Labral Ossification and Sacroiliac Joint Disease: Could There Be a Link to an Autoimmune Etiology?

PURPOSE: To determine the prevalence of ipsilateral sacroiliac (SI) joint disease among patients with symptomatic femoroacetabular impingement (FAI) associated with labral ossification (LO) who underwent hip arthroscopy compared with a matched control group of patients with symptomatic FAI and no LO. METHODS: Computed tomography (CT) scans of all patients undergoing arthroscopic correction of FAI were obtained. The inclusion criterion for the study group was a diagnosis of FAI with a secondary diagnosis of LO made by plain radiography, CT, or magnetic resonance imaging or made intraoperatively. The exclusion criterion was the absence of evidence of LO. We reviewed 52 patients (56 hips) with LO to assess the SI joint and compared them with a control group matched by age, sex, and FAI type. The SI joints were graded according to the modified New York criteria. RESULTS: CT scans were available for evaluation of the ipsilateral SI joint in 28 patients (29 hips) with LO: 17 women and 11 men with an average age of 44.6 years (range, 26-56 years). Of the hips, 23 had combined FAI and 6 had pincer-type FAI. The control group consisted of 29 hips, exactly matched for sex and FAI type, with an average age of 44.8 years (range, 21-58 years). Grade 3 SI joint abnormalities were significantly more prevalent in the LO group (28%) than in the control group (7%, P = .037), and grade 0 or 1 changes (relatively normal SI joints) were significantly less common in patients with LO (38%) than in controls (72%, P = .008). Subanalysis showed that 35% of the LO group aged 45 years or younger had ipsilateral grade 3 SI joint abnormalities compared with none of the control patients aged 45 years or younger (P = .041). Grade 3 changes were found in 42% of male patients with LO compared with 8% of male controls (P = .155). Grade 3 changes were noted in 18% of women in the LO group compared with 6% of female controls (P = .601). CONCLUSIONS: Patients with symptomatic FAI and LO are more likely to show associated SI joint pathology than patients with FAI not involving LO. These differences are greatest among men and among patients aged 45 years or younger. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Femoral Neck Fractures in Young Patients.

Femoral neck fractures in patients 55 years or younger, although relatively uncommon, may cause considerable surgeon stress because they may be thought to be surgical emergencies and are difficult to manage, resulting in serious complications. Orthopaedic surgeons should understand the optimal timing for, the reduction options and techniques for, the fixation options for, and the results of surgical management of femoral neck fractures in patients 55 years or younger. The optimal timing of the surgical management of femoral neck fractures in these patients is a subject of debate. Anatomic reduction, which correlates with patient outcomes, is the goal in the management of femoral neck fractures whether it is attained via open or closed means. Multiple surgical approaches, including the Watson-Jones, Smith-Petersen, and Hueter approaches, may be used for the open reduction of femoral neck fractures. Multiple options are available for fixation, with cannulated screws and the compression hip screw most used in the literature. These implants should provide torsional stability, minimal bone loss, and a length-stable construct. Currently, no ideal implant exists. The outcomes of young patients with a femoral neck fracture who undergo surgical treatment depend more on fracture type, fracture reduction, and stable fixation than early surgical management; however, surgical management should not be excessively delayed.

The Morel-Lavallée lesion revisited: management in spinopelvic dissociation.

BACKGROUND CONTEXT: The Morel-Lavallée lesion occurs from a compression and shear force that usually separates the skin and subcutaneous tissue from the underlying muscular fascia. A dead space is created that becomes filled with blood, liquefied fat, and lymphatic fluid from the shearing of vasculature and lymphatics. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas. PURPOSE: To review appropriate identification and treatment of Morel-Lavallée lesions in spinopelvic dissociation patients. STUDY DESIGN: Uncontrolled case series. METHODS: Retrospective review of medical records. No funding was received in support of this study. The authors report no conflicts of interest. RESULTS: We present four cases of patients with traumatic spinopelvic dissociation. All had concomitant lumbosacral Morel-Lavallée lesions. All four trauma patients suffered traumatic spinopelvic dissociation with concomitant lumbosacral Morel-Lavallée lesions. Appropriate treatment included irrigation and debridement, drainage, antibiotics, and vacuum-assisted wound closure. CONCLUSIONS: Our series reflects an association of Morel-Lavallée lesion in spinopelvic dissociation trauma patients. Possibly, the rotatory injury that occurs at the spinopelvic junction creates a shear force to form the Morel-Lavallée lesion. When presented with a spinopelvic dissociation patient, one should be prepared to treat a Morel-Lavallée lesion.

Contemporary management of femoral neck fractures: the young and the old.

The optimal management strategy for femoral neck fractures remains highly debated. The femoral neck is intracapsular and the vascular supply is fragile. Furthermore, the curvature of the proximal femur results in high mechanical stresses through the femoral neck. Poor outcomes of nonunion and avascular necrosis (AVN) are common. This chapter reviews the current evidence with respect to the treatment principles of femoral neck fractures in two distinct patient populations: "young" and "old." Contemporary controversies including surgical timing, choice of implant, arthroplasty options, nonoperative management, capsulotomy, and associated complications will be discussed.

Fragility fractures of the pelvis.

Fragility fractures of the pelvis are common and the incidence is increasing with the aging population. The primary risk factor is osteoporosis. Diagnosis is challenging and advanced imaging with computed tomography (CT), bone scintigraphy, and magnetic resonance imaging (MRI) is helpful. These injuries result in significant morbidity, including prolonged hospitalization, immobility, and loss of autonomy in previously active patients. The mortality rate is high, similar to hip fracture patients. This problem is underappreciated and deserves attention. An opportunity exists to improve outcomes with medical and surgical management.

Symphysis pubis width in the pediatric population: A computerized tomography study.

BACKGROUND: Defining pathologic widening of the pubic symphysis in the pediatric population continues to be a clinical challenge. The purpose of this study is to define a normal range of pubic symphyseal widths in various age and gender groups using axial computerized tomography (CT) scans. METHODS: Axial CT images of 140 patients aged between 2 years and 15 years were obtained from our database of preexisting scans. Using a commercially available software package, the single image with the narrowest pubic symphyseal width was identified and measured. Patients were further stratified based on gender and by age into three groups: group A (age 2-5 years), group B (age 6-11 years), and group C (age 12-15 years). RESULTS: The mean width ± 95% confidence interval for all cases was 4.59 mm ± 0.18 mm. The mean width for male and female patients was 4.86 mm ± 0.26 mm and 4.33 mm ± 0.24 mm, respectively. Based on the two-way analysis of variance, both age group and gender had a statistically significant effect. Post hoc testing demonstrated a statistically significant difference in mean symphyseal width between groups A and C (p < 0.0001) and groups B and C (p = 0.0025) but not between groups A and B (p = 0.055). When grouped by age, the mean male pubic symphyseal width was found to be 5.10 mm, 4.93 mm, and 4.45 mm, while the mean female width was found to be 4.94 mm, 4.33 mm, and 3.54 mm at 2 to 6 years, 7 to 11 years, and 12 to 15 years of age, respectively. CONCLUSION: In the pediatric population, males seem to have a wider pubic symphysis than females of the same age group. In both males and females, pubic symphyseal width decreases during the transition from infancy toward skeletal maturity. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Optimal treatment of femoral neck fractures according to patient's physiologic age: an evidence-based review.

For decades, the basic tenets of managing displaced femoral neck fractures have not changed, but the optimal treatment choice continues to be highly debated. The contemporary controversies associated with the treatment principles of displaced femoral neck fractures are distinct between young and old patients and are considered individually in this article about the current evidence. Although fixation constructs all seem to have similar complication rates, there is increasing evidence suggesting that total hip replacement improves patient functional outcomes for healthy, independent, elderly patients compared with hemiarthroplasty and should be considered as the treatment of choice for these patients.