Pavlik吊带治疗6个月内婴儿髋关节发育不良

目的探讨Pavlik吊带治疗6个月内婴儿髋关节发育不良的方法和疗效以及高频超声在诊断治疗中的价值。方法回顾性总结我院2004年1月至2012年1月收治的102例(124髋)6个月内发育性髋关节异常的婴儿,其中男性14例,女性88例,单侧80例,双侧22例,年龄3~24周。据Graf超声波髋关节分型,20髋为Ⅱa(-)型,50髋为Ⅱb型,34髋为Ⅱc型,18髋为Ⅲ型,2髋为Ⅳ型。常规新生儿体检均发现有双侧臀纹不对称,或伴有髋关节屈曲外展受限,经Garf静态超声技术确认。均采用Pavlik吊带治疗,平均间隔2~3周超声监测髋关节发育变化。吊带治疗时间4~20周,随访时间15~30个月,平均24个月。结果 92例(112髋)经Pavlik吊带治疗后,复查超声和X线片指标恢复正常,确认治愈。4例(5髋)治疗过程中超声指标改善明显,58°α角60°,年龄超过8个月后,改用髋外展矫形器固定,4周后X线片指标恢复正常。6例(7髋)年龄超过6个月,指标未恢复正常,且伴有内收肌紧张,予以内收长肌松解后石膏固定。在此6例患儿中,3例(3髋)随访至18个月,髋臼指数大于25°,Sheton氏线不连续,行Salter骨盆截骨术。所有患儿均无股骨头无菌性坏死等并发症。结论 Pavlik吊带对于GrafⅡ型患儿治愈率高,而对于GrafⅢ、Ⅳ型患儿,Pavlik吊带治愈率降低,部分患儿需后续进一步治疗。超声检查可动态观察Pavlik吊带治疗效果。早期超声检查为及时应用Pavlik吊带治疗提供了可能,对减轻患儿晚期畸形和并发症有重要意义。     

Treatment of developmental dysplasia of the hip with Pavlik harness: prospective study in Graf type IIc or more severe hips

Successful treatment of developmental dysplasia of the hip (DDH) is associated with early diagnosis and appropriate treatment. In this prospective study, the results of the treatment with Pavlik harness followed by an abduction brace in patients with severe DDH were presented. Twenty-two hips of 18 patients with a mean age of 14.8+/-5.9 weeks (range, 6-26) when diagnosed were followed for an average of 24.2+/-10.8 months (range, 10-46). The hips were staged according to the classification of Graf with ultrasonography and Pavlik harness was instituted as the first line of treatment in all hips. If there was no improvement of ultrasonographic stage at the third week follow-up the harness treatment was discontinued. After the infant became too large for Pavlik harness an abduction brace was used. In all but one hip the treatment was successful (95.4%). In two hips type I avascular necrosis was noted. Of the dislocated hips 90% were reduced. The Pavlik harness is a safe and effective method of treatment of severe DDH in infancy if potential pitfalls are avoided.     

An Increased Iliocapsularis-to-rectus-femoris Ratio Is Suggestive for Instability in Borderline Hips

Background

The iliocapsularis muscle is an anterior hip structure that appears to function as a stabilizer in normal hips. Previous studies have shown that the iliocapsularis is hypertrophied in developmental dysplasia of the hip (DDH). An easy MR-based measurement of the ratio of the size of the iliocapsularis to that of adjacent anatomical structures such as the rectus femoris muscle might be helpful in everyday clinical use.

Questions/purposes

We asked (1) whether the iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference is increased in DDH when compared with hips with acetabular overcoverage or normal hips; and (2) what is the diagnostic performance of these ratios to distinguish dysplastic from pincer hips?

Methods

We retrospectively compared the anatomy of the iliocapsularis muscle between two study groups with symptomatic hips with different acetabular coverage and a control group with asymptomatic hips. The study groups were selected from a series of patients seen at the outpatient clinic for DDH or femoroacetabular impingement. The allocation to a study group was based on conventional radiographs: the dysplasia group was defined by a lateral center-edge (LCE) angle of < 25° with a minimal acetabular index of 14° and consisted of 45 patients (45 hips); the pincer group was defined by an LCE angle exceeding 39° and consisted of 37 patients (40 hips). The control group consisted of 30 asymptomatic hips (26 patients) with MRIs performed for nonorthopaedic reasons. The anatomy of the iliocapsularis and rectus femoris muscle was evaluated using MR arthrography of the hip and the following parameters: cross-sectional area, thickness, width, and circumference. The iliocapsularis-to-rectus-femoris ratio of these four anatomical parameters was then compared between the two study groups and the control group. The diagnostic performance of these ratios to distinguish dysplasia from protrusio was evaluated by calculating receiver operating characteristic (ROC) curves and the positive predictive value (PPV) for a ratio > 1. Presence and absence of DDH (ground truth) were determined on plain radiographs using the previously mentioned radiographic parameters. Evaluation of radiographs and MRIs was performed in a blinded fashion. The PPV was chosen because it indicates how likely a hip is dysplastic if the iliocapsularis-to-rectus-femoris ratio was > 1.

Results

The iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference was increased in hips with radiographic evidence of DDH (ratios ranging from 1.31 to 1.35) compared with pincer (ratios ranging from 0.71 to 0.90; p < 0.001) and compared with the control group, the ratio of cross-sectional area, thickness, width, and circumference was increased (ratios ranging from 1.10 to 1.15; p ranging from 0.002 to 0.039). The area under the ROC curve ranged from 0.781 to 0.852. For a one-to-one iliocapsularis-to-rectus-femoris ratio, the PPV was 89% (95% confidence interval [CI], 73%–96%) for cross-sectional area, 77% (95% CI, 61%–88%) for thickness, 83% (95% CI, 67%–92%) for width, and 82% (95% CI, 67%–91%) for circumference.

Conclusions

The iliocapsularis-to-rectus-femoris ratio seems to be a valuable secondary sign of DDH. This parameter can be used as an adjunct for clinical decision-making in hips with borderline hip dysplasia and a concomitant cam-type deformity to identify the predominant pathology. Future studies will need to prove this finding can help clinicians determine whether the borderline dysplasia accounts for the hip symptoms with which the patient presents.

Level of Evidence

Level III, prognostic study.     

Minimum 10-Year Results of Cementless Ceramic-On-Ceramic Total Hip Arthroplasty Performed With Transverse Subtrochanteric Osteotomy in Crowe Type IV Hips

BackgroundTotal hip arthroplasty (THA) performed for developmental dysplasia of the hip is a technically difficult procedure with a high complication rate, especially in the presence of completely dislocated hips. This study aimed to evaluate at least 10 years of follow-up results of cementless, ceramic-on-ceramic (CoC) THA performed with transverse subtrochanteric osteotomy in Crowe type IV hips.MethodsWe retrospectively reviewed 50 patients’ 67 hips that underwent CoC, cementless THA with transverse subtrochanteric osteotomy between 2008 and 2011. Clinical and radiological data of the hips were examined. Clinical results were evaluated using the Harris Hip Score and the Western Ontario and McMaster Universities Osteoarthritis Index.ResultsThe mean Harris Hip Score improved from 22.9 ± 9.9 preoperatively to 94.1 ± 8.1 at the final follow-up (P < 0.001). The median Western Ontario and McMaster Universities Osteoarthritis Index score improved from 72 (interquartile range: 17) preoperatively to 2 (interquartile range: 17) postoperatively (P < 0.001). The preoperative mean leg length discrepancy was improved from 4.9 ± 1 cm to 1.5 ± 1 cm in unilateral cases at the last follow-up (P < 0.001). Revision surgery was required because of nonunion in two patients, prosthetic infection in one patient, and aseptic femoral loosening in the other patient. The overall ten-year survival rate was 94% for femoral stems and 98.5% for acetabular components as per Kaplan-Meier survival analysis.ConclusionTransverse subtrochanteric shortening osteotomy combined with using cementless acetabular and femoral components with a CoC bearing surface promises successful clinical results and high prosthesis survival in the treatment of Crowe IV hips at long-term follow-up.     

Insulin Resistance Is Associated With Higher Intramyocellular Triglycerides in Type I but Not Type II Myocytes Concomitant With Higher Ceramide Content

OBJECTIVE

We tested the primary hypotheses that sphingolipid and diacylglycerol (DAG) content is higher within insulin-resistant muscle and that the association between intramyocellular triglycerides (IMTG) and insulin resistance is muscle fiber type specific.

RESEARCH DESIGN AND METHODS

A nested case-control analysis was conducted in 22 obese (BMI >30 kg/m²) women who were classified as insulin-resistant (IR; n = 12) or insulin-sensitive (IS; n = 10), determined by hyperinsulinemic-euglycemic clamp (>30% greater in IS compared with IR, P < 0.01). Sphingolipid and DAG content was determined by high-performance liquid chromatography–tandem mass spectrometry. Fiber type–specific IMTG content was histologically determined. Gene expression was determined by quantitative PCR.

RESULTS

Total (555 ± 53 vs. 293 ± 54 pmol/mg protein, P = 0.004), saturated (361 ± 29 vs. 179 ± 34 pmol/mg protein, P = 0.001), and unsaturated (198 ± 29 vs. 114 ± 21 pmol/mg protein, P = 0.034) ceramides were higher in IR compared with IS. DAG concentrations, however, were similar. IMTG content within type I myocytes, but not type II myocytes, was higher in IR compared with IS subjects (P = 0.005). Insulin sensitivity was negatively correlated with IMTG within type I myocytes (R = −0.51, P = 0.026), but not with IMTG within type II myocytes. The proportion of type I myocytes was lower (41 vs. 59%, P < 0.01) in IR subjects. Several genes involved in lipid droplet and fatty acid metabolism were differentially expressed in IR compared with IS subjects.

CONCLUSIONS

Human skeletal muscle insulin resistance is related to greater IMTG content in type I but not type II myocytes, to greater ceramide content, and to alterations in gene expression associated with lipid metabolism.Skeletal muscle insulin resistance is a key factor in the development of type 2 diabetes, although the exact mechanisms that underlie insulin resistance in humans remain elusive. Considerable efforts have been made in the past several decades to better understand the role of impaired fatty acid metabolism in skeletal muscle insulin resistance (1,2). Many earlier studies, both in animal models (3) and in humans (4,5), indicated that intramyocellular triglyceride (IMTG) accumulation was associated with insulin resistance, thereby providing a potential link between dysregulated fatty acid metabolism and insulin resistance. However, it has become increasingly apparent that IMTGs do not directly confer insulin resistance but rather, under certain circumstances, likely provide a surrogate for other bioactive lipid metabolites within muscle such as sphingolipids (including ceramide) and diacylglycerol (DAG) (4,6).Studies in animal and cell culture models indicate that sphingolipids and DAG can be key mediators of insulin resistance (7–9). However, a recent study of acute hyperlipidemia in rodents indicates that ceramide and DAG content are not associated with muscle insulin resistance (10). Furthermore, studies conducted in humans do not provide a firm consensus as to whether ceramides or DAGs are associated with muscle insulin resistance (11). Some studies indicate that muscle ceramide content is elevated in obese compared with lean individuals (12,13), or that increases in muscle ceramide content as a result of lipid infusion (14), or conjugated linoleic acid supplementation (15), were associated with decreased insulin sensitivity. Endurance training in obese subjects reduced muscle ceramide content with a concomitant improvement in insulin sensitivity (16,17). In contrast, a recent study by Skovbro et al. (18) found that total muscle ceramide content was similar in subjects despite a wide range of insulin sensitivity. Also refuting a role for ceramide in human muscle insulin resistance, Itani et al. (19) reported that lipid-induced insulin resistance did not alter ceramide content.The role of muscle DAG content in insulin resistance is also unclear. Muscle DAG content has been shown to be elevated in obese and type 2 diabetic subjects (20) and increased after a 6-h lipid infusion that reduced insulin sensitivity (19). In contrast, IMTG, but not DAG content in muscle, was reported to be elevated in obese diabetic compared with obese nondiabetic subjects (21). Therefore, to help address the controversy in the literature surrounding the role for specific lipid metabolites in insulin resistance, we conducted comprehensive mass spectrometry–based DAG and sphingolipid profiling in human muscle insulin resistance while accounting for factors well known to influence insulin sensitivity—namely obesity and physical activity.Quantification of intramyocellular lipids in humans is further complicated by a heterogeneous myocyte or fiber composition. Type I myocytes have a greater capacity for oxidative phosphorylation (22,23) and typically can contain two to three times more IMTG than type II myocytes (22,24,25). Furthermore, type I myocytes have been reported to be more insulin sensitive than type II myocytes (26,27). However, it is not clear whether insulin sensitivity is related to differences in myocyte-specific IMTG content, nor is it known whether sphingolipid or DAG content is related to muscle cell type. We tested the primary hypotheses that sphingolipid and DAG content is higher within insulin-resistant muscle and that type I myocyte IMTG content is specifically related to insulin resistance. We also explored whether differences in the expression of several genes related to lipid metabolism could play a role in insulin resistance associated with IMTG accumulation.     

Location of Femoral Vessels Around the Acetabulum in Crowe Type 4 Dysplastic Hips

BackgroundThere are anatomical differences in the femur and acetabulum on the dysplastic hips. Yet, although there are detailed researches on bony structure differences, studies regarding anatomical differences for the vascular structure are insufficient. The study aimed to determine the relationship between the femoral artery and vein with acetabulum in computed tomography evaluation of Crowe type 4 hips and to compare with normal hip femoral vein and artery anatomic position.MethodsForty patients with one side hip Crowe type 4 deformity and opposite side normal hip were found suitable for the study. Pelvis CT was previously applied to all patients for the planning of total hip arthroplasty surgery. Normal hip acetabulum and the true acetabulum of the dysplastic hip were marked with the Ranawat’s triangle and were then divided into quarters with four axial slices of the acetabulum; as dome, proximal one-fourth, center, and distal three-fourths. The shortest distance from the femoral vessels to the pelvis was measured at these 4 axial slices at the dysplastic side and compared with the healthy side.ResultsThe distance of the vein to the acetabulum is closer to the dysplastic side. At distal three-fourths of Ranawat's triangle axial images, both femoral artery and femoral vein are closer to acetabulum at the dysplastic side.ConclusionThe analysis of preoperative images in cases of Crowe type 4 hip shows that the femoral vessels are closer to the anterior wall of the dysplastic true acetabulum at the level of the center of the hip (vein, mean: 2.7 mm closer) and below the center of the hip (vein, mean: 3 mm; and artery, mean: 3.3 mm closer) when compared with the normal acetabulum. Anatomic relationships knowledge can be used intraoperatively to avoid iatrogenic vascular injury during Crowe type 4 dysplastic hip arthroplasty surgery.     

Effect of Bearing Type on Taper Material Loss in Hips From 1 Manufacturer

Background

Numerous studies have reported on clinical significant volumes of material loss and corrosion at the head-stem junction of metal-on-metal (MOM) hips; less is understood about metal-on-polyethylene (MOP) hips. We compared the effect of bearing type (MOM vs MOP) on taper material loss for a hip system of a single design.

青少年先天性髋关节脱位手术治疗

目的 :探讨青少年先天性髋关节脱位的手术治疗。方法 :18例 2 2髋青少年先天性髋关节脱位 ,其中 16髋术前不牵引 ,一期综合手术矫正全部畸形。手术步骤包括彻底软组织松解 ,股骨粗隆下短缩、去旋转、内翻截骨 ,髋臼覆盖重建 ,准确地同心圆中心关节复位。双侧脱位 4髋行原位髋臼加盖术。结果 :本组 16髋术后均获得满意复位 ,其中 12例 14髋随访 18～ 72个月 ,平均 (3 8± 10 .5 )个月 ,按Muller和Seddon的标准 ,优 4髋 ,良 7髋 ,可 2髋 ,差 1髋。结论 :对青少年单侧先天性髋关节脱位应积极综合手术复位 ,对双侧脱位者应慎重选择复位术。     

Posttransplant Proteinuria Is Associated With Higher Risk of Cardiovascular Disease and Graft Failure in Renal Transplant Patients

In this study, we sought to determine whether proteinuria after renal transplantation was associated with cardiovascular disease (CVD), patient survival, and long-term allograft survival. One hundred twenty-six patients included 102 males and 24 females of mean age 30.7 ± 8.9 years. Their mean follow-up was 63.21 ± 19.9 months. All patients were evaluated for CVD, namely, ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. Proteinuria was defined as urinary protein ≥500 mg/d which persisted for >6 months after transplantation. We retrospectively examined pre- and posttransplant data, including sex, age at transplantation, smoking, pretransplant dialysis duration, donor status, number of acute rejection episodes, body mass index, systolic and diastolic blood pressure levels, lipid profile and other biochemical parameters, immunosuppressive regimens, as well as pulse steroid dose. Proteinuria was significantly associated with CVD (P = .001; RR = 6.43; confidence interval [CI] 2.15-19.22). Patients with proteinuria showed significantly lower graft survival rates than those without proteinuria (58.62% vs 80.41%; P = .02). The mean time to appearance of proteinuria was 14.1 ± 11.4 months (range, 1-36 months). There was no significant association between proteinuria and patient survival. Patients with persistent proteinuria displayed a greater number of acute rejection episodes (1.20 ± 1.17 vs 0.62 ± 0.85; P = .004) and higher pulse steroid dosages (4380.0 ± 3123.4 vs 2800.0 ± 2766.7; P = .022). In conclusion, persistent proteinuria is a strong risk factor for CVD among renal transplant patients. Therefore, an etiologic search and antiproteinuric strategy should be considered routinely to improve patient and graft outcomes.     

Subspine Hypertrophy: Higher Incidence of Symptomatic versus Asymptomatic Hips in Patients with Unilateral Femoroacetabular Impingement

ObjectiveTo compare the difference of anterior inferior iliac spine (AIIS) and subspine hypertrophic deformity between symptomatic and asymptomatic hips in patients traditionally diagnosed with femoroacetabular impingement (FAI), and investigate the correlation of subspine decompression with AIIS variation and subspine hypertrophic deformity.MethodsWe retrospectively reviewed 70 patients with unilateral symptomatic FAI who underwent hip arthroscopy. The operative hips and contralateral hips naturally formed the symptomatic groups and asymptomatic control groups, respectively. The morphometric comparison of the hip joint was performed between the operative and contralateral sides of each patient. Radiological assessment was performed by two observers (an experienced musculoskeletal radiologist and an experienced surgeon). Three‐dimensional (3D)‐CT images of each patient were blindly reviewed to determine the AIIS variation and subspine hypertrophic deformity. Reformatted two‐dimensional (2D)‐CT images and anterior–posterior (AP) pelvic plain radiographs were blindly reviewed to determine FAI‐related morphological measurements. Moreover, the surgical assessment was reviewed by one experienced surgeon to interpret whether subspine decompression was performed. The correlation of subspine decompression with AIIS variation and subspine hypertrophy was analyzed.ResultsOut of 70 patients with unilateral symptomatic FAI, 37 were males (52.9%) and 23 (32.9%) had symptoms involving the left hip. The mean age was 39.3 ± 10.4 years and the mean BMI was 24.3 ± 3.6. The distribution of AIIS variants in symptomatic hips did not differ significantly from that in asymptomatic hips (χ² = 3.092, P = 0.213). Twenty‐nine hips in the symptomatic group (41.4%) and 12 hips in the asymptomatic group (17.1%) were identified as positive for subspine hypertrophy. The incidence of positive subspine hypertrophy was significantly higher in the symptomatic hips compared to the asymptomatic hips (χ² = 9.968, P = 0.002). FAI‐related morphological parameters including α angle, lateral center‐edge angle, acetabular anteversion, crossover sign, and Tonnis grade were highly symmetrical and did not show significant differences between symptomatic and asymptomatic hips. Fifty‐four of 70 hips (77.1%) had labral tears extended to the acetabular rim corresponding to the AIIS. Forty‐seven hips of 70 hips (67.1%) underwent subspine decompression, which was significantly correlated with AIIS variation and subspine hypertrophic deformity (P = 0.019 and 0.001, respectively).ConclusionSubspine hypertrophic deformity was found to be more common in symptomatic side vs asymptomatic side in patients with unilateral symptomatic femoroacetabular impingement. Subspine hypertrophy may be considered as an underlying indication for subspine decompression besides low‐lying AIIS.     

A Strategy for Treatment of Type III and IV Thoracoabdominal Aortic Aneurysm

The aim of this study was to describe the results of resection and graft replacement for type III and IV thoracoabdominal aortic aneurysm repair. In this retrospective study, 27 patients underwent resection and graft replacement for type III (10) or type IV (17) thoracoabdominal aortic aneurysms. Nine patients had rupture, 12 were symptomatic, and 6 were operated on electively. The clamp-and-sew technique was applied in six cases. In 12 patients with type IV aneurysm the proximal part of the vascular graft was beveled, including the orifices of the celiac, superior mesenteric, and one or both renal arteries in the proximal anastomosis. Finally, eight patients underwent surgical application of a shunt for perfusion of the celiac and superior mesenteric arteries. One patient was treated with a combination of open and endovascular surgery. There were four early deaths (14.8%), all following operations for rupture, which represents a 45% mortality rate in this subgroup of patients. Two patients with type III aneurysm had postoperative paraparesis. One was symptomatic whereas the other was operated on electively. Excluding the patients with rupture, the accumulated 5-year survival rate was 65%. These results indicate that direct cross-clamping of the aorta gives limited time for performing the necessary anastomoses without inducing mesenteric ischemia. Inclusion of the orifices of the visceral arteries in the upper anastomosis is a feasible method during surgery for type IV aneurysms. Finally, shunting of the celiac and the superior mesenteric arteries seems to be useful, especially during surgery for type III aneurysms.     

Pulmonary Embolism Complicating Human Chorionic Gonadotropin Treatment in a Patient with Type IV Hyperlipoproteinemia

Human chorionic Gonadotropin (HCG) therapy has been used beneficially in men with subfertility especially after varicocele surgery. Very few side effects have been observed in male patients. Herein, we report a case of pulmonary embolism in a male patient following the use of HCG. The patient was subsequently found to have type IV hyperlipoprotenemia. The etiology of the thrombo-embolic episode is conjectural, but this case emphasizes the need for stricter criteria of patient selection and screening for conditions that predispose to thrombo-embolism before starting HCG therapy.     

Improvement in Semen Quality in Infertile Males after Treatment with Tamoxifen

The effect of the anti-oestrogen Tamoxifen on the seminal quality of 131 men was studied. Parameters studied before and after treatment were sperm density, total ejaculate count, percentage progressive motility, progressively motile ejaculate count, percentage total motility and total motile ejaculate count. In a group of 38 males, the effect on serum LH, FSH, testosterone, oestradiol and prolactin was also studied. Tamoxifen significantly improved (p less than 0.05) the progressive motility in all patient groups where there was reduced pretreatment motility. Sperm density was also significantly improved in oligozoospermic patients. Elevations in the basal serum levels of FSH was noted, even in those patients where the basal level was elevated before treatment. Increases were also observed in the serum levels of the four other hormones studied.