Aims

We analyzed the long-term outcomes of patients observed over ten years after resection en bloc and reconstruction with extracorporeal irradiated autografts

To explain the knee kinematics, the vector of the quadriceps muscle, the primary extensor, is important and the relationship of the quadriceps vector (QV) to other kinematic and anatomic axes will help in understanding the knee.

Knee kinematics is important for understanding knee diseases and is critical for positioning total knee arthroplasty components. The relationship of the quadriceps to knee has not been fully elucidated. Three-dimensional imaging now makes it possible to construct a computer based solid model of the quadriceps and to calculate the vector of the muscle as individual parts and as a whole. Two studies are presented, one American and one Japanese subjects.

Using CT data from subjects who had CT for reasons other than lower extremity pathology (American) or specifically for the study (Japanese), 3-D models of each quadriceps component (vastus medialis, intermedius, lateralis and rectus femoris) were generated. Using principal component analysis for direction and volume for length, a vector for each muscle was constructed and addition of the vectors gave the QV. Three anatomic axes were defined: Anatomic Axis (AA) – long axis of the shaft of the femur; Mechanical Axis (MA) center of the femoral head to the center of the trochlear and the Spherical Axis (SA) – a line from the geometric center of the head of the femur to the geometric center of the medial condyle of the femur at the knee.

Fourteen American cases (mean age 39.1, 9 male 5 female) and 40 Japanese subjects (mean age 29.1, 21 male, 19 female) were evaluated. In all subjects the quadriceps vector at the level of the center of the femoral head was anterolateral to the center of the femoral head. The position of the QV was more lateral in Japanese compared to Americans; and, in Japanese, the vector was more lateral and posterior for women than for men. In both study populations, the QV was most closely aligned with the SA as compared to the AA or the MA.

The vector representing the quadriceps pull, originating at the top of the patella, progresses proximally toward the neck (not the head) of the femur. With the femur in anatomic position in the coronal plane, the vector crosses the femoral neck lateral to the femoral head approximately at the midpoint of the neck. While there were significant differences between the passing point of the vector based on sex and ethnicity, the QV vector most closely parallels the SA (< 1° different) for all subjects in this study. The relationship of the SA to the kinematic flexion axis (KFS) of the knee is being evaluated with the hypothesis that the relationship is 90°. If this is correct, the SA may prove a robust axis to which to align total knee arthroplasty.

We conclude that the QV as calculated progresses from the top of the patella to the mid-femoral neck and the SA is most closely parallel to this vector.

Several studies have reported the assessment of the femoral head coverage on plane radiograph and CT data in supine position, though young patients with the dysplastic hip often have symptoms during activities such as standing, walking, and running. On the other hand, some investigators have used a method of CT which allows standardization of the femoral head coverage against an anterior pelvic plane based on the anterior superior iliac spines and the pubic tubercle. We believe both the weight-bearing position and the standardized position to be more relevant for diagnosis and preoperative surgical assessment. So, we show the femoral head coverage in standardized position using 3D-CT method and in weight-bearing position using the plane radiograph and the three-dimensional lower extremity alignment assessment system before and after Curved periacetabular osteotomy (CPO). Especially the covered volume of the femoral head, a new concept, using the three-dimensional lower extremity alignment assessment system which differs from the affected area and is measured by the ratio of the covered area in the medial part of the line connecting the anterior point of the acetabulum with the posterior to the femoral head area in each axial slice, superior slices than the slice passing through the femoral head center, obtained from the reproduced 3D model of the pelvis and the femur in standing position allows us to integrate various measurements reported by past researchers.

We studied the consecutive 16 patients treated with CPO. In standardized position the sagittal sectional angles on the slice passing through the femoral head center using 3D-CT method gave us how the anterior, lateral, and posterior coverage was lack compared with normal subjects and whether the adequate transfer of the rotated fragment was performed after operation. The covered volume of the femoral head decides generally the deficiency or the adequateness. In standing position, though the pelvic tilt changes, the femoral head coverage on plane radiograph, representation by the CE angle, the VCA angle, AHI and ARO, was significantly improved, and the covered volume of the femoral head was significantly improved from 25.7% preoperatively to 51.1% postoperatively.

Our study showed the improvement of the femoral head coverage, including the covered volume of the femoral head as a new concept, after CPO in weight-bearing and standardized position. The morphological and functional assessment of the femoral head coverage on both pre- and post-CPO should be performed because we can obtain the objective information in standardized position and the femoral head coverage in standing position is closely connected with the pain.

We examined osteochondral autografts, obtained at a mean of 19.5 months (3 to 48) following extracorporeal irradiation and re-implantation to replace bone defects after removal of tumours. The specimens were obtained from six patients (mean age 13.3 years (10 to 18)) and consisted of articular cartilage (five), subchondral bone (five), external callus (one) and tendon (one). The tumour cells in the grafts were eradicated by a single radiation dose of 60 Gy. In three cartilage specimens, viable chondrocytes were detected. The survival of chondrocytes was confirmed with S-100 protein staining. Three specimens from the subchondral region and a tendon displayed features of regeneration. Callus was seen at the junction between host and irradiated bone.

We describe two patients with a diffuse haemangioma of the lower limb complicated by pathological fracture of the femoral shaft, one of whom was treated by a bone graft and immobilisation in a cast, and the other by external fixation and injection of bone marrow. A review of the literature identified difficulty in control of bleeding and obtaining bony union.