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PubMed2002

The floating hip injury: patterns of injury.

OBJECTIVE: To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury. DESIGN: Historical retrospective. PATIENTS: Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur. INTERVENTION: Statistical analysis of the correlation between the mechanism of injury and fracture type. RESULTS: Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur. CONCLUSIONS: This observation explains the biomechanical nature of this injury and has treatment related implications.

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PubMed2004

Malformation of the acetabular fossa as a cause of intrapelvic injury in total hip arthroplasty: a report of 2 cases.

We report 2 cases of bone defects of the acetabulum. The first case was a patient who underwent a total hip arthroplasty. An intraoperative bleeding occurred because of an injury of an intrapelvic artery. Preoperative radiographs did not show this bone defect. A similar abnormality of the acetabulum was found in a series of 30 pelves that were dissected for a cadaver study. In this case, the bone defect was located in the center of the right acetabulum.

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PubMed2002

Load transfer and fixation mode of press-fit acetabular sockets.

Adequate initial fixation is a prerequisite for osseointegration and secondary stability of noncemented cups. Physiologic force transmission between the cup and acetabulum guarantees the best long-term fixation. To study load transfer within the natural hip joint and in the bone-implant interface of 2 different hemispherical noncemented press-fit cups, 10 hips were investigated in an experimental setup simulating single-leg stance. Load distribution and contact area were measured using prescale pressure-sensitive films and digital image analysis. Three dominant locations near the periphery of the acetabulum could be identified. Main load transfer occurs in the cranial region of the acetabulum, where it is buttressed by the iliac bone; the second location is at the posterior-inferior region at the ischial facet, and the third location is at the anterior region, where support is provided by the pubic bone. Peripheral rim contact was present in both cups but not completely circumferential. It showed marked loading at the same 3 locations similar to the natural hip joint. The ilioischial diagonal axis produced the highest press-fit. Peak local forces were found at the ischial and iliac facets. Local forces can be grouped into an iliac, an ischial, and a pubic group contributing 55%, 25%, and 20% to the total hip joint force. Pole contact was not present in the natural hip and with the biradial press-fit cup with flattened pole area but was observed with the pure hemispherical cup. Hence, stable fixation of an acetabular cup is achieved best by a 3-point-like bony support at the iliac, ischial, and pubic bone. The acetabular fovea does not provide functional support of the femoral head or endoprosthetic socket. In revision surgery, remaining peripheral bone stock at the iliac, ischial, and pubic locations allows stable implantation of primary cups.

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PubMedDate not supplied

[Decreased acetabular anteversion and femur neck antetorsion cause pain and arthrosis. 2: Etiology, diagnosis and therapy].

ETIOLOGY: Differences in the anteversion of the acetabulum and the femur must be attributed to the different rotational postures of the fetus as investigations and experiments have shown. After delivery there is a spontaneous improvement, but in perhaps 15% of the joints, diminished or increased acetabular or femoral anteversion will persist during later life. The results of the investigation of Part 1 are compared with the literature. So far no correlations between AA/FA and different clinical consequences have been reported. The deformity of diminished AA and FA is found as a singular entity, also as one of the causes of slipped capital femoral epiphysis. It is frequently combined with coxa vara, also with deep acetabula and occasionally with developmental hip dysplasia and children with PFFD. DIAGNOSIS: A hint for diagnosis is the limited range of internal rotation and an excess of external rotation of the hip besides some changes in the projection of femur and acetabulum. A CT in prone position with a summation of tomographic slices of the femoral neck and other details are necessary to measure AA and FA correctly. THERAPY: Therapy is indicated when pain occurs and osteoarthritis is developing. Decreased femoral anteversion is corrected by rotational osteotomies. Significant differences of acetabular anteversion are treated by rotation of the acetabulum after triple pelvic osteotomy. The normal value of acetabular and femoral anteversion to be achieved is 15 to 20 degrees.

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PubMedDate not supplied

[Growth disorders of the acetabular roof after acetabuloplasty in congenital hip dysplasia].

PURPOSE: The aim of this long-term study was to evaluate whether the Lance acetabuloplasty for congenital dysplasia of the hip causes a growth disturbance of the acetabular roof during or after puberty. METHOD: 71 hips of 58 patients were followed clinically and radiologically over a maximum time of 16 years after the operative procedure of a Lance acetabuloplasty. The average age of the patients at the time of operation was 2.8 years (1-6 years). In order to assess the growth of the acetabulum in the early and long-term postoperative phase quantitative parameters (acetabular index of Hilgenreiner, CE angle of Wiberg, ACM angle of Idelberger) as well as qualitative parameters (disturbance of the ossification of the acetabulum and the femoral head) were determined in standardized X-rays of the pelvis, done routinely 6 months, 3 years, 5 years, 8 years and at an average of 11 years as the last follow-up examination after the operation. The assessment of these metrical parameters were carried out in accordance to the classification of the study-group "hip dysplasia" of the DGOT (normal--slight pathological--serious pathological) respecting the different age-groups and degrees of dysplasia. RESULTS: Although in the early postoperative phase the acetabular roof showed a positive development (65% of the CE angles could be considered normal 3 years after operation), the further growth of the acetabulum was disturbed in the period of puberty (8 years after operation only 33% of the CE angles could be considered normal, 51% were extremely pathological). And also in the last X-ray control after an average follow-up time of 11 years a significant retardation of the acetabular roof was seen in 51% of all cases. CONCLUSION: The Lance acetabuloplasty seems to damage the Ossa acetabuli, which are as centers of ossification the essential anatomic structures for the growth of the acetabular rim in adolescence. CLINICAL RELEVANCE: Other procedures such as the Salter osteotomy are to be preferred for the therapy of hip dysplasia.

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PubMedDate not supplied

[A biomechanical solution for permanent anchoring of artificial hip joint acetabula].

This paper describes models of artificial acetabula which are better adapted to the structural conditions of the fixation bed than the prostheses used hitherto. The most important design feature is the increased area of surface contact between the artificial acetabulum and bone by means of stepped anchoring pins, which extend radially into the spongiosa from the surface of the acetabulum. The location and length of these small anchoring pins depends on the bone architecture of the acetabulum.

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PubMed2006

Computed tomography measurement of acetabular dimensions: normal values for correction of dysplasia.

BACKGROUND: A successful periacetabular osteotomy includes reliable planning based on radiographs and CT scanning. However, we lack normative CT values in planning realignment of the osteotomized acetabulum. PATIENTS AND METHODS: We retrospectively studied 70 hips that had been CT-scanned. Patients who showed no signs of developmental disturbances in either of the hip joints were eligible for the study. Sex differences were also studied. RESULTS: The AA-angle, CE-angle, ACE-angle and AcetAV-angle, depicting frontal, sagittal and horizontal alignment, averaged 3 degrees (SD 4 degrees ), 41 degrees (7 degrees ), 31 degrees (5 degrees ) and 21 degrees (7 degrees ), respectively. The upper normal value (+ 2SD) for the AA-angle was 12 degrees , normal range (+/- 2SD) for CE-angle was 27 degrees -55 degrees , lower normal value (- 2SD) for the ACE-angle was 22 degrees , and normal range (+/- 2SD) for the AcetAV-angle was 6 degrees -35 degrees . However, comparison of mean angles in women with those in men showed a statistically significant difference for the AA-angle and AcetAV-angle, but we found no significant differences between the mean figures for right and left hips. INTERPRETATION: Knowledge of the normal dimensions of the acetabulum is essential in the diagnosis of the type and severity of DDH, as well as in preoperative planning. Accurate estimation of the normal contact surface orientation permits correct realignment of the osteotomized acetabulum.

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PubMed1997

Evaluation of hip stability after simulated transverse acetabular fractures.

One of the major goals in managing acetabular fractures is the prevention of posttraumatic arthrosis. Unreduced fractures involving the weightbearing portion of the acetabulum may lead to posttraumatic arthrosis, whereas fractures outside this area portend a better prognosis. The purpose of this study was to help distinguish among fractures that require operative reduction, those that can be treated with traction, and those that require even less aggressive treatment. A model was developed to test hip stability after simulated transverse acetabular fractures. The results from this investigation suggest that transverse fractures with a roof arc angle of 90 degrees do not affect the weightbearing portion of the acetabulum. Fractures with a roof arc angle of 60 degrees begin to infringe on the weightbearing area, and those with roof arc angles of less than 60 degrees are clearly in the weightbearing region. Hip stability was significantly affected by the roof are angle and by the interaction of the roof arc angle and the angle of hip abduction or adduction. The data from the current study suggest that the area of the acetabulum considered to be weightbearing in transverse acetabular fractures may be more expansive than previously thought. The model developed may be used to investigate anterior and posterior column fractures.

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PubMed2004

The high hip center.

Revision of a failed acetabular component presents many challenges to the arthroplasty surgeon. The goal in most cases should be to reconstruct the acetabulum by positioning the hip center as close as possible to the anatomic hip center. However, severe acetabular bone stock deficiency and distorted acetabular anatomy often preclude placement of the acetabular component at the true anatomic hip center. In these cases, many options exist for reconstruction of the acetabulum, including placement of the cup superiorly at a high hip center. Although biomechanical studies have shown that superolateral placement of the hip center may lead to increased moments and forces across the hip (leading to potentially higher rates of loosening), superior only displacement of the hip center does not seem to adversely affect the forces about the hip. Proximal placement of the hip center facilitates contact between intact, viable host bone and the acetabular implant, thereby reducing the need for structural bone grafts, and increasing the chances for stable bony ingrowth. With proper patient selection and meticulous surgical technique, the high hip center can be a useful technique for reconstruction of the deficient acetabulum in the patient with a loose acetabular component after total hip arthroplasty.

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PubMedDate not supplied

Diagnosing childhood acetabular dysplasia using the lateral margin of the sourcil.

The purpose of this study was to evaluate the lateral edge of the acetabulum and locate the most accurate marking point on a plain radiograph when measuring the acetabular index (AI) and the center-edge (CE) angle. We studied the radiographs of 53 patients with unilateral developmental dysplasia of the hip (DDH), all of whom were treated by closed reduction. In addition to plain radiographs, eight patients had magnetic resonance imaging (MRI) studies, 16 had three-dimensional computed tomography (3-DCT) studies, and six underwent arthrographic studies. We found that the most lateral bony margin of the acetabular roof on plain radiograph represents the anterolateral portion of the acetabulum. The lateral end of the sourcil indicates the lateral margin of the mid-superior portion of the acetabulum. To reduce intra- and interobserver errors, we suggest that when measuring the AI and the CE angle, physicians clearly indicate in the medical records which of the two marking points was used.

Acetabulum↗
PubMed1989

Nonunion of acetabular fractures: evaluation with interactive multiplanar CT.

Nonunions involving fractures of the acetabulum are reportedly rare, with few citings and little discussion in the literature. It is possible that acetabular nonunions go undetected because imaging of the acetabulum is difficult by conventional radiography. We report two cases of fracture nonunion involving the weight-bearing surface of the acetabulum diagnosed with the aid of computed tomography (CT) and a newly developed interactive 2D/3D orthotool (copyright and trademark of the Body CT Imaging Laboratory, Department of Radiology, The Johns Hopkins Medical Institutions) that uniquely processes and reformats routine CT data. The interactive 2D/3D orthotool is a sophisticated computer program that allows dynamic viewing of standard multiplanar reconstructions in the axial, coronal, and sagittal planes as well as multiple oblique projections. The 2D/3D orthotool provides on screen correlation of two-dimensional multiplanar images with three-dimensional reconstructions of the pelvis. The authors found this capability ideally suited for studying fractures with off-axis orientation such as those through the acetabular dome, greatly facilitating the diagnosis of nonunion.

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PubMed1993

The computerized tomography subchondral arc: a new method of assessing acetabular articular continuity after fracture (a preliminary report).

The criteria to treat acetabular fractures operatively versus nonoperatively continue to evolve. The technique of roof arc measurements was developed to identify the extent of superior acetabulum left intact after fracture. Computerized tomography (CT) of the superior 10 mm of the acetabular articular surface evaluates the area equivalent to roof arc measurements of 45 degrees. CT provides increased detail of the superior acetabulum involved with the fracture. Our current criteria for selecting cases for nonoperative treatment are as follows: 1. The acetabular articular surface is intact in the superior 10 mm of the joint on CT evaluation. (Fractures that enter the acetabular fossa, but not the articular surface in the superior 10 mm are included in this group.) 2. The femoral head remains congruent with the superior acetabulum out of traction on the anteroposterior and 45 degree oblique radiographic views of the pelvis. 3. When a posterior wall fracture is part of the injury pattern, a minimum of 50% of the posterior wall articular surface is intact at the most involved level as determined by CT.

Acetabulum↗
PubMed2000

Superior gluteal artery in the extended iliofemoral approach.

OBJECTIVE: To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis. DESIGN: Prospective protocol, consecutive cases. SETTING: A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors. PATIENTS: Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters). INTERVENTION: All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column. MAIN OUTCOME MEASURE: Wound complications, abductor manual muscle testing, hip range of motion. RESULTS: Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength. CONCLUSIONS: No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.

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PubMedDate not supplied

Pathomorphologic characteristics of posttraumatic acetabular dysplasia.

OBJECTIVES: The pathomorphology of posttraumatic acetabular dysplasia differs fundamentally from the classic developmental dysplasia of the adolescent. The aim of this report is to qualify and quantify the pathomorphologic characteristics of the posttraumatic acetabular dysplasia and to define the requirements for adequate corrective surgery in this type of dysplasia. DESIGN AND MATERIAL: Retrospective review of the anteroposterior (AP) radiographs of ten patients with symptomatic posttraumatic acetabular dysplasia. In five cases, false profile views and in five cases computed tomography (CT) scans were also available for investigation. Measurements of distances and angles on radiographs and CT scans were made by pencil and goniometer. RESULTS: On the AP radiographs, posttraumatic acetabular dysplasia shows uniformly deformed true pelvis with an angular deformation of the innominate bone averaging 20 degrees in the region of the acetabular fossa that causes the concavity of the pelvic brim to increase in direction of the involved acetabulum and creates both a lateral and a caudal displacement of the acetabulum, averaging twenty-three millimeters and nine millimeters, respectively. The increased width of the inner wall of the acetabulum, measuring an average of eleven millimeters, makes lateralization of the center of the femoral head reach a mean of forty-three millimeters. The acetabular deformity in all cases shows a pronounced lateral deficiency. Ventral deficiency is moderate. All ten posttraumatic dysplastic acetabuli show marked retroversion averaging 27 degrees. In contrast, the contralateral acetabuli shows a mean anteversion of 23 degrees. CONCLUSIONS: The morphology of this kind of acetabular dysplasia is uniform and differs significantly from that seen in classic developmental dysplasia of the hip. For reconstructive surgery of such a hip, the challenge to abolish the lateralization of the hip joint to restore normal body weight lever arm is imperative. Because acetabular retroversion is a reproductive feature of posttraumatic dysplasia, it is important to avoid further reduction of the posterolateral containment of the femoral head and augmentation of the anterior acetabular wall, increasing the risk of anterior impingement.

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PubMed1982

Computed axial tomography in musculoskeletal trauma.

In the evaluation of patients with musculoskeletal trauma routine X-ray studies are often limited by difficulty in delineating overlapping structures and tissues of similar density. Computerized axial tomography (CT) has proven to be of great value in many diagnostic situations in orthopaedic surgery, particularly in the evaluation of mass lesions. This new technique resolves many of the problems of standard X-rays. It is noninvasive, and can be safely employed in the evaluation of critically ill patients. To assess the usefulness of this technique to trauma, computerized axial tomography has been employed in the diagnosis of injuries of the spine and acetabulum. CT studies of 26 patients with spinal injuries demonstrated accurate localization of displaced bone fragments and other elements of fracture anatomy, obviating the need for myelography. CT scanning of 28 fractures of the acetabulum defined intra-articular fragments and precise details of fracture lines. The additional data provided by CT scanning in these patients was a major asset in the management of their injuries. It influenced the decisions in regard to the need for surgery, and when surgery was indicated, the data helped to define the most appropriate operative approach. Use of the CT did not delay therapy or cause any complications. This experience with spinal injuries and fractures of the acetabulum indicates that computerized axial tomography is a valuable adjunct to the management of musculoskeletal trauma.

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PubMed2004

Lateral shelf acetabuloplasty in the treatment of Legg-Calvé-Perthes disease.

Although head containment is extremely important for the development of the acetabulum and femoral head, there are debates about conservative and surgical treatment. Shelf acetabuloplasty is an effective means of treatment as regards the coverage of the femoral head within the acetabulum, which is the most important issue for the normal development of the hip joint. Nineteen hips of 18 patients were evaluated radiographically using the acetabulum-head index of Heyman and Herndon and the center-edge angle for containment. It was shown that postoperatively both indices improve to increase the containment, thus demonstrating the effectiveness of shelf acetabuloplasty.

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PubMed2003

Acetabular retroversion is associated with osteoarthritis of the hip.

Primary osteoarthritis of the hip may have a structural basis. It was hypothesized that the radiographic appearance of acetabular retroversion could be created by altering the morphologic features of the acetabular walls, and that acetabular retroversion, as defined on an anteroposterior radiograph of the pelvis, is associated with osteoarthritis of the hip. A model pelvis was used to simulate normal, augmented, deficient, and rotated walls of the acetabulum, and radiographs were taken to compare the projections of the modified acetabular walls with the known plain radiographic appearance of a retroverted acetabulum. One hundred thirty-one good quality anteroposterior radiographs of the pelvis taken before total hip arthroplasty for idiopathic hip osteoarthritis were compared with 99 good quality radiographs taken for nonorthopaedic reasons. The prevalence of radiographic acetabular retroversion is 20% among patients with idiopathic hip osteoarthritis and 5% among the general population. The appearance of acetabular retroversion on an anteoroposterior radiograph of the pelvis is created by deficiency of the posterior wall of the acetabulum. There is a statistically significant association between radiographic acetabular retroversion and hip osteoarthritis. These findings have applicability to understanding the mechanical etiology of hip osteoarthritis, and to surgical technique during periacetabular osteotomy and total hip arthroplasty.

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PubMed2003

Induction of bone ingrowth from acetabular defects to a porous surface with OP-1.

Reliable ingrowth of bone into porous-coated cementless total hip components can be expected in primary surgery. In the revision scenario, however, bone deficiency frequently is encountered and the remaining bone may have less ingrowth potential. Allograft bone and bone graft substitutes may be successful in healing bone defects, but have virtually no capacity to induce bone growth from the defect into the porous surface. To evaluate the role osteoinductive bone proteins may play in enhancing bone ingrowth, six canines had bilateral total hip arthroplasties with a cementless press-fit porous-coated acetabular component. A defect 8 mm in diameter and 5 mm in depth was created in the superior weightbearing area of each acetabulum. One defect in each animal was filled with recombinant human osteogenic protein-1. Each contralateral defect was filled with allograft bone, left empty (defect healing control), or no defect was created (intact) to serve as a control for ideal conditions for bone ingrowth. The osteogenic protein-treated defects healed more completely than allograft bone-treated or empty defects and achieved a bone density equivalent to the intact acetabulum. Bone ingrowth also occurred to a significantly higher degree in the osteogenic protein group compared with the allograft or empty defects achieving a degree of ingrowth equivalent to the intact acetabulum controls. The osteogenic bone protein was successful in achieving complete defect healing and inducing extensive ingrowth from the defect into the adjacent porous coating.

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