation in the same year. In the Morbus Down group, we performed surgery for preservation of the hip in 49 cases. This included 13 osteotomies according to Chiari, 11 triple osteotomies according to Tönnis, 10 corrections by femoral varus derotation osteotomy, 8 pelvic osteotomies according to Pemberton, 5 pelvic osteotomies according to Salter and 2 open reductions of the hip. With respect to the moment of surgery, we detected three peaks of age. There was no difference in course of disease and quantity of complications between the groups. Satisfactory results concerning clinical and radiological outcome were achieved predominantly by complete redirectional acetabular osteotomies. Half of the patients who were solely treated by femoral varus derotation osteotomy needed follow-on surgery in the form of pelvic osteotomy. Comparison of preoperative and postoperative range of motion of the hip joint between groups detected capsular insufficiency, increased ligamentous laxity and muscular hypotonia in patients with Down syndrome. Comparison of pelvic radiographs demonstrated significant improvement concerning measured angles in both groups. Preoperative values with respect to AC angle and CE angle were demonstrated to be lower in the hip dysplasia group (p < 0.01); whereas values for ACM angle were comparable between groups. Hypermobility and secondary dislocation of the hip joint is a common problem in patients with Down syndrome, which often requires surgical intervention at an early stage. According to our data and clinical results we suggest a complete redirectional acetabular osteotomy in combination with capsular plication for treatment of this challenging condition.

Risk factors and complications in hip reconstruction for nonambulatory patients with cerebral palsy

Hip dysplasia is prevalent in nonambulatory children with cerebral palsy, and may contribute to a decreased quality of life (Lonstein in J Pediatr Orthop 6:521-526, 1). Reconstructive procedures such as a femoral varus derotation osteotomy with or without a pelvic osteotomy are commonly employed with the goal of achieving and maintaining well reduced hips. The goals of this study are both to characterize the complications of reconstructive procedures and to identify risk factors that may contribute to these complications. A retrospective analysis was conducted among 61 nonambulatory children (93 hips) with cerebral palsy who underwent a femoral varus derotation osteotomy, with or without an open reduction and/or pelvic osteotomy, from 1992 through 2008 at our institution. The average patient age was 8.1years (2.6-14.7) and the mean follow-up time was 5.9years (2.1-15.9). The cumulative complication rate per patient including failures to cure was 47.6%. Spica casting was found to be a risk factor for all complications (P=0.023); whereas patients younger than 6years old (P=0.013) and children with a tracheostomy (P=0.004) were found to be risk factors for resubluxation following surgery. Although reported complication rates of hip reconstructive procedures performed upon children with cerebral palsy have varied considerably, those with more severe disease have experienced more complications. We report our tertiary referral center's complication rate and our institutional experiences with risk factors for complications and failures to cure. IV, Retrospective case series.

Hip Dysplasia in Patients With Hurler Syndrome (Mucopolysaccharidosis Type 1H)

Hip dysplasia is common in patients with Hurler syndrome (HS). However, its prevalence and optimal management is not yet clear because of the rarity of the disease and the prior short life span of these patients. Recent advances in the management of these children using allogeneic hematopoietic cell transplant (HCT) has significantly increased their life expectancy, with many surviving into adulthood. This review was conducted to describe the experience of a single center with hip dysplasia in HS after HCT. We performed a retrospective review of hip dysplasia in a consecutive series of patients with HS treated with HCT from 1985 to 2008. At 4.5 (± 2.9) years after HCT all 51 children (102 hips) with HS showed acetabular dysplasia and proximal femur valgus deformity. Mean age at HCT was 1.6 ± 0.9 years. Forty hips (39%) underwent hip reconstructive osteotomies at mean age of 6.8 ± 3.1 years. Significant radiographic improvement was noted in all radiographic parameters at 5.4 ± 3.7 years after hip surgery (P<0.001). Acetabular index improved from 33.3 degrees (± 7.9) preoperative to 24.7 degrees (± 8) after surgery, lateral center edge angle improved from -5.3 degrees (± 10.9) to 35.2 degrees (± 17.8), migration index from 50.7% (± 15.7) to 9.6% (± 13.6), and femoral-neck-shaft angle from 150.9 degrees (± 5.8) to 130.8 degrees (± 12.4). Ten of the 40 hips underwent only proximal femoral varus derotation osteotomy and 30 underwent combined proximal femoral varus derotation osteotomy+pelvic osteotomy. This study reports high prevalence of hip dysplasia (100%) in patients with HS. As significant radiographic improvement was achieved in those patients treated with surgical interventions we recommend annual orthopaedic evaluation of hips in patients with HS after HCT and intervention with reconstructive femoral and pelvic osteotomies for their hip dysplasia.

The Relationship of Gross Motor Functional Classification Scale Level and Hip Dysplasia on the Pattern and Progression of Scoliosis in Children With Cerebral Palsy

PurposeThe primary aim of the study was to determine whether progression and magnitude of scoliosis were related to the Gross Motor Functional Classification Scale (GMFCS) and whether laterality (and associated pelvic obliquity) of the spinal curvature affected severity of recurrent hip subluxation in patients with cerebral palsy who had undergone varus derotational osteotomy (VDRO). MethodsA total 115 patients underwent VDRO surgery at a single institution between 1980 and 2001. Adequate radiographs were available for 98 patients. Average age at time of VDRO was 6.5 years and follow-up post-VDRO was 8.2 years. Children were divided into lower severity (GMFCS 1–3; 13 patients), high severity (GMFCS 4; 42 patients), and highest severity (GMFCS 5; 43 patients). A single observer measured all spine radiographs using standardized technique. A separate observer measured hip migration index on all pelvis radiographs. ResultsThere was a significant increase in coronal deformity over time in each GMFCS category (p < .0001). The GMFCS 1–3 and GMFCS 4 groups had nearly identical time trends, each increasing at roughly 1° to 2° annually, whereas the GMFCS 5 group increased by 3.5°/year (p = .0153). Increasing Cobb angle was not a significant predictor of severity of recurrent subluxation. Furthermore, there was no significant difference in severity of recurrent hip subluxation when hips were evaluated based on whether they were on the same side as the concavity or convexity of the scoliosis (ie, high or low side of pelvic obliquity). ConclusionsThe relationship between GMFCS and rate of scoliosis progression differed between groups. Severity of hip subluxation did not increase significantly over time after VDRO, nor was it significantly related to magnitude or laterality of scoliosis in children in this cohort. SignificanceTreatment decisions regarding hip subluxation and scoliosis in patients with cerebral palsy may be made independent of each other.

Management of Hip Instability in Trisomy 21

The unstable hip in Trisomy 21 presents with a spectrum of hip instability with different problems at different ages. What links this multiphase problem, in many patients, is the final common pathway of untreated instability, that of a stiff, dislocated, and often-painful hip, leading to significant functional disability. Historically, the results of treating hip instability in Trisomy 21 were variable with a notable frequency of poor results. With an improved understanding of the Trisomy 21 hip in terms of its pathoanatomy and a more contemporary surgical approach to hip reconstruction, much improved results can be expected and indeed have recently been shown. The mainstay of treatment for the habitual dislocation group presenting before 8 years of age is the femoral varus derotation osteotomy. The older group presenting with painful subluxation often show signs of secondary acetabular dysplasia and thus are best treated with redirectional acetabular osteotomy with or without the use of femoral varus derotation osteotomy. The presence of radiographic features of degenerative arthritis in the fixed dislocation group precludes the use of joint-preserving techniques for hip reconstruction, and these patients can achieve excellent results with total joint arthroplasty. The natural history, historical results, assessment, treatment, and management of complications of hip instability in Trisomy 21 are addressed in this paper.

Long-term outcome of reconstruction of the hip in young children with cerebral palsy

We reviewed the long-term radiological outcome, complications and revision operations in 19 children with quadriplegic cerebral palsy and hip dysplasia who underwent combined peri-iliac osteotomy and femoral varus derotation osteotomy. They had a mean age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations and subluxations. We also studied the outcome for the contralateral hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade 3 in five, and grade 5 in one. There were five complications seen in four hips (21%, four patients), including one dislocation, one subluxation, one coxa vara with adduction deformity, one subtrochanteric fracture and one infection. A recurrent soft-tissue contracture occurred in five hips and ten required revision surgery. In pre-adolescent children with quadriplegic cerebral palsy good long-term outcomes can be achieved after reconstruction of the hip; regular follow-up is required.

Are hips stable in children with cerebral palsy?

This commentary is on the original article by Terjesen on pages 951-957 of this issue. In 2010, the mechano-biological principles of proximal femoral geometry and muscle forces were implemented on a three-dimensional finite element model of the proximal femur, in order to predict changes in morphology over time in both typically developing children and children with cerebral palsy (CP).1 The simulation relies on the assumption that cyclic octahedral shear stress promotes growth and cyclic hydrostatic compressive stress inhibits growth. This finite element model predicts an increase in femoral anteversion and coxa valga for load conditions in children with CP when compared with typically developing children. In this study, growth was simulated over a period of approximately 5 months. From three population-based studies2–4 we know that hip displacement is common in children with CP (with an overall incidence of approximately one-third); it is often present by 2–3 years of age; range of motion is a poor indicator of hips at risk; and it is directly related to gross motor function as graded by the Gross Motor Function Classification System (GMFCS). In these studies the cut-off values for the migration percentage were set at slightly different levels: 30–33% for hip subluxation and 90–100% for hip dislocation.2–4 In a new study, Terjesen has carefully evaluated and reported a population-based hip surveillance programme for children with CP in Norway.5 A large number of children (n=335) were included and the data were collected and analysed meticulously. Hip displacement occurred in 26% of all children (subluxation in 22% and dislocation in 4%) and in 63% of those at GMFCS levels IV and V. The mean migration percentage was 20.4% at the initial radiographs and 34.0% at the end of the study. The rate of increase in migration percentage increased with decreasing functional level, from 0.2% per year at GMFCS level I to 9.5% at GMFCS level V. Radiographic hip surveillance from age 1 to 2 years was recommended for non-ambulatory children with CP on a regular basis. Current management options for hip displacement in children with CP include reconstructive procedures such as varus derotation osteotomy of the proximal femur,6 preventive surgery such as adductor releases,7 or a combination of both.8 A large recently published study7 demonstrated that the success of preventive surgery for hip displacement was directly related to GMFCS level. ‘Success’ was defined as the absence of subsequent surgical procedures during the study period of 7 years and a migration percentage of less than 50%. The success rate was 32%. However, the success rate was predicted by GMFCS level, with 94% at GMFCS level II decreasing to 14% at GMFCS level V. Finally, the question remains as to when the hip is stable or unstable in patients with CP. The data from current studies support the fact that hips in children with CP on a high functional level (GMFCS levels I, II, and III) are usually stable, or easily made so – but that hips in non-ambulatory children with CP (GMFCS levels IV and V) are usually not stable! Hip surveillance is important and needs to start by the age of 2 years in non-ambulatory children. The main goal of systematic hip screening is to prevent hip dislocation. Future research, based on the understanding of the biomechanics of the proximal femur, should focus on specific management guidelines for each GMFCS level or at least for ambulatory and non-ambulatory children with CP.

Surgical treatment of hip dislocation in Kabuki syndrome: Use of incomplete periacetabular osteotomy for posterior acetabular wall deficiency

Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome. Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7years, with an average of 3.6years. The follow-up postoperative period ranged from 3.2 to 6.3years, with an average of 5.0years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum. Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.

The Lower Extremity in Morquio Syndrome

The modalities and results of surgical intervention in the lower extremity in children with Morquio syndrome type A [mucopolysaccharidosis-IV (MPS-IVA)] have not been well described. The aims of this study are to define the lower extremity deformities, and describe the results of intervention in MPS-IVA patients. Retrospective chart and radiograph review of 23 MPS-IVA patients with a minimum follow-up of >2 years. Patients were divided into no intervention and surgical groups. Demographic data, surgical details, clinical results, and complications were recorded. Standard lower extremity radiographic measurements made on standing radiographs at initial presentation, preoperatively (in surgical group), and at the final follow-up were used to study the deformities and effects of hip, knee, and ankle surgery. Descriptive statistics were performed. There were 11 boys and 12 girls. The average age at presentation was 6.8±3.4 years and at the last visit was 13.5±5 years with a mean follow-up of 6.7±3.7 years. Progressive hip subluxation, genu valgum, and ankle valgus were observed in all patients without intervention. Twenty patients had a total of 159 lower extremity surgical procedures (average, 8 procedures per patient). There were 61 hip, 78 knee, and 20 ankle procedures. Surgery resulted in improvement of the center edge angle, femoral head coverage, lateral distal femoral angle, medial proximal tibial angle, tibiofemoral angle, and lateral distal tibial angle. Mechanical axis of the lower extremities improved after intervention. Six patients (12 hips) had recurrence of hip subluxation after acetabular osteotomies and/or femoral varus derotation osteotomy, and 8 patients (16 knees) had postoperative genu valgum recurrence requiring subsequent intervention. There was no recurrent hip subluxation after shelf acetabuloplasty. Progressive hip subluxation, genu valgum, and ankle valgus were seen and often needed surgery. After shelf acetabuloplasty and varus derotation osteotomy, there was no recurrent hip subluxation. Recurrence after genu valgum correction was common. Level IV, therapeutic case series.

Early results of one-stage correction for hip instability in cerebral palsy.

BackgroundWe evaluated the clinical and radiological results of one-stage correction for cerebral palsy patients.MethodsWe reviewed clinical outcomes and radiologic indices of 32 dysplastic hips in 23 children with cerebral palsy (13 males, 10 females; mean age, 8.6 years). Ten hips had dislocation, while 22 had subluxation. Preoperative Gross Motor Function Classification System (GMFCS) scores of the patients were as follows; level V (13 patients), level IV (9), and level III (1). Acetabular deficiency was anterior in 5 hips, superolateral in 7, posterior in 11 and mixed in 9, according to 3 dimensional computed tomography. The combined surgery included open reduction of the femoral head, release of contracted muscles, femoral shortening varus derotation osteotomy and the modified Dega osteotomy. Hip range of motion, GMFCS level, acetabular index, center-edge angle and migration percentage were measured before and after surgery. The mean follow-up period was 28.1 months.ResultsHip abduction (median, 40°), sitting comfort and GMFCS level were improved after surgery, and pain was decreased. There were two cases of femoral head avascular necrosis, but no infection, nonunion, resubluxation or redislocation. All radiologic indices showed improvement after surgery.ConclusionsA single event multilevel surgery including soft tissue, pelvic and femoral side correction is effective in treating spastic dislocation of the hip in cerebral palsy.

Surgical Management of Hip Subluxation and Dislocation in Children With Cerebral Palsy

Controversy exists regarding surgical treatment of hip subluxation/dislocation in children with cerebral palsy (CP). The purpose of this study was to compare isolated varus derotational osteotomy (VDRO) and VDRO combined with open hip reduction and/or pelvic osteotomy in children with CP and hip subluxation/dislocation. Retrospective review was performed of 75 patients with CP (116 hips) and hip subluxation/dislocation treated surgically, with a minimum of 2 years follow-up. Ninety-two hips had undergone VDRO alone, and 24 had undergone VDRO and open reduction and/or pelvic osteotomy (with the decision to proceed with open hip reduction and/or pelvic osteotomy made intraoperatively based on fluoroscopy and arthrogram). Clinical variables, functional level, radiographic variables, and complications/revisions were compared between groups. Patients requiring combined surgery (VDRO+) had higher baseline migration percentages (MP) (84% ± 18 VDRO+, 51% ± 21 VDRO), higher acetabular indices (34 ± 10 VDRO+, 28 ± 7 VDRO), more negative center-edge angles (-36 ± 28 VDRO+, -0.3 ± 18 VDRO), and higher neck-shaft angles (162 ± 12 VDRO+, 157 ± 10 VDRO) (all P < 0.02). Postoperative radiographic variables were similar between groups. The percentage of patients with MP >30% at final follow-up was similar between groups (38% VDRO+, 33% VDRO). There were no differences in complications or revision rates between groups. Of the hips with MP >50% preoperatively and treated with VDRO alone, 41% developed postoperative MP of ≥ 30% and 21% developed a MP of ≥ 40%. The study results confirm that combined procedures should be considered in patients with high MP. However, this study supports a sequential approach to surgical management of subluxated/dislocated hips in patients with CP as many hips with MP >50% were successfully managed with VDRO alone. We recommend performing VDRO and soft tissue release first, assessing reduction using fluoroscopy and arthrogram and proceeding with open reduction and/or pelvic osteotomy if reduction and/or femoral head coverage are inadequate. Level III, retrospective comparative study.

Multilevel Surgery Improves Gait in Spastic Hemiplegia But Does Not Resolve Hip Dysplasia

Multilevel orthopaedic surgery may improve gait in Type IV hemiplegia, but it is not known if proximal femoral osteotomy combined with adductor release as part of multilevel surgery in patients with hip dysplasia improves hip development. We asked whether varus derotational osteotomy of the proximal femur, combined with adductor release, influenced hip development in patients with Type IV hemiplegia having multilevel surgery. We retrospectively reviewed 11 children and adolescents with Type IV hemiplegia who had a proximal femoral osteotomy due to unilateral hip displacement to correct gait dysfunction between 1999 and 2006. The mean age at the time of surgery was 11.1 years (range, 7 to 16 years). We obtained the Movement Analysis Profile and Gait Profile Score before and after surgery. We also measured the Migration Percentage of Reimers and applied the Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The minimum followup was 2 years 3 months (mean, 6 years 6 months; range, 2 years 3 months to 10 years 8 months). The majority of gait parameters improved but hip development was not normalized. According to the MCPHCS at last followup, no hips were classified as Grade I, two hips were classified as Grade II, and the remainder were Grade III and IV. Unilateral surgery including a proximal femoral osteotomy improved gait and walking ability in individuals with spastic hemiplegic cerebral palsy. However, hip dysplasia persists. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Perioperative Ketorolac Use in Children Undergoing Lower Extremity Osteotomies

Ketorolac has previously been shown to afford good pain relief in children undergoing surgery. Due to concerns about potential complications, particularly nonunion, delayed union, and excessive blood loss, ketorolac use has been limited in pediatric orthopaedics. The goal of this study is to examine complications associated with the perioperative use of ketorolac in children undergoing lower extremity osteotomies. A retrospective review was conducted of 327 consecutive children undergoing osteotomy surgery who had a minimum of 6 months follow-up. Of the 327 patients, 299 patients (625 osteotomies) had received ketorolac perioperatively and 28 (57 osteotomies) had not. There was no significant difference in the rate of either osseous or soft tissue complications between the 2 groups. There were no nonunions in either of the groups. Delayed union occurred in 5 of 682 osteotomies (0.7%), including 0.6% in the ketorolac group (4/625 osteotomies), and 1.8% (1/57 osteotomies) in the nonketorolac group (P=0.893). Wound complications occurred in 16/327 patients overall (4.9%), including 13/299 (4.3%) in the ketorolac group and 3/28 (10.7%) in the nonketorolac group (P=0.301). There was no significant difference in estimated blood loss (EBL) (P=0.584) or the need for blood transfusion (P=0.777) between the 2 groups. Of the 19 occasions when blood was transfused perioperatively in the ketorolac group, 15 patients had undergone unilateral (3 patients) or bilateral (12 patients) varus derotational osteotomy as part of their surgery. Overall, 15 of 113 patients (13.3%) in the ketorolac group who underwent unilateral or bilateral varus derotational osteotomy required blood transfusion, with rates of 31.8% (7/22) in those who had undergone concomitant pelvic osteotomy(ies) and 8.7% (8/91) in those who had not. The results of this study support the safety of perioperative ketorolac use in children undergoing lower extremity osteotomies. Level III.

Femoral Varus Derotation Osteotomy for the Treatment of Habitual Subluxation and Dislocation of the Pediatric Hip in Trisomy 21

Habitual hip subluxation and dislocation are potentially disabling features of the trisomy 21 syndrome. We describe outcomes after a femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation. All individuals with trisomy 21, who underwent hip surgery at our institution between 1998 and 2008, were searched using the hospital databases. The clinical notes and radiographs were reviewed from presentation to final follow-up. Nine children (16 hips) aged below 10 years, were identified. All had a femoral varus derotation osteotomy with a target femoral neck-shaft angle (NSA) of 105 degrees and external rotation of < 20 degrees of the distal fragment. All were performed by the senior author. Mean age at first known hip dislocation was 4.6 years (range, 4 to 5.2 y), mean age at surgery was 6.1 years (range, 5.2 to 7.0 y), and mean follow-up was 5.4 years (range, 3.8 to 7.1 y). Mean NSA fell postoperatively to 106.0 degrees (range, 103.1 to 110.2 degrees) from 166.7 degrees (range, 162.2 to 171.1 degrees). In 2 hips, intraoperative instability remained, requiring immediate periacetabular osteotomy and capsulorraphy.Postoperatively, all patients demonstrated an asymptomatic waddling gait, which persisted in 1 individual. Fourteen hips developed peritrochanteric varus deformities with a mean center of rotation and angulation of 21 degrees (range, 16 to 25 degrees). Two hips (12.5%) sustained implant-related fractures 4 and 8 years postoperatively. One hip (6.3%) developed arthritis and none had redislocated at latest follow-up. Sequelae from recurrent subluxation or dislocation of hips in trisomy 21 may require surgery to prevent eventual disability.We recommend a varus producing proximal femoral osteotomy correcting the NSA to approximately 105 degrees. This should be performed before the age of 7 years or a widened or V-shape teardrop develops. After 2 implant-related fractures, we recommend implant removal once the osteotomy has healed and the hip stabilized.In our experience, this approach is effective in maintaining hip stability. A level 4 study, looking at a specific patient population undergoing a particular procedure.

Femoral Varus Osteotomy in Legg-Calve-Perthes Disease

In a preliminary report in 1965, Axer proposed femoral varus derotation osteotomy as an alternative method for treating Legg-Calve-Perthes disease. Thereafter, this became one of the most popular operative methods in the treatment of the disease. A literature analysis of this method experienced during the years is discussed and the investigator's personal approach is described.

Treatment outcome in the most severely affected Legg-Perthes patients, comparing prolonged traction in abduction with femoral varus derotation treatment.

Compare conservative and operative treatment in the most severely affected Legg-Perthes disease patients. 29 patients (14 conservative and 15 operative) with 32 affected hips (16 conservative and 16 operative) were evaluated, all Catterall 3 or 4. The conservative group, with a median age-at-onset of 4.8 (range, 2.5-9.5) years, was treated by a rigorous regime of traction in abduction for an average of two years. Follow-up was performed at a median of 28.6 (range, 17.4-31.6) years with a median patient age of 34.1 (range, 19.9-39.3) years. The operative group, with a median age-at-onset of 4.7 (range, 2.0-7.8) years, was treated by femoral varus derotation osteotomy. Follow-up was performed at a median of 14 (range, 8-21.4) years, with a median patient age of 20.7 (range, 12.8-28) years. Median age-at-onset (P=0.16) and Catterall classification (P=0.29) were comparable. No differences could be found for the Stulberg classification (P=0.83), functional parameters (Harris Hip score and Merle d'Aubigné and Postel), and leg-length differences. Career choices were similar for both patient groups, as well. Given methodological issues, femoral varus derotation osteotomy did not show apparent better results than the conservative containment regime in Catterall 3 and 4 patients with a median age-at-onset around 4.8years. This result is fairly similar to recent literature suggesting a conservative approach in most severely affected patients with a young age-at-onset. However, based on unacceptable socioeconomic issues, the conservative regime evaluated in the present study cannot be justified, nowadays.