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Periacetabular osteotomy has been recommended for reconstructing symptomatic dysplastic hips in adolescents and young adults, but requires substantial incisions and exposure. To minimize large incisions, we asked whether periacetabular osteotomy could be performed with a mini-incision under direct endoscopic control. We used five fresh-frozen cadaver pelves and developed curved guides and osteotomes for the osteotomy. We were able to perform a periacetabular osteotomy under endoscopic and image intensifier control and to fix the osteotomy with two cannulated screws. We identified no damage to vital structures or intraarticular fracture in any of the five cadavers we subsequently dissected. We believe periacetabular osteotomy may be performed with a mini-incision under direct endoscopic control. Our preliminary observations suggest the approach might be explored in limited prospective clinical trials by experienced individuals.

Incomplete transiliac osteotomy is commonly used in the surgical treatment of spastic hip disease in children with cerebral palsy. The osteotomy hinges through an intact sciatic notch and an open triradiate cartilage. We asked whether incomplete transiliac osteotomy, combined with varus osteotomy of the femur and soft tissue reconstruction, performed after skeletal maturity could improve hip coverage and acetabular shape and provide pain relief in patients with spastic hip disease. We retrospectively evaluated 27 consecutive adolescent patients (33 hips) with cerebral palsy in whom an incomplete transiliac osteotomy was performed after closure of the triradiate cartilage. The mean age at surgery was 15 years. Five hips were dislocated and 28 hips were subluxated preoperatively. The minimum followup was 2 years (mean, 3.3 years; range, 2 years-7.5 years). The subluxated hips had a minimum Reimers' migration index of 23% (mean, 52%; range, 23-95%), which was reduced to 0% (mean, 7%; range, 0-39%) at followup. The minimum preoperative Sharp's angle was 34 degrees (mean, 52 degrees ; range, 34 degrees -70 degrees ), which was reduced to 20 degrees (mean, 35 degrees ; range, 20 degrees -50 degrees ) at followup. A painless hip was achieved in 26 of 33 hips at followup. An incomplete transiliac osteotomy can be performed after skeletal maturity, resulting in a painless and stable hip in the majority of patients.

We hypothesized the extent of involvement of the proximal femoral growth plate in Perthes disease determined the final radiographic outcome after containment by shelf acetabuloplasty. We retrospectively evaluated the extent of growth plate involvement using a modified version of the method described by Yasuda and Tamura. In our modification, we used only the epiphyseal border for measurements, which was clearly visible as a thin white line, unlike Yasuda and Tamura who used the metaphyseal and epiphyseal borders. We could not clearly demarcate the metaphyseal border in the radiographs of our patient population between 1944 and 1998, which consisted of 69 patients who had surgery at a mean age of 9 years (range, 6.0-14.1 years). From these measurements, we formulated an index termed "growth plate involvement." Radiographic results were classified as described by Stulberg et al A growth plate involvement index less than 0.25 resulted in a good radiographic outcome. We found 93.2% sensitivity and 100% specificity in predicting Stulberg's outcomes. The growth plate involvement index is a reliable and reproducible measurement method and may be used prospectively as a useful prognostic factor to predict radiographic outcomes after containment acetabuloplasty.

Predicting patients' remaining angular growth and timing for hemiepiphysiodesis are crucial for correcting coronal plane knee deformities in children. We asked whether the Angular Deformity Versus Growth Remaining Chart predicted correction of coronal angular deformities of the knee in children. Serial orthoroentgenograms and the predictive chart were used to time percutaneous hemiepiphysiodesis, and the children were followed until skeletal maturity. Twenty-five consecutive children (35 extremities) with a mean skeletal age of 13 years (range, 9.6-16 years) had percutaneous hemiepiphysiodeses as described by Bowen and Johnson, and were followed up until skeletal maturity. At skeletal maturity, correction of varus and valgus coronal plane deformities were within 2 degrees (range, 0 degrees - 6 degrees) of the predicted value. The maximum limb-length discrepancy resulting from the procedure was 1.5 cm. The only complication was failure of a physeal bar formation hemiepiphysiodesis; this was treated successfully with a repeat percutaneous hemiepiphysiodesis. The percutaneous hemiepiphysiodesis is effective and has a low complication rate. Angular correction and timing for hemiepiphysiodesis can be predicted by using the Angular Deformity Versus Growth Remaining Chart in children with coronal plain knee deformities.

Knee anomalies are common in patients with congenital short femurs who require lengthening to correct limb-length discrepancies. We retrospectively reviewed the incidence of knee arthritis and the factors influencing its occurrence after femoral lengthening using the Wagner method. Twenty-three patients with congenital short femurs treated with the Wagner method were followed up until skeletal maturity (minimum, 5 years postoperatively). The mean age of the patients at lengthening was 10.8 years (range, 8.4-14.5 years). The mean leg-length discrepancy at the time of surgery was 9.7 cm (femur, 7.6 +/- 3.7 cm; tibia, 2.1 +/- 1.8 cm). Femoral lengthening (mean, 7.9 cm) was performed in 17 patients. Femoral lengthening and tibial lengthening were performed simultaneously in six patents (mean, 11.8 cm). The mean age of the patients at the last followup was 16.8 years (range, 14-20.3 years). Eighteen patients had arthritis at followup. Nine patients had severe arthritis develop, seven of whom had knee instability preoperatively and temporary subluxation during the lengthening procedure. Seventy-eight percent of patients had arthritis develop in the knee after lower-limb lengthening using the Wagner method for congenital short femurs. Patients who had an unstable knee before surgery had temporary knee subluxation develop during the lengthening procedure, and patients who had simultaneous lengthening of the femur and tibia had a high association with degenerative arthritis changes in the knee.

We describe a 14-year-old girl with intermediate-type osteopetrosis who presented with a 4.8-cm leg-length discrepancy secondary to premature distal femoral growth plate closure. She had a projected leg-length discrepancy of 7 cm at maturity, which was predicted using Moseley charts. The patient was treated successfully with an epiphysiodesis. Her remaining growth was predicted by Moseley charts. A percutaneous epiphysiodesis can treat leg-length discrepancies in patients with osteopetrosis.

Unlabelled: Pelvic support osteotomies for chronically dislocated hips improve stability but result in limb-length discrepancy and valgus deformity of the knee. We prospectively evaluated and followed up 16 patients (14 females, two males) to ascertain whether a monolateral external fixator could achieve a pelvic support osteotomy and eliminate the limb-length discrepancy without disturbing knee motion. The patients had a mean age of 25.3 years at the time of surgery. The Harris hip score, knee range of motion, and Trendelenburg sign were evaluated preoperatively and at followup. The average time from fixator application until removal was 7 months (range, 5.2-9.5 months). The followup averaged 52.5 months (range, 26-84 months). The mean Harris hip score increased from 50 points (range, 32-73 points) preoperatively to 87.6 points (range, 67-98 points) at last followup. Four patients retained a positive Trendelenburg sign. At the time of fixator removal, 88% of preoperative knee range of motion was retained, and preoperative knee motion was achieved at last followup in all patients. The monolateral external fixator was suitable for a pelvic support osteotomy, equalizing limb-length discrepancy, and obtaining lower extremity alignment. This method achieved a pain-free, functional hip and good knee motion., Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Unlabelled: Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved., Level of Evidence: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.