Preoperative Rather Than Postoperative Intra-Articular Cartilage Degeneration Affects Long-Term Survivorship of Periacetabular Osteotomy.

PURPOSE: To determine whether intra-articular lesions changed in short-term follow-up after periacetabular osteotomy (PAO) and whether the intra-articular lesion changes impacted the long-term survivorship of PAO. METHODS: We reviewed patients with hip dysplasia who underwent PAO with arthroscopic observation between 1990 and 2001. Patients who underwent second-look arthroscopy were included. The correlations between the intra-articular lesion changes and the long-term outcome of PAO were analyzed for patients with >10 years of follow-up. The possible risk factors included demographic factors (age, sex, and body mass index), radiographic factors (Tönnis grade, lateral center-edge angle, Tönnis angle, acetabular head index, crossover sign, posterior wall sign, and joint congruity), and arthroscopic findings (full-thickness lesions at the time of PAO and lesions changes at the time of second-look arthroscopy). RESULTS: A total of 64 patients (72 hips) were studied. Second-look arthroscopy was performed at a median of 1.4 years after PAO. Intra-articular lesions were observed in 93% in the acetabulum, 81% in the femoral head, and 97% in the labrum, respectively. These lesions unchanged in 74% in the acetabulum, 76% in the femoral head, and 79% in the labrum, respectively. Cartilage repair was observed in the acetabulum and the femoral head in 24% and 17% of hips, respectively. Labral repair occurred in 10%. Intra-articular lesion changes were not a predictor of failure. Multivariate analysis identified International Cartilage Repair Society grade 4 lesion in the femoral head as an independent risk factor for failure. CONCLUSIONS: Our results suggest that PAO prevents further deterioration in mild cartilage lesions and results in cartilage repair in some cases with advanced cartilage degenerations in the short term. However, these postoperative changes were not associated with long-term survivorship. Thus, appropriate surgical indications based on the preoperative intra-articular cartilage degeneration is paramount to achieving long-term success in PAO. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Arthroscopic validation of radiographic minimum joint space width associated with the subchondral bone exposure in symptomatic hip dysplasia.

OBJECTIVE: The purpose of this study was to clarify the minimum joint space width (MJSW) that leads to subchondral bone exposure (SBE) in patients with hip dysplasia. METHODS: We included 82 subjects (86 hips) who had hip dysplasia with center-edge angle less than 20° and who underwent periacetabular osteotomy combined with hip arthroscopy. The acetabular and femoral cartilages were divided into three regions: anterosuperior, superior, and posterosuperior; for each region, we analyzed the correlation between the incidence of SBE and the MJSW measured on plain radiographs. The disease stage was defined according to the Kellgren and Lawrence grades (KL grade). RESULTS: SBE was found in 51 hips (59.3%) in total, involved the acetabulum in 49 hips (57.0%), and involved the femoral head in 26 hips (30.2%). SBE was more frequent in the acetabulum, with the highest incidence in the anterosuperior region, followed by the superior region. SBE was present in six hips (22.2%), 17 hips (56.7%), and 28 hips (96.5%), at KL-1, KL-2, and KL-3, respectively. MJSW of hips with SBE was significantly smaller than those without SBE (2.3 vs 4.0 mm, p < 0.001), and the cut-off value for MJSW that led to SBE was 3.7 mm (sensitivity: 0.902, 1 - specificity: 0.343). SBE was present in 23.3% in patients with MJSW ≥3.7 mm, whereas 76.7% in those <3.7 mm. CONCLUSIONS: Cartilage degeneration is more advanced than would be predicted on plain radiographs. The cut-off value of MJSW for SBE was 3.7 mm in patients with symptomatic hip dysplasia.

Factors Associated With Severity of Intra-articular Lesions in Patients With Severe Hip Dysplasia.

PURPOSE: To identify demographic and morphologic factors associated with the severity of intra-articular lesions in patients with severe hip dysplasia. METHODS: One hundred twenty-one patients (134 hips) with symptomatic hip dysplasia were retrospectively reviewed. The cartilage and labral lesions were scored according to the Outerbridge and the original classification systems, respectively. The association of the cartilage and labrum scores with patient demographics (age, gender, body mass index, bilateral hip dysplasia, and treatment history for developmental hip dislocation) and morphologic factors (the lateral center-edge angle, Sharp angle, acetabular index, acetabular head index, acetabular depth ratio, Shenton line disruption, roundness index of the femoral head, and femoral neck shaft angle) were determined using a multiple linear regression analysis. RESULTS: The cartilage and labral scores were significantly associated with radiographic osteoarthritis; however, these scores showed wide distribution among hips with equivalent degrees of radiographic osteoarthritis. Age (38.4 ± 12.8 years) (P < .001), lateral center-edge angle (0.2 ± 9.0°) (P = .014), acetabular head index (54.4 ± 9.1%) (P = .001), and the roundness index of the femoral head (55.6 ± 4.6%) (P = .022) were identified as independent factors associated with the cartilage score. Age (P < .001), having a medical history of developmental hip dislocation (P = .002), acetabular index (27.8 ± 6.8°) (P = .011), and the roundness index of the femoral head (P = .022) were identified as independent factors associated with the labral score. CONCLUSIONS: Our findings suggest that the morphologic factors responsible for severe intra-articular lesions differ for cartilage degeneration and labral tears in patients with severe hip dysplasia. Decreased acetabular coverage of the femoral head was responsible for cartilage degeneration severity, whereas an increased acetabular index was responsible for labral tear severity. LEVEL OF EVIDENCE: Level III, diagnostic study.

A Gustilo type IIIB open forearm fracture treated by negative pressure wound therapy and locking compression plates: a case report.

A 91-year-old female sustained injuries to her left forearm while walking across a crosswalk. X-rays showed left radial shaft and ulna shaft fractures, and the injury was a type IIIB open fracture. On the day of admission, irrigation and debridement of the open wound, and temporary fixation of the radius and ulna using an external fixator and a Kirschner wire were peformed. Six days after the surgery, we used negative pressure wound therapy (NPWT) using the V.A.C.ATS system for the open wound. Thirteen days after the first surgery, definitive fixation was performed by using locking compression plates, and full thickness skin grafting was undertaken for the open wound. NPWT is a treatment that accelerates the wound healing process through the delivery of continuous subatmospheric pressure within a closed environment. In our case, we could reduce the healing period of the soft tissue and could convert to the definitive fixation in a timely fashion. NPWT is thought to be a useful adjunct in the management of the soft tissues of open fractures.

Transposition osteotomy of the acetabulum for advanced-stage osteoarthritis of the hips.

BACKGROUND: Transposition osteotomy of the acetabulum (TOA) was the first periacetabular osteotomy in which the acetabulum was transposed with articular cartilage. TOA improves coverage of the femoral head and joint congruity. The purpose of this study was to investigate whether TOA is an appropriate option for treating osteoarthritis of the hips at the advanced stage by comparing it with matched control hips at the early stage. METHODS: Between 1998 and 2001, TOA was performed in 104 hips of 98 patients. Altogether, 16 of 17 hips (94%) with osteoarthritis at the advanced stage were examined and compared with 37 matched control hips at the early stage. The mean age at the operation was 48 years (38-56 years), and the mean follow-up period was 88 months (65-107 months). RESULTS: TOA corrected the acetabular dysplasia and significantly improved containment of the femoral head. Clinical scores were also significantly improved in both groups. In the advanced osteoarthritis cases, there was a tendency for abduction congruity before transposition osteotomy of the acetabulum to reflect the clinical outcome. CONCLUSIONS: TOA is a promising treatment option for advanced osteoarthritis of the hips as well as for patients at an early stage when preoperative radiographs show good congruity or containment of the joint.

Constitutively activated ALK2 and increased SMAD1/5 cooperatively induce bone morphogenetic protein signaling in fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by congenital malformation of the great toes and by progressive heterotopic bone formation in muscle tissue. Recently, a mutation involving a single amino acid substitution in a bone morphogenetic protein (BMP) type I receptor, ALK2, was identified in patients with FOP. We report here that the identical mutation, R206H, was observed in 19 Japanese patients with sporadic FOP. This mutant receptor, ALK2(R206H), activates BMP signaling without ligand binding. Moreover, expression of Smad1 and Smad5 was up-regulated in response to muscular injury. ALK2(R206H) with Smad1 or Smad5 induced osteoblastic differentiation that could be inhibited by Smad7 or dorsomorphin. Taken together, these findings suggest that the heterotopic bone formation in FOP may be induced by a constitutively activated BMP receptor signaling through Smad1 or Smad5. Gene transfer of Smad7 or inhibition of type I receptors with dorsomorphin may represent strategies for blocking the activity induced by ALK2(R206H) in FOP.

Intraarticular findings in symptomatic developmental dysplasia of the hip.

BACKGROUND: The purpose of this study was to examine intraarticular pathology in patients younger than 20 years with symptomatic developmental dysplasia of the hip. METHODS: We performed hip arthroscopy during corrective osteotomy in 23 hips in 22 patients. All patients were female, and the average age at operation was 16.4 years. Eighteen hips were in a prearthritic stage, and 5 hips were in an early stage. The presence and location of cartilage degeneration and labral tears were evaluated. Second-look arthroscopy was performed in 13 hips in 12 patients. RESULTS: Fourteen hips (77.8%) in the prearthritic stage had cartilage degeneration. Cartilage lesions were more frequent in the acetabulum than in the femoral head (72.2% vs 16.7%). Sixty-one percent of acetabular lesions were located at the anterosuperior area. Labral tears were observed in 77.8% of hips in prearthritic stages located at the anterosuperior (72.2%) and superior (44.4%) areas. The degree of cartilage and labral lesions in the early stage was more severe than in the prearthritic stage. On second-look arthroscopy, there were no changes in the state of the cartilage and labrum in the majority (84.6%) of hips. CONCLUSIONS: The incidence of intraarticular lesions in developmental dysplasia of the hip was high, even in the prearthritic stage. These lesions tended to originate in the anterosuperior area of the acetabulum and were generally progressive.

Improved total synthesis of the potent HDAC inhibitor FK228 (FR-901228).

A scaleable synthesis of the potent histone deacetylase (HDAC) inhibitor FK228 is described. A reliable strategy for preparing the key beta-hydroxy mercapto heptenoic acid partner was accomplished in nine steps and 13% overall yield. A Noyori asymmetric hydrogen-transfer reaction established the hydroxyl stereochemistry in >99:1 er via the reduction of a propargylic ketone.

An external snapping hip caused by osteochondroma of the proximal femur.

We herein report the findings of a 17-year-old boy who suffered from a right external snapping hip, which was caused by an osteochondroma of the proximal femur. He has been asymptomatic since the excision of the tumor. This case shows a rare etiology in which an external snapping hip occurred between the iliotibal band and the osteochondroma.

Correlation between center-edge angle and acetabulum-head index in developmental dysplasia of the hip with avascular necrosis of the femoral head.

In order to clarify the relationship between the center-edge angle and the acetabulum-head index, we reviewed 97 hips in 86 patients suffering from developmental dysplasia of the hip. We measured the center edge angle and the acetabulum-head index, and evaluated avascular necrosis of the femoral head according to Kalamchi classification. The center-edge angle correlated highly with the acetabulum-head index in non-avascular necrosis, and in Kalamchi groups I and II, but not in Kalamchi groups III and IV. Because of difficulties in measurement, it is possible that the center-edge angle does not precisely indicate acetabular coverage of developmental dysplasia of the hip with avascular necrosis.

Epidemiology and demographics of slipped capital femoral epiphysis in Japan: a multicenter study by the Japanese Paediatric Orthopaedic Association.

Anationwide survey of the epidemiology and demographics of slipped capital femoral epiphysis (SCFE) was carried out using questionnaires to investigate the incidence, clinical characteristics, and frequently used treatment procedures in Japan. Inquiries were sent to 2040 of the leading hospitals nationwide. Data were collected for the period between January 1997 and December 1999. Inquiries included onset age, sex, past medical history, type of slip, height, weight, and treatment procedure. Altogether, 314 cases were reported (237 boys, 77 girls) from 131 hospitals. The average annual incidence was estimated to be at least 2.22 for boys and 0.76 for girls for every 100 000 in the age group of 10- to 14-year-olds. These estimations are five times higher than the 1976 statistics from the eastern half of Japan. The average onset age was 11 years 10 months in boys and 11 years 5 months in girls. The most common treatment was surgery including in situ fixation (61.4%), osteotomies (25.9%), fixation after manual reduction (11.9%), and skeletal traction (0.9%). All patients except two were treated surgically. We concluded that SCFE has markedly increased during the last 25 years in Japan, and therefore further study of SCFE is needed to understand this disorder.

Brodie's abscess of the proximal femoral epiphysis in an adult woman with systemic lupus erythematosus.

We report an unusual case of pathologically proved femoral head Brodie's abscess mimicking avascular necrosis of bone in a 51-year-old woman with a 2-year history of corticosteroid treatment for systemic lupus erythematosus. On plain radiographs, a rounded lucency and thin sclerotic margins together with subchondral collapse and a lytic region were observed in the femoral head. The histopathologic examination revealed a central abscess formation surrounded by fibrous tissue with the aggregation of neutrophils and plasma cells. To our knowledge, this is the first case report describing a Brodie's abscess which had developed within the proximal femoral epiphysis in an adult.

Relationship between the maximum flexion-internal rotation test and the torn acetabular labrum of a dysplastic hip.

To determine the relationship between pain at flexion-rotation and the status of a labral tear in patients with dysplastic hips, physical examination maneuvers and hip arthroscopy were carried out in 59 patients with dysplastic osteoarthritis (5 men and 54 women; mean age, 41 years; range, 16 to 64 years). Between January 1998 and June 2000, these patients underwent 60 hip arthroscopies at Kyushu University Hospital. All hip joints arthroscoped demonstrated incomplete or complete detaching tears of the acetabular labrum in one portion of the weight-bearing area. Twenty-three patients (39%) experienced pain during the maximum flexion-internal rotation test; 16 patients (27%) showed a positive result for the maximum flexion-external rotation test. There was no statistically significant relationship between the results of the maximum flexion-external rotation test and the arthroscopic findings of labral tears. A positive maximum flexion-internal rotation test result, however, correlated well with incomplete detaching tears in the posterosuperior portion of the acetabular labrum. In contrast, a complete detaching tear of the posterosuperior labrum was associated with a negative maximum flexion-internal rotation test result. The maximum flexion-internal rotation test is useful for assessing the magnitude of a labral tear in the posterosuperior portion of the acetabular labrum in dysplastic hips.