Radiographic course after acetabuloplasty and femoral osteotomy in hip dysplasia

The radiographic course of 101 hips with residual dysplasia treated with roof plasty combined with intertrochanteric varus derotation osteotomy using the osteotomy wedge as a roof graft after Mittelmeier were reviewed. The average followup period was 8.8 years. The acetabular angle was improved by an average of 16 degrees (postoperative mean, 19 degrees; average at followup, 18 degrees). The center edge angle also was improved by 16 degrees and was stable at 25 degrees average at followup. The neck shaft angle, abnormal in 70% of hips preoperatively, was reduced by the varus osteotomies to a mean of 111 degrees and showed a spontaneous postoperative increase to normal values of an average of 129 degrees. There was no correlation of the postoperative of the neck shaft angle to patient age, preoperative valgus extension, correction angle, or length of followup. In nearly all cases, an almost anatomic joint shape was achieved. With a complication rate of only 1%, especially regarding the rate of necroses of the femoral head, the presented surgical technique can be recommended as highly effective, reliable, and safe for the treatment of congenital hip dislocation.     

How to evaluate suspected immunodeficiency

The periacetabular osteotomy is a strategy for the treatment of residual hip dysplasia in young adults with the aim of preventing secondary coxarthrosis. This polygonal, juxta-articular osteotomy respects the vascular blood supply to the acetabular fragment and thus facilitates an extensive acetabular reorientation with improvement of the insufficient coverage of the femoral head, including medial displacement of the fragment. All osteotomies are performed by one approach, the modified Smith-Petersen, which allows an anterior capsulotomy. Inspection of the joint not only provides information on acetabular rim pathologies, but also facilitates the control of impingement-free range of motion after the correction. The posterior column remains partially intact, allowing minimal internal fixation of the acetabular fragment and early mobilization similar to that after an intertrochanteric osteotomy. The dimensions of the true pelvis are unchanged, providing the capacity to have an unimpeded delivery in women. This paper describes the preoperative evaluation, current indications, surgical technique, postoperative care, and the results of this osteotomy.     

Acetabular growth potential in congenital dislocation of the hip and some factors upon which it may depend

The factors which determine the rate and amount of acetabular growth in congenital dislocation of the hip are ill-understood. A prospective radiological study has been devised in order to assess the influence of the age of congruity, femoral anteversion and neck/shaft angles on acetabular growth. To be included, the children must have reached at least 8 years of age. Those with associated congenital abnormalities and subluxation were excluded, as were those who had operations for acetabular reconstruction. Seventy-four hips were suitable for analysis, and the age range at follow-up was from 8 to 17 years. The acetabular angle was used as an index of acetabular growth. Measurement of this angle, and the anteversion and neck/shaft angles were made before, and each year after reduction of the hip. Congruity was assessed from a radiograph with the legs in the functional position. A satisfactory acetabulum was obtained in 44 hips and the mean age of congruity was 33 months; the acetabulum was unsatisfactory in 30 hips, with a mean age of congruity of 48 months. Four years is the critical age, for if congruity is obtained later, the risk of producing a moderate or severely dysplastic acetabulum is more than doubled. If congruity is obtained under four years of age, growth of the acetabulum with continue in most patients up to 8 and in some to 11 YEARS OF age; the resulting acetabulum was normal or mildly dysplastic. Fifty-nine per cent of the satisfactory hips at follow-up had a normal anteversion angle, and 6 per cent a normal neck/shaft angle. Correction of these angles by themselves, seems not to be a major importance for promoting acetabular growth.     

Bilateral coxarthroses and avascular necrosis of the femur head in adults

Based on the authors' personal experience, it was concluded that in surgical treatment for coxarthrosis intertrochanteric osteotomy is to be preferred, since it proved to be effective even in advanced cases of the lesion in the extent of residual motions of 30--40degrees. If indicated, the procedure may be bilateral. The operation yielded the best results also in avascular articular trophesy with resorption of sequestrae. In grave cases it is rational to begin with prosthesizing of one of the joints.     

Quantitative analysis of incongruity, contact areas and cartilage thickness in the human hip joint

Joint incongruity and cartilage thickness have been shown to determine the contact stresses and the load partitioning between the solid and fluid phases of articular cartilage. Matrix stresses, which are relevant in the development of osteoarthrosis, can, however, not be determined experimentally but must be calculated using numerical methods. The aim of the present study was to quantify the incongruity and cartilage thickness of the human hip, in order to allow for the construction of morphologically accurate finite element models. Twelve cadaveric specimens (34-86 years), two fresh and ten fixed, were investigated. The loading configuration was based on in vivo measurements of hip joint forces during midstance. The incongruity and contact areas were determined using a polyether casting technique, in the minimally and the fully loaded state. The cartilage thickness was measured at identical coordinate points with an A-mode ultrasonic system. Generally, the contact started at lower loads at the edge of the lunate surface, and the joint space increased towards its central aspects. In some specimens the contact started in the acetabular roof, leaving a joint space of up to 2 mm in the horns of the lunate surface. In others, the initial contact was observed in the anterior and posterior horns of the lunate surface with a joint space width of up to 0.75 mm in the acetabular roof. The size of the contact areas increased from about 20% of the lunate surface to 98% at higher loads. The articular cartilage thickness ranged from 0.7 to 3.6 mm, the maxima being located in the ventral aspects of the femoral head and acetabulum. These quantitative data on joint space width, contact, and cartilage thickness in the human hip joint may be used to construct and validate finite element models which are required to elucidate the mechanical factors involved in osteoarthrosis.     

Management of comminuted fractures of the distal radius in the adult. Conservative or surgical?

Displaced fractures of the distal radius are difficult to treat successfully by traditional nonoperative methods. The goal in the management of these fractures is to achieve extraarticular alignment and an articular step off of less than 2 mm. Cast immobilization has been supplemented with pins and plaster technique and external fixators. Percutaneous are limited open reduction techniques, combined with wrist arthroscopy, have been shown to be useful in the management of intraarticular distal radius fractures. Despite these advances, there are still a significant number of fractures in which the articular surface cannot be reconstructed without open reduction and internal fixation. The main objective is to restore articular integrity as perfectly as possible. Attention to meticulous surgical technique will facilitate good results. When articular restoration cannot be accomplished, early arthrodesis or arthroplasty should be indicated. In the absence of osteoarthritis, intraarticular osteotomy can be used for intraarticular malunions with a step off greater than 2 mm. Radius malalignment usually requires a dorsal opening wedge osteotomy, insertion of a corticocancellous graft, and a dorsal buttress plate. Early recognition and treatment of distal radioulnar joint injuries associated with fractures of the distal radius are paramount to reduce the incidence of painful sequelae and functional deficits.     

Disease and nonbattle injury among United States soldiers deployed in Bosnia-Herzegovina during 1997: summary primary care statistics for Operation Joint Guard

Lesions of the acetabular labrum should be treated by correcting the causes. In a steep acetabulum where the femoral head brings the acetabular labrum under tension and traction, the acetabulum should be rotated by triple pelvic osteotomy to slightly over-corrected acetabular measurements. Severely diminished acetabular and femoral anteversion can also lead to tears and impingement of the labrum. Then rotation of the femoral neck and/or rotations of the acetabulum by triple osteotomy to 15-20 degrees of anteversion are indicated. Our triple osteotomy technique differs from that of others mainly in the ischial osteotomy. It is performed from the posterior approach between the sciatic notch next to the ischial spine and the obturator foramen and is directed 20-30 degrees anteriorly from the frontal (coronal) plane. The osteotomies therefore are placed close enough to the acetabulum to allow free rotation, but they do not interfere with the circulation of the acetabulum, and the ligaments between the sacrum and ischium are left in normal tension. Our normal values of the acetabular position were tested by correlating the measurements with the absence of pain. The optimum is reached with a CE angle and a VCA angle of 30-35 degrees, an angle of the weight-bearing zone of +5 to -5 degrees and a migration index of 10-15%. Overcorrections again caused pain and should be avoided. Diminished anteversion of femur and acetabulum towards 0 degree also caused pain and should be corrected by triple and femoral osteotomy to 15-20 degrees of anteversion. In earlier follow-ups of 216 hips 5-10 years postoperatively, 82.3% of the joints showed no change in the degree of osteoarthrosis. Survival rate curves regarding the absence of pain demonstrated that pain was experienced again when joints were corrected insufficiently or overcorrected, while in good corrections the joints were free of pain in about 75%.     

Ganglion cysts of the knee: articular communication revealed by delayed radiography and CT after arthrography

OBJECTIVE: The diagnosis of ganglion cysts of articular origin may sometimes be uncertain when communication with the joint is not evident. Because we have observed that opacification of ganglion cysts revealed by arthrography can be significantly delayed, the purpose of this study was to determine retrospectively in 20 cases the time delay needed to show with arthrography a communication between the articular cavity and ganglion cysts of the knee. CONCLUSION: Arthrographic evidence of a communication between the articular cavity of the knee and communicating ganglion cysts requires delayed radiography performed at least 1 hr after intraarticular injection of contrast material. The best results are obtained with additional CT performed 1-2 hr after injection.     

The Donauspital-Stolzalpe concept (Danube Hospital, Vienna, Austria). Corrective osteotomy with selective labrum surgery following preoperative MRI arthrography

Concomitant pathologies (labral lesions, intra-/extra-osseous ganglia and stress bone marrow edema) in adult residual hip dysplasia (RHD) might influence the outcome of conservative hip surgery. The aim of our prospective clinical study was to assess the value of preoperative MR arthrography in diagnosing concomitant lesions and in making surgical decisions in RHD. The first 37 consecutive patients with a minimum follow-up of 18 months have been analysed. All 37 patients presented RHD with the clinical symptomatology of labral lesions and underwent routine preoperative MRA. According to clinical, radiological and MR arthrographical criteria, these 37 patients were subdivided into four therapeutic subgroups: (1) reorientation of the acetabulum using the T?nnis triple pelvic osteotomy (TPO); (2) intertrochanteric varisation osteotomy (IVO); (3) palliative decompression with only symptomatic partial resection of the torn labrum (PALL); (4) primary total hip replacement (TEP). Based on the preliminary clinical and radiological outcomes of these four subgroups, the following conclusions can be drawn: labral lesions are considered to be a sign of chronic joint instability. Therefore, acetabular malorientation should be corrected by redirectional osteotomy of the acetabulum (TPO-subgroup) even in low grades of RHD if labral lesions are present. "Palliative" labral resections without corrective osteotomy (PALL subgroup) in secondary osteoarthritis due to RHD are definitively obsolete, because they rapidly progress to severe osteoarthritis due to surgically accelerated joint instability. In RHD with highly osteoarthritic hip joints and concomitant lesions, one should not hesitate to perform primary THR even in young patients.     

Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury

The results were reviewed for 259 patients who had open reduction and internal fixation of 262 displaced acetabular fractures within twenty-one days after the injury. Two hundred and fifty-five hips were followed for a mean of six years (range, two to fourteen years) after the injury; the remaining seven, which clearly had a poor result, were followed for less than two years. According to the classification of Letournel and Judet, associated fracture types accounted for 208 (79 per cent) of the fractures, with both-column fractures being the most common type (ninety-two hips; 35 per cent). Two hundred and fifty-eight hips were operated on with a single operative approach (Kocher-Langenbeck, ilioinguinal, or extended iliofemoral). The four remaining hips were operated on with a Kocher-Langenbeck as well as an ilioinguinal approach. The reduction was graded as anatomical in 185 hips (71 per cent). The rate of anatomical reduction decreased with increases in the complexity of the fracture, the age of the patient, and the interval between the injury and the reduction. The over-all clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. The clinical result was adversely affected by associated injuries of the femoral head, an older age of the patient, and operative complications. It was positively affected by an anatomical reduction and postoperative congruity between the femoral head and the acetabular roof. Osteonecrosis of the femoral head was noted in eight hips (3 per cent), and progressive wear of the femoral head was seen in thirteen (5 per cent). Subsequent operations included a total replacement of seventeen hips (6 per cent), an arthrodesis in four (2 per cent), and excision of ectopic bone in twelve (5 per cent). These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. An increase in the rate of anatomical reduction and a decrease in the rate of operative complications should be the goals of surgeons who treat these fractures.     

Salvage operation for neglected ankle fractures

From 1986 to 1993, 49 cases of untreated or poorly treated ankle fractures who received salvage surgery were followed up for an average of 36.4 months. The patients included 31 males & 18 females with an average age of 41.6y/o and the time interval from initial injury to reconstructive surgery average due 17.6 months. They were classified and treated according to their grade of reduction and degree of arthrosis. The surgical methods included arthrotomy & joint debridement, revised open reduction, lower tibial osteotomy and ankle arthrodesis, depending on different individual conditions. After surgery, all cases had symptomatic relief and functional improvement with an average score increased from 26.3 preoperatively to 86.8 at follow up. The goals of ankle fractures is as articular fractures, they are treated by surgical anatomic reduction with rigid fixation as early as possible in order to provide good functional results. Nevertheless they are varied in neglected ankle fractures according to their individual conditions: open reductions were performed on cases with no or little arthritic change even though arthrosis might occur later because, if necessary, future conversion to osteotomy or arthrodesis would be easier. As for late cases with advanced arthritis, ankle arthrodesis were done by compressive arthrodesis with necessary bone graft to secure fusion in an optimal position.     

Identification of Ce-AF-6, a novel Caenorhabditis elegans protein, as a putative Ras effector

Three female patients with osteoarthrotic hips received total hip replacement arthroplasties after failed rotational acetabular osteotomies (RAO) were reported. In the first case, there was necrosis of the thin acetabular fragment and a collapse of the large grafted iliac bone because of technical problems. The second case had residual development dislocation of the hip preoperatively which resulted in pseudoarthrosis and instability of the pubic bone postoperatively. This patient was considered to be a bad candidate for rotational acetabular osteotomy. The last case was 65 years old, too old to treat by osteotomy. Deterioration of the articular cartilage was expected. All of them were successfully treated with total hip arthroplasties. The ages of the patients, the stage of osteoarthrosis, the thickness of the osteotomized acetabular fragment, and the size of the grafted bone seemed to be factors influencing the outcome of the RAO.     

Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children

A one-stage, combined operative procedure for reduction of congenitally dislocated hips in older children consists of shortening of the femur; open reduction by an inferior approach to the joint; reconstruction of the acetabular roof; correction of anteversion of both the femoral neck and the neck-shaft angle; anterior transposition of the iliopsoas muscle. On 60 hips operated in children, ages 5 to 15 with a follow-up period, ranging from 5 to 9 years, the results were found to be excellent in 3 per cent, good in 60 per cent, fair in 30 per cent, and poor in 7 per cent. The procedure is indicated in children up to the time of early puberty. The primary indication is high bilateral dislocation. In unilateral dislocations some residual leg-length discrepancy frequently occurs. This procedure should be done only by orthopedic surgeons who have special training and experience in the treatment of congenital dislocation of the hip.     

Pelvic osteotomies: anatomic pitfalls at the pubic bone. A cadaver study

Pelvic osteotomies for acetabular dysplasia include an osteotomy of the pubic bone. The anatomical consequences of two different approaches to the pubic bone were assessed by performing a triple osteotomy on a series of 12 fresh cadaver hemipelvises. The medial approach through a separate incision over the pubic symphysis was compared with the lateral approach through the incision used for the innominate osteotomy. Although the medial approach appears technically easy, there are several anatomical structures at risk, such as the femoral vein and the corona mortis. The lateral approach is safer, and it is easier to make the osteotomy close to the hip joint. The closer the osteotomy is to the hip joint, the smaller the chance of developing a non-union.     

Evaluation of treatment of hip subluxation in myelomeningocele by intertrochanteric varus derotation femoral osteotomy

A retrospective study of 27 subluxed hips was carried out in 18 patients with myelomeningocele treated by varus derotation intertrochanteric osteotomy. Twenty-three of the 27 hips were stable at follow-up review. The causes of failure were related to the presence of pelvic obliquity secondary to scoliosis or to a dysplastic acetabulum (acetabular index above 25 to 30 degrees). Transfer of the iliopsoas tendon was not found to be necessary in order to achieve stable reduction.     

Fibrous dysplasia of the proximal part of the femur. Long-term results of curettage and bone-grafting and mechanical realignment

We reviewed the long-term outcomes of treatment of fibrous dysplasia of the proximal part of the femur in twenty-two patients (twenty-seven femora). There were fifteen male patients and seven female patients. Patients who had monostotic disease had no involvement of the calcar femorale, fewer microfractures, less deformity, and stronger bone that could support internal fixation. Patients who had polyostotic disease had frequent involvement of the calcar femorale; more microfractures; severe deformity, including shepherd's crook deformity; and, in many instances, bone that could not support internal fixation. Twenty-two of the twenty-seven femora had a microfracture at the time of the initial presentation. At least one osteotomy was performed in four femora that had monostotic disease and in nine femora that had polyostotic disease. Curettage and cancellous or cortical bone-grafting did not appear to have any advantage compared with osteotomy alone in the treatment of symptomatic lesions, as all grafts resorbed with persistence of the lesion. At the time of the latest follow-up evaluation, no lesion had been eradicated or had decreased in size. A satisfactory clinical result was achieved in twenty patients (twenty-four femora): nine who had monostotic disease and eleven who had polyostotic disease. Two patients who had polyostotic disease and an endocrinopathy (one of whom had bilateral involvement) had an unsatisfactory result. All three femora in these two patients had a neck-shaft angle of less than 90 degrees at the time of the most recent follow-up evaluation. Varus deformity of the proximal part of the femur is best treated with valgus osteotomy and internal fixation early in the course of the disease. If the calcar of the femoral neck is involved or if the quality of the bone is such that internal fixation is not possible, a medial displacement valgus osteotomy can provide a more mechanically favorable position for healing of the microfracture.     

Colchicine in chronic hepatitis B: a pilot study

INTRODUCTION: The authors report the case of an internal rotation of the lower limb, lately ascribed to a posterior placement of the acetabular component during total hip arthroplasty. MATERIAL AND METHOD: A 58 years old female had an irreducible internal rotation of the right hip 3 years after total hip arthroplasty for arthritis. When the hip was extended, the lower limb showed an irreducible internal rotation of 45 degrees. In flexion of the hip this rotation disappeared. AP radiograms showed femur and femoral stem in internal rotation, a healed fracture of the acetabulum, and the acetabular component seemed to be in correct position. On CT scan the acetabular component was 4 cm posterior to the anatomic location, although there was no abnormal anteversion of the stem and acetabular component. Revision, with relocation of the acetabular component, corrected lower limb rotation. DISCUSSION: Posterior position of the acetabular component has not been described as a cause of lower limb malrotation. Normally the strength of the external hip rotators muscles is three times as important as of the internal rotators. The transverse acetabular fracture led to backwards placement of the acetabular component and yelded in an automatic internal rotation of the femur, because the trochanter kept an anatomical position in the horizontal plane. The posteriorised rotation center of the hip had changed the balance of the different rotator muscles, some of them, originally external rotators, becoming internal rotators.     

Eruption times of third molars in young rural Nigerians

The mechanical stability of proximal femoral osteotomies fixed by the tension band wire technique was studied in flexion-compression and torsion tests. The fixation consisted in crossing the section with two Kirschner wires and with a wire cerclage applied to the tension surface. The study was conducted in three steps. First, cyclinders of wood were cut either transversely or at 30 degrees of inclination in relation to the long axis of the specimen, and fixed with two Kirschner wires and a wire cerclage. We concluded that the inclination of the plane of section significantly increased the stability of fixation. No significant difference was observed when oblique sections were made in the reverse orientation. Second, 30 degrees subtrochanteric varus osteotomies were performed in dog femurs, so that the section plane was transverse in one group and oblique in another, after closing the osteotomy. In both groups the fixation was achieved by two Kirschner wires that crossed the osteotomy and a wire cerclage placed on the lateral cortex (tension surface). We concluded that inclination of the osteotomy plane increased the stability of osteosynthesis in bone specimens, as already seen with the wood pieces. Third, the stability of tension band wire fixation was compared with that provided by the AO/ASIF paediatric angled plate. Varus osteotomies (30 degrees) were created at the subtrochanteric level of paired dog femurs. On one side, the femur was fixed with Kirschner wires and a wire cerclage as described previously. For the other femur, the osteotomy was fixed with the angled plate. We found that both types of fixation presented the same stability in flexion-compression tests. However, under torsion the tension band wire fixation was 30%-50% less stable than the plate fixation.     

Development of the metatarsophalangeal joint of the chick embryo: morphological, ultrastructural and histochemical studies

The histogenesis and mechanism of joint clefting of the developing chick embryo up to the fifteenth day of incubation have been studied morphologically, ultrastructurally, and by histochemical methods. Cell degeneration was consistently noted 24 hours after differentiation of the joint tissue, and it is postulated that this early cell necrosis might account for the loosening of the medial part of articular mesenchyme (interzone) leading to differentiation of a three-layered embryonic joint. At the time of joint clefting degenerative cells were also seen in the peripheral parts of the developing articular cavity. In some cases clefting was immediately preceded and/or accompanied by the appearance of elongated, basophilic and electron-opaque cells closely arranged along the zone of tissue cleavage. These cells were thought to be implicated in some way in the clefting process and later to constitute a surface cell layer of articular cartilage. In addition to these observations clear morphological and histoautoradiographic evidence was found for the presence of an organic component, presumably mucopolysaccharide, in the primitive synovial fluid. Fluid secretion might also account for tissue cleavage at the sites of its accumulation. The data reported here suggest that joint cavity formation results from a combination of both intrinsic, genetically expressed and extrinsic mechanical factors acting synchronously.     

Further characterization of the syndrome of right bundle branch block, ST segment elevation, and sudden cardiac death

There is a lack of defined reference points for reproducible femoral tunnel placement during posterior cruciate ligament (PCL) reconstruction. The PCL, consisting of two major bands, anterolateral (AL) and posteromedial (PM), has a femoral origin that spans 3 cm, which cannot be covered by a substitute graft positioned in one femoral tunnel to reconstruct the PCL. The purpose of this study was to define the location of the anatomic origin of both bands of the PCL in reference to local anatomy to develop landmarks that can be used to reproducibly position two femoral tunnels (one to each band's origin) during PCL reconstruction. The anatomy of the PCL origin was dissected and studied in 20 knees at the time of total knee replacement. The central origin point for each band was marked, and its distance was measured in reference to three axes. The AL band centrally originated 13 +/- 0.5 mm posterior to the medial articular cartilage-intercondylar wall interface and 13 +/- 0.5 mm inferior to the articular cartilage-intercondylar roof interface. The PM band centrally originated 8 +/- 0.5 mm posterior to the medial articular cartilage-intercondylar wall interface and 20 +/- 0.5 mm inferior to the articular cartilage-intercondylar roof interface. These distances were noted to be relatively constant despite varying knee morphologies and size. For this reason, referencing the articular cartilage-intercondylar roof, and wall interfaces may be used as a method to facilitate more reproducible anatomic femoral tunnel placements during PCL reconstruction.