The aim of the study was to evaluate radiological and clinical outcomes of surgical treatment of developmental dysplasia of the hip (DDH) with Periacetabular Osteotomy (PAO) and to determine the values of radiological parameters allowing us to obtain an optimal clinical result.

Radiological evaluation included a standardized AP digital radiograph of the hip joints. Centre edge angle (CEA), medialization, distalization, femoral head coverage (FHC) and ilioischial angle were measured. Clinical evaluation based on HHS, WOMAC, Merle d'Aubigne-Postel scales and Hip Lag Sign. Radiological and clinical evaluation was performed preoperatively and approximately 12 months after the surgery.

Statistically significant (p<0.05) differences in radiological measurements and all clinical scales have been observed pre- and postoperatively for all of the parameters. The results of PAO presented decreased medialization by 3.4mm (range: 3 to 3.7), distalization by 3.5mm (range: 3.2 to 3.8) and the ilioischial angle by 2.7° (range: 2.2 to 3.7). There was also an improvement in the femoral head bone coverage: CEA increased by 16.3° (range: 12.1˚ to 20.5˚) and FHC by 15.2% (range: 10.8 to 19.8). Clinically we observed an increase in HHS by 22 points (range: 15.8 to 28.2) and M. Postel d'Aubigne by 3.5 points (range: 2.0 to 4.4) and a decrease in WOMAC by 24% (range: 22.6 to 25.8). HLS improvement of gluteal muscles’ efficiency has been observed in 67% of patients postoperatively.

This study revealed that the qualification of patients with DDH for an elective PAO is more justified due to the predicted optimal clinical outcomes based on three parameters: CEA <25 degrees, FHC <75%, and ilioischial angle >85.9 degrees. Accordingly, to achieve better clinical results for all scales, it is necessary to increase the average CEA value by 11˚, the average FHC by 11%, and reduce the average ilioischial angle by 3˚.

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Developmental dysplasia of the hip (DDH) is defined as abnormal, pathological relations between the elements of the hip joint, resulting from disorders of its development. Since 1984, periacetabular bernese osteotomy (PAO) has been a method of treating DDH. The aim of this study was to evaluate the results of the PAO in persistent deformity from childhood and primary late dysplasia in adolescents and adults.

Patients were divided into four groups: A - adolescent patients not operated of DDH in childhood, B – adolescent patient after a surgical treatment of DDH in childhood, C - adults with hip dysplasia not previously operated, D - control group. Radiological evaluation of standard AP view of hip joints was performed before and after the surgery and included parameters: Wiberg angle (CEA), femoral head cover (FHC), medialization, distalisation, the ilio-ischial angle.

Improvement in radiological parameters and statistical significance were achieved in all measurements in all patients. The greatest improvement was achieved in: CEA − 19˚ in Group B, Medialization − 3mm in Group C, Distalization − 6mm in Group B, FHC − 17% in Group B, Ilio-ischial angle − 5˚ in Group B.

The greatest correction of radiological parameters was obtained in children operated in childhood. Surgical treatment of DDH in childhood worsens the operating conditions in adolescents and adults due to scars, adhesions and altered bone anatomy but leaves the need for less deformity correction. The surgical treatment of DDH in childhood has a beneficial effect on the final outcome of the treatment of patients undergoing PAO surgery in adolescents and young adults.

Aims

The aim of the study was to compare two methods of calculating pelvic incidence (PI) and pelvic tilt (PT), either by using the femoral heads or acetabular domes to determine the bicoxofemoral axis, in patients with unilateral or bilateral primary hip osteoarthritis (OA).

The femoral head receives blood supply mainly from the deep branch of the medial femoral circumflex artery (MFCA). In previous studies we have performed anatomical dissections of 16 specimens and subsequently visualised the arteries supplying the femoral head in 55 healthy individuals. In this further radiological study we compared the arterial supply of the femoral head in 35 patients (34 men and one woman, mean age 37.1 years (16 to 64)) with a fracture/dislocation of the hip with a historical control group of 55 hips. Using CT angiography, we identified the three main arteries supplying the femoral head: the deep branch and the postero-inferior nutrient artery both arising from the MFCA, and the piriformis branch of the inferior gluteal artery. It was possible to visualise changes in blood flow after fracture/dislocation.

Our results suggest that blood flow is present after reduction of the dislocated hip. The deep branch of the MFCA was patent and contrast-enhanced in 32 patients, and the diameter of this branch was significantly larger in the fracture/dislocation group than in the control group (p = 0.022). In a subgroup of ten patients with avascular necrosis (AVN) of the femoral head, we found a contrast-enhanced deep branch of the MFCA in eight hips. Two patients with no blood flow in any of the three main arteries supplying the femoral head developed AVN.

Cite this article: Bone Joint J 2013;95-B:1453–7.

The femoral head receives its blood supply primarily from the medial femoral circumflex artery, with its deep branch being the most important.

In a previous study, we performed classical anatomical dissections of 16 hips. We have extended our investigation with a radiological study, in which we aimed to visualise the arteries supplying the femoral head in healthy individuals. We analysed 55 CT angiographic images of the hip.

Using 64-row CT angiography, we identified three main arteries supplying the femoral head: the deep branch of the medial femoral circumflex artery and the posterior inferior nutrient artery originating from the medial femoral circumflex artery, and the piriformis branch of the inferior gluteal artery. CT angiography is a good method for visualisation of the arteries supplying the femoral head. The current radiological studies will provide information for further investigation of vascularity after traumatic dislocation of the hip, using CT angiography.

We performed a series of 16 anatomical dissections on Caucasian cadaver material to determine the surgical anatomy of the medial femoral circumflex artery (MFCA) and its anastomoses. These confirmed that the femoral head receives its blood supply primarily from the MFCA via a group of posterior superior nutrient arteries and the posterior inferior nutrient artery. In terms of anastomoses that may also contribute to the blood supply, the anastomosis with the inferior gluteal artery, via the piriformis branch, is the most important. These dissections provide a base of knowledge for further radiological studies on the vascularity of the normal femoral head and its vascularity after dislocation of the hip.

Improvement in coverage achieved by double or triple osteotomies is limited by the size of the acetabular fragment and the ligaments connected with the sacrum. Correction is achieved with the notable asymmetry of the pelvis. In periacetabular Ganz osteotomy (PAO) the acetabular fragment has no connection with the sacrum, which creates enormous possibilities for correction, leaving the pelvic ring untouched.

The aim of the study is to present our experience and early results of using PAO in the treatment of hip dysplasia in adolescents and young adults who were previously treated operatively in childhood, and to find the technical and clinical impact of previous operations on our Results: In the years 1998–2005 262 periacetaubular osteotomies were performed in our hospital. All the patients were operated by one surgeon (JC). From this group 41 patients (43 hips) had previously been operated in childhood for the treatment of hip dysplasia. The previous treatment consisted of: open reduction in 10 hips, DVO in 14 hips, pelvic osteotomy (Salter, Dega, Chiari) in 8 hips, combined: open reduction+DVO+pelvic osteotomy in 10 hips, greater trochanter transfer in 3 hips, bone lengthening in 4 hips, acetabular cyst removal in 1 hip. The age at the primary operation ranged from 1–20.. The follow-up period ranged from 1–7,5 ys av. 2 ys.

In 31 hips the Smith-Petersen, and in 12 hips ilioinguinal approach were performed.

Methods. In clinical pre-op, and post-op examination the following factors were considered: pain, limping, Trendelenburg sign, range of motion, length discrepancy. Radiographic pre-op and post-op examination consisted of: AP view of the pelvis, false profile and AP view with the leg in abduction. Classic and anterior CE angle were measured. During the last examination Harris Hip Score was used.

Results. Flexion slightly decreased from pre-op. 90–140° (av. 118°) to 80–130° (av. 104°) post-op. abduction remained unchanged 15–60° (av. 40°) and 15–60° (av. 40°) respectively, adduction slightly increased 15–40° (av. 31) and 20–50° (av. 33°). The range of rotation did not change after the operation. The sign of Trendelenburg was found in 27 hips before operation and in 8 hips post-op. Pain (acetabular rim syndrome) was found in 40 hips before operation and in 4 hips after the surgery. Either classic or anterior CE angle increased after the surgery in all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. But in cases previously operated and in males we strongly recommend Smith-Petersen approach extended into the frontal part of the hip for a better exposure in the scarred and hardened tissues.

We find the technique of PAO as a safe, and effective tool for treating hip joint pathology increasing treatment possibilities for hip joint preservation.

Introduction The consequence of discongrency of the hip joint may be early, secondary osteoarthritis of the hip joint, that leads to important limits in movement abilities of an individual. The deficit of the femoral head coverage can be rather easily corrected, but only until the growth and maturation of the pelvis is completed. Redirection of the acetabular fragment can be performed by use of the periacetabular osteotomy according to Ganz. This type of the osteotomy is mainly used in the treatment of the acetabular displasia in patients with closed Y cartilage, but also in the treatment of the osteoarthritis of the hip joint. The Aim of the study was to present our early results of treatment of the patients with the secondary osteoarthritis of the hip joint by use of the periacetabular osteotomy according to Ganz.

Material and Methods. Our material consisted of 64 patients, 72 hip joints, operated on between 1998–2004. 20 patients (24 hip joints) were selected from this group. In these 20 patients the indication for the treatment was not only the acetabular displasia, but also osteoarthritis of the hip joint. Our group consisted of 17 female and 3 male. In 4 cases the both hip joints were affected. The age of the patients was 26–44 years, average 34 years. The observation period was from 4 months to 6 years, average 2,5 years. The most important clinical symptom was the groin pain on the rest or while flexing the hip joint with internal rotation and adduction. The radiological symptoms in patients before the operation were: decentration, narrowing of the articular space, cysts beyond the sclerotic zone, fatigue fractures of the acetabular edge.

Results. In all the patients, except of one, the pain disappeared. Abduction and internal rotation in the hip joint increased, but flexion decreased. The Wiberg’s angle increased from 10–15° to 25–40°, and the interior Wiberg’s angle from 10–0° to 15–20°. During follow up we observed remodeling of the cysts. The treatment was subjectively assessed by the patients as very good.

Conclusion. The use of the periacetabular osteotomy occording to Ganz is the operation that corrects the hip joint. But in some cases of the osteoarthritis of the hip joint it allows to improve the quality of life and we hope may also delay the arthroplasty in the young age.

The aim of the study was to assess the results of posterolateral fusion (PLF) of L5/S1 level spondylolisthesis.

Materials 19 children (5 girls, 14 boys) aged 10–18 years (average 14) were treated surgically PLF in years 1985–2002. 18 cases before surgery were classified as grade I and II, 1 as grade III according to Meyerding classification. Long lasted low back pain, progression of the slippage was the main indication for operative treatment.

In every case suspension in prone position were applied before surgery.

Methods The Denis clinical classification was used to evaluate results. On radiographs we evaluated the verticalisation of the sacrum, lordosis at lumbosacral area by drawing Whitman-Ferguson, Boxall, Fernand-Fox angles. The mobility of the fused segment was estimated on the functional radiographs.

Results In clinical evaluation improvement was achieved in 18 cases, in 1 no improvement was achieved. In radiological estimation the slippage decreased in 17 cases varying from 1 grade to 39 grades (average 10 grades). In 1 case no improvment was achieved and in 1 the slippage increased (8 grades). The value of Fernand-Fox angle increased from 1 grade to 35 grades in 16 cases; in 1 no improvement was achieved and in 2 cases the value decreased. In every patient the posterior segmental union was achieved.

On MRI scans disc degeneration was observed in 2 patients.

Conlusions Our results confirm the existence of the remodeling process in the lumbo-sacral area of the spine.

We think that PLF in painful grade I and II spondylolisthesis is adequate method of treatment.

The term of hip dysplasia means an abnormality of shape, size or spatial configuration of the acetabulum. It also concerns the femoral head, with mutual relationships, proportions and alignment between the femoral head and the acetabulum the most crucial factors. The reason of any symptoms in hip dysplasia is the dysplastic acetabulum and its disproportion in relation to the femoral head. Dysplasia of the acetabulum appearing at puberty has been attributed to secondary “absorption” of bony acetabulum. The presence of fatigue fractures at a later age has been considered as resulting from trauma. However, the fragments of the acetabular rim should be ascribed to overloading of the rim in dysplastic hips, causing fracture and separation of its segment. They are sometimes associated with cysts in the acetabular roof. Limbus tears with or without an associated bony fragment are known to occur after traumatic dislocation of the hip but also without any history of injury. There is no explanation of their cause or their relation to acetabular dysplasia. Limbus tears have been diagnosed by arthroscopy, arthrography and CT scans.

Clinical signs. No hip dysplasia in adults is really symptom-free. A casual examination applied between the painful episodes may appear so normal, that the articular origin of the pain may be doubted. In most cases pain is elicited by passive movement of the thigh into full flexion, adduction and internal rotation. This combination of movements brings the proximal and anterior parts of the femoral neck into the contact with the rim of the acetabulum, exactly at the point where the labrum is likely to be damaged.

Preop imaging. An anteroposterior radiograph, or “faux profil” view of Lequesne de Seze may demonstrate a congruent but short acetabular roof (Type II) or an incongruent hip with a shallow acetabulum and a more vertical than normal acetabular roof (Type I). Type I hip is potentially or really unstable. The femoral head has migrated laterally or anteriorly or in both directions, distorting the spherical shape of actebular inlet into an oval. A simple 3-dimensional classification is recommended by myself using conventional X-ray and CT scan on equatorial level. The CE angle and sectors angle acc. Anda are used to describe the anterior, lateral and posterior coverage. To check the possibilities of reduction, the anteroposterior radiograph is made in max. abduction of the hip. To simulate the correction movement of the acetabular part we use our own “Super pelvis” software.

Intra-op control. For intraoperative correction control we use a C-arm, which also controls step by step all stages of the periacetabular osteotomy. To check the final correction the X-ray of both hips is absolutely obligatory. What we should check is: the displacement of the acetabular fragment (to avoid lateralization, if necessary to make medialisation) and the positions of the anterior and posterior acetabular rim. If this is impossible with the normal a-p X-ray, the C-arm is used for achieving the “faux profil”. The computer assisted orthopaedic surgery system appears the most accurate intra-op control.

Reorientation of the dysplastic acetabulum can be achieved with a simple Salter or Dega osteotomy. While this may be beneficial in children, it is usually insufficient in more severe adolescent or adult dysplasias. Improvement in coverage with double and triple oste-otomies is limited by the size of the acetabular fragment and the ligaments connected to the sacrum. Correction is achieved with the notable asymmetry of the pelvis. The development of these osteotomies results in making the acetabular fragment smaller and smaller and without ligamentous connection between sacrum and sciatic bone. The periacetabular Ganz osteotomy (PAO) is a compromise of the size of acetabular fragment between triple and dial (spherical) osteotomies. The acetabular fragment as in triple Carlioz and Tonnis osteotomies has no connection with the sacrum, what results in enormous possibilities for correction . Finally, the pelvic ring is left untouched.

The aim of the study is to present our experience and early results in using this technique in the treatment of dysplasia with subluxation in adolescent and young adults.

Our material consists of 42 hips in 35 patients (29 females and 6 males) operated in years 1998 – 2001. In 7 cases there was bilateral involvement, the rest were unilateral. The age at operation was between 11 and 39 years, mean 17,5 years. The indication for the PAO in all cases was acetabular dysplasia with different degree of subluxation. In 10 hips there was severe subluxation with CE below 0°, in 4 hips the signs of osteoarthritis were found. The follow-up ranged from 1 to 4 years. Methods. The PAO as a single procedure was done in 39 hips. In only 3 hips the subtrochanteric DVO was done simultaneously. In clinical pre-op. and post-op. examination the following factors were regarded: pain, limping, Trendelenburg sign, range of motion, leg length discrepancy. Radiographic pre-op. and post-op. examination consisted of AP view of the pelvis, false profile and AP view with leg in abduction. Classic and anterior CE angles were measured.

Results. Flexion slightly decreased from pre-op. 90-140° (av.118°) to 80-130° (av.104°) post-op., abduction left unchanged 15-80° (av.40°) and 15-80° (40°) respectively, adduction slightly increased 15-50° (av.31°) and 20-50° (av. 33°). The range of rotation did not change after operation. The sign of Trendelenburg was found in 27 hips pre-op. and in 8 hips post-op. Pain was found in 29 hips before operation and in 4 after surgery. Either classic or anterior CE angle increased after surgery to the normal value in almost all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. In our group 35 operations were done without any complications. In 7 hips the following complications were found: in 1 hip overcorrection and in 2 others insufficient correction, 2 urinary infections, ectopic bone formation in 1 hip, local soft tissue infection in 1 hip and in 1 bad scar formation. We did not find any signs of AVN in our series.

There is a very long way from diagnosis to treatment of the developmental dysplasia of the hip. Everything is complex: clinical examination is subtle and requires a long training. Treatment is not as simple as could be thought. The risks include approximate examinations and of standard, ready-made ones. The discussion has not been settled as to whether all children with hip instability can be clinically detected at birth. The complexity of the problem arises from the fact that only 10% of children who have instability at birth develop long-term problems if they are left untreated. It is well known, affirmed by several different studies that at birth the incidence of hip instability in approximately 1–4% of patients, with figure being higher in girls. There is also a consensus that a large majority of these unstable hips will become stable during the first few days of life, even without treatment. What is not known, however, is how many of those hip that become stable will become completely normal as the child grows. These two fundamental issues are of the utmost importance. They emphasize the significance of early examination (first 48 hours) in order to detect instability and employ careful follow-up of any newborn in whom hip instability has been identified.

Some children are at particular risk of hip instability. Those infants are labeled as “high risk”. They include children born in families with hip instability, those presented by breech, first born children or products of oligohydramniotic pregnancies, particularly girls, those with the generalized joint laxity, those with torticollis and scoliosis, those with foot deformities and increased birth-weight over 4000g. Whilst all children should be screened at birth by a doctor experienced in clinical examination with particular attention directed to those children, who are considered high risk.

It must be emphasized that clinical examination is the most important for the detection of hip instability in newborns. Clinical examination should be very delicate, gentle, based on feelings rather than signs. Clinically, hip instability can be divided into: 1. irreducible dislocation, 2. reducible dislocation, 3. dislocatability, 4. subluxability. The clinical tests of instability were described by Ortolani and Barlow. Fully dislocated irreducible hip is a very rare condition and may be associated with neuromuscular abnormality. It represents dislocation well before delivery. In this form acetabulum is vacant, femoral head palpable posteriorly. There are no singns of Ortolani and Barlow tests. We can only find the sings of “pump”, which means there exists a movement along the long axis of the leg. This is the most severe pathology of the hip in DDH.The reducible dislocation is characterized by the Ortolani maneuver. With the hip flexed 90 degrees, we abduct the hip and than we feel and hear the click which is the sign of the reduction of the hip. Dislocatable and subluxatable are the most common types of pathology of the hip in DDH. This deformity arises at the end of pregnancy. This is characterized by positive Barlow test, which is the provoked-dislocation test. Using it we can dislocate or subluxate the hip. It is very rare to find restricted hip movements in newborns. The limited abduction of the affected hip is the sign typical for older children, more the 3 months of age. It is crucial to repeat the clinical examination even during the same office visit. Ultrasonography has changed our diagnostic ability for DDH. These direct examinations help us in hip evaluation in the first days of the newborn period. The exact Graf classification and methodology makes possible to classify all types of hip pathology irrespective of the examiner. Another important feature of ultrasonography is the ability to monitor the treatment not only in newborn period.

How to start with the prevention of DDH in newborn period? There is no any really good screening without collaboration of orthopedics surgeons and pediatricians. To achieve this, we must control our own environment, especially maternity hospitals and constantly keep pediatricians, pediatric nurses and obstetricians informed. There is no consensus in screening programs – general or limited. I personally recommend limited program. All newborns should be examined clinically after the delivery. The infants with positive or doubtful clinical signs and those with signs of high risk should be examined ultrasonographically immediately after delivery within first 2 weeks. The other children should be screened ultrasonographically at the time when most of the hips are mature enough. It is important, that if we live in the region with high percentage of late detected DDH (more than 3 months of age) the general clinical and ultasonographical screening program should be used.