Hip Preservation Surgery Research Articles

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios

In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to -15°. No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy.

There are no clear guidelines regarding optimal venous thromboembolism (VTE) prophylaxis for patients undergoing hip preservation surgery (HPS), in particular pelvic osteotomy, which is considered to be a major orthopaedic procedure. The aim of this study was to determine the efficacy of aspirin for VTE prophylaxis in a large cohort of patients undergoing femoroacetabular osteoplasty (FAO) and periacetabular osteotomy (PAO). This was a retrospective study of prospectively collected data on patients undergoing HPS. A total of 603 patients (643 cases) underwent FAO and 80 patients (87 cases) underwent PAO between 2003 and 2016. The mean age of patients was 34.3 years (range 14.3–68.1 years). The type of VTE prophylaxis administered changed over time with earlier patients receiving warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg twice daily (238 cases). The complications of symptomatic pulmonary embolism (PE), deep venous thrombosis (DVT) and major bleeding events within 90 days of surgery were documented. There were zero patients that developed major bleeding events or required evacuation of a hematoma. One patient who underwent FAO and received aspirin 325 mg, developed post-operative symptomatic DVT. One patient who underwent PAO and received aspirin 325 mg developed DVT and PE. This study demonstrates that the incidence of VTE following joint preservation procedure is acceptably low. Administration of aspirin to patients undergoing FAO or PAO appears to be adequate in reducing the risk of VTE. Only two patients in this cohort developed VTE following HPS.

The management of the painful borderline dysplastic hip.

Improved imaging and the evolution of surgical techniques have permitted a rapid growth in hip preservation surgery over the last few decades. The management of the painful borderline dysplastic hip however remains controversial. In this review, we will identify the pertinent issues and describe the patient assessment and treatment options. We will provide our own recommendations and also identify future areas for research.

Combined open and arthroscopic approaches in hip preservation surgery

Beyond the recent advances of intra-articular hip arthroscopy, this review article introduces endoscopic assisted osteotomies including periacetabular osteotomy and shelf acetabuloplasty, management for snapping hip and nerve entrapment in the deep gluteal space using innovative strategies.

Conversion vs Primary Total Hip Arthroplasty: Increased Cost of Care and Perioperative Complications

BackgroundWith the increasing incidence of hip fractures and hip preservation surgeries, there has been a concomitant rise in the number of conversion total hip arthroplasties (THAs) performed. Prior studies have shown higher complication rates in conversion THA. However, there is a paucity of data showing differences in cost between these 2 procedures. Currently, the Center for Medicare and Medicaid Services bundles primary and conversion THA in the same Medicare Severity–Diagnosis Related Group for hospital reimbursement. More evidence is needed to support the reclassification of conversion THA. MethodsThe cohort provided by the institutional database included 163 conversion THAs between January 1, 2012 and December 31, 2015. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and perioperative cost data were analyzed for 163 primary THA patients matched to the conversion THA cohort. ResultsCompared with primary THA, conversion THA had significantly (P < .05) greater cost for direct labor, other direct costs, intermediate nursing services, other diagnostic/therapy, surgery services, physical/occupational/speech therapy, radiology, laboratories, blood, medical/surgical supply, and total direct costs. In addition, the conversion THA group had significantly greater operative times, estimated blood loss, length of stay, intraoperative complications, and postoperative complications. ConclusionConversion THA, as compared with primary THA, is associated with greater costs (approximately 19% greater), increased surgical times, and perioperative complications. To prevent these additional expenses from creating patient selection bias and a barrier to care, the conversion THA Medicare Severity-Diagnosis Related Group should be reclassified, or modifiers created.

Fenestration and debridement combined with percutaneous minimally invasive fibula implantation in the treatment of senile degenerative osteonecrosis of the femoral head: A study protocol for a non-randomized, controlled, clinical trial

Background and objectives: Osteonecrosis of the femoral head is one of the common forms of senile degenerative osteoarthropathy. The hip preservation surgery techniques that are currently commonly used include femoral head fenestration, debridement and bone grafting through an anterior approach, and debridement and impaction bone grafting with fibula support through a lateral approach with subtrochanter drilling. These two techniques cause great trauma to the patients, and surgery costs are high. Femoral head collapse occurs easily after surgery. The course inhibition of necrosis of the femoral head and repair effect are not ideal. Thus, we hope to develop a new repair method that can make up for the shortcomings of conventional hip preservation surgery. We will observe the therapeutic effect of fenestration and debridement combined with percutaneous minimally invasive fibula implantation. This low-cost procedure for senile osteonecrosis of the femoral head should have little intraoperative trauma. We will determine if it also prevents postoperative femoral head collapse. Design: This is a prospective, multicenter, non-randomized, controlled, clinical trial. Methods: Seventy patients (117 hips) with senile degenerative osteonecrosis of the femoral head will be recruited from the Hebei Provincial Youfu Hospital and the Third Hospital of Hebei Medical University, Shijiazhuang, China. The patients will be allocated into three groups according to the repair method. (1) Patients in the drilling debridement group will undergo conventional debridement and impaction bone grafting with fibula support through a lateral approach with subtrochanter drilling. (2) Patients in the fenestration debridement group will undergo conventional femoral head fenestration, debridement, and bone grafting through an anterior approach. (3) Patients in the combination repair group will undergo fenestration, debridement, and impaction bone grafting combined with percutaneous minimally invasive fibula implantation. Each group will include 39 hips. Follow-up will be conducted for 12 months. Outcome measures: The primary outcome measure is the incidence of femoral head collapse on the affected side at 12 months after surgery. The secondary outcome measures are intraoperative blood loss, operation time, hospital costs, and Harris hip score for hip function before surgery and 6 and 12 months after surgery and the incidence of adverse reactions at 6 and 12 months after surgery. Discussion: Our results can verify whether the effect of fenestration and debridement combined with percutaneous minimally invasive fibula implantation is better than those of the other two types of conventional hip preservation techniques in the treatment of senile osteonecrosis of the femoral head. In addition, we will validate whether the combined method clearly inhibits postoperative femoral head collapse and improves hip function. Ethics and dissemination: This trial has been approved by the Ethics Committee of Third Hospital of Hebei Medical University of China (approval number: KE2016-011-1). The study protocol will be conducted in accordance with the Declaration of Helsinki, formulated by the World Medical Association. Written informed consent will be obtained from all participants. This trial was designed in January 2014. Ethics approval was done in December 2014. The recruitment of subjects will begin in June 2018. Samples and data will be collected from June 2018 to June 2019. Outcome measures will be analyzed in August 2019. This trial will be completed in December 2019. The results of the trial will be reported in a scientific conference or disseminated in a peer-reviewed journal. Trial registration: This trial was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR1800015124).

Intra-Articular Hip Injection Is a Valuable and Cost-Effective Diagnostic Tool but Replacing Advanced Diagnostic Methods Is Not Currently the Way to Go: Commentary on an article by Daniel J. Cunningham, MD, MHS, et al.: "Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome".

Commentary Cunningham et al. conducted a cost-effectiveness analysis of the diagnostic process for femoroacetabular impingement (FAI) syndrome. With the tremendous increase of the therapeutic and diagnostic costs of this pathology, the data presented in this study are noteworthy from a clinical and a financial standpoint. The article concludes that advanced imaging, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA), are not cost-effective methods when compared with the history and physical examination (H&P) with or without diagnostic hip injection, and thus should not be routinely performed to diagnose FAI. It was suggested that hip MRI and MRA should have a place in the diagnostic algorithm of FAI only in cases of “challenging clinical scenarios.” The use of diagnostic hip injection was proven to be favorable for general practitioners and less useful for hip specialists. FAI syndrome was redefined in an international consensus statement and was endorsed by 25 clinical societies1. Hip pain can be the result of bone lesions and cartilage damage, as well as labral, capsular, and ligamentum teres pathology. Although the H&P and hip radiographs can identify osseous abnormalities, labral or capsular pathology is left undiagnosed, and evaluation of the cartilage is impossible without MRI. With the substantial expansion of hip arthroscopic techniques2, it is possible to address osseous and soft-tissue lesions that, if left untreated, result in deterioration of hip biomechanical function and osteoarthritis3. The novelty of and rapid progression in diagnostic and treatment modalities in hip preservation surgery have resulted in an imbalance of medical knowledge between general practitioners and hip specialists. Cunningham et al. propose that H&P with injection is more likely to be cost effective for general practitioners. Administration of hip injection requires technical expertise since severe damage can occur in the hip when performed inappropriately. The former point is reflected in the results of the study: the willingness to pay (WTP) was $57,000/quality-adjusted life year (QALY) using the injection sensitivity rate in the general practitioner scenario. This amount is almost 50% lower than the accepted WTP threshold in the United States, which is $100,000. The elimination of the use of MRI and MRA in cases of “challenging clinical scenarios” would be reasonable if the level of education was equal between general practitioners and hip specialists because characterizing a clinical scenario as “clinically challenging” relies substantially on clinical expertise, which can differ considerably even among hip specialists. Hip joint ultrasonography in the diagnosis of FAI syndrome has attracted research interest. Ultrasound is less expensive and more accessible than MRI and MRA examination, but diagnostic accuracy depends on the examiner’s skills. Buck et al. reported that the acetabular labrum can be visualized using ultrasound, but only partially4. Evaluation of the interference of the labrum with the other joint structures during hip motion under ultrasound visualization could help to better understand the patient’s symptomatology and aid in preoperative planning. MRI has been used in studies as the gold standard to validate ultrasound for the diagnosis of cam impingement, with promising outcomes4,5, but not enough evidence exists to establish it as a reliable examination to diagnose FAI syndrome. Another advantage of preoperative MRI examination is the detection of occult malignant bone or soft-tissue tumors concomitant with FAI pathology, where arthroscopic hip intervention could cause tissue spread and subsequent metastatic disease. While Cunningham et al. support the reduction of MRI and MRA usage to diagnose FAI syndrome, currently there is no other validated tool to diagnose hip soft-tissue and cartilage lesions. A possible solution to limit the financial burden when diagnosing FAI syndrome would be an increase in training opportunities for health-care professionals to advance their knowledge of FAI syndrome (apart from the cam and pincer mechanisms), with specialized physical examination tests and radiographic views (cross-table lateral, Dunn view, or false-profile view). This would eliminate the need for repeated radiographs by specialized physicians who usually encounter a patient who has been diagnosed with FAI syndrome based on symptomatology, impingement tests, and/or anteroposterior pelvic radiographs. Overuse of MRI and MRA and the associated costs need to be addressed by establishing validated hip-screening protocols to diagnose FAI syndrome. This will bridge the “gap” between general practitioners and hip specialists when diagnosing this disease and prevent the misuse of MRI and MRA and overcharging of the health-care system.

Hip preservation surgery—Can we change the natural history of osteoarthritis?

Structural abnormalities of the hip including developmental dysplasia (DDH) and femoroacetabular impingement (FAI) are a predominant cause of primary osteoarthritis. While affected patients may have significant pain and functional limitations, many may remain asymptomatic and will likely incur intra-articular damage over time. The objective of this review is to explore the natural history of DDH, FAI, and the current outcomes of hip preservation surgery including peri-acetabular osteotomy, hip arthroscopy, and surgical hip dislocation.

Experience and outcome data of the British non-arthroplasty hip registry

The non-arthroplasty hip registry (NAHR) is a United Kingdom national register that monitors the efficacy of hip preservation surgery. We aim to highlight early experiences of incorporating the NAHR into our practice at a tertiary centre. Between December 2013 and February 2015, 381 patients were identified on the NAHR database that had undergone non-arthroplasty hip surgery. Patient-related outcome measures EuroQuol 5D-5L (EQ-5D) and the International Hip Outcome Tool 12 (iHOT-12) were recorded at baseline and 6 months. The 289 arthroscopic surgeries showed a statistical significant difference (p<0.05) in iHOT-12 for both males (45.21-65.07) and females (34.57 to 55.53), and in EQ-5D for both males (0.59-0.75) and females (0.56-0.65). The 92 open procedures showed a statistical significant difference (p<0.05) in both iHOT-12 (31.71-62.42) and EQ-5D (0.54-0.68). Overall our results from the NAHR indicate hip preservation surgery is effective at relieving pain and improving quality of life in the short term.

Relationship Between Age at Onset of Symptoms and Intraoperative Findings in Hip Arthroscopic Surgery.

Background:Hip arthroscopic surgery is intended to treat multiple abnormalities in an effort to delay the progression to osteoarthritis, especially in young patients. However, the length of time in which patients experience joint pain before seeking a specialist for a diagnosis can delay hip preservation surgery and influence clinical outcomes.Purpose:To investigate the relationship between age at symptom onset and findings during hip arthroscopic surgery as well as outcomes after 2 years of clinical follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:From February 2008 to March 2015, data were prospectively collected on all patients undergoing hip arthroscopic surgery at a single institution. Anatomic and pathological characteristics were recorded intraoperatively. The mean age at onset of symptoms was calculated and correlated with intraoperative findings using Pearson correlation and logistic regression. All patients were assessed preoperatively and postoperatively with 4 patient-reported outcome measures: the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL), and the Hip Outcome Score–Sport-Specific Subscale (HOS-SSS). Pain was estimated using a visual analog scale (VAS). Furthermore, patients with an age at onset of symptoms below the mean (34.6 years) were compared with those of an age at onset of symptoms above the mean. The 2 groups were compared using the Student t test and the chi-square test. P values <.05 were considered significant.Results:A total of 1697 patients met the inclusion criteria. Body mass index was weakly correlated with age (r = 0.3). Younger patients had a lower prevalence of combined Seldes type 1 and 2 labral tears; acetabular labrum articular disruption (ALAD) grade 2, 3, and 4 acetabular chondral lesions; and Outerbridge grade 2, 3, and 4 femoral head chondral lesions (P < .05 for all). More advanced age was correlated with wider labral tears and chondral lesions based on a clock face (r ≥ 0.2, P < .05). Patients younger than 34.6 years had a lower prevalence of gluteus medius and ligamentum teres tears (P ≤ .001). The prevalence of synovitis was positively correlated with age, while instability was negatively correlated with age (P = .04). The improvement of scores from preoperatively to 2-year follow-up in the younger patient group was 62.69 to 83.82 for the mHHS, 64.97 to 87.35 for the HOS-ADL, 43.46 to 73.37 for the HOS-SSS, 63.01 to 85.19 for the NAHS, and 5.61 to 2.53 for pain VAS. All score improvements were statistically significant (P < .001). Regarding the older patient group, the improvement of scores from preoperatively to 2-year follow-up was 58.55 to 78.27 for the mHHS, 57.59 to 79.66 for the HOS-ADL, 35.63 to 61.88 for the HOS-SSS, 55.28 to 77.55 for the NAHS, and 5.72 to 3.01 for pain VAS. All score improvements were statistically significant (P < .001).Conclusion:Of the multiple intraoperative findings in hip arthroscopic surgery, many are related to age at onset of symptoms. Although we found a statistically significant improvement in clinical outcomes in both groups after 2-year follow-up, apparently the less complex and smaller lesions observed in both the articular cartilage and the labrum of younger patients result in better outcomes compared with older patients.

Multimodal Neuromonitoring During Safe Surgical Dislocation of the Hip for Joint Preservation: Feasibility, Safety, and Intraoperative Observations.

Introduction:Nerve injuries can occur from major hip surgeries, and some may be significant. Our goal was to assess the feasibility and safety of neuromonitoring during hip preservation surgery and the incidence of alerting events during such monitoring.Methods:Twenty-five adult patients underwent surgical hip dislocation for femoroacetabular impingement. Upper and lower extremity somatosensory evoked potentials, lower extremity transcranial motor evoked potentials, and lower extremity electromyography were recorded.Results:We observed a temporary reduction of the monitored parameters in twelve patients (48%) during surgery. There were no clinically significant neurological deficits postoperatively in any cases.Discussion:Neuromonitoring did demonstrate events during hip surgery in our case series. Although it may not be practical to use neuromonitoring in all major hip surgeries, it may be prudent from the perspective of patient safety to use it in high-risk cases, including those requiring prolonged surgical time; in patients with high body mass index, excessive deformity correction, and preexisting neuropathy; and in revision cases, among others.

Prevalence of Femoral and Acetabular Version Abnormalities in Patients With Symptomatic Hip Disease: A Controlled Study of 538 Hips

Background: Variations in femoral and acetabular version are becoming increasingly recognized as contributing factors to the development of hip pain in patients with femoroacetabular impingement (FAI) and hip dysplasia. It is still unknown what the true prevalence of these rotational abnormalities is in this patient population. Purpose: To determine (1) the prevalence of femoral version abnormalities in symptomatic hips with FAI and hip dysplasia, (2) the prevalence of combined abnormalities of femoral and acetabular version in these patients, and (3) which specific hip morphologies are associated with abnormalities of femoral version. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 462 symptomatic patients (538 hips) were included who had hip pain attributed to FAI or hip dysplasia and who presented to our tertiary referral center for hip preservation surgery between 2011 and 2015. We retrospectively examined femoral and acetabular version among 11 subgroups with predefined hip morphologies and compared findings with a control group. The allocation to each subgroup was based on morphologic reference values for femoral head coverage, lateral center edge angle, alpha angle, and neck-shaft angle calculated on plain radiographs. Results: Of the 538 hips included, 52% were found to have abnormal femoral version; severe abnormalities were found in 17%. Severely decreased femoral version (<0°) was found in 5%; moderately decreased femoral version (0°-10°), in 17%; moderately increased femoral version (26°-35°), in 18%; and severely increased femoral version (>35°), in 12%. The most frequent abnormal combination was increased femoral version combined with normal acetabular version (22%). We found significantly lower mean femoral version for the cam-type FAI group (15°) and significantly higher mean femoral version for the Perthes hips (32°; ie, Legg-Calvé-Perthes disease) as compared with the control group (22°). The mean femoral version of the study group was 19°; for male patients, 15°; and for female patients, 22°. Conclusion: Abnormalities in femoral version are highly prevalent in patients with hip pain who are eligible for hip preservation surgery, and severe abnormalities are prevalent in 1 of 6 patients (17%). Based on these results, the evaluation of young patients with hip pain should always include an assessment of femoral version and acetabular version to best decide what treatment approach should be undertaken to optimize outcomes.

Biologic Reconstruction of Full Sized Cartilage Defects of the Hip: A Guideline from the DGOU Group "Clinical Tissue Regeneration" and the Hip Committee of the AGA

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm2. Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary.

A summary of hip-preservation surgery based on peri-collapse stage of osteonecrosis of femoral head

To summarize surgical procedures of hip-preservation based on peri-collapse stage of osteonecrosis of the femoral head (ONFH). The basic points of peri-collapse stage theory was expounded. The related literature on surgical procedures was summarized and analyzed based on the theory. Surgical procedures of hip-preservation tend to emphasize on mechanical repair, giving consideration to biological repair. It is consistent with the essence of peri-collapse stage theory, which attaches great importance to biomechanical stability. Peri-collapse stage theory has a guiding significance to the choice of surgical timing and approach, and it is one of the important theoretical basis for hip-preservation treatment.

Management of osteonecrosis of the femoral head with pedicled iliac bone flap transfer: A multicenter study of 2190 patients

Osteonecrosis of the femoral head (ONFH) often affects young active adults and leads to destruction of the hip joint and disabling arthritis. Several procedures have been developed to arrest the progress of osteonecrosis and postpone the procedure of total hip replacement especially in young patients. The aim of this multicenter study was to analyze the results of the use of the vascularized iliac bone flap transfer for management of ONFH. From January 1985 to December 2012, a total of 2190 patients (2690 hips) with the mean age of 43.15 years (ranging from 18 to 65 years) underwent hip-preserving surgery with the pedilced iliac bone flap transfer for management of ONFH with Ficat and Arlet stage II-IV in 8 hospitals. There were 1733 hips in stage II, 776 hips in stage III, and 181 hips in stage IV preoperatively. The complications were recorded. The outcomes were evaluated by radiograph, the Harris hip-scoring system (HHS). Postoperative complications occurred in 128 patients (5.84%). Among them, 25 patients had deep venous thromboses, 16 patients had sensory deficits, 40 patients had superficial infection and hematoma, and 47 patients had wound dehiscence. A total of 1912 patients (2179 hips) were followed up with a median time of 12 years (ranging from 5 to 25 years). There were 1787 hips with no radiographic osteonecrotic progress during follow-up, while osteonecrosis progress was observed in 186 hips with stage II (13.1%), 170 hips with stage III (25.6%) and 36 hips with stage IV (36.4%; P < .001). Two hundred fifteen hips (9.87%) in 203 patients were converted to THA during follow-up, including 19 hips with stage II (1.34%), 162 hips with stage III (24.4%), and 34 hips with stage IV (34.3%).The mean HHS at the end of follow-up was significantly improved when compared to preoperative mean HHS (83.63 ± 5.03 vs. 66.54 ± 6.05, P < .001). In this evaluation of a large series of cases, the vascularized iliac bone flap transfer showed good results for arresting the osteonecrosis progress and improving the hip function of patients with pre-collapse stages of ONFH.

Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement.

The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI. Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis. International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found. Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.

The Application of the Patient Reported Outcomes Information System (PROMIS) on Hip Arthroscopy Patients

Objectives:Legacy measures, such as the modified Harris Hip Score, have traditionally been utilized in the assessment of hip arthroscopy patients, but have been criticized for their application in this active patient population. Recently, the NIH funded the establishment of the Patient Reported Outcomes Information System (PROMIS). This computer adaptive testing (CAT) scale has multiple components and has been validated using various other orthopedic patient populations. To date, no published studies have utilized PROMIS as an assessment tool among patients who have undergone hip arthroscopy for the treatment of FAI, labralchondral pathology, and/or other associated conditions. The purpose of this study was to determine whether there is an association between a patient’s pre-operative outcome score and their likelihood of experiencing a clinically meaningful change at specified postoperative intervals following arthroscopic hip preservation surgery.Methods:A piecewise longitudinal regression models was used to examine changes over time in the primary outcomes of function, pain, and mood evaluated by PROMIS. This was accomplished by determining the regression of these outcomes from pre-op measurement to the first follow-up visit and then from the first follow-up visit through the 5-7 week, 3-4 month, 5-7 month and 10-14 month visits. Patient enrollment at each of the intervals were 405, 396, 336, 192, 93 and 42 respectively. Assessed variables included demographic characteristics, labral repair vs debridement, iliopsoas lengthening, number of allergies, body mass index (BMI), institutional team based physical therapy vs. non-specialized therapy, and insurance type.Results:As anticipated, function was found to be poorer and pain scores greater at the first postoperative follow-up visit (βFunction= -12.66, p<0.0001 βPain= 4.23, p<0.0001) compared with pre-op values. Subsequent visits demonstrated statistically significant improvements in function and reduction in pain (βFunction = 19.70, p<0.0001; and βPain= -13.54, p=<0.0001). Associated p-values indicated that the slopes were significantly different than 0, indicating that a trend was present, and showing a change in performance as anticipated. The mood scale presented a slightly different picture with the first segment (βMood= -1.28, p=0.20) suggesting that there was no change in depression from pre-op to first follow-up but there was a marked decrease from first follow-up to the 10-14 month visit (βMood = -3.27, p=0.0012).As anticipated, function was found to be poorer and pain scores greater at the first postoperative follow-up visit (βFunction= -12.66, p<0.0001 βPain= 4.23, p<0.0001) compared with pre-op values. Subsequent visits demonstrated statistically significant improvements in function and reduction in pain (βFunction = 19.70, p<0.0001; and βPain= -13.54, p=<0.0001). Associated p-values indicated that the slopes were significantly different than 0, indicating that a trend was present, and showing a change in performance as anticipated. The mood scale presented a slightly different picture with the first segment (βMood= -1.28, p=0.20) suggesting that there was no change in depression from pre-op to first follow-up but there was a marked decrease from first follow-up to the 10-14 month visit (βMood = -3.27, p=0.0012).Conclusion:Results from this study suggest that use of the PROMIS CAT tool was applicable to patient centered outcomes and informed decision making following arthroscopic hip surgery and may be used to facilitate discussions with patients regarding expected benefits for patient specific attributes. Prior to surgery, it is equally important that surgeons convey accurate prognostic information to patients, and that surgeons are able to identify patients who are unlikely to improve by a clinically important margin if surgery is undertaken. This study suggests that PROMIS offers potential to achieve these valuable objectives in a population of hip arthroscopy patients, and should be considered as a highly efficient and generalizable tool to collect pre- and postoperative data during clinical patient encounters.

The Iliofemoral Line: A Radiographic Sign of Acetabular Dysplasia in the Adult Hip

Background: Several radiographic parameters utilized for the diagnosis of acetabular dysplasia in adults suffer from poor reproducibility and reliability. Purpose: To define and validate a novel radiographic parameter (the iliofemoral line [IFL]) for the detection of frank and borderline hip dysplasia and to compare the sensitivity and specificity of this radiographic marker to those of previously validated qualitative parameters. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A consecutive cohort of 222 adult patients (436 hips) undergoing hip preservation surgery was included. The IFL, which extends from the lateral femoral neck through the inner cortical lip of the iliac crest, intersects the femoral head in cases of dysplasia. Percent medialization of the IFL was defined as the horizontal distance of the exposed femoral head lateral to the IFL, relative to the horizontal femoral head width at the center of the femoral head. Results: Percent medialization of the IFL was strongly correlated to the lateral center edge angle (P < .0001). Values of percent medialization ranging from 15% to 22% predicted the presence of borderline hip dysplasia with a sensitivity of 62% and specificity of 89%, while values exceeding 22% predicted the presence of frank acetabular dysplasia with a sensitivity of 77% and specificity of 94%. By comparison, abnormality of the Shenton line demonstrated a sensitivity of 3.7% and specificity of 97% for the detection of borderline dysplasia and a sensitivity of 16% and specificity of 99% for the detection of frank acetabular dysplasia. Compared with the Shenton line, percent medialization of the IFL was significantly more sensitive for the detection of both borderline and frank acetabular dysplasia (both P < .0001). The intraobserver and interobserver reproducibility of the horizontal difference outside the IFL were 0.99 and 0.96, respectively. Conclusion: Percent medialization of the IFL is a reliable and accurate radiographic marker of frank acetabular dysplasia and, to a lesser extent, borderline dysplasia. The use of this radiographic parameter as an additional tool may enable the earlier detection of borderline and frank hip dysplasia in young adults presenting with hip pain.

Modified capsular arthroplasty for young patients with developmental dislocation of the hip

Developmental dislocation of the hip(DDH) is one of the most serious hip diseases. Patients with unilateral DDH are prone to secondary osteoarthritis, low back pain, gait disturbance and compensatory scoliosis because of the leg length discrepancy. Total hip arthroplasty(THA) is the highly effective treatment for patients with hip pain or dysfunction caused by unilateral DDH, thus decrease the demand for hip-preserving surgeries such as capsular arthroplasty which may postpone or avoid hip replacement. However, the failure rate of THA for young patients is high and the majority of young patients may require one or more revision arthroplasties throughout their lifetime. The basic principle of capsular arthroplasty is that the femoral head wrapped by capsule is placed into a newly reamed socket on the location of true acetabulum. Therefore, hip replacement for patients with previous capsular arthroplasty becomes easier and safer than primary THA. However, the early capsular arthroplasty have been abandoned due to the relatively high rates of femoral head necrosis and hip stiffness. Ganz modified the early procedure with the technique of surgical hip dislocation in 2012, and emphasized the importance of postoperative rehabilitation. The incidence of complication, therefore, decreased greatly due to the preservation of main blood supply of femoral head as well as the proper postoperative management. In order to improve the clinical outcomes of this modified procedure, the selection of indications and surgeons' experience should also be taken into consideration.

Differential expression of miR-195-5p in collapse of steroid-induced osteonecrosis of the femoral head.

BackgroundFemoral head collapse is a key reference point for determining a treatment regimen of femoral head osteonecrosis. However, there are no effective preventive measures and the efficacy of hip-preserving surgery is unsatisfactory due to the unclear mechanism of collapse. This study aimed to identify and validate miRNAs differentially expressed in collapse and non-collapse areas of the osteonecrotic femoral head, and to predict the target genes and pathways of these miRNAs.ResultsNine samples passed the quality control test. A total of 2085 differentially expressed miRNAs were detected, among which 433 miRNAs showed differential expression in the T1 group compared to the W1 group; 344 miRNAs showed differential expression in the T2 group compared to the W2 group; 107 miRNAs showed differential expression in the T3 group compared to the W3 group. After combining data from all three patients, 10 miRNAs showed differential expression in the collapse area (T1+T2+T3) compared to the non-collapse area (W1+W2+W3). Compared to the normal area, has-miR-195-5p showed the most significant downregulation. Expression results from RT-PCR revealed that the expression of hsa-miR-195-5p in the collapse area (T1+T2+T3) was significantly lower than that in the non-collapse area (W1+W2+W3) and normal area (Z1+Z2+Z3). 157 genes were perdicted as the target gene of hsa-miR-195-5p.Materials and MethodsFemoral heads of three patients (2 males and 1 female) treated by total hip arthroplasty surgery for steroid-induced femoral head osteonecrosis were selected based on inclusion and exclusion criteria. Bone tissue samples were obtained from the collapse area (T), non-collapse area (W), and normal area (Z) according to the anatomical structure of osteonecrotic femoral heads. Total RNA was extracted from the samples and the microarray chip was scanned. miRNAs showing differential expressions of more than 1.5-fold were selected and was validated by RT-PCR. TargetScan, mirBase and miRanda bioinformatics software was used to predict target genes and identify possible pathways involving these genes.ConclusionsmiR-195-5p showed the most significant difference in the collapse area of osteonecrotic femoral heads, suggesting that collapse may be related to the downregulation of miR-195-5p.