Arthrodiastasis for stiff hips in young patients

Innovative Hip Distraction Approaches for Total Hip Arthroplasty in Crowe IV Developmental Dysplasia or Similar High-Riding Patients

BACKGROUND

Total hip arthroplasty (THA) for dislocated hips (Crowe IV dysplasia) presents unique challenges. Conventional approaches involve subtrochanteric osteotomies, but are complex with additional fixation and potentially lead to limb length discrepancies, nerve palsies, and other complications. An alternative strategy is a staged approach, where the femoral head (or remnant) is gradually lowered (distraction technique) to align with the true acetabulum over a period of time, followed by a second-stage anatomically acetabular-positioned THA. External fixation distraction and telescoping internal lengthening devices have been utilized to achieve preoperative alignment. We evaluated these techniques, including the types, time, and amount of distraction needed, as well as outcomes and complication rates.

METHODS

In this retrospective case series, 14 patients (9 women, 5 men), who had a mean age of 32 years (range, 16 to 67), underwent staged surgical interventions using hip distraction using external fixators or internal lengthening devices for hip dysplasia and other pathologies (Perthes disease, osteonecrosis) in preparation for a second-stage anatomically placed THA. The mean follow-up duration for external-fixation patients was 10 years (range, 6.5 to 13.4).

RESULTS

Staged treatment involved external fixators (n = 8) or internal lengthening devices (n = 6) with a device placement mean of 48 days (range, 42 to 71). The amount of distraction ranged from 6 to 12 cm. There were 2 patients who required uncomplicated revision of the internal lengthening devices, and another patient had a temporary peroneal nerve palsy. There was 1 patient who underwent an acetabular revision at 7 years.

CONCLUSIONS

We focused on a challenging patient cohort that emphasizes the efficacy of staged interventions in managing Crowe Type IV dysplasia and similar cases. Favorable outcomes were found with the immediate transition to THA after device removal that effectively addressed soft-tissue contractures and femoral migration. Despite the need for further validation via larger, prospective studies, this innovative approach may pave the way toward optimizing this strategy for these difficult hip pathologies.

Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases

PURPOSE

Idiopathic chondrolysis of the hip is characterized by the loss of the articular cartilage of the hip joint with spectrum ranging from full recovery to fibrous ankylosis. Study assessed outcomes following intra-articular steroid injections, joint manipulation and traction immobilization.

METHODS

Retrospective (2012-2021) review of 41 cases treated for idiopathic chondrolysis of hip, assessed pre-operatively and post-operatively (minimum 2-year follow-up) using Children's Hospital Oakland Hip Evaluation Score (CHOHES), visual analogue scale (VAS) and range of motion measurements.

RESULTS

Twenty-five patients (62%) achieved painless mobility, 6 (14%) had hip stiffness without pain and 10 (24%) had painful and stiff hips at final follow-up. They had a mean age of 12.49 ± 2.4 years and a mean follow-up duration of 33.15 ± 13.1 months. Range of motion improved significantly (p < 0.05). VAS improved to 3.93 ± 1.3 from 7.8 ± 0.7. CHOHES improved from 29.12 ± 9.9 to 56.37 ± 17.6.

CONCLUSION

Intra-articular steroid injection, manipulation and traction immobilization may effectively treat idiopathic chondrolysis of the hip by enhancing patient function and reducing the need for further surgical intervention.

MRI Features and Treatment for Idiopathic Chondrolysis of the Hip (ICH) in Children: Outcomes of a Systematic Review

BACKGROUND

The purpose of this paper was to review the MRI features and treatment for idiopathic chondrolysis of the hip (ICH) in patients aged 18 years or less.

METHODS

We included studies published in English up to August 2021. We accessed major electronic bibliographic databases on ICH that described MRI features, treatment, or both. We used the Joanna Briggs Institute (JBI) Critical appraisal checklist for case reports for Risk of bias assessment.

RESULTS

We pooled 136 hips (125 participants) from 35 studies with 11.6 ± 3.4 years mean age. We had 46, 8, and 106 hips to assess ICH's MRI, pharmacological, and operative interventions. Geometric marrow edema (GME) (P < 0.01), diffuse marrow edema (DME) (P < 0.05), diffuse cartilage loss (DCL) (P < 0.05), and joint effusion (P < 0.05), were significantly associated with time in first MRI reviews. GME (P < 0.01) and focal cartilage loss (FCL) (P < 0.01) decreased significantly between two MRI reviews at median time of 1.75 (IQR 0.93-4.25) and 12.5 (IQR 3.75-19.5) months. Diffuse cartilage loss (P < 0.01) and degenerative changes (P < 0.01) increased significantly between the two MRI reviews. Etanercept, Methotrexate, and Botulinum Neurotoxin A drugs were used by 3, 3, and 1 report to treat ICH. Capsulectomies, total hip arthroplasty, arthrodiastasis, arthrodesis, arthroscopy operations treated 45, 18, 5, 5, and 2 hips.

DISCUSSION

GME may be the most specific and early MRI feature in diagnosing ICH. GME and DME show an inverse relationship over time. So, it is with FCL and DCL. Despite reports on the efficacy of biologics, immunomodulators, and operations, early and late ICH management remains controversial due to poor quality studies.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00684-7.

Arthrodiastasis in the management of Perthes disease: a systematic review

This systematic review explores the relevant literature to assess the efficacy of the use of arthrodiastasis in the management of Perthes disease. Until this moment, arthrodiastasis is not well established for its use in Perthes disease as opposed to other containment procedures. Furthermore, there are no clear indications for its use in this disease. Twelve articles were matched to the inclusion criteria and all articles were reviewed and radiological and clinical data were collected and compiled. As regards the hip flexion range of motion, the average preoperative flexion range of motion was 55.32°, while the postoperative was 90°. The average preoperative hip abduction range of motion was 12.28° and postoperative was 35.28°. Mean preoperative hip internal rotation range of motion was 8.69° and postoperatively was 24.93°. Mean preoperative external rotation range of motion was 21.73°, while the postoperative range was 33.71°. Final Stulberg classification was ascertained showing most patients ending with stages two and three. Complications were also assessed with most of which being superficial pin tract infections. The use of arthrodiastasis is a valid treatment option for Perthes disease; however, more articles need to be produced showing comparative data of arthrodiastasis versus other containment procedures. Level of evidence - level 1: systematic review.

Avascular necrosis post unstable slipped capital femoral epiphysis: a treatment algorithm with staged hinged hip distraction: mid-term results

BACKGROUND

Management of avascular necrosis (AVN) of the femoral head in slipped capital femoral epiphysis (SCFE) is difficult. We proposed to ascertain if staged hip distraction could prevent collapse and recover the femoral head.

METHODS

A retrospective review of the hip database retrieved 16 children with unstable SCFE and AVN. All underwent capital realignment by surgical dislocation followed by 2nd-stage hinged hip distraction. Patient demographics and radiographic parameters of deformity, AVN and arthritis were collected. The patients scored their hip function both before and after intervention and at follow-up using the modified Harris Hip Score and Nonarthritic Hip score.

RESULTS

7 boys and 9 girls formed the study group (n = 16). The average age at surgery was 12.7 years (9-16 years). 8 rights hips and 8 left hips were involved. The average follow-up was 45 months (33-66 months). Group A (n = 7) had hip distraction only if the follow-up radiographs showed AVN changes and collapse. Based on the observations in Group A, the protocol was changed for Group B. Group B (n = 9) underwent hip distraction at 6 weeks of capital realignment for avascularity of the femoral head. In Group A, all patients had further collapse and advanced arthritis at follow-up. In Group B all patients had hip joint space restored and good hip function without pain at follow-up.

CONCLUSIONS

Pre-emptive application of hip distractor for those children with proven lack of blood flow to the femoral head is a potential option to stall the progression of AVN and to help recover useful hip function.

Arthrodiastasis followed by open reduction associated with pelvic and femoral osteotomies for the treatment of high inveterate congenital hip dislocation

Our purpose is to analyze results, following the use of arthrodiastasis for the treatment of inveterate congenital hip dislocations. The study included eight patients. The mean age was 6 years. Three (37.5%) were male patients, and five (62.5%) were female patients. The patients were followed-up for 46 months. Teratologic, neurologic, rheumatic, and syndrome-associated dislocations were excluded. The following scores were used: Harris Hip Score, displacement of femoral head with respect to Hilgenreiner's line, Acetabular index, Wiberg angle, Reimer's extrusion index, and leg length discrepancy. Statistical analysis was carried out using Wilcoxon's test and Fisher's test. P values less than 0.05 were considered significant. We performed surgical technique in two stages. First, arthrogram and an adductor and a psoas tenotomy through an inguinal approach were performed; two 3.2 mm hydroxiapatite-coated screws were positioned in the supra-acetabular region and femoral shaft, joined using monolateral LRS fixator with a proximal locking T clamp. Distraction began the day after the procedure at a rate of 1 mm/day until restoration of Shenton's arc. Second, we performedan arthrogram intraoperatively, which included the anterior approach to the hip with open reduction, capsulorrhaphy and Salter osteotomy, and proximal femoral varus derotational osteotomy. Harris Hip Score improved significantly. Acetabular index and Wiberg angle decreased significantly in an average time of 14 months. Reimer's index showed no difference with respect to a healthy hip. Final leg length discrepancy was 14.9 mm. The complications that occurred were superficial pin tract infections: 25% of patients. We believe that arthrodiastasis, compounded by monolateral external fixation and an adductor and psoas tenotomy, combined with open reduction and pelvic and femoral osteotomies, is an optional tool to resolve the treatment approach to high inveterate congenital dislocation of the hip.

Initial experience of use of an articulated external fixator in treating Legg-Calvé-Perthes disease by means of arthrodiastasis during the active phase of the disease

Objective

To present the preliminary results from treating patients with Legg-Calvé-Perthes Disease (LCPD) by means of hip arthrodiastasis using a monolateral external fixator applied to the hip and to succinctly describe the surgical technique used, in a prospective study.

Methods

Prospective study on 18 patients with LCPD who underwent surgical treatment by means of the hip arthrodiastasis technique using a monolateral external fixator. There were 13 male and five female patients of mean age 8.5 years, ranging from five to 13 years. All the patients presented unilateral hip impairment: nine on the right side and nine on the left. The results were evaluated at maturity using clinical and radiological criteria.

Results

All the patients evolved with improvement of joint mobility, and pain relief was achieved in 88.9% of them. Reossification of the femoral epiphysis occurred within the first three months of the treatment. The hips operated at the necrosis stage of the disease did not passed through the fragmentation stage, thus shortening the evolution of the disease. The results were 77.8% satisfactory and 22.2% unsatisfactory.

Conclusion

Hip arthrodiastasis with a monolateral external fixator during the active phase of LCPD improved the degree of joint mobility. Use of the arthrodiastasis technique at the necrosis stage or at the fragmentation stage (active phase of the disease) presented satisfactory results from treatment of LCPD.

Hip arthrodiastasis in Legg-Calvé-Perthes disease

INTRODUCTION AND OBJECTIVE

Arthrodiastasis consists of the mobilisation of the hip while distracted by a hinged distractor. The aim of our study is to show the results of the treatment of late-onset Perthes disease with this technique in our institution.

MATERIAL AND METHODS

Ambispective review of all the cases that underwent this surgery in our Department of Paediatric Orthopaedics between 2010 and 2014 with the following inclusion criteria: patients over 8 years old, with minimal deformity, and poor prognosis. Mobility, pain, Trendelenburg sign, radiographic sphericity, and complications were assessed.

RESULTS

A total of 13 patients (9 male, 4 female) were included. The mean age was 11.93 years. Radiographic risk signs were present in 7 cases. The mean decrease in pain measured with a visual analogue scale (VAS) after the surgery was 3.83 points (P<.05). Cephalic sphericity was maintained in 11 cases during follow up (1.75 years). Complications were observed complications in 84.6% of the patients, with infection of the screw tract being the most frequent. All of them were easy to treat.

CONCLUSIONS

Arthrodiastasis is a minimally invasive technique, useful in the treatment of late onset Perthes disease. It improves clinical results and maintains cephalic shape when applied in early stages. However, it is not free of complications, which can involve as many as 8 out of 10 patients treated with the technique.

Arthrodiastasis of the lateral column with medial fusion: a retrospective examination of medial double and Lapidus arthrodeses

Arthrodiastasis of the calcaneocuboid joint after medial double arthrodesis has been described, but the extent remains unreported. We present our comparative findings after medial double and Lapidus fusion on the effects of the calcaneocuboid joint. Adults undergoing medial column fusion with internal fixation and a minimal clinical and radiographic follow-up period of 3 months were included. Subjects were excluded for Charcot deformity, previous arthrodesis surgery, and history of calcaneocuboid joint trauma or surgery. Although 52 patients were identified, 32 (mean age 56.69 ± 12.56 years; 11 males) met the study criteria (15 medial double and 17 Lapidus procedures). The height of the calcaneocuboid joint on the lateral radiograph and width of the calcaneocuboid joint on the anteroposterior radiograph were measured postoperatively and fixed, given the overlap often noted preoperatively in flatfoot deformities. The joint depth was measured at 3 points and averaged both preoperatively and postoperatively on lateral and anteroposterior radiographs. The volume of the calcaneocuboid joint (mm(3)) was the primary endpoint. Medial column fusion elicited a statistically significant mean increase of 32% in calcaneocuboid joint diastasis (p < .001). The percent change in diastasis volume was statistically different between the medial double (61.90% ± 40.59%) and the Lapidus (5.71% ± 14.84%, p < .001) fusion procedures. These results confirmed our hypothesis that arthrodesis of the more proximal medial column joints would produce greater lateral column arthrodiastasis. Adding to the published data, medial double arthrodesis increased the volume of the calcaneocuboid joint by 62%.

Management of late onset perthes: evaluation of distraction by external fixator-5-year follow-up

Background. Hip distraction in Perthes' disease unloads the joint, which negates the harmful effect of the stresses on the articular surfaces, which may promote the sound healing of the area of necrosis. We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes' disease. Methods and Materials. Twelve children with age more than 8 years with Perthes' disease of less than one year were treated with hip distraction by a hinged monolateral external fixator. Observation and Results. Mean duration of distraction was 13.9 days. These children were evaluated by clinicoradiological parameters for a mean period of 32.4 months. There was a significant improvement in the range of movements and mean epiphyseal index, but the change in the percentage of uncovered head femur was insignificant. There was significant improvement in Harris Hip score. Conclusions. Hip distraction by hinged monolateral external fixator seems to be a valid treatment option in cases with Perthes' disease in the selected group of patients, where poor results are expected from conventional treatment.

Articulated distraction

Articular hip distraction can be applied either by using a monolateral articulated distractor or a circular fixator. The fixator should be aligned such that its axis is aligned with the transverse axis of the hip joint. Following distraction, the range of motion is maintained with regular physiotherapy. It is a useful salvage procedure in older children with hip stiffness, when other methods of containment are not applicable.

Principles of treatment in late stages of Perthes disease

It is of paramount importance to distinguish hips that may or may not be suitable for containment in the transitional stage (fragmentation to early reossification stage), because long-term clinical and radiological outcomes may be influenced by the choice of treatment. This article summarizes the definition of hinge abduction, pathoanatomy of hinge segment, assessment of hinge abduction, determination of reducible and irreducible hinge abduction, and treatment strategies for containable and uncontainable hips in the transitional stage.

Articulated hip distraction: a treatment option for femoral head avascular necrosis in adolescence

PURPOSE

To describe the clinical outcomes of adolescent patients treated with articulated hip distraction (AHD) for avascular necrosis (AVN) of the femoral head. Outcomes were examined in order to better understand the usefulness of and indications for performing hip arthrodiastasis in this patient population.

METHODS

: Retrospective review was performed on 31 hips with femoral head AVN treated with AHD. Mean age at treatment was 14.7 years. Preoperative and follow-up pain and physical limitations, as well as follow-up range of motion, were assessed.

RESULTS

Follow-up assessment was obtained at 18.7 years. Time of follow-up was 57.4 months after distraction. The etiologies of AVN were the following: 10 slipped capital femoral epiphysis (SCFE), 5 idiopathic AVN, 3 with hip dysplasia, and 12 others. There was a significant difference in pain preoperatively and postoperatively (P<0.001), most patients (78.6%, n=22) had less pain after the treatment. Multivariate regression model demonstrated that patients with SCFE were likely to have less improvement in pain than patients with other etiologies (odds ratio, 22.7; P=0.035). All patients had activity limitations before the treatment; at the postoperative assessment, half of our patients (n=14) reported no limitations in their regular daily activities. Eight patients had minor complications with the fixator. At follow-up, 5 patients (17.2%) converted to total hip replacement or arthrodesis. Survival rates were 90.6% at 5 years, 77.7% at 10 years, and 38.8% at 15 years.

CONCLUSIONS

Hip distraction arthroplasty in adolescent patients with symptomatic AVN reduces the amount of pain and limitation in daily activities at a follow-up of 4.7 years. Arthrodiastasis is not the final solution to AVN. With longer follow-up, patient's symptoms increases. Patients with AVN secondary to SCFE do not seem to benefit from this procedure as much as other patients do. Articulated hip distraction is a safe and appropriate procedure to perform in these patients. The procedure might be able to delay definitive surgical procedures at an early age, restoring function and improving the patient's quality of life.

Peri-acetabular external fixation for hip disease: an anatomical study

Hip distraction using cross joint articulated external fixation has been used by a number of orthopaedic centres for the treatment of osteoarthritis, chrondrolysis, and osteonecrosis, as an alternative to hip arthroplasty or arthrodesis in the adolescent and young adults . The hip, however, is problematic with respect to external fixation, as it lies deep, surrounded by powerful muscles and in intimate contact with major neurovascular structures and intrapelvic organs. The numbers of patients treated by this technique to date remains small and the technical detail and potential complications, with respect to the application of the external fixation, unclear. In this study we used anatomical information from CT scans combined with computer modelling of the hip and pelvis to identify safe screw positions in the periacetabular region. The surgical insertion of the pins was then performed on five cadavers and anatomical dissections undertaken to confirm the structures at risk. This study indicated that whilst there are a number of anatomic constraints, it is still possible to insert three pins with good divergence into the limited bony corridor of the peri-acetabular region recognising that the more posterior of the laterally inserted pins poses a potential risk to the sciatic nerve if not inclined away from the sciatic notch.

Treatment of severe late-onset Perthes' disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity

PURPOSE

Late-onset Perthes' disease is diagnosed after 9 years of age. Conservative treatment and conventional surgical techniques have limited ability to reduce the pressure in the joint or change the shape of the femoral head. We used a combination of soft tissue release and joint distraction with a hinged mono-lateral external fixator for these patients. Ten of our patients reached skeletal maturity and were evaluated.

METHODS

Clinical assessment included: Harris hip score, hip range-of-motion (ROM), limb length discrepancy, and the Oxford hip questionnaire for pain and function. Radiographic assessment included: Sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and, at last follow-up, the epiphyseal quotient (of Sjovall) and the Stulberg classification.

RESULTS

Our study included eight boys and two girls (mean age at surgery 12.3 years, range 9.4-15.1, mean age at last follow-up 18.1 years, range 15.2-22.8). The mean follow-up was 5.7 years (range 4.3-7.8). The mean Harris hip score was 86.3/100 (range 48.5-96); one patient had <85 points. The hip ROM was slightly limited in most patients, and seven patients had limb shortening between 1-4 cm. The mean Oxford hip questionnaire score was 17.4/60 (range 12-31). The mean Sharp transverse acetabular inclination of the affected side was 42 degrees (range 36-54) compared to 39 degrees for the unaffected side (P = 0.045). The mean uncoverage percentage was 37% (range 27-47) compared to 20% for the unaffected side (P = 0.017). The mean epiphyseal index was 0.71 (range 0.31-0.92) before surgery, 0.79 (range 0.50-0.93) at frame removal (P = 0.012), and 0.72 (range 0.51-0.89) at last follow-up (P = 0.646). The epiphyseal quotient for the eight unilateral cases was 0.72 (range 0.49-0.91), and the Stulberg classification was type III for three cases and type IV for seven.

CONCLUSION

Patient satisfaction for function and pain following the combined procedure was good. Radiographic parameters did not change significantly. This should be regarded as a salvage procedure.

[Bed rest and skin traction for Perthes' disease: review of the literature]

Long-term bed rest with skin traction, which isolates children with Perthes' disease from their social and educative environment, could be considered as incompatible with the ethics of modern therapeutics. Adaptation for home care has been proposed, but remains burdensome. We searched the literature in order to ascertain the real advantages and disadvantages of bed rest with skin traction and to evaluate the statistical value of published results. Considering that poor outcome is the natural course of the disease in 10-20% of patients, and that the number of patients in this group is further divided according to age and treatment, the number of patients in each treatment arm is rarely sufficient to validate any given treatment. For hips with limited abduction, traction does not appear to be warranted. Conversely, traction could be useful if the aim is to modify the natural course of the disease in precise situations, for example for Herring group B and or B/C patients with bone age above 6 years with a stiff hip. In this case, skin traction should not last more than two weeks and, to be considered useful, should achieve 30 degrees abduction documented on the ap view.

Hinged distraction of the adolescent arthritic hip

From 1996 to 2000, 11 adolescents with hip joint arthritis secondary to osteonecrosis or idiopathic chondrolysis were treated with articulated hinged distraction arthroplasty. Indications for surgery were severe pain and limited ambulation. Charts and radiographs were reviewed. Clinical status was assessed preoperatively and at latest follow-up (mean 4.8 years after surgery) using criteria of pain, range of motion, and ambulation level. Ten patients showed improved clinical status, with seven having an excellent outcome and three a good outcome. One patient failed distraction. Mean joint space was 2.6 mm before surgery and 4.8 mm at latest follow-up. Average duration of fixator use was 4.4 months. Four patients (36.4%) had complications. Articulated hip distraction was effective in eliminating pain, improving function, and preventing progressive degenerative changes in young patients' hips. It should be considered a salvage procedure for arthritic hips and an alternative to arthrodesis in this difficult-to-treat group of patients.

Treatment of severe late onset Perthes' disease with soft tissue release and articulated hip distraction: early results

Sixteen children with late onset Perthes' disease were surgically treated at an average age of 12 years 1 month (9 years 4 months to 15 years) by soft tissue release and articulated hip distraction. Two patients had additional diagnosis of Down syndrome and one suffered from geleophysic epiphyseal dysplasia. Fifteen hips were graded Catterall IV and Herring C and one hip was graded Catterall III Herring B. On preoperative arthrograms, 14 patients had a saddle-shape subluxating femoral head with hinge abduction. The distraction discontinued when Shenton line was corrected. The fixation lasted 4-5 months. At a mean follow-up of 2 years 7 months (1-5 years), an improvement of hip range of motion was found in all patients. Hip joint arthrograms upon removal of the fixator showed disappearance of the saddle-shape femoral head in 10 of the 14 patients with this deformation. Shenton line breakage improved from 7.6 mm to 2.1 mm at last follow-up. The epiphyseal index improved by 14%. The average pain score on an analog scale dropped from a preoperative 7.0 to 1.6 at last follow-up (filled in by patients or parents in case of Down syndrome). Separate analysis of data from the group having only Perthes disease (13 children) showed better results. These preliminary data suggest that soft tissue release combined with unloading of the femoral head and restoration of joint space can improve the function and epiphyseal height.

Avascular necrosis of the femoral head in childhood: the results of treatment with articulated distraction method

The treatment of avascular necrosis of the femoral head in children is still being debated. We performed articulated distraction in 11 children with avascular necrosis of the femoral head between March 1994 and February 1997. The reasons for avascular necrosis were: Perthes disease in eight patients, fracture of the femoral neck in two, and complication arising because of treatment of developmental hip dysplasia in one. Mean age was 7.9 years. Fixator duration time was 3.5 months and mean follow-up was 32 months. At follow-up, the femoral head was spherical and congruent in four patients, aspherical and congruent in five, and aspherical and incongruent in two according to Stulberg's criteria. The aim of the articulated distraction method is to neutralize muscle and weight-bearing forces, to prevent stress fractures of subchondral immature bone, to encourage synovial circulation, and to promote creeping substitution.