Disorders of the Acromioclavicular Joint

Objective To determine whether total hip arthroplasty is associated with lower reoperation rates, mortality, and complications, and better function and quality of life than hemiarthroplasty for displaced fractures of the femoral neck in older patients. Design Systematic review and meta-analysis of randomised trials, quasirandomised trials, and cohort studies. Data sources Medline, Embase, Cochrane register of controlled trials, publishers’ databases, and manual search of bibliographies. Study selection Randomised controlled trials, quasirandomised trials, and cohort studies (retrospective and prospective) comparing hemiarthroplasty with total hip arthroplasty for treating displaced femoral neck fractures in patients aged more than 60 years. Data extraction Relative risks, risk differences, and mean differences from each trial, aggregated using random effects models. Analyses were stratified for experimental and non-experimental designs, and two way sensitivity analyses and tests for interaction were done to assess the influence of various criteria of methodological quality on pooled estimates. Data synthesis 3821 references were identified. Of the 202 full papers inspected, 15 were included (four randomised controlled trials, three quasirandomised trials, and eight retrospective cohort studies, totalling 1890 patients). Meta-analysis of 14 studies showed a lower risk of reoperation after total hip arthroplasty compared with hemiarthroplasty (relative risk 0.57, 95% confidence interval 0.34 to 0.96, risk difference 4.4%, 95% confidence interval 0.2% to 8.5%), although this effect was mainly driven by investigations without concealed treatment allocation. Total hip arthroplasty consistently showed better ratings in the Harris hip score (three studies, 246 patients, weighted mean difference 5.4, 95% confidence interval 2.7 to 8.2) after follow-up periods of 12 to 48 months. The standardised mean difference of different scores from five studies was 0.42 (95% confidence interval 0.24 to 0.61), indicating a medium functional advantage of total hip arthroplasty over hemiarthroplasty. Total hip arthroplasty was associated with a slightly higher risk of dislocation (relative risk 1.48, 95% confidence interval 0.89 to 2.46) and general complications (1.14, 0.87 to 1.48). Conclusion Single stage total hip arthroplasty may lead to lower reoperation rates and better functional outcomes compared with hemiarthroplasty in older patients with displaced femoral neck fractures. However, heterogeneity across the available trials and distinct subgroup effects preclude definitive statements and require further research in this area.

https://www.bmj.com/content/bmj/340/bmj.c2332.full.pdf

Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review

The etiology of developmental dysplasia of the hip (DDH) is unknown. There are many insights, however, from epidemiologic/demographic information. A systematic medical literature review regarding DDH was performed. There is a predominance of left-sided (64.0%) and unilateral disease (63.4%). The incidence per 1000 live births ranges from 0.06 in Africans in Africa to 76.1 in Native Americans. There is significant variability in incidence within each racial group by geographic location. The incidence of clinical neonatal hip instability at birth ranges from 0.4 in Africans to 61.7 in Polish Caucasians. Predictors of DDH are breech presentation, positive family history, and gender (female). Children born premature, with low birth weights, or to multifetal pregnancies are somewhat protected from DDH. Certain HLA A, B, and D types demonstrate an increase in DDH. Chromosome 17q21 is strongly associated with DDH. Ligamentous laxity and abnormalities in collagen metabolism, estrogen metabolism, and pregnancy-associated pelvic instability are well-described associations with DDH. Many studies demonstrate an increase of DDH in the winter, both in the northern and southern hemispheres. Swaddling is strongly associated with DDH. Amniocentesis, premature labor, and massive radiation exposure may increase the risk of DDH. Associated conditions are congenital muscular torticollis and congenital foot deformities. The opposite hip is frequently abnormal when using rigorous radiographic assessments. The role of acetabular dysplasia and adult hip osteoarthritis is complex. Archeological studies demonstrate that the epidemiology of DDH may be changing.

https://downloads.hindawi.com/archive/2011/238607.pdf

The Epidemiology and Demographics of Hip Dysplasia

Osteoarthritis (OA) has a considerable hereditary component and is considered to be a polygenic disease. Data derived from genetic analyses and genome-wide screening of individuals with this disease have revealed a surprising trend: genes associated with OA tend to be related to the process of synovial joint development. Mutations in these genes might directly cause OA. In addition, they could also determine the age at which OA becomes apparent, the joint sites involved, the severity of the disease and how rapidly it progresses. In this Review, I propose that genetic mutations associated with OA can be placed on a continuum. Early-onset OA is caused by mutations in matrix molecules often associated with chondrodysplasias, whereas less destructive structural abnormalities or mutations confer increased susceptibility to injury or malalignment that can result in middle-age onset. Finally, mutations in molecules that regulate subtle aspects of joint development and structure lead to late-onset OA. In this Review, I discuss the genetics of OA in general, but focus on the potential effect of genetic mutations associated with OA on joint structure, the role of joint structure in the development of OA--using hip abnormalities as a model--and how understanding the etiology of the disease could influence treatment.

Etiology of osteoarthritis: genetics and synovial joint development

Intra-articular corticosteroid injection (IACI) is a very popular procedure. In this review, we wanted to review all that had been published about local effects of IACIs. English literature search was made through PubMed using the terms intra-articular and local effect. Effects on subjective, functional, structural, cellular, humoral, molecular, and imaging aspects were included. Also, all local adverse effects were documented. The main beneficial effect of IACI is pain relief. The duration of this effect is variable and depends on underlying disease, type of disease, amount of structural damage, type of IACI, dose of IACI, presence of joint effusion, level of inflammatory mediators, emptiness of joint effusion, availability of imaging, and others. At large, inflammatory problems had higher rate of favorable response in terms of pain and function. IACI at the knee joint in juvenile idiopathic arthritis patients resulted in remission for >6 months in >80% of the patients with a mean duration of ∼1.2 years, while in the osteoarthritic knee there was a pain relief for 3 weeks only and in rheumatoid arthritis (RA) knee for 8 weeks. There was no joint space loss at the knee joint following multiple IACI in osteoarthritis and also no increase in cartilage or bone erosions in RA following a single IACI. IACI guide imaging is important in achieving better results in particular joints. Joint infection rate is very low. Other adverse effects included intra-articular and periarticular calcifications, cutaneous atrophy, cutaneous depigmentation, avascular necrosis, rapid destruction of the femoral head, acute synovitis, Charcot’s arthropathy, tendinopathy, Nicolau’s syndrome, and joint dislocation. IACI is associated with a wide range of local effects. Subjective and functional favorable response is prominent mainly in juvenile idiopathic arthritis patients. Adverse effects are either rare or insignificant.

Local effects of intra-articular corticosteroids.

We investigated the association of developmental dysplasia of the hip (DDH) and primary protrusion acetabuli (PPA) with Vitamin D receptor polymorphisms Taq I and Fok I and oestrogen receptor polymorphisms Pvu II and Xba I. 45 patients with DDH and 20 patients with PPA were included in the study. Healthy controls (n = 101) aged 18–60 years were recruited from the same geographical area. The control subjects had a normal acetabular morphology based on a recent pelvic radiograph performed for an unrelated cause. DNA was obtained from all the subjects from peripheral blood. Genotype frequencies were compared in the three groups. The relationship between the genotype and morphology of the hip joint, severity of the disease, age at onset of disease and gender were examined. The oestrogen receptor Xba I wild-type genotype (XX, compared with Xx and xx combined) was more common in the DDH group (55.8%) than controls (37.9%), though this just failed to achieve statistical significance (p = 0.053, odds ratio = 2.1, 95% CI = 0.9–4.6). In the DDH group, homozygosity for the mutant Taq I Vitamin D receptor t allele was associated with higher acetabular index (Mann-Whitney U-test, p = 0.03). Pvu II pp oestrogen receptor genotype was associated with low centre edge angle (p = 0.07). This study suggests a possible correlation between gene polymorphism in the oestrogen and vitamin D receptors and susceptibility to, and severity of DDH. The Taq I vitamin D receptor polymorphisms may be associated with abnormal acetabular morphology leading to DDH while the Xba I oestrogen receptor XX genotype may be associated with increased risk of developing DDH. No such correlations were found in the group with PPA.

/pdf/vitamin-d-and-oestrogen-receptor-polymorphisms-in-4uduiu9wpz.pdf

Vitamin D and oestrogen receptor polymorphisms in developmental dysplasia of the hip and primary protrusio acetabuli--a preliminary study.

Joint registers audit the performance of different types of prosthesis. The data from these registers is invaluable, as the conclusions are evidence based and are not based on the results from a small clinical trial or a case series. The 3 rd National Joint Registry Annual Clinical Report (2005) of England and Wales was compared with the latest available online report of other national joint registers, particularly with reference to the usage of total hip replacement performed for fracture of the neck of the femur. In Sweden, total hip replacement is performed for the management of a fracture of the neck of the femur six times more often than in England and Wales, four times more often than in Australia, twice more often than in Canada. Hip fracture registers could provide us with the much needed clinical evidence that could help us solve the last controversy of this unsolved fracture.

Total hip replacement for acute femoral neck fracture: a survey of National Joint Registries.

Background Several cementing techniques are used for the proximal femur. Material and methods We evaluated 3 femoral cement pressurization techniques (standard, pressurizer in situ, and thumb press...

https://www.tandfonline.com/doi/pdf/10.1080/00016470410004076

Femoral cement pressurization in hip arthroplasty: a laboratory comparison of three techniques.

This study is aimed at evaluating the short-term effects of a single corticosteroid injection of the acromioclavicular joint on the range of motion of the shoulder joint using a three dimensional electromagnetic tracking system (FASTRAK) in patients with isolated unilateral acromioclavicular joint (ACJ) arthropathy. Eighteen patients (16 male, 2 female ; mean age : 47.53 years), with isolated unilateral ACJ arthropathy were included in the study. Injection of the symptomatic ACJ with local anaesthetic and corticosteroid was performed under image intensifier guidance. Bilateral shoulder FASTRAK assessment before and two weeks after injection of the symptomatic ACJ was performed, measuring flexion/extension, anatomical abduction, scapular abduction and horizontal cross body adduction. Pain was measured using a visual analogue scale. There was a significant difference in the range of movement between the symptomatic and asymptomatic shoulder before the injection (p < 0.01). Range of extension and pain score of the symptomatic shoulder improved significantly (p < 0.05 and p < 0.001, respectively) after the injection. In patients with radiographical evidence of degenerative ACJ disease, there was also significant improvement in the range of horizontal flexion (p < 0.05). Injection of the ACJ with local anaesthetic and corticosteroid was found to produce short-term pain relief and partial improvement in the range of movement. FASTRAK is useful in the measurement and documentation of range of motion, and can be used to assess the treatment outcome in patients with isolated ACJ arthropathy.

The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy.

Background Various studies have reported good long-term results using femoral stems with either smooth or rough surfaces. In this retrospective cross-sectional survivorship study, we reviewed the 10-year results of 51 bilateral staged cemented total hip arthroplasties using the Harvard or the Charnley femoral stems—which have almost similar geometry but a different surface finish.Methods 51 patients were reviewed at median interval of 10 (Harvard group) and 11 years (Charnley group) after the primary operation. We evaluated cement mantle thickness, alignment of the components, presence of radiolucent lines, and aseptic loosening. Kaplan-Meier analysis was performed to calculate the survival rate using various endpoints.Results 8 hips in the Harvard group were revised for aseptic loosening of thefemoral component at a median interval of 6.3 years after the primary procedure. 3 hips in the Charnley group were revised for aseptic loosening of the femoral and acetabular components between 10 and 11 years afte...

https://www.tandfonline.com/doi/pdf/10.1080/17453670510045417

Charles Wynn-Jones

Papers

Vitamin D and oestrogen receptor polymorphisms in developmental dysplasia of the hip and primary protrusio acetabuli--a preliminary study.

Total hip replacement for acute femoral neck fracture: a survey of National Joint Registries.

Femoral cement pressurization in hip arthroplasty: a laboratory comparison of three techniques.

The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy.

Staged bilateral total hip arthroplasty using rough and smooth surface femoral stems with similar design: 10-year survivorship of 48 cases.