Pediatric update #9. Revision surgery in congenital dislocation of the hip.

Of 759 dislocated hips operated on in our department, 667 received their primary treatment in our hands, while 92 were revised by us after failure of primary surgery. In 71 hips, reconstructive operations were possible, whereas in 21, the joint was destroyed beyond any possibility of repair and a total hip replacement was performed. The reconstructive operations included 16 reopen reductions, five Colonna arthroplasties, six varization derotations, four open reductions and derotations, two valgization osteotomies, and 38 combined procedures. The latter included a shortening varization derotation osteotomy with an open reduction and a Chiari osteotomy of the pelvis. All the revised cases were improved in comparison with their functional status prior to revision. Of the 71 reconstructed joints, the result was good in 59. In the remaining 12, function was improved as compared with the preoperative status, but a total hip replacement will most probably be required in the future. Revision surgery after failure of previous operations for congenital dislocation of the hip can always improve function, but can rarely result in a normal joint. Primary operations should be performed with maximum caution, and it is certainly better to leave limping pain-free children alone than to transform them into limping children in pain.

Congenital dislocation of the hip treated by total hip arthroplasty.

Thirty-two total hip arthroplasties (THAs) were performed on 26 severely incapacitated patients with congenital dislocation of the hip. The arthroplasty technique varied with the problems encountered, but the cup was always placed in the true acetabulum. In 19 cases, femoral head autografts were transplanted. The overall results were satisfactory. Roentgenologic evaluation of the bone grafts showed no nonunion or secondary displacement. Nineteen previously invalid patients now lead normal lives. Five patients are minimally incapacitated and only two were unimproved by the operation. THA with autogeneic grafts to deepen the acetabulum is recommended whenever a congenital dislocation of the hip in an adult is associated with severe pain.

Spondylothoracic dysplasia. A report of ten cases with follow-up.

Details of ten new cases of spondylothoracic dysplasia (the Jarcho-Levin syndrome) are presented. During follow-up, lasting between 8 and 21 years, two children in this group died. Our observations did not confirm Heilbronner's theory concerning the existence of two distinctive types of this syndrome: Type 1 or fatal, and Type 2, with a normal longevity. From the two illustrative cases presented in some detail, and the pertinent literature review, familiarity with spondylothoracic dysplasia is necessary in order to avoid an unjustifiably pessimistic prognosis and to permit correct parent counseling.

Popliteal pterygium syndrome.

Popliteal pterygium syndrome is rare, with 50 cases described in the literature. Three additional cases are reported. The syndrome includes a popliteal web extending from the ischium to the heel associated with toenail dysplasia, eventual deformities of the foot and toes, and oral cavity abnormalities, such as cleft palate or lip pits. The main orthopedic problem is a severe flexion contracture of the knee and an equinus foot. Surgical treatment consists of resection of the web. A technical problem emerges on liberating or reconstructing the sciatic nerve or its branches, which are sometimes included within the contracted cord.

Radical wedge resection for ingrown toenail: long-term results.

This paper describes an operation for ingrown toenail that is simple, has a low recurrence rate, leaves patients with an intact, pain-free, cosmetically acceptable nail-bearing toe, and permits the wearing of normal shoes within a short period of time. Among the numerous techniques devised for the treatment of ingrown toenail, no other operation fulfills all of these criteria. It is usual to sacrifice appearance in the hope of cure. During the last 20 years we have adopted a radical wedge resection that has the advantage of resulting in permanent healing and a good-looking toe. After a first series of 67 cases thus treated without a single recurrence, the technique was used in a further series of 339 cases reported here.

External fixation for fractures and pedicle flap immobilization: a convenient and inexpensive substitute.

A simple, inexpensive, broadly applicable, and quickly applied substitute for the Hoffman apparatus is demonstrated. The procedure uses materials commonly available in hospital operating rooms and provides an excellent immobilization of transosseous pins in pedicled flap surgery and various open and closed fractures of long bones.

Salvage operations for failure of previous surgery in congenital dislocation of the hip.

Salvage operations for failure of previous surgery were performed on 27 children with 35 congenitally dislocated hips. In two children with rigid joints, surgery was limited to the correction of flexion contracture and of fixed pelvic obliquity. In all cases where the affected hip was mobile, concentric reduction and good coverage were obtained. In difficult cases, a combined operation including femoral shortening, open reduction, varization derotation, and a Chiari osteotomy gave satisfactory results.

Reconstruction of severely injured forearm bones.

Twenty open and severe forearm fractures treated either immediately following crush injury or after primary treatment in other hospitals are reported. Soft tissue coverage required repeated debridement and skin grafting. Internal bone fixation was either delayed, primary or secondary, while tendon and nerve repair was always postponed. Two patients with avascular gangrene required amputation: six were initially placed in a plaster cast (in five there was non-union and in one, malunion); in five intramedullary nailing was used (in two there was non-union); in seven in whom compression plating was used for primary bone fixation and those in whom it was used for treatment of non-union after other methods of fixation, solid union was always obtained.

The long neck.

Lateral x-rays of the cervical spine showed more than seven vertebrae above the clavicle in 65 cases. Comparison with "short-necked" individuals, where the corresponding number of vertebrae was seven of less, revealed a much lower incidence of arthrosis in the long-necked individuals. Neurovascular examination revealed no significant differences between the two groups. The increased incidence of arthrotic changes in the short-necked individuals could be related to the repartition of an equal range of cervical mobility between a smaller number of articulations.

Unilateral congenital hip dislocation with contralateral avascular necrosis.

Seventy-six children with previoulsy undiagnosed unilateral congenital dislocation of the hip were examined after 2 years of age. Nine had radiologic signs of dislocation on one side and avascular necrosis of the contralateral femoral head. The incidence of necrosis on the contralateral side in older children with unilateral dislocation is much higher than among the normal population. The cause of these occurrences of aseptic necrosis is not known but could be associated with abnormal stress on an undislocated femoral head from dysfunction of a contralateral unstable dislocated femoral head.

Avascular necrosis of the femoral head in congenital dislocation of the hip.

A study of the X-rays of 450 children treated for congenital dislocation of the hip revealed 56 hips with total or partial avascular necrosis of the femoral head. These hips were classified into four groups. Group 1 consisted of 13 hips in which the femoral head was normal before treatment and avascular necrosis appeared during or after orthopedic or surgical procedures. These are the iatrogenic cases. Group 2 consisted of 22 hips in which avascular necrosis was evident before any treatment. The necrosis was considered a dystrophy arising from malposition. Group 3 included 12 hips in which the avascular necrosis might have been either iatrogenic or a dystrophy due to malposition. This could not be determined because these hips were treated early, before avascular necrosis was seen on X-ray. Group 4 consisted of nine hips in which unilateral dislocation was associated with avascular necrosis of the unaffected normal side prior to any treatment of the affected hip.

Reduction of neglected congenital dislocation of the hip in children over the age of six years.

Thirty-two neglected congenital dislocations of the hip in twenty-two children over the age of six years were treated by traction, open reduction and Chiari osteotomy. In five hips, where prolonged traction failed to bring the femoral heads into the vicinity of the acetabulum, a shortening subtrochanteric osteotomy of the femur was performed. The overall results were good and this regime of treatment is recommended.

Avascular necrosis of the femoral head in children under the age of three.

Avascular necrosis of the femoral head in very young children may be secondary to traumatic, septic, metabolic, iatrogenetic causes. In most cases, however, the etiology is unclear and generally described in the orthopedic literature in ambiguous terms. Radiologically, the femoral head ossification center may be condensed, deformed or fragmented. Etiologically, the cases placed in 3 groups: idiopathic osteochondritis of the femoral head or early discovered Perthes' disease; dysplasia capiti femoris or a malformation belonging to the group of spondylo epiphyseal dysplasia; deformation of the femoral head through malposition such as C.D.H. Though it is a typical complication of the treatment of dislocated hips, avascular necrosis may occur in association with untreated and even mild subluxation.

Surgical correction of congenital dislocation of the hip in children aged two to six years.

We report on a consecutive series of 68 children, between the ages of two and six years, with 97 neglected dislocated hips. The standard treatment consisted of traction, open reduction and innominate osteotomy. The results were satisfactory in most cases and the number of complications decreased significantly with improved surgical techniques. Additional operations, such as femoral varisation derotation osteotomy or Colonna arthroplasty, were performed only in exceptional cases for the treatment of complications. The treatment of neglected congenital dislocation of the hip after the patient has begun walking is a difficult orthopedic problem and and uniformly good results cannot be expected. Open reduction and innominate osteotomy appear to be the best form of treatment in the age group studied.

Congenital sensory neuropathy with anhidrosis: orthopedic complication and management.

This report of 2 sisters with an extremely rare severe form of congenital sensory neuropathy with anhidrosis demonstrates the differential diagnosis, the orthopedic complications, and management. A review of the literature reveals only 7 previously reported cases.

Tibial torsion in untreated congenital clubfoot.

Current methods of measurement were reassessed by the study of tibial torsion in 1000 normal legs using the tropometer, the caliper and X-rays. No significant difference in the reproducibility of results was found and the simpler clinical methods appeared to be satisfactory for practical purposes. The spontaneous evolution of leg torsion in clubfoot was studied in forty-two neglected and previously untreated cases, who were seen for the first time after they had begun walking. Comparison with the torsion observed in the legs of healthy children of a corresponding age proved that untreated clubfoot is not associated with pathological torsion. The place of rotation osteotomy in the treatment of clubfoot is discussed.