Avascular Changes Research Articles

Surgical treatment of late developmental displacement of the hip

The outcome of displaced hips treated by Somerville and Scott's method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change. The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

Avascular necrosis after surgical treatment for development dysplasia of the hip.

We reviewed the medical records of 101 patients with developmental dysplasia of the hip who were treated with Dega's (102 hips), or Salter's (42 hips)osteotomy preceded by open reduction and femoral intertrochanteric osteotomy. The minimal follow-up was 17 years. At the last follow-up, there were proximal fem-oral growth disturbances in 52 hips (36%). In 20 hips, the disturbances were graded as mild and in six as severe. We found significantly better clinical and radiological results in hips without avascular changes. Risk factors for the development of avascular necrosis were: involvement of the left side and surgical treatment initiated after 2 years of age without pre-operative traction and without femoral shaft shortening. We found that the incidence of avascular necrosis increased with the length of follow-up. The avascular necrosis influenced both clinical and radiological results.

Closed reduction of developmental dislocation of the hip by prolonged traction

The efficacy of traction before an attempted closed reduction for patients with developmental dislocation of the hip remains controversial. We treated 55 children (62 dislocations of the hip) by preliminary, prolonged traction for a mean of eight weeks. All were followed up for at least two years in order to observe the development of any avascular changes within the femoral head. Of the 55 children, 27 (31 dislocations) were followed up until they were over six years of age. Fifty-seven of the 62 hips (92%) showed a successful closed reduction. Only one had radiological evidence of avascular necrosis of the femoral head. Of the 31 hips which were followed up to over six years of age, 15 (48%) showed residual subluxation. Our method of prolonged preliminary traction leads to a high rate of successful closed reduction, a low incidence of avascular necrosis and a reduced need for secondary operations.

The arterial supply of the lesser metatarsal heads: a vascular injection study in human cadavers.

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.

Femoral nailing with transverse locking screws through the femoral neck.

We treated 55 patients with subtrochanteric or comminuted femoral fractures with a transverse locking femoral nail (Alta, Howmedica). This nail was positioned more cephalad than usual so that at least one fixation screw was located in the femoral neck or head. Forty-seven fractures (20 subtrochanteric and 27 diaphyseal) were available for follow-up averaging 12 months (3-35). The time to radiographic healing averaged 7 months (3-21). There was one delayed union, one non-union, two superficial infections, one broken proximal screw, one compartment syndrome of the thigh, and one peroneal nerve palsy. There were no femoral neck fractures, avascular changes of the femoral head, or gluteal irritation at the most recent follow up. The described technique appears safe and effective, is technically easy, and avoids intra-articular screws.

Possible applications of pedicled vascularized bone transplants of the distal radius

Reverse-flow pedicle vascularized bone grafts (VBGs) from the distal radius may be used for the surgical treatment of carpal fracture nonunions and avascular necrosis. Such grafts remain viable with quantifiable blood flow as demonstrated in a recent canine experiment. In this paper, the vascular anatomy of the distal radius is demonstrated and the surgical technique of VBG harvest is described. Our indications and results for treatment of scaphoid nonunion and Kienböck's disease are discussed and compared with the current literature. Fifteen patients with scaphoid nonunion and nine patients with Kienböck's disease stage IIIa were treated by reverse-flow pedicled VBG. Range of motion and grip strength were measured postoperatively and compared to the contralateral hand in all patients. An outcome questionnaire was used to measure patient's satisfaction and ADL's in the patients with Kienböck's disease. The radiologic diagnostic was performed with conventional X-rays, trispiral tomograms and MRI. In the scaphoid nonunion group, all patients were male, with an average age of 27.6 years. Five patients had prior attempts of autogenous bone grafting which failed. Six patients had a radiographic suggestion of proximal fragment avascular necrosis. All scaphoids healed. Time to union was 11.1 weeks on average. Average follow-up was 36.2 months. Pain relief, range of motion and grip strength were very promising. The treatment of Kienböck's disease was also promising in nine patients. Mean patient age was 31 years, and follow-up averaged 32 months. Six patients had complete pain relief, and three had occasional pain. Grip strength reached 86% of the contralateral side (a 25% improvement from preoperative values). Postoperative MRI demonstrated progressive revascularization with time. The results of treating scaphoid nonunions are promising. The use of vascularized bone graft facilitates rapid, reliable union of established scaphoid nonunion, even with proximal location and/or avascular changes. Clinical results in Kienböck's disease have been gratifying as well, with MRI evidence of gradual revascularization on follow-up studies.

Herbert Screw Fixation for Scaphoid Nonunions; An Analysis of Factors Influencing Outcome

A retrospective review of 160 cases of scaphoid nonunion treated by internal fixation using a Herbert screw with bone grafting was conducted at an average followup of 24 months. Definite radiographic union was achieved in 90% of cases. Based on Cooney's clinical scoring system, 80 cases had an excellent result, 37 had a good result, 33 had a fair result, and 10 had a poor result. Failure of union was related to the existence of avascular changes of the proximal fragment, instability of the fracture fragment, the prolonged delay in surgery, and the location of the fracture site. In the united scaphoids, the lengthy period of postoperative immobilization, the existence of osteoarthritis, and the prolonged delay in surgery were significant factors in the patient's functional outcome. Overall, the results do not support the view that a residual flexion deformity of the scaphoid is less likely to yield a satisfactory outcome, although it seems worthwhile to correct excessive angulation at the time of repair to promote an anatomic union, thereby preventing early arthritis. A bone graft with internal fixation using a Herbert screw and a shorter period of immobilization may give a satisfactory functional result when the nonunion is treated before the onset of arthritic changes in the wrist.

LUDLOFF’S MEDIAL APPROACH FOR OPEN REDUCTION OF CONGENITAL DISLOCATION OF THE HIP

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff’s medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff’s medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

Ludloff's medial approach for open reduction of congenital dislocation of the hip. A 20-year follow-up.

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff's medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff's medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

Lunate dislocation with ulnar nerve paresis

A case of volar dislocation of the lunate, associated with transient ulnar nerve palsy, is described in a 39-year-old man, with temporary avascular changes of the left lunate.

Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion

A clinical impression of avascular changes in the hook of the hamate after fracture led to this study of the pattern and size of the hamate hook vascular foramina. It appears that vessels enter the hamate hook at primarily two sites. The radial base foramina are large and always present, while the ulnar tip foramina are small and absent in 29% of specimens. In these hamates, fracture at the hook base could potentially compromise blood supply to the hook fragment, and this may be a factor in hamate hook nonunion.

Avascular necrosis of the hamate: A case report with reference to the hamate blood supply

Avascular necrosis of the hamate bone has not previously been reported. In this case the proximal fragment of the fractured hamate underwent avascular necrosis and prolonged healing. In an attempt to explain this sequela, angiography of the cadaver carpus followed by dissection of intact wrists and a study of enzyme-cleaned hamates showed that their wedge-shaped proximal segments were mostly enveloped by a distal extension of the midcarpal joint cavity and thus totally dependent on intraosseous nutrition. Consequently, the segment is at risk when a fracture line transects the body proximal to the base of the wedge. Clinically, this condition resulted in persistent discomfort and limitations of motion. A postinjury bone scan of the wrist indicated avascular changes in the proximal third of the hamate, and a delayed union was followed by later revascularization and a more normal scan image.

Metachondromatosis and Avascular Necrosis of the Femoral Head

Summary: We report the case histories, radiographic and computed tomographic studies, and histologic findings of two children with metachondromatosis who developed avascular necrosis (AVN) of the femoral ossific nucleus. The first was a 9-year-old boy with involvement of both femoral heads; the second was an 8-year-old girl with involvement of her right femoral head. The changes were associated with either exostoses or enchondromalike lesions of the femoral neck. Interference with the integrity of the lateral epiphyseal vessels by these lesions would explain the avascular changes that occurred. The findings in these cases and other reports associating AVN with skeletal dysplasia should encourage treating physicians to analyze carefully a sudden increase in hip pain or rapid radiographic development of femoral head collapse in a child with a skeletal dysplasia. Recognition of true AVN, in contrast to the gradual evolution of head shape change in typical skeletal dysplasia, may change treatment recommendations and prognosis.

Metachondromatosis and Avascular Necrosis of the Femoral Head

We report the case histories, radiographic and computed tomographic studies, and histologic findings of two children with metachondromatosis who developed avascular necrosis (AVN) of the femoral ossific nucleus. The first was a 9-year-old boy with involvement of both femoral heads; the second was an 8-year-old girl with involvement of her right femoral head. The changes were associated with either exostoses or enchondromalike lesions of the femoral neck. Interference with the integrity of the lateral epiphyseal vessels by these lesions would explain the avascular changes that occurred. The findings in these cases and other reports associating AVN with skeletal dysplasia should encourage treating physicians to analyze carefully a sudden increase in hip pain or rapid radiographic development of femoral head collapse in a child with a skeletal dysplasia. Recognition of true AVN, in contrast to the gradual evolution of head shape change in typical skeletal dysplasia, may change treatment recommendations and prognosis.

Preiser's disease

Nine patients with the diagnosis of unilateral Preiser's disease were seen between 1970 and 1987. The mean age of four male and five female patients was 37 years (range, 20 to 70 years). The diagnosis was based on radiographic evidence of sclerosis, fragmentation, erosion, and collapse of the proximal pole of the scaphoid. Onset was usually insidious but two had a preexisting radial hypoplasia, a third had a modest scaphoid malunion, and a fourth had a recent fall. Treatment consisted of scaphoid excision and silicone rubber prosthetic replacement in three, debridement of necrotic bone fragments in one, and different periods of cast support and observation in the remaining five. No relationship to ulnar variance was seen. Mean follow-up was 6.9 years. Of the scaphoid implants, two had subluxated, but only one was painful. In the more conservatively treated group, pain and function were only modestly limiting in four, who returned to their original occupations as did the one treated by curettage of necrotic bone in the proximal pole. One patient (case 4) was severely incapacitated because of associated severe congenital anomalies of the lower extremities. Polyaxial tomography permitted a better assessment of the degree of involvement and carpal alignment. Preiser's disease is a rare affliction of the carpal scaphoid which may involve the entire bone in avascular changes but primarily leads to fragmentation and collapse of the proximal pole. A conservative approach to treatment is favored based on this experience.

距骨骨折の治療成績 Ｘ線学的検討

Talus fractures are an infrequent occurrence and because of their anatomic unigueness, avascular necrosis often occurs.We performed open reduction on 9 patients with 7 talar neck fractures and 2 body fractures and kept all patients non weight bearing for at least 6 months after surgery.The mean follow up time was 6 years and 5 months with a range of 9 months to 15 years and 9 months.The results of examination were evaluated by X-ray.X-ray changes were as follows, except two cases.(1) Hawkins' sign was seen at an average of 2 months after surgery. (2) Sclerotic changes were seen at an avarage of 6 months after surgery. (3) Recovery of the avascular change was seen at an average 6 months after surgery.In summary, our treatment of talus fractures was satisfactory.

Late Treatment of a Dorsal Transscaphoid, Transtriquetral Perilunate Wrist Dislocation With Avascular Changes of the Lunate

The outcome of delayed treatment of an unreduced transscaphoid, transtriquetral, perilunate fracture dislocation of the carpus is unpredictable. Long-term follow-up observations in a 22-year-old man treated three months postinjury showed changes in the lunate consistent with avascular necrosis at the time of open reduction and internal fixation. Early resolution of this was evident by nine months, and complete resolution was seen at the follow-up examination (four years and two months). Despite delay in treatment, this patient had full, pain-free wrist motion. Consequently, avascular changes of the carpus following wrist dislocation do not preclude a good result. Anatomic reduction of the scaphoid, as well as the midcarpal joint, and restoration of the articular surface of the lunate, are most important in determining prognosis.

Undisplaced fracture of the neck of the femur: results of treatment of 100 patients treated by single Watson-Jones nail fixation

In a review of 100 patients with clinical and radiological evidence of undisplaced Garden stage I and II fractures of the neck of the femur treated by fixation with a single Watson-Jones nail, the early mortality was 4 per cent and in 93 cases with complete radiological data important displacement of the fracture during surgery occurred on one occasion. Of 72 patients with a mean follow-up of 22.6 months (range 3–83 months) 68 patients (94.4 per cent) achieved union and non-union occurred in 4 patients (5.6 per cent) all of whom required further surgery. In 40 patients with united fractures with a minimum follow-up of 2 years (mean 41.2 months; range 24–83 months) the overall incidence of avascular changes was 22.5 per cent; three patients required revisional surgery for late segmental collapse and a further six patients had avascular changes with minimal symptoms. Single nail fixation is a safe reliable procedure and there appears to be little indication for multiple fixation or compression devices for this fracture.

The 'silent hip' of idiopathic ischemic necrosis of the femoral head in adults.

Of thirty-three patients with the asymptomatic (so-called silent) stage of idiopathic ischemic necrosis of the femoral head, eleven had serial roentgenograms available to review the progression of the disease during this stage. Pathological specimens obtained during bone-grafting of eleven femoral heads were available for histological study in another eleven patients. It was found that the duration of the asymptomatic period averaged 5.5 years (range, three to eight years). No evidence of spontaneous regression of the avascular change was found. Typical histological findings were: (1) early clogging of the marrow spaces by amorphous material in the necrotic zone, and (2) limited evidence of so-called crreping substitution (seams of new bone laid on old, dead bone trabeculae) during the early stages of idiopathic ischemic necrosis.

Clinical Study of Revalgisation after Detorsion Varus Osteotomy in Congenital Dislocation of the Hips

Revalgisation after detorsion varus osteotomy for C. D. H. was studied in 38 hips of 35 patients. These patients had no avascular changes of capital femoral epiphysis and were observed more than five years.Results were as follows:(1) The degree of revalgisation mostly correlates with changes of the neck-shaft angle gained by the operation, especially of the epiphyseal angle.(2) In spite of the revalgisation, good congruity of the hips which was obtained by the operation seems to be preserved.