See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/15023117

Cure of the limp in children with congenital dislocation of the hip and ischaemic
necrosis. Fifteen cases treated by trochanteric transfer and contralateral
epiphysiodesis

Article  in  The Bone & Joint Journal · June 1994

DOI: 10.1302/0301-620X.76B3.8175855 · Source: PubMed

CITATIONS READS

8 46

3 authors, including:

Charles Howard

59 PUBLICATIONS   1,397 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Clubfoot View project

All content following this page was uploaded by Charles Howard on 04 April 2014.

The user has requested enhancement of the downloaded file.

CURE OF THE LIMP IN CHILDREN WITH CONGENITAL
DISLOCATION OF THE HIP AND ISCHAEMIC NECROSIS
FIFTEEN CASES TREATED BY TROCHANTERIC TRANSFER AND CONTRALATERAL
EPIPHYSIODESIS

SHLOMO PORAT, GORDON C. ROBIN, CHARLES B. HOWARD

From Hadassah University Hospital and the Alyn Children ‘s Hospital, Jerusalem, Israel

Fifteen patients who limped and had early fatigue on weakness (Compere, Garrison and Fahey 1940; Bucholz
walking caused by ischaemic necrosis after treatment and Ogden 1978; Kalamchi and MacEwen 1980), and
for congenital dislocation of the hip had distal and severe shortening may give a leg-length discrepancy of
lateral transfer of the greater trochanter. Nine of them up to 4 cm. This combination may lead to a Trendelenburg
in whom the predicted leg-length discrepancy was limp and fatigue after walking even short distances.
more than 3 cm also had epiphysiodesis of the It seems logical to try to improve the abductor power
contralateral leg. At skeletal maturity the limp was and equalise limb lengths. We report a trial of the
eliminated and walking distance was significantly combination of trochanteric advancement and contra-
improved in them all. In those who had epiphysiodesis lateral epiphysiodesis.
the average leg-length discrepancy was 0.7 cm at
maturity. Two of those not treated by epiphysiodesis
PATIENTS AND METhODS
used a heel raise of 1.5 cm. In seven cases the two
operations were performed simultaneously without We treated 15 girls at a mean age of 12.5 years (1 1 to 17).
serious complications. This procedure is recommended They had all developed ischaemic necrosis of the femoral
at about the age of 12 years. head after treatment for CDH. Thirteen had unilateral
CDH (6 left, 7 right), and two had bilateral CDH but
J Bone Joint Surg [Br] 1994; 76-B:463--7.
ischaemic necrosis on only one side.
Received 9 September 1993; Accepted 5 November1993
The mean age at diagnosis of CDH was three months
(1 to 24). Primary treatment had been by Frejka pillow in
nine cases, an abduction frame in five and open reduction
and Salter osteotomy in one. On the radiographic
The incidence of ischaemic necrosis (AVN) after treat- classification of Kalamchi and MacEwen (1980), seven
ment for congenital dislocation of the hip (CDH) has been patients were in group II, four in group III, three in
reduced by improvements such as the abandonment of group IV and one could not be classified. The average
forced reduction and the use of prereduction traction and age at which a limp had first been noticed was 9.2 years
femoral shortening, but it is still a significant complication. (6to 12).
AVN causes three major deformities. Premature partial or Examination. We assessed gait pattern, range of hip
complete growth arrest at the proximal femoral physis movements and the presence of an immediate or a delayed
may deform the femoral head, relative overgrowth of the Trendelenburg sign. Hip abductor efficiency was measu-
greater trochanter may produce functional coxa vara and red with the patient lying on the unaffected side. The
a short femoral neck may cause leg-length discrepancy affected leg was elevated passively to 30#{176}
abduction and
(Fig. 1). Relative overgrowth of the greater trochanter and the patient was asked to maintain this position for as long
shortening of the femoral neck both produce abductor as possible. Gluteal weakness was diagnosed if the
position could not be maintained for at least one minute.
Maximal abduction power was measured by a load meter
placed just above the ankle (Fig. 2). These tests were
repeated at each review, and a summary of the results is
S. Porat, MD, MCh Orth, Chief of Paediatric Orthopaedic Unit
given in Table I.
G. C. Robin, FRCS, Professor of Orthopaedic Surgery Radiographs. The articulotrochanteric distance (ATh)
C. B. Howard, FRCS, Consultant Orthopaedic Surgeon
Orthopaedic Department, Hadassah University Hospital, Kiryat Hadassah,
(Edgren 1965), greater trochanteric overgrowth (GTOG)
P0 Box 12000, Jerusalem 91 120, Israel. and degree of trochanteric lateralisation (LAT) were
Correspondence should be sent to Dr S. Porat. measured from anteroposterior radiographs (see Fig. la).
©1994 British Editorial Society of Bone and Joint Surgery The centre-edge (CE) angle of Wiberg (Wiberg 1939)
0301-620X/94/3782 $2.00 was recorded from preoperative and final radiographs.

VOL 76-B, No. 3, MAY 1994 463

464 S. PORAT, G. C. ROBIN, C. B. HOWARD

Leg-length discrepancy (LLD) was measured in the early the transferred abductors; on the tenth day non-weight-
cases by scanograms, but later we used CT. bearing walking was allowed, progressing several days
Indications. Transfer of the greater trochanter was later to partial weight-bearing. For patients who had an
considered to be indicated for fatigue after walking half a epiphysiodesis, crutch walking was delayed until three to
kilometre and marked abductor weakness as determined four weeks after the operation.
by the Trendelenburg test, the ‘minute’ test, and a Follow-up. All patients were followed until skeletal
maximal abductor power of less than 75% of the normal maturity, an average of 5 years (2.8 to 7). The average
side. A secondary, radiological indication was a progres- age at final review was 18.2 years (Table I).
sive decrease in ATD. All 15 patients met these criteria.
Epiphysiodesis of the contralateral distal femur and, if
RESULTS
necessary, the proximal tibia was indicated if the pre-
dicted leg-length discrepancy was greater than 3 cm. The Before operation, serial radiographs of the affected hip
timing of epiphysiodesis was determined from the showed a progressive decrease in ATD (Fig. 3a, left) and
‘straight-line graph’ of Moseley (1977) or, where there at about the age of ten years this became negative. On the
were insufficient data, from Green and Anderson’s resid- normal side the ATD remained almost constant at about
ual growth curves (Anderson, Green and Messner 1963). 2 cm from five years to skeletal maturity. This confirms
Nine patients required epiphysiodesis; in seven this the findings of Langenskiold and Salenius (1967).
was performed at the same time as the trochanteric Postoperatively, the trochanter had been transferred
transfer. At the time of operation (12 ± 1.2sD years) the distally by a mean of 3 ± 1 cm and laterally by 1 ± 0.8 cm.
average LLD was 3.0 cm (2.7 to 3.3) with a predicted This produced an ATh and lateralisation similar to that

Figure la - An anteroposterior radiograph

of a normal hip showing the articulotro-
chanteric distance (ATh), and the mea-
surement of greater trochanteric
overgrowth (GTOG) and lateralisation
(LAT). Figures lb,c - Two hips with the
late deformities caused by AVN. They
show relative overgrowth of the greater
trochanter, deformity of the femoral head,
a short broad femoral neck and some
dysplasia of the acetabulum.

Fig. 1

mean discrepancy of 4 cm at skeletal maturity. The six

patients not treated by epiphysiodesis had a mean
predicted discrepancy of 2.5 cm. They had transfer of the
greater trochanter at a mean age of 14 years 4 months.
Techniques. Trochanteric transfer was as described by
various authors (Jani 1969; Cohen 1971; Wagner 1978;
Kelikian et al 1983). In the first seven cases of
epiphysiodesis we used the Phemister technique and in
the last two a percutaneous method (Bowen and Johnson
1984; Canale, Russel and Holcomb 1986; Porat, Peyser
and Robin 1992). Eight patients had epiphysiodeses of
both femur and tibia and one of the distal femur only.
Postoperatively, abduction was maintained with a
Charnley pillow. After three or four days the limb was
mobilised with slings and springs, but the leg was not Fig. 2

allowed to reach the midline. Between the seventh and

Measurement of abductor power using a load meter which reads up to 8 lb
tenth days, resistance exercises were started to strengthen (3.6 kg).

ThE JOURNAL OF BONE AND JOINT SURGERY

 CURE OF THE LIMP IN CHILDREN WITh CONGENITAL DISLOCATION OF ThE HIP AND ISCHAEMIC NECROSIS 465

Table I. Details of 15 patients treated by trochanteric transfer

Age (yr/mth) at Abduct or force (Ib) ATDt Trochantenc mov ement (cm)
trochantenc
Case transfer Follow-up AVN class Preop Postop Preop Postop Distal (GTOG)t Lateral (LAT)t

1 12 19 II 3 7 -0.9 1.9 2.8 2.5

2 11.7 18 II 2 8 -1.2 2.2 3.4 1

3 15.2 21 IV 8 -0.2 4 4.2 1.1

4 12 18.6 III 2 8 0.2 3.8 3.6 0.2

5 13.2 18 III 4 8 -0.7 3.2 3.9 2

6 12.2 17 II 5 8 0 3.5 3.5 1.4

7 12 18 III o -0.5 2.3 2.8 1.3

8 12 18 III 6 1.7 4.7 3 2.5

9 12.8 17 II 3 6.5 0.4 1.7 1.3 1

10 15 17.1 II 6 7 1.2 2.4 1.2 1

11 19 22 IV 6 8 -0.7 1.8 2.5 0.5

12 13.1 18.9 III 3 8 -0.9 1.2 2.1 1

13 1 1.5 17.5 Unclassified 3 8 -0.6 1.8 2.4 0.5

14 12.6 16.6 IV 3 8 -0.6 1.5 2.1 1

15 12.3 16.6 II 5 6 -1 1.2 2.2 0

a Kalamchi and MacEwen (1980)

t see text and Figure 2

Radiographs of case 9 before trochanteric

transfer (a) and seven years later (b). The
acetabulum was dysplastic before operation,
but there has been no subluxation or reduction
of CE angle.

Fig. 3a Fig. 3b

of the normal hip. The mean difference between the mean the normal side (p = 0.001, Student’s t-test for paired
ATDs of affected and normal hips before operation was observations). At final review the mean abductor power
2.6 cm (SEM 0.200; p = 0.0001). After operation this was was virtually equal in affected and normal hips, at 7.5 lb
reduced to 0.06 cm (SEM 0.278; p = 0.821; Figs 3 and 4). (3.4 kg) and 7.2 lb (3.3 kg) respectively (Table I).
Before operation, there
of the abduc- was limitation In the nine patients who had epiphysiodeses, the
tion/adduction range ± 6#{176}
(42#{176} on the normal
side, 30#{176}
± average leg-length discrepancy at maturity was 0.7 cm (0
2#{176}
on the affected side), and this range was not changed to 2). In those whose predicted discrepancy was less than
by surgery. All 15 patients lost their limp; the Trendelen- 3 cm, who had no epiphysiodesis, the difference at
burg test became negative within four months of the maturity ranged from 1.0 to 2.2 cm. Two ofthese six girls
operation. All recovered the ability to walk long distances required heel raises of 1.5 cm for limp-free walking.
without fatigue and all were satisfied with the result. The average preoperative CE angles were 36#{176}
in the
Before operation mean maximal abductor power was normal hips and 19#{176}
in the affected hips (Table II). Only
3.75 lb (1.7 kg) on the affected side and 5.8 lb (2.6 kg) on one patient showed a significant decrease in this angle

VOL. 76-B, No. 3. MAY 1994

466 S. PORAT, G. C. ROBIN, C. B. HOWARD

Table II. Centre-edge angles (Wiberg) in 15 patients treated by trochanteric

3.0 transfer
Normal hip
0
U) Normal hip Dislocated hip
N ‘0
+1 2.0 Before After Before After
Case transfer transfer Difference transfer transfer Difference
C-)
C
1 30 30 0 24 30 6
0 1.0 Dislocated hip
2 33 34 1 10 11 1

3
0

-1.0
VN 4

5
47

37
38

32
-9

-5
10

12
11

18 6
1

I I I I I I I I I _1 6 50 42 -8 ‘U) 40 0
5 6 7 8 9 10 11 12 13 1 15 16 17
Years 7 30 27 -3 10 12 2

8 46 40 -6 23 23 0

9 39 23 24 1

10 35 40 5 27 27 0

11 35 20 23 3

0 12 30 32 2 14 16 2
(I)
N
+1 13 32 30 -2 29 25 -4

C-) 14 22 24 2 -4 -17 -13

C

0 15 38 26 -12 28 26 -2
I-.
C Mean 36 33 -3 19 19 0

Videman 1970; Bucholz and Ogden 1978; Fernbach et al

1985; O’Brien, Miles and Griffin 1986).
In some cases there may be 3 cm loss of ATh by the
age of 1 1 to 12 years, with a predicted leg-length
discrepancy of up to 4 cm.
Fig. 4b The resultant severe limp and early fatigue on
Figure 4a - Change in mean ATh during follow-up, with shaded areas
walking are serious functional disturbances for young and
representing two standard deviations. Figure 4b - Postoperative results in previously active children. Symptoms appeared to start
the affected hips superimposed to show that trochanteric transfer has
when the ATh became 0.5 cm or less, confirming other
eliminated the difference.
reports (Langenskiold and Salenius 1967; Gage and Cary
1980; Kalamchi and MacEwen 1980; Thomas, Gage and
during follow-up, from -4#{176} to -17#{176}. She required a Chiari Ogden 1982; Iwersen, Kalen and Eberle 1989). The limp
osteotomy at the age of 15.5 years. is caused by abductor weakness alone or in combination
Complications. There were no infections, but one patient with leg-length discrepancy.
had a reaction to Dexon intracuticular sutures which Our study has shown that restoration of the normal
resolved quickly. Two patients developed knee effusions relationship between the greater trochanter and its fulcrum
after percutaneous epiphysiodesis, but both settled within produces a return of muscle strength, as shown by
two months with no specific treatment. One patient had a objective measurement of abductor power. To our
tourniquet palsy with complete foot drop, but recovered knowledge this is the first study to assess objectively the
full function within two years. One girl developed a abductor function using a load meter.
painful bursa over the screws which resolved when they The importance of early dynamic rehabilitation was
were removed. In another patient, a screw broke during stressed by Kelikian et al (1983); we agree with this.
its removal; the inner fragment was left in situ. Lloyd-Roberts, Wetherill and Fraser (1985) considered
that immobilisation in abduction required a plaster spica
for eight weeks, but they used only one screw or a wire to
DISCUSSION
reattach the trochanter. We found that the use of at least
Ischaemic necrosis during treatment is a serious compli- two AO cancellous screws provided enough fixation to
cation of CDH, which may produce deformity and allow immediate mobilisation, although at first with some
symptoms (Salter, Kostuik and Dallas 1969; Salenius and restriction on adduction.

ThE JOURNAL OF BONE AND JOINT SURGERY

 CURE OF ThE LIMP IN CHILDREN WITH CONGENITAL DISLOCATION OF ThE HIP AND ISCHAEMIC NECROSIS 467

Trochanteric advancement must increase upward of one or both potential defects at a later date is preferable
and outward forces on the hip. Ruszkowski and Sakic to an unpredictable operation in a young asymptomatic
(1982) found increased subluxation of the hip after child.
trochanteric advancement in patients with preoperative A limp may appear at the age of 9 to 10 years, but at
acetabular dysplasia, but only one child in our series first such patients have an unlimited walking capacity and
showed this. It could be argued that patients showing can keep up with their classmates. Significant disability
marked acetabular dysplasia should have some form of usually appears at about 12 years of age. At this age,
acetabuloplasty at the same time as the trochanteric trochanteric transfer can correct this, but if significant leg
advancement. shortening is anticipated, we consider that the double
Epiphysiodesis of the greater trochanter to reduce operation is indicated. It is fortunate that this age is
overgrowth was reported by Langenskiold and Salenius appropriate for epiphysiodesis. We have had good results
(1967) and by Gage and Cary (1980), but both papers from simultaneous procedures with no important compli-
suggest that it is not effective after the age of eight years. cations.
A limp rarely appears before this age, however, and it
may be several years later that the gait becomes No benefits in any form have been received or will be received from a
uncompensated. We consider that a one-stage correction commercial party related directly or indirectly to the subject of this article.

REFERENCES

Anderson M, Green WT, Messner MB. Growth and predictions of growth Kelikian AS, Tachdjian MO, Askew Mi, Jasty M. Greater trochanteric
in the lower extremities. J BoneJoint Surg [Am] 1963; 45-A:1-l4. advancement of the proximal femur: a clinical and biomechanical
study. In: Hungerford DS, ed. The Hip. Procs of the eleventh open
Bowen JR, Johnson WJ. Percutaneous epiphysiodesis. Clin Orthop 1984; scientific meeting of the Hip Society. St Louis: CV Mosby, 1983:
190:170-3. 77-105.
Bucholz RW, Ogden JA. Patterns of ischaemic necrosis of the proximal Langenski#{246}ld A, Salenius P. Epiphyseodesis of the greater trochanter.
femur in nonoperatively treated congenital hip disease. In: The Hip. Acta OrthopScand 1967; 38:199-219.
Procs of the 6th meeting of the Hip Society, 1978. St. Louis, etc: CV
Mosby Co, 1978:43-63. lloyd-Roberts GC, Wetherill MH, Fraser M. Trochanteric advancement
for premature arrest of the femoral capital growth plate. J Bone Joint
Canale ST, Russell TA, Holcomb RL Percutaneous epiphysiodesis, Surg[BrJ 1985; 67-B:21-4.
experimental study and preliminary clinical results. J Pediatr Orthop
1986; 6:150-6. Moseley CF. A straight-line graph for leg-length discrepancies. J Bone
Joint Surg [Am] 1977; 59-A:174-9.
Cohen J. Congenital dislocation of the hip: case report of an unusual
complication and unusual treatment. J Bone Joint Surg [Am] 1971; O’Brien T, Milles MB, Griffin PP. The early identification and
53-A:1007-1 1. classification of growth disturbances of the proximal end of the femur.
J BoneJoint Surg [Am] 1986; 68-A:970-80.
Compere EL, Garrison M, Fahey JJ. Deformities of the femur resulting
Porat 5, Peyser A, Robin GC. Equalization of lower limbs by
from arrestment of growth of the capital and greater trochanteric
epiphysiodesis: results of treatment. J Pediatr Orthop 1992; 11:442-8.
epiphyses. J Bonefoint Surg 1940; 22:909-15.
Ruszkowski I, Sakic S. Transposition of the greater trochanter of the femur
Edgren W. Coxa plana: a clinical and radiological investigation with
during growth. Arch Orthop Trauma Surg 1982; 100:43-8.
particular reference to the importance of the metaphyseal changes for
the final shape of the proximal part of the femur. Acta Orthop Scand Salenius P, Videman T. Growth disturbances of the proximal end of the
1965 Suppl: 84. femur: an animal experimental study with tetracycline. Acta Orthop
Scand 1970; 41:199-212.
Fernbach 5K, Poznanski AK, Kelikian AS, Tachd.jian MO, Marzano
Mi. Greater trochanteric overgrowth: development and surgical Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as
correction. Radiology 1985; 154:661-4. a complication of treatment for congenital dislocation of the hip in
young children: a clinical and experimental investigation. Can J Surg
Gage JR, Cary JM. The effects of trochanteric epiphysiodesis on growth 1969; 12:44-61.
of the proximal end of the femur following necrosis of the capital
femoral epiphysis. J BoneJoint Surg lAm] 1980; 62-A:785-94. Thomas CL, Gage JR, Ogden JA. Treatment concepts for proximal
femoral ischemic necrosis complicating congenital hip disease. J Bone
Iwersen 14, Kalen V, Eberle C. Relative trochanteric overgrowth after JointSurg[Am] 1982; 64-A:817-28.
ischaemic necrosis in congenital dislocation of the hip. J Pediatr
Orthop 1989; 9:381-5. Wagner H. Femoral osteotomies for congenital hip dislocations. In: Weil
UH, ed. Progress in orthopaedic surgery. No 2, Acetabular dysplasia
Jani L. Die entwicklung des Schenikelhalses nach der trochanter- and skeletal dysplasia in childhood. New York, etc: Springer-Verlag,
versetzung. Arch Orthop Unfalichir 1969; 66:127-32. 1978:85-105.
Kalamchi A, MacEwen GD. Avascular necrosis following treatment of Wiberg G. Studies on dysplastic acetabula and congenital subluxation of
congenital dislocation of the hip. J Bone Joint Surg [Am] 1980; 62- the hip joint, with special reference to the complication of osteo-
A:876-88. arthritis.Acta ChirScand 1939; 83 Supp 58:1-135.

VOL. 76-B, No. 3, MAY 1994

View publication stats