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Biomechanical analysis of the percutaneous compression plate and sliding hip screw in intracapsular hip fractures: experimental assessment using synthetic and cadaver bones.

We compared the mechanical behaviour of osteosynthesis with the percutaneous compression plate (PCCP) compared with the standard osteosynthesis sliding hip screw (SHS) in intracapsular hip fractures. We created 10 stable and 10 unstable intracapsular hip fractures in 20 synthetic femurs. Each fracture was fixed with either the SHS or PCCP. In six pairs of cadaver femurs, we created unstable intracapsular hip fractures and fixed them with the SHS or PCCP, at random on the left or right side. All femoral heads were exposed to a cyclic, combined axial and torque load until failure. In each group, the PCCP resisted a significantly higher load than the SHS. Clinical prospective studies are needed to confirm these in vitro findings that the PCCP is more stable than the SHS.

Biomechanical Phenomena↗

Development and testing of a specific quality-of-life questionnaire for knee and hip osteoarthritis: OAKHQOL (OsteoArthritis of Knee Hip Quality Of Life).

OBJECTIVE: To design a quality-of-life (QOL) instrument specific for patients with knee or hip osteoarthritis and to assess its validity and reproducibility. METHODS: One-on-one or group interviews were conducted with 79 patients and 28 healthcare professionals. Of the 80 potential items identified from the results, 46 were selected based on their content and were used to develop version 1 of the OsteoArthritis of Knee and Hip Quality of Life Scale (OAKHQOL). The psychometric characteristics of the scale were evaluated in patients who met Altman's criteria for knee or hip osteoarthritis. RESULTS: Based on the results of psychometric analyses in 263 patients, three items were excluded, leaving 43 items in the final version (2.3) of the OAKHQOL. Principal components analysis identified four domains: physical activities, mental health, social functioning, and social support. A pain domain was individualized later. Construct validity, reproducibility, and discriminating power of the domains were satisfactory. Standardized response means after joint replacement surgery were close to 1 for the pain and physical functioning domains and equal to 0.7 for the mental health domain, indicating good sensitivity to change. CONCLUSIONS: The OAKHQOL is the first QOL tool specifically dedicated to lower-limb osteoarthritis. It captures specific aspects of QOL in patients with knee or hip osteoarthritis and exhibits psychometric properties consistent with use in longitudinal studies.

Aged↗

Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips.

100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

Aged↗

Outcome after total hip arthroplasty: Part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.

The Swedish National Total Hip Arthroplasty register, which was started in 1979, is one of the oldest national quality registers in the world and consists of over 160,000 primary operations and 12,500 revisions. The register identifies risk factors for poor outcomes related to the patient, implant and surgical techniques. The end-point for failure, i.e., revision, does not provide information about the patient's general health after the primary procedure. The aim of this study was twofold. First, to validate the end-point for failure in the Swedish National Total Hip Arthroplasty register and secondly, to study general health after total hip arthroplasty. We validated the outcome of 1,056 primary THRs randomly selected from the Discharge register in Sweden by comparing the data to the Swedish THA register. These patients had answered the SF-36 and Nottingham Health Profile questionnaires. By comparing the clinical outcome, measured as general health, with the results obtained from the register, we evaluated the importance of the end-point for failure. We found that the end-point was useful, but further evaluations are desirable. Patients operated on with hip replacement do very well up to 10 years postoperatively and those who are not revised have good general health. The findings in this study can be used as a reference for others as it shows results from a national register, with a random selection of the study cohort.

Activities of Daily Living↗

Impacted morsellized bone grafting and cemented primary total hip arthroplasty for acetabular protrusion in patients with rheumatoid arthritis: an 8- to 18-year follow-up study of 36 hips.

Between 1979 and 1989, we performed 36 primary total hip replacements in 31 rheumatoid arthritis patients with protrusio acetabuli. The deficient acetabulum was reconstructed with autologous morsellized bone grafts from the femoral head. 3 patients were lost to follow-up. 12 patients (13 hips) died within 8 years postoperatively, none had a revision. 16 patients (20 hips) were reviewed at an average follow-up of 12 (8-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component, 65 and 8 years after primary surgery, which means a 90% (95% CI: 77%-100%) survival rate at 12 years (Kaplan Meier analysis). This technique is a good option in cases with protrusio acetabuli due to rheumatoid arthritis.

Acetabulum↗

Survivorship of hip prosthesis in primary arthrosis: influence of bilaterality and interoperative time in 45,000 hip prostheses from the Finnish endoprosthesis register.

We studied the influence of bilaterality and interoperative time on survivorship of the hip prosthesis. The material consisted of 45,000 (3,153 bilateral) total hip arthroplasties and 38,000 patients operated on for primary osteoarthrosis, using data from the Finnish Endoprosthesis Register between 1980 and 1999. Cox regression analysis showed that male sex, young age, uncemented prosthesis and time of surgery (first 10-year period) were significant risk factors for aseptic loosening. We found no difference between the survivorship of the first bilateral and that of unilaterals, but second bilaterals survived better than the unilaterals. Bilateral prostheses survived better when the second prosthesis was implanted during the first postoperative year. The risk of loosening of a bilateral prosthesis increased when the second prosthesis was implanted a few years later. Survivorship of bilateral prosthesesin a 1-stage bilateral operation was about the same as in those operated on within the first postoperative year. Better survivorship of the second bilateral can cause bias in per hip survivorship analyses. In bilateral cases, the second hip should be operated on as soon as possible or be considered for a 1-stage bilateral procedure.

Aged↗

Registration in the danish hip arthroplasty registry: completeness of total hip arthroplasties and positive predictive value of registered diagnosis and postoperative complications.

BACKGROUND: There are few publications regarding the validity of data in hip arthroplasty registers. The Danish Hip Arthroplasty Registry (DHR) is a nationwide clinical database of THAs and revisions in Denmark. PATIENTS AND METHODS: We assessed the completeness of registration of primary total hip arthroplasties (THAs) and revisions in the DHR from 1995-2000. In addition, the positive predictive value (PPV) of registered data for diagnoses in patients undergoing primary THA and postoperative complications was analyzed. Completeness was assessed using the Danish National Registry of Patients (NRP) as a reference, which is a nationwide and population-based registry of all somatic hospital admissions since 1977. The positive predictive value of registered data was assessed by review of medical records and preoperative radiographs from samples of randomly selected patients registered in the DHR using a standardized form. RESULTS: The overall completeness of registration for primary THAs and/or revisions was 94% (26,129 patients registered in both NRP and DHR and 27,757 patients registered in the NRP). There was a lower degree of completeness for revisions than for primary THAs (81% versus 94%). The completeness did not vary substantially according to gender and age. Completeness of registration was lower for university hospitals than for other hospitals (91% versus 95%), and for low-volume hospitals (87%) relative to those with medium (92%) and high volumes (96%). Overall, the diagnoses in patients undergoing primary THA could be confirmed in 84% (387/459) of the patients who were reviewed. The diagnosis of fresh fracture of the proximal femur was confirmed in only one third (22/73) of the cases. Postoperative complications were confirmed in two-thirds (36/54) of the patients reviewed. The specificity of the registration of postoperative complications was, however, only one-third (8/26). INTERPRETATION: We conclude that the Danish Hip Arthroplasty Registry is a potentially valuable tool for quality improvement and research due to the high degree of completeness of registrations regarding THA, and its moderate-to-high positive predictive value of registration for diagnoses in patients undergoing primary THA. However, information on several diagnoses for primary THA and on postoperative complications should be used with caution.

Aged↗

A powder made from seeds and shells of a rose-hip subspecies (Rosa canina) reduces symptoms of knee and hip osteoarthritis: a randomized, double-blind, placebo-controlled clinical trial.

OBJECTIVE: The aim of this study was to determine whether a herbal remedy made from a subspecies of rose-hip (Rosa canina) might reduce symptoms of osteoarthritis and consumption of rescue medication in patients suffering from osteoarthritis. METHODS: Ninety-four patients with osteoarthritis of the hip or knee were enrolled in a randomized, placebo-controlled, double-blind crossover trial. Forty-seven patients were given 5 g of the herbal remedy daily for a period of 3 months and the remaining patients were given a similar amount of placebo. The group initially treated with placebo was then changed to rose-hip and vice versa for another 3-month period. Upon inclusion and after 3 weeks and 3 months of each treatment period, pain, stiffness, disability, and global severity of the disease were scored on a Western Ontario and McMaster Universities (WOMAC) questionnaire. After 3 weeks of treatment, patients, if possible, were allowed to reduce their consumption of 'rescue medication'. Data were analysed on the basis of intention to treat. RESULTS: Rose-hip resulted in a significant reduction in WOMAC pain (p<0.014) as compared to placebo, when testing after 3 weeks of treatment. The consumption of 'rescue medication' significantly declined as a result of active treatment (p<0.027). WOMAC disability, stiffness, and global assessment of severity of the disease were not altered by 3 weeks but decreased significantly (p<0.018, p<0.038, and p<0.035, respectively) after 3 months of treatment. CONCLUSION: The data suggest that the present herbal remedy can alleviate symptoms of osteoarthritis and reduce the consumption of 'rescue medication'.

Adult↗

The prevalence of osteoarthrosis of the hip requiring total hip replacement in the elderly.

A community study of the prevalence of osteoarthrosis of the hip requiring total hip replacement in elderly people is reported. It was found that 5.6% of the population studied had symptoms suggestive of osteoarthrosis of the hip, or had been successfully treated for it. In particular, 0.7% of the survey group had already been operated upon for this condition, and a further 0.5% would have benefited from total hip replacement. An additional 1.3% of the persons studied needed this operation, but were unfit for surgery.

Aged↗

Radiographic change is common in new presenters in primary care with hip pain. PCR Hip Study Group.

OBJECTIVE: To determine the prevalence of radiographic osteoarthritis in subjects with hip pain newly presenting to primary care. METHODS: The study was cross-sectional in design, set in 35 general practices across the UK. It included 195 men and women aged 40 yr and over (median 63 yr) presenting with a new episode of hip pain. Hip radiographs were scored for minimum joint space (MJS) and overall-Croft's modification of the Kellgren and Lawrence (Croft)-grade of osteoarthritis. RESULTS: In all, definite evidence of radiographic change in the painful joint was common: Croft grade > or =2 in 44%, > or =3 in 34%. MJS of 2.5 mm or less was seen in 30% of whom half were below 1.5 mm. There were no significant gender differences in radiographic severity. CONCLUSIONS: Radiographic change is common in patients newly presenting with hip pain and many already have advanced disease.

Adult↗

Cementless total hip arthroplasty with autologous bone grafting for hip dysplasia.

The fate of autologous femoral head bone grafts in acetabular roof reconstruction for severely dysplastic hips was investigated in 25 patients (25 cementless total hip arthroplasties). Twenty patients were women and 5 were men, whose average age was 55 years old; their average followup was 58 months. The average Harris Hip Rating improved from a preoperative value of 49 points to a postoperative value of 85 points. Radiographic measurements did not indicate any vertical or horizontal socket migration >2 mm. The grafted bone was incorporated by an average time of 7 months, and the acetabular sclerosis had disappeared in 23 hips by 9.4 months. One year after operation, the grafted bone was reduced in size significantly. Radionuclide uptake at the site of the bone graft remained high for as long as 18 months after the operation, then normalized. The autologous acetabular bone grafts were incorporated completely and remodeled 18 months after surgery.

Acetabulum↗

Recurrent anterior hip instability after a simple hip dislocation: a case report.

A 35-year-old woman sustained a simple anterior hip dislocation after a fall. Initial treatment involved a closed reduction under sedation with brace immobilization. Nine months after the initial dislocation, she began having recurrent anterior hip instability (four events) requiring closed reduction under anesthesia. Secondary to the recurrent dislocations, she had a derotational subtrochanteric femoral osteotomy at an outside hospital for the anterior instability. After this procedure she sustained five additional anterior dislocations requiring closed reduction under anesthesia. After nine anterior dislocations, she had periacetabular osteotomy retroverting her acetabulum with repair of the anterior hip capsule which has successfully solved the recurrent instability. To the author's knowledge this is the first reported case of recurrent anterior hip instability treated successfully with a periacetabular osteotomy.

Acetabulum↗

Location of acetabular deficiency and associated hip dislocation in neuromuscular hip dysplasia: three-dimensional computed tomographic analysis.

Forty-one hips in 24 patients with neuromuscular disease (NMD) were studied using three-dimensional computed tomography (3DCT). The location of the acetabular deficiency was posterior (37%), anterior (29%), midsuperior (15%), and mixed (19%) (anterosuperior, posterosuperior, and global). Although subtle morphologic changes occurred in the entire acetabulum, the major acetabular deficiency coincided with the direction of the subluxation or dislocation. The location of the acetabular deficiency that develops in cerebral palsy is not always posterosuperior, as suggested by other authors. The pattern of spasticity that results in muscle imbalance around the hip joint and changes in proximal femur architecture causes hip subluxation or dislocation, which may be either, posterior, anterior, or midsuperior. 3DCT studies are required to analyze accurately and understand acetabular deficiency in childhood NMD. These image data also allow more accurate planning for surgery in neuromuscular hip dysplasia.

Acetabulum↗

Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw.

OBJECTIVE: To compare the results after operative treatment of unstable per- and subtrochanteric fractures with the Gamma nail, compression hip screw (CHS), or dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP). DESIGN: Prospective. PATIENTS: One hundred seventy patients with unstable trochanteric femoral fractures surviving six months after operation. Eighty-five patients were randomized to treatment with the Gamma nail (n = 50, Gamma group) or the compression hip screw (n = 35, CHS group) and compared with a consecutive series of eighty-five patients operated with the dynamic hip screw with a laterally mounted trochanteric stabilizing plate (DHS/TSP group) MAIN OUTCOME MEASUREMENTS: Radiographs were analyzed for fracture classification, evaluation of fracture reduction, implant positioning, later fracture dislocation, and other complications. Pre- and postoperative functional status of the patients were recorded, with a minimum of six months follow-up. RESULTS: Eighteen percent of the patients in the Gamma group, 34 percent in the CHS group, and 9 percent in the DHS/TSP group suffered significant secondary fracture dislocation during the six months follow-up, leading to a varus malunion, lag screw cutout, or excessive lag screw sliding with medialization of the distal fracture fragment. Two patients (4.0 percent) in the Gamma group suffered an implant-related femoral fracture below the nail, and one had a deep infection. The reoperation rates were 8.0 percent in the Gamma group, 2.9 percent in the CHS group, and 5.9 percent in the DHS/TSP group. All but one fracture in the Gamma and CHS groups and two fractures in the DHS/TSP group healed within six months. Approximately three-fourths of the patients had returned to their preoperative walking ability after six months, with a trend toward better functional outcome in the DHS/TSP group. Use of a TSP reduced the secondary lag screw sliding as compared with the conventional CHS, without affecting fracture healing. CONCLUSION: The TSP may be an aid in the treatment of these difficult fractures because the problem with femoral shaft fractures using the Gamma nail is avoided and the medialization of the distal fracture fragment frequently associated with the CHS is prevented.

Activities of Daily Living↗

Measuring physical function in children with spina bifida and dislocated hips: the Spina Bifida Hips Questionnaire.

The objective of this study was to develop a questionnaire to evaluate the activities of daily living that are important to children with spina bifida and dislocated hips and their families. Ninety-six items were generated from a review of the literature and interviews with clinicians, parents, and children with spina bifida and dislocated hips. Items were rated independently for "importance" and "severity" by the children and their parents. The 26 most important and severe items were formatted into a self-administered questionnaire, the Spina Bifida Hips Questionnaire (SBHQ). Parents and children completed 2 weeks apart the SBHQ, the Activities Scale for Kids (ASK), and the Pediatric Outcomes Data Collection Questionnaire (PODCQ). The SBHQ showed excellent test-retest reliability (intraclass correlation = 0.97). Construct validity was established by correlations with the ASK (r = 0.79, P < 0.01) and the PODCQ (r = 0.84, P < 0.01). In conclusion, the SBHQ is a valid and reliable questionnaire for the evaluation of treatment outcomes for children with spina bifida and dislocated hips.

Activities of Daily Living↗

Treatment of hip dislocation in Kabuki syndrome: a report of three hips in two patients.

The incidence of hip dislocation in Kabuki syndrome (KS) is thought to be between 18% and 40%. Although hip dislocation is apparently well recognized in KS, to our knowledge, its management and outcome have not previously been addressed in the literature. We report 2 children (3 hips) with KS and hip dislocation who underwent surgical treatment with a minimum of 24-month follow-up. In addition, we review the current literature on the treatment of orthopaedic problems in KS.

Abnormalities, Multiple↗

Value of limited hip abduction in developmental dysplasia of the hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US. METHODS: In total, 464 infants referred from the pediatrics clinic with LHA, aged between 30 and 120 days, were included in the study. RESULTS: Physical examination revealed LHA in 186 (41%) infants, 26 of which were unilateral and 160 were bilateral. US examination showed that 13 (8.1%) patients in the bilateral LHA group and 18 (69.2) patients in the unilateral LHA group, had DDH (total number 31, 7%). CONCLUSION: Unilateral limitation of hip abduction was found to be a sensitive sign for developmental hip dysplasia, but US could be defined once again as the best golden standard before initiating treatment.

Bone Diseases, Developmental↗

Hormone replacement therapy and risk of hip fracture: population based case-control study. The Swedish Hip Fracture Study Group.

OBJECTIVE: To determine the relative risk of hip fracture associated with postmenopausal hormone replacement therapy including the effect of duration and recency of treatment, the addition of progestins, route of administration, and dose. DESIGN: Population based case-control study. SETTING: Six counties in Sweden. SUBJECTS: 1327 women aged 50-81 years with hip fracture and 3262 randomly selected controls. MAIN OUTCOME MEASURE: Use of hormone replacement therapy. RESULTS: Compared with women who had never used hormone replacement therapy, current users had an odds ratio of 0.35 (95 % confidence interval 0.24 to 0.53) for hip fracture and former users had an odds ratio of 0.76 (0.57 to 1.01). For every year of therapy, the overall risk decreased by 6% (3% to 9%): 4% (1% to 8%) for regimens without progestin and 11% (6% to 16%) for those with progestin. Last use between one and five years previously, with a duration of use more than five years, was associated with an odds ratio of 0.27 (0.08 to 0.94). After five years without hormone replacement therapy the protective effect was substantially diminished (-7% to 48%). With current use, an initiation of therapy nine or more years after the menopause gave equally strong reduction in risk for hip fracture as an earlier start. Oestrogen treatment with skin patches gave similar risk estimates as oral regimens. CONCLUSIONS: Recent use of hormone replacement therapy is required for optimum fracture protection, but therapy can be started several years after the menopause. The protective effect increases with duration of use, and an oestrogen-sparing effect is achieved when progestins are included in the regimen.

Administration, Cutaneous↗