G. Dean MacEwen

A review of 119 patients with congenital dislocation of the hip complicated by avascular necrosis, of whom fifty-one patients were skeletally mature, showed that damage to the physis was very common. Changes in the secondary ossification center (ossific nucleus) alone were found to be of very little value in predicting the nature of the development of the hip, while the change in the proximal femoral physis was the key to predicting residual deformity. The vascular disturbances were classified into four groups depending on the amount of damage involving the ossific nucleus and the physis during treatment of the dislocation. This classification was found to be accurate in predicting the natural history of avascular necrosis. The more severe forms of avascular necrosis were found to be most prevalent in those patients in whom treatment was begun between birth and the age of six months. We also found that preliminary traction and the use of general anesthesia reduced the incidence of the more severe form of avascular necrosis. The functional results found in the skeletally mature patients coincided with the types of vascular changes; the presence of avascular necrosis enhanced the development of arthritis, especially if residual dysplasia and subluxation also were present.

A survey conducted by the Scoliosis Research Society found eighty-seven patients with acute neurological complications resulting from the treatment of scoliosis. The incidence of these complications was determined to be 0.72 per cent. Seventy-four major complications involving the spinal cord were reported, half of them complete paraplegia and half partial paraplegia. Thirty-six per cent recovered completely, 32 per cent had partial recovery, and 32 per cent had no return of function. Thirteen minor complications involving cranial and peripheral nerves were reported. Major complications occurred in forty-two cases of posterior spine fusion with Harrington instrumentation and in twenty cases of posterior spine fusion without instrumentation. Six patients became paraplegic following skeletal traction alone.

A twenty-year follow-up on the use of the Dunlap-Shands method for the determination of torsion of the femur is presented, with the results of a total of 1,990 torsion studies in normal children and children with congenital dislocation of the hip, coxa plana, toeing-in, and cerebral palsy. The effect of increased anteversion is discussed as it relates to each hip condition discussed. Increased anteversion should be considered a very significant factor in the treatment of many hip conditions.

Of fifty patients with the diagnosis of Klippel-Feil syndrome, less than half had the classic clinical triad of findings, while more than half had scoliosis, and a third had renal anomalies. All patients were at risk of having other serious, but less apparent, anomalies, including: Sprengel's deformity (twenty-one patients), impairment of hearing (fifteen patients), synkinesia (nine patients), and congenital heart disease (seven patients). The discovery of one of these lesions should, therefore, stimulate a careful search for associated anomalies.

From 1968 to 1972, twenty-three infants under six months old with twenty-seven dislocated hips were treated with a Pavlik harness. All the dislocations except three were successfully reduced. Only one child required hospitalization. All the patients were followed for more than two years. All but three of the hips were clinically and roentgenographically normal at follow-up, and none had avascular necrosis. In infants, the Pavlik harness successfully utilizes the principle of reduction in flexion, avoiding forced abduction.