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The dorsal part of the external iliac a. may extend down into the pelvis minor either lateral or medial to the external iliac v. as well as to the obturator nerve. In such cases, the relationship to the direct projection of the acetabulum on the inner surface of the pelvis minor may be of interest to orthopedic surgeons in hip-joint replacement operations and to vascular surgeons.
Special problems are associated with fractures of bones with implanted endoprostheses. These problems are a result of unusual fracture-types often combined with damage and loosening of parts of the prosthesis, the limited applicability of standard osteosynthesis-procedures and the impaired blood supply of the bone caused by the destruction of the medullary vessels after filling the medullary canal with bone cement. Special operative techniques for the treatment of those problem-fractures are demonstrated such as the extension of the prosthesis by an elastic shaft and the concentric osteosynthesis of an unstable acetabulum by a newly developed implant.
Conventional röntgenologic examinations of fifty patients with posttraumatic pelvic bone injuries were compared with computertomographic examinations. The major advantage of computertomography of the pelvis is in our view the more precise evaluation of injuries of the dorsal pelvic ring. Almost fifty percent of the fractures of the sacrum and two thirds of the injuries of the iliosacral joint in our series could not be diagnosed on conventional examinations. Computertomography of fractures of the sacrum and fractures of the acetabulum give us important informations about the extension of the fracture, its dislocation, its degree of instability and accompanying soft tissue injuries. So planning of operative treatment becomes much easier.
In this paper the results of operative and conservative intervention of acetabulum fractures are analysed. It was possible to re-examine 80 of 146 Patients after a period of 5.46 years in mean. 23 patients were treated by osteosynthesis. Time from accident to operation was 13 days in mean. Posterior wall fractures seemed to be the most frequent (classified by Letournel). Results were evaluated according to the following criteria: clinical status (classified by the scheme of Merle d'Aubigne), X-ray, and subjective well-being. In the surgically treated group total hip prosthesis had to be implanted in five patients because of aseptic necrosis of the femoral head, 52.9% of the patients in this group had good results. In the conservative treated cases no total hip prosthesis had to be implanted. 77.8% of the patients had good results. A main aspect is that the average age of the patients who underwent a treatment by osteosynthesis is lower although the fractures were more severe.
48 injuries to the pelvis were treated from January 1991 through December 1991. We found 45 fractures of the pelvic ring with associated acetabular fractures in 15 cases and three isolated acetabular lesions. 19 injuries were caused by car accidents, 18 fractures resulted from a fall, especially in older patients. Isolated fractures of the pelvis occurred in 18 cases. The average total severity of the injuries was 19.7 points according to the Hannover Polytrauma Score (PTS). Every fracture was classified using the Tile-classification. There were 15 (33%) Tile A lesions, 18 (40%) Tile B fractures and twelve (27%) type C pelvic ring injuries. In 18 cases surgery was the method of treatment. Seven out of 18 injuries to the acetabulum were treated with open reduction and internal fixation. In ten patients the unstable pelvic ring was fixed by means of an external fixator. To do so, a pair of 6 mm diameter pins were placed on both sides in the supraacetabular region of the iliac bone directed towards the sacroiliac joints. We used a triangular form of external fixation. An open reduction and internal fixation (ORIF) was necessary in five cases, one injury required a combination of external and internal procedures. There were 14 cases in which we found sacral fractures as an additional dorsal lesion. Nine of 14 sacral fractures were recognized only by CT examination. In eleven cases the conventional radiographs showed simple anterior pelvic ring fractures while the CT examination revealed an additional lesion of the sacroiliac joint in nine of these cases.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: Reduction and retention of unstable and/or severely displaced fractures of the upper pubic ramus with an associated risk of injury to the pelvic organs with transpubic screw fixation. Restoration of form and function of the pelvis. INDICATIONS: Injuries to the pelvic ring with displaced and/or unstable fractures of the upper pubic ramus. Stabilization of the anterior column of the acetabulum in isolated fractures of the anterior column. Additional internal fixation as part of the management of acetabular fractures with transverse components, combined with stabilization of the posterior column. CONTRAINDICATIONS: Poor general health, local soft-tissue injury. SURGICAL TECHNIQUE: Pfannenstiel's incision to achieve open reduction and screw fixation of the pubic ramus under image intensification. POSTOPERATIVE MANAGEMENT: Depending on the general condition of the patient and pelvic ring stability, mobilization on forearm crutches with partial weight bearing (one fifth of body weight) of the side with injury to the posterior pelvic ring. RESULTS: Transpubic screw fixation was performed in 16 patients with displaced fractures of the upper pubic ramus as part of pelvic ring injuries (twice type A, six times type B, eight times type C). Intraoperative complications were not observed. Postoperative complications occurred in two cases (one rectus hernia, one screw pullout with manifestation of chronic osteomyelitis of the pubic ramus). All other fractures healed within 3 months.
Computed tomography (CT) scanning is the gold standard for displaying and visualizing complex anatomic structures such as the calcaneus, pelvis, and spine, etc. In orthopedic surgery CT scanning is unfortunately not available in the OR where it would be highly effective if scans could be done prior to wound closure. The reasons are high costs, need for constructional changes in the OR, and additional staff (radiologic technologist), etc. For the first time the ISO C(3D) enables the surgeon to generate multiplanar reconstruction (MPR) pictures during surgery within an acceptable time frame at a reasonable price with a familiar instrument (a modified C-arm). Since February 2001 we have been able to use the ISO C(3D) in our hospital and meanwhile we have scanned 442 surgical sites including the calcaneus, cervical spine, and acetabulum, etc. The intraoperative scans revealed fracture gaps and steps, unsatisfactory fragment alignment, or incorrectly positioned implants, leading to an overall revision rate of 7.3%The ISO C(3D) is a first step towards a new future for bone visualization. The next steps will bring an increase in scan area and resolution, and the high-contrast pictures will be replaced by ones very similar to modern CT slices showing certain soft tissue structures.
Acetabular fractures in elderly patients are rare injuries, but their incidence is increasing. Poor bone quality due to osteoporosis and an increased operative risk due to concomitant disease are factors complicating surgical therapy. Literature does not provide generally accepted treatment protocols. In a 4-year period, 27 patients who were 65 years or older and who had an acute displaced fracture of the acetabulum were admitted to our department. Four minimally displaced and stable fractures were managed conservatively. Internal fixation was performed in 16 cases. According to the Merle d'Aubigné score, in 15 out of 18 surviving patients excellent or good results were found. Treatment strategy should be planned individually for each fracture, taking into account the patients biological age and general condition, fracture type, bone quality and associated injuries. Primary endoprosthetic replacement should only be considered when the acetabular bone stock allows stable cup fixation. Osteosynthesis in combination with early endoprosthetic replacement should be considered in acetabular fractures with associated femoral head or neck fractures or when significant articular steps and/or bone defects remain after open reduction and internal fixation.
Increasing numbers of total hip arthroplasties in combination with increasing age and growing daily activities of the elderly lead to increasing numbers of periprosthetic fractures and revision arthroplasties in osteoporotic bone. The prosthesis nail is a hybrid of a hip prosthesis and an intramedullary nail allowing immediate full weight bearing and early rehabilitation. The prosthesis nail consists of three self-locking components: a distally locked intramedullary nail, different lengthening modules, and a hip prosthesis module. From 1992 to 1999, 28 prosthesis nails were implanted in 26 patients (40-88 years, mean age: 71 years). The indications were 21 peri- and subprosthetic fractures caused by trauma, 2 fractures of the proximal femur in combination with a fracture of the femoral head or severe degenerative arthritis, and 4 revision arthroplasties associated with poor bone quality. A combination of the prosthesis nail and bone cement was used in one patient suffering from a pathological fracture of the distal femur. Patients were additionally treated with wire cerclage (six patients) and autogenous bone grafting (ten patients). All patients-except those who received a reconstruction of the acetabulum in the same session (four patients)-were mobilized with full weight bearing on the operated side as soon as wound pain diminished. Bone healing was observed in all periprosthetic fractures. In three patients the prosthesis nail had to be revised: one patient suffered from recurrent dislocations and in one patient weighing 350 pounds limb shortening occurred after the distal locking screw broke. Intramedullary infection was observed once after treatment of a periprosthetic fracture. When bone union was achieved the prosthesis nail was removed and the patient was mobilized with a girdlestone situation. The idea of the prosthesis nail is based on the logical consequence of treating femur fractures with the most efficient procedure, which is intramedullary nailing. The prosthesis nail can be applied according to the requirements of the fracture as a reamed or unreamed nail and immediate full weight bearing is possible. Considering the high average age of the patients, low morbidity, short rehabilitation time, and low costs are the major advantages of this new device. Taking into account the unfavorable preoperative conditions associated with elderly and multimorbid patients, the rate of complications is relatively low.
The acetabulum fracture with chronic dislocation of the femoral head is relatively uncommon. Due to complex morphology and bone defect of the acetabular dome, stable internal fixation is difficult. Primary total hip arthroplasty represents an alternative treatment. We report the case of a 66-year-old patient with a 3-month history of acetabular fracture with central dislocation of the femoral head. The patient was treated with cemented total hip arthroplasty and cancellous bone grafting of the central dome defect for stable cup fixation.
Only a few cases of specific tuberculous infections of total hip arthroplasties have been published. We report the case of a 66-year-old male patient who received a cementless total hip arthroplasty due to osteoarthritis of the left hip in 1990. Four years later, revision arthroplasty with a Wagner revision stem was performed because of aseptic loosening. In 1995 revision of a loosened acetabular cup was necessary. In 1996 we saw the patient for the first time in our outpatient unit. He complained of increasing pain in the region of the left hip. X-rays showed loosening of the Wagner stem. Aspiration of the synovial fluid of the left hip revealed an infection with mycobacterium tuberculosis (radioimmunoassay). There were no signs of tuberculous infection in the patient's history. Treatment consisted of removal of the prosthesis followed by antituberculosis chemotherapy for 12 months with rifampicin, ethambutol, isoniazid, and pyrazinamide. In April 2001 revision of the left hip joint and implantation of a MRP titanium revision stem and reconstruction of the acetabulum with an acetabular reconstruction ring was done. Until today the patient exhibits no signs of recurrence of the tuberculous infection.
The anatomy of the hip must be taken into account in order to ensure primary stability of cementless acetabular implants. In this study we analyzed the shapes of osteoarthritic acetabula and compared these to normal non-degenerative acetabula and to pressfit implants. We measured 92 acetabula with osteoarthritic deformations and 35 non-degenerative acetabula. Bone tissue samples from 50 osteoarthritic acetabula were microradiographically analyzed. Furthermore, the size of the entrance plane of 37 pressfit cups was determined. The craniocaudal and ventrodorsal diameters of osteoarthritic acetabula correlate strongly ( r=0.87). In craniocaudal direction, the acetabular diameter correlates significantly to both the radius of the lunate surface ( r=0.42) and the acetabular base ( r=0.54). Osteoarthritic acetabula have a deeper shape as degeneration increases and the entrance plane becomes significantly more circular ( p<0.05). When comparing osteoarthritic and non-arthrotic acetabula, the following values differ significantly (p<0.05): craniocaudal radius of the acetabular base, craniocaudal and ventrodorsal radius of the lunate surface, and ventrodorsal divergence between lunate surface and acetabular base. To reconstruct an acetabular offset which concurs with central points of the femoral head and the radius of the lunate surface, the level of the insert's entrance plane must be outside the entrance planes of the cup and acetabulum. The rims of hemispheric cups need to be trimmed to prevent these cups from extending beyond the acetabular rim.
The biomechanical reasons for moving and loosening of the acetabular cup and femoral prosthesis are still unclarified. Especially, chronic and mechanical overloads of the interfaces, which are caused by the change of stiffness and damping properties of the whole system, cannot be excluded. To date, the description of dynamic behaviour of hip-joint endoprostheses from the viewpoint of material selection and design is insufficient. On the basis of comparative experiments, this publication aims to complete the knowledge about mechanical properties of artificial hip joints. Primarily, we focused on the quantitative registration of certain influences (e.g. design, dimensions and material) on the dynamic properties of different kinds of acetabulum cups. Therefore, a significant new test method was developed for this examination. Conventional test methods work according to the principle of constancy of maximum forces and excitation frequencies. They do not consider the forces of inertia resulting from body mass, even though these reaction forces are decisive for the dynamic properties and mechanical behaviour of the components of endoprostheses. A selection of representative implants from several manufacturers were tested according to the new test method, which is based on the "mass-spring, absorber" principle. The examined prostheses concerned differed in material, method of fixation and geometric dimensions. The results of these examinations give clues to the repercussions of the mentioned parameters on the dynamic behaviour of endoprosthetic systems. In order to evaluate the results, hip joints from animals were also examined and provided relevant information for desirable alternative solutions to the problem in view of construction and material.
Between 1990 and 1996, 129 children (mean age 4.8 years) with hip pain were examined consecutively. In group I (n = 100, mean age 4.14 +/- 2.2), transient synovitis of the hip was diagnosed; group II (n = 29, mean age 7.3 +/- 2.1) showed the following diagnoses: Perthes' disease (n = 12), early slipped capital femoral epiphysis (n = 5), Meyer's dysplasia (n = 2), septic arthritis of the hip (n = 2), osteomyelitis of the acetabulum (n = 1), abscess of the psoas (n = 1), chondromatosis of the hip joint (n = 1), Ewing's sarcoma of the os pubis (n = 1), hip dysplasia (n = 1). Three patients who had synovitis developed Perthes' disease and were assigned to group II. The efficiency of ultrasound, scintigraphy and MRI as diagnostic tools was tested in the examination of painful hip. A capsular distension was present in 73 cases and showed a significant statistical difference (t-test, P < 0.001) in group I between affected and unaffected hips. There were no differences in the measurements of the epiphyseal and metaphyseal width in group I between the affected and the nonaffected side (t-test, P = 0.91, P = 0.57) and between the first sonographic evaluation at presentation and at the follow-up (t-test, P = 0.053, P = 0.75). MRI was performed, because of persistent joint effusion, in 10 cases in group I, and Perthes' disease was excluded. In group II the use of an MRI allowed the diagnosis in 89% of the cases. Sonographic examination, together with X-ray examination and serological testing, represent the first choices in the evaluation of a painful hip at presentation and in the follow-up of transient synovitis. MRI should always be performed when abnormalities are present at the clinical and sonographic examination, and when the X-ray does not allow a clear diagnosis.
The acetabular labrum appears as a bundle of distinctly circular lined up collagenous fibers. It surrounds the limbus tangentially and is separated from the cartilagenous covered facies lunata through a thin gap (fissure) except of a small zone in the craniocaudal part. The labrum is strongly fixed with the transverse acetabular ligament. A vascular anastomotic ring surrounds the capsular attachment. It derives its blood supply especially from the superior gluteal vessels, the obturator artery and one ascending branch of the medial femoral circumflex artery. The innervation of the acetabular labrum is coming from a branch of the nerve to the quadratus femoris muscle and from the obturator nerve. There are all types of mechanoreceptors in the labrum. The acetabular labrum is able to exert a high tensional force on the rim of the acetabulum. This plays a very important role in view of the physiological, load depending incongruity of the articulating parts of the hip-joint.
The long-term results of acetabular revision after total hip arthroplasty (THA) with the use of a reinforcement ring with hook were evaluated. The study included 57 cases of surgery dating back 10 years or more. Of a total of 54 patients (57 operated hips), 18 patients (19 hips) died during the 10-year period and 2 patients (2 hips) were completely lost to follow-up. At the time of the revision surgery, the mean age of the remaining 34 patients (36 hips) was 62.5 years (range: 47-80). A THA revision was done in 25 cases and an acetabular revision only in 11 cases. The most common acetabular defect was a combined segmental and cavitary defect (n = 19), and in three cases there was pelvic discontinuity. Autologous or homologous cancellous bone grafts were used to fill acetabular cavities in 17 hip joints. Structured bone grafts, predominantly homologous bone, were used in ten cases for acetabular reconstruction. At a mean follow-up of 11.4 years (range: 10-14.5) three hip joints (8%) had undergone further revision. The revisions were done for aseptic loosening of the acetabular component in two cases and a septic loosening of both components in one case. Three further cases (8%) revealed signs of acetabular loosening. Two of these three patients were symptomatic but refused further revision surgery. In the 33 unrevised hip joints, a good or excellent clinical result with a d'Aubingé score of more than 14 points was found in 30 cases (92%). Osseous acetabular reconstruction with the use of a reinforcement ring leads to favorable results compared to other techniques. In the authors' opinion, this technique is preferable to those using oversized cups without osseous reconstruction of the acetabulum.
BACKGROUND: The arterial vascularity of the hip has been investigated in normal infants using duplex Doppler sonography. This study addressed the differences in hip vascularity in infants with respect to gender and acetabular morphology. OBJECTIVE: To determine whether there is a relationship between the resistive index of the vessels of the femoral chondroepiphysis and the alpha angle in normal infant hips and in those with developmental dysplasia of the hip. MATERIALS AND METHODS: We studied 76 hips (38 patients) with gray-scale and power Doppler US. The patients were referred because of a possible abnormal clinical hip examination or had risk factors for developmental dysplasia of the hip. The infants ranged in age from 1 day to 6 weeks. There were 13 boys and 25 girls. Gray-scale images were initially performed in the coronal and transverse planes to evaluate acetabular morphology, alpha angle and position of the femoral chondroepiphysis relative to the acetabulum. The hips were then examined with power Doppler US, in both sagittal and transverse planes, to identify arterial vessels within the femoral epiphysis. Resistive indices were then recorded from the spectral analysis in each vessel identified. Each examination was performed by one of five pediatric radiologists. Mixed model regression was used to assess the relationship between resistive index and alpha angle, age and gender. RESULTS: Of the 76 hips, 34 had an alpha angle of 60 degrees or greater and were classified as normal, 26 had an alpha angle between 50 degrees and 59 degrees and were classified as immature, and 13 had an alpha angle of less than 50 degrees and were either subluxed or dislocated at the time of examination. At least two vessels were documented in each femoral epiphysis except in three hips, in which no vessels could be documented because of technical factors. There was a statistically significant linear relationship between the alpha angle and resistive index, such that the resistive index tended to rise with increasing alpha angle (P=0.0022). In addition, female infants had a significantly higher average resistive index than the average resistive index in male infants with the same alpha angle (P=0.0005). CONCLUSION: There is a direct linear relationship between alpha angle and resistive index in the infant hip. Female infants have a higher average resistive index than male infants. We believe that these results might serve as a model for predicting an infant hip at risk of ischemia. In addition, the fact that lower resistive indices of the femoral epiphysis are associated with acetabular dysplasia might help explain the documented low incidence of avascular necrosis in untreated hip dysplasia.
OBJECTIVE: To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. DESIGN AND PATIENTS: One hundred and seventy-eight active duty military endurance trainees with a history of activity-related hip pain were evaluated by both MRI and bone scan over a 2-year period. Patients in the study ranged in age from 17 to 45 years. They had hip pain related to activity and had plain radiographs of the hip and pelvis that were interpreted as normal or equivocal. The study was originally designed to evaluate the MRI and scintigraphic appearance of femoral neck stress fractures. Patients had scintigraphy and a limited MRI examination (coronal imaging only) within 48 h of the bone scan. Twelve patients demonstrated imaging findings compatible with acetabular stress fractures. RESULTS: Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. CONCLUSIONS: Stress fractures are commonplace in military populations, especially endurance trainees. Acetabular stress fractures are rare and therefore unrecognized, but do occur and may be a cause for activity-related hip pain in a small percentage of military endurance athletes and recruits.