Advanced MRI cartilage imaging such as T1-rho
(T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic
radiological changes may provide prognostic information in the management
of joint disease. This study aimed first to determine the normal
T1ρ profile of cartilage within the hip, and secondly to identify
any differences in T1ρ profile between the normal and symptomatic
femoroacetabular impingement (FAI) hip. Ten patients with cam-type
FAI (seven male and three female, mean age 35.9 years (28 to 48))
and ten control patients (four male and six female, mean age 30.6
years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation
times for full thickness and each of the three equal cartilage thickness
layers were calculated and compared between the groups. The mean
T1ρ relaxation times for full cartilage thickness of control and
FAI hips were similar (37.17 ms ( These results suggest that 1.5T T1ρ MRI can detect acetabular
hyaline cartilage changes in patients with FAI.
Hip resurfacing arthroplasty (HRA) is an alternative to conventional
total hip arthroplasty for patients with osteonecrosis (ON) of the
femoral head. Our aim was to report the long-term outcome of HRA,
which is not currently known. Long-term survivorship, clinical scores and radiographic results
for 82 patients (99 hips) treated with HRA for ON over a period
of 18 years were reviewed retrospectively. The mean age of the 67
men and 15 women at the time of surgery was 40.8 years (14 to 64).
Patients were resurfaced regardless of the size of the osteonecrotic
lesion.Aims
Patients and Methods
This review summarises the evidence for the treatment
of displaced fractures of the femoral neck in elderly patients.
Results from randomised clinical trials and national register studies are
presented when available. The advantages of arthroplasty compared with internal fixation
are supported by several studies. A number of studies contribute
to the discussions of total hip arthroplasty (THA) The direct lateral approach reduces the risk of dislocation compared
with the posterior approach. Cemented implants lower the risk of
periprosthetic fracture and its subsequent morbidity and mortality.
As the risk of peri-operative death related to bone cement can be reduced
by adequate measures, cemented implants are recommended in fracture
cases. Take home message: There remains a great variation in the surgical
management of patients with a hip fracture, and an evidence-based
approach should improve the outcomes for this vulnerable patient
group. Cite this article:
The use of joint-preserving surgery of the hip
has been largely abandoned since the introduction of total hip replacement.
However, with the modification of such techniques as pelvic osteotomy,
and the introduction of intracapsular procedures such as surgical
hip dislocation and arthroscopy, previously unexpected options for
the surgical treatment of sequelae of childhood conditions, including
developmental dysplasia of the hip, slipped upper femoral epiphysis
and Perthes’ disease, have become available. Moreover, femoroacetabular
impingement has been identified as a significant aetiological factor
in the development of osteoarthritis in many hips previously considered to
suffer from primary osteoarthritis. As mechanical causes of degenerative joint disease are now recognised
earlier in the disease process, these techniques may be used to
decelerate or even prevent progression to osteoarthritis. We review
the recent development of these concepts and the associated surgical
techniques. Cite this article:
The August 2015 Children’s orthopaedics Roundup360 looks at: Learning the Pavlik; MRI and patellar instability; Cerebral palsy and hip dysplasia; ‘Pick your poison’: elastic nailing under the spotlight; Club feet and surgery; Donor site morbidity in vascularised fibular grafting; Cartilage biochemistry with hip dysplasia; SUFE and hip decompression: a good option?
The August 2015 Hip &
Pelvis Roundup360 looks at: The well-fixed acetabular revision; Predicting complications in revision arthroplasty; Is infection associated with fixation?; Front or back? An enduring question in hip surgery; Muscle-sparing approaches?; Gabapentin as a post-operative analgesic adjunct; An Indian take on AVN of the hip; Weight loss and arthroplasty
The bicompartmental acetabulum is one of the morphological changes which may be seen in children with Legg-Calvé-Perthes’ disease. Three-dimensional CT and MRI were used to analyse the detailed morphology of the acetabulum with special reference to its inner surface, in 16 patients with Perthes’ disease and a bicompartmental acetabulum. The bicompartmental appearance was seen on the coronal plane image through the acetabular fossa. The lunate surface was seen to grow laterally resulting in an increased mediolateral thickness of the triradiate cartilage. On the horizontal plane images, the acetabular fossa had deepened and had a distinct prominence at its posterior border. The combination of these morphological changes resulted in a bicompartmental appearance on plain radiography. Acetabular bicompartmentalisation appears to be the result of an imbalance of growth between the cartilage-covered lunate surface and the cartilage-devoid acetabular fossa.
We undertook a randomised controlled trial to
compare bipolar hemiarthroplasty (HA) with a novel total hip replacement
(THR) comprising a polycarbonate–urethane (PCU) acetabular component
coupled with a large-diameter metal femoral head for the treatment
of displaced fractures of the femoral neck in elderly patients. Functional
outcome, assessed with the Harris hip score (HHS) at three months
and then annually after surgery, was the primary endpoint. Rates
of revision and complication were secondary endpoints. Based on a power analysis, 96 consecutive patients aged >
70
years were randomised to receive either HA (49) or a PCU-THR (47).
The mean follow-up was 30.1 months (23 to 50) and 28.6 months (22
to 52) for the HA and the PCU group, respectively. The HHS showed no statistically significant difference between
the groups at every follow-up. Higher pain was recorded in the PCU
group at one and two years’ follow-up
(p = 0.006 and p = 0.019, respectively). In the HA group no revision
was performed. In the PCU-THR group six patients underwent revision
and one patient is currently awaiting
re-operation. The three-year survival rate of the PCU-THR group
was 0.841 (95% confidence interval 0.680 to 0.926). Based on our findings we do not recommend the use of the PCU
acetabular component as part of the treatment of patients with fractures
of the femoral neck. Cite this article:
The October 2012 Research Roundup360 looks at: whether you can escape your genes; oral prophylaxis for DVT; non-responders and the internet; metal-on-metal, mice and damaged livers; sleeping on the job; cartilage contact stress in the normal human hip; and a perfect reason to subscribe to
Surgical interventions consisting of internal
fixation (IF) or total hip replacement (THR) are required to restore
patient mobility after hip fractures. Conventionally, this decision
was based solely upon the degree of fracture displacement. However,
in the last ten years, there has been a move to incorporate patient
characteristics into the decision making process. Research demonstrating
that joint replacement renders superior functional results when compared
with IF, in the treatment of displaced femoral neck fractures, has
swayed the pendulum in favour of THR. However, a high risk of dislocation
has always been the concern. Fortunately, there are newer technologies
and alternative surgical approaches that can help reduce the risk
of dislocation. The authors propose an algorithm for the treatment
of femoral neck fractures: if minimally displaced, in the absence
of hip joint arthritis, IF should be performed; if arthritis is
present, or the fracture is displaced, then THR is preferred. Cite this article:
Idiopathic calcium pyrophosphate deposition disease (pseudogout) has a variable presentation. Many joints are usually affected; single joint disease is uncommon. We present a case report of primary monoarticular pseudogout affecting the hip. The diagnosis was made on the appearance and analysis of specimens obtained at arthroscopy. Monoarticular pseudogout is rare, but should be considered in the differential diagnosis of any presentation of joint pain.
We report the clinical and radiological outcome
of subcapital osteotomy of the femoral neck in the management of symptomatic
femoroacetabular impingement (FAI) resulting from a healed slipped
capital femoral epiphysis (SCFE). We believe this is only the second
such study in the literature. We studied eight patients (eight hips) with symptomatic FAI after
a moderate to severe healed SCFE. There were six male and two female
patients, with a mean age of 17.8 years (13 to 29). All patients underwent a subcapital intracapsular osteotomy of
the femoral neck after surgical hip dislocation and creation of
an extended retinacular soft-tissue flap. The mean follow-up was
41 months (20 to 84). Clinical assessment included measurement of
range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster
Universities Osteoarthritis score (WOMAC). Radiological assessment
included pre- and post-operative calculation of the anterior slip
angle (ASA) and lateral slip angle (LSA), the anterior offset angle
(AOA) and centre head–trochanteric distance (CTD). The mean HHS
at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores
for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6)
and 3.6 (0 to 19) respectively. There was a statistically significant
improvement in all the radiological measurements post-operatively.
The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°)
(p <
0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4°
(8° to 21°) (p <
0.01). The mean AOA decreased from 64.4° (50°
to 78°) 32.0° (25° to 39°) post-operatively (p <
0.01). The mean
CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0)
(p <
0.01). Two patients underwent further surgery for nonunion.
No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more
challenging than subcapital re-orientation in those with an acute
or sub-acute SCFE and an open physis. An effective correction of
the deformity, however, can be achieved with relief of symptoms
related to impingement. Cite this article:
Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.
Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade >
2, lateral sourcil height <
2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection.
Between June 2001 and November 2008 a modified Dunn osteotomy with a surgical hip dislocation was performed in 30 hips in 28 patients with slipped capital femoral epiphysis. Complications and clinical and radiological outcomes after a mean follow-up of 3.8 years (1.0 to 8.5) were documented. Subjective outcome was assessed using the Harris hip score and the Western Ontario and McMaster Universities osteoarthritis index questionnaire. Anatomical or near-anatomical reduction was achieved in all cases. The epiphysis in one hip showed no perfusion intra-operatively and developed avascular necrosis. There was an excellent outcome in 28 hips. Failure of the implants with a need for revision surgery occurred in four hips. Anatomical reduction can be achieved by this technique, with a low risk of avascular necrosis. Cautious follow-up is necessary in order to avoid implant failure.
This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage.
We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage. At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012). Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.
The April 2013 Children’s orthopaedics Roundup360 looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.