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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_VI | Pages 1 - 1
1 Mar 2012
Cooke S Rees R Edwards D Kiely N Evans G
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The long term results of closed reduction of the hip for DDH were reviewed to determine if the presence of the ossific nucleus had an effect on outcome.

The clinical and radiological outcome of a single-surgeon series of closed reduction for DDH was assessed in a strictly defined group of 48 hips in 42 patients with an average of 11.1 years follow up.

In 50% of cases, the ossific nucleus was absent. 100% of patients had an excellent or good result (Severin classification) at final follow-up. 8.3% (4 hips) demonstrated evidence of avascular necrosis. Three were Kalamchi & MacEwen Type I and one was type II. Two of the AVN cases did not demonstrate an ossific nucleus at closed reduction, and both developed type I AVN. 6 hips underwent further surgery. The acetabular index and center-edge angle were not significantly different between the affected and unaffected hip at final follow-up.

There was no relationship between the presence or absence of an ossific nucleus at the time of closed reduction and the final outcome.

In this well defined group, closed reduction is safe and provides excellent results in the long-term. The absence of an ossific nucleus is not detrimental to the final outcome.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 74 - 74
1 Feb 2012
Debnath U Guha A Karlakki S Evans G
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In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years.

The improvement of general mobility was marginal, but those who were community walkers benefited the most. Pre-operative radiological measurements have been modified post-operatively to use lateral margin of the neo-acetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% to 13.7% [p<0.0001]. The mean changes in CE angle and Sharp's angle were 72° (range 56°- 87°) [p<0.0001] and 12.3° (range 9°- 15.6°) [p< 0.0001] respectively. Radiological evidence of progressive arthritic change was seen in only one hip, in which only a partial reduction had been achieved, and there was early joint space narrowing in another. Heterotopic ossification was observed in one patient with athetoid quadriplegia who remained pain free. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

This combined procedure provides a stable hip with sustained pain relief for the adolescent and young adult presenting with pain.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 143 - 143
1 Mar 2008
Debnath U Guha A Karlakki S Evans G
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Purpose: This is a retrospective study, analysing the long term outcome following Chiari osteotomy and varus derotation osteotomy, which was performed as a part of one stage surgical reconstruction for painful subluxed or dislocated hips in cerebral palsy patients

Methods: Between 1986 and 1993, 12 hips in 11 patients underwent the above procedure. Adequate hip reduction was achieved in 11 hips and an acceptable reduction in the other. Immediate pain relief and subsequent improvement in range of movement of the hip, sitting posture and ease of perineal care was recorded in all. Average age at the surgery was 14.1 (9.1–17.8) years. At the recent follow-up, patients were seen along with the parents or carers and reassessed for pain, sitting comfort, mobility and ease of perineal care. Radiographs were obtained and assessed for acetabular cover, degree of femoral head lateralisation, changes in the hip joint including secondary arthritic changes

Results: At an average follow-up of 13.4 years (range 8.1–17.2 years), all patients remain pain free and continue to maintain improved sitting posture and personal hygiene. Improvement to mobility was marginal, but those who were community walkers to begin with benefited the most. No significant progressive arthritic changes or lateral migration were seen in any of the patients except one, in whom only a partial reduction was achieved. Minor joint changes were seen in 2 other patients.

Conclusions: Overall, Chiari osteotomy produces lasting benefits and the possible avascular necrosis and secondary arthritic changes in the hip joint appear to be minimal when compared with the long term benefits


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_I | Pages 40 - 40
1 Mar 2005
Hart W Goude W Roberts A Richardson J Evans G
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Aim: A retrospective review of the triple pelvic osteotomies performed between 1988 and 2002 identifying the factors that may predict a favourable outcome from surgery.

Method: A case note and x-ray review identifying various parameters that influence outcome.

Results: 30 osteotomies in 26 patients have been studied. 3male and 27 female patients have been identified. All patients were symptomatic prior to surgery complaining of pain and reduced exercise tolerance. Following surgery 21 patients were satisfied with their outcome and 9 patients had poor results.

The average age of patients with a good outcome was 20.9 years. The average age of patients with a poor outcome was 30.9 years.

There was no correlation between the correction of either the Sharp angle or the centre-edge angle and outcome. Sphericity of the head was unrelated to outcome. Obesity was associated with a poorer outcome in older patients.

Conclusion: Triple pelvic osteotomy provides a reliable method of improving symptoms in younger patients with dysplastic hips. An increased rate of failure should be expected in patients over thirty years of age.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_III | Pages 265 - 265
1 Mar 2003
Plasschaert F Bouwen L Andrews R Patrick J Evans G
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A chance observation of asymmetrical bone ages in a child with spastic hemiplegia stimulated a prospective gathering of bilateral hand radiographs in 33 hemiplegic patients, and on a single occasion in a control group of 23 patients with leg length discrepancy in the absence of neurological disorder. The bone age assessments according to Greulich and Pyle, which by convention has used the left hand only, were done by a single expert observer blinded to the clinical details.

13 hemiplegic patients (39%) had delayed bone ages of 6 months or more. When present it was always delayed on the hemiplegic side. The mean delay for the whole group was 2.5 months, whereas there was no mean difference in the control group (p = 0.001). The oldest bone age with asymmetry was 14.5 years in males and 12 years in females, indicating that when present the delay “catches up” in the last 2-3 years of growth.

In hemiplegia the percentage leg length discrepancy also tends to decrease during later growth, and after 80% of growth the hemiplegic side outgrows the normal leg by a mean of 0.3cm/year. No correlation could be found between the delay of bone age and the severity of either the neurological abnormality or the actual discrepancy of length. The implications for clinical management will be discussed.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 109 - 110
1 Feb 2003
Narayan B Walsh HPJ Evans G
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This is a retrospective study describing four patients who developed symptomatic subluxation of the hip after stabilisation to the pelvis for myopathic scoliosis in Duchenne Muscular Dystrophy (DMD).

Fusion to the pelvis is recommended for treatment of scoliosis in DMD. Non-spinal extra-pulmonary complications following this have not been described.

4 patients (average age: 14 years) out of a cohort of patients who have undergone spinal stabilisation for DMD between 1991 and 1998 developed symptomatic subluxation of the hip at an average of three months after fusion from the upper thoracic spine to the pelvis. All four had pain and three noticed clicking in the hip.

X-rays revealed subluxation of the hip in all patients, and conservative treatment by adjustment of seating position in the wheelchair was successful in reducing the symptoms in all patients.

Flexion-abduction contractures of the hip, which are a feature of DMD, are known to cause uncovering of the contralateral hip. We postulate that the spine compensates for this uncovering to a large degree, and that spinopelvic fusion for scoliosis in patients with pre-existent abduction contractures negates the capacity of the spine to provide compensation. This leads to uncovering of the hip with the lesser degree of contracture, and the resultant symptoms.

We recommend screening for, and treatment of, flexion-abduction contractures of the hip in all patients undergoing spinal fusion for DMD, to avoid the possibility of development of symptomatic subluxation of the hip.


The Journal of Bone & Joint Surgery British Volume
Vol. 77-B, Issue 3 | Pages 510 - 510
1 May 1995
Van der Rijt A Evans G


The Journal of Bone & Joint Surgery British Volume
Vol. 75-B, Issue 3 | Pages 488 - 494
1 May 1993
Nene A Evans G Patrick J

We assessed the outcome after simultaneous multiple operations performed on 18 children with spastic diplegia, with emphasis on the changes in the physiological cost index (PCI) of walking. Fourteen patients had a measurable reduction at one year, but the more severely affected patients took up to two years to reach a new functional plateau. The level of the preoperative PCI allows prediction of the outcome of surgery in terms of reducing the effort of walking, or improving its appearance only. Intrapelvic intramuscular psoas tenotomy produced an improvement of hip flexion deformity in 15 of 17 patients without the loss of muscle power to initiate the swing phase. Fractional lengthening corrected hamstring tightness in 17 cases, and the mean popliteal angle was reduced from 63 degrees preoperatively to 30.2 degrees, with almost complete resolution of the fixed knee flexion deformity present in ten patients. Distal transfer of the rectus femoris, when it was shown to be contracting inappropriately, improved the knee flexion arc during walking from a mean of 28.3 degrees to 45.2 degrees.


The Journal of Bone & Joint Surgery British Volume
Vol. 72-B, Issue 5 | Pages 794 - 796
1 Sep 1990
Richards R Evans G Egan J Shearer

We compared, under laboratory conditions, the resistance to cutting out of the AO dynamic hip screw and the Pugh sliding nail. The mean load at cut out, adjusted for bone strength, was 70% greater for the Pugh sliding nail. The reasons for this difference are discussed.


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 3 | Pages 371 - 375
1 May 1984
van der Rijt A Evans G

Nine patients have been reviewed at an average period of 22 years after a Watson-Jones tenodesis performed for chronic instability of the ankle. Only three patients had complete relief of symptoms. Two favourable early results deteriorated 7 and 10 years after operation. Radiographic examination revealed full correction of both anterior and lateral instability of the talus in only two cases. Talar tilt was controlled more successfully than increased anterior drawer movement. Long-standing instability was associated with the formation of marginal exostoses, the severity of which appeared proportional to the degree of instability.


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 2 | Pages 209 - 212
1 Mar 1984
Evans G Hardcastle P Frenyo A

One hundred patients with acute ruptures of the lateral ligaments of the ankle were randomly allocated either to conservative treatment in a plaster cast or to operative repair. With the aid of stress tenography, the extent of the injury was established. There were 30 patients with isolated anterior talofibular ruptures and 20 with additional calcaneofibular ligament ruptures in each treatment group. Operative repair was associated with a higher incidence of complications in the first weeks, and slightly delayed the patients' return to work. At an independent two-year review there was no evidence that operative repair offered improved symptomatic or functional benefit.


The Journal of Bone & Joint Surgery British Volume
Vol. 64-B, Issue 4 | Pages 432 - 434
1 Aug 1982
Itani M Evans G Park W


The Journal of Bone & Joint Surgery British Volume
Vol. 63-B, Issue 4 | Pages 516 - 522
1 Nov 1981
Evans G Drennan J Russman B

The majority of patients with chronic infantile and juvenile forms of spinal muscular atrophy survive to adult life. Forty-four patients have been reviewed at an average of 17 years after diagnosis. The subdivision of patients into four groups, based on the maximal physical function developed by the individual, correlates well with the onset and severity of secondary deformity of the limbs and spine. This information allows anticipation of the problems and plans for their treatment to be made from early childhood. After analysis of the orthotic and surgical treatment received by these patients, a specific programme of care is recommended for each of the functional groups.


The Journal of Bone & Joint Surgery British Volume
Vol. 61-B, Issue 3 | Pages 347 - 351
1 Aug 1979
Evans G Frenyo S

The stress-tenogram is a radiological technique for the investigation of injuries to the lateral ligament of the ankle, and combines the information previously provided by inversion and anterior stress radiographs, and the peroneal tenogram. It is designed to differentiate between stable and unstable ankles, and between isolated ruptures of the anterior talofibular ligament and combined tears of the anterior talofibular and calcaneofibular ligaments. A high degree of diagnostic accuracy has been confirmed at operative repair in a group of thirty-two patients.


The Journal of Bone & Joint Surgery British Volume
Vol. 60-B, Issue 3 | Pages 416 - 419
1 Aug 1978
Evans G Park W

Three members of a family with a symmetrical distribution of multiple metaphysial lesions presented during childhood with pathological fractures and showed a tendency to spontaneous resolution after maturity. The histological and radiological features suggested multiple non-osteogenic fibromata of bone.