Coxa valga and antetorta configuration leads to underestimation of the femoral component size: a matched case-control study of patients undergoing cementless total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is the gold standard procedure for patients with end-stage osteoarthritis after failed conservative therapy. Digital templating is commonly employed in preoperative preparation for THA and contributes positively to its outcome. However, the impact of coxa valga and antetorta (CVA) configurations on stem size prediction accuracy remains not reported. Previous studies demonstrated that the size of the lesser trochanter (LT) can be used to determine femoral anteversion on pelvis radiographs. This study investigates the accuracy of preoperative digital templating in predicting stem size in patients with CVA undergoing cementless THA. METHODS: Preoperative radiographs of 620 patients undergoing cementless THA were retrospectively investigated. Radiographs were standardized with patients standing and the leg internally rotated by 15°. A CVA group was established including patients with a CCD angle greater than 140° and a lesser trochanter (LT) size of at least 10 mm for men and 8 mm for women. For the control group, radiographs with a CCD angle ranging from 125-135° and LT size 3-10 mm for men and 3-8 mm for women were selected. Preoperative templating was performed using mediCAD. To reduce confounding factors, case-control matching was carried out for BMI and body height. RESULTS: After case-control matching, a total of thirty-one matches were analyzed. Stem size was underestimated in 74% (23/31) in the CVA and 13% (4/31) in the control group (p < 0.001). Moreover, patients with CVA were more likely to be underestimated by two sizes compared to controls (p < 0.004). In contrast, the exact stem size was predicted more frequently in the control group (p < 0.001). CONCLUSION: Stem size in patients with a CVA configuration are at high risk of being underestimated when using digital templating. These findings can be valuable for guiding in intraoperative decisions and lowering the risk of complications associated with an undersized femoral component.

Treatment of Chronic Degenerative Hip Pain in a Male Patient With Cerebral Palsy Four Decades After Reverse Osteotomy.

Patients with cerebral palsy (CP) frequently require surgical hip interventions in early adulthood due to spasticity-related gait abnormalities. In most instances, these cases are characterized by severe restrictions on mobility. This is the case of a male patient with CP who underwent right proximal femoral open reduction internal fixation (ORIF) and reverse osteotomy for right hip subluxation in young adulthood. Patients with CP who undergo total hip arthroplasty (THA) or ORIF with reverse osteotomy often require future revision. The patient was initially given an estimated 10-year longevity for his plate and screw construct (hardware). Forty-four years later, the patient presented with debilitating chronic bilateral hip pain, requiring the assistance of a cane for ambulation. There is a limited body of knowledge on ORIF and reverse osteotomy follow-up in patients with CP within a 30- to 50-year period. At the 44th-year follow-up, CT and X-ray imaging found postoperative changes in the right femur, including intact hardware, bilateral acetabular dysplasia, right femoral stress fracture, progression of hip arthritis, and right iliopsoas bursitis. Surgery for hardware revision was not indicated. Gradual restoration of function was achieved over a 14-month period with conservative management. This case suggests that physical therapy (PT), exercise, and sporadic non-steroidal anti-inflammatory drug (NSAID) use are effective for improving chronic degenerative changes, associated bursitis, and loss of function in patients who developed CP-induced gait complications in young adulthood. These improvements can be made several decades after undergoing ORIF and osteotomies. This course of treatment was effective in improving the patient's quality of life without additional surgical interventions.

A Stop-gain Variant c.220C>T (p.(Gln74*)) in FLNB Segregates with Spondylocarpotarsal Synostosis Syndrome in a Consanguineous Family.

Spondylocarpotarsal synostosis (SCT) syndrome is a very rare and severe form of skeletal dysplasia. The hallmark features of SCT are disproportionate short stature, scoliosis, fusion of carpal and tarsal bones, and clubfoot. Other common manifestations are cleft palate, conductive and sensorineural hearing loss, joint stiffness, and dental enamel hypoplasia. Homozygous variants in FLNB are known to cause SCT. This study was aimed to investigate the phenotypic and genetic basis of unique presentation of SCT syndrome segregating in a consanguineous Pakistani family. Three of the four affected siblings evaluated had severe short stature, short trunk, short neck, kyphoscoliosis, pectus carinatum, and winged scapula. The subjects had difficulty in walking and gait problems and complained of knee pain and backache. Roentgenographic examination of the eldest patient revealed gross anomalies in the axial skeleton including thoracolumbar and cervical fusion of ribs, severe kyphoscoliosis, thoracic and lumbar lordosis, coxa valga, fusion of certain carpals and tarsals, and clinodactyly. The patients had normal faces and lacked other typical features of SCT like cleft palate, conductive and sensorineural hearing loss, joint stiffness, and dental enamel hypoplasia. Whole exome sequencing (WES) of two affected siblings led to the discovery of a rare stop-gain variant c.220C>T (p.(Gln74*)) in exon 1 of the FLNB gene. The variant was homozygous and segregated with the malformation in this family. This study reports extensive phenotypic variability in SCT and expands the mutation spectrum of FLNB.

Panhypopituitarism diagnosed in adulthood: Imaging findings of bone and other organs.

A 38-year-old man who was delivered in a breech position presented with delayed development of secondary sexual characteristics and malaise. He was diagnosed with panhypopituitarism caused by interruption of the pituitary stalk due to perinatal complications. Brain magnetic resonance imaging findings for pituitary stalk interruption syndrome are well-documented; however, reports of the imaging findings of the bones and several organs related to the effects of panhypopituitarism are limited. In this patient with anterior pituitary dysfunction, imaging revealed diverse sequelae, including delayed skeletal maturation, osteopenia, genital atrophy, fatty liver, and adrenal atrophy. Radiologists may find it difficult to discern complex imaging findings unless they are informed of the clinical course of the patient. Therefore, radiologists should coordinate with clinicians to arrive at a diagnosis.

Coxa valga and antetorta increases differences among different femoral version measurements : potential implications for derotational femoral osteotomy planning.

AIMS: To evaluate how abnormal proximal femoral anatomy affects different femoral version measurements in young patients with hip pain. METHODS: First, femoral version was measured in 50 hips of symptomatic consecutively selected patients with hip pain (mean age 20 years (SD 6), 60% (n = 25) females) on preoperative CT scans using different measurement methods: Lee et al, Reikerås et al, Tomczak et al, and Murphy et al. Neck-shaft angle (NSA) and α angle were measured on coronal and radial CT images. Second, CT scans from three patients with femoral retroversion, normal femoral version, and anteversion were used to create 3D femur models, which were manipulated to generate models with different NSAs and different cam lesions, resulting in eight models per patient. Femoral version measurements were repeated on manipulated femora. RESULTS: Comparing the different measurement methods for femoral version resulted in a maximum mean difference of 18° (95% CI 16 to 20) between the most proximal (Lee et al) and most distal (Murphy et al) methods. Higher differences in proximal and distal femoral version measurement techniques were seen in femora with greater femoral version (r > 0.46; p < 0.001) and greater NSA (r > 0.37; p = 0.008) between all measurement methods. In the parametric 3D manipulation analysis, differences in femoral version increased 11° and 9° in patients with high and normal femoral version, respectively, with increasing NSA (110° to 150°). CONCLUSION: Measurement of femoral version angles differ depending on the method used to almost 20°, which is in the range of the aimed surgical correction in derotational femoral osteotomy and thus can be considered clinically relevant. Differences between proximal and distal measurement methods further increase by increasing femoral version and NSA. Measurement methods that take the entire proximal femur into account by using distal landmarks may produce more sensitive measurements of these differences.Cite this article: Bone Jt Open 2022;3(10):759-766.

Severe Cranio-Cervical Stenosis in a Child with Saul-Wilson Syndrome: A Case Report.

INTRODUCTION: Saul Wilson syndrome (SWS) is a rare congenital syndrome characterized by a variety of symptoms, mostly skeletal changes. Saul and Wilson were the first to describe children with extremely short stature and craniofacial dysmorphism. CASE REPORT: We present a case of a 15-years-old boy with clinical and radiological characteristics of SWS. Genetic examination identified a pathogenic heterozygous variant in the COG4 gene. Magnetic resonance imaging revealed a critical stenosis of the cranio-cervical junction (CCJ) which required surgical treatment to attempt sufficient neurological decompression. The patient underwent decompression of CCJ under general anesthesia. There was no significant radiological and clinical improvement during the postoperative period. CONCLUSIONS: SWS is presented as an extremely rare congenital disease in children. The clinical condition of our patient confined surgical possibilities, therefore further treatment in such patients should be appropriately evaluated.

The association between femoral neck shaft angle and degenerative disease of the hip in a cadaveric model.

BACKGROUND: While the influences of acetabular dysplasia and overcoverage on hip arthritis have been studied, the impact of femoral neck-shaft angle on hip arthritis is much more poorly understood. The purpose of this study is to determine if a relationship exists between neck shaft angle and the development of osteoarthritis, a better understanding of which would be useful to surgeons planning osteotomies about the hip. METHODS: 533 cadaveric femora and acetabulae (1066 total) from the Hamann-Todd Osteological Collection (Cleveland, OH) were acquired. We measured true neck shaft angle using an AP photograph with the femoral neck parallel to the table. Femoral head volume to acetabular volume ratio, representing femoral head coverage, as well as femoral version were utilised. Correlation between neck shaft angle, femoral version, femoral head coverage and osteoarthritis were evaluated with multiple regression analysis. RESULTS: The mean age and standard deviation was 56 ± 10 years. There were 64 females (12%) and 469 males. There were 380 Caucasians (71%) and 153 African-Americans. Mean femoral version was 11° ± 12° and mean true neck shaft angle was 127.7° ± 5.9° There was a strong correlation between age and arthritis (standardised beta 0.488, p < 0.001). There was a significant correlation between increasing true neck shaft angle and decreasing hip arthritis (standardised beta -0.024, p = 0.038). In the femoral head overcoverage subset, increasing true neck shaft angle was still significantly associated with decreasing hip arthritis (standardised beta -0.088, p = 0.018), although this relationship was not significant with femoral head undercoverage subset. CONCLUSIONS: With sufficient acetabular coverage, a relative increase in femoral neck shaft angle within the physiologic range is associated with decreased hip osteoarthritis. CLINICAL RELEVANCE: An understanding of the relationship between femoral neck shaft angle and hip osteoarthritis could be useful for surgeons planning pelvic or proximal femur osteotomies in children.

Reconstruction of the Hip in Multiple Hereditary Exostoses.

The hip joint involvement in multiple hereditary exostoses (MHE) occurs in 30-90%, causing pain and limitation of motion by femoroacetabular impingement, coxa valga, acetabular dysplasia, hip joint subluxation, and osteoarthritis. The purpose of this study was to investigate the clinical and radiographic outcomes of ten hips in seven patients treated by surgical dislocation and corrective osteotomies between 2004 and 2009. Surgical dislocation and excision of the osteochondromas and varus intertrochanteric osteotomies were performed in all cases when the neck-shaft angle was > 150°. Common sites of osteochondromas were medial, posterior, and anterior neck of the femur. Neck-shaft angle of the femur was improved from a mean of 157° to 139°, postoperatively. On an average, the center-edge angle improved from 20° to 30° postoperatively. We believe that Ganz's safe surgical dislocation technique is the preferred treatment of MHE. This safeguards the circulation of the femoral head and the osteochondromas can be resected under direct vision. It can be combined with additional corrective osteotomies because the hip affected by MHE is frequently associated with dysplastic changes which can result in premature osteoarthritis.

Multivariate analysis of the relationship between gluteal muscle contracture and coxa valga.

BACKGROUND: Gluteal muscle contracture (GMC) is a disease characterized by the limited function of the hip joint, knee pain, and abnormal gait. There is a lack of research on the effect of GMC on the hip joint structure to date. This study aims to analyze the association between GMC and the deformity of the hip and pelvis. METHODS: Standing anteroposterior pelvic radiographs of 214 patients (152 with gluteal muscle contracture and 62 without gluteal muscle contracture) were retrospectively collected. Neck-shaft angle, lateral center edge angle, Tönnis angle, femoral head coverage index, acetabular depth, Sacro-femoral-pubic angle, and obturator foramen ratio were respectively measured and included in the following statistical analysis. The collected data were analyzed using logistical regression and multiple linear regression to explore the factors influencing coxa valga and SFP angle. RESULTS: GMC was identified as a common factor significantly associated with coxa valga and increased SFP angle. There is a difference of risk factors in logistic regression for coxa valga between the left and right sides. CONCLUSION: GMC is a significant risk factor for coxa valga and increased SFP angle. Given that GMC can cause coxa valga and likely alter the pelvis's position, GMC should be paid attention to and treated early.

Characteristics of hip impingement syndrome in patients with multiple hereditary exostoses.

BACKGROUNDS: This study aimed to investigate the characteristic deformities of the hip in multiple hereditary exostoses patients (MHE) and its association with the hip impingement syndrome. MATERIALS AND METHODS: Between 2001 and 2019, total 51 patients (102 hips) were evaluated in this study. Patients with MHE were classified to femoro-acetabular impingement (FAI) symptom group, ischio-femoral impingement (IFI) symptom group and non-impingement symptom group by comparing the symptoms, clinical signs and imaging studies. To assess the morphometry of the hip in patients with MHE, the femoral neck-shaft angle, Sharp's acetabular angle and center-edge (CE) angle were evaluated. Alpha angle was further evaluated to investigate the FAI using radiographs, and the minimum ischio-femoral distance was further measured to investigate the IFI using computed-tomographic (CT) study. RESULTS: On hip impingement symptom analysis, FAI symptom and IFI symptom were confirmed in 14 hip joints and 18 hip joints, respectively. Unlike general population, the number of the hip with IFI-symptom was higher than those with FAI symptom in this study. In morphometric evaluation of MHE hips, coxa valga was most prominent deformity with occasional tendency of mild acetabular dysplasia. In a comparison of morphometric study between the impingement symptom group and non-symptom group, the FAI symptom showed significant differences of morphometric measure values than those of the non-symptom group (FAI symptom group vs. Non-FAI symptom group; Femoral neck-shaft angle (153.9 vs 142.6), Sharp's angle (45.0 vs 41.5), CE angle (21.1 vs 28.8) and alpha angle (76.7 vs 57.9)). Similarly, the IFI symptom group also showed significant differences of morphometric measure values than those of the non-symptom group (IFI-symptom vs. Non-IFI symptom; Femoral neck-shaft angle (150.9 vs 142.7), Sharp's angle (44.7 vs 41.4), CE angle (21.1 vs 29.3) and alpha angle (73.3 vs 56.8)). In addition, the minimum ischio-femoral distance measured using CT was significantly decreased in the IFI symptom group (IFI symptom group: 6.6, Non-IFI symptom group: 16.4). CONCLUSION: The results suggest that the characteristic deformities represented by coxa valga in the MHE hip act as an offset for FAI symptoms, on the contrary, act as a trigger for IFI symptoms. LEVEL OF EVIDENCE: Level III.

Statistical shape modeling of the hip and the association with hip osteoarthritis: a systematic review.

OBJECTIVE: To summarize available evidence on the association between hip shape as quantified by statistical shape modeling (SSM) and the incidence or progression of hip osteoarthritis. DESIGN: We conducted a systematic search of five electronic databases, based on a registered protocol (available: PROSPERO CRD42020145411). Articles presenting original data on the longitudinal relationship between radiographic hip shape (quantified by SSM) and hip OA were eligible. Quantitative meta-analysis was precluded because of the use of different SSM models across studies. We used the Newcastle-Ottawa Scale (NOS) for risk of bias assessment. RESULTS: Nine studies (6,483 hips analyzed with SSM) were included in this review. The SSM models used to describe hip shape ranged from 16 points on the femoral head to 85 points on the proximal femur and hemipelvis. Multiple hip shape features and combinations thereof were associated with incident or progressive hip OA. Shape variants that seemed to be consistently associated with hip OA across studies were acetabular dysplasia, cam morphology, and deviations in acetabular version (either excessive anteversion or retroversion). CONCLUSIONS: Various radiographic, SSM-defined hip shape features are associated with hip OA. Some hip shape features only seem to increase the risk for hip OA when combined together. The heterogeneity of the used SSM models across studies precludes the estimation of pooled effect sizes. Further studies using the same SSM model and definition of hip OA are needed to allow for the comparison of outcomes across studies, and to validate the found associations.

Femoral neck shaft angle in relation to the location of femoral stress fracture in young military recruits: femoral head versus femoral neck stress fracture.

OBJECTIVE: To evaluate the influences of the femoral neck shaft angle (FNSA) on the location of the femoral stress fracture and to assess the potential differences in FNSA between fractured and normal femurs. MATERIALS AND METHODS: Thirty-seven patients with femoral stress fractures who underwent both plain hip radiographs and MRI, from January 2016 to September 2019, were retrospectively included. Patients were classified as having either femoral head stress fracture (group A, n = 26) or femoral neck stress fracture (group B, n = 11). The FNSA was measured in anteroposterior (AP) hip radiograph. The Mann-Whitney U testing was used to compare the continuous values between the two groups. A receiver operating characteristic (ROC) analysis was used to evaluate the value of FNSA for predicting the risk of femoral stress fracture. RESULTS: The FNSA was significantly higher in group A (median 135.9°, range 129.5-138.6°) than group B (median 124.3°, range 119.5-129.0°) (p < 0.001), but there were no significant differences in other clinical factors. Furthermore, the FNSA was significantly higher at the fractured femurs (median 135.9°, range 129.9-138.6°) than contralateral normal femurs (median 127.9°, range 123.8-132.1°) in the patients with unilateral femoral head stress fracture (n = 22) (p < 0.001). The ROC analysis revealed that the area under curve (AUC), sensitivity, and specificity for predicting the risk of femoral head stress fracture were 0.807, 72.7%, and 68.2%, respectively, at a FNSA cutoff of 131.0°. CONCLUSION: FNSA was associated with the location of the femoral stress fracture. In addition, FNSA could serve as a predictive factor for the risk of femoral head stress fractures.

Femoral neck osteotomy in skeletally mature patients: surgical technique and midterm results.

PURPOSE: Using an extended retinacular flap containing the blood supply for the femoral head, proximal femur osteotomies can be performed at the neck level increasing the potential of correction of complex morphologies. The aim of this study was to analyze the safety, clinical, and radiographic results of this intra-articular surgical technique performed in skeletally mature patients with a minimum follow-up of three years. METHODS: Fourteen symptomatic adult patients (16 hips) with a mean age of 26 years underwent FNO using surgical hip dislocation and an extended soft tissue flap. Radiographs and radial magnetic resonance imaging (MRI) were obtained before and after surgery to evaluate articular congruency, cartilage damage, and morphologic parameters. Clinical functional evaluation was done using the Nonarthritic Hip Score (NAHS), the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). RESULTS: After surgery, no avascular necrosis was observed, and all the osteotomies healed without complication. The initial neck/shaft angle (range 120 to 150°) improved in all cases to a mean value of 130° ± 4.6 (p < 0.001). In eight of nine valgus hips, the high-positioned fovea capitis changed to a normal position after surgery. The NAHS score improved from a mean of 36.5 ± 14.9 to 82.9 ± 13.9 points after surgery (p < 0.001). After surgery, the mean HOS was 87.1 ± 17.6 points, and the mean mHHS was 78.6 ± 17 points. CONCLUSIONS: In this series, femoral neck osteotomy in the adult, although technically more demanding compared with other classic osteotomies, can be considered a safe procedure with considerable potential to correct hip deformities.

Radiographic characteristics of the hip joint in skeletally mature patients with multiple hereditary exostoses.

OBJECTIVE: To elucidate the radiological characteristics of the hips, especially in proximal femur, of skeletally mature patients with multiple hereditary exostoses (MHE). MATERIALS AND METHODS: Fifty eligible patients (100 hips) were included in the study and assigned to the MHE group. The control group included age- and sex-matched individuals, and the radiographs of 100 hips were used as controls. We examined the anatomical characteristics of the acetabulum and the proximal femur, including the acetabular depth-width ratio (ADR), Sharp's angle, femoral neck-shaft angle (NSA), Wiberg's centre-edge angle (CEA), femoral neck axis length (FNAL), femoral head diameter, (FHD), femoral neck width (FNW), femoral shaft width (FSW), femoral neck-shaft angle (NSA), and femoral head-neck ratio (FHNR = FHD/FNW). p value < 0.05 was considered significant. RESULTS: Osteochondroma was frequently observed in the medial femoral neck (79%), but it was rarely found in the femoral head (1%). ADR and Sharp's angle were not significantly different between the MHE and control groups (p = 0.2056, p = 0.5025). CEA was significantly different between the two groups (p < 0.0001). FNW was significantly larger in the MHE group than in the control group (p < 0.0001). FHNR was significantly different between the two groups (p < 0.0001). NSA was significantly larger than the MHE group (141.8° ± 9.7° vs 129.5° ± 5.6°, p < 0.0001). CONCLUSIONS: Hip dysplasia in the pelvic side was not commonly observed in skeletally mature MHE patients. However, they showed femoral neck widening and coxa valga. The occurrence of osteochondroma around the femoral neck affects the degree of valgus deformity. These facts could be useful for orthopaedic surgeons treating MHE patients.

Femoral neck shortening after internal fixation of Garden I fractures increases the risk of femoral head collapse.

BACKGROUND: Arthroplasty has not been proven superior over internal fixation for the treatment of non-displaced femoral neck fractures. However, internal fixation has been followed by high rates of revision for mechanical complications and of femoral neck impaction within the first postoperative year. The objective of this study was to determine whether femoral neck impaction was associated with avascular necrosis (AVN). HYPOTHESIS: Fracture healing with femoral neck shortening by impaction after internal fixation of a femoral neck fracture is associated with AVN. MATERIAL AND METHODS: A single-centre retrospective study in patients with Garden I fractures managed by screw fixation was performed to compare outcomes in the groups with and without femoral neck impaction. Follow-up radiographs were assessed for evidence of the femoral neck impaction during fracture healing. The occurrence of AVN was the primary evaluation criterion. The secondary evaluation criteria were risk factors for impaction and complications. RESULTS: Of the 75 included patients, 9 (12%) experienced AVN. Impaction was significantly associated with AVN (p=0.02; relative risk, 4.38). Significant risk factors for impaction were a higher body mass index (p=0.0003) and valgus-impacted fracture reduction between the radiographs at baseline and immediately after surgery (p=0.0001). DISCUSSION: Femoral neck impaction was a significant risk factor for AVN after screw fixation of Garden I fractures. Valgus-impacted fracture reduction must receive careful attention during fixation. We suggest static internal fixation if the impaction is reduced on a traction table and advise caution when using parallel screws. The diagnostic and therapeutic strategy proposed here deserves to be evaluated in a prospective study. LEVEL OF EVIDENCE: III, retrospective comparative study.

Leri-Weill Dyschondrosteosis Syndrome: Analysis via 3DCT Scan.

Background: Leri-Weill dyschondrosteosis (LWD) is a pseudoautosomal form of skeletal dysplasia, characterized by abnormal craniofacial phenotype, short stature, and mesomelia of the upper and lower limbs. Methods: We describe two female patients with LWD. Their prime clinical complaints were severe bouts of migraine and antalgic gait. Results: Interestingly, via a 3D reconstruction CT scan we encountered several major anomalies. Notable features of craniosynostosis through premature fusion of the squamosal sutures and partial closure of the coronal sutures were the reason behind the development of abnormal craniofacial contour. A 3D reconstruction CT scan showed apparent bulging of the clavarium through the partially synostosed coronal and totally synostosed squamosal sutures. Additional deformities include deficient number of ribs (10 ribs on both sides), defective ossification of the ischium and dysplasia of the iliac-ischial junction, and coxa valga have been noted. Conclusions: The constellation of observed deformities can be considered as a novel features associated with LWD.

Determinants of Hip and Femoral Deformities in Children With Spastic Cerebral Palsy.

OBJECTIVE: To find factors affecting hip and femoral deformities in children with spastic cerebral palsy (CP) by comparing various clinical findings with imaging studies including plain radiography and computed tomography (CT) imaging. METHODS: Medical records of 709 children with spastic CP who underwent thorough baseline physical examination and functional assessment between 2 to 6 years old were retrospectively reviewed. Fifty-seven children (31 boys and 26 girls) who had both plain radiography of the hip and three-dimensional CT of the lower extremities at least 5 years after baseline examination were included in this study. RESULTS: The mean age at physical examination was 3.6 years (SD=1.6; range, 2-5.2 years) and the duration of follow-up imaging after baseline examination was 68.4 months (SD=22.0; range, 60-124 months). The migration percentage correlated with motor impairment and the severity of hip adductor spasticity (R1 angle of hip abduction with knee flexion). The femoral neck and shaft angle correlated with the ambulation ability and severity of hip adductor spasticity (R1 and R2 angles of hip abduction with both knee flexion and extension). CONCLUSION: Hip subluxation and coxa valga deformity correlated with both dynamic spasticity and shortening of hip adductor muscles. However, we found no correlation between femoral deformities such as femoral anteversion, coxa valga, and hip subluxation.

[Surgical therapy of ischiofemoral impingement by lateralizing intertrochanteric osteotomy]. / Chirurgische Therapie des ischiofemoralen Impingements mittels lateralisierender intertrochantärer Korrekturosteotomie.

OBJECTIVE: Lateralizing, derotating intertrochanteric varus osteotomy to increase the ischiofemoral space to counter painful impingement of the lesser trochanter and the os ischium with resulting entrapment of quadratus femoris muscle. INDICATIONS: Symptomatic ischiofemoral impingement (IFI) caused by Coxa valga et antetorta, Coxa valga or Coxa antetorta, or a short femoral neck. CONTRAINDICATIONS: Anatomic configuration suggestive of IFI in asymptomatic patients. Symptomatic IFI caused by another underlying pathology. Valgus deformity of the knee. SURGICAL TECHNIQUE: Measurement of femoral antetorsion. Planning of the osteotomy, lateralization, varus angle for correction, rotation and offset correction, leg length change, and osteosynthesis plate. General or spinal anesthesia in supine or lateral position. Skin incision (15 cm) beginning lateral of the greater trochanter tip, distally along the axis of the femur. Preparation onto the femur by L­shaped dissection of the vastus lateralis from the bone. A Kirschner(K-)wire is then positioned along the anterior femoral neck to designate the femoral neck antetorsion. A triangle set on the lateral femoral cortexis is used to determine the osteotomy angle. In the thus determined angle, a second K­wire is shot centrally along the femoral neck axis just inferior to its cranial cortex. About 5 mm distal to the second wire, the entry for the blade is prepared using a drill. Using the blade setting instrument, the blade is introduced into the femoral neck, then slightly pulled back. The rotation is then marked on the anterior femoral cortex proximal and distal to the planned osteotomy and the osteotomy is performed. A blade plate without displacement is impacted. The osteotomy is then reduced, the distal fragment pulled laterally onto the plate, and the screws inserted after compression of the osteotomy with a tension device. POSTOPERATIVE MANAGEMENT: Touch-toe bearing for 6 weeks, then radiological assessment of osteotomy healing before an increase in weight bearing (15 kg/week). Hip flexion limited to 90° for 6 weeks. Elective implant removal after 12-18 months. RESULTS: Studies of this lateralizing varus osteotomy have not been published. The 25-year results of the conventional derotating intertrochanteric varus osteotomy technique show good functional results and low complication rates, with non-union being the most common. Arthroscopic resection of the lesser trochanter has been reported as a surgical alternative in the treatment of IFI in case reports and small series. Advantages of the osteotomy are the restoration of biomechanics and preservation of iliopsoas tendon insertion.

Determinants of Hip and Femoral Deformities in Children With Spastic Cerebral Palsy

OBJECTIVE: To find factors affecting hip and femoral deformities in children with spastic cerebral palsy (CP) by comparing various clinical findings with imaging studies including plain radiography and computed tomography (CT) imaging. METHODS: Medical records of 709 children with spastic CP who underwent thorough baseline physical examination and functional assessment between 2 to 6 years old were retrospectively reviewed. Fifty-seven children (31 boys and 26 girls) who had both plain radiography of the hip and three-dimensional CT of the lower extremities at least 5 years after baseline examination were included in this study. RESULTS: The mean age at physical examination was 3.6 years (SD=1.6; range, 2–5.2 years) and the duration of follow-up imaging after baseline examination was 68.4 months (SD=22.0; range, 60–124 months). The migration percentage correlated with motor impairment and the severity of hip adductor spasticity (R1 angle of hip abduction with knee flexion). The femoral neck and shaft angle correlated with the ambulation ability and severity of hip adductor spasticity (R1 and R2 angles of hip abduction with both knee flexion and extension). CONCLUSION: Hip subluxation and coxa valga deformity correlated with both dynamic spasticity and shortening of hip adductor muscles. However, we found no correlation between femoral deformities such as femoral anteversion, coxa valga, and hip subluxation.

Burnei's technique of femoral neck variation and valgisation by using the intramedullary rod in Osteogenesis imperfecta.

BACKGROUND: Varus or valgus deviations of the femoral neck in osteogenesis imperfecta have been an ignored chapter because the classic correction procedures were applied in medical practice with unsatisfying results. Until the use of telescopic rods, coronal deviations remained unsolved and the distal configuration of the proximal femoral extremity remained uncorrected or partially corrected, which required an extensive use of the wheel chair or bed immobilization of the patient. The concomitant correction of the complex deformities, coxa vara/valga and femoral integrated configuration, have been a progress which allowed the patients to walk with or without support. PURPOSE: The purpose of this study is to present the Burnei's technique, a therapeutic alternative in deformity corrections of the varus or valgus hip in children with osteogenesis imperfecta. STUDY DESIGN: The paper is about a retrospective study done in a single center, which analyses Burnei technique and other procedures described in literature. PATIENT SAMPLE: The content of the article is based on a 12 years experience on a batch of 51 patients with osteogenesis imperfecta from which 10 patients (13 hips) presented frontal plane deviations of the femoral neck. OUTCOME MEASURES: All the patients with osteogenesis imperfecta who presented coxa vara or valga were submitted to investigations with the purpose of measuring blood loss, the possibility of extending the surgical intervention to the leg, the association of severe deformities of the proximal extremity of the femur and the necessity of postoperative intensive care. Burnei's technique: The operation was first performed in 2002. A subtrochanteric osteotomy was made in an oblique cut, from the internal side to the external side and from proximal to distal for coxa vara, or by using a cuneiform resection associated with muscular disinsertions. Only telescopic rods were used for osteosynthesis. DISCUSSIONS: There are a few articles in literature, which approach corrections of vara or valgus deviations in osteogenesis imperfecta. Some of them are the techniques described by Finidori, Wagner and Fassier. CONCLUSIONS: Burnei's technique is simple; it corrects the varus and valgus deviations concomitantly with Sofield-Millar. Even though only a telescopic rod is used, no stress fractures were seen postoperatively, deviation recurrence or assembly loss.