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.     

Immunologic aspects of Helicobacter pylori infection and malignant transformation of B cells

We studied the use of overhead traction in the treatment of congenital dislocation of the hip in thirty-five children (fifty hips) whose mean age at the time of the diagnosis was thirty-three months (range, eighteen to seventy-two months). None of the children had had any previous treatment. The mean time in traction was twenty-three days (range, eight to thirty-six days). Closed reduction was successful for relocation of the femoral head in thirty-eight of the fifty hips; twenty of these hips needed no additional treatment, sixteen were treated with an innominate osteotomy because of severe acetabular dysplasia, and two needed femoral derotation and an innominate osteotomy to correct persistent subluxation. In the remaining twelve hips, closed reduction failed at the outset and an open reduction was necessary. Femoral shortening also was performed in seven of the twelve hips to maintain concentric reduction. After a mean duration of follow-up of forty-eight months (range, thirty-two to sixty-five months), thirty-three hips were rated as class 1; seven, as class 2; four, as class 3; and five, as class 4, according to the criteria of Severin. The remaining hip could not be so classified. Avascular necrosis developed in two hips that had been treated with closed reduction followed by Salter osteotomy and in three hips that had been treated with primary open reduction. We found that preliminary overhead traction facilitated closed reduction of untreated congenitally dislocated hips in children who were eighteen to seventy-two months old.     

Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture

Sixteen consecutive patients with cutout of a lag screw of a dynamic hip screw fixation in an intertrochanteric fracture were treated with reinsertion of a lag screw, bone cement supplementation in the neck-trochanter, and subtrochanteric valgus osteotomy. Postoperatively, patients were permitted to ambulate with protected weight-bearing. Fourteen patients were followed-up for at least 1 year (median 2 years; range 1-3 years), and all had a solid union. The union period took a median of 5 months, with a range of 3-7 months. Usually, union of an intertrochanteric fracture was faster than that of subtrochanteric osteotomy (P < 0.01). There were no complications of wound infection, loss of reduction, cutout of a lag screw, or osteonecrosis of the femoral head. From clinical and theoretical considerations, we conclude that despite cutout of a lag screw of a dynamic hip screw fixation being difficult to treat, out technique still can provide an excellent outcome. Therefore, we strongly recommend its wide use.     

Joint salvaging surgery for an extensive giant cell tumor of the proximal femur complicated by a transcervical fracture

The case of a 20-year-old man with an unusually large giant-cell tumor of the proximal right femur complicated by a transcervical fracture is presented. In view of the patient's age, stabilization with a dynamic hip screw combined with valgus osteotomy, curettage and bone grafting was preferred to total hip replacement. Femoral head salvage has been successful to date.     

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.     

Femoral remodelling after subtrochanteric osteotomy for developmental dysplasia of the hip

Children who present late with hip dislocation may require femoral osteotomy after reduction, to correct valgus and anteversion deformity of the femoral neck. After these procedures proximal femoral growth is unpredictable. We have studied proximal femoral growth in 40 children who had been treated by femoral osteotomy. Preoperatively, the mean femoral neck-shaft angle was 5 degrees greater on the affected side than on the contralateral side. Postoperatively, it was 28 degrees less. There was progressive recorrection; after five years the angle was not significantly different from that on the contralateral side. In our series 70% of the capital epiphyses became abnormally shaped, taking the appearance of a 'jockey's cap'. All the growth plates became angulated but this corrected with time. Correction of the neck-shaft angle probably results from the more normal mechanical environment provided by reduction. The abnormal radiographic appearance of the epiphysis and growth plate is probably due to the rotation produced by the osteotomy.     

Implant stability in revision total hip arthroplasty: allograft bone packing following extended proximal femoral osteotomy

One method of revising the femoral component in revision total hip arthroplasty in the presence of compromised femoral bone stock is to pack the upper femur with particulate allograft and then to cement the femoral component into the allograft bed. This technique is being used clinically with encouraging results. Additionally, surgical exposure of the femoral canal during revision total hip arthroplasty can be greatly improved with an extended trochanteric osteotomy, which is subsequently repaired with wires or cables. To assess the feasibility of performing the allograft bone packing technique following an extended trochanteric osteotomy, the stability of this construct in a cadaver model was measured, using micromotion sensing instruments and loads applied on a materials testing machine. The stability of the cemented allograft impaction construct following extended trochanteric osteotomy was comparable to the stability of the control construct, which consisted of a similar impacted allograft construct without osteotomy. The stability of the osteotomized side was comparable to that of the control side. It is concluded that the initial in vitro stability of the allograft impaction technique following extended proximal femoral osteotomy is adequate to justify experimental in vivo use.     

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.     

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.     

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.     

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.     

Laser Doppler flowmetry during open reduction for developmental dysplasia of the hip

Laser Doppler flowmetry was used intraoperatively to monitor femoral head perfusion during open reduction of 13 congenital hip dislocations in 11 patients. Laser Doppler determinations ranged from 12 to 400 mV before reduction and 30 to 300 mV after reduction. Three patients had magnitude changes in excess of 50%. One had increased perfusion, and two had decreased blood flow. Avascular necrosis of the hip occurred in one patient that was not predicted by laser Doppler flowmetry. Femoral head perfusion measured 175 mV for the dislocated hip and 180 mV after reduction of the femoral head and completion of the pelvic osteotomy. The authors conclude that laser Doppler flowmetry is not a reliable method for monitoring femoral head perfusion during open reduction of the hip for developmental hip dysplasia.     

Management of late induced abortions in France

OBJECTIVE: To evaluate the clinical results of comminuted patella fracture fixation after an extensile surgical approach by using a tibial tuberosity osteotomy. DESIGN: Prospective, clinical. PATIENTS: Six knees with displaced comminuted patella fractures had stable internal fixation after an osteotomy of the tibial tubercle. All had immediate postoperative continuous knee motion and were followed for an average of thirty-one months (minimum of eighteen months). OUTCOME MEASURES: Time to clinical and radiographic union, Hospital for Special Surgery (HSS) Knee Scores and comparisons with literature cohort studies. RESULTS: Clinical union of the osteotomy occurred at an average of eight weeks (range 6 to 12 weeks) and of the patella fractures at an average of eleven weeks (range 8 to 21 weeks). There was no radiographic evidence of osteotomy displacement, fracture implant loosening, migration, or failure. All patients had clinical residua, which included loss of motion, thigh muscle atrophy, and barometric complaints. HSS Knee Scores averaged 75 points with four good, one fair, and one poor result. These results were comparable to those of previously published reports of ablative surgery for this type of fracture. CONCLUSION: Comminuted patella fractures are severe injuries that usually result in some lingering morbidity. Internal fixation preserves bone stock, which facilitates future reconstructive procedures. The described tibial tuberosity osteotomy, patella eversion technique of fracture exposure improved visualization and reduction of the articular surface. The osteotomy healed in all cases and did not adversely affect the clinical results.     

Fall-related factors and risk of hip fracture: the EPIDOS prospective study

BACKGROUND: Most hip fractures result from falls. However, the role of fall-related factors has seldom been examined. Comparison of the predictive value of these factors with that of bone mineral density (BMD) has important implications for the prevention of hip fractures. METHODS: We assessed femoral-neck BMD by dual-photon X-ray absorptiometry and potential fall-related risk factors, which included self-reported physical capacity, neuromuscular function, mobility, visual function, and use of medication in 7575 women, aged 75 years or older, with no history of hip fracture recruited at five centres in France. We followed up these women every 4 months to record incident hip fractures. During an average of 1.9 years of follow-up 154 women suffered a first hip fracture. FINDINGS: In age-adjusted multivariate analyses, we found four independent fall-related predictors of hip fracture: slower gait speed (relative risk = 1 . 4 for 1 SD decrease [95% Cl 1.1-1.6)]; difficulty in doing a tandem (heel-to-toe) walk (1.2 for 1 point on the difficulty score [1.0-1.5]); reduced visual acuity (2.0 for acuity < or = 2/10 [1.1-3.7]); and small calf circumference (1.5 [1.0-2.2]). After adjustment for femoral-neck BMD, neuromuscular impairment--gait speed, tandem walk--and poor vision remained significantly associated with an increased risk of subsequent hip fracture. With high risk defined as the top quartile of risk, the rate of hip fracture among women classified as high risk based on both a high fall-risk status and low BMD was 29 per 1000 women-years, compared with 11 per 1000 for women classified as high risk by either a high fall-risk status or low BMD; for women classified as low risk based on both criteria the rate was five per 1000. INTERPRETATION: We conclude that neuromuscular and visual impairments, as well as femoral-neck BMD, are significant and independent predictors of the risk of hip fracture in elderly mobile women, and that their combined assessment improves the prediction of hip fractures.     

Relation of heart rate variability and serum lipoproteins in type 1 diabetes mellitus and chronic stable angina pectoris

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.     

Unobserved heterogeneity and censoring in the demand for health care

OBJECTIVE: To compare the accuracy of reduction, biomechanical characteristics, and mode of failure of two methods of acetabular osteotomy repair. STUDY DESIGN: Acetabular osteotomies were created in 16 paired hemipelves and stabilized with a screw/wire/polymethylmethacrylate composite fixation technique (SWP) or a 2-mm veterinary acetabular plate (VAP). Eight intact hemipelves were used as controls. SAMPLE POPULATION: Twelve canine cadavers. METHODS: Accuracy of osteotomy reduction was evaluated grossly and by measurement of articular incongruencies formed in polyvinylsiloxane impression casts. Acetabula were loaded in modified bending until failure using a universal testing machine. Data from load-deformation curves were used to determine the biomechanical characteristics of the repaired and intact acetabula. Mode of failure was evaluated grossly and radiographically. RESULTS: Osteotomy reduction was superior in acetabula stabilized with SWP. Mean values +/- standard deviation for load at failure and stiffness of the intact acetabula were 2,796 +/- 152.9 N and 267.5 +/- 61.9 N/mm. Corresponding values for SWP and VAP were 1,192 +/- 202.7 N and 136.3 +/- 76.5 N/mm, and 1.100.5 +/- 331.6 N and 110.0 +/- 51.3 N/mm, respectively. The mean load at failure and stiffness of intact acetabula was significantly greater than acetabula stabilized with SWP or VAP. There was no significant difference between SWP and VAP for load at failure or stiffness. Failure of acetabula stabilized with SWP occurred by fracture of the polymethylmethacrylate and ventrolateral bending of the wires. Acetabula stabilized with VAP failed by ventrolateral twisting of the plate and bending of the caudal screws. CONCLUSIONS: SWP and VAP provide comparable rigidity, however, the SWP facilitates more accurate osteotomy reduction. CLINICAL RELEVANCE: These findings support the use of the SWP technique as an alternative method of acetabular fracture repair.     

Optimizing interstitial delivery of BCNU from controlled release polymers for the treatment of brain tumors

OBJECTIVE: To determine quality of hip fracture services provided by "generalist" general surgeons (generalists) in Nova Scotia. DESIGN: Chart review and postoperative, blinded, random-ordered radiologic analysis. SETTING: Three community hospitals and 1 tertiary care hospital in Nova Scotia. PARTICIPANTS: Seven generalists who performed 120 hip fracture repairs and 7 orthopedic surgeons (specialists) who performed 135 hip fracture repairs. OUTCOME MEASURES: Patient demographics, preoperative, perioperative, postoperative and discharge information, technical quality of reduction as determined through postoperative radiologic assessment. RESULTS: There were no differences between patients treated by generalists and those treated by specialists with respect to age, sex, American Society of Anesthesiologists' class, level of function and fracture type. Intraoperatively, the patient groups were similar with respect to type of anesthesia, use of antibiotics, number of transfusions and surgical complications. Significant differences were noted in length of operation (54.4 v. 41.1 minutes), use of C-arm imaging (6.7% v. 85.9%) and management of Garden classes 1 and 2 subcapital fractures. Postoperatively, the 2 groups had similar numbers of medical complications, wound complications, reoperations, readmissions and deaths, and a similar level of function on discharge. Significant differences included the number of intensive care unit admissions (5.8% v. 15.6%) and length of stay there (5.7 v. 2.8 days) and of postoperative stay (14.5 v. 10.7 days). The assessment of radiographs did not demonstrate any significant difference in the quality of reduction. CONCLUSION: In Nova Scotia the outcomes of hip fracture surgery performed by generalists are comparable to those performed by specialists.     

Modified medial displacement and valgus osteotomy for unstable intertrochanteric fractures

We have described previously a modification of the medial displacement and valgus osteotomy of Dimon and Hughston to manage non-unions of intertrochanteric fractures. In this study, we have used the same modification to manage fresh, unstable intertrochanteric fractures. Eighty-seven patients underwent this procedure. Four died within 4 months. The remaining 83 patients were evaluated over a period ranging from 4 to 49 months. There was a low complication rate with this method. They included one perforation of the femoral head, one post operative infection that recurred as a deep infection, one partial superior migration of the implant, one varus fixation with noticeable shortening and two cases where the trochanteric wire had snapped. In the others, the hip movement, abductor function, functional recovery and rate of union (8-12 weeks) were good. The method permits early weight-bearing and avoids some of the problems seen with anatomical fixation of unstable fractures using the sliding screw plate. We feel that medial displacement and valgus osteotomy with an angled blade plate has a definite role in the treatment of unstable intertrochanteric fractures in some situations.     

Norian SRS cement augmentation in hip fracture treatment. Laboratory and initial clinical results

Bone quality, initial fracture displacement, severity of fracture comminution, accuracy of fracture reduction, and the placement of the internal fixation device are important factors that affect fixation stability. New high strength cements that are susceptible to remodeling and replacement for fracture fixation may lead to improved clinical outcome in the treatment of hip fractures. Norian SRS is an injectable, fast setting cement that cures in vivo to form an osteoconductive carbonated apatite of high compressive strength (55 MPa) with chemical and physical characteristics similar to the mineral phase of bone. It can be used as a space filling internal fixation device to facilitate the geometric reconstruction, load transfer, and healing of bone with defects and/or fractures in regions of cancellous bone. Furthermore, this cement can improve the mechanical holding strength of conventional fixation devices. Use of this material potentially could improve fracture stability, retain anatomy during fracture healing and improve hip function, thus achieving better clinical outcomes. In vivo animal studies have shown the material's biocompatibility, and cadaveric studies have shown the biomechanical advantage of its use in hip fractures. Initial clinical experience (in 52 femoral neck fractures and 39 intertrochanteric fractures) showed the potential clinical use of this innovative cement in the treatment of hip fractures.     

Traumatic hip dislocation with spontaneous reduction and capsular interposition. A report of 2 children

We present 2 cases of posterolateral hip dislocation in children followed by spontaneous reduction and interposition of soft tissue. After reduction of a dislocated hip joint, interposition of soft tissues or fracture fragments must be excluded. When reduction has occurred spontaneously, the condition may be misjudged, correct treatment delayed and the hip joint permanently damaged, as occurred in one of our cases. In the second case, prompt surgery was undertaken and the patient recovered completely.