Nonoperative Hip Research Articles

Relevance of physical activity with decrease in minimal joint space of the nonoperative hip in female patients after unilateral THA.

To clarify the relevance of physical activity (PA) with respect to a decrease in minimal joint space (MJS) of the nonoperative hip in female patients at 24 months post-contralateral total hip arthroplasty (THA). This prospective cohort study was conducted from six to 24 months post-THA. The subjects were 85 female patients with hip osteoarthritis (OA) who had undergone unilateral THA. The primary outcome was a change in MJS (ΔMJS). Daily step counts and moderate to vigorous physical activity were measured. To identify factors related to ΔMJS, a generalized linear model approach was used, with adjustment factors, Kellgren-Lawrence (KL) grade, PA, and interaction terms between PA and KL grade as explanatory variables. The interaction term between daily step count and KL grade was significant. The regression coefficient of the daily step count for ΔMJS was significant in the KL ≥ 1 group, but not in the KL = 0 group. A model with adjustment factors, an interaction term, and PA showed that the daily step count increased ΔMJS. PA was related to ΔMJS of the nonoperative hip in female patients with KL grade ≥1, but was not related to ΔMJS in patients without OA post-THA. Excessive daily step count may be a risk factor for a decrease in MJS of the nonoperative hip.

Paper 46: Modern Hip Arthroscopy for FAIS Delays the Natural History of Osteoarthritis in a Fourth of Patients: A 12-Year Follow-Up Analysis

Objectives: Little is known about the impact of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation. The purpose of this investigation was to (1) characterize the natural history of FAIS and (2) understand the impact of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of ten years. Methods: Between 2010-2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary unilateral hip arthroscopy (labral repair, femoroplasty, capsular closure), and minimum ten-year follow-up. The preoperative and minimum ten-year postoperative radiographs of patients were evaluated at each timepoint. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by two independent reviewers. Subgroup analyses were performed. Results: A total of 200 hips from 100 patients were available with 74% follow-up at a mean of 12.0 years were evaluated. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared to 28% (28/100) among operative hips (Table 1). At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time (Table 2). Modern hip arthroscopy conferred a relative risk reduction of 42% in osteoarthritis progression. Borderline dysplasia, age, preoperative Tönnis grade, and alpha angle > 65° were key risk factors in the radiographic progression of osteoarthritis. Conclusions: While the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history was favorably altered in a quarter of patients after arthroscopic correction (Figure 1). Modern hip arthroscopy indications and techniques represent a valid joint preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Mixed patterns of impingement and instability that underwent arthroscopy were the fastest to degenerate.

Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis.

Little is known about the effect of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation. To (1) characterize the natural history of FAIS and (2) understand the effect of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of 10 years. Cohort study; Level of evidence, 3. Between 2010 and 2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopic surgeon. Inclusion criteria were FAIS, bilateral radiographic findings of femoroacetabular impingement, primary unilateral hip arthroscopy (labral repair, femoroplasty, or capsular closure), and minimum 10-year follow-up. The preoperative and minimum 10-year postoperative radiographs of patients were evaluated at each time point. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by 2 independent reviewers. Subgroup analyses were performed. A total of 200 hips from 100 patients were evaluated at a mean follow-up of 12.0 years. Preoperatively, 98% and 99% of operative and nonoperative hips were evaluated as Tönnis grades 0 and 1, respectively; 5% of nonoperative hips had worse Tönnis grades than operative hips. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared with 28% (28/100) among operative hips. At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time. Modern hip arthroscopy was associated with a relative risk reduction of 42% in osteoarthritis progression. Impingement with borderline dysplasia, age, preoperative Tönnis grade, and alpha angle >65° were key risk factors in the radiographic progression of osteoarthritis. Although the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history may be favorably altered for 25% of patients whose Tönnis grade was better after undergoing arthroscopic correction. Modern hip arthroscopy indications and techniques represent a valid joint-preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Arthroscopy for mixed patterns of impingement and instability were the fastest to degenerate.

Musculoskeletal injections for palliative treatment of neuromuscular hip dysplasia patients: how I do it.

This review describes our institution's standardized technique as well as potential pitfalls for therapeutic steroid injections in children with symptomatic neuromuscular hip dysplasia. Symptomatic, painful neuromuscular hip dysplasia can dramatically affect quality of life. Steroid injections are used to identify the source of perceived pain, temporarily treat pain while awaiting surgical intervention, or for therapeutic management for nonoperative hip joints.

Non-operative Treatment Options for Osteoarthritis in the Hip.

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

Clinician perspectives on nonoperative management of hip fractures during COVID-19.

To identify factors influencing clinicians' decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)'s Perioperative Special Interest Group and clinicians' personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people.

Poster 216: Comparison of Joint Space Narrowing to the Contralateral Side During Hip Arthroscopy: Predictor of Conversion to THA?

Objectives: Reduced joint space at the time of joint-preserving hip arthroscopy has been shown to be correlated with rates of eventual conversion to total hip arthroplasty (THA). With an increasingly aging population and increased utilization of hip arthroscopy, it is important to identify factors that may predict early failure and the eventual need for arthroplasty. For some patients, hip arthroscopy may provide symptomatic relief for years, while others garner limited benefit and require conversion THA soon after their index surgery. This study sought to determine if quantitative differences in joint space width (JSW) between the operative and non-operative hip predicted the likelihood of conversion to THA at the time of hip arthroscopy. Methods: After obtaining institutional review board approval, a retrospective review identified 105 patients treated for labral tears with arthroscopic hip surgery by a single-surgeon with a minimum of 5- year follow-up. Patients were stratified into cohorts based on whether they received a subsequent THA. Preoperative, anteroposterior pelvic radiographs were obtained for each patient and semi-automated, quantitative JSW measurements were performed at 3 predefined fixed locations per hip (10, 30, and 50 degrees with respect to a polar coordinate system; Figure 1). All measurements were obtained by an independent assessor blinded to other radiographic or clinical information, with high reliability (intra- class correlations &gt; 0.8), as previously described in literature. Differences in JSW at each prefixed angle were calculated by subtracting the width (millimeters) of each patient’s operative hip from the measurements obtained from their non-operative hip. Categorical variables were analyzed using chi- square test or Fisher exact test, as appropriate. After assessing for normality with Shapiro-Wilk tests, continuous variables were compared using Student t-tests or Mann-Whitney U tests to determine baseline differences between patients that converted to THA and those that did not. Logistic regression was run for JSW at each prefixed angle, followed by adjusted, multivariable logistic regression to determine independent predictors of conversion to THA. Results: Mean [standard deviation (SD)] follow-up was 8.81 [2.68] years, identifying 16 (15.2%) patients that converted to THA and 89 (84.8%) that did not. When comparing baseline demographic and intraoperative characteristics between cohorts, THA patients were found to have higher mean [SD] age 41.8 [13.4; p=0.003], BMI 29.3 [4.2; p&lt;0.001], Tönnis grade (p&lt;0.001), Outerbridge grade (p=0.002) and higher percentage of males (p=0.014; Tables 1&amp;2). THA patients were found to have a significantly greater difference in JSW at 30° compared to those that did not require subsequent hip arthroplasty (0.566 ± 0.883mm versus 0.038 ± 0.499mm, p=0.035). Differences in JSW between cohorts were not significant at the 10° (p=0.104) or 50° (p=0.096) locations. When adjusting for significantly different covariates, the difference in JSW at 30° was correlated with an increased likelihood of conversion to THA (Adjusted Odds Ratio [AOR]: 4.00; 95% Confidence Interval [CI]: 1.06 to 15.13; p =0.041). Finally, adjusted analysis controlling for differences in JSW at all predefined angles found that narrowing at 30° was significantly associated with increased odds of conversion ([AOR]: 3.88; [CI]: 1.06 to 14.22; p=0.041), while 10° (p=0.630) and 50° (p=0.995) were not. Conclusions: To best educate patients on the risk of THA following hip arthroscopy, identifying objective predictors of early failure is imperative during preoperative evaluation. This study identified that differences in JSW at 30° between the operative and non-operative hip were significantly associated with increased risk of conversion after controlling for demographic and intraoperative factors. Analysis was limited by predetermined locations for JSW and future studies may identify stronger correlations by incorporating additional measurements within the acetabular sourcil. Quantitative differences in JSW comparing the operative hip to the contralateral side predicts patients progressing to THA at the time of hip arthroscopy. [Table: see text] [Table: see text]

GLOBAL CLINICIAN PERSPECTIVES ON NON-OPERATIVE HIP FRACTURE MANAGEMENT DURING COVID-19

Abstract There are currently no guidelines regarding clinician decision making in the type of hip fracture management among older adults. Cultural, social, structural and economic differences between global healthcare systems may result in differing approaches. This study’s objectives were to identify possible factors influencing clinicians’ decision to undertake a non-operative hip fracture management approach among older adults, and to determine whether there is global heterogeneity regarding these factors between high income countries (HIC), and low- and middle-income countries (LMIC) clinicians. A SurveyMonkey questionnaire was distributed to clinicians through the Fragility Fracture Network’s Perioperative Special Interest Group and clinicians’ personal networks between May 24 and July 25, 2021. 406 respondents from 51 countries returned the questionnaire, of which 225 respondents came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median [IQR] estimated proportion of admitted patients with hip fracture undergoing surgery (96% [95–99]) than those from LMIC (85% [75–95]) of mean (SD) at 94% (8) compared to 81% (16) among LMIC clinicians (p=2.94e-23). Several factors seemed to influence the clinician hip fracture management decision making process. Global heterogeneity seems to exist between HIC and LMIC clinicians regarding factors such as anticipated life expectancy, ability to pay, treatment costs, insufficient resources, and perception of risk in hip fracture management decision-making. This is the first international sampling of clinician perspectives regarding hip fracture management. Further research is necessary for the development of best practice guidelines to improve hip fracture management decision-making and quality of hip fracture care among older adults.

Patient Perceptions of Wearable and Smartphone Technologies for Remote Outcome Monitoring in Patients Who Have Hip Osteoarthritis or Arthroplasties.

Although there is interest in wearables and smartphone technologies for remote outcome monitoring, little is known regarding the willingness of hip osteoarthritis (OA) and/or total hip arthroplasty (THA) patients to authorize and adhere to such treatment. We developed an Institutional Review Board-approved questionnaire to evaluate patient perceptions of remote monitoring technologies in a high-volume orthopedic center. Forty-seven THA patients (60% female; mean age: 66 years) and 50 nonoperative OA hip patients (52% female; mean age: 63 years) participated. Patient perceptions were compared using Pearson's chi-squared analyses. THA patients were similarly interested in the use of smartphone apps (91% vs 94%, P= .695) in comparison to nonoperative hip OA patients. THA patients were more receptive to using wearable sensors (94% vs 44%, P < .001) relative to their nonoperative counterparts. THA patients also expressed stronger interest in learning to use custom wearables (87% vs 32%, P < .001) vs nonoperative patients. Likewise, the majority of THA patients were willing to use Global Positioning System technology (74% vs 26%, P < .001). THA patients also expressed willingness to have their body movement (89%), balance (89%), sleep (87%), and cardiac output (91%) tracked using remote technology. Overall, we found that THA patients were highly receptive to using wearable technology in their treatments. Nonoperative OA hip patients were generally unreceptive to using smart technologies, with the exception of smartphone applications. This information may be useful as utilization of these technologies for patient care continues to evolve.

The impact of nonoperative hip and core injuries on National Football League athlete performance

ABSTRACT Objectives Hip and core injuries are common in National Football League (NFL) athletes; however, the impact following injury remains unclear. The goal of this manuscript was to determine the impact of nonoperative hip and core injuries on return to play and performance. Methods NFL athletes who sustained a hip or core injury treated nonoperatively between 2010 and 2016 were identified. Offensive and defensive power ratings were calculated for each player’s injury season and two seasons before and after to assess longitudinal impact. A matched control group without an identified hip and/or core injury was assembled for comparison. Results A total of 41 offensive and 71 defensive players with nonoperative hip or core injury were analyzed. All athletes returned to play; offensive and defensive players missed 4.0 ± 5.2 and 3.1 ± 2.6 games after injury, respectively. Offensive players played fewer cumulative career games returning from core injury versus hip (23.5 ± 20.6 vs 41.0 ± 26.4). Defensive players played fewer games (58.1 ± 41.1 versus 37.4 ± 27.1, p < 0.05) with lower defensive power rating (133.9 ± 128.5 versus 219.8 ± 212.2, p < 0.05) cumulatively after hip or core injury. Additionally, 2 years following injury, defensive players played fewer games compared to controls (9.5 ± 7.0 versus 10.9 ± 6.8, p < 0.05). Following hip injury specifically, NFL defenders played fewer games (39.8 ± 27.9 vs 61.9 ± 38.8; p < 0.05) and had a lower defensive power rating (145.9 ± 131.7 vs 239.0 ± 205.9; p < 0.05) compared to before injury. Conclusion Overall, NFL players return to play following nonoperative hip and core injuries. Defensive players played in fewer games following hip or core injury compared to controls; offensive players were unaffected. Hip injuries have a greater impact on performance compared to core injuries in defensive athletes; offensive players played fewer games upon return from core injury.

Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data.

Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients' survival compared with those treated with operative management (OM). This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36months was compared with those treated surgically. From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient's refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1year (29%). Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM's superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question - well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.

The Effect of Self-Reported Lactose Intolerance and Dairy Consumption on Bone Mineral Density Among American Hip Arthroplasty Patients: A Cross-Sectional Study.

The relationship between osteoporosis and lactose intolerance is unclear. This study aims to evaluate the association between self-reported lactose intolerance and symptom severity caused by lactose malabsorption and bone mineral density (BMD). A total of 496 American hip arthroplasty patients took part in this study. Information on BMD and socio-demographic factors were retrospectively extracted from medical records. BMD of the lumbar spine (LS), femoral neck of the operative hip (FNOH), and femoral neck of the non-operative hip (FNH) were measured via dual-energy x-ray absorptiometry scans (DXA). Patients also completed a survey regarding dietary and lifestyle habits from the time of surgery. We found that 9.3% of participants reported lactose intolerance and 33.3%% suffered from either osteopenia or osteoporosis in at least one (location). The population that did not self-identify as lactose intolerant consumed significantly more dairy (p < 0.0001) and animal protein (p = 0.004) than those with intolerance. There was no significant difference in BMD between self-identified lactose intolerant individuals and non-lactose intolerant individuals. In a stepwise multiple regression analysis, body mass index (BMI) and age were the only common predictors of BMD for all locations (p < 0.05). However, yogurt intake was a significant predictor of BMD of FNOH in the multivariate analysis. This study suggests that lactose intolerance is not associated with bone mineral density. We also found that being vegan or vegetarian may increase the risk of low BMD.

Does unilateral total hip arthroplasty improve pain and function in the non-operative hip joint?

Some reports suggested that the status of the opposite-side hip affects clinical outcomes of unilateral total hip arthroplasty (THA) for hip osteoarthritis (HOA). This study aimed to determine whether unilateral THA could improve pain and movement of the non-operative hip. The analysis included 195patients divided into three groups according to contralateral hip status based on radiographic change assessed by Kellgren-Lawrence (KL) grade: normal hip (Group N: n =124), HOA with KL grade > 2 (Group O: n =39), and THA patients who already underwent THA in their opposite hip joint (Group T: n =32). All patients were interviewed and examined preoperatively and at 1-year intervals after surgery. Hip function was evaluated with Harris Hip Score (HHS) and range of motion (ROM) preoperatively and at 1-year follow-up. We used the Japanese Orthopedic Association Hip-Disease Evaluation Questionnaire (JHEQ) and the Visual Analogue Scale (VAS) for separately evaluated right and left hip joints. The mJHEQ movement, which indicated the activity, and flexion of ROM in the non-operative hip improved in group N and group T. The VAS and JHEQ pain values did not differ between preoperative and 1-year follow-up in all groups. In the operative side, HHS function, JHEQ movement values in group O were significantly lower than those of groups N and T at 1-year follow-up. Unilateral THA may improve non-operative hip movement and active daily life except when the non-operated hip shows osteoarthritis. It did not improve non-operative hip pain, regardless of the condition on the other side. Clinical outcomes of unilateral THA may be affected by opposite hip status each other.

Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study.

To report the mortality data and life expectancy of geriatric hip fracture patients who underwent nonoperative management and compare that with a matched operative cohort. Retrospective cohort study. Level 1 trauma center. Geriatric (65 years of age and older) femoral neck or intertrochanteric fracture (OTA/AO 31A and 31B) patients. Operative treatment with either arthroplasty, cannulated screws, sliding hip screw device, or cephalomedullary nail compared with nonoperative cohort. In-hospital, 30-day, and 1-year mortality. Two hundred thirty-one patients, comprising 154 operative and 77 nonoperative patients, were compared. There were no significant differences among age, sex, fracture location, Charlson Comorbidity Index, preinjury living location, dementia, and history of cardiac arrhythmia between the 2 cohorts. Nonoperatively managed patients were found to have a significantly higher percent in-hospital (28.6 vs. 3.9; P < 0.0001), 30-day (63.6 vs. 11.0; <0.0001), and 1-year (84.4 vs. 36.4; P < 0.0001) mortality. The mean life expectancy after a hip fracture for the nonoperative cohort was significantly shorter than the operative group (221 vs. 1024 days; P < 0.0001). Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that was significantly higher than a matched operative cohort. Our results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment. Our findings offer helpful information by providing updated mortality data when discussing nonoperative hip fracture management with patients and their family. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Possible New Radiographic Predictor of Progression of Osteoarthritis in Developmental Dysplasia of the Hip: The Center Gap.

Patients with comparable severities of developmental dysplasia of the hip (DDH) may variably progress to osteoarthritis (OA) over time. Although joint congruency may be associated with OA progression in patients with DDH, it has only been assessed subjectively. We assessed the gap between the rotational centers of the acetabulum and femoral head (center gap) as a possible predictive measure of OA progression in patients with DDH. In patients with bilateral DDH, we asked: (1) What is the probability of OA progression (Tönnis grade) or symptom development (pain) in the asymptomatic contralateral hip of patients with DDH undergoing unilateral joint-preserving surgery? (2) Is the center gap measurement associated with OA progression or symptom development in these hips? (3) Is the center gap measurement correlated with previous radiographic parameters? A total of 297 patients (319 hips) underwent unilateral eccentric rotational acetabular osteotomy at our institution between July 1989 and December 1999. We performed no other joint-preserving surgery to treat patients with DDH during this timeframe. The inclusion criteria for the study were patients younger than 55 years of age, the contralateral hip classified as Tönnis Grade 0, no previous surgical interventions, and asymptomatic at the time of eccentric rotational acetabular osteotomy (155 patients, 155 hips). The exclusion criteria were a contralateral hip without dysplasia (four patients, four hips), loss to followup before 10 years (42 patients, 42 hips [27%]), or missing medical records or radiographs (21 patients, 21 hips [14%]). The remaining 88 patients (88 hips; 11 males and 77 females) with a mean age of 39 years (range, 17-53 years) and mean followup of 20 years (range, 10-27 years) were analyzed. From the institutional database, radiographic parameters including the center gap in the AP view were assessed using radiographs at the time of eccentric rotational acetabular osteotomy, and the Tönnis grade was recorded 1 year postoperatively and annually thereafter retrospectively. We defined migration of the rotational center of the femoral head based on the rotational center of the acetabulum in the horizontal plane as center gap X (mm) and in the vertical plane as center gap Y (mm) and defined the absolute value between the centers as center gap distance (mm). Using κ statistics, intra- and interobserver reliabilities were determined to be 0.896 and 0.857 for center gap X, 0.912 and 0.874 for center gap Y, and 0.912 and 0.901 for the center gap distance, respectively. When patients reported any contralateral ipsilateral hip pain during clinic visits, the hip was considered symptomatic. Kaplan-Meier survivorship analyses were performed with OA progression or symptom development in the nonoperative hip as the endpoint. Multivariate analyses were performed to assess risk factors for each outcome using the Cox proportional hazards model. Correlation analyses between the center gap and other parameters including lateral center-edge angle, femoral head extrusion index, acetabular depth-to-width index, femoral head lateralization, minimum width of the joint space, head sphericity, and joint congruency were performed using Pearson's correlation coefficient. At 20 years postoperatively, the probability of OA progression in the nonoperative hip was 13% (95% confidence interval [CI], 7.1-22.1) and the probability of symptom development was 34% (95% CI, 24.7-46.1). The center gap X measurements in the groups with OA progression (lateral 2.0 ± 2.1 [SD] mm) or symptom development (lateral 0.9 ± 2.4 mm) took a more lateral direction than those in the group without OA progression (medial 0.4 ± 2.1 mm) or symptom development (medial 0.5 ± 2.0 mm) (OA progression, p < 0.001; symptom development, p = 0.005). The center gap Y measurements in the groups with OA progression (distal 2.7 ± 7.1 mm) or symptom development (distal 2.1 ± 6.0 mm) took a more distal direction than those in the group without OA progression (proximal 1.6 ± 6.2 mm) or symptom development (proximal 2.5 ± 6.1 mm) (OA progression, p = 0.027; symptom development, p = 0.001). Independent risk factors for OA progression were the femoral head extrusion index (hazard ratio [HR], 1.11; 95% CI, 1.01-1.22; p = 0.028) and the center gap X (HR, 1.52; 95% CI, 1.07-2.16; p = 0.019), whereas no independent risk factors for symptom development were found. The center gap in the horizontal plane had no correlations with any other radiographic parameter studied. The center gap in the horizontal plane had a modest association with OA progression in this group of patients with DDH. Future studies are needed to determine the normal value of the center gap for patients without DDH and to assess the center gap in lateral radiographic views. Level IV, prognostic study.

Trends in Operative and Nonoperative Hip Fracture Management 1990-2014: A Longitudinal Analysis of Manitoba Administrative Data.

To evaluate longitudinal trends in the use of total hip arthroplasty (THA), hemiarthroplasty (HA), internal fixation (IF), and nonoperative management and to identify individual-level factors associated with nonoperative treatment of hip fracture (HF). Longitudinal analysis of administrative data. Manitoba, Canada. All adults who experienced nontraumatic hip fractures between 1990 and 2014 (N = 19,626; mean age 80.6, 72.3% female). Billing codes were used to identify surgical treatment, and trends in treatment over time were examined. Regression models were developed to identify individual factors associated with receiving nonoperative management. Use of THA increased from 0.6% for all HFs in 1990-94 to 5.3% in 2010-14, use of HA increased from 19.3% to 29.7%, and use of IF declined from 71.8% to 59.9% (P < .001 for all); increase in THA and HA were largest in individuals with femoral neck fracture. Nonoperative management declined from 8.3% in 1990-94 to 5.1% in 2010-14 (P < .001). Factors associated with nonoperative management included aged 90 and older, male sex, residing in a care facility before fracture, and rural residence. HF is increasingly treated with THA and HA, whereas rates of nonoperative management and IF are declining. Future efforts should focus on ensuring that all individuals are optimally triaged to the best procedure for them, with nonoperative management considered for individuals with extremely poor prefracture health.

Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients

The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy. All patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) with routine capsular closure between January 1, 2012, and December 31, 2015, were eligible. Only patients with unilateral surgery and a postoperative magnetic resonance imaging (MRI; ordered for persistent symptoms) were included. Four independent reviewers evaluated each hip capsule for thickness and the absence or presence of defects. During the study, 1,463 patients had hip arthroscopy for FAI with routine capsular closure, and 53 (3.6%) underwent a postoperative MRI. Fourteen of the 53 were excluded owing to revision status or additional procedures. The final study population included 39 patients (23 female patients and 16 male patients), with an average patient age of 31.7 ± 11.4years and an average body mass index of 23.3 ± 2.9. There were 3 (7.5%) capsular defects, and the intraclass correlation coefficient (ICC) was 0.82. The operative hip capsule was significantly thicker in the zone of capsulotomy, and subsequent repair as compared with the unaffected, contralateral hip capsule (5.0 ± 1.2mm vs 4.6 ± 1.4mm; P= .02), ICC 0.83. Additionally, males had thicker hip capsules as compared with their female counterparts, on the operative side (5.4 ± 1.1mm vs 4.5 ± 1.2mm; P= .02) and the nonoperative side (4.8 ± 1.6mm vs 4.1 ± 0.9mm; P= .08). In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect. Level IV, prognostic case series.

Factors Associated With Early Improvement in Low Back Pain After Total Hip Arthroplasty: A Multi-Center Prospective Cohort Analyses

This study identified factors associated with an improvement in low back pain (LBP) at six-month follow-up after total hip arthroplasty (THA). Data from a national registry of 3054 patients were analyzed. Factors under analysis included demographics, comorbid conditions, operative and nonoperative joint pain severity, physical function, and mental health. Differences in these factors between patients with and without improvement in LBP were examined. Among patients reporting severe or moderate LBP preoperatively, 56% improved 6months after surgery. Patients without improvement were more likely to be on Medicare, have a high school education or less, have household income less than $45,000 and have one or more comorbid conditions. Patients with improvement in LBP experienced more resolution of pain in both the operative and nonoperative hip.

Cane-assisted gait biomechanics and electromyography after total hip arthroplasty

Ajemian S, Thon D, Clare P, Kaul L, Zernicke RF, Loitz-Ramage B. Cane-assisted gait biomechanics and electromyography after total hip arthroplasty. Objective To quantify the effects of cane use during walking on hip joint kinematics, kinetics, and muscle activity patterns after unilateral total hip arthroplasty (THA). Design Nonrandomized experimental design. Setting Urban inpatient hospital. Participants Adults (n=9 men, 2 women) with no history of orthopedic or neuromuscular disease who underwent elective unilateral THA. Intervention Gait was assessed preoperatively and 4 and 8 months postoperatively. Main outcome measures Three-dimensional hip joint motion and moments and electromyographic patterns of gluteus medius, tensor fascia latae, lateral hamstring, and vastus lateralis were measured during level walking, with and without use of a straight cane. Results When a cane was held in the contralateral hand, the abduction moment of the affected hip decreased by 26%, whereas that of the contralateral hip increased by 28%. Use of a cane in THA rehabilitation is important because it reduces the load on the operative hip so that bone and soft tissues can heal. Our results suggest that load reduction was successful on the operative side, but the loads on the contralateral side were increased. Conclusions After unilateral arthroplasty, subjects using a cane had increased hip abduction moments on the nonoperative hip and decreased hip abduction moments on the operative hip. Clinicians should be mindful of the effects of cane use on the contralateral hip.

Spontaneous Ankylosis of the Contralateral Hip After Unilateral Adductor Tenotomy in Cerebral Palsy

This is the case report of a 15-year-old black male with spastic quadriplegia cerebral palsy who developed heterotopic ossification and spontaneous ankylosis of his contralateral nonoperative hip after unilateral adductor tenotomy. To the authors' knowledge, this is the only reported case of such an occurrence. The mechanism and possible risk factors are discussed as well as management of this complication.