Type-B-IIIa hip rotationplasty: an alternative operation for the treatment of malignant tumors of the femur in early childhood

BACKGROUND: The biological plasticity of the cartilaginous proximal part of the tibia in children makes it possible to use the tibia to reconstruct the lower extremity after excision of a sarcoma of the thigh. A type-B-IIIa rotationplasty is an alternative to prosthetic replacement in very young children who have a malignant tumor of the femur that requires extensive resection. METHODS: A type-B-IIIa rotationplasty was done in eight patients who had a femoral tumor: four had a Ewing sarcoma; three, an osteosarcoma; and one, a primitive neuroectodermal tumor. The ages ranged from two years and eight months to ten years and six months at the time of the procedure. RESULTS: All eight patients were able to bear full weight and had a good range of motion of the hip joint at a median of five years and one month (range, two years and four months to eight years) postoperatively. They also were able to participate in sports activities. Radiographs and magnetic resonance imaging studies confirmed that the lateral part of the tibial plateau had remodeled to form a structure that resembled a developing femoral head. Seven patients were operated on only once, and a second hospital stay was not necessary. The remaining patient had a prolonged hospitalization for revision of the wound. CONCLUSIONS: As an alternative to amputation or an extendable tumor prosthesis, a type-B-IIIa rotationplasty offers not only a better functional result but also biological reconstruction. Placement of the cartilaginous head of the tibia into the acetabulum permits development of a new femoral head. Thus, not only is the foot preserved as a functional knee joint but a newly formed hip joint develops as well.     

Gait analysis after rotationplasty hip surgery for malignant tumor of the proximal femur

Rotationplasty of the hip joint is a special surgical technique used for the treatment of malignant tumors of the proximal part of the femur. We report a clinical case and gait analysis results before and after rehabilitation training. Evaluation of joint motion, kinetic moments, and the electromyographic findings enabled us to document progressive adaptation of muscle and joint function to their new role in the motor pattern, demonstrating the exceptional strength of rotationplasty. Active control of two fulcrums in the lower limb, the pseudo hip proximally and the pseudo knee intermedially, makes this type of operation extremely advantageous compared to the alternative of hip disarticulation or hemipelvectomy. Total absence of pain together with the preservation of articular and cutaneous proprioception are important advantages. Rotationplasty is an attractive alternative for treatment of malignant tumors of the proximal part of the femur.     

Reconstruction for defects of the proximal part of the femur using allograft arthroplasty

One of the most difficult problems in orthopaedic oncology is reconstruction after resection of a tumor of the proximal end of the femur. In order to achieve a wide margin about a primary or secondary malignant neoplasm of bone, it is often necessary to resect not only the hip joint and fifteen or more centimeters of the proximal part of the femur, but also the surrounding envelope of soft tissue. In some patients, little is left but the sciatic and femoral nerves and vessels. Since 1971, we have done reconstructions in forty-four patients, using an allograft and an implant or else an osteoarticular graft alone to replace the proximal end of the femur. Twenty-eight of these reconstructions were performed in patients who had had a malignant tumor and were followed for two to fifteen years postoperatively. Fifteen of the patients had only an osteoarticular graft, and thirteen had an allograft and a prosthesis (nine Austin Moore, two bipolar, and two long-stem total hip replacements). The average length of the femoral segment was 18.4 centimeters; the longest one measured thirty-one centimeters. Using an evaluation system of functional end-results that includes failures as a result of recurrence of the tumor, we recorded approximately 70 per cent excellent and good results for both groups. When the two failures that were due to recurrence of the tumor were omitted from the statistics (in order to evaluate the allograft procedure more fully), the successful results increased to about 80 per cent. In general, the patients who had an osteoarticular reconstruction fared less well than did those who had an allograft and a prosthesis, but the series were not quite comparable. The major complications were metastases in nine patients (five of whom died), infection in five, and fracture of the allograft in six. Restoration of the reconstruction was possible for most of the patients who had a problem that was not related to the tumor, and only one patient required an amputation for recurrent tumor. Despite the many difficulties, we think that an allograft, with or without a prosthetic implant, should be given primary consideration as a means of reconstruction of the limb when resection of a tumor necessitates resection of a long segment of the proximal end of the femur.     

Resection, rotationplasty, and femoropelvic arthrodesis in severe congenital femoral deficiency. A report of the surgical technique and three cases

BACKGROUND: The major problems associated with severe congenital deficiency of the femur are an unstable hip joint and a femur that is more than 50% shorter than the contralateral, normal femur. The usual treatment of these extreme cases of congenital femoral deficiency is a Syme or Boyd amputation when the child begins to walk. A knee fusion is done when the child is older, and the patient functions as an above-the-knee amputee. Rotationplasty has been described as an alternative treatment that allows the patient to function as a below-the-knee amputee. None of the currently described types of rotationplasty address the problem of the unstable hip. METHODS: Three patients with severe congenital femoral deficiency underwent a unique single-stage reconstruction. In this procedure, the limb is completely detached except for the sciatic nerve and the femoral vessels. The proximal part of the dysplastic femur and some muscles are resected. The residual limb is externally rotated 180 degrees and the rotated distal part of the femur is fused to the pelvis. All of the muscles distal to the knee remain undisturbed. RESULTS: The anatomical knee in its rotated position functioned as a hip with flexion and extension, and the femoropelvic arthrodesis provided a more stable support. The rotated ankle acted as a knee, and the patients functioned as below-the-knee amputees. The duration of follow-up of these three patients was eight, six, and four years. Active hip flexion was 10 degrees to 70 degrees , 10 degrees to 90 degrees , and 0 degrees to 80 degrees , and active knee flexion was 900 and 95 . The patients' gait continued to improve as they matured. CONCLUSIONS: The femoropelvic arthrodesis provides a stable hip. Since the muscles distal to the knee are not disturbed, the problem of derotation of the limb, which is often seen following the Van Nes rotationplasty, is not seen after this operation.     

Osteosarcoma: A Multifactorial Clinical and Histopathological Study with Special Regard to Therapy and Survival

A multifactorial analysis was performed on all 153 unequivocal cases of genuine osteosarcoma recorded in the Swedish Cancer Registry for the years 1958 through 1968. Cases of so-called parosteal osteosarcoma, soft-tissue osteosarcoma and osteosarcoma secondary to Paget's disease of bone were not included. The osteosarcomas were subclassifiecl as follows: osteoblastic (69 per cent), chondroblastic (19 per cent) and fibroblastic (12 per cent). The overall 5-year survival rate was 22 per cent; 55 per cent for those who had undergone amputation above the joint proximal to the involved skeletal part, 22 per cent for those amputated on the involved skeletal part, 11 per cent for those treated with local extirpation of the tumor, and 1 per cent in cases in which the lesion was not radically removed. Tumors of the femur, humerus and scapula were as malignant as axial tumors. The former carried a 5-year survival rate of 13 per cent, regardless of whether the patients had been treated with exarticulation or amputation on the involved skeletal part. Patients with axial tumors showed a 5-year survival rate of 15 per cent. These survival data suggest that proximal amputation alone might suffice for lesions situated distally to the knee and elbow joints, while tumors in the humerus and femur should be treated with amputation combined with multicytostatic treatment or immunotherapy and axial tumors with local resection and multicytostatic or immunologic treatment.     

Osteosarcoma. A multifactorial clinical and histopathological study with special regard to therapy and survival.

A multifactorial analysis was performed on all 153 unequivocal cases of genuine osteosarcoma recorded in the Swedish Cancer Registry for the years 1958 through 1968. Cases of so-called parosteal osteosarcoma, soft-tissue osteosarcoma and osteosarcoma secondary to Paget's disease of bone were not included. The osteosarcomas were subclassified as follows: osteoblastic (69 per cent), chondroblastic (19 per cent) and fibroblastic (12 per cent). The overall 5-year survival rate was 22 per cent; 55 per cent for those who had undergone amputation above the joint proximal to the involved skeletal part, 22 per cent for those amputated on the involved skeletal part, 11 per cent for those treated with local extirpation of the tumor, and 1 per cent in cases in which the lesion was not radically removed. Tumors of the femur, humerus and scapula were as malignant as axial tumors. The former carried a 5-year survival rate of 13 per cent, regardless of whether the patients had been treated with exarticulation or amputation on the involved skeletal part. Patients with axial tumors showed a 5-year survival rate of 15 per cent. These survival data suggest that proximal amputation alone might suffice for lesions situated distally to the knee and elbow joints, while tumors in the humerus and femur should be treated with amputation combined with multicytostatic treatment or immunotherapy and axial tumors with local resection and multicytostatic or immunologic treatment.     

Stump lengthening after hip disarticulation using a modular endoprosthesis in 5 patients

To reduce the disability after hip disarticulation, we developed a special surgical procedure in patients having a proximal femoral tumor with a large tumor involving the sciatic nerve or neoplasms involving the tibia and femur. The hip was disarticulated, but we preserved a musculocutaneous flap. A modular endoprosthesis was then placed in the acetabulum or, in case of an extraarticular resection of the hip joint, it was placed in the iliac bone. A trevira tube was used for reconstruction of the joint capsule and fixation of soft tissues. We performed this procedure in 5 patients who had a good functional outcome.     

Stump lengthening after hip disarticulation using a modular endoprosthesis in 5 patients

To reduce the disability after hip disarticulation, we developed a special surgical procedure in patients having a proximal femoral tumor with a large tumor involving the sciatic nerve or neoplasms involving the tibia and femur. The hip was disarticulated, but we preserved a musculocutaneous flap. A modular endoprosthesis was then placed in the acetabulum or, in case of an extraarticular resection of the hip joint, it was placed in the iliac bone. A trevira tube was used for reconstruction of the joint capsule and fixation of soft tissues. We performed this procedure in 5 patients who had a good functional outcome.     

Stump lengthening after hip disarticulation using a modular endoprosthesis in 5 patients.

To reduce the disability after hip disarticulation, we developed a special surgical procedure in patients having a proximal femoral tumor with a large tumor involving the sciatic nerve or neoplasms involving the tibia and femur. The hip was disarticulated, but we preserved a musculocutaneous flap. A modular endoprosthesis was then placed in the acetabulum or, in case of an extraarticular resection of the hip joint, it was placed in the iliac bone. A trevira tube was used for reconstruction of the joint capsule and fixation of soft tissues. We performed this procedure in 5 patients who had a good functional outcome.     

The influence of the amount of variation of cervical-thoracic angle on the hip status and radiological results of the treatment of developmental hip dysplasia by torsion osteotomy]

The aim of this paper was to determine the differences in hip remodeling and final outcomes of hip dysplasia treatment by fixing a certain amount of varus during varus-detorsion osteotomy of the proximal femur. The analysis included 33 children who underwent 48 osteotomies. During final follow-up at skeletal maturity it was found that the amount of varus fixed during the osteotomy influenced significantly femur remodeling and some containment measurements. However it played only slight part in acetabular remodeling. The outcomes at final follow-up proved significantly better in the group in whom a greater amount of varus was fixed.     

Alloplasty of the hip joint and the proximal part of the femoral shaft

The possibilities of the use of untypical prostheses of the hip in cases with lesion of the proximal femoral end together with a part of the shaft have been presented. A hip prosthesis with the upper part of the femur was implanted in two cases for neoplastic disease, and in one case for pseudoarthrosis of the femur within the intertrochanteric region. Good early clinical and radiological results was obtained and the total range of motion in the implanted joint was 210 degrees. After operation the patients did not complain about pain and they walked with the aid of a cane.     

Growth prediction in extendable tumor prostheses in children

Limb salvage procedures for malignant bone tumors of the lower limb in children usualy involve resection of at least one growing physis. To achieve equal leg length, reconstruction relies on accurate prediction of the remaining growth potential of the child. The current authors present the results of predicted growth versus actual prosthetic elongation observed in a group of 15 children fitted with extendable tumor endoprostheses of the lower limb who subsequently have reached skeletal maturity. All patients had at least one of the distal femoral or proximal tibial physes resected for a primary malignant bone tumor. Eight patients underwent distal femoral resection, four patients underwent proximal tibial resection, and three patients had total resection of the femur. All patients received custom-made Howmedica extendable prostheses. In two patients, a newly developed automatic elongation module was used. At followup, between 70 and 158 months, the patients achieved a mean elongation of the surgically treated limb of 10.4 cm (range, 1.1-19.5 cm), which exceeded the predicted growth by 24.3%. Final leg length discrepancies did not exceed 1 cm. Using incremental extendable tumor endoprostheses, individual adaptation of the elongation procedures could be achieved for equalization of leg length discrepancies in children after resection of primary malignant bone tumors of the lower limb.     

Articulated distraction of the hip joint in the treatment of benign aggressive tumors located around the hip joint

Introduction The proximal femur and acetabulum are frequent sites for benign active and aggressive lesions. The risk of pathologic fracture is great when a bone-destroying pathology involves an anatomic location such as the hip joint that undergoes profound mechanical loading. If the destruction involves a large area around the joint, secure fixation cannot be achieved with internal fixation implants. The study investigates use of articulated hip distraction to protect reconstructions performed for the treatment of benign active or aggressive tumors presenting with pathologic fracture.Patients and methods Five patients with a pathologic fracture of the proximal, intracapsular femur or the acetabulum were operated on at the authors' institution between 1997 and 1999. Following histopathologic approval of a benign tumor, all lesions were curetted, chemocauterized, and grafted and osteosynthesis was performed. The reconstruction was protected with an articulated hip distraction external fixator. All patients were mobilized in the immediate postoperative period.Results The patients were kept in external fixators for an average of 19.8 weeks (range: 16–24). The fixator was removed when bony consolidation was observed in anteroposterior and lateral x-rays of the lesion. The patients were followed for an average of 47 months (range: 38–56) after frame removal. None of the lesions recurred. At the last follow-up examination, all patients displayed an excellent function according to the Musculoskeletal Tumor Society Rating Scale. Conclusion According to the authors' knowledge, this investigation is the first in the literature describing the use of articulated joint distraction in the treatment of benign active and aggressive lesions around the hip joint. The procedure adopts principles of joint distraction into bone tumor surgery.     

Lengthening of proximal femoral focal deficiency using a hybrid fixation with inclusion of the knee joint

BACKGROUND: A major problem in lengthening a short femur in proximal focal deficiency of the femur (PFFD) is the development of contractures and dislocation of the hip and knee joint. The knee joint is particularly prone to dislocation because of the cruciate ligament insufficiency associated with PFFD. Axis deviations also need specific attention. PATIENTS AND METHODS: In four patients (age 2.5-11 years) with PFFD (PAPPAS class III in one patient and VII in three patients), five femoral lengthenings with mechanical axis corrections were performed by the callotasis technique using a hybrid fixation system (Monotube/Triax) connecting the femur and the tibia with a fixed hinged knee joint to protect the knee against contracture and dislocation. RESULTS: All patients retained their hip and knee function. Hip flexion contracture during lengthening may make inclusion of the hip joint into the fixation system necessary, but was not carried out in the four patients presented. CONCLUSION: Four consecutive lengthenings of the femur with focal deficiency were carried out under protection by a hinged knee bridging external fixator. A dislocation could be prevented in all patients. We consider that such a system could be used during these lengthening procedures.     

Experimental substantiation of a transosseous approach in arthroplasty of the hip joint

The author analyses the results of 40 experimental operations on cadavers to work through and to improve the approach for the hip joint arthroplasty performed by means of intertrochanteric osteotomy of the femur. The main parameters of the approach at various stages of the procedure have been evaluated according to O. Y. Sozon--Yaroshevich, the traumatizing factors of the operation have been determined and the peculiarities of mobilization of the proximal part of the femur and the possibility of displacement of the femoral head in various directions have been studied. Variations of the approach have been proposed taking into consideration the degree of limitation of the movements and the character of pathologic changes in the joint for performing hip joint arthroplasty in clinical practice. An approach to the supraacetabular area from the part of the joint cavity has been worked out which preserves the gluteal muscles, at the same time allowing to perform the arthroplasty and to reconstruct the supraacetabular area.     

Long-term effects of neonatal bone and joint infection on adjacent growth plates.

Review of children with physeal damage from neonatal infection other than the hip at Winnipeg Children's Hospital showed that six patients had residual growth interference from adjacent infection in the bone or joint. Several of the infections involved multiple joints, with growth plate arrest occurring in the distal femoral growth plate in four, in the proximal humerus in four, in the proximal femur in two, in the distal radius in one, and in the distal humerus in one. Although the initial infection was frequently believed to be successfully treated in the neonate, the clinical effect of these infections on the growth plate was not fully appreciated in five of the infants until the children reached a mean age of 9 years. Because growth abnormalities in physeal bars may not be clinically evident for several years after the initial infection has been treated, we recommend that children with bone and joint infections occurring in the first month of life be followed to skeletal maturity, observing the adjacent physis for late tethering.     

Intra-acetabular localisation of an osteochondroma causing subluxation of the hip joint

INTRODUCTION: Intra-acetabular localisation of an osteochondroma causing subluxation of the hip joint is a rare entity in children suffering from multiple hereditary exostoses. In literature only 6 operatively treated cases have been reported. CASE: We add the case of an 8-year-old boy with an intraarticular exostosis of the left acetabulum causing subluxation of the hip. Using an anterolateral approach to the hip joint this exostosis was removed surgically together with some extraarticular exostoses of the proximal femur. The hip could be re-centered in combination with an additional varus derotation osteotomy of the proximal femur. Intraoperatively the femoral head was only subluxated to minimise the risk of avascular necrosis. After a follow-up of two years the patient has complete remission of symptoms and there is no evidence of avascular necrosis radiologically with good remodelling of the left hip. CONCLUSION: The operative treatment of an intraarticular exostosis of the hip joint is a difficult and risky surgical procedure. The reported open surgical procedure allowed resection of the intraarticular exostosis in combination with therapy of additional pathologies of the proximal femur.     

The Relationship between Osteoarthritis of the Knee and Bone Mineral Density of Proximal Femur: A Cross-Sectional Study from a Korean Population in Women

Background

The relationship between osteoarthritis (OA) and osteoporosis (OP) is complicated and it may differ according to the site or stage of disease. The purpose of this cross-sectional study is to examine the relationship between the severity of radiological knee OA and the degree of OP in the ipsilateral proximal femur as denoted by bone mineral density (BMD) in a Korean population, especially among women.

Methods

One hundred ninety-five female patients who had knee pain and radiological knee OA were investigated with respect to the relationship of knee OA severity with BMD. The BMD of the proximal femur and spine was measured by dual energy X-ray absorptiometry, and the severity of knee OA was evaluated based on Kellgren-Lawrence (K-L) radiographic criteria, joint space narrowing (JSN) and mechanical axis of knee alignment. Partial correlation analysis and ANCOVA adjusted for confounding factors (age and body mass index) were performed to assess the relationship.

Results

There was a statistically significant relationship between the BMD of the proximal femur and JSN, and the BMD of the proximal femur was positively associated with increased joint space width. There was a lack of association between the spine BMD and JSN. The BMD of the proximal femur was also significantly lower in patients who had a higher K-L grade.

Conclusions

The radiographic finding of severe OA in the knee is associated with decreased BMD of the ipsilateral proximal femur including the femoral neck, trochanter, intertrochanter, and region of the entire hip (neck, trochanter, and Ward''s triangle).     

髋关节陈旧性骨折脱位伴股骨干上1／3骨折畸形愈合的功？…

目的 探讨髋关节陈旧性骨折脱位伴股骨止１／３骨折畸形愈合及膝关节功能病废的修复重建。方法 １９９７年４月￣８月为１例髋关节功能完全袁失且膝已行融合导致整个下肢残废的患者,采用人工关节置换及带锁股骨假体柄髓关节功能竽建,结果 术后随访１年患者置手杖行无不适,恢复日常生活及轻体力工作,结论对髋关节陈旧性骨折脱痊伴股骨干上１／３骨折畸形愈合,采用人工关节置换和带锁股骨假体柄髓内固定方法重建髓关节功能是有