Avascular necrosis of the femoral head after closed intramedullary shortening in an adolescent

Closed intramedullary shortening has become a popular treatment method for limb-length inequality in adolescents. An important, potentially devastating complication of closed intramedullary fixation only recently described is avascular necrosis of the femoral head. We believe alternative treatment options must be considered to avoid this irreversible and catastrophic complication. A larger series may define the inherent risks of this complication and help determine the ideal treatment for femoral shortening and stabilization in the adolescent.

The management of severe avascular necrosis following slipped capital femoral epiphysis by transtrochanteric rotational osteotomy. Results of successful treatment in two cases with longterm follow-up

We present two cases of unstable slipped capital femoral epiphysis complicated by avascular necrosis that were successfully treated with transtrochanteric anterior rotational osteotomy. These two cases both had severe avascular necrosis and were felt to be unsalvageable. We recommend this surgical technique as a viable alternative to other forms of treatment in this selected patient population.

Osteonecrosis of the hip in sickle cell hemoglobinopathy

Osteonecrosis secondary to sickle cell anemia and its genetic variants has many presentations depending on the age of onset and the extent of femoral head involvement. Total hip arthroplasty provides the greatest opportunity for clinical improvement of all treatment options, though early and late complication rates are high. Technical difficulties of total hip arthroplasty are related to marrow hyperplasia and the presence of sclerotic intramedullary bone. Surgical complications related to sickle cell hemoglobinopathy include vaso-occlusive crises, congestive heart failure, major transfusion reactions, intraoperative femoral fracture, femoral perforation, late aseptic loosening of acetabular and femoral components, and sepsis.

Secondary avascular necrosis after treatment for congenital dislocation of the hip

We made a radiographic study of 104 unilateral congenital dislocations of the hip (CDH) that had an average age of 12 months (range 4-24), were treated with the same therapeutic protocol, and had an average six years follow-up (range 3-13). Radiographic changes were evident in the proximal femoral epiphysis in 57 hips (55%). In 7 (7%) the changes consisted of central osteoporosis with a cystic aspect, without metaphyseal or physeal changes, and had a normal end result without sequelae. This group was classified as type I. Fifty hips (48%) that were type II showed epiphyseal changes consisting of trabecular rarefaction with osteoporosis and irregular sclerosis, followed by a decrease of epiphyseal height and trabecular recovery. Forty-two hips (40%) were type IIA, with < 75% decrease in epiphyseal height with respect to the healthy side; five of these had a normal evolution, 35 had coxa magna and/or decrease of epiphyseal height, and only two cases had physeal lesion. In type IIB, hips, with > 75% decrease of epiphyseal height, 8 cases (8%) had a final physeal lesion.

Gadolinium-enhanced MR imaging demonstrates abduction-caused hip ischemia and its reversal in piglets

Purpose. To determine whether gadolinium-enhanced MR imaging can detect early reversible ischemia of the capital femoral epiphysis and physis induced by hip hyperabduction in piglets. Materials and methods. Thirteen 1- to 3-week-old piglets were placed in maximal abduction of both hips and studied with dynamic gadolinium-enhanced MR imaging 1-6 h later to assess ischemia of the 26 femoral heads. They were then allowed to ambulate freely for 1 or 7 days, and reimaged in neutral position to assess reperfusion. Enhancement was evaluated on MR images and compared with histologic findings.Results. Ischemia after hyperabduction developed in all 26 cartilaginous epiphyses and in 85 % of the physes. The most frequent abnormality was a sharply marginated nonenhancing area in the anterior part of the femoral head. A smaller area of ischemia developed in the posterior part of the femoral head, adjacent to the acetabular rim. The secondary center of ossification was ischemic in 56 % of the hips after 1 h of abduction and in all hips after 4 or 6 h (p = 0.02). The overall severity of ischemia was greater with increasing abduction time (p < 0.001) and increasing degree of abduction (p < 0.01). There was partial reperfusion in 83 % of the hips after 1 day of ambulation and complete reperfusion in all 26 hips (100 %) after 1 week.Conclusion. Enhanced MRI detects early ischemia of the epiphyseal and physeal cartilage and the epiphyseal marrow. In piglets, ischemia due to hyperabduction is reversible if corrected within 6 h.

Femoral head avascular necrosis associated with intramedullary nailing in an adolescent

An adolescent developed avascular necrosis of the femoral head after intramedullary nailing for a femoral diaphyseal fracture. This complication is most likely secondary to injury to the posterior superior ascending branch of the medial circumflex artery at the time of rod insertion. This artery is situated close to the proximal insertion hole just posterior to the trochanteric notch and piriformis fossa. Other methods of fracture treatment, either operative or nonoperative, should be considered in skeletally immature patients.

Gaucher disease--the orthopaedic aspect. Report of seven cases

Seven patients with Gaucher type 1 disease are presented: five female and two male. The orthopaedic problems encountered were: avascular necrosis of both femoral heads in two girls, bilateral bone infarctions of the femurs in all three girls, complicated by staphylococcal osteomyelitis of the right femur in one girl and by pathological fractures of both femurs in another girl, osteonecrosis of both humeral heads in one male adult patient, osteonecrosis of the femoral heads in two further adults (male and female), and a pathological fracture of the fourth lumbar vertebra in another adult woman with concomitant humeral head involvement. The patient with osteonecrosis of the humeral head was treated with a total shoulder arthroplasty, and the two patients with osteonecrosis of the femoral heads were treated with total hip arthroplasties, with satisfactory intermediate and long-term results.

Intracapsular fractures of the femoral neck. Results of cannulated screw fixation

The results of stabilization of an intracapsular fracture of the femoral neck with cannulated screws placed in parallel in 141 patients between 1980 and 1985 were reviewed retrospectively. Fifty patients (35 per cent) had a non-displaced fracture (Garden Stage I or II) and ninety-one (65 per cent) had a displaced fracture (Garden Stage III or IV). The median age of the patients was sixty-eight years (range, twenty-four to ninety-five years). The mean duration of follow-up was eight years. No patient died or had a wound infection during the stay in the hospital. Twenty-nine patients, who had a median age of seventy-five years (range, fifty-six to ninety-five years), died within sixty months after treatment; eleven of them (median age, seventy-five years [range, sixty-five to eighty-six years]) died within the first twelve months. There was a loss of position or a non-union of the fracture in five patients (4 per cent) and healing of the fracture in 136 patients (96 per cent). Thirteen patients (11 +/- 3 per cent) had histological or roentgenographic evidence of osteonecrosis within twenty-four months after treatment. Ten of these patients had had a displaced fracture. Osteonecrosis developed in thirteen additional patients during the remaining period of follow-up. Eight of these patients had had a displaced fracture. The prevalence of osteonecrosis at the time of the most recent follow-up (mean duration, eight years) was 22 +/- 4 per cent. Osteonecrosis developed in eight of the forty-one patients who had had a Garden Stage-II fracture, in six of the thirty patients who had had a Garden Stage-III fracture, and in twelve of the forty patients who had had a Garden Stage-IV fracture. The fifty-five surviving patients in whom the fracture healed without complications were found to be functioning well more than sixty months after the fracture.

Bone-marrow transplantation in Hurler's syndrome. Effect on skeletal development

Between 1980 and 1988, displacement bone-marrow transplantation was performed on 25 children with Hurler's syndrome (type-1 mucopolysaccharidosis). We describe the musculoskeletal development of 11 of the 12 surviving children and the orthopaedic procedures undertaken to treat progressive thoracolumbar kyphosis, hip subluxation and carpal tunnel syndrome. We found abnormal bone modelling, focal failures of ossification and an avascular disorder of the femoral head in every patient and offer an explanation for these phenomena. Increasing valgus deformity of the knees and progressive generalised myopathy caused loss of mobility as the children entered adolescence. The benefit of bone-marrow transplantation as a treatment for the skeletal disorders of Hurler's syndrome is limited by the poor penetration of the musculoskeletal tissues by the enzyme derived from the leucocytes.

Progression of bone disease without deterioration of hematological parameters in a child with Gaucher disease during low-dose glucocerebrosidase therapy

Gaucher disease is the most prevalent lysosomal storage disease. Although the efficacy of the macrophage-targeted human placental glucocerebrosidase is well known, it is still difficult to develop definitive guidelines regarding the appropriate therapy schedule. We describe an 8-year-old Japanese boy with Gaucher disease who had avascular necrosis of the right femoral head without deterioration of hematological variables during low-dose enzyme replacement therapy (12-13 IU/kg). This case demonstrates that continuous normal hematological findings may not preclude progression of other aspects of Gaucher disease in some patients during enzyme replacement therapy.

Primary total hip arthroplasty using noncemented porous-coated femoral components in patients with osteonecrosis of the femoral head

Ninety consecutive total hip arthroplasties in 73 patients with osteonecrosis of the femoral head yielded 81 hips in 64 patients (37 men and 27 women) available for evaluation after a 4-8-year follow-up period. The average age at surgery was 39.9 years (range, 20-66 years). Osteonecrosis etiology was idiopathic in 13 hips, alcohol-induced in 15, femoral neck fracture in 12, and slipped capital femoral epiphysis in 2. The remaining 39 cases were related to steroids, which were administered for a variety of reasons. Two types of noncemented, porous-coated, straight-stem femoral components and three types of acetabular components were utilized. Good or excellent clinical results were recorded in 80.2% of the patients. Average Harris hip scores improved from 52.9 to 87.9 points. Nine patients required revision of at least one component and were significantly younger than those with unrevised components. A revision rate of 24.1% was recorded in patients under 35 years of age at the time of primary surgery. Good or excellent clinical results were seen in 92.3% of the idiopathic cases, 86.7% of the alcohol-induced cases, 77.8% of the renal transplant cases, and 62.5% of the systemic lupus erythematosus cases. The overall mortality rate at the follow-up evaluation was 14%; it was 50% in renal transplant patients. Analysis of the clinical results based on the implants showed no significant differences in Harris hip scores or pain and function scores. While total hip arthroplasty using noncemented porous-coated femoral stems appears to give better results than cemented procedures in patients with osteonecrosis of the femoral head, the results appear to be inferior to those reported in patients with other diagnoses.

Operative stabilization of pediatric femur fractures

Femur fractures represent approximately 1.7% of all pediatric bony injuries. Most femur fractures were treated nonoperatively prior to the early 1980s. Recent refinements in the operative techniques used to treat pediatric femur fracture have led to a reduction in the use of traction and casting treatment methods.

[Clinical and pathological changes of ischemic necrosis of the femoral head in children]

A total of 54 cases (73 hips) with ischemic necrosis of the femoral head after treatment of CDH have been followed up with an average of 7 years. We found that 89% cases of type I and 70% of type II recovered to normal and 83% cases of type III and IV developed the coxa breva deformity due to injury of longitudinal growth plate of the proximal end of the femur. According to the value of ATD, the coxa breva was divided into three types. The L shape growth disturbance line revealed by X-ray is considered as a marker for determination of early epiphyseal plate injury by the authors.

[Sugioka rotational osteotomy in ischemic osteonecrosis of the femoral head]

The treatment of ischemic necrosis of the femoral head depends on the stage and the age of the patient. Sugioka's rotational osteotomy is an alternative between the different conservative techniques. We have used this technique in 12 patient and 13 hips. The mean age of the patients was 31.8 ranging from 20 to 40. In the first 4 patients we performed the classic technique, as described by Sugioka. In the rest of the patients we used a DHS to stabilize the rotation and a maleolar screw for trochanteric osteotomy. The follow-up ranged between 24 and 67 months, average 42.46 months. The main complications were: 1 embolism, 1 trochanteric pseudoarthrosis and 1 common personal nerve lesion. The radiologic study showed progression in the majority of the cases. Clinical examination was performed following Merle D'Aubigné criteria pre and post surgery. We found 1 excellent result, 3 good, 3 fair and 6 poor (four of them needed a T.H.R.). Based on our experience, we have suggested a protocol for the treatment of ischemic necrosis of the femoral head. We believe that Sugioka's osteotomy can be indicated in patients younger than 50 and with less than 200 degrees affected (Stage III). The modifications we have made may be useful to achieve a better stabilization of the osteotomy and to improve the postoperative period. We have observed an improvement in the pain and gait in 60% of the patients. The radiologic study showed a progressive deterioration but there was no correlation between the clinical and radiological findings. Sugioka's technique allows the preservation of the femoral head delaying the total hip replacement.

Guided abduction traction in the treatment of congenital hip dislocation

Guided abduction is a form of overhead traction conceptually similar to the Pavlik harness. It is used in older children or in children in which the Pavlik harness has failed. The results of 27 congenitally dislocated hips treated by guided abduction traction from December 1979 to June 1989 were reviewed. Ages ranged from 1 month to 28 months. Twenty (74%) of the 27 hips underwent a gentle, often spontaneous, closed reduction, followed by abduction casting and bracing. Two hips developed radiographic evidence of avascular necrosis; five hips developed temporary irregular ossification. Closed reduction was unobtainable in any child older than 24 months. Two children needed additional reconstructive procedures, one an innominate pelvic osteotomy and the other a valgus derotation osteotomy. Both had had open reductions. Recent reports stated that preliminary traction in the treatment of congenitally dislocated hips is of no value. We consider guided abduction traction a valuable treatment modality resulting in a reduced incidence of open reduction. When comparing our results with those of a Salt Lake City study performed without preliminary traction, our incidence of open reduction is lower (26 versus 49%). Our study supports the use of preliminary traction to decrease the need for open reduction in congenitally dislocated hips.

Salter's innominate osteotomy in the treatment of congenital hip dislocation: a long-term review

We reviewed 39 patients with 52 congenitally dislocated hips, all managed by open reduction and Salter's innominate osteotomy. Mean follow-up period was 13 years (range, 8 to 25 years); 78.9% of the hips had a good or excellent clinical result, and 71.1% were good or excellent radiologically. The patients who underwent Salter's innominate osteotomy before the age of 4 had better clinical and radiological results (88.4 and 81.4%, respectively). The radiographs of the unilateral normal hips were compared to the surgically treated hips according to their acetabular index angles, center-edge angles of Wiberg, and femoral neck-shaft angles. No statistical differences were found between these two groups. The Bucholz-Ogden classification was used for the diagnosis and classification of avascular necrosis. The late radiographic signs of types 2, 3, and 4 avascular necrosis were seen in 34.6% of this series. The results show that Salter's innominate osteotomy provides good lateral coverage of the femoral head. The results are better if the operation is performed between the ages 18 months and 4 years.

Prevalence of previously undetected osteonecrosis of the femoral head in renal transplant recipients

PURPOSE

To determine the prevalence of osteonecrosis (ON) of the femoral head in renal transplant recipients and determine the natural history of previously undetected lesions.

MATERIALS AND METHODS

The hips of 132 renal transplant recipients were examined with magnetic resonance (MR) imaging, with radiographs obtained only in the patients with positive MR images.

RESULTS

Ten patients (15 hips) were considered to have ON (prevalence, 7.6%). Eleven of the hips had Ficat stage 0 disease (asymptomatic, preradiographic) and were followed up with serial radiography and MR imaging. Over an average follow-up of 22 months, only one of these lesions showed progression. The other 10 hips did not show progression at MR imaging or radiography.

CONCLUSION

Previously undetected ON may have a benign course in many cases. Although a substantial number of patients have previously unsuspected disease, further study is necessary to assess the need for "prophylactic" surgery in such cases.

Avascular necrosis of the femoral epiphysis complicating a minimally displaced fracture of solitary bone cyst of the neck of the femur in a child. A case report

Reported herein is a rare case of a patient with a pathologic fracture through a cyst in the femoral neck that resulted in avascular necrosis of the femoral epiphysis. This type of necrosis is commonly understood to follow displaced fractures of the femoral neck in children, but has also been reported to follow undisplaced fractures.

Osteonecrosis of the femoral head associated with pregnancy. Report of two cases

Osteonecrosis of the femoral head developed in two patients, that had taken oral contraceptives for four and eight years respectively, during pregnancy. There were non demonstrable predisposing factors. The symptoms were first noted during the last trimester, and after the delivery improved significantly. Results of examinations, radiography and scanning were consistent with diagnosis of avascular osteonecrosis of the femoral head. The possibility that the long term use of oral contraceptives, might have played a role in the development of femoral head necrosis is stressed by the authors.

Current concepts on the pathogenesis of osteonecrosis of the femoral head

Treatment of atraumatic osteonecrosis of the femoral head is presently based not on disease prevention, but instead on the end-stage changes of bone associated with the necrotic lesion. Current diagnostic modalities are limited, by both cost and efficacy, in their ability to diagnose early-stage osteonecrosis. While many studies have assumed the cause of osteonecrosis is vascular occlusion, recent work suggests that alternate processes are primarily involved in the pathogenesis. By examining these concepts, a better understanding of osteonecrosis of the femoral head may lead to earlier diagnostic modalities and treatment protocols to prevent this devastating process from developing.

Traction reduction of acute and acute-on-chronic slipped capital femoral epiphysis

Gentle reduction of acute or the acute portion of acute-on-chronic severe slipped capital femoral epiphyses (SCFE) is generally recommended. Reports of the use of longitudinal traction with medial rotation traction, although few, are uniform in describing a high rate of success with rare complications. Of 30 acute or acute-on-chronic SCFEs examined at the author's institution between 1970 and 1990, 13 underwent attempted traction reduction with longitudinal traction and medial rotation. Only five of these 13 hips had discernible reduction. One of these five hips developed aseptic necrosis; however, this hip was clearly distracted from the acetabulum by excessive longitudinal traction that may have contributed to the development of osteonecrosis. One of the seven hips that failed traction reduction developed aseptic necrosis, and one of the 17 acute SCFEs pinned in situ developed aseptic necrosis. All three hips developing necrosis were in a group of 14 hips with moderate to severe SCFEs and complete inability to bear weight with severe pain.