Richard J. Montgomery

Proximal femoral osteotomies in children using the Richards hip screw: techniques, outcome and subsequent removal

IntroductionWe investigated the clinical and radiological outcome of proximal femoral osteotomies in children using the Richards hip screw. We also describe previously unreported techniques used in the insertion of the screw to aid satisfactory correction of the neck shaft angle and medialisation.MethodsSeventy-two children undergoing 81 proximal femoral osteotomies under the care of the senior author over a 10-year period were reviewed.ResultsFor the primary procedure, there was an overall complication rate of 5%. This included two (2.5%) cases requiring re-operation. There were no fractures and no long-term complications. For subsequent removal of the metalwork, the complication rate was 5%, with a re-operation rate of 1%.ConclusionWe conclude that the Richards hip screw is a safe, atraumatic and easy-to-use method of fixation for proximal femoral osteotomies in children, with lower complication.

Severe slipped upper femoral epiphysis; fish osteotomy versus pinning-in-situ: an eleven year perspective.

PURPOSE Slipped upper femoral epiphysis (SUFE) is not common with a reported incidence of 10 per 100 000. The management of SUFE is controversial and evolving, with advancing surgical skills and expertise. The infrequency of cases, the various classifications in use, the various surgical treatments, and lack of robust evidence for outcomes, has resulted in the lack of clear, evidence-based recommendations for treatment. Although mild slip can be treated with pinning-in-situ (PIS) with predictably good outcome, moderate and severe slips present a challenge for the treating surgeons. It is logical to reduce the slip to near anatomical position; however, this desire has always been tempered by concerns about the potentially devastating complications of osteonecrosis and Chondrolysis METHODS This is a single centre, retrospective study comparing (PIS) and Fish femoral neck osteotomy. Seventy four children presented with SUFE (90 hips). The mild and the moderate groups were treated with a single pining-in-situ (PIS). The severe group had either a surgical reduction by Fish femoral neck osteotomy or PIS. The study was approved by the regional and local ethic committee. Demographic data, clinical findings, radiographic features were collected. RESULTS Avascular necrosis of the femoral head (osteonecrosis) was the primary outcome. There were 11 cases of osteonecrosis (12.2%): 3/41(6.9%) in the stable group compared to 7/22 (31.8%) in the unstable group, statistically significant [P < 0.001]. In the severe slip group, the osteonecrosis rate was 33.3% in the PIS group and 26.6% in the Fish osteotomy (P = 0.539). This is not statistically significant, but the trend favours surgical reduction. CONCLUSIONS Then reduction of the deformity is valuable. The majority of cases that do not suffer osteonecrosis will benefit by reduction of the deformity; those who are destined to develop osteonecrosis are still better off with the femoral head in a reduced position. The unstable slip is more likely to be severe and more likely therefore to receive surgical reduction than a stable and less severe hip. The implication here is that the osteotomy might not be the cause of the osteonecrosis; it is the vascular damage due to the instability of the slip that is responsible.

Interventions for treating slipped upper femoral epiphysis (SUFE)

Although a rare condition, slipped upper femoral epiphysis (SUFE) is one of the most common types of paediatric and adolescent hip disorder. SUFE involves instability of the growth plate (often called the physis) at the junction between the head and neck of the thigh bone (femur) resulting in the head of the femur staying in the acetabulum and the neck slipping forward and outward. Although, the cause is poorly understood, several anatomical features and medical conditions have been implicated. The following features lead to an increase in the shear forces across the physis and can lead to SUFE (Herring 2008): 1. increased weight (> 80th centile); 2. femoral retroversion (> 10o); 3. increased physis height due to widened hypertrophic zone; 4. more vertical slope of the physis; and 5. trauma. Medical conditions associated with SUFE include endocrine disorders, renal failure osteodystrophy and previous radiation therapy (Loder 2000). About 30% of SUFE patients subsequently develop bilateral SUFE with the other hip slipping as well.

Legg-Calvé-Perthes disease in a child with osteopetrosis

Osteopetrosis is a rare inherited disorder of bone causing increased bone density. Legg-Calvé-Perthes disease (LCPD), by contrast, is a more common idiopathic condition leading to variable avascular necrosis of the immature femoral head. We present a case of a 5-year-old boy presenting with these co-morbidities. We have found only one previous reference suggesting these two conditions can coexist in the literature. We discuss the basic principles of management of this interesting case.