Corrigendum to "Anterolateral Approach in the Treatment of Femoroacetabular Impingement of the Hip".

[This corrects the article on p. 337 in vol. 11, PMID: 31475056.].

Anterolateral Approach in the Treatment of Femoroacetabular Impingement of the Hip.

Background: Ganz surgical hip dislocation via a posterior (Kocher-Langenbeck) approach is a popular procedure in the management of femoroacetabular impingement (FAI). We report the results of surgery performed through an anterolateral (Watson-Jones) approach in the management of anterolateral FAI. Methods: Twenty-one hips in 20 patients (mean age at the time of operation, 17.3 years) were treated surgically using an anterolateral approach: 12 hips with Legg-Calvé-Perthes disease, three septic hips, three hips with avascular necrosis (combined with slipped capital femoral epiphysis [SCFE], femoral neck fracture, and developmental dislocation of the hip), two hips with epiphyseal dysplasia, and one hip with SCFE. All patients had anterolateral FAI. Surgical hip dislocation was performed in four hips with trochanteric osteotomy. Combined osteotomies were for neck lengthening in 11 hips, varus or valgus osteotomy in the proximal femur in four hips, and pelvic osteotomy in four hips. Clinical results were evaluated using a modified Harris hip score (mHHS). Results: Range of hip flexion and abduction showed statistically significant improvement after surgery; however, the improvement in mean mHHS was not statistically significant. Conclusions: An anterolateral approach can be used as an alternative to a posterior approach in the management of anterolateral FAI with or without hip dislocation while safely preserving the blood supply to the femoral head and allowing simultaneous procedures in the proximal femur.

Treatment of Brachymetatarsia Involving the Great Toe.

BACKGROUND: Brachymetatarsia is usually treated by lengthening the metatarsals, but excessive lengthening can be associated with complications. Our technique combines 1-stage step-cut lengthening of the first metatarsal with shortening and/or lengthening of the neighboring metatarsals and/or phalanges. METHODS: Twenty-four feet (15 patients) were treated for first-ray brachymetatarsia. Widely available commercial image-editing software was used to make a preoperative plan for each patient, with emphasis on the creation of a cosmetically satisfying toe-length arc with minimum shortening and lengthening of the affected metatarsals and proximal phalanges. Length gain and percentage increase were also recorded postoperatively. The American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scoring system was used for clinical evaluation. RESULTS: In all 24 feet, smooth parabolas were created at the level of the metatarsal heads and at the toe tips. All patients showed osseous union, and no complications were noted. However, most patients showed mildly restricted range of motion of the first metatarsophalangeal joint. The mean AOFAS score of the hallux significantly improved from 88.3 preoperatively to 98.1 at the latest follow-up (p < 0.001). CONCLUSIONS: One-stage step-cut lengthening of the first metatarsal combined with shortening and/or lengthening of the adjacent metatarsal and phalangeal bones provides excellent cosmetic and functional results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Double-Layered Lateral Meniscus Including a Ring-Shaped Accessory Meniscus: A Case Report.

CASE: We report the rare case of a double-layered lateral meniscus that was comprised of a normal meniscus and a ring-shaped accessory meniscus. An 11-year-old boy presented with left knee pain, and magnetic resonance imaging initially was interpreted as showing a horizontal meniscal tear. However, arthroscopic exploration revealed a double-layered meniscus. A superior accessory meniscus was fused with the inferior normal meniscus at the posterior horn and had more mobility compared with the normal meniscus. The symptoms improved substantially after resection of the superior accessory meniscus. The patient returned to sports at 4 months postoperatively; at 15 months postoperatively, radiographs demonstrated no evidence of degenerative changes. CONCLUSION: A double-layered lateral meniscus that includes a ring-shaped accessory meniscus is a rare abnormality that can be corrected arthroscopically by resection of the accessory meniscus.

Analysis of Radiographic Parameters of the Forearm in Traumatic Radial Head Dislocation.

BACKGROUND: Various deformities can occur in the forearm bones when the traumatically dislocated radial head is untreated for a long period. Without correction of all deformities, reduction of the dislocated radial head is difficult to maintain, and forearm and elbow motion will deteriorate after reduction. We evaluated radiographic parameters of forearms with traumatically dislocated radial heads (and of the normal sides) to understand the resulting deformities and the effectiveness of surgical treatment. METHODS: We analyzed pre- and postoperative anteroposterior and lateral radiographs of 22 forearms (22 patients) with traumatic radial head dislocation. We divided the forearm into three equal parts and measured various morphological parameters. All patients underwent surgical treatment and evaluation of radial head reduction and range of motion pre- and postoperatively. RESULTS: Before treatment, the middle of the ulna was significantly different from the unaffected side in both anteroposterior and lateral views. After surgery, the proximal ulna was significantly different from the unaffected side and the abnormal proximal radial neck angle persisted. The radial head was successfully reduced in 20 of 22 cases. Overall, the mean range of motion decreased after surgery, except for increased flexion-extension. CONCLUSIONS: Complicated deformities developing during long-term remodeling after injury indicate that stable reduction is difficult to achieve with conventional one-bone osteotomy. Even after successful reduction, secondary deformity in the proximal ulna and/or remaining deformity in the proximal radius can hinder forearm rotation.

The Fate of DDH Hips Showing Cartilaginous or Fibrous Tissue-filled Joint Spaces Following Primary Reduction.

BACKGROUND: Because the use of magnetic resonance imaging is still not universal for the patients with developmental dysplasia of the hip patients, orthopaedists do not generally distinguish widened joint spaces which are "empty" after primary treatment (and therefore still reducible), from those which are filled and much more difficult to treat. To date no studies have focused on the latter hips. We treated and observed the outcomes for 19 hips which showed filled joint spaces after primary treatment. METHODS: We retrospectively reviewed 19 cases of developmental dysplasia of the hip: (1) who showed a widened joint space on radiographs after primary treatment; and (2) whose magnetic resonance imaging showed that the widened joint space was accompanied by acetabular cartilage hypertrophy and/or was filled with fibrous tissues. All patients were over 1 year old at the time of primary reduction (reduction was closed in 4 patients, open in 6, and open with pelvic osteotomy in 9). Thirteen patients received at least 1 secondary treatment. Final results were classified using a modified Severin classification. RESULTS: Final outcomes were satisfactory in 10 (52.6%) and unsatisfactory in 9 (47.4%). The widened joint spaces gradually filled with bone, resulting in a shallow acetabulum in the patients with unsatisfactory results. Of 9 patients who underwent combined pelvic osteotomy at the time of primary reduction, results were satisfactory in 6 (66.7%), whereas all patients who had only closed or open primary reduction had unsatisfactory results. CONCLUSIONS: Combined pelvic osteotomy at the time of primary reduction is advisable in hips with widened joint spaces. However, hips with filled joint spaces after primary treatment often have unsatisfactory results even after additional pelvic and/or femoral osteotomy. LEVEL OF EVIDENCE: Level IV-prognostic study.

A Graphic Overlay Method for Selection of Osteotomy Site in Chronic Radial Head Dislocation: An Evaluation of 3D-printed Bone Models.

PURPOSE: Three-dimensional (3D) computed tomography imaging is now being used to generate 3D models for planning orthopaedic surgery, but the process remains time consuming and expensive. For chronic radial head dislocation, we have designed a graphic overlay approach that employs selected 3D computer images and widely available software to simplify the process of osteotomy site selection. METHODS: We studied 5 patients (2 traumatic and 3 congenital) with unilateral radial head dislocation. These patients were treated with surgery based on traditional radiographs, but they also had full sets of 3D CT imaging done both before and after their surgery: these 3D CT images form the basis for this study. From the 3D CT images, each patient generated 3 sets of 3D-printed bone models: 2 copies of the preoperative condition, and 1 copy of the postoperative condition. One set of the preoperative models was then actually osteotomized and fixed in the manner suggested by our graphic technique. Arcs of rotation of the 3 sets of 3D-printed bone models were then compared. RESULTS: Arcs of rotation of the 3 groups of bone models were significantly different, with the models osteotomized accordingly to our graphic technique having the widest arcs. CONCLUSIONS: For chronic radial head dislocation, our graphic overlay approach simplifies the selection of the osteotomy site(s). Three-dimensional-printed bone models suggest that this approach could improve range of motion of the forearm in actual surgical practice. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Interaction of stem cells with nano hydroxyapatite-fucoidan bionanocomposites for bone tissue regeneration.

The combination of bioceramics with biopolymers are playing major role in the construction of artificial bone. Hydroxyapatite (HA) has been extensively studied as a material in bone repair and replacement in last two decades. In the present study, we have prepared the hydroxyapatite-fucoidan (HA-Fucoidan) nanocomposites by in situ chemical method and biologically characterized them for bone graft substitute. Biological results inferred that mineralization effect of HA-F nanocomposites shows significant enhancement compared to HA in adipose derived stem cell (ADSC). It may be due to the addition of fucoidan in the nanocomposites. The important gene expression such as osteocalcin, osteopontin, collagen and runx-2 were checked using ADSC with HA and HA-fucoidan nanocomposites and the results show that the enhancements were found at 7th day. Furthermore, we have performed in vivo study of HA-fucoidan nanocomposites with rabbit model and a slight amount of bone formation was observed in HA-fucoidan nanocomposites. Herewith, we suggest that HA-fucoidan nanocomposites will be good biomaterials for bone repair/replacement in future.

Z-lengthening of the Achilles tendon with transverse skin incision.

BACKGROUND: The risk of various complications after Achilles tendon lengthening is mainly related to the length of surgical exposure and the lengthening method. A comprehensive technique to minimize the complications is required. METHODS: The treatment of Achilles tendon tightness in 57 patients (95 ankles) were performed by using a short transverse incision on a skin crease of the heel and by Z-lengthening of the tendon. In the severe cases, two or three transverse incisions were required for greater lengthening of the tendon, and a serial cast or Ilizarov apparatus was applied for the gradual correction. The results of these 95 ankles were compared to those of 18 ankles, which underwent percutaneous sliding lengthening, and to the 19 ankles, which received Z-lengthening with a medial longitudinal incision. RESULTS: The functional and cosmetic satisfaction was achieved among those who underwent the tendon lengthening with the new technique. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score improved from 56.1 to 81.8. The second operations to correct recurrence were performed in the two cerebral palsy patients. CONCLUSIONS: The new technique has a low rate of complications such as scarring, adhesion, total transection, excessive lengthening, and recurrence of shortening. The excellent cosmesis and the short operation time are the additional advantages.

What is the usefulness of the fragmentation pattern of the femoral head in managing Legg-Calvé-Perthes disease?

BACKGROUND: Within the lateral pillar classification of the Legg-Calvé-Perthes (LCP) disease, hips seem quite variable in the pattern of fragmentation as seen in radiographs. The purpose of this study was to determine: if it is possible to reliably subdivide the lateral pillar groups into femoral head fragmentation patterns, and if such a subdivision of the lateral pillar groupings is clinically useful in managing LCP disease. METHODS: Two hundred and ninety-three anteroposterior radiographs taken at the maximal fragmentation stage (189 lateral pillar B, 57 B/C border, and 47 C hips; mean bone/chronologic age at the time of first visit, 6.2/7.9 years) and at skeletal maturity (mean age, 16.6 years) were analyzed. We distinguished 3 fragmentation patterns in each pillar group based on the region of major involvement. We tested the inter- and intraobserver reliability of our classification system and analyzed the relationships between the fragmentation patterns and the Stulberg outcomes as well as other factors such as surgical treatment and age. RESULTS: Inter- and intraobserver consistency in fragmentation pattern assignments was found to be substantial to excellent. A statistically significant trend (p = 0.001) in the proportion of Stulberg III or IV outcomes in comparison with Stulberg I and II was only found for the different fragmentation patterns in our lateral pillar B patients: fragmentation patterns having mainly lateral-central necrosis led to poor outcomes. No significant association was found between fragmentation patterns and Stulberg outcomes in pillar groups B/C border and C. CONCLUSIONS: Our results are consistent with the lateral pillar classification itself. Therefore, fragmentation patterns in each lateral pillar classification did not provide clinical usefulness in the management of LCP disease.

In vivo study of chitosan-natural nano hydroxyapatite scaffolds for bone tissue regeneration.

Significant development has been achieved with bioceramics and biopolymer scaffolds in the construction of artificial bone. In the present study, we have developed and compared chitosan-micro hydroxyapatite (chitosan-mHA) and chitosan-nano hydroxyapatite (chitosan-nHA) scaffolds as bone graft substitutes. The biocompatibility and cell proliferation of the prepared scaffolds were checked with preosteoblast (MC3T3-E1) cells. Total Volume (TV), bone volume (BV), bone surface (BS), trabecular thickness (Tb.Th), trabecular number (Tb.N) and trabecular separation (Tb.Sp) were found to be higher in chitosan-nHA than chitosan-mHA scaffold. Hence, we suggest that chitosan-nHA scaffold could be a promising biomaterial for bone tissue engineering.

Does valgus femoral osteotomy improve femoral head roundness in severe Legg-Calvé-Perthes disease?

BACKGROUND: Many surgeons perform a varus femoral or Salter pelvic osteotomy in patients with Legg-Calvé-Perthes (LCP) disease. However, more severely deformed femoral heads show greater congruency in adduction rather than in abduction. Therefore, a valgus-(flexion) femoral osteotomy (VFO) seems preferable rather than a varus femoral or Salter pelvic osteotomy. QUESTIONS/PURPOSES: We evaluated whether the VFO improves (1) femoral head roundness, (2) radiographic parameters reflecting hip subluxation, and (3) function. METHODS: We treated 25 patients (25 hips; 18 lateral pillar C and seven B) in the late fragmentation stage by VFO. Seven patients had additional pelvic procedures. VFO was performed at a mean age of 9.8 years. Three hips were Stulberg Class II, 20 were Class III, and two were Class IV. The following components of femoral head roundness were calculated from preoperative MRI and final radiographs: lateral and medial head roundness (LHR and MHR); anterior and posterior head roundness (AHR and PHR); central head height; and the ratios MHR/LHR and PHR/AHR. Continuity of Shenton's line, medial gap ratio were evaluated. Function was determined with the Iowa hip score. Minimum followup was 3.1 years (mean, 6.3 years; range, 3.1-11.2 years). RESULTS: All femoral head roundness measurements improved, with greatest improvement in the lateral and anterior head. Pillar C hips showed greater relative improvement than pillar B hips. The continuity of Shenton's line improved and the mean medial gap ratio decreased. Mean Iowa hip score improved from 71 before surgery to 90 at the last followup. CONCLUSIONS: VFO appears to help the deformed femoral head in the fragmentation stage to remodel to fit the acetabulum. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Metatarsal lengthening by callotasis in adults with first brachymetatarsia.

BACKGROUND: Brachymetatarsia is a rare clinical entity that presents a challenging problem for surgeons. One-stage lengthening with an autologous bone graft has been preferred for metatarsals that require a limited lengthening. With a gradual lengthening of metatarsals, callus distraction (callotasis) can achieve a greater length gain and a concomitant lengthening of the soft tissue. This article presents results of callotasis for adults with first brachymetatarsia. METHODS: The outcomes of nine cases of first brachymetatarsia in five adult patients who underwent metatarsal lengthening by callotasis between March 1999 and February 2005 were retrospectively reviewed and analyzed. RESULTS: The average length gain was 16.4 mm and the average lengthening percentage was 43.7%. In addition, the average healing index was calculated as 3.8 months/cm, which was higher than that reported previously in the fourth brachymetatarsia. CONCLUSION: It was concluded that the period of bony consolidation following callotasis is longer in the first brachymetatarsia than in the fourth brachymetatarsia. Presumably, this might be because of the anatomically larger osteotomized cut surface and its weight-bearing function.

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

BACKGROUND: We evaluated the clinical and radiological results of one-stage correction for cerebral palsy patients. METHODS: We 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. RESULTS: Hip 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. CONCLUSIONS: A single event multilevel surgery including soft tissue, pelvic and femoral side correction is effective in treating spastic dislocation of the hip in cerebral palsy.

MR-based parameters as a supplement to radiographs in managing developmental hip dysplasia.

BACKGROUND: Some dysplastic hips with favorable radiographic parameters fail to develop normally, suggesting that we should consider cartilaginous or soft tissue structures for further information regarding the condition of the hip. The purpose of this study was to provide a clear definition of concentric reduction in developmental dysplasia of the hip (DDH) based on magnetic resonance imaging (MRI), and to determine how radiographic and MR-based parameters could be used together to treat dysplastic hips. METHODS: We studied range of motion (ROM)-MRI of 25 patients with unilateral hip dysplasia (mean age at the time of MR imaging, 44.1 months). Each ROM-MRI consisted of a set of bilateral hip scans in the following positions: neutral; abduction; abduction- internal rotation; abduction-internal rotation-flexion; and adduction. Before MR scanning, the 25 patients received the following primary treatments: closed reduction (n = 15; at a mean age of 14.5 months); and open reduction (n = 10; at a mean age of 10.0 months). The following new parameters appear to be useful in treating DDH: 1) the labral angle, the angle the labrum makes with the acetabulum; 2) the uncorrected labral deformity (ULD), the "residual deformity" (deflection of the labrum) when the affected labrum is freed from pressure in abduction; and 3) the zone of compressive force (ZCF), the region of the acetabulum through which the body weight acts on the femoral head. RESULTS: A concentrically-reduced hip is one in which the labrum points downward in the neutral position, at the same angle as that of the normal side; and in which the ZCF is zone 3, the inner acetabular zone as defined herein. The ULD and the ZCF may be determined precisely as we have done, or the physician may simply observe the changes in the orientation of the labrum and compare the changes qualitatively to the unaffected side, and likewise for the medial joint space. CONCLUSIONS: Detailed analysis of the labrum as permitted by ROM-MRI, together with acetabular index and other parameters measured from radiographs, provides important information for physicians treating childhood hip dysplasia.

Reconstruction of acetabular posterior wall fractures.

BACKGROUND: The results after acetabular fracture are primarily related to the quality of the articular reduction. We evaluated the results of internal fixation of posterior wall fractures with using three-step reconstruction. METHODS: Thirty-three patients (mean age at the time of injury, 47.9 years; 28 males and 5 females) were followed for a minimum of 2 years after surgery. The three-step reconstruction included 1) preservation of soft tissues and reduction of the marginally impacted osteochondral (articular) fragments using screws, 2) filling the impacted cancellous void with a bone graft, and 3) reinforcement with buttress-plating. Clinical evaluation was done according to the criteria of D'aubigne and Postel, while the radiological criteria were those of Matta. The associated injuries and complications were evaluated. RESULTS: The clinical results were excellent in 15 (45.5%) patients and they were good in 5 (15.2%), (i.e., satisfactory in 60.7%), while the radiologic results were excellent in 10 (30.3%) and good in 14 (42.4%) (satisfactory in 72.7%). Heterotopic ossification was common, but this did not require excision, even without prophylactic treatment with indomethacin. Deep infection was the worst complication and this was accompanied by a poor outcome. CONCLUSIONS: This study confirms that three-step reconstruction facilitates accurate and firm reduction of displaced posterior wall fractures of the acetabulum. Therefore, we anticipate less long-term arthrosis in the patients treated this way.

MR imaging as a supplement to traditional decision-making in the treatment of LCP disease.

BACKGROUND: Heretofore, the general concept in treating Legg-Calve-Perthes (LCP) disease has been containment of the diseased femoral head into the acetabulum. However, surgery or bracing for containment of a deformed femoral head without accurate information on its dynamic relationship with the hip may aggravate hip congruity and lead to impingement between the femoral head and the acetabulum. We used magnetic resonance imaging on an outpatient clinic basis to evaluate the relationship between the deformed femoral head and the acetabulum in moderate-to-severe LCP disease, and applied these findings to management. METHODS: For 103 moderately and severely affected LCP patients (mean age 7.5 y), we made a total of 151 range of motion-magnetic resonance imagings (termed range of motion as each patient was scanned in 5 positions: neutral, abduction, abduction-internal rotation, abduction-internal rotation-flexion, and adduction). For each position, we calculated epiphyseal extrusion index (EEI), head coverage (HC), and medial gap ratio (MGR), and looked for differences between parameter values in neutral and the other positions. Disease severity was noted for each patient according to 3 classification systems (lateral pillar, Catterall, and Salter-Thompson), and differences in parameter values were examined for the various severity grades. The position of greatest congruity, and adjacent soft tissue changes, were also noted. Stulberg results were obtained for 54 patients who had reached skeletal maturity. RESULTS: For moderately affected (lateral pillar-B) patients, all 3 parameters (EEI, HC, and MGR) improved on abduction, supporting traditional containment theory. For severely affected (lateral pillar-C) patients, EEI and HC improved on abduction, but MGR did not, indicating hinge abduction by the deformed femoral head. The results do not seem to be greatly affected by 1 of the 3 classification systems which we use. In these patients, congruency was improved in adduction, and was aided by the surrounding soft tissues. Our pillar-B patients were treated conservatively and had mostly Stulberg I and II outcomes. Both conservative and operative treatment of our pillar-C patients resulted in mostly Stulberg III outcomes. CONCLUSIONS: For moderately affected patients, we support traditional treatment aimed at containment of the diseased femoral head into the acetabulum. For severely affected patients who show improved congruency in adduction, a valgus femoral osteotomy, aimed at achieving stable congruency rather than containment, may be used as a primary treatment to minimize acetabulofemoral impingement. LEVEL OF EVIDENCE: Therapeutic study, level II.

How much varus is optimal with proximal femoral osteotomy to preserve the femoral head in Legg-Calvé-Perthes disease?

BACKGROUND: Although proximal femoral varus osteotomy is an established operative treatment for Legg-Calvé-Perthes disease, there is a lack of data on how much varus at the osteotomy is optimal for preserving the spherical shape of the femoral head. The purpose of this study was to determine if there is a correlation between the amount of varus used and the Stulberg radiographic outcome at maturity and to determine if the varus angulation improved over time. METHODS: The database and the radiographs of fifty-two patients treated with proximal femoral varus osteotomy from a multicenter prospective study were analyzed. The neck-shaft angles were measured before the operation, after the operation, and at the time of final follow-up, and the amount of varus placed was correlated with the Stulberg outcome at skeletal maturity. Spearman correlations and logistic regression were used for statistical analysis. RESULTS: All patients were six years of age or older at the time of diagnosis (mean 8.0 ± 1.4 years), and all were skeletally mature at the time of follow-up (mean age [and standard deviation] at the time of follow-up, 16.5 ± 2.0 years). The mean neck-shaft angle was 138° ± 7° preoperatively and 115° ± 11° postoperatively with a mean varus change of 23° ± 10°. No significant correlation was observed between the postoperative neck-shaft angle at maturity and the Stulberg outcome (r = -0.15, p = 0.17) and between the amount of varus placed and the Stulberg outcome (r = 0.14, p = 0.36). However, when the lateral pillar groups were analyzed separately with use of logistic regression, a significant relationship was observed for the lateral pillar group B (p = 0.025), with a higher postoperative neck-shaft angle having a greater probability of being associated with a Stulberg class-I or II outcome. At maturity, the mean neck-shaft angle had improved from 115° ± 11° following the initial surgery to 124° ± 8°. However, nineteen (37%) of the fifty-two patients showed no improvement (defined as a change of >5°) and fifteen (29%) of the fifty-two patients had an overriding greater trochanter. CONCLUSIONS: Contrary to the conventional belief, greater varus angulation does not necessarily produce better preservation of the femoral head following proximal femoral varus osteotomy. Given the results, our recommendation is to achieve 10° to 15° of varus correction when performing proximal femoral varus osteotomy on hips that are in the early stages of Legg-Calvé-Perthes disease.

Preoperative plan for corrective osteotomy of the hip: a method using picture-editing software.

BACKGROUND: As the Picture Archiving and Communication System (PACS) has been adopted by many health centers for radiographic image storage and analysis, fewer and fewer physicians are using radiographic films and the traditional paper-drawing technique for creating preoperative surgical plans. Therefore, a new technique is required using the digital images in stored PACS. Any new method should not only be easy to perform while accurately reflecting the actual techniques of hip osteotomy, but also it should hopefully not require the purchase of expensive software. METHODS: We developed a method using widely available commercial image-editing software (Adobe Photoshop and Microsoft PowerPoint) that works with preoperative anteroposterior and lateral radiographs in stored PACS. To compare our technique with the traditional paper-drawing approach, we measured the time it took for 5 orthopaedic residents to prepare 1 surgical plan using each technique, for 6 different procedures (3 femoral osteotomy and 3 femoral plus pelvic osteotomy). RESULTS: The new method has been used in planning surgery on 133 hips. For femoral osteotomy, the average time required for the traditional and new techniques was 54 and 49 minutes, respectively; whereas for a combined femoral and pelvic osteotomy, the traditional technique took 71 minutes compared with 63 for the new approach. CONCLUSIONS: The new technique is not only cost effective and easy to learn, but also is more efficient and clearer than the conventional method using hand-made drawings, thus making the surgery itself easier to perform. LEVEL OF EVIDENCE: Level III, therapeutic study.

Fibrous hamartoma of infancy in the hand: unusual location and MR imaging findings.

Fibrous hamartomas of infancy (FHIs) are benign, poorly-circumscribed, soft tissue growths presenting during the first 2 years of life and characteristically affecting the axilla, upper arm, upper trunk, inguinal region, and external genital area. Involvement of the hands and feet is extremely rare. We report a case of FHI unusually occurring in a deep portion of the hand. MRI revealed atypical features similar to that of a vascular malformation, hemangioma, fibromatosis, or neurofibromatosis of the hand. Partial resection of the mass was performed to correct the contracture of the second finger and an additional operation was not performed because of the benign nature of FHIs.