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PubMed2005

The bicompartmental acetabulum in Perthes' disease: 3D-CT and MRI study.

The bicompartmental acetabulum is one of the morphological changes which may be seen in children with Legg-Calvé-Perthes' disease. Three-dimensional CT and MRI were used to analyse the detailed morphology of the acetabulum with special reference to its inner surface, in 16 patients with Perthes' disease and a bicompartmental acetabulum.The bicompartmental appearance was seen on the coronal plane image through the acetabular fossa. The lunate surface was seen to grow laterally resulting in an increased mediolateral thickness of the triradiate cartilage. On the horizontal plane images, the acetabular fossa had deepened and had a distinct prominence at its posterior border. The combination of these morphological changes resulted in a bicompartmental appearance on plain radiography. Acetabular bicompartmentalisation appears to be the result of an imbalance of growth between the cartilage-covered lunate surface and the cartilage-devoid acetabular fossa.

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PubMed2006

Indometacin as prophylaxis for heterotopic ossification after the operative treatment of fractures of the acetabulum.

Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo. We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.

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PubMed2006

Outcome of surgery for reconstruction of fractures of the acetabulum. The time dependent effect of delay.

This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.

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PubMed1994

Comminuted fractures of the posterior wall of the acetabulum. A biomechanical evaluation of fixation methods.

Reproducible simple fractures and osteotomies of the posterior wall of the acetabulum were created in twenty paired hemipelves from fresh human cadavera. Comminution was created with an additional fracture line that was either parallel (concentric comminution) or perpendicular (transverse comminution) to the posterior rim of the acetabulum. Under simulated weight-bearing, the stiffness of fixation of the transversely comminuted fractures that had been achieved with use of a reconstruction plate and screws was significantly higher than that achieved with fixation with screws alone (p < 0.05). The load to failure of the fixation of transversely comminuted fractures treated with a reconstruction plate and screws was also significantly higher than that of fixation of such fractures with screws alone (p = 0.05). The load to failure of the fixation of concentrically comminuted fractures was significantly higher when a reconstruction plate and accessory spring plates had been used than when a reconstruction plate alone had been employed (p < 0.05).

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PubMed1997

Allograft reconstruction of the acetabulum after resection of stage-IIB sarcoma. Intermediate-term results.

Seventeen consecutive patients were managed with an allograft reconstruction of the pelvis (including the acetabulum) following resection of a stage-IIB bone sarcoma during a twelve-year period. The initial diagnosis was chondrosarcoma in nine patients, osteosarcoma in six, Ewing sarcoma in one, and leiomyosarcoma in one. All patients who had osteosarcoma or Ewing sarcoma received chemotherapy preoperatively and postoperatively. Fifteen patients were managed with an allograft-total hip prosthesis composite. Two patients initially were managed with an osteoarticular allograft without a prosthesis, but one had a subsequent revision to an allograft-implant composite. Four patients died with an intact allograft reconstruction. Eight patients survived with an intact allograft reconstruction, and they were followed for at least four years (mean, seven years; maximum, fourteen years). All but one was able to walk in the community with one or two canes at the time of the latest follow-up. There was a high rate of local recurrence, which occurred in three of the seventeen patients, and of infection, which developed in two patients. The five patients had a subsequent hindquarter amputation or removal of the allograft. The mean functional score (and standard deviation), according to the rating system of the Musculoskeletal Tumor Society, was 65 +/- 21.16 per cent (median, 70 per cent; range, 13 to 87 per cent) for the thirteen patients who were thus evaluated. Preservation of the limb and reconstruction with an allograft may be considered as an alternative to hindquarter amputation in carefully selected patients who have a bone sarcoma involving the acetabulum. However, patients who have a high-grade bone sarcoma must be warned that there is a substantial risk of local recurrence or infection. In the present series, more than half of the patients either died or had failure of the reconstruction.

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PubMed2002

Results of operative treatment of fractures of the posterior wall of the acetabulum.

BACKGROUND: The purpose of this study was to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. METHODS: One hundred patients who had had open reduction and internal fixation of an unstable unilateral fracture of the posterior wall of the acetabulum were studied. Ninety-four patients were assessed at a mean of five years (range, two to fourteen years) after the injury. Six patients with a poor result were followed for less than two years. The functional outcome was evaluated with use of the clinical grading system adopted by Letournel and Judet with incorporation of modifications by Matta. Patient, fracture, and radiographic variables were analyzed to identify possible associations with functional outcome. RESULTS: The reduction of the fracture, as determined with plain radiography, was graded as anatomic in ninety-seven patients and as imperfect in three. The clinical outcome at the time of final follow-up was graded as excellent in fifty-five patients, very good in twenty-five, good in nine, fair in one, and poor in ten. The radiographic result was excellent in eighty-one patients, good in five, fair in four, and poor in ten. There was a strong association between the clinical outcome and the final radiographic grade. Variables identified as risk factors for an unsatisfactory clinical result included a delay of greater than twelve hours before reduction of an associated hip dislocation, an age of fifty-five years or older at the time of injury, intra-articular comminution, and osteonecrosis. CONCLUSIONS: The uncomplicated radiographic appearance and relatively simple operative approach for fractures of the posterior acetabular wall belie the risk of poor results. Prompt reduction of an associated hip dislocation is imperative. Fractures in elderly patients and those with extensive comminution are more likely to have a poor clinical result. However, a high likelihood of a long-term good-to-excellent result can be expected following anatomic reduction and internal fixation of these fractures.

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PubMed2003

Computed tomographic assessment of fractures of the posterior wall of the acetabulum after operative treatment.

BACKGROUND: The purpose of this study was to evaluate the results after operative treatment of fractures of the posterior wall of the acetabulum in relationship to the quality of the fracture reduction as assessed by postoperative two-dimensional computed tomography. METHODS: The functional results for sixty-seven patients who had open reduction and internal fixation of an unstable fracture of the posterior wall of the acetabulum and the findings of two-dimensional computed tomography performed postoperatively were analyzed. Sixty-one patients were followed for a mean of four years after the injury, and the remaining six patients who had poor early results necessitating reconstructive surgery were followed for less than two years. All patients were evaluated preoperatively and postoperatively with use of three standard plain radiographs (one anteroposterior and two Judet 45 degrees oblique pelvic radiographs) and a two-dimensional computed tomography scan. The functional outcome for the patients was evaluated with use of a modification of the clinical grading system described by Letournel and Judet. The radiographs were graded according to the criteria described by Matta. The two-dimensional computed tomography scans were used to determine fracture gap and offset measurements. RESULTS: The clinical outcome was graded as excellent in thirty-one patients (46%), very good in twenty (30%), good in eight (12%), and poor in eight (12%). The final radiographic results were graded as excellent in fifty-three hips (79%), good in four (6%), fair in three (5%), and poor in seven (10%). There was a strong association between clinical outcome and final radiographic grade. Fracture reductions were graded as anatomic in sixty-five and imperfect in two, as determined with use of plain radiography. However, postoperative computed tomography revealed an incongruency (offset) of >2 mm in eleven hips and fracture gaps of > or = 2 mm in fifty-two. Fracture gaps of > or = 10 mm in any dimension or a total gap area of > or = 35 mm(2) were associated with a poor result. The main risk factors for a poor result were a residual fracture gap width of > or = 10 mm and osteonecrosis of the femoral head. CONCLUSIONS: The degree of residual fracture displacement is detected more accurately on postoperative computed tomography scans than on plain radiographs. The accuracy of surgical reduction as assessed on postoperative computed tomography is highly predictive of the clinical outcome. LEVEL OF EVIDENCE: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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PubMed2003

Treatment of the dysplastic acetabulum with Wagner spherical osteotomy. A study of patients followed for a minimum of twenty years.

BACKGROUND: The purpose of this study was to evaluate the long-term clinical and radiographic results of spherical acetabular osteotomy, performed with the surgical technique described by Wagner, in patients with hip dysplasia. METHODS: The results of the first twenty-two spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum of twenty years (median, 23.9 years; maximum, 29.3 years) postoperatively. Preoperative and follow-up radiographic measurements included the lateral and anterior center-edge angles, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Anteroposterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint-space narrowing, increased sclerosis of the subchondral bone, and bone cysts. Clinical evaluation was performed with use of the Harris hip score. RESULTS: Osteotomy improved the mean lateral center-edge angle from -2 degrees to +13 degrees and the mean acetabulum-head index from 52% to 72%. The mean postoperative anterior center-edge angle was 23 degrees (range, -1 degrees to 62 degrees ). Seven (32%) of the twenty-two hips were converted to a total hip replacement. At the latest follow-up examination, the average Harris hip score of the remaining fifteen patients was 86 points (range, 50 to 100 points). The clinical result was rated good or excellent for eleven of the fifteen patients. At the latest follow-up examination, the severity grade of the osteoarthritis was unchanged in thirteen hips. Only three of the nine hips that subsequently required a total hip replacement or that showed progressive osteoarthritis had been congruent after the index operation, whereas ten of the thirteen hips that did not require total hip replacement or show progressive osteoarthritis had been congruent after the index operation. The twenty-year Kaplan-Meier survival estimate, with conversion to total hip replacement as the end point, was 86.4% (95% confidence interval, 63.4% to 95.4%). The twenty-five-year survival estimate was 65.1% (95% confidence interval, 35.6% to 83.7%). CONCLUSIONS: The Wagner spherical osteotomy prevented progression of osteoarthritis both clinically and radiographically in a high proportion of patients with residual hip dysplasia who were followed for a minimum of twenty years. Operative restoration of joint congruency is associated with a satisfactory long-term outcome in a very high proportion of cases.

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PubMed2004

The Wagner spherical osteotomy of the acetabulum. Surgical technique.

BACKGROUND: The purpose of this study was to evaluate the long-term clinical and radiographic results of spherical acetabular osteotomy, performed with the surgical technique described by Wagner, in patients with hip dysplasia. METHODS: The results of the first twenty-two spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum of twenty years (median, 23.9 years; maximum, 29.3 years) postoperatively. Preoperative and follow-up radiographic measurements included the lateral and anterior center-edge angles, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Anteroposterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint-space narrowing, increased sclerosis of the subchondral bone, and bone cysts. Clinical evaluation was performed with use of the Harris hip score. RESULTS: Osteotomy improved the mean lateral center-edge angle from -2 degrees to +13 degrees and the mean acetabulum-head index from 52% to 72%. The mean postoperative anterior center-edge angle was 23 degrees (range, -1 degrees to 62 degrees ). Seven (32%) of the twenty-two hips were converted to a total hip replacement. At the latest follow-up examination, the average Harris hip score of the remaining fifteen patients was 86 points (range, 50 to 100 points). The clinical result was rated good or excellent for eleven of the fifteen patients. At the latest follow-up examination, the severity grade of the osteoarthritis was unchanged in thirteen hips. Only three of the nine hips that subsequently required a total hip replacement or that showed progressive osteoarthritis had been congruent after the index operation, whereas ten of the thirteen hips that did not require total hip replacement or show progressive osteoarthritis had been congruent after the index operation. The twenty-year Kaplan-Meier survival estimate, with conversion to total hip replacement as the end point, was 86.4% (95% confidence interval, 63.4% to 95.4%). The twenty-five-year survival estimate was 65.1% (95% confidence interval, 35.6% to 83.7%). CONCLUSIONS: The Wagner spherical osteotomy prevented progression of osteoarthritis both clinically and radiographically in a high proportion of patients with residual hip dysplasia who were followed for a minimum of twenty years. Operative restoration of joint congruency is associated with a satisfactory long-term outcome in a very high proportion of cases.

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PubMed2006

Functional results and quality of life after treatment of pelvic sarcomas involving the acetabulum.

BACKGROUND: Limb salvage after resection of a pelvic sarcoma that involves the acetabulum represents a surgical challenge. The ideal method of reconstruction after acetabular resection remains a subject of controversy, and the outcome in terms of the impact of therapy is still unknown. The purpose of this study was to determine the impact of surgery on health-related quality of life and function after acetabular resection. METHODS: Eighty-one patients with a pelvic sarcoma underwent acetabular resection at a single institution. Functional evaluation and quality-of-life examination were performed in forty-five patients, and these patients comprised the study group. Quality of life was assessed with use of the European Organization for Research and Treatment of Cancer core quality-of-life questionnaire. Function was assessed with use of the Musculoskeletal Tumor Society system. RESULTS: The median age of the patients was 30.4 years at the time of the acetabular resection and 35.7 years at the time of follow-up. The median time interval from the index operation to the latest follow-up was sixty-nine months. At the latest follow-up evaluation, the mean functional status score was 14.5 points of a maximum of 30 points. In a comparison of endoprosthetic replacement and hip transposition following resection, significantly better functional results (p = 0.017) and a lower number of complications were found in patients who had a hip transposition. Quality-of-life assessment results were also better in patients with a hip transposition, especially in role functioning (p = 0.043). CONCLUSIONS: On the basis of the low complication rate and the good functional and quality-of-life results, hip transposition after acetabular resection seems to be the optimal technique for treating patients with a pelvic sarcoma involving the acetabulum.

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PubMed1997

Placement of screws in the uncemented acetabulum: anatomic analysis of the danger zone.

Six cadavers were used to define the projection of the external iliac artery on the inner table of the acetabulum, and to quantitatively determine bony dimensions of the danger zone with regard to screw placement. The results showed that the majority of projections of the external iliac arteries were located on the superior portion of the posterosuperior quadrant and extended to the mid-superior portion of the anterosuperior quadrant (danger zone). The inferior portion of the danger zone was relatively far from the external iliac artery. The greatest depths of bone were found in the inferior portion of the danger zone, and the depths of bone in the middle and superior portion of the danger zone were relatively thinner. This anatomic study showed that the real danger zone was found in the middle and superior portions of the anterosuperior quadrant of the acetabulum. The inferior portion of the anterosuperior quadrant was relatively safer. This area may be considered if transacetabular screw replacement in the anterosuperior quadrant is required.

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PubMed1999

Intra-articular benign osteoblastoma of the acetabulum: a case report.

The acetabulum is an unusual location for benign osteoblastoma, usually seen in adolescents and young adults. This article reports a case of an intra-articularly expanding benign osteoblastoma of the acetabulum in a 6-year-old boy. The diagnostic and surgical features of the disease in this unusual location at this young age are discussed. Excisional biopsy and curettage of the lesion followed by bone grafting resulted in healing of the acetabular lesion without acetabular dysplasia, but with a resultant coxa magna.

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PubMed1999

Osteoid osteoma of the acetabulum. Three cases treated by percutaneous resection.

The acetabulum is a rare location for osteoid osteoma. Conventional surgery of such lesions may require either a large bone resection, an arthrotomy, or a hip dislocation. This report describes the technique and results of percutaneous lesion removal using computed tomography guidance in three osteoid osteomas of the acetabulum. Histologic confirmation was obtained in the three cases. The three patients experienced complete pain relief with a mean followup of 36 months.

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PubMedDate not supplied

Significance of the lateral epiphysis of the acetabulum to hip joint stability.

Normal development of the acetabulum is crucial to the growth and stability of the hip. Twenty-five New Zealand White rabbits (postweaning) weighing 1.5-2.2 kg were used. Both hips were exposed through an anterolateral approach. On the right hip, a fixed area of superolateral physeal cartilage was damaged with drills. Sham open reduction was performed for the left hip. Radiographic changes of the right hips were evident at 6 weeks. At 12 weeks, the right hip dislocated in a posterior and superior direction. The left hip remained normal. Histopathologic analysis correlated strongly with the radiographic findings. There were thinning of cartilage cells of the acetabulum, with disorganization. The acetabular roof was poorly formed. The lateral acetabular epiphysis is vital to the development of the acetabular roof. Damage to this epiphysis may result in acetabular maldevelopment and subsequent hip instability. We tested the hypothesis that abnormality in this epiphysis can give rise to abnormal acetabular development.

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PubMedDate not supplied

Posterior wall fractures of the acetabulum: characteristics, management, prognosis.

A consecutive series of 60 fractures of the posterior wall of the acetabulum, treated operatively in a Level I Trauma center, is reviewed retrospectively. Characteristics of the lesion, type of treatment, early and late postoperative complications and two-year functional results were recorded. In 27 patients (45%), additional damage to the cartilage of the acetabular cavity such as subchondral impaction, free articular fragments or separation of the posterior wall into several pieces was present. Seven patients (11.6%) showed preoperative neurological deficit. All fractures were treated with open reduction and internal fixation through a Kocher-Langenbeck approach. Secondary nerve damage was present in 8.3%. Early secondary surgery was necessary in 8.3%. During the first two years, additional surgery was performed in 7 patients (15.2%). The rate of periarticular ossifications was 26.1%. The rate of excellent and good results was 69.5%. The posterior wall fracture of the acetabulum is a more complex injury than generally is accepted. A large variety of articular lesions with varying degree of complexity is collected in this fracture type. Even in experienced hands, excellent and good long-term results will not exceed 75%. Poor results are due to suboptimal reconstruction of the posterior wall, partial osteonecrosis and/or complications of the Kocher-Langenbeck approach.

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PubMed2001

[Experience in reconstruction of bony deficits of the acetabulum in total hip arthroplasty (THA)].

The past 40 years have been a period of spectacular advances in the technologies related to orthopedic surgery, especially for THA. One of the major problems of THA is reconstruction of bony stock deficits of the acetabulum. The material consisted of 113 patients aged from 43 to 81 years (average age: 62.5 years), who were found to have bony stock deficits and endoprosthesis loosening. In the group there were 78 women (average age 65 years) and 35 men (average age 61 years). Acetabulum bony stock deficiency was classified according to the Paprosky Classification System. Deficits classified as 1st, 2nd and 3rd A grade were treated using the X-Change technique, while deficits classified as 3rd B and C grade were treated by application of a reinforcing ring and bone packing of morselized bone.

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PubMed2003

Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty.

Periprosthetic fractures of the acetabulum that occur in association with a total hip arthroplasty are unusual injuries that present several challenges to successful management. As the number of total hip arthroplasties performed each year increases along with the number of patients with severe bone loss who require revision surgery, periprosthetic fractures of the acetabulum are becoming more prevalent. However, there is little information available to guide the orthopaedic surgeon in the management of these injuries. A comprehensive classification of these injuries is presented that is useful for guiding the management of these complex problems.

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PubMed2003

7th Yahya Cohen Lecture. Significance of the lateral epiphysis of the acetabulum to hip joint stability.

Normal development of the acetabulum is crucial to the growth and stability of the hip. Twenty-five New Zealand white rabbits (postweaning) weighing 1.5 to 2.2 kg were used. Both hips were exposed through an anterolateral approach. On the right hip, a fixed area of superolateral physeal cartilage was damaged with drills. Sham open reduction was performed for the left hip. Radiographic changes of the right hips were evident at 6 weeks. At 12 weeks, the right hip dislocated in a posterior and superior direction. The left hip remained normal. Histopathologic analysis correlated strongly with the radiographic findings. There were thinning of cartilage cells of the acetabulum, with disorganisation. The acetabular roof was poorly formed. The lateral acetabular epiphysis is vital to the development of the acetabular roof. Damage to this epiphysis may result in acetabular maldevelopment and subsequent hip instability. We tested the hypothesis that abnormality in this epiphysis can give rise to abnormal acetabular development.

Acetabulum↗