Range of motion after computed tomography-based simulation of intertrochanteric corrective osteotomy in cases of slipped capital femoral epiphysis: comparison of uniplanar flexion osteotomy and multiplanar flexion, valgisation, and rotational osteotomies

BACKGROUND: Various osteotomy techniques have been developed to correct the deformity caused by slipped capital femoral epiphysis (SCFE) and compared by their clinical outcomes. The aim of the presented study was to compare an intertrochanteric uniplanar flexion osteotomy with a multiplanar osteotomy by their ability to improve postoperative range of motion as measured by simulation of computed tomographic data in patients with SCFE. METHODS: We examined 19 patients with moderate or severe SCFE as classified based on slippage angle. A computer program for the simulation of movement and osteotomy developed in our laboratory was used for study execution. According to a 3-dimensional reconstruction of the computed tomographic data, the physiological range was determined by flexion, abduction, and internal rotation. The multiplanar osteotomy was compared with the uniplanar flexion osteotomy. Both intertrochanteric osteotomy techniques were simulated, and the improvements of the movement range were assessed and compared. RESULTS: The mean slipping and thus correction angles measured were 25 degrees (range, 8-46 degrees) inferior and 54 degrees (range, 32-78 degrees) posterior. After the simulation of multiplanar osteotomy, the virtually measured ranges of motion as determined by bone-to-bone contact were 61 degrees for flexion, 57 degrees for abduction, and 66 degrees for internal rotation. The simulation of the uniplanar flexion osteotomy achieved a flexion of 63 degrees, an abduction of 36 degrees, and an internal rotation of 54 degrees. CONCLUSIONS: Apart from abduction, the improvement in the range of motion by a uniplanar flexion osteotomy is comparable with that of the multiplanar osteotomy. However, the improvement in flexion for the simulation of both techniques is not satisfactory with regard to the requirements of normal everyday life, in contrast to abduction and internal rotation. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Operative treatment of congenital hip osteoarthritis with high hip luxation (Crowe type IV)

OBJECTIVE The aim of the therapy is mechanical and functional stabilization of high dislocated hips with dysplasia coxarthrosis using total hip arthroplasty (THA). INDICATIONS Developmental dysplasia of the hip (DDH) in adults, symptomatic dysplasia coxarthrosis, high hip dislocation according to Crowe type III/IV, and symptomatic leg length inequality. CONTRAINDICATIONS Cerebrospinal dysfunction, muscular dystrophy, apparent disturbance of bone metabolism, acute or chronic infections, and immunocompromised patients. SURGICAL TECHNIQUE With the patient in a lateral decubitus position an incision is made between the anterior border of the gluteus maximus muscle and the posterior border of the gluteus medius muscle (Gibson interval). Identification of the sciatic nerve to protect the nerve from traction disorders by visual control. After performing trochanter flip osteotomy, preparation of the true actetabulum if possible. Implantation of the reinforcement ring, preparation of the femur and if necessary for mobilization, resection until the trochanter minor. Test repositioning under control of the sciatic nerve. Finally, refixation of the trochanteric crest. POSTOPERATIVE MANAGEMENT During hospital stay, intensive mobilization of the hip joint using a continuous passive motion machine with maximum flexion of 70°. No active abduction and passive adduction over the body midline. Maximum weight bearing 10-15 kg for 8 weeks, subsequently, first clinical and radiographic follow-up and deep venous thrombosis prophylaxis until full weight bearing. RESULTS From 1995 to 2012, 28 THAs of a Crow type IV high hip-dislocation were performed in our institute. Until now 14 patients have been analyzed during a follow-up of 8 years in 2012. Mid-term results showed an improvement of the postoperative clinical score (Merle d'Aubigné score) in 86 % of patients. Good to excellent results were obtained in 79 % of cases. Long-term results are not yet available. In one case an iatrogenic neuropraxia of the sciatic nerve was observed and after trauma a redislocation of the arthroplasty appeared in another case. In 2 cases an infection of the THA appeared 8 and 15 months after index surgery. No pseudoarthrosis of the trochanter or aseptic loosening was noticed.

Head Reduction Osteotomy With Additional Containment Surgery Improves Sphericity and Containment and Reduces Pain in Legg-Calvé-Perthes Disease.

BACKGROUND Severe femoral head deformities in the frontal plane such as hips with Legg-Calvé-Perthes disease (LCPD) are not contained by the acetabulum and result in hinged abduction and impingement. These rare deformities cannot be addressed by resection, which would endanger head vascularity. Femoral head reduction osteotomy allows for reshaping of the femoral head with the goal of improving head sphericity, containment, and hip function. QUESTIONS/PURPOSES Among hips with severe asphericity of the femoral head, does femoral head reduction osteotomy result in (1) improved head sphericity and containment; (2) pain relief and improved hip function; and (3) subsequent reoperations or complications? METHODS Over a 10-year period, we performed femoral head reduction osteotomies in 11 patients (11 hips) with severe head asphericities resulting from LCPD (10 hips) or disturbance of epiphyseal perfusion after conservative treatment of developmental dysplasia (one hip). Five of 11 hips had concomitant acetabular containment surgery including two triple osteotomies, two periacetabular osteotomies (PAOs), and one Colonna procedure. Patients were reviewed at a mean of 5 years (range, 1-10 years), and none was lost to followup. Mean patient age at the time of head reduction osteotomy was 13 years (range, 7-23 years). We obtained the sphericity index (defined as the ratio of the minor to the major axis of the ellipse drawn to best fit the femoral head articular surface on conventional anteroposterior pelvic radiographs) to assess head sphericity. Containment was assessed evaluating the proportion of patients with an intact Shenton's line, the extrusion index, and the lateral center-edge (LCE) angle. Merle d'Aubigné-Postel score and range of motion (flexion, internal/external rotation in 90° of flexion) were assessed to measure pain and function. Complications and reoperations were identified by chart review. RESULTS At latest followup, femoral head sphericity (72%; range, 64%-81% preoperatively versus 85%; range, 73%-96% postoperatively; p = 0.004), extrusion index (47%; range, 25%-60% versus 20%; range, 3%-58%; p = 0.006), and LCE angle (1°; range, -10° to 16° versus 26°; range, 4°-40°; p = 0.0064) were improved compared with preoperatively. With the limited number of hips available, the proportion of an intact Shenton's line (64% versus 100%; p = 0.087) and the overall Merle d'Aubigné-Postel score (14.5; range, 12-16 versus 15.7; range, 12-18; p = 0.072) remained unchanged at latest followup. The Merle d'Aubigné-Postel pain subscore improved (3.5; range, 1-5 versus 5.0; range, 3-6; p = 0.026). Range of motion was not observed to have improved with the numbers available (p ranging from 0.513 to 0.778). In addition to hardware removal in two hips, subsequent surgery was performed in five of 11 hips to improve containment after a mean interval of 2.3 years (range, 0.2-7.5 years). Of those, two hips had triple osteotomy, one hip a combined triple and valgus intertrochanteric osteotomy, one hip an intertrochanteric varus osteotomy, and one hip a PAO with a separate valgus intertrochanteric osteotomy. No avascular necrosis of the femoral head occurred. CONCLUSIONS Femoral head reduction osteotomy can improve femoral head sphericity. Improved head containment in these hips with an often dysplastic acetabulum requires additional acetabular containment surgery, ideally performed concomitantly. This can result in reduced pain and avascular necrosis seems to be rare. With the number of patients available, function did not improve. Therefore, future studies should use more precise instruments to evaluate clinical outcome and include longer followup to confirm joint preservation. LEVEL OF EVIDENCE Level IV, therapeutic study.

Osteotomy of the greater trochanter: effect on gluteus medius function

PURPOSE Advancement of the greater trochanter alters the function of the gluteus medius muscle. However, with the exception of clinical studies and biomechanical lever arm studies, no publications that analyze the consequences of advancement of the greater trochanter on the muscle function exist. The aim of the study was to analyze the mechanical changes of gluteus medius after osteotomy of the greater trochanter in a lab setting. METHODS An anatomical study of origin and insertion of the gluteus medius was carried out on four hips. Based on the dissections, a string model was developed dividing the muscle into five sectors. Changes in muscle fiber length were measured for every 10° of flexion, internal and external rotation and abduction with the trochanter in anatomic, proximalized and distalized positions. RESULTS Distalization of the trochanter leads to an imbalance of muscle action, moving the isometric sector of the muscle anteriorly with more muscle sectors being active during flexion and less during extension. Stretching of the muscle increases passive forces but decreases the force generation capacity of the muscle and at the same time increased muscle fiber excursion may require more energy consumption, which may explain earlier fatigue of the abductor musculature after distalization of the trochanter. For abduction, distalization of the muscle attachment leads to a change in contraction pattern from isometric to isotonic. Optimal balancing and excursion of the muscle is when the tip of the greater trochanter is at level with the hip rotation center. CONCLUSIONS In hips with high riding trochanter, the optimal position is at the level of the center of hip rotation. Excessive distalization should be avoided. As the conclusions and considerations are based on a lab setting, transfer to clinical practice may not necessarily apply.

Relative femoral neck lengthening improves pain and hip function in proximal femoral deformities with a high-riding trochanter

BACKGROUND Complex proximal femoral deformities, including an elevated greater trochanter, short femoral neck, and aspherical head-neck junction, often result in pain and impaired hip function resulting from intra-/extraarticular impingement. Relative femoral neck lengthening may address these deformities, but mid-term results of this approach have not been widely reported. QUESTIONS/PURPOSES Do patients who have undergone relative femoral neck lengthening show (1) less hip pain and greater function; (2) improved radiographic parameters; (3) significant complications requiring subsequent surgery; and (4) progression of osteoarthrosis (OA) or conversion to total hip arthroplasty (THA) at mid-term followup? METHODS We retrospectively reviewed 40 patients (41 hips) with isolated relative femoral neck lengthening between 1998 and 2006 with sequelae of Legg-Calvé-Perthes disease (38 hips [93%]), slipped capital femoral epiphysis (two hips [5%]), and postseptic arthritis (one hip [2%]). During this time, the general indications for this procedure included a high-riding greater trochanter with a short femoral neck with abductor weakness and symptomatic intra-/extraarticular impingement. Mean patient followup was 8 years (range, 5-13 years), and complete followup was available in 38 patients (39 hips [95%]). We evaluated pain and function with the impingement test, limp, abductor force, Merle d'Aubigné-Postel score, and range of motion. Radiographic parameters included trochanteric height, alpha angle, and progression of OA. Subsequent surgeries, complications, and conversion to THA were summarized. RESULTS The proportion of positive anterior impingement tests decreased from 93% (38 of 41 hips) preoperatively to 49% (17 of 35 hips) at latest followup (p = 0.002); the proportion of limp decreased from 76% (31 of 41 hips) to 9% (three of 35 hips; p < 0.001); the proportion of normal abductor strength increased from 17% (seven of 41 hips) to 91% (32 of 35 hips; p < 0.001); mean Merle d'Aubigné-Postel score increased from 14 ± 1.7 (range, 9-17) to 17 ± 1.5 (range, 13-18; p < 0.001); mean internal rotation increased to 25° ± 15° (range, 0°-60°; p = 0.045), external rotation to 32° ± 14° (range, 5°-70°; p = 0.013), and abduction to 37° ± 13° (range, 10°-50°; p = 0.004). Eighty percent of hips (33 of 41 hips) showed normal trochanteric height; alpha angle improved to 42° ± 10° (range, 27°-90°). Two hips (5%) had subsequent surgeries as a result of lack of containment; four of 41 hips (10%) had complications resulting in reoperation. Fourteen of 35 hips (40%) showed progression of OA; four of 40 hips (10%) converted to THA. CONCLUSIONS Relative femoral neck lengthening in hips with combined intra- and extraarticular impingement results in reduced pain, improved function, and improved radiographic parameters of the proximal femur. Although lack of long-term complications is gratifying, progression of OA was not prevented and remains an area for future research.

Periacetabular osteotomy restores the typically excessive range of motion in dysplastic hips with a spherical head

BACKGROUND Residual acetabular dysplasia is seen in combination with femoral pathomorphologies including an aspherical femoral head and valgus neck-shaft angle with high antetorsion. It is unclear how these femoral pathomorphologies affect range of motion (ROM) and impingement zones after periacetabular osteotomy. QUESTIONS/PURPOSES (1) Does periacetabular osteotomy (PAO) restore the typically excessive ROM in dysplastic hips compared with normal hips; (2) how do impingement locations differ in dysplastic hips before and after PAO compared with normal hips; (3) does a concomitant cam-type morphology adversely affect internal rotation; and (4) does a concomitant varus-derotation intertrochanteric osteotomy (IO) affect external rotation? METHODS Between January 1999 and March 2002, we performed 200 PAOs for dysplasia; of those, 27 hips (14%) met prespecified study inclusion criteria, including availability of a pre- and postoperative CT scan that included the hip and the distal femur. In general, we obtained those scans to evaluate the pre- and postoperative acetabular and femoral morphology, the degree of acetabular reorientation, and healing of the osteotomies. Three-dimensional surface models based on CT scans of 27 hips before and after PAO and 19 normal hips were created. Normal hips were obtained from a population of CT-based computer-assisted THAs using the contralateral hip after exclusion of symptomatic hips or hips with abnormal radiographic anatomy. Using validated and computerized methods, we then determined ROM (flexion/extension, internal- [IR]/external rotation [ER], adduction/abduction) and two motion patterns including the anterior (IR in flexion) and posterior (ER in extension) impingement tests. The computed impingement locations were assigned to anatomical locations of the pelvis and the femur. ROM was calculated separately for hips with (n = 13) and without (n = 14) a cam-type morphology and PAOs with (n = 9) and without (n = 18) a concomitant IO. A post hoc power analysis based on the primary research question with an alpha of 0.05 and a beta error of 0.20 revealed a minimal detectable difference of 4.6° of flexion. RESULTS After PAO, flexion, IR, and adduction/abduction did not differ from the nondysplastic control hips with the numbers available (p ranging from 0.061 to 0.867). Extension was decreased (19° ± 15°; range, -18° to 30° versus 28° ± 3°; range, 19°-30°; p = 0.017) and ER in 0° flexion was increased (25° ± 18°; range, -10° to 41° versus 38° ± 7°; range, 17°-41°; p = 0.002). Dysplastic hips had a higher prevalence of extraarticular impingement at the anteroinferior iliac spine compared with normal hips (48% [13 of 27 hips] versus 5% [one of 19 hips], p = 0.002). A PAO increased the prevalence of impingement for the femoral head from 30% (eight of 27 hips) preoperatively to 59% (16 of 27 hips) postoperatively (p = 0.027). IR in flexion was decreased in hips with a cam-type deformity compared with those with a spherical femoral head (p values from 0.002 to 0.047 for 95°-120° of flexion). A concomitant IO led to a normalization of ER in extension (eg, 37° ± 7° [range, 21°-41°] of ER in 0° of flexion in hips with concomitant IO compared with 38° ± 7° [range, 17°-41°] in nondysplastic control hips; p = 0.777). CONCLUSIONS Using computer simulation of hip ROM, we could show that the PAO has the potential to restore the typically excessive ROM in dysplastic hips. However, a PAO can increase the prevalence of secondary intraarticular impingement of the aspherical femoral head and extraarticular impingement of the anteroinferior iliac spines in flexion and internal rotation. A cam-type morphology can result in anterior impingement with restriction of IR. Additionally, a valgus hip with high antetorsion can result in posterior impingement with decreased ER in extension, which can be normalized with a varus derotation IO of the femur. However, indication of an additional IO needs to be weighed against its inherent morbidity and possible complications. The results are based on a limited number of hips with a pre- and postoperative CT scan after PAO. Future prospective studies are needed to verify the current results based on computer simulation and to test their clinical importance.

Inclination-dependent changes of the critical shoulder angle significantly influence superior glenohumeral joint stability.

BACKGROUND The critical shoulder angle combines the acromion index and glenoid inclination and has potential to discriminate between shoulders at risk for rotator cuff tear or osteoarthritis and those that are asymptomatic. However, its biomechanics, and particularly the role of the glenoid inclination, are not yet fully understood. METHODS A shoulder simulator was used to analyze the independent influence of glenoid inclination during abduction from 0 to 60°. Spindle motors transferred tension forces by a cable-pulley on human cadaveric humeri. A six-degree-of-freedom force transducer was mounted directly behind the polyethylene glenoid to measure shear and compressive joint reaction force and calculate the instability ratio (ratio of shear and compressive joint reaction force) with the different force ratios of the deltoid and supraspinatus muscles (2:1 and 1:1). A stepwise change in the inclination by 5° increments allowed simulation of a critical shoulder angle range of 20° to 45°. FINDINGS Tilting the glenoid to cranial (increasing the critical shoulder angle) increases the shear joint reaction force and therefore the instability ratio. A balanced force ratio (1:1) between the deltoid and the supraspinatus allowed larger critical shoulder angles before cranial subluxation occurred than did the deltoid-dominant ratio (2:1). INTERPRETATION Glenoid inclination-dependent changes of the critical shoulder angle have a significant impact on superior glenohumeral joint stability. The increased compensatory activity of the rotator cuff to keep the humeral head centered may lead to mechanical overload and could explain the clinically observed association between large angles and degenerative rotator cuff tears.

Traductología : Exploración de un enfoque feminista de la traducción

Este trabajo se propone presentar la transformación de la Traductología desde la perspectiva de los Estudios de Género, dos campos del conocimiento que reconocen una impronta multi e interdisciplinaria. En cuanto a la primera, el giro cultural de los ochenta marca el momento en que se incluye a la traducción dentro del conjunto de subsistemas culturales con intereses competitivos y sujetos a las ideologías predominantes (Molina Martínez, 2006: 37). Paralelamente se instala en Canadá un terreno de estudio que vincula los desarrollos transculturales y translingüísticos surgidos de los movimientos feministas de los años setenta con la producción y recepción de textos, temas que son abarcados por la investigación sobre género y traducción. En ese contexto surge la noción de traducción en femenino o reescritura en femenino cuya finalidad es subvertir el lenguaje patriarcal y reivindicar las ideas feministas (Lotbinière-Harwood, 1991). Las estrategias discursivas y textuales utilizadas para resolver los problemas de traducción relacionados con el género "suplementación o compensación, la metatextualidad, el secuestro y el pacto especular" suelen recurrir al empleo de un lenguaje con alteraciones semánticas, neologismos o innovaciones lingüísticas, cuyo propósito es cuestionar la lengua actual y, a su vez, visibilizar la presencia femenina (Castro Vázquez, 2008: 296-298). En esta ponencia, nos detendremos en discutir y ejemplificar las estrategias citadas

La representación y la génesis de hipótesis : Una lectura psicoanalítica

Puede seguirse una lectura de la obra freudiana que afirma la heterogeneidad de la materialidad psíquica , ampliando los alcances explicativos del psicoanálisis para entender el origen de la representación. Es posible articular estas ideas con el concepto de abducción de C. S. Peirce, en particular cuando hace referencia al carácter sorpresivo con que esta adviene a la mente del científico, como un destello , es decir, como un producto que emerge a espaldas de la actividad voluntaria 'conciente' del sujeto que piensa. Esta articulación puede erigirse en un argumento para una justificación psicológica de la génesis de hipótesis , constituyendo un aporte desde el psicoanálisis al problema del descubrimiento en ciencia

Mala gente que camina : De la expropiación a la reconstrucción de la memoria

Las indagaciones de la última década sobre el robo de niños en la dictadura franquista y el silencio por parte de los gobiernos democráticos españoles, han despertado el interés tanto de historiadores como de escritores. Quienes no vivieron directamente el exterminio físico e ideológico del régimen dictatorial, recomponen las identidades que quedaron sepultadas en fosas comunes, pero también esclarecen las apropiaciones por parte del Estado, para que aquellos que aún viven engañados puedan saberlo. Benjamín Prado con Mala gente que camina, se inscribe en el conjunto de autores que trabajan por escribir una memoria histórica capaz de llenar los vacíos que han dejado las generaciones anteriores

La representación y la génesis de hipótesis : Una lectura psicoanalítica

Puede seguirse una lectura de la obra freudiana que afirma la heterogeneidad de la materialidad psíquica , ampliando los alcances explicativos del psicoanálisis para entender el origen de la representación. Es posible articular estas ideas con el concepto de abducción de C. S. Peirce, en particular cuando hace referencia al carácter sorpresivo con que esta adviene a la mente del científico, como un destello , es decir, como un producto que emerge a espaldas de la actividad voluntaria 'conciente' del sujeto que piensa. Esta articulación puede erigirse en un argumento para una justificación psicológica de la génesis de hipótesis , constituyendo un aporte desde el psicoanálisis al problema del descubrimiento en ciencia

Mala gente que camina : De la expropiación a la reconstrucción de la memoria

Las indagaciones de la última década sobre el robo de niños en la dictadura franquista y el silencio por parte de los gobiernos democráticos españoles, han despertado el interés tanto de historiadores como de escritores. Quienes no vivieron directamente el exterminio físico e ideológico del régimen dictatorial, recomponen las identidades que quedaron sepultadas en fosas comunes, pero también esclarecen las apropiaciones por parte del Estado, para que aquellos que aún viven engañados puedan saberlo. Benjamín Prado con Mala gente que camina, se inscribe en el conjunto de autores que trabajan por escribir una memoria histórica capaz de llenar los vacíos que han dejado las generaciones anteriores

Traductología : Exploración de un enfoque feminista de la traducción

Este trabajo se propone presentar la transformación de la Traductología desde la perspectiva de los Estudios de Género, dos campos del conocimiento que reconocen una impronta multi e interdisciplinaria. En cuanto a la primera, el giro cultural de los ochenta marca el momento en que se incluye a la traducción dentro del conjunto de subsistemas culturales con intereses competitivos y sujetos a las ideologías predominantes (Molina Martínez, 2006: 37). Paralelamente se instala en Canadá un terreno de estudio que vincula los desarrollos transculturales y translingüísticos surgidos de los movimientos feministas de los años setenta con la producción y recepción de textos, temas que son abarcados por la investigación sobre género y traducción. En ese contexto surge la noción de traducción en femenino o reescritura en femenino cuya finalidad es subvertir el lenguaje patriarcal y reivindicar las ideas feministas (Lotbinière-Harwood, 1991). Las estrategias discursivas y textuales utilizadas para resolver los problemas de traducción relacionados con el género "suplementación o compensación, la metatextualidad, el secuestro y el pacto especular" suelen recurrir al empleo de un lenguaje con alteraciones semánticas, neologismos o innovaciones lingüísticas, cuyo propósito es cuestionar la lengua actual y, a su vez, visibilizar la presencia femenina (Castro Vázquez, 2008: 296-298). En esta ponencia, nos detendremos en discutir y ejemplificar las estrategias citadas

Traductología : Exploración de un enfoque feminista de la traducción

Este trabajo se propone presentar la transformación de la Traductología desde la perspectiva de los Estudios de Género, dos campos del conocimiento que reconocen una impronta multi e interdisciplinaria. En cuanto a la primera, el giro cultural de los ochenta marca el momento en que se incluye a la traducción dentro del conjunto de subsistemas culturales con intereses competitivos y sujetos a las ideologías predominantes (Molina Martínez, 2006: 37). Paralelamente se instala en Canadá un terreno de estudio que vincula los desarrollos transculturales y translingüísticos surgidos de los movimientos feministas de los años setenta con la producción y recepción de textos, temas que son abarcados por la investigación sobre género y traducción. En ese contexto surge la noción de traducción en femenino o reescritura en femenino cuya finalidad es subvertir el lenguaje patriarcal y reivindicar las ideas feministas (Lotbinière-Harwood, 1991). Las estrategias discursivas y textuales utilizadas para resolver los problemas de traducción relacionados con el género "suplementación o compensación, la metatextualidad, el secuestro y el pacto especular" suelen recurrir al empleo de un lenguaje con alteraciones semánticas, neologismos o innovaciones lingüísticas, cuyo propósito es cuestionar la lengua actual y, a su vez, visibilizar la presencia femenina (Castro Vázquez, 2008: 296-298). En esta ponencia, nos detendremos en discutir y ejemplificar las estrategias citadas

La representación y la génesis de hipótesis : Una lectura psicoanalítica

Puede seguirse una lectura de la obra freudiana que afirma la heterogeneidad de la materialidad psíquica , ampliando los alcances explicativos del psicoanálisis para entender el origen de la representación. Es posible articular estas ideas con el concepto de abducción de C. S. Peirce, en particular cuando hace referencia al carácter sorpresivo con que esta adviene a la mente del científico, como un destello , es decir, como un producto que emerge a espaldas de la actividad voluntaria 'conciente' del sujeto que piensa. Esta articulación puede erigirse en un argumento para una justificación psicológica de la génesis de hipótesis , constituyendo un aporte desde el psicoanálisis al problema del descubrimiento en ciencia