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Background Closed reduction is generally attempted on children under 18 months of age who present as older infants or who fail nonoperative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will ultimately require open reduction (OR). Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. Methods Prospectively collected data from 4 select centers of an international multicenter study group sharing a common treatment approach were reviewed for all DDH infants under 18 months old that required operative management. Patients were categorized into 2 groups: those whose hips were successfully closed reduced or those who ultimately required OR. Factors were compared between the closed reduction and OR groups for 2 separate cohorts-those presenting early in life with ultrasound (US) data, and those presenting later with radiographic data. Results A total of 154 patients (166 hips) were included in the analysis. Overall, 87.3% were female. In the early-presenting cohort, purposeful entry multivariate regression revealed that patients with Graf IV hips on US had 3.8 times higher odds of requiring an OR. For the later cohort, hips that were clinically irreducible (ie, negative Ortolani sign) had 3.3 times higher odds of requiring OR. Patients with International Hip Dysplasia Institute (IHDI) grade IV hips had 2.5 times higher odds of needing an OR versus those with grade III hips and 15.4 times higher odds than those with grade II hips. Children with an IHDI grade IV hip and a negative Ortolani sign had 4.4 times higher odds of needing OR. Conclusion Children younger than 18 months with dislocated hips who require OR are more likely to have a high-grade radiographic dislocation (IHDI grade IV), negative preoperative Ortolani sign, and a Graf IV classification on initial US. This information may help surgeons budget the use of operating room time and better counsel parents about intraoperative expectations. Level of evidence Level III-Prognostic.

One of the important pathologic changes in developmental dysplasia of the hip (DDH) is increased acetabular version angle (AA). Reasonable correction for excessive AA is an important step in the treatment of DDH, making accurate AA measurement very crucial. However, the results of different AA measurement methods vary. Thus, this study aimed to compare the difference in AA measurements between 2-dimensional computed tomography (2D-CT) and 3-dimensional computed tomography (3D-CT) in children with DDH and to identify the AA degree in children with DDH to guide treatment.AA was measured by 2D-CT and 3D-CT in 186 children with DDH, and the measurement results were compared with the physical measurement result in the 3D-printed pelvis (3D-PP) model. The 3D-PP was a 1:1 model identical to the human pelvis. All patients were unilaterally affected.The results of AA measurement through 2D-CT, 3D-CT, and 3D-PP of normal hips were 14.0±6.6, 11.9±5.3, and 11.9±3.4 degrees, respectively, whereas those of the dislocated hips were 24.9±8.9, 19.8±5.2, and 19.5±4.3 degrees, respectively. In both the normal and dislocated hip groups, the results between 2D-CT and 3D-CT was significantly different (P0.05), but there was no difference between the results of 3D-CT and 3D-PP (P0.05). The AA of the normal and dislocated hips as measured by 3D-PP was 11.9±3.6 and 19.6±4.3 degrees, respectively, with statistically significant difference (P0.05). In the dislocated hips, a significant positive correlation was found between age and AA (r=0.756, P0.05) and between AA and degree of dislocation (r=0.837, P0.05).3D-CT is more accurate than 2D-CT for AA measurement, and compared with normal hips, AA in dislocated hips increased by ∼7.7 degrees on average. AA increases as age and degree of dislocation increase.Level II.

Background: The use of a brace has been shown to be an effective treatment for hip dislocation in infants; however, previous studies of such treatment have been single-center or retrospective. The purpose of the current study was to evaluate the success rate for brace use in the treatment of infant hip dislocation in an international, multicenter, prospective cohort, and to identify the variables associated with brace failure. Methods: All dislocations were verified with use of ultrasound or radiography prior to the initiation of treatment, and patients were followed prospectively for a minimum of 18 months. Successful treatment was defined as the use of a brace that resulted in a clinically and radiographically reduced hip, without surgical intervention. The Mann-Whitney test, chi-square analysis, and Fisher exact test were used to identify risk factors for brace failure. A multivariate logistic regression model was used to determine the probability of brace failure according to the risk factors identified. Results: Brace treatment was successful in 162 (79%) of the 204 dislocated hips in this series. Six variables were found to be significant risk factors for failure: developing femoral nerve palsy during brace treatment (p = 0.001), treatment with a static brace (p < 0.001), an initially irreducible hip (p < 0.001), treatment initiated after the age of 7 weeks (p = 0.005), a right hip dislocation (p = 0.006), and a Graf-IV hip (p = 0.02). Hips with no risk factors had a 3% probability of failure, whereas hips with 4 or 5 risk factors had a 100% probability of failure. Conclusions: These data provide valuable information for patient families and their providers regarding the important variables that influence successful brace treatment for dislocated hips in infants. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background We posed 2 questions: what is the long-term result of open reduction surgery in developmental dysplasia of the hip, and is there an age at surgery above which the outcome was too poor to recommend the operation? Methods Between 1955 and 1995, 148 patients with 179 dislocated hips had open reduction surgery for developmental dysplasia of the hip (141 anterior and 38 Ludloff medial approaches). We attempted to locate all 148 patients for the follow-up evaluation. Results Fifty-three patients (36%) with 66 hips (37%) were located and participated in the study. These 66 hips represented 34% of the anterior open reductions and 47% of the Ludloff medial reductions. Twenty-two of the 66 hips had Severin IV or worse outcomes and included 7 with total hip arthroplasties and 2 with hip fusions. Age at surgery was significantly lower for Severin I, II, and III, compared with Severin IV and above (P=0.003, 0.001, 0.003) with outcomes deteriorating substantially after age 3. Approximately half of the hips required further surgery for dysplasia. All hips that sustained osseous necrosis had Severin IV or worse outcomes, and hips that redislocated and required revision surgery only achieved Severin I or II ratings 18% of the time. Nine "normal" hips became dysplastic and 3 had pelvic osteotomies as teenagers. Two other normal hips developed osseous necrosis during treatment of the contralateral hip. Conclusions Results deteriorate as the age at surgery increases. Osseous necrosis and redislocation predict a poor functional and radiographic result. The "normal" hip may develop insidious dysplasia and also may be injured during treatment of the involved hip. Above age 3, some patients may not have sufficient acetabular growth to remodel a surgically reduced hip. Level of evidence Level IV--case series.

BACKGROUND: The purpose of this study is to evaluate the efficacy of the Pavlik harness treatment in patients with bilaterally dislocated hips, and to compare them with cases with unilaterally dislocated hips. METHODS: Twenty-nine patients (58 hips) were identified who presented with bilateral dislocated hips with no earlier treatment and received dynamic ultrasound examination. The comparison group consisted of 38 patients (38 hips) with unilateral hip dislocation treated with the same protocol. Successful treatment was defined as relocation/reduction of the hips within 3 weeks of Pavlik harness application. RESULTS: Seventeen of 29 patients (59%) in the bilateral group (7 bilateral, 10 unilateral) and 22 of 38 patients (58%) in the unilateral group failed the harness treatment. There was no difference in the duration of harness wear for successful patients regardless of presentation. CONCLUSIONS: Patients presenting with bilaterally dislocated hips treated with the Pavlik harness are at no greater risk for failure than patients presenting with unilateral hip dislocation. LEVEL OF EVIDENCE: Level 3.

The correlations between the commonly used radiographic parameters, center-edge angle (CEA), acetabular-head index (AHI), acetabular index angle (AIA), acetabular angle (AA) and ACM angle, in normal, subluxated and dislocated hips were investigated in the radiographs of 364 normal, 23 subluxated and 19 dislocated hips of patients between 5 and 18 years of age. A significant correlation was observed between all the parameters in normal hips. A significant correlation between AIA and the other four parameters, and between CEA-AHI and AA-ACM, was noted in subluxated hips. AIA-AA and AIA-ACM had significant correlations in dislocated hips. It was concluded that measurement of more than one radiographic parameter might be better to exactly evaluate the radiographic hip anatomy in developmental dysplasia of the hip.

A new technique using a hinged external fixator to stabilize an open reduction with pelvic and femoral osteotomies has been developed for treating high-dislocated hips in older children with developmental dislocated hip (DDH). This technique was performed in 11 patients (12 hips) at a mean age of 8.2 years. At follow up, radiographic results showed no redislocation/subluxation and clinical results demonstrated 11 hips as excellent/good and only one hip as poor from persistent stiffness. In conclusion, this new technique produces acceptable results in the treatment of older children with high dislocation of the hip from DDH.

Forty-four developmentally dislocated hips occurring in 30 patients with an average age at initial surgery of 10.7 (range 2-19) months underwent medial open reduction by Ferguson's approach. All patients were skeletally mature at most recent evaluation. Mean follow-up was 19.8 (range 13-27.5) years. No redislocation or sub-luxation occurred. Additional surgery was required in 11 hips (25%). Avascular necrosis was detected in nine hips (20%). The acetabular index was decreased and the center-edge angle was increased during follow-up. Excellent or good outcome (Severin group 1 or 2) was observed in 79% of the hips at skeletal maturity. At the most recent evaluation, all but two patients had the highest score on the Iowa Hip Rating. The authors conclude that open reduction through the medial approach is effective in developmental dislocation of the hip. Follow-up until skeletal maturity is necessary for an accurate assessment of treatment.

A group of 86 developmentally dislocated hips in children aged 6-48 months was treated by closed reduction before 1957 without preliminary traction, and another group of 176 hips was treated after 1957 with prereduction traction. The results in these two groups were compared to clarify the effect of prereduction traction. During the treatment of these cases, subcutaneous adductor tenotomy was performed when obviously indicated. Otherwise preliminary traction was the only variable between the two groups. To rule out tenotomy as a factor influencing the result, the hips of children aged 6-36 months who had prereduction traction as the single variable were taken out of the group and the results analyzed. It is concluded that prereduction traction decreases the incidence of avascular necrosis of the femoral head when developmentally dislocated hips of children aged 6-36 months are treated with closed reduction with traction as the single variable.

In this prospective study, 41 dislocated hips in 40 patients were classified according to Graf's sonographic classification. Of them, 29 hips were Graf type III and 12 hips Graf type IV. All were treated in a Pavlik harness to relocate the dislocated hip dynamically. In type III hips, this was successful in 97% and 50% in type IV hips. We conclude that Graf's classification in dislocated hips has prognostic significance in treatment with the Pavlik harness.

Twelve consecutive dislocated hip prostheses and one dislocated hip joint were reduced in the emergency room using the method described in this paper. This method has multiple advantages. It uses a lever and fulcrum technique and therefore is capable of producing substantial levels of force with less effort. The patient and physician are in relatively comfortable positions and little assistance is necessary.

This study was undertaken to verify the efficacy of the Pavlik harness in the treatment of developmental disturbances of the hip (DDH) when reduction and stabilization of the hip and conclusion of the treatment are monitored by sonography. With active mother participation, under direct supervision of one consistent orthopaedist, 547 patients (60 with 91 unstable hips; 196 with 232 dysplastic hips, types IIb, IIc, and D; and 291 with 376 dislocated hips types IIIa, IIIb, and IV), with an average age of 2.3 months were evaluated. The initial hip flexion in the harness was 60 degrees to 70 degrees, which was adjusted frequently until concentric hip reduction. Sonographic reduction was achieved in 89.7% of the hips in 2 weeks, in 8.3% in 3 weeks, and in 2% in 4 weeks. Sonographic hip stabilization was achieved in 87.4% in 4 weeks, in 9.8% in 5 weeks, and in 2.9% in 6 weeks. Soft tissue landmarks (the cartilaginous roof angle and capsule) were used for assessment of reduction and stabilization, but for conclusion of the treatment, bony roof angle was used as well. Fulltime harness treatment averaged 2.7 months for the whole group (1.4 months for unstable hips, 2.3 months for dysplastic hips, and 3 months for dislocated hips). The harness was abandoned in five patients, four because of mother noncompliance and one because of abdominal surgery. Other serious complications, including avascular necrosis (AVN), did not occur in this study. It was concluded that paying attention to the minute details of treatment with active engagement of the mother in the form of group therapy under direct and consistent supervision of one orthopaedist coupled with sonographic monitoring can ensure satisfactory outcome with a shorter period of treatment in a very high percentage of the cases.

We studied the outcome of ultrasound-monitored Pavlik harness treatment of 47 infants (nine boys and 38 girls) with 55 frankly dislocated hips documented by dynamic ultrasonography. The success and failure groups were of similar ultrasound status (hip-status score) at the time of initial examination, but a significant difference emerged at the 7- and 14-day examinations. Detection of frank dislocation and institution of treatment with the Pavlik harness within 3 weeks of birth increased the probability of a successful result. Of 33 infants (27 girls and six boys) with 41 dislocated hips who were seen before the age of 21 days, 26 (63%) hips were reducible in the Pavlik harness alone, and 15 (37%) hips were irreducible and required a subsequent procedure to achieve reduction. Fourteen infants (three boys and 11 girls) with 14 dislocated hips were first seen after the age of 21 days. Three (20%) were successfully treated in the Pavlik harness alone, and 11 (80%) required further treatment. In our opinion, persistent dislocation without improvement after 3 weeks of treatment in the Pavlik harness mandates discontinuation of use of this device. No anatomic factors were seen at the time of the initial ultrasound examination that permitted prediction of those hips likely to succeed or fail treatment with the Pavlik harness.

We retrospectively reviewed the radiographs of the pelvis and hips of forty-five patients who had unilateral congenital dislocation of the hip treated with closed reduction and application of a cast without subsequent operations. The radiographs were made at the time of the initial diagnosis, two years after the reduction, when the child was ten years old, and at skeletal maturity. The width, shape, and type of the teardrop; the thickness of the acetabular floor; the acetabular index; the center-edge angle; the articulotrochanteric distance; and the Severin class at maturity were measured in the dislocated and contralateral, normal hips. At the time of the initial diagnosis, a well defined teardrop was seen in thirty-six (80 per cent) of the normal hips and in seven (16 per cent) of the dislocated hips. There was no difference in the width of the teardrop in the seven dislocated hips compared with that in the normal hips, although the v-shaped and crossed types of teardrops were more frequent in the dislocated hips. The v shape was not observed in the normal hips but was seen in sixteen dislocated hips two years after the reduction and in twelve dislocated hips when the children were ten years old. The superior and inferior widths of the teardrop of the dislocated hips were significantly greater than those of the normal hips (p < 0.001 and p < 0.05, respectively) when the children were ten years old. The hips with residual acetabular dysplasia had a v-shaped teardrop, widening of the superior width of the teardrop, and thickening of the acetabular floor. These hips, which were usually Severin class IV at the time of skeletal maturity, had a poor prognosis in adult life.

A meticulous capsuloplasty is needed to maintain concentric reduction in the surgical treatment of developmental dysplasia of the hip (DDH). The authors present a new capsuloplasty technique that was named as 'reverse U-shaped capsuloplasty'. It was performed in 72 dislocated hips of 62 children with a mean age of 2.7 years. The reverse U-shaped flap, created in the redundant superolateral capsule was turned downwards, advanced medially, anteriorly and inferiorly and brought over the anteroinferior capsular incision. After a mean follow-up period of 3 years there was neither redislocation nor restriction of the hip joint motion in any hips.

The benefit of preliminary traction in the treatment of developmental dislocation of the hip has not been clearly demonstrated. We retrospectively analyzed the results of traction treatment of 90 dislocated hips in 72 patients. After a 3-week course of traction, patients underwent attempted closed reduction. Fifty-two hips (58%) were managed successfully by closed reduction, whereas 38 hips (42%) required primary open reduction. chi 2 analysis revealed no significant difference in either the rate of successful closed reduction or the incidence of avascular necrosis compared to recently published series in which preliminary traction was not used. On the basis of presentation radiographs and arthrograms, we were unable to identify a subgroup of patients that clearly benefited from the use of traction in the treatment of developmental dislocation of the hip.

Guided abduction is a form of overhead traction conceptually similar to the Pavlik harness. It is used in older children or in children in which the Pavlik harness has failed. The results of 27 congenitally dislocated hips treated by guided abduction traction from December 1979 to June 1989 were reviewed. Ages ranged from 1 month to 28 months. Twenty (74%) of the 27 hips underwent a gentle, often spontaneous, closed reduction, followed by abduction casting and bracing. Two hips developed radiographic evidence of avascular necrosis; five hips developed temporary irregular ossification. Closed reduction was unobtainable in any child older than 24 months. Two children needed additional reconstructive procedures, one an innominate pelvic osteotomy and the other a valgus derotation osteotomy. Both had had open reductions. Recent reports stated that preliminary traction in the treatment of congenitally dislocated hips is of no value. We consider guided abduction traction a valuable treatment modality resulting in a reduced incidence of open reduction. When comparing our results with those of a Salt Lake City study performed without preliminary traction, our incidence of open reduction is lower (26 versus 49%). Our study supports the use of preliminary traction to decrease the need for open reduction in congenitally dislocated hips.

Spontaneous arthrodesis occurred after bilateral, extraarticular shelf augmentation and femoral varus osteotomies in a child with dislocated hips secondary to muscle imbalance from cerebral palsy. The proposed cause is heterotopic bone formation in the hip abductors in the face of insufficient range of motion exercise.

In forty-one children who had forty-seven congenitally dislocated hips, the results of attempted closed reduction with general anesthesia, but without preliminary traction, were studied. Twenty (43 per cent) of the hips could not be reduced closed, and an open reduction was needed. After the reduction, all of the involved hips were immobilized in the so-called human position (marked flexion and slight abduction). At a minimum follow-up of two years, osteonecrosis of the femoral head had developed in only two hips (4 per cent). Patients who were more than one year old when the hip was reduced had a higher incidence of osteonecrosis of the femoral head and were more likely to need reconstructive procedures later. Patients who were more than eighteen months old at the time of the attempted closed reduction were more likely to need an open reduction of the hip. Treatment of congenital dislocation of the hip in young children remains an extremely complex problem. It has not been clearly established that the use of preliminary traction decreases the incidence of osteonecrosis of the femoral head or improves the outcome of treatment. In our experience, uncomplicated (non-teratological, postnatal) congenital dislocation of the hip has been safely treated with either open or closed reduction without preliminary traction in patients who were younger than two years old, provided that the reduction could be obtained without excessive force.

Twenty-two consecutive patients with 26 dislocated hips were evaluated for a mean of 7 years after open reduction through a medial adductor approach. Severin classification of grade I or II and center-edge angles greater than 20 degrees were present in 73% of hips and 88% of patients treated between the ages of 5 and 14 months. Avascular necrosis (AVN) with partial head involvement occurred in 15% of hips and correlated positively with increased age at surgery, but did not preclude a satisfactory Severin classification. Best results were obtained in children treated between the ages of 5 and 14 months.

The newborn screening results of 1,310 children examined by Ortolani's and Barlow's manual test, as well as 2,587 children investigated by sonography, have been compared. Of the sonographically pathological hips (technique of Graf), 52.2% had no sign of instability. This was especially true in dysplastic and decentering hip joints, but was found to a smaller degree even in dislocated hips. As a result, twice as many abduction pillows were ordered during the second period. Sonography also detected joints that were immature at birth, but became worse during development (8.9% of hips labeled type 2a, after Graf). A total of 6.54% pathological hips were detected by newborn screening and follow-up of immature hips.

Several complications following Pavlik harness splintage for congenital dislocated hips have been described. Two cases are reported where prolonged Pavlik splintage without concentric hip reduction caused posterior acetabular deficiency. Open reductions were required in both cases to correct deformity.

Various techniques for improving the success of needle placement in hip arthrography have been described. The authors describe a simple consistent sign that occurs in both subluxated and dislocated hips and is present only when the needle is correctly placed within the hip joint. This, in conjunction with other techniques, has improved their quality of hip arthrography.

Two unrelated children with developmental delay, anterior chamber-cleavage disorder, proportionate short stature and striking similarity in facial appearance appear to have an identical syndrome. Peters' plus syndrome has to be considered but additional abnormalities not described in this syndrome and their apparently different facies may be evidence for a hitherto undescribed condition. The further malformations both children have in common are cerebellar hypoplasia, hypothyroidism, tracheostenosis and dislocated hips.

The iliac crest is a frequent insertion site for external fixation pins in treating unstable pelvic or acetabular fractures and in iliofemoral distraction for superiorly dislocated hips. The pin-bone interface is critical for the success of treatment, but studies of the iliac crest are lacking. The purpose of this study was to investigate the strength of the pin-bone interface of different pins and different insertion methods. Four types of commercial pins, Wagner pins, Orthofix cortical and cancellous screws, and AO pins, were driven into sheep iliac crests by 2 methods: the intercortical and the transcortical. Specimens were tested for pullout and bending with an Instron testing machine (Model 1343) at a extension rate of 0.02 mm/sec to failure. The results revealed that the intercortical method had a stronger pullout force than the transcortical in all types of screws (p < 0.05), probably caused by longer insertion in the bone. In the pullout tests, the Wagner pins were the strongest and the Orthofix cancellous screws were the weakest. There were no differences in bending. In the iliac crest, the intercortical method was the better way of driving pins, and the new Orthofix screws were not proven to be stronger than the Wagner pins, nor were the cancellous screws more suitable than the cortical ones.

Five practical questions, concerning which hips should be treated, method of treatment, duration of treatment, treatment failure, and whether pretreatment traction is advised in congenitally dislocated hips, are discussed and answered. All hips positive for Ortolani's sign, hips positive for Barlow's sign, dislocated and irreducible hips, and hips that appear unstable by sonography should be treated. A large number of studies document the safety and effectiveness of early treatment in the Pavlik harness. Treatment may be stopped at six weeks in the newborn and three or four weeks after stability is achieved in children three or four months old at the time of initial treatment. Sonography is helpful in determining when to stop treatment. Hips that fail Pavlik harness treatment are at risk to fail with other types of treatment as well and require a cautious approach. Traction before treatment of congenital dislocation of the hip (CDH) may not be necessary. Recent studies have shown that safe reductions may be performed without preliminary traction.

A study of acetabular development in 148 patients with 185 congenitally dislocated hips treated by closed reduction from 1940 to 1968 showed that eight years after reduction the acetabular index was normal (less than 20 degrees) in 49.2 per cent, satisfactory (from 20 to 24 degrees) in 34 per cent, and poor (more than 24 degrees) in 16.7 per cent. Early treatment led to the best acetabular development. Significant and continuing improvement of the acetabular index was observed between two and eight years after reduction when the femoral head remained concentrically reduced. Failure to maintain proper reduction and necrosis of the femoral head led to poor results.

The pathological anatomy of chronically dislocated hips makes reconstruction for more difficult in them than in most cases. The acetabular component must be seated at the site of the original triradiate cartilage and the femur must be shortened four or more centimeters to prevent excessive limb lengthening. This means that the femoral component must be seated in the smallest, strightest portion of the intramedullary canal. A specially designed prosthesis is often needed. Twenty-two hips were operated on in this series, and all patients had relief of pain and improvement of gait. One major complication occured: a sciatic-nerve palsy due to overlengthening of the femur and improper postoperative positioning.

Quantitative studies of femoral head blood flow by the hydrogen washout technique with the hips in various positions of immobilization were determined. Immobilization in flexion consistently resulted in the highest rate of femoral head blood flow. A position of relaxed abduction seemed to slightly, but significantly, decrease the rate of blood flow. The position of forced frog-leg abduction and forced internal rotation obliterated or drastically reduced circulation in the femoral head. We think that the ischemia of forced acute immobilization is secondary to compression of the immature cartilaginous femoral head. These experimental data further indicate the importance of the selected position of immobilization in the treatment of congenital dislocated hips as a cause of iatrogenic avascular necrosis.

Thirty-six patients with arthrogryposis have been followed at The James Lawrence Kernan Hospital of Baltimore since 1951. In this group, nine patients sustained 16 perinatal fractures. Femoral shaft fractures and epiphyseal separations were found more commonly in patients with fixed knee extension or dislocated hips and were related to relative stiffness and obstructed delivery. Femoral fractures were more common than humeral or tibial fractures. Arthrogrypotic infants displaying irritability and poor feeding are suspect of skeletal trauma. Thickening of limbs or joints may be the only clinical indication of fracture of epiphyseal injury. Plain radiographs of joints were inadequate for the diagnosis of epiphyseal separation when the epiphysis was not yet ossified. Arthrography is therefore recommended as a primary diagnostic tool.

A retrospective review of fifty-three congenitally dislocated hips (in forty-four patients) in which ischemic necrosis developed was undertaken to assess patterns of growth disturbance and to establish treatment protocols. We utilized the Bucholz and Ogden classification of the four roentgenographic patterns of ischemic necrosis complicating the treatment of congenital hip disease. Patients with Type-I disease had transient ischemia with early recovery. Significant growth disturbances requiring surgical treatment were not observed. Limb-length discrepancy, increased height of the greater trochanter relative to the femoral neck and head, and problems with femoral head coverage were more likely to develop in hips with Type-II or Type-III ischemic necrosis. Equalization of limb lengths, trochanteric epiphyseodesis, and surgical means of improving femoral head coverage were also more commonly indicated in these patients. In patients with Type-IV disease, mild deformities of the femoral head and occasional limb-length discrepancies developed; other sequelae were uncommon and surgical intervention was rarely required.

In six patients avascular necrosis of the normal hip developed while the opposite hip was being treated for dislocation. The ages of the patients ranged from one to sixteen months. All children were immobilized bilaterally with plaster casts. In addition to avascular necrosis of the originally normal hips, the dislocated hips also became avascular. The problem in five of the originally normal hips resolved without serious final deformity, but in one the growth plate and the capital epiphysis closed prematurely, resulting in a short femoral neck.

To The Editor: I am writing in response to "Pain: Friend or Foe?" (2001;83-A:1424-5), an Orthopaedic Forum article by Dr. Whitesides. As an Acute Pain Clinical Nurse Specialist, I took great exception to his blanket condemnation of acute pain services. As a trained orthopaedic nurse, I began my practice as an Acute Pain Nurse at Sandwell NHS Trust. The orthopaedic consultants within the Trust were confident in my ability to recognize the complications of orthopaedic surgery. However, the general surgeons, similarly to Dr. Whitesides, did not trust the clinical judgment of a pain specialist. After four years, I have gained their trust, through my recognition of complications and my alerting them to situations such as anastomosis rupture and peritonitis, in which the chief symptoms were a sudden increase in pain. The risky clinical situations that are described in the article seem to be attributed to an overzealous use of analgesia in "overtherapeutic" doses. The dosages of epidural analgesia were not stated, but if low-dose local anesthesia is used in combination with low-dose opioids, then a "mobilizing epidural" may be achieved. In this state of medication, the patient is able to move his or her limbs easily, and any decrease in motor function will facilitate the discontinuation of the epidural to allow for evaluation of a true clinical picture. However, for patients with a tibial fracture treated with surgery, a patient-controlled intravenous system of analgesia that utilizes morphine may be more appropriate, as the vasodilating effects of the local anesthetic could aggravate any compartment syndrome formation. The …

From 1977 to 1983, 17 patients with 20 long-standing congenitally dislocated hips were treated with a one-stage combined operation and then followed for more than 3 years by our institution. The growth of the proximal femur after femoral osteotomy was studied. The average neck-shaft angle was 111 degrees immediately after operation, and 128 degrees at follow-up. The outcome was largely independent of either age at operation or bilateral involvement. Our findings revealed 30% good and 50% excellent results in our patients.

We determined the acetabular angles, center-edge angles, comprehensive quotients, and Shenton's lines from sequential roentgenograms of thirty-seven children with congenitally dislocated hips treated by closed non-manipulative reduction in early infancy. The values were compared with those obtained from roentgenograms of 164 normal children who ranged in age from three months to five years and of forty-three adolescents and adults. The hip recovering from congenital dislocation developed similarly to the normal hip but differed in that it showed a greater rate of decrease of the acetabular angle and an increase in the center-edge angle. Significant development after the age of five years still was manifested in the reduced hips.

Twelve children with lumbar-level myelodysplasia (average age, eight and three-quarter years) underwent twenty-one pelvic displacement osteotomies for subluxated or dislocated hips. Nineteen of the twenty-one hips remained reduced on three-year follow-up. Gains in gait pattern, ease of bracing, and reduced pelvic obliquity were noted. Active function about the hips was not improved, nor was there a decrease in the amount of bracing needed following the osteotomy. Pelvic displacement osteotomy can be utilized in selected cases as part of the over-all management of chronic hip dislocation in myelodysplasia.

The so-called protrusio socket technique of total hip arthroplasty was shown to be very effective in a series of twenty-two chronically dislocated or subluxated hips. In seventeen patients with follow-up of sixteen to fifty-nine months, excellent results were obtained in all but two hips. Obesity and rheumatoid arthritis or other systemic causes of osteopenia are considered contraindications to the procedure.

The use of computed tomography (CT) in the postoperative evaluation of 19 congenitally dislocated hips is presented so that appropriate indications for reduction can be determined and radiologic criteria can be defined for judging whether reduction is satisfactory. The radiologic technique is presented. CT is an accurate and cost-effective modality that is capable of demonstrating subtle changes in femoral head position.

The results in fifty-one congenitally dislocated hips in forty-two children who were between one and three years old when treatment was begun have been reviewed. Thirty-eight hips (75 per cent) were treated by traction prior to reduction, gentle closed reduction under anesthesia, selective adductor tenotomy, and immobilization in a hip-spica cast. Thirteen hips (25 per cent) required an open reduction when stable closed reduction could not be achieved. Secondary femoral or acetabular procedures were performed after either form of treatment if subluxation became apparent after the child had resumed walking. At an average twelve-year follow-up (range, five to twenty-two years), thirty-six hips (71 per cent) were rated as Class I; six, as Class II; eight, as Class III; and one, as Class IV, according to the classification system of Severin. Significant avascular necrosis developed in three hips. We think that in this age group congenital dislocation of the hip is best treated by closed reduction, followed by femoral or acetabular procedures as needed. Open reduction should be done only in those hips that cannot be reduced by closed methods.

A retrospective study involving 276 patients with 319 congenitally dislocated hips was undertaken to assess whether premanipulation fraction prevents avascular necrosis. Roentgenographic criteria were utilized and only cases of frank dislocation unassociated with other disorders were included. It was found that in a child less than one year old, premanipulation traction of twenty-one days or more substantially reduces the incidence of avascular necrosis. For the child more than a year old, however, the prognosis is not as good, even if premanipulation traction is prescribed for twenty-one days or more. We found a 14 per cent incidence of avascular necrosis in children less than three months old and suggest that the cartilaginous femoral head prior to the appearance of the ossific nucleus is particularly vulnerable to vascular injury.

1. Acute hematogenous osteomylitis in infants runs a rapid course. The correct diagnosis is often made late, after irreparable damage to joint components and growth centers has already taken place. 2. Normal temperature and absence of general reaction to infection are often misleading. This disease should be suspected if an infant becomes irritable and if swelling, tenderness, or loss of function of an extremity develop. 3. There is little controversy concerning the general treatment of the sick infant, but the present tendency is to pay too little attention to the local bone and joint lesion. 4. The intra-articuler tension and lytic action of pyogenic exudate in pyarthrosis of the hip rapidly destroy cartilage, thus causing disruption of the joint, pathological dislocation, and serious growth disturbances which result in severe crippling. 5. In those dislocated hips which were later observed at open operation it was found that internal rotation was necessary to place the remaining elements of the proximal end of the femur into the acetabulum. 6. The chief fault in present-day treatment is the tardiness of surgical drainage of localized abscesses, particularly when a hip joint is involved. Study of this series suggests that early surgical drainage, followed by traction in abduction and particularly with internal rotation, would have minimized absorption of cartilage and saved some of these hips.

The case reported exhibited bilateral posterior dislocation of the hip associated with bilateral frature of the femoral shaft. It is believed to be the only such recorded case. An excellent result was obtained following closed reduction of the dislocated hips and secondary open reduction and medullary nailing of the femoral fractures.

1. The main factor that determines a satisfactory result is the operative technique; 2. The shelf operation for dislocated hips in spastic paralysis is without value; 3. The age of the patient appears to have little influence on the result; 4. Changes in the ilium induced by shelf implantation appear to be extremely important: 5. When the local condition indicates the need to stabilize a hip in a child, a shelf can be an invaluable asset.

1. Approximately 25 per cent. of dislocated hips may be expected to become perfect or excellent after bloodless reduction. This percentage is increased to 35 in hips in which the dislocation is reduced during the first three years of life. 2. Another 15 per cent. of hips may be expected to become functionally satisfactory for a varying number of years, with the understanding that eventually symptoms of fatigue, pain, and limp may arise. This percentage is increased to 20 when the dislocation has been reduced before the end of the third year. 3. Failure (subluxation or recurrence of complete dislocation) may be expected in 60 per cent. of all primarily reducible dislocations, and in 45 per cent. of those reduced in the first three years. 4. The form and the degree of the dysplasia of the various structures of the hip joint which is present at birth, and the ability or inability of resumption and continuation of normal growth after reduction, are the essential factors that determine the end result. 5. The time factor (age of the child at time of reduction) is of secondary influence, inasmuch as the end results are better in hips in which the reduction was carried out during the first three years of life than in those reduced after this age. It is not this factor, however, which determines the result in the large group of hips in which reduction was achieved early. The high percentage of cures nesulting from the treatment of predislocation seems to prove the great importance of the time factor; but this is open to question, because many cases of predislocation are cured spontaneously or by minimal treatment. 6. The "perfect" end results are to be found only among those cases that are amenable to bloodless reduction. If open operation is necessary for reduction, one can always observe the presence of one or more of those structural deformities that make the development of a perfect hip impossible. Of marked importance and frequency among these are the deformities of the neck of the femur and a high capsular attachment. 7. Various operative procedures are of great value to restore stability of the hip and to improve its function. Complete restoration of normal function and a close approach to normal anatomy may be obtained by a timely, wisely selected, and properly executed operation in cases of prolonged acetabular aplasia, unaccompanied by other, more serious deformities.

In a retrospective clinical review of patients with congenital dislocation of the hip who underwent open reduction through the Ludloff medial approach, stability of reduction, acetabular development and presence of avascular necrosis were evaluated in 11 patients with 15 dislocated hips. This approach was reserved for patients younger than 18 months of age in whom closed reduction had failed. Ten patients with 14 hips underwent preoperative traction. All 15 hips at follow-up or just prior to subsequent surgery displayed dysplastic and insufficient acetabular development, with persistent subluxation in nine hips. Subsequent surgery to obtain better concentric reduction and acetabular coverage was performed in six hips, and further surgery is being considered in four other hips. Ten hips showed signs of avascular necrosis of the ossific nucleus, with additional involvement of the growth plate in four hips. The medial approach resulted in inadequate concentric reduction, with a high incidence of avascular necrosis. In the majority of patients in this small series, a secondary procedure was needed to improve hip stability and the acetabular dysplasia.

Neonatal infants with Ortolani-positive dislocated hips are easily managed by reduction and maintenance of the reduction using a divarication splint, cast, or Pavlik harness. Sixty-six patients with 85 complete, congenitally dislocated hips (Ortolani negative) unassociated with other neuromuscular disorders were examined to assess a method of prereduction traction in the treatment of congenital dislocation of the hip. Forty of the 66 patients were six months of age or younger at the beginning of traction treatment. The remaining 26 were younger than 12 months of age prior to the treatment protocol. Overhead traction with the hip flexed to 90 degrees was employed. Gradual hip abduction to 70 degrees (140 degrees combined abduction) was accomplished over the next ten to 14 days. If the dislocated hip was still in a station above Hilgenreiner's line, then cross traction was applied to add another vector of force to pull the femoral head distally. At an average of 18 days into the treatment protocol, an examination under anesthesia with closed reduction was performed and the patient immobilized in a double hip spica in the "human" position for six to eight weeks. This was followed by use of an Ilfeld divarication splint for nine months. This traction/reduction program was effective in 91% of these cases (60 of 66). Six patients (ten hips) required an open procedure because of persistent instability in spite of reducibility. To date, there is no incidence of avascular necrosis using the criteria of Salter for whole head avascular necrosis and the criteria of Kalamchi and MacEwen for partial head avascular necrosis.