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.     

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.     

Femoral and spinal bone mineral density in Japanese osteoporotics with hip fracture

In the present study, bone mineral density (BMD) of femoral neck and lumbar spine was compared between 38 Japanese female patients with hip fracture (age 63-89 years, mean +/- SD 76 +/- 7 years) and 162 age-matched female controls (age 62-90 years, mean +/- SD 75 +/- 7 years). BMD was measured in the femoral neck and lumbar spine (L2-4) using dual-photon absorptiometry (Norland model 2600). BMD values of femoral neck as well as lumbar spine were significantly lower in patients with hip fracture than in controls (0.504 +/- 0.097 v 0.597 +/- 0.101, p < 0.01, for femoral neck; 0.661 +/- 0.146 v 0.720 +/- 0.128, p < 0.05, for lumbar spine). Patients with hip fracture and controls were stratified according to their BMD levels at two measuring sites, and the ratio of the number of patients and controls at each BMD level was calculated as an indicator of fracture rate. This ratio showed an exponential increase as the femoral neck BMD declined, but only a gradual increase as the lumbar spine BMD declined. Specificity-sensitivity analysis revealed that BMD values of 0.59 and 0.54 g/cm2 at the femoral neck provided a specificity of 52% and 68% with a sensitivity of 90% and 75%, respectively. These findings suggest that Japanese patients with hip fracture are more osteoporotic than age-matched controls and that the selective measurement of femoral neck would be useful for predicting the risk of hip fracture.     

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.     

Results of total hip arthroplasty for Crowe Type III developmental hip dysplasia

From 1969 through 1980, 90 hips in 82 patients had cemented total hip arthroplasty for Type III developmental hip dysplasia. Seventy hips were reviewed at an average of 16.6 years (range, 5-23 years) after operation. Aseptic loosening developed in 53% of acetabular cups and 40% of femoral stems. Despite attempts to place acetabular components in the anatomic center, 18 cups (25.7%) were placed outside that area. Using a measurement method to determine the true acetabular region and approximate femoral head center, final acetabular loosening strongly correlated with initial cup placement. Loosening occurred in 15 of 18 cups (83.3%) initially positioned outside of the true acetabular region compared with loosening in 22 of 52 cups (42.3%) initially positioned within the true acetabular region. Acetabular loosening also correlated with initial lateral displacement or initial superior displacement of the hip center from the approximate femoral head center. Initial cup placement medial to the approximate femoral head center was predictive of successful long term acetabular component fixation. The method of acetabular reconstruction did not affect eventual cup loosening. Placement of the hip arthroplasty center of rotation in or near the true acetabular region is recommended.     

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.     

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.     

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.     

Insulin resistance and essential hypertension in Vietnamese subjects

Several epidemiological and experimental studies suggest that essential arterial hypertension is associated with hyperinsulinism and insulin resistance in obese subjects and also in subjects with normal body weight. Undernutrition remains frequent in adult Vietnamese people and mean body mass index is around 18.5 kg/m2 in Vietnam. The aim of this study was to look for insulin resistance in hypertensive Vietnamese subjects, despite a markedly lower BMI in Vietnam than in occidental countries. One hundred and eight hypertensive patients (51 men and 57 women) over 40 years (mean = 65.4 years) were compared with 36 healthy subjects (23 men and 13 women) over 40 years (mean = 63.8 years). Hypertensive patients had significantly higher BMI (20.5 +/- 0.3 (SEM) kg/m2 vs 18.4 +/- 0.4 kg/m2; p < 0.01), thicker triceps skinfold (1.26 +/- 0.07 cm vs 0.71 +/- 0.07 cm; p < 0.001) and not significantly different waist/hip ratio (0.88 +/- 0.01 vs 0.85 +/- 0.01). Blood glucose at fasting and 2 hours after 75 g glucose taken orally were similar in hypertensive and normotensive subjects. Plasma insulin at fasting and 2 hours after glucose were significantly higher in hypertensive patients (44.4 +/- 5.1 pmol/L vs 21.6 +/- 3.2 pmol/L; p < 0.05 and 271.1 +/- 21.6 pmol/L vs 139.1 +/- 15.2 pmol/L; p < 0.001). Thus, despite under-nutrition, hypertensive Vietnamese patients have a moderate but significant increase in BMI and fat mass without predominant abdominal localization, and a state of insulin-resistance, compared with normotensive healthy subjects.     

Radiographic evaluation of penetration by the femoral head into the polyethylene liner over time

We examined the pattern of temporal penetration by thirty-two-millimeter-diameter femoral heads into polyethylene liners in a group of 105 hips (103 patients) in which an Arthropor metal-backed cup had been implanted. Each patient was evaluated radiographically and clinically at a minimum of four different postoperative intervals. The initial evaluation was performed a mean of 2.9 weeks (range, one to fifteen weeks) postoperatively, and the latest evaluation was performed a mean of 7.9 years (range, five to ten years) postoperatively. Two-dimensional wear - that is, penetration by the femoral head into the ultra-high molecular weight polyethylene liner - was determined from anteroposterior radiographs of the pelvis with a computer analysis system that calculated the change in the position of the center of the head relative to the center of the cup. Three new findings are reported. First, there was a large difference (mean, 1.1 millimeters) between the center of the head and that of the cup as measured on the initial postoperative radiographs. This difference underscores the need for researchers to consider the initial displacement of the head when measuring and reporting polyethylene wear. Second, although there was wide variation in responses among individuals, temporal examination of the data revealed a trend toward a decreasing rate of penetration with time. Moreover, the rate of penetration appeared to reach a steady-state value after the sixth postoperative year and remained nearly constant until the ninth postoperative year. Third, by comparing the subsets of patients who had the greatest and the least initial penetration by the head, we found that penetration behavior, although remarkably different between the groups in the first three years postoperatively, became similar with time. CLINICAL RELEVANCE: When making decisions regarding individual patients or hip systems that demonstrate penetration by the femoral head into the polyethylene liner, clinicians should consider the patterns of penetration over time. Measurements of the amount and rate of penetration that are based solely on the most recent radiograph do not represent the full clinical picture. We advocate more frequent radiographic follow-up and, when available, analysis of serial radiographs for patients who have excessive penetration by the femoral head into the acetabular liner.     

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.     

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.     

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.     

Surface replacement hemiarthroplasty for the treatment of osteonecrosis of the femoral head

We reviewed the results of thirty-three femoral resurfacing procedures in twenty-five patients who had stage-III or early stage-IV osteonecrosis of the femoral head according to the classification system of Ficat and Arlet. There were no perioperative complications. Thirty hip prostheses (91 percent) survived for a minimum of five years. At a mean of 10.5 years (range, four to fourteen years) postoperatively, sixteen (62 percent) of the twenty-six hips with stage-III disease had a good or excellent Harris hip score. Four of the seven hips with stage-IV disease did not have or need a total hip arthroplasty. Overall, twenty hips (61 percent) had a good or excellent result according to the scoring system of Harris, and thirteen (39 percent) had a fair or poor result and subsequently had or needed a total hip arthroplasty. The mean interval between the hemiarthroplasty and the total hip arthroplasty was sixty months (range, thirty-six to 136 months). These thirteen hips all had a successful clinical result (a Harris hip score of at least 80 points) at a mean of thirty months (range, twenty-four to seventy-two months) after the total hip arthroplasty. The results of the present study suggest that resurfacing of the femoral head can be a successful interim procedure for the management of patients who have Ficat and Arlet stage-III or early stage-IV disease with a large lesion that is not amenable to other treatment options except total hip arthroplasty.     

Failure of intraoperatively customized non-porous femoral components inserted without cement in total hip arthroplasty

Seventy-four primary total hip arthroplasties were performed in sixty-eight patients between August 1990 and September 1991. Clinical assessments were made with use of the Harris hip score and, specifically, the pain component of that score. The preoperative radiographs were digitally quantified for calculation of the so-called canal-to-calcar ratio and the so-called cortical index. The postoperative radiographs were evaluated for the percentage of the cross-sectional area of the femoral canal that was occupied by the prosthesis; subsidence of the prosthesis; and adaptive osseous changes, including hypertrophic cortical remodeling, osteolysis, formation of sclerotic radiolucent lines around the prosthesis, and formation of a pedestal at the tip of the prosthesis. The indication for the arthroplasty was osteoarthrosis in fifty hips (68 per cent), avascular necrosis in fourteen (19 per cent), congenital dysplasia in six (8 per cent), and another diagnosis in four (5 per cent). The average duration of follow-up was thirty-one months (range, eleven to forty-six months). The average Harris hip score (and standard deviation) was 75 +/- 16.8 points (range, 29 to 100 points), and the average score for the pain component was 37 +/- 7.5 points (range, 0 to 44 points). The average canal-to-calcar ratio of the hips was 0.44 (range, 0.32 to 0.74), and the average cortical index was 0.54 (range, 0.33 to 0.66). The average subsidence of the component was 0.6 centimeter (range, 0.0 to 2.3 centimeters). The average fill of the canal was 100 per cent proximally, 97 per cent at the middle of the stem, and 92 per cent distally as measured on the anteroposterior radiographs made immediately postoperatively and 100, 95, and 90 per cent, respectively, as measured on the lateral radiographs. A failure occurred in twenty-one hips (28 per cent) in twenty-one patients, with an average time to failure of 21 +/- 13 months (range, one to forty-four months). The Kaplan-Meier survival estimate (and standard error) for this population was 0.45 +/- 0.11 (confidence interval, 0.67 to 0.23) at forty-four months. The average subsidence of the components that failed was 0.7 centimeter (range, 0.1 to 2.3 centimeters). There was no significant relationship between failure of the component and the age or sex of the patient, the diagnosis, or the side of the operation. Postoperative severity of pain (p = 0.09) or subsidence (p = 0.08) alone did not reach significance for predicting outcome. The Harris hip score alone (p = 0.05), the Harris hip score in combination with subsidence of the femoral component (p = 0.01), and the pain component of the Harris hip score in combination with subsidence of the femoral component (p = 0.01) were all significant for predicting outcome. No other measured radiographic variable was predictive of failure. Despite optimization of the fit of the component within the femoral canal and the percentage of the cross-sectional area of the femoral canal occupied by the component, the clinical results indicated a high rate of failure. Thus, these criteria are not the only requisites for stabilization of these femoral components without cement. On the basis of these data, we have discontinued the use of these intraoperatively customized, non-porous, smooth femoral prosthesis.     

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.     

Developing and implementing interprofessional learning in a Faculty of Health Professions

Although medial displacement calcaneal osteotomy has been advocated for treatment of acquired pes planus, no studies have determined the biomechanical consequences at the ankle of such a procedure. The present investigation examined the alteration in ankle motion that resulted from a medial sliding calcaneal osteotomy. In dorsiflexion, the ankle specimens were found to have altered internal rotation and varus alignment. At maximal dorsiflexion, there was a 76% increase in internal rotation (4.4 degrees +/- 2.5 degrees versus 2.5 degrees +/- 1.7 degrees for intact ankles, P < 0.0004) and an increase of 425% in varus (0.42 degrees +/- 0.56 degrees versus 0.08 degrees +/- 0.34 degrees for intact ankles, P < 0.003). There were no significant differences seen in plantar flexion. Based on these results, caution is advised in the indiscriminate use of medial sliding osteotomies, because this procedure may predispose the patient to premature ankle arthritis as a consequence of the altered ankle motions.     

Dual-energy X-ray absorptiometry in osteonecrosis of the femoral head

Osteonecrosis of the hip classically produces a heterogeneous density in the femoral head, although the bone marrow ischemia extends down to the femoral neck and trochanters. Also, bone insufficiency fractures due to diffuse bone loss have been implicated in the genesis of osteonecrosis. OBJECTIVES: To use dual-energy X-ray absorptiometry to quantify the bone changes produced by osteonecrosis of the hip and to compare bone mineral density values in patients with osteonecrosis of the hip and in controls. METHODS: Bone mineral density was measured at the femoral neck (total femoral neck, Ward's triangle, and trochanter), femoral head and lumbar spine using dual-energy X-ray absorptiometry (DPX, L Lunar) in 22 patients with osteonecrosis of the hip and in 22 age- and sex-matched controls. RESULTS: In the patients with osteonecrosis, bone mineral density on the affected side was higher than on the opposite side at the femoral head (+18%), femoral neck (+7%), and Ward's triangle (+6%) and lower at the trochanter (-4%). These differences were most marked at the more advanced end of the osteonecrosis spectrum. As compared to age-specific normative values, the osteonecrosis patients had moderately decreased bone mineral density values at the lumbar spine (-0.53 +/- 1.1 SD or -6 +/- 1.5%) and at the femoral neck on the normal side (-0.9 +/- 1.4 SD or 12 +/- 1.8%). As compared to the controls, bone mineral density was significantly decreased at Ward's triangle (-25%; P: 0.04) and nonsignificantly decreased at the lumbar spine (-4.7%; P: 0.15) and at the femoral neck (-15%; P: 0.09).     

Hip fusion through an anterior approach with the use of a ventral plate

A new technique to achieve a reliable fusion of the hip joint through an anterior approach with use of a ventral low contact dynamic compression plate and a lateral 6.5 mm lag screw is presented in detail. The advantages of this technique are that the approach does not jeopardize the vascularity of the femoral head, that the fixation on the pelvic side uses the strong bone stock of the sciatic buttress, and that the hip abductor muscles and greater trochanter are preserved. The authors also present the indications and the results of their experience with 12 patients. The followup period averaged 24.8 months (range, 10-42 months). Ten patients (83%) achieved a solid fusion by radiologic and clinical criteria. Although a moderately symptomatic nonunion developed in 1 patient, another patient went on to a painful nonunion to whom another attempt for fusion has been recommended. According to the hip score of Merle d'Aubigné and Postel, the average figures for pain and ambulation increased from 3.2 points to 5.0 points and from 2.7 points to 4.5 points, respectively, after surgery. Six of the 12 patients regained the ability to work in their former jobs or in new occupations. Eight patients felt no or minor restrictions in doing their former sports activities. Patient satisfaction was high with a majority reporting minor discomfort mainly around the fused hip.     

Proteasomal regulation of nuclear receptor corepressor-mediated repression

We analyzed the clinical results of 195 Harris Design-2 total hip replacements performed with so-called second-generation cementing techniques in 166 consecutive patients who had osteoarthrosis. The mean age of the patients at the time of the replacement was sixty-seven years and nine months (range, thirty-one to eighty-nine years). Forty-eight patients (fifty-four hips) died before the time of the latest follow-up, but the implants were apparently functioning well at the time of death. Three patients (four hips) were lost to follow-up. Five patients (five hips; 3 percent) had a revision because of aseptic loosening of the acetabular or femoral component, or both, that was related to wear-induced osteolysis. The mean Harris hip score for the 131 hips that were available at the latest follow-up examination at a mean of twelve years (range, ten to fifteen years) after the operation was 89 +/- 10 points. On the basis of the Harris hip score, seventy-six hips had an excellent result, thirty-four had a good result, fifteen had a fair result, and six had a poor result at the latest follow-up examination. Radiographically, twelve (9 percent) of the 131 acetabular components and three (2 percent) of the 131 femoral components were probably or definitely loose. At a mean of twelve years, 186 (97 percent) of 191 Harris Design-2 implants were in situ or had been in situ at the time of the patient's death.