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cta Vol 14 n 4 30 08 06 Layout 3 Inglês.indd 183 1/8/2006 16:09:54 ACTA ORTOP BRAS 14(4) - 2006 X-ray ParametersClassificationNecrosisWIBERGs angleGOOD0 … INL0 mmFAIRII … IIINL or Dysplasic0 … 2 mm20 … 30 mmBADIII - IVDysplasic or Dislocated&#x 20 ;&#xmm00; 2 mm&#x 20 ;&#xmm00; 30 mmdivided into two dif-ferent groups, named A and B, considering Twenty-four hips of 20 patients operat-ed between Febru-ary 1985 and March 1993 (Table 1) were included in group A, and in group B, 33 hips of 30 patients submitted to surgical treatment performed between November 1992 and September 1997 (Table 2) were included. In this group, two (10.00%) patients were males and 18 (90.00%) were fe-males. At the time of surgery, ages ranged from 35 months compromising, we observed 15 (75.00%) patients with unilateral disease and 5 (25.00%) bilateral cases, 10 (41.67%) right sided In group B, 1 (3.33%) patient was male and 29 (96.67%) were fe-time of surgery (average = 52.88 months). Regarding ethnicity, 23 were Caucasians and 7 were non-Caucasians. We observed (16.67%), with 14 (42.42%) right sided and 19 (57.58%) We quantified the degree of dislocation on affected hip, according to the methodology selected by Thus, in group A, we ob-served 4 (16.66%) grade I dislocations, 7 (29.17%) grade II, and13 (54.17%) grade III. In group B, we had 5 (15.15%) grade I grade II, and 23 (69.70%) Traction was established at preoperative period, in both lower limbs, keeping thigh-femoral flexion at 90º and the performed in both lower limbs was slow and progressive, until 30º - 45º were achieved on each side. In older chil-dren, we used a horizontal traction keeping hips in flexion and abduction position of approximately 45º and 30º, with lower limbs laid on a ferule when the previously described technique could not be applied. We maintained traction for a period between 2 and 4 weeks, aiming to guide femoral head below Gage e WinterTable 1 … Clinical ParametersFunctional PAINFLABDIRORSTRENGTHTrendelenburgGOODAbsent&#x 20 ;&#xmm00;90º&#x 20 ;&#xmm00; 20º&#x 20 ;&#xmm00; 20º&#x 20 ;&#xmm00; 40ºGrade 4 or 5NegativeFAIRAbsent60º-90º10º-20º10º-20º20º-40ºGrade 3 or 4PositiveBADPresent 10º 20º Grade 3PositiveNGenderEthnicityAgeInvolvementSideFemoral1FC88UnilateralLIII30ST + BR + FS +V + D + C 2MC49UnilateralRIII63ST + BR + FS + V + S3FC60UnilateralLIII30ST + BR + FS + V + D + S4FC44UnilateralLIII30ST + BR + FS + V + D + S5FC35UnilateralRI30ST + BR + FS + V + S 6FNC125UnilateralLIII60ST + BR + FS + V + D + C7FC92UnilateralLI35ST + BR + FS + V + S8FC39Bilateral RII35ST + BR + FS + D + S9FC37BilateralLII35ST + BR + FS + D + S10FNC125UnilateralLIII70ST + FS + D + V +C11MNC48BilateralRIII62ST + FS + V + D + S 12MNC65BilateralLIII62ST + FS + V + D + S13FNC56UnilateralRII49ST + BR + FS + V + D + S14FC191UnilateralRII50ST + BR + FS + V + D + C 15FC37UnilateralRIII54ST + BR + FS + V + D + S16FC49UnilateralLIII42ST + BR + FS + C17FNC50UnilateralLII52ST + BR + FS + D + S18FNC49UnilateralLII35ST + BR + FS + V + D + S19FC82UnilateralRIII55ST + BR + FS + V + D + S20FC72Bilateral RI30ST + BR + FS + V + S21FC69BilateralLI32ST + BR + FS + V + D + S22FC48UnilateralLII40ST + BR + FS + S + TA23FC37BilateralRIII37ST + BR + FS + V + D + S24FC35BilateralLIII47ST + BR + FS + V + D + SC - Chiaris osteotomy; FS - femoral shortening; N - Sequential number; VO - Varusing osteotomy; AO - Anti-rotative osteotomy; BR - Bloody reduction; S - Salters osteotomy; ST - Skin traction; TA - Adductor muscles tenotomy (intra-operative) cta Vol 14 n 4 30 08 06 Layout 3 Inglês.indd 184 1/8/2006 16:09:55 ACTA ORTOP BRAS 14(4) - 2006 Functional Num%Good2369.70Fair1030.30Bad00.00Total33100.00Group AGroup BX-ray Num%Num%TotalGood1458.332369.7037Fair1041.671030.3020Total243357 = 0.788P Functional Num%Good1458.33Fair1041.67Bad00.00Total24100.00Group AGroup BX-ray Num%Num%TotalGood937.502369.7032Bad1041.67515.1515Fair520.83515.1510Total243357X-ray resultNum%Good2369.70Fair515.15Bad515.15Total33100.00X-ray resultNum%Good937.50Fair520.83Bad1041.67Total24100.00Table 3 -Table 4 -Table 5 -Table 6 -Table 7 - Distribution of the 33 hips of 30 patients, according to functional Table 8 -gical steps described for patients in group A were applied (Table 4). In 19 of the 33 hips oper-ated, the Salter surgery nal technique. Instead of with threaded Kirschner . In 11 of the 33 scription, and, in 3 or the 33 After 6 or 8 weeks, in aver-age, immobilization was be initiated. Kirschner wires fixating bone graft were gration to adjacent bone tissue, or when the Chiarisigns of union. From that Method for X-rayFor quantifying the many kinds of postoperative ne-crosis on hips of patients we employed the classifica-tion described by Kalam-divide changes into four on ossification core; gr- lateral physis compromised; group III - physis central injury; group IV - femoral epiphysis Total measurement of lower limbs determining its length was performed by scan-ning, measuring the distance between the top edge of Measurements of Wibergangle were achieved by odology by that author, concen-tion proposed by Laredo . We used, then, normal measurements of that variable found by him in order to compare them to the measurements achieved tients in this study. sessed with the aid of a rule especially made for that with 1-mm increments, (18)The following have also Rate, introduced by Klein-Sharps Acetabular Angle ; Shentons arc; Hilgen-heiners Line; center-ac-acetabulum Coefficient; triple-irradiated cartilage In our methodology, we ruled out the following X-ray The Wiberg angle, of which normal values used have been drawn from the re-The avascular necrosis epiphysis roundness by lower limbs, measured in We considered the X-ray ables are within satisfactory limits, fair w Acta Vol 14 n 4 30 08 06 Layout 3 Inglês.indd 186 1/8/2006 16:09:55 ACTA ORTOP BRAS 14(4) - 2006 obtaining a satisfactory joint stability and, currently, we prescribe anterior and inferior excision of its excesses. Reduction instability was recognized in patient number 2, from the moment it was from neck throughout the acetabulum. Femoral osteotomy, for being intertrochanteric, may have damaged the branches of medial circumflex artery, which are located surrounding this helped the complication described, agreeing with Tönnis and propositions. The excessive proximity of this artery 2 and 4. The perspective of a varusing solution has resulted, for patient number 23, in a change characterized by excessive proximal portion. We also believe that the diameter and length as an additional aggressive factor. On group B patients hips, we observed a total of 7 necroses to with intermediate values of 4.8% among the authors in our research. Bad X-ray 26. On the hips of patients 5 and 15 in this series, after surgical acetabulo-plasty during postoperative follow-up period because the graft separated due to its reduced size. On patient 19s hip (table 7), probably, the Salters osteotomy was not the proper one to re-patient 23s hip, we saw a discrepancy of 35.00 mm, which could be justified by the presence of necrosis. Apparently, we did not evidence technical problems regarding the application of surgical steps when we report to the surgical description in that patients medical files. Perhaps an insufficient release, an excessive dis-section, or a reduction under tension would justify the emergence of the ischemic injury. Finally, for patient 26s hip, we observed, at the 35.00 mm anisomelia worsened by femoral shortening, be-cause, in this case, a bone fragment of 65 mm was dried. For that observed discrepancy, we should also consider the age of age may have been determinant of a lower biological response of femoral hyper-growth. We also found that two surgeries had been previously performed, before last treatment. Due to all exposed facts, we believe that the emergence of lack of experience or adversity, and should not have causes ruled by casualty. Regarding the evaluation of treatments results, we found in radiographic classification by Severin which is considered However, we developed a classification that could gather several X-ray parameters enabling a simple and more reliable normality related to HDD.In order to determine normality limits for Wibergswe applied the X-ray measurements of this variable as obtained by Laredo Filho. We advocate this position, because the cov-erage provided by acetabulum over femoral head verified by gressive development and growth of the thigh-femoral joint. This fact refuses the condition that a single angle value, as adopted we believe that the evaluation of results may be performed with a higher level of accuracy when this system is applied. Several specific classifications for clinical outcomes analysis have been developed and employed to verify the effective-However, those methodologies come from adjustments to classifications originated in experiences acquired by treating adult individuals submitted to total prosthesis implantation or femoral and pelvic osteotomies. Nevertheless, we think than some of those evaluations are difficult to apply in certain situ-ations. Those are ruled by strict standards, not applying to all age groups, such as, for example, the ambulation resistance, parameter usually employed by authors considered in our study. We believe that the simple visual analysis of ambulation can be subjectively influenced by Therefore, there is no optimal and absolute classification that meets all requirements and, of course, each author advocates his/ her own ideas and points of view. There are individual fac-tors making each patient to give a different response to surgical aggressions suffered by him/ her. Thus, there is a lot of difficult in and its results. This perhaps justifies the reason why there is no consensus about the way to evaluate the joint function in oper-this study have not been randomly chosen. We gathered those most commonly mentioned by researched authors and added important parameters that could indicate motor function, of which changes are known to interfere on functional pattern of patients. could be easily applicable and reproducible. restraints or not, it makes final clinical evaluation to be considered . Joint stiffness may also be found and it is possibly justified by capsule and adjacent tissues adherences or as a result of avascular necrosis or condhrolysis. In 49 of the 57 hips operated, we chose the osteotomy procedure, as described by Salter. Redirection, from the biomechanical point of view, is a positive factor for thigh-femoral joint, producing an adequate The concurrent femoral shortening, when employed, provides the necessary relax to adjacent soft tissues, which mitigate the When this surgical step is added, femoral epiphysis reduction Acta Vol 14 n 4 30 08 06 Layout 3 Inglês.indd 188 1/8/2006 16:09:56