Varus Shortening Research Articles

A COMPREHENSIVE PELVIC AND FEMORAL OSTEOTOMY REVISION TO TREAT A FAILED PELVIC AND FEMORAL OSTEOTOMY: A CASE REPORT

Hip’s open reduction combined with Salter innominate osteotomy and femoral osteotomy is the treatment of choice when treating Developmental Dislocation of the Hip (DDH) at walking age. We report a case of a five-year-old girl who underwent a failed surgical procedure of hip’s open reduction, Salter innominate osteotomy, and the femoral osteotomy. One year later, one-stage surgical procedure of hip’s open reduction, Dega pelvic osteotomy, and femoral de-rotation varus shortening osteotomy was performed. During the five-year follow-up, the clinical outcome was evaluated as excellent. The Dega pelvic osteotomy is an effective pelvic osteotomy for DDH, in a case of a failed Salter osteotomy.

One-stage treatment of hip dislocation with cerebral palsy via soft tissue release, hip reduction and osteotomy

Objective To investigate the methods and outcomes of surgical treatment for hip dislocation with cerebral palsy (CP) via soft tissue release, hip reduction and osteotomy. Methods Nineteen CP patients (male: 9, female: 10; total 23 hips) with hip dislocation underwent reconstructive surgery between April 2010 and December 2016. The average age was 12.5±2.4 years. There were 17 diplegic, 1 hemiplegic and 1 quadriplegic patient. Gross motor function classification system distribution were type I in 2 patients, type II in 10 patients, type III in 5 patients, type IV in 2 patients. Combine one-stage surgical procedures included soft tissue release, close or open reduction of hip joint and femoral varus shortening or de-rotational osteotomy and pelvic osteotomy. During the follow-up period, the clinical symptom and radiological parameters including Sharp angle and acetabular index were recorded. Results The average follow-up duration was 2.1 years (1-4.5 years). The radiological parameters were evaluated at one year postoperatively. The migration percentage corrected to 6%±8% from 68%±21% with statistically significant different (t=12.760, P<0.001). The mean Sharp angle was 42°±8.9°, which was statistically significant reduced compared with the pre-operative value 59°±6.1° (t=9.058, P<0.001). In 15 patients with triradiate cartilage open, the acetabular index also improved from 34°±8.7° pre-operatively to 18°±10° with statistical significance (t=5.598, P<0.001). Total of 15 patients had gained hip stability and improved functional status. Hip pain, which happened in 11 patients preoperatively, all had relieved after operation. Four patients had dissatisfied results and re-subluxation happened in 3 hips. All of them had CE angle <20° immediately after operation (average, 17°±2.6°), which was significantly different compared with average CE angle 32°± 8.0° in non-recurrence hips (t=3.143, P=0.005). One patient, who underwent proximal hamstring release, had decline of function status and contralateral hip dislocation. Conclusion Dislocation hips in CP patients can be effectively treated with one stage soft tissue release, hip reduction and femoral and pelvic osteotomy. The selection of osteotomy method is based on the age and pathological changes of patients. Key words: Cerebral palsy; Hip dislocation; Osteotomy

Percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in nonambulatory GMFCS level IV and V cerebral palsy patients

This study evaluated the outcome of severe cerebral palsy patients (Gross Motor Function Classification System level IV and V) treated by simultaneous percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy for hip subluxation or dislocation between 2002 and 2011. Twenty-four patients (30 hips) with an average age of 9.4 years (5-16.5) were reviewed at a mean follow-up of 35.9 months (6-96). Percutaneous pelvic osteotomy lasted on average 30 min/patient per side (25-40) and was always performed through a skin incision of 2-3 cm. The migration percentage and acetabular angle were assessed on plain radiographs. The mean Reimers' migration percentage improved from 67.1% (42-100) preoperatively to 7.7% (0-70) at the last follow-up and the mean acetabular angle improved from 31.8° (22-48) to 15.7° (5-27). Five patients presented complications: one redislocation, one bone graft dislodgement, and three with avascular necrosis of the femoral head. This study should be considered as a pilot study. These results indicate that this combined approach is an effective, reliable, and minimally invasive alternative method for the treatment of spastic dislocated hips in severe cerebral palsy patients with an outcome similar to standard techniques reported in the literature.

Das arthrogrypotische Hüftgelenk

In a retrospective review of 70 hips in 35 patients with arthrogryposis 56 of all hips studied were affected by the disorder. Clinically 4 types of arthrogrypotic hip deformity could be distinguished. In 19 hip joints not only a deformity and a restriction of movement but also a dislocation was found. Based on the results of this study a one-stage open reduction combined with a varus shortening, femoral derotation osteotomy for unilateral hip dislocations is recommended. In cases of bilateral dislocations the above mentioned surgical procedure is indicated only if there is a less severe generalized involvement of AMC. For correction of hip deformities type II during neonatal period conservative treatment by traction or by plaster cast redression has proved be successful. The authors experience is compared with reports of other authors and guidelines for clinical classification and treatment are presented.

Complications des ostéotomies du premier rayon: À propos d’une série continue de 475 pieds traités par ostéotomies du premier métatarsien (Scarf) et de la première phalange

Purpose of the study Available studies on Scarf osteotomies of the first metatarsal (M1) and first phalange (P1) shortening and varus displacement have reported good results, but have have not focused on complications. We reviewed a consecutive series of 475 feet operated on over a five year period. Our goal was to determine the incidence of complications and to compare our data with reports in the literature. We wanted to know if association with Weil osteotomy on the lateral metatarsals affects the rate of complications. Material and methods We used the following inclusion criteria: hallux valgus > 35°, adult subject, with or without impact on the lateral ray, no prior foot surgery, no systemic disease, no other co-morbid condition. We distinguished two groups: group 1 with isolated first ray disease, and group 2 with hallux valgus and lateral metatarsalgia requiring surgery. Results We determined the incidence of each complication. Metatarso-phalangeal joint (MTP1) stiffness was the most frequent complication: incidence declined with postoperative time: 41.7% at day 35, 5.7% at day 120. The joint was very stiff with defective pulp weight-bearing in 1.3% of the feet at 12 months. Late wound healing was observed in 5.7% of feet and secondary osteotomy displacement in 1%. Incidence of other complications, including operative site infection, was less than 1%. General complications were: reflex dystrophy (1.3%) and deep vein thrombosis (0.6%). Excepting a longer period of postoperative stiffness, we were unable to identify any change in the rate of postoperative complications in feet with an associated Weil osteotomy of the first ray. Discussion Our findings confirm that Scarf M1 osteotomies with varus shortening of P1 generates fewer complications than the techniques used earlier. Certain complications have disappeared: nonunion after M1 and P1 osteotomy, great toe claw, symptomatic iatrogenic hallux valgus. Complications with a very low incidence in all series are: operative site infection, osteonecrosis of the M1 head, fracture of M1 at weight bearing. Notching of the two osteotomy pieces with elevation of the metatarsal head and transfer metatarsalgia has been reported by authors using short diaphyseal osteotomies. A stiff MTP1 remains the most frequent complication. Overtly stiff joints (30% loss of range of motion) were observed in 4.6% of our patients at 12 months; 1.3% had major stiffness (20° extension, 0° plantar flexion). This stiffness has been reported by others using the same technique but the risk factors have not been identified. Conclusion This prospective work enabled us to establish the rate of secondary complications of first ray surgery for M1 Scarf osteo-tomy and P1 osteotomy. Complications are rare, a further argument favoring use of these osteotomies. This statistical study enables us discuss the risk of complications at the preoperative interview, keeping in mind the specific elements inherent in each particular situation.

Reconstruction of the dysplastic spastic hip with peri-ilial pelvic and femoral osteotomy followed by immediate mobilization.

All children with cerebral palsy who had a pelvic osteotomy performed by the senior author (F.M.) from 1989 through 1991 were reviewed. Indications for operative reconstruction were failed muscle lengthening in a child younger than 8 years or a painful hip. The operative procedure included adductor muscle lengthening, varus shortening femoral osteotomy, and peri-ilial pelvic osteotomy. Patients were immediately mobilized after surgery by physical therapy. Fifty-one children had reconstruction of 49 subluxated and 21 dislocated hips. Femoral and pelvic osteotomies were performed on 59 hips, and 11 hips had only a femoral osteotomy. Forty-nine hips had adductor muscle lengthening, and 27 hips had femoral osteotomy to provide for relief of contractures. At mean follow-up of 34 months, two hips in two patients had redislocated, requiring repeated surgery. Two hips remained subluxated and asymptomatic. Twenty-three hips in 18 patients were painful before surgery. One hip continued with severe pain after surgery, requiring further surgery. Three hips continued with mild pain not requiring surgery, and 14 (82%) hips had complete pain relief. Of 37 caretakers interviewed, 80% felt the procedure was beneficial and would recommend it to others. Eight percent were uncertain, and 6% (two caretakers) thought it was not helpful.

A PLAN OF MANAGEMENT AND TREATMENT RESULTS IN THE ARTHROGRYPOTIC HIP

In a retrospective review of 52 hips in 26 patients with arthrogryposis, 65% of all hips studied were affected by the disorder; 46.6% of the patients were independent ambulators, 33.3% required some type of bracing for ambulation, and 20% were confined to a wheelchair. Based on the results of the authors' treatment as determined by a functional hip score, the authors recommend a one-stage open reduction, varus shortening femoral derotational osteotomy for all unilateral hip dislocations and those bilateral hip dislocations that have a less severe generalized involvement. They also recommend an aggressive traction program with appropriate soft-tissue releases during the neonatal period for patients with subluxation and/or marked limitation of motion of the hip.

A Plan of Management and Treatment Results in the Arthrogrypotic Hip

In a retrospective review of 52 hips in 26 patients with arthrogryposis, 65% of all hips studied were affected by the disorder; 46.6% of the patients were independent ambulators, 33.3% required some type of bracing for ambulation, and 20% were confined to a wheelchair. Based on the results of the authors' treatment as determined by a functional hip score, the authors recommend a one-stage open reduction, varus shortening femoral derotational osteotomy for all unilateral hip dislocations and those bilateral hip dislocations that have a less severe generalized involvement. They also recommend an aggressive traction program with appropriate soft-tissue releases during the neonatal period for patients with subluxation and/or marked limitation of motion of the hip.