Eiji Gotoh

Minimum 10-year results of Sugioka's osteotomy for femoral head osteonecrosis.

Sugiokas transtrochanteric rotational osteotomy was performed on 14 hips (12 patients) before 1987 for avascular necrosis of the femoral head involving a large part of the weight-bearing area. Three hips required a secondary total hip arthroplasty within 5 years after the osteotomy. The remaining 11 hips were examined at a mean of 13.2 years after surgery (range, 10-17.7 years). The clinical and radiologic results were related to the preoperative radiographic stage of the disease. In the hips with less than 2 mm of collapse, highly satisfactory results were maintained more than 15 years after surgery, with minimal development of degenerative changes. In hips with 2 mm or more of collapse or with acetabular changes, the results tended to deteriorate gradually during the long course of observation but were fairly acceptable. This study shows the osteotomy can enable hip joints to survive and function well for more than 10 years with proper patient selection and operative procedure.

Valgus-extension osteotomy for advanced osteoarthritis in dysplastic hips

We treated 31 consecutive patients of mean age 43 years (22 to 59) with severe osteoarthritis of the hip secondary to dysplasia by valgus-extension osteotomy. The clinical results were analysed for factors which may have affected the outcome. The procedure was carried out only on one side and was combined with a Chiari pelvic osteotomy in four patients. The angle of valgus was between 30 and 40° with 10 to 20° of extension. The mean follow-up was 15 years (12 to 18). Clinical evaluation using Charnley’s modification of the system of Merle d’Aubigne and Postel showed that the mean score for pain had improved from 2.3 before operation to 4.2 at 15 years, and function from 2.3 to 4.2. Range of movement had decreased from 4.2 to 3.5. Fifteen patients (48.4%) had a pain score of 5 or 6 and were evaluated as satisfactory. Kaplan-Meier survivorship analysis showed a survival rate of 51% at 15 years after operation. Two preoperative factors had a significant positive correlation with the radiological results, namely the thickness of the capital drop osteophyte and the length of the roof osteophyte. We suggest that this procedure is effective for advanced osteoarthritis in the dysplastic hip in young and active patients if these factors are satisfactory on the preoperative radiographs.

Acetabular development after reduction in developmental dislocation of the hip.

A radiologic study was conducted on 56 patients with developmental dislocation of the hip (63 hips). Fifty hips in which neither acetabular nor femoral osteotomy was performed were classified as satisfactory (Severin Groups I and II) or unsatisfactory (Severin Groups III and IV) based on radiographs when growth was completed. The sequential changes in the center edge angle and the acetabular index were compared when the patients were ages of 5, 10, and 15 years. There was a significant relationship between the center edge angle and the acetabular index when the patients were 5 years of age and at final outcome. Most (85.7%) patients with a center edge angle less than 8° and an acetabular index greater than 26° at 5 years of age eventually were classified as Severin Groups III and IV at skeletal maturity. These findings suggest that radiologic results at the time when growth is completed can be predicted based on the center edge angle and the acetabular index in radiologic measurements at 5 years of age. The authors recommend that if at 5 years of age the center edge angle is less than 8° and the acetabular index is greater than 26°, consideration be given to an osteotomy to bring these values to a more normal range to improve final outcome.

Tangential view arthrogram at closed reduction in congenital dislocation of the hip

Of 119 previously untreated hips with congenital dislocation (complete dislocation), a classification of tangential view arthrograms at closed reduction was attempted in 34 joints that could not be reduced with a Pavlik harness or by traction but could be reduced manually under anesthesia. Conservative or open reduction was selected according to this classification. None of the hips had total femoral head necrosis, and only two femoral heads showed mild permanent necrosis. These results suggest the usefulness of this classification for selection of treatment for congenital hip dislocation.

Significance of Inguinal Folds for Diagnosis of Congenital Dislocation of the Hip in Infants Aged Three to Four Months

Summary: We evaluated the usefulness of the appearance of asymmetrical inguinal folds in the frog leg position as a screening indicator for congenital dislocation of the hip (CDH) in the hope that we might be able to decrease the frequency of radiographic examinations of 3–4-month-old infants. Abnormal inguinal folds were observed in 499 (23.8%) of the 2,111 patients examined at the Asahikawa Health Center, and these 499 included all patients with complete dislocation or subluxation. Abnormal inguinal folds were also present in all 29 previously untreated patients with complete dislocation and in 11 with subluxation seen in our department. Because limited passive hip abduction is less sensitive than abnormal inguinal folds, we recommend inguinal fold assessment as a useful adjunct to other screening methods for CDH in 3–4-month-old infants.

The pathogenesis of femoral head deformity in congenital dislocation of the hip. Experimental study of the effects of articular interpositions in pigs.

An experimental study was conducted based on the hypothesis that articular interpositions such as inverted limbi are major factors influencing deformities of the femoral head and neck that complicate treatment of congenital dislocation of the hip. In 24 neonatal pigs, the hip was fixed in a cast for one to three hours in the frog-leg position after insertion of an allogeneic meniscus into the hip joint. No macroscopic changes were observed immediately and one day after the above procedure, but electron microscopy showed degeneration of the cells in the physis. After 29-39 days, varus deformity and flattening of the femoral head were observed in all animals. After five months, marked deformity of the femoral head and replacement of the physis by fibrous tissue were noted. Angiograms obtained during cast fixation and 30 minutes after removal of the cast showed no circulatory occlusion. A short period of immobilization in the frog-leg position combined with articular interposition plays a major role in degeneration of the physis and predisposes to deformities of the femoral head and neck.

PRIMARY CHARNLEY TOTAL HIP ARTHROPLASTY FOR CONGENITAL DYSPLASIA

We performed Charnley total hip arthroplasties on 64 patients (71 hips) between 1976 and 1984 for moderate congenital acetabular dysplasia in which a superolateral cement thickness of less than 20 mm was expected when the cup was placed in the true acetabulum at an angle of 45 degrees. Of these, 59 hips were examined 10 to 17 years after operation; 37 (group A) had been operated on between 1976 and 1982 using Charnleys original technique of cementing the acetabulum and 22 (group B) between 1983 and 1984 using more modern techniques. In group A, aseptic loosening of the socket was observed in ten hips (27.0%) and the 17-year survival rate was 81.5%. In group B, loosening was noted in only one socket (4.5%) and the 13-year survival rate was 100%. The improved techniques produced significantly better long-term results in fixation of the cup in dysplastic hips without bone grafting.

Safety of Fettweis squatting position in congenital dislocation of the hip: Experimental study of prevention of deformity of the femoral head and neck in pigs

The safety of the Fettweis squatting position for immobilization after reduction in congenital dislocation of the hip was evaluated in an experimental model in pigs. In seven neonatal pigs, the hips were fixed in a plaster cast for 3 h in the Fettweis squatting position after the insertion of an allogenic meniscus into the hip joint. Three to 5 months later, no obvious deformity of the femoral head or neck was noted. The results demonstrate that the squatting position is an appropriate position for immobilization after the reduction of dislocated hip joints.