Femoral Head Resection Research Articles

PR_113: Proximal Femoral Head Resection in Children With Neuromuscular Hip Dysplasia: Long-Term Evaluation of Patient Satisfaction and Functional Outcome

Objective: To investigate the long-term effects of surgery on the overall functional outcome of our patients, using a prospective questionnaire we devised to evaluate functional outcome and patient satisfaction following surgery. Design: Retrospective case series with a prospectively administered questionnaire. Setting: Orthopedic and rehabilitation department at a tertiary referral center. Participants: A consecutive sample of 31 children with neuromuscular hip dysplasia (41 proximal femoral head resections) who had surgery between 1988 and 2004 was evaluated.

Endoprothetischer Hüftgelenkersatz bei zerebralparetischen Patienten

The treatment of painful osteoarthritis of the hip in cerebral palsy requires a therapy concept that considers the pathoanatomical features and adapts the treatment to the individual physical and mental abilities. Femoral head resection has been proven be effective in severely dislocated hip joints in completely immobilized patients, whereas no satisfactory outcome is achieved in those patients with sufficient walking ability and moderate expression of spasticity. The following study investigates the results of total hip replacement (THR) in patients with tetraspastic cerebral palsy. Between 1992 and 2004, 19 total hip arthroplasties were performed in 175 patients with an average follow-up of 4,6 years. In all patients the walking ability improved significantly; 84% of the patients were pain free. Aseptic loosening of the femoral component was registered in one patient. A periprosthetic fracture in another patient required the implantation of a modular non-cemented femoral component. In this study total hip arthroplasty represents an important expansion of operative treatment options in secondary osteoarthritis of cerebral palsy in selected and cooperative patients. Taking the contradictions into consideration (severe athetosis, absence of adequate weight bearing, severe pelvic obliquity), THR promises to be an effective alternative to femoral head resection with significant pain reduction and improvement of walking abilities.

Finding the unexpected: pathological examination of surgically resected femoral heads

To study the clinically diagnosed disease process but also identify additional, clinically undetected pathologies in femoral heads resected for replacement arthroplasty. A retrospective review was carried out of the pathological findings in 460 surgically resected femoral heads. Serial sections were submitted to low-energy fine-detail radiography, then decalcified sections stained by the WHO method were examined. The preoperative clinical and imaging diagnoses were compared with the pathological findings and special interest was placed on assessing the clinical significance of any unexpected, clinically undetected findings. The most common findings included the presence of bone islands (solitary osteomas) and areas of avascular necrosis in addition to the primary joint disease for which the patient underwent surgery. The preoperative symptomatology did not distinguish between the known primary disease and the additional pathological findings. Some of the clinically unidentified lesions were of a size that fell below the ability of current clinical investigations to detect. However, the finding of lesions by tissue fine-detail radiography indicates that current, more sensitive clinical imaging techniques may identify them. Careful examination of surgically resected femoral heads is important to ensure that all pathologies are identified and assessed for clinical relevance.

Femoral Head Resection for Painful Hip Subluxation in Cerebral Palsy

Patients with severe cerebral palsy who underwent either a femoral head resection with traction or a McHale procedure (femoral head resection and valgus osteotomy) were studied retrospectively and then contacted by telephone to assess whether removing the femoral head or proximal femur as a salvage procedure improved sitting tolerance, relieved pain, or improved hygiene. Twenty-seven patients (36 involved hips) were available for a retrospective chart and x-ray review, and over half (56%) of these patients or caretakers were able to complete a telephone questionnaire. Of the study cohort, 16 patients underwent femoral head resection with traction and 11 patients had a McHale procedure. The average age at surgery was 19 years and average follow-up was 3.4 years. For those in the McHale group, the length of stay in the hospital was shorter, the postoperative superior migration of the femoral head was less pronounced, and the surgical and medical complications were lower. The telephone survey showed that both groups had increased sitting tolerance and decreased pain, and both showed overall satisfaction with the surgical outcome.

Cementless total hip arthroplasty using an autograft of the femoral head for marked acetabular dysplasia: case series.

To assess the short-term outcome of cementless total hip arthroplasty involving an autograft of the femoral head in Japanese patients. Cementless total hip arthroplasty with autogenous bone block grafting was performed on 18 hips in 15 patients with marked acetabular dysplasia. The resected femoral head was used as a graft for the superior-lateral region of the true acetabulum. Clinical outcome was correlated with the placement of the acetabular component, as revealed in radiographs. The 13 women and 2 men had a mean age of 60.2 years (range, 37.0-73.0 years) at primary surgery and a mean follow-up duration of 3.3 years (range, 2.0-5.3 years). According to the classification of Crowe, 4 hips were in group I, 3 were in group II, one in group III, and 10 in group IV. The mean Harris Hip Score preoperatively was 45.7 (range, 19-69) and that at follow-up was 82.5 (range, 44-100). All 15 cases showed a good clinical outcome. There were no major intra-operative complications in this series. The grafted bones united in all patients. Two patients need surgical revision because the lateral insertion of the acetabular component resulted in loosening of it. Medial insertion of the acetabular component provides satisfactory short-term outcomes. Lateral insertion of the acetabular component during total hip arthroplasty should be avoided in patients with marked acetabular dysplasia.

Bone density in osteoarthritic femoral heads removed at joint replacement surgery – quantitative assessment by histologic and fine-detail radiographic analysis

Objective. To determine if there is a change in bone density in osteoarthritic femoral heads removed at joint replacement surgery and to compare bone density in different arthropathies. Materials and methods. All femoral heads removed at joint replacement surgery at St. Michael's Hospital were examined in the Laboratory of Bone and Joint Pathology, intact as received, following sectioning in the coronal and sagittal planes by fine-detail, low-energy radiology with high-resolution, single-emulsion film. Sections were submitted for histomorphology and the study was undertaken to determine quantitatively, with the computer-assisted system, the bone density of the femoral heads. Results. Values in non-weight-bearing areas of cases of rheumatoid arthritis, fracture, and some zones of osteoarthritis were below normal values. The interesting feature was that the cortex at the calcar of the neck tended to show a greater porosity than expected for cortical bone in all cases. There was difference in density, with statistical significance in comparing weight-bearing zones of osteoarthritis versus fracture, and in osteonecrosis versus fracture, in both weight-bearing and non-weight-bearing zones. There was a strong statistically significant difference in P values between the weight-bearing and non-weight-bearing areas of patients with osteoarthritis and a relatively nonsignificant difference in patients with rheumatoid arthritis. There also was a statistically significant difference between weight-bearing and non-weight-bearing areas in the patients with fractures. Conclusion. The study demonstrated the static morphologic and morphometric variables in surgically resected femoral heads at the time of total hip arthroplasty. Obviously, this data is not a measure of outcome but must be regarded as a potential indicator of implant/host bone relationship with morphologic and morphometric implications. One can only speculate that assessment of bone density/porosity can be a predictor of long-term outcome.

Vital staining of bone in stable, retrieved femoral surface replacement prostheses: A microscopic study of undecalcified ground sections

We used vital staining with tetracycline to detect viability of bone at the bone–cement interface in 11 stable ICLH femoral surface replacement prostheses that were retrieved at revision surgery for acetabular loosening. The resected femoral heads were processed for undecalcified ground sections with the prostheses in situ. All sections showed direct bone-to-cement contacts. Bone in direct contact with or close to the cement sometimes showed an abnormal staining, indicating that the bone was not fully mineralized. Areas with fluorescence were observed within all femoral heads but never in direct bone-to-cement contact. From this study, we conclude that the mechanical stability of these cemented femoral surface replacement prostheses depends mainly on the original bone present at the time of primary operation.

Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis. 1971.

Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis. 1971.

Treatment of dysplastic and congenitally dislocated hips with the Zweymueller total hip prosthesis.

Uncemented Zweymueller total hip prostheses were implanted in 35 dysplastic or dislocated hips in 33 patients. Sixteen hips were dislocated and 19 hips were dysplastic; in 12 hips, an intertrochanteric or pelvic osteotomy was performed in early childhood. In all cases, the titanium screw socket was implanted at the level of the original cotyloid cavity. Osteotomy of the greater trochanter, shortening osteotomy, or roof acetabuloplasty were not performed. In cases in which the femoral cavity was too narrow for the Zweymueller stem, an anterolateral longitudinal window-shaped osteotomy was performed. In cases of severe dysplasia, cotyloid cavity bone grafts from the resected femoral head were placed medially to reinforce the acetabular bottom. Clinical and radiographic follow-up ranged from 3-8 years. Average Harris hip score improved from 47 points preoperatively to 86.2 points postoperatively. Complications included two primary anterior dislocations, two temporary femoral nerve pareses, and two deep vein thromboses. At longest follow-up evaluation, no revision was indicated in any of the hips. Satisfactory results in this series were attributed to careful patient selection, precise preoperative radiographic planning, and an operative technique that included implantation of the socket at the primary acetabulum and achievement of primary stability using press-fit fixation.

MR evaluation of the articular cartilage of the femoral head during traction. Correlation with resected femoral head.

The purpose was to evaluate the articular cartilage of the hip joint with MR during traction and compare the findings with the resected specimen or arthroscopic findings. Eight healthy volunteers, 5 patients with osteonecrosis, 5 with acetabular dysplasia, and 5 with advanced osteoarthrosis underwent MR imaging to evaluate the articular cartilage of the hip joint. Coronal fat-suppressed 3D spoiled gradient-echo (SPGR) images were obtained during traction. Identical imaging was performed of all the resected femoral heads of the osteonecrosis and advanced osteoarthrosis patients, and was correlated with the macroscopic pathological findings. The traction was effective and the femoral articular cartilage was clearly identified in all 8 control subjects, and in all cases of osteonecrosis and acetabular dysplasia. In 4 cases of osteonecrosis, chondral fracture was identified in the boundary between the necrosis and the normal area. In all cases of advanced osteoarthrosis, cartilage was identified only at the medial side. The MR images of osteonecrosis and advanced osteoarthrosis corresponded well with the MR images of the resected femoral heads and the macroscopic findings. Fat suppressed 3D-SPGR during continuous leg traction was useful in detecting cartilage abnormalities.

MR Evaluation of the Articular Cartilage of the Femoral Head during Traction

Objective: The purpose was to evaluate the articular cartilage of the hip joint with MR during traction and compare the findings with the resected specimen or arthroscopic findings.Material and Methods: Eight healthy volunteers, 5 patients with osteonecrosis, 5 with acetabular dysplasia, and 5 with advanced osteoarthrosis underwent MR imaging to evaluate the articular cartilage of the hip joint. Coronal fat-suppressed 3D spoiled gradient-echo (SPGR) images were obtained during traction. Identical imaging was performed of all the resected femoral heads of the osteonecrosis and advanced osteoarthrosis patients, and was correlated with the macroscopic pathological findings.Results: The traction was effective and the femoral articular cartilage was clearly identified in all 8 control subjects, and in all cases of osteonecrosis and acetabular dysplasia. In 4 cases of osteonecrosis, chondral fracture was identified in the boundary between the necrosis and the normal area. In all cases of advanced osteoarthrosis...

Clinical and Pathologic Findings in Hemochromatosis Hip Arthropathy

During a 9-year period, 15 patients with hemochromatosis hip arthropathy required 19 total hip arthroplasties for disabling hip pain. Preoperative presentation, hip function, pathologic evaluation of the femoral head, and radiographic findings were reviewed. Postoperative followup averaging 5.7 years (range, 2-11 years) was performed to assess hip pain and function after total hip arthroplasty. The average preoperative Hospital for Special Surgery hip score was 15 points (range, 4-24 points), and this improved to 30 points (range, 4-38 points) after total hip arthroplasty. Only one of 15 patients required revision surgery at 10 years for acetabular loosening. All other patients were pain free, with improved function at latest followup. Histologic evaluation of the resected femoral heads revealed evidence of primary or secondary osteonecrosis in seven of 19 (37%) specimens. Articular cartilage avulsion at the level of the tidemark was identified in eight of 19 (42%) specimens, and calcium pyrophosphate deposition was identified in five of 19 (26%) specimens. These pathologic findings suggest a predictable progression of the arthritic process in patients with hemochromatosis.

A case of spontaneous femoral neck fracture associated with multicentric reticulohistiocytosis. Oversecretion of interleukin‐1β, interleukin‐6, and tumor necrosis factor α by affected synovial cells

We describe a case of left femoral neck fracture associated with multicentric reticulohistiocytosis (MR). Biopsy specimens from a skin nodule and from synovial tissue showed histiocytic multinucleated giant cells (MR cells) that are characteristic of MR. A surgical specimen from the resected femoral head revealed that multinucleated giant cells and mononuclear cells invaded the marginal subchondral bone, without evident pannus. These cells also infiltrated into the fracture site, with bone resorption by activated osteoclasts. Immunohistochemical studies of synovium from the left hip joint showed positive staining for interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor alpha, and abundant cytokine production by cultured synovial cells was demonstrated. These findings suggest that the subchondral invasion and intramedullary infiltration by MR cells caused articular destruction and/or fracture as a result of oversecretion of the cytokines.

Total hip replacement in presence of acetabular dysplasia type II according to the AAOS classification

Incorporation of the acetabular cup in ideal position in patients with a primary dysplastic acetabulum. Two thirds of the surface of the cup must be covered by bone. Joint replacement in patients with acetabular dysplasia type II according to the AAOS classification. Presence of acetabular dysplasia types I and III according to the AAOS classification. Radiographic measurement of the acetabular depth and width using templates. Supine, affected side of pelvis slightly elevated. General or spinal anaesthesia. Special set of instruments mandatory. Insertion of an acetabular cup through a lateral approach. Reaming of the acetabulum and filling of the defect under compression with a mixture of autogenous, morcellized bone from the resected femoral head and fibrin glue. Coverage of the transplanted bone with a pedicled capsular flap. Phlebitis prophylaxis. Walking with 2 forearm crutches on the first postoperative day. Removal of stitches after 10 days. Thereafter gradual increase of weight bearing (10 kg every second day, use a bathroom scale to check loading). Once full weight bearing and full muscle control have been reached, use of 1 crutch is allowed. Radiographic control after 6 weeks, 3,6 and 12 months and yearly thereafter. Perforation of the bony acetabulum. Fracture of the anterior or posterior acetabular rim. Thrombophlebitis, lung embolism, infection and/or periarticular ossification. Between 1986 and 1994 the technique has been used in 140 hips with congenital dysplasia (type II according to the AAOS classification) and secondary osteoarthritis. 132 hips were regularly assessed and the mean of follow-up was 6.2 years (1 to 9 years). The mean age of the mostly female patients was 48 years (28 to 62 years). Only porous surfaced metallic cups without cement were used. The following complications were observed: thrombophlebitis 1, superficial infection 1, transient paresis of the fibular nerve 1 and transient irritation of the femoral nerve 3 (see Table 2). Additional complications such as thigh pain, periarticular ossification and resorption of the bone graft are listed in Table 3. Complete bony incorporation of the bone grafts was seen in 122 hips. Resorption up to 8 mm occurred in the remaining 10 hips.

Femoral head autograft in simultaneous primary and revision total hip arthroplasty

Bilateral total hip arthroplasty during one anesthetic procedure can be beneficial in properly selected patients. For patients who have a failed hip arthroplasty requiring revision and a contralateral arthritic hip requiring primary arthroplasty, bilateral surgery permits the resected femoral head from the primary procedure to be used as a fresh autogenous bone—graft during the revision procedure. Four patients underwent combined primary hip arthroplasty and contralateral revision hip arthroplasty during one anesthetic procedure. The femoral head obtained during the primary procedure was used as a structural acetabular bone—graft in three patients, and bone slurry was used to fill cavitary acetabular defects in one patient. A femoral neck autograft was used to reconstruct a calcar defect in one of the patients. After an average follow-up period of 27 months, all hips were functioning well with healed bone—grafts and stable prosthetic components.

Ｂｉｐｏｌａｒ型人工骨頭置換術後のｏｕｔｅｒ ｈｅａｄの移動に関する検討

Radiographic assessment was done to investigate outer head migration after bipolar arthroplasty in 44 osteoarthritic hips (35 patients). Bone graft was performed on the lateral edge of the acetabulum using resected femoral heads in 19 cases who had dysplastic acetabulae.There was a significant correlation at six months between CE angle and medial migration (r=-0.43, p 6mm) is significantly greater than that in the shallower reaming group (<5mm).Thickness of the grafted bone correlated strongly with superior migration at 12 months (r=0.93, coefficient for slope=0.85). This result shows that the grafted bone did not act as a brake on the superior migration of the outer head.

The use of the resected femoral head as a bond graft during total hip replacement

Surgical Principles Augmentation and enlargement of the lateral wall of the acetabulum through an autogenous specially tailored bone transplant using the resected femoral head. Fixation of the bone graft to the outer wall of the ilium employing the tongue and groove principle and two additional spongiosa screws.

Histological appearance of naturally occurring canine physeal fractures.

The Salter-Harris classification system is widely used to describe the anatomical appearance of and predict the prognosis for physeal fractures in canine clinical patients. Salter and Harris classified experimentally induced physeal fractures on radiographic and histological appearance, however, the good prognosis afforded Salter-Harris type I and II fractures in experimental animals has been questioned for the canine patient. Twelve naturally occurring physeal fractures from five traumatized dogs, who were euthanatized at the request of their owners, and one resected femoral head were examined histologically. Ten of the 13 physeal fractures disrupted the cells in the proliferative zone. The histological appearance of growth plate disruption in the injured animal correlates more closely with the clinical observations of growth retardation than the experimental observation of continued growth after fracture through the hypertrophic zone. The results of this study indicated that considerable damage to the physeal cartilage occurred during the traumatic incident in most of these clinical animal patients.

人工股関節置換術における血管系合併症の２例

We report 2 cases of vascular complications experienced in 76 bipolar hip arthroplasties (BHA) carried out since 1987. Case 1 was a 58-year-old woman with bilateral OA hip. Left BHA and acetabular plasty using resected femoral head were performed. Low blood pressure and progressing anemia were observed after surgery. Anemia persisted for 3 days in spite of blood infusion. Abdominal CT scan revealed retroperitoneal hematoma (700ml). Femoral vein obstruction was found on venography. It was suspected that injury to the external iliac vein occurred during acetabular drilling for reconstruction of acefabular roof using femoral head. Case 2 was a 75-year-old woman with right OA hip. Right BHA was performed without any trouble. On the 2nd postoperative day, she developed sudden dyspnea, cyanosis and shock. In spite of cardiopulmonary resuscitation and intensive care, she died 2 hours later. Ultrasonic cardiogram showed a dilatated right ventricle and filling failure of the left ventricle. A massive pulmonary embolism was found on pulmonary angiogram. In conclusion, accidental perforation of the external iliac vessels can be avoided by careful planning and careful surgical techniques. In a case with massive pulmonary embolism, immediate diagnosis and removal of thrombus may save the patient.

Magnetic Resonance Imaging of the Hip After Displaced Femoral Neck Fractures

This study was designed to determine the sensitivity of magnetic resonance imaging (MRI) in the detection of ischemia or avascular necrosis after displaced intracapsular hip fractures. Magnetic resonance imaging was performed on 20 patients who had hemiarthroplasties performed for Garden IV intracapsular fractures. Sixteen patients had in vivo coronal T1-weighted spin-echo imaging from the day of injury to 60 days after fracture. After hemiarthroplasty, all 20 resected femoral heads had in vitro T1 imaging. A coronal slab was then cut from the center of the femoral head and studied histologically. The in vivo, in vitro, and histologic slides correlated well. None of the MRI images depicted areas of ischemia or avascular necrosis in patterns observed in nontraumatic necrosis. Avascular bone can be indistinguishable from normal bone in both MRI and histologic sections for a considerable amount of time after vascular insult. Magnetic resonance imaging is not a prognosticator for posttraumatic osteonecrosis in the first two weeks after fracture.