Flat Femoral Heads Research Articles

A framework for three-dimensional statistical shape modeling of the proximal femur in Legg-Calvé-Perthes disease.

The pathomorphology of Legg-Calvé-Perthes disease (LCPD) is a key contributor to poor long-term outcomes such as hip pain, femoroacetabular impingement, and early-onset osteoarthritis. Plain radiographs, commonly used for research and in the clinic, cannot accurately represent the full extent of LCPD deformity. The purpose of this study was to develop and evaluate a methodological framework for three-dimensional (3D) statistical shape modeling (SSM) of the proximal femur in LCPD. We developed a framework consisting of three core steps: segmentation, surface mesh preparation, and particle-based correspondence. The framework aims to address challenges in modeling this rare condition, characterized by highly heterogeneous deformities across a wide age range and small sample sizes. We evaluated this framework by producing a SSM from clinical magnetic resonance images of 13 proximal femurs with LCPD deformity from 11 patients between the ages of six and 12 years. After removing differences in scale and pose, the dominant shape modes described morphological features characteristic of LCPD, including a broad and flat femoral head, high-riding greater trochanter, and reduced neck-shaft angle. The first four shape modes were chosen for the evaluation of the model's performance, together describing 87.5% of the overall cohort variance. The SSM was generalizable to unfamiliar examples with an average point-to-point reconstruction error below 1mm. We observed strong Spearman rank correlations (up to 0.79) between some shape modes, 3D measurements of femoral head asphericity, and clinical radiographic metrics. In this study, we present a framework, based on SSM, for the objective description of LCPD deformity in three dimensions. Our methods can accurately describe overall shape variation using a small number of parameters, and are a step toward a widely accepted, objective 3D quantification of LCPD deformity.

Effect of Postoperative Femoral Neck Shaft Angle on Femoral Head Sphericity Following Proximal Femoral Osteotomy in Legg-Calve-Perthes Disease.

Herein, we aimed to examine the relationship between the postoperative neck shaft angle (NSA) and the Stulberg outcome at skeletal maturity in patients with Legg-Calvé-Perthes disease (LCPD) who underwent proximal femoral varus osteotomy (PFVO) and to determine the optimal angle of varization. In this retrospective study, we analyzed the data of 90 patients aged older than 6 years at the time of diagnosis with LCPD who underwent PFVO at our institution between 1979 and 2014. Univariate and multivariate logistic regression analyses were used to examine the effects of variables on the sphericity of the femoral head at skeletal maturity, including the age at onset, sex, stage at operation, extent of epiphyseal involvement and epiphyseal collapse, presence of specific epiphyseal, metaphyseal, and acetabular changes, and postoperative NSA. The sphericity of the femoral head on the final plain follow-up radiographs of the hip joint at skeletal maturity was assessed using the Stulberg classification. Cases of spherical femoral head (Stulberg I or II) were rated as good, whereas those of ovoid or flat femoral head (Stulberg III, IV, or V) were rated as bad. The mean age at diagnosis was 7.93 (range, 6.0-12.33) years. The average follow-up period was 10.11 (range, 5.25-22.92) years. The pre and postoperative mean NSAs were 137.31±6.86 degrees (range, 115.7-158 degrees) and 115.7±9.83 degrees (range, 88.6-137.6 degrees), respectively. The age at diagnosis, lateral pillar classification, and postoperative NSA were found to be closely related to the sphericity of the femoral head at skeletal maturity. Patients with a postoperative NSA of <105 degree or more than 125 degree were less likely to have a spherical femoral head. Our study showed that patients with a postoperative NSA between 105 and 125 degrees were more likely to have a spherical femoral head. When performing PFVO in patients with LCPD, reasonable varus angulation of PFVO should be taken into consideration for the success of the operation. Level III retrospective cohort study.

Arthrose destructrice rapide ou rapidement progressive

Rapidly destructive osteoarthritis (RDOA) is considered as a rare and poorly diagnosed disease. RDOA is a destructive arthropathy that occurs most commonly in elderly women. The most typical radiological features are narrowing of the articular cartilage (chondrolysis) subchondral bone fracture, cysts in the femoral head/acetabulum, absence of osteophytes, flat femoral heads, and signs of joint effusion. RDOA was originally described in the hip but may also involve the shoulder and the knee. Pathogenesis is not well understood, but subchondral fracture probably plays a role in the development of destruction of the joint. Nevertheless, early diagnosis of the patients with rapid destructive arthritis of the hip is important to try to reduce complexity of surgical intervention.

The mysteries of rapidly destructive arthrosis of the hip joint: a systemic literature review.

Rapidly destructive arthrosis (RDA) is considered a rare and poorly diagnosed disease but is now seen more frequently in practice due to ageing populations. The most typical radiological features are flat femoral heads, absence of articular cartilage, subchondral bone destruction and signs of joint effusion. These features could be found on X-ray or magnetic resonance imaging (MRI). Surgeons should consider the presence of RDA when patients show rapid femoral head destruction. The purpose of this study is to review the distinct clinical features and successful treatments which may lead to the diagnosis and early handling of RDA. A comprehensive review of the literature was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with no language restrictions. Overall 23 publications with 17 detailed cases of RDA met the inclusion criteria. We found that the only prevalent factors associated with RDA were: (I) age greater than 60 years; (II) female gender; (III) presence of underlying systemic diseases such as rheumatoid arthritis, diabetes mellitus or systemic lupus erythematosus. Further studies should be conducted to clarify the histopathology and define the diagnosis as well as the treatment.

The outcome and prognostic factors in children with bilateral Perthes' disease: a prospective study of 40 children with follow-up over five years.

The aims of this study were to describe the course of non-operatively managed, bilateral Perthes' disease, and to determine specific prognostic factors for the radiographic and clinical outcome. We identified 40 children with a mean age of 5.9 years (1.8 to 13.5), who were managed non-operatively for bilateral Perthes' disease from our prospective, multicentre study of this condition, which included all children in Norway who were diagnosed with Perthes' disease in the five-year period between 1996 and 2000. All children were followed up for five years. The hips were classified according to the Catterall classification. A modified three-group Stulberg classification was used as an outcome measure, with a spherical femoral head being defined as a good outcome, an oval head as fair, and a flat femoral head as a poor outcome. Concurrent, simultaneous bilateral Perthes' disease was seen in 23 children and 17 had the sequential onset of bilateral disease. The mean delay in onset for the second hip in the latter group was 1.9 years (0.3 to 5.5). The five-year radiographic outcome was good in 30 (39%), fair in 25 (33%) and poor in 21 (28%) of the hips. The strongest predictors of poor outcome were > 50% necrosis of the femoral head, with odds ratio (OR) 19.6, and age at diagnosis > 6 years (OR 3.3). Other risk factors for poor outcome were the timing of the onset of disease, where children with the sequential onset of bilateral disease had a higher risk than those with the concurrent onset of bilateral disease (p = 0.021, chi-squared test). Following a diagnosis of Perthes' disease in one hip, there was a 5% chance of developing it in the contralateral hip. These results imply that we need to distinguish between children with concurrent onset and those with sequential onset of bilateral Perthes' disease, as the outcomes may be different. This has not been previously described. Children with concurrent onset of bilateral disease had a similar outcome to our previous series of those with unilateral disease, whereas children with sequential onset of bilateral disease had a worse prognosis. The increased risk of developing Perthes' disease in the contralateral hip in those with unilateral disease is important information for the child and parents.

Implant Retrieval Analysis of Bilateral Hip Resurfacings Obtained at Autopsy: A Case Report.

Hip resurfacing arthroplasty with use of metal-on-metal bearings and hybrid fixation (femoral cement and acetabular porous ingrowth) has been in clinical use for more than a decade. Although femoral neck fracture1,2, femoral or acetabular loosening3, and soft-tissue masses associated with high wear4,5 are known failure modes, long-term clinical results in men generally have been reported to be good6,7. Many metal-on-metal hip resurfacing arthroplasty failures occur within the first one or two years postoperatively, and there have been few long-term specimens available for analysis. This paper describes the analysis of bilateral hip resurfacings from a patient who donated the components as part of a Willed Joint Program at the senior author’s (H.C.A.) institution. A fifty-seven-year-old man with a history of Legg-Calve-Perthes disease, diagnosed at age seven and treated at age ten with several months of traction, had presented with bilateral osteoarthritis of the hip joints. A hip radiograph had revealed broad, flat femoral heads with markedly shortened necks and incongruent acetabula (Fig. 1). The patient had received a 52-mm CONSERVE PLUS (Wright Medical Technology, Arlington, Tennessee) femoral component along with a 62-mm CONSERVE PLUS acetabular component on the left side; four months later, he had received a 48-mm CONSERVE PLUS femoral component and a 58-mm CONSERVE PLUS acetabular component on the right side. The surgical technique has been detailed previously8. Specifically, the “second-generation femoral fixation” technique had been used, which included the use of a high-speed burr to remove cystic tissue, drilling an increased number of femoral dome and chamfer holes, suction to clean the bone, and cement to secure the stem. The prepared femoral heads are shown in Figure 2, and the implanted hips are shown in Figure 3. Postoperatively, the patient had …

Varus Femoral Osteotomy Improves Sphericity of the Femoral Head in Older Children With Severe Form of Legg-Calvé-Perthes Disease

In the Norwegian prospective study on Legg-Calvé-Perthes disease (LCPD), we found varus femoral osteotomy gave better femoral head sphericity at a mean of 5 years postoperative than physiotherapy in children older than 6.0 years at diagnosis with femoral head necrosis of more than 50%. That study did not include separate analyses for hips with 100% necrosis and those with a percentage of necrosis between 50% and 100%. We asked whether (1) femoral osteotomy improves femoral head sphericity at followup in all patients with more than 50% femoral head necrosis or in selected groups only and (2) there is a critical age between 6.0 and 10.0 years over which femoral osteotomy does not improve the prognosis. We treated 70 patients with unilateral LCPD, age at diagnosis of more than 6.0 years, and femoral head necrosis of more than 50% with varus femoral osteotomy between 1996 and 2000. We classified necrosis using the Catterall classification. We established a control group of 51 similar children who received physiotherapy. At the 5-year followup visit, the hips were graded according to femoral head shape: spherical, ovoid, or flat. At 5-year followup, there was no difference between the treatment groups in radiographic outcome in Catterall Group 3 hips. In Catterall Group 4 hips, femoral head sphericity was better in the osteotomy group, with flat femoral heads in 14% compared to 75% after physiotherapy. The same trend toward better head sphericity occurred when the lateral pillar classification was used. In children aged 6.0 to 10.0 years, in whom the whole femoral head is affected, femoral head sphericity 5 years after femoral osteotomy was better than that after physiotherapy.

The natural history of Perthes' disease

Background The prognosis in Perthes' disease varies considerably according to certain risk factors, but there is no concensus regarding the relative importance of these factors. We assessed the natural history of the disease and defined prognostic factors of value in deciding the proper treatment.Patients and methods During the 5-year period 1996–2000, a nationwide study on Perthes' disease was performed in Norway. 425 patients were registered. The present study involved the 212 children (mean age 5.1 years, 77% boys) who were affected unilaterally and who had been treated with physiotherapy only (which is considered not to change the natural history). They were followed by taking radiographs at the time of diagnosis and after 1, 3, and 5 years. At the 5-year follow-up, the outcome was evaluated according to a modification of the Stulberg classification: good (spherical femoral head), fair (ovoid femoral head), and poor (flat femoral head).Results The 5-year radiographic results were strongly dependent on 4 risk factors: age 6 years or more at diagnosis, total femoral head necrosis, height of the lateral pillar of the epiphysis less than 50% of normal height, and femoral head cover less than 80%. As the number of risk factors increased from 0 to 4, the proportion of patients with good radiographic 5-year outcome decreased from 79% to 0% and the proportion with poor outcome increased from 3% to 91%.Interpretation Most children under 6 years of age do not need any special treatment. In older children, no special treatment is indicated if the whole femoral head is not necrotic and the femoral head cover is > 80%. In the most severe forms of the disease (i.e. more than 2 risk factors), surgical containment treatment seems advisable.

A multiplex family with possible metaphyseal Spahr‐type dysplasia and exclusion of RMRP and COL10A1 as candidate genes

We report a consanguineous Lebanese family where six individuals had disproportionate short stature, short limbs, and bilateral genu varum that were apparent after 2 years of age. Major radiographic features in infancy included flared, cupped, and ragged metaphyses of all long bones, delayed maturation of the scaphoid, trapezoid, and trapezium bones, wide and slightly irregular ribs, short femoral necks, flat femoral heads, and irregularity of the iliac crest. Radiographs of an affected adult showed diminished metaphyseal changes and slightly short femoral necks, when compared to the younger patients. We suggest that this family is affected with the Spahr type of metaphyseal chondrodysplasia. Sequencing of RMRP, and a haplotype analysis using highly informative markers around the COL10A1 excluded both genes from being pathogenic in this family. We are aware of only two previous reports of families with clinical features similar to the Spahr type of metaphyseal chondrodysplasia.

Long-term results of Chiari pelvic osteotomy in patients with developmental dysplasia of the hip: indications for Chiari pelvic osteotomy according to disease stage and femoral head shape

BackgroundWe evaluated the long-term results of Chiari pelvic osteotomy for developmental dysplasia of the hip (DDH) after follow-up of 10years or more. The indications for Chiari osteotomy were assessed based on the results. MethodsWe evaluated 74 hips in 69 patients treated for DDH with Chiari osteotomy. The average postoperative follow-up period was 13years. The mean age at the time of surgery was 32years (range 6–64 years). The disease was classified into two stages based on joint space measurements on radiographs: an early stage (36 hips) in which the mean age at surgery was 21years (range 6–48 years) and an advanced stage (38 hips) in which the mean age at surgery was 41years (range 18–64 years). Femoral head shape was classified into two types based on measurements of the sphericity of the femoral head: spherical (33 hips) or flat (41 hips). Clinical manifestations were evaluated according to Japanese Orthopaedic Association (JOA) hip scores. The joint space was measured on radiographs as an index of the progression of osteoarthritis. We attempted to identify factors that affected the long-term results of Chiari osteotomy, especially in regard to disease stage and femoral head shape. ResultsThe mean total JOA score was 72 preoperatively and 87 at final follow-up. It had improved in 66 hips and was worse in 7 hips. All of the worse cases were at the advanced stage at the time of surgery, and in 6 of the worse cases the femoral head was spherical. Hips with advanced DDH and a spherical femoral head had poor outcomes and exhibited joint space narrowing postoperatively. ConclusionsEarly DDH is considered a good indication for Chiari pelvic osteotomy because of the good results at 10years or more. Even with advanced DDH, a flat femoral head predicts a good surgical outcome, but patients with a spherical femoral head may experience early progression to osteoarthritis.

Factors influencing the outcome of Chiari pelvic osteotomy: a long-term follow-up

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6 ± 8.4 points and the final mean JOA clinical score was 89.4 ± 12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0 ± 2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2 ± 7.9 points and the final score 84.0 ± 12.0 points. TRA was eventually carried out on four hips. Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.

Factors influencing the outcome of Chiari pelvic osteotomy: a long-term follow-up.

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6+/-8.4 points and the final mean JOA clinical score was 89.4+/-12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0+/-2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2+/-7.9 points and the final score 84.0+/-12.0 points. TRA was eventually carried out on four hips. Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.