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Congenital dysplasia and dislocation of the hip in children and adults

The etiology of an insufficient femoral head-neck offset has not been identified yet. It was investigated whether a decreased head-neck offset might be correlated with an unusual orientation of the physeal capital scar. Therefore, the femoral head-neck offset and the extension of the physeal scar onto the femoral neck were measured with specific magnetic resonance imaging arthrography. The measurements were done in 15 patients with anterior femoroacetabular impingement attributable to a nonspherical head and were compared with 15 age- and gender-matched control subjects. Eight serial magnetic resonance imaging sections perpendicular to the femoral neck axis were used in each hip to measure the head-neck offset and the epiphyseal extension toward the femoral neck at 16 measurement points. In both groups there was an inverse correlation between the amount of head-neck offset and the relative extension of the capital physeal scar in the cranial hemisphere of the head. Within the anterosuperior head quadrant, there was statistically significant different decrease of the head-neck offset and increase of the lateral epiphyseal extension in the patients compared with the control subjects. These findings suggest a growth abnormality of the capital physis as one probable underlying cause for a nonspherical head.

Abnormal extension of the femoral head epiphysis as a cause of cam impingement.

Morphological and spatial abnormalities of the proximal femur and acetabulum have been recently recognized as causes of femoroacetabular impingement. During joint motion in hips with femoroacetabular impingement, abnormal bony contact occurs, and soft tissue structures (chondral and labral) often fail. Femoroacetabular impingement has been reported to be a contributor to early-onset joint degeneration. Ganz et al have described good midterm success with an open surgical dislocation approach to reconstruct normal joint clearance. The purpose of this report is to discuss relevant literature and describe an arthroscopic approach to treat femoroacetabular impingement. This approach has particular relevance in high-demand patients, particularly in athletes seeking to return to high-level sport.

Arthroscopic Management of Femoroacetabular Impingement Osteoplasty Technique and Literature Review

J Bone Joint Surg [Br] 2010;92-B:1144-7. Received 19 November 2009; Accepted after revision 15 March 2010 This study was designed to provide normal reference values for the centre-edge angle of Wiberg in the Chinese population by measuring 1494 radiographs according to the criteria of Tonnis. The mean angle was 23.1° (4.7° to 46.4°) in childhood (four to nine years), increasing to 28.9° (6° to 48°) in adolescence (10 to 18 years) and reaching 32.8° (13.7° to 58.8°) in adults. The angle was positively correlated with age, increasing by a mean of 0.78° annually before adulthood and by 0.070° annually in adults. A relative upward tendency after middle age might contribute to degenerative changes. No gender difference was discovered. The change in the angle with age was similar to that observed in other ethnic groups, showing moderate differences in the average of individual age groups, but the ethnic differences are not sufficient to explain the variation of incidence of developmental dysplasia of the hip in different races.

A population-based cross-sectional study

Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity. The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms. Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself. Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine. The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.

Etiology of idiopathic scoliosis: current trends in research.

This paper is a theoretical and experimental study of the processes involved in the development of curvature of the spine which we have come to call scoliosis. Reasons are advanced why the term scoliosis in its modern meaning may be misleading and an alternative title of Rotational Lordosis is suggested. It is admitted that it is more cumbersome, but I maintain that it is more accurately descriptive of the deformity under discussion and differentiates it from other curvatures which are produced differently but at present all of which come under the heading of scoliosis. I am conscious that many gaps still remain unfilled, especially the important but unexplained problem of the nature of the growth disturbance. If we could solve this we would be near to a solution of one of the most bizarre, mysterious and crippling deformities with which we are faced.

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Rotational lordosis: the development of the single curve

1. The condition of persistent foetal alignment is discussed both as an entity and in its relationship to the development of a normal hip, and also to the varying degrees of congenital dislocation of the hip. A possible connection with osteoarthritis is also mentioned. 2. The secondary deformities to which it may give rise are discussed, and the way in which both primary and secondary deformities may be corrected is described. 3. The importance of estimating rotation with the hip in full extension is emphasised. 4. The results in eight patients so treated are mentioned.

Persistent foetal alignment of the hip.

1. It is suggested that the obstruction causing delayed reduction of the congenitally dislocated hip is the infolded limbus. 2. An operation is described by which the infolding limbus may be easily and safely removed. 3. The early results of the operation are reported. 4. The evidence for the original assumption is discussed.

Open reduction in congenital dislocation of the hip

1. A brief description is given of normal epiphysial growth of the human femur. 2. Some ways in which abnormality of the growth plates may affect the shape and length of the human femur are described. 3. The influence of the blood supply on growth is discussed with particular reference to the etiology and treatment of congenital coxa vara.

Normal and abnormal growth at the upper end of the femur

Based on the constancy with which the limbus is inverted into the joint in a typical congenital dislocation of the hip, a hypothesis is presented which suggests that the sequence of events leading to established dislocation is: 1) lateral rotation aided and abetted by anteversion; 2) extension of the hips causing subluxation; 3) dislocation and inversion of the limbus; 4) secondary changes in the upper end of the femur, pelvis and acetabulum which will also develop if the deformity does not progress beyond a subluxation. A pen picture is drawn showing how anteversion is either moulded away during growth to produce a normal hip, or persists with or without dislocation. The fate of the persistently inverted limbus is discussed and a line of treatment based on these findings is briefly considered.

E. W. Somerville

Papers

Rotational lordosis: the development of the single curve

Persistent foetal alignment of the hip.

Open reduction in congenital dislocation of the hip

Normal and abnormal growth at the upper end of the femur

Development of congenital dislocation of the hip