Background. There are few reports including natural course of initial gap in total hip arthroplasty. The purpose of this study is to investigate the incidence of initial gap in the PSL type shells and its natural course. Methods. Total of 386 THAs with Trident or TriAD PSL shells were performed between January 2000 and December 2014. Exclusion criteria were shells with screw fixations (n=189), previous pelvic osteotomy (n=15) and less than 3 years’ follow-up (n=11). Finally, our study included 171 hips. Average age was 56.8 (17∼83) years at THA and average follow-up time was 8.3 (3∼16.3) years; 112 (66%) were women; and 120 hips (70.2%) had osteoarthrosis. As radiographic evaluation, we checked presence or absence of initial gap, maximum size of it, gap filling and cup stability. The presence of initial gap was defined as gap present on post-operative anteroposterior X-ray measuring 1mm or greater. Gap filling was defined as confirmed trabecular formation between the cup and acetabular floor without cup migration. And we determined the time to gap filling. As clinical evaluation, we retrospectively checked Harris Hip Score (HHS) at pre-operative and final follow-up period, and presence of shell revision. Furthermore, we compared clinical results with or without initial gap. Results. Initial gap was confirmed at 85 hips (49.7%) and mean maximum size was 2.1 (1∼6.3) mm. Mean gap filling occurred at 2.5 (± 1.4) years and there was no unstable cup. Comparing clinical results with or without initial gap, pre-operative HHS was not significantly associated with initial gap (57.8 and 56.3, respectively, p=0.41). HHS at final follow-up period was also not significantly associated with initial gap (88.4 and 87.5, respectively, p=0.49). There was no shell revision with or without initial gap. Discussion. Initial gap of hemispherical type shell is reported that its incidence is 16∼38% and initial gap is not associated with clinical outcome. Our results show that PSL type shell occurs initial gap more frequently than hemispherical type shells. Conclusion. Initial gap of PSL type shell was confirmed at 85 hips (49.7%) and mean gap filling occurred at 2.5 years. Initial gap did not affect shell revision and clinical outcome

Aim: In patients without infections following primary total hip (PTHA) and knee (PTKA) arthroplasty, the natural course of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated. The effects of gender, anesthesia type, cementing, and tourniquet use on the natural course of CRP and ESR were determined. Understanding the natural course of plasma ESR and CRP is helpful in terms of the diagnosis and follow-up of infections, especially in the early postoperative period. Methods: A total of 82 patients with normal preoperative CRP and ESR, both in accordance with gender and age; without any chronic condition, infection, or inflammatory disease; and with no intra–and post-operative complications were included. PTHA was performed on 38 (Groups I–II) and PTKA on 44 patients (Groups III-IV). CRP and ESR measurements were performed on the 1st preoperative day; 1st, 2nd, 3rd, 5th, 7th, 14th, and 21st postoperative days; and the 1st, 2nd, 3rd, 6th, 9th, and 12th months. CRP measurements were performed with the nephelometric (Dade Behring S.p.A., Italy) and quantitative Methods: Westergren method was used for ESR measurements. The PTHA group was further classified as femoral component fixed with (Group I; 28 patients) and with-out cement (Group II; 10 patients), while PTKA as with (Group III; 32 patients) and without tourniquet (Group IV; 12 patients). Furthermore, epidural (Group IIIa) and general anesthesia (Group IIIb), and gender differences (Group Ia; female and Group Ib; male) were compared. Wilcoxon test, paired-t test, Students’-t test, ANOVA, and chi-square tests were used for statistical analysis. Results: After the operation, separate peak CRP and ESR levels of each patient and days of reaching peak and normalization were evaluated. When the mean of peak CRP levels were compared, groups III and IV had significantly higher levels with regard to groups I and II (p=0.037), However, the days of reaching peak levels were statistically similar between PTHA and PTKA groups (p=0.245). The same comparison was repeated for the mean of peak ESR levels, the results were similar (p=0.547). In cemented PTHA, CRP normalized earlier than cementless PTHA and PTKA (p=0.035) and ESR also normalized earlier, but this was not significant (p= 0.074). Among groups comparing gender and anesthesia type, mean values of CRP and ESR peaks, distribution of these two levels on the days controlled, and days of reaching peaks and normalization were statistically similar (p> 0.05). Conclusions: In the PTKA group, the mean CRP peak was higher than PTHA. CRP levels normalized earlier in cemented PTHA cases. Anesthesia type, gender differences, and use of tourniquet in PTKA did not affect the course of CRP and ESR following arthroplasty

Aim

To evaluate the influence of arthrodiatasis in the natural history of the stages of the disease radiologically and also the timing of arthrodiatasis.

Tennis elbow (lateral epicondylitis or lateral elbow tendinopathy) is a self-limiting condition in most patients. Surgery is often offered to patients who fail to improve with conservative treatment. However, there is no evidence to support the superiority of surgery over continued nonoperative care or no treatment. New evidence also suggests that the prognosis of tennis elbow is not influenced by the duration of symptoms, and that there is a 50% probability of recovery every three to four months. This finding challenges the belief that failed nonoperative care is an indication for surgery. In this annotation, we discuss the clinical and research implications of the benign clinical course of tennis elbow.

Cite this article: Bone Joint J 2023;105-B(2):109–111.

Aims: A review of the existing literature is presented and compared with the results of a cohort study. These data are compared with the natural course of fracture healing. Methods: In a prospective cohort study 56 patients with nonunions and 14 patients with delayed unions after fracture or osteotomy were treated with shock wave therapy and followed for 2 years or to consolidation. These results and the previous data were assembled and were compared with the results of three studies on the natural course of fracture healing. Results: Consolidation was seen in 56% of patients with nonunions after a mean of 5.2 months, and in 93% of patients with delayed unions. The success rate of shock wave therapy was strongly associated with the time between primary diagnosis and shock wave therapy. Discussion: The success rate in the own cohort was quite similar to the results reported in the literature, after 3 months 52%, 41%, 19%, 40% or 25%, and 41%, 67%, 61% or 38% after 6 months respectively. At 12 months, healing occurred in up to 80%. The fractures were usually immobilised until union was assessed. It is not likely that a single intervention of shock wave therapy causes effects that last for several months. The results were compared with the natural course of fracture healing, also showing a time dependend healing rate. Conclusion: A considerable part of the effect of shock wave therapy may be attributed to the natural course of fracture healing, where healing is seen even after 6 or 12 months. Only a randomised study will be able to show whether shock wave therapy has any effect on fracture healing

Aims. Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. Methods. Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed. Results. Data were extracted from the clinical records of 32 children diagnosed with Perthes’ disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period. Conclusion. The results of this case review demonstrate a variation of care provided to children in the UK with Perthes’ disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes’ disease. Cite this article: Bone Joint Open 2020;1-11:691–695

Rotational acetabular osteotomy (RAO) is a circumacetabular osteotomy of the acetabulum designed to correct the dysplastic hip. In this procedure, the femoral head is covered with the articular cartilage of the acetabulum and the forces of weight-bearing are distributed more evenly. The purpose of this study was to determine whether RAO is effective in delaying the onset of arthrosis in patients with painful hip dysplasia. We determined the outcome of 20 female patients in whom RAO was performed between 1975 and 1984; all were aged 20 to 29 years at the time of surgery. The pre-operative centre-edge angle of Wiberg was 0 or negative with proximal subluxation of the femoral head. Of these, 10 were lost to follow-up before the age of 42. In these patients, however, radiographs showed no signs of arthrosis at the last follow-up. The remaining 10 patients were examined 15 to 25 years after surgery, when they were 42 to 47 years old. Radiographs revealed findings of arthrosis in only two of them who had had the secondary acetabulum before surgery. To evaluate the efficacy of preventive medicine, it is necessary to compare the results of intervention with the natural course of the disease. Wiberg reported on the natural history of seven female patients with severe hip dysplasia in 1939. When these patients were 13 to 34 years old, radiographs demonstrated no sign of arthrosis and the centre-edge angle was equal to or less than 12 degrees with proximal subluxation of the femoral head. These hips deteriorated to advanced arthrosis by the age of 42 years. Thus the outcome of our patients was significantly better than the natural course. In conclusion, our study suggests that RAO is effective in delaying the onset of arthrosis in patients with painful hip dysplasia

Background. Although thigh pain is an annoying problem after total hip arthroplasty (THA), little information has been known about its natural course. Methods. To determine the frequency, time of onset, and duration of thigh pain after cementless THA, we evaluated 240 patients (240 hips) who underwent primary THA because of femoral head osteonecrosis with the use of a single tapered stem. Results. Twenty-seven patients (11.3%) experienced thigh pain during the follow-up of 3–11 years(mean, 84 months). The pain developed 2–78 months (median, 25 months) after THA. The 75% of pain developed within 36 months. In 25 patients, the pain disappeared postoperatively 1 month-64 months (mean, 17.4 months), and 2 patients (7.4%, 2/27) had persistent thigh pain. There were no differences in the latest Harris Hip Score between the thigh pain group and no thigh pain group. Conclusion. Our results provided basic information about the natural history of thigh pain after cementless THA with a tapered stem design

Purpose. Our primary purpose was to study the rate of occurrence and the natural course of pseudotumors in patients who had not required a revision procedure. Our secondary purpose was to see if there is a relationship between serum metal ion analysis and clinical symptoms with metal-on-metal (MOM) hip arthroplasty. Patients and Methods. We used repeated metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) to screen 17 unrevised hips (mean patient age 63.0 years, 43 to 83 years) with pseudotumors and 26 hips (mean patient age 63.2 years, 47 to 83 years) without pseudotumors. Patients with 17 MOM, 17 ceramic-on-polyethylene (COP) and 7 ceramic on ceramic (COC) who had undergone repeated MARS MRI were evaluated with or without any symptoms. We utilized MARS MRI to score the type of pseudotumors using the Hart method. The mean post-operative time to the first MARS MRI scan was 30.0 months (8 to 96), and the time between the first and the second MARS MRI scan was eleven months (6 to 12). Serum Cr and Co ion measurements were undertaken at the time of both MRIs and analyzed only after MOM total hip arthroplasty. Results. The rate of occurrence of pseudotumors was 47.5% with MOM, 33.0% with COP, and 25.0% with COC. There was a significant difference in number of abnormalities between MOM and COP and COC bearing. At the second MRI scan, the grade of severity of pseudotumors had not changed in 40 hips. Two new asymptomatic pseudotumors (MOM:1 case, COP:1 case) were detected and one pseudotumor was downgraded. In 17 patients with pseudotumors, two cases (11.7%) were symptomatic and in 26 patients without pseudotumors, 4 cases (15.3%) were symptomatic, with no significance between the two groups. In 17 patients with MOM cases, only two cases with pseudotumors were symptomatic, and both cases showed elevated blood metal ion levels. However, in these series 13 cases (6 with pseudotumors and 7 without pseudotumors) (76.4%) were overtaken baseline. So there was no significance in terms of metal ion levels with or without pseudotumors. Discussion. Overall, there was the same tendency in terms of occurrence of pseudotumors compared with our previous studies regarding MARS MRI. Pseudotumors can occur in patients with COP and COC bearing secondary to corrosion at modular femoral head neck taper. This feature is similar to pseudotumors seen in patients with a MOM bearing. In general, the characteristics of the pseudotumors hardly changed. Repeated MARS MRI scans within one year after total hip arthroplasty showed little or no variation. On the other hand, in 26 patients without pseudotumors, two new asymptomatic pseudotumors were detected. Moreover, there was no clinically useful association among symptoms, serological markers and the severity of MR findings. In conclusion, MRI abnormalities are present in normal asymptomatic THA and, regardless of the type of bearing surface, the occurrence of pseudotumors suggests that it might originate from head neck junction and indicate subclinical disease

Spinal fusion still is considered to be the most appropriate treatment for lumbar spinal disease not responding to conservative measures. Various forms of lumbar instability require surgical stabilisation. As an alternative to fusion, mobile, dynamic stabilisation restricting segmental motion would be advantageous under certain conditions, allowing greater physiological function and reducing the inherent disadvantages of rigid instrumentation and fusion. The “Dynamic Neutralization System for thèeSpine” is a pedicle screw system for mobile stabilisation, consisting of titanium alloy screws connected by an elastic synthetic compound, controlling motion in any plane (non-fusion system). Clinical success after solid fusion is unpredictable because it does not necessarily prevent painful loading across the disc, and it may also interfere with maintenance of sagittal balance in various postures. This system reduces movement both in flexion and extension and appears to be better. These study results compare well with those obtained by conventional procedures; in addition to which, mobile stabilisation is less invasive than fusion. Long-term screw fixation is dependent on correct screw dimensions and proper screw positioning. The natural course of polysegmental disease in some cases necessitates further surgery as the disease progresses. Dynamic neutralisation proved to be a safe and effective alternative in the treatment of unstable lumbar conditions

Introduction. Previous work has shown that C57BL/6 mice develop scoliosis when rendered bipedal. Our previous work suggested that tamoxifen (TMX) might change the natural course of scoliosis when administered before scoliotic curves develop. We analysed whether the incidence of scoliosis or the magnitude of curves may be decreased by the administration of tamoxifen after curves are observed. Methods. 20 female, 3-week-old C57BL/6 mice underwent amputations of forelimbs and tails at 3 weeks, 18 of which were included in analyses. Posteroanterior scoliosis radiographs were obtained at week 20, and scoliotic curves were recorded. After week 20, all mice received 10 mg TMX per L of daily water supply for 20 weeks. The course of deformities in this group (week 20 group) was compared with that of previous study groups (receiving TMX from week 3; week 3 group). Results. At week 20, overall, upper thoracic (UT), thoraco-lumbar (TL), and double curve scoliosis rates were similar in both groups, but the thoracic (T) scoliosis rate was lower in the week 3 group. At week 40, although T, TL, and double curve scoliosis rates were similar between groups, overall rate and the rates of UT scoliosis were significantly lower in week 3 group (table). We recorded no significant change of curve rates in week 20 group apart from the TL rate, which showed a significant increase (p=0·025). Mean Cobb angles were similar in both study groups (p>0·05) at 20 and 40 weeks. Conclusions. This study has shown that TMX administered after scoliotic changes are observed seems to be less effective compared with prior TMX protocol in C57BL/6 mice model. This information is important for the planning of possible pharmacological intervention in human beings

The aim of the study is to evaluate the prognostic value of Herring’s classification for treatment planning of Perthes Disease and predicting the final outcome of the disease. We analysed 45 patients treated in our department in the period of 1992 – 2005. The analysis consisted of determining the lateral pillar collapse in fragmentation stage and the containment of the femoral head in the residual stage. We did retrospective analysis of the x-rays in fragmentation stage and classified the patients according to Herring’s classification. Group A included 10 patients, group B – 20 patients and group C included 15 patients. We used Hayman – Herndon Acetabulum – Head Index (AHI) to analyse the x- rays in the residual stage. The statistical analysis of the results included the analysis of the differences between the lateral pillar collapse among the groups and the differences between affected hip and the contralateral control hip. Correlation between the degree of lateral pillar collapse and the AHI in the residual stage was also analyzed. Correlation between the age of onset of the disease and AHI was determined for each group, too. The results show significant differences between the lateral pillar collapse in Herring groups, and among the affected and control hips. Differences of AHI values were also significant between the groups. Correlation between the AHI and lateral pillar collapse for each group shows moderate connection just as the one between AHI and age. Herring’s classification is reliable in classifying patients with Perthes disease. It enables good prediction of the natural course of the disease and thus influences the treatment decision-making

Introduction. Calmodulin probably has a regulatory role in muscle contraction and its antagonism may decrease the magnitude and progression of scoliosis. A separate study has shown that tamoxifen (TMX), a known antagonist, is effective in altering the natural history in an avian model; however, whether the same effect is conceivable in mammals is unknown. We aimed to analyse whether the natural course of scoliosis in mice may be altered by the administration of TMX. Methods. 60 female, 3-week-old, C57BL/6 mice underwent amputations of forelimbs and tails. 57 mice were assigned to three groups: control group, no medications; TMX group, 10 mg TMX/L drinking water; and combined group, 10 mg TMX plus 10 mg trifluoperazine (TFP)/L drinking water. PA scoliosis radiographs were taken at 20 and 40 weeks and evaluated for presence and magnitude of spinal curves. Results. Four mice were lost to follow-up in the TMX group. Overall scoliosis rate was significantly lower in the TMX group (33%) than in the control (90%) and combined (68%) groups (p=0·001) at week 40. Similarly, upper thoracic scoliosis rate was lower in the TMX group (27%) than in control (74%) and combined (47%) groups (p=0·01). The thoracic scoliosis rate was also lower in the TMX group (7%) group than in control (63%) and combined (26%) groups (p=0·001). Combined drug group had lower thoracic and lumbar Cobb angles (17·50° [□}3·45]) than did the control group (29·40° [□}5·98]; p=0·031). Furthermore, double curve incidence at week 40 was lower in TMX group (12%) than in control (74%) and combined (47%) groups (p=0·001). Triple curve incidence was lower in combined (0%) and TMX (6%) groups than in the control group (15%), but this result was not significant (p=0·167). Conclusions. TMX effectively decreased the incidence and magnitude of the scoliotic curves in C57BL/6 mice scoliosis model. This is a novel finding, and could be very important in opening a pathway for the conservative treatment of idiopathic scoliosis by oral drugs

Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES. The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES. Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months). The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease

Aims: The aim of the study is to evaluate the prognostic value of Herringñs classiþcation for treatment planning and predicting the þnal outcome of the disease. Methods: We analysed 45 patients treated in our department in the period between 1992 Ð 2000. The analysis consisted of determining the lateral pillar collapse in fragmentation stage and the containment of the femoral head in the residual stage. We did retrospective analysis of the x-rays in fragmentation stage and classiþed the patients according to Herring classiþcation. Group A included 10 patients, group B Ð 20 patients and group C included 15 patients. For analysis of the x- rays in residual stage we used Hayman Ð Herndon Acetabulum Ð Head Index (AHI). The statistical analysis of the results included the analysis of the differences between the lateral pillar collapse among the groups and the differences between affected hip and the contralateral control hip. Correlation between the degree of lateral pillar collapse and the AHI in the residual stage was also analyzed. Correlation between the age of onset of the disease and AHI was determined for each group, too. Results: The results show signiþcant differences between the lateral pillar collapse in Herring groups, and among the affected and control hips. Differences of AHI values were also signiþcant between the groups. Correlation between the AHI and lateral pillar collapse for each group shows moderate connection just as the one between AHI and age. Conclusions: Herringñs classiþcation is reliable in classifying patients with Perthes disease. It enables good prediction of the natural course of the disease and thus inßuences the treatment decision-making

Purpose: Although transient osteoporosis of the hip was initially described in pregnant women, now most frequently identified in middle-age and older men. Has also been reported to occur in either hip and in both successively. This condition is referred as migratory transient osteoporosis of the hip. In this study the authors describe five cases of migratory hip osteoporosis and the differential diagnosis with osteonecrosis is also discussed. Material and Methods: Thirty-four patients with transient osteoporosis were presented. Of the 34 patients five had a similar episode of severe pain in the contralateral hip 14 months mean time later. Early bone scans and MRI of the hips had been carried out in all of the patients. After the evaluation of these findings and thorough exclusion of other conditions diagnosis of migratory transient osteoporosis was demonstrated, and confirmed by the natural course of the disease. Results: All cases were treated with nonsteroidal anti-inflammatory medications and protected weight-bearing. The course of the disease has not been appreciably altered by medical treatment, and the mean time interval from the onset of symptoms to clinical recovery was 4.6 months (range 3 to 6 months). Imaging findings on MR confirmed the diagnosis during both episodes and paralleled the reduction of pain. Conclusions: Migratory transient osteoporosis of the hip is a rare self-limited condition of uncertain etiology and pathogenesis, which “migrate” from one hip to the other. Magnetic resonance imaging is highly sensitive in the early detection of this condition and moreover is helpful in the exclusion of other entities. Although the diagnosis is one of exclusion, it must be considered and contrasted with hip osteonecrosis

Purpose: The prevalence of groin pain following total hip resurfacing is unknown. Based on recent literature, 4.3% of total hip replacement patients will complain of groin pain/iliopsoas tendonitis. This study aims to determine the prevalence of groin pain after metal on metal hip resurfacing. Method: Out of 163 patients that underwent hip resurfacing at the Ottawa General Hospital by two orthopedic surgeons with a minimum follow up of 6 months, 93 patients were evaluated in this study. Patients were questioned about post-operative groin pain in detail. A physical exam was completed by an independent orthopaedic surgeon to measure range of motion, assess for a positive impingement sign, and assess pain with straight leg raise. Radiographic evaluation included anterior femoral head/neck offset ratio, presence of acetabular component uncoverage and component loosening. Results: A total of 98 hips, in 93 patients were evaluated. Mean age was 50 years, with a mean follow up of 21.7 months (range 6–48 months), 21% had ongoing groin pain, 8% reported taking analgesics and 10% reported limitation of activities due to pain. 5 patients received a cortisone injection with a variable response. There were no statistically significant differences detected between groin pain and the radiological parameters inspected. There was no evidence of component loosening. Decreased range of motion was slightly correlated with groin pain. Patients with groin pain had lower RAND and WOMAC scores. Patients reporting a pain score of 5 or above on a visual pain score were found to have lower functional scores than those who scored less, though not statistically significant. Neither the surgeon nor the approach were associated significantly to pain, Pain distribution did not change over the course of the post operative period from 6 months to four years. Conclusion: Groin pain after hip resurfacing appears more common than that after total hip replacement. The origin is most likely multi-factorial: surgical approach, implant positioning and reaction to wear debris. Further research is required in determining predisposing factors as well as its natural course

Purpose of the study: Management of the spinal neuroarthropathy of Charcot’s disease is recommended. Vertebral fusion should be extensive and often circumferential. The natural history of this disease, often diagnosed late, is poorly understood and the results of functional treatments not well studied. The purpose of this study was to describe the elements motivating surgical abstention and to analyse the natural course of the vertebral lesions. Material and methods: The diagnosis of spinal neuroarthropathy was established in seven patients from 1997 to 2007. Six has paraplegia and one female patient Friedrich ataxia. The initial neurological disease was known for 18 years on average before diagnosis of the spinal neuroarthropathy. The management decision was based on patient motivation, comorbid conditions, and successive functional, clinical and imaging assessments. The patients were classed by the progression of vertebral destruction. Four patients had a non-evolving destruction, two with a stable spine and two with spinal hypermobility. Results: The spinal stability, the absence of progression of the spinal neuroarthropathy, and in certain cases the presence of an ossification process were determining in deciding to abstain from surgery. Despite the collapse of the trunk, surgical abstention was decided for two patients basically because of the loss of spinal mobility resulting from the arthrodesis. For three other patients with progressing spinal lesions, the presence of comorbid factors (major risk of infection), patient refusal of the risk of temporary or definitive loss of function were the reasons surgery was decided against. Discussion: According to the literature, it is assumed that abstention from surgery will invariably lead to neurological or infectious complications and even patient death. We did not observe these events in our series. The major surgery exposes to a risk of failure; certain authors have reported a complication rate of 60% and others have had 40% repeat operations. The instability induced by the spinal neuroarthropathy can be considered providential by the patient. The fact that several patients declined surgery because of the fear of worsening their handicap after arthrodesis is noteworthy. Simulation with a rigid corset was determining. The spinal neuroarthropathy does not appear to be a continuous destructive process but its natural history is not well known. Predictive elements were not identified in this study. Conclusion: Charcot’s spinal neuroarthropathy is a challenging condition in frail patients. Disease progression, comorbid conditions, and multidisciplinary functional assessments are needed for adequate management and decision making

Introduction: The purpose of this prospective study was to evaluate the therapeutic value of Pulsed Electromagnetic Fields (PEMF) in the treatment of the osteonecrosis of the femoral head (ONFH). Materials and Methods: One hundred-eight consecutive hips with ONFH (80 patients) treated with PEMF between June 1990 and June 1998 were analyzed. The average age was 37 years. The average follow-up period was 6.9 years. According to the ARCO staging system, 3 hips were stage I, 85 hips stage II, and 20 hips stage III. Hips were evaluated clinically with a modified Harris hip scoring system and degree of pain relief. Radiographic progression was defined as either an advance in ARCO stage or progressive collapse of the femoral head more than 2 mm. Results: Clinical improvement was achieved in 81 hips (75%). Hip pain was relieved or decreased at an average of six months following initiation of PEMF therapy in the 81 hips with clinical improvement as well as some radiographically progressed hips. Radiographic progression was seen in 35 hips (32.4%). Total hip arthroplasty (THA) had been performed in 20 hips (18.5%). Kaplan-Meier survivorship analysis demonstrated that the probability of conversion to THA within 5 years after PEMF was 16% overall. Conversion to THA was significantly higher in patients who had the necrotic lesion laterally, in the subgroup C (more than 30% involvement of necrosis), and in patients older than the mean age. Discussion: These results demonstrate that PEMF can modifiy the natural course of ONFH. PEMF is recommended in patients who are less than forty years old with early stage disease with small necrotic involvement. Refinement of PEMF could make it a more efficacious non-invasive method of treatment

Purpose: Congenital absence of the anterior cruciate ligament (ACL) is an uncommon finding. Cases reported in the literature have been sporadic. The aetiology remains obscure. The purpose of this study was to describe results obtained in five patients (eight knees) with agenesia of the ACL to determine the characteristic features and search for elements differentiating the natural course of agenesia and post-traumatic ACL rupture. Material and methods: The patients were four men and one woman, mean age 46 years. All five patients had a common ancestor, raising the question of the hereditary nature of the condition. Results: The cardinal sign was medial femorotibial and femoropatellar pain, found in all patients. Physical exam revealed major anterior laxity (pivot shift +, Trillat Lachman +) and an abnormal protrusion of the anterior tuberosity of the tibia. The standard x-rays revealed elements suggestive of ACL agenesia and the MRI confirmed the diagnosis in all cases. Discussion: In comparison with reports in the literature, our patients illustrated a few specific points:. - the familial nature of the condition in our patients suggestive autosomal dominant inheritance with variable penetration;. - the rare occurrence of instability, probably due to adaptation since childhood;. - hypoplasia of the tibial spines and the lateral condyle, consequence of ACL agenesia. Comparing the natural history of ACL agenesia with that of post-trauma rupture led to certain observations:. - clinical and radiological congenital laxity is well tolerated;. - degeneration appears inevitable in case of congenital anterior laxity. It occurs late, progresses slowly, slower than after traumatic rupture of the ACL;. - unlike trauma-induced rupture, the lateral femototibial and femoro-patellar compartments are preserved for a very long period. The lack of genetic studies and the familial nature of the cases reported here suggest that genetic surveys would be useful to elucidate this condition