Low-energy trauma-induced intercondylar femoral fracture.

We present a 44-year-old female patient with recurrent fragility fractures including an intercondylar femoral fracture and with normal planar bone densitometry. Diagnosis of hypophosphatasia was suggested by low volumetric cortical bone mineral density and laboratory findings. DNA sequencing revealed heterozygous mutations in the exons 5, 6 and 9 of the ALPL gene, thus confirming the suspected diagnosis.

Five-year results of the uncemented RM pressfit cup clinical evaluation and migration measurements by EBRA.

This was a prospective consecutive, study of 50 patients (mean age 72 years, 56% males) treated unilaterally for primary osteoarthrosis using the uncemented, isoelastic, monoblock RM Pressfit Cup. Migration and wear were assessed using the EBRA (Ein-Bild-Röntgen-Analyse) software (201 radiographs from 36 patients). Mean migration was 0.82 mm after 2 years and 1.25 mm after 5 years. A decreasing migration rate over the period was observed. The mean annual wear rate was 0.09 mm/y. Five years after surgery, 84% of patients reached good or excellent Harris hip score values. No revisions related to the acetabular component were necessary. All cups appeared to have high primary stability.

Surgical hip dislocation for the treatment of femoroacetabular impingement in high-level athletes.

BACKGROUND: Midterm outcome studies show that symptomatic femoroacetabular impingement (FAI) can be successfully treated by addressing the underlying pathomorphology with open or arthroscopic surgery. Although athletes may be vulnerable to hip injury from impingement, limited information is available regarding the results of open surgery in this group. HYPOTHESIS: High-level athletes with FAI can resume their sports after surgical hip dislocation and continue professional careers for a significant period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-two professional male athletes (19.7 ± 2.2 years) were evaluated by postal survey at a mean of 45.1 months (range, 12 to 79) after treatment by surgical hip dislocation (30 hips, cam- or mixed-type FAI; mean α angle, 69.3°; 14 ice hockey players). Evaluation included types and level of sports, subjective ratings, and CLINICAL OUTCOMES: Hip Outcome Score, SF-12, UCLA (University of California, Los Angeles) activity scale, Hip Sports Activity Scale, visual analog scale for pain. The primary outcome variable was return to professional sports; the clinical result was the secondary outcome variable. RESULTS: At follow-up, 21 of 22 patients (96%) were still competing professionally: 19 at their previous level and 2 in minor leagues. Eighteen (82%) were satisfied with their hip surgery and 19 (86%) with their sports ability. Mean activity levels were 9.8 per the UCLA scale and 7.6 per the Hip Sports Activity Scale. Mean scores of the Hip Outcome Score-Activities of Daily Living and Sport subscales were 94.5 and 89.1. Mean scores of the SF-12 physical and mental component summaries were 51.1 and 54.3. Pain levels during sports were 1.8 per the visual analog scale. CONCLUSION: Surgical hip dislocation for the treatment of FAI allows athletes to resume sports and continue professional careers at the same level for several years. Clinical outcomes in terms of subjective ratings and scores were favorable.

Stepped osteotomy of the trochanter for stable, anatomic refixation.

Refixation of a trochanteric osteotomy carries a high complication rate. To enhance stability and facilitate anatomic reduction of the trochanteric fragment, we have introduced a stepped osteotomy. Between April 2006 and June 2007, we performed surgical hip dislocations using the modified trochanteric osteotomy combined with a relatively aggressive rehabilitation program. Full weightbearing was allowed at a mean of 42 days (range, 33-54 days). The minimum followup was 8 months (median, 13 months; range, 8-24 months). Postoperative radiographs were assessed prospectively for consolidation or the appearance of malreduction/nonunion/malunion of the osteotomy and heterotopic ossification. In 110 of 113 hips, the trochanteric osteotomy healed in the anatomic position. Two patients had a trochanteric delayed union with loss of anatomic position, and one additional patient underwent revision surgery for a pseudarthrosis and cranial migration of the trochanteric fragment. All three complications related to healing occurred in the first 60 patients when the step height was 3 to 4 mm. After increasing the step heights to 6 mm, we observed no healing complications. Despite more aggressive postoperative mobilization, the incidence of malunion or nonunion related to the new stepped osteotomy is low and approaches zero for steps of 6 mm. It is now our technique of choice.

Tension controlled ligament balanced total knee arthroplasty: 5-year results of a soft tissue orientated surgical technique.

INTRODUCTION: Posterior cruciate ligament (PCL)-retaining prostheses give good outcomes and are commonly used. This retrospective study investigated outcomes from total knee arthroplasty (TKA) using the ligament balancing technique to implant a PCL-retaining knee prosthesis (balanSystrade mark knee system) with either a mobile or a fixed bearing polyethylene inlay. MATERIALS AND METHODS: A retrospective study was performed on patients treated with TKA at one surgical centre between 1997 and 2001. In this period 182 surgeries were performed. Clinical assessments of the implant used the Knee Society Score (KSS). Subjective assessments used visual analogue scale (VAS) for pain and patient satisfaction. The Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) was used to assess pain, stiffness and function of the knee. Radiographic analysis was performed to determine frontal and sagittal alignment and loosening. RESULTS: A total of 109 knee implants in 95 patients (26 men; 69 women) were followed up. Seventy-three cases were not available for follow-up due to bad health or death of the patient; 74% of 109 reviewed implants had fixed bearings and 26% had mobile bearings. The mean age at surgery was 72.9 +/- 7.35 years (range 54.7-92.4). The mean KSS was 160 +/- 28.3 points. The KSS was greater for men and was significantly reduced when another disease was present. The type of bearing, surgical approach, and pre-operative alignment for patients affected by varus or valgus gonarthrosis had no significant impact on KSS and ROM. According to VAS the mean scores for pain and satisfaction were 1.48 (0 = no pain) and 9.2 (10 = very satisfied), respectively. The WOMAC mean scores for pain (87.0), stiffness (82.3) and function (78.6) were high (best outcome score of 100). There were no revisions due to aseptic loosening or wear. CONCLUSION: Total knee arthroplasty performed with a PCL-retaining prosthesis implanted by using a soft tissue oriented surgical technique is a safe procedure and was associated with good results. So far, there were few complications and no need for revision due to aseptic loosening. In addition, most of the patients reported little pain and were satisfied with the outcome. These good outcomes are comparable with other studies reporting on PCL-retaining prostheses.

Correlation between internal rotation and bony anatomy in the hip.

Femoroacetabular impingement has been implicated as a risk factor for degenerative arthritis in young people with normally concentric hips. On presentation, patients with impingement have groin pain, limited internal rotation in 90 degrees flexion, and focal articular lesions. We hypothesized that the amount of internal rotation is dictated primarily by the underlying bony anatomy and not secondary to contractures. We compared 23 consecutive patients (32 hips) with 40 asymptomatic control subjects using positional magnetic resonance imaging, physical examination, and a questionnaire regarding symptoms and their commencement. There was a strong correlation between internal rotation in 90 degrees flexion and the measurable free space between the relevant bony contours on magnetic resonance imaging (r = 0.97) in the patient group and the control subjects. The range of internal rotation is closely related to skeletal anatomy, and internal rotation can be used as a noninvasive tool to predict the risk of impingement.

A mechanical equinometer to measure the range of motion of the ankle joint: interobserver and intraobserver reliability.

BACKGROUND: Clinical measurement of passive dorsiflexion of the ankle joint is essential for the diagnosis of various pathologic conditions of the foot and ankle but is of unreliable precision with high interobserver variability in nonweightbearing tests. This work was designed to develop and test a precise, standardized, and reliable technique for measurement of passive and active ankle range of motion. METHODS: The proposed measurement tool is composed of two mobile parallelograms, one attached to the tibia, the second one to the plantar surface of the foot. The parallelograms are connected with a hinge with an angular scale to measure the angle between the foot and tibia. RESULTS: Interobserver correlation between clinical measurements for maximal passive foot dorsiflexion were 0.03 with knee extension and 0.38 with knee flexion, while for measurements with the proposed tool they reached 0.89 and 0.97, respectively, with a mean measurement error of 0.9 degrees. Intraobserver correlations reached values of r = 0.98 and 0.99. CONCLUSIONS: The proposed tool allows measurement of the ankle range of motion with very high precision and reproducibility far superior to clinical measurements. CLINICAL RELEVANCE: Precise measurement of ankle range of motion is clinically challenging. With the use of the proposed tool, measurement precision and reliability are decisively improved.

Cartilage lesions in the hip: diagnostic effectiveness of MR arthrography.

PURPOSE: To evaluate the diagnostic performance of magnetic resonance (MR) arthrography in the detection of articular cartilage lesions in patients suspected of having femoroacetabular impingement and/or labral abnormalities. MATERIALS AND METHODS: Forty-two MR arthrograms obtained in 40 patients with a clinical diagnosis of femoroacetabular impingement and/or labral defect were retrospectively analyzed. Two readers independently interpreted the images for cartilage lesion location, depiction, and characteristics. Within 6 months after MR arthrography, each patient underwent open hip surgery, during which the entire cartilage of the hip joint was inspected. Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. kappa values were calculated to quantify the level of interobserver agreement. RESULTS: At surgery, most (37 [88%] of 42) cartilage defects were identified in the anterosuperior part of the acetabulum. In 23 (55%), 12 (29%), 10 (24%), and 10 (24%) hips, lesions were found in the posterosuperior acetabulum, anteroinferior acetabulum, posteroinferior acetabulum, and femoral head, respectively. The sensitivities and specificities of MR arthrographic detection of cartilage damage in all regions combined were 79% (73 of 92 regions) and 77% (91 of 118 regions), respectively, for reader 1 and 50% (46 of 92 regions) and 84% (99 of 118 regions), respectively, for reader 2. At interobserver comparison, agreement was fair (kappa = 0.31) for detection of cartilage lesions in the femoral head and poor (kappa