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PubMed2004

Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement.

Despite the fact that classic studies on osteoarthritis of the hip have shown the periphery of the hip to be prone to degeneration, it was not until recently that an abnormal acetabular labrum has been associated with osteoarthritis. This study was designed to determine whether magnetic resonance arthrography can show differences in disorders of the labrum (tears, size, ganglion formation) expected in symptomatic patients with developmental dysplasia of the hip and anterior femoroacetabular impingement. Fourteen patients in each group were evaluated preoperatively not only clinically but also with conventional radiographs and magnetic resonance arthrographs. In both conditions, disorders of the labrum localized identically with a predilection to the anterosuperior quadrant of the acetabulum. Labral tears were observed in nine hips of each group. The labrum was enlarged in 12 hips with dysplasia but in none of the hips with impingement. Ganglion formation in the periacetabular area was seen in 10 hips with dysplasia and three hips with impingement. These findings provide evidence that the anterosuperior acetabulum represents the initial fatiguing site of the hip under both conditions. Based on these data, the size of the labrum and the presence of soft tissue ganglia seem to be good predictors for the presence of developmental dysplasia, whereas the presence of tears did not differentiate between conditions. The capability of magnetic resonance arthrography to show these differences in labral disorders suggests this method is a helpful diagnostic tool that can aid in defining the most appropriate treatment strategy.

Adolescent↗
PubMed2004

Late Perthes disease after satisfactory treatment of congenital dislocation of the hip.

Late Perthes disease in children treated conservatively for congenital dislocation of the hip with good results seems rare. To our knowledge 14 cases have been reported in the literature. Three new cases, found among 2500 children with congenital dislocations of the hip, treated during the last 35 years are presented. The ages of the patients at admission were 14, 3, and 18 months, and late Perthes disease was seen 24, 26, and 36 months, respectively, after successful conservative treatment of congenital dislocation of the hip. This condition has differences from other types of ischemic necrosis of the proximal end of the femur. The changes are severe and involvement of the acetabulum contributes significantly to acetabular deficiency and subluxation. Severe deformities of the proximal end of the femur and the acetabulum are responsible for failure of reconstructive procedures such as shelf and Chiari's operations in two of our patients. The cause of this condition is unknown.

Female↗
PubMed2004

Disassembly of bipolar cup with self-centering system: a report of seven cases.

Disassembly of bipolar cups with a self-centering system occurred in six patients (seven hips; five women, one man) and the cause of the failure was evaluated. The mean age of the patients at the time of arthroplasty was 49.7 years (range, 27-85 years), and mean weight was 48.4 kg (range, 37-65 kg). The mean time to failure was 7.5 years (range, 4.8-9.2 years). Before failure, all implants functioned well and none of the patients had sustained trauma. Retrieval study showed that the cause of failure of the locking mechanism with a self-centering system was severe polyethylene abrasion at the rim attributable to impingement and deformity of the locking ring. After the locking ring detached, the inner head dislocated from the outer head resulting in a varus position of the outer head in the acetabulum. If the deformed locking ring did not detach, the inner head could dislocate, with the varus outer head remaining in the acetabulum. The incidence of this failure was 11%. This disassembly is not a rare occurrence numerous years after a well-functioning bipolar hemiarthroplasty, even with the self-centering system.

Adult↗
PubMedDate not supplied

Early diagnosis and treatment of hinge abduction in Legg-Perthes disease.

A review of 106 cases of Legg-Perthes disease disclosed 26 in whom a particularly poor radiographic appearance was seen. Hinge abduction was detected in 19 of these patients and was suspected but not proven in the remainder. Hinge abduction was found to occur early in the course of Legg-Perthes, and hinging frequently occurred about an unossified portion of femoral head, making detection difficult. Failure of movement of the lateral corner of the epiphysis under the edge of the acetabulum on an internally rotated and abducted radiograph is prima facie evidence of hinge abduction. Confirmation is easily obtained by arthrography. Hinging must be relieved if guidance of femoral head growth by the healthy acetabulum is to be possible. Both clinical and radiographic outcomes were worse in patients with unrelieved hinge abduction. Relief of hinging can frequently be accomplished by traction, and containment can then be maintained by appropriate surgery.

Arthrography↗
PubMedDate not supplied

Graphic analysis of femoral growth in young children with Perthes' disease.

A cohort of 20 children, younger than 5.5 years at the time of onset of unilateral Perthes' disease, were studied by computer graphic analysis. Graphic outlines derived from each child's series of anterior posterior radiographs of the pelvis and hips were aligned on layers in a computer application such that changes over time could be directly visualized and measured. In these young children, injury to the cartilaginous growth mechanisms accounted for almost all of the abnormal change in the shape of the proximal femur; growth abnormalities had been established by the time of initial radiographs and persisted both as constant growth-rate change and growth-direction change until skeletal maturity. Despite the similar degree of radiographic bone necrosis, outcomes differed, and the specific growth aberrations were highly unique to the individual. At the time of the most recent radiographs, among the diseased hips 7 had spherical femoral heads larger than the normal side, eight had elliptical femoral heads congruent with the acetabulum, and five had elliptical femoral heads with a flat area congruent with the acetabulum. The study did not provide evidence to support a logic for brace or surgical treatment of young children with Perthes' disease.

Adolescent↗
PubMedDate not supplied

Ultrasonographic evaluation of hip morphology in osteochondrodysplasias.

The developing hip in children with osteochondrodysplasias has not been well-described because of delayed ossification and limitations of conventional radiologic techniques. Twenty-four children with various osteochondrodysplasias were evaluated by ultrasonography. Variation in the configuration of the acetabulum included a horizontal acetabular roof owing to delayed iliac development and a notched acetabular roof with lateral bone deficiency. All children had thickened acetabular cartilage except for one child with osteogenesis imperfecta. Coxa vara was a common finding. All neonates displayed a very small beta angle (mean, 42 degrees) because the labrum lay more vertically, secondary to deep engagement of the femoral head in the acetabulum. Proximal femoral ossification was delayed in most children, which allows use of ultrasonography at a later age than is possible in the normal pediatric population. Hip ultrasonography in children with skeletal dysplasias can aid in early diagnosis and is useful in assessing hip morphology and development.

Achondroplasia↗
PubMedDate not supplied

Developmental dysplasia of the hip: nursing implications and anticipatory guidance for parents.

Developmental dysplasia of the hip (DDH) is a comprehensive term used to describe an abnormal relationship between the femoral head and the acetabulum. Developmental dysplasia of the hip includes a very wide spectrum of abnormality from a frank dislocation (very unstable) to a stable hip with a slightly shallow acetabulum. As many of these findings may not be present at birth, the term developmental more accurately reflects the biologic features than does the term congenital. Despite the recent increased awareness of DDH and the importance of thorough screening programs, hip dysplasia continues to be a frequently missed diagnosis in pediatrics. Earlier detection and diagnosis of DDH is associated with a much more successful and less invasive outcome.

Algorithms↗
PubMed1997

The sagittal pelvic tilt index as a criterion in the evaluation of spondylolisthesis. Preliminary observations.

STUDY DESIGN: Radiographic analysis of a pediatric population with spondylolisthesis was performed to examine sagittal plane pelvic rotation and degree of slip over time. OBJECTIVES: To determine whether the degree of standing sagittal offset of L5 with respect to the acetabulum correlated with slip progression and symptoms. SUMMARY OF BACKGROUND DATA: The natural history of isthmic spondylolisthesis remains unclear. Attempts to predict slip progression in the clinical setting, and thus the possible need for eventual surgical intervention, remain imprecise. Predicting slip progression based on sagittal alignment of the L5 vertebra with respect to the acetabulum has been proposed by some investigators. METHODS: Fifty-two children and adolescents were followed clinically and radiographically for an average of 5.6 years. Serial lateral standing radiographs that included the hips and lumbar spine were measured to compute a sagittal pelvic tilt index. The latter value is a ratio of relative distances from the center of S2 to the projection of L5 and the center of the femoral heads on the horizontal. RESULTS: Of the 52 patients studied, 38 have remained asymptomatic without significant slip progression or change in sagittal pelvic tilt index ratio. Of the original group, 13 patients had significant symptoms and revealed a decrease in the sagittal pelvic tilt index over time. Eight of the 13 stabilized at the end of adolescence, whereas 5 had continued decrease in the sagittal pelvic tilt index ratio. These five required operative treatment for pain and progressive slip. CONCLUSIONS: The sagittal pelvic tilt index gives the examiner an objective measure of the stability of the lumbosacral junction by quantifying the relationship between S2, the center of the hip, and L5. A decreasing sagittal pelvic tilt index ratio in this preliminary series correlated with slip progression and risk of conservative treatment failure, whereas those patients with a stable sagittal pelvic tilt index did not progress and remained clinically asymptomatic.

Adolescent↗
PubMed2005

How does a femoral varus osteotomy alter the natural evolution of Perthes' disease?

To study how a femoral osteotomy alters the natural evolution of Perthes' disease, records and radiographs of 640 patients with Perthes' disease were analyzed. The data of 314 patients who underwent femoral osteotomy were compared with those of non-operated patients. A new modification of classification of the stages of evolution of the disease was used to identify the timing of surgery and to monitor the progress of the disease following surgery. The duration of each stage of the disease, the extent of epiphyseal extrusion, the extent of widening of the femoral metaphysis and the dimensions of the acetabulum were noted on sequential radiographs. The changes in the femoral epiphysis and metaphysis and changes in the acetabulum were also noted. It was observed that a varus osteotomy clearly alters the natural evolution of Perthes' disease. Of patients who were operated in the stage of avascular necrosis, 34% bypassed the stage of fragmentation. The duration of the disease was shorter in these patients. The duration of the stage of fragmentation was reduced in operated children who passed through the stage of fragmentation. The extent of femoral head extrusion was minimized at the stage when it was most vulnerable for deformation. Metaphyseal widening and subsequent femoral head enlargement were also minimized in children who underwent a femoral osteotomy. The chances of retaining the sphericity of the femoral head were much higher in those children who had a femoral osteotomy. These beneficial effects of a varus osteotomy, were most evident when the operation was performed either in the stage of avascular necrosis or in the early stage of fragmentation.

Case-Control Studies↗
PubMedDate not supplied

Coxa magna following surgical treatment of congenital hip dislocation.

We studied coxa magna after operative treatment of congenital dislocation of the hip, including incidence, relationship to treatment, and influence of coxa magna on the acetabulum. Coxa magna was defined as a femoral head with a horizontal diameter at least 15% greater than the symmetrical position on the opposite side. Coxa magna developed in 16 hips (33%). The mean increase was 20.9% (range 15-30%). Three factors correlated with coxa magna: femoral osteotomy (100%), open reduction (75%), and operation at a younger age (mean 15.6 vs. 35.8 months). Four of the 16 hips developed coxa magna following Type 1 avascular necrosis; no other growth deformities appeared. At follow-up, the acetabular indices and the center edge angles were not statistically different between the coxa magna and the control groups. One must avoid confusing coxa magna with hip subluxation or inadequate reduction, of which the latter requires appropriate treatment. Coxa magna gives a good hip if a concentric, congruous reduction is obtained, providing the acetabulum has enough growth potential for remodeling.

Child↗
PubMedDate not supplied

Neonatal hip instability: normal values for physiological movement of the femoral head determined by an anterior-dynamic ultrasound method.

A total of 910 clinically normal hips in neonates younger than 48 h old was examined using an anterior-dynamic ultrasound method to determine normal values for the femoral head diameter and physiological movement of the femoral head in relation to the acetabulum. The femoral head diameters were found to correlate positively with both birthweight and gestational age and to be larger in boys than in girls, the mean values being 16.08 +/- 1.49 mm and 15.56 +/- 1.43, respectively. The values for maximal movement of the femoral head in relation to the acetabulum at provocation by Palmén/Barlow's test were 6.0, 6.6, and 6.8 mm for the birthweights 2,000, 3,000, and 4,000 g, respectively. No significant difference was found between the results of four independent observers in the femoral head movement at provocation. The results of the first and the fourth examination were not significantly different, suggesting that more than four examinations are required to induce hip instability by using the Palmén/Barlow test. Repeated examination after 4 h did not show any significant difference between examinations.

Female↗
PubMed1992

Age-related marrow changes in the pelvis: MR and anatomic findings.

Short repetition time magnetic resonance images of the pelvis in 70 subjects (aged 1 day to 24 years) without history of bone marrow disease were retrospectively analyzed for the distribution and appearance of red and yellow marrow. The signal intensity and degree of mottling of marrow in six anatomic regions of the pelvis were observed and were assigned a grade. Anatomic correlation was provided with gross and microscopic examination of bone marrow biopsy specimens taken from selected pelvic sites in cadavers of children. Marrow signal intensity increased in all pelvic regions except the acetabulum from birth to age 24 years. Marrow heterogeneity was most prominent in the acetabulum at all ages. Patterns of bone marrow signal intensity and heterogeneity are recognized for four age groups: the infant, child, adolescent, and young adult. Regional and age-related differences in the signal intensity of pelvic marrow correlate with the percentage of fat seen microscopically in marrow.

Adolescent↗
PubMed1978

The assessment of prognosis in Perthes' disease.

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side.

Age Factors↗
PubMed1981

The use of computerised tomography in dislocation of the hip and femoral neck anteversion in children.

Computerised tomography is useful in the diagnosis of abnormalities of the hip in children, particularly in assessing the size and shape of the acetabulum, the position and congruity of the femoral head relative to the acetabulum, and the degree of femoral anteversion or retroversion. It is most useful when limited hip movement and previous operations preclude adequate clinical examination and assessment by routine radiographic techniques. It is not recommended for routine use in screening congenital dislocation of the hip or in diagnosis or follow-up of Perthes' disease or slipped capital femoral epiphysis.

Adolescent↗
PubMed1993

Extra-articular augmentation for residual hip dysplasia. Radiological assessment after Chiari osteotomies and shelf procedures.

The Chiari osteotomy and various shelf procedures are used to augment the weight-bearing area in dysplastic acetabula. The new articular surface derives by metaplasia from the acetabular rim and joint capsule, and is therefore of poorer quality than congruous hyaline cartilage. We reviewed 32 patients after augmentation procedures, using conventional radiographs and three-dimensional reconstruction from CT scans. We showed that Chiari osteotomy and shelf procedures generally achieve less than complete cover, especially over the posterolateral quadrant of the femoral head. Our results suggest that alternative methods which reorientate the whole of the acetabulum are the treatment of choice. Augmentation procedures remain as a salvage option when reorientation is inappropriate or the original hyaline cartilage surface is absent, as in subluxed joints with a secondary acetabulum. Computerised assessment is recommended before operation to assess existing cover and the possible extent of provision of new cover.

Adolescent↗
PubMed1997

Primary Charnley total hip arthroplasty for congenital dysplasia: effect of improved techniques of cementing.

We performed Charnley total hip arthroplasties on 64 patients (71 hips) between 1976 and 1984 for moderate congenital acetabular dysplasia in which a superolateral cement thickness of less than 20 mm was expected when the cup was placed in the true acetabulum at an angle of 45 degrees. Of these, 59 hips were examined 10 to 17 years after operation; 37 (group A) had been operated on between 1976 and 1982 using Charnley's original technique of cementing the acetabulum and 22 (group B) between 1983 and 1984 using more modern techniques. In group A, aseptic loosening of the socket was observed in ten hips (27.0%) and the 17-year survival rate was 81.5%. In group B, loosening was noted in only one socket (4.5%) and the 13-year survival rate was 100%. The improved techniques produced significantly better long-term results in fixation of the cup in dysplastic hips without bone grafting.

Adult↗
PubMed2000

Radial MRI of the hip with moderate osteoarthritis.

We carried out radial MRI in 30 hips with moderate osteoarthritis and in ten normal hips. On a scout view containing the entire acetabular rim, 12 vertical radial slices were set at 15 degrees intervals. Different appearances were observed in different parts of the joint. In the weight-bearing portion, from 45 degrees anterosuperior to 45 degrees posterosuperior, 'attenuation' (n = 16) and 'disappearance' (n = 25) were observed as abnormalities of the labrum with 'capsular stripping' (n = 29) and 'extraosseous high signal lesion' (n = 27) as capsular abnormalities, seen more often in the anterosuperior portion. In all 12 planes there were osteophytes on the acetabular edge (n = 24), femoral head (n = 22) and/or at the central acetabulum (n = 6), a bone cyst on the acetabulum (n = 18) and/or the femoral head (n = 9), irregularity of the articular cartilage (n = 30), and an effusion (n = 28). Our findings indicate that radial MRI may be a useful non-invasive diagnostic method for demonstrating pathology in moderate osteoarthritis of the hip.

Adult↗
PubMed2006

Congenital dislocation of the hip. A re-appraisal of the upper age limit for treatment.

Difficulties posed in managing developmental dysplasia of the hip diagnosed late include a high-placed femoral head, contracted soft tissues and a dysplastic acetabulum. A combination of open reduction with femoral shortening of untreated congenital dislocations is a well-established practice. Femoral shortening prevents excessive pressure on the located femoral head which can cause avascular necrosis. Instability due to a coexisting dysplastic shallow acetabulum is common, and so a pelvic osteotomy is performed to achieve a stable and concentric hip reduction. We retrospectively reviewed 15 patients (18 hips) presenting with developmental dysplasia of the hip aged four years and above who were treated by a one-stage combined procedure performed by the senior author. The mean age at operation was five years and nine months (4 years to 11 years). The mean follow-up was six years ten months (2 years and 8 months to 8 years and 8 months). All patients were followed up clinically and radiologically in accordance with McKay's criteria and the modified Severin classification. According to the McKay criteria, 12 hips were rated excellent and six were good. All but one had a full range of movement. Eight had a limb-length discrepancy of about 1 cm. All were Trendelenburg negative. The modified Severin classification demonstrated four hips of grade IA, six of grade IB, and eight of grade II. One patient had avascular necrosis and one an early subluxation requiring revision. One-stage correction of congenital dislocation of the hip in an older child is a safe and effective treatment with good results in the short to medium term.

Age Factors↗