Biomarkers of muscle damage increased in anterolateral compared to direct lateral approach to the hip in hemiarthroplasty: no correlation with clinical outcome : Short-term analysis of secondary outcomes from a randomized clinical trial in patients with a displaced femoral neck fracture.

In this study, we found elevated levels of serum CK in the anterolateral approach to the hip compared to the direct lateral approach in patients with a displaced femoral neck fracture. No correlation was found between levels of CK and functional outcomes. INTRODUCTION: To compare increase in serum creatine kinase (CK) and its association with functional outcome between the muscle-sparing anterolateral approach and the direct lateral approach to the hip in patients with displaced femoral neck fracture (FNF). METHODS: In this randomized trial, we enrolled eligible patients between 70 and 90 years of age with FNF. Patients were allocated to an uncemented hemiarthroplasty inserted through a direct lateral or an anterolateral approach. The primary endpoints were pain and patient satisfaction assessed by the Visual Analogue Scale (VAS). Among secondary endpoints was increase in CK at 24 and 48 h compared to baseline and its association with surgical parameters, Timed up and Go Test (TUG), Harris Hip Score (HHS), and the presence of a Trendelenburg sign using correlation analysis. This paper reports on increase in serum CK and its association with functional outcome. RESULTS: At 24 h, there was a mean increase from baseline in total CK of 228 U/L (95% CI 187 to 269; P < 0.001). There was a difference between groups at 24 h in CK increase with higher levels in the anterolateral group (mean difference 80 U/L; 95% CI - 0.5 to 162; P = 0.05). Likewise, at 48 h, there was a mean difference of 117 U/L (95% CI 22 to 212; P = 0.01). No correlation was found between CK values and functional assessments. CONCLUSIONS: Compared with the direct lateral approach, the anterolateral approach yielded higher levels of postoperative CK. However, there was no correlation between levels of CK and functional outcome. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02028468.

The gluteal muscles in end-stage osteoarthritis of the hip: intra- and interobserver reliability and agreement of MRI assessments of muscle atrophy and fatty degeneration.

AIM: To assess the intra- and interobserver reliability and agreement of muscular atrophy and fatty degeneration of the gluteal muscles on magnetic resonance imaging (MRI) in patients with end-stage osteoarthritis of the hip. MATERIALS AND METHODS: Thirty-nine patients with end-stage osteoarthritis of the hip, who scheduled for hip replacement surgery, were included in the study. The cross-sectional areas of the gluteus medius and minimus muscles were manually circumscribed and automatically calculated, while intramuscular fatty degeneration was assessed using the semi-quantitative classification system of Goutallier. Two independent observers performed all the evaluations. RESULTS: Good agreement and excellent reliability were found for the cross-sectional areas of the gluteus medius and gluteus minimus (intraclass correlation coefficient [ICC] for intra-observer 0.97 and 0.93, ICC for interobserver 0.98 and 0.95). Fair reliability was found for fatty degeneration of the gluteus muscles (mean kappa 0.23 and mean prevalence-adjusted kappa 0.53). The average proportion of agreement for the raters was 0.71. CONCLUSION: The present study demonstrated substantial agreement and excellent intra- and interobserver reliability for the measurements of the cross-sectional areas of the gluteus medius and gluteus minimus. Assessment of fatty degeneration had fair intra- and interobserver reliability, but acceptable agreement.

Capsular lesions with glenohumeral ligament injuries in patients with primary shoulder dislocation: magnetic resonance imaging and magnetic resonance arthrography evaluation.

The glenohumeral ligaments are important structures for the stability of the shoulder. They are integrated parts of the capsule and are at risk to be injured in a traumatic shoulder dislocation. The aim was to examine the prevalence of capsular ligament lesions in the acute phase and at minimum 3 weeks' follow-up after first-time traumatic shoulder dislocation. Forty-two patients aged 16-40 years were included. All patients underwent computed tomography and magnetic resonance imaging (MRI) scans shortly after the injury and MR-arthrography (MRA) at follow-up. The median time from dislocation to MRI was 7 (range 2-14) days and to MRA 30 (range 21-54) days. We found capsular ligament lesions in 22 patients (52.4%) in the acute stage and in five patients (11.9%) at follow up. Nine patients (21.4%) had a humeral avulsion of the anterior glenohumeral ligament (HAGL lesion) on MRI. Three patients (7.1%) had this lesion at follow-up. The rate of HAGL lesions in the acute stage was higher than reported previously, but the prevalence at follow-up was in keeping with earlier published studies.

The epidemiology of shoulder dislocations in Oslo.

There are few previous studies on the incidence of shoulder dislocation in the general population. The aim of the study was to report the incidence of acute shoulder dislocations in the capital of Norway (Oslo) in 2009. Patients of all ages living in Oslo, sustaining a dislocation of the glenohumeral joint, were identified using electronic diagnosis registers, patient protocols, radiological registers of the hospitals, and the Norwegian Patient Register (NPR). The overall incidence rate was 56.3 [95% confidence interval (CI) 50.2-62.4] per 100,000 person-years, with rates of 82.2 (95% CI 71.7-92.8) and 30.9 (95% CI 24.5-37.3) in men and women, respectively. The incidence of primary dislocations was 26.2 (95% CI 22.1-30.4). The overall incidence of shoulder dislocations in Oslo was higher than previously reported incidences. The incidence of primary dislocations was also higher than that in previously reported studies for the general population but it was close to the incidence reported in Malmø, Sweden.

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomized trial in patients with femoral neck fracture.

AIMS: The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty. PATIENTS AND METHODS: A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months. RESULTS: A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups. CONCLUSION: The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome. Cite this article: Bone Joint J 2019;101-B:793-799.

The epidemiology and aetiology of Perthes' disease in Norway. A nationwide study of 425 patients.

A nationwide study of Perthes' disease in Norway was undertaken over a five-year period from January 1996. There were 425 patients registered, which represents a mean annual incidence of 9.2 per 100 000 in subjects under 15 years of age, and an occurrence rate of 1:714 for the country as a whole. There were marked regional variations. The lowest incidence was found in the northern region (5.4 per 100 000 per year) and the highest in the central and western regions (10.8 and 11.3 per 100 000 per year, respectively). There was a trend towards a higher incidence in urban (9.5 per 100 000 per year) compared with rural areas (8.9 per 100 000 per year). The mean age at onset was 5.8 years (1.3 to 15.2) and the male:female ratio was 3.3:1. We compared 402 patients with a matched control group of non-affected children (n = 1 025 952) from the Norwegian Medical Birth Registry and analysed maternal data (age at delivery, parity, duration of pregnancy), birth length and weight, birth presentation, head circumference, ponderal index and the presence of congenital anomalies. Children with Perthes' disease were significantly shorter at birth and had an increased frequency of congenital anomalies. Applying Sartwell's log-normal model of incubation periods to the distribution of age at onset of Perthes' disease showed a good fit to the log-normal curve. Our findings point toward a single cause, either genetic or environmental, acting prenatally in the aetiology of Perthes' disease.

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

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

Anatomical pulmonary magnetic resonance imaging segmentation for regional structure-function measurements of asthma.

PURPOSE: Pulmonary magnetic-resonance-imaging (MRI) and x-ray computed-tomography have provided strong evidence of spatially and temporally persistent lung structure-function abnormalities in asthmatics. This has generated a shift in their understanding of lung disease and supports the use of imaging biomarkers as intermediate endpoints of asthma severity and control. In particular, pulmonary (1)H MRI can be used to provide quantitative lung structure-function measurements longitudinally and in response to treatment. However, to translate such biomarkers of asthma, robust methods are required to segment the lung from pulmonary (1)H MRI. Therefore, their objective was to develop a pulmonary (1)H MRI segmentation algorithm to provide regional measurements with the precision and speed required to support clinical studies. METHODS: The authors developed a method to segment the left and right lung from (1)H MRI acquired in 20 asthmatics including five well-controlled and 15 severe poorly controlled participants who provided written informed consent to a study protocol approved by Health Canada. Same-day spirometry and plethysmography measurements of lung function and volume were acquired as well as (1)H MRI using a whole-body radiofrequency coil and fast spoiled gradient-recalled echo sequence at a fixed lung volume (functional residual capacity + 1 l). We incorporated the left-to-right lung volume proportion prior based on the Potts model and derived a volume-proportion preserved Potts model, which was approximated through convex relaxation and further represented by a dual volume-proportion preserved max-flow model. The max-flow model led to a linear problem with convex and linear equality constraints that implicitly encoded the proportion prior. To implement the algorithm, (1)H MRI was resampled into ∼3 × 3 × 3 mm(3) isotropic voxel space. Two observers placed seeds on each lung and on the background of 20 pulmonary (1)H MR images in a randomized dataset, on five occasions, five consecutive days in a row. Segmentation accuracy was evaluated using the Dice-similarity-coefficient (DSC) of the segmented thoracic cavity with comparison to five-rounds of manual segmentation by an expert observer. The authors also evaluated the root-mean-squared-error (RMSE) of the Euclidean distance between lung surfaces, the absolute, and percent volume error. Reproducibility was measured using the coefficient of variation (CoV) and intraclass correlation coefficient (ICC) for two observers who repeated segmentation measurements five-times. RESULTS: For five well-controlled asthmatics, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) was 83% ± 7% and FEV1 was 86 ± 9%pred. For 15 severe, poorly controlled asthmatics, FEV1/FV C = 66% ± 17% and FEV1 = 72 ± 27%pred. The DSC for algorithm and manual segmentation was 91% ± 3%, 92% ± 2% and 91% ± 2% for the left, right, and whole lung, respectively. RMSE was 4.0 ± 1.0 mm for each of the left, right, and whole lung. The absolute (percent) volume errors were 0.1 l (∼6%) for each of right and left lung and ∼0.2 l (∼6%) for whole lung. Intra- and inter-CoV (ICC) were <0.5% (>0.91%) for DSC and <4.5% (>0.93%) for RMSE. While segmentation required 10 s including ∼6 s for user interaction, the smallest detectable difference was 0.24 l for algorithm measurements which was similar to manual measurements. CONCLUSIONS: This lung segmentation approach provided the necessary and sufficient precision and accuracy required for research and clinical studies.

Osteopenia after plated and nailed femoral shaft fractures.

Twenty-six patients who had been operated for isolated femoral shaft fractures were studied. Fourteen had been treated with intramedullary nailing and 12 with AO plates. Only nailed patients were allowed early weight-bearing. Bone mineral density and muscle strength in knee extension and flexion were determined. There was a considerable loss of bone mineral in the distal femoral metaphysis and a moderate loss in the tibia. The mean loss was almost identical in the two groups. Muscle power in extension was better preserved in the nailed than in the plated patients. There was a significant correlation between loss of bone mineral and loss of muscle power.

The acetabulum in Perthes' disease: a prospective study of 123 children.

PURPOSE: We assessed the radiographic changes of the acetabulum during the course of Perthes' disease and investigated whether they were associated with femoral head sphericity 5 years after diagnosis. METHODS: We studied 123 children with unilateral Perthes' disease, femoral head necrosis more than 50 % and age at diagnosis 6 years or older. Pelvic radiographs were taken at onset, 1 year and 5 years after diagnosis. Sharp's angle, acetabular depth-to-width ratio (ADR) and lateral acetabular inclination were measured. RESULTS: Compared to the unaffected hips, the Perthes' hips developed significantly higher Sharp's angles (p < 0.001) and a higher proportion with an upward-sloping lateral acetabular margin (Perthes' hips: 49 %, unaffected hips 1 %). The mean ADR values were significantly lower on the affected side at all stages (p < 0.001). ADR values at diagnosis were associated with a more spherical femoral head at the 5-year follow-up [odds ratio (OR) 1.012, 95 % confidence interval (CI) 1.002-1.022, p = 0.016]. None of the other acetabular parameters were significantly associated with the femoral head shape 5 years after diagnosis. CONCLUSION: The acetabulum developed an increasingly dysplastic shape in the course of Perthes' disease. Early dysplastic changes of the acetabulum were not associated with a poor radiological outcome 5 years after diagnosis. Routine measurement and monitoring of acetabular changes in plain radiographs were of little prognostic value and can, therefore, hardly be recommended in clinical practice.

Femoroacetabular impingement after slipped upper femoral epiphysis: the radiological diagnosis and clinical outcome at long-term follow-up.

Deformity after slipped upper femoral epiphysis (SUFE) can cause cam-type femoroacetabular impingement (FAI) and subsequent osteoarthritis (OA). However, there is little information regarding the radiological assessment and clinical consequences at long-term follow-up. We reviewed 36 patients (43 hips) previously treated by in situ fixation for SUFE with a mean follow-up of 37 years (21 to 50). Three observers measured the femoral head ratio (FHR), lateral femoral head ratio (LFHR), α-angle on anteroposterior (AP) and frog-leg lateral views, and anterior femoral head-neck offset ratio (OSR). A Harris hip score < 85 and/or radiologically diagnosed osteoarthritis (OA) was classified as a poor outcome. Patients with SUFE had significantly higher FHR, LFHR and α-angles and lower OSR than a control group of 22 subjects (35 hips) with radiologically normal hips. The interobserver agreement was less, with wider limits of agreement (LOA), in hips with previous SUFE than the control group. At long-term follow-up abnormal α-angles correlated with poor outcome, whereas FHR, LFHR and OSR did not. We conclude that persistent deformity with radiological cam FAI after SUFE is associated with poorer clinical and radiological long-term outcome. Although the radiological measurements had quite wide limits of agreement, they are useful for the diagnosis of post-slip deformities in clinical practice.

Prognostic factors and outcome of treatment in Perthes' disease: a prospective study of 368 patients with five-year follow-up.

This nationwide prospective study was designed to determine prognostic factors and evaluate the outcome of different treatments of Perthes' disease. A total of 28 hospitals in Norway were instructed to report all new cases of Perthes' disease over a period of five years and 425 patients were reported and followed for five years. Of these, 368 with unilateral disease were included in the present study. The hips were classified radiologically according to a modified two-group Catterall classification and the lateral pillar classification. A total of 358 patients (97%) attended the five-year follow-up, when a modified three-group Stulberg classification was used as a radiological outcome measure. For patients over six years of age at diagnosis and with more than 50% necrosis of the femoral head (152 patients), the surgeons at the different hospitals had chosen one of three methods of treatment: physiotherapy (55 patients), the Scottish Rite abduction orthosis (26), and proximal femoral varus osteotomy (71). Of these hips, 146 (96%) were available for the five-year follow-up. The strongest predictor of outcome was femoral head involvement of more or less than 50% (odds ratio (OR) = 7.76, 95% confidence interval (CI) 2.82 to 21.37), followed by age at diagnosis (OR = 0.98, 95% CI 0.92 to 0.99) and the lateral pillar classification (OR = 0.62, 95% CI 0.40 to 0.98). In children over six years at diagnosis with more than 50% of femoral head necrosis, proximal femoral varus osteotomy gave a significantly better outcome than orthosis (p = 0.001) or physiotherapy (p = 0.001). There was no significant difference between the physiotherapy and orthosis groups (p = 0.36), and we found no difference in outcome after any of the treatments in children under six years (p = 0.73). We recommend proximal femoral varus osteotomy in children aged six years and over at the time of diagnosis with hips having more than 50% femoral head necrosis. The abduction orthosis should be abandoned in Perthes' disease.

The effects of function and fixation stiffness on experimental bone healing.

In tibial shaft fractures in the rabbit, the early stage of bone healing after metal-plate fixation was compared with that after treatment with a long or short plaster cast. The animals were killed after 6 weeks. The plate-fixed bones healed more rapidly, with less periosteal callus and less angulation of the fragments, than those treated with a cast. The results indicated that function of the muscles and joints of the injured limb, including weight bearing, promotes bony union, whereas the degree of fixation stiffness is relatively unimportant.

Function promotes fracture healing. Plate-fixed osteotomies studies in rabbits.

Unilateral midshaft tibial osteotomies in rabbits were fixed with 6-hole steel plates. In half the animals, no additional fixation was used, whereas in the other half, a plaster bandage from the toes to the midthigh was applied. At 6 weeks all the osteotomies had healed radiographically with little or no periosteal callus. The median strength of bones without plaster was 107 per cent of the normal value compared with 55 per cent in the plaster group. The results indicated a severely adverse effect of plaster immobilization on the healing of plate-fixed osteotomies.

[Idiopathic femur anteversion]. / Idiopatisk økt femuranteversjon.

Intoeing is one of the most common reasons for referral of children to orthopaedic evaluation. The most frequent cause is increased femoral anteversion (AV). The AV-angles have traditionally been measured by radiographic methods. In recent years, ultrasonographic techniques for such measurements have been introduced. Relatively liberal indications for surgical correction of increased anteversion by derotational osteotomy have previously been practised in Norway. The indications are now much more restrictive, because several reports have documented spontaneous reduction of the AV-angles during growth. We think operative treatment should be considered if markedly increased AV-angles and serious complaints persist at age 10-12 years.

Tibial fractures treated with Hoffmann's external fixation: a comparative analysis of Hoffmann bilateral frames and the Vidal-Adrey double frame modification.

The results after treatment of 50 open and comminuted tibial fractures with Hoffmann's external fixation were analysed. Half of the fractures were treated with bilateral Hoffmann frames, the other half with the Vidal-Adrey double frame modification. The groups were found to be comparable. The results of the study confirm that Hoffmann's external fixation is a safe method for treating the bone and soft tissue lesions in such fractures. There was only one case of osteomyelitis, no definite pseudarthrosis and no leg amputation. The considerably increased stability of the Vidal-Adrey double frame modification did not reduce the length of the healing period compared to fractures treated with bilateral Hoffmann frames. The duration of external fixation was on average 24 weeks, and the radiological healing time 27 weeks. A slightly greater number of residual deformities were found in the group treated with bilateral Hoffmann frames. Most of the deformities were so minor, however, that they were of little practical consequence for the patients. Thus it seems that the original Hoffmann apparatus, if duplicated, is a stable enough fixation in most cases.

Poor results of anterior cruciate ligament repair in adolescence.

Eight adolescents were followed 3-8 years after primary suture of a substance rupture of the anterior cruciate ligament. Only 3 patients had good function, and 5 were unstable. We conclude that the Palmer-Marshall technique should not be used in children and adolescents.

[Postoperative autologous transfusion in primary hip arthroplasties]. / Postoperativ autotransfusjon ved innsetting av primaere totalproteser i hoften.

100 patients who underwent primary, total hip arthroplasty were consecutively included in this study. Their postoperative sanguineous wound drainage was reinfused, and the purpose of the study was to evaluate if such reinfusion reduced the use of homologous blood. 100 patients who were operated immediately prior to the reinfusion group were used as a historical control group. The mean volume reinfused was 426 milliliters. The mean haemoglobin of the wound drainage was 7.3 g/100 ml. There was no statistically significant reduction in the use of homologous blood. Nor was there any reduction in the number of patients exposed to such blood. Autotransfusion of postoperative sanguineous wound drainage does not seem to be indicated as a routine procedure in primary total hip arthroplasties.

Splenogonadal fusion.

A case of splenogonadal fusion of the discontinuous type in a 7-year-old boy is reported. The literature is reviewed and the common clinical features of the malformation are discussed. The condition should be considered in the differential diagnosis of scrotal tumours.

Operative versus conservative treatment of Calvé-Legg-Perthes disease.

The results of treatment in two groups of patients with Calvé-Legg-Perthes disease are compared, one group having received conservative treatment consisting of bed rest and avoidance of weight-bearing, and the other operative treatment consisting of a subtrochanteric varus-rotational osteotomy without any restrictions of physical activity after healing of the osteotomy. In both groups the femoral head destruction was classified according to Catterall, and thus the operatively treated group on the whole had more seriously affected hips than the conservatively treated group. Although the main advantage of operative treatment is the short period of time spent in bed and the otherwise unrestricted physical activity, the results showed very little difference between the degree of femoral head congruity, the covering of the head by the acetabulum and the preservation of leg length and hip motility after operative as compared with conservative treatment. A retardation of skeletal maturity is present particularly in patients with bilateral affections.