Femoral head and acetabular necrosis combined with hip subluxation in people with HIV: a case report and literature review.

INTRODUCTION: HIV is widely prevalent in all regions of the world. The use of antiretroviral drugs has dramatically reduced the mortality rate of HIV-related diseases, but correspondingly increased the incidence of chronic complications in HIV-positive people. Related studies have found that the incidence of osteonecrosis of the femoral head is higher in HIV-positive people, but the co-occurrence of femoral head necrosis, acetabular necrosis and hip joint dislocation in HIV-positive patients is rare. METHODS: We report a 50-year-old man with a 15-month history of progressively worsening right hip pain with movement restriction. According to the CT findings of the other hospital, the patient was admitted to the hospital with femoral head necrosis. After the admission, the relevant X-ray, CT and MRI examinations showed that the right femoral head collapsed and deformed, with the surrounding bone sclerosis, bone fragments, loose body of the joint, right hip subluxation, acetabular marginal osteogeny, and local microcystic degeneration. The left femoral head was in good shape, and cystic degeneration can be seen under the articular surface. The patient was finally diagnosed with femoral head necrosis and acetabular necrosis combined with hip subluxation. RESULTS: The pain of the patient was significantly relieved after the operation, and the patient was discharged from the hospital one week after the start of treatment to continue rehabilitation training. During the follow-up one month after the operation, the self-reported pain disappeared completely, and the limitation of activity was significantly improved.

Does adding sacroiliac (type IV) resection to periacetabular (type II) resection increase complications or provide worse clinical outcomes? An institutional experience and systematic review.

BACKGROUND AND OBJECTIVES: Internal hemipelvectomy is a limb sparing procedure most commonly indicated for malignant bone and soft tissue tumors of the pelvis. Partial resection and pelvic reconstruction may be challenging for orthopedic oncologists due to late presentation, high tumor burden, and complex anatomy. Specifically, wide resection of tumors involving the periacetabular and sacroiliac (SI) regions may compromise adjacent vital neurovascular structures, impair wound healing, or limit functional recovery. We aimed to present a series of patients treated at our institution who underwent periacetabular internal hemipelvectomy (Type II) with or without sacral extension (Type IV) in combination with a systematic review to investigate postoperative complications, functional outcomes, and implant and patient survival following pelvic tumor resection via Type II hemipelvectomy with or without Type IV resection. MATERIALS AND METHODS: A surgical registry of consecutive patients treated with internal hemipelvectomy for primary or secondary pelvic bone tumors at our institution since 1994 was retrospectively reviewed. All type II resection patients were stratified into two separate cohorts, based on whether or not periacetabular resection was extended beyond the SI joint to include the sacrum (Type IV), as per the Enneking and Dunham classification. Patient demographics, operative parameters, complications, and oncological outcomes were collected. Categorical and continuous variables were compared with Pearson's chi square or Fisher's exact test and the Mann-Whitney U test, respectively. Literature review according to PRISMA guidelines queried studies pertaining to patient outcomes following periacetabular internal hemipelvectomy. The search strategy included combinations of the key words "internal hemipelvectomy", "pelvic reconstruction", "pelvic tumor", and "limb salvage". Pooled data was compared using Pearson's chi square. Statistical significance was established as p < 0.05. RESULTS: A total of 76 patients were treated at our institution with internal hemipelvectomy for pelvic tumor resection, of whom 21 had periacetabular resection. Fifteen patients underwent Type II resection without Type IV involvement, whereas six patients had combined Type II/IV resection. There were no significant differences between groups in operative time, blood loss, complications, local recurrence, postoperative metastasis, or disease mortality. Systematic review yielded 69 studies comprising 929 patients who underwent internal hemipelvectomy with acetabular resection. Of these, 906 (97.5 %) had only Type II resection while 23 (2.5 %) had concomitant Type II/IV resection. While overall complication rates were comparable, Type II resection alone produced significantly fewer neurological complications when compared to Type II resection with sacral extension (3.9 % vs. 17.4 %, p = 0.001). No significant differences were found between rates of wound complications, infections, or construct failures. Local recurrence, postoperative metastasis, and survival outcomes were similar. Type II internal hemipelvectomy without Type IV resection on average produced higher postoperative MSTS functional scores than with Type IV resection. CONCLUSION: In our series, the two groups exhibited no differences. From the systematic review, operative parameters, local recurrence or systemic metastasis, implant survival, and disease mortality were comparable in patients undergoing Type II internal hemipelvectomy alone compared to patients undergoing some combination of Type II/IV resection. However, compound resections increased the risk of neurological complications and experienced poorer MSTS functional scores.

The clinical application value of 3.0T magnetic resonance T2 mapping imaging in evaluating the degree of acetabular cartilage degeneration in joint replacement surgery running title: MRI and acetabular cartilage degeneration.

BACKGROUND: To explore and compare the values of 3.0T magnetic resonance imaging (MRI) T2 mapping in evaluating the degree of acetabular cartilage degeneration in hip replacement surgery. METHODS: A total of 26 elderly patients with femoral neck fractures who were scanned in 3.0T MRI T2 mapping quantification technique were included. Basing on MRI images, the degree of acetabular cartilage degeneration was classified into Grade 0, 1, 2, 3 and 4, according to the International Cartilage Repair Society (ICRS) scores. In addition, 8 healthy volunteers were included for control group. RESULTS: By comparison with health population, T2 relaxation values in the anterior, superior, and posterior regions of acetabular cartilage in patients with femoral neck fracture were obviously increased (P < 0.001). Among the patients with femoral neck fractures, there were 16 hip joint with Grade 1-2 (mild degeneration subgroup) and 10 hip joints with Grade 3-4 (severe degeneration subgroup), accounting for 61.54% and 38.46%, respectively. Additionally, T2 relaxation values in the anterior and superior bands of articular cartilage were positively related to the MRI-based grading (P < 0.05); while there was no significant difference of T2 relaxation values in the posterior areas of articular cartilage between severe degeneration subgroup and mild degeneration subgroup (P > 0.05). Importantly, acetabular cartilage degeneration can be detected through signal changes of T2 mapping pseudo-color images. CONCLUSION: 3.0T MRI T2 mapping technology can be used to determine the degree of acetabular cartilage degeneration, which can effectively monitor the disease course.

Morphological features of the acetabulum with coxa profunda in women: a retrospective observational study.

BACKGROUND: The morphology of coxa profunda remains inadequately understood. However, knowledge about the characteristics of the acetabulum in coxa profunda can help to predict pelvic morphology in three dimensions based on radiographic findings, as well as help to diagnose and predict hip pathologies. Therefore, this study aimed to investigate the relationship between the morphological characteristics of the pelvis and coxa profunda. METHODS: We conducted a retrospective analysis including women who had undergone unilateral total hip arthroplasty. Only those with normal hip joint morphology on the opposite side, as evidenced by anteroposterior pelvic radiography showing a distance of ≥ 2 mm between the ilioischial line and acetabular floor, were included. Five parameters related to acetabular anteversion, thickness, and the position of the ilioischial line were measured using axial computed tomography at the central hip joint. The coxa profunda group (n = 39) and control group (n = 34) were compared. RESULTS: The mean acetabular anteversion angle was 12.5° ± 4° in the control group and 22.3° ± 5.6° in the coxa profunda group. The mean thickness from the acetabular fossa to the medial wall was 7.5 ± 1.7 mm in the control group and 3.9 ± 1.2 mm in the coxa profunda group. Furthermore, the bony region representing the ilioischial line was positioned more posteriorly in the coxa profunda group than it was in the control group. CONCLUSION: Our findings suggest that coxa profunda in women is associated with anterior acetabular dysplasia and a thin acetabulum, in contrast to previous interpretations of excessive coverage. This insight suggests a conversion of coxa profunda from a finding of pincer-type femoroacetabular impingement to a finding of acetabular dysplasia, a revelation that also draws attention to cup positioning for total hip arthroplasty.

Distinctiveness of Femoral and Acetabular Mesenchymal Stem and Progenitor Populations in Patients with Primary and Secondary Hip Osteoarthritis Due to Developmental Dysplasia.

Primary hip osteoarthritis (pOA) develops without an apparent underlying reason, whereas secondary osteoarthritis arises due to a known cause, such as developmental dysplasia of the hips (DDH-OA). DDH-OA patients undergo total hip arthroplasty at a much younger age than pOA patients (50.58 vs. 65 years in this study). Recently, mesenchymal stem and progenitor cells (MSPCs) have been investigated for the treatment of osteoarthritis due to their immunomodulatory and regenerative potential. This study identified cells in subchondral bone expressing common MSPC markers (CD10, CD73, CD140b, CD146, CD164, CD271, GD2, PDPN) in vivo and compared the proportions of these populations in pOA vs. DDH-OA, further correlating them with clinical, demographic, and morphological characteristics. The differences in subchondral morphology and proportions of non-hematopoietic cells expressing MSPC markers were noted depending on OA type and skeletal location. Bone sclerosis was more prominent in the pOA acetabulum (Ac) in comparison to the DDH-OA Ac and in the pOA Ac compared to the pOA femoral head (Fh). Immunophenotyping indicated diagnosis-specific differences, such as a higher proportion of CD164+ cells and their subsets in DDH-OA, while pOA contained a significantly higher proportion of CD10+ and GD2+ cells and subsets, with CD271+ being marginally higher. Location-specific differences showed that CD271+ cells were more abundant in the Fh compared to the Ac in DDH-OA patients. Furthermore, immunohistochemical characterization of stromal bone-adjacent cells expressing MSPC markers (CD10, CD164, CD271, GD2) in the Ac and Fh compartments was performed. This research proved that immunophenotype profiles and morphological changes are both location- and disease-specific. Furthermore, it provided potentially effective targets for therapeutic strategies. Future research should analyze the differentiation potential of subsets identified in this study. After proper characterization, they can be selectively targeted, thus enhancing personalized medicine approaches in joint disease management.

Hip Capsulolabral Complex: Anatomy, Disease, MRI Features, and Postoperative Appearance.

The hip is a uniquely constrained joint with critical static stability provided by the labrum, capsule and capsular ligaments, and ligamentum teres. The labrum is a fibrocartilaginous structure along the acetabular rim that encircles most of the femoral head. Labral tears are localized based on the clock-face method, which determines the extent of the tear while providing consistent terminology for reporting. Normal labral variants can mimic labral disease and can be differentiated by assessment of thickness or width, shape, borders, location, and associated abnormalities. The Lage and Czerny classification systems are currently the most well-known arthroscopic and imaging systems, respectively. Femoroacetabular impingement is a risk factor for development of labral tears and is classified according to bone dysmorphisms of the femur ("cam") or acetabulum ("pincer") or combinations of both (mixed). The capsule consists of longitudinal fibers reinforced by ligaments (iliofemoral, pubofemoral, ischiofemoral) and circular fibers. Capsular injuries occur secondary to hip dislocation or iatrogenically after capsulotomy. Capsular repair improves hip stability at the expense of capsular overtightening and inadvertent chondral injury. The ligamentum teres is situated between the acetabular notch and the fovea of the femoral head. Initially considered to be inconsequential, recent studies have recognized its role in hip rotational stability. Existing classification systems of ligamentum teres tears account for injury mechanism, arthroscopic findings, and treatment options. Injuries to the labrum, capsule, and ligamentum teres are implicated in symptoms of hip instability. The authors discuss the labrum, capsule, and ligamentum teres, highlighting their anatomy, pathologic conditions, MRI features, and postoperative appearance. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Precise single column resection and reconstruction with femoral head plus total hip replacement for primary malignant peri-acetabulum tumors.

To evaluate whether single acetabular column can be reserved and the effect of reconstruction with femoral head plus total hip replacement (THR) for primary malignant peri-acetabulum tumors. From 2007 to 2015, nineteen patients with primary malignant peri-acetabulum tumors were enrolled. All cases underwent single column resection with clear surgical margins. Ten of the 19 tumor's resections were assisted by computer navigation. Femoral heads were applied to reconstruct anterior or posterior column defects; THR was used for joint reconstruction. The surgical safety, oncologic outcome and prosthesis survivorship and function were evaluated by regular follow-up. The average follow-up period was 65.9 months. Surgical margins contained wide resection in 12 cases and marginal resection in 7 cases. One patient with Ewing's sarcoma died 14 months postoperative due to lung metastasis. One case with chondrosarcoma had recurrence. One prosthesis was removed due to infection. The average MusculoSkeletal Tumor Society (MSTS) function score was 83.7%. Due to the relative small number of cases, there was no significant difference in the recurrence rate and prosthesis failure rate between the navigation group and non-navigation group. Single column resection and reconstruction with femoral head autograft plus THR is an effective, safe method with less complication rate and better functional outcome for patients with peri-acetabular tumors.

Editorial Commentary: Concomitant Hip Arthroscopy and Periacetabular Osteotomy Treat Both the Cause and the Effects of Hip Dysplasia: The Best of Both Worlds.

In the management of true hip dysplasia, the bony deformity is nearly always accompanied by, and often causal of, intra-articular pathology. It is strongly recommended to conduct a comprehensive preoperative evaluation as well as arthroscopic evaluation and treatment of coexisting hip joint conditions prior to performing an open Bernese periacetabular osteotomy. The osteotomy improves coverage of the femoral head and corrects the abnormal joint mechanics and loading patterns, which result in cartilage damage and subsequent osteoarthritis. Arthroscopy allows treatment of the intra-articular pathology. Combining the hip arthroscopy and periacetabular osteotomy procedures into a single surgical intervention, performed by either a single surgeon or a collaborative surgical team, allows us to address both the cause and the effects of dysplasia. This once-controversial combined technique has become a standard practice in the field with widespread adoption.

Management of chondral and osteochondral lesions of the hip : A comprehensive review.

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

Presence of subchondral fracture in cases diagnosed as transient osteoporosis of the hip: a retrospective independent reader-based study.

OBJECTIVE: Transient osteoporosis of the hip (TOH) is an uncommon, typically self-limited diagnosis of uncertain etiology. We hypothesize that TOH represents an underlying subchondral fracture, and a discrete fracture line can often be detected on high-resolution MRI. MATERIALS AND METHODS: A retrospective PACS query identified patients meeting imaging criteria for TOH with intense bone marrow edema (BME) in the femoral head on MRI. Those with poor quality studies, other underlying pathologies, or antecedent trauma were excluded. Three musculoskeletal radiologists independently reviewed each case for presence of a definite subchondral fracture line on small field of view (FOV) MR images of the affected hip. Extent of BME, reciprocal acetabular BME, and joint effusion size were also recorded. Binomial logistic regression was performed to determine statistically significant predictors of subchondral fracture. RESULTS: Fifty patients met inclusion criteria (29 females, 0 pregnant). Mean age was 62±12 years (range 35-84). Average duration of symptoms before MRI was 102±135 days. Ten patients had bone densitometry within 2 years of MRI, six demonstrating osteopenia or osteoporosis. Subchondral fractures were unanimously identified in 44/50 (88%). Interclass correlation coefficient with absolute agreement was 0.73, 95% CI (0.57-0.84), indicating near-excellent agreement. Most cases demonstrated a large joint effusion (23/50, 46%) and acetabular BME (31/50, 62%). Increasing size of joint effusion was a statistically significant predictor of subchondral fracture (p=0.05), with 6.9 higher odds. There was a strong correlation with osteopenia/osteoporosis and fracture (p<0.001). CONCLUSION: Discrete subchondral fractures were identified unanimously on small FOV imaging in the majority of TOH cases.

Hip Morphology on Post-Reduction MRI Predicts Residual Dysplasia 10 Years After Open or Closed Reduction.

BACKGROUND: There is limited evidence supporting the value of morphological parameters on post-reduction magnetic resonance imaging (MRI) to predict long-term residual acetabular dysplasia (RAD) after closed or open reduction for the treatment of developmental dysplasia of the hip (DDH). METHODS: We performed a retrospective study of 42 patients (47 hips) undergoing open or closed reduction with a minimum 10 years of follow-up; 39 (83%) of the hips were in female patients, and the median age at reduction was 6.3 months (interquartile range [IQR], 3.3 to 8.9 months). RAD was defined as additional surgery with an acetabular index >2 standard deviations above the age- and sex-specific population-based mean value or Severin classification grade of >2 at last follow-up. Acetabular version and depth-width ratio, coronal and axial femoroacetabular distance, cartilaginous and osseous acetabular indices, transverse ligament thickness, and the thickness of the medial and lateral (limbus) acetabular cartilage were measured on post-reduction MRI. RESULTS: At the time of final follow-up, 24 (51%) of the hips had no RAD; 23 (49%) reached a failure end point at a median of 11.4 years (IQR, 7.6 to 15.4 years). Most post-reduction MRI measurements, with the exception of the cartilaginous acetabular index, revealed a significant distinction between the group with RAD and the group with no RAD when mean values were compared. The coronal femoroacetabular distance (area under the receiver operating characteristic curve [AUC], 0.95; 95% confidence interval [CI], 0.90 to 1.00), with a 5-mm cutoff, and limbus thickness (AUC, 0.91; 95% CI, 0.83 to 0.99), with a 4-mm cutoff, had the highest discriminatory ability. A 5-mm cutoff for the coronal femoroacetabular distance produced 96% sensitivity (95% CI, 78% to 100%), 83% specificity (95% CI, 63% to 95%), 85% positive predictive value (95% CI, 65% to 96%), and 95% negative predictive value (95% CI, 76% to 100%). A 4-mm cutoff for limbus thickness had 96% sensitivity (95% CI, 78% to 100%), 63% specificity (95% CI, 41% to 81%), 71% positive predictive value (95% CI, 52% to 86%), and 94% negative predictive value (95% CI, 70% to 100%). CONCLUSIONS: Coronal femoroacetabular distance, a quantitative metric assessing a reduction's concentricity, and limbus thickness, a quantitative metric assessing the acetabulum's cartilaginous component, help to predict hips that will have RAD in the long term after closed or open reduction. LEVEL OF EVIDENCE: Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

[Hip dysplasia]. / Hüftdysplasie.

BACKGROUND: Hip dysplasia is one of the most common malformations in childhood and has a significant impact on the further life of those affected. A distinction must be made between congenital and the much rarer acquired dysplasia. Early diagnosis and therapy are pivotal for further development of patients. OBJECTIVES: The paper gives an overview of current radiological possibilities of diagnosis with focus on congenital hip dysplasia supplemented by insights into therapeutic options. MATERIALS AND METHODS: Basic and review papers were analyzed. RESULTS: Clinical examination of the newborn has low sensitivity and specificity in the diagnosis of hip dysplasia. The introduction of Graf ultrasound screening has significantly improved the early detection of dysplastic hips. With the help of sonography, but also magnetic resonance imaging (MRI), the shape of the acetabulum and the position of the femoral head in the socket can be precisely and quickly determined, while X­ray examinations have their place especially in the context of follow-up examinations after treatment from the age of 1 year and in the diagnosis of secondary dysplasia. Therapeutic options range from spreading treatment to open reduction with fixation in the newborn as well as conversion osteotomy in older children. CONCLUSION: Early detection of hip dysplasia is critical to the course of treatment. The right choice of examination method and correct performance are essential for further treatment.

Editorial Commentary: Cam Femoroacetabular Impingement Requires Dynamic Assessment of Beta-Angle (Femoroacetabular Excursion Angle) and Consideration of Femoral and Acetabular Version: Cam Impingement in Patients With Acetabular or Femoral Retroversion May Warrant Greater Osteoplasty.

Radiographs, magnetic resonance imaging, and computed tomography scans have been commonly used to evaluate femoroacetabular impingement (FAI) and are well accepted forms of surgical planning. Assessing and addressing both the femoral and acetabular sides result in a combination of "one-sided" treatments that, in sum, net a successful treatment of FAI. However, combining one-sided approaches may not consider the dynamic interaction of the femoral head with the acetabulum. Elevated alpha angles alone can be indicative of a cam-type lesion without necessitating the presence of functional FAI. The presence of a cam-type lesion on lateral radiographs, as suggested by a positive alpha angle, does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle. Assessment of the beta angle, or femoroacetabular excursion angle, has the potential to address dynamic nature of FAI more accurately by directly measuring the degree of clearance between the femoral head and acetabulum. In addition, a comprehensive assessment of physical examination findings, particularly range of motion, as well as a summation of acetabular and femoral version (as measured by the McKibbin Index), are required. Cam-type of FAI poses a larger challenge in the patient with acetabular or femoral retroversion, which may warrant greater and more localized osteoplasty, distally, during hip arthroscopy.

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification.

Aims: Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system. Methods: A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected. Results: A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015). Conclusion: There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.

Complete Ossification of Transverse Acetabular Ligament - Embryological and Clinical Perspective.

Abstract: Transverse acetabular ligament (TAL) is one of the important ligaments, which provide stability to the hip joint. On rare occasions, it can get ossified leading to limited mobility of the hip joint. Ossified TAL also converts acetabular notch to a foramen and neurovascular structures passing through the notch can get compressed leading to ischaemic symptoms. During routine demonstration of hip bone to undergraduate students, complete ossification of TAL was found in a right sided hip bone. Present case report with this rare finding also includes a short review of literature impressing on embryological and clinical perspectives of ossified TAL. Ossification of this ligament can be caused by defective ossification of hip bone as three secondary ossification centres develop around the acetabulum in triradiate carti-lage. Also, this can be caused due to heterotopic ossification of TAL after an inflammatory or traumatic injury. This ligament is extremely important in total hip replacement surgery being utilised in determining the position of the acetabular component. Anatomical knowledge of abnormal ossification of TAL is imperative in diagnosis and treatment of various pathologies of the hip joint.

Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma.

INTRODUCTION: Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications. METHODS: A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis. RESULTS: Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis. CONCLUSION: A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions. LEVEL OF EVIDENCE (OXFORD): Level 4.

[Modified Harrington Procedure in the Treatment of Extensive Tumor Defects of the Acetabulum]. / Modifikovaná Harringtonova operace v terapii rozsáhlých nádorových defektu acetabula.

PURPOSE OF THE STUDY The increasing prevalance of patients with metastatic bone cancer and their improved survival puts more emphasis on the quality of treatment of bone metastases. Although most pelvic lesions are treated non-operatively, extensive destruction of the acetabular segment poses a therapeutic challenge. A potential treatment option may be the modified Harrington procedure. MATERIAL AND METHODS At our department, this surgical procedure has been opted for in 14 patients (5 men and 9 women) since 2018. The mean age at the time of surgery was 59 years (range 42 to 73). Twelve patients suffered from metastatic cancer, one patient had a fibrosarcoma metastasis and one female patient presented with aggressive pseudotumor. Radiological and clinical followup of the patients was performed. Pain was assessed using the Visual Analogue Scale, and the Harris Hip Score and the MSTS score were used to evaluate the functional outcome. The paired samples Wilcoxon test was used to analyze the statistical significance of the difference. RESULTS The mean follow-up period was 25 months. At the time of assessment, ten patients were alive with the mean follow-up of 29 months (range 2 to 54 months) and four patients had died of cancer progression, with the mean follow-up being 16 months. No perioperative death or mechanical failure were reported. One female patient developed a hematogenous infection during febrile neutropenia, which was successfully managed with early revision and implant preservation. Statistically, a significant improvement in the MSTS (median 23) and HHS (median 86) functional scores compared to the preoperative values (MSTS median 2, p<0.01, r-effect size = 0.6; HHS preop median 0, p<0.005, r-effect size = -0.7) was observed. There was also a statistically significant reduction in pain (VAS postoperative median 1, VAS preoperative median 8, p<0.01, r-effect size = -0.6). All patients were capable of independent ambulation after the surgery, nine patients walked without support. DISCUSSION There are not many alternatives to this surgical procedure. Apart from non-operative palliative treatment, the options include ice cream cone prostheses or customized 3D implants which are, impractical in terms of time and cost. Our results are comparable to other studies, confirming the reproducibility and reliability of the method. CONCLUSIONS The Harrington procedure is an efective method for management of large acetabular tumor defects with good functional outcomes, an acceptable perioperative risk and a low risk of failure in the medium term, thus suitable also for patients with good cancer prognosis. Key words: umor, metastasis, acetabulum, pelvis, Harrington, reconstruction.

Editorial Commentary: In Patients With Hip-Spine Syndrome, a Single Simple Solution May Not Apply: Occam's Razor Becomes Blunt.

The importance of hip-spine syndrome in a nonarthritic population, in which patients present with coexisting symptoms in both the hip and lumbar spine, is becoming more clear. Several studies have shown inferior outcomes in patients undergoing treatment for femoral acetabular impingement syndrome with coexisting spinal symptoms. The most important factor when treating HSS patients is understanding each patient's pathology. A history and physical examination with provocative tests for spinal and hip pathology often provide the answer. Routine standing and seated lateral radiographs are required to assess spinopelvic mobility. If the cause of pain is unclear, diagnostic intra-articular hip injections with local anesthetic and further imaging of the lumbar spine are recommended. In patients with degenerative spine disease with neural impingement, these symptoms may persist after hip arthroscopy, particularly if not improved by intra-articular injections. Patients should be appropriately counseled. If hip symptoms predominate, treatment of femoroacetabular impingement syndrome results in improved outcomes, even with coexisting neural impingement. If spine symptoms predominate, referral to an appropriate specialist may be required. In patients with HSS, Occam's razor becomes blunt; thus, a single simple solution may not apply, and we may need to consider treating each pathology separately.