Clinically occult avascular necrosis of the hip in systemic lupus erythematosus

OBJECTIVE: To study the natural history of clinically occult avascular necrosis (AVN) of the hip in patients with systemic lupus erythematosus (SLE). METHODS: Sixty-six patients with SLE (without symptoms referable to the hip) receiving at least 5 mg/day prednisone for > or = 6 months were screened by magnetic resonance imaging (MRI) for AVN of the hip. A complete MRI evaluating class and percentage of femoral head involvement, AP and lateral radiographs of the hips, bone scan, and physical examination were performed for patients with positive MRI. Medical records were reviewed for serologic and clinical variables that might predict AVN. Repeat MRI were obtained at 3, 6, and 12 months to assess possible progression or resolution of the lesion. Patients with negative screening MRI underwent repeat screening after one year to assess the one year incidence rate. RESULTS: Eleven asymptomatic hips (8%) in 8 patients (12%) had MRI documented AVN. The percentage of femoral head involvement ranged from 1 to 46%. One lesion was MRI class B, the remaining lesions were class A. The radiographic stage of 10 hips was stage 1, the MRI class B hip was stage 2. Risk factors for clinically occult AVN included Afro-American origin, Raynaud's phenomenon, migraine headaches, and a maximal corticosteroid dose of at least 30 mg/day. After 12 months, 43 of 58 patients with an initially negative MRI underwent repeat screening examinations; no new lesions were observed. CONCLUSION: Clinically occult AVN of the hip is common in patients with SLE. The short term natural history of these lesions appears stable without spontaneous healing or clinical or radiographic progression. Risk factors for these asymptomatic lesions are similar to the risks for symptomatic AVN and surgical intervention appears not to be indicated in these patients.     

Role of ultrasound and harness treatment in the management of developmental dysplasia of the hip

INTRODUCTION: Pustular candidiasis in heroin addicts is a rare entity in dermatology. We report a case. CASE REPORT: A 29-year-old female heroin addict developed a painful pustular growth on the scalp. There was no fever. Multiple follicular pustulae measuring 2 to 3 mm were associated with hyperesthesia of the scalp and painful cervical nodes. Biopsy showed acute ostiofolliculitis with a few blastospores and mycelial filaments. Candida albicans was isolated from the pustulae and the buccal cavity. Candida serology was positive (indirect immunofluorescence 1/100, coelectrosyneresis: 4 archs). Search for other localizations and HIV serology were negative. The last injection of brown heroin had been taken 15 days earlier; lemon had been added. Treatment with flucanazole (400 mg/d) led to improvement within 48 hours. DISCUSSION: Sudden development of pustulae or nodules in pilous zones in a heroin addict should suggest the diagnosis. Outcome depends on early treatment after diagnosis and search for other localizations. Our case presented two particular aspects: ostiofollicular localization of the pustulae and a long delay (15 days) between the (presumably) last injection and the development of the lesion. Folliculitis develops almost exclusively in addicts who use brown heroin. Contamination by Candida albicans results from the lemon used to improve solubility at injection.     

Total avascular necrosis of the capital femoral epiphysis in congenital dislocated hips

Ninety-four hips involved with total avascular necrosis in the treatment of congenital dislocation of the hips were reviewed in a search for etiological factors and effective salvage procedures. Pre-reduction traction and adductor tenotomy did not prevent avascular necrosis. Abduction of the hip in the "frog" position was the incriminating common denominator. This position may cause (1) interference of the blood supply to the femoral head by compression of the medial branch of the deep profundus artery; and (2) pressure on the intraepiphyseal grooves by the glenoid labrum. The containment of the femoral head by acetabuloplasty (preferably) below age 8, followed at a later date (over age 10) by transfer distally of the greater trochanter, with the abductor muscles, offers a satisfactory salvage procedure.     

Screening for congenital dislocation of the hip by physiotherapists. Results of a ten-year study

We report a prospective study of the feasibility of employing specially trained physiotherapists to screen neonates for congenital dislocation of the hip. During ten years 42,241 babies were screened, using clinical tests; 255 were diagnosed and treated by a Pavlik harness. In the same period 13 children presented late with congenital dislocation of the hip which had not been detected by the screening programme.     

An evaluation of conservative and operative methods in the treatment of congenital hip dislocation

An evaluation of different methods of closed reduction of dislocated hips during different periods of time shows that manual reduction and fixation in Lorenz position account for a high rate of avascular necrosis. Even with functional and slow reduction by Pavlik harness and overhead extension, there is still a certain percentage of femoral capital necrosis. The fetal position recommended by Fettweis and Salter seems to reduce the incidence of necrosis. Acetabuloplasty combined with detorsion-varus-ostcotomy provides the means of normalizing a hip joint with a greater degree of success than most other methods.     

Magnetic resonance tomography in diagnosis and therapy follow-up of patients with congenital hip dysplasia and hip dislocation

PROBLEM: Human chrionic gonadotropin (hCG) is a placental glycoprotein hormone, a heterodimeric molecule, consisting of alpha and beta chains. It induces the synthesis of progesterone, which is essential for the maintenance of the fertilized egg. Antibodies directed against hCG can, therefore, prevent pregnancy and serve as a vaccine. hCG belongs to the glycoprotein hormone family and shares the alpha chain with the other members. The beta chain is a hormone-specific subunit that is unique to hCG, but still possesses 85% amino acid homology with the beta chain of luteinizing hormone (LH), which means that prolonged immunization with hCG produces antibodies that cross-react with LH. METHOD OF STUDY: We have taken an approach involving the mutation of beta hCG to eliminate cross-reactive epitopes without affecting the natural folding of the polypeptide chain and thus the unique beta hCG-specific epitopes. RESULTS: Several mutants have been constructed that have maintained the binding to hCG-specific monoclonal antibodies (mAbs) but have lost the ability to bind to a panel of LH cross-reactive mAbs. To investigate the immunogenicity of selected mutants, mice were immunized with expression plasmid DNA, containing the gene for wild-type beta hCG and two mutants: mutant 3, with four amino acid substitutions (68 Arg-->Glu; 74 Arg-->Ser; 75 Gly-->His; 79 Val-->His), and mutant 7, with a single amino acid substitution (68 Arg-->Glu). CONCLUSIONS: Although both mutants were able to elicit antibody responses in at least some animals, the levels were less than those seen with the wild-type beta hCG DNA, and there seems still to be a residual cross-reactivity with LH. Attempts to improve the immunogenicity of the mutants and to further modify the sequence to remove the cross-reactivity are currently underway.     

Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release

The incidence of avascular necrosis of the metatarsal head following distal first metatarsal osteotomy combined with adductor tendon release has not been documented in a large series of patients. Of 82 consecutive procedures in 64 patients performed between 1986 and 1988, 42 patients (58 procedures) were available for clinical and radiographic examination. Average follow-up was 2.5 years (range 1.0-4.2 years). There were 35 L-shaped and 23 chevron osteotomies which were combined with a lateral soft tissue release that included adductor tenotomy. Preoperative hallux valgus angle averaged 25 degrees (range 15-40 degrees), and intermetatarsal angle averaged 12 degrees (range 5-24 degrees). Follow-up amount of correction averaged 13 degrees and 5 degrees, respectively. Eighty-four percent of patients were satisfied with their result. There was one case of avascular necrosis. The patient was asymptomatic at 4.2 years' follow-up, and the remaining patients included two with infections, one hallux varus, and no nonunions.     

Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip

In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1-4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2-13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin's criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old.     

Corticosteroids and avascular necrosis of the femoral head in childhood

The time-course of psychopathological symptoms, of extrapyramidal side effects, and of changes in cerebrospinal fluid (CSF) concentration of homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) were simultaneously studied during Haloperidol treatment of 14 psychotic patients with chronic organic brain damage. After 15 days of treatment significant antipsychotic effect was found, while Parkinsonism scores in clinical and experimental tests increased only slightly. CSF concentration of HVA increased significantly by 150% compared to the baseline value (p less than 0.05) and 5-HIAA remained unchanged. No correlation was found between the clinical and biochemical variables studied. The comparison of these results with those obtained in patients without brain damage suggests that different psychopathological and extrapyramidal responses to neuroleptics are not strictly associated with specific HVA changes in CSF.     

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.     

Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council

BACKGROUND: Universal clinical screening for congenital dislocation of the hip to detect hip instability in neonates was introduced in the UK as a national policy in 1969, but its effectiveness is not known. We aimed to assess the extent to which surgery for congenital dislocation of the hip is the result of a failure of detection through screening or follows non-surgical treatment after detection by screening. METHODS: We established a national orthopaedic surveillance scheme and used routine hospital data for inpatients for 20% of births in the UK (Scotland and the Northern and Wessex regions) to ascertain the number of children aged under 5 years per 1000 livebirths who had received at least one operative procedure for congenital dislocation of the hip from April, 1993, to April, 1994. Estimates of the incidence of operative procedures were adjusted for under-ascertainment by capture-recapture techniques. FINDINGS: The ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip in the UK was 0.78 per 1000 livebirths (95% CI 0.72-0-84). Congenital dislocation of the hip had not been detected by routine screening in 222 (70%) of 318 children reported to the national orthopaedic surveillance scheme. In 112 (35%) children the diagnosis was made primarily as a result of parental concern. 67 (21%) children had previously received non-surgical treatment. In Scotland and the Northern and Wessex regions, 81 cases were notified to the national orthopaedic surveillance scheme, 62 cases were identified only through routine hospital data on inpatients, and an estimated 20 cases were not identified by either source, making a total of 163 cases. Thus, 81 (50%) of these 163 cases were identified by surveillance, 125 (77%) by routine data, and 143 (88%) by both sources. INTERPRETATION: The incidence of a first operative procedure for congenital dislocation of the hip in the UK was similar to that reported before screening was introduced. In most children who received surgery, congenital dislocation of the hip was not detected by screening. Formal evaluation of current and alternative screening policies, including universal primary ultrasound imaging, is needed.     

Isolated traumatic dislocation of the hip. Long-term results in 50 patients

From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries.     

A study of the factors in hip replacement dislocation. Part 2

Dislocation is a dramatic and distressing common complication following total hip replacement. The first article describing this study, published last week, considered some of the factors thought to predispose to dislocation. The authors emphasised the multifactorial nature of hip replacement dislocation and in this second article they examine the factors relating to acetabular position and orientation, and femoral component placement.