Cafe'  Door

          Cafe' Door ??   vs    VRO??



Why another operation for the hip? There are so many already? That's a clue that what is out there isn't wonderful. But beware. While we will assert that this SEEMS to be a better choice than some of the other "traditional" surgeries . . .

 IT'S   NEW!     Wooowee!

But that means there is no long term assessment possible. We are riding on our gut instincts and the mechanics of it.

DripEtherThe problem is that VRO thing. It was shown how conservative cast positioning for congenital hip dislocation could be abbreviated by leaving the top of the femur abducted and inward rotated by cutting the bone to bring the rest of the legs together.Lorenz_VRO_Sm

Given a late diagnosis of DDH and a potential several years in a nasty body cast holding a leg in bizarre position, cutting the bone at the top let the part that needed to be that way - be that way - while the rest was more humanely positioned (held by metal plate & screws etc). So the CAUSE was gone - uterus crush. The blue print for growth was perfect and young. Just get the pressure off the dent in the acetabulum and nature in good form will do the rest.

Ta-dahhhh.  A hero operation! So when you have a great football team with huge linemen who won the trophy... do you just say attaboy to them? No you send them off to swim the  English channel. So big muscle guys with no body fat sink like stones and are never seen again?

What? The VRO - hero of newborn babies with a dislocated hip... was champ of baby hips and so sent into battle with spastic dystonia [which takes perfectly normal hips and over time grinds them down and pulls them apart]. Go VRO! Go get'em!. Do do it like you do'd it in DDH!

But in DDH,  VRO had no opposition. THAT was gone with birth. It was a sweep up job after the riot - not during. In  CP, hips are perfectly normal good hips that are being destroyed by force clashes that are still ongoing and in excess of what the human natural blue print can endure! It's not the same. Fighting a war with a dust pan? And even if it did get things back, what stops more damage?

So VRO went off to fight another war, a different war. But did it do well anyway? Is it a hip lucky operation? No. Failures abound. Rehab from the surgery itself is awful. We have data now  from all kinds of really good places (extensive data too) that tells us what any private surgeon would have known in a month... not good. How can you have so many failures (where there are few if any good outcomes and so much overt failure that you have to reoperate are on the the majority) - how can there be that many failures and nobody notice it for over 50 years!!!!!!!! Come on! People in white coats. I blame you!! You refuse to acknowledge anything unless there is 1000 of it.

Pig headed number worshipers. Have to have scores of ruined kids to satisfy 'p' value nonsense? And the AACPDM presenters are adoring themselves over their scientificness and decimal places? They are still pushing this approach.

Yes. I am old and grouchy. Couldn't I say it nice? I guess but that was years ago. Ahem, hasn't anybody noticed that this procedure is unstable in CP? Residents come & go and do NOT follow the outcomes - assuming everything they touch is golden. So the professors call for numbers. Oooo, not good. Maybe use sharper tools. Do a thousand more. Nope. Do it younger. Worse. Another thousand. Do it older. But never: "Don't do it at all."

Then along comes a really cockamamie theory calling itself lever arms. Hey did you notice that the human body has bones?


Yes and they act as levers.

Oooooo. Really? Do tell.

Yes and levers ,contain physics and you can name drop Newton. They come in three kinds: One two and three. So cerebral palsy is when the levers get vectors that cause the levers to do naughty things.

You mean it isn't a neurologically driven muscle mediated process? So when baby seals are being battered it is the club's fault? Damn them vectors! Cut all those leverage bones. Big cuts every where. Then call it "The shark bite method". [Seriously that is the name]. Make sure you look doctorly. Gotta have a starched white coat to get away with spewing that nonsense.  Did anyone ever see an octopus escape by squeezing through a tiny hole? No bones. No bone vectors. Shape shifting out the wazoo. Explain.

Madam, your child is falling all over the place because she has vectors. We need to break all her bones.


With VRO the surgeon does not even see the hip. [Top image right part]. She sees the greater trochanter through a slit cut in the tensor and outer thigh muscle. The femur bone gets cut without seeing the socket at all, without any clue of what is amiss in the shape of the socket or ball or ligaments. So, based on faith, tilt the top end down with a bit of back rotation to take pressure off the front of the socket. Oooo wait? In DDH that is where the dent is.

In CP, is it? Yes? No?

No. The dent is usually on the back side. So is the R turning (the R in VRO for rotate) the turn the WRONG way? mmmmmmmm... looks that way to me. But you wouldn't know, would you? You can't even see the  hip ball or socket from here. There was a time when real hip surgeons actually looked at the hip itself. They still do. [Top image left part]. They would look and see what is specifically wrong and hands on determine what specifically seems to make it behave better.

Click the above for a PDF of the surgical exposure for Cafe' Door.
           Very graphic. Not for those weak of heart!



      Cafe' Door in flip version (Windows only).
      (Photography by Dr. Paul Jordan)

Whoa. That is not smaller surgery. No. Not at all. Best bet is don't let it get so bad that this is what we are led to. Prevention. Do not wait for x-ray changes to rid a child of obviously potential damaging forces. You don't kneel on a child's neck and require an x-ray of the wind pipe to determine whether to stop. Strong hip adduction forces with leg crossing and prolonged sitting damage hips. We have huge data that clearly shows Botox doe not protect the hips. Indeed the love affair with Botox is making us awash in bad hips. We like Botox for lots of stuff but hip protection is nil.

The Scandinavian publishing gurus are pushing to just do nothing until certain changes are seen on x-ray. Joint damage but the top professor actually denies that there is any damage to the hip if the x-ray shows displacement.  Huh? Not proven with 'p' value that the hip is damaged. By the way there is no proof with sufficient 'p' value that the bulk of buried Ebola victims are still dead. If you don't look for one will one just walk up to you and say "Hi. I am the 'p' value that says your shoelace is untied."

One of the most common and gravest errors in computer programming (and math) is to assume a specific value in the absence of data. The rarest number of all in the natural world is zero. Assuming zero (something is not there) because of no study is not only wrong it is uneducated and stupid all rolled together.

However we need more experience and definitely much more time to know whether this method - which does the initial intent well, (put the ball in the hole) does it well and without the immobility and long term convalescence. But will it prove to have been worth while. 


6dayspostop IMG_0369 RecycledABDbitLOW


A teratologic hip with missing anterior third of acetabulum went suddenly 'north' bringing this ambulatory youngster to writhing pain. Unable to sit nor stand. Cafe' Door used building the anterior third from a slice of pubis section slid laterally and held by sutures with additional shaped and packed bone graft. Cafe'door allowed thigh rotation to not translate to nor disturb the socket repair for over 2 weeks. During that time the socket build solidified before the femur osteotomy was healed. What was intact of the original socket was good allowing this odd choice. The position of fixation of the femoral osteotomy was the position that was not unstable and happy in motion (not trying to pop out). The flexion abduction posture is probably NOT uniform among the many other reasons a hip can go out.  Post operative walking at two months is seen.


The above video begins with an examination of the model itself and is related to "VIEWS" as might be taken by normal x-rays (see left side for wire model of typical AP view etc).  Emphasis in on the relationships of certain 'key' lines (as examined in 3D space) used by radiologists & screeners to judge whether the hip is abnormal and if so how much. Not exhaustive. The easy point to be seen is that when deformed, the lines may be quite a bit different depending on the forward slant of view (and how lordotic the patient). Easy to be mislead.

The second half of the video dwells on anatomy changes that MUST occur as deformity shifts even a small amount. The small muscles of the hip - sort of the rotator cuff of the hip - seem to have a disproportionate alteration and may well drive the mechanics of failure afterward.