Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty

We describe three distinct types of congenital hip disease in adults. The first type is dysplasia, in which the femoral head is contained within the original true acetabulum. The second type is low dislocation, in which the femoral head articulates with a false acetabulum, the inferior lip of which contacts or overlaps the superior lip of the true acetabulum, giving the appearance of two overlapping acetabula. The third type is high dislocation, in which the femoral head has migrated superoposteriorly and there is no contact between the true and the false acetabulum. We describe and classify the acetabular abnormalities and deficiencies found with these three types. If the anterior, posterior, and superior aspects of the acetabular component cannot be covered during a total hip arthroplasty because of a deficient acetabulum in an adult who has congenital hip disease, we advocate and acetabuloplasty technique (which we have named a cotyloplasty) that involves medial advancement of the acetabular floor by the creation of a controlled comminuted fracture of its medial wall, autogenous bone-grafting, and the implantation of a small acetabular component with cement. This procedure was performed in sixty-six patients (eighty-six hips). Forty-nine of the hips had a high dislocation, thirty-one had a low dislocation, and six were dysplastic. Two to fifteen years (mean, seven years) after the operation, the clinical and radiographic results were satisfactory. Only two acetabular components needed to be revised for aseptic loosening, at 5.3 and 7.5 years postoperatively. Moreover, the cumulative success rate for the acetabular components was 100 percent at five years and 93.2 percent at ten years.

Total hip arthroplasty for congenital hip disease

BACKGROUND

It is generally agreed that the clinical and radiographic results of total hip replacement performed for degenerative arthritis secondary to congenital hip disease vary depending on the severity of the anatomical abnormality. In this study, we report the mid-term and long-term clinical and radiographic results of total hip arthroplasty performed for each of the three different types of congenital hip disease.

METHODS

Between 1976 and 1994, the senior author performed 229 consecutive primary total hip arthroplasties in 168 patients with osteoarthritis secondary to congenital hip disease. Seventy-six hips were dysplastic, sixty-nine had a low dislocation, and eighty-four had a high dislocation. The Charnley low-friction technique was performed in 178 hips, and the so-called hybrid technique was performed in forty-six hips. Cementless arthroplasty was used in only five hips.

RESULTS

After a minimum of seven years of follow-up, the rates of revision of the acetabular components were 15% in the dysplastic hips, 21% in the hips with a low dislocation, and 14% in those with a high dislocation. The rates of revision of the femoral components were 14%, 14%, and 16%, respectively. Survivorship analysis predicted an overall rate of prosthetic survival at fifteen years of 88.8% +/- 4.8% in the dysplastic hips, 73.9% +/- 7.2% in the hips with a low dislocation, and 76.4% +/- 8.1% in those with a high dislocation.

CONCLUSIONS

An understanding of the anatomical abnormalities and the use of appropriate techniques and implants make total hip arthroplasty feasible for treatment of the three types of congenital hip disease. In patients with a low dislocation, the major technical problem is reconstruction of the natural acetabulum. In those with a high dislocation, the challenge is to place the acetabular component inside the reconstructed true acetabulum and to use an appropriate femoral implant in the hypoplastic narrow femoral diaphysis.

Analgesic effect of salmon calcitonin in osteoporotic vertebral fractures: a double-blind placebo-controlled clinical study

Back pain due to vertebral collapse is the main symptom of postmenopausal osteoporosis. The clinical picture in these crush fractures varies, depending on the type and the location of fracture, but in general, a new vertebral crush fracture gives rise to severe pain that immobilizes the patient and necessitates bedrest. In this double-blind controlled clinical trial, 56 patients who had recently (within the last 3 days) suffered an osteoporotic vertebral fracture were hospitalized for a period of 14 days. Salmon calcitonin (100 IU) or placebo injections were given daily. Pain was rated daily on a 10-point scale by the same observers. Blood and urinary parameters were also evaluated. The results showed a significant (P less than 0.001) difference in pain intensity between the calcitonin group and the placebo group. This beneficial effect was generally apparent from the second day of treatment onward, and over the following 2 weeks, the patients were able to sit and stand, and gradually started to walk again. A significant decrease in urinary hydroxyproline and urinary calcium was also noted in the calcitonin group. It is concluded that calcitonin exerts a beneficial effect on back pain following a vertebral crush fracture.

Mechanical stimulation in the form of vibration prevents postmenopausal bone loss in ovariectomized rats

Physical exercise is recommended for the prevention and treatment of osteoporosis. However, its exact role and effectiveness in adulthood is unclear. While vigorous exercise of long duration enhances bone density, few adult individuals comply with such training programs. The present study evaluates the influence of nonphysiological mechanical stimulation, in the form of low intensity vibration (frequency: 50 Hz, acceleration: 2 g, 30 min/day for 5 days/week), on the prevention of bone loss in an animal model of postmenopausal osteoporosis. In the ovariectomised groups of rats a statistically significant (p < 0.05) decrease of bone density (femur and tibia) was recorded at 5 weeks postovariectomy. This effect was maintained for the 12 week duration of the study. Vibration prevented early bone loss after ovariectomy. Vibrated ovariectomised rats showed statistically significantly higher (p < 0.05) BMD values compared to those of their ovariectomised controls at 5 weeks. Vibration did not influence the bone density of the SHAM-operated rats. Although vibration increased ultimate strength (fracture load of the rat femur) in the ovariectomised rats, this finding was not statistically significant. Our data indicate that this method of safe and easily applicable vibration, in the form of a vibrating platform, is effective in preventing early postovariectomy bone loss in an animal model.

Severe varus and valgus deformities treated by total knee arthroplasty

We report a prospective case-controlled study which compared the outcome of knee replacement in seriously deformed and slightly deformed knees. There were 51 knees with varus or valgus deformity greater than 20 degrees matched for age, gender, disease, type of prosthesis and time of operation with a control group in which the alignment of the leg was within 5 degrees of normal. The clinical outcome at a mean 5.5 years was similar in the two groups. Some deformity persisted in 14 patients in the first group, 13 of whom were initially in valgus. These patients had a significantly poorer mean clinical outcome. Lateral dislocation or subluxation of the patella was found in four knees, all of which had had valgus deformity of 30 degrees or more.

The long-term clinical relevance of calcar atrophy caused by stress shielding in total hip arthroplasty: a 10-year, prospective, randomized study

Eighty osteoarthritic female patients were randomly allocated to 4 equal groups; the Zwey-Muller, the Corail, the Optifix, or Autophor 900S cementless total hip arthroplasties (THAs) were implanted; and bone density changes, at different sites, were prospectively studied. In zone 7, the greatest reduction of bone density values was observed at 2 years (group A: 24%, group B: 8%, group C: 14.8%, and group D: 18.5%). In all groups, a similar pattern of slow but progressive recovery of bone mineral density changes after the third year was observed, approaching baseline values at 10 years, during which all patients showed satisfactory clinical results. We suggest that the clinical and theoretical relevance of the stress-shielding phenomenon in THA has been overestimated in the literature.

Total hip arthroplasty: Survival and modes of failure

Total hip arthroplasty (THA) is a very satisfactory surgical procedure for end-stage hip disorders.

Implant modifications, such as large femoral heads to improve stability, porous metals to enhance fixation and alternative bearings to improve wear, have been introduced over the last decade in order to decrease the rate of early and late failures.

There is a changing pattern of THA failure modes.

The relationship between failure modes and patient-related factors, and the time and type of revision are important for understanding and preventing short and late failure of implants.

The early adoption of innovations in either technique or implant design may lead to an increased risk of early failure.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170068

Treatment of high dislocation of the hip in adults with total hip arthroplasty. Operative technique and long-term clinical results

The clinical results of eighty-four total hip arthroplasties performed through a transtrochanteric approach in sixty-seven patients who had a high dislocation of the hip (the femoral head completely out of the acetabulum), from 1976 to 1994, were reviewed. The acetabular component was placed in the true acetabulum and the femur was shortened at the level of the femoral neck, along with release of the psoas tendon and the small external rotators, in order to facilitate reduction of the components and to avoid neurovascular complications. Eleven hip prostheses (13 per cent) failed at a mean of 6.4 years (range, two months to sixteen years) postoperatively; the failure was due to aseptic loosening of both components in four hips, aseptic loosening of the stem only in three, late infection in three, and malpositioning of the acetabular component that caused recurrent dislocations in one. The other seventy-three hips were functioning well at the latest follow-up examination, two to twenty years (mean, 7.1 years) postoperatively. The overall cumulative rate of success was 92.4 per cent (95 per cent confidence interval, 89.5 to 95.3 per cent) at five years and 88.0 per cent (95 per cent confidence interval, 82.2 to 93.8 per cent) at ten years. We believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip.

Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty

BACKGROUND

To investigate and compare the impact of primary hip (THA) and knee (TKA) arthroplasty on quality of life in patients with osteoarthritis, to determine patients' satisfaction with total joint arthroplasty, and to detect the effect of patients' demographic and clinical characteristics on outcome.

METHODS

Three hundred seventy eight (378) patients with hip (174) and knee (204) osteoarthritis undergoing total joint arthroplasty (174 THA-204 TKA) were assessed pre- and post-operatively (6 weeks, 3, 6, and 12 months) using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and Centre for Epidemiological Studies Depression Scale (CES-D10). The patients' satisfaction with the results of total joint arthroplasty was also assessed. Differences were analyzed using general linear model for repeated measures.

RESULTS

The one-year response rate was 97 % for THA and 90 % for TKA. WOMAC and CES-D10 scores improved significantly after one year for both THA and TKA (P < 0.0001). The improvement in WOMAC total score was significantly greater for TKA patients (P < 0.0001 at 12 months). WOMAC pain and stiffness improved earlier for THA (6 weeks), while TKA had equivalent improvements at 3 and 6 months respectively. Both THA/TKA displayed significant improvement of WOMAC function at 3 months but TKA had greater improvement. Age, body mass index, residence, education and social support were not significant predictors of quality of life after total joint arthroplasty. One year postoperatively 88 % of patients were satisfied.

CONCLUSIONS

WOMAC and CES-D10 improved significantly one year postoperatively. Although pain and stiffness improved earlier in THA, functional improvement was inferior in THA compared to TKA.

The natural history of the osteoporotic vertebral fracture

The clinical picture of the osteoporotic fractures of the spine presents an heterogeneity in their intensity and duration. In 210 cases of osteoporotics with acute pain and radiological evidence of spinal fracture we separate their clinical picture in two groups. In Type I (121 cases) pain is acute and severe, improving gradually; the vertebral wedging is obvious from the beginning and remain unchanged. The duration of this event exceeds 4-8 weeks. In Type II (89 cases) pain is less and of shorter duration, but after 6-16 weeks a new attack of acute pain presents. This picture can be repeated for 6-18 months. Radiologically the fracture is not clear during the first attack but wedging gradually developed during the next months. Bone density of the lumbar spine (DPA) was measured in all cases. Type I had a significantly lower BMC than Type II. We suggest that patients with unclear vertebral fractures, minor symptoms and relatively high bone mass must classified in Group II and deterioration can occur during the next months. Long term treatment and additional orthopaedic prevention is needed. In Group I a short term calcitonin treatment helps early relief and mobilization.

Pain relief from nasal salmon calcitonin in osteoporotic vertebral crush fractures. A double blind, placebo-controlled clinical study

We examined the analgesic effect of nasal salmon calcitonin in patients with acute pain due to recent, nontraumatic osteoporotic vertebral crush fractures. 32 men and 68 postmenopausal women were studied using a prospective, double-blind, placebo-controlled clinical design. Men and women taking 200 IU of nasal salmon calcitonin daily for a period of 28 days had a dramatic decrease of spinal pain. This analgesic effect was accompanied by early mobilization and gradual restoration of the locomotor functions, such as sitting, standing and walking. Patients receiving the placebo nasal spray remained in bed for almost the entire period of observation. The consumption of high doses of paracetamol did not help placebo patients to get out of bed during the 4 weeks of hospitalization. Nasal salmon calcitonin and early mobilization also reduced hydroxyproline excretion, thus preventing massive bone loss during the period of bedrest.

Analgesic effect of salmon calcitonin suppositories in patients with acute pain due to recent osteoporotic vertebral crush fractures: a prospective double-blind, randomized, placebo-controlled clinical study

OBJECTIVE

To evaluate the analgesic efficacy of calcitonin suppositories (200 IU) in comparison with bed rest and paracetamol tablets, as a rescue analgesic.

DESIGN

A prospective, double-blind, randomized, placebo-controlled, clinical trial.

PATIENTS

Forty patients (8 men and 32 postmenopausal women), who had recently (within the last 5 days) suffered a nontraumatic osteoporotic vertebral fracture.

SETTING AND INTERVENTIONS

All patients were admitted to the hospital, divided randomly into two groups and received either one calcitonin or placebo suppository once a day, respectively, for 28 days. All patients were allowed to take paracetamol tablets (500 mg), with a maximum dose of six tablets daily.

OUTCOME MEASURES

Spinal pain evaluation was performed at the beginning of the study (before the initiation of treatment) and then daily until the end of the study (day 28) using the Huskinsson's visual analog scale (VAS) and a painmeter device, by direct pressure on the fractured vertebra. Pain was evaluated with the patients attempting or performing four different locomotor functions, e.g., bed rest, sitting, standing, and walking functions. Biochemical urine and plasma measurements were carried out before the initiation of treatment and on days 14 and 28.

RESULTS

All calcitonin-treated patients experienced an overall statistically significant (all p values < 0.001) decrease of spinal pain as assessed by the VAS and the painmeter device. Pain relief allowed for early mobilization and the gradual restoration of the locomotive functions in the calcitonin-treated group. Placebo-treated patients remained in bed for almost the whole of the observation period. At the end of the study (28th day), fasting osteocalcin, hydroxyproline/creatinine, and calcium/creatinine ratio values were statistically significantly (all p values < 0.001), lower in the calcitonin-treated than in the placebo-treated patients. In the placebo group these values showed a gradual increase. In the calcitonin-treated group side effects mainly included dizziness and enteric irritation caused by the suppositories. Enteric irritation was also present in the placebo-treated group.

CONCLUSIONS

Salmon calcitonin suppositories (200 IU daily) caused a dramatic decrease in spinal pain in patients with recent osteoporotic vertebral fractures and influenced the early mobilization and the gradual restoration of their locomotor functions.

Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis?

STUDY DESIGN

A 10-year follow-up evaluation of the effectiveness of school screening for scoliosis performed in a closed island population.

OBJECTIVES

To evaluate the diagnostic accuracy of methods used for screening scoliosis and to re-examine the long-term effectiveness of the school scoliosis screening program.

SUMMARY OF BACKGROUND DATA

The diagnostic accuracy of the forward-bending test and the long-term efficacy of the screening programs have not been clearly established.

METHODS

In 1987, 2700 pupils aged 8 to 16 years from the island of Samos were screened for scoliosis. The Adams forward-bending test, Moire topography, the scoliometer, and the humpometer were used. Radiologic evaluation of the spine was available for each pupil and the number of false-negative and false-positive results of the screening methods was calculated. Subsequently, sensitivity, specificity, and positive and negative predictive values were estimated for each screening technique. Pupils found positive for spinal deformity were then followed up regularly at yearly intervals. In 1997, all positive subjects attended a 10-year clinical and radiologic follow-up, and the remaining subjects were re-evaluated by a postal questionnaire and were clinically examined if necessary.

RESULTS

Spinal deformity was found in 153 (5.66%) pupils. Scoliosis (defined as a spinal curvature > or = 10 degrees) was found in 32 pupils, for a prevalence of 1.18%. For scoliosis, the Adams forward-bending test showed a number of false-negative results (in five cases), for a sensitivity of 84.37% and specificity of 93.44%. The sensitivities of Moire topography, the humpometer, and the scoliometer were 100%, 93.75%, and 90.62%, respectively, and specificity was 85.38%, 78.11%, and 79.76% respectively. The negative predictive value of the forward-bending test was inferior to those of the other methods. During this scoliosis screening program, if cutoff limits for referral had been used, such as the asymmetry of two Moire fringes, a humpogram deformity of (D + H) = 10 mm, and 8 degrees of scoliometer angle, it would have been possible to reduce radiologic examination by 89.4%. Three (0.11%) pupils aged between 12 and 14 years with scoliotic deformities greater than 20 degrees underwent satisfactory nonoperative treatment with Boston braces. One pupil with a 40 degrees thoracic curvature, underwent satisfactory surgical treatment because of progression 1 year later. Of the 121 spinal deformities with an initial Cobb angle less than 10 degrees, 44 (35.8%), and of the 29 scoliotic deformities with an initial Cobb angle between 10 degrees and 20 degrees, 14 (48.3%) progressed (a Cobb angle difference of at least 5 degrees in more than one examination). Observation and physiotherapy were the only treatments applied to all except one of the pupils in these groups.

CONCLUSIONS

The Adams forward-bending test cannot be considered a safe diagnostic criterion for the early detection of scoliosis (especially when it is used as the only screening tool) because it results in an unacceptable number of false-negative findings. For the early detection of scoliosis, a combination of back-shape analysis methods can be safely used with the introduction of cutoff limits for referral being a useful procedure. The incidence of significant scoliosis is low, and its natural history seems to be independent of early detection. The wide-spread use of school scoliosis screening with the use of the forward-bending test must be questioned.

Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty

Antibiotic-impregnated cement is used frequently in revision procedures of infected total hip and knee arthroplasties. Local antibiotic treatment is as effective as the use of systemic antibiotics. The purpose of such treatment is to provide high tissue concentrations of antibiotics and minimize systemic toxicity, especially nephrotoxicity. Though antibiotic-impregnated cement is considered safe in terms of nephrotoxicity, two cases that have implicated aminoglycoside-impregnated cement in acute renal failure (ARF) after surgery for an infected total knee arthroplasty (TKA) have been reported [Curtis et al. 2005, Van Raaij et al. 2002]. Two more cases of postoperative ARF after use of combined tobramycin- plus vancomycin-impregnated cement, this time in total hip arthroplasty, have been recently reported [Patrick et al. 2006]. We report a case of ARF in a 61-year-old patient with a history of diabetes mellitus and hypertension after treatment of a febrile infection of a TKA with combined gentamicin- plus vancomycin-impregnated cement. The ARF could not sufficiently be attributed to other causes and though serum concentrations of antibiotics obtained from the 8th postoperative day and thereafter were far below the trough levels associated with nephrotoxicity, gentamicin and vancomycin seem to have contributed significantly to ARF in our case.

Radiological evaluation of the metal-bone interface of a porous tantalum monoblock acetabular component

Between January 1998 and December 1998, 82 consecutive patients (86 hips) underwent total hip arthroplasty using a trabecular metal monoblock acetabular component. All patients had a clinical and radiological follow-up evaluation at six, 12 and 24 weeks, 12 months, and then annually thereafter. On the initial post-operative radiograph 25 hips had a gap between the outer surface of the component and the acetabular host bed which ranged from 1 to 5 mm. All patients were followed up clinically and radiologically for a mean of 7.3 years (7 to 7.5). The 25 hips with the 1 to 5 mm gaps were studied for component migration at two years using the Einzel-Bild-Roentgen-Analyse (EBRA) digital measurement method. At 24 weeks all the post-operative gaps were filled with bone and no acetabular component had migrated. The radiographic outcome of all 86 components showed no radiolucent lines and no evidence of lysis. No acetabular implant was revised. There were no dislocations or other complications. The bridging of the interface gaps (up to 5 mm) by the trabecular metal monoblock acetabular component indicates the strong osteoconductive, and possibly osteoinductive, properties of trabecular metal.

Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears

BACKGROUND

Clinical tests used for the detection of meniscal tears in the knee do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or magnetic resonance imaging studies. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears.

METHODS

Two hundred and thirteen symptomatic patients with knee injuries who were examined clinically, had magnetic resonance imaging studies performed, and underwent arthroscopic surgery and 197 asymptomatic volunteers who were examined clinically and had magnetic resonance imaging studies done of their normal knees were included in this study. For clinical examination, the medial and lateral joint-line tenderness test, the McMurray test, the Apley compression and distraction test, the Thessaly test at 5 degrees of knee flexion, and the Thessaly test at 20 degrees of knee flexion were used. For all clinical tests, the sensitivity, specificity, false-positive, false-negative, and diagnostic accuracy rates were calculated and compared with the arthroscopic and magnetic resonance imaging data for the test subjects and the magnetic resonance imaging data for the control population.

RESULTS

The Thessaly test at 20 degrees of knee flexion had a high diagnostic accuracy rate of 94% in the detection of tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus, and it had a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of joint-line tenderness, which presented a diagnostic accuracy rate of 89% in the detection of lateral meniscal tears, showed inferior rates.

CONCLUSIONS

The Thessaly test at 20 degrees of knee flexion can be used effectively as a first-line clinical screening test for meniscal tears, reducing the need for and the cost of modern magnetic resonance imaging methods.

Epidemiology, demographics, and natural history of congenital hip disease in adults

This study examined the epidemiology and demographics of congenital hip disease in 468 (660 hips) patients who were examined between 1970 and 1996. In 356 (54%) hips, the diagnosis was secondary osteoarthritis due to congenital hip disease, and in 272 (41%) hips, the diagnosis was idiopathic osteoarthritis. In the remaining 32 (5%) hips, the diagnosis was uncertain. Of the hips with congenital hip disease, 170 (47.7%) hips were dysplastic, 85 (23.9%) had low dislocation, and 101 (28.4%) high dislocation. The majority of patients with congenital hip disease were women (338 [95%] hips). The natural history of the three types of congenital hip disease was studied in 157 patients (202 hips: 102 dysplastic, 42 low dislocation, and 58 high dislocation) who had received no treatment before the initial examination. Average length of follow-up was 17 years. In dysplastic hips, the disease remained undiagnosed until the onset of symptoms at an average age of 34.5 years. In patients with low dislocation, pain had started at an average of 32.5 years due to progressive degenerative arthritis within the false acetabulum. In patients with high dislocation, in the presence of a false acetabulum, pain started at an average age of 31.2 years, while in its absence, pain started at an average age of 46.4 years due to muscle fatigue. These findings suggest dysplasia, low dislocation, and high dislocation in adults are the results of untreated dysplasia, subluxation, and complete dislocation in infancy, respectively.

A mid-term clinical outcome study of the Advance Medial Pivot knee arthroplasty

The Advance Medial Pivot Total Knee Arthroplasty (Wright Medical Technology, Arlington, Tennessee, USA) has been designed to reproduce modern ideas of knee kinematics. We report a prospective clinical outcome study of 284 arthroplasties in 225 consecutive patients with a mean follow-up of 6.7 years (range 4 to 9 years). For evaluation, both objective and subjective clinical rating systems and serial radiographs were used. At final follow-up, 10 (4.4%) patients (10 knees) only were lost from follow-up and four (1.8%) patients (five knees) had died for reasons unrelated to the surgery with their knees performing well. There was an 82% compliance in the intervals of follow-up evaluation. All patients showed a statistically significant improvement (p=0.01) in the Knee Society clinical rating system, WOMAC questionnaire, SF-12 questionnaire, and Oxford knee score. The majority of patients (92%) were able to perform age-appropriate activities with a mean knee flexion of 117 degrees (range 85 degrees to 135 degrees) at final follow-up. Survival analysis showed a cumulative success rate of 99.1% at 5 years. Two (0.7%) arthoplasties, in which patient selection and surgical errors were identified, were revised due to aseptic loosening, one due to infection and one due to a traumatic dislocation. This study demonstrates satisfactory mid-term clinical results for this knee design.

A Randomized, Placebo-Controlled Study of Romosozumab for the Treatment of Hip Fractures

BACKGROUND

Romosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures.

METHODS

Patients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed "Up & Go" (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH).

RESULTS

A total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo.

CONCLUSIONS

Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Low-intensity transosseous ultrasound accelerates osteotomy healing in a sheep fracture model

BACKGROUND

Low-intensity transcutaneous ultrasound can accelerate and augment the fracture-healing process. The aim of this study was to investigate the effect of transosseous application of low-intensity ultrasound on fracture-healing in an animal model.

METHODS

A midshaft osteotomy of the left tibia was performed in forty sheep. An external fixator was used to stabilize the osteotomy site. A thin stainless-steel pin was inserted into the bone, 1.0 cm proximal to the osteotomy site. Ultrasound was transmitted through the free end of this pin, with a PZT-4D transducer. In twenty animals, the treated limb received a 200-microsec burst of 1-MHz sine waves repeated at 1 kHz with an average intensity of 30 mW/cm(2) for twenty minutes daily. Twenty other animals underwent the same surgery but did not receive the ultrasound (controls). Animals were killed at seventy-five and 120 days postoperatively. Radiographic evaluation was performed every fifteen days. Mechanical testing and quantitative computed tomography were performed after death.

RESULTS

Fractures treated with ultrasound healed significantly more rapidly, as assessed radiographically, than did the controls (seventy-nine compared with 103 days, p = 0.027). On day 75, the mean cortical bone mineral density (and standard deviation) was 781 +/- 52 mg/mL in the treated limbs compared with 543 +/- 44 mg/mL in the control group (p = 0.014), and the average ultimate strength (as assessed with a lateral bending test) was 1928 +/- 167 N in the treated limbs compared with 1493 +/- 112 N in the control group (p = 0.012). No significant differences were noted on day 120.

CONCLUSIONS

This study demonstrated that low-intensity transosseous ultrasound can significantly accelerate the fracture-healing process, increase the cortical bone mineral density, and improve lateral bending strength of the healing fracture in a sheep osteotomy model.

Congenital hip disease in adults: terminology, classification, pre-operative planning and management

This paper reviews the current knowledge relating to the management of adult patients with congenital hip disease. Orthopaedic surgeons who treat these patients with a total hip replacement should be familiar with the arguments concerning its terminology, be able to recognise the different anatomical abnormalities and to undertake thorough pre-operative planning in order to replace the hip using an appropriate surgical technique and the correct implants and be able to anticipate the clinical outcome and the complications.

Survivorship of monoblock trabecular metal cups in primary THA : midterm results

Monoblock trabecular metal cups are made of a novel porous material intended to enhance ingrowth and improve fixation. We prospectively followed 223 consecutive patients with 245 trabecular metal acetabular cups implanted during primary total hip arthroplasties to determine the overall survivorship of the implant, and any association of survivorship to primary diagnosis and age, and to determine the fate of polar gaps and cysts. Minimum followup was 36 months (mean, 60 months; range, 36-112 months). Patients were assessed with the Harris Hip score and the Oxford questionnaire and radiographically with standardized serial radiographs. At last followup, all cups were radiographically stable with no evidence of migration or progressive radiolucencies. The survivorship with reoperation as the end point was estimated at 98.75% with a 95% confidence interval. Three reoperations occurred during the first 36 months. The Harris hip score increased from 48 to 94 and the Oxford score was 16.4 at the last examination. We observed no difference in terms of survivorship among patients with osteoarthritis, osteonecrosis, or hip dysplasia. Seven of 14 (50%) osteoarthritis cysts and 10 of 33 (33.3%) polar gaps detected on postoperative radiographs decreased or filled, whereas none of the remainder deteriorated with time. Our midterm results suggest this implant may enhance fixation, but long-term followup is needed to confirm our findings.

LEVEL OF EVIDENCE

Level IV Therapeutic study.

Comparison of MR-arthrography and MDCT-arthrography for detection of labral and articular cartilage hip pathology

OBJECTIVE

To compare the diagnostic ability of MR arthrography (MRa) and MDCT arthrography (CTa) in depicting surgically proven hip labral tears and articular cartilage degradation.

MATERIALS AND METHODS

Labral pathology and articular cartilage were prospectively evaluated with MRa and CTa in 14 hips of 10 patients. The findings were evaluated by two independent observers (a musculoskeletal fellow and one senior musculoskeletal radiologist). Sensitivity, specificity, accuracy, and positive predictive value were determined using arthroscopic and open surgery findings as the standard of reference. Interobserver agreement was recorded. All images were assessed for the presence of a labral tear (according to Czerny classification) and for cartilage erosion using a 3 point scale for both methods: 1 = complete visualization-sharp edges, 2 = blurred edges fissuring-partial defects, 3 = exposed bone. The same classification was applied surgically.

RESULTS

Disagreement between the senior observer and the fellow observer was recorded in three cases of labral tearing with MRa and six with CTa. Disagreement was also found in four cases of cartilage erosion with both MRa and CTa. The percent sensitivity, specificity, accuracy, and positive predictive value for correctly assessing the labral tear were as follows for MRa/CTa, respectively: 100/15, 50/13, 90/14, and 90/13 (P < 0.05). The same values for cartilage assessment were 63/66, 33/40, 50/57 and 55/66 (P > 0.05).

CONCLUSION

Interobserver reproducibility with MRa is very good for labral tearing assessment. MRa is better for assessing labral tears. CTa shows better, but not statistically significant, demonstration of the articular cartilage.

Romosozumab in Skeletally Mature Adults with a Fresh Unilateral Tibial Diaphyseal Fracture: A Randomized Phase-2 Study

BACKGROUND

Romosozumab is an antibody that binds and inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption. A double-blinded, randomized, phase-2, dose-finding trial was performed to evaluate the effect of romosozumab on the radiographic and clinical outcomes of surgical fixation of tibial diaphyseal fractures.

METHODS

Patients (18 to 82 years old) were randomized 3:1:1:1:1:1:1:1:1:1 to a placebo or 1 of 9 romosozumab treatment groups. Patients received subcutaneous injections of romosozumab or the placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary outcome was the time to radiographic evidence of healing ("radiographic healing") analyzed after the week-24 assessments had been completed for all patients.

RESULTS

A total of 402 patients were randomized: 299 to the romosozumab group and 103 to the placebo group. The median time to radiographic healing (the primary outcome) ranged from 14.4 to 18.6 weeks in the romosozumab groups and was 16.4 weeks (95% confidence interval [CI]: 14.6 to 18.0 weeks) in the placebo group, which was not a significant difference. There was also no significant difference in the median time to clinical healing, no relationship between romosozumab dose/frequency and unplanned revision surgery, and no apparent treatment benefit in terms of physical function. The safety and tolerability profile of romosozumab was comparable with that of the placebo.

CONCLUSIONS

Romosozumab did not accelerate tibial fracture-healing in this patient population. Additional studies of patients at higher risk for delayed healing are needed to explore the potential of romosozumab to accelerate tibial fracture-healing.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

MR imaging findings in early osteoarthritis of the knee

PURPOSE

To carry out a modern diagnostic survey among patients with a clinical and radiological diagnosis of early osteoarthritis of the knee.

MATERIALS AND METHODS

A magnetic resonance imaging survey was performed on 70 patients (82 knees) with a mean age of 59 years. (range, 40-71 years) who had chronic knee pain, clinical diagnosis of early osteoarthritis of the knee and conventional knee radiographs classified as 1 and 2 on the Kellgren-Lawrence scale.

RESULTS

A variety of different disorders was found; degenerative meniscal lesions with or without ruptures of the anterior cruciate ligament in 70.7% of the knees, osteonecrosis of the femoral and tibial condyles in 9.75%, osteophytes and degenerative articular cartilage lesions in 8.54%, transient osteoporosis in 2.44% and benign neoplasms and cysts in 6.1%.

CONCLUSIONS

The existence of such a heterogenous group of disorders in these "early osteoarthritic knees" may explain failures in treatment and it may justify a modern MRI imaging approach to proper diagnosis.