Femoroacetabular Impingement and Acetabular Labral Tears - Part 2: Clinical Diagnosis, Physical Examination and Imaging / Impacto femoroacetabular e lesão do lábio acetabular - Parte 2: Diagnóstico clínico, exame físico e imagiologia

Abstract The clinical diagnosis of femoral acetabular impingement (FAI) continues to evolve as the understanding of normal and pathological hips progresses. Femoral acetabular impingement is currently defined as a syndrome in which the diagnosis consists of the combination of a previously-obtained comprehensive clinical history, followed by a consistent and standardized physical examination with specific orthopedic maneuvers. Additionally, radiographic and tomographic examinations are used for the morphological evaluation of the hip, and to ascertain the existence of sequelae of childhood hip diseases and the presence of osteoarthritis. The understanding of the femoral and acetabular morphologies and versions associated with images of labral and osteochondral lesions obtained through magnetic resonance imaging (MRI) contributes to the confirmation of this syndrome in symptomatic patients, and helps in the exclusion of differential diagnoses such as iliopsoas tendon snaps, subspine impingement, ischiofemoral impingement, and other hip joint pathologies.

Resumo O diagnóstico clínico do impacto femoroacetabular continua a evoluir conforme o entendimento dos quadris normal e patológico progride. Impacto femoroacetabular é atualmente definido como uma síndrome na qual o diagnóstico se baseia no somatório de uma história clínica abrangente obtida previamente, seguida de um exame físico coerente e padronizado com manobras ortopédicas específicas. Além disso, exames radiográficos e tomográficos são usados para a avaliação morfológica do quadril, e para verificar a existência de sequelas de doenças do quadril da infância e a presença de osteoartrose. O entendimento da morfologia e versão femoral e acetabular associado às imagens de lesões labrais e osteocondrais obtidas com a ressonância magnética contribuem para a confirmação da síndrome nos pacientes sintomáticos, além de auxiliar na exclusão de diagnósticos diferenciais, como ressalto do tendão do músculo iliopsoas, impacto subespinhal, impacto isquiofemoral, e outras patologias da articulação do quadril.

Comparative Evaluation of Cross-table and Ducroquet Incidences for Measurement of the Hip Alpha Angle / Avaliação comparativa das incidências radiográficas cross-table e Ducroquet para a medição do ângulo alfa do quadril

Abstract Objective The purpose of the present paper is to compare the equivalence of the measurement of the alpha angle using the Ducroquet and cross-table lateral views. Methods We have recruited 90 patients, resulting in 95 hips. We have standardized the realization of the radiographic views. The incidence of the lateral cross-table views were takenwith 15° of internal rotation with the patient in the supine position, and the incidence of the Ducroquet viewswas standardizedwith the patient in the supine position,with 90° of flexion and 45° of abduction of the hip. The alpha angle wasmeasured in both lateral views, by two musculoskeletal radiologists. The measurements were performed in 2 different times: an initial evaluation andanother 4weeks afterwards. The t Student test was usedand calculated the intraclass correlation coefficient (ICC). Results We have found a good intraobserver correlation for both views in different times; there was no statistically significant difference between the measurements performed by the two views. However, the interobserver correlation was low. Conclusion In conclusion, the Ducroquet profile view is a good choice for the α angle measurement and can be used instead of the cross-table view.

Resumo Objetivo O objetivo do presente trabalho é comparar a equivalência da medida do ângulo alfa do quadril usando as incidências laterais de Ducroquet e de cross-table. Método Estudamos 90 pacientes, com um total de 95 quadris, e padronizamos a realização das radiografias conhecidas como "Ducroquet" e "cross-table." A incidência de perfil de cross-table foi realizada em 15° de rotação interna com o paciente em posição supina, e a incidência de perfil de Ducroquet foi padronizada com o paciente posicionado em decúbito dorsal, em 90° de flexão e 45° de abdução do quadril. O ângulo alfa foi medido em ambas as radiografias de perfil, por dois radiologistas especializados em afecções musculoesqueléticas. As medidas foram realizadas em 2 épocas diferentes: uma avaliação inicial e outra após 4 semanas. O teste t de Student foi utilizado e calculou o coeficiente de correlação intraclasse (CCI). Resultados Encontramos boa correlação intraobservador para ambas as incidências radiográficas em diferentes momentos. Não houve diferença estatisticamente significante entre as medidas feitas pelas duas visualizações. No entanto, a correlação interobservadores foi baixa. Conclusão A incidência radiográfica de perfil de Ducroquet é uma boa opção para a medida do ângulo alfa e pode ser usada ao invés da incidência radiográfica de perfil cross-table.

Tuberculosis osteoarticular y osificaciones heterotópicas: reporte de un caso / Heterotopic ossification and osteoarticular tuberculosis: case report

La osificación heterotópica es una condición patológica que conduce al desarrollo de hueso en el tejido blando. En la piel se denomina osteoma cutis. Estas lesiones se clasifican en primarias o secundarias. Las causas secundarias constituyen el 85% y son consecuencia de enfermedades inflamatorias, infecciones, tumores, traumatismos, lesiones de médula espinal y cirugías. Si bien la osificación heterotópica es benigna e infrecuente, puede ser una enfermedad debilitante que, asociada a dolor y rigidez, provoque mayor comorbilidad en relación con la enfermedad que la desencadenó. Comunicamos el caso de un paciente que padeció osteoma cutis asociado a tuberculosis osteoarticular

Heterotopic ossification is a patologic condition that leads bone formation in soft tissue. In particular, osteoma curtis, which can be primary or secundary, occurs when ossification if found in the skin. Secondary lessions account 85% of the cases described and they are by inflammatory diseases, infections, tumors, traumas, spinal cord lesions and surgeries. Whereas heterotopic ossification is benign and rare, it may result in wasting sickness that in combination with pain and stiffness, adding comorbidity to the disease that triggers. We report here a patient suffering osteomas cutis and osteoarticular tuberculosis. (AU)

Total Hip Arthroplasty around the Inception of the Interface Bioactive Bone Cement Technique

BACKGROUND: To augment cement-bone fixation, Dr. Hironobu Oonishi attempted additional physicochemical bonding through interposition of osteoconductive crystal hydroxyapatite (HA) granules at the cement-bone interface in 1982. He first used the interface bioactive bone cement (IBBC) technique in 12 selected patients (12 hips) in 1982 (first stage) and followed them for 2 years. In 1985, the technique was applied in 25 total hip arthroplasty (THA) patients (second stage) and the effects were investigated by comparing the side with the IBBC technique and the other side without the IBBC technique. He has employed this technique in all THA patients since 1987 (third stage). METHODS: In the IBBC technique, HA granules (2 to 3 g) were smeared on the bone surface just before the acetabular and femoral components were cemented. In the first stage, 12 hips were operated using the IBBC technique in 1982. In the second stage, THA was performed without the IBBC technique on one side and with the IBBC technique on the other side within 1 year in 25 patients. In the third stage, THA was performed with the IBBC technique in 285 hips in 1987. RESULTS: In the first stage patients, implant loosening was not detected at 30 years after operation. In the second stage patients, revision was required in 7 hips without the IBBC technique due to cup loosening (5 hips) and stem loosening (2 hips), whereas no hip was revised after THA with the IBBC technique at 26 years after operation. In the third stage patients, the incidence of radiolucent lines and osteolysis was very few at 25 years after operation. CONCLUSIONS: The long-term follow-up of THA performed around the inception of the IBBC technique has revealed low incidences of radiolucent lines, osteolysis, and revision surgery.

Miositis osificante traumática de cadera bilateral / Bilateral hip traumatic myositis ossificans

RESUMEN La miositis osificante traumática es un proceso proliferativo, benigno, donde ocurre una metaplasia de tejido blando a hueso. El objetivo de este trabajo es presentar el caso de un paciente masculino de 17 años de edad con diagnóstico de miositis osificante postraumática en ambas caderas. A pesar de la rareza de dicha patología, su frecuencia puede ir creciendo debido al aumento de traumatismos de alta energía por accidentes de tránsito. Presentamos además una revisión bibliográfica sobre este tópico.

ABSTRACT Traumatic myositis ossificans is a proliferative benign process, where a metaplasia of soft tissue to bone occurs. The aim of this paper is to present the case of a 17-year-old male patient, diagnosed with traumatic myositis ossificans in both hips. Despite the rarity of this disease, its frecuency may increasedue to the increase in high energy trauma secondary to traffic accidents. We also present the literature review on this topic.

Xantoma intraóseo pelviano: reporte de un caso y revisión de la literatura / Pelvic intraosseous xanthoma: a case report and literature review

El xantoma intraóseo (XIO) es un tumor óseo benigno extremadamente raro. En la histología se caracteriza por presentar macrófagos mononucleares, abundantes células espumosas y células gigantes multinucleadas. Puede aparecer asociado a otras enfermedades (XIO secundario), principalmente a desórdenes lipídicos, o en forma aislada (XIO primario). Los XIO son lesiones líticas expansivas que a menudo se encuentran en pacientes con condiciones hiperlipidémicas. En la mayoría de los casos la evaluación inicial se realiza con radiografía, aunque otros procedimientos pueden ser necesarios para confirmar el diagnóstico. Se presenta el caso de un hombre de 48 años que consultó por lumbalgia con irradiación al miembro inferior derecho e impotencia funcional de 3 meses de evolución. Tenía hallazgos imagenológicos de XIO en el hueso ilíaco derecho, sin hiperlipidemia o lesiones preexistentes. Se llevó a cabo la extirpación total del tumor y el posterior estudio histopatológico de la pieza operatoria confirmó el diagnóstico. El tratamiento resultó exitoso. El objetivo de este artículo es describir los hallazgos clínicos e imagenológicos (radiografía, resonancia magnética, tomografía computada y medicina nuclear) de un XIO primario y su tratamiento. Además, realizamos una breve revisión de la literatura.

Abstract Intraosseous xanthoma is an extremely rare benign bone tumor. Histology shows mononuclear macrophages, abundant foam cells and multinucleated giant cells. The intraosseous xanthoma may appear associated with other diseases (secondary intraosseous xanthoma), mainly lipid disorders or without an underlying lipid disorder (primary intraosseous xanthoma). The intraosseous xanthoma is a lytic, expansive tumor, often seen in patients with hyperlipidemic conditions. In most cases, the initial evaluation is performed with X-ray, although other procedures may be necessary to confirm the diagnosis. We report the case of a man aged 48, who consulted for back pain radiating to the right leg and functional disability 3 months duration, with imaging findings in the right iliac XIO in the absence of pre-existing injuries or hyperlipidemic conditions, so surgery for total removal of the tumor was performed with histological examination of the surgical specimen, confirming the preoperative diagnosis of XIO. Such treatment resulted curative. The aim of this article is to describe the clinical, imaging findings (RX, MRI, CT, nuclear medicine) and the course of treatment of a committing the iliac primary intraosseous xanthoma a and a normolipidemic patient brief review of the literature.

Caracterización matemática de la enfermedad de Legg-Calvé-Perthes mediante geometría fractal / Caractérisation mathématique de la maladie de Legg-Calvé-Perthes par géométrie fractale / Mathematical characterization of Legg-Calve-Perthes disease through the fractal geometry

Introducción: la geometría fractal permite la medición objetiva de estructuras irregulares tales como las del cuerpo humano. Esta geometría se aplicó al desarrollo de una nueva metodología de caracterización de imágenes radiográficas frontales para la evaluación de enfermedad de Legg-Calve-Perthes. Objetivos: desarrollar una nueva metodología de caracterización matemática, objetiva y reproducible de la radiografía diagnóstica de Perthes, a partir de las imágenes radiográficas frontales obtenidas de la articulación de la cadera, mediante geometría fractal. Métodos: estudio exploratorio descriptivo en el que se evaluó la morfología de la cabeza del fémur mediante la dimensión fractal obtenida por el método de Box-Counting, aplicada a 20 placas radiográficas con enfermedad de Legg-Calve-Perthes, estableciendo una nueva medida morfométrica objetiva para esta enfermedad. Resultados: se obtuvieron nuevas medidas morfométricas objetivas y reproducibles de imágenes radiográficas frontales para la evaluación de enfermedad de Perthes a partir de dimensiones fractales. Conclusiones: la geometría fractal permite la caracterización matemática objetiva y reproducible de imágenes radiográficas frontales de la cadera para la evaluación de enfermedad de Perthes(AU)

Introduction: fractal geometry allows the objective measurement of irregular structures such as those of the human body. This geometry is applied to the development of a new methodology for characterization of front radiographic images for the evaluation of Legg-Calve-Perthes disease. Objectives: to develop a new methodology for the mathematical, objective and reproducible characterization of diagnostic radiography of Perthes disease from the front radiographic images of the hip joint by using the fractal geometry. Methods: descriptive and exploratory study that evaluated the morphology of the femur head through the fractal dimension estimated by the Box-Counting method, which was then applied to 20 radiographies of Legg-Calve-Perthes disease, thus establishing a new objective morphometric measure for this disease. Results: new objective reproducible morphometric measures of front radiographic images were reached to evaluate Perthes disease, taking fractual dimensions as a basis. Conclusions: fractal geometry allows the mathematical, objective and reproducible characterization of front radiographic images of the hip for the final evaluation of Perthes disease(AU)

Introduction: la géométrie fractale permet de mesurer objectivement les structures irrégulières telles que celles du corps humain. Cette géométrie a été appliquée au développement d'une nouvelle méthodologie de caractérisation des images radiographiques frontales pour l'évaluation de la maladie de Legg-Calve-Perthes. Objectifs: le but de cette étude est de développer une nouvelle méthodologie de caractérisation mathématique, objective et reproductible de la radiographie diagnostique de Perthes, à partir des images radiographiques frontales obtenues de l'articulation de la hanche par géométrie fractale. Méthodes: une étude descriptive préliminaire a été réalisée afin d'évaluer la morphologie de la tête fémorale par mesure de la dimension fractale (méthode de box-counting), appliquée à 20 plaques radiographiques de la maladie de Legg-Calve-Perthes, en établissant une nouvelle mesure morpho-métrique objective pour cette maladie. Résultats: on a obtenue de nouvelles mesures morpho-métriques objectives et reproductibles des images radiographiques frontales pour l'évaluation de la maladie de Legg-Calve-Perthes à partir des dimensions fractales. Conclusions: la géométrie fractale permet une caractérisation mathématique objective et reproductible des images radiographiques frontales de la hanche pour l'évaluation de cette maladie(AU)

New Reference Data on Bone Mineral Density and the Prevalence of Osteoporosis in Korean Adults Aged 50 Years or Older: The Korea National Health and Nutrition Examination Survey 2008-2010

This cross-sectional study was performed to investigate the reference values for bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) and the prevalence of osteoporosis in the Korean population by applying domestic reference data. In total, 25,043 Korean adults > or =20 yr of age (11,792 men and 13,251 women) participated in the study. The BMDs of the total hip, femoral neck, and lumbar spine were measured by DXA (Discovery-W, Hologic Inc.), and subjects with a BMD - 2.5 standard deviations or lower than the mean BMD for young adults (20-29 yr old) were considered to have osteoporosis. When applying the new reference values determined in this study from Korean subjects, the overall prevalence of osteoporosis increased in men aged > or =50 yr compared with that provided by the DXA manufacturer from Japanese subjects (12.2% vs. 7.8%, P or =50 yr (32.9% vs. 38.7%, P<0.001). According to the findings of this study, use of the reference values provided by the DXA manufacturer has resulted in the underdiagnosis of osteoporosis in Korean men and the overdiagnosis of osteoporosis in Korean women. Our data will serve as valuable reference standards for the diagnosis and management for osteoporosis in the Korean population.

Cementless Total Hip Arthroplasty for Patients with Crowe Type III or IV Developmental Dysplasia of the Hip: Two-Stage Total Hip Arthroplasty Following Skeletal Traction after Soft Tissue Release for Irreducible Hips

BACKGROUND: Total hip arthroplasty (THA) for severe developmental dysplasia of the hip (DDH) is a technically demanding procedure for arthroplasty surgeons, and it is often difficult to reduce the hip joint without soft tissue release due to severe flexion contracture. We performed two-stage THAs in irreducible hips with expected lengthening of the affected limb after THA of over 2.5 cm or with flexion contractures of greater than 30 degrees in order to place the acetabular cup in the true acetabulum and to prevent neurologic deficits associated with acute elongation of the limb. The purpose of this study is to evaluate the outcomes of cementless THA in patients with severe DDH with a special focus on the results of two-stage THA. METHODS: Retrospective clinical and radiological evaluations were done on 17 patients with Crowe type III or IV developmental DDH treated by THA. There were 14 women and 3 men with a mean age of 52.3 years. Follow-ups averaged 52 months. Six cases were treated with two-stage THA followed by surgical hip liberalization and skeletal traction for 2 weeks. RESULTS: The mean Harris hip score improved from 40.9 to 89.1, and mean leg length discrepancy (LLD) in 13 unilateral cases was reduced from 2.95 to 0.8 cm. In the patients who underwent two-stage surgery, no nerve palsy was observed, and the single one-stage patient with incomplete peroneal nerve palsy recovered fully 4 weeks postoperatively. CONCLUSIONS: The short-term clinical and radiographic outcomes of primary cementless THA for patients with Crowe type III or IV DDH were encouraging. Two-stage THA followed by skeletal traction after soft tissue release could provide alternative solutions to the minimization of limb shortenings or LLD without neurologic deficits in highly selected patients.

Differences in Bone Mineral Density between the Right and Left Hips in Postmenopausal Women

Bone mineral density (BMD) using dual energy radiography absorptiometry are commonly used for the diagnosis of osteoporosis. It is usually measured at the spine and also at one hip joint. Controversy still exists regarding the use of bilateral hip scanning. We analyzed the difference of BMD at bilateral hips in 384 postmenopausal women, retrospectively. The concordance and discordance rates of the lowest T-score and BMD between both hips were evaluated. The BMDs of the femoral neck and trochanter were significantly different between both hips (P < 0.05). There were also discrepancies between the lowest T-scores of both hips (P < 0.05). The discordance rates were about 30%. Due to significant differences in BMD between both hips at the femoral neck and trochanter and high discordance rate, bilateral hip measurements using DEXA are recommended to avoid underestimating osteoporosis.

Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

BACKGROUND: Bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients is a viable option that can prevent the complications of an open reduction, such as nonunion and metal failure. This study evaluated the clinicoradiological results of cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients. METHODS: Forty hips were followed for more than 2 years after cementless bipolar hemiarthroplasty using a Porocoat(R) AML Hip System. The mean age was 78.8 years and the mean follow-up period was 40.5 months. The Harris hip score and postoperative hip pain were analyzed clinically. The radiological results were assessed using a range of indices. RESULTS: At the last follow-up, the mean Harris hip score was 80.6 points. There were one case of hip pain and one case of thigh pain. Twenty-four cases (60%) showed no decrease in ambulation capacity postoperatively. Radiologically, there were 23 cases (57.5%) of fixation by bone ingrowth and 17 cases (42.5%) of stable fibrous fixation. There were no cases of osteolysis. Eleven cases (27.5%) of new bone formation were found around the stem. All stems were stable without significant changes in alignment or progressive subsidence. CONCLUSIONS: The short-term results of cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures were satisfactory.

Charnley Ogee-flanged cup in primary total hip arthroplasty for acetabular dysplasia

Ogee-flanged socket was introduced by Sir John Charnley for use in low-friction hip arthroplasty. The results of 18 primary total hip arthroplasties performed in 17 patients with moderate congenital acetabular dysplasia were reviewed. Charnley total hip prosthesis including a non-modular femoral stem and an ogee-flanged acetabular socket were used in all patients. The average duration of follow up after arthroplasty was 5.3 years [range 4-7 years]. All patients were evaluated using a modified Harris hip scoring system and a standardized anteroposterior pelvis radiograph for hips. Differences between the preoperative and postoperative [last evaluation] scores were assessed with the student's t-test and Chi-square test. The mean overall modified Harris hip score was improved from 48 points preoperatively to 89 points at the last follow up evaluation, this improvement was significant. A low percentage of radiological demarcation at the bone-cement interface around the acetabular sockets was observed in the immediate postoperative and the last follow up radiographs

Similarity of bone mass measurement among hip, spines and distal forearm.

From January-December 1995, bone mineral density (BMD) of lumbar spine, hip and distal forearm were studied in 325 healthy women visiting the menopause clinic, Chulalongkorn Hospital. This retrospective analysis was conducted to assess the correlation of BMD among various measurement sites. Bone mass measurement at hip and spine were performed utilizing dual energy X-ray absorptiometer (DEXA), Hologic QDR 2000 and at distal forearm by single energy X-ray absorptiometer (SEXA), Hologic DTX 100. By canoconical correlation, the results revealed a significant correlation of BMD of distal and ultra-distal part of forearm with various sites of hip (r = 0.602, p < 0.001). There was also significant correlation of distal and ultra-distal part of forearm with various sites of spines (r = 0.619, p < 0.001). Though there is some heterogeneity of bone mass density among different measurement sites, practically with this fairly good level of correlation, bone mass measurement of distal forearm might be used to predict the BMD of hip and spine in Thai women. The accuracy of predicting the BMD of hip and spine by BMD of distal forearm in the mass screening programme in Thailand is now going on. The results will be followed.

A ten years analysis of 500 intertrochantric fractures of the femur with impression to residual deformity and shortening.

A study of 500, cases with follow up period of 1 to 10 years were treated by conservative and operative means. The result of conservative treatment in type III and IV fractures were comparatively favourable with result of operative treatment in same grade of fractures. It can be concluded that if an anatomical reduction was achieved by proportioned vertical and horizontal traction forces and the reduction was monitored by periodic skiagram till sound clinical and reasonable radiological union, good functional end result could be obtained.

Evaluation of osteoporosis in patients with fracture neck of femur using conventional radiography.

Osteoporosis was assessed at the hip (Singh's index) and calcaneus (calcaneal index) using conventional radiography in 80 patients (31 men, 49 women) with fracture neck of femur. Forty four patients had intracapsular fracture neck of femur (ICFN), and 36 extracapsular fracture neck of femur (ECFN). Fractures occurred more with increasing age in both groups, with female preponderance in the older age group. Osteoporosis was more severe as age advanced. Singh's index decreased from 5.2 to 3 (ICFN), and from 4.1 to 2.65 (ECFN) with age. Calcaneal index decreased from 4.4 to 2.9 (ICFN) and from 4.1 to 2.6 (ECFN) with age. In summary degree of osteoporosis, assessed at the hip and calcaneus, increased with increasing age. Other recent studies have shown that calcaneal bone density is a valid method to predict future risk of hip fracture.

Does routine sonography of the neonate hips induce over treatment? A suggestion for a new treatment protocol of dysplastic hips

Two groups of dysplastic hips diagnosed by ultrasound were statistically assessed. The treatment protocol in group A was based only on ultrasound examination as advocated by Graf. Most dysplastic hips in group B [86.9%] were not treated and showed spontaneous maturation. In their series, there was evident difference in the behavior of clinically stable and unstable hips. Ultrasonic examination alone did not give a convincing high correlation with the final outcome of dysplastic hips in either group A [r = 0.37, r = 0.41] or group B [r = 0.36], whereas, the clinical assessment gave a fairly good correlation in group B [r = 0.61]. A combination of both ultrasound and clinical examination in describing protocols for treatment of dysplastic hips was suggested in a modified classification of hips at birth

Neglected antero-inferior dislocation of the hip

Unreduced antero-inferior dislocation of hip of weeks or months duration would be a highly unusual sight in an orthopaedic department in the developed world, but it may not be too uncommon in Pakistan. Two cases of neglected antero-inferior dislocation of the hip are presented and their management discussed