Labrum lesions and residual dysplasia of the hip joint. Definition and prospectives

Labral lesions are a sign of biomechanical decompensation of the hip joint and often represent the first clinical symptom of residual hip dysplasia (RHD) in the adult. Provocation tests (impingement, apprehension) are typical but not specific. Labral lesions and concomitant findings (intra- and extraosseous ganglia, stress bone marrow oedema) can be detected by magnetic resonance arthrography (MRA) with an accuracy of 91%. Primary therapeutic goal is the normalization of the underlying pathomorphology and instability by a redirectional acetabular osteotomy. There are several concepts concerning simultaneous arthrotomy at the time of osteotomy: no arthrotomy at all, selective arthrotomy, routine arthrotomy in every case. There are more clinical studies necessary before one of these concepts can be widely accepted and recommended. Based on preliminary results, palliative arthrotomy with partial labral resection but without corrective osteotomy in osteoarthritis secondary to residual hip dysplasia gives poor results; we therefore urgently dissuade from palliative labral surgery via arthrotomy. Whether labral surgery via arthroscopy might be a useful concept in symptomatic residual hip dysplasia, is still an open question. In this review article, the "state of the art" presented at the "Vienna Labral Symposium 1997" is reflected and summarized. At the end of this article, a "common statement" of the experts is published in English and German language.     

The Boston concept. peri-acetabular osteotomy with simultaneous arthrotomy via direct anterior approach

To this point, we have only a relatively short term followup in 32 patients with known labral lesions who have been treated by combined periacetabular osteotomy (PAO) and debridement of the damaged anterior labrum. A positive clinical history in association with pain demonstrated with the impingement test of flexion-adduction-internal rotation nearly always indicates macroscopic pathology within the anterior portion of the hip joint. Labral lesions associated with acetabular dysplasia seem more common with increasing age. Labral lesions seem to correlate with arthrosis. We suspect that uncorrected impinging lesions of the anterior rim have led to some of our early clinical failures after PAO. We feel that intra-articular treatment of certain impinging lesions may improve the clinical outcome in these patients. Correction of the pathological mechanics in the mature, dysplastic hip certainly requires restoration of stability by reorienting osteotomy. If intra-articular derangements of the anterior rim are also present, though, intra-articular surgery may also be necessary to optimize the outcome. Our early results suggest that the earlier and more complete the correction of the disordered mechanics in the dysplastic hip, the more complete and long-lasting will be both relief of clinical symptoms and preservation of a joint free from arthrosis. Anterior arthrotomy to explore the anterior rim, carried out at the time of PAO, employing the direct anterior abductor-sparing approach (DAA), seems a safe and useful adjunct in treating the mature, dysplastic hip. Much longer clinical followup and larger treatment groups will be necessary to allow firm conclusions concerning optimal treatment programs for different patient subgroups of the adult hip dysplasia syndrome.     

Saline magnetic resonance arthrography in the evaluation of glenohumeral instability

Sixty-five patients underwent magnetic resonance (MR) shoulder arthrography. Forty-eight of these patients underwent examination under anesthesia (EUA). MR images were retrospectively evaluated for signs felt to be imaging indicators of shoulder instability, including evaluation of various capsular measurements and the presence of glenoid labral tears, as well as Hill-Sachs fractures. Statistical analysis of the results showed that no correlation between capsular indicators with EUA-documented instability was found. However, there was a statistically significant correlation between the presence of a Bankart cartilaginous deformity (p = 0.000) and Hill-Sachs fractures (p = 0.022) with EUA-documented instability. Sensitivity to labral tears was 89% and specificity was 98%, whereas Hill-Sachs fracture detection was 69% and 87%, respectively. We believe that MR saline arthrography is of benefit in the evaluation of the anterior labrum when unenhanced MR imaging is inconclusive, and we speculate on the role of MR arthrography as a primary investigative tool.     

Hip fusion in young adults. Using a medial displacement osteotomy and cobra plate

Eight consecutive patients, mean age 17.25 years, underwent a medial displacement osteotomy and hip arthrodesis with a nine-hole Cobra plate. A transverse innominate osteotomy facilitated medial displacement of the femoral head and acetabulum. Alignment of the lower limb at 25 degrees flexion, neutral abduction, and neutral rotation was assisted by a long-limbed protractor and Steinmann pins placed in both anterior superior iliac spines. The greater trochanter was reattached to the Cobra plate so that hip abductor function could be restored should the fusion ever be converted to an arthroplasty. No postoperative immobilization was required. All patients had radiographic evidence of union by 12 months. One patient had a postoperative brachial plexus neuropraxia that resolved at three months. One patient required an ipsilateral femoral lengthening for limb-length inequality secondary to collapse of his femoral head before hip fusion. At a mean follow-up interval of 2.8 years (range, one to 4.5 years), all patients had significant improvements in pain (p < 0.05), function (p < 0.01), and gait (p < 0.01). The average preoperative Harris Hip Score of 45 points +/- 8 points (mean +/- SEM) improved to 84 points +/- 2 points (p < 0.01).     

Bone scan in ossifying fibromyxoid tumor of soft parts

Twenty paediatric patients with congenital dislocation of the hip were treated with a modification of the classic technique of Salter's osteotomy. Along with open reduction and femoral shortening osteotomy, the resected femoral segment, which measured 10-40 mm in width (mean 16 mm), was used to stabilize the Salter's osteotomy. The patients were aged between 2 and 9 years (mean 3.8 years). After a mean follow-up of 16 months (range 6-60 months) all patients had full bone healing and complete incorporation of femoral bone graft with the acetabulum. No patient had re-dislocation, subluxation or displacement of the graft.     

Protracted treatment with tegafur and low dose oral leucovorin in patients with advanced colorectal carcinoma

A retrospective analysis was done of the results of the Pemberton osteotomy for the treatment of developmental dysplasia of the hip in 16 hips of 14 children older than 7 years. The average age of the patients at the time of surgery was 11+6 years and the average follow-up was 4+10 years. Eleven hips required one or more surgical procedures concomitant with the Pemberton osteotomy to achieve a concentric and congruous reduction of the hip joint. None of the hips developed avascular necrosis of the acetabular fragment. The center-edge angle improved from a preoperative average of 1 degree to an average of 30 degrees at the most recent follow-up. Correction of acetabular dysplasia was noted in 14 of the 16 hips, as demonstrated by the improvement in the acetabular index, the center-edge angle, and the Severin class. We believe that the Pemberton osteotomy can be a safe and effective procedure for the treatment of developmental dysplasia of the hip in the older child.     

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.     

A modified technique of the triple pelvic osteotomy: early results

A modification of the triple pelvic osteotomy for children over 8 years and the young adult is described. The results of the first 32 cases are reviewed. These show that the indications for the operation can be widened so that not only primary dysplasias but also subluxated or dislocated hips with secondary dysplasia can be operated on successfully. The operation is done in two stages. At first the patient is lying prone. The osteotomy of the ischial ramus is done dorsally by cutting the connection between the sciatic notch and obturator foramen immediately behind and below the acetabulum. In the second stage, with the patient lying supine, the pubic and the iliac osteotomy are performed rather circular and parallel to the hip joint. These modifications have several advantages: (a) the operator has a direct field of view at all times; (b) the osteotomy is performed close to the acetabulum, thus allowing a great amount of lateral rotation and medial displacement of the acetabulum, thereby providing good coverage of the femoral head by hyaline cartilage; and (c) the ischial ramus and its ligaments to the sacrum are left intact, leading to greater stability of the pelvis and spine.     

Glenohumeral instability: evaluation with MR arthrography

Magnetic resonance arthrography is superior to other imaging techniques in evaluation of the glenohumeral joint. Normal variants that can be diagnostic pitfalls include the anterosuperior sublabral foramen, the Buford complex, and hyaline cartilage under the labrum. Anteroinferior dislocation is the most frequent cause of anterior glenohumeral instability and produces a constellation of lesions (anteroinferior labral tear, classic and osseous Bankart lesions, Hill-Sachs lesion). Variants of anteroinferior labral tears include anterior labroligamentous periosteal sleeve avulsion and glenoid labral articular disruption. Anterior glenohumeral instability can also involve tears of the anterior or anterosuperior labrum or the glenohumeral ligaments. Posterior glenohumeral instability can involve a posterior labral tear, posterior capsular stripping or laxity; fracture, erosion, or sclerosis and ectopic ossification of the posterior glenoid fossa; reverse Hill-Sachs lesion; McLaughlin fracture; or posterosuperior glenoid impingement. Superior labral anterior and posterior lesions involve the superior labrum with varying degrees of biceps tendon involvement.     

Influence of the Crowe rating on the outcome of total hip arthroplasty in congenital hip dysplasia

Few studies have examined the relationship between the severity of congenital dysplasia of the hip (CDH) and the clinical outcome of total hip arthroplasty. The authors have used a prospective design to study this question, using the Crowe grade to assess the severity of CDH. There were 71 patients with CDH operated on using the S-ROM total hip (Joint Medical Products, Stamford, CT); the control group was composed of 22 patients without CDH operated on using the same implant during the same period as the CDH patients. The patients with mild CDH did not have a different outcome from the patients without CDH with respect to Harris hip score or limp. The higher the Crowe grade, the more complications occurred. It was also found that the patients in whom the true acetabulum was not used had a significantly higher incidence of limp.     

The pelvic osteotomy of Chiari: an anatomical study of the hazards and misleading radiographic appearances

The medial displacement osteotomy of Chiari has an established place in the management of older children and adults with severe hip dysplasia. The results claimed for the operation are, however, variable. There have also been reports of sciatic nerve lesions. In this study ten cadavers were operated upon. Chiari osteotomy was performed upon five, and five acted as controls. The hemipelvis was removed from each cadaver; each specimen was deep-frozen and sectioned transversely. The distance of the sciatic nerve from the nearest bony point was measured in each section and the results were recorded graphically. A further radiographic and photographic study was performed to determine whether apparent displacement at the osteotomy might be misleading. The conclusion was drawn that the sciatic nerve is angulated at the osteotomy and further endangered by the risk of bone splintering at the sciatic notch. The radiographic study suggested that some poor clinical results may be explained by a radiological artefact, because there is a tendency for the osteotomy to hinge posteriorly at the sciatic notch opening anteriorly like a book. Radiographs may suggest excellent medial displacement whereas in fact the femoral head is very poorly covered.     

Avascular osteonecrosis of the acetabulum

OBJECTIVE: To investigate the possible occurrence of osteonecrosis in the acetabulum in patients with non-traumatic necrosis of the femoral head. DESIGN AND PATIENTS: One hundred and seventy-nine patients with non-traumatic femoral head necrosis were assessed by MRI and radiography for the presence of acetabular necrosis. Three criteria were established to differentiate between osteonecrosis and osteoarthritic changes: (1) heterogeneous morphology and irregular contours of the lesion; (2) typical demarcation lines of osteonecrosis; (3) deficient accumulation of intravenous gadolinium in the affected regions. RESULTS: In four patients histological confirmation of acetabular necrosis was obtained. The MR analysis of 22 acetabula (9.5% of those examined) showed changes which suggested osteonecrosis. No cystic lesions were demonstrated in the subchondral bone of any patient. Two cases of acetabular necrosis were found without an ipsilateral femoral head necrosis. In two patients of the 14 who had undergone total hip replacement following necrosis of the femoral head, aseptic loosening of the acetabular component was found. CONCLUSION: The study suggests that acetabular necrosis may be an accompaniment to aseptic necrosis of the femoral head. Further work is required to assess its importance in premature loosening of the acetabular element of total hip arthroplasty.     

Hip arthroplasty by matching cups

A total hip surface arthroplasty consisting of matching cups and uncemented prosthetic components is a noteworthy operation. The femoral cup obtains cylindrical support from the femoral head which is reamed in the shape of a cylinder. The acetabular cup is metallic with a polyethylene liner. It is mobile over the bone but its position is constrained by contact with the femoral cup and therefore "self-centering." On the femoral side, the cup must be placed strictly in the axis of the femoral neck. The main consideration in femoral head surface replacement is the vitality of the underlying bone. Necrosis was observed in the earliest clinical trials but there have been no cases of necrosis in the past 3 1/2 years. This is attributed to a more limited surgical approach in which only the anterior part of the gluteus medius is divided and all the posterior elements of the hip are preserved. The acetabulum is sufficiently reamed to receive the cup, which protrudes beyond the external margins of the acetabulum in all positions. Errors have been committed while perfecting the prosthetic material, but the results as determined by a 6 1/2 year follow-up on purely metallic cups are encouraging. Metal-polyethylene cups presently under investigation have almost a 2 year follow-up. The reaction of the acetabulum to an uncemented cup is not yet known. However, the existence of 2 sliding surfaces and the fact that the acetabular cup moves only during the extremes of hip movement, is reason to assume that if the acetabulum is not reamed to expose cancellous bone, the risks of protrusion are minimal or delayed. Total surface arthroplasty by concentric cups has been performed in 335 hips to date. The operation is especially recommended when osteotomy is no longer possible and disabling coxarthrosis is present in relatively young patients.     

Salvage of failed femoral megaprostheses with allograft prosthesis composites

The records of 11 consecutive adult patients who underwent revision of a failed femoral megaprosthesis (aseptic loosening, nine; periprosthetic fracture, one; and prosthesis fracture, one) to an allograft prosthesis composite were reviewed retrospectively. Complications included radiographic component subsidence in two patients (18%), hip instability in three patients (27%), deep infection in two patients (18%), and allograft fractures in two patients (18%). Five patients (45%) required subsequent reoperations; four patients underwent removal of the allograft prosthesis composite at a mean of 16 months (range, 5-41 months) and one patient (9%) with hip instability underwent revision of the failed megaprosthesis to a constrained acetabulum. Reconstruction of a failed femoral megaprosthesis is a complex problem caused by extensive bone loss and violation of soft tissue attachments. Despite a high complication rate, six patients (55%) remained ambulatory and had mild or no pain at a mean followup exceeding 5.5 years.     

Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24-84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.     

Static and dynamic function of the lower esophageal sphincter before and after laparoscopic Nissen fundoplication

SUBJECT: We analysed the periprosthetic bone mineral density (BMD) in a prospective longitudinal study over two years after operation and in a separate cross-sectional study more than five years after implantation of cementless total hip arthroplasty (CLS-stem, Mecron threaded acetabular cup) by using dual-energy X-ray absorptiometry (DEXA). MATERIALS AND METHODS: In n = 53 patients (29 women, 24 men) we analysed the periprosthetic BMD prospectively in certain periods. All patients had an uncomplicated postoperative course and good clinical outcome (Merle d'Aubigne score > 12). In the cross-sectional study we analysed 23 patients (13 women, 10 men). Regions of Interest (ROI) were defined according to Gruen et al. for the periprosthetic femur and to De Lee and Charnley for the periprosthetic acetabulum. RESULTS: BMD significantly decreases in the periprosthetic femur as well as in the periprosthetic acetabulum during the first three months. In men BMD reaches its lowest values between six months (femur) and one year (acetabulum) after operation and then increases to 96.2% at the femur and 93.8% at the acetabulum. In women BMD decreases during the entire follow-up to 89.4% at the periprosthetic femur and 80.0% at the periprosthetic acetabulum. In the proximal zones 1 and 7 of the femur and the cranial-medial zone II of the acetabulum we observed the highest decrease of mineralisation. More than five years after implantation of the prosthesis BMD in the femur showed only little changes. On the other side BMD around the threaded acetabular cup significantly decreased to 67.4% in women and 79.1% in men. CONCLUSION: The results reflect the different stress on the periprosthetic bone after implantation of the prosthesis and fit to earlier reported good clinical results of the CLS-stem and to increased loosening rate of threaded acetabular cups after five years. Analysing changes of mineralisation in cementless total hip arthroplasty DEXA together with the analization scheme according to Gruen at the femur and to De Lee and Charnley at the acetabulum is a useful method and has been reliable in clinical practise.     

Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip

We report the results of proximal femoral osteotomy that was performed to treat osteoarthrosis in twenty-three consecutive young adults (twenty-five hips) who had a mean age of thirty-eight years (range, eighteen to fifty-three years). The mean duration of follow-up was seven years (range, two to twelve years). With conversion to a total hip replacement as the end point, the rate of survival at twelve years was 67 per cent (95 per cent confidence interval, 37 to 88 per cent). Four hips (16 per cent) were converted to a total hip replacement at a mean of eight years after the osteotomy. For the patients who did not have conversion to a total hip replacement, the mean score for pain, according to the system of Merle d'Aubigné and Postel as modified by Charnley, improved from 3.4 points preoperatively to 5.1 points postoperatively, the mean score for walking ability improved from 3.9 to 4.7 points, and the mean score for range of motion improved from 3.2 to 4.2 points. These results compare favorably with those following other forms of operative treatment of osteoarthrosis of the hip in young adults. In addition, the osteotomy does not preclude subsequent replacement arthroplasty if one is necessary.     

Magnetic resonance imaging of the musculoskeletal system. Part 6. The Shoulder

The role of magnetic resonance imaging in the diagnosis and treatment of patients with shoulder pain has increased remarkably in recent years, largely because of improved resolution of images and increased experience of musculoskeletal radiologists. In rotator cuff disease/impingement and instability, magnetic resonance imaging adds a new dimension to the clinical findings through the noninvasive visualization of either the pathology itself or frequently associated abnormalities. It is the associated abnormalities that are depicted in instability: glenoid irregularities, labral tears, capsular laxity, and Hill-Sachs deformities. Glenoid, labral, and Hill-Sachs abnormalities can be assessed with either magnetic resonance imaging or computed tomography arthrography. Magnetic resonance imaging has the advantages of noninvasiveness, multiplanar imaging capability and exquisite soft tissue contrast. In rotator cuff disease, magnetic resonance imaging depicts the status of the rotator cuff itself, revealing partial and full thickness tears, allowing an estimation of size and quality of tendon edges. Possible impingement sites can be identified. Primary instability with secondary impingement may be first suspected on magnetic resonance imaging. Postoperative complications, including recurrent tendon detachment, deltoid dehiscence, and infection, are clarified. Unsuspected but clinically important lesions, such as neoplasm, osteonecrosis, and ganglion with entrapment of the suprascapular nerve, each have characteristic magnetic resonance imaging appearances.     

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.     

Non-nodal neck masses

Planar imaging has made significant contributions to the evaluation of patients with non-nodal neck masses. The clinical history, physical examination, and imaging characteristics of these lesions are often complimentary. Yet, planar imaging much more accurately defines the size, location, and extent of these lesions than is revealed on physical examination. The CT and MR characteristics are often sufficiently specific to arrive at the correct preoperative diagnosis in these patients. We present the classical radiographic and clinical features of several non-nodal neck masses.