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PubMed1997

Surgical approaches to the acetabulum.

This article presents a concise outline of the indications, surgical techniques, and approaches to the acetabulum: Kocher-Langenbeck approach, ilioinguinal approach, iliofemoral approach, combined approaches, extended iliofemoral approach, and the triradiate approach. No one surgical appproach is ideal for all fractures of the acetabulum. The type of approach used is determined by the fracture pattern and condition of the soft tissues in the area under consideration.

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PubMed2002

Acetabular defect reconstruction with impacted morsellized bone grafts or TCP/HA particles. A study on the mechanical stability of cemented cups in an artificial acetabulum model.

In revision surgery of the acetabulum bone defects can be filled with impacted human morsellized bone grafts. Because of a worldwide limited availability of human bone, alternatives are being considered. In this study we compared the initial stability of acetabular cups after reconstructing a cavitary defect with various compositions of impacted tricalciumphosphate-hydroxyapatite (TCP/HA) particles and mixes of TCP/HA particles and human grafts in a realistic acetabulum model. Primary cemented cups and reconstructions with impacted human cancellous grafts were used as reference. A dynamic load displaced the acetabular cups superomedially. The primary cemented cups showed the highest stability. The cups with impacted human grafts produced the most displacement. All reconstructions with the TCP/HA particles showed a high stability of the cups. However, especially when using large TCP/HA particles this was probably due to a large amount of cement penetration. Mixing TCP/HA particles with human grafts seemed to decrease cement penetration. although still a high stability was obtained. In this perspective, we concluded that TCP/HA particles might be useful as a bone graft extender in the reconstruction of acetabular bone defects.

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PubMed1989

Three-dimensional angio-computed tomography. New technique for imaging the acetabulum and adjacent vessels in a patient with acetabular protrusio.

An arterial injury is an infrequent but potentially lethel occurrence after primary or revision total hip arthroplasty complicated by an acetabular protrusio. Frequently, a plain radiograph and an arteriogram are used to assess the major arteries around the hip. The limitations of these techniques are well documented. A novel technique for documenting the spatial relationships of the external iliac and common femoral arteries to the acetabulum employs an arterial study combined with a three-dimensional computed scan. An angiocatheter is inserted by conventional radiographic technique and a standard computed scan with 3-mm sections is obtained and reconstructed to a three-dimensional image. The scan provides an accurate three-dimensional image of the osseous architecture and arterial images around the acetabulum. Even in the presence of a metallic arthroplastic component, the resolution of the three-dimensional angio-computed scan is sufficient to identify the external iliac artery adjacent to the pelvis.

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PubMed2000

Radiographic anatomic structure of the arthritic acetabulum and its influence on total hip arthroplasty.

Acetabular bone structure is not the same in all patients and can be defined by the radiolucent triangle superior to the acetabulum. Of 132 hips, 81 had an isosceles triangular shape, which was named type A acetabulum. Forty-six hips had an extension of the triangle into the teardrop, which created a thickened medial wall and was named type B. Five hips had a right-angle triangle, which was found only with congenital disease of the hip and was named type C. The density of the superior acetabular bone in the triangle could be normally radiolucent (stage I), have vertical and transverse trabeculae throughout the triangle (stage II), or have the triangle filled with bone and cysts (stage III). The relationship between progressive radiolucent lines and acetabular type showed that type A3 (thin medial wall with dense triangle bone) had the highest incidence of progressive radiolucent lines (P < .05).

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PubMedDate not supplied

[Long-term outcome of Dega acetabulum-plasty].

The authors reviewed the results of Dega acetabuloplasty in developmental dysplasia of the hip performed simultaneously with intertrochanteric osteotomy (predominant derotation-varusosteotomy DVO). 74 hips in 55 patients were assessed at a follow-up of 7-17 years (mean 10 years). Measurements of the acetabulum and the head-acetabulum-relation were found to be normal or slightly pathologic in 80-93% of the hips. Values of the femoral head and neck were in the low normal percentage. Poor clinical and radiological outcome was caused by avascular necrosis of the femoral head or revalgisation after DVO. The rate of avascular necrosis after conservative treatment was 23.4%, the rate as a consequence of the operation was 5.4%. Therefore, we prefer at present the subtrochanteric osteotomy of the femur.

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PubMedDate not supplied

[Remodeling of the acetabulum after experimental hip joint dislocation--an animal experiment study of the rabbit].

PURPOSE: Little is known about the remodeling potential of the acetabulum after dislocation and relocation of the hip joint. Most clinical data rely on radiographic measurements in a clinical setting, with only few singular reports on histologic changes at the time of surgery. This study was undertaken to examine the remodeling potential of the rabbit acetabulum after different length of hip dislocation and to gain insight into the histology of the remodeling process involved. METHOD: The right knee joint was immobilized in 28 matched New Zealand white rabbits, causing dislocation of the associated hip joint. Assessment of the joint status was made by serial X-rays in a reproducible standardized way, allowing measurement of the Acetabular Index (AI). The untreated left hip joints served as controls in the histologic sections and also allowed to develop an age matched scale of normal acetabular development for radiographic assessment. Dislocation was unsuccessful in 2 rabbits, 9 animals were sacrificed with the joint dislocated, and in 13 animals a closed reduction was performed and maintained in a Petrie type position for 10 days. Reduction was unsuccessful in 4 cases. The reduced group was sacrificed after 4 to 12 weeks, the point of harvesting being determined by no further change in the serial standardized radiographic measurements of the AI. All surgical procedures were done under the supervision of a veterinary surgeon and followed an approved protocol. RESULTS: In the time observed, the normal values of the Acetabular Index drop from 30 degrees to 20 degrees over a time of 3 months. In animals with a dislocated hip the AI increased to 40 degrees, which was completely reversible and reached normal values in 4 weeks, if reposition was done at this time (group A). Later reposition did improve the AI, but compared to normal age matched values, the AI remained elevated (> 30 degrees), demonstrating a residual dysplasia (group B). The histologic sections of the control left joints showed normal hyaline cartilage with physiologic vertical stacking of the cartilage zones. In the dislocated group the vertical stacking was lost, with chondrocytes demonstrating a fibro-cartilaginous metaplasia. There was hypocellularity with loss of nuclear staining. These changes were completely reversed in the group A, but remained in group B. CONCLUSIONS: This study demonstrates that an early reduction will not only allow for a normalisation of the radiographic values, but that the histologic changes as they develop during dislocation can completely be reversed. Long standing dislocation will lead to a permanent tissue metaplasia similar to the one seen in compression testing of joint cartilage, therefore loosing the potential for remodeling. Similar processes may occur in the human situation and the findings here underline the necessity for early reduction to allow for a complete remodeling of the hip joint.

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PubMedDate not supplied

[The hip joint in the frontal projection. A contribution to the roentgenologic comprehension of the femur head-acetabulum relation].

The development of hip deformities is strictly dependent on the congruence between the head of the femur and the acetabulum. The routine radiological examination shows this relationship in one plane only. The combination of the anterior-posterior and the frontal projection opens the view into the third dimension of the hip joint. The frontal projection is especially suitable for measuring the anteversion of the acetabulum which in combination with a marked antetorsion of the femoral neck leads to a reduction of the weight-bearing articular surface. As every decentration of the femoral head should be considered for operative procedures the frontal projection is of special interest in the radiological examination of the hip joint.

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PubMed1997

Replacement of deficient acetabulum using Burch-Schneider cages. 22 patients followed for 2-10 years.

The absence of good bone stock with massive acetabular deficiency has been a major problem in both revision hip arthroplasty and in primary arthroplasty for congenital dislocation of the hip (CDH). 22 patients (24 hips; 21 revision and 3 primary replacements: mean age 58 years) with substantial bone loss underwent acetabular reinforcement with Burch-Schneider cages. Classification of acetabular deficiency was made according to the AAOS system. The surgical procedure involved preparation of acetabulum, filling the defect with bone autografts, placement of the cage with its flanges, fixation with screws on the lateral wall only and placement of a cement and plastic cup. Radiographic loosening with breakage of the screws was observed in only 1 patient. After a mean follow-up of 8 (2-10) years, good stability was achieved in all patients and no mechanical failure was observed. Satisfactory results were observed in all but one of the cases, indicating that effective support of the acetabulum can be achieved using Burch-Schneider cages.

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PubMed1997

Biomechanics of the hip joint and the effects of fracture of the acetabulum.

The biomechanical analysis of the normal and arthritic hip joint have been the subject of numerous publications in orthopaedics. Biomechanical investigations focusing on the effect of fractures of the acetabulum on the alteration of hip joint mechanics have been a recent development. This paper outlines currently available methodologies for simulating load across the hip, and as measuring articular contact and contact stresses. Results of investigations of posterior wall fractures and transverse fractures of the acetabulum are presented. Directions for future research in the area of mechanical investigations of acetabular fractures are discussed.

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PubMed1999

Revision arthroplasty of the acetabulum with restoration of bone stock.

Bone defects on the acetabular side are defined as contained (cavitary) and uncontained (segmental). Contained (cavitary) defects can be treated by morselized allograft bone with an uncemented cup if contact can be made with 50% host bone. If contact cannot be made with 50% host bone, the author prefers to use a ring and a cemented cup. Defining success as a stable implant, no additional surgery, and improvement in hip score of at least 20 points, the success rate was 90% in 51 hips in 51 patients at an average followup of 7 years. Segmental defects involving between 30% and 50% of the acetabulum are treated by minor column allografts (shelf graft), and a cemented or an uncemented cup. In 29 hips in 28 patients with an average followup of 7 years the success rate was 86%. Segmental defects involving more than 50% of the acetabulum are treated by major column allografts. These grafts are fixed by cancellous screws and protected by a reconstruction ring that extends from ilium to ischium. In 33 hips in 32 patients with an average followup of 7 years, the success rate was 76%.

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PubMed2002

Subchondral cysts arise in the anterior acetabulum in dysplastic osteoarthritic hips.

The distribution of subchondral cysts in 57 dysplastic osteoarthritic hips of 38 patients was assessed by computed tomography and by a new computerized technique. The cyst count in osteoarthritic hips was inversely correlated with the width of the joint space. A greater accumulation of cysts was found in the acetabulum than in the femoral head, and more cysts were found in the anterior part of the hip than in the posterior part. Osteoarthritic change was more predominant in the acetabulum than in the femoral head, and was more predominant in the anterior part of the hip than in the posterior part.

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PubMedDate not supplied

Biomechanical consequences of anterior column fracture of the acetabulum.

OBJECTIVES: To measure biomechanical consequences of a high anterior column acetabular fracture. DESIGN: A benchtop biomechanical model using quasi-static loading of the hip joint in a simulated single-leg stance. Pressure-sensitive prescale (Fuji) film was used to determine hip joint loading parameters. PARTICIPANTS: Six cadaveric hemipelvi with one hip tested in each specimen. Three right and three left hips were tested. INTERVENTION: Creation of an anterior column fracture with anatomic reduction and fixation, followed by gap malreduction/fixation, and subsequently step malreduction/fixation. MAIN OUTCOME MEASUREMENTS: Contact pressure, contact area, and load distribution throughout the hip joint in each experimental condition. RESULTS: There were significant increases in load (p<0.01) and peak pressures (p<0.01) in the superior acetabular region after gap malreduction and in peak contact pressures after step malreduction (p<0.01) as compared with the intact acetabulum. Anatomic reduction was not associated with increased mean or peak contact pressures (in any region). CONCLUSIONS: Both step and gap malreductions of a high anterior column fracture resulted in significantly increased peak contact pressures in the superior acetabular region. These biomechanical data cannot be directly extrapolated to clinical applications, but these data suggest that anatomic reduction of anterior column fracture affords the best opportunity to restore contact pressures, contact area, and load distribution within the hip to levels similar to those seen in the intact acetabulum.

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PubMed2005

The effect of screening for deep vein thrombosis on the prevalence of pulmonary embolism in patients with fractures of the pelvis or acetabulum: a review of 973 patients.

OBJECTIVES: In patients with pelvic or acetabular fractures, to compare the prevalence of pulmonary embolism in a time period without screening for deep vein thrombosis to that seen when a screening protocol was in place. DESIGN: Retrospective. SETTING: County hospital. PATIENTS: All patients with closed fractures of the pelvis or acetabulum treated during the study periods. INTERVENTION: Prophylaxis for deep vein thrombosis was the same for both groups. From November 1, 1997 though November 31, 1999, a screening protocol for deep vein thrombosis was employed using ultrasound and magnetic resonance venography. From January 1, 2000 through December 1, 2001, no screening was used. MAIN OUTCOME MEASUREMENT: Pulmonary emboli were recorded. RESULTS: The 1997 to 1999 time period included 486 patients with fractures of the pelvis or acetabulum; the 2000 to 2001 time period included 487. In the period when a screening protocol was in place, 10 patients (2%) were diagnosed with pulmonary embolism by pulmonary arteriogram, autopsy, or ventilation perfusion scan. All but 2 who were diagnosed with pulmonary embolism had undergone screening for deep vein thrombosis, and none of the screening tests were positive. In the 2000 to 2001 time period, when no screening for deep vein thrombosis was done, 7 patients (1.4%) were diagnosed with pulmonary embolism, by pulmonary arteriogram, autopsy, spiral computed tomography scan, or high clinical suspicion. There was no significant difference between the prevalence of pulmonary embolism seen in 1997 to 1999 and that seen in 2000 to 2001 (P = 0.48). CONCLUSION: Discontinuation of screening for the diagnosis of deep vein thrombosis did not change the rate of pulmonary embolism.

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PubMed2004

Lateral shelf acetabuloplasty in the early stage of Legg-Calvé-Perthes disease with special emphasis on the remaining growth of the acetabulum: a preliminary report.

This study reports on the preliminary results in 43 patients with an early stage of unilateral Legg-Calvé-Perthes disease, treated with a shelf acetabuloplasty. The mean postoperative follow-up was 3.7 years (1.3-6.2 years). The results suggest an improved outcome in children older than 5 years of age at onset. According to the Stulberg classification, 16 hips were classified as Stulberg 2, 19 hips as Stulberg 3 and eight hips as Stulberg 4. The acetabular size, which is a measurement of the length of the acetabulum relative to the size of the shelf, increased from 48.86 to 69.13%. This reflects an incorporation of the shelf-graft into the pelvis as a result of continued growth of the lateral acetabular structures. The coverage of the femoral head by the bony acetabulum increased from 68.51 to 73.83%. The acetabular cover increases in children younger than 8 years of age and decreases in patients older than 8 years. We suggest that shelf acetabuloplasty can be considered as an appropriate surgical treatment for children older than 5 years of age, with severe Legg-Calvé-Perthes disease.

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PubMed1997

Morphology of the acetabulum in hip dislocations caused by cerebral palsy.

Twenty-four hip joints in 20 children with spastic cerebral palsy were assessed by standardised three-dimensional reconstructions from computed tomographic scans. All the hip joints showed a channel-like ebony deformity of the acetabulum along which the femoral bead had slid out, indicating a unidirectional instability. The channel was oriented along the longitudinal axis of the body within a sector of 25 degrees anteroposteriorly. In relation to the pelvis, the dislocation was directed more dorsally by 20 degrees as a result of a flexion contracture of the hip. The size of the femoral head corresponded with the size of the acetabulum in every case, even in long-standing dislocations.

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PubMedDate not supplied

Osteoid osteoma of the acetabulum: two cases.

We report two cases of osteoid osteoma of the acetabulum associated with severe chronic synovitis. The diagnosis is difficult and usually delayed because the acetabulum is a rare site for this tumor and clinical signs are nonspecific. Computed tomography (CT) scanning is the best diagnostic technique. An intraarticular surgical approach allows complete resection, but one case required spongy bone grafts. Postoperative results are excellent.

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PubMed2004

A comparison of structural and mechanical properties in cancellous bone from the femoral head and acetabulum.

Mechanical interlock obtained by penetration of bone cement into cancellous bone is critical to the success of cemented total hip replacement (THR). Although acetabular component loosening is an important mode of THR failure, the properties of acetabular cancellous bone relevant to cement penetration are not well characterized. Bone biopsies (9 mm diameter, 10 mm long) were taken from the articular surfaces of the acetabulum and femoral head during total hip replacement. After mechanical and chemical defatting the two groups of bone specimens were characterized using flow measurement, mechanical testing and finally serial sectioning and three-dimensional computer reconstruction. The mean permeabilities of the acetabular group (1.064 x 10(-10) m2) and femoral group (1.155 x 10(-10) m2) were calculated from the flow measurements, which used saline solution and a static pressure of 9.8 kPa. The mean Young's modulus, measured non-destructively, was 47.4 MPa for the femoral group and 116.4 MPa for the acetabular group. Three-dimensional computer reconstruction of the specimens showed no significant differences in connectivity and porosity between the groups. Results obtained using femoral head cancellous bone to investigate bone cement penetration and fixation are directly relevant to fixation in the acetabulum.

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PubMed1999

Retroversion of the acetabulum. A cause of hip pain.

We describe a little-known variety of hip dysplasia, termed 'acetabular retroversion', in which the alignment of the mouth of the acetabulum does not face the normal anterolateral direction, but inclines more posterolaterally. The condition may be part of a complex dysplasia or a single entity. Other than its retroversion, the acetabulum is sited normally on the side wall of the pelvis, and its articular surface is of normal extent and configuration. The retroverted orientation may give rise to problems of impingement between the femoral neck and anterior acetabular edge. We define the clinical and radiological parameters and discuss pathological changes which may occur in the untreated condition. A technique of management is proposed.

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