The Surgical Challenges of Intertrochanteric Hip Fracture in a Patient with Polio Dysplastic Hip and Previous Distal Femur Fracture: A Case Report

@#Poliomyelitis is on the verge of eradication since the introduction of the vaccine in 1950. In developed countries, those afflicted with the disease are primarily in their sixth decade and beyond, usually with disabling complications. Due to the diminished muscle power coupled with the abnormal bony anatomy and joint contractures, patients with polio present unique surgical challenges when they sustain fragility fractures. We report an uncommon case of intertrochanteric hip fracture in a limb affected with polio and hip dysplasia, on a background of ipsilateral distal femur fracture with previous surgical fixation. We aim to outline the challenges encountered during the surgery and the preoperative planning to overcome these shortcomings.

Curved Periacetabular Osteotomy for the Treatment of Dysplastic Hips

Curved periacetabular osteotomy (CPO) was developed for the treatment of dysplastic hips in 1995. In CPO, the exposure of osteotomy sites and osteotomy of the ischium are made in the same manner as Bernese periacetabular osteotomy, and iliac and pubic osteotomies are performed in the same manner as rotational acetabular osteotomy. We studied the dynamic instabilities of 25 dysplastic hips before and after CPO using triaxial accelerometry. Overall magnitude of acceleration was significantly decreased from 2.30 +/- 0.57 m/sec2 preoperatively to 1.55 +/- 0.31 m/sec2 postoperatively. Pain relief and improvement of acetabular coverage resulting from acetabular reorientation seem to be related with reduction of dynamic instabilities of dysplastic hips. Isokinetic muscle strengths of 24 hips in 22 patients were measured preoperatively and after CPO. At 12 months postoperatively, the mean muscle strength exceeded the preoperative values. These results seem to be obtained due to no dissection of abductor muscles in CPO. The preoperative presence of acetabular cysts did not influence the results of CPO. An adequate rotation of the acetabular fragment induced cyst remodeling. Satisfactory results were obtained clinically and radiographically after CPO in patients aged 50 years or older. CPO alone for the treatment of severe dysplastic hips classified as subluxated hips of Severin group IV-b with preoperative CE angles of up to -20degrees could restore the acetabular coverage, weight-bearing area and medialization of the hip joint. CPO without any other combined procedure, as a treatment for 17 hips in 16 patients with Perthes-like deformities, produced good mid-term clinical and radiographic results. We have been performing CPO in conjunction with osteochondroplasty for the treatment of acatabular dysplasia associated with femoroacetabular impingement since 2006. The combined procedure has been providing effective correction of both acetabular dysplasia and associated femoral head-neck deformities without any increased complication rate. We have encountered an obturator artery injury in one case and two intraoperative comminuted fractures. Although serious complications such as motor nerve palsy, deep infection, necrosis of the femoral head or acetabulum, and delayed union or nonunion of the ilium were reported, such complications have never occurred in our 700 cases so far.

Cementless Total Hip Arthroplasty in Dysplastic Hips

PURPOSE: To evaluate the clinical and radiological results after cementless total hip arthroplasty in dysplastic hips. MATERIALS AND METHODS: This study included 36 cases that underwent total hip arthroplasty using a cementless prosthesis in our hospital from July 1990 to May 2008. The average time of of follow-up was 103.7 months. In total, 27 cases about 24 patients were women, and 8 cases about 7 patients were men. The average age at the time of operation was 55.7 years(29-80 years). In total, 26 cases were Crowe type I and 8 cases were Crowe type II. One case was Crowe type IV. Acetabular cup angles and the contact ratio between the acetabular cup and the host bone were measured, and the grafting bone was observed for absorption in the follow-up radiographs. Revision of components was defined as a failure. RESULTS: Harris hip score was improved from 55.1 points pre-operatively to 86.1 points in the last follow-up. Revision was done in 12 cases(33.3%). Altogether, 10 cases revised the acetabular cup for osteolysis and polyethylene wear and 2 cases exchanged a polyethylene liner for only liner wear. CONCLUSION: Total hip arthroplasty in the dysplastic hip using a cementless acetabular cup, not a hydroxyapatite-coated acetabular cup, showed good clinical and radiological results when the contact ratio between acetabular cup and bone was above 70%.

MR-based Parameters as a Supplement to Radiographs in Managing Developmental Hip Dysplasia

BACKGROUND: Some dysplastic hips with favorable radiographic parameters fail to develop normally, suggesting that we should consider cartilaginous or soft tissue structures for further information regarding the condition of the hip. The purpose of this study was to provide a clear definition of concentric reduction in developmental dysplasia of the hip (DDH) based on magnetic resonance imaging (MRI), and to determine how radiographic and MR-based parameters could be used together to treat dysplastic hips. METHODS: We studied range of motion (ROM)-MRI of 25 patients with unilateral hip dysplasia (mean age at the time of MR imaging, 44.1 months). Each ROM-MRI consisted of a set of bilateral hip scans in the following positions: neutral; abduction; abduction- internal rotation; abduction-internal rotation-flexion; and adduction. Before MR scanning, the 25 patients received the following primary treatments: closed reduction (n = 15; at a mean age of 14.5 months); and open reduction (n = 10; at a mean age of 10.0 months). The following new parameters appear to be useful in treating DDH: 1) the labral angle, the angle the labrum makes with the acetabulum; 2) the uncorrected labral deformity (ULD), the "residual deformity" (deflection of the labrum) when the affected labrum is freed from pressure in abduction; and 3) the zone of compressive force (ZCF), the region of the acetabulum through which the body weight acts on the femoral head. RESULTS: A concentrically-reduced hip is one in which the labrum points downward in the neutral position, at the same angle as that of the normal side; and in which the ZCF is zone 3, the inner acetabular zone as defined herein. The ULD and the ZCF may be determined precisely as we have done, or the physician may simply observe the changes in the orientation of the labrum and compare the changes qualitatively to the unaffected side, and likewise for the medial joint space. CONCLUSIONS: Detailed analysis of the labrum as permitted by ROM-MRI, together with acetabular index and other parameters measured from radiographs, provides important information for physicians treating childhood hip dysplasia.

Total Hip Arthroplasty Using S-ROM Prosthesis for Dysplastic Hip

PURPOSE: The purpose of this study was to evaluate the clinical and radiological results of total hip arthroplasty using a proximal modular femoral stem in patients who had secondary coxarthrosis associated with a dysplastic hip. MATERIALS AND METHODS: Forty-two patients (45 hips) with secondary coxarthrosis were evaluated after undergoing primary total hip arthroplasty using an S-ROM proximal modular femoral stem. The average follow-up was 80 months (range: 60 to 96 months). Clinical and radiological assessments were performed based on the Harris hip score and the radiological changes around the prosthesis. RESULTS: The average Harris hip score improved from 52.2 points to 88.5 points. All femoral stems showed stable fixation; there were 37 cases by bony ingrowth and 8 cases by stable fibrous ingrowth. Neither osteolysis nor progressive radiolucent lines around the femoral stem were found at the last follow-up. Forty-one hips (91.9%) revealed excellent or good clinical results at the most recent follow-up. CONCLUSION: For advanced secondary coxarthrosis, total hip arthroplasty with the use of the proximal modular femoral stem yielded good mid-term results with respect to the clinical and radiological criteria.

Analysis of Failure Cause of Acetabular Components Among Total Hip Replacement Arthroplasties Using RB Wagner Acetabular Cup

PURPOSE: The purpose of this study was to analyze the cause of failure of acetabular component cases after metal-on-metal primary total hip arthroplasty using RB Wagner acetabular cup. MATERIALS AND METHODS: Between January 1993 and January 2005, we retrospectively studied failure cause of 27 patients who underwent acetabular revision surgery among 468 consecutive cementless total hip arthroplasties using RB Wagner acetabular component. The duration of primary arthroplasty to revision ranged from 5.1 years to 11.5 years (mean 9.2 years). The clinical evaluation was performed using preoperative and last follow-up modified Harris hip scores. The radiological evaluation was performed in terms of the stability, such as inclination, anteversion, cup size, acetabular bone coverage, osteolysis, radiolucency and gap. RESULTS: The average Harris hip scores was 49.6 preoperatively and 91.3 at the most recent follow-up. In revision cases, the score was 41.2 to 51.7. Among 468 cases, 27 patients underwent revision surgery (7%, 27/468) and there was no osseointegration in all cases. The radiological evaluation in revision cases revealed inclination (46.04+/-5.328, p=0.0031), anteversion (14.14+/-2.95, p=0.584), cup size (54 mm+/-2.5, p=0.042) and acetabular bone coverage (67.9%+/-4.77, p=0.003). Focusing on the relation between disease entities, there was relatively high risk in patients with hip dysplasia (Fisher's exact test, p=0.0095). CONCLUSION: Although Wagner acetabular cup relatively showed as high survival rate as 93%, failure rate is significantly high in dysplastic hip patients.

Periacetabular Osteotomy for Treating Dysplastic Hips That Were Misdiagnosed as Having Acetabular Bone Tumor: Report of Two Cases

The incidence of primary bone tumor of the acetabulum is 1-2% of all the bone tumors. Degenerative cystic change can occur in patients with hip dysplasia and this can be misdiagnosed as primary bone tumor. We have experienced 2 patients with painful dysplastic hips that were treated with curettage and autogenous bone graft for a cystic lesion that was originally misdiagnosed as primary bone tumor. The patients'hip pain and limitation of motion recurred, and so Bernese periacetabular osteotomy was performed for the dysplastic hips. At over one year follow-up, the corrected hips showed a painless and good range of motion.

Periacetabular Osteotomy in Hip Dysplasia with Deformed Femoral Head / 대한정형외과학회잡지

PURPOSE: To evaluate the results of a periacetabular osteotomy (PAO) combined with a femoral osteotomy (FO) for a dysplastic hip with a deformed femoral head. MATERIALS AND METHODS: Thirteen hips with dysplasia and a deformed femoral head were followed up for more than 12 months. Eight hips were in the PAO group and 5 hips were in the PAO and FO group. The two groups were compared clinically according to the HHS (Harris hip score), pain and limping VAS (visual analogue scale), and radiologically according to the CEA (central edge angle of Wiberg), Tonnis angle (acetabular index of weight bearing surface), FHC (femoral head coverage), AA (acetabular angle of Sharp), DBSPFH (distance between symphysis pubis and femoral head) and AI (acetabular index of depth to width). RESULTS: Regarding the clinical results, the PAO group showed improvement in the HHS from 66.5 preoperatively to 90.4 postoperatively (p=0.01) and the pain VAS from 6.7 to 1.9 (p=0.01). However, there was no significant improvement in limping (p=0.39). In the PAO with FO group, the HHS was improved from 78 to 91 (p=0.04). Radiologically, the CEA, Tonnis angle, FHC, AA and AI improved significantly but there were no significant improvement in the DBSPFH in the two groups. In addition, there was no significant clinical or radiological difference between the two groups. CONCLUSION: Periacetabular osteotomy is recommended for dysplastic hips with deformed femoral head. A concomitant femoral osteotomy should be considered in hips with a severely deformed femoral head.

Incidence of Acetabular Retroversion in Dysplastic Hip / 대한정형외과학회잡지

PURPOSE: This study analysed the incidence and the degree of an acetabular retroversion in a dysplastic hip. MATERIALS AND METHODS: 28 cases of dysplastic hips, in whom the CE angle was <20 degrees, and 20 cases of control group with a normal CE angle were enrolled in this study. Four cuts among the CT images (most superior cut of the femoral head, middle cut of the proximal half, middle portion, and middle cut of the distal half of the femoral head) were used to measure the acetabular anteversion. RESULTS: In the control group, anteversion of four cuts (form the cranial to caudal) were observed with an average of 4.1, 10.3, 16.5, 19.7degrees, and there was one case with a retroversion. In the dysplastic hips, the average anteversion angles were 4.4, 11.0, 17.9, 20.8degrees, and 9 cases with retroversion were discovered. In all cases showing retroversion, an overlapping of the acetabular anterior and posterior wall (cross-over sign) was observed on the simple pelvis AP radiography. CONCLUSION: There was a 32% incidence of acetabular retroversion, which was much higher than the control group (p<0.05). Therefore, in order to prevent an over-correction of the retroversion, which may cause impingement, the presence and the amount of retroversion must be recognized using CT before performing a periacetabular osteotomy.

The Shelf Procedure for the Dysplastic Hip in Poliomyelitis Patients / 대한정형외과학회잡지

The hip joint subluxation and dislocation due to poliomyelitis worsen the limping and caused the painful hip. Shelf procedure has been described as a safe, conservative and reliable approach to the of a dysplastic acetabulum. We performed shelf procedure for the dysplastic hip in poliomyelitis in thirteen patients since May, 1990. The age at operation was 21 to 38 years old and three of them were male and ten were female. All the patients were followed up for average 2.5 years(1-4. 5yrs). The hip joints showed better stability after shel'f procedure and less limping. There was no complication except one redislocation.

Bipolar Endoprosthesis with Acetabular Bone Graft in Dysplasia of the Hip: Report of eight cases / 대한정형외과학회잡지

Total hip replacement arthroplasty is one of the excellent treatment modalities of adult hip joint disease. But those who have severe dysplasia of the hip usually require augmentation of acetabular bone stock in order to carry out the total hip replacement arthroplasty and technical difficulties are often encountered in estabilishing an adequate acetabular bed for the prosthesis. From July 1988 to January 1990, we attempted to treat patients of dysplastic hip by bipolar endoprosthesis with acetabular bone graft using femoral head autograft in 8 patients and then reviewed these cases. The mean follow up period was 3 years ranging from 1 year and 10 months to 3 years and 10 months. The results obtained were as follows : 1. All the bone grafts were united well(average bone union time : 5.3 months). 2. According to Gerber and Harris' classification, there was no evidence of resorption of the graft in 1 case, and there were minor resorption in 5 cases, moderate resorption in 1 case, and major resorption in 1 case. 3. The average preoperative Harris hip score was 47.5 points and the average Harris hip score at last follow up was 79.0 points. 4. Because of the high rate of graft resorption and component migration, bipolar endoprosthesis with acetabular bone graft was not to be recommended as a reconstructive procedure for the dysplastic hip which have segmental bony deficiency in the acetabulum.