Contralateral Hip In Patients Research Articles

Study of Contralateral Hip in Patients with Hip Fracture

Background: This study was done to know whether patients with hip injury have pre-existing osteoporosis due to which, the patient sustained the fracture, subsequent fracture of the contralateral hip, any osteoarthritic changes of the contralateral hip at the time of index fracture, and ten-year probability of a major osteoporotic fracture by calculating fracture risk assessment percentage (FRAX%).
 Methods: 34 patients were evaluated for age, gender, body mass index (BMI), fracture type, Singh index, bone mineral density (BMD), T-scores using dual-energy X-ray absorptiometry (DEXA) scan, and ten-year probability of fracture using FRAX%.
 Results: Average age of the patients with hip fractures was 72.1 years. About 85% of patients were women. 67.6% of the patients were with BMI of 18.5-25 kg/m2 . The Singh index for osteoporosis fell in grades 2 and 3 in most patients. The mean interval between index fracture and contralateral hip injury was 4.25 years. Osteoarthritis of the contralateral hip was seen in 9%. The probability in ten years of hip fracture in 30 indexed patients using the FRAX% tool was 15%, and for 4 patients who were having bilateral hip fractures was 22.75%. There was a significant relationship between FRAX% with the Singh index and osteoarthritis of the contralateral hip. FRAX% was high in female patients.
 Conclusion: Contralateral hip fracture in patients with osteoporosis was high in women and patients with low and high BMI. Fractures were also high in patients with low Singh index and T-scores. FRAX% increased with an increase in age and increased with a decrease in T-score.

MRI hip morphology is abnormal in unilateral DDH and increased lateral limbus thickness is associated with residual DDH at minimum 10-year follow-up.

The purpose of the study was to compare the post-reduction magnetic resonance imaging morphology for hips that developed residual acetabular dysplasia, hips without residual dysplasia, and uninvolved contralateral hips in patients with unilateral developmental dysplasia of the hip undergoing closed or open reduction and had a minimum 10-year follow-up. Retrospective study of patients with unilateral dysplasia of the hip who underwent open/closed hip reduction followed by post-reduction magnetic resonance imaging. Twenty-eight patients with a mean follow-up of 13 ± 3 years were included. In the treated hips, residual dysplasia was defined as subsequent surgery for residual acetabular dysplasia or for Severin grade > 2 at latest follow-up. On post-reduction, magnetic resonance imaging measurements were performed by two readers and compared between the hips with/without residual dysplasia and the contralateral uninvolved side. Magnetic resonance imaging measurements included acetabular version, coronal/ axial femoroacetabular distance, acetabular depth-width ratio, osseous/cartilaginous acetabular indices, and medial/lateral (limbus) cartilage thickness. Fifteen (54%) and 13 (46%) hips were allocated to the "no residual dysplasia" group and to the "residual dysplasia" group, respectively. All eight magnetic resonance imaging parameters differed between hips with residual dysplasia and contralateral uninvolved hips (all p < 0.05). Six of eight parameters differed (all p < 0.05) between hips with and without residual dysplasia. Among these, increased limbus thickness had the largest effect (odds ratio = 12.5; p < 0.001) for increased likelihood of residual dysplasia. We identified acetabular morphology and reduction quality parameters that can be reliably measured on the post-reduction magnetic resonance imaging to facilitate the differentiation between hips that develop with/without residual acetabular dysplasia at 10 years postoperatively. level III, prognostic case-control study.

Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Index Surgery Patient Reported Outcome Measures Predict Contralateral Surgery Results at 2 Years

To determine whether (1) patient-reported outcome (PRO) scores after index hip arthroscopy correlate with PRO scores for the contralateral hip in patients undergoing staged bilateral hip arthroscopy and (2) patients who achieved minimal clinically important difference (MCID) or patient-acceptable symptom state (PASS) for the index hip were more likely to achieve MCID or PASS for the contralateral hip. Patients who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome were retrospectively reviewed. PRO scores were prospectively collected at preoperative and 1- and 2-year timepoints. Odds ratios for achievement of MCID and PASS for the contralateral hip given achievement for the index hip were calculated. Improvements from before surgery to 2 years after surgery were correlated between both hips. A total of 143 patients (286 hips) were included in the final analysis. Average time between surgeries was 8.5 months (range, 0.7-57.2). Both hips demonstrated significant improvement (P<.05 for all) in all PROs at 2 years. Achievement of MCID in Hip Outcome Score Activities of Daily Living (HOS-ADL) at the 1-year timepoint for the index hip was predictive of achievement of MCID in HOS-ADL at 2 years for the contralateral hip. Achievement of PASS in all PROs at the 1-year timepoint for the index hip were predictive of achievement of PASS in the equivalent outcome score at the 2-year mark for the contralateral hip. Achievement of MCID or PASS at the 2-year timepoint for the index hip was predictive of achievement of the equivalent outcome at the 2-year timepoint for the contralateral hip. The strongest correlation between improvement in PRO scores for the index and contralateral hips was noted in patients who underwent staged hip arthroscopy within less than 3 months. Patients experience significant clinical benefit in both hips after staged bilateral hip arthroscopy. Results from the initial hip arthroscopy at either 1- or 2-year follow-up can be used to predict outcomes on the contralateral side; however, there is a higher degree of predictive value using 2-year results. Average correlations between 2-year PROs on the index and contralateral hips were moderate to strong, regardless of the time between surgeries. Level III, retrospective cohort study.

Factors Associated With Disease Progression in the Contralateral Hip of Patients With Symptomatic Femoroacetabular Impingement: A Minimum 5-Year Analysis

Background: Femoroacetabular impingement (FAI) is one of the most common causes of hip osteoarthritis, yet the factors controlling disease progression are poorly understood. Purpose: To investigate rates of initial and subsequent symptoms in the contralateral hip of patients with FAI, and identify predictors of disease progression (symptom development and surgical intervention) in the contralateral hip. Study Design: Cohort study; Level of evidence, 2. Methods: This prospective study included a minimum 5-year follow-up of the contralateral hip in 179 patients undergoing FAI surgery. Symptoms (moderate pain) and surgical progression were monitored. Univariate and multivariate analyses compared patient-specific and imaging characteristics of symptomatic patients with those who remained asymptomatic to identify factors associated with disease progression. Results: A total of 150 patients (84% follow-up) were followed for a mean of 7.1 years (range, 5-11 years). Thirty-nine of these patients (26% [39/150]) had contralateral hip symptoms at initial evaluation. Of those without contralateral hip symptoms at initial evaluation, 32% (36/111) had developed contralateral hip symptoms by latest follow-up. Those who developed symptoms during the study period had a lower anteroposterior head-neck offset ratio (0.153 vs 0.165; P = .005), decreased total arc of rotation in 90° of flexion (39.9° vs 51.1°; P = .005), and decreased external rotation in 90° of flexion (28.6° vs 37.1°; P = .003) compared with those who never developed symptoms. Age, sex, body mass index, alpha angle, lateral center-edge angle, internal rotation in flexion, and University of California, Los Angeles (UCLA), activity score were similar between these groups. Those with contralateral symptoms at initial evaluation progressed to contralateral surgery at a rate of 41% (16/39) and those who developed contralateral symptoms during the study period progressed to contralateral surgery at a rate of 28% (10/36). Among those with contalateral hip symptoms (either present initially or developed during study period)), younger age (24.6 vs 34.1 years; P < .001) and baseline UCLA activity score ≥9 (P = .003) were associated with progression to surgery. By Kaplan-Meier analysis, 64%, 54%, and 48% of patients remained free of contralateral hip symptoms at 2, 5, and 10 years. Conclusion: At a mean follow-up of 7.1 years, significant symptoms in the contralateral hip of patients with FAI were present in approximately 50% of patients. FAI disease progression (symptom development and surgical intervention) was associated with decreased hip rotation arc, decreased external rotation, and decreased head-neck offset ratio. In symptomatic patients, younger age and UCLA activity score ≥9 were associated with progression to surgery. These findings represent important factors for patient counseling and risk modeling in FAI.

Femoroacetabular impingement in the unpinned contralateral hip in patients with primary unilateral slipped capital femoral epiphysis: preliminary radiographic outcomes.

The study evaluated femoroacetabular impingement (FAI) in the unpinned contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) and verified initial age, posterior sloping angle (PSA) and center-edge angle (CEA) as predictors of FAI in the contralateral hip. 152 patients with unilateral SCFE with a mean index age of 13.2 years (8.2-17.2 years) were enrolled retrospectively into the study. Mean follow-up was 8 years (3-14 years). PSA and CEA were measured on initial radiographs of the unaffected hip. Alpha-angle and CEA were measured on radiographs taken at the last follow-up to identify FAI. Four groups of patients were distinguished: (1) no FAI (10 patients, 17.54%); (2) CAM-type FAI (41 patients, 71.9%); (3) pincer-type FAI (3 patients, 5.26%) and (4) mixed-type FAI (13 patients, 22.8%). The mean PSA was 12.1°, 12°, 16.8°, 11.9° for groups 1, 2, 3 and 4, respectively, with no significant difference ( P = 0.65). The mean initial CEA for groups 1, 2, 3 and 4 was 34.4°, 35.5°, 42° and 42° respectively, with significant differences between groups 1 versus 4 ( P = 0.034) and 2 versus 4 ( P = 0.009). Conclusions are as follows: 1. Radiographic features of FAI were present in 85.1% of unpinned contralateral hips in patients with unilateral SCFE. 2. 71.9% of unpinned contralateral hips developed CAM deformity. 3. CEA can be used in predicting pincer-type FAI in the contralateral hip in unilateral SCFE. 4. PSA and age revealed negligible value in predicting FAI.

RADIOGRAPHIC STUDY OF THE MEDIAL JOINT SPACE OF THE HIP IN LEGG-CALVÉ-PERTHES DISEASE.

To evaluate medial joint space in affected and normal contralateral hips in patients with Legg-Calvé-Perthes disease (LCPD). To compare joint space, femoral head extrusion (FHE), medial space coefficient (MSC) of the hip, and femoral head width (FHW) in affected and normal hips, using 127 radiographs of patients with unilateral LCPD and considering age groups under and over six years old as well as their disease stage. No statistically significant differences were observed regarding MSC between normal and affected hips regardless of disease staging. However, medial joint distance was significantly greater in affected hips than in normal hips. In the necrosis and fragmentation phase, distance from medial space in affected hips was significantly greater than in contralateral normal hips. Comparing only affected hips, MSC and FHW showed statistically significant differences and the group > 6 yo presented higher values. Among normal hips, the group < 6 yo presented a statistically significant difference considering the MSC and FHW. No statistically significant difference was found between the medial joint space of affected and normal hips, except for early stages of the disease (necrosis and fragmentation). The isolated use of radiographic study is insufficient in LCPD and the lack of complementation with other exams, such as magnetic resonance, can delay diagnosis of and onset of treatment for the disease. Level of Evidence III, Study of Non Consecutive Patients; without Consistently Applied Reference "Gold" Standard.

Identification of Factors Associated with Disease Progression in the Contralateral Hip of Patients with Symptomatic Femoroacetabular Impingement. (139)

Objectives:Femoroacetabular Impingement (FAI) is one of the most common causes of hip osteoarthritis. Nevertheless, the factors contributing to symptom development and FAI disease progression are poorly understood. The purpose of this study was to (1) investigate rates of symptom development in the contralateral hip of patients with FAI at mid-term follow-up, and (2) identify predictors of disease progression (symptom development) in the contralateral hip.Methods:This prospective study included 179 patients undergoing ipsilateral FAI surgery with no history of previous contralateral hip surgery. In the current study, the contralateral hip was assessed at minimum 5 year follow-up. Symptoms (defined as moderate pain) and the need for surgery were monitored over the study course. Statistical analysis compared patient and FAI imaging characteristics of patients developing symptoms to those who remained asymptomatic.Results:A total of 146 hips (81.5%) were included at a mean 6.7 years of follow-up. Thirty-nine (26.7%) presented with symptoms in the contralateral hip, while an additional 35 (23.9%) developed symptoms during the follow-up period. Twenty-Six (17.8%) progressed to surgery for their contralateral hip. Head-neck offset ratio (HNOR) on AP pelvis radiographs was significantly lower among hips that developed symptoms (0.16 vs. 0.15 p=0.03). Maximum alpha angle (p=0.41), lateral center edge angle (p=0.70), and crossover sign (p=0.12) were not predictive of symptoms. Patients with a UCLA activity score greater than 9 were less likely to develop symptoms (14% vs. 46%, p=0.081), but this was not statistically significant. The total arc of rotation in 90° of flexion (40.0° vs 50.8°, p=0.01) as well as external rotation at 900 of flexion (28.9° vs 36.6°, p=0.02) were decreased in hips developing symptoms. Internal rotation in flexion was not significantly decreased in symptomatic patients (11.1° vs 14.2°, p=0.11). Kaplan Meier survival analysis demonstrated 53% and 45% of patients remaining asymptomatic at 5 and 8 year time points (Figure).Conclusions:At a mean follow-up of 6.7 years, significant symptoms in the contralateral hip of patients with FAI are present in 50.7% of patients, while 49.3% remain asymptomatic or minimally symptomatic. We identified unique radiographic and physical exam findings that are associated with symptom development in patients with FAI. Specifically, decreased hip rotation arc and decreased HNOR were strongly associated with disease progression and may represent important factors for future risk modeling in FAI patients.

THREE-DIMENSIONAL PREDICTORS OF FAI DISEASE PROGRESSION IN THE CONTRALATERAL HIP

Background:Bony morphologies contributing to femoroacetabular impingement (FAI) are relatively common in the general population, but drivers of symptom development are not well understood.Hypothesis/Purpose:The purpose of this study was to determine the role of three-dimensional bony morphology in symptom development in the contralateral hip in patients undergoing ipsilateral surgical treatment for FAI.Methods:The study included a prospective cohort of 161 consecutive patients (101 females, 60 males) who presented for ipsilateral FAI surgical treatment from 2013-2018. The average age was 29.1 years. Minimum follow-up was 1 year (mean, 2.3 years; range, 1-6 years). Low-dose CT scans were obtained prior to surgical treatment. Three-dimensional hip analysis of the contralateral hip was performed relative to normative data and allowed measurements of 15 key parameters. Prior to surgery and at routine follow-up, patients completed standardized questionnaires that included pain in the contralateral hip. Univariate and multivariate analyses were performed to identify independent predictors.Results:There were 133 patients (83%) with follow-up. Significant levels of pain in the contralateral hip were reported in 25 (18.8%) patients at presentation and 50 (35.3%) patients at follow-up. Twenty-six (19.5%) patients progressed to surgery at an average of 1.12 years. Significant predictors of symptom development were alpha angle >55° at 1:00 (p=0.037), femoral version <0° or > 20° (p=0.027), and decreased central acetabular version at 3:00 (p=0.048). Significant predictors of surgery were age <30 years (p=0.023) and alpha angle >55° at 1:00 (p=0.005).Conclusion:We found that roughly 1 in 5 patients undergoing surgical treatment for ipsilateral FAI experienced pain in the contralateral hip at presentation, over one third reported pain at follow-up, and 1 in 5 progressed to surgery. Higher alpha angle, abnormal femoral version, and decreased acetabular version were correlated with symptom development, while higher alpha angle and age under 30 were associated with progression to surgery.

IDENTIFICATION OF FACTORS ASSOCIATED WITH DISEASE PROGRESSION IN THE CONTRALATERAL HIP OF PATIENTS WITH SYMPTOMATIC FEMOROACETABULAR IMPINGEMENT

Introduction:Femoroacetabular Impingement (FAI) is one of the most common causes of hip osteoarthritis. Nevertheless, the factors contributing to symptom development and FAI disease progression are poorly understood.Hypothesis/Purpose:The purpose of this study was to (1) investigate rates of initial and subsequent symptom development in the contralateral hip of patients with FAI, and (2) identify predictors of disease progression (symptom development) in the contralateral hip.Methods:This prospective study included a minimum 5 year follow-up of the contralateral hip in 179 patients undergoing FAI surgery. Symptoms (moderate pain) were monitored over the study course. Univariate analysis compared patient and FAI imaging characteristics of patients developing symptoms to those who remained asymptomatic.Results:146 patients (146 hips, 81.5%) were included (min 5 year, mean 6.7 years). Thirty-nine (26%) presented with symptoms in the contralateral hip while 34 (23%) developed symptoms. Head-neck offset ratio (HNOR) on AP pelvis radiographs was significantly lower among hips that developed symptoms (0.164 vs. 0.153 p=0.025). Maximum alpha angle (p=0.413), lateral center edge angle (p=0.704), and crossover sign (p=0.115) were not predictive of symptoms. Patients with a UCLA activity score greater than 9 were less likely to develop symptoms (14% vs. 46%, p=0.081), but this was not statistically significant. The total arc of rotation in extension (35.740 vs 45.140, p=0.012) and 900 of flexion (40.00 vs 50.800, p=0.009) as well as external rotation at 900 of flexion (28.940 vs 36.590, p=0.020) were decreased in hips developing symptoms. Internal Rotation in flexion was not significantly decreased in symptomatic patients (11.060 vs 14.20, p=0.113).Conclusions:We identified unique radiographic and physical exam findings that are associated with symptom development in patients with FAI. Specifically, decreased hip rotation arc and decreased HNOR were strongly associated with disease progression and may represent important factors for future risk modeling in FAI patients.

SLIPPED CAPITAL FEMORAL EPIPHYSIS ACETABULAR ORIENTATION AND SHAPE: A THREE-DIMENSIONAL CT STUDY

Background:Previous studies have analyzed the acetabulum in patients affected by slipped capital femoral epiphysis (SCFE), however controversy remains over how the acetabular shape may be altered in hips experiencing SCFE. In particular, changes in acetabular over-coverage and acetabular version are thought to contribute to SCFE.Hypothesis/Purpose:The purpose of this study was to determine the acetabular morphology in hips with SCFE and compare them to normally developing children.Methods:Images from patients with the diagnosis of SCFE who had a computed tomography (CT) exam of their pelvis were compared to images from an age- and sex-matched cohort of patients with CT exams of the pelvis/abdomen for a non-orthopedic related evaluation (controls). Three dimensional (3D) reconstructions were created from each CT exam (MIMICs software). Custom MATLAB software was used to uniformly align and calculate acetabular parameters from the 3D reconstructions. The acetabular parameters calculated were articular surface area, acetabular tilt, acetabular version, and acetabular coverage angles measured in a radial fashion in 5 out of 8 octants.Results:Two-hundred-ninety-eight hips were evaluated, including 67 hips with SCFE, 39 unaffected contralateral hips in patients with SCFE, and 192 normal controls. The SCFE group consisted of 33 males and 34 females. Acetabular version was similar amongst all SCFE affected hips, unaffected contralateral hips, and normal controls (p=0.575). Control hips had higher acetabular tilt than SCFE affected hips (p=0.001) and unaffected contralateral hips (p=0.012). Acetabular surface area was higher in SCFE affected hips compared to controls (p=0.003)(Table 1). SCFE affected hips had significantly increased acetabular coverage compared to controls in the superior, superior-anterior, and anterior octants (p<0.01). The unaffected contralateral sides had significantly increased acetabular coverage compared to controls in all five regions (p<0.02)(Table 2).Conclusions:Contrary to some previous studies, we did not find the acetabulum to be retroverted in hips with SCFE compared to normal hips. Both the affected and unaffected hips of SCFE patients have decreased acetabular tilt. Acetabular surface area is high in both the affected and unaffected sides in SCFE, suggesting it may be involved in the pathogenesis of the condition. There is increased acetabular coverage in the superior regions of SCFE hips. The shared morphological characteristics of both affected and unaffected sides in SCFE patients suggest that their hip anatomy may predispose them to slips.

Three-dimensional Analysis of Acetabular Morphology and Orientation in Patients With Slipped Capital Femoral Epiphysis.

Previous studies analyzing the acetabuli in patients with slipped capital femoral epiphysis (SCFE) have not definitively addressed the relationship between SCFE and acetabular shape. Femoral head overcoverage and acetabular version are thought to contribute to SCFE. The purpose of this study was to determine the acetabular morphology and orientation in hips with SCFE and compare them with normally developing children. Pelvic computed tomography (CT) images of patients with SCFE were compared with pelvic CTs of patients without orthopedic abnormalities (normal controls). Three-dimensional (3-D) reconstructions were created from each CT examination. Custom software uniformly aligned the pelvis then determined acetabular measures from the reconstructions including acetabular version, acetabular tilt, articular surface area, and acetabular coverage angle measured in a radial manner dividing the acetabulum into octants. Two-hundred forty-four hips were included (53 SCFE, 31 unaffected contralateral hips in patients with SCFE, and 160 controls). The acetabular version was similar among SCFE hips, unaffected contralateral hips, and normal controls (P=0.48). Control hips had higher acetabular tilt than SCFE-affected hips (P=0.01) and unaffected contralateral hips (P=0.04). The acetabular surface area was higher in SCFE-affected hips compared with controls (P<0.05). SCFE-affected hips and the unaffected contralateral hips in patients with SCFE had increased acetabular coverage compared with controls in all 5 acetabular octants. Contrary to some previous studies, the authors did not find the acetabulum to be retroverted in patients with SCFE compared with controls. Both affected and unaffected hips of patients with SCFE have decreased acetabular tilt. Acetabular surface area is higher in hips with SCFE compared with normal controls, and both the SCFE-affected hips and unaffected hips had increased acetabular coverage compared with controls in all 5 octants of the acetabulum. The shared morphology of affected and unaffected hips in patients with SCFE suggests that their acetabular anatomy may predispose them to slip. Level III.

CORR Insights®: What is the Accuracy and Reliability of the Peritubercle Lucency Sign on Radiographs for Early Diagnosis of Slipped Capital Femoral Epiphysis Compared With MRI as the Gold Standard?

BACKGROUND The diagnosis of slipped capital femoral epiphysis (SCFE) often is delayed. Although lack of clinical suspicion is the main cause of delayed diagnosis, typical radiographic changes may not be present during the initial phases of SCFE. The peritubercle lucency sign for follow-up of the contralateral hip in patients with unilateral SCFE may be beneficial in assisting the early diagnosis. However, the accuracy and reliability of this sign in patients with SCFE is unknown. QUESTIONS/PURPOSES (1) What is the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the peritubercle lucency sign on radiographs for the early diagnosis of SCFE compared with MRI as the gold standard? (2) What are the interobserver and intraobserver reliabilities of the peritubercle lucency sign on radiographs? METHODS Between 2000 and 2017, 71 patients underwent MRI for an evaluation of pre-slip or a minimally displaced SCFE. Sixty percent of hips (43 of 71) had confirmed SCFE or pre-slip based on the presence of hip pain and MRI changes, and these patients underwent in situ pinning. Three independent experienced observers reviewed MR images of the 71 hips and agreed on the presence of a juxtaphyseal bright-fluid signal suggesting bone marrow edema in these 43 hips with SCFE, and absence MRI changes in the remaining 28 hips. The same three experienced observers and two inexperienced observers, including a general radiologist and an orthopaedic surgery resident, blindly assessed the radiographs for the presence or absence of the peritubercle lucency sign, without information about the diagnosis. Diagnostic accuracy measures including sensitivity, specificity, PPV, and NPV were evaluated. Intraobserver and interobserver agreements were calculated using kappa statistics. RESULTS The overall accuracy of the peritubercle lucency sign on radiographs was 94% (95% CI 91 to 96), sensitivity was 97% (95% CI 95 to 99), specificity was 89% (95% CI 90 to 96), PPV was 93% (95% CI 90 to 96), and NPV was 95% (95% CI 92 to 99). All accuracy parameters were greater than 85% for the five observers, regardless of experience level. Intraobserver agreement was perfect (kappa 1.0), and interobserver agreement was excellent for the peritubercle lucency sign on radiographs across the five observers (kappa 0.81 [95% CI 0.73 to 0.88]). The reliability was excellent for experienced observers (kappa 0.88 [95% CI 0.74 to 1.00]) and substantial for inexperienced observers (kappa 0.70 [95% CI 0.46 to 0.93]), although no difference was found with the numbers available (p = 0.18). CONCLUSIONS The peritubercle lucency sign on radiographs is accurate and reliable for the early diagnosis of SCFE compared with MRI as the gold standard. Improving the early diagnosis of SCFE may be possible with increased awareness, high clinical suspicion, and a scrutinized evaluation of radiographs including an assessment of the peritubercle lucency sign. LEVEL OF EVIDENCE Level III, diagnostic study.

What Is the Prevalence of Cam Deformity After Prophylactic Pinning of the Contralateral Asymptomatic Hip in Unilateral Slipped Capital Femoral Epiphysis? A 10-year Minimum Followup Study.

Prophylactic pinning of the asymptomatic and normal-appearing contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) remains controversial. Understanding the minimal 10-year clinical, functional, and radiographic outcomes of the contralateral asymptomatic hip in unilateral SCFE may be helpful in the decision regarding whether the benefits associated with potentially preventing a SCFE are outweighed by the risk of additional surgery. Among patients with SCFE treated with prophylactic pinning of the asymptomatic and contralateral hip, we sought (1) to determine the complications and reoperations; (2) to evaluate the development of cam deformities and the frequency and severity of osteoarthritis progression; and (3) to characterize hip pain and function as measured by the Harris hip score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) at minimal 10-year followup. Between 1998 and 2005 all patients with SCFE seen at our institution were treated with the modified Dunn procedure and all were offered prophylactic pinning of the contralateral asymptomatic hip. Of the 41 patients who underwent the unilateral modified Dunn procedure and who had an asymptomatic contralateral hip, 37 patients (90%) underwent pinning of that contralateral hip. Of those, 33 patients (80%) were available for clinical and radiographic evaluation for this retrospective study at a minimum of 10 years (mean followup 12 ± 2 years) after surgery. Three patients of the 37 patients only had 10-year clinical followup, including questionnaires sent by mail and telephone, because they refused further radiographic followup and one patient was lost to followup. The group included 19 males and 17 females whose age at surgery was a mean of 13 ± 2 years. Medical charts were reviewed and patients were asked about complications and additional surgical procedures. Most recent postoperative radiographs were evaluated for measurement of the alpha angle, head-neck offset, epiphysis orientation, and osteoarthritis grading according to Tönnis classification and minimum joint space width. The presence of a cam deformity was defined by an alpha angle measurement > 60° on the AP radiograph and/or > 55° on the lateral radiograph. Hip function and pain were assessed by the HHS and HOOS outcome measures. No complications with prophylactic in situ pinning were recorded. Four of 36 (11%) patients underwent subsequent surgical treatment for cam-type femoroacetabular impingement (FAI), and hardware removal was performed in four hips (11%). The mean alpha angle was 53° ± 8° on the AP radiograph and 49° ± 8° on the lateral view at followup. In total, 10 of 33 hips (30%) had a cam morphology at the femoral head-neck junction and four (12%) were symptomatic and underwent FAI surgery. Six of 33 patients (18%) developed an asymptomatic cam morphology at the femoral head-neck junction; in three of 33 hips (9%), the cam deformity instead of lesion were visible only on the lateral projection, and 9% were visible on both the AP and lateral projections. The preoperative offset of the femoral head-neck junction was 10 ± 3 mm on the AP view and 11 ± 4 mm on the lateral view. At followup, the AP offset was 7 ± 3 mm and the lateral offset was 6 ± 3 mm, and on the lateral view, the offset was < 10 mm in eight hips (22%). No patient had radiographic signs of hip osteoarthritis (Tönnis Grade 0). The mean minimum joint space width was 4 ± 0.4 mm. The mean HHS for the 32 patients who did not undergo subsequent surgery was 97 ± 5 at latest followup. The mean postoperative HOOS was 94 ± 8 for the 32 patients at latest followup. At a minimum followup of 10 years after prophylactic pinning of a contralateral asymptomatic hip, most patients achieve excellent hip scores; however, a substantial proportion will develop a symptomatic cam deformity despite prophylactic pinning. No patient had signs of osteoarthritis at a minimum of 10 years, but almost one-third of the patients who underwent prophylactic pinning developed a cam deformity. Level IV, therapeutic study.

A Prospective Analysis of the Contralateral Hip Among Patients With Femoroacetabular Impingement: What Are the Risk Factors for Disease Progression?

Background: The pathophysiology of femoroacetabular impingement (FAI) remains to be better understood, including factors affecting symptom development and disease progression. Purpose: (1) To determine rates of initial and subsequent symptom development in the contralateral hip of patients with symptomatic FAI and (2) to identify predictors of the development of symptomatic contralateral FAI. Study Design: Case-control study; Level of evidence, 3. Methods: This prospective study cohort included the contralateral hip of 179 consecutive patients undergoing primary surgical treatment of FAI. At presentation and follow-up time points, patients recorded the presence of symptoms in the contralateral hip. Patients with a minimum 1-year follow-up were included in the final cohort. Univariate analysis compared the patient characteristics and FAI imaging characteristics (cam and pincer) of initially asymptomatic patients who developed symptoms and those who remained asymptomatic. Kaplan-Meier survival curves were calculated to demonstrate symptom development over time. Results: A total of 148 patients (83%) were followed for at least 1 year (mean, 2.9 years). Thirty-four (23%) patients had symptoms in the contralateral hip at the time of the initial presentation. An additional 27 hips (24% of the initially asymptomatic) developed symptoms during the follow-up period at a mean 2.0 years from presentation. Head-neck offset ratio on the anteroposterior pelvis radiograph was significantly lower among hips that developed symptoms (0.153 vs 0.163 asymptomatic group, P = .027). Maximum alpha angle (P = .503), lateral center edge angle (P = .975), and crossover sign (P = .865) were not predictive of the development of symptoms. Patients developing contralateral hip symptoms were less likely to have a UCLA (University of California, Los Angeles) activity score of 9 or 10 at presentation (18.2% vs 43.8%, P = .032). The total arc of rotation in flexion (internal rotation in 90° of flexion + external rotation in flexion) was significantly decreased in hips developing symptoms (39.4º vs 50.4º, P = .012). Kaplan-Meier survival analysis demonstrated that 72%, 67%, 56%, and 48% of all patients remained asymptomatic at 1, 2, 3, and 4 years, respectively. Conclusion: Approximately 1 in 4 patients with FAI presents with symptoms in the contralateral hip, and an additional 1 in 4 patients develops significant symptoms in the following 4 years. Several factors, including low activity level, less hip rotational motion, and decreased head-neck offset ratio, were significantly associated with the development of symptoms, while the alpha angle and crossover sign were not.

Morphologic Features of the Contralateral Femur in Patients With Unilateral Slipped Capital Femoral Epiphysis Resembles Mild Slip Deformity: A Matched Cohort Study

AbstractBackgroundHip osteoarthritis has been reported in the contralateral hip in patients who had been treated for unilateral slipped capital femoral epiphysis (SCFE) during adolescence. Although this might be related to the presence of a mild deformity, the morphologic features of the contralater

The Fate of the Contralateral Hip in Femoroacetabular Impingement

Objectives:The pathophysiology of femoroacetabular impingement (FAI) remains to be better understood. Only a fraction of all individuals with bony FAI morphology will ever develop hip symptoms or osteoarthritis. The purpose of the current study was to determine (1) rates of initial and subsequent symptom development in the contralateral hip of patients with symptomatic ipsilateral FAI and (2) to identify predictors of symptomatic contralateral FAI.Methods:The study cohort included 179 consecutive patients presenting for surgical treatment of FAI. Patients were excluded if they had previously underwent contralateral surgery. At baseline and postoperative follow-up time points, patients recorded standardized outcome questionnaires, including the presence of symptoms in the contralateral hip. Significant symptoms were defined as the presence of at least mild pain, while none or slight pain was not included. All patients underwent AP pelvis and bilateral 45 degree Dunn lateral radiographs at baseline. Patients developing symptoms in the contralateral hip were subclassified as having symptoms at presentation (initial symptoms) or developing symptoms during the follow-up period (symptom development). Patients were followed over a minimum of one year time period postoperatively. Multivariate logistic regression was performed to identify independent predictors of symptoms development.Results:The study cohort had a mean age of 30.2 years and included 60.3% females. FAI was classified as isolated cam in 63.1% (n=113), isolated pincer 1.1% (n=2), and combined type in 35.8% (n=64). Forty-two (23.5%) of patients had initial symptoms in the contralateral hip. Twenty-two additional hips developed symptoms during the follow-up period (16.1% of initially asymptomatic hips). For multivariate logistic regression of any symptoms development (initial or subsequent), competitive athletes (p=0.041) and contralateral HNO ratio on AP pelvis (p=0.009). However, the overall model poorly predicted symptoms development.Conclusion:Approximately one in four patients with FAI presents with symptoms in the contralateral hip. Additionally, 16% of initially asymptomatic contralateral hips will develop symptoms during the next several years. A variety of clinical, radiographic, and physical examination factors poorly predict the development of symptoms. Competitive athletes may be less likely to have contralateral symptoms, while significant contralater al cam deformity on the AP pelvis radiograph may make a patient more likely to have contralateral symptoms.

Radiological findings that may indicate a prior silent slipped capital femoral epiphysis in a cohort of 2072 young adults

The reported prevalence of an asymptomatic slip of the contralateral hip in patients operated on for unilateral slipped capital femoral epiphysis (SCFE) is as high as 40%. Based on a population-based cohort of 2072 healthy adolescents (58% women) we report on radiological and clinical findings suggestive of a possible previous SCFE. Common threshold values for Southwick's lateral head-shaft angle (≥ 13°) and Murray's tilt index (≥ 1.35) were used. New reference intervals for these measurements at skeletal maturity are also presented. At follow-up the mean age of the patients was 18.6 years (17.2 to 20.1). All answered two questionnaires, had a clinical examination and two hip radiographs. There was an association between a high head-shaft angle and clinical findings associated with SCFE, such as reduced internal rotation and increased external rotation. Also, 6.6% of the cohort had Southwick's lateral head-shaft angle ≥ 13°, suggestive of a possible slip. Murray's tilt index ≥ 1.35 was demonstrated in 13.1% of the cohort, predominantly in men, in whom this finding was associated with other radiological findings such as pistol-grip deformity or focal prominence of the femoral neck, but no clinical findings suggestive of SCFE. This study indicates that 6.6% of young adults have radiological findings consistent with a prior SCFE, which seems to be more common than previously reported.

What Are the Risks of Prophylactic Pinning to Prevent Contralateral Slipped Capital Femoral Epiphysis?

Two decision analyses on managing the contralateral, unaffected hip after unilateral slipped capital femoral epiphysis (SCFE) have failed to yield consistent recommendations. Missing from both, however, are sufficient data on the risks associated with prophylactic pinning using modern surgical techniques. We determined the incidence and nature of complications after contemporary prophylactic fixation of the contralateral, unaffected hip in patients with a unilateral SCFE. We retrospectively identified and reviewed 99 children (mean age, 11 years; range, 8-15 years) who underwent prophylactic pinning of the contralateral hip after treatment of a unilateral SCFE at four tertiary-care children's hospitals from 2001 to 2010. Complications on the prophylactic side, such as avascular necrosis (AVN), chondrolysis, fractures, implant pain, and need for further surgery, were recorded. Minimum followup was 12 months (median, 26 months; range, 12-110 months). On the prophylactic side, we found two cases of focal AVN (2%) and no cases of chondrolysis (0%). Two patients sustained periimplant femur fractures (2%). Three patients had symptomatic hardware (3%), two of whom required surgery for implant removal. In three patients (3%), growth occurred off the end of the prophylactic screw before physeal closure, but they did not require revision fixation. No patients developed a subsequent slip on the side of the prophylactic pinning. While prophylactic pinning prevents SCFE, it is not an entirely benign procedure. The possibility of developing complications such as AVN and periimplant fracture should be considered when determining the best management for the contralateral hip in patients who present with unilateral SCFE. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Management of the contralateral hip in patients with unilateral slipped upper femoral epiphysis

In the majority of patients with slipped upper femoral epiphysis only one hip is involved at primary diagnosis. However, the contralateral hip often becomes involved over time. There are no reliable factors predicting a contralateral slip. Whether or not the contralateral hip should undergo prophylactic fixation is a matter of controversy. We present a number of essential points that have to be considered both when choosing to fix the contralateral hip prophylactically as well as when refraining from surgery and instead following the patients with repeat radiographs.

Prediction of Contralateral Slipped Capital Femoral Epiphysis Using the Modified Oxford Bone Age Score

The purpose of the present study was to determine whether the modified Oxford bone score can be used as a predictor for the risk of developing contralateral slipped capital femoral epiphysis (SCFE) in children who present with a unilateral slip. We identified 260 patients treated for unilateral SCFE between 1980 and 2002 and followed them up to skeletal maturity or until development of contralateral slip. Exclusion criteria included patients with endocrine or metabolic disorder, Down syndrome, and those with radiographs inadequate to determine the modified Oxford bone score. The initial radiographs were given a score ranging from 16 to 26. Statistical analysis was used to determine whether the modified Oxford bone score was predictive of future development of contralateral slip. A linear regression model was used to estimate the probability of future development of a contralateral slip as related to the modified Oxford bone score. Of the 260 patients, 64 (24%) developed a contralateral slip, at an average of 10 months after initial presentation. Race, sex, age, and weight at initial presentation were not predictive of the development of contralateral slip. The modified Oxford score and a triradiate score of 1 were found to be significant (P<0.0001) predictors, with the modified Oxford score a better overall predictor. The modified Oxford bone age score is the best predictor of the risk of development of a contralateral SCFE in patients presenting with a unilateral slip. Controversy exists regarding prophylactic pinning of a normal hip in patients presenting with unilateral SCFE. The benefits of prophylactic pinning must outweigh risk. This study provides probability data for predicting a contralateral slip based on the modified Oxford bone maturity score that can be shared with families and allows physicians to decide their threshold for prophylactically pinning the contralateral hip in patients presenting with a unilateral slip. Therapeutic level IV, Case series.