The transtrochanteric anterior rotational osteotomy of sugioka

Summary The early and late results of 39 transtrochanteric anterior rotational osteotomies of Sugioka, performed since 1975 in idiopathic aseptic necroses of the femoral head, are presented; 23 results are excellent and good. The rates of postoperative complications and reoperations are high, more than 40% each. Reoperations in smaller necrotic areas are far less frequent. There is no deterioration of the result when the hip joint is replaced by an endoprosthesis after Sugioka osteotomy. Insufficiency of the gluteus muscles is more frequent, but, on the other hand, range of motion of the hip joint increases after total hip replacement. Based on the results, we feel that there are fewer indications for this operation. The procedure is indicated for young patients with good function of the hip joint and sectors of necrosis up to 90°, especially when there is no other way to remove the area of necrosis from the weight-bearing zone of the femoral head.

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Zusammenfassung Es wird über 39 Früh- and Spätergebnisse nach transtrochanterer ventraler Rotationsosteotomie nach Sugioka berichtet, die seit 1975 bei idiopathischer Hüftkopfnekrose vorgenommen wird. In 23 Fällen waren die Ergebnisse sehr gut und gut. Der Prozentsatz der postoperativen Komplikationen und Reoperationen ist hoch, er beträgt für beide mehr als 40%. Reoperationen sind bei kleineren Nekrosen wesentlich seltener. Der totale Hüftgelenkersatz nach der Sugioka Osteotomie führt zu keiner Verschlechterung des Resultates. Einerseits kommt es häufiger zur Insuffizenz der Glutaeus-Muskeln, andererseits verbessert sich die Hüftgelenksbeweglichkeit nach Hiifttotalendoprothesen-Reoperation. Die Ergebnisse zwingen zu einer engen Indikationsstellung für these Operation. Für junge Patienten mit guter Funktion des Gelenkes and Nekrosen bis 90° ist die Operation indiziert, vor allem wenn die Nekrosezone durch andere gelenkerhaltende Maßnahmen nicht aus der Belastungszone des Hüftkopfes zu bringen ist.

     

Rotational osteotomy for non-traumatic avascular necrosis of the femoral head.

We reviewed 41 hips in 40 patients at three to 11 years (average 6.3 years) after Sugioka transtrochanteric rotational osteotomy for non-traumatic avascular necrosis of the femoral head. The clinical results were excellent or good in 23 hips (56%) and the radiological success rate was 56%. Failure was due to fracture of the femoral neck, nonunion of the osteotomy, secondary collapse, or osteoarthritis. Nonunion and femoral neck fracture were more common after the use of the large screws described by Sugioka than with AO blade plates. Secondary collapse was significantly more common when less than one-third of the posterior articular surface was intact (p = 0.002). Postoperative degenerative changes were seen in cases with stage III avascular necrosis. We conclude that success depends to a large extent on the amount and stage of necrosis of the femoral head, but that careful technique and the use of AO hip plates may increase the likelihood of a satisfactory result.     

Sugioka's trans-trochanteric osteotomy. Results of interventions 1975-1983

The long-term results of 46 Sugioka osteotomies are presented: In 22 patients no joint replacement had yet been necessary, and 17 hip joints had already been replaced by total hip prostheses. Of the 22 preserved joints, 12 were graded as clinically excellent and good, 10 as fair or poor. The radiological course showed worsening osteoarthritic changes in almost all cases. In the "survival curve" for the Sugioka osteotomy in the group with 17 total hip prostheses the most significant slope can be seen during the first 3 years postoperatively; between 5 and 10 years there are no failures; and then the curve descends again. Fair and poor results are noted most frequently between 6 and 10 years after the operation in the group of 22 patients with no joint replacement. The preoperative extent of necrosis and the radiological stage are the main factors determining the result. Over the years it has been possible to define a narrow spectrum of indications: the greatest benefit is obtained in young, cooperative patients with necrotic sectors of about 90 degrees and good function of the hip joint.     

Gelenkerhaltende Hüftchirurgie im Erwachsenenalter

Due to advances in total joint replacement, intertrochanteric osteotomy (ITO) is performed more infrequently in spite of good clinical results. Nevertheless, there are several good indications for this joint-preserving procedure in adults. Detailed biomechanical knowledge and precise clinical examination are prerequisites for correct indications and planning of ITO. The main target of this surgical procedure is improvement of joint congruency and normalization of load transfer to protect damaged cartilage. Very good results can be obtained in hip dysplasia, non-union of the femoral neck and proximal femoral deformities if the therapeutic principles are followed. Higher failure rates have to be expected in femoral head necrosis and osteoarthritis, depending on the degree of pre-existing cartilage damage.     

Transposition of the apophysis of the greater trochanter for reconstruction of the femoral head after septic hip arthritis in children

Background and purpose

Total necrosis of the femoral head after infection in children during their first months of life gives a dislocated hip with severe leg shortening. A new femoral head can be achieved with subtrochanteric osteotomy and transposition of the apophysis of the greater trochanter into the acetabulum. Previous reports have dealt with short-term results (up to 12 years). Here I present some results of this procedure 15–24 years after operation.

Patients and methods

4 children aged 1–6 years with complete necrosis of the femoral head were operated on with transposition of the greater trochanter. Secondary shelf plasty was performed later in 1 child, distal femoral epiphysiodesis in another, and femoral bone lengthening in 1 child. The mean follow-up period was 19 (15–24) years.

Results

A new femoral head developed in all hips. 2 of them had a spherical head with a good acetabular cover, and without any osteoarthritis except for slight reduction of cartilage height. These hips were painless, with a mobility that allowed good walking function after 16 and 24 years, respectively. In the other 2 patients, in which there was a severe acetabular dysplasia at the primary operation, the new femoral head was somewhat flattened; painful osteoarthritis led to hip replacement 15 and 21 years after trochanter arthroplasty. Even these patients had a relatively good walking function until the last couple of years before hip replacement. Maximum leg length discrepancy was 7 cm.

Interpretation

Trochanter arthroplasty with subtrochanteric osteotomy in total femoral head necrosis after septic arthritis in children may give satisfactory long-term results provided adequate acetabular cover is obtained. Although the method cannot provide a normal hip, it can contribute to less length discrepancy, less pain, improved gait, and more favorable conditions for later hip replacement.Acute septic arthritis of the hip in children during their first months of life occasionally leads to total necrosis of the femoral head. This results in dislocation of the joint and severe limb shortening. A 6-year-old girl suffering from this condition was admitted to our department in 1985. Bearing in mind that apophyseal cartilage has the potential to develop into a kind of joint cartilage when transplanted to a joint (Benum 1974), I transposed the apophysis of the greater trochanter into the acetabulum in an attempt to reconstruct the femoral head. Encouraged by the short-term result after this operation, and by medium-term results reported after similar operations (Hunka et al. 1982, Dal Monte et al. 1984), I later used this method in 3 other children. I now present the method and the long-term results after this procedure.     

Follow-up analysis of total hip endoprosthesis after femoral neck fracture with and without previous operation]

Damage occurring after joint-preserving surgical treatment of femoral neck--mostly femoral head necrosis of pseudoarthrosis-necessitates endoprosthetic joint replacement. In the case of inferior bone quality and unfavorable fracture forms as well as after failed conservative therapy, surgical treatment consists of implanting a total hip endoprosthesis. Between 1971 and 1989, 120 patients received total hip replacement after suffering fractures of the femoral neck: 61 patients did not have previous surgery, 59 patients had had joint-preserving surgery. Statistical analysis of the results showed that the primary stabilizing operation to preserve the joint did not have a negative influence on the survival probability of the total hip replacement in comparison with primary implantation. If the joint-preserving primary intervention fails, total hip replacement is a good choice for secondary surgery. In the case of complications such as femoral head necrosis or pseudoarthrosis the indication for total hip replacement should therefore be made early on.     

Rapid and Severe Idiopathic Aseptic Necrosis of the Contralateral Femoral Head after Unilateral Total Hip Arthroplasty

BackgroundOsteonecrosis of the femoral head (ONFH) is a multifactorial disease, and agnogenic ONFH, otherwise known as idiopathic ONFH, is rare in clinic. Idiopathic ONFH that exhibits severe necrosis and progresses extremely rapidly is called rapidly destructive hip disease (RDHD). RDHD greatly affects patients but is rarely reported in clinical practice and literature.Case PresentationIn this study, a 64‐year‐old male patient with complete collapse and necrosis of the right femoral head complicated with severe bone destruction at 10 months after left total hip arthroplasty (THA) was reported. The period from the intact structure of the right femoral head to the first discovery of its complete collapse, according to imaging results, was 7 months. The duration from the occurrence of symptoms in the right hip joint to the first discovery of complete collapse and necrosis of the femoral head was only 5 months. At present, the cause has not been determined based on medical history, symptoms, signs, imaging evaluation results, laboratory examination results, and pathological examination results, though it has been identified as severe idiopathic aseptic necrosis of the femoral head with rapid progression, or RDHD. Finally, right THA was performed, and a good outcome was observed in the patient at present.ConclusionsAs a rare hip joint disease, RDHD greatly influences the normal life of patients. RDHD of the contralateral side after unilateral THA is even scarcer. Left THA may be one of the important factors accelerating the necrosis of the right femoral head. Hopefully, with this case report, more attention will be paid to the contralateral hip joint in patients undergoing unilateral THA by clinicians and rehabilitation physicians, and a clinical reference will be provided for the research on RDHD.     

Die Kirschner-Draht-Spickung der Hüftkopfepiphyse bei Epiphyseolysis capitis femoris juvenilis

OBJECTIVE: To stabilize the unstable capital femoral epiphysis to stop further slippage. To prevent imminent epiphyseal dislocation with subsequent articulation disorders of the hip joint and joint degeneration. To prevent additional growth disorders of the proximal femur. INDICATIONS: Epiphyseolysis capitis femoris acuta.Epiphyseolysis capitis femoris lenta. Epiphyseolysis capitis femoris incipiens (incipient epiphyseolysis). Epiphyseolysis capitis femoris imminens (imminent epiphyseolysis of the so-called healthy contralateral side). CONTRAINDICATIONS: None. The diagnosis of slipped capital femoral epiphysis is an absolute indication for surgery unless there is an internal or pediatric disorder that dictates a conservative approach. SURGICAL TECHNIQUE: Three, possibly four, Kirschner wires, at least 2 mm thick, are inserted through a short subtrochanteric approach under image intensification into the femoral neck so that they are seen to be spread uniformly over the cross section of the femoral head when viewed in both planes. The opposite side is transfixed prophylactically. POSTOPERATIVE MANAGEMENT: 3 weeks partial loading at 10 kg, then increased loading after radiologic assessment. Radiologic assessment every 6 months until the end of the growth phase so that migration of the Kirschner wiresout of the femoral head can be identified early. If necessary, renewed Kirschner wire transfixation. Implants are removed after consolidation and closure of the growth plate. RESULTS: 59 therapeutic and 48 prophylactic transfixations of slipped capital femoral epiphysis were performed from 1970 to 1995. The average follow-up period was 4 years (0.1-17.3 years). The most frequent complications were incipient secondary joint degeneration arising in most cases from femoral head necrosis, and postoperative identification of Kirschner wire malalignment. At the time of follow-up 27 patients had an excellent result on the pathologic side according to Southwick's classification, 26 a good, three a moderate, and three a poor result. In particular, a poor result ensued subsequent to femoral head necrosis.     

Sugioka's Modified Hungria-Kramer intertrochanteric osteotomy in the treatment of severe slipped capital femoral epiphysis

From May 1990 to November 1997, 24 cases of severe slipped capital femoral epiphysis were treated by an osteotomy that is a modification of the Hungria-Kramer intertrochanteric osteotomy proposed by Sugioka (Hungria-Kramer-Sugioka osteotomy or HKS osteotomy). The degree of displacement as seen on the frog-leg lateral radiograph of the proximal femur was measured according to the deviation of the longitudinal axis of the epiphysis from the center line of the neck (Fish classification). All hips were considered as grade III and underwent HKS osteotomy. Sugioka's radiographic study (true AP view with the limb internally rotated until the patella is perpendicular to the x-ray beam, and lateral view with the hip in 90 degrees flexion and 45 degrees abduction) was performed before surgery to show that the real direction of the slip was posterior in relation to the neck. Clinical results were assessed according to Merle-D'Aubigné and Postel system modified by Charnley (hip score system that takes into consideration pain, gait, and joint motion). Roentgenographic results were considered good if none of the following was present: joint space decreased by more than 2 mm (chondrolysis), avascular necrosis of the femoral head, neck-shaft angle of less than 120 degrees, nonunion at the osteotomy site, and a epiphyseal plate still open. Follow-up varied from 31 to 120 months (average 65.1 months).     

The mechanical cause of congenital dislocation of the hip joint: Dynamic ultrasound study of 5 cases

5 hip joints with untreated congenital dislocation of the hip were examined for hip movement by ultrasound. With the hip joint flexed, the direction of the dislocated femoral head was posterior to the acetabulum. The dislocated femoral head displaced more posteriorly when the knee joint was extended, with the hip joint held in flexed position. As the dislocated hip was extended, on the other hand, the direction of the dislocated femoral head was anterior to the acetabulum. The dislocated femoral head displaced more anteriorly when the baby tried to bend the hip with the joint held in extended position.

These findings indicate that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH by the action of hamstrings, and that an infant posture with the hip extended is likely to provoke femoral head dislocation by the action of the iliopsoas.     

Hip fracture-dislocation with transepiphyseal separation. Case report and literature review.

Fracture-dislocation of the hip is an infrequent injury in adolescence. In combination with transepiphyseal separation of the capital femoral epiphysis, the injury is rare and catastrophic. A review of orthopaedic literature shows varied recommendations as to treatment approaches. The most recent articles have suggested that open reduction through a posterior approach and internal fixation is the best way to treat this problem initially. Later reconstructive measures are usually required because this injury often leads to avascular necrosis of the femoral head. The patient and family should be advised that the prognosis after such a fracture-dislocation is not good. Potential reconstructive measures after collapse of the femoral head include total hip arthroplasty and hip arthrodesis. Total hip arthroplasty is not a reliable means of providing a long-term painless joint in an active adolescent with one-joint disease. Hip arthrodesis has been shown to be a good alternative treatment for patients who develop avascular necrosis after this severe injury.     

Pemberton手术加辅助手段治疗大龄儿童先天性髋脱位

目的应用Pemberton手术加辅助手段治疗大龄儿童先天性髋脱位,从而进一步降低术后关节僵硬和股骨头坏死发生率。方法自1987年2月～1998年2月,用Pemberton手术加辅助手段治疗大龄儿童(7～14岁)先天性髋脱位58例76髋,随访2～11年,平均5年2个月。辅助手段包括1术前充分牵引;2术后应用中立位外展木板鞋加尼龙套皮牵引制动;3髋关节早活动,晚负重;4术后被动活动髋关节加主动功能锻炼。结果髋关节屈曲小于90°者6髋,占7.9%。按照Salter提出的股骨头坏死诊断标准,58例76髋中股骨头坏死29髋,占38.2%,明显降低了大龄儿童先天性髋脱位术后髋关节僵硬及股骨头坏死的发生率。结论Pemberton手术是治疗大龄儿童先天性髋脱位的首选术式,辅助手段较好地克服了髋脱位术后出现的股骨头坏死与髋关节僵硬两大难题,并降低了发生率。     

碳—钛组合式人工股骨头临床应用15年随访

自1980年4月至1995年4月,应用碳—钛组合式人工股骨头治疗髋关节疾患319例。随访最短1年,最长15年。随访结果:股骨颈骨折组优良率93％,股骨头无菌性坏死组优良率89.8％。余者2例失败,4例髋关节周围钙化,2例碳质头略大,3例假体下沉,1例类风湿性髋关节强直,术后关节再强直。1例髋臼硬化,4例6髋关节明显疼痛。4例死于心血管疾病。我们体会到碳质材料具有良好的物理、化学性能和生物相容性,是一种优良的人工关节材料。碳—钛组合式人工股骨头是目前优良的人工假体之一。     

难复的髋关节中心性脱位骨折手术治疗商榷

报告22例难复的髋关节中心脱位骨折,11例随访4年9个月,发生股骨头缺血环死或创伤性关节炎81.8%.作者在手术中观察到髋白骨折的移位、股骨头对髋臼的压迫作用和骨折、微骨折,提出髋关节中心性脱位骨折的分类方法.采用外固定架稳定头臼复位,髋臼骨折复位后植骨和钢板固定,术后六周用CPM良好的主被动功能训练,是取得良好疗效的重要条件.     

旋髂深血管蒂骨瓣移植预防先髋术后股骨头坏死

目的探索发育性髋关节脱位术后股骨头坏死的预防措施。方法对20例发育性髋关节脱位分为A、B两组，A组常规切开复位加带旋髂深血管蒂骨瓣移植，B组单行常规切开复位。结果A组病例获1～6g随访，平均3．5年，股骨头坏死2例，Ficat分期I期，A组髋关节功能评定：优6例，良2例，差2例。B组病例获4～14年随访，平均7．8年，股骨头无菌坏死5例，Ficat分期：ⅡA期1例、ⅡB期2例、Ⅲ期2例，B组髋关节功能评定：优4例，良1例，差5例。结论带旋髂深血管蒂骨瓣移植能有效预防发育性髋关节脱位术后股骨头坏死，改善关节功能。     

Hip joint development after closed reduction, complicated by growth disturbance of the capital femoral epiphysis]

The purpose of the study was to assess hip joint development after the treatment of DDH with overhead traction and closed reduction complicated by growth disturbances of the proximal femoral epiphysis. Comparison was also made between joints affected by AVN and other treated joints. Antero-posterior radiographs of 107 hip joints (81 children) done during treatment and follow-up were retrospectively reviewed. The average age was 14.2 months (from 5 to 33 months) and age at the final follow up 20.7 years (minimum 14 years). AVN was detected in 31 (29%) of the hip joints. Type II necrosis according to Bucholz and Ogden classification system was the most common one. In the hips affected by growth disturbances of proximal femoral epiphysis there were worse final clinical and radiological results, osteoarthrosis and elongation of acetabulum were more often seen in comparison to other treated joints. There was no difference in terms of other parameters describing acetabulum. In 19 out of 31 cases deformity of femoral head was noted. AVN may present as a wide spectrum of pathology from mild, probably not significant growth disturbances of physis to severe deformity and lateralisation of femoral head. Statistically hips with AVN had worse final results and in cases with good congruity prognosis is often uncertain due to aspherical femoral head and secondary osteoarthrosis. Acetabular development is most often unaffected by AVN.     

生物臼盖的研制与临床应用

目的研制生物臼盖并将其用于治疗发育性髋关节发育不良患儿。方法采用异种皮质骨加工制成生物臼盖主体及生物螺钉,并将其应用于2～10岁发育性髋关节发育不良儿童13例(16髋)。术后定期复查,随访终末时,采用Mckay临床疗效评定标准和SeverinX线影像学评定标准评价复位后髋关节的功能及发育情况。结果所有病例均获得18个月以上随访。随访终末时,Mckay临床疗效评定结果,优9髋,良6髋,可1髋,优良率为94%;SeverinX线影像学评定结果,优9髋,良4髋,可3髋,优良率为81%。本组无一例发生术后再脱位、股骨头骨骺缺血性坏死、再骨折、髋关节僵硬等严重并发症。结论经临床初步观察,生物臼盖能有效维持复位后髋关节的稳定,增大头臼接触面积,增加髋臼对股骨头的包容,为髋关节的发育塑形提供良好的生物力学环境。     

高龄患者的人工髋关节置换疗效观察

目的观察人工髋关节置换治疗高龄老年股骨颈骨折及股骨头无菌性坏死的临床疗效。方法对70岁以上股骨颈骨折及股骨头无菌性坏死患者16例,经髋外侧切口施行半髋置换5例,全髋置换11例。结果随访1～4年,在3～6周患者扶拐下地逐渐负重行走,3个月屈髋>90°,后伸髋>5°。6～12个月基本恢复伤前功能,生活自理,髋关节无疼痛,无假体松动、下沉现象,Harris评分平均91±3.4分。结论高龄患者做好充分的术前准备是可以胜任人工髋关节置换术的,能在短时间内恢复一个无痛的髋关节,降低并发症的发生,提高生活质量。     

影响髋关节表面置换术后关节功能恢复的多因素分析

目的探讨影响股骨头缺血性坏死患者行髋关节表面置换术后关节功能恢复的因素。方法1997年6月至2008年7月对股骨头缺血性坏死患者45例47髋行半髋关节表面置换,男25例,女20例;年龄29—49岁,平均36．6岁。应用Harris髋关节评分对疗效进行评定。研究患者的年龄、性别、体重指数、职业、病因、Ficat分期、髋部手术史、股骨假体柄干角、术后开始锻炼时间等相关因素,在单因素分析基础上应用Logistic回归模型作多因素分析。应用SPSS13．0进行统计学分析,其中Harris髋关节评分作为因变量,分为优、较好、良、差4类,其中前2类视为功能恢复满意。结果45例患者随访1—11年,平均8．6年。Harris髋关节评分：优15例,较好20例,良8例,差2例,满意率为77．8％。单因素分析结果发现患者的体重指数、Ficat分期、股骨假体柄干角、术后开始锻炼时间4个因素与髋关节功能恢复显著相关（P〈0．05）。Logistic回归发现此4个因素是影响髋关节功能恢复的主要因素。结论体重指数、Ficat分期、股骨假体柄干角、术后锻炼时间可明显影响髋关节表面置换术后功能恢复。     

Sugioka’s osteotomy for femoral-head necrosis in young Caucasians

The transtrochanteric rotational osteotomy described by Sugioka is used to preserve the femoral head and to prevent secondary osteoarthritis in young patients with osteonecrosis of the femoral head. Several Japanese studies have shown favourable results, but European and American studies were disappointing. An explanation for these outcomes may be that the original protocol was not followed exactly. The objective of our study was to investigate this trans-trochanteric rotational osteotomy in Caucasian patients with osteonecrosis in which we followed the original method of Sugioka as closely as possible, including a 6-month period of non-weight bearing. We included 26 hips in 22 consecutive patients who were followed up for 8.7 (range 6.6-10) years. At review, 17 hips had been converted to total hip arthroplasty. The clinical survival rate was 56% after 7 years (95% CI 36-76%). The radiological survival rate was 54% after one year (95% CI 35-73%). Even after excluding the failures due to problems with osteosynthesis and infection, the results were not satisfactory and the osteoarthritic process was not delayed. Based on our results, we cannot recommend this technique as an alternative for total hip arthroplasty in Caucasians.