Congenital Dysplasia and Dislocation of the Hip in Children and Adults

1 Anatomic Aspects.- 1.1 Anatomy of the Hip Joint.- 1.1.1 The Acetabulum.- 1.1.2 Position of the Acetabulum.- 1.1.3 The Femoral Head.- 1.1.4 The Femoral Neck.- 1.1.5 Angle of Femoral Torsion.- 1.1.6 Femoral Shaft Axis, Mechanical Axis, and Knee Joint Axis.- 1.1.7 Tibial Torsion.- 1.1.8 The Role of the Acetabular Labrum and Atmospheric Pressure in Stabilizing the Hip.- 1.1.9 The Capsule and Ligaments of the Hip.- 1.1.10 The Muscles of the Hip.- 1.2 Vascular Supply of the Hip.- 1.2.1 Vascular Supply of the Femoral Head and Femoral Neck.- 1.2.2 Vascular Supply of the Acetabulum.- 1.3 Innervation of the Hip Joint.- 2 Development of the Hip Joint.- 2.1 Development of the Acetabulum.- 2.2 Principles of Pelvic Growth.- 2.2.1 External Apposition (Perichondrial and Periosteal).- 2.2.2 Internal, Proportional Resorption in the Pelvic Aperture.- 2.2.3 Chondral Growth Principle.- 2.2.4 Details of Growth.- 2.3 Development of the Proximal Femur.- 2.4 Factors Influencing the Growth and Shape of the Proximal Femur.- 2.4.1 Static Forces.- 2.4.2 Muscular Forces.- 2.5 Shape and Position of the Hip Joint During Development.- 2.6 Growth of the Juvenile Hip Joint as Established from Planimetric Measurements.- 3 Development of the Vascular System of the Hip Joint and Its Variations with Reference to Ischemia.- 3.1 Vascular Pattern at Birth.- 3.2 Infantile Phase (from About Four Months to Four Years).- 3.3 Intermediate Phase from About Four to Seven Years.- 3.4 Preadolescent Phase from 9 to 10 Years.- 3.5 Adolescent Phase.- 3.6 Variations of the Vascular Pattern.- 3.7 Clinical Implications.- 4 Introduction to the Biomechanics of the Hip.- 4.1 General.- 4.2 Loads and Stresses on the Hip.- 4.3 Current Knowledge on the Biomechanics of the Hip (Literature Survey).- 4.4 Anatomic Aspects.- 4.5 Radiographic Aspects.- 4.6 Principles of Biomechanical Analysis.- 4.7 The Load on the Hip.- 4.7.1 Load Model.- 4.7.2 Discussion of Geometric Parameters Used to Determine the Hip Load.- 4.7.3 Procedure for Calculating the Hip Load.- 4.7.4 Remarks on Load Calculations.- 4.8 The Stress on the Hip.- 4.8.1 Model for Calculating Joint Pressure (Maximum Pressure, Equal Pressure Distribution).- 4.8.2 Correction of the Pressure Calculation (Position of the Femoral Head Center C, Acetabular Anteversion).- 4.8.3 Calculation of Weight-Bearing Area with Allowance for the “Mean Inlet Plane”.- 4.8.4 Pressure Distribution (Linear Pressure Rise, Hooke’s Law).- 4.9 Explicit Calculation of Load and Stress.- 4.9.1 The Normal Hip.- 4.9.2 Illustrative Case.- 4.9.3 Published Reports on Biomechanical Data in the Normal Hip.- 4.10 Standard Treatments of Hip Dysplasia in Adults and Their Biomechanical Efficacy.- 4.10.1 Intertrochanteric Osteotomies.- 4.10.2 Trochanteric Transfer.- 4.10.3 Pelvic Operations.- 4.11 Questions Relating to the Planning of Operative Tactics.- 4.12 Conclusion.- 5 Etiology of Congenital Dislocation of the Hip.- 5.1 Older Causation Theories.- 5.2 Anatomic and Racial Predisposition.- 5.3 Prevalence and Geographic Distribution.- 5.4 Sex Incidence and Ratio of Affected Sides.- 5.5 Inheritance.- 5.6 Exogenous, Mechanical Causative Factors.- 5.7 The Study of P. M.Dunn.- 5.8 Further Studies on Mechanical Causative Factors.- 5.9 Hormonal Effects on the Hip Capsule.- 5.10 Capsular and Ligament Laxity.- 5.11 Seasonal Influences.- 5.12 Summary and Conclusion.- 6 Pathologic Anatomy of Congenital Dislocation of the Hip.- 6.1 Grade 1 Dislocation of the Hip.- 6.2 Grade 2 Dislocation of the Hip.- 6.3 Grade 3 Dislocation of the Hip.- 6.4 Direction of Dislocation and Orientation of the Acetabulum.- 6.5 The Proximal Femur.- 6.5.1 Coxa Valga.- 6.5.2 Femoral Antetorsion.- 6.5.3 The Femoral Head.- 6.6 Vascular Supply in High Dislocations.- 6.7 The Muscles in Congential Dislocation of the Hip.- 7 Nomenclature and Classification of Congenital Hip Dislocation.- 7.1 Nomenclature.- 7.2 Classification of Congenital Hip Dislocation and Anatomic Findings.- 7.3 Grades of Dislocation According to Howorth and Dunn.- 7.4 Grades of Dislocation According to the CSHD.- 7.5 Graf’s Classification by Sonographic Appearance.- 8 Clinical Examination of the Hip.- 8.1 History.- 8.1.1 Newborns and Infants.- 8.1.2 Older Children and Adults.- 8.2 Examination During Walking and Standing.- 8.2.1 Limp with a Positive Trendelenburg Sign.- 8.2.2 Limp Due to Shortening.- 8.2.3 Limp Due to Pain.- 8.2.4 Limp Due to Ankylosis.- 8.2.5 Examination in Stance.- 8.3 Testing the Range of Hip Motion in Older Children and Adults.- 8.3.1 Flexion and Extension.- 8.3.2 Abduction and Adduction.- 8.3.3 Internal and External Rotation.- 8.4 Testing the Range of Hip Motion in Newborns.- 8.5 Limitations of Hip Motion in Congenital Hip Dysplasia and Dislocation.- 8.6 Further Tests for Exclusion of Hip Dysplasia and Dislocation in Infants.- 8.6.1 Leg Length Examination in Infants.- 8.6.2 Skin Relief and Skin Folds.- 8.6.3 Manual Examination of the Hip.- 8.6.4 Expanded Classification of Palpatory Findings.- 8.6.5 Techniques of Manual Examination.- a) Ortolani’s Examination.- b) Examination of Coleman and Palmén.- c) Barlow’s Examination.- d) Dislocation and Reduction Sign of Klopfer.- e) Our Examination Technique.- 8.7 Anatomic Basis of the Roser-Ortolani Sign.- 8.8 DryHipClick.- 8.9 Naming the Roser-Ortolani Sign.- 8.10 Definition of the Roser-Ortolani Sign.- 8.11 Ludloff’s Sign.- 9 General Radiography of the Hip Joint.- 9.1 Radiographic Evaluation of the Acetabulum.- 9.1.1 AP Pelvic Film for Evaluating the Lateral Acetabular Roof.- 9.1.2 Faux Profil View for Demonstrating the Anterior Acetabular Roof.- 9.1.3 View of Chassard and Lapiné for Evaluating the Posterior Acetabular Rim and Acetabular Anteversion.- 9.1.4 View of Dunlap et al. for Evaluating the Posterior Acetabular Rim and Acetabular Anteversion.- 9.2 Radiographic Evaluation of the Femoral Neck.- 9.2.1 Frontal (Anteroposterior) View.- 9.2.2 Lateral Views of the Femoral Neck.- a) Axial Hip Views of Dunn, Rippstein and Müller for Evaluating Femoral Antetorsion.- b) Axial Orthograde View of the Hip for Evaluating the Second Plane of the Femoral Head and Neck.- c) Axial Views of the Hip in the Vertical Projection (Lauenstein’s View) and in the Horizontal Projection (Sven Johansson’s View).- 9.3 Functional Views of the Hip Joint.- 9.3.1 View of Andrén and von Rosen for the Diagnosis of Hip Dislocation.- 9.3.2 Abduction-Medial Rotation View (Lange’s Position) in Small Children.- 9.3.3 Functional Views in Older Children and Adults.- 9.4 Commonly Used Reference Lines for the Diagnosis of Hip Dislocation in Newborns and Infants.- 9.4.1 Hilgenreiner’s Line.- 9.4.2 Line of Ombrédanne and Perkins.- 9.4.3 The Epiphyseal Triangle of Mittelmeier for Evaluating the Position of the Capital Femoral Ossification Center.- 9.4.4 Linear Measurements of Trochanteric Height and Femoral Displacement.- 9.4.5 Orienting Line of Shenton and Ménard.- 9.4.6 Orienting Line of Calvé.- 9.4.7 Parallelogram of Kopits.- 9.4.8 Measurements for Diagnosing Hip Instability in Children and Adolescents.- 9.5 Radiographic Indicators of Correct Positioning.- 9.5.1 Quotient of Pelvic Rotation (Tönnis and Brunken).- 9.5.2 AP Pelvic Tilt (Tönnis and Brunken).- 9.5.3 Pelvic Tilt Index (Ball and Kommenda).- 9.5.4 Neutral Position of the Femoral Neck.- 9.6 Radiographic Indicators of Hip Dysplasia.- 9.6.1 Acetabular Inlet Plane.- a) Measuring the Transverse Acetabular Inclination (After Ullmann, Sharp, Stulberg and Harris).- b) Anteversion of the Acetabular Inlet Plane (as Measured by the Radiographic Projection of Chassard and Lapiné and CT).- 9.6.2 The Acetabular Index.- a) Acetabular Index of Hilgenreiner (AC Angle).- b) Acetabular Index of the Weight-Bearing Zone in Adolescents and Adults.- c) ACM Angle of Idelberger and Frank.- 9.6.3 Angles Which Evaluate the Femoral Head-Acetabular Relationship.- a) Lateral Coverage: the Center-Edge (CE) Angle of Wiberg.- b) Anterior Coverage: VCA Angle of Lequesne and de Sèze.- c) Entry Angle of von Lanz.- d) Composite Evaluation of the Hip Joint (the “Hip Value”).- 9.6.4 Angular Measurements of the Femoral Neck.- a) The Neck-Shaft Angle (CCD Angle = Centrum-Collum-Diaphyseal Angle of M. E. Müller).- b) The Antetorsion Angle (AT Angle) of Dunn-Rippstein-Müller.- 9.7 Angle Changes Caused by Positioning Errors.- 9.7.1 The AP Pelvic View.- 9.7.2 The Antetorsion View.- 9.8 Normal Values of the Neck-Shaft Angle and Antetorsion.- 9.8.1 CCD Angle.- 9.8.2 AT Angle.- 9.9 Historical Development of Torsion Determination.- 9.9.1 Determination of Antetorsion from the Angle of Medial Rotation.- 9.9.2 Determination ofthe AT Angle on Lateral Radiographs.- 9.9.3 Determination ofthe AT Angle in Abduction.- 9.9.4 Determination ofthe AT Angle on Orthograde Films.- 9.9.5 Determination of Torsion Using the Projected Neck-Shaft Angle and Projected AT Angle in Abduction.- 9.9.6 Other New Techniques.- 9.10 Angle of the Capital Femoral Epiphysis.- 9.10.1 Defining the Epiphyseal Line.- 9.10.2 Epiphysis-Triradiate Cartilage Angle (EY Angle) of Cramer and Haike.- 9.10.3 Epiphysis-Femoral Neck Angle (KE Angle) of Jäger and Refior.- 9.10.4 Epiphysis-Shaft Angle of Jones and Immenkamp.- 9.10.5 Malprojection Caused by Antetorsion and Lateral Rotation.- 9.11 Indices and Quotients for Evaluations of the Hip Joint.- 9.11.1 Definition.- 9.11.2 Various Indices and Quotients.- 10 Arthrography of the Hip Joint.- 10.1 Importance of Arthrography.- 10.2 History of Arthrography.- 10.3 Technique of Hip Arthrography.- 10.3.1 Selecting a Contrast Medium.- 10.3.2 Approaches for Arthrography of the Hip.- 10.4 The Question of Harmful Effects.- 10.5 Arthrographic Features of the Normal Hip.- 10.6 Arthrographic Features of the Abnormal Hip.- 10.7 Classification Systems and Therapeutic Guidelines of Various Authors Based on Arthrographic Findings.- 10.7.1 Classification of Leveuf and Bertrand.- 10.7.2 Classifications of Howorth, Mitchell, Dörr, and P.M.Dunn.- 10.7.3 Grades of Dislocation According to Guilleminet et al.- 10.7.4 Other Classifications.- 10.7.5 Arthrographic Classification of Acetabular Dysplasia Unaccompanied by Dislocation.- 10.7.6 Classification of Schwetlick.- 10.7.7 Peic’s Classification of Labrum Morphology.- 10.7.8 Arthrographic Grades of Dislocation According to Tönnis.- 10.7.9 Arthrographic Grades of Reduction (Tönnis).- 10.8 Evaluation of Treatment Options Based on Arthrograms.- 11 Computed Tomography of the Hip Joint.- 11.1 General.- 11.2 Prerequisites.- 11.3 Positioning.- 11.4 The Diagnostic Value of Pelvic CT.- 11.5 Indication.- 11.6 Illustrative Cases.- 12 Radiation Exposure and Radiation Protection.- 12.1 Effect of Radiation.- 12.2 Radiation Exposure and Genetically Significant Dose.- 12.3 Radiation Protection.- 13 Clinical and Radiographic Schemes for Evaluating Therapeutic Results.- 13.1 Problems of Hip Evaluation.- 13.2 Evaluation Scheme Based on Grades of Deviation from Normal.- 13.2.1 Clinical Findings.- a) Limitation of Motion.- b) Trendelenburg’s Sign.- c) Pain.- 13.2.2 Radiographic Findings.- a) General Criteria.- b) Classification of Radiographic Indicators by Their Degree of Deviation from Normal.- 14 The Ultrasound Examination of the Hip.- 14.1 Technical Principles.- 14.1.1 Basic Physical Concepts.- 14.1.2 The Production of Ultrasound Waves.- 14.1.3 Physical Phenomena That Are Important in Sonography.- 14.1.4 Techniques for Producing an Ultrasound Image.- 14.1.5 Artifacts.- 14.1.6 Real-Time Scanners.- 14.2 Physical Effects, Biologic Effects, and Questions of Safety.- 14.2.1 Physical Effects.- 14.2.2 Biologic Effects.- 14.3 Ultrasound Instruments for Orthopedic Applications.- 14.3.1 Basic Requirements of the Ultrasound Instrument for Use in the Infant Hip.- 14.3.2 Linear or Sector Scanner.- 14.3.3 Adjusting the Ultrasound Instrument.- 14.3.4 Instrument Adjustments for Hip Sonography.- 14.4 Image Documentation and Recording Systems.- 14.4.1 Basic Requirements for the Documentation of Hip Sonograms.- 14.4.2 Recording Systems.- 14.5 Anatomic Aspects of Hip Sonography.- 14.5.1 Beam Direction and the Soft-Tissue Envelope.- 14.5.2 The Femoral Neck, the Femoral Head, and the Capital Femoral Ossification Center.- 14.5.3 The Acetabulum: Anatomic Aspects and Questions of Nomenclature.- 14.5.4 The Sonographic Appearance of the Acetabular Roof and Perichondrium.- 14.5.5 The Topographic Relationships of the Labrum, the Perichondrial Hole, and the Proximal Third of the Perichondrium.- 14.5.6 The Standard Situation.- 14.5.7 The Fluid Film.- 14.5.8 The Echogenicity of the Acetabular Fossa.- 14.6 The Standard Plane, Measuring Technique, and Errors of Measurement.- 14.6.1 The Problem of the Standard Plane.- 14.6.2 Conclusion and Definition of the Standard Plane.- 14.6.3 Measuring Technique and Errors of Measurement.- 14.7 Grades of Dislocation on Sonograms (Sonographic Hip Types).- 14.7.1 Description of Findings.- 14.7.2 Type 1 Hip.- 14.7.3 Type 2 Hip.- 14.7.4 Type 3 a und 3 b Hip.- 14.7.5 Type 4 Hip.- 14.7.6 Evaluating the Structure of the Roof Cartilage.- 14.8 Sonographic Assessments of Hip Maturity with the Sonometer.- 14.8.1 The Sonometer.- 14.8.2 The Fine Differentiation of Hip Types.- 14.8.3 Significance of the ?- and ?- Angles.- 14.9 Positioning and Scanning Technique.- 14.9.1 Principle.- 14.9.2 The Positioning Apparatus.- 14.9.3 Scanning Technique.- 14.9.4 The Dynamic Examination.- 14.10 Sonographic Follow-Ups, and Comparisons of Sonography, Radiography, and Arthrography.- 14.10.1 Sonograms of Normal Hips at Various Age Levels.- 14.10.2 Individual Sonograms of Type 2a Through 2c Hips.- 14.10.3 Monitoring the Response of Type 2b-2d Hips to Therapy.- 14.10.4 Comparisons of Sonograms and Radiographs.- 14.10.5 Sonographic Monitoring of Therapeutic Response.- 15 Diagnosis of Congenital Dysplasia and Dislocation of the Hip and Indications for Therapeutic Measures.- 15.1 Early Diagnosis and Indications for Therapeutic Measures.- 15.5.1 General.- 15.1.2 Findings on Clinical Examination.- 15.1.3 Absolute and Relative Indications for Sonography and Radiography.- 15.1.4 Sonographic Diagnosis and Indications for Treatment.- 15.1.5 Radiography of the Infant Hip and Its Role in Diagnosis and Management.- 15.2 Late Diagnosis.- 16 The Conservative Treatment of Congenital Dysplasia and Dislocation of the Hip.- 16.1 Treatment of Hip Dysplasia.- 16.2 Treatment of the Dislocated Hip.- 16.2.1 Reduction of the Dislocated Hip.- 16.2.2 Resolution of Instability (Stabilization Phase).- 16.2.3 Resolution of Residual Dysplasia.- 16.2.4 Complications of Closed Reductions.- 17 Technique of the Conservative Treatment of Hip Dysplasia and Dislocation.- 17.1 Manual Reduction Methods.- 17.1.1 The Lorenz Technique of Manual Reduction.- 17.1.2 The Lange Technique of Manual Reduction.- 17.2 Methods of Immobilizing Unstable and Dysplastic Hips.- 17.2.1 The von Rosen Splint.- 17.2.2 The Abduction Pillows of Becker and Mittelmeier.- 17.2.3 Abduction Splints.- 17.3 Harnesses for Reducing the Dislocated Hip.- 17.3.1 The Pavlik Harness.- 17.3.2 The Hoffmann-Daimler Harness.- 17.4 Traction in the Treatment of Congenital Hip Dislocation.- 17.4.1 Longitudinal Traction.- 17.4.2 Traction in Abduction and Medial Rotation.- 17.4.3 Overhead Traction.- 17.4.4 The Krämer Method of Hip Reduction by Traction.- 17.5 Reduction of the Hip in the Hanausek Apparatus.- 17.6 The Fettweis “Squatting Position” of Cast Immobilization.- 17.7 Hip Reduction Under Arthrographic Control (Our Technique).- 18 Ischemic Necrosis of the Femoral Head in the Treatment of Congenital Hip Dislocation.- 18.1 Causes of Ischemic Necrosis Complicating the Treatment of Congenital Hip Dislocation.- 18.1.1 Summary and Conclusion.- 18.2 Nomenclature and Classification of Ischemic Necrosis.- 18.3 Studies on the Dependence of Ischemic Necrosis on Treatment Method, Position of Immobilization, Length of Immobilization, Grade of Dislocation, and Age.- 18.4 Studies on the Dependence of Ischemic Necrosis on Arthrographic Findings.- 18.4.1 Discussion of Results.- 19 On the History of the Treatment of Congenital Hip Dislocation.- 20 Published Results on the Early Diagnosis and Treatment of Congenital Hip Dislocation.- 20.1 Frequency of Palpable Signs in Newborns.- 20.2 Adduction Contracture in Newborns.- 20.3 Detection of Congenital Hip Dislocation and Results of Treatment.- 20.4 Ischemic Necrosis of the Femoral Head Complicating Neonatal Treatment.- 20.5 On the Pathologic Significance of Neonatal Hip Instability with and Without the Roser-Ortolani Sign and “Dry Hip Click”.- 20.6 Dysplasia and Dislocation in Hips That Are Clinically Stable at Birth.- 20.7 Factors Which Promote or Inhibit the Development of Hip Dysplasia.- 21 Reports on the Results of the Closed Treatment of Congenital Hip Dislocation at Different Ages Using Various Methods.- 21.1 Overview of Results.- 21.2 Ischemic Necrosis of the Femoral Head.- 21.3 Age at Start of Treatment.- 21.4 Initial Status: Dysplasia, Subluxation, Dislocation, and Acetabular Index.- 21.5 Duration of Treatment and Follow-Up.- 21.6 Concentric Reduction, Normal Function, Surgical Intervention.- 21.7 Dependence of Joint Parameters on One Another and on the Immobilized Position of the Femur.- 21.8 Our Own Treatment Results, Classified According to the Scheme of the CSHD.- 22 Technique of Open Reduction of the Congenitally Dislocated Hip.- 22.1 Obstacles to Reduction.- 22.2 Approaches for Open Reduction of the Hip.- 22.2.1 The Medial Approach of Ludloff.- 22.2.2 The Anterior Approach.- a) Longitudinal Incision.- b) Inguinal Incision.- c) Our Technique.- 22.2.3 The Anterolateral Approach.- 22.2.4 The Lateral Approach.- 22.2.5 The Posterior Approach.- 22.3 Open Reduction of the Hip in the First Six Months of Life.- 22.4 Open Reduction of the Hip up to Three Years of Age.- 22.4.1 Ischemic Necrosis.- 22.4.2 Postoperative Adhesions, Limitations of Motion, Stiffness.- 22.4.3 Redislocation.- 22.4.4 Operative Technique.- 22.5 Open Reduction of the High, Longstanding Hip Dislocation.- 22.5.1 Preliminary Traction.- 22.5.2 Traction After Prior Release of Muscles and Soft Tissues.- 22.5.3 Femoral Shortening as a Preliminary to Hip Reduction.- 22.5.4 Arthroplasty of Codivilla and Colonna.- 22.5.5 Our Technique.- 23 Review of the Literature on Open Reduction of the Hip.- 23.1 General Overview.- 23.2 Indications.- 23.3 Operative Technique in Small Children.- 23.4 Results of Open Reductions in Small Children.- 23.5 Hip Reductions in Older Children.- 23.6 Current Indications for Late Open Reduction of the Hip.- 24 Femoral Osteotomies to Improve the Hip Joint.- 24.1 Classification of Femoral Osteotomies.- 24.2 Technique of the Intertrochanteric Derotation Varus Osteotomy in Children.- 24.2.1 Preoperative Preparations.- 24.2.2 Exposure of the Operative Site.- 24.2.3 Intertrochanteric Osteotomy.- 24.2.4 Techniques of Wedge Resection for Varus Osteotomy.- 24.2.5 Amount of Varus Angulation and Derotation.- 24.2.6 Amount of Medialization in Varus Osteotomy.- 24.2.7 Fixation ofthe Osteotomy.- 24.2.8 Details of the Conduct of the Operation and Aftertreatment.- 24.3 Valgus Osteotomy in Children.- 24.4 Intertrochanteric Osteotomies in Adolscents and Adults.- 24.4.1 Prophylactic Osteotomies.- 24.4.2 Osteotomies in the Presence of Osteoarthritis.- 24.4.3 Internal Fixation of Intertrochanteric Osteotomies in Adolescents and Adults.- 24.5 Subtrochanteric Osteotomy at Various Age Levels.- 24.6 Shortening Osteotomy in Open Reductions of the Hip.- 24.7 Inter- and Subtrochanteric Step-Cut Shortening Osteotomy.- 24.8 Angulation Osteotomy (Buttress Osteotomy, Pelvic Support Osteotomy).- 24.9 Resection-Angulation Osteotomy.- 24.10 Transfer of the Greater Trochanter.- 24.11 Valgus Osteotomy for Extreme Coxa Vara (Intertrochanteric Double Osteotomy with Trochanteric Transfer).- 25 Pelvic Operations for Dysplasia of the Hip.- 25.1 Shelf Operations.- 25.2 Acetabuloplasties.- 25.2.1 Lateral Approach.- a) Location of the Hinge for Various Acetabuloplasties.- b) Age and Prerequisites.- c) Our Technique of Acetabuloplasty.- 25.2.2 Anterior Approach.- 25.3 Pelvic Osteotomies That Redirect the Acetabulum.- 25.3.1 Salter’s Single Innominate Osteotomy.- 25.3.2 Double and Triple Osteotomies with Acetabular Rotation.- a) Double Osteotomy of LeCoeur.- b) Double Osteotomy of Sutherland and Greenfield.- c) Double and Triple Osteotomy of Hopf.- d) Triple Osteotomy of Steel.- e) Triple Osteotomy of Tönnis.- 25.3.3 Spherical Osteotomies.- a) Spherical Osteotomy of Blavier and Blavier and Wagner.- b) The Dial Osteotomy.- 25.4 Chiari’s Medial Displacement Osteotomy.- 26 Total Hip Arthroplasty for the Treatment of Hip Dysplasia with Osteoarthritis.- 27 Survey of the Literature on the Surgical Management of Hip Dysplasia and Femoral Neck Deformities.- 27.1 Shelf Operation and Acetabuloplasty.- 27.2 Correction of Antetorsion.- 27.3 Corrective Osteotomies of the Femoral Neck.- 27.4 Correction of Valgus and Antetorsion.- 27.5 Operations on the Acetabular Roof and Pelvis.- 27.6 Should Pelvic Operations Be Combined with Femoral Osteotomy?.- 27.7 Age Limits of Various Procedures.- 27.8 Acetabular Rotation.- 27.9 Comparative Studies on the Capabilities of Various Operative Methods and the Postoperative Behavior of the Joint.- 27.9.1 Collective Statistics of the CSHD on the Results of Operative Treatment in Children.- 27.9.2 Conclusions.- 28 On the Indications for Operative and Nonoperative Treatment Measures in Hip Dysplasia.- 28.1 General.- 28.2 Principles of Decision-Making During Growth.- 28.3 Principles of Decision-Making After the Cessation of Growth.- 28.4 Other Factors Affecting the Choice of Treatment.- 28.5 Summary and Conclusions.- 29 Clinical Examples of Indications for Operative and Nonoperative Treatment Measures, and the Management of Complications.- 29.1 General.- 29.2 Examples of Radiograph Interpretation in Infants and Small Children.- 29.3 Special Problems in Hip Reductions.- 29.4 Problems of Further Management After Hip Reduction: The Unstable Hip.- 29.5 Management of Coxa Magna.- 29.6 Varus Osteotomy Alone or Only in Conjunction with Acetabuloplasty?.- 29.7 Spontaneous Development of the Hip.- 29.7.1 Examples of Hip Dysplasia with Excessive Antetorsion.- 29.7.2 Toeing-In Syndrome (Antetorsion Syndrome).- 29.7.3 Retrotorsion.- 29.7.4 Spontaneous Development of the Dysplastic Hip.- 29.8 The Radiographic Features of Hip Dysplasia in Adolescents and Adults.- 29.9 Methods for the Operative Treatment of Hip Dysplasia in Adults.- 29.10 Techniques to Handle Complications.- 29.11 On the Indication of Surgery After Ischemic Necrosis.- 30 Literatur.- 31 Subject Index.