The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. Variability exists in the duration of brace treatment after successful reduction of the dislocated hip. In this study we evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database.

We retrospectively studied prospectively enrolled infants with at least one dislocated hip that were initially treated with a PH and had a recorded AI at two-year follow-up. Subjects were treated at one of two institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured 12-week brace treatment protocol. Hip dislocation was defined as less than 30% femoral head coverage at rest on the pre-treatment ultrasound or IHDI grade III or IV on the pre-treatment radiograph.

Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace 3x longer than hips from institution 2 (adjusted mean 8.9±1.3 months vs 2.6±0.2 months)(p < 0 .001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (p=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9˚) compared to Institution 2 (adjusted mean 23.5±0.8˚) (p=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age- and sex- matched AI normal data (p=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia, compared to a 22% (6/27) from Institution 2 (p=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (p=0.071).

Our findings suggest that prolonged brace treatment does not result in improved acetabular index at age two years. Hips treated at Institution 1 had the same AI at age two years as hips treated at Institution 2, while spending about 1/3 the amount of time in a brace. We recommend close follow-up for all children treated for dislocated hips, as ~1/4 of infants had acetabular index measurements at or above the 90th percentile of normal. Continued follow-up of this prospective cohort will be critical to determine how many children require acetabular procedures during childhood. The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at two-year follow-up.

Securing the osteotomized greater trochanter (GT) during total hip arthroplasty (THA) for dislocated dysplastic hips (DDH) poses a significant challenge. This study evaluates the union rate and effectiveness of a 2-strand transverse wiring technique utilizing the lesser trochanter for wire anchorage and tensioning.

A digastric anterior slide trochanteric osteotomy was performed in 106 patients (118 hips) undergoing THA for DDH. Following uncemented stem insertion, the GT was transferred and fixed to the lateral cortex of the proximal femur using monofilament stainless steel wires. In 72 out of 106 patients (80 hips), the GT was fixed with 2 transverse wire cerclages threaded through 2 drill holes in the base of the lesser trochanter, spaced vertically 5–10 millimeters apart. The wires were wrapped transversely over the GT and tightened, avoiding contact with its tendinous attachments. Patients were regularly monitored, and GT union was assessed clinically and radiographically.

Patient ages ranged from 20 to 57 years (mean 35.5), with a follow-up period ranging from 1.5 to 12 years (mean 6.2). The mean union time was 3.3 months (range 2–7). Among all hips, two developed stable nonunion and single wire breakage, but no fragment displacement (2.5%). Two hips exhibited delayed union, eventually healing at 6 and 7 months after surgery.

Reattachment of the greater trochanter utilizing a 2-strand transverse wire cerclage anchored at the base of the lesser trochanter demonstrated a high rate of union (97.5%) following THA in dislocated DDH cases.

Introduction and Objective

Joint malleolar fractures have been estimated around 9% of all fractures. They are characterized by different both early and late complications. Among the latter, arthrofibrosis and early secondary arthrosis represent the two most common ones. Moreover, these two complications could be considered related to each other. Their real cause is still under investigation, even if residual post-operative hematoma and acute post-traumatic synovitis appear to be the most accredited. Supporting this hypothesis, joint debridement and the evacuation of the post-operative hematoma could represent a possible solution. The aim of this prospective study is to evaluate the role of arthroscopic lavage and debridement during internal fixation in order to prevent late joint complications.

Background

The patients with high hip dislocation due to the sequelae of septic hip or neglected Developmental Dysplasia of the Hip (DDH) show severely impaired gait pattern. Total hip arthroplasty (THA) for these patients are expected to restore gait pattern by establishing better joint stability and biomechanics. To our knowledge, no study have investigated about objective change in gait parameters after total hip arthroplasty (THA) for these patients. So, we are to prospectively evaluate change in gait patterns after THA.

Abduction braces are commonly prescribed following the closed reduction of a dislocated prosthetic hip joint. Their use is controversial with limited evidence to support their use. We have conducted a retrospective review of dislocations in primary total hip replacements over a nine year period and report redislocation rates in patients braced, compared to those who were not. 67 patients were identified. 69% of those patients who were braced had a subsequent dislocation. Likewise 69% of those who did not receive a brace re-dislocated. 33% of patients that were braced dislocated whilst wearing the brace. Bracing was associated with patient discomfort, sleep disturbance, skin irritation and breakdown. Small femoral head size, monoblock femoral components and poor biomechanical reconstruction was prevalent amongst dislocators. Abduction bracing following closed reduction of a total hip replacement is costly(e950), does not prevent redislocation and may be the cause of considerable morbidity to the patient.

Abduction braces are commonly prescribed following the closed reduction of a dislocated prosthetic hip joint. Their use is controversial with limited evidence to support their use. We have conducted a retrospective review of dislocations in primary total hip replacements over a nine year period and report redislocation rates in patients braced, compared to those who were not. 67 patients were identified. 69% of those patients who were braced had a subsequent dislocation. Likewise 69% of those who did not receive a brace re-dislocated. 33% of patients that were braced dislocated whilst wearing the brace. Bracing was associated with patient discomfort, sleep disturbance, skin irritation and breakdown. Small femoral head size, monoblock femoral components and poor biomechanical reconstruction was prevalent amongst dislocators. Abduction bracing following closed reduction of a total hip replacement does not prevent redislocation and may be the cause of considerable morbidity to the patient.

We assessed the management of 11 neglected developmental dislocated hips in terms of shape of the acetabulum and femoral head pre-operatively and the level of the position of the reduction immediately post-operatively. We compared it with medium term clinical and radiological results.

The shape of the acetabulum and the femoral head can be determined in two planes doing CT or MR of the pelvis. The studies were done to determine the development of the acetabulum and the anatomical fit of the femoral head in the acetabulum. Radius of curvature in the axial and coronal planes was determined of the acetabulum and the femoral head. MR spin echo specification for visualization of the cartilage bone was used. Post-operative radiological namely CT when still in spika, and Shenton’s line and central location of the hip in the direction of the triradiate were subsequently assessed.

Radius of curvature was determined in 6 cases. It varied according to age, but for the older patients the acetabulum was 5mm smaller on average on the coronal views. Eight hips were treated with open reduction. Postoperatively one hip gradually subluxed and dislocated eventually. The hips that remained reduced were initially inferiorly located with an irregular Shenton’s line. Three were treated conservatively with pelvic support osteotomies and planned bone lengthening procedures.

Shape of the femoral head and acetabulum is the most important determining factor in open reduction of neglected DDH. Axial plane MR radius of curvature is not necessarily a true reflection of the shape of the acetabulum. MR coronal views with cartilage enhancement are necessary in assessing the shape of the acetabulum. The inferior position of the reduced hip can be ascribed to the conical shape of the acetabulum and is associated with a maintained reduction.

Evaluation of the anatomical features, details of surgical technique and results of the THA in patients with CDH (type C1 and C2 by G. Hartofilakidis).

From 2001 to 2016 years one surgical team performed 683 THA in patients with CDH. We retrospectively studied 561 total hip arthroplasties in 349 patients, follow-up rate was 82.1%, from 12 to 188 months (mean 69.4). The results were evaluated by clinical examination, X-rays analysis, Harris Hip Score.

Unilateral high hip dislocation was observed in 175 patients (31.2%), in these cases often have underdeveloped half of the pelvis on the side of the dislocation. Type C1 was observed in 326 cases and type C2 – in 235 cases. Type C1 in comparison with C2 has less leg length discrepancy, developed shape of proximal femur, presence of supraacetabular osteophyte. The mean displacement of femoral head was 47.6 mm (from 29 to 55) for C1 and 63.4 mm (from 41 to 78) for C2. Average offset in C1 was 50.1 mm (37–63) and in C2 − 44.3 mm (34–52).

Shortening osteotomy by T. Paavilainen performed in 165 cases (50.6%) with C1 dysplasia and in 235 cases (100%) with C2. The features of surgical technique were small size of the cups with obligatory additional screw fixation of the cup and small offset of the stems. The cup was positioned into the true acetabulum in 99.1% cases of C2 type, for C1 – only 69.0%). The cups size 44 mm were used in 97.3% cases for type C2 and in 78.6% cases for type C1. For shortening osteotomy in 76.3% cases Wagner Cone stems were used.

Early complications included 9 dislocations (1.6%), 8 femoral nerve neuropathies (1.4%) and 3 infections (0.5%). There is no sciatic nerve palsy. Late complications included dislocation in two hips (1.1%), nonunion of the greater trochanter (8.4%), aseptic loosening of the femoral component − 2 (0.8 %), aseptic loosening of the cup − 11 (1.6%). Average Harris Hip score improved from 39.5 to 83.6 with unsignificant diffence between types C1 and C2 (from 37.3 to 81.4 and from 40.4 to 85.1 consequently). Revision rate was 2.1% for type C1 and 5.5% for type C2.

Hip replacement surgery in patients with high hip dislocation is very challenging. Type C2 dysplasia has only one surgical option with good long-term results – placement of the cup into the true acetabulum and shortening osteotomy. Its advantages include leg length alignment and decreased risk of sciatic nerve injury. Type C1 dysplasia presents more heterogenic group of patients and allows to use several surgical options – different placement of the cup and surgical approach without shortening osteotomy. Functional results in patients with type C1 are a little bit worse in comparison with type C2, but C1 had less risk of complications. The main problem of shortening osteotomy by Paavilainen is delayed union and non-union of great trochanter.

Though THA against the perfect dislocation coxarthropathy is a rare operation, you should defend the shortening bone cutting of the femoral bone along with the position of establishment of the implant, the bone graft method and the amount of lower extremity extension and neuroparalysis perioperative treatment degree operation. We report it because we put 23 cases of postoperative results which passed for more than postoperative 28 months together.

Material is The coxarthrosis of the congenital dislocated 23 hip cases. An age was an average 56.4 years old to 67 years old more than 51 years old at the time of the operation. A follow-up period was an average 77 months from 28 months until 142 months. JOA score was used as the clinical evaluation. thigh pain was investigated again, too. Subsidence and Spot Welds were investigated as an X-rays evaluation.

When it is left, a congenital dislocated hip case causes the trouble of the spine and the knee opposite. THA that it faces a congenital dislocated hip case with the sufficient preoperative plan by the accurate operating technique can be said as the effective means by this investigation when both of the clinical evaluation and the X-rays evaluation consider that it was a good results, too.

There are some special features involving replacement surgery of totally dislocated or severely dysplastic hips (Eftekhar Stage C and D). To achieve abduction strength strong enough to balance the pelvis and reliable fixation of the acetabular component, the cup must be seated near the anatomic level or even lower. Therefore, the femoral component in most cases is to be mounted below the intertrochanteric level in order to get the prosthesis reduced and the greater trochanter with intact attachment of the gluteus medius muscle distally advanced. At these levels the femoral diaphysis is straight and requires a straight stem. We started these techniques over 15 years ago with Lord’s madreporic prosthesis, but the stem – especially the calcar part – was too curved. A totally straight cementless, collared stem was designed with Biomet Inc. and has been used since 1988.

For this stem the femur was prepared with broaches, but it was far too easy to get a proximal split when rasping the cortical bone or inserting the stem. For this reason a new stem with a tapered, oval proximal part was designed in 1993. The femur is prepared with reamers and no broaches are needed. Because the stem is collarless, vertical/rotational stability is achieved by the oval wedge shape of the proximal stem, and not by the collar. Therefore, rotational instability and loosening of the stem are avoided.

We present the operative methods. The collarless stem has been used since 1993 in 58 hips of 43 patients. Mean age of the patients was 54 years (range: 21 to 71). Only six of the patients were men. The most common cause of hip deformity was DDH (47 hips). Five hips had congenital coxa vara, two cases had tuberculosis of the hip, and two patients had diastrophic dysplasia. There was one arthrogryphosis multiplex patient and one congenital proximal femoral deficiency. Schanz osteotomy had been performed in 11 of the DDH cases. Forty-four of the 47 DDH hips were high dislocations (Eftekhar C or D).

Complications: There were three dislocations, three late fractures of the greater trochanter fixed with a hookplate, two splits of the proximal diaphysis fixed with a cable, and one late fracture dislocation revised with a collared stem. Deep infection occurred in one case and removal of the prosthesis was necessary. In two cases the stem migrated 3 to 7 mm but stabilised spontaneously with osteointegration. In one case the stem migrated 15 mm. Fibrous union remained, but it is painless.

The final outcome was good in all other cases, but the patient with deep infection is waiting for a rearthroplasty, and the case with fibrous union is likely to be revised when it becomes symptomatic. Pain relief and the functional results including improvement of gait and abduction strength were generally good. Most of the patients were highly satisfied.

The aim of the work is an analysis results of the þxation of dislocated femoral neck fractures by DHS-YU implant. The analysis of the patients age inßuence, reposition type, fracture type and time tistance length between þxation and fracture to the level of fracture unhealing and the femoral head avascular necrosis. During the period from January 1995 to January 2000, 150 dislocated femoral neck fractures were þxed by same number of patients with DHS-YU implant with two diaphysis perforations at the Orthopedics Traumatology Ward of Pozarevac Hospital. The average age of the observed patients is 62. The relation according tisex is 1:7 in favor of females. The fractures are classiþed by Gared clasiþcation type, type III angular fractures and type IV completely dislocated fractures. The complications were specially analysys in relation to the fractures type. The fractures were replaced by closed and oped reposition with out routine effort of closed reposition by all patients. The complication level was specially analysed in relation to the patients age the group younger that 60 and the group older that 60. The inßuence of postpoing the operation longer that 72 hours to the appearance of complications was analysed too. The complications (fractures unhealing and femoral head avascular necrosis) Were analysed by regular checkups every 3,6,12 and 24 months.

The whole complications level is not signiþcantly higher accordig to statistics with the group of patients younger that 60. The level avascular necrosis is signiþcantly higher with the group of patients younger that 60 while unhealing is signiþcantly more frequent with the group older that 60. The whole complications level is signiþcantly higher with the group of patients with closed reposition. Also the avascular necrosis level is signiþcantly higher with the group of patients with closed reposition. (p< 0.01) The total number of complications is signiþcantly higher with the group of patients by whom the fracture has been replaced after 72 hours. Avascular necrosis is highly signiþcant according to statistics with the group of patients by whom the fracture has been replaced after 72 hours and statistically the unhealing level is signiþcantly higher with this group of fractures. (p< 0.01) The total number of complications is signiþcantly higher with the Garden IV group of fractures.(p< 0.001)

The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient, and to determine radiographic factors that correlate with symptoms.

Between 1989 and 1997 56 patients/hips were operated on. The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status, sitting tolerance, weight bearing for transfers, and ambulatory status were sent to all families. Radiographs were reviewed for changes in the centre edge angle (CE), acetabular index (AI), migration index (MI) and femoral head defect (FHD). 27 caregivers completed the questionnaires. Radiographs (pre-operative – latest follow-up) were available for 42 patients. 21 patients had both questionnaire and radiograph information.

Logistic regressions were used to test whether the radiographic measures could predict each of the questionnaire outcomes which were grouped as ‘improved’ and ‘not improved’.

The average age at surgery was 8.9 years (n=56: 1.8 – 16.5) for all patients, for patients with a completed questionnaire 9.4 years (n=27: 4.2–15.4). Time from surgery to follow-up was in average 5.5 years (1.8–9.5).

All but 2 of the patients with completed questionnaire were nonambulatory (2 were functional ambulatory). As a group, the results of the PEDI did not significantly change following surgery. From the results of the second questionnaire: hygiene care improved for 11 patients, weight bearing for transfers improved for 7, sitting status improved for 10, and sitting tolerance improved for 18 patients.

At follow-up, pain worsened in 2 patients, did not improve in 2 patients, and the remainder were pain free. The ability to provide hygiene care worsened for the 2 patients with worsening pain. Weight bearing for transfers and sitting status worsened in 3 patients, 2 of who were the patients with worsening pain, and the other had an unreduced dislocation of the opposite hip. Sitting tolerance worsened in 3 patients, 2 of who were the patients with worsening pain.

Four patients who did not have femoral head defects prior to surgery developed them after surgery. Two of these four patients were the ones who developed worsening pain but had normal CE, AI and MI measures. Other radiographic measures of the hips did not correspond with function or symptoms. Eight patients had a femoral head defect prior to surgery and none were symptomatic at follow-up.

Our assessment method shows that open reduction for the dislocated hip in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function. However, the postoperative development of a femoral head defect is associated with worse pain and poorer function. A pre-existing femoral head defect is not a contraindication to surgery.

The goal of the present study was to evaluate the results of a one-stage operation performed on dislocated hips in children with infantile cerebral palsy. Our data indicate that the one-stage operation is a quite useful method to treat hip dislocation in children with infantile cerebral palsy. Based on our experience we emphasize the use of an individual operation plan in every instance. In selected cases it seems to be justified to ignore an element of the method.

We used the radiological findings for evaluation by comparing the geometric parameters in the affected hips before and after surgery.

During the last ten years, 21 dislocated hips in 13 patients were operated on by the one-stage surgical technique used at the Department of Orthopaedic Surgery of University Medical School of Pécs. The technique consists of the following steps: open reduction, iliopsoas tendon transfer, and femoral varus derotational osteotomy with shortening, modified Tönnis acetabuloplasty, and open adductor tenotomy. Spastic diplegia occurred in eight children and hemiplegia in five. During this period, eight girls and five boys were operated, with 12 procedures on the right hip and 9 on the left. Mean age was 11.4 years. The average age of the children at the time of operations was 6.5 years. In eight hips of five children, all elements of the surgery were carried out in one sitting; in six hips of four children the surgery was performed without acetabuloplasty. In nine hips of seven children there was no need for open reduction, and in six hips of five children we used deep frozen allograft to perform acetabuloplasty. A varus derotational femoral osteotomy with shortening was a part of the surgical approach in all cases.

We evaluated Hilgenreiner (H), Wieberg (CE) and collodiaphyseal (CCD) angle preoperatively and postoperatively. The average preoperative H angle decreased from 39.7 to 24 degrees postoperatively. The average preoperative CE angle increased from minus 18.6 to 31.9 degrees postoperatively. The minus means that all of the patients had dislocation in their hips. The average preoperative CCD angle decreased from 165.2 to 131.4 degrees postoperatively. The results were evaluated by the modified Severin classification based on age and anatomical changes of hips: 17 cases were evaluated as excellent, 2 as good, and 2 as acceptable.

We did not see any complications such as avascular necrosis of the femoral head, absolute revalgisation (compared to the opposite side), subluxation, re-dislocation, or disturbed development of the acetabulum.

Eighty-nine patients (8 males, 81 females) with an average age of 52 years had 119 high dislocations (Crowe IV, 30 bilateral and 59 unilateral). The patients underwent 118 total hip arthroplasties between 1970 and 1986 using original or modified Charnley prostheses. Only 39 patients had not had a previous operation. Pain in the hip associated with stiffness and limitation in activity was the main indication for surgery. Back or knee pain was the chief complaint of 11 patients. Pre-operatively and post-operatively, a thorough assessment of the patients was made including hips, pelvis lumbosacral spine, knee, leg length discrepancy and static body balance.

The operation was performed through a transtrochanteric approach. A small socket was always inserted and cemented into the true acetabulum augmented by an autogenous graft, and a straight femoral component implanted at the level of the lesser trochanter. Muscle releases and tenotomies were not performed. Twenty-nine patients (35 hips) had died or were lost to follow-up. Sixty patients were still alive at the last examination in 1996, and regularly seen with a mean follow-up of 16 years. The mean follow-up of the whole series was 12.8 years.

At the last examination, clinical results according to the d’Aubigne rating system were classified as excellent 59.3%, very good 15.2%, good 15.2%, fair 5.1%, and poor 5%. Only 10 patients had a persistent waddling gait and a positive Trendelenburg sign. The results were slightly less good when a major femoral angulation needed an alignment osteotomy.

One femoral and seven acetabular loosenings were revised. In addition, five hips were revised for severe polyethylene wear and osteolysis before definite loosening, and two hips for heterotopic ossifications. The rate of revision was 12.7%. At twenty years, the survival rate was 99% for the femoral component and 87% for the socket, cemented fixation as end point, whereas the cumulative survival rate of the prosthesis was 78%, revision as end point.

The leg shortening, mean 4.84 cm (range 3-8 cm), was accurately corrected 63 times and within 1 cm 42 times. The lengthening was an average of 3.80 cm (2 to 7 cm). Leg length discrepancy was, on the whole, reduced as much as possible (mean 2.6 cm pre-operatively, 0.4 cm post-operatively). Of the 18 pre-operative painful knees, 10 were greatly improved, but four of these needed an operation.

Lateral pelvic tilt was corrected in more than 50%, pelvic frontal asymmetry was substantially reduced, as well as lordosis and lateral curve of the lumbar spine. As a result, low back pain has been relieved in 40 patients, but two required a laminectomy for a lumbar canal stenosis.

Total hip arthroplasty on high riding hips may be a wonderful operation, but this operation is full of pitfalls, technically demanding, and may represent a serious risk of complication. A successful result depends on a complete pre-operative assessment of the patient, a perfectly performed surgical procedure, and a reasonable selection of its indications.

Introduction

Total hip arthroplasty (THA) for a highly dislocated hip can be problematic and technically challenging. Our previous study on cemented THA with subtrochanteric femoral shortening osteotomy revealed a high incidence (20%) of non-union. Therefore, in 2008, we introduced reverse hybrid THA using S-ROM stem for the treatment of a highly dislocated hip. The purpose of this study was to assess the short-term clinical outcomes of this new method.

Background

Several risk factors for the development of osteonecrosis following treatment of developmental dislocated hip have been reported. The need for further research with a large-enough sample size including statistical adjustment of confounders was demanded. The purpose of the present study was to find reliable predictors of osteonecrosis in patients managed for developmental dislocation of the hip.

Aims: The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient and to determine radiographic factors that correlate with sypmtoms. Methods: The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status and ambulatory status were sent to the caregivers of 52 patients who were operated on. Radiographs were reviewed for changes in centre edge angle, acetabular index, migration index and femoral head defect. Results: 27 caregivers completed the questionnaires. Complete pre-operative radiographs and radiographs from latest follow-up were available in 42 patients and complete radiographs and completed questionnaires were available for 21 patients. The average age at surgery was 9 years with a mean follow-up of 5.5 years. The results of the PEDI did not change signiþcantly following surgery. The second questionnaire showed an improvement of hygiene care for 11 patients, weight bearing for transfers for seven, sitting status for 10 and sitting tolerance for 18. Pain improved for 17 and deteriorated for two patients. There was no correlation between radiographic measures and function or symptoms. Conclusions: Open reduction with pelvic and femoral osteotomy for dislocated hips in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function.

Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and tendon transfer to the metatarsophalangeal (MTP) joints of the lesser toes in both rheumatoid and non-rheumatoid patients. The procedure was carried out on 114 toes, in 58 feet of 55 patients over a 5-year period.

Background Historically, partial proximal phalangectomy was complicated by recurrence of the extension deformity. Stainsby (1990) described a technique of 7/8ths phalangectomy, repositioning of the plantar plate, extensor to flexor attachment and K-wire stabilisation to treat dislocated MTP joints of the lesser toes. However, it is recognised that the use of K-wires can be complicated by infection or premature removal. Angel reported the re-routing of the extensor tendon through a drill hole in the metatarsal head for MTP joint instability; this technique was attributed to Nigel Cobb. We have utilised the Stainsby technique and combined it with a Cobb tendon transfer to impart immediate stability to the toe, allowing K-wire fixation to be discarded.

Technique Following a percutaneous proximal extensor tenotomy, a radical partial proximal phalangectomy (via a dorsal incision) reduces a dislocated MTP joint and the plantar plate is repositioned beneath a mobilised metatarsal head. A drill hole is then placed in the metatarsal head and the extensor tendon is re-routed from a plantar to dorsal direction. This maintains the reduction of the toe and provides interposition between the cut end of the proximal phalanx and the metatarsal head.

Conclusion We believe that this modified combined technique is a reproducible alternative to the Stainsby procedure but, in addition, provides immediate stability of the MTP joint without the need for K-wire fixation.

Purpose: Fracture-posterior dislocation of the femoral head is an exceptional hip injury. Emergency reduction is required. Relocation into the acetabular cavity of the displaced femoral head may not be feasible. Irreducibility, instability, and more rarely accidental fracture of the femoral neck may also occur. We encountered this latter complication in four patients and report here its frequency and mechanism and propose preventive therapeutic measures.

Material and methods: Seventy dislocations and fracture-dislocations of the hip were treated in our unit from March 1997 to February 2003. Among these cases, fourteen hip dislocations were complicated by femoral head fractures. Fracture of the femoral neck occurred during reduction in four. All four cases occurred in men, mean age 49.7 years, who were traffic accident victims (drivers or passengers). There were two Pipkin IV fracture-dislocations and two Pipkin II. The first reduction, achieved under general anaesthesia in an emergency setting, was performed by an orthopaedic surgeon in one patient and a general surgeon in three patients. Arthroplasty was used to treat the femoral neck fracture in three patients and pinning in one. We reviewed retrospectively the clinical and imaging data before and after reduction.

Results: Sub-capital fracture situated 4.0 cm (mean, range 3.5–4.5 cm) from the lesser trochanter occurred in all four cases. The head remained attached above and posteriorly to the acetabulum and was rotated less than 90°. The fragment remaining in the acetabulum was displaced in two cases. In one patient, the fracture-dislocation of the head was associated with a fracture of the posterior rim of the acetabulum.

Discussion: Neck fracture during reduction of traumatic hip dislocation is a serious complication. Prevention of this iatrogenic event requires a slow, progressive reduction limiting the trauma to a minimum; first intention open surgery may be required in selected cases.

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip.

The purpose of the study was to evaluate a number of clinical and radiological risk factors for AVN after non-operative treatment of DDH.

Clinical data and radiographs of 77 patients with103 abnormal hips treated because of developmental dysplasia of the hip by closed reduction followed by cast immobilization were reviewed retrospectively. The average age of patients at the time of reduction was 16 months (ranged, 4 to 28) and the average final follow up was 22,4 years (ranged from 13 to 47 years). Kalamchi and MacEwen classification system was used for evaluation of the AVN. Avascular necrosis was found in 35,9% of the treated hips. We established the influence of several radiological and clinical data on the incidence and severity of AVN.

Conclusion: In our analysis the degree of initial dislocation according to Tönnis classification is an important risk factor for AVN. Age at the onset of treatment, presence and size of ossific nucleus, the use and period of preliminary traction, previous treatment with Frejka pillow or Pavlik splint, sex and side were not associated with the incidence and severity of ischemic necrosis. The results have been analysed statistically.