Falk Thielemann

[The natural history of developmental dysplasia of the hip. A meta-analysis of the published literature].

Assessment of the natural history of developmental dysplasia of the hip (DDH) is indispensable for age-dependent treatment of these patients. Based on a systematic meta-analysis of the published literature, this study gives an overview of the spontaneous course of DDH in different age decades. Furthermore, these results are discussed in the context of physiologic development of the hip. The data were compiled by a systematic literature search of medical databases from 1975 through 2007. For this evaluation, only papers that presented as high a level of evidence as possible were included. In early childhood, DDH with subluxation or dislocation necessitates treatment; otherwise, the spontaneous course leads invariably to osteoarthritis of the hip. However, a stable, well-centered dysplastic hip has a high potential of developing as a physiologic joint. In the analyzed data, an association between mild or moderate DDH after the end of growth and the development of osteoarthritis could not be demonstrated. The level of evidence of existing data is not sufficient to determine that persisting mild dysplasia is a relevant ethiopathological factor for osteoarthrosis of the hip. Therefore, prospective epidemiological studies are required.

Natürlicher Verlauf von Hüftreifungsstörungen und Hüftdysplasie

Assessment of the natural history of developmental dysplasia of the hip (DDH) is indispensable for age-dependent treatment of these patients. Based on a systematic meta-analysis of the published literature, this study gives an overview of the spontaneous course of DDH in different age decades. Furthermore, these results are discussed in the context of physiologic development of the hip. The data were compiled by a systematic literature search of medical databases from 1975 through 2007. For this evaluation, only papers that presented as high a level of evidence as possible were included. In early childhood, DDH with subluxation or dislocation necessitates treatment; otherwise, the spontaneous course leads invariably to osteoarthritis of the hip. However, a stable, well-centered dysplastic hip has a high potential of developing as a physiologic joint. In the analyzed data, an association between mild or moderate DDH after the end of growth and the development of osteoarthritis could not be demonstrated. The level of evidence of existing data is not sufficient to determine that persisting mild dysplasia is a relevant ethiopathological factor for osteoarthrosis of the hip. Therefore, prospective epidemiological studies are required.

Multiscale, converging defects of macro-porosity, microstructure and matrix mineralization impact long bone fragility in NF1

Bone fragility due to osteopenia, osteoporosis or debilitating focal skeletal dysplasias is a frequent observation in the Mendelian disease Neurofibromatosis type 1 (NF1). To determine the mechanisms underlying bone fragility in NF1 we analyzed two conditional mouse models, Nf1Prx1 (limb knock-out) and Nf1Col1 (osteoblast specific knock-out), as well as cortical bone samples from individuals with NF1. We examined mouse bone tissue with micro-computed tomography, qualitative and quantitative histology, mechanical tensile analysis, small-angle X-ray scattering (SAXS), energy dispersive X-ray spectroscopy (EDX), and scanning acoustic microscopy (SAM). In cortical bone of Nf1Prx1 mice we detected ectopic blood vessels that were associated with diaphyseal mineralization defects. Defective mineral binding in the proximity of blood vessels was most likely due to impaired bone collagen formation, as these areas were completely devoid of acidic matrix proteins and contained thin collagen fibers. Additionally, we found significantly reduced mechanical strength of the bone material, which was partially caused by increased osteocyte volume. Consistent with these observations, bone samples from individuals with NF1 and tibial dysplasia showed increased osteocyte lacuna volume. Reduced mechanical properties were associated with diminished matrix stiffness, as determined by SAM. In line with these observations, bone tissue from individuals with NF1 and tibial dysplasia showed heterogeneous mineralization and reduced collagen fiber thickness and packaging. Collectively, the data indicate that bone fragility in NF1 tibial dysplasia is partly due to an increased osteocyte-related micro-porosity, hypomineralization, a generalized defect of organic matrix formation, exacerbated in the regions of tensional and bending force integration, and finally persistence of ectopic blood vessels associated with localized macro-porotic bone lesions.

A Modification of Periacetabular Osteotomy Using a Two-Incision Approach

In residual hip dysplasia periacetabular osteotomy (PAO) can improve insufficient coverage of the femoral head. It requires a broad dissection of the pelvic bones and detachment of muscle insertions, however. We have developed a modification of the Bernese periacetabular osteotomy with reduced soft tissue exposure. It uses two small skin incisions and offers therefore the perspective of nicer scars but also increases the risk of technical complications due to impaired vision. To be able to draft these risks, the clinical and radiographic results of 23 patients with PAO through the modified Smith-Petersen approach of Ganz (group A) and 24 patients with our two-incision modification (group B) have been reviewed retrospectively with an average follow-up of 19 (group A) and 12 (group B) months postoperatively. Functional improvement (Harris Hip Score) and center-edge-angle normalization did not differ significantly in both groups. Scars of patients in group B were significantly shorter. However, the overall patient satisfaction (as measured with a visual analogous scale) was the same in both groups. 4 patients in group A and one patient in group B developed superficial or deep wound infections. In conclusion, the experience with our cohort study showed that approach-related morbidity can be reduced without increasing the risk for the individual patient. This observation clearly holds a promise for further minimal invasive approaches as well as for further morbidity reduction of PAO. Level of Evidence: Retrospective comparative study (Level III).

What Are the Results of Surgical Treatment of Hip Dysplasia With Concomitant Cam Deformity

BackgroundPeriacetabular osteotomy (PAO) is a reliable procedure to correct the deficient acetabular coverage in hips with developmental dysplasia. It is unclear how the presence of additional femoral cam-type deformity might influence the clinical and radiographic treatment results of PAO.Questions/purposes(1) Are there differences in clinical scores (WOMAC, EQ-5D) and examination findings (impingement sign) or radiographic measures of acetabular orientation and head sphericity after PAO for isolated acetabular dysplasia when compared with the combined pathology of dysplasia and additional femoral cam deformity? (2) Are these clinical and radiographic findings after combined surgical therapy for additional cam deformity influenced by different pathology-adjusted surgical techniques?MethodsFrom July 2005 to December 2010, 86 patients (106 hips) underwent PAO for hip dysplasia. Surgical and outcome data were prospectively collected and retrospectively reviewed in a comparative observational study. Indications for surgery were a lateral center-edge angle less than 25° and hip pain for at least 6 months. The contraindications for surgery were advanced radiographic osteoarthritis (Kellgren-Lawrence Grade 3), incongruency of joint space, and patient age > 50 years. Depending on preoperative hip ROM, impingement test, and presence of a radiographically visible cam deformity, treatment allocation was performed: Group I: isolated PAO in patients without symptomatic asphericity, Group IIa: PAO with subsequent osteochondroplasty through arthrotomy for patients with symptomatic cam deformity and no labrochondral pathology, and Group IIb: arthroscopically assisted osteochondroplasty and additional labrochondral repair with subsequent PAO when patients had labrochondral lesions in addition to a symptomatic cam deformity. Clinical outcome (impingement test, EQ-5D, WOMAC) as well as radiographic parameters (lateral center-edge angle, crossover sign, alpha angle, osteoarthritis grade) were obtained after a mean followup of 63 ± 18 months (range, 31–102 months) and compared with the baseline data. Eleven patients (13%) were lost to followup. With the numbers available, our study had 80% power to detect a difference between Groups I and II of 10 points on the WOMAC scores.ResultsThere was no difference in the increase of WOMAC scores in patients with PAO alone (Group I; preoperative score 74 ± 17 versus postoperative 91 ± 15, p = 0.033) when compared with PAO and concurrent osteochondroplasty (Groups II A and B preoperative 73 ± 19 versus postoperative 90 ± 13 p < 0.001). The mean postoperative alpha angles in Group II (38° ± 6°) improved when compared with preoperative values (56° ± 15°; p < 0.001) and were even lower than native offset alpha angles in Group I (47° ± 11°). Clinical scores as well as postoperative radiographic parameters were not different between patients with conventional osteochondroplasty alone (Group IIA) and patients with arthroscopically assisted cam resection and intraarticular labrochondral repair (Group IIB).ConclusionsWith the numbers available, we detected no differences in outcome scores and radiographic results between patients who had been treated with PAO alone and patients who underwent combined PAO and offset correction for cam deformity. Although arthroscopically assisted treatment of advanced labrochondral lesions together with osteochondroplasty is possible during PAO and the results were not different in this small study when compared with patients with PAO and osteochondroplasty alone, the type and extent of damage that would indicate additional cartilage surgery over cam resection alone remain unclear.Level of EvidenceLevel III, therapeutic study.

Koinzidenz von Hüftdysplasie und femuroazetabulärem Impingement

ZusammenfassungWährend die Diagnose und Behandlungsstrategie von Hüftdysplasie und femuroazetabulärem Impingement als jeweils getrennt auftretendes Erkrankungsbild mittlerweile recht standardisiert ist, gibt es noch kaum Empfehlungen zum adäquaten Vorgehen, wenn beide Probleme gleichzeitig bestehen.Ein diagnostischer Algorithmus und eine neue Operationstechnik mit simultaner Durchführung von periazetabulärer Osteotomie und arthroskopisch assistierter Offsetverbesserung über einen weniger invasiven Zugang wird vorgestellt. Kurzfristige Behandlungsergebnisse einer Pilotstudie von bisher 19 damit behandelten Patienten zeigen, dass eine effektive Verbesserung der radiologischen Deformität und klinischer Beschwerden möglich ist.AbstractDevelopmental Dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions.We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.Developmental dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions. We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.

[Combined hip-dysplasia and femuroacetabular impingement. Diagnosis and simultaneous surgical treatment].

ZusammenfassungWährend die Diagnose und Behandlungsstrategie von Hüftdysplasie und femuroazetabulärem Impingement als jeweils getrennt auftretendes Erkrankungsbild mittlerweile recht standardisiert ist, gibt es noch kaum Empfehlungen zum adäquaten Vorgehen, wenn beide Probleme gleichzeitig bestehen.Ein diagnostischer Algorithmus und eine neue Operationstechnik mit simultaner Durchführung von periazetabulärer Osteotomie und arthroskopisch assistierter Offsetverbesserung über einen weniger invasiven Zugang wird vorgestellt. Kurzfristige Behandlungsergebnisse einer Pilotstudie von bisher 19 damit behandelten Patienten zeigen, dass eine effektive Verbesserung der radiologischen Deformität und klinischer Beschwerden möglich ist.AbstractDevelopmental Dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions.We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.Developmental dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions. We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.

Is MRI an adequate replacement for CT scans in the three-dimensional assessment of acetabular morphology?

Background Appropriate three-dimensional imaging of the hip joint is a substantial prerequisite for planning and performing surgical correction of deformities. Although surgeons still use computed tomography (CT), modern and fast acquisition techniques of volumetric imaging using magnetic resonance imaging (MRI) for pelvic measurements enable similar resolution. Purpose This study was designed to determine if already described measures of acetabular morphology are comparable in both techniques and if assessment can be performed with equal intra-observer and inter-observer reliability. Material and Methods Thirty-two hips (16 patients) were examined with a pelvic CT and a MRI with 3-T. Pelvic orientation was standardized by each observer in coronal, axial, and sagittal planes. Acetabular version as well as seven acetabular sector angles were measured by two observers twice with a minimum of four weeks between sessions. Results Inter-rater reliability showed excellent results for intra- and inter-rater reliability for CT (0.977–0.999) and MRI (0.969–0.998) measuring acetabular version and sector angles. Evaluating the reliability of CT and MRI for each observer revealed excellent results (0.972–0.998). Evaluating the Bland–Altman plots for intra-observer reliability showed an equal distribution of angles, within acceptable 95% limits of agreement. The same results were observed for inter-observer reliability evaluating CT and MRI as well as inter-method reliability. Conclusion Modern MRI scans are equally applicable to assess the bony pelvis as CT scans. In addition, MRI would enable the examination of soft tissues such as chondrolabral structures and muscle in the same examination. Since hip-preserving surgery is mostly conducted in younger patients, the reduction of radiation exposure is a benefit.

Koinzidenz von Hüftdysplasie und femuroazetabulärem Impingement@@@Combined hip-dysplasia and femuroacetabular impingement: Klinisches Bild und simultane operative Korrektur@@@Diagnosis and simultaneous surgical treatment

ZusammenfassungWährend die Diagnose und Behandlungsstrategie von Hüftdysplasie und femuroazetabulärem Impingement als jeweils getrennt auftretendes Erkrankungsbild mittlerweile recht standardisiert ist, gibt es noch kaum Empfehlungen zum adäquaten Vorgehen, wenn beide Probleme gleichzeitig bestehen.Ein diagnostischer Algorithmus und eine neue Operationstechnik mit simultaner Durchführung von periazetabulärer Osteotomie und arthroskopisch assistierter Offsetverbesserung über einen weniger invasiven Zugang wird vorgestellt. Kurzfristige Behandlungsergebnisse einer Pilotstudie von bisher 19 damit behandelten Patienten zeigen, dass eine effektive Verbesserung der radiologischen Deformität und klinischer Beschwerden möglich ist.AbstractDevelopmental Dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions.We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.Developmental dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions. We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.

Koinzidenz von Hüftdysplasie und femuroazetabulärem ImpingementCombined hip-dysplasia and femuroacetabular impingement

ZusammenfassungWährend die Diagnose und Behandlungsstrategie von Hüftdysplasie und femuroazetabulärem Impingement als jeweils getrennt auftretendes Erkrankungsbild mittlerweile recht standardisiert ist, gibt es noch kaum Empfehlungen zum adäquaten Vorgehen, wenn beide Probleme gleichzeitig bestehen.Ein diagnostischer Algorithmus und eine neue Operationstechnik mit simultaner Durchführung von periazetabulärer Osteotomie und arthroskopisch assistierter Offsetverbesserung über einen weniger invasiven Zugang wird vorgestellt. Kurzfristige Behandlungsergebnisse einer Pilotstudie von bisher 19 damit behandelten Patienten zeigen, dass eine effektive Verbesserung der radiologischen Deformität und klinischer Beschwerden möglich ist.AbstractDevelopmental Dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions.We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.Developmental dysplasia of the hip as well as femuroacetabular impingement are recognized causes of hip pain and degenerative disorders. While accepted treatment recommendations for both entities currently exist, there are no standardised approaches published for the management of combined lesions. We therefore present an algorithm of diagnosis and simultaneous surgical treatment based on a combination of periacetabular osteotomy and arthroscopically-assisted minimally invasive anterior osteochondroplasty. Short-term treatment results of 19 patients show an effective improvement of clinical symtoms and radiographic deformity.