Aims

The preventive effects of bisphosphonates on articular cartilage in non-arthritic joints are unclear. This study aimed to investigate the effects of oral bisphosphonates on the rate of joint space narrowing in the non-arthritic hip.

1. A case of arthritis of hip complicating osteitis pubis after retropubic prostatectomy is described. 2. It seems likely that bacterial infection was responsible in this case, although it was not proved. 3. Antibiotics did not appear to influence the course of the disease. 4. The progress of the disease was followed clinically and radiologically to its conclusion by natural healing with absorption of the femoral head, leaving a painless joint with good function

Young adults with hip pain secondary to femoroacetabular impingement (FAI) are rapidly being recognised as an important cohort of orthopaedic patients. Interest in FAI has intensified over the last decade since its recognition as a precursor to arthritis of the hip and the number of publications related to the topic has increased exponentially in the last decade. Although not all patients with abnormal hip morphology develop osteoarthritis (OA), those with FAI-related joint damage rapidly develop premature OA. There are no explicit diagnostic criteria or definitive indications for surgical intervention in FAI. Surgery for symptomatic FAI appears to be most effective in younger individuals who have not yet developed irreversible OA. The difficulty in predicting prognosis in FAI means that avoiding unnecessary surgery in asymptomatic individuals, while undertaking intervention in those that are likely to develop premature OA poses a considerable dilemma. FAI treatment in the past has focused on open procedures that carry a potential risk of complications. Recent developments in hip arthroscopy have facilitated a minimally invasive approach to the management of FAI with few complications in expert hands. Acetabular labral preservation and repair appears to provide superior results when compared with debridement alone. Arthroscopic correction of structural abnormalities is increasingly becoming the standard treatment for FAI, however there is a paucity of high-level evidence comparing open and arthroscopic techniques in patients with similar FAI morphology and degree of associated articular cartilage damage. Further research is needed to develop an understanding of the natural course of FAI, the definitive indications for surgery and the long-term outcomes. Cite this article: Bone Joint J 2013;95-B, Supple A:26–30

Aims

Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips.

Purpose. Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy. Methods. 16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed. Results. Mean age at first known hip dislocation was 4.1 years (range 3, 7 years). All had a femoral varus derotation osteotomy (VDRO). In 2 hips, significant intraoperative instability persisted and a periacetabular osteotomy and capsulorraphy were required. Mean Femoral neck shaft angle (NSA) fell from 166.7° (+/-6.9°) to 106.0° (+/-5.4°). Mean follow-up was 5.9 years (+/-2.9). 1 hip (6.2%) developed painful arthritis. 14 hips developed peri-trochanteric varus deformities. 2 (12.5%) developed periprosthetic fractures 4 and 8 years post-operatively. Conclusion. Prevention of long term disabling pain from habitually dislocating or recurrently subluxed hips, in patients with Trisomy 21, requires surgical intervention to increase hip containment. In those aged =9 who have not developed hip incongruency, a VDRO with adequate varisation and minimal derotation was sufficient. Reducing the femoral NSA to approximately 100°, intraoperatively stabilised most hips. If instability persisted, a periacetabular osteotomy and capsulorraphy were performed. The 2 hips requiring additional procedures had the least corrected NSAs (115° and 122°) in our series. These patients were also older, aged 7 and 10, a factor that may have also contributed to the need for acetabular correction. We believe surgical management of habitually subluxed or dislocated Trisomy 21 hips allows for a predictable result. We recommend a varus producing proximal femoral osteotomy to correct the NSA to 100-110°. This should be performed before either the age of 8 years or teardrop development. In our experience this has been effective in maintaining hip stability

Giant synovial cyst is commonly seen in association with rheumatoid arthritis. The Baker’s cyst around the knee is the commonest example but it has also been described at the elbow and hip. The possibility of a synovial cyst around the hip is unfamiliar to most clinicians including those who regularly deal with inguinal swellings and those specialising in musculoskeletal conditions. This is often overlooked as a cause of symptoms in inguinal area and lower limb. We present a report on two patients in whom abnormal pulsatile masses in the groin caused diagnostic difficulty. Patients were initially admitted under vascular surgeons with a clinical diagnosis of aneurysm. Ultrasound examination was useful in excluding aneurysm. Detailed clinical examination revealed painful restricted hip movements and an X–ray showed evidence of arthritis in hip joint. CT Scan confirmed it to be a synovial cyst. Computed Arthrotomogram or Arthrography showed communication of the cyst with hip joint. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported. They may present as a pulsatile mass due to close proximity to femoral vessels and should be considered as a differential diagnosis in patients with unusual inguinal swelling

To evaluate the results critically of cemented total hip arthroplasty using a fourth generation cement technique and polished femoral stem, a prospective study was performed in patients under 50 years of age who underwent primary total hip arthroplasty. 55 patients (64 hips) were enrolled in the study (43 were male and 12 were female). Average age of patients was 43.4 years (21–50 years). Elite plus stems (DePuy, Leeds, UK) were cemented and cementless Duraloc cups (DePuy, Warsaw, IN.) were implanted in all hips. 22 mm zirconia femoral head (DePuy, Leeds UK) was used in all hips. All surgeries were performed by one surgeon (YHK). The diagnosis was osteonecrosis (43 hips or 67%), osteoarthritis (5 hips or 4%), O.A. 2° to childhood T.B. or pyogenic arthritis (4 hips or 6%), R.A, (3 hips or 5%), DDH (2 hips or 3%) and others (7 hips or 11%). The average F.U. was 7.2 years (6–8 years). The 4th generation cement technique was utilized including: medullary plug, pulsatile lavage, vaccum mixing of Simplex P cement; cement gun, distal centralizer and proximal rubber seal to pressurize cement. Thigh pain was evaluated using a visual analog scale (10 points). Clinical (Harris hip score) and x-ray follow-up was performed at 6 weeks, 3 months, 6 months, 1 year and then annually. Cementing technique was graded. Abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion were measured in all hips. Linear and volumetric wear were measured by software program. Osteolysis was identified. There was no aseptic loosening or subsidence of components. One hip was revised due to late infection. Incidence of thigh pain was 11% (7 hips). All thigh pain disappeared at 1 year postoperatively. Preoperative Harris hip score was 47.2 (7–67) points and 92.2 (81–100) points at the final F.U. Femoral cementing was classified as grade A in 50 hips (78%), grade B in 6 hips (9%), and grade C1 in 8 hips (13%). There was no cases in grades C2 and D. All bones had type A femoral bone. The average linear wear and annual rate were 1.25 and 0.21 mm, respectively. The average volumetric wear was 473.48 mm3. There was statistically significant relationship between the liner wear, age (under 40), male patient, and the cup angle. Yet there was no statistical relationship between the wear and Dx., wt., hip score, R-O-M, anteversion, anbductor moment arm, femoral offset, neck and limb length and center of rotation of hip. Osteolysis was identified in zone 7A in 6 hips (9%). No hip had distal osteolysis. Advanced cementing technique, polished improved stem design, strong trabecular bone, and utilizing a smaller head and thick polys greatly improved the mid-term survival of the implants in these young patients. Good cementing technique eliminated distal osteolysis and markedly reduced the proximal osteolysis. Yet high linear and volumetric wear of polyethylene liner remains to be a challenging problem

To determine the results critically of cementless third generation prosthesis (proximal fit, porous coated, and tapered distal stem), a prospective study was performed only in Charnley class A patients under 50 years of age who underwent primary total hip arthroplasty. 50 patients (50 hips) were included in study (37 were male and 13 were female). Average age of patients was 45.4 years (26–50 years). IPS(Immediate Postoperative Stability) stems (DePuy, Leeds, UK) were implanted in all hips. Cementless Duraloc cups (DePuy, warsaw, IN.) were used in all hips. 22 mm zirconia femoral head was used in all hips. All surgeries were performed by one surgeon (YHK). The redominant Dx. was osteonecrosis (30 hips or 60%), O.A. 2° to childhood T.B. or pyogenic arthritis (8 hips or 16%) and others (12 hips or 24%). The average F.U. was 6.3 years (5–7 years). Thigh pain was evaluated using a visual analog scale (10 points). Clinical (Harris hip score) and x-ray follow-up was performed at 6 weeks, 3 months, 6 months, 1 year and then annually. Linear and volumetric wear were measured by software program. Abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion were measured and the results were compared between normal and operated hips. All hips had satisfactory fit in A-P and lateral planes. There was no aseptic loosening or subsidence of components. Incidence of thigh pain was 14% (7 of 50 hips). All thigh pain disappeared at 3 years postoperatively. Preoperative Harris hip score was 52.3 (7–64) points and 92.9 (80–100) points at the final F.U. The values of abductor moment arm, femoral offset, neck and limb length, center of rotation of hips, cup angle and anteversion of operated hips were comparable to normal unoperated hips. The average linear wear and annual wear rate were 1.25 and 0.21 mm, respectively. The average volumetric wear was 473.48 mm3. There was statistically significant relationship between the liner wear, age (under 40), male patient, and the cup angle. Yet there was no statistical relationship between the wear and Dx., wt., hip score, R-O-M, anteversion, abductor moment arm, femoral offset, neck and limb length and center of rotation of hip. Osteolysis was identified in zones 1A and 7A in 4 hips (8%). No hip had distal osteolysis. Close fit cementless stem in coronal and saggital planes without having distal stem fixation were proved to have an excellent mechanical fixation and provided favorable mechanical loading. Close fit in the proximal canal with a circumferential porous coating reduced the incidence of osteolysis. Factors contributing to good results in this young patient group are improved design of the prosthesis, improved surgical technique, strong trabecular bone and the use of smaller femoral head and thick polys. Although there was no aseptic loosening of the hip, high incidence of linear and volumetric wear of polyethylene liner in these young patients remains to be a challenging problem

The D.D.H screening programme until the second half of ’80 was based on the clinical Ortolani-Barlow’s manoeuvre at newborn age and by xray examination of the pelvis at three – four month old to discover hip joint anomalies that could be address at a future dislocation. Never less the so-called Dislocation of the Hip was a quite common pathology around Europe. The close reduction of a dislocated hip has been the treatment of choice in order to attempt to reduce a dislocated hip without surgical operation. Close reduction was preferred to be obtained after a period of skin traction on bed, at which a special frame were added, to perform a progressive gentle reduction gaining, in an average of three weeks time, complete abduction before applying a spica cast. Two main methods were used: reduction with the hips extended, abducted and internal rotated according to Sommerville- Petit and reduction in over head position with the hips flexed, abducted and external rotated. These two systems were designed to decrease the Avascular Necrosis of the femoral head that often occurs if the reduction was obtained during a sudden manoeuvre under general anaesthesia. Generally the correct position of the femoral head into the acetabular socket, at the moment to apply the plaster, was assessed by an arthrogram, to avoid the bad surprise of further dislocation due to false reduction after the traction period. The child so treated had to be followed during her/his growth to assess the development of acetabular roof and the position of the femoral head linked at the antiversion of the femoral neck. Any hip joint, in which acetabular index do not improve during growth, needs acetabular and femoral osteotomies to overcome these anatomical defects as cause of a persisting genetic defect. At the end of ’80, a deep change of the natural history of D.D.H. in Italy is related to the introduction of screening programme based on accurate clinical examination of the hip of the babies at the nursery, selection of babies with risk signs of D:D.H. such as clinical anomalies, instability of the hip at Ortolani-Barlow’s, familiarity for D.D.H. and breech delivery. The hips of those babies are immediately assessed by ultrasonographic examination according to Graf’s method. The general population, on the contrary, is examined by US between the second and the third months of age. The National Health Service encourages the US screening paying its cost. In this way the incidence of late-D.D.H. and late-dislocation is enormously decreased and the outcome of the pathology has been improved. The conservative treatment of the hip affected by different grade of anomalies early discovered trough US examination, in fact, are treated by simple harness in abduction for mild dyspalsia to plaster spica cast in human position if the hip is severely unstable and Ortolani positive. There are same rare cases of true Congenital Dislocation at birth that can not be conservatively reduced and it will be necessary to perform a open reduction generally when the ossified nucleus of femoral head appeares. Our experience:. From 1975, when our Children Orthopaedic Department was created in the Medical School of “Federico II” University of Naples and the first authors become the Chief, we admitted 374 patients affected by dislocation of the hip (F=308 – M= 66 F:M= 5:1) with a mean age of 7 and half months (min.4 mths.– max 20 mths). All these patients were put in traction on the Morel’s bed in order to attempt a close reduction in extended, abducted and internal rotated position according to Sommerville- Petit method. Average time of traction was 25 days (min. 7 max 38). 120 patients were undergone at an arthrographic examination in general anaesthesia. 46 patients did not achieve the reduction and were operated on. A spica cast were applied for 60 days followed by an harness in abduction. Total amount of time of treatment was a mean of 7 months (min 110 days max. 12 months). Residual dysplasia was observed in 48 patients that needed a further surgical procedure. The number of inpatient affected by D.D.H. were an average of 21 per year until 1990 to drop dramatically at 3 per year in the last decade. On the other hand the D.D.H. outpatient clinic increased. The selected babies examined were 6930 at an average age of 4 months old. All the babies were undergone to clinical and Us examination and classified according to Graf. Hip anomalies were seen in 630 babies. The treatment was related to clinical and Us observation. Simple abduction pillow or simple harness in abduction were used in hip clinically negative at Ortolani-Barlow’s manoeuvre and 2c or 2b type according to Graf.’s classification. Milgram harness or Coxaflex harness (Thamert –Burgwedel –Germany) or plaster spica cast in “human position” were applied in instable hip type D or worse and clinically positive at Ortolani-Barlow manoeuvre. 25 patients were hospitalised because affected by irreducible hip. Conclusion:. The experience that we have done over decades in treatment of D.D.H. confirms the assumption of Treadwell and Bell (1981) that claimed that D.D.H. screening deeply changed the natural history of D.D.H. The problem was to find a good screening test helpful to diagnose as soon as possible a pathological hip. Graf’s method, after a decade of scientific criticism, can be elected at a worth method to screen an infant hip. Screening program based on ultrasound and clinical examination decreases hospitalisation, cost and sequels of D.D.H. in term of surgical operation and degenerative arthritis of hip joint at least at a medium follow up. The hip that need to be hospitalised are the true congenital dislocated hip for which early diagnosis probably should not effect their clinical history. A danger is hidden in US screening. Ultrasonography has to be performed by a skill examiner and it has to be implemented by careful clinical examination with anamnestic recording of the data in order to obtain the best result of the D.D.H. screening program

A number of studies have reported satisfactory results from the isolated revision of an acetabular component. However, many of these studies reported only the short- to intermediate-term results of heterogeneous bearing surfaces in a mixed age group.

We present our experience of using a ceramic-on-ceramic (CoC) bearing for isolated revision of an uncemented acetabular component in 166 patients (187 hips) who were under the age of 50 years at the time of revision. There were 78 men and 88 women with a mean age of 47.4 years (28 to 49). The most common reason for revision was polyethylene wear and acetabular osteolysis in 123 hips (66%), followed by aseptic loosening in 49 hips (26%).

We report the clinical and radiological outcome, complication rate, and survivorship of this group. The mean duration of follow-up was 15.6 years (11 to 19).

The mean pre-operative Harris hip score was 33 points (1 to 58), and improved to a mean of 88 points (51 to 100) at follow-up. The mean pre-operative total Western Ontario and McMaster Universities Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8 points (9 to 61) post-operatively. Overall, 153 of 166 patients (92%) were satisfied with their outcome. Kaplan–Meier survivorship analysis, with revision or radiological evidence of implant failure (13 patients, 8%) as end-points, was 92% at 15 years (95% confidence interval 0.89 to 0.97).

Isolated revision of a cementless acetabular component using a CoC bearing gives good results in patients under 50 years of age.

Cite this article: Bone Joint J 2015;97-B:1197–1203.

The April 2015 Research Roundup360 looks at: MCID in grip strength and distal radial fracture; Experiencing rehab in a trial setting; Electrical stimulation and nerve recovery; Molecular diagnosis of TB?; Acetabular orientation: component and arthritis; Analgesia after knee arthroplasty; Bisphosphonate-associated femoral fractures

The Bone & Joint Journal provides the latest evidence to guide the clinical practice of orthopaedic surgeons. The benefits of one intervention compared with another are presented using outcome measures; some may be specific to a limb or joint and some are more general health-related quality of life measures. Readers will be familiar with many of these outcome measures and will be able to judge the relative benefits of different interventions when measured using the same outcome tool; for example, different treatments for pain in the knee measured using a particular knee score. But, how should readers compare outcomes between different clinical areas using different outcome measures? This article explores the use of standardised effect sizes.

Cite this article: Bone Joint J 2014;96-B:853–4.

The October 2014 Trauma Roundup³⁶⁰ looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

Percutaneous epiphysiodesis using transphyseal screws (PETS) has been developed for the treatment of lower limb discrepancies with the aim of replacing traditional open procedures. The goal of this study was to evaluate its efficacy and safety at skeletal maturity. A total of 45 consecutive patients with a mean skeletal age of 12.7 years (8.5 to 15) were included and followed until maturity. The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%) at six months and 66% (21% to 100%) at maturity. The mean efficacy of the tibial epiphysiodesis was 46% (18% to 73%) at six months and 66% (25% to 100%) at maturity. In both groups of patients the under-correction was significantly reduced between six months post-operatively and skeletal maturity. The overall rate of revision was 18% (eight patients), and seven of these revisions (87.5%) involved the tibia. This series showed that use of the PETS technique in the femur was safe, but that its use in the tibia was associated with a significant rate of complications, including a valgus deformity in nine patients (20%), leading us to abandon it in the tibia. The arrest of growth was delayed and the final loss of growth at maturity was only 66% of that predicted pre-operatively. This should be taken into account in the pre-operative planning.

We evaluated the outcome of 104 consecutive primary cemented Exeter femoral components in 78 patients (34 men, 44 women) under the age of 40 years who underwent total hip replacement between October 1993 and May 2004. The mean age at operation was 31 years (16 to 39). No hip was lost to follow-up, but three patients (four hips) died. None of the deaths were related to the surgery. At a mean follow-up of 6.2 years (2 to 13), three femoral components had been revised for septic loosening. Using Kaplan-Meier survival analysis, the seven-year survival of the component with revision for any reason as the endpoint was 95.8% (95% confidence interval 86.67 to 98.7). The seven-year survival with aseptic femoral loosening as the endpoint was 100% (95% confidence interval 100).

The cemented Exeter femoral component in patients under the age of 40 shows promising medium-term results. As it is available in a wide range of sizes and offsets, we could address all types of anatomical variation in this series without the need for custom-made components.

The outcome of displaced hips treated by Somerville and Scott’s method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change.

The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.