Incidence Of Avascular Necrosis Research Articles

Internal fixation of femoral neck fractures in the elderly

Objective To evaluate the outcome of the old patients who were treated for femoral neck fractures in our hospital during 2000-2007. Methods A retrospective study was conducted to evaluate outcomes of the 139 old patients who had received internal fixation for femoral neck fractures in our department during 2000-2007. The mechanism of injury, duration between injury and hospitalization, severity of fracture, anamnesis, time of hospital stay, anaesthesia, operation, postoperative complications, fracture healing, in-cidence of avascular necrosis of femoral head, failure of fixation, and functional restoration of the patients were documented. Results Fracture healing was found in 126 cases (90.6%). Time to healing ranged from 2 to 20 months (average, 6.2 months). Failure of fixation and nonunion were found in 13 cases (9.4%). Avascular necrosis of femoral head occurred in 9 cases (6.5% ). Of them, 81 patients(58.3%) restored their gait as normal as before whereas 50 patients(36.0%) walked with crutches. Conclusions Internal fix-ation can be suggested for old patients with femoral neck fracture, considering a high rate of fracture healing and a low rate of avascular necrosis of the femoral head. Early operation is recommended if the general con-dition of the patient has been well controlled. Key words: Femoral fractures; Fracture fixation, internal; Aged

Avascular necrosis after internal fixation of intracapsular hip fractures; a study of the outcome for 1023 patients

We prospectively studied 1023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using contemporary methods. The overall incidence of avascular necrosis (AVN) was 6.6%. AVN was less common for undisplaced (4.0%) than for displaced fractures (9.5%) and in men (4.9%) than women (11.4%) who had a displaced fracture. The incidence of AVN for those aged less than 60 years and who sustained a displaced fracture was 20.6%, compared to 12.5% for those aged 60–80 years and 2.5% for those aged more than 80 years. Our study showed an increased risk of AVN with younger age and in females with a displaced fracture. We found no association between the incidence of AVN and the interval between injury to surgery.

Bone Complications Following Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Prospective Study.

Osteoporotic fractures (OF) and avascular necrosis (AN), are major late complications after allogeneic hematopoietic stem cell transplantation (HSCT). We prospectively studied bone complications (BC) after HSCT. Patients and Methods: Pts having received allogeneic HSCT in hospital Saint-Louis from February 2004 to May 2006 were included. The study was approved by the Institutional Ethical Board and patients' informed consent was obtained. 121 adult pts, 72 males and 49 females, mean aged 37.4 ± 12.3 years old (y.o.) at the time of the transplantation and 25 children (18 males and 7 females, mean aged 11.6 ± 3 y.o.) were included. Pts presented acute leukemia (48 myeloid and 30 lymphoblastic), myelodysplastic syndromes (11pts), lymphomas (8pts Hodgkin and 9pts non-Hodgkin), myeloproliferative syndromes (14pts), aplastic anemia (13pts), multiple myeloma (10pts) or chronic lymphocytic leukemia (3pts). 71pts received bone marrow, 59pts peripheral blood stem cells and 16pts cord blood cells. 99pts were transplanted following a myeloablative conditioning, while 47pts following reduced intensity regimen. 37pts received 12Gy of total body irradiation (TBI), 31pts 2Gy and 78pts did not receive TBI. 69pts presented acute GVHD and 54 chronic GVHD. All pts received calcineurin inhibitors for a median of 356 ± 339 days. 15pts did not receive corticoids (CD) posttransplant, 11pts did not receive CD treatment at all (pre- and post-transplant), while 75pts had received CD therapy pre-transplant. Cumulative dose of CD was 164.5 ± 136.2 mg/kg and median duration of CD treatment was 350 ± 363.5 days (27–1501 days). Of the 131pts having received CD post-transplant, 60pts (46%) received at least one biphosphonate (BS) perfusion. Bone turnover was assessed by c-telopeptide (C-TP) and TRAP 5 (serum band 5 Tartrate Resistant Acid Phosphatase) (markers of bone resorption) and osteocalcin (OC-marker of bone formation) measurements, pre-transplant and on day 60 (D60) and at 1 year post-transplant. Bone mineral density (BMD) was evaluated by dual energy X-ray absorptiometry (DEXA) on D60 and at 1 year post-transplant, on the femoral site (FS) and lumbar spine (LS). Results: 136pts (93%) and 104pts (71%) were still alive on D60 and 1 year respectively. C-TP was increased pre-transplant and on D60 (8068 ± 6848 pmol/l and 8293 ± 6388 pmol/l respectively, normal= 920–4200 pmol/l), while it significantly decreased and reached normal values at 1 year post-transplant (5807 ± 4742 pmol/l, p=0.01 compared to pre-transplant and to D60). TRAP5 did not significantly change throughout the study period and remained within normal limits, while OC significantly decreased on D60 compared to pre-transplant values (4.4 ± 5.6 ng/ml versus 10 ± 6.4 ng/ ml, p<0.05) and returned to pre-transplant levels at 1 year post-transplant (10 ± 6.3 ng/ ml). 87 of 136 pts alive on D60 had a DEXA. 13/30 female pts (43%) and 47/57 male pts (82%) showed osteopenia (43 pts on FS and 37 on LS) or osteoporosis (2 pts on FS and 11 pts on LS). Of these 87 pts, 71 were still alive at 1 year post-transplant and 32 (45%) had a DEXA. All pts showed improvement of BMD. Based on this observation, we did not perform DEXA in all pts. Follow up of all pts was 823 ± 474 days (48–1544). 15 pts presented AN of at least one joint (10% of studied pts) and 11 pts OF (7.5%), 19 males (73%) and 7 females (27%), mean aged 28.2 ± 14.4 y.o. at the time of the transplantation. Among them 6 pts were children (23%). BC occurred on day 409 ± 264 post-transplant (62–884). The cumulative dose of CD was 166.6 ± 138.1 mg/kg, duration of CD treatment 269 ± 229 days, duration of IS treatment 266 ± 206 days and the median dose of CD at the time of the BC was 0.2 mg/kg. Initial disease, type of transplanted stem cells, conditioning regimen, acute GVHD or TBI did not appear to significantly affect the incidence of AN or OF. Chronic GVHD and male sex appeared as the only risk factors associated with AN or OF. C-TP, TRAP5, OC and DEXA mean values in pts presenting BC did not differ from the mean values obtained from all studied pts. A total of 20/26 pts (77%) had received at least one BS perfusion prior to the BC. Conclusions: Approximately 18% of pts receiving allogeneic HSCT present a BC, mostly in the first year post-transplant. Chronic GVHD (and subsequent CD administration) and male sex appear to be the most important risk factors. BS prophylactic treatment does not seem to prevent BC, while markers of bone resorption and formation or DEXA could not predict BC.

Ligamentum Teres Tenodesis in Medial Approach Open Reduction for Developmental Dislocation of the Hip

When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule. The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast. At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures. We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.

Die Femurkopfnekrose bei Luxationshüften und ihre Prognose (eine Literaturübersicht)

In this article are discussed the classifications of avascular necrosis following treatment of congenital dislocation of the hip. The reported incidences of avascular necrosis according to the method of treatment are reviewed. The long-term follow-up and end results of conservative treatment of congenital dislocation of the hip with and without avascular necrosis have been analysed.

Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy

Talar neck fractures are a rare injury that account for less then 2% of all foot fractures. Displaced fractures are associated with an exceedingly high rate of avascular necrosis (AVN). The incidence of AVN following Hawkins Type 3 fractures of the talar neck may approach 100%, particularly if diagnosis and reduction are delayed. Severe cases may present as pain and disability of the ankle and the subtalar joints due to a talar dome collapse, resulting in degenerative changes that usually require hind foot arthrodesis. We present two cases of traumatic displaced talar neck fractures which were treated surgically more than 2 weeks following injury due to a delay in diagnosis. Both patients underwent hyperbaric oxygen therapy (HBOT) after the operation and neither resulted in AVN of the talus in a three-year follow-up. We suggest that this favorable result may be due to the beneficial effects of HBOT.

The Effectiveness of Capsular Decompression for Internal Fixation of Intracapsular Hip Fractures

To compare the results of screw fixation plus capsular decompression versus screw fixation alone for managing intracapsular hip fractures. Of 201 patients with intracapsular hip fractures, 99 underwent screw fixation with capsular decompression (capsular decompression group) and 102 underwent screw fixation alone (control group). The incidence and time to development of avascular necrosis of the femoral head, union rate, time to union, and other clinical parameters were compared. In patients with displaced fractures, the incidence of avascular necrosis was significantly higher in the control than capsular decompression group, whereas the time to development of this complication was significantly shorter. Capsular decompression did not improve the union rate and time to union in undisplaced intracapsular hip fractures, but in displaced fractures it appeared to reduce the incidence and delay the onset of avascular necrosis.

High incidence of avascular necrosis in adolescents with acute lymphoblastic leukaemia: a UKALL XII analysis

Avascular necrosis (AVN) is a serious complication of acute lymphoblastic leukaemia (ALL) therapy. Little is known of the scope and magnitude of this problem among adults with ALL. We analysed the incidence and risk factors for AVN in 1053 patients on the UKALLXII/ECOG2993 study. AVN affected 99 joints in 42 patients at a median of 2.2 years post-diagnosis, giving a crude incidence rate of 4.0%. Statistically significant risk factors for the development of AVN were age and treatment with chemotherapy. Patients receiving prolonged chemotherapy without stem cell transplant were at significantly greater risk of developing AVN than stem cell transplant recipients (P<0.00005). The actuarial incidence of AVN was 29% at 10 years in patients <20 years old compared to 8% at 10 years in those >20 years old; P=0.0004; odds ratio 0.28 (95% CI=0.14-0.56).

Avascular necrosis of the femoral head in HIV infected patients

Avascular necrosis (AVN) of the femoral head is an emerging complication in HIV infected patients. It has been suggested that the increased incidence of AVN in this population may be caused by an increased prevalence of predisposing factors for osteonecrosis, including protease inhibitors, hyperlipidemia, corticosteroid use, alcohol and intravenous drug abuse. The aim of this study was to assess the risk factors for avascular necrosis developing in the femoral head of HIV infected individuals. This study consisted of meta-analysis of the secondary data extracted from current literature. The selected articles allowed two study groups to be drawn up for comparison. Group 1 comprised 324 individuals infected by the HIV virus, who did not present femoral head AVN. Group 2 comprised 32 HIV positive patients, who presented femoral head AVN. The parameters used for analysis were as follows: age, gender, sexual preference, use of intravenous drugs, time of diagnosis, CD4+ cell count, use of antiretroviral agents and duration, serum cholesterol and serum triglycerides. The present study found a statistically significant association between hypertriglyceridemia, hypercholesterolemia, sexual preference and intravenous drug abuse. The authors concluded that femoral head osteonecrosis is associated with hyperlipidemia (hypercholesterolemia and hypertriglyceridemia) and intravenous drug abuse. This study supports the hypothesis that protease inhibitors play a role in the development of osteonecrosis through a tendency to cause hyperlipidemia.

VARUS DEROTATIONAL OSTEOTOMY AND CLOSED REDUCTION IN THE TREATMENT OF SPASTIC HIP DISLOCATION IN CEREBRAL PALSY.

Summary This study presents the results of a long-term retrospective study investigating the outcomes of a varus derotational osteotomy (VDRO) without concomitant capsulorrhaphy for the treatment of spastic hip dislocation in children with cerebral palsy (CP). The patient population consisted of 57 patients (107 hips) with spastic neuromuscular hip dislocation, all with migration indices greater than 90%. All patients selected obtained adequate clinical and radiographic follow-up lasting until skeletal maturity. Medical records and radiographs were examined for the presence of complications associated with treatment of their spastic hips, as well as the need for revision procedures at the hip. Results of the study indicate that the closed reduction has few risks associated with it, as indicated by a low incidence of complications, especially serious postoperative complications such as avascular necrosis (AVN). Whereas other studies in which a concomitant capsulorrhaphy was performed showed incidences of AVN as high as 50%, this study reports AVN in only 1.8% of the patients. Even without a concomitant capsulorrhaphy, only three patients required a revision procedure, indicating that good reduction of the hip can be achieved without a capsulorrhaphy. It is the authors9 opinion that if an acceptable reduction can be achieved without opening the joint capsule then performing a VDRO without a capsulorrhaphy is preferred due to the much lower incidence of AVN and other serious complications.

The Spike Osteotomy for Hallux Valgus: A Clinical and Radiological Evaluation

A distal metatarsal osteotomy with soft tissue correction is a frequently performed operation to correct mild to moderate hallux valgus deformity. This is a prospective study of 28 feet in 25 patients who underwent spike osteotomy of the first metatarsal with medial capsulorraphy for symptomatic hallux valgus. The osteotomy is a distal metatarsal osteotomy with a spike fashioned in the plantar and lateral quarter of the proximal fragment and impacted into the trough created in the center of the distal fragment, providing lateral and plantar shift of the distal fragment. The American Orthopaedic Foot and Ankle Society's rating scale was used for functional assessment, and a visual analog scale gauged pain. The average follow-up was 27 months. The rating scale score improved from a mean preoperative value of 39/100 to 84/100. Twenty-six feet had complete pain relief, whereas 2 feet had a lesser degree of persistent metatarsalgia. A review of preoperative and postoperative radiographs showed that the hallux valgus angle improved from a mean 36 degrees preoperatively to 18 degrees postoperatively. Likewise, the mean 1 to 2 intermetatarsal angle improved from 13 degrees to 7.3 degrees. There was no incidence of avascular necrosis. Fourteen patients (16 feet) rated the outcome as excellent, 10 (11 feet) as good, and 1 patient with asymptomatic mild hallux varus deformity rated the result as fair. These results demonstrate that the spike osteotomy is a suitable operation for treatment of mild to moderate hallux valgus.

The relationship between alpha angle and resistive index of the femoral epiphysis in the normal and abnormal infant hip

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. 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. 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. 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). 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.

Risk Factors for Avascular Necrosis After Femoral Neck Fractures in Children: 25 Cincinnati Cases and Meta-analysis of 360 Cases

Avascular necrosis (AVN) is one of the most serious complications of femoral neck fractures in children. Variability in the reported rates of AVN and lack of statistical evidence has minimized the prognostic power of individual studies. The purpose of our study was to review our own cases as well as those from the literature in an effort to identify the risk factors for AVN. We conducted a computerized search of medical records to identify all children with femoral neck fractures treated at our institution from 1980 to 2003. Records were reviewed to determine fracture type (Delbet type I to IV), displacement, age, treatment, and incidence of AVN. A structured search of PubMed was also performed to identify all reports published in English, on femoral neck fractures in children, from 1965 to 2003. Hand searches of major orthopedic journals and reference lists of publications identified additional cases. Of the 275 citations initially identified through our computerized search, 47 met the criteria for further evaluation. These citations were reviewed by 2 investigators, and data was abstracted from 20 reports that provided patient-level data and met our criteria for inclusion. Twenty-four patients with 25 femoral neck fractures from our institution were identified including 12 boys and 12 girls with an average age of 8 years (range 1.5 to 16). Over 300 patients who met our study criteria were also identified from the literature, and a total of 360 patients were included in the analysis. Fracture type, displacement, age, and treatment were all statistically significant independent predictors of AVN with P values <or=0.05. With logistic regression analysis, however, fracture type and age were identified as the only significant predictors of AVN. Older children were 1.14 times more likely to develop AVN for each year of increasing age. Type I to III fractures were 15, 6, and 4 times, respectively, more likely to develop AVN than type IV fractures. AVN rate by Delbet class was I=38%, II=28%, III=18%, and IV=5%. Although several factors may contribute to the development of AVN, our meta-analysis provides statistical evidence that fracture type and age are the most significant predictors.

The role of arthrography-guided closed reduction in minimizing the incidence of avascular necrosis in developmental dysplasia of the hip

Avascular necrosis of the femoral head is the most serious complication after closed reduction in developmental dysplasia of the hip. Although arthrography has a well-established role in the treatment of developmental dysplasia of the hip, its use is not universal. A prospective study was conducted to compare the incidence of avascular necrosis after closed reduction in developmental dysplasia of the hip performed with and without arthrography in 85 patients, with a minimum of 5 years follow up. Arthrographic criteria were evaluated including lateralization of the femoral head and the type of limbus encountered. Hips treated by closed reduction based on arthrographic evaluation had significantly less incidence of avascular necrosis when compared with those treated by closed reduction without arthrographic guidance. Closed reduction with lateralization of more than 4 mm, and those hips with an inverted limbus were associated with an increased risk of avascular necrosis.

Blood Flow to the Metatarsal Head After Chevron Bunionectomy

Avascular necrosis (AVN) of the metatarsal head is a known, but infrequent, complication of a chevron bunionectomy. An increased incidence of AVN has been reported with the addition of an adductor tenotomy and lateral release. The purpose of this study was to document the vascular insult to the metatarsal head during a chevron bunionectomy with adductor tenotomy and lateral release through direct blood flow measurements during the procedure. A prospective study of 20 patients was performed. A chevron bunionectomy was performed under regional anesthesia without tourniquet control by two surgeons. Blood flow recordings were documented during key portions of the procedure: baseline, medial capsulotomy, adductor tenotomy and lateral release, and chevron osteotomy. The Periflux PF3 laser Doppler probe (Perimed, Inc., North Royalton, OH) was used to record blood flow. Mauchly's test of Sphericity and a pairwise comparison were performed with significance defined as p < 0.05. All patients had radiographs 3 months postoperatively to assess AVN. There was a statistically significant decrease in blood flow to the metatarsal head at each portion of the procedure. The greatest insult occurred with the medial capsulotomy (45% decrease). The lateral release and adductor tenotomy caused a 13% decrease and the chevron osteotomy caused a 13% decrease, totaling 71% decrease from the baseline. There was no evidence of AVN at 3 months, and all patients had radiographic evidence of union without recurrence or over-correction. The addition of the adductor tenotomy with lateral release often is crucial to obtain the desired correction and avoid the complication of recurrence. The disruption of microvascular blood flow to the metatarsal head after a chevron bunionectomy with adductor tenotomy and lateral release was not complete, totaling 71% in the study population. The greatest insult occurred with the medial capsulotomy. There were no occurrences of AVN. Despite the fear of AVN, this study demonstrated that an adductor tenotomy and lateral release could be done safely completed with a chevron bunionectomy.

Complications after intracapsular hip fractures in young adultsA meta-analysis of 18 published studies involving 564 fractures

Intracapsular hip fractures in young adults have a significant risk of complications. Consequently, some authors advocate urgent and/or open fracture reduction. Our aim was to analyse outcomes following such fractures with reference to influence of fracture displacement, timing of surgery and method of reduction (open/closed) on the incidence of non-union (NU) and avascular necrosis (AVN). Methods: Specific search terms were used to retrieve relevant published studies from 1966 to May 2003. Results: Eighteen studies involving 564 fractures were analysed. The overall incidence of NU was 50/564 (8.9%) and AVN was 130/564 (23.0%). There was a higher incidence of NU and AVN following displaced than undisplaced fractures. NU occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%]). There was an increased incidence of AVN after closed than open reduction but this was no longer statistically significant when one study with a markedly higher reported incidence of AVN was excluded. The difference in the incidence of NU and AVN following early (<12 h) or late (>12 h) surgery was not significant for either NU or AVN. Conclusion: Early or open reduction of these fractures may not reduce the risk of NU or AVN. There is a suggestion of a higher incidence of NU following open reduction than closed reduction. Randomised studies with 2 year follow-up are required to report on a larger number of patients before definite conclusions on treatment can be made.

Complications after intracapsular hip fractures in young adults: A meta-analysis of 18 published studies involving 564 fractures

Intracapsular hip fractures in young adults have a significant risk of complications. Consequently, some authors advocate urgent and/or open fracture reduction. Our aim was to analyse outcomes following such fractures with reference to influence of fracture displacement, timing of surgery and method of reduction (open/closed) on the incidence of non-union (NU) and avascular necrosis (AVN). Methods: Specific search terms were used to retrieve relevant published studies from 1966 to May 2003. Results: Eighteen studies involving 564 fractures were analysed. The overall incidence of NU was 50/564 (8.9%) and AVN was 130/564 (23.0%). There was a higher incidence of NU and AVN following displaced than undisplaced fractures. NU occurred more frequently after open reduction than closed reduction (10/89 [11.2%] versus 13/275 [4.7%]). There was an increased incidence of AVN after closed than open reduction but this was no longer statistically significant when one study with a markedly higher reported incidence of AVN was excluded. The difference in the incidence of NU and AVN following early (<12 h) or late (>12 h) surgery was not significant for either NU or AVN. Conclusion: Early or open reduction of these fractures may not reduce the risk of NU or AVN. There is a suggestion of a higher incidence of NU following open reduction than closed reduction. Randomised studies with 2 year follow-up are required to report on a larger number of patients before definite conclusions on treatment can be made.

Entrapment of the acetabular labrum following reduction of traumatic hip dislocation in a child

In traumatic hip dislocation, concentric reduction can be prevented by various causes. Soft-tissue interposition, such as entrapment of the acetabular labrum, is a rare but important cause of failed reduction of a hip. Early diagnosis of incomplete reduction due to interposition of soft tissue is important, because delayed treatment is associated with a greater incidence of avascular necrosis of the femoral head and early onset of osteoarthritis. This report describes a case of acetabular labral entrapment following reduction of traumatic hip dislocation in a child. The importance of CT and MRI in arriving at an early diagnosis is emphasized.

Undisplaced Intracapsular Hip Fractures

Three hundred seventy-five patients with an undisplaced intracapsular proximal femoral fracture were treated with internal fixation. Nonunion occurred in 24 patients (6.4%) and avascular necrosis occurred in 15 patients (4.0%). Reoperation with an arthroplasty was required in 29 patients (7.7%). The age, walking ability of the patient, and degree of impaction seen on the anteroposterior radiograph or angulation seen on the lateral radiographs were of statistical significance in predicting fracture healing complications. The results for this series of patients were compared with the results in published reports identified by a comprehensive literature search. Summation of the results indicated that the overall risk of redisplacement or nonunion of the fracture was 4.3% (95% confidence interval, 3.4%-5.3%) with internal fixation of an undisplaced intracapsular fracture. For conservative treatment, the failure rate was 19.6% (95% confidence interval, 17.2%-22.1%). The incidence of avascular necrosis with internal fixation at 1 year was 2.2% (95% confidence interval, 1.6%-2.9%) compared with 2.8% (95% confidence interval, 1.9%-4.0%) with nonoperative treatment. Internal fixation is recommended for the treatment of undisplaced intracapsular hip fractures.

A radiographic evaluation of the scarf osteotomy for the correction of hallux valgus

A prospective radiographic study was performed on 13 patients (22 ft) undergoing SCARF osteotomy with an average age of 52 years (range, 25–78). Standardised weight bearing anterior-posterior radiographs were taken preoperatively and at 6 months post-operatively. These were compared to determine changes in the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA) and joint congruency angle (JCA). Correction of sesamoid position and metatarsal length changes were also assessed. The results showed a median reduction of IMA of 6°, HVA of 16°, DMAA of 6° and an improvement in JCA of 11°. Improvement of medial sesamoid displacement beneath the first metatarsal head was seen post-operatively. Metatarsal length was assessed by comparing the ratio of the length of the first to second metatarsal pre and post-operatively. No shortening was found. There was no incidence of avascular necrosis or delayed union. This study indicates that the SCARF osteotomy produces effective radiological correction of hallux valgus. It corrects sesamoid displacement and avoids shortening of the first metatarsal.