Acetabular component position of the noncemented total hip endoprosthesis after previous Chiari pelvic osteotomy

INTRODUCTION

The aim of the study was to determine the validity of acetabular component position of the noncemented total hip endoprosthesis after Chiari pelvic osteotomy.

MATERIAL AND METHODS

The study involved 75 patients operated on at the Institute of Orthopedic Surgery "Banjica" in the period from 1990-2009. The first group consisted of 39 patients (46 hips) who underwent Chiari pelvic osteotomy and also later the implantation of a noncemented total hip endoprosthesis. A control group consisted of 36 patients (47 hips) who underwent total hip arthroplasty due to degenerative hip dysplasia.

RESULTS

In the previously operated patients the centre of rotation of the hip was on the average placed more proximally, while in the control group of patients the position of the acetabular component was closer to the anatomical one. In the group of patients after Chiari osteotomy the mean acetabular cup abduction angle rated 41.8°±9.8°, while in the control group this value was on the average higher (45.4°±8.6°).

DISCUSSION

There was a significant difference between the studied groups in relation to the distance between the acetabular component of endoprosthesis and the acetabular teardrop (t=-2.763; p=0.007). No statistically significant difference was determined in the mean value of the angle of acetabular abduction component of endoprosthesis between the studied groups of patients (t=1.878; p=0.064).

CONCLUSIONS

Acetabular component position of the total hip endoprosthesis was not compromised by anatomic changes of the acetabulum caused by Chiari pelvic osteotomy.

[Treatment of missed Monteggia lesion in children--case report]

INTRODUCTION

A Monteggia lesion is a dislocation of the radial head associated with a fracture with the proximal third of the ulna. It is rare in children and the dislocation of the radial head is often missed at the time of injury. There are a lot of described treatment methods: open reduction of the radial head and reconstruction of the annular ligament combined with ulnar osteotomy, the same method without reconstruction of the annular ligament, gradual lengthening and angulation of the ulna by Ilizarov method without the opening of radiocapitelar joint.

CASE OUTLINE

A 14-year-old boy had been diagnosed with Monteggia lesion type Bado II three years before the admission to hospital. Previously nonoperatively treated, the missed radial head dislocation Bi-phase treatment had been done. Firstly, the distraction Ilizarov device was placed on the forearm, corticotomy of the ulna was done, distraction lasted fifteen days. Secondly, after achieving 1.5 cm of new bone and good level of the radial head, a reduction mechanism was incorporated into the Ilizarov device. The radiocapitelar joint was not opened, the reconstruction of the annular ligament was not done. After the radial head reduction and new bone maturation (1.5 months), the Ilizarov device was taken off.

CONCLUSION

The described method of treatment has several important advantages: radial head reduction may be done without the joint opening, the recovery is very fast and easy after that; the elbow and forearm appear cosmetically very well after the operation; the treatment process is short, the arm is in use all the time, the absence from school is not needed, the achieved result is permanent.

[Developmental dislocation of the hip is still important problem--therapeutic guidelines]

The authors are describing currently important problem--developmental dislocation of the hip. Guidelines for the treatment have been given according to literature date and upon their own experience. Therapeutic suggestions for the first twelve months of life are based on the ultrasound typing--it is advised to perform nonoperative treatment (abduction devices, "over head" traction, Pavlik harnesses). During the second year of life a pause in the treatment should be adviced in order to avoid postreduction avascular hip necrosis as a very important complication. After that period surgical treatment has to be done (open reduction, pelvic and femoral osteotomies). Special suggestions have been given for the treatment of consecutive leg length inequality and the deformities caused by postreduction avascular hip necrosis.

[Chondrofibrosis of adolescent hip]

Authors present 420 hips with slipped capital epiphysis treated in the IOHB "Banjica", during the period between 1970 and 2005. Research includes the analysis of incidence, diagnostics and causes which contribute to the genesis of hip chondrofibrosis. Risk factors are shown, as well as the approach to eliminate them. 39 hips in which this complication occured were individually analyzed. Every hip was separately studied with intent to determine the cause of the condition's genesis, it's evolution, treatment and it's final functionality result. Synovia biopsy was performed in 7 cases, as well as the biopsy of the capsule, articular hyaline cartilage and subchondral bone of the femoral head, which enabled detailed description of both microscopic and macroscopic changes that follow this condition. Regardless of still hypothetical comprehension of the inception of chondrofibrosis, authors clearly state all the risky procedures during treatment that can contribute to the development of chondrofibrosis. The importance of early diagnostics and well-timed treatment are highlighted in this article, for they are crucial. Results of treated hip chondrofibrosis presented here give hope for the destiny of the ill joint, which was considered highly uncertain for a long time.

[Effect of resection of the lateral retinaculum of the knee in surgical treatment of symptomatic patello-femoral incongruency]

Biomechanical malfunction of the knee extensor mechanism in the patello femoral joint is regarded as patella malalignment but major patients complaints are anterior knee pain and patellar slipping. Lateral retinacular release is one of the basic surgical procedures in the treatment of patellar malalignment. The aim of the study was to estimate the achievements of the lateral retinacular release in solving particular biomechanical disorders of the patello femoral joint, as well as individual patients complaints. Evaluation of objective parameters x-ray and clinical findings before and after the operation, shows statistically highly significant difference, thus confirming implementation of the fore mentioned surgical procedure. Despite the fact that anterior knee pain subsided postoperatively in the number of patients, statistically significant values, comparing to the preoperative findings, could not be obtained. Incidence of the patellar slipping has shown statistically significant reduction two years following the surgery. Achieving proper biomechanical alignment of the patello femoral joint is obviously not sufficient to provide relief of subjective complaints, especially concerning anterior knee pain, although considerable improvements were registered in the number of patients.

[Factors influencing the development of avascular necrosis in non-operative treatment of the acute slipped capital femoral epiphysis]

INTRODUCTION

The acute slipped capital femoral epiphysis can result in development of avascular necrosis of the femoral head which is very difficult condition to treat. Orthopedic surgeon can influence the development of avascular necrosis.

OBJECTIVE

The main objective in our study was to identify factors influencing the development of avascular necrosis in nonoperative treated patients for the acute slipped capital femoral epiphysis.

METHOD

A total of 53 patients and 59 hips treated for the acute slipped capital femoral epiphysis at the Institute for Orthopedic Surgery,Banjica" between 1968-2004 were studied. Necessary data were obtained from the accurate medical records.

RESULTS

Avascular necrosis of the femoral head was diagnosed in 8 patients (13.56%). Six of them (75%) were treated by manipulative reduction in general anesthesia and spica cast immobilization. Fischer test, used for statistical data processing, found significant difference between two non-operative methods of treatment (p = 0.0008).

CONCLUSION

Higher-degree epihyseal displacement as well as complete separation of the physis and metaphysis were found to be the risk factors of avascular necrosis. Every manipulation with the affected hip was also associated with higher percentage of avascular necrosis of the femoral head.

[Diagnosis and treatment of chondroblastoma--our experience]

The paper presented the results of diagnostics and treatment of patients with diagnosis of chondroblastoma, treated at the Institute of Orthopedic Surgery "Banjica", Belgrade. A total of 30 patients were analyzed, involving the period from 1975-2004. All important data were obtained using the complete medical documentation, physical examination, radiographic findings and available additional diagnostic procedures. The proximal part of tibia, the proximal part of humerus and the distal part of femur were the most common sites of tumor, accounting for 63% of cases. Higher incidence of chondroblastoma was found in male patients, especially in the second decade of life. Pathohistological tumor verification was done in all patients. The patients were then treated by different surgical procedures, both on account of primary lesion and recurrence. Curettage and osteoplasty using the auto- and homograft were carried out in 21 patients, wide resection in nine cases, and amputation was performed in three cases. One patient had radiotherapy due to recurrence of lesion, nevertheless malignant transformation of chondroblastoma occurred in time. Seven patients manifested local recurrence, and one of them even had relapse on two occasions and malignant transformation of chondroblastoma. Malignant lesions were found in three cases (10% of patients); one lesion was diagnosed as primary while other two malignancies were detected only after recurrence, and the treatment was completed by lower leg amputation.

[Complications of slipped capital femoral epiphysis]

Slipped capital femoral epiphysis is well known disorder of the hip in adolescents, which is characterized by displacement of the capital femoral epiphysis from the metaphysis through the physeal plate. The incidence of slipped capital femoral epiphysis is about 5-8 cases per 100,000 adolescents. Etiology of slipped capital femoral epiphysis is still unknown, but this disorder is probably combination of genetic, hormonal and mechanical factors. On the basis of patient's history, physical examination, and radiographs, slipped capital femoral epiphysis can be classified as acute or chronic. Two most severe complications of slipped capital femoral epiphysis are avascular necrosis and chondrolysis. Avascular necrosis is more commonly associated with the acute slips when the lateral epiphyseal vessels are disrupted. In chronic slips, avascular necrosis can occur as a result of treatment. Chondrolysis or cartilage necrosis can occur in untreated slips, but is often associated with spica cast imobilization or penetratation of the internal fixation screws into the joint space. The final outcome of avascular necrosis and chondrolysis is extremly poor for a patient. Therefore, the baseline of management of slipped capital femoral epiphysis is treatment by adequate techniques that have high rate of success with minimal risk of complications.

[Postoperative cognitive deficits]

Cognitive dysfunctions are relatively common in postoperative and critically ill patients. This complication not only compromises recovery after surgery, but, if persistent, it minimizes and compromises surgery itself. Risk factors of postoperative cognitive disorders can be divided into age and comorbidity dependent, and those related to anesthesia and surgery. Cardiovascular, orthopedic and urologic surgery carries high risk of postoperative cognitive dysfunction. It can also occur in other types of surgical treatment, especially in elderly. Among risk factors of cognitive disorders, associated with comorbidity, underlying psychiatric and neurological disorders, substance abuse and conditions with elevation of intracranial pressure are in the first place in postoperative patients. Preoperative and perioperative predisposing conditions for cognitive dysfunction and their incidence were described in our paper. These are: geriatric patients, patients with substance abuse, preexisting psychiatric or cognitive disorders, neurologic disease with high intracranial pressure, cerebrovascular insufficiency, epilepsia, preeclampsia, acute intermittent porphyria, operation type, brain hypoxia, changes in blood glucose level, electrolyte imbalance, anesthetic agents, adjuvant medication and intraoperative awareness. For each of these factors, evaluation, prevention and treatment strategies were suggested, with special regard on anesthetic technique.

[Chondroblastoma--current opinion]

Chondroblastoma of bone is rare bone tumor, representing around 1% of benign bone lesions. It is considered a benign lesion, although primary malignant form as well as malignant alteration in the form of chondrosarcoma has been documented. It occurs predominantly in the second decade, more commonly in males. Predilection sites include proximal humeral epiphysis, femoral and tibial condyles, but it can be found in other bones, too (skull, pelvis, posterior vertebral structures, tarsal bones). Radiographically, it appears as an ovoid lesion with thin sclerotic margin, located centrally in the epiphysis. Pathohistologically, it is described as highly cellular tissue, variably differentiated and with discrete granulated to meshy calcification of the matrix and large multinuclear cells present in 20% of cases. Secondary formation of aneurysmal bone cyst has been documented. Tumor is presented with a few nonspecific local symptoms, which makes diagnostic procedure more difficult. Definitive diagnosis is made only by pathohistological verification. A pathological fracture of weakened epiphysis is possible. The treatment of chondroblastoma is strictly surgical, with a view to counteract the propagation into the joint or adjacent soft tissue, and diminish the recurrence rate. Chemotherapy is not indicated for treatment of this tumor, and radiotherapy is contraindicated as it stimulates malignant alteration. If malignant chondroblastoma of bone is verified pathohistologically, radical treatment by surgical resection is indicated, also avoiding any adjuvant therapy.

[Modern aspects of the ankle fracture treatment]

The ankle fractures continue to be a topical issue in orthopedic surgery. X-ray diagnostics, but primarily also other modem diagnostic procedures such as CT, MRI, and arthroscopy enable detection of not only fractures but also osteocartilaginous fractures and soft-tissue ligamentary lesions, which are frequent causes of pain and instability of the ankle. The key segment is the posterio-lateral segment and tibio-fibular syndesmosis whose integrity is sometimes only surgically establishable. In the ankle treatment, stable fixation - since recently by means of resorptive osteofixation materials - and early rehabilitation of the operated ankle are aimed at. The open and pylon fractures, as the most severe forms of ankle fractures, are treated by external fixation with minimum internal fixation (hybrid fixation) of the ankle with conversion of the rigid into a dynamic (articulated) external fixator enabling movement and nutrition of the damaged articular cartilage.

[Reconstruction of the infected war defects of the tibia: a fragment elongation according to the Ilizarov technique]

INTRODUCTION/AIM

The treatment of tibia defects complicated with chronic osteomyelitis is difficult, often requiring one or more surgical interventions with prolonged periods of functional incapacity.

METHODS

We treated 20 patients with tibia defects, who had been wounded during the war operations in the former Yugoslavia, complicated with chronic osteomyelitis by applying the Ilizarov apparatus. In 10 patients with the average defect of 4.7 cm, interfragmentary diastasis of 1.5 cm, and 3.1 cm of shortening we applied the bilocal synchronous compressive - distractive method (BSCD). In the remaining 10 patients with average defect of 6.4 cm, interfragmentary diastasis of 5.5 cm, and 1.6 cm of shortening we applied bilocal alternating distractive - compressive osteosynthesis (BADC).

RESULTS

The average followup was 93 months. In the group A, the average distraction index was 10.6, maturation index 39.8, and external fixation index 52.5. In the group B, the average distraction index was 11.7, maturation index 47.1, and external fixation index 60.1. The average time from the application to the apparatus removing was in the group A 6.5 months, and in the group B 11.9 months. There were 27 complications: 11 problems, 8 disturbs, and 8 true complications. Pin-track inflammation of the soft tissue was noted most frequently (6 patients).

CONCLUSIONS

One stage of repairing inflamation and the restitution of defect in lower leg tissue was the advantage of this type of treatment. All of the patients recovered. There was not any bad result, either in osteal or in functional outcome.

[Review of thirty patients with bone chondroblastoma]

BACKGROUND/AIM

To analyse the results of the treatment of the patients with the diagnosis of chondroblastoma, to confirm the possible malignancy and to recommend the best and the safest method of the treatment.

METHODS

We reviewed the cases of 30 patients with chondroblastoma who were treated between 1975 and 2004. Data were obtained using complete medical documentation, physical examinations, radiographic findings, and the available additional diagnostic procedures.

RESULTS

We found that the proximal part of the tibia, proximal part of the humerus, and distal part of the femur were the most common sites of the tumor in 63% of the cases. The higher prevalence of chondroblastoma in male patients was found, especially in the second decade of life. The patients were treated with different surgical procedures after histologically confirmed chondroblastoma. In 1 of the patients, radiation therapy was performed because the lesion recurred, after which the malignant transformation of chondroblastoma occured. We found two more malignant chondroblastomas, one of which had been diagnosed as a primary tumor. Seven patients had a local recurrence, one of them had a second recurrence and the malignant transformation of chondroblastoma. The only solution was a below-knee amputation.

CONCLUSION

Chondroblastoma of bone is a rare lesion with the high local recurrence rate. We emphasized the need for an adequate and rapid diagnosis, including histological verification. The treatment was strictly surgical. The basic goal of the treatment was to avoid tumor penetration into articular cavity and/or local soft tissues. Malignant chondroblastoma of bone should be treated with radical surgical resection, avoiding any adjuvant therapy.

[Thoracic disc herniation causing myelopathy. Our experience using transthoracic approach]

The authors have reported six cases of thoracal discus hernia in five patients. All the patients have recently been examined in neurosurgery institutions. They had different degrees of neurological deficit, with tendency to aggravation. The same procedure has been applying: thoracotomy, large decompression of neural structures, and obligatory spondylodesis with the patient's own rib. In three cases a full recovery has been achieved, a partial recovery in other two. Complete and definitive paraplegia developed in one patient. The degree of the neurological recovery was between one and two points by Frankel scale. Better results have been obtained where symptoms were present for a short period of time, and myelopathic signs were mild. The follow up period was between 43 and 68 months. Three of the patients have been returned to their professional work. In one patient, three years after the first surgery, there has been diagnosed another discus hernia, one level below. She was treated with the same surgical technique as described, for the second time. Multilevel symptomatic thoracic disc herniations are extremely rare. Although a small series, it is clearly pointed the need to think of a discus hernia, and its early diagnostics and adequate surgical treatment. The first experience with the operative technique described, demonstrated that this procedure is good and justified.

[Idiopathic avascular necrosis of the femoral head in adolescents--diagnostics and management]

Idiopathic avascular necrosis of the femoral head still represents incompletely explained clinical entity. In the period 1978-2003. we have treated sixteen hips in ten patients with this condition in the IOHB "Banjica". Diagnosis have been founded on clinical and radiographic features, in addition to MRI findings. One patient have been operated, curretaging necrotic part of the femoral head and placing homografts instead. The other fifteen patients have been treated by the same procedure: skin traction for several months following immediate rehabilitation of the hip. The goal of treatement was reducing the pain, increasing the range of movements and preservation of the normal joint space. Evaluation of the treatement was based on unique criteria founded on Howorth-Ferguson index, clinical and radiographic features.The follow-up period was 2-7 years. The authors have stressed the following advantages of the non-operative treatement in adolescents with idiopathic avascular necrosis if the femoral head: increased range of joint movements, decreased pain and low risk rate of any complications following surgical procedures. Formed changes in the femoral head are irreversible, and they are real basic for premature arthrosis of the hip.

[Treatment of gigantocellular tumor of the tibia metaphysis by means of the Ilizarov method--a case study]

The authors show a 36-year old female patient with a gigantocellular tumor of the distal metaphysis of the left tibia (stage III by Campanacci). A 7.6 cm long distal articular defect of the tibia has been formed by radical segmentary resection. The defect was compensated by the extension of the rest of the tibia; whereas the support function of the limb was provided through tibio-talar arthrodesis. 5.5 years after the surgery, there are no signs of local relapses; the patient walks without any orthopedic aids and works at the same job as prior to the operation.

[Anterior cruciate ligament (ACL)]

The anterior cruciate ligament or ACL (ligamenturn cruciatum anterius) is often injured, either alone or within complex ligament injuries of the knee. Therefore, the knowledge of detailed anatomic (macro- and micro-morphological) characteristics of this ligament is of key importance in therapy. The anatomy, structure, insertions, vascularization and inervation of the anterior cruciate ligament of the knee are described from the aspect of modern treatment and rehabilitation methods.