A comparison of three strategies to reduce the burden of osteoarthritis: A population-based microsimulation study

Objectives

The purpose of this study was to compare three strategies for reducing population health burden of osteoarthritis (OA): improved pharmacological treatment of OA-related pain, improved access to joint replacement surgery, and prevention of OA by reducing obesity and overweight.

Methods

We applied a validated computer microsimulation model of OA in Canada. The model simulated a Canadian-representative open population aged 20 years and older. Variables in the model included demographics, body mass index, OA diagnosis, OA treatment, mortality, and health-related quality of life. Model parameters were derived from analyses of national surveys, population-based administrative data, a hospital-based cohort study, and the literature. We compared 8 what-if intervention scenarios in terms of disability-adjusted life years (DALYs) relative to base-case, over a wide range of time horizons.

Results

Reductions in DALYs depended on the type of intervention, magnitude of the intervention, and the time horizon. Medical interventions (a targeted increase in the use of painkillers) tended to produce effects quickly and were, therefore, most effective over a short time horizon (a decade). Surgical interventions (increased access to joint replacement) were most effective over a medium time horizon (two decades or longer). Preventive interventions required a substantial change in BMI to generate a significant impact, but produced more reduction in DALYs than treatment strategies over a very long time horizon (several decades).

Conclusions

In this population-based modeling study we assessed the potential impact of three different burden reduction strategies in OA. Data generated by our model may help inform the implementation of strategies to reduce the burden of OA in Canada and elsewhere.

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D) Program across Canada for the Management of Hip and Knee Osteoarthritis

Good Life with osteoArthritis in Denmark (GLA:D®) is a program for the management of patients with hip and knee osteoarthritis (OA). Adapted for the Canadian population, the GLA:DTM Canada program implements evidence-based strategies to support the prevention, early diagnosis and effective management of hip and knee OA. GLA:D assists local communities in implementing OA strategies across the spectrum of disease severity. An integral part of this program is a national quality and outcomes registry, which includes data concerning participant characteristics and both patient-reported and functional outcomes. This registry helps healthcare providers and healthcare decision makers ensure that individuals with OA receive effective, high-quality care through the GLA:D Canada program.

Gait abnormalities following slipped capital femoral epiphysis treated with in situ fixation

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common disorder in adolescent for which no consensus exists regarding management. The aim of the present study was to analyze gait modifications following SCFE treated with in situ fixation (ISF) and to relate it to radiologic stage.

RESEARCH QUESTION

To verify if gait biomechanics are impaired in patients with SCFE and to try to determine a degree of slippage from which gait modifications would appear.

METHODS

We evaluated 16 patients treated by ISF for SCFE with slippage ranging from 11° to 61°. Gait variables were compared to normal population according to age and walking speed and were normalized in Z-scores.

RESULTS

Spatiotemporal parameters, mechanical and energetic variables were inferior to |1.5| Z-scores and considered as normal. Kinematics showed increase of pelvic tilt and hip adduction. Kinetic variables showed modifications with increased hip extension moment. There was also a strong increase in power of hip extensor. Hip extension moment and power of hip extensors were significantly correlated to radiologic stage. Analysis of ROC curves showed a cut-off value of slippage about 25°-30° affecting kinematics of pelvis and hip and kinetic variables.

CONCLUSION

The gait variables were close to normal values. Main modifications were observed in kinematic and kinetic data with a significant increase in extension moment and power generated at the operated hip. This could participate to long-term joint degradation observed in SCFE, even in mild slips. The clinical message is to control regularly SCFE with initial slippage greater than >25-30° to allow for early diagnosis of premature hip osteoarthritis.

Osteoarthritis prevalence and modifiable factors: a population study

BACKGROUND

This study's objectives were to investigate the prevalence of self-reported knee and hip osteoarthritis (OA) stratified by age and sex and to examine the association of modifiable factors with knee and hip OA prevalence. The study was conducted using randomly sampled data gathered from four communities in the province of Alberta, Canada.

METHODS

A large adult population sample (N = 4733) of individuals ≥18 years were selected. Health-related information was collected through telephone interviews and community measurement clinics for which a sub-sample (N = 1808) attended. Participants self-reported OA during telephone interviews. Clinic interviews further assessed if the diagnosis was made by a health care professional. Statistical analyses compared prevalence of OA between sexes and across age categories. Associations between modifiable factors for OA and the prevalence of knee and hip OA were assessed using binary logistic regression modelling.

RESULTS

Overall prevalence of self-reported OA in the total sample was 14.8 %, where 10.5 % of individuals reported having knee OA and 8.5 % reported having hip OA. Differences in prevalence were found for males and females across age categories for both knee and hip OA. In terms of modifiable factors, being obese (BMI >30 kg/m2) was significantly associated with the prevalence of knee (OR: 4.37; 95 % CI: 2.08,9.20) and hip (OR: 2.52; 95 % CI: 1.17,5.43) OA. Individuals who stand or walk a lot, but do not carry or lift things during their occupational activities were 2.0 times less likely to have hip OA (OR: 0.50; 95 % CI: 0.26,0.96). Individuals who usually lift or carry light loads or have to climb stairs or hills were 2.2 times less likely to have hip OA (OR: 0.45; 95 % CI: 0.21,0.95). The odds of having hip OA were 1.9 times lower in individuals consuming recommended or higher vitamin C intake (OR: 0.52; 95 % CI: 0.29,0.96). Significant differences in prevalence were found for both males and females across age categories.

CONCLUSION

The prevalence of knee and hip OA obtained in this study is comparable to other studies. Females have greater knee OA prevalence and a greater proportion of women have mobility limitations as well as hip and knee pain; it is important to target this sub-group.

[Neglected traumatic dislocation of the hip treated with total hip arthroplasty: report of 2 cases]

Les luxations négligées de la hanche sont des lésions exceptionnelles. Elle concerne généralement des traumatismes graves, où les lésions ostéo-articulaires ne sont pas minutieusement recherchées, ou relayer au second plan. L’évolution inéluctable se fait vers la nécrose de la tête fémorale et la coxarthrose. L'arthroplastie permet de raccourcir cette évolution et de réinsérer rapidement ces patients.

Femoroacetabular impingement: current concepts in diagnosis and treatment

As a result of reading this article, physicians should be able to: 1. Identify the etiology of femoroacetabular impingement. 2. Assess femoroacetabular impingement on physical examination. 3. Recognize femoroacetabular impingement on imaging studies. 4. Discuss modern techniques to effectively treat femoroacetabular impingement, both open and arthroscopic. Femoroacetabular impingement (FAI) is a recently proposed concept describing abnormal anatomic relationships within the hip joint that may lead to articular damage. Impingement is caused by bony deformities or spatial malorientation of the femoral head-neck junction and/or the acetabulum. These abnormalities lead to pathologic contact and shearing forces at the acetabular labrum and cartilage during physiological hip motion. There is an increasing body of evidence that these forces lead to cartilage wear and eventual osteoarthritis. Treatment options for FAI are evolving rapidly. Although the gold standard remains open hip dislocation, arthroscopic techniques have shown significant promise. It is possible that early recognition and treatment of subtle deformity about the hip may reduce the rate of hip osteoarthritis in the future.

Common questions about developmental dysplasia of the hip

Developmental dysplasia of the hip is a common musculoskeletal condition in newborns. Infants with developmental dysplasia of the hip, whether treated or untreated, have a higher incidence of early-onset hip osteoarthritis in adulthood. Evidence to support universal screening by physical examination or ultrasonography is limited and often conflicting. The U.S. Preventive Services Task Force found insufficient evidence that screening for developmental dysplasia of the hip prevents adverse outcomes. Physical examination screening is recommended by the American Academy of Pediatrics and the Pediatric Orthopaedic Society of North America. These organizations recommend use of the Ortolani and Barlow maneuvers to screen infants up to three months of age. Several recent studies support starting assessment for limited hip abduction at eight weeks of age, which is the most sensitive test for developmental dysplasia of the hip from this age on. Infants with overtly dislocated or dislocatable hips should be referred to an orthopedist on a priority basis at the time of diagnosis. Infants with equivocal hip examination findings at birth can be reexamined in two weeks. If there is subluxation or dislocation at the follow-up examination, referral should be made at that time. If the examination findings are still equivocal, the infant can undergo ultrasonography of the hips or be reexamined every few weeks through the first six weeks of life. Although equivocal findings commonly resolve spontaneously, infants with persistent equivocal findings of developmental dysplasia of the hip longer than six weeks should be evaluated by an orthopedist. Treatment generally involves flexion-abduction splinting. The benefits of treatment are unclear, and there are risks to treatment, most notably an increased occurrence of avascular necrosis of the femoral head.

[Crooked legs- just an aesthetic problem]

Because the lower extremities are weight bearing, malalignment plays a key role in the development of degenerative disease of the joints. This is particularly true as degenerative arthropathy is of mechanical and not inflammatory cause. Deviation of the axis has been shown to alter the load and force distribution in the joint and thereby causing excessive wear. Whether or not a deformity is clinically relevant or not depends on the symptoms, the amount of the deformity and the location of the deformity. Relevant deformities can be treated with orthotics or corrective osteotomies in early stages. In late stages fusions or joint replacement is the mainstay of treatment.

Effects of age on lower extremity joint kinematics and kinetics during level walking with Masai barefoot technology shoes

BACKGROUND

The age-associated loss of physical function engenders gait patterns which jeopardise the knee and hip to osteoarthritis. Masai Barefoot Technology (MBT) shoes have been shown to provide a facility to address specific needs for load modification in terms of musculoskeletal disease prevention in people with restricted proprioceptive or strength abilities. Therefore, a readjustment of lower extremity joint loading profiles in the elderly was hypothesised when using this type of footwear.

AIM

The aim of this study was to evaluate the effects of MBT shoes on gait kinematics and kinetics in both an elderly and young cohort during walking.

DESIGN

This was a cross-sectional study.

SETTING

A 3-dimensional motion analysis laboratory.

POPULATION

Eleven healthy elderly men and 11 healthy young men.

METHODS

A conventional sport shoe served as control situation to MBT. Subjects were advised to walk eight trials per shoe at a criterion speed of 1.5 ± 0.1 m·s(-1) in block-randomised order. Peak joint angles, moments and powers at the ankle, knee and hip were calculated through an inverse dynamic model. Data were compared by a two-way repeated measure ANOVA (α=0.05).

RESULTS

MBT reduced external ankle joint moments and powers independent of age. At the hip, MBT footwear led to decreases in external hip flexion moments and concentric hip power output during early and late stance. Herein, no age-by-condition effects were present. Moreover, MBT reduced external knee flexion moments and concentric knee extensor powers at loading response, with the greater changes observed in the elderly. Additionally, a main effect of condition showing a general decrease in the MBT situation, but no interaction effect was noted for first peak external knee adduction moments.

CONCLUSION

These results suggest that MBT shoes diminish joint loads among age groups, whereas compared to young adults, the elderly, in particular, benefited from MBT footwear with regard to relief stress on the knee joint region.

CLINICAL REHABILITATION IMPACT

Based on these findings, the use of MBT shoes may attenuate the risk of developing knee and hip osteoarthritis in the elderly and may play an important role regarding pain avoidance and/or disability.

Coxarthrosis--disease of multifactorial etiology methods of prevention and treatment. The role of kinesitherapy in coxarthrosis

Coxarthrosis is a disorder of the physiological balance between the strength of the articular cartilage and articular bone, and between the pressures exerted on the joint. It is a disease with a slow progressive and long course. Its insidious onset and progression, marked by variable periods of stagnation lasting months or even years make it difficult to establish the time of onset.

MATERIAL AND METHODS

The study was conducted between January 2012 and December 2012, on a series of 27 coxarthrosis patients, diagnosed at the Rheumatology Clinic of the lasi Rehabilitation Hospital.

RESULTS AND DISCUSSION

Of the 27 patients, 11 (40.74%) had primary bilateral coxarthrosis, 8 (29.63%) early coxarthrosis. right, 6 (22.22%) coxarthrosis, left, secondary to aseptic femoral head osteonecrosis, and 2 (7.41%) patients had bilateral coxarthrosis secondary to acetabular insufficiency. Kinesitherapy proved to be highly effective in the rehabilitation of coxarthrosis patients by alleviating pain, mechanical protection of the hip joint, walking rehabilitation in total hip arthroplasty, and social and professional integration of the patients. The massage besides its analgesic effect also acted as a muscle relaxant. Once the objectives have been met, the kinesiology program becomes global and functional rather than analytical, as it aims at reintegrating the coxofemoral joint into normal movement patterns.

CONCLUSIONS

Kinesitherapy has been shown to be a physical treatment that can not be replaced by other rehabilitation methods and is crucial in the recovery of lost functions.

Advances in hip preservation after slipped capital femoral epiphysis

The metaphyseal deformity, in even a mild slipped capital femoral epiphysis (SCFE), results in acetabular labral and cartilage injury. SCFE is the most extreme form of femoroacetabular impingement, and the mechanism of cartilage and labral injuries is similar. Recent surgical advances for treating femoroacetabular impingement have made it possible to consider applying these techniques to the surgical treatment of SCFE deformities to lessen the risk of secondary osteoarthritis. The goals of treatment are to arrest slip progression and restore normal proximal femoral anatomy, thereby decreasing damage to the hip joint secondary to impingement. In situ pinning is the most effective treatment to halt short-term slip progression; outcomes are favorable in many hips. In medical centers with substantial experience with hip preservation techniques, open or arthroscopic osteochondroplasty can be used to treat mild SCFE, and a modified Dunn epiphyseal reorientation can be used for more severe deformities to decrease the potential for secondary osteoarthritis.

Assessment of adult hip dysplasia and the outcome of surgical treatment

Hip dysplasia and hip joint deformities in general are recognized as possible precursors of osteoarthritic development. Early and correct identification of hip dysplasia is important in order to offer timely joint preserving treatment. In the contemporary literature, several controversies exist, and some of these were the focus of this doctoral thesis. Categorized into subjects, the major findings and their possible importance are listed below. DIAGNOSTIC ASSESSMENT OF HIP DYSPLASIA: A multi-observer study quantified the variability of different methods for diagnostic assessment of hip dysplasia and osteoarthritis and resulted in general recommendations regarding diagnostic assessment of hip dysplasia. Pelvic tilt was shown to differ significantly between the supine and weight-bearing positions in patients with dysplastic hip joints. This is a finding that adds controversy to the application of neutral pelvic positioning during assessment of hip deformities because pelvic tilt affects the appearance of acetabular version. Weight-bearing assessment of acetabular version showed the presence of retroversion in 33% of dysplastic hips. The establishment of retroversion as a rather frequent entity in dysplastic hips is contradictory to the historical finding that hip dysplasia is characterized by insufficient anterior and lateral coverage. In general, the findings have important implications for orthopedic surgeons and radiologists dealing with diagnostic assessment of painful hips in young adults, and for surgeons planning and performing joint-preserving periacetabular osteotomies. ASSESSMENT OF ACETABULAR LABRAL TEARS IN HIP DYSPLASIA: The roles of ultrasound and clinical tests in acetabular labral tear diagnostics were established. After overcoming an initial learning curve, ultrasound investigation was highly reliable in diagnosing labral tears, whereas only a positive impingement or FABER test was reliable in identifying a labral tear. It seems that non-invasive and rapid ultrasound examination performed by an experienced examiner can potentially alter the traditional diagnostic algorithm in which magnetic resonance arthrography remains the gold standard. PERIACETABULAR OSTEOTOMY FOR SURGICAL TREATMENT OF HIP DYSPLASIA IN ADULTS: Encouraging hip joint survival and clinical outcome were reported at medium-term follow-up after periacetabular osteotomy. The small number of studies reporting the outcome beyond a 5-year follow-up is in contrast to the wide application of the periacetabular osteotomy. The performed analysis of predictors of conversion to total hip replacement following periacetabular osteotomy documented the importance of different biomechanical and degenerative factors. Knowledge about factors predicting early conversion to total hip replacement has the potential to refine patient selection and to improve treatment by periacetabular osteotomy. Cartilage thickness was documented to be preserved up to 2,5 years after periacetabular osteotomy. All but 1 hip joint had acetabular labral tears, thus indicating that the presence of labral tears does not accelerate cartilage degeneration after periacetabular osteotomy.

Osteochondroplasty as a treatment of femoroacetabular impingement

BACKGROUND

Femoroacetabular impingement (FAI) is a condition characterized by repetitive abnormal contact of the femoral acetabulum with the femoral head-neck region, which leads to the development of early-stage coxarthrosis. Early diagnosis and appropriate treatment of FAI can halt the development of coxarthrosis.

MATERIAL AND METHODS

We present the early results of surgical treatment of 13 patients with FAI by osteochondroplasty of the head-neck region. An anterior approach to the hip joint was employed without surgical dislocation of the femoral head. The follow-up period ranged from 1.5 to 4 years. Clinical assessment was conducted according to the Harris classification. The FAI index was measured during radiographic evaluation.

RESULTS

Clinical assessment revealed an improvement in 12 patients. Radiographically, the value of FAI index was normal in all the patients who underwent the surgery.

CONCLUSIONS

Osteochondroplasty of the head-neck region appears to be an effective treatment of FAI in early-stage coxarthrosis.

Treatment of experimental osteonecrosis of the hip in adult rabbits with a single local injection of recombinant human FGF-2 microspheres

Basic fibroblast growth factor (FGF-2) exerts anabolic actions on bone formation. Here we investigated the potential effects of recombinant human FGF-2 (rhFGF-2) on the repair process of osteonecrosis of the femoral head (ONFH) and the development of secondary osteoarthritis (OA) in adult rabbits. ONFH was induced by intramuscular injection with methylprednisolone, and vascular occlusion of the capital femoral epiphysis by electrocoagulation, in adult Japanese white rabbits. Animals were randomized into two groups: treatment and control. The treatment group was given a single local injection into the femoral head of 100 μg rhFGF-2 in 100 μl gelatin hydrogel microspheres 8 weeks after the ONFH procedure, and the control group was given phosphate-buffered saline in 100 μl gelatin hydrogel microspheres. Morphological, histopathological, and radiologic analyses, including micro-computed tomography scans and magnetic resonance imaging, showed collapse of the femoral head and progression of articular cartilage degeneration in the control group at 16 weeks after the single local injection of rhFGF-2. In contrast, rhFGF-2 treatment resulted in new bone formation in the femoral head and prevented the femoral head from collapsing. In addition, the changes in OA, assessed by the modified Mankin score, was significantly lower in the treatment group. Our results indicate that a single local injection of rhFGF-2 microspheres promoted the repair of the osteonecrotic femoral head and inhibited femoral head collapse and OA progression. rhFGF-2 may be a promising strategy for the treatment of ONFH.

Do we need radiological guidance for hip joint injections?

Intra-articular injections are widely used in treatment of early hip osteoarthritis and may help to offset the need for a joint replacement. Most orthopaedic surgeons do this under radiological guidance while some rheumatologists and pain specialists do it without. Our study was aimed at assessing accuracy of blind intra-articular injections to the hip joint. Forty-three hips in 40 consecutive patients who had hip injections were included in the study. The anatomical landmarks were marked and the needle was placed from an antero-lateral approach. Radio-opaque dye was then injected and the position of the needle was checked under image intensifier. The success rate of blind injections was 65.1%. Obese patients, patients with severe grade 4 arthritis with no joint space and those with flexion deformity were the majority of failed cases. We propose that hip injections should be carried out by trained specialists under radiological guidance.

Postoperative acetabular retroversion causes posterior osteoarthritis of the hip

We retrospectively reviewed 68 hips in 62 patients with acetabular dysplasia who underwent curved periacetabular osteotomy. Among the 68 hips, 33 had acetabular retroversion (retroversion group) and 35 had anteversion (control group) preoperatively. All hips were evaluated according to the Harris hip score. Radiographic evaluations of acetabular retroversion and posterior wall deficiency were based on the cross-over sign and posterior wall sign, respectively. The clinical scores of the two groups at the final follow-up were similar. In the retroversion group, 12 hips had anteverted acetabulum postoperatively. The posterior wall sign disappeared in these hips, but remained in 21 hips with retroverted acetabulum postoperatively. Among the 21 hips with retroverted acetabulum, posterior osteoarthritis of the hip developed postoperatively in five hips. When performing corrective osteotomy for a dysplastic hip with acetabular retroversion, it is important to correct the acetabular retroversion to prevent posterior osteoarthritis of the hip due to posterior wall deficiency.

[Periacetabular osteotomy and hip dysplasia in young adults]

The periacetabular osteotomy is recognized as the surgical treatment of choice in young adults with symptomatic hip dysplasia. The procedure is performed to delay or prevent the development of osteoarthritis. The procedure has the ability to improve function and preserve hip joints in > 80% of cases for more than ten years following surgery. A new minimally invasive technique is safe and reduces blood loss, transfusion requirements and duration of surgery. Overall, the results support the use of periacetabular osteotomy, though further documentation of long-term effects is warranted.

Imaging of femoroacetabular impingement: pictorial review

Femoroacetabular impingement (FAI) is a cause of progressive osteoarthritis of the hip in younger patients. Three types of FAI have been described: a cam-type, a pincer-type and a mixed type. Early recognition of the morphologic hip features of each type of impingement is important, because arthroscopic treatment is still successful in the initial stage to prevent or delay further hip degeneration. This article reviews the imaging features of the different types of FAI. Magnetic resonance arthrography (MRA) is the preferred modality to detect, localise and characterise the type of FAI and the resulting injuries of the acetabular hyaline cartilage and fibrocartilaginous labrum.

Mean 20-year followup of Bernese periacetabular osteotomy

The goal of the Bernese periacetabular osteotomy is to correct the deficient acetabular coverage in hips with developmental dysplasia to prevent secondary osteoarthrosis. We determined the 20-year survivorship of symptomatic patients treated with this procedure, determined the clinical and radiographic outcomes of the surviving hips, and identified factors predicting poor outcome. We retrospectively evaluated the first 63 patients (75 hips) who underwent periacetabular osteotomy at the institution where this technique was developed. The mean age of the patients at surgery was 29 years (range, 13-56 years), and preoperatively 24% presented with advanced grades of osteoarthritis. Four patients (five hips) were lost to followup and one patient (two hips) died. The remaining 58 patients (68 hips) were followed for a minimum of 19 years (mean, 20.4 years; range, 19-23 years) and 41 hips (60%) were preserved at last followup. The overall mean Merle d'Aubigné and Postel score decreased in comparison to the 10-year value and was similar to the preoperative score. We observed no major changes in any of the radiographic parameters during the 20-year postoperative period except the osteoarthritis score. We identified six factors predicting poor outcome: age at surgery, preoperative Merle d'Aubigné and Postel score, positive anterior impingement test, limp, osteoarthrosis grade, and the postoperative extrusion index. Periacetabular osteotomy is an effective technique for treating symptomatic developmental dysplasia of the hip and can maintain the natural hip at least 19 years in selected patients.

LEVEL OF EVIDENCE

Level III, prognostic study.

Slotted acetabular augmentation for the treatment of residual hip dysplasia in adults: early results of 12 patients

INTRODUCTION

Different pelvic osteotomies and various shelf procedures are used for the operative treatment of hip dysplasia. Slotted acetabular augmentation (SAA) is a well-established technique for the treatment of children and adolescents with hip dysplasia. It has not been widely accepted for treating hip dysplasia in adults although good outcomes have been reported with other augmentation techniques in adults.

MATERIALS AND METHODS

Since 1997, SAA has been used for the prevention of hip arthrosis in 14 dysplastic hips in 12 female patients. The median age at operation was 38.5 (17-42) years; the median follow-up period was 4 (1-8) years. The patients were evaluated on the basis of radiographic, biomechanical and clinical data prior to surgery and at follow-up.

RESULTS

The median centre-edge angle of Wiberg increased from 9 degrees (1-26) before the operation to 43 degrees (31-55) at the latest follow-up (P < 0.001). The median peak stress on the weight-bearing area of the hip, calculated mathematically, was reduced from 14.9 (6.3-28-1) MPa prior to the operation to 4.1 (3-6.1) MPa at the latest follow-up (P < 0.001); the median Harris Hip Score increased from 60 (45-98) points preoperatively to 93 (49-100) points at the follow-up (P < 0.001). There was no difference between the preoperative and follow-up hip joint-space width (P = 0.2).

CONCLUSION

There were no postoperative complications. In our series, the procedure has proved reliable and safe. Its advantages include symptomatic pain relief, adequate acetabular roof coverage and reduced peak stress on the weight bearing area of the hip. It can be used to postpone the development of hip arthrosis in adults with acetabular dysplasia.

Medium-term results of the Bernese periacetabular osteotomy in the treatment of symptomatic developmental dysplasia of the hip

We studied the medium-term outcome of the Bernese periacetabular osteotomy in 52 patients (58 hips) with symptomatic developmental dysplasia of the hip and a mean age of 37.6 years (13 to 48). The operations were performed between 1993 and 2005 by the senior author with a mean follow-up of 66.7 months (13 to 153). There were 42 women (47 hips) and ten men (11 hips). Of these patients, 24 (30 hips) had an osteotomy on the right side and 22 (28 hips) on the left. Six patients had bilateral operations. The clinical outcome was assessed using the modified Merle d'Aubigne scale, and pre- and post-operative radiological evaluation using the modified Tonnis osteoarthritis score, the centre-edge angle, the acetabular index, the status of Shenton's line, and the cross-over sign. The mean centre-edge angle and the acetabular index were 14 degrees (2 degrees to 34 degrees ) and 23.6 degrees (0 degrees to 40 degrees ) before operation, and 36.6 degrees (16 degrees to 72 degrees ) and 7.9 degrees (0 degrees to 28 degrees ) after, respectively (p < 0.001, analysis of variance (ANOVA)). Shenton's line was intact in 23 hips (39.6%) before operation and in 48 hips (82.8%) after. The cross-over sign was present in 31 hips (53.4%) before and in three hips (5.2%) after operation (p < 0.001, ANOVA). The total Merle d'Aubigne clinical score improved from a mean of 12.6 (9 to 15) to 16.0 (12 to 18) points (p < 0.001, ANOVA). Only four hips required subsequent total hip replacement. Our results indicate that the Bernese periacetabular osteotomy provides good symptomatic relief for patients with little to no arthritis (Tonnis type 0 or 1) with an underlying deformity that can be corrected to a position of a stable, congruent hip joint.

Evaluation of a circumferential femoral head osteophyte as an early indicator of osteoarthritis characteristic of canine hip dysplasia in dogs

OBJECTIVE

To determine the relationship between a circumferential femoral head osteophyte (CFHO) and osteoarthritis characteristic of canine hip dysplasia, and to ascertain whether CFHO, like osteoarthritis, varies between diet-restricted and control-fed dogs.

DESIGN

Longitudinal cohort study.

ANIMALS

48 Labrador Retrievers.

PROCEDURES

Dogs were paired by size, sex, and litter and assigned to 1 of 2 equal groups at 2 months of age. The control-fed group was fed ad libitum, and the diet-restricted group was fed 25% less on a pairwise basis of the same diet for life. The dogs' hip joints were radiographed yearly for life. Each radiograph was evaluated for radiographic signs of osteoarthritis characteristic of hip dysplasia and for the presence and severity of a CFHO.

RESULTS

41 of the 48 (85.4%) dogs had a CFHO, which was detected at a median age of 5.4 years, and 33 of those 41 (80.5%) developed radiographic evidence of osteoarthritis. Nineteen (79.2%) dogs in the diet-restricted group and 22 (91.7%) in the control-fed group had a CFHO at a median age of 9 and 3 years, respectively. Of the dogs with a CFHO, 12 (63.2%) in the diet-restricted group and 20 (90.0%) in the control-fed group developed radiographic evidence of osteoarthritis characteristic of hip dysplasia at a median age of 11 and 6.5 years, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated a relationship between the CFHO and subsequent development of radiographic signs of osteoarthritis. If a CFHO is present in Labrador Retrievers, it might be considered an early indicator of osteoarthritis.

Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip

The primary goal in treatment of slipped capital femoral epiphysis (SCFE) is to prevent further slip by stabilizing the physis. Debate exists concerning prophylactic fixation of the uninvolved hip at presentation. Our goal was to determine predictive factors for a contralateral slip after presentation with a unilateral SCFE. Ninety patients with SCFE and complete radiographs were followed up until the bilateral closure of the proximal femoral physis. Chronological age at presentation, sex, and race were recorded. Open or closed triradiate cartilage was recorded, and a modified Oxford bone age assessment was performed. Twenty patients (22%) had bilateral SCFE at presentation, and 70 patients (78%) were unilateral. Of these 70 patients, 16 (23%) later developed a contralateral SCFE. Analysis revealed that chronological age was the only significant (P = 0.010) predictor for developing a contralateral slip. All girls younger than 10 years and all boys younger than 12 years who presented with unilateral SCFE developed a contralateral slip. Twenty-five percent of girls younger than 12 years and 37% of boys younger than 14 years developed a contralateral slip. No girl older than 13 years and no boy older than 14 years developed a contralateral slip in our series. Surgical complications were infrequent and isolated to the side of the initial SCFE. Chronological age is a predictor for a contralateral slip in patients presenting with a unilateral SCFE. The authors recommend that all girls younger than 10 years and all boys younger than 12 years presenting with unilateral SCFE should undergo strong consideration for prophylactic screw fixation on the contralateral side. In older age groups, prophylactic treatment may be considered on a case-by-case basis.

Rotational acetabular osteotomy through an ollier lateral u approach

Various methods of periacetabular osteotomy have been described. Since 1990, we have performed rotational acetabular osteotomy through an Ollier lateral U transtrochanteric approach without massive bone graft. This study investigated whether our technique could provide relief from symptoms, whether postoperative hip abductor weakness would be a critical complication, and whether appropriate acetabular coverage could be achieved. We followed in 101 patients (110 consecutive hips) with a mean age at surgery of 32.5 years and a minimum followup of 5 years (mean, 8.3 years; range, 5-16.2 years). Satisfactory results were found in 94 (85%) hips. A positive Trendelenburg sign was observed in eight (7%) hips at last followup. Appropriate postoperative coverage was provided with an average center-edge angle of 35 degrees . We found radiographic evidence of deterioration of osteoarthritic changes in 14 (13%) hips. Complications included deep infection (one patient); pulmonary embolism (one patient); osteonecrosis of the rotated acetabular fragment (two patients); and proximal displacement of the greater trochanter because of breakage of the polylevolactic acid screws (four patients). This procedure allows osseous cuts with good operative exposure and provides relief from symptoms in most painful dysplastic hips.

Strategies for the prevention and management of osteoarthritis of the hip and knee

Osteoarthritis (OA) is one of the most common forms of musculoskeletal disorders and incurs significant economic, social and psychological costs. OA increases in prevalence and also progresses with aging. Clinically OA is characterised by joint pain, crepitus, stiffness after immobility and limitation of movement. Many cases are 'idiopathic' (disease or condition of unknown course or which arises spontaneously), but OA can also be the end result of several other conditions or due to the combination of several other factors. There are various lifestyle factors that increase the risk of developing OA. Preventable or modifiable risk factors include obesity, occupational factors, sports participation, muscle weakness, nutritional factors and hormonal influence. Pharmacological therapies reduce pain and may reduce joint damage. Surgical interventions correct altered biomechanics to prevent OA. For severely damaged joints, partial or total replacement of the joint is possible for all of the large joints that are commonly affected by OA. OA is commonly associated with a limited function that can be improved with a wide variety of rehabilitative interventions: joint specific exercises, physical fitness, physical modalities. Education and self-management are very important to prevent overuse and to use the joints in the most adequate way.

Effect of hormone therapy on risk of hip and knee joint replacement in the Women's Health Initiative

OBJECTIVE

To determine the effect of hormone therapy on arthroplasty rates.

METHODS

We examined data from the Women's Health Initiative placebo-controlled, double-blind, randomized trials. Community-dwelling women ages 50-79 years were enrolled at 40 US clinics. Women with prior arthroplasty were excluded, yielding a sample size of 26,321 subjects. Women who had had hysterectomies (n = 10,272) were randomly assigned to receive 0.625 mg/day conjugated equine estrogens (n = 5,076), or placebo (n = 5,196), with a mean followup of 7.1 years. Those who had not had hysterectomies (n = 16,049) were randomly assigned to receive estrogen plus progestin (n = 8,240), given as 0.625 mg/day conjugated equine estrogens plus 2.5 mg/day medroxyprogesterone acetate, or placebo (n = 7,809), with a mean followup of 5.6 years. Participants reported hospitalizations, and arthroplasties were identified by procedure codes. Arthroplasties due to hip fracture were censored. Cox proportional hazards regression was used to assess hazard ratios (HRs) and 95% confidence intervals (95% CIs) using intent-to-treat methods and outcome of time to first procedure.

RESULTS

In the estrogen-alone trial, women receiving hormone therapy had significantly lower rates of any arthroplasty (HR 0.84 [95% CI 0.70-1.00], P = 0.05). However, this effect was borderline statistically significant for hip arthroplasty (HR 0.73 [95% CI 0.52-1.03], P = 0.07), and not significant for knee arthroplasty (HR 0.87 [95% CI 0.71-1.07], P = 0.19). In the estrogen-plus-progestin trial, there was no association for total arthroplasty (HR 0.99 [95% CI 0.82-1.20], P = 0.92) or for individual hip (HR 1.14 [95% CI 0.83-1.57], P = 0.41) or knee (HR 0.91 [95% CI 0.72-1.15], P = 0.41) arthroplasties.

CONCLUSION

These data suggest that hormone therapy may influence joint health, but this observed decrease in risk may be limited to unopposed estrogen and may possibly be more important in hip than in knee osteoarthritis.

Lifelong diet restriction and radiographic evidence of osteoarthritis of the hip joint in dogs

OBJECTIVE

To evaluate the effects of diet restriction on development of radiographic evidence of hip joint osteoarthritis in dogs.

DESIGN

Longitudinal cohort study.

ANIMALS

48 Labrador Retrievers from 7 litters.

PROCEDURES

Forty-eight 6-week-old puppies from 7 litters were paired with littermates by sex and weight, and each pairmate was randomly assigned to 1 of 2 groups of 24 dogs each. Starting at 8 weeks of age, 1 group was fed ad libitum (control fed) and the other was fed 25% less (restricted fed) of the same diet for life on a pairwise basis. The dogs' hip joints were radiographed in the standard ventrodorsal hip-extended view at multiple intervals prior to 1 year of age and at annual intervals thereafter on the basis of birth anniversary. A board-certified radiologist unaware of group assignment scored the radiographs for evidence of osteoarthritis.

RESULTS

Prevalence of radiographic evidence of hip joint osteoarthritis in all dogs increased linearly throughout the study, from an overall prevalence of 15% at 2 years to 67% by 14 years. Restricted-fed dogs had lower prevalence and later onset of hip joint osteoarthritis. Median age at first identification of radiographic evidence of hip joint osteoarthritis was significantly lower in the control-fed group (6 years), compared with the restricted-fed group (12 years).

CONCLUSIONS AND CLINICAL RELEVANCE

Restricted feeding delayed or prevented development of radiographic signs of hip joint osteoarthritis in this cohort of Labrador Retrievers. Lifetime maintenance of 25% diet restriction delayed onset and reduced severity of hip joint osteoarthritis, thus favorably affecting both duration and quality of life. In addition, the data indicated that development of hip joint osteoarthritis was not bimodal in these dogs but occurred as a continuum throughout life.

Walking pattern in 9 women with hip dysplasia 18 months after periacetabular osteotomy

BACKGROUND

Periacetabular osteotomy improves radiographic predictors of osteoarthrosis and diminishes pain and functional impairment. No changes in function quantified by gait analysis have yet been documented. We evaluated the functional outcome of periacetabular osteotomy in relation to gait.

METHODS

The gait pattern of 9 women (median age 39 years) with hip dysplasia who were treated with unilateral periacetabular osteotomy was analyzed before periacetabular osteotomy and an average of 1.5 years afterwards. Data were collected using 5 video cameras and 2 force plates. An inverse dynamics approach was used to calculate sagittal joint angles and moments in the stance phase.

RESULTS

Postoperatively, all subjects walked with an increased extension of the knee joint during the entire stance phase compared to the preoperative movement pattern.

INTERPRETATION

The subjects achieved a more upright walking pattern but continued to relieve the hip joint by maintaining a reduced flexor moment.

Protrusio acetabuli in Marfan syndrome. History, diagnosis, and treatment

Marfan syndrome is an autosomal dominant disorder of connective tissue, with ocular, skeletal, and cardiovascular manifestations. Protrusio acetabuli is a criterion for the diagnosis of Marfan syndrome. Prolonged protrusio acetabuli may result in secondary osteoarthritic changes in the hip joint. Radiographic criteria for protrusio acetabuli include an abnormally positioned acetabular line, a center-edge angle of Wiberg of >40 degrees, and crossing of the teardrop by the ilioischial line. In a skeletally immature patient with Marfan syndrome in whom the triradiate physis of the acetabulum is still open, closure of the triradiate physis can interrupt and decrease the progression of the deformity. In older patients, valgus intertrochanteric osteotomy and eventually total hip arthroplasty are the only methods available for correction of the protrusio acetabuli.

Arthroskopische Behandlung des femoroazetabulären Impingements

Femoroacetabular impingement (FAI) is likely one of the main causes for osteoarthritis in young adults. Surgical treatment has until now been performed via open dislocation of the hip joint. With respect to its invasive nature and long rehabilitation, arthroscopic techniques have become established in recent years. The following article presents the latest developments in hip arthroscopy for FAI with a detailed description of technical aspects, pitfalls, and limitations. Hip arthroscopy is performed in the standard fashion with and without traction for arthroscopy of the central and peripheral compartments. Under traction, the anterosuperior cartilage and adjacent base of the acetabular labrum have to be inspected for frequent lesions such as cartilage flap tears and delaminations of the cartilage from the subchondral bone. An ossified labrum can be trimmed back with a burr. Currently, techniques are being developed for temporary detachment of the labrum, trimming of the acetabular rim, and refixation of the labrum with suture anchors. Without traction, femoroacetabular impingement has to be confirmed arthroscopically under flexion, internal rotation, and adduction of the hip. With respect to the frequent loss of internal rotation, the zona orbicularis and the iliofemoral ligament are released and removed if needed. The anterolateral bump of the head-neck junction is trimmed back for restoration of a more physiological head-neck offset. Postoperatively, continuous passive motion is important to prevent adhesions between the bleeding bone of the head-neck junction and the articular capsule. Weight bearing as tolerated is allowed if no treatment of cartilage defects or refixation of the acetabular labrum was performed. The early results after hip arthroscopy for FAI are very promising. Arthroscopic techniques will upstage open exposures of the hip joint for the treatment of FAI.

The Bernese periacetabular osteotomy: clinical, radiographic and mechanical 7-15-year follow-up of 26 hips

BACKGROUND

The Bernese periacetabular osteotomy is used in dysplastic hips to increase the load-bearing area of the hip and to prevent osteoarthritis. The aim of our work was to determine the contact hip stress before and after the osteotomy and to compare the relief of stress with the long-term radiographic and clinical outcome.

PATIENTS AND METHODS

We followed 26 dysplastic hips (26 patients) for 7-15 years after the index operation. Clinical evaluation was based on the WOMAC score, osteoarthrosis was evaluated with the Tönnis classification, the angles of lateral (CE) and anterior (VCA) femoral coverage were measured, and biomechanical parameters were studied.

RESULTS

Periacetabular osteotomy increased the mean CE from 15 degrees to 37 degrees , and the mean VCA from 22 degrees to 38 degrees . The mean normalized peak contact stress was reduced from 5.2 to 3.0 kPa/N. Four hips required total hip arthroplasty after an average of 4.5 years, 8 hips showed considerable arthrosis progression, and 14 hips had no or mild arthrosis at follow-up. Preoperative WOMAC score, preoperative Tönnis grade and postoperative normalized peak contact stress were the most important predictors of outcome.

INTERPRETATION

The Bernese periacetabular osteotomy improves the mechanical status of the hip. Long-term success depends on the grade of arthrosis preoperatively and on the magnitude of operative correction of the contact hip stress.

Sugioka's osteotomy for femoral-head necrosis in young Caucasians

The transtrochanteric rotational osteotomy described by Sugioka is used to preserve the femoral head and to prevent secondary osteoarthritis in young patients with osteonecrosis of the femoral head. Several Japanese studies have shown favourable results, but European and American studies were disappointing. An explanation for these outcomes may be that the original protocol was not followed exactly. The objective of our study was to investigate this trans-trochanteric rotational osteotomy in Caucasian patients with osteonecrosis in which we followed the original method of Sugioka as closely as possible, including a 6-month period of non-weight bearing. We included 26 hips in 22 consecutive patients who were followed up for 8.7 (range 6.6-10) years. At review, 17 hips had been converted to total hip arthroplasty. The clinical survival rate was 56% after 7 years (95% CI 36-76%). The radiological survival rate was 54% after one year (95% CI 35-73%). Even after excluding the failures due to problems with osteosynthesis and infection, the results were not satisfactory and the osteoarthritic process was not delayed. Based on our results, we cannot recommend this technique as an alternative for total hip arthroplasty in Caucasians.

[Hip sonography for newborn screening]

In the past, congenital dysplasia and dislocation of the hip joint have, despite treatment, led frequently to late sequals (deformations and incongruous articular surfaces), requiring repeated corrective interventions. Nevertheless, life-long handicaps could not always be prevented. It is known for a long time that sequels, such as articular deformations and desorders of growth of the femoral head, can be prevented the better, the earlier the treatment is initiated. However, a reliable method for early diagnosis has been lacking to date. Even systematic clinical examinations of all newborn babies have not been able to prevent late appearance of dysplasia and dislocation. This is not due to poor practice of clinical examination, but is explained by to day's knowledge that most dislocations are not present at birth but develop later on. Deformations of the acetabular roof without any dislocation of the femoral head are clinically not papable and do not cause any symptoms in adults until the onset of coxarthritis. Hip sonography according to Graf has proven to be an effective imaging procedure for early diagnosis. Right at birth, it allows very reliable detection of all cases that, if left untreated, will cause later major therapeutic difficulties, such as dislocations of the femoral head or coxarthritis due to dysplasia of the acetabular roof. If diagnosed early--at best immediately after birth--successful healing can be achieved even in severe cases resulting in an anatomical and functional normal hip joint, only by conservative and out-patient treatment. That is why many centers have established sonographic screening programs of all newborns as a preventive measure. Screening is medically most effective, if practiced at the earliest possible stage (at best immediately after birth). From an economical point of view, no disadvantage of early screening (despite of higher rates of findings requiring review) has been found in terms of overall costs (screening, follow-up, treatment).

The Wagner spherical osteotomy of the acetabulum. Surgical technique

BACKGROUND

The purpose of this study was to evaluate the long-term clinical and radiographic results of spherical acetabular osteotomy, performed with the surgical technique described by Wagner, in patients with hip dysplasia.

METHODS

The results of the first twenty-two spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum of twenty years (median, 23.9 years; maximum, 29.3 years) postoperatively. Preoperative and follow-up radiographic measurements included the lateral and anterior center-edge angles, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Anteroposterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint-space narrowing, increased sclerosis of the subchondral bone, and bone cysts. Clinical evaluation was performed with use of the Harris hip score.

RESULTS

Osteotomy improved the mean lateral center-edge angle from -2 degrees to +13 degrees and the mean acetabulum-head index from 52% to 72%. The mean postoperative anterior center-edge angle was 23 degrees (range, -1 degrees to 62 degrees ). Seven (32%) of the twenty-two hips were converted to a total hip replacement. At the latest follow-up examination, the average Harris hip score of the remaining fifteen patients was 86 points (range, 50 to 100 points). The clinical result was rated good or excellent for eleven of the fifteen patients. At the latest follow-up examination, the severity grade of the osteoarthritis was unchanged in thirteen hips. Only three of the nine hips that subsequently required a total hip replacement or that showed progressive osteoarthritis had been congruent after the index operation, whereas ten of the thirteen hips that did not require total hip replacement or show progressive osteoarthritis had been congruent after the index operation. The twenty-year Kaplan-Meier survival estimate, with conversion to total hip replacement as the end point, was 86.4% (95% confidence interval, 63.4% to 95.4%). The twenty-five-year survival estimate was 65.1% (95% confidence interval, 35.6% to 83.7%).

CONCLUSIONS

The Wagner spherical osteotomy prevented progression of osteoarthritis both clinically and radiographically in a high proportion of patients with residual hip dysplasia who were followed for a minimum of twenty years. Operative restoration of joint congruency is associated with a satisfactory long-term outcome in a very high proportion of cases.

Treatment of patients with arthrosis of hip or knee with an aqueous extract of devil's claw (Harpagophytum procumbens DC.)

Preparations made from the secondary tubers of Devil's claw (Harpagophytum procumbens) are successfully used in patients with rheumatic diseases (arthrosis and low back pain). In order to add data on the efficacy and long-term safety of an aqueous extract (Doloteffin; 2400 mg extract daily, corresponding to 50 mg harpagoside), which has been tested successfully in patients with low back pain, an uncontrolled multicentre drug surveillance study for about 12 weeks was conducted in 75 patients with arthrosis of the hip or knee. To standardize the assessment of treatment effects, the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index (10 point scale) as well as the 10 cm VAS pain scale were used. The results of the study revealed a strong reduction of pain and the symptoms of osteoarthritis. There was a relevant improvement of each WOMAC subscale as well as of the total WOMAC index: 23.8% for the pain subscale, 22.2% for the stiffness subscale and 23.1% for the physical function subscale. The WOMAC total score was reduced by 22.9%. VAS pain scores were decreased by 25.8% for actual pain, 25.2% for average pain, 22.6% for worst pain and 24.5% for the total pain score. The physicians reported a continuous improvement in typical clinical findings such as 45.5% for pain on palpation, 35% for limitation of mobility and 25.4% for joint crepitus. Only two cases of possible adverse drug reactions were reported (dyspeptic complaints and a sensation of fullness). Although this was an open clinical study, the results suggest that this Devil's claw extract has a clinically beneficial effect in the treatment of arthrosis of the hip or knee.

Three-dimensional gait analysis of adults with hip dysplasia after rotational acetabular osteotomy

Dysplasia of the hip, the most common cause of secondary coxarthrosis, has a relatively high prevalence in Japan. Rotational acetabular osteotomy (RAO) is an interventional strategy that seeks to reduce the abnormal amount of high stress concentration in the acetabulum and thereby to prevent the development of coxarthrosis. Long-term clinical results have been reported, but functional evaluations of the gait before and after RAO are underreported. The aim of our recently initiated long-term prospective study is to assess the effect of RAO on the gait characteristics of patients using quantitative gait analysis. Thus far 22 patients (1 male, 21 females; mean age 30 years, range 15-43 years) have been enrolled, treated, and completed the preoperative and postoperative gait analyses. Hip pain during walking decreased in all patients after the RAO. The postoperative hip extension motion angle on the treated side increased significantly and correlated positively with the improvement in the Japanese Orthopaedic Association (JOA) pain score. The current study shows that coxalgia and gait function improved after RAO.

Structure-modifying agents for osteoarthritis: an update

The terms "chondroprotective" and "structure-modifying" were coined to identify a class of drugs capable of preventing, stabilizing, or repairing joint damage caused by osteoarthritis. The method of reference for evaluating structure-modifying effects in knee or hip osteoarthritis is the measurement of joint space loss on serial plain radiographs. Joint space width can be measured manually or by a computer. Several radiological techniques have been described for measuring joint space width in the medial femorotibial compartment of the knee and the superolateral part of the hip. Most studies of potentially structure-modifying effects evaluated slow-acting drugs for osteoarthritis, which are currently used for their delayed symptomatic effect in osteoarthritis. Although most of these agents have shown promising effects in vitro, none has been proven to produce clinically meaningful structure-modifying effects in humans with osteoarthritis.

Body mass and physical capacity indicators of hip osteoarthritis patients with and without malignancy histories: implications for prevention and rehabilitation

The prevalence of patients with cancer histories and types of cancers prevailing among a cohort of adults with end-stage hip osteoarthritis was established in order to determine if this group might require some form of enriched pre- and postoperative rehabilitation in view of their adverse medical history. Body weights and selected physical capacity indicators were specifically compared among hip surgical patients with and without cancer histories to specify characteristics that could direct potentially desirable and improved intervention efforts. The medical records of 1,000 hip osteoarthritis surgical candidates were scrutinized, and numbers with and without malignancy histories were recorded. Malignancy typologies and selected body mass and physical capacity indices were recorded. Specific subgroup comparisons among these variables were then made for 40 cancer survivors and an age- and gender-matched subgroup of 40 otherwise healthy osteoarthritis patients, and for selected breast, prostate, and colon cancer survivors. (1) Fourteen percent of the present patient group had a cancer history. (2) The most common malignancy noted was breast cancer, followed by prostate and then colon cancer. (3) Among subjects matched for age and gender, 85% with a cancer history were overweight or obese, compared with 60% of those with no comorbid disease history. (4) Patients with cancer histories were more impaired immediately before, and after, surgery than patients with no cancer history. (5) Patients with breast and colon cancer histories had significantly slower recovery rates after hip surgery than those with a prostate cancer history (p < 0.05). Thus, breast, prostate, and colon cancer survivors constitute a modest proportion of patients undergoing surgery for painful disabling hip osteoarthritis. As a subgroup, cancer survivors, especially breast cancer survivors, are overweight, and more impaired before and after surgery than adults of the same age without a cancer history undergoing hip surgery.

[Complications of operative treatment of acetabular fractures]

OBJECTIVE

To improve the effect of operative management of acetabular fractures.

METHODS

One hundred and seventy eight acetabular fractures were treated operatively from August 1993 to December 2000. Their functional results and complications were analyzed.

RESULTS

One hundred and twelve hips were followed up for an average of 45.7 months. Heterotopic ossification was noted in 26 hips, post-operative osteoarthritis in 22 hips, avascular necrosis of the femoral head in 8 hips, and sciatic nerve injury in 7 hips after operations. No death and infection were found in this series.

CONCLUSIONS

Ectopic bone formation develops at extended ilio-femoral and Kocher-Langeneck approaches. Cartilaginous injury of the femoral head is contributable to post-operative osteoarthritis, and imperfect reduction is an important factor in the genesis of osteoarthritis.

Treatment of the dysplastic acetabulum with Wagner spherical osteotomy. A study of patients followed for a minimum of twenty years

BACKGROUND

The purpose of this study was to evaluate the long-term clinical and radiographic results of spherical acetabular osteotomy, performed with the surgical technique described by Wagner, in patients with hip dysplasia.

METHODS

The results of the first twenty-two spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum of twenty years (median, 23.9 years; maximum, 29.3 years) postoperatively. Preoperative and follow-up radiographic measurements included the lateral and anterior center-edge angles, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Anteroposterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint-space narrowing, increased sclerosis of the subchondral bone, and bone cysts. Clinical evaluation was performed with use of the Harris hip score.

RESULTS

Osteotomy improved the mean lateral center-edge angle from -2 degrees to +13 degrees and the mean acetabulum-head index from 52% to 72%. The mean postoperative anterior center-edge angle was 23 degrees (range, -1 degrees to 62 degrees ). Seven (32%) of the twenty-two hips were converted to a total hip replacement. At the latest follow-up examination, the average Harris hip score of the remaining fifteen patients was 86 points (range, 50 to 100 points). The clinical result was rated good or excellent for eleven of the fifteen patients. At the latest follow-up examination, the severity grade of the osteoarthritis was unchanged in thirteen hips. Only three of the nine hips that subsequently required a total hip replacement or that showed progressive osteoarthritis had been congruent after the index operation, whereas ten of the thirteen hips that did not require total hip replacement or show progressive osteoarthritis had been congruent after the index operation. The twenty-year Kaplan-Meier survival estimate, with conversion to total hip replacement as the end point, was 86.4% (95% confidence interval, 63.4% to 95.4%). The twenty-five-year survival estimate was 65.1% (95% confidence interval, 35.6% to 83.7%).

CONCLUSIONS

The Wagner spherical osteotomy prevented progression of osteoarthritis both clinically and radiographically in a high proportion of patients with residual hip dysplasia who were followed for a minimum of twenty years. Operative restoration of joint congruency is associated with a satisfactory long-term outcome in a very high proportion of cases.

Periacetabular osteotomy of the hip: the ilioinguinal approach

Developmental hip dysplasia (DDH) is characterized by an anomalous growth of the hipjoint. Without adequate treatment, the natural history of DDH is development of secondary osteoarthritis in adulthood. The correction of the deformities modifies the biomechanics of the hip, which is important in order to slow down the progression of osteoarthritis and maybe to prevent and postpone this development. The Bernese periacetabular osteotomy is a procedure which reorientates the acetabular articular surface. Several surgical approaches have been used to achieve the same effective osteotomy. No surgical approach represents "the optimum", with selection of appropriate exposure representing a balance of advantages and disadvantages. We used the ilioinguinal approach in 32 periacetabular osteotomies for acetabular dysplasia performed between 1996 and 2002. The operation was successful in 30 patients with acceptable operation time and blood loss and few complications. The advantages and disadvantages with the ilioinguinal approach as compared to other possibile incisions are discussed.

Usefulness of arthroscopic surgery in hip trauma cases

PURPOSE

The goal of this study is to clarify the usefulness of arthroscopic surgery as an adjunct in the management of hip trauma.

TYPE OF STUDY

Clinical case series.

METHODS

Eleven joints from 10 hip trauma cases were studied. All joints had been injured in traffic accidents. Seven joints were classified as Thompson and Epstein (T-E) type I, 2 joints as type II, and 1 joint as type IV. The remaining case was a fracture of the acetabular weight-bearing region that was not included within these classifications. The 5 femoral head fractures associated with hip dislocation were further classified according to Pipkin: 3 joints were type 1, 1 joint was type 2, and 1 joint was type 3. The interval from injury to arthroscopy ranged from 1 to 7 days, with a mean of 3.2 days.

RESULTS

In 7 cases, small free osteochondral or chondral fragments that were not detectable on either plain radiographs or computed tomography scans were seen arthroscopically. These fragments were debrided. Arthroscopic osteosynthesis using absorbable pins and fragment extraction were performed in 1 case each of the Pipkin's type 1 femoral head fractures. In the case of the acetabular weight-bearing region fracture, reduction and percutaneous pinning were performed under arthroscopic observation. After a mean postoperative follow-up period of 9 years and 6 months, no abnormalities were observed in 9 of the joints. However, the T-E type IV joint developed osteoarthritis and the Pipkin type 3 joint developed aseptic osteonecrosis of the femoral head.

CONCLUSIONS

Arthroscopic surgery allows procedures such as washout and debridement of small free osteochondral and chondral fragments, which were previously neglected in T-E type I and II dislocations despite the fact that they may cause osteoarthritis. In addition, arthroscopic surgery allows procedures such as the extraction or osteosynthesis of fracture fragments in cases associated with femoral head fractures.

The Kingston periacetabular osteotomy utilizing computer enhancement: a new technique

OBJECTIVE

To develop a new periacetabular osteotomy technique that can be performed safely and reliably using computer-enhanced technology.

MATERIALS AND METHODS

This technique uses a modified posterior approach with a trochanteric osteotomy. A 3D surface model is generated from CT data. The osteotomy is planned using custom software developed by our team. A dynamic reference body is fixed to the iliac crest and the pelvis is registered using an optically tracked probe (Optotrak, Northern Digital, Ontario, Canada). A tracked probe is used to mark the osteotomies in three dimensions. The posterior column is osteotomized between the sciatic notch and hip joint. The pubic ramus is osteotomized under fluoroscopic guidance. The acetabular fragment is rotated into a more appropriate position and fixed with pelvic reconstruction plates. Subjective and objective data are collected pre- and postoperatively.

RESULTS

This procedure has been performed on eight patients. Average center-edge angle correction has been 17 degrees. The computer and optical guidance system has provided accurate information in seven of eight cases, and there have been no complications.

CONCLUSIONS

This technique has enabled us to perform periacetabular osteotomies with safety and predictability. Using this computer-enhanced technique, periacetabular osteotomy may become a more common procedure in the practice of hip reconstruction surgeons.