Posterior Wall Index Research Articles

Measurement of acetabular wall indices: comparison between CT and plain radiography.

The purpose of this study was to compare measurements of anterior wall index (AWI) and posterior wall index (PWI) on computed tomography (CT) to those on radiographs (XR). A consecutive cohort of 33 patients (45 hips total) being evaluated for hip pain with both XR and CT was examined. Preoperative measurements of AWI and PWI were performed utilizing supine anteroposterior pelvic XR and coronal and swiss axial CT scans by two independent raters. Mean differences between XR and CT measurements were compared, and agreement between measurements was assessed using the concordance correlation coefficient (rc) and Bland–Altman analysis. A total of 39 hips in 28 patients were analyzed. The mean patient age was 31.1 ± 9.0 years, and 50% were female. Mean AWI and PWI on XR was 0.50 ± 0.14 and 0.91 ± 0.12, respectively. Measured values of AWI were consistently larger (0.08 ± 0.10, P < 0.01) on XR compared with both coronal and swiss axial CT, with moderate agreement between XR and CT measurements (rc = 0.68–0.70). Measured values of PWI were consistently smaller (0.15 ± 0.12, P < 0.05) on XR compared with both coronal and swiss axial CT, with poor agreement between XR and CT measurements (rc = 0.37–0.45). Measured values of acetabular wall indices on XR were consistently larger for AWI and smaller for PWI relative to CT. Agreement between XR and CT measures of the indices were moderate to poor. This highlights the need for standardization of XR- and CT-based measurements to improve assessment of acetabular coverage and subsequent clinical decision-making.

The Severity of Acetabular Retroversion Does Not Influence Outcomes of Arthroscopic Management of FAI

Objectives:Controversy exists regarding optimal treatment of FAI in the setting of acetabular retroversion. The purpose of this study was to investigate changes in pain and function among patients with acetabular retroversion treated with hip arthroscopy. Secondarily, to assess if the severity of posterior wall deficiency influences post-operative outcomes following hip arthroscopy.Methods:A retrospective review of patients with acetabular retroversion with hip arthroscopic surgery at a single institution was performed. Acetabular retroversion was defined by three radiographic criteria: the presence of crossover sign, ischial spine sign, and posterior wall sign. Anteroposterior radiographs were used to measure lateral center edge angle (LCEA), Tonnis grade, anterior wall index (AWI) and posterior wall index (PWI), and alpha angle. Patient-reported outcome (PROs) included modified Harris Hip Score (MHHS), visual analog scale (VAS) and quality of life with Veterans RAND-12 (VR-12). Spearman correlation coefficients were used to determine correlation of PWI with pre- and post-PROs. Multivariate analysis was performed and generalized estimating equation was used to determine independent predictors for outcome scores. Significance was set at p<0.05.Results:Between 2013 and 2019, 138 patients with FAI and acetabular retroversion underwent hip arthroscopy, 67% were female. The average follow-up was 29 months, with minimum of 6 months. Average preoperative LCEA 28, alpha angle 70.1, postoperative alpha angle 44.6 (p<0.05). All PROs demonstrated significant improvement from preoperative baseline to follow-up scores (MHHS (59.5 +/- 14.7 vs 80.8 +/- 18.8), VAS (6.3 +/- 1.7 vs 3.0 +/- 2.7), p<0.0001). Four patients (3%) underwent revision procedures. Upon multivariate analysis, no association between PWI and PROs was not found. Preoperative mHHS was the strongest predictor of clinical outcome.Conclusions:This is the largest study of patients with acetabular retroversion assessing for a correlation between PWI on patient-reported outcomes following arthroscopic management of FAI. In patients with acetabular retroversion, outcomes are good following arthroscopic management with low complication and revision rate following hip arthroscopy. Posterior wall deficiency was not a predictor of poor outcome in patients with acetabular retroversion. In this single surgeon selected series, the severity of retroversion (measured by PWI) does not appear to have a threshold or any correlation with postoperative outcomes in following FAI treatment.

The Acetabular Wall Index Is Associated with Long-term Conversion to THA after PAO.

Periacetabular osteotomy (PAO) has been shown to be a valuable option for delaying the onset of osteoarthritis in patients with hip dysplasia. Published studies at 30 years of follow-up found that postoperative anterior overcoverage and posterior undercoverage were associated with early conversion to THA. The anterior and posterior wall indices are practical tools for assessing AP coverage on standard AP radiographs of the pelvis pre-, intra-, and postoperatively. However, no study that we know of has evaluated the relationship between the postoperative anterior and posterior wall indices and survivorship free from arthroplasty. In a study including patients after PAO for developmental dysplasia of the hip (DDH), we evaluated whether the acetabular wall index is associated with conversion to THA in the long-term after PAO. We asked: (1) Is an abnormal postoperative anterior wall index associated with conversion to THA after PAO? (2) Is an abnormal postoperative posterior wall index associated with conversion to THA after PAO? (3) Are there other factors associated with joint replacement after PAO? This retrospective study involved pooling data of PAO for DDH from two previously published sources. The first series (1984-1987) comprised the very first 75 PAOs for symptomatic DDH performed at the inventor's institution. The second (1997-2000) comprised a series of PAOs for symptomatic DDH completed at the same institution 10 years later. No patient was lost to follow-up. Fifty hips (44 patients) were excluded for predefined reasons (previous surgery, substantial femoral pathomorphologies, poor-quality radiographs), leaving 115 hips (102 patients, mean age 29 ± 11 years, 28% male) for analysis with a mean follow-up of 22 ± 6 years. One observer not involved in patient treatment digitally measured the anterior and posterior wall indices on postoperative AP pelvic radiographs of all patients. All patients were contacted by mail or telephone to confirm any conversion to THA and the timing of that procedure relative to the index procedure. We performed univariate and multivariate Cox regression analyses using conversion to THA as our endpoint to determine whether the anterior and posterior wall indices are associated with prosthetic replacement in the long-term after PAO. Thirty-one percent (36 of 115) of hips were converted to THA within a mean of 15 ± 7 years until failure. The mean follow-up duration of the remaining patients was 22 ± 6 years. A deficient anterior wall index was associated with conversion THA in the long-term after PAO (adjusted hazard ratio 10 [95% CI 3.6 to 27.9]; p < 0.001). Although observed in the univariate analysis, we could not find a multivariate association between the posterior wall index and a higher conversion rate to THA. Grade 0 Tönnis osteoarthritis was associated with joint preservation (adjusted HR 0.2 [95% CI 0.07 to 0.47]; p = 0.005). Tönnis osteoarthritis Grades 2 and 3 were associated with conversion to THA (adjusted HR 2.3 [95% CI 0.9 to 5.7]; p = 0.08). A deficient anterior wall index is associated with a decreased survivorship of the native hip in the long-term after PAO. Intraoperatively, in addition to following established radiographical guidelines, the acetabular wall indices should be measured systematically to ascertain optimal acetabular fragment version to increase the likelihood of reconstructive survival after PAO for DDH. Level III, therapeutic study.

Does the Rule of Thirds Adequately Detect Deficient and Excessive Acetabular Coverage?

Assessment of AP acetabular coverage is crucial for choosing the right surgery indication and for obtaining a good outcome after hip-preserving surgery. The quantification of anterior and posterior coverage is challenging and requires either other conventional projections, CT, MRI, or special measurement software, which is cumbersome, not widely available and implies additional radiation. We introduce the "rule of thirds" as a promising alternative to provide a more applicable and easy method to detect an excessive or deficient AP coverage. This method attributes the intersection point of the anterior (posterior) wall to thirds of the femoral head radius (diameter), the medial third suggesting deficient and the lateral third excessive coverage. What is the validity (area under the curve [AUC], sensitivity, specificity, positive/negative likelihood ratios [LR(+)/LR(-)], positive/negative predictive values [PPV, NPV]) for the rule of thirds to detect (1) excessive and (2) deficient anterior and posterior coverages compared with previously established radiographic values of under-/overcoverage using Hip2Norm as the gold standard? We retrospectively evaluated all consecutive patients between 2003 and 2015 from our institutional database who were referred to our hospital for hip pain and were potentially eligible for joint-preserving hip surgery. We divided the study group into six specific subgroups based on the respective acetabular pathomorphology to cover the entire range of anterior and posterior femoral coverage (dysplasia, overcoverage, severe overcoverage, excessive acetabular anteversion, acetabular retroversion, total acetabular retroversion). From this patient cohort, 161 hips were randomly selected for analysis. Anterior and posterior coverage was determined with Hip2Norm, a validated computer software program for evaluating acetabular morphology. The anterior and posterior wall indices were measured on standardized AP pelvis radiographs, and the rule of thirds was applied by one observer. The detection of excessive anterior and posterior acetabular wall using the rule of thirds revealed an AUC of 0.945 and 0.933, respectively. Also the detection of a deficient anterior and posterior acetabular wall by applying the rule of thirds revealed an AUC of 0.962 and 0.876, respectively. For both excessive and deficient anterior and posterior acetabular coverage, we found high specificities and PPVs but low sensitivities and NPVs. We found a high probability for an excessive (deficient) acetabular wall when this intersection point lies in the lateral (medial) third, which would qualify for surgical correction. On the other hand, if this point is not in the lateral (medial) third, an excessive (deficient) acetabular wall cannot be categorically excluded. Thus, the rule of thirds is very specific but not as sensitive as we had expected. Level II, diagnostic study.

Imaging Markers of Hip Instability are Associated with Worse Outcomes at Two to Four-year Follow-up in Female Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Objectives:To investigate the effect of radiographic markers of hip instability on outcomes of female patients undergoing hip arthroscopy for femoroacetabular impingement.Methods:This was a retrospective reviewof a prospectively collected cohort of females undergoing hip arthroscopy with a diagnosis of FAI treated with femoral osteoplasty with or without labral repair. iHOT-12 was collected preoperatively and at 2 to 4-year follow-up. Radiographs were reviewed and anterior wall index (AWI), posterior wall index (PWI), femoro-epiphyseal acetabular roof (FEAR) index, and lateral center edge angle (LCEA) were recorded in all patients. Computed tomography was used to quantify femoral anteversion in all patients. A laterally oriented FEAR index is considered positive (unstable), while a medially oriented fear index is considered negative (impingement/stable). An AWI of <0.30 and a PWI<0.80 were considered anterior wall deficient (AWD) and posterior wall deficient (PWD), respectively. Patients with borderline acetabular dysplasia (LCEA≤25) were groups as medially or laterally oriented FEAR index. Similarly, patients with borderline acetabular dysplasia(LCEA≤25) were groups as elevated femoral anteversion (>15 degrees) or not. Differences in means were tested using a students t-test or an analysis of variance with a post-hoc tukey’s test.Results:There were 175 Female patients with a mean age of 33 years. Mean follow up was 34.6 months. Mean preoperative iHOT12 was 30.4. Mean postoperative iHOT12 was 74.8. Mean FA was 11.7 (Range 1 to 34) degrees. There were 64 patients with an LCEA≤25, 138 patients had no AWD or PWD, 18 patients with an AWI <0.30 and 18 patients with a PWI <0.80. One patient was excluded from the analysis for having both an AWI<0.30 and a PWI<0.8. Patients with AWD had lower mean iHOT at follow up (54.5 compared with those with no wall deficiency 77.7, p=0.001.) Patents with PWD did not (72.4 compared with those with no wall deficiency 77.7, p=0.669.) Similarly, patients with AWD had lower mean iHOT improvement at follow up (24.2 compared with those with no wall deficiency 47.0, p=0.001). Patents with PWD did not (43.1 compared with those with no wall deficiency 47.0, p=0.808). Mean FEAR index was -7.1(Range -30 to 15) degrees. The FEAR index correlated with both the iHOT12 at follow up (-0.171, p=0.024) and the improvement in the iHOT12(-0.192, p=0.011). There were 31 patients with a laterally oriented FEAR index. These patients had worse iHOT12 at follow-up (64.9 points versus 77.0 points, p=0.037) and less improvement in iHOT12 (34.3 points versus 46.6 points, p=0.015). There were 110 patients with LCEA>25, 42 patients with LCEA≤25 with a medially oriented FEAR index and 23 patients with an LCEA≤25 with a laterally oriented FEAR index. Patients with LCEA≤25 and a laterally oriented FEAR index had worse iHOT12 at follow-up (60.7 points versus 78.9 points, p=0.005) and less improvement in iHOT12 from surgery (30.0 points versus 49.5 points, p=0.002) compared to those with an LCEA>25. There were 110 patients with LCEA>25, 46 patients with LCEA≤25 and FA <15 degrees and 17 patients with LCEA≤25 and FA≥15 degrees. Patients with LCEA≤25 had worse iHOT12 at follow-up (68.0 points versus 78.9 points, p=0.010) and less improvement in iHOT12 from surgery (36.0 points versus 49.5 points, p=0.001) compared to those with an LCEA>25. Patients with LCEA≤25 and FA≥15 degrees had worse iHOT12 at follow-up (59.5 points versus 78.9 points, p=0.008) and less improvement in iHOT12 from surgery (28.2 points versus 49.5 points, p=0.003) compared to those with an LCEA>25. In addition, patients with LCEA≤25 and FA<15 degrees had less improvement iHOT12 from surgery (38.0 points versus 49.4 points, p=0.026) compared to those with an LCEA>25.Conclusion:Imaging markers of hip instability, including borderline acetabular dysplasia, increased femoral anteversion, a laterally oriented FEAR index, and anterior wall deficiency are predictive of worse outcomes of hip arthroscopy for FAI in female patients. A more thoughtful imaging analysis of female patients preoperatively may identify patients at risk of worse outcomes after hip arthroscopy and may guide treatment with other joint preserving procedures, including periacetabular or femoral osteotomy.

Is Hip Arthroscopy an Adequate Therapy for the Borderline Dysplastic Hip? Correlation Between Radiologic Findings and Clinical Outcomes.

Background:Recent studies have shown that assessment of the lateral center-edge angle (LCEA) between 18° and 25° is not sufficient to adequately classify mildly dysplastic hips and that further radiological features should be considered. However, no correlation between different morphologic features and clinical outcomes has been investigated so far.Purpose:To analyze the clinical outcomes of patients with different subtypes of borderline dysplastic hips who underwent arthroscopic surgery.Study Design:Cohort study; Level of evidence, 3.Methods:We examined patients with an LCEA between 18° and 25° who underwent arthroscopic treatment for femoroacetabular impingement syndrome between January 2015 and December 2016. A hierarchical cluster analysis was performed to identify hip morphologic subtypes according to radiographic parameters, including the LCEA, femoro-epiphyseal acetabular roof (FEAR) index, anterior and posterior wall indices (AWI and PWI), Tönnis angle, alpha angle, and femoral neck-shaft angle. In addition, the International Hip Outcome Tool 12 (iHOT-12) and a visual analog scale (VAS) for pain were applied preoperatively and at follow-up, and the results were compared among the different clusters. Previously reported minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values were used to determine clinically significant improvements.Results:A total of 40 patients were identified. Of these, 36 patients were available for evaluation at a mean follow-up of 43.8 months. In total, 4 sex-independent clusters with different morphologic patterns of the hip were identified: cluster 1, unstable anterolateral deficiency (FEAR index >2°, AWI <0.35); cluster 2, stable anterolateral deficiency (FEAR index <2°, AWI <0.35); cluster 3, stable lateral deficiency (FEAR index >2°, normal AWI and PWI); and cluster 4, stable posterolateral deficiency (FEAR index <2°, PWI <0.85). At follow-up, clusters 1, 2, and 3 showed significantly improved iHOT-12 (P < .0001) and VAS pain (P < .0001) scores, and cluster 4 showed no significant improvements. The MCID of 15.2 points was achieved by all patients in clusters 2 and 3, by 63% of patients in cluster 1, and by 23% of patients in cluster 4. Clusters 2 and 3 differed significantly from clusters 1 and 4 (P = .02). A postoperative PASS score of 60 was achieved by all patients in cluster 3, by 86% of patients in cluster 2, by 63% of patients in cluster 1, and by 20% of patients in cluster 4. The differences between the groups were statistically significant (P = .01).Conclusion:Arthroscopic surgery yielded good results in the treatment of stable borderline hip dysplasia with anterolateral and lateral deficiency. In contrast, borderline hip dysplasia with acetabular retroversion showed no improvements after arthroscopic therapy. This study underlines the need for an accurate analysis of all possible radiological signs to adequately classify borderline dysplastic hips.

LOW DOSE CT SCAN FOLLOWING PERIACETABULAR OSTEOTOMY: ASSESSMENT OF REDUCTION AND CORRELATION WITH RADIOGRAPHIC MEASURES

Introduction:Periacetabular osteotomy (PAO) has become a favored treatment for symptomatic acetabular dysplasia worldwide. Nevertheless, the parameters for optimal correction to avoid residual instability or iatrogenic impingement have not been defined.Purpose:The purposes of this study were (1) to assess the ability of PAO to correct femoral head coverage to normal ranges as measured by 3D CT scan and (2) to determine if postoperative radiographic parameters of dysplasia are accurate markers of optimal acetabular correction.Methods:A total of 43 hips (in 38 patients, mean 27.7 years, 88.4% female) were enrolled in this prospective cohort study at minimum 1 year after PAO. Postoperative femoral head coverage was assessed via low-dose CT and compared to normative data of asymptomatic hips from the literature. Anterior (3:00-1:15), lateral (1:00-11:00), and posterior (11:25-9:00) sector coverage was defined by averaging the coverage at 15 minute increments in each zone. Postoperative radiographs were utilized to measure lateral center edge angle (LCEA), anterior wall index (AWI), posterior wall index (PWI), and anterior center edge angle (ACEA). Good correction for each sector was defined as coverage from 1 SD below mean to 2 SD above mean.Results:Postoperatively, the anterior sector was normalized in 84% of hips, lateral sector in 84% of hips, and posterior sector in 86% of hips. Sixty-seven percent of hips were corrected to normative range in all three sectors and 19% were corrected in two sectors (86% in at least two sectors). LCEA and PWI showed the highest correlation with lateral and posterior sector coverage with Pearson’s correlation coefficients of 0.67 and 0.71 (p < 0.001), respectively. Weaker correlations were found between anterior coverage and the AWI and ACEA coverage (-0.16 and 0.15, respectively). Good correction was best correlated with the following target values for acetabular correction: LCEA 28°, AI 1°, AWI 0.37, ACEA 32°, and PWI 1.0.Conclusion:PAO can effectively normalize femoral head coverage compared to normative data. Good correction of each sector coverage ranged from 84-86% of cases. The proposed set of radiographic parameter targets were found to be reliable markers of femoral head coverage.

Does Compensatory Anterior Pelvic Tilt Decrease After Bilateral Periacetabular Osteotomy?

The kinetic link among the lumbar spine, pelvic tilt, and the hip has been hypothesized, but this relationship requires further study in acetabular dysplasia. Anecdotal reports suggest that patients may compensate for acetabular dysplasia with an involuntary increase in anterior pelvic tilt; it is not known if this relationship is affected by acetabular reorientation. (1) Does compensatory pelvic tilt decrease on preoperatively obtained standing AP pelvis radiographs compared with those obtained at a minimum of 6 months after bilateral periacetabular osteotomy (PAO)? (2) Does a modified surrogate measurement of pelvic tilt, the pubic symphysis to sacroiliac (PS-SI) index, correlate with a physical synthetic bones model in which pelvic tilt can be directly measured? (3) Can the PS-SI index demonstrate high interrater reliability? We assessed the surgical records of one surgeon, who participates in the longitudinally maintained Academic Network of Conservational Hip Outcomes Research (ANCHOR) registry, for patients who had undergone the second side of a staged bilateral PAO between 2007 and 2016; there were 113 such patients. Of those, 70 (62%) were lost to followup within 6 months of the second PAO or did not have adequate imaging studies, and another three (3%) were excluded for prespecified reasons, leaving 40 (35%) for evaluation in this retrospective study. Standing preoperative and most recent postoperative AP pelvis radiographs were used to measure the Tönnis angle, anterior wall index, posterior wall index, lateral center-edge angle, pubis symphysis-to-sacrococcygeal junction distance, and the PS-SI index. The most recent radiographs were obtained at a mean of 16 ± 6 months after the second PAO. We chose 6 months as the minimum because at this time point, the majority of patients have reached their maximum clinical improvement and are no longer limited by postoperative muscle dysfunction. Statistical analysis was performed using the intraclass correlation coefficient (ICC) for interrater reliability and paired t-tests for assessing change in measurements from pre- to postoperative. Additionally, a model was created using a physical synthetic bones model in which pelvic tilt could be directly measured. This model was secured through bilateral acetabuli on a mount and rotated through 5° increases in pelvic tilt. AP pelvis radiographs were obtained at each point, the PS-SI index was measured, and a regression analysis performed to evaluate for trend. Overall, 37 of 40 patients (93%) had a decrease in pelvic tilt, as measured by the PS-SI index. The mean amount of pelvic tilt as measured by the PS-SI index decreased after surgery when comparing the preoperative with latest radiographs on this parameter (97 ± 14 mm versus 89 ± 13 mm, mean difference 8 ± 9 mm; 95% confidence interval, -11 to -5; range 17 increase to 24 decrease, p < 0.001). A linear relationship between pelvic tilt and PS-SI index (PS-SI index = 5.0° + 3.6° tilt, R = 0.99) was identified in the synthetic bones validation model. Finally, the interrater reliability was found to be excellent for the PS-SI index preoperatively (ICC = 0.986) and postoperatively (ICC = 0.988). We found a modest reduction in anterior pelvic tilt after bilateral PAO. This finding suggests that acetabular reorientation affects pelvic position. In clinical practice, patients with acetabular dysplasia may compensate with dynamic and reversible changes in pelvic tilt. The PS-SI index is a reproducible tool to measure the height of the pelvic inlet as an assessment of pelvic tilt. In the future, clinical studies should evaluate the clinical implications of these radiographic findings, including the assessment of back pain, which although multifactorial may be influenced by pelvic tilt. Level III, therapeutic study.

Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18° and 25° Appropriately?

Background: Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population. Hypothesis: Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tönnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO. Results: Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P < .001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients. Conclusion: A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.

Organoprotection with arterial hypertension 2-3 degrees

Objective. Arterial hypertension (AH) is one of the most common and socially significant diseases worldwide. Despite years of experience gained in studying hypertension, the problems concerning selection of antihypertensive therapy with pleiotropic organ-protecting effects are still of current importance. Purpose - to assess therapeutic efficacy and pleiotropic organ-protective capability of third-generation calcium antagonist lercanidipine in patients with stage 2-3 hypertension. Materials and methods. Our study enrolled a total of ninety-two 31-to-84-year-old patients. Of these, 72 patients diagnosed as having stage 2 or 3 AH composed the Study Group and 20 apparently healthy subjects were included into the Control Group. At baseline and after 6 months, all patients of the Study Group underwent examinations consisting in measuring biochemical parameters [total cholesterol (TCH), triglycerides, low-density lipoprotein cholesterol (LDL CH), uric acid, urea, creatinine, glucose], 24-hour ambulatory BP monitoring, echocardiography in order to assess the dimensions and volume of the cardiac chambers, thickness of the left ventricular posterior wall (LVPW) and left-ventricular myocardium mass index (LVMMI), studying microalbuminuria (MAU), a known marker of endothelial dysfunction and early renal lesion; assessing the state of the vascular wall by the ankle-brachial index (ABI) and pulse pressure (PP). Antihypertensive therapy consisted in lercanidipine alone taken at a dose of 10-20 mg/day, failure to thereby achieve the target BP level was followed by additionally prescribing an angiotensin converting enzyme (ACE) inhibitor, enalapril, given at a dose of 5-20 mg twice daily. Results. All patients by the end of the study achieved the target level of AP (p≤0.05), also demonstrating significantly improved (p≤0.01) parameters of endothelial dysfunction and an early marker of renal damage (MAU), indices of elastic properties of the vascular wall ABI (p≤0.05) and PP (p=0.01). Significantly positive dynamics was observed for the following parameters: decreased creatinine concentration (p≤0.001), increased GFR (p≤0.001), decreased levels of TCH (p≤0.01) and LDL CH (p≤0.001). Conclusion. Lercanidipine therapy of patients with stage 2-3 AH proved highly efficient, well tolerated, metabolically neutral with pleiotropic organprotecting properties in the form of improved condition of the vascular wall, correction of endothelial dysfunction, nephroprotective action

Anteverting Bernese periacetabular osteotomy in the treatment of neurogenic hip dysplasia in cerebral palsy.

All patients with hypertonic cerebral palsy undergoing Bernese periacetabular osteotomy (PAO) between 2005 and 2014 were reviewed. Clinical and radiographic parameters, including the cerebral palsy hip classification and anterior and posterior wall indices were collected to assess acetabular reorientation. Twenty (83%) of 24 procedures involved the correction of posterolateral acetabular insufficiency and were 'anteverting PAOs'. All 20 experienced improvements in radiographic indices. Eleven (58%) of 19 PAOs in ambulatory patients were performed in the setting of other multilevel orthopedic surgery. The anteverting PAO is successful in correcting the posterolateral acetabular insufficiency present in spastic hip dysplasia, and can be performed in conjunction with a single-event multilevel surgery.

Periacetabular Osteotomy Improves Pain and Function in Patients With Lateral Center-edge Angle Between 18° and 25°, but Are These Hips Really Borderline Dysplastic?

AbstractBackgroundThe treatment of mild or borderline acetabular dysplasia is controversial with surgical options including both arthroscopic labral repair with capsular closure or plication and periacetabular osteotomy (PAO). The degree to which improvements in pain and function might be achieved u

Mid-Term Results of Periacetabular Osteotomy for the Treatment of Hip Dysplasia Associated with Down Syndrome: Minimum Follow-up of Five Years.

The treatment of hip dysplasia in patients with Down syndrome is challenging. We investigated the clinical, functional, and radiographic outcomes of periacetabular osteotomy (PAO) as well as factors associated with its failure at a minimum of 5 years of follow-up. Between 1992 and 2011, 19 patients with Down syndrome (26 hips) underwent PAO at a mean age of 16.2 ± 4.7 years. Hip pain and function were assessed with use of the modified Harris hip score (HHS) and the Gross Motor Function Classification System (GMFCS). The criteria for PAO failure were progression of osteoarthritis with a recommendation for total hip arthroplasty or hip arthrodesis, or an HHS of <60 points. Preoperative and most recent radiographs were assessed for measurement of the lateral and anterior center-edge angles, Tönnis angle, extrusion index, and anterior and posterior wall indices, and for evaluation of the Tönnis grade of osteoarthritis. At an average follow-up of 13.1 ± 5.2 years (range, 5.4 to 24 years), 13 (62%) of 21 hips with an HHS demonstrated good or excellent HHS results (median, 91 points; interquartile range, 65 to 96 points). Ninety-five percent of the patients were independent in ambulation. All radiographic parameters significantly improved after PAO. Eight (31%) of the 26 hips were considered to have failed the procedure. Tönnis grade-2 osteoarthritis (4 hips compared with 1 hip; p = 0.008; odds ratio [OR] = 17.00) and older patient age at the time of the procedure (19.6 ± 6.7 compared with 14.7 ± 2.4 years; p = 0.017; OR = 1.36 per year) were demonstrated to be factors associated with PAO failure in an analysis of hips that failed compared with those without failure at the time of latest follow-up. PAO improves radiographic deformity and helps to preserve independent ambulation in patients with hip dysplasia and Down syndrome. Although nearly 70% of the hips were preserved at an average of 13 years postoperatively, 1 in 3 hips met the criteria for failure, which was associated with older age at the time of the procedure and a moderate osteoarthritis grade (Tönnis grade 2). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acetabular Wall Indices Help to Distinguish Acetabular Coverage in Asymptomatic Adults With Varying Morphologies.

The anterior wall index (AWI) and posterior wall index (PWI) have been proposed to quantify anterior and posterior acetabular coverage using AP pelvic radiographs. However, these indices have only been reported in symptomatic patients with apparent pathomorphologies (dysplasia, overcoverage, and retroversion) undergoing osteochondroplasty or reorientation osteotomy. (1) What are the ranges for AWI and PWI from measurements obtained on AP pelvic radiographs of asymptomatic senior athletes with well-functioning hips? (2) Is there a difference between the AWI and PWI in asymptomatic athletes with acetabular morphology consistent with acetabular dysplasia, overcoverage, and retroversion when compared with asymptomatic hips that do not meet the radiographic definitions for those morphologies (controls)? Five hundred five athletes (998 asymptomatic native hips) were independently evaluated by two readers on AP pelvic radiographs for AWI and the PWI after excluding hips with prior surgery, inadequate radiographs, or poor function (modified Harris hip score<80). Hips with a lateral center-edge angle (LCEA)≥20° and≤38° and without acetabular retroversion, based on a positive crossover sign, were used as controls. Hips were categorized as developmental dysplasia of the hip (DDH; undercoverage) if the LCEA was<20°. Finally, overcoverage was defined as an LCEA>38°. The mean age of the athletes was 67years (range, 50-91years) and 55% were men. Linear generalized estimating equation regression was used to compare each individual diagnosis (DDH, retroversion, overcoverage) with the controls for both AWI and PWI adjusting for age and sex. The mean AWI in the study population was 0.36 (range, -0.02 to 0.91). The mean PWI was 1.13 (range, 0.12-1.74). The mean AWI and PWI in controls (n=740) was 0.35 (range, -0.02 to 0.91) and 1.13 (range, 0.64-1.70), respectively. There were 25 (3%) with DDH in whom the mean AWI was 0.26 (range, 0.05-0.5) and the mean PWI was 1.03 (range, 0.71-1.3). There were 112 (11%) retroverted hips in whom the mean AWI was 0.42 (range, 0.1-0.89) and PWI was 1.02 (range, 0.61-1.5). There were 121 (12%) overcovered hips in whom the mean AWI was 0.43 (range, -0.18 to 0.85) and PWI was 1.22 (0.12-1.74). The AWI in the control hips was no different than that of DDH hips (β -0.06; 95% confidence interval [CI], -0.12 to 0.002; p=0.059) but was found to be lower than retroverted hips (β 0.08; 95% CI, 0.04-0.11; p<0.001) and overcovered hips (β 0.05; 95% CI, 0.03-0.08; p<0.001). The PWI in control hips was greater than that of DDH hips (β -0.08; 95% CI, -0.14 to -0.02; p=0.013) and retroverted hips (β -0.07; 95% CI, -0.11 to -0.04; p<0.001) but was less than overcovered hips (β 0.07; 95% CI, 0.04-0.10; p<0.001). The measurements of AWI and PWI in well-functioning, asymptomatic hips may be useful in assessing anterior and posterior acetabular coverage because it was able to distinguish between different types of known pathologic morphology. Despite evidence of these morphologic variances, these senior athletes continued to function at a high level. Thus, the identification of morphologic variance was not consistent with signs of pathology, which further supports that early screening of morphology may not predict the development of symptomatic pathology. Future work should focus on comparing these indices for morphologic variance in both symptomatic and asymptomatic hips to determine whether these measurements can be used in identifying problematic hips and as reference ranges for surgical correction. Level III, diagnostic study.

Thyroid Function Status and Echocardiography Abnormalities in Patients with Beta Thalassemia Major in Bahrain

Background:Thyroid gland dysfunction and echocardiographic cardiac abnormalities are well-documented in patients with transfusion dependent beta-thalassemia major (β-TM).Aim:This cross-sectional analytic study was conducted to investigate left ventricle (LV) diastolic and systolic function using pulsed Doppler (PD) and tissue Doppler (TD) echocardiography and correlate that with serum level thyroid stimulating hormone in patients with β-TM.Methods:The study was conducted on patients with β-TM (n = 110, age 15.9 ± 8.9 years) and compared with a control group (n = 109, age 15.8 ± 8.9 years). In all participants, echocardiographic indices of PD and TD were performed and blood samples were withdrawn for measuring the serum level of TSH, free T4, and ferritin. A linear regression analysis was performed on TSH level as the dependent variable and serum ferritin as independent. Stepwise multiple regression analysis was used to determine the odds ratio of different biochemical and echo variables on the risk of developing hypothyroidism.Results:Patients with β-TM compared with controls had thicker LV septal wall index (0.65 ± 0.26 vs. 0.44 ± 0.21 cm/M2, P < 0.001), posterior wall index (0.65 ± 0.23 vs. 0.43 ± 0.21 cm/m2, P < 0.01) and larger LVEDD index (4.35 ± 0.69 vs.3.88 ± 0.153 mm/m2, P < 0.001). In addition, β-TM patients had higher transmitral E wave velocity (E) (70.81 ± 10.13 vs. 57.53 ± 10.13 cm/s, P = 0.02) and E/A ratio (1.54 ± 0.18 vs. 1.23 ± 0.17, P < 0.01) and shorter deceleration time (DT) (170.53 ± 13.3 vs. 210.50 ± 19.20 m sec, P < 0.01). Furthermore, the ratio of transmitral E wave velocity to the tissue Doppler E wave at the basal septal mitral annulus (E/Em) was significantly higher in the β-TM group (19.68 ± 2.81 vs. 13.86 ± 1.41, P < 0.05). The tissue Doppler systolic wave (Sm) velocity and the early diastolic wave (Em) were significantly lower in the β-TM group compared with controls with Sm, 4.82 ± 1.2 vs. 6.22 ± 2.1 mm/sec, P < 0.05 and (Em), 3.51 ± 2.7 vs. 4.12 ± 2.5 mm/sec. P < 0.05, respectively). The tricuspid valve velocity was significantly higher in β-TM patients compared with controls 2.85 ± 0.56 vs. 1.743 ± 0.47 m sec, respectively, P < 0.01). The prevalence of subclinical hypothyroidism in patients with β-TM was 15.4%, with significantly higher mean serum TSH compared with controls (6.78 ± 1.5 vs. 3.10 ± 1.02 μIU/mL, P < 0.01) and positively correlated with the serum ferritin level (r = 0.34, P = 0.014). On multiple regression analysis, the LV mass, LVEF%, and E/A ratio were not positive predictors of hypothyroidism in patients with β-TM.Conclusion:We conclude that patients with β-TM had a high prevalence of subclinical hypothyroidism of 15.4%. Thyroid stimulating hormone was significantly high and positively correlated with the serum ferritin level. Echo cardiographic pulsed Doppler showed a restrictive LV diastolic pattern suggestive of severe diastolic dysfunction with preserved left ventricle systolic function.

The Acetabular Wall Index for Assessing Anteroposterior Femoral Head Coverage in Symptomatic Patients

Understanding acetabular pathomorphology is necessary to correctly treat patients with hip complaints. Existing radiographic parameters classify acetabular coverage as deficient, normal, or excessive but fail to quantify contributions of anterior and posterior wall coverage. A simple, reproducible, and valid measurement of anterior and posterior wall coverage in patients with hip pain would be a clinically useful tool. We (1) introduce the anterior wall index (AWI) and posterior wall index (PWI), (2) report the intra- and interobserver reliability of these measurements, and (3) validate these measurements against an established computer model. We retrospectively reviewed 87 hips (63 patients) with symptomatic hip disease. A validated computer model was used to determine total anterior and posterior acetabular coverage (TAC and TPC) on an AP pelvis radiograph. Two independent observers measured the AWI and PWI on each film, and the intraclass correlation coefficient (ICC) was calculated. Pearson correlation was used to determine the strength of linear dependence between our measurements and the computer model. Intra- and interobserver ICCs were 0.94 and 0.99 for the AWI and 0.81 and 0.97 for the PWI. For validation against the computer model, Pearson r values were 0.837 (AWI versus TAC) and 0.895 (PWI versus TPC). Mean AWI and PWI were 0.28 and 0.81 for dysplastic hips, 0.41 and 0.91 for normal hips, 0.61 and 1.15 for hips with a deep acetabulum. Our data suggest these measures will be helpful in evaluating anterior and posterior coverage before and after surgery but need to be evaluated in asymptomatic individuals without hip abnormalities to establish normal ranges. Level III, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Is left ventricular dysfunction reversed after treatment of active acromegaly?

It has been suggested that control of GH and IGF excess can arrest the progression of cardiovascular abnormalities and normalize cardiac performance. The aim of the present study was to investigate the reversibility of acromegalic cardiomyopathy in patients with active and inactive disease and to evaluate the effect of the inactivity of the disease on left ventricular (LV) diastolic dysfunction, irrespective of the applied treatment. The patient population consisted of 55 patients who were studied in the active and/or inactive phase. A complete M-mode, two-dimensional and color-flow Doppler echocardiographic examination was performed. LV mass index and posterior wall index were significantly lower in patients with inactive acromegaly compared to those with active disease (P < 0.03 respectively). Diastolic dysfunction was improved in patients with inactive compared to those with active disease (E/A ratio P < 0.009). IGF was positively correlated with LV mass index (r = 0.28, P < 0.02). Multivariate linear regression analysis showed that in active patients the E/A ratio was independently related to age (β = -0.674, P < 0.001) and GH (β = 0.282, P < 0.03), whereas in inactive patients none of the parameters were related significantly with the E/A ratio. In a subgroup of 15 patients who were studied in both the active and inactive phase of the disease, the reduction in GH levels was correlated positively with the reduction in LV mass index (r = 0.89, P < 0.0001) and negatively with the improvement in E/A ratio (r = -0.74, P < 0.001). In conclusion, the results of the present study indicate an improvement of left ventricular diastolic function and a significant improvement of cardiac hypertrophy in patients with inactive acromegaly and normal systolic cardiac function compared to those with active disease.

Evaluation of myocardial systolic function of heart failure induced by myocardial infarction in rats with strain and strain rate imagine

To quantitatively detect variation in regional myocardial systolic function in heart failure rat model induced by myocardial infarction by strain and strain rate imaging. Seventy 2-month-old adult male SD rats were randomly assigned to 4 groups: a 4-week and a 8-week group after the operation (each n = 25) had thoracotomy, the pericardium opened and the anterior descending branch of left coronary artery ligated; a sham operation group (n = 10) had thoracotomy and the arcula cordis opened, but did not ligate the artery; a control group (n = 10) had no treatment. The changes of general state of health of the rats were observed and recorded every day. To assess the change of heart function, echocardiography was used at the end of the 4th week and 8th week after the surgery. To evaluate the change of heart function in heart failure rats, we quantitatively analyzed the regional myocardial systolic function in all rats by strain and strain rate imaging and myocardium to detect the level of MMP-9 at the end of the 4th week and 8th week. The repeatability and discrepancies of the results were all analyzed. Obviously objective signs of heart failure manifested themselves in the survived mice 10 to 14 days after the surgery. Compared with the control group and the sham operation group, the fraction shortening (FS) and ejection fraction (EF) of the 4-week group after the operation were lower (P < 0.05), the left ventricle index (LV index) of the 8-week group after the operation was higher, left ventricle posterior wall index (LVPW index), interventricular septum index (IVS index), FS, and EF of the 8-week group after the operation were lower (P < 0.05), EF and FS of the 8-week group after the operation were lower than those of the 4-week group. Except the mid-inferior wall and base-inferior wall, the systolic peak strain, systolic peak strain rate, the strain of end-systole in all segments of the operation group were lower than those of the other 2 groups (P < 0.05). The post-systolic strain index of the operation group was higher than that of the other 2 groups (P < 0.05). Strain and strain rate imaging of echocardiography can quantitatively evaluate the changing of regional myocardial systolic function in the heart failure rat model induced by myocardial infarction, with good repeatability.

The pro-BNP Serum Level and Echocardiographic Tissue Doppler Abnormalities in Patients with Beta Thalassemia Major

BackgroundDoppler echocardiographic studies of the left ventricle (LV) function in patients with β-Thalassemia Major (β-TM) had shown different patterns of systolic and diastolic dysfunctions associated with abnormal serum brain natriuretic peptide (BNP).AimThis cross-sectional study was designed to study the LV systolic and diastolic functions and correlate that with serum level of N-terminal pro brain natriuretic hormone (NT- pro BNP) in patients with β-TM using Pulsed Doppler (PD) and Tissue Doppler (TD) echocardiography.MethodsThe study was conducted on patients with β-TM (n = 38, age 15.7 ± 8.9 years) and compared with an age-matched controls (n = 38, age 15.9 ± 8.9 years). In all participants, PD and TD echocardiography were performed and blood samples were withdrawn for measuring the serum level of NT-pro BNP, ferritin, and alanine transaminase.ResultsPatients with β-TM compared with controls, have thicker LV septal wall index (0.65 ± 0.26 vs. 0.44 ± 0.21 cm, P < 0.001), posterior wall index (0.65 ± 0.23 vs. 0.43 ± 0.21 cm, P < 0.01), and larger LVEDD index (4.35 ± 0.69 vs.3.88 ± 0.153 mm, P < 0.001). In addition, β-TM patients have higher transmitral E wave velocity (E) (70.818 ± 10.139 vs. 57.532 ± 10.139, p = 0.027) and E/A ratio (1.54 ± 0.17 vs. 1.23 ± 0.19, P < 0.01) and shorter deceleration time (DT) (160.13 ± 13.3 vs. 170.50 ± 19.20 m sec, P < 0.01). Furthermore, the ratio of transmitral E wave velocity to the tissue Doppler E wave at the basal septal mitral annulus (E/Em−) was significantly higher in β-TM group (19.6 ± 2.81 vs. 13.868 ± 1.41, P < 0.05). The tissue doppler systolic wave (Sm) velocity and the early diastolic wave (Em) were significantly lower in β-TM group compared to controls (Sm: 4.82 ± 1.2 vs. 6.22 ± 2.1 mm/sec, P < 0.05; Em: 3.51 ± 2.7 vs. 4.12 ± 2.5 mm/sec P < 0.05, respectively). The tricuspid valve velocity was significantly higher in β-TM patients compared with controls (2.993 ± 0.569 vs. 1.93 ± 0.471 m/sec, respectively, P < 0.01). The mean serum NT pro-BNP in β-TM was significantly higher compared with controls (37.6 ± 14.73 vs. 5.5 ± 5.4pg/ml, P < 0.05). The left ventricle ejection fraction (EF%) and fractional shortening (FS%) were not significantly different between both groups.ConclusionWe conclude that patients with β-TM had a significantly higher serum level of NT-pro BNP that is positively correlated with the E/Em ratio on tissue Doppler. Furthermore, we confirm our previous findings that patients with β-TM exhibit LV diastolic pattern on echocardiogram suggestive of restrictive type with well preserved left ventricle systolic function.

QTc Interval and QT Dispersion in Patients with Thalassemia Major: Electrocardiographic (EKG) and Echocardiographic Evaluation

Doppler echocardiographic studies in patients with beta-Thalassemia Major (beta-TM) had shown different patterns of left ventricle (LV) systolic and diastolic dysfunctions. This cross-sectional study was designed to study the LV systolic and diastolic function in patients with beta-TM using Pulsed Doppler (PD) Echocardiogram and assess the QTc interval and QT dispersion (QTd) on 12 leads ECG. All patients were evaluated clinically as well as by echocardiography and 12 leads ECG. The study included patients with beta-TM (n = 38, age 15.7 +/- 8.9 years), compared with an age-matched healthy control group (n = 38, age 15.9 +/- 8.9 years). In 38 patients with beta-TM Compared with healthy control group, The QTc interval and the QTd dispersion on ECG were increased with no significant difference mode echo showed that beta-TM patients have thicker LV septal wall index (0.659 +/- 0.23 vs. 0.446 +/- 0.219 cm/M(2), P < 0.001), posterior wall index (0.659 +/- 0.235 vs. 0.437 +/- 0.214 cm/M(2), P < 0.01), and larger LVEDD index is (3.99 +/- 0.48 vs. 2.170 +/- 0.57 cm/M(2). P < 0.05). Pulsed Doppler showed high LV trans-mitral E wave velocity index (70.818 +/- 10.139 vs. 57.532 +/- 10.139, P < 0.05) and E/A ratio (1.54 vs.1.23, P < 0.01). The duration of deceleration time index (DT) and isovolumic relaxation time index (IVRT) were significantly shorter in patients with beta-TM (150.234 +/- 20.0.23 vs. 167.123 +/- 167.123 +/- 19.143 msec/M(2), P < 0.01) and (60.647 +/- 6.77 vs. 75.474 +/- 5.83 msec/M(2), P < 0.001), respectively. The tricuspid valve velocity in patients with beta-TM was significantly higher than controls (2.993 +/- 0.569 vs. 1.93 +/- 0.471 m/sec, respectively, P < 0.01), with calculated pulmonary artery pressure of 2.4 times the control (36.0 vs. 14.8 mmHg). However, the LVEF% or fractional shortening were not significantly different. In this study, beta-thalassemia major patients compared with controls have differences of QT dispersion and corrected QT interval that is of no statistical significance. A significantly thicker LV wall and LV diastolic filling indices are suggestive of restrictive diastolic pattern. These data indicate that LV diastolic abnormalities compromised initially in patients with beta-thalassemia major.