Posteromedial bowing of the tibia: a benign condition or a case for limb reconstruction?

PURPOSE: To review the initial deformity and subsequent remodelling in posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. PATIENTS AND METHODS: In all, 38 patients with posteromedial bowing of the tibia presenting between 2000 and 2016 were identified. Mean follow-up from presentation was 78 months. A total of 17 patients underwent lengthening and deformity correction surgery, whilst three further patients are awaiting lengthening and deformity correction procedures. RESULTS: The greatest correction of deformity occurred in the first year of life, but after the age of four years, remodelling was limited. The absolute leg-length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45 mm (35 to 60). Mean duration in frame was 192 days, with a mean healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of ten years (p = 0.046). Four contralateral epiphysiodeses were also performed. CONCLUSION: Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening LLD. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator should be considered as part of the treatment options. LEVEL OF EVIDENCE: Level IV (Case series).

A protocol for the use of closed reduction in children with developmental dysplasia of the hip incorporating open psoas and adductor releases and a short-leg cast: Mid-term outcomes in 113 hips.

AIMS: Our aim was to assess the effectiveness of a protocol involving a standardised closed reduction for the treatment of children with developmental dysplasia of the hip (DDH) in maintaining reduction and to report the mid-term results. METHODS: A total of 133 hips in 120 children aged less than two years who underwent closed reduction, with a minimum follow-up of five years or until subsequent surgery, were included in the study. The protocol defines the criteria for an acceptable reduction and the indications for a concomitant soft-tissue release. All children were immobilised in a short- leg cast for three months. Arthrograms were undertaken at the time of closed reduction and six weeks later. Follow-up radiographs were taken at six months and one, two and five years later and at the latest follow-up. The Tönnis grade, acetabular index, Severin grade and signs of osteonecrosis were recorded. RESULTS: A total of 67 hips (51%) were Tönnis grade 3/4 hips. By 12 months, 20 reductions (15%) had not been maintained, and these required open reduction. In all, 55% of these were Severin 1; the others were Severin 2, due to minor acetabular dysplasia. Of the 113 successful closed reductions, 98 hips (87%) were Severin 1. Surgery for residual DDH was offered for ten hips. Osteonecrosis was seen in 32 hips (29%) but was transient in 28. In total, two children (1.5%) had severe osteonecrosis. Bilateral dislocations were significantly more likely to fail and most Tönnis 4 hips failed. CONCLUSION: Closed reduction, with concomitant adductor and psoas release when required and the use of a short leg plaster of Paris cast for three months, can produce good mid-term results in children with DDH aged less than two years. This protocol is not recommended for Tönnis 4 hips. Cite this article: Bone Joint J 2016;98-B:1548-53.

Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis.

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head-shaft slip angle from 53.8(°) (standard deviation (SD) 3.2) pre-operatively to 9.1(°) (SD 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, SD 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

The influence of the choice of closing wedge angle on leg length discrepancy after proximal femoral varus osteotomy.

Proximal femoral varus osteotomy improves the biomechanics of the hip and can stimulate normal acetabular development in a dysplastic hip. Medial closing wedge osteotomy remains the most popular technique, but is associated with shortening of the ipsilateral femur. We produced a trigonometric formula which may be used pre-operatively to predict the resultant leg length discrepancy (LLD). We retrospectively examined the influence of the choice of angle in a closing wedge femoral osteotomy on LLD in 120 patients (135 osteotomies, 53% male, mean age six years, (3 to 21), 96% caucasian) over a 15-year period (1998 to 2013). A total of 16 of these patients were excluded due to under or over varus correction. The patients were divided into three age groups: paediatric (< 10 years), adolescent (10 to 16 years) and adult (> 16 years). When using the same saw blades as in this series, the results indicated that for each 10° of angle of resection the resultant LLD equates approximately to multiples of 4 mm, 8 mm and 12 mm in the three age groups, respectively. Statistical testing of the 59 patients who had a complete set of pre- and post-operative standing long leg radiographs, revealed a Pearson's correlation coefficient for predicted versus radiologically observed shortening when using a wedge of either 10° or 20° of 0.93 (p < 0.001). The 95% limits of agreement from the Bland-Altman analysis for this subgroup were -3.5 mm to +3.3 mm. It has been accepted that a 10 mm discrepancy is clinically acceptable. This study identified a geometric model that provided satisfactory accuracy when using specific saw blades of known thicknesses for this formula to be used in clinical practice.

A new technique of endoprosthetic replacement for osteosarcoma of proximal femur with intra-articular extension.

INTRODUCTION: Osteosarcoma is the most common primary malignant tumour of bone and commonly involved sites are the distal femur, proximal tibia, and humerus. Osteosarcoma of proximal femur usually arises at the metaphysis and articular cartilage acts as a relative barrier to tumour spread, with extension into the hip joint being extremely rare. PRESENTATION OF CASE: A previously fit and well sixteen-year-old male presented with a 2month history of right hip pain and a limp. Plain radiographs and magnetic resonance imaging (MRI) showed an expansile lesion in the right femoral neck, extending 16cm distally from the proximal femoral articular surface through the intertrochanteric region into the upper right femoral shaft. There was also clear evidence of intra-articular extension into the acetabulum. DISCUSSION: Endoprosthetic replacement following resection is a good treatment option for proximal femoral tumours due to the low complication rate and achievement of good postoperative function. However, treatment of a proximal femoral lesion with intra-articular involvement by prosthetic reconstruction is challenging. We report a patient who presented with osteosarcoma of the proximal femur extending into the hip joint and describe the technique of en-bloc extra-articular resection of the acetabulum and proximal femur with reconstruction using a custom made prosthesis. CONCLUSION: We conclude that extra-articular resection and endoprosthetic reconstruction using a coned hemi-pelvic implant with fluted stem and a modular femoral implant is a useful treatment option in the management of a proximal femoral lesion involving the hip-joint. It allows adequate tumour clearance and stable reconstruction for rapid post-operative recovery with early mobilisation.

Varus proximal femoral osteotomy for hip dysplasia in adults.

A retrospective study was carried out to evaluate the role of varus proximal femoral osteotomy in relieving symptoms and improving function in adults affected by hip dysplasia. A group of 24 patients were identified that underwent 26 varus proximal femoral osteotomies between the period May 1979 and January 2001. All were investigated by dynamic hip arthrography to confirm restoration of congruency in the abducted position and the position of ''best fit''. The mean age of the patients at the time of operation was 26 years (range 16 to 47) and the median duration of follow-up was 5.1 years (range 1.6 to 23.1 years). Clinical improvement was evaluated by determining the Harris Hip Score at the time of admission with a further assessment at the most recent follow-up. Additionally, radiological change was evaluated by measuring acetabular femoral head index, the centre-edge angle of Wiberg and the Tonnis grade of osteoarthritis. The results revealed an improvement in Harris hip score from a mean of 72.1 pre-operatively (range 58.8 to 88.53) to 96.83 at the most recent follow-up (range 85.1 to 100). The centre edge angle and acetabular head index also increased in all patients. The results were statistically significant (p value <0.05). The procedure was found to reduce discomfort and improve function in patients affected by hip dysplasia. No patients required further intervention to alter disease progression during the follow-up period. The best results were found when the operation was performed for long leg dysplasia. Only one patient required surgery for non-union at the osteotomy site. Varus proximal femoral osteotomy appears to be a good treatment option in young adults with hip dysplasia, even when early degenerative change is present.

Outcomes of subcapital cuneiform osteotomy for the treatment of severe slipped capital femoral epiphysis after skeletal maturity.

We reviewed prospectively, after skeletal maturity, a series of 24 patients (25 hips) with severe acute-on-chronic slipped capital femoral epiphysis which had been treated by subcapital cuneiform osteotomy. Patients were followed up for a mean of 8 years, 3 months (2 years, 5 months to 16 years, 4 months). Bedrest with 'slings and springs' had been used for a mean of 22 days (19 to 35) in 22 patients, and bedrest alone in two, before definitive surgery. The Iowa hip score, the Harris hip score and Boyer's radiological classification for degenerative disease were used. The mean Iowa hip score at follow-up was 93.7 (69 to 100) and the mean Harris hip score 95.6 (78 to 100). Degenerative joint changes were graded as 0 in 19 hips, grade 1 in four and grade 2 in two. The rate of avascular necrosis was 12% (3 of 25) and the rate of chondrolysis was 16% (4 of 25). We conclude that after a period of bed rest with slings and springs for three weeks to gain stability, subcapital cuneiform osteotomy for severe acute-on-chronic slipped capital femoral epiphysis is a satisfactory method of treatment with an acceptable rate of complication.

The management of avascular necrosis after slipped capital femoral epiphysis.

Avascular necrosis is a serious complication of slipped capital femoral epiphysis and is difficult to treat. The reported incidence varies from 3% to 47% of patients. The aims of treatment are to maintain the range of movement of the hip and to prevent collapse of the femoral head. At present there are no clear guidelines for the management of this condition and treatment can be difficult and unrewarding. We have used examination under anaesthesia and dynamic arthrography to investigate avascular necrosis and to determine the appropriate method of treatment. We present 20 consecutive cases of avascular necrosis in patients presenting with slipped capital femoral epiphysis and describe the results of treatment with a mean follow-up of over eight years (71 to 121 months). In patients who were suitable for joint preservation (14), we report a ten-year survivorship of the hip joint of 75% and a mean Harris hip score of 82 (44 to 98).

Does Chiari osteotomy compromise subsequent total hip arthroplasty?

We compared 28 total hip arthroplasties done in dysplastic hips after previous Chiari osteotomy (group I) with a well-matched control group of 50 primary procedures (group II) done during the same period at an average follow-up of 5 years (range, 25-199 months). Group I required significantly less acetabular augmentation, had significantly shorter operative times, had less intraoperative blood loss, and had fewer complications than group II. There was no significant difference between the 2 groups in terms of clinical or radiographic outcome. Total hip arthroplasty after a successful Chiari osteotomy leads to medium-term results similar to those of other dysplastic hips. In our experience, less bone grafting was required, better coverage of the cup by host-bone was obtained, and the center of motion of the hip was more anatomic. Chiari osteotomy may delay the need for total hip arthroplasty, may facilitate acetabular reconstruction, and does not seem to compromise the medium-term clinical or radiographic outcome.

Diagnosing slipped upper femoral epiphysis.

The key to diagnosing slipped upper femoral epiphysis is a high index of suspicion. This article summarizes the important clinical features of the disorder and points out the pitfalls in diagnosis.

A novel TRK A (NTRK1) mutation associated with hereditary sensory and autonomic neuropathy type V.

A boy with recurrent pyrexial episodes from early life sustained a painless ankle injury and was found to have a calcaneus fracture and, later, neuropathic joint degeneration of the tarsus. Examination revealed distal loss of pain and temperature sensation and widespread anhidrosis. Sural nerve biopsy demonstrated severe reduction in small-caliber myelinated fiber density but only modest reduction in unmyelinated axons, the pattern of type V hereditary sensory and autonomic neuropathy (HSAN V). DNA analysis showed that he was homozygous for a mutation in the NTRK1/high-affinity nerve growth factor (TrkA) gene, his parents being heterozygous. Mutations in this gene are known to be responsible for HSAN IV (congenital insensitivity to pain with anhidrosis). The two disorders are therefore likely to be allelic.

Slipped capital femoral epiphysis: is the displacement always posterior?

The initial direction of displacement on slipped capital femoral epiphysis is generally accepted to be posterior as a consequence of retroversion of the femoral neck. We report the case of a 15-year-old boy with slipped capital femoral epiphysis in the medial direction, confirmed by three-dimensional computerized imaging. This was associated with an elongated neck without retroversion of the femoral neck. We suggest a correlation between elongated femoral neck with increased offset of the hip and the medial direction of slip. This case also underlines the need for precise definition of deformity prior to undertaking surgical treatment.

Valgus extension osteotomy for 'hinge abduction' in Perthes' disease. Results at maturity and factors influencing the radiological outcome.

Valgus extension osteotomy (VGEO) is a salvage procedure for 'hinge abduction' in Perthes' disease. The indications for its use are pain and fixed deformity. Our study shows the clinical results at maturity of VGEO carried out in 48 children (51 hips) and the factors which influence subsequent remodelling of the hip. After a mean follow-up of ten years, total hip replacement has been carried out in four patients and arthrodesis in one. The average Iowa Hip Score in the remainder was 86 (54 to 100). Favourable remodelling of the femoral head was seen in 12 hips. This was associated with three factors at surgery; younger age (p = 0.009), the phase of reossification (p = 0.05) and an open triradiate cartilage (p = 0.0007). Our study has shown that, in the short term, VGEO relieves pain and corrects deformity; as growth proceeds it may produce useful remodelling in this worst affected subgroup of children with Perthes' disease.

Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip.

After open reduction for developmental dysplasia of the hip (DDH), a pelvic or femoral osteotomy may be required to maintain a stable concentric reduction. We report the clinical and radiological outcome in 82 children (95 hips) with DDH treated by open reduction through an anterior approach in which a test of stability was used to assess the need for a concomitant osteotomy. The mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25). All patients have been followed up until closure of the triradiate cartilage with a mean period of 15 years (8 to 23). At the time of open reduction before closure of the joint capsule, the position of maximum stability was assessed. A hip which required flexion with abduction for stability was considered to need an innominate osteotomy. If only internal rotation and abduction were required, an upper femoral derotational and varus osteotomy was carried out. For a 'double-diameter' acetabulum with anterolateral deficiency, a Pemberton-type osteotomy was used. A hip which was stable in the neutral position required no concomitant osteotomy. Overall, 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II) with an incidence of 7% of secondary procedures for persistent dysplasia including one hip which redislocated. The results were better (p = 0.04) in children under the age of two years. Increased leg length on the affected side was associated with poor acetabular development and recurrence of joint dysplasia (p = 0.01). The incidence of postoperative avascular necrosis was 7%. In a further 18%, premature physeal arrest was noted during the adolescent growth spurt (Kalamchi-MacEwen types II and III). Both of these complications were also associated with recurrence of joint dysplasia (p = 0.01). Studies with a shorter follow-up are therefore likely to underestimate the proportion of poor radiological results.

Incomplete healing of simple bone cysts after steroid injections.

We reviewed 32 children after the treatment of simple bone cysts by intralesional injections of methylprednisolone acetate. The age of the child and the activity and size of the cyst did not significantly affect the radiological outcome. The earliest time at which the radiological response could be reliably determined was three months. After a median period of review of five years, four (13%) cysts had healed, 20 (62%) cysts were partially visible but sclerotic, four (12.5%) were still visible but opaque and four (12.5%) were clearly visible. The healed and partially visible but sclerotic cysts were classified as having satisfactory radiological healing. This was observed in 13 of 32 cysts (41%) after the first injection, in eight of 21 (38%) after the second injection, but in relatively few of the remaining cysts after subsequent injections. A satisfactory symptomatic outcome was achieved in all of the 18 children with humeral cysts and in the one child with a fibular cyst irrespective of the radiological outcome, but only in nine (67%) of the 13 children with femoral or tibial lesions, in whom the cysts were healed or sclerotic. The remaining four children had exertional bone pain and repeated fractures of their femoral or tibial cysts which were incompletely healed with sclerosis in one and opacities in three. We conclude that the healing response to intralesional corticosteroids is unpredictable and usually incomplete even after multiple injections. The failure rate in weight-bearing bones is too high.

Multiple guide wire technique for removal of the short distal fragment of a fractured intramedullary nail.

A method of removing a short distal fragment of a fractured intramedullary nail, using impacted olive-tipped guide wires, is described. We have used this technique with success when there has been a very short segment of nail left distally. This method gives improved grip and control of alignment of the nail fragment during extraction.

Natural history and treatment of instability of the hip in proximal femoral focal deficiency.

We studied 67 patients with 78 affected femurs to determine the natural history of proximal femoral focal deficiency (PFFD) with respect to hip instability and to establish guidelines for management. Using the classification systems of Aitken and Fixsen and Lloyd-Roberts as applied to a radiograph taken at age 12-15 months, we could accurately predict development of hip instability, defined as formation of a pseudoarthrosis or complete failure of hip development. The pseudoarthrosis occurred either at the cervical or subtrochanteric level of the femur. Cervical instability was difficult to treat operatively, but subtrochanteric instability fused spontaneously in 30% of cases and responded well to operative treatment when necessary. For unilateral failure of hip joint formation, various surgical procedures were used to assist prosthetic fitting, but bilateral cases were treated nonoperatively.

Current attitudes to cementing techniques in British hip surgery.

Aseptic loosening is the major problem in hip joint replacement. Improved cementing techniques have been shown to improve the long-term survival of implants significantly. To assess the use of modern cementing techniques in British surgeons, a detailed questionnaire was sent to all Fellows of The British Orthopaedic Association (BOA) regarding cement preparation, bone preparation, cementing technique and prostheses used in total hip arthroplasty. Excluding retired fellows, surgeons who use no cement, and those who had filled in forms inadequately, 668 responded, who between them performed 43,680 hip arthroplasties per year. In this survey, 21 different types of hip prostheses were implanted by the surgeons; 48% of hips implanted were Charnley type. Of the surgeons, 46% used Palacos with gentamicin as their cement for both the femur and acetabulum. For the femur, 44% of surgeons remove all cancellous bone, 40% use pulse lavage, 59% use a brush to clear debris, 94% dry the femur, 97% plug the femur, 76% use a cement gun and 70% pressurise the cement. For the acetabulum, 88% of surgeons retain the subchondral bone, 40% use pulse lavage, 100% dry the acetabulum, 22% use hypotensive anaesthesia and 58% pressurise the cement. Overall only 25% of surgeons (26% of hips implanted) use 'modern' cementing techniques. This has implications for the number of arthroplasties that may require early revision.

Surgical treatment of the rheumatoid hand.

Many rheumatoid patients either present late or are denied access to surgery which would benefit them if undertaken at an early stage. Combined clinics involving physicians, surgeons and therapists allow better assessment and help patients to receive maximum benefit from treatment. An understanding of the principles of surgery of the rheumatoid hand is important in the management of these patients.