AIMS. We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors. MATERIAL AND METHODS. We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows: . Group A – failed Pavlik harness;. Group B – late presentations not treated in Pavlik harness. RESULTS. The series included 50 patients (5 males; 45 females). The average age at presentation was 21 weeks (1-160). The average age at reduction was 15 months (4-45). The average follow-up was 6.7 years (4-15). 4 hips required revision due to loss of reduction. The number of surgical interventions throughout the treatment course ranged 4-12 (average – 7.3). AVN occurred in 17 hips (17%). Previous Pavlik harness treatment, CR and higher height of dislocation (HD) were associated with an increased rate of AVN. 42 pelvic (PO) and 12 femoral (FO) osteotomies (54%) were performed. CR and greater HD increased the pelvic osteotomy rate, while Pavlik harness treatment failure did not affect it. The mean AI demonstrated a gradual decline following reduction. While there was no difference between OR vs CR, and Group A vs B, the HD≥3 was associated with a significant acetabular development delay when compared to HD≤2. CONCLUSIONS. Despite the complexity of CDH cases, it is possible to achieve an acceptable level of inevitable complication (AVN – 17%, PO – 42%, FO – 12%, revision reduction – 4%). The rate of AVN was independently negatively affected by CR and prolonged immobilisation. Only the hips with initial HD of ≤2 had their acetabular index return to normal (<21°) before the age of 4 years. This is the first comprehensive analysis of bilateral CDH cases, emphasising the difficulty of treatment of this condition and providing the foundation for an outcomes-predicting system

Introduction: Fractures of the femoral stem component in total hip Arthroplasty have been a well documented complication. The incidence over recent years has decreased due to improvements in surgical technique and implant design and manufacture. Methods/Results: We report two cases of femoral stem fracture. Both occurred in CDH stems from the C-stem system (Depuy International, Leeds, UK). These are the first reported fractures in this stem. Both patients were women weighing 83kgs and 98kgs at the time of fracture giving them BMI’s of 31 and 41 respectively. In both cases the BMI had increased since the time of operation. Discussion: The design of the CDH stem is fundamentally different from the rest of the standard stems with absence of the medial strut. In addition to this factor, both stems fractured through the insertion hole which acted as a stress raiser. Finally both patients BMI’s were above 25. At the time of operation no weight limit was imposed on this prosthesis. We conclude that if possible, a standard C-stem should be inserted but if a CDH stem is used attention to patients’ weight is paramount

Fractures of the femoral stem component in total hip Arthroplasty have been a well documented complication. The incidence over recent years has decreased due to improvements in both surgical technique and implant design and manufacture. We report two cases of femoral stem fracture. Both occurred in CDH stems from the C-stem system (Depuy International, Leeds, UK). Both patients were women weighing 83kgs and 89kgs at the time of fracture. The fractures occurred at 46 and 24 months respectively. The design of the CDH stem is fundamentally different from the rest of the primary stems with absence of the medial strut. In addition to this factor, both stems fractured through the insertion hole, which acted as a stress raiser. Also of note was the fact that both patients BMI’s were above 25. No weight restrictions have been imposed by the company on this implant. We conclude that if at all possible, a primary C-stem should be inserted but if a CDH stem is used attention to patients’ weight is paramount

Aims: Evaluation of the clinical and radiological results after primary surgical treatment of CDH in children with late discovered CDH. Methods: We have studied 64 hips of 58 patients (51 female and 7 male), who were between 18 months-8 years old with late discovered CDH. The study was made between 1991–2000. Teratological and neuromuscular cases were excluded. None of the patients have had previous treatment before admission in hospital. Preoperative radiographic evaluation of the cases was made based on the Tšnnis classiþcation system (12-gr.I, 26-gr.II, 19-gr.III, 7-gr.IV). Preliminary traction was used in 5 hips (4 patients). 8 of them were treated by open reduction, 18 by open reduction and pericapsular osteotomy of the ilium described by Pemberton, 38 by combined pelvic osteotomy (29 Pem-berton osteotomy, 9 Chiari osteotomy) and femoral derotation and/or varus osteotomy (with femoral shortening in 8 cases). Postoperatively, a plaster cast was applied for 6 weeks. Average follow-up period was 6.8 years. Results: The radiological results are based on Severin Classiþcation. We obtained in 77.5% of the cases excellent, good and satisfactory results. Using the clinical rating system of Fergusson and Howard, the results were good and satisfactory in 78.8 of the cases. Avascular necrosis occurred in 6 cases, being rated as group II and III according to the Kalamchi and Mac Ewen classiþcation system. Conclusions: In case of late discovered CDH, the results of conservative treatment are not satisfactory, the surgical treatment being recommended. Four years old or elder children can be treated safely with one stage operation consisting of open reduction, pelvic osteotomy with or without femoral derotation and varus osteotomy (with shortening if it is necessary)

Aim: In Germany an ultrasound screening for CDH is recommended for all children in the þrst 6 weeks of life. We evaluated this program together with the German Association of health insurance carriers over þve years to show if an early ultrasound of the hip can reduce the number and the required operative procedures of children with CDH. Methods: From 1997 to 2002, we documented monthly all otherwise healthy children with CDH aged ten weeks up to þve years in all German orthopaedic paediatric departments with a registration card and questionnaire. Results: Overall we registered 645 children, 534 with single operative procedure. 68% received a closed reduction of the hip, 11% open, while 21% required an osteotomy of the acetabulum and/or femur. The percentage of the single operative procedures did not change over the years. The number of children, who underwent no ultrasound of the hip before diagnosis decreased from 20% in the þrst year to 10% in the last. The þrst ultrasound examination revealed no pathological þndings in 20% of the cases. Children received the þrst screening more and more at the age four to six weeks than during the þrst days of life. Nevertheless, the yearly number of cases declined by 50%. Conclusion: Despite the ultrasound-screening-program late or undiagnosed CDH still exists in our country. A possible reason can be the quality of ultrasound examination, the form of treatment as well as a later worsening of CDH and the so-called endogenous dysplasia

Aims: Stemmed cup is the evolution of Ring cup. The iliac stem is positioned in direction of sacro-iliac sin-condrosis, in axis with weight-bearing lines. It allows an optimal stability in the iliac bone avoiding the dameged acetabular region. The stemmed cup is indicated:. Ð in CDH primary implant. Ð in revision surgery (grade 2–4 according to Paproskyñs classiþcation). In severe bone loss cases (grade 3–4) we preferred to use auto or homologous bone grafts impacted to þll the bone defect. Methods:We report about 168 stemmed cup implants in 159 patients (9 bilateral cases). 37 CDH was treated as a primary implant (6 bilateral patients). The average age is 69 years (range 38–87). The mean follow up is 36 months (range 6 months Ð 6 years). 21 cases were lost at follow up. We evaluated all patients by X-rays at 1,3,6 months and every year and CT in some cases to check the iliac stem position. Results: 13 patients died because of non-related surgery. Superþcial infections 5 cases; deep infections 6 cases (two-stages revision); proximal migration < 1 cm. In 9 cases without loosening; malpositioning of the stem 7 cases; sciatic nerve palsy 5 cases (1 permanent case); DVT 3 cases. Radiolucency around stem < 2 mm. 19 cases, radiolucency around the cup in 11 cases; bone grafts resorption 10 out of 57 cases. Mean preoperative Harris Hip Score was 60; mean postoperative HHS 85. Conclusions: The good mid-term results reported conþrm that stemmed cup is a valid solution in revision surgery with mid and severe bone loss but also in CDH when conventional cup are not indicated

Of 4,617 babies born in Coventry in 1986, a total of 448 (9.7%) had either clinical abnormality of the hip or at risk factors for CDH. All were examined by ultrasound, but only 17 required treatment (3.7 per 1,000); in five of these no clinical abnormality had been detected. An additional 81 babies had ultrasound abnormalities but did not require treatment, despite the fact that ultrasound at first showed major hip displacement in 17 of them. Three late cases of CDH have presented among the babies born in 1986, but not examined by ultrasound. This incidence of late CDH is unchanged compared with the previous nine years, although ultrasound had detected covert displacement in a number of hips

We used ultrasound to investigate the anatomy and stability of the hip during the phase of joint stabilisation after closed reduction of unilateral late CDH in 15 infants aged from two to 15 months. Conservative treatment by splintage in abduction led to complete stability in all hips in from three to 13 weeks. Immediately after reduction, interposed soft tissue caused lateralisation of the femoral head, but this progressively disappeared, and the initially smaller femoral head on the dislocated side regained normal size. Ultrasonic evaluation of the hip in late CDH is a valuable and safe tool; it reduces the need for radiographic examination and improves treatment by visualising the actual pathology. The more frequent use of ultrasound can reduce the need for open reduction in the age group that we studied

The various surgical prosthetic solutions in coxarthrosis on a dysplastic basis were evaluated in a critical way. In our institute more than 3,750 hip prostheses were implanted from 1994 to 1999, and 366 (9.76%) were used for dysplastic coxarthrosis. This high percentage can be explained by the particular geographical position of our institute that has patients coming from the Lombardia region area where CDH is endemic. Our evaluations consider the highest number of possible parameters in order to realize which is the most modern and reliable surgical solution. Of course, each case is individual and our advantage is to have a prosthesis that is the most suitable for each patient. The number and type of prostheses used were: 27 ABG, 35 CONUS, 25 CUSTOM MADE, 7 HN, 5 MALLORY, 35 OMNIFLEX, 3 PARHOFER PLASMAPORE, 4 PERSONALISED CUSTOM MADE, 3 RIPPEN, 18 RMHS, 45 SAMO PG, 130 ZWEYMULLER, 18 P507, 6 OMNIFIT, and 5 GYPSE. From our unique perspective we can consider that in the last several years the use of a cemented prosthesis is progressively disappearing (less than 13%). The use of a cementless prosthesis in young patients (age range 20 to 65) preserves bone stock during implantation, placement and replacement when necessary. If the patient’s age and general conditions allow, we generally operate both dysplastic hips in one stage. All cases were evaluated with DEXA, which provides qualitative and quantitative data about the periprosthetic bone stock. Various parameters were studied, including restoration of normal biomechanics, centre of rotation, equalisation of limb-length, the Trendelenburg sign, and nerve complications

Introduction: Angular and torsional deviations of femur are usually combined with Congenital Dislocation of the Hip (CDH) and increase the complications of hip arthroplasty. The aim of this study is to evaluate surgical and reconstructive options for the treatment of CDH. Material and Methods: In this retrospective study, we evaluated the results and complications of 55 primary cementless total hip arthroplasties, all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 8,1 years postoperatively. Results: From 1984, more than 2000 cases of arthroplasty have been performed in dysplastic hip, 565 cases had a previous femoral osteotomy; 128 cases needed correction of femoral side deformity; 64 had a greater trochanteric osteotomy. In 9 cases rotational abnormality and shortening were controlled with plate and distal femur osteotomy. 55 cases were treated by a shortening subtrochanteric osteotomy. Only non-cemented stems were used. 4 failures occurred for the incorrect fixation of the metaphysis. The fixation can be obtained only by prosthetic press-fit, but it is preferable to use metal wires. There was no sciatic injury; indeed shortening osteotomy provides an easy control of deformity and lengthening, with a maximum of 4 cm. One case was reviewed for heterotopic calcification (grade 4). One infection of the soft tissue was medically cured. There were two revisions for polyethylene failure at 8 and 12 years postoperative. Discussion: The anatomic abnormalities associated with CDH and previous femoral osteotomy increase the complexity of hip arthroplasty. We had best results with the femoral shortening subtrochanteric osteotomy where a rapid consolidation was obtained. Moreover, the functional result was better for the management of the insertion of the muscle tendons in particular the mediogluteus and also for the relatively correct positioning in favour of the reciprocal relationship of the pelvic-trochanter. The detachment of the greater trochanter associated with a metaphyseal proximal shortening, remains an effective technique for the treatment of malformations that are difficult to treat, but there is a high risk of pseudarthrosis of greater trochanter. Conclusion: Femoral shortening subtrochanteric osteotomy preserves the proximal femoral anatomy, avoids the problems associated with reattachment of the greater trochanter, and facilitating a cementless femoral reconstruction in relatively young patients

Objectives. There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments. Methods. A long-term follow-up beyond the age of hip-joint maturity was performed for 115 hips in 103 patients who underwent open reduction using Ludloff’s medial approach in our hospital. The mean age at surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3 years (15 to 28). The radiological condition at full growth of the hip joint was evaluated by Severin’s classification. Results. All 115 hips successfully attained reduction after surgery; however, 74 hips (64.3%) required corrective surgery at a mean age of 2.6 years (one to six). According to Severin’s classification, 69 hips (60.0%) were classified as group I or II, which were considered to represent acceptable results. A total of 39 hips (33.9%) were group III and the remaining seven hips (6.1%) group IV. As to re-operation, 20 of 21 patients who underwent surgical reduction after 12 months of age required additional corrective surgeries during the growth period as the hip joint tended to subluxate gradually. Conclusion. Open reduction using Ludloff’s medial approach accomplished successful joint reduction for persistent CDH or DDH, but this surgical treatment was only appropriate before the ambulating stage. Cite this article: Bone Joint Res 2014;3:1–6

Ultrasound was used to observe the entire course of spontaneous reduction of CDH in the Pavlik harness in nine infants. In six infants with Suzuki type-A dislocations, the femoral head settled slowly into the bottom of the acetabulum by gliding on its posterior wall. In type-B dislocations, passive abduction of the legs during sleep caused it to approach the entrance to the socket and then suddenly to slip in. Reduction with the Pavlik harness is due to passive mechanical factors, and occurs only during muscle relaxation in deep sleep: no active movement is involved

We describe two cases of fracture of Corin Taper-Fit stems used for cement-in-cement revision of congenital dysplasia of the hip. Both prostheses were implanted in patients in their 50s, with high offsets (+7.5 mm and +3.5 mm), one with a large diameter (48 mm) head and one with a constrained acetabular component. Fracture of the stems took place at nine months and three years post-operatively following low-demand activity. Both fractures occurred at the most medial of the two stem introducer holes in the neck of the prosthesis, a design feature that is unique to the Taper-Fit stem. We would urge caution in the use of these particular stems for cement-in-cement revisions.

Sixty-nine hips in 62 patients were treated by the Pavlik harness for congenital dislocation. Ultrasonography showed three degrees of residual head displacement when the harness was first applied. In type A, the femoral head showed contact with the inner posterior wall of the acetabulum. In type B, it contacted the posterior margin of the socket, with its centre at or anterior to the acetabular rim. In type C, the femoral head was displaced outside the socket, with its centre posterior to the acetabular rim. All 51 hips with type A displacement remained reduced. Of nine hips of type B, five were reduced, but the other four were not. None of the nine hips with type C dislocation became reduced with continued use of the harness. The Pavlik harness is indicated for type A and some type B dislocations, but the latter need daily ultrasound monitoring, with a change in method of treatment if type C displacement appears or if the hip is not reduced within one or two weeks. Treatment by Pavlik harness is not indicated in hips with type C dislocations.

Aim

This study presents the early results of a novel procedure, both in timing and surgical technique, aimed to treat those cases of congenital hip dysplasia that present late or fail conservative treatment.

Introduction: It has been proposed that the presence of the capital femoral ossific nucleus confers protection against ischaemic injury or avascular necrosis (at the time of reduction of a congenitally dislocated hip). The current literature is contradictory.

Materials & Methods: A prospective study was undertaken of the clinical and radiological outcomes following closed or open reduction. 50 hips were included in the study. These cases had either presented late or had failed conservative treatment. In 28 hips treatment was intentionally delayed until the appearance of the ossific nucleus (but not beyond 13 months) and in 22 the ossific nucleus was present at clinical presentation. 6 hips reached the age of 13 months without an ossific nucleus appearing and progressed to treatment. The significant avascular necrosis rate (> grade 1) was 7% for closed reduction and 14% for open. However, the amended rate if hips were excluded that had failed Pavlik harness treatment was 0.0% and 9% respectively (4% overall). Further surgical procedures were necessary in 57% of hips undergoing closed reduction and 41% after open, which compares favourably with other series.

Discussion: It is concluded that the presence of the ossific nucleus is an important factor in the prevention of AVN, particularly after late closed reduction. Intentional delay in the timing of surgery does not condemn a hip to open surgery but there is a comparable rate of secondary procedures becoming necessary particularly after closed reduction. The delayed strategy to await the appearance of the ossific nucleus for previously untreated dislocation allows a simple treatment algorithm to be employed which produces good clinical and radiological outcomes. The use of the Pavlik harness has been abandoned in cases of irreducible dislocation of the hip.

Introduction: The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur.

Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required.

Purpose of the study is to analize surgical procedure and then reconstruction options on severe hip dysplasia.

Materials and methods: From 1984 till today 2308 cases of arthroplasty were performed in dysplastic hip, 565 cases have a previous femoral osteotomy; out of these 2308 cases 128 cases need treatment for corrections of femural side deformity.

64 cases were subjected to a greater trochanteric osteotomy. In 12 cases proximal femural shortening was associated. In 9 cases rotational abnormality and shortening were controlled with a distal femur osteotomy.

55 cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only uncemented stems were used and in the majority of cases a specific device for displastic hip (Wagner Conus produced by Zimmer).

Discussion: Long-term results in these patients are steadily inferior to that in the general population (70% survival at 15 yrs). On femural side early failures are the reflection of learning curve and are due to insufficient fixation of the osteotomy.

Despite this, the more promising outcomes are concerning shortening subtrochanteric osteotomy with uncemented stem but only early and mid-term data are available.