Hip Deformity Research Articles

Pre-operative templating in THA. Part I: a classification of architectural hip deformities.

While numerous classifications of hip arthritis have been proposed, none considered the magnitude and direction of femoral head translation relative to the native acetabulum. A more precise classification of architectural hip deformities is necessary to improve preoperative templating and anticipate surgical challenges of total hip arthroplasty (THA). The purpose of the present study was to introduce a classification system to distinguish different types of architectural hip deformities, based on femoral head translation patterns, and to evaluate its repeatability using plain radiographs (qualitative) and Computed Tomography (CT) measurements (quantitative). We studied pre-operative frontal and lateral hip radiographs and CT scans of 191 hips (184 patients) that received primary THA. The distance between the femoral head center (FC) and the acetabular center (AC) was measured, as well as femoral offset, acetabular offset, head center height, acetabular floor distance and femoral neck angle. The hips were classified qualitatively using frontal plain radiographs, and then quantitatively using CT scans (with an arbitrary threshold of 3mm as Centered, Medialized, Lateralized, Proximalized or Proximo-lateralized. The agreement between qualitative and quantitative classification methods was compared for applying the same classification. Qualitative classification identified 120 centered (63%), 8 medialized (4%), 49 lateralized (26%), 3 proximalized (2%), and 11 proximo-lateralized (6%) hips, while quantitative classification identified 116 centered (61%), 8 medialized (4%), 51 lateralized (27%), 5 proximalized (3%), and 11 proximo-lateralized (6%) hips. The agreement between the two methods was excellent (0.94; CI 0.90-0.98). Medialization reached 9.7mm, while lateralization reached 10.9mm, and proximalization reached 8.5mm. Proximalized and proximo-lateralized hips had more valgus necks, while medialized hips had more varus necks (p = 0.003). The classification system enabled repeatable distinction of 5 types of architectural hip deformities. The excellent agreement between quantitative and qualitative methods suggests that plain radiographs are sufficient to classify architectural hip deformities.

Cerebral palsy - beyond hip deformities.

Cerebral palsy is a neurologic condition with myriad musculoskeletal and articular manifestations. While every patient is unique with innumerable variations in presentation, symptoms and treatments, there are broad themes and recognizable patterns of development. Many of these findings spill over to other neurodevelopmental disorders, and lessons learned from children with cerebral palsy translate well to multiple neurologic conditions. This review focuses on the more common manifestations involving the spine, knee, foot and ankle, with an emphasis on collecting and describing imaging features, along with clinical and radiologic pearls and pitfalls.

Postural Stability in Children with High Sacral Level Spina Bifida: Deviations from a Control Group

Objective: To assess static and dynamic postural stability changes in children with high sacral level spina bifida.Methods: Thirty-five children with high sacral level spina bifida and 35 age-matched healthy controls were enrolled. Their lower extremity muscle strengths and static and dynamic postural stability parameters were measured with the use of a dynamometer and the NeuroCom Balance Master® device, respectively. Functional gait and balance were evaluated using the five times sit-to-stand test (5STS) and the 6-minute walk test (6MWT). Spinal, hip, and ankle deformities of the patient group were measured by radiologic evaluation.Results: In comparison with controls, patients were found to have lower ankle dorsiflexion and plantar-flexion strength, increased 5STS duration, and decreased 6MWT distance while both static and dynamic postural stability parameters were significantly different. Bilateral ankle muscle strengths were found to be negatively correlated with postural stability parameters. The presence of hydrocephalus or meningomyelocele in the patient group was found to have negative effects on static postural stability.Conclusion: Static and dynamic postural stability is affected even in children with high sacral level spina bifida who are expected to have best condition in this patient population. The ankle muscle strength is the main factor influencing these changes.

Patient-Specific 3-D Magnetic Resonance Imaging–Based Dynamic Simulation of Hip Impingement and Range of Motion Can Replace 3-D Computed Tomography–Based Simulation for Patients With Femoroacetabular Impingement: Implications for Planning Open Hip Preservation Surgery and Hip Arthroscopy

Background: Femoroacetabular impingement (FAI) is a complex 3-dimensional (3D) hip abnormality that can cause hip pain and osteoarthritis in young and active patients of childbearing age. Imaging is static and based on 2-dimensional radiographs or computed tomography (CT) scans. Recently, CT-based 3D impingement simulation was introduced for patient-specific assessments of hip deformities, whereas magnetic resonance imaging (MRI) offers a radiation-free alternative for surgical planning before hip arthroscopic surgery. Purpose: To (1) investigate the difference between 3D models of the hip, (2) correlate the location of hip impingement and range of motion (ROM), and (3) correlate diagnostic parameters while comparing CT- and MRI-based osseous 3D models of the hip in symptomatic patients with FAI. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: The authors performed an institutional review board–approved comparative and retrospective study of 31 hips in 26 symptomatic patients with FAI. We compared CT- and MRI-based osseous 3D models of the hip in the same patients. 3D CT scans (slice thickness, 1 mm) of the entire pelvis and the distal femoral condyles were obtained. Preoperative MRI of the hip was performed including an axial-oblique T1 VIBE sequence (slice thickness, 1 mm) and 2 axial anisotropic (1.2 × 1.2 × 1 mm) T1 VIBE Dixon sequences of the entire pelvis and the distal femoral condyles. Threshold-based semiautomatic reconstruction of 3D models was performed using commercial software. CT- and MRI-based 3D models were compared with specifically developed software. Results: (1) The difference between MRI- and CT-based 3D models was less than 1 mm for the proximal femur and the acetabulum (median surface distance, 0.4 ± 0.1 mm and 0.4 ± 0.2 mm, respectively). (2) The correlation for ROM values was excellent (r = 0.99, P < .001) between CT and MRI. The mean absolute difference for flexion and extension was 1.9°± 1.5° and 2.6°± 1.9°, respectively. The location of impingement did not differ between CT- and MRI-based 3D ROM analysis in all 12 of 12 acetabular and 11 of 12 femoral clock-face positions. (3) The correlation for 6 diagnostic parameters was excellent (r = 0.98, P < .001) between CT and MRI. The mean absolute difference for inclination and anteversion was 2.0°± 1.8° and 1.0°± 0.8°, respectively. Conclusion: Patient-specific and radiation-free MRI-based dynamic 3D simulation of hip impingement and ROM can replace CT-based 3D simulation for patients with FAI of childbearing age. On the basis of these excellent results, we intend to change our clinical practice, and we will use MRI-based 3D models for future clinical practice instead of CT-based 3D models. This allows radiation-free and patient-specific preoperative 3D impingement simulation for surgical planning and simulation of open hip preservation surgery and hip arthroscopic surgery.

Arthroplasty for Congenital Hip Deformity

Development dysplasia of the hip is complex problem encompassing a spectrum of anatomical abnormalities. Total hip arthroplasty (THA) has emerged as the gold standard for management of secondary osteoarthritis due to hip dysplasia. Unique acetabular and femoral anatomy presents many challenges to reconstructive surgeons. However, the goals of THA for these patients mirror the goals of THA for nondysplastic patients. Classification systems, such as the Crowe and Hartofilakidis systems, have been created to facilitate discussion and management of these unique challenges, and numerous techniques have been described to meet these demands, with the goal of recreating normal anatomy for these patients. On the acetabular side, surgeons aim to restore the native hip center will ensuring adequate acetabular implant coverage, while on the femoral side, they seek to restore normal femoral anteversion and provide equal leg lengths. This article details the various challenges reconstructive surgeons face, and the tools at their disposal to achieve the stated goals. When properly executed, THA for development dysplasia of the hip has shown excellent results, with no difference in outcomes for mildly dysplastic hips, though higher rates of mechanical failure for severely dysplastic hips.

Analyzing risk factors for recurrence of developmental coxa vara after surgery.

PurposeTo evaluate the risk factors for developmental coxa vara (DCV) recurrence following valgus osteotomy of the proximal femur.MethodsWe retrospectively reviewed records of 32 DCV patients (46 hips) treated surgically (2005 to 2012). Recurrence-related factors, including age at initial surgery, side, sex, fixation methods, diagnosis of coxa vara, premature capital femoral physeal closure and postoperative Hilgenreiner epiphyseal (HE) angle, head-shaft (HS) angle, medial femoral offset and posterior slope angle (PSA) were analyzed.ResultsAt 4.7-year mean follow-up, 12 hip deformities recurred (26%). Postoperative HE angle > 41° and negative offset were statistically significant univariate and multivariate risk factors for the deformity recurrence. Increased PSA was common preoperatively, which accounted for 59% of hips. Postoperative PSA > 20° was associated with a high recurrence rate in the univariate analysis. Age was another univariate risk factor for the recurrence. Recurrence rate was 52% in the < 6.5-year age group versus 4% in the > 6.5-year age group. Other factors were not statistically significantly related to recurrence.ConclusionDCV is a 3D deformity. To prevent recurrence, HE angle should be restored to < 41° in the coronal plane. Sagittal malalignment (abnormal PSA) should be corrected concurrently, so that, the direction of surgical correction is along the true deformity plane. During valgus osteotomy, the distal fragment should be lateralized to maintain a normal mechanical axis.Level of EvidenceIV

Hip Radiograph Findings in Patients Aged 40 Years and Under with Posterior Pelvic Pain.

Several sacroiliac joint (SIJ) provocative tests used to assess posterior pelvic pain involve moving and stressing the hip. It is unknown if there is a subgroup of patients with posterior pelvic pain who have underlying hip deformity that could potentially influence performance and interpretation of these tests. To describe the prevalence of radiographic hip deformity and hip osteoarthritis in a group of adults 40 years old and under who met the clinical diagnostic criteria for treatment of posterior pelvic pain with an image guided intra-articular SIJ injection. Retrospective cohort study. Tertiary university orthopedic department PATIENTS (OR PARTICIPANTS): One hundred and forty-eight patients were evaluated (83% (123/148) female; mean age 31.3 ± 6.2 years). All had completed a trial of comprehensive noninvasive treatment for posterior pelvic pain and had a minimum of three positive SIJ provocative tests on physical examination. Retrospective review identified patients undergoing SIJ injection for pain recommended and performed by seven physiatrists between 2011 and 2017. Hip radiographs were read by a physician with expertise in hip measurements with previously demonstrated excellent intrarater reliability. Percentage of patients with hip deformity findings. No patients meeting the inclusion criteria had significant radiographic hip osteoarthritis (Tonnis ≥2 indicating moderate or greater radiographic hip osteoarthritis) and 4/148 (3%) were found to have mild radiographic hip osteoarthritis. Prearthritic hip disorders were identified in 123 (83%, 95% CI: 76, 89%) patients. For those patients with prearthritic hip disorders, measurements consistent with femoroacetabular impingement (FAI) were seen in 61 (41%) patients, acetabular dysplasia in 49 (33%) patients, and acetabular retroversion in 85 (57%) patients. Acetabular retroversion was identified in 43% (crossover sign) and 39% (prominent ischial spine) of patients. Approximately 57% of adult patients under the age of 40 years with the clinical symptom complex of SIJ pain were found to have radiographic acetabular retroversion. This is a higher percentage than the 5%-15% found in asymptomatic people in the current literature. Further study is needed to assess links between hip structure, hip motion, and links to pelvic pain including peri and intra-articular SIJ pain. III.

Automatic MRI-based Three-dimensional Models of Hip Cartilage Provide Improved Morphologic and Biochemical Analysis.

The time-consuming and user-dependent postprocessing of biochemical cartilage MRI has limited the use of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). An automated analysis of biochemical three-dimensional (3-D) images could deliver a more time-efficient and objective evaluation of cartilage composition, and provide comprehensive information about cartilage thickness, surface area, and volume compared with manual two-dimensional (2-D) analysis. (1) How does the 3-D analysis of cartilage thickness and dGEMRIC index using both a manual and a new automated method compare with the manual 2-D analysis (gold standard)? (2) How does the manual 3-D analysis of regional patterns of dGEMRIC index, cartilage thickness, surface area and volume compare with a new automatic method? (3) What is the interobserver reliability and intraobserver reproducibility of software-assisted manual 3-D and automated 3-D analysis of dGEMRIC indices, thickness, surface, and volume for two readers on two time points? In this IRB-approved, retrospective, diagnostic study, we identified the first 25 symptomatic hips (23 patients) who underwent a contrast-enhanced MRI at 3T including a 3-D dGEMRIC sequence for intraarticular pathology assessment due to structural hip deformities. Of the 23 patients, 10 (43%) were male, 16 (64%) hips had a cam deformity and 16 (64%) hips had either a pincer deformity or acetabular dysplasia. The development of an automated deep-learning-based approach for 3-D segmentation of hip cartilage models was based on two steps: First, one reader (FS) provided a manual 3-D segmentation of hip cartilage, which served as training data for the neural network and was used as input data for the manual 3-D analysis. Next, we developed the deep convolutional neural network to obtain an automated 3-D cartilage segmentation that we used as input data for the automated 3-D analysis. For actual analysis of the manually and automatically generated 3-D cartilage models, a dedicated software was developed. Manual 2-D analysis of dGEMRIC indices and cartilage thickness was performed at each "full-hour" position on radial images and served as the gold standard for comparison with the corresponding measurements of the manual and the automated 3-D analysis. We measured dGEMRIC index, cartilage thickness, surface area, and volume for each of the four joint quadrants and compared the manual and the automated 3-D analyses using mean differences. Agreement between the techniques was assessed using intraclass correlation coefficients (ICC). The overlap between 3-D cartilage volumes was assessed using dice coefficients and means of all distances between surface points of the models were calculated as average surface distance. The interobserver reliability and intraobserver reproducibility of the software-assisted manual 3-D and the automated 3-D analysis of dGEMRIC indices, thickness, surface and volume was assessed for two readers on two different time points using ICCs. Comparable mean overall difference and almost-perfect agreement in dGEMRIC indices was found between the manual 3-D analysis (8 ± 44 ms, p = 0.005; ICC = 0.980), the automated 3-D analysis (7 ± 43 ms, p = 0.015; ICC = 0.982), and the manual 2-D analysis.Agreement for measuring overall cartilage thickness was almost perfect for both 3-D methods (ICC = 0.855 and 0.881) versus the manual 2-D analysis. A mean difference of -0.2 ± 0.5 mm (p < 0.001) was observed for overall cartilage thickness between the automated 3-D analysis and the manual 2-D analysis; no such difference was observed between the manual 3-D and the manual 2-D analysis.Regional patterns were comparable for both 3-D methods. The highest dGEMRIC indices were found posterosuperiorly (manual: 602 ± 158 ms; p = 0.013, automated: 602 ± 158 ms; p = 0.012). The thickest cartilage was found anteroinferiorly (manual: 5.3 ± 0.8 mm, p < 0.001; automated: 4.3 ± 0.6 mm; p < 0.001). The smallest surface area was found anteroinferiorly (manual: 134 ± 60 mm; p < 0.001, automated: 155 ± 60 mm; p < 0.001). The largest volume was found anterosuperiorly (manual: 2343 ± 492 mm; p < 0.001, automated: 2294 ± 467 mm; p < 0.001). Mean average surface distance was 0.26 ± 0.13 mm and mean Dice coefficient was 86% ± 3%. Intraobserver reproducibility and interobserver reliability was near perfect for overall analysis of dGEMRIC indices, thickness, surface area, and volume (ICC range, 0.962-1). The presented deep learning approach for a fully automatic segmentation of hip cartilage enables an accurate, reliable and reproducible analysis of dGEMRIC indices, thickness, surface area, and volume. This time-efficient and objective analysis of biochemical cartilage composition and morphology yields the potential to improve patient selection in femoroacetabular impingement (FAI) surgery and to aid surgeons with planning of acetabuloplasty and periacetabular osteotomies in pincer FAI and hip dysplasia. In addition, this validation paves way to the large-scale use of this method for prospective trials which longitudinally monitor the effect of reconstructive hip surgery and the natural course of osteoarthritis. Level III, diagnostic study.

Complications associated with combined surgical hip dislocation and periacetabular osteotomy for complex hip deformities.

Surgical hip dislocation (SD) and periacetabular osteotomy (PAO) are well-described treatments for femoroacetabular impingement (FAI) and acetabular dysplasia, respectively. Occasionally, complex deformities require a combined SD/PAO; the morbidity of performing both procedures in a single stage has not been fully investigated. We performed a retrospective review of a consecutive group of patients undergoing combined SD/PAO to investigate the incidence and character of perioperative complications. Forty-five patients (46 hips) were identified. Perioperative complications were graded by the modified Clindo-Davien complication scheme. Mean follow-up was 36 months (range 12–128), and no patients were lost to follow-up. Six complications occurred in six hips (13%). Four (8.7%) complications were minor (Grades I or II): one Brooker Grade III heterotopic ossification requiring no treatment, one superior pubic ramus nonunion requiring no treatment and two superficial wound infections requiring antibiotics. Two (4.3%) complications were major (Grades III or IV): one coxa saltans interna and labral tear requiring hip arthroscopy with labral repair and iliopsoas lengthening, and one deep surgical site infection requiring irrigation and debridement followed by development of arthritis requiring conversion to arthroplasty. The average Harris hip score improved from 62 ± 13 preoperatively to 80 ± 19 at final follow-up. Except for the single joint replacement, there were no long-term disabilities. There were no major neurovascular injuries, osteonecrosis, fractures or trochanteric nonunions. Combined SD/PAO for the treatment of complex, concomitant deformities of the proximal femur and acetabulum is associated with an acceptable risk of complications. The vast majority of complications that occurred were managed without permanent disability. Level of Evidence: IV

Sportsmen's groin : Definition, differential diagnosis and treatment

Groin pain in athletes is acommon problem and can have extensive consequences for professional athletes. The anatomical and functional complexity of the groin as well as radiating pain from remote anatomical regions can make the differential diagnosis achallenge and requires special attention. As there are awide variety of possible causes for groin pain, amultidisciplinary approach is required. The treating orthopedic surgeon needs to pay special attention to pre-arthritic hip deformities to avoid irreversible damage of the hip joint. By ameticulous patient history and identification of the pain character, followed by clinical, sonographic and radiographic investigations, adifferential diagnosis can usually be achieved. Besides typical orthopedic causes, pathological findings particularly in the area of the groin need to be considered, clarified and adequately treated; therefore, aclear terminology of the different diseases is necessary. Sportsmen's groin is not ahernia but should be perceived as aseparate entity due to its typical pain character and detection of ameasurable protrusion of the posterior wall of the inguinal canal by ultrasound.

The clinical presentation, diagnosis and pathogenesis of symptomatic sports-related femoroacetabular impingement (SRFAI) in a consecutive series of 1021 athletic hips.

Aim:To examine the pathogenesis and clinical presentation of sports-related femoroacetabular impingement (SRFAI) in a large consecutive series of symptomatic athletes.Methods:Between January 2009 and February 2017 prospectively collected data from competitive athletes within the Gaelic Athletic Association (GAA), and who subsequently underwent arthroscopic treatment for symptomatic FAI, were analysed. Data was collected using internationally validated health questionnaires (Harris Hip Score, UCLA, SF-36, WOMAC) and recognised clinical (ROM, symptom presentation, provocation tests) and radiological (AP pelvis, Dunn, False profile) indicators/measures of FAI.Results:A total of 1021 consecutive cases (mean 26.6 ± 6.2 years) were included. In every case, conservative treatment failed to resolve symptoms with athletes attending an average of 2.4 ± 1.1 health care professionals prior to referral. Symptoms developed gradually (78%) and consisted primarily of groin pain (76.1%) and hip stiffness (76.5%) following activity.An acetabular rim deformity (pincer) was present in all cases; a cam deformity in 72.1%. The prevalence and degree of cam deformity increased with progressing age groups (p < 0.001); mean lateral centre-edge angle remained static (p = 0.456). Increasing CEA, alpha angle and presence of rim fracture was associated with a reduction in all ranges of hip movement (p < 0.001).Conclusion:Symptomatic SRFAI presented in this large series of GAA athletes failed to resolve with non-operative treatment. Increasing hip deformity resulted in poorer ROM. Abnormal acetabular morphology remains static with increasing athletic age while cam deformity is progressive and most likely a secondary pathology.

Utilization of electromyography during selective obturator neurotomy to treat spastic cerebral palsy accompanied by scissors gait.

Selective obturator neurotomy is a commonly used neurosurgical intervention for spastic cerebral palsy with scissors gait. Here we report the use of surface electromyography to assess the accuracy and effect of selective obturator neurotomy procedures. Selective obturator neurotomy was carried out on 18 patients while using intraoperative electromyography. Contractions of adductor muscles were recorded by electromyography before and after neurotomy and assessed using root mean square and integrated electromyography tests. Passive and voluntary movements were recorded for all patients. Our results show that adductor spasms and adductive deformity of hip were improved in all patients with spastic cerebral palsy. Adductor muscle spatiality was improved significantly, confirmed by a significant decrease in the values of root mean square and integrated electromyography in both passive and voluntary movements after surgery. We show that electromyography is an effective tool for accurately and safely targeting nerve tracts during selective obturator neurotomy. Thus, we demonstrate a valuable noninvasive method to objectively evaluate the effect of treatment in spastic cerebral palsy patients.

The effects of residual hip deformity on coronal alignment of the lower extremity in patients with unilateral slipped capital femoral epiphysis.

PurposeThe aim of our explorative study was to compare the differences in the coronal alignments of the hip, knee and ankle on the slip side and non-slip sides in patients with slipped capital femoral epiphysis (SCFE).MethodsThe study group consisted of 28 patients. On the full-length standing radiographs, measurements of articulo-trochanteric distance (ATD), neck-shaft angle (NSA), femoral offset, hip-knee-ankle axis, femur-tibial angle, mechanical axis deviation ratio (MAD-r), anatomical medial proximal femoral angle (aMPFA), mechanical lateral proximal femoral angle (mLPFA), anatomical lateral distal femoral angle (aLDFA), mechanical lateral distal femoral angle (mLDFA), knee joint line congruency angle, mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal tibial angle (mLDTA), ankle joint line orientation angle (AJOA), and leg length discrepancy (LLD) were performed. The data from the slip side were compared with those from the non-slip side.ResultsAt skeletal maturity, there were significant differences between the slip side and non-slip side in ATD (p <0.001), NSA (p <0.001), MAD-r (p <0.001), aMPFA (p <0.001), aLDFA (p = 0.03), mLDFA (p = 0.04), mLDTA (p = 0.02), AJOA (p <0.001) and LLD (p<0.001).ConclusionResidual deformity in the proximal femur after epiphyseal slip and premature epiphysiodesis could cause changes in the coronal alignment of the lower extremity. We can add lower extremity alignment examination to follow-up protocol to rule out secondary problems in patients with SCFE.Level of EvidenceLevel III, retrospective comparative study

Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities.

The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities. Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle. The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty. FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities.

Can We Discriminate Symptomatic Hip Patients From Asymptomatic Volunteers Based on Anatomic Predictors? A 3-Dimensional Magnetic Resonance Study on Cam, Pincer, and Spinopelvic Parameters

Background: Given the high prevalence of patients with hip deformities and no ongoing hip dysfunction, understanding the anatomic factors predicting the symptomatic state is critical. One such variable is how the spinopelvic parameters (SPPs) may interplay with hip anatomic factors. Hypothesis/Purpose: SPPs and femoral- and acetabular-specific parameters may predict which patients will become symptomatic. The purpose was to determine which anatomic characteristics with specific cutoffs were associated with hip symptom development and how these parameters relate to each other. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: 548 participants were designated either symptomatic patients (n = 176, scheduled for surgery with hip pain and/or functional limitation) or asymptomatic volunteers (n = 372, no pain) and underwent 3-dimensional magnetic resonance imaging. Multiple femoral (α angle, Ω angle, neck angle, torsion), acetabular (version, coverage), and spinopelvic (pelvic tilt, sacral slope [SS], pelvic incidence) parameters were measured semiautomatically. Normative values, optimal differentiating thresholds, and a logistic regression analysis were computed. Results: Symptomatic patients had larger cam deformities (defined by increased Ω angle and α angle), smaller acetabular coverage, and larger pelvic incidence and SS angles compared with the asymptomatic volunteers. Discriminant receiver operating characteristic analysis confirmed that radial 2-o’clock α angle (threshold 58°-60°, sensitivity 75%-60%, specificity 80%-84%; area under the curve [AUC] = 0.831), Ω angle (threshold 43°, sensitivity 72%, specificity 70%; AUC = 0.830), acetabular inclination (threshold 6°, sensitivity 65%, specificity 70%; AUC = 0.709), and SS (threshold 44°, sensitivity 72%, specificity 75%; AUC = 0.801) (P < .005) were the best parameters to classify participants. When parameters were entered into a logistic regression, significant positive predictors for the symptomatic patients were achieved for SS, acetabular inclination, Ω angle, and α angle at 2-o’clock, correctly classifying 85% of cases (model sensitivity 72%, specificity 91%; AUC = 0.919). Conclusion: Complex dynamic interplay exists between the hip and SPPs. A cam deformity, acetabular undercoverage, and increased SPP angles are predictive of a hip symptomatic state. SPPs were significant to discriminate between participants and were important in combination with other hip deformities. Symptomatic patients can be effectively differentiated from asymptomatic volunteers based on predictive anatomic factors.

Hip Arthroscopy for Femoroacetabular Impingement.

The first recorded attempt at arthroscopic visualization of the hip can be attributed to Dr. Michael Burman in 1931. Since then, hip arthroscopy has become widely used for the management of femoroacetabular impingement (FAI) because of its clear benefits, including a low complication rate and limited patient morbidity as compared with traditional open approaches. Arthroscopic management of FAI begins with arthroscopy of the central compartment, where the intra-articular damage is identified. Standard portal placement provides optimal access for surveying and accessing intra-articular injury. The pathological findings identified preoperatively and confirmed during diagnostic arthroscopy dictate the necessary arthroscopic procedures. Correction of acetabular overcoverage and repair of the labrum to the acetabular rim can correct pincer lesions. Femoral-sided cam lesions require removal of traction and application of hip flexion in order to perform a femoral osteoplasty to recreate a normal anatomic femoral head-neck offset. Finally, capsular management is performed as clinically indicated. Appropriate management of FAI typically begins with nonoperative care consisting of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy1. Intra-articular corticosteroid injections can also provide relief2. Open procedures involving surgical hip dislocation can be utilized to address pathological conditions not accessible arthroscopically. Additionally, a "mini-open" procedure in which intra-articular disorders are treated arthroscopically and cam lesions are resected via a small anterior exposure can be employed3,4. Hip arthroscopy offers a minimally invasive technique that can be effective for treating intra-articular hip disorders and is usually favored over open surgical dislocation. Hip arthroscopy has been shown to result in higher functional outcome scores than open procedures, with lower rates of complications5. Hip arthroscopy is playing an increasingly important role as an adjunct diagnostic and therapeutic tool in conjunction with open femoral and/or periacetabular osteotomy for complex hip deformities.

Treatment of Pipkin I and II hip fractures by anterolateral hip approach

To investigate the clinical effect of absorbable screw fixation by anterolateral approach (McFarland and Osborne approach) for the treatment of Pipkin type I and type II fractures. From March 2008 to February 2016, 8 cases of femoral head fractures were treated by absorbable screw fixation through anterolateral approach (McFarland and Osborne approach) including 5 males and 3 females with an average age of 36 years old ranging 23 to 58 years old. The course of the disease was 3 to 12 days (means 5 days). The symptoms at admission included hip pain, deformity and dysfunction. The X-ray and CT image showed femoral head fracture and posterior femoral dislocation. There were 2 cases of Pipkin type I and 6 cases of Pipkin type II. All patients received emergency reduction (Allis) of the posterior dislocation of the hip under the combined intravenous anesthesia. Bone traction was performed after successful reduction. The operation through McFarland and Osborne approach, the Thompson-Epstein system used to evaluate the curative effect postoperative. All the patients had primary healing after operation without other complications occurred. The 8 patients were followed up for 12 to 36 months with an average of 30 months. All of the patients review of X-ray and CT 6 months postoperative showed fractures consolidated, and the healing time was 3 to 6 months with an average of 4 months. According to Thompson-Epstein scoring system, hip function was excellent in 5 cases, good in 2 cases and fair in 1 case. The anterolateral approach of hip joint can not only retain the residual blood supply of femoral head, but also fully expose the acetabulum and femoral head. It is a relatively ideal surgical approach for the treatment of Pipkin type I and type II fractures.

Surgical correction of coxa vara: Evaluation of neck shaft angle, Hilgenreiner-epiphyseal angle for indication of recurrence

BackgroundCoxa vara is a hip deformity in which the femoral neck-shaft angle decreases below its normal value. Standard surgical treatment for this condition is corrective valgus osteotomy. Appropriate correction of the Hilgenreiner-epiphyseal angle is important to prevent recurrence. The purpose of this study is to: 1) evaluate the recurrence of the deformity at the latest follow up; and 2) find the appropriate angle of correction associated with the lowest recurrence. Methods34 hips in 31 patients who underwent surgery for treatment of coxa vara from 2005 to 2014 were included. Patient-reported outcomes, Hilgenreiner-epiphyseal angle, and neck-shaft angle were assessed preoperatively, postoperatively, and at latest follow-up. ResultsThe mean age at surgery was 10.99, with a range of 5–30, years. Preoperative neck-shaft angle ranged from 60 to 100 degrees, and Hilgenreiner-epiphyseal angle ranged from 60 to 90 degrees. At the latest follow up, the neck-shaft angle ranged from 120 to 135 degrees and the Hilgenreiner-epiphyseal angle ranged from 22 to 35 degrees (p < 0.001). The Harris hip score improved from 47.20 (34–66) to 79.68 (60–100) (p < 0.001). There was no recurrence of deformities at the mean follow up of 37.87 months. ConclusionSurgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to ≤ 35 degrees or the neck shaft angle corrected to > 120 degrees in order to prevent recurrence of the deformity. Majority of the patients were reported improvement of hip function. However, a longer-term follow up is required to determine further outcomes regarding to recurrence of the deformity.

Опыт использования аппаратов внешней фиксации в условиях ригидных деформаций тазобедренного сустава на этапе предоперационной подготовки и планирования сложных случаев первичного и ревизионного эндопротезирования

Опыт использования аппаратов внешней фиксации в условиях ригидных деформаций тазобедренного сустава на этапе предоперационной подготовки и планирования сложных случаев первичного и ревизионного эндопротезирования

Incidence and Diagnostic Evaluation of Postoperative Fever in Pediatric Patients With Neuromuscular Disorders

Children with neuromuscular disorders have a significant chance of developing scoliosis and/or hip dislocation during childhood and adolescence and often undergo surgical reconstruction. Because of their high rate of medical comorbidities, these patients are at higher risk of postoperative complications and are therefore often comanaged, along with orthopaedics, by pediatric medicine and critical care teams. Fever during the postoperative stay is a frequent occurrence and often prompts extensive diagnostic workup which increases the cost and burden on the health system but have unclear effects on the care of the patient. The objective of our study was to evaluate the frequency of postoperative fever in pediatric patients with neuromuscular disorders after spine and hip deformity correction surgery and evaluate the utility of the diagnostic tests performed for the assessment of postoperative fever. We performed an IRB-approved retrospective study on patients who underwent corrective surgery for neuromuscular scoliosis or hip dislocation at a single institution. The occurrence of postoperative fever was characterized by maximum temperature, postoperative day (POD) of occurrence, and frequency as defined by either single or multiple temperature spikes. Diagnostic tests performed for the workup of postoperative fever were reviewed. The cost per health effect was estimated by dividing the total costs of diagnostic tests by the number of tests that changed patient care. In total, 108 patients (62 females and 46 males) were identified. A total of 42 patients (38.9%) underwent posterior spinal fusion and 66 (61.1%) patients underwent hip surgery (pelvic osteotomy in 8 patients, femoral osteotomy in 31 patients, and both pelvic and femoral osteotomy in 27 patients). The mean age at the time of surgery was 11.1 years (range, 3 to 18 y). In total, 66 patients (61.1%) developed postoperative fever (mean temperature, 38.6°C). The frequency of fever was in the form of multiple temperature spikes in 37 patients (56%) and in the form of a single spike in 29 patients (44%). Of the 149 diagnostic tests performed for postoperative fever, there were a total of 16 positive tests (10.7% of total tests ordered; n=16/149) including 5/27 urine analysis, 4/26 urine culture, 4/28 chest x-ray, 1/1 wound culture, 0/1 sputum culture, urine Gram stain 0/1, tracheal aspirate culture 0/1, throat culture 1/1, adenovirus polymerase chain reaction (PCR) 0/5, human metapneumovirus PCR 0/5, parainfluenza PCR 0/5, rhinovirus PCR 0/1, 1/3 bronchoalveolar culture, and 0/7 respiratory virus panel. A total of 37 blood cultures were drawn and all were negative. There was a significant difference (P=0.04) in frequency of negative diagnostic workup performed at the first, second, and third POD as compared with positive diagnostic workup. Total cost of the diagnostic tests was $65,284 and the cost per health effect was $6582 ($65,284/10). Diagnostic tests in patients with postoperative fever were associated with prolonged length of hospital stay in comparison with patients who did not perform any diagnostic workup using the Spearman ρ test (P=0.02). In total, 61% of pediatric patients developed postoperative fever after surgical correction of neuromuscular deformity. An infectious source of postoperative fever was identified in 32.4% of patients with postoperative fever who underwent diagnostic workup. Urinary tract infection was the most common finding in patients with postoperative fever. Poor association between the development of postoperative fever and wound infection was found. Only 10.7% of fever diagnostic workup tests were positive in our population. The diagnostic workup tests might be less valuable if performed early on the first, second, and third PODs than those performed late after the third POD with exceptions based on clinical assessment. No patients with postoperative fever had positive blood cultures, therefore the routine use of blood cultures in the evaluation of postoperative fever in such population is not recommended. Level IV-retrospective.