Bilateral Hip Surgery Research Articles

Can the Acetabular Labrum Be Reconstructed With a Meniscal Allograft? An In Vivo Pig Model.

No single graft type has been shown to have a benefit in acetabular labral reconstruction. The native labrum and lateral meniscus share many similarities, suggesting that the meniscus may be a promising source of graft material in labral reconstruction. Using a pig model, we sought to evaluate the healing process of fresh-frozen meniscus allograft for acetabular reconstruction by assessing (1) MRI and macroscopic observations of the meniscus allograft; (2) histologic appearance and immunohistologic evaluation of the meniscus allograft, native meniscus, and labrum; (3) microscopic assessment of the native labrum and meniscus via scanning electron microscopy; and (4) biomechanical assessment of tensile properties. Twelve skeletally mature male miniature Bama pigs (24 hips) were randomly divided into two groups: labral defect group (control) and lateral meniscus allograft group. The selection of Bama pig specimens was based on the similarity of their acetabular labrum to that of the human acetabular labrum, characterized by the presence of fibrocartilage-like tissue lacking blood vessels. The pigs underwent bilateral hip surgery. Briefly, a 1.5-cm-long section was resected in the anterior dorsal labrum, which was left untreated or reconstructed using an allogeneic lateral meniscus. The pigs were euthanized at 12 and 24 weeks postoperatively, and then evaluated by macroscopic observations and MRI measurement to assess the extent of coverage of the labral defect. We also performed a histologic analysis and immunohistologic evaluation to assess the composition and structure of meniscus allograft, native labrum, and meniscus, as well as scanning electron microscopy assessment of the microstructure of the native labrum and meniscus and biomechanical assessment of tensile properties. Imaging measurement and macroscopic observations revealed that the resected area of the labrum was fully filled in the lateral meniscus allograft group, whereas in the control group, the labral defect remained at 24 weeks. The macroscopic scores of the meniscus allograft group (8.2 ± 0.8) were higher than those of the control groups (4.8 ± 1.0) (mean difference 3.3 [95% CI 1.6 to 5.0]; p < 0.001). Moreover, in the meniscus allograft group, histologic assessment identified fibrocartilage-like cell cluster formation at the interface between the graft and acetabulum; cells and fibers arranged perpendicularly to the acetabulum and tideline structure that were similar to those of native labrum could be observed at 24 weeks. Immunohistochemical results showed that the average optical density value of Type II collagen at the graft-acetabulum interface was increased in the meniscus allograft group at 24 weeks compared with at 12 weeks (0.259 ± 0.031 versus 0.228 ± 0.023, mean difference 0.032 [95% CI 0.003 to 0.061]; p = 0.013). Furthermore, the tensile modulus of the lateral meniscus allograft was near that of the native labrum at 24 weeks (54.7 ± 9.9 MPa versus 63.2 ± 11.3 MPa, mean difference -8.4 MPa [95% CI -38.3 to 21.4]; p = 0.212). In a pig model, lateral meniscus allografts fully filled labral defects in labral reconstruction. Regeneration of a fibrocartilage transition zone at the graft-acetabulum interface was observed at 24 weeks. The use of an autograft meniscus for labral reconstruction may be a viable option when labral tears are deemed irreparable. Before its clinical implementation, it is imperative to conduct a comparative study involving tendon grafts, which are extensively used in current clinical practice.

The Cartilage Protective Effect of Labrum Reconstruction Using Meniscus Allograft Compared with Labrum Resection in a Porcine Model.

This study aimed to verify the femoral head cartilage protective effect of labral reconstruction in a porcine model. Twelve pigs (24 hips) were divided into 3 groups: labrum defect group, lateral meniscus (LM) allograft group, and LM allograft wrapped with acellular peritoneum matrix (LM-APM) group before undergoing bilateral hip surgery. The pigs were sacrificed at 12 and 24 weeks postoperatively, while the femoral head cartilage was retrieved and then subjected to imaging measurement, macroscopic observations, and biomechanical and histological assessment. Imaging measurement and macroscopic observations revealed that the defect area of the labrum was filled in LM and LM-APM allograft groups after 24 weeks, whereas the labrum defect remained at 24 weeks in the control group. The femoral head cartilage corresponding to the area of labral resection in the labral defect group had worse macroscopic Osteoarthritis Research Society International (OARSI) scores, uneven and discontinuous cartilage on hematoxylin and eosin (H&E) staining and Safranin O staining, decreased histopathology OARSI Osteoarthritis Cartilage Histopathology Assessment System (OOCHAS) scores, and decreased elastic modulus and hardness at 12 and 24 weeks after surgery compared with the meniscus allograft groups. This study demonstrated that the LM allograft with or without APM for labral reconstruction had a chondroprotective effect on the femoral head in a porcine model.

Unilateral versus bilateral reconstructive hip surgery in children with cerebral palsy: A survey of pediatric orthopedic surgery practice and decision-making.

Purpose:This study explored whether surgeons favor unilateral or bilateral reconstructive hip surgery in children with cerebral palsy who have unilateral hip displacement.Methods:An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopedic surgeons. The case of an 8 year old at Gross Motor Function Classification System level IV with migration percentages of 76% and 22% was described. Surgeons selected their surgical treatment of choice and provided their rationale. Respondents were also asked to list and rank radiographic parameters used for decision-making and multidisciplinary team members involved in decision-making.Results:Twenty-eight orthopedic surgeons from nine countries with a mean 21.3 years (range, 5–40 years) of experience completed the survey. A “bilateral VDROs with a right pelvic osteotomy (PO) was selected by 68% (19/28) of respondents; risk of contralateral subluxation (9/19; 47%) and maintaining symmetry (7/19; 37%) were the most common rationales for bilateral surgery. The remaining 32% (9/28) chose a ‘right VDRO with a right PO’” with most of these (8/9; 89%) stating the left hip was sufficiently covered. Of 31 radiographic parameters identified, migration percentage, acetabular angle/index, Shenton line, neck shaft angle, and presence of open/closed triradiate growth plates were the most common. Physical therapists (68%) and physiatrists (43%) were most likely to be involved in pre-operative surgical consultation.Conclusion:There is a lack of agreement on management of the contralateral hip in children with unilateral hip displacement. Further studies comparing patient important outcomes following unilateral and bilateral surgery are required.Level of Evidence:V

Demographic and clinical profile of patients treated with proximal femoral nails – a 10-year analysis of more than 40,000 Cases

BackgroundHip fractures are common in elderly populations and can be life threatening. Changes in healthcare delivery and outcomes for patients with hip fracture treated with intramedullary nails are not well characterized. The objectives of our study were: 1) the characterization of patients treated with the Trochanteric Fixation Nail -Advanced™(TFNA) Proximal Femoral Nailing System or comparable nails (index) and estimate 12-month all-cause readmissions (ACR) and reoperations following index; and 2) the evaluation of 10-year healthcare utilization (HCU) trends for treatment of femoral fractures with femoral nails.MethodsThis is a retrospective database analysis using the Premier hospital database. All adults with femoral fracture treated with an intramedullary nail, from 2010 to Q3 2019, in the inpatient setting, were identified. Exclusion criteria included patients with bilateral hip surgery and presence of breakage at time of initial surgery. The primary outcome was ACR and reoperation, the secondary outcomes were healthcare utilization metrics. Variables included demographics, comorbidities (Elixhauser Index (EI)), surgical intervention variables and hospital characteristics.ResultsForty-one thousand one hundred four patients were included in the study, of which 14,069 TFNA patients, with average age 77.9 (Standard deviation (SD): 12.0), more than 60% with 3 or more comorbidities (more than 64% for TFNA), 40% with severe or extreme disease severity and one third with severe or extreme risk for mortality. ACR reached 60.1% (95% confidence interval (CI): 59.6%-60.5%) – for TFNA: 60.0% (95%CI: 59.2%-60.8%). The reoperation rate was 4.0% (95%CI: 3.8%-4.2%) – for TFNA: 3.8% (95%CI: 3.5%-4.1%). Length of stay (LOS) averaged 5.8 days (SD: 4.8), and 12-month hip reoperation was 4.0% (3.8%-4.2%), in TFNA cohort: 3.8% (3.5%-4.1%). From 2010 to 2019: the percentage patients operated within 48 h of admission significantly increased, from 75.2% (95%CI: 74.3%-76.1%) to 84.3% (95%CI: 83.9%-84.6%); LOS significantly decreased, from 6.2 (95%CI: 6.0–6.4) to 5.6 (95%CI: 5.5–5.7) days; discharge to skilled nursing facilities (SNF) increased from 56.0% (95%CI: 54.8%-57.2%) to 61.5% (95%CI: 60.8%-62.2%); ACR rates decreased but reoperation rates remained constant.ConclusionsACR and reoperation rates were similar across device types and averaged 60.1% and 4.0%, respectively. Ten-year analyses showed reductions in hospital HCU and greater reliance on SNF.

Peri-Operative Anesthetic Management of a Patient with Aplastic Anemia for Total Hip Replacement: Case Report

Aplastic anemia is rare hematological disorder with approximate incidence 1.5-7 cases per million individuals per year. Osteonecrosis, a frequently seen in patients with aplastic anemia. With improved treatment modalities, the life expectancy of patients with aplastic anemia has increased considerably, so are the patients undergoing surgery for various pathologies. Due to rarity of the diseases, there are no specific formulated guidelines on the anesthetic management of these patients. Here, we describe successful anesthetic management of a young male patient with aplastic anemia who was posted for bilateral hip surgery.

V03-02 TOTALLY ROBOTIC INTRACORPOREAL YANG-MONTI CONTINENT ILEOVESICOSTOMY IN PATIENT WITH PREVIOUS ROBOTIC SURGERY - TECHNIQUE DESCRIPTION

You have accessJournal of UrologyPediatrics (V03)1 Sep 2021V03-02 TOTALLY ROBOTIC INTRACORPOREAL YANG-MONTI CONTINENT ILEOVESICOSTOMY IN PATIENT WITH PREVIOUS ROBOTIC SURGERY - TECHNIQUE DESCRIPTION Cinthia Galvez, Diana M. Lopategui, Laura Horodyski, and Miguel Castellan Cinthia GalvezCinthia Galvez More articles by this author , Diana M. LopateguiDiana M. Lopategui More articles by this author , Laura HorodyskiLaura Horodyski More articles by this author , and Miguel CastellanMiguel Castellan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001991.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the last 4 decades, since the description of the appendix continent vesicostomy by Mitrofanoff, many variations have been described, including the Yang and Monti procedures in 1993 and 1997 respectively. The introduction of minimally invasive technologies challenged the pediatric urologists to develop these techniques and transition from open to robotic assisted. We present a video case report of a pediatric patient who underwent robotic assisted Monti-Yang continent ileovesicostomy. METHODS: Patient is a 10-year-old female patient with a history of neurogenic urinary incontinence due to spina bifida. She had a past surgical history of several surgical procedures including myelomeningocele repair at birth, ventriculoperitoneal (VP) shunt at 3-month-old, robotic assisted Malone procedure and robotic assisted artificial urethral sphinter (AUS 800) placed 4 years ago. She used to void and do clean intermittent catheterization (CIC) per urethra but, after her bilateral hip surgery, she had significant difficulty for catheterization due to reduced leg mobility. Decision was made to perform an intracorporeal Monti-Yang ileovesicostomy procedure to allow her to avoid urethral catheterization. For the procedure, a “V”-shape flap incision was made at the umbilicus and under an open Hasson technique a 5-mm assistant laparoscopic port was introduce. A 12 mm robotic port at the superior right quadrant. Additional three robotic working arm 8-mm were placed: at midline 4 cm above the umbilicus, at the superior left quadrant and 4cm below on the left of the prior trocar. The robot was docked. At twenty centimeters from the ileocecal valve, a 3 cm segment of ileum was dissected and suspended intrabdominal through percutaneous sutures. Then it was transected, detubularized and retubularized around a 10 Fr catheter using continuous suture with 4-0 Polydioxanone and second layer with interrupted suture 5-0 Poliglecaprone 25. This conduit was anastomosed to the anterior wall of the bladder with creation of an anti-reflux tunnel with 4-0 Polydioxanone and fixated to the skin at the level of the umbilicus with 5-0 Poliglecaprone 25. A 10 Fr Foley catheter was left in place in the conduit. RESULTS: Total operative time was 3h 56min (skin to skin). Patient tolerated the procedure well and her pain was well controlled immediately in the post-operative (PO) period. He started Malone flushing in PO day 2, and regular diet in PO day 5. She was discharged home on PO day 6 with the 10 Fr Foley camped catheter placed on the umbilicus. Three weeks later, the umbilicus catheter was removed, and patient initiated her CIC through the umbilicus stoma q3hr. At 3 months follow up, patient continues catheterizing through her stoma each 3 hours without leaking between cath. CONCLUSIONS: The Monti-Yang continent Ileovesicostomy is an effective well-validated method to allow self-catheterization in selected patients. Even that our patient had multiple past abdominal surgeries (robotic assisted AUS, Malone procedure and, VP shunt placement), this procedure was performed totally robotic intracorporeal with good outcome. Expansion of robotic surgery make minimal invasive surgery more accessible even for complex urologic procedure in the pediatric population. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e222-e223 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cinthia Galvez More articles by this author Diana M. Lopategui More articles by this author Laura Horodyski More articles by this author Miguel Castellan More articles by this author Expand All Advertisement Loading ...

Relieved Low Back Pain after Total Hip Arthroplasty in Patients with Both Hip Osteoarthritis and Lumbar Degenerative Disease.

ObjectiveTo investigate the relief of low back pain after hip arthroplasty in patients with hip joint and spinal degenerative diseases, and to discuss the effects of unilateral and bilateral hip surgery on the relief of low back pain.MethodsIn this retrospective study, we followed 153 patients (69 males and 84 females, age: 43–88 years) who had undergone total hip arthroplasty (THA) via a posterolateral approach and also suffered from lumbar degenerative diseases in the period of 2009 to 2019. The inclusion criteria were: (i) patients who had been diagnosed with severe hip degenerative disease and also been diagnosed with lumbar degenerative disease; (ii) patients who had undergone THA surgery; and (iii) patients who were retrospectively recruited. The exclusion criteria were: (i) patients who had undergone lumbar fusion or internal fixation surgery; or (ii) patients who had vascular claudication, history of major trauma, diabetic polyneuropathy, lumbar and pelvic infections, tumor diseases; (iii) or patients who had undergone THA because of femoral neck fracture or ankylosing spondylitis. The improvement of hip joint function and the relief of low back pain (LBP) were studied, and the effect of unilateral and bilateral THA on the relief of LBP were discussed. Hip pain and function were evaluated by the Harris Hip Score (HHS), LBP was evaluated by Visual Analog Scale (VAS), and lumbar function was evaluated by the Japanese Orthopaedic Association (JOA) scoring system.ResultsThe average follow‐up time was 44.3 months (24–108 months). All patients recovered smoothly without complications. The LBP VAS of 153 patients decreased from 4.13 ± 1.37 preoperatively to 1.90 ± 1.44 postoperatively. The average HHS increased from 45.33 ± 13.23 preoperatively to 86.44 ± 7.59 postoperatively at the latest follow‐up. According to Japanese Orthopaedic Association scoring system, the proportion of patients with good response to treatment in these 153 patients reached 93.46%. LBP VAS decreased from 4.18 ± 1.38 preoperatively to 1.95 ± 1.49 postoperatively in unilateral group and from 3.94 ± 1.32 preoperatively to 1.73 ± 1.23 postoperatively in bilateral group, respectively. There were only nine patients with persistent or aggravated LBP after operation. Among them, six patients underwent subsequent lumbar surgery (five patients had pain relieved after reoperation and one patient had not) and the other three patients chose conservative treatment for pain.ConclusionTHA can relieve LBP while relieving hip pain and restoring hip function in patients with both hip and lumbar degenerative disease, thus possibly avoiding further spinal surgery.

Totally robotic intracorporeal Monti-Yang continent ileovesicostomy in patient with previous robotic surgery–Technique description

We present a video case report of a pediatric patient with previous robotic abdominal surgery who underwent robotic assisted Monti-Yang continent ileovesicostomy. This 10-year-old female had a history of spina bifida, with previous myelomeningocele repair and ventriculoperitoneal shunt as an infant and robotic-assisted Malone procedure and artificial urethral sphincter placed 4 years ago. After undergoing bilateral hip surgery, she presented with difficult urethral catheterization due to reduced leg mobility. A Monti-Yang ileovesicostomy procedure was planned. A 5mm laparoscopic port placed through the umbilicus followed by four additional DaVinci XI working ports. Twenty centimeters proximal the ileocecal valve, a 3cm segment of ileum was dissected, then transected, detubularized, and retubularized around a 10 Fr catheter. This conduit was reimplanted to the anterior bladder wall. The other edge was fixed to the umbilicus. A 10 Fr Foley catheter was left clamped in the conduit, and a urethral Foley was left to gravity. Total operative time was 3h 56min. The patient did well post-operatively. She was discharged home on POD 6. Starting three weeks after surgery, the patient began catheterizing through the umbilical stoma. At 3 month follow-up, the patient catheterizes through her stoma every 3h without leakage between catheterizations.

Validation of scoring hip osteoarthritis with MRI (SHOMRI) scores using hip arthroscopy as a standard of reference.

To validate SHOMRI gradings in preoperative hip magnetic resonance imaging (MRI) with intra-arthroscopic evaluation of intraarticular hip abnormalities. Preoperative non-arthrographic 3.0-T MRIs of 40 hips in 39 patients (1 patient with bilateral hip surgery) with femoroacetabular impingement (FAI) syndrome (mean age, 34.7 years ± 9.0; n = 16 females), refractory to conservative measures, that underwent hip arthroscopy were retrospectively assessed by two radiologists for chondrolabral abnormalities and compared with intra-arthroscopic findings as the standard of reference. Arthroscopically accessible regions were compared with the corresponding SHOMRI subregions and assessed for the presence and grade of cartilaginous pathologies in the acetabulum and femoral head. The acetabular labrum was assessed for the presence or absence of labral tears. For the statistical analysis sensitivity and specificity as well as intraclass correlation (ICC) for interobserver agreement were calculated. Regarding chondral abnormalities, 58.8% of the surgical cases showed chondral defects. SHOMRI scoring showed a sensitivity of 95.7% and specificity of 84.8% in detecting cartilage lesions. Moreover, all cases with full-thickness defects (n = 9) were identified correctly, and in n = 6 cases (out of n = 36 with partial-thickness defects) the defective cartilage was identified but the actual depth overestimated. Labral tears were present in all cases and the MR readers identified 92.5% correctly. ICC showed a good interobserver agreement with 86.3% (95% CI 80.0, 90.6%) CONCLUSION: Using arthroscopic correlation, SHOMRI grading of the hip proves to be a reliable and precise method to assess chondrolabral hip joint abnormalities. • Assessment of hip abnormalities using MRI with surgical correlation. • Comparing surgery and MRI by creating a hybrid anatomic map that covers both modalities. • Non-arthrographic use of 3.0-T MRI provides detailed information on cartilage and labral abnormalities in hip joints.

Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option.

BackgroundThe optimal treatment of osteonecrosis of the femoral head has not been established yet. The aim of this study was to report preliminary clinical results of focal anatomic-resurfacing implantation for the treatment of osteonecrosis of the femoral head.MethodsFive patients (four male, one female) with seven surgical procedures, ages between 37 and 52 with an average age of 45.2 (+/− 7.2), diagnosed as femoral head avascular necrosis and who were unresponsive to conservative management or had failed previous surgical treatments were treated with a focal anatomic femoral head resurfacing between the years 2011–2012 and were retrospectively reviewed. Five patients with at least two years of follow-up, one left hip, two right hips, and two patients with bilateral hip surgery were included in this review. After safe surgical dislocation of the hip, full exposure of the femoral head was established. A focal-resurfacing implant matching patient anatomy and femoral head curvature was performed accordingly. Neither intraoperative or postoperative complications nor revision ensued. Visual analogue scores and Harris Hip Scores were recorded both preoperatively and at postoperative 2 years for all seven surgeries.ResultsThe mean follow-up period was 26.6 +/− 3.8 months, with a range between 24–33 months. The mean visual analogue scores were 8.9 +/− 0.9 preoperatively and 2.3 +/− 1.0 postoperatively at year two (p = 0.017). Harris Hip Scores at postoperative follow-up were found to improve significantly from good to excellent scores (86.0 +/− 7.9), compared with preoperative poor scores (26.7 +/− 11.8) (p = 0.018). The clinical improvements in visual analogue scores (VAS) and Harris Hip Scores were also found to correlate with each other (p < 0.05).ConclusionsIn the present study, the alternative technique of focal anatomic hip resurfacing with HemiCAP® yielded preliminary successful results for the treatment of osteonecrosis of the femoral head. To the best of our knowledge, this is the first case series in the literature, reporting functional clinical results with the use of a focal anatomic-resurfacing implant for the treatment of focal femoral head osteonecrosis.

Rehabilitation and return to sport after bilateral open surgery for femoroacetabular impingement in a professional ice hockey player: A case report

Study designCase report. BackgroundThe aim of this case report was to describe the rehabilitation and return to sport of a professional ice hockey player with symptomatic femoroacetabular impingement (FAI) after bilateral open hip surgery. Case descriptionA 21-year-old professional ice hockey player with symptomatic FAI underwent bilateral surgical hip dislocations within a 6-week time period. After the second surgery (right hip), he experienced right hip pain due to iliotibial band dehiscence, which required additional revision surgery. The athlete underwent a standardized rehabilitation protocol. Hip muscle strength was objectively assessed during rehabilitation. OutcomesIliotibial band dehiscence did not allow the athlete to increase ipsilateral hip abductor strength. This prolonged the rehabilitation period for 12 weeks. The athlete returned to training on the ice without physical contact and to competitive matchplay after 7 and 8 months, respectively. DiscussionThis case report showed that iliotibial band dehiscence occurred after open hip surgery and delayed the return to sport of this athlete. Standardized rehabilitation following bilateral open hip surgery was however successful for the return to sport of this professional ice hockey player with bilateral symptomatic FAI.

EVALUATION OF DIFFERENT MODALITIES OF SURGICAL TREATMENT FOR AVASCULAR NECROSIS OF THE FEMORAL HEAD IN BASRAH

This prospective study was done in Basrah General Hospital, from June 2009 to December 2011. It included 92 hips in eighty one patients affected clinically and radiologically by femoral head avascular necrosis. They were 50 males and 31 females, mean age 41 years with a range of 15-67 years with stage II-IV of femoral head AVN according to Ficat and Arlet radiological staging system. The aims of this study are; to know the pattern of avascular necrosis of the femoral head, and to evaluate the outcome of the different surgical modalities. Surgery was conducted in form of; group I includes twenty four hips (24.4%) which were treated by core decompression (12 hips =12.2% by multiple small drilling (group I-a); seven patients were satisfied with the result of surgery. Infection was reported in one patient. Twelve hips =12.2% by wide bore drilling "gutter" and bone graft(group I-b); nine patients were satisfied by the result of surgery). Group II includes fifty three hips (54.1%) which were treated by total hip arthroplasty (25=25.5% cemented THR (group II-a); seventeen patients were satisfied with the procedure; Complications were reported in three cases, and 28=28.6% cementlessTHR (group II-b); twenty one patients were satisfied; complications had been encountered in five cases); five patients had bilateral hip surgery. Group III includes twenty one hips (21.4%) which were tackled by Girdlestone (resection arthroplasty); six patients had bilateral hip surgery. Only nine patients were satisfied with this procedure. In conclusion, core decompression surgery in form of wide bore drilling with bone graft is suitable treatment for early stages of avascular necrosis. Total hip replacement is suitable option for AVN in advance stage. Resection arthroplasty still is an option for patients in certain situations (e.g. infection), although the results were less favorable.

A Phase II Study of Bortezomib (Velcade®), Cyclophosphamide (Cytoxan®), Thalidomide (Thalomid®) and Dexamethasone as First-Line Therapy for Multiple Myeloma

Background: This phase II trial evaluated the response rate of sequential bortezomib (VELCADE®), cyclophosphamide (Cytoxan®), and dexamethasone ([VCD]; 3 cycles) followed by bortezomib, thalidomide (Thalomid®), and dexamethasone ([VTD]; 3 cycles) as first-line therapy for patients with multiple myeloma. The primary endpoints were overall response, achievement of „d very good partial response (VGPR), as well as assessment of safety and tolerability.Methods: Patients with newly diagnosed, untreated symptomatic myeloma were eligible. Treatment consisted of three 21-day cycles of bortezomib 1.3mg/m2 days 1, 4, 8, and 11, cyclophosphamide 300mg/m2 IV days 1 and 8 and dexamethasone 40mg p.o. or IV days 1, 2, 4, 5, 8, 9, 11, 12; followed by three 21-day cycles of bortezomib 1.0mg/m2 days 1, 4, 8, and 11; thalidomide 100 mg p.o. daily and dexamethasone same as cycles 1–3. Patients received thrombosis prophylaxis with ASA 325mg daily during cycles 4–6. Upon completion of the 6 cycles, patients proceeded to autologous stem cell harvest, transplant and/or maintenance therapy. Responses were defined as a decrease in serum and/or urine monoclonal (M) protein by 50% or greater. VGPR and other responses were as per the International Response Criteria.Results: This report provides results for all 44 eligible patients: median age 59 years; 68% male; 61% Stage III (D/S); documented ISS Stage II/III 59%; IgG 66%, IgA 17%; 17% light chain only. To date the first 30 patients are fully evaluable for response with 28-day post therapy follow up. The overall response rate (ORR; ≥PR) is 90% with 18/30 (60%) achieving CR + VGPR (CR 33%); 9/30 (30%) PR and 3/30 (10%) stable disease or not evaluable. Overall, both components of the sequential regimen were very well tolerated. One patient had a ruptured colonic diverticulum possibly related to dexamethasone, but recovered well and achieved VGPR on trial. There have been 49 therapy attributed toxicity events which have required drug/schedule adjustments. Of these, 9 events were Gd 3/4: 3 attributed to cyclophosphamide, 3 to dexamethasone, 2 attributed to bortezomib and 1 to thalidomide. DVT occurred in one patient who was at high risk because of prior bilateral hip surgery. Fourteen patients have proceeded to successful stem cell harvest and autologous transplant. Post transplant follow up as well as response information for all 44 patients will be presented.Conclusion: This bortezomib/cyclophosphamide/dexamethasone (VCD) based combination induction therapy followed by VTD is a promising addition to the treatment armamentarium for previously untreated patients. The response rates: ORR 90%; □ VGPR (60%) and CR (33%) are extremely encouraging and improve over our bortezomib/dexamethasone 2-drug experience which produced 90% □ PR and 38% □ VGPR. This very well tolerated new regimen is potentially an important step forward in induction therapy with presentation of more mature data.Supported by the Aptium Oncology Research Network and a research grant from Millennium Pharmaceuticals, Inc.

High Reoperation Rates After Early Treatment of the Subluxating Hip in Children With Spastic Cerebral Palsy

Hip subluxation and dislocation are well-recognized complications of spastic cerebral palsy. Alternatives for treatment include observation, bracing, or surgery. The purpose of this study is to compare the rates of reoperation and acetabular development after early soft tissue procedures with those of varus derotational osteotomies performed to maintain reduced hips in severely involved children. A series of 60 patients with spastic cerebral palsy and hip subluxation younger than 6 years who underwent primary bilateral hip surgery at one hospital between 1980 and 1996, with a minimum of 4 years of follow-up, were retrospectively reviewed. Fifty-two patients had spastic tetraplegia and 47 were nonambulators. Measures of proximal femoral and acetabular development were made via radiographic analysis. Twenty-two patients underwent primary bilateral soft tissue procedures. At a mean 6-year follow-up, there was modest improvement seen in mean femoral head coverage and little improvement seen in mean indices of acetabular development. Seventeen of these 22 patients (77%) underwent reoperation. Thirty-eight patients underwent primary bilateral varus derotational osteotomies. At a mean follow-up of 5 years, there was also modest improvement noted in mean femoral head coverage with little change in the mean indices of acetabular development. Twenty-eight of these 38 patients (74%) underwent reoperation. In this population of severely involved patients with spastic cerebral palsy, the reoperation rate was high. Acetabular remodeling did not reliably occur as a result of either early soft tissue or proximal femoral procedures when performed at an average age of 4 years.

Heterotopic Ossification Following Hip Osteotomies in Cerebral Palsy

The aims of this study are, first, to determine the incidence of heterotopic ossification (HO) in patients with cerebral palsy (CP) who have undergone pelvic and/or proximal femoral osteotomies and, second, to identify any risk factors that may contribute to its development in this patient population. The radiographs of 219 consecutive patients with CP who underwent proximal femoral osteotomies with or without pelvic osteotomies were reviewed. Risk factors including gender, age, and degree of involvement, ambulatory status, previous hip operations, bilateral hip surgery, capsular release, concomitant pelvic osteotomy, infection, and history of exuberant callus were evaluated. Thirty-five (16%) patients were diagnosed with HO and the 5 factors that cause HO were identified, which are degree of involvement (quadriplegic), ambulatory status, capsular release, infection, and previous hip operations. Based on logistic regression analysis, if a patient had quadriplegic type of CP, then they have 17.5 times more risk for HO than a patient with hemiplegic type, and capsular release increases the risk 237 times. Although HO occurred in 16% of patients treated with bony procedures in the hip, in a small group (2%) of children it had a clinically significant limitation requiring surgical resection. In this study, clear risk factors were presented for the development of HO; however, none of these risk factors can be altered in ways that will reduce the risk for HO. These risk factors might be used to define a high-risk group in whom attempts at prophylactic treatment for prevention of HO could be initiated.

Case 95:

A 22-year-old man who previously had undergone bilateral hip surgery presented with left knee pain after a fall. Physical examination revealed a flexed knee, with pain and swelling along the anterior aspect of the knee. Radiographs of the knee were obtained. Magnetic resonance (MR) imaging of the knee was performed subsequently.

Optimal Timing of Preoperative Radiation for Prophylaxis Against Heterotopic Ossification

In a previous study, we developed a rabbit model of heterotopic ossification and demonstrated that 800 or 1200 cGy of radiation before an operation on the hip significantly decreased postoperative ectopic bone formation compared with that seen after the operation on the non-irradiated, contralateral hip. The purpose of this study was to determine the optimal preoperative timing of radiation prophylaxis against heterotopic ossification following hip surgery in this same experimental model. Seventy-two hips in thirty-six New Zealand White rabbits were divided into four treatment groups corresponding to four preoperative points in time (four hours, twenty-four hours, seventy-two hours, and three weeks). The hips were irradiated with 1200 cGy at the different preoperative time points (eighteen hips at each time) to investigate the efficacy of the four preoperative radiation protocols. The rabbits then underwent bilateral hip surgery. They were killed and radiographs were made four months postoperatively. Heterotopic ossification was graded according to a modification of the scale of Brooker et al. The mean grade, the interobserver and intraobserver reliability, and the significance (p < 0.05) of the differences between the groups were evaluated. Radiation delivered at twenty-four hours preoperatively was significantly more effective for prophylaxis against heterotopic ossification than was radiation delivered at four hours or seventy-two hours preoperatively (p < 0.05), and the difference between the twenty-four-hour and three-week groups approached significance (p = 0.088). Furthermore, the twenty-four-hour group had a significantly lower percentage of hips with high-grade heterotopic ossification than did the four-hour (p = 0.02), seventy-two-hour (p = 0.002), and three-week (p = 0.03) groups. Preoperative irradiation to prevent heterotopic ossification optimally should be administered twenty-four hours before the operation. This latency period probably allows expression of radiation-induced sublethal mutations in the genetic code of pluripotential stem cells and precludes differentiation to osteoblastic cell lines.

OPTIMAL TIMING OF PREOPERATIVE RADIATION FOR PROPHYLAXIS AGAINST HETEROTOPIC OSSIFICATION

Background: In a previous study, we developed a rabbit model of heterotopic ossification and demonstrated that 800 or 1200 cGy of radiation before an operation on the hip significantly decreased postoperative ectopic bone formation compared with that seen after the operation on the non-irradiated, contralateral hip. The purpose of this study was to determine the optimal preoperative timing of radiation prophylaxis against heterotopic ossification following hip surgery in this same experimental model. Methods: Seventy-two hips in thirty-six New Zealand White rabbits were divided into four treatment groups corresponding to four preoperative points in time (four hours, twenty-four hours, seventy-two hours, and three weeks). The hips were irradiated with 1200 cGy at the different preoperative time points (eighteen hips at each time) to investigate the efficacy of the four preoperative radiation protocols. The rabbits then underwent bilateral hip surgery. They were killed and radiographs were made four months postoperatively. Heterotopic ossification was graded according to a modification of the scale of Brooker et al. The mean grade, the interobserver and intraobserver reliability, and the significance (p < 0.05) of the differences between the groups were evaluated. Results: Radiation delivered at twenty-four hours preoperatively was significantly more effective for prophylaxis against heterotopic ossification than was radiation delivered at four hours or seventy-two hours preoperatively (p < 0.05), and the difference between the twenty-four-hour and three-week groups approached significance (p = 0.088). Furthermore, the twenty-four-hour group had a significantly lower percentage of hips with high-grade heterotopic ossification than did the four-hour (p = 0.02), seventy-two-hour (p = 0.002), and three-week (p = 0.03) groups. Conclusions: Preoperative irradiation to prevent heterotopic ossification optimally should be administered twenty-four hours before the operation. This latency period probably allows expression of radiation-induced sublethal mutations in the genetic code of pluripotential stem cells and precludes differentiation to osteoblastic cell lines. Clinical Relevance: If the findings of this study are validated in human clinical trials, they may allow preoperative outpatient radiation prophylaxis for patients at risk for heterotopic ossification. This approach would minimize patient discomfort and eliminate the risk of prosthetic hip dislocation associated with transport and positioning of the patient for radiation therapy in the early postoperative period.

The origin of osteoprogenitor cells responsible for heterotopic ossification following hip surgery: an animal model in the rabbit

Purpose. To investigate the source of osteoprogenitor cells responsible for heterotopic ossification (HO) following total hip arthroplasty in an animal model. Methods. New Zealand White (NZW) rabbits ( n=20) received a radiation treatment 24 h preoperatively to the hip joint of one hindquarter and to the femoral shaft of the contralateral side. Subjects underwent bilateral hip surgery 24 h after treatment. Subjects were euthanized and radiographed 4 months postoperatively. Heterotopic ossification was graded according to a modified Brooker scale. Mean grade, intra-observer reliability, and statistical significance ( p<0.05) were evaluated to compare the severity of heterotopic ossification between hindquarters treated with hip irradiation versus those treated with femoral shaft irradiation. Results. The Fleiss Weighted Kappa Statistic indicated “almost perfect” (0.872) intra-rater reliability of radiographic heterotopic ossification grading. The average heterotopic ossification grade for the group receiving radiation to the hip was significantly greater than that for the group receiving radiation to the femoral shaft (2.575 versus 2.0, p<0.02). Conclusion. Although both have some beneficial effect, our results demonstrate that irradiation of the femoral canal is significantly more effective than irradiation of the hip joint and abductor musculature for heterotopic ossification prophylaxis. This suggests that osteoprogenitor cells responsible for heterotopic ossification originate from both the hip abductors and the femoral canal, but the data provide indirect evidence that the femoral canal may be a more dominant source of these cells in the rabbit model.

Connecting bar for hip spica reinforcement: does it help?

The purpose of this prospective study was to determine if a connecting bar prevented mechanical failure of hip spicas. Eighty-two hip spicas were applied to 70 patients between April 2000 and June 2001 following open or closed reduction for developmental dysplasia of the hip. Bilateral hip surgery was undertaken in 12 patients. Thirty-six spicas were applied with a bar whilst 46 were without. The technique of application was similar in all patients. Overall nine (11%) hip spicas failed (mechanically) prematurely and had to be replaced in hospital under general anaesthesia. All nine were inpatients whose spica did not have a connecting bar (P < 0.005). The rate of spica revision increased with the age of the patient. All parents of failed spica cases (nine cases) preferred the new spica with a bar to the previous one without, because they agreed that the bar made the spica more secure. The bar did not hamper toileting or handling.