Aresh Hashemi-Nejad

Custom Cementless THA in Patients With Legg-Calve-Perthes Disease

Legg-Calve-Perthes disease is characterized by osteonecrosis of the femoral head during childhood. Outcomes of total hip arthroplasty (THA) for these patients are less satisfactory than for those with primary osteoarthritis, often complicated by young patient age, multi-planar deformities and previous childhood surgery. To our knowledge no one has reported the long-term outcomes of cementless custom-made THA in patients with Legg-Calve-Perthes disease. We reviewed 15 THAs with an average follow-up of ten years. Survivorship rates of the femoral and acetabular components were 100% and 79% respectively. Mean Harris Hip Scores improved from 41 preoperatively to 80 at final follow-up. With excellent functional outcome, custom-made cementless prostheses should be considered as a treatment option for osteoarthritis secondary to Legg-Calve-Perthes disease in the presence of abnormal proximal femoral and acetabular anatomy.

Idiopathic chondrolysis of the hip: presentation, natural history and treatment options.

Idiopathic chondrolysis of the hip is a rare disorder characterized by pain, stiffness, limp and radiological loss of joint space of the affected hip. The clinical outcome varies from complete recovery to fibrous ankylosis. Management remains controversial. We aim to outline the natural history and pathology of the disease and treatment strategies.

Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head-shaft slip angle from 53.8(°) (standard deviation (SD) 3.2) pre-operatively to 9.1(°) (SD 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, SD 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

Surveillance after treatment of children with developmental dysplasia of the hip: current UK practice and the proposed Stanmore protocol.

Monitoring of a patient with developmental dysplasia of the hip (DDH) is required after initial treatment to ensure early detection and correction of complications or poor progression. We established the current practice of surveillance in DDH in the UK. A protocol has been designed at this unit with the aim of identifying the stages in the progression of DDH when imaging of the hip is necessary to detect failure or possible complications of treatment. The outcomes and secondary procedure rates under the surveillance protocol used at this unit, for a UK population, have been reviewed with a minimum of 5 years of follow-up. Frequency of follow-up has been reported as yearly or more frequently until skeletal maturity by 70% of respondents. Ninety patients presenting with DDH were managed under the protocol developed at this unit, with equivalent outcomes as those in patients who reported yearly follow-up. Following our proposed protocol we believe it is possible to limit disruption to the patient’s life, reduce costs and maintain compliance and ensure timely detection of any complications, without significant increase in secondary procedure rates.

A protocol for the use of closed reduction in children with developmental dysplasia of the hip incorporating open psoas and adductor releases and a short-leg cast: Mid-term outcomes in 113 hips.

AIMS Our aim was to assess the effectiveness of a protocol involving a standardised closed reduction for the treatment of children with developmental dysplasia of the hip (DDH) in maintaining reduction and to report the mid-term results. METHODS A total of 133 hips in 120 children aged less than two years who underwent closed reduction, with a minimum follow-up of five years or until subsequent surgery, were included in the study. The protocol defines the criteria for an acceptable reduction and the indications for a concomitant soft-tissue release. All children were immobilised in a short- leg cast for three months. Arthrograms were undertaken at the time of closed reduction and six weeks later. Follow-up radiographs were taken at six months and one, two and five years later and at the latest follow-up. The Tönnis grade, acetabular index, Severin grade and signs of osteonecrosis were recorded. RESULTS A total of 67 hips (51%) were Tönnis grade 3/4 hips. By 12 months, 20 reductions (15%) had not been maintained, and these required open reduction. In all, 55% of these were Severin 1; the others were Severin 2, due to minor acetabular dysplasia. Of the 113 successful closed reductions, 98 hips (87%) were Severin 1. Surgery for residual DDH was offered for ten hips. Osteonecrosis was seen in 32 hips (29%) but was transient in 28. In total, two children (1.5%) had severe osteonecrosis. Bilateral dislocations were significantly more likely to fail and most Tönnis 4 hips failed. CONCLUSION Closed reduction, with concomitant adductor and psoas release when required and the use of a short leg plaster of Paris cast for three months, can produce good mid-term results in children with DDH aged less than two years. This protocol is not recommended for Tönnis 4 hips. Cite this article: Bone Joint J 2016;98-B:1548-53.

Resurfacing hip arthroplasty in neuromuscular hip disorders – A retrospective case series

BACKGROUND Management of the degenerate hip in patients with neuromuscular conditions should be aimed at improving quality of life and ease of nursing care. Arthroplasty poses a significant challenge with predisposition to dislocation and loosening due to anatomical abnormalities, soft tissue contractures and impaired muscle tone. METHODS We present a series of 11 hips (9 patients) following total hip resurfacing arthroplasty for painful osteoarthritis in patients with differing neuromuscular conditions. Patients were assessed clinically and radiographically and also for satisfaction of their carers due to improved ability to provide nursing care. Mean patient age was 33.1 years (range 13-49 years) with mean follow up at publication 63.7 months (41-89 months). All patients were operated by a single surgeon (AHN) and received the required post operative care and physiotherapy. Soft tissue releases were performed when necessary. All hips were assessed clinically and radiographically at 6 weeks and 6 months and 1 year post-operatively. Six month follow-up also included a questionnaire with scoring of care-provider satisfaction. RESULTS Ten hips had good clinical results with improvement in pain and function and radiologically showed no signs of loosening. One hip required revision to proximal femoral excision due to dislocation and loose acetabular component with severe pain. None of the other hips dislocated. Analysis of care provider satisfaction assessing ability to provide personal care, positioning and transferring, comfort, interaction and communication scored excellent to good in 10 patients and satisfactory in one. CONCLUSION We believe hip resurfacing arthroplasty to be a viable option in the treatment of the complex problem of osteoarthritis in the hips of patients with neuromuscular disease. The improved biomechanics confer greater stability when compared to conventional total hip arthroplasty. Although technically demanding, a successful result has been shown to improve patient pain, function and ease of nursing care. LEVEL OF EVIDENCE Level IV.

The Bernese peri-acetabular osteotomy through a modified approach. A technical note

IntroductionA modification of the technique for performing the Bernese periacetabular osteotomy is described.Materials and methodsA medial approach to the Ischium and a subtle re-orientation of the pubic osteotomy are detailed.ConclusionSurgical morbidity is likely decreased with a concurrent cosmetic advantage without compromise to surgical correction or patient safety.

Total hip arthroplasty in teenagers: an alternative to hip arthrodesis

Debilitating arthritis in teenage patients is a complex problem with limited surgical options. Hip arthrodesis is unpopular amongst patients, and contemporary total hip arthroplasty (THA) may be a promising alternative. We report on the outcomes of THA in patients less than 20 years of age. All consecutive teenage patients undergoing THA at a tertiary referral centre were reviewed. Mean follow-up was 3.4 years (range 0.6–6.8) and 9 patients had at least 5 years follow-up. There were 51 THAs in 43 patients with a mean age of 17 years (range 12–19). The commonest indication was osteonecrosis (35 cases), mostly secondary to slipped upper femoral epiphysis (15 cases). Forty-six were uncemented and 5 were reverse hybrid THAs of which 7 were computer assisted design/manufacture (CADCAM) components. The commonest bearing surface used was ceramic on ceramic (40 cases). The survival rate was 96% and there were 2 complications. At latest follow-up, the mean Harris hip score was 90 (range 68–99) and UCLA activity score was 6 (range 4–9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. We report good short to intermediate term survivorship and outcomes, and feel THA represents a valid alternative option to hip arthrodesis.

The modified Tonnis triple pelvic osteotomy in the young adult - early results

Acetabular dysplasia may present as previously undiagnosed or as a sequel to treated DDH in a young adult, with a natural history of subsequent development of early osteoarthritis.Patients with ace...

Posteromedial bowing of the tibia: a benign condition or a case for limb reconstruction?

Purpose To review the initial deformity and subsequent remodelling in posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. Patients and Methods In all, 38 patients with posteromedial bowing of the tibia presenting between 2000 and 2016 were identified. Mean follow-up from presentation was 78 months. A total of 17 patients underwent lengthening and deformity correction surgery, whilst three further patients are awaiting lengthening and deformity correction procedures. Results The greatest correction of deformity occurred in the first year of life, but after the age of four years, remodelling was limited. The absolute leg-length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45 mm (35 to 60). Mean duration in frame was 192 days, with a mean healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of ten years (p = 0.046). Four contralateral epiphysiodeses were also performed. Conclusion Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening LLD. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator should be considered as part of the treatment options. Level of evidence Level IV (Case series)