Harry E. Jergesen

Recovery of function after hip fracture: The role of social supports.

Previous studies have found that social support may reduce mortality after myocardial infarction and reduce overall mortality among the elderly. To determine whether social support also influences the recovery of function among patients who have had hip fractures and to describe other potential predictors of recovery after hip fractures, 111 patients with hip fractures were interviewed and examined before discharge from the hospital. The functional status of surviving patients was assessed again 6 months later. Patients who had a greater number of social supports had more complete recovery of their prefracture level of function (r = .21; P = .04). This association was strongest for patients over 60 years old (r = .31; P = .006); among these patients, this association remained statistically significant after adjustment for other significant (P < .05) predictors of recovery: arm strength, mental status, and serum albumin. Additional studies should be done to test whether interventions to increase social supports can improve the recovery of function among elderly patients with hip fractures and other illnesses. In the meantime, health professionals should counsel elderly patients about the potential rehabilitative and preventive benefits of social supports.

The natural history of untreated asymptomatic hips in patients who have non-traumatic osteonecrosis.

The aim of this study was to evaluate retrospectively the rate of disease progression in the asymptomatic hip of patients who had non-traumatic osteonecrosis and pain in the other hip. Of seventy-five consecutive patients with non-traumatic osteonecrosis who were initially evaluated between 1978 and 1987, forty-six (61 per cent) initially had pain in only one hip. Radiographs were made for all patients, but routine magnetic resonance images and computed tomography images were not. Twenty-two of the asymptomatic hips had radiographic evidence of involvement, but three of them were excluded because they were treated with elective prophylactic core-drilling; this left nineteen hips with radiographic evidence of involvement in the final study group. The other twenty-four asymptomatic hips had normal findings on the initial radiographs; one of these was treated with elective core-drilling, leaving twenty-three hips with normal radiographs in the final study group. All but one patient, who died at fifty-one months, were followed for at least five years or until symptoms developed in the asymptomatic hip. Of the nineteen untreated asymptomatic hips with initial radiographic evidence of involvement, five were still asymptomatic at the most recent follow-up examination. The other fourteen hips had become painful: nine, within five years after presentation, and five, more than five years after presentation. Pain or radiographic changes developed only rarely in the twenty-three asymptomatic hips with normal findings on the initial radiographs, and only one hip had both pain and radiographic changes within five years after presentation. Nineteen (83 per cent) were still asymptomatic at the most recent follow-up examination. The prolonged pain-free interval for many of the asymptomatic hips with radiographic evidence of involvement contrasts with the over-all rapid progression of disease reported for most hips with non-traumatic osteonecrosis. The present study draws attention to the fact that an adequate period of follow-up is needed for asymptomatic hips that are treated operatively in order to determine whether such intervention alters the natural history of the disease. Our results also showed that few asymptomatic hips with normal findings on initial radiographs are at risk for pain or radiographic abnormalities; when disease does develop, deterioration is slow and operative intervention is rarely indicated.

Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease: Results of a multicenter study at a mean of three years after treatment

BACKGROUND Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and collapse of the femoral head occurs in 90% of patients within five years after the diagnosis of the osteonecrosis. However, the efficacy of hip core decompression to prevent the progression of osteonecrosis in these patients is still controversial. METHODS In a prospective multicenter study, we evaluated the safety of hip core decompression and compared the results of decompression and physical therapy with those of physical therapy alone for the treatment of osteonecrosis of the femoral head in patients with sickle cell disease. Forty-six patients (forty-six hips) with sickle cell disease and Steinberg Stage-I, II, or III osteonecrosis of the femoral head were randomized to one of two treatment arms: (1) hip core decompression followed by a physical therapy program or (2) a physical therapy program alone. Eight patients withdrew from the study, leaving thirty-eight who participated. RESULTS Seventeen patients (seventeen hips) underwent decompression combined with physical therapy, and no intraoperative or immediate postoperative complications occurred. Twenty-one patients (twenty-one hips) were treated with physical therapy alone. After a mean of three years, the hip survival rate was 82% in the group treated with decompression and physical therapy and 86% in the group treated with physical therapy alone. According to a modification of the Harris hip score, the mean clinical improvement was 18.1 points for the patients treated with hip core decompression and physical therapy compared with 15.7 points for those treated with physical therapy alone. With the numbers studied, the differences were not significant. CONCLUSIONS In this randomized prospective study, physical therapy alone appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and postponing the need for additional surgical intervention at a mean of three years after treatment.

An inexpensive molding method for antibiotic-impregnated cement spacers in infected total hip arthroplasty

Placement of an antibiotic-impregnated cement endoprosthesis facilitates patient mobilization and treatment of infection complicating total hip arthroplasty. Molds, particularly to form the spherical head of the cement endoprosthesis, are not readily available, however. We have found that the rubber bulb portion of an irrigation syringe can be conveniently used as a mold to shape the proximal end of a cement endoprosthesis during surgery.

Imaging of the hip joint. Computed tomography versus magnetic resonance imaging

The authors reviewed the applications and limitations of computed tomography (CT) and magnetic resonance (MR) imaging in the assessment of the most common hip disorders. Magnetic resonance imaging is the most sensitive technique in detecting osteonecrosis of the femoral head. Magnetic resonance reflects the histologic changes associated with osteonecrosis very well, which may ultimately help to improve staging. Computed tomography can more accurately identify subchondral fractures than MR imaging and thus remains important for staging. In congenital dysplasia of the hip, the position of the nonossified femoral head in children less than six months of age can only be inferred by indirect signs on CT. Magnetic resonance imaging demonstrates the cartilaginous femoral head directly without ionizing radiation. Computed tomography remains the imaging modality of choice for evaluating fractures of the hip joint. In some patients, MR imaging demonstrates the fracture even when it is not apparent on radiography. In neoplasm, CT provides better assessment of calcification, ossification, and periosteal reaction than MR imaging. Magnetic resonance imaging, however, represents the most accurate imaging modality for evaluating intramedullary and soft-tissue extent of the tumor and identifying involvement of neurovascular bundles. Magnetic resonance imaging can also be used to monitor response to chemotherapy. In osteoarthrosis and rheumatoid arthritis of the hip, both CT and MR provide more detailed assessment of the severity of disease than conventional radiography because of their tomographic nature. Magnetic resonance imaging is unique in evaluating cartilage degeneration and loss, and in demonstrating soft-tissue alterations such as inflammatory synovial proliferation.

Histologic Correlation in Magnetic Resonance Imaging of Femoral Head Osteonecrosis

The present study was undertaken to determine whether a correlation exists between localized magnetic resonance image (MRI) signal behavior and specific histopathologic features of femoral head osteonecrosis. Contiguous, 5-mm coronal MRI sections were compared with corresponding histologic sections from six surgically excised femoral heads. After identifying specific areas of interest on the images, signal intensity was evaluated, both subjectively and objectively, and T1 and T2 relaxation times were calculated. Mean values for these data were compared among the following histologic categories: normal bone, unrepaired dead bone and marrow, unrepaired dead bone with marrow replaced by amorphous debris, and zones of repair. For each type of tissue, MRI signal intensity on T1- and intermediately T2-weighted images behaved in a distinctive fashion. Active repair tissue could be differentiated from both necrotic bone and normal bone by a tendency for the signal to increase in intensity on intermediately T2-weighted images. These findings suggest that MRI may provide a noninvasive means of quantitatively analyzing the volume and spacial distribution of repair tissue in osteonecrotic femoral heads. In clinical practice, such analysis may lead to improvements in disease staging and treatment planning.

Bilateral total hip and knee replacement in adults with rheumatoid arthritis: an evaluation of function.

Sixteen patients with advanced rheumatoid arthritis who underwent total joint replacements of both hips and both knees were followed for an average of 22.8 months postoperatively. Their functional status before and after surgery was assessed by use of a special rating system for function. Fourteen of the 16 patients demonstrated higher total function scores at follow-up. Improvement was most marked in walking endurance, need for walking aids, and ability to climb stairs. Factors which were believed to predispose to less functional improvement included older age at initial surgery, longer duration of disease, more severe upper extremity involvement, and more frequent medical illnesses. There were 8 patients in whom combined hip and knee flexion in one or both lower extremities did not exceed 190 degrees after surgery. When this deficiency was combined with severe involvement of the upper extremities, difficulty with activities such as climbing stairs and arising from a chair was more common. Therefore, the goal of surgical treatment is to provide combined hip and knee flexion in excess of 190 degrees in these patients. Total joint arthroplasty has increased the likelihood of functional improvement in patients with severe rheumatoid arthritis involving the hips and knees, and encouraged the surgeon to operate earlier in the course of the disease as well as on patients with severely deformed joints.

Representation of developing countries in orthopaedic journals: a survey of four influential orthopaedic journals.

BackgroundThe developing world contains more than ¾ of the world’s population, and has the largest burden of musculoskeletal disease. Published studies provide crucial information that can influence healthcare policies. Presumably much information regarding burden in the developing world would arise from authors from developing countries. However, the extent of participation of authors from the developing world in widely read orthopaedic journals is unclear.PurposeWe surveyed four influential English-language orthopaedic journals to document the contributions of authors from developing countries.MethodsWe surveyed Clinical Orthopaedics and Related Research, Journal of Orthopaedic Trauma, and the American and British volumes of The Journal of Bone and Joint Surgery, from May 2007 through May 2010. The country of origin of all authors was identified. We used the designations provided by the International Monetary Fund to define countries as either developed or developing.ResultsTwo hundred sixty-five of 3964 publications (7%) included authors from developing countries. Ninety percent of these had authors from developing countries with industrialized and emerging-market economies. Publications from Sub-Saharan Africa accounted for only 0.4% of the 3964 articles reviewed and 5.6% of the 265 articles with developing world authorship. Countries with the least robust economies were least represented. Less than 1/3 of articles with authors from the developing world had coauthors from developed or other developing countries.ConclusionAdditional studies are needed to determine the reasons for the low representation noted and to establish strategies to increase the number of orthopaedic publications from parts of the world where the burden of musculoskeletal disease is the greatest.

Magnetic resonance imaging of the ischemic femoral head in pigs. Dependency of signal intensities and relaxation times on elapsed time.

The magnetic resonance (MR) signal behavior of freshly excised pig femoral heads undergoing ischemic necrosis in vitro was evaluated. Ten femoral heads removed from skeletally immature pigs were stored at 37 degrees in a sealed, sterile container during the observation period. Imaging was initially performed 40 minutes after excision (base-line) and repeated at six, 12, 24, 48, and 72 hours. Changes in MR signal intensity were measured, and the T1 and T2 relaxation times were calculated for selected epiphyseal and metaphyseal areas. Signal intensities decreased during the first 24 hours and returned to baseline by 72 hours. T1 relaxation time increased most significantly between baseline and 24 hours and then decreased to near baseline level between 48 and 72 hours. T2 changes over time were not statistically significant. The type of localized, distinctive decreases in MR signal intensity occurring in clinical cases of early nontraumatic femoral head osteonecrosis was not observed in pigs. Such changes appear to require the presence of an intact and vigorous repair response within adjacent viable bone. However, the transient decrease in signal intensity and prolongation of T1 relaxation time at 12, 24, and 48 hours after traumatic vascular insult may be indicators of early femoral head ischemia.

Signal variability in magnetic resonance imaging of femoral head osteonecrosis.

The present study was designed to document the pattern and extent of magnetic resonance imaging (MRI) changes in femoral head osteonecrosis and also to correlate MRI findings with technetium bone scans and computed tomograms. Over a three-year period, MRI was performed on 26 patients who had clinical and roentgenographic evidence of femoral head necrosis in one or both hips. MRI abnormalities were present in all 41 hips with osteonecrosis, even when symptoms were absent and roentgenographic findings were nonspecific or not yet apparent. A single possible false-positive MRI was noted in a hip with mild degenerative change. There was considerable variation in the pattern and extent of MRI abnormalities. The most common findings were irregularity of the subchondral cortical outline (82.9%), an inhomogeneous pattern of signal loss (50%), focal increases in signal intensity with T2 weighting (35.5%), and effusion (33.3%). Regions of dense cancellous bone on computed tomograms correlated with bands of low-intensity MRI signal. In the diagnosis of asymptomatic hips, MRI was clearly more sensitive than technetium bone imaging. The role of MRI in defining prognosis and treatment selection remains to be established.