Aims

To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures.

Objective

To compare the effectiveness of arthrodiastasis with shelf acetabuloplasty for Perthes' disease in older children, by assessing the radiological outcome in matched pairs of children at skeletal maturity.

Northern Ireland has previously demonstrated high incidence of Perthes' disease (11.6 per 100,000). The aim of this study is to confirm a declining incidence in this diagnosis in Northern Ireland.

In Northern Ireland the Health Visitor assessment at 6 months was demonstrated to be successful in detecting the majority of cases of DDH and was maintained, although moved to 4 months. There has been increased numbers of referrals resulting in prolonged waiting times for low risk infants.

Aims and Objectives Lateral condyle fractures can be difficult diagnose and the treatment still remains controversial. It is well known that these fractures are prone to a number of complications, both early and late. The aim of this paper was to review the treatment practice of lateral condyle fractures presenting to a children’s hospital fracture unit over the past 5 years to identify any consistency in the management of these fractures. We also aimed to try and determine if a particular treatment method was more favourable than others in terms of complications and the need for further surgery with a view to developing a treatment protocol.

Methods: We conducted a chart and x-ray review of all lateral condyle fractures treated operatively from December 1998 to August 2004. We recorded patients’ age, sex, side of injury and month of injury. The fractures were classified according to the Milch classification. We also measured the preoperative and postoperative fracture displacement. We recorded the nature of surgery (Examination Under Anaesthetic (EUA) and casting, Manipulation Under Anaesthetic (MUA) and wiring and Open Reduction and wiring). We documented whether the wires were percutaneous or buried. Length of time in cast and length of time to wire removal were also noted. Finally any complications and the need for further surgery were documented.

Results: 90 patients were identified. 72% were male and 28% female, with an average age of 5.6. 28% of injuries were right sided, 72% were left sided. 21 (23%) patients were Milch Type 1 fractures and 66 (73%) were Type II fractures. Preoperative fracture classification was unavailable for 3 patients. In 78 patients we were able to determine the initial fracture displacement. 8 (9%) patients were displaced < 2 mm, 18 (20%) were displaced 2–4 mm and 52 (58%) were displaced > 4 mm. 7 patients (10%) had associated elbow dislocations – all of these were Milch type II fractures. 5 patients had EUA and casting, 19 had MUA and K wiring and 63 had open reduction and wiring. In the 19 patients who had MUA and K wiring, 13 were percutaneous and 6 were buried. In the open reduction and wiring group 59 patients had their wires buried and 6 were percutaneous. 1 patient did not have that information recorded.

The average time in cast was 41 days. In those with buried wires average length of time to wire removal was 63 days. Average percutaneous wire removal was at 42 days. For the 5 patients undergoing EUA and casting residual displacement was < 2 mm in all. 2 of these patients (40%) had complications of lateral spur formation and delayed union. For the 19 having MUA and k wiring, 14 had a post op displacement of< 2 mm and 5 had 2–4 mm displacement. 3 of the 14(21%) had the complications of spur formation, pin site infection and wire prominence. 2/5 (40%) of those with residual displacement of 2–4 mm developed complications, 1 patient had ulceration of wires through the skin and another had loss of position requiring further surgery.

In the patients treated with open reduction and wiring 51 had a residual displacement of < 2 mm, 14 had 2–4 mm residual displacement and 1 remained displaced > 4 mm. 11/51 (22%) in the first category developed complications. 6 were problems with the wires, 1 lost position requiring re-operation, 1 lateral spur development. 2 malunions and 1 delay in ossification of the lateral condyle. In the 2–4 mm group 8/14 (57%) developed complications. – 2 wire ulcerations, 2 wound infections, 1 non-union and 3 malunions. Finally the 1 patient with residual displacement > 4 mm developed a malunion requiring further operative intervention.

In total 5 patients had further surgery - 1 patient for wire prominence 2 for loss of position and 2 patients required corrective surgery for malunion.

Conclusion: This study highlights the variety in treatment methods for these fractures. Complications occurred in all treatment groups. The short term complications such as wire problems and initial loss of position had no long term sequelae. All malunions occurred in the open reduction and wiring group, despite 2 patients having post operative fracture displacement of < 2 mm. The patient with a non union was a late referral but underwent open reduction and wiring at our unit and subsequently healed. We recommend that displaced fractures should be reduced either closed or open and all fractures should be secured with k wires to prevent loss of position. These should be bent and buried allowing them to remain insitu for 3 months. Postoperative casting should be for 6 weeks. These fractures need to be followed closely at fracture clinic for the short and long term problems they can develop.

Aim: To determine the clinical, functional and radiological results of triple pelvic osteotomy for DDH.

Method: An independent, retrospective review of 35 osteotomies, in 32 patients, with an average follow up of 48 months (4–48 months).

Results: 75% achieved excellent to good results in The Harris Hip Score. The centre edge angle improved significantly from 10° to 35°. 3 hips have required further surgery in the form of total hip arthroplasty. We had 3 cases of incomplete sciatic nerve palsy (8%).

Conclusion: On the basis of our results the Triple Pelvic osteotomy can be recommended for the treatment of acetabular dysplasia in adolescents and young adults.

Objectives: To measure the abductor moment at the hip joint in internal and external rotation and neutral position. To study the relationship between femoral ante-version and the abductor moment generated.

Design: A controlled prospective study comparing a group of children with cerebral palsy with an age-matched control group.

Setting: Gait Analysis Laboratory.

Subjects: The study group of 15 children with cerebral palsy was selected from new referrals with internal rotation sent to the gait lab and our existing database, aged between 6 and 8 years. The control group was recruited from siblings of patients and children of staff.

Methods: The child is positioned supine on a table with their legs hanging over the edge. The knee is bent and the shank placed in a frame at a given position of either 30° internal, neutral or 30° external rotation. An abduction wedge of 15° is inserted between the thighs to give a starting point. The table height is adjusted so that the hip is in 0° flexion and the knee remains in 90° flexion. The position for the dynamometer is marked on the leg, a known distance from the Anterior Superior Iliac Spine. The pelvis is stabilised by an assistant. The child is asked to push the dynamometer away as hard as possible. The maximum force generated is recorded. 3 consecutive readings are taken with a 30 second recovery period between each trial. The test is repeated for each leg position.

An MRI scan of the pelvis and femur is performed. Femoral anteversion and abductor cross sectional area are measured.

Results: Wilcoxon Signed Ranks Tests and paired t-tests were performed.

The maximum moment generated increased with internal rotation – p< 0.002.

Conclusion: Moments are a product of lever arm length x muscle strength. Differences between groups in abductor moments cannot be attributed to changes in lever arm length. In children with cerebral palsy there is a clear reduction in muscle CSA and therefore strength. These findings suggest that the internal rotation is a compensation for muscle weakness. Initial treatment should therefore entail extensive strengthening exercises, not derotation osteotomy.

Over a 4 year period 27 children with cerebral palsy underwent proximal femoral derotation osteotomy resulting in a total of 42 operations performed. Each of these children had pre operative gait analysis performed followed by derotation osteotomy. The degree of derotation varied individually and was judged to be correct when the foot lay in a neutral position. Gait analysis was not repeated until 1 year after surgery to allow for complete bony union, recovery of the soft tissues and general patient rehabilitation. Pre-operative and post-operative data were compared to give a quantitative analysis of the actual derotation obtained.

The mean age at the time of operation was 9.7 years (range 4.5–14.5 years). The male : female ration was 6 : 5. the mean amount of femoral derotation achieved was 26.25 degrees (minimum 7 degrees, maximum 66 degrees). The goal of the operation was to correct internal rotation and achieve a hip in a neutral position throughout the majority of the gait cycle. The average hip rotation in a normal able-bodied person is 1.72 degrees of external rotation. 84% achieved more than 75% derotation to neutral. The remainder were considered operational failures.

These results quantitatively demonstrate that proximal femoral derotation osteotomy is a successful operation in cerebral palsy to correct intoeing.