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Femoral valgus osteotomies
Published in K. Mohan Iyer, Hip Preservation Techniques, 2019
Proper surgical treatment includes: Adductor tenotomy, which allows for less forceful correction and improved stability.5Proximal femoral shortening osteotomy if necessary to help relieve excessive femoral head pressure when the valgus angle is restored.Stable internal fixation and hip spica cast if needed.The aim of surgical treatment is to produce an overcorrection of the valgus angle to greater than 150–160°, as well as correction of the epiphyseal angle to less than 30° .
Paediatric orthopaedics
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Successful treatment using a harness is unusual after the age of 4-6 months. For the late-presenting hip or the hip that fails conservative treatment, an examination under anaesthetic may result in a closed reduction. The arthrogram shows whether a concentric reduction is present and, if not, it will indicate which structures are blocking reduction. A psoas/ adductor release can be performed as necessary. Following a closed reduction, the hip will need to be held reduced with a hip spica cast for several months.
The hip
Published in Ashley W. Blom, David Warwick, Michael R. Whitehouse, Apley and Solomon’s System of Orthopaedics and Trauma, 2017
Martin Gargan, Ashley Blom, Stephen A. Jones, Amy Behman, Simon Kelley
Following reduction, the hip is immobilized in a hip spica cast within the ‘safe zone of Ramsey’. This safe zone is the arc of motion through which the hip remains reduced without forced abduction. Adductor tenotomy is often performed at the time of closed reduction in order to increase the abduction range and therefore increase the safe zone.
Massive femur defect after Ewing’s sarcoma resection reconstructed with a free vascularised fibular graft in a four-year-old girl
Published in Acta Chirurgica Belgica, 2020
Nicolas Vermeersch, Benjamin Peters, Johan Somville, Koenraad Van Landuyt, Filip Thiessen, Thierry Tondu
A four-year-old girl was referred to the orthopaedic department with leg pain during the evening and at night. A plain film radiograph revealed a multi-layered periosteal reaction (“onion skin”) in the right femur diaphysis (Figure 1). MRI of the lesion showed an endomedullar mass in the proximal half of the right femur diaphysis, without cortical extension or expansion and with a total length of 10 cm. A jamshidi biopsy was performed and the pathology report showed an Ewing’s sarcoma. Further staging was negative for metastasis. The management consisted of chemotherapy (VIDE - Vincristine, Ifosfamide, Doxorubicin, Etoposide), a wide resection of the affected bone and immediate reconstruction of the massive femoral bone defect with a FVFG. The surgery was performed by two teams existing of orthopaedic and reconstructive surgeons. First, a 13.5cm long segment of the femur containing the tumour was resected through an anterior incision, with proximal transsection at the tip of the lesser trochanter. The growth plates remained uninjured. Secondly, the ipsilateral fibula was harvested in a standard way including the peroneal vessels and a skin island. This FVFG was then placed intramedullary in the femur defect and fixated by plate and screws. After fibular graft fixation, the vascular pedicles were anastomosed. The donor peroneal artery was anastomosed to the lateral circumflex femoral artery in an end-to-end fashion and the donor peroneal vein was anastomosed end-to-end to the great saphenous vein. The pathology report showed no more malignancy. The postoperative course was uneventful except for proximal screw loosening requiring revision and refixation after one week. Then temporary immobilisation in a hip spica cast was added to increase stability. The skin island and bone graft remained viable at all times. Adjuvant chemotherapy (VAC – Vincristine, Actinomycin D, cyclophosphamide) was continued as planned. Bone union and hypertrophic changes were followed by plain radiographs each month during the first year and every 2–3 months during the second year (Figure 2). Partial weight bearing was allowed after 14 months and ambulation was initiated at 23 months postoperatively. At 30 months of follow up, there is no disease recurrence, excellent bone union, graft hypertrophy of 188% approximating femur thickness and there is no discrepancy in leg length. Donor site morbidity exists of delayed wound healing, weakness in dorsiflexion of the foot and an equinovarus deformity. The patient could walk without braces and had acceptable functional result (Figure 3). However, at 34 months postoperative, she sustained a right distal femur fracture while playing on an outdoor swing. The reconstructed part of the femur was unharmed (Figure 4). The fracture was treated by closed reduction and cast immobilization. This had a major repercussion on her mobility. One year after the fracture, which healed well, she is still rehabilitating with slow but promising results. A total graft hypertrophy of 312% is noted at this moment.