Cara Beth Lee

Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip.

Background: Acetabular dysplasia is a common cause of hip pain that can lead to premature osteoarthritis. This study explores whether demographic characteristics of patients diagnosed with acetabular dysplasia in adolescence and adulthood [adult-diagnosed dysplasia (AD)] differ from those who are diagnosed with developmental dysplasia of the hip (DDH) in infancy. Methods: Database review identified 633 patients undergoing periacetabular osteotomy for dysplasia from August 1991 to January 2008. Excluding patients with syndromal conditions and 80 lacking contact information, 421 patients received a questionnaire regarding birth and family history; 324 (70.3%) completed the survey. Thirteen were excluded because of unrelated hip conditions, leaving 311 patients for analysis. Results: Respondents were divided into 2 groups according to whether they had a history of DDH in infancy (102 patients) or were diagnosed in adolescence/adulthood (209 patients). Statistically significant differences (P<0.05) were found in sex distribution (female: DDH=98.0%, AD=88.0%), affected limb (left hip: DDH=33.3%, AD=19.1%), bilaterality (DDH=45.1%, AD=61.2%), and breech presentation (DDH=25.3%, AD=9.4%). Over 50% of all the respondents had a family history of hip disease; over 40% were first-order relatives. First-order family members of patients with AD had a higher incidence of hip replacement by the age of 65 (50.0% vs. 22.7%). Patients with DDH were more likely to have first-order family members with DDH (59.0% vs. 15.8%). Conclusions: This study confirms demographic differences between patients diagnosed with hip dysplasia in infancy versus adolescence/adulthood and supports the hypothesis that these represent distinct forms of dysplasia. In both, there is a familial tendency toward hip disease with a higher incidence of arthroplasty in the AD group’s family members and higher frequency of infantile dysplasia in the DDH group’s family members. Clinical Relevance: Infantile DDH is diagnosed with neonatal examination and patients are routinely followed into adolescence. Adolescent/adult AD is not detected until symptoms develop. Further study is needed to determine whether younger family members of patients with hip osteoarthritis should be screened to detect potentially at-risk hips.

Case Reports: Acetabular Damage After Mild Slipped Capital Femoral Epiphysis

BackgroundSlipped capital femoral epiphysis (SCFE) is a common hip problem in adolescents that results in a cam-type femoroacetabular impingement (FAI) deformity. Although the treatment for mild (slip angle of 0°–30°) and moderate (slip angle of 31°–60°) SCFE has historically been in situ fixation, recent studies have demonstrated impingement-related articular damage, irrespective of slip severity. Our series confirms previous reports that acetabular chondral injury occurs in mild to low-moderate (slip angle of ≤ 40°) SCFE.Case DescriptionWe retrospectively reviewed five patients who underwent arthroscopy and femoral osteoplasty within 18 months after in situ stabilization. All had labral and/or acetabular damage.Literature ReviewOsteoarthritis rates after SCFE range from 24% to 92% at 11 to 28 years, depending on how osteoarthritis is defined. Long-term followup suggests patients have acceptable outcomes, but these studies are limited by heterogeneity and a ceiling effect from the instruments used to assess function. Although the femoral deformity remodels, it is unclear what secondary changes occur in the acetabulum. Recent investigations suggest patients are functionally limited after SCFE owing to FAI compared with controls. MRI findings and surgical reports document impingement-related joint damage after SCFE, even in the absence of symptoms. Based on this, some advocate timely correction of the cam deformity inherent in SCFE.Purposes and Clinical RelevanceFurther study is warranted to determine whether immediate osteoplasty after in situ fixation of mild SCFE is beneficial to limit articular damage and improve long-term outcomes.

Predictors of blood loss and haematocrit after periacetabular osteotomy

Background Acetabular dysplasia is a common cause of hip pain that can lead to osteoarthritis. Periacetabular osteotomy (PAO) is an effective procedure to treat symptomatic dysplasia in properly selected patients. Purpose This study aims to determine patient or perioperative variables that are predictive of blood loss (EBL) and postoperative haematocrit (HCT) with PAO. Patients and Methods Between March 2009 and October 2011, 169 PAOs in 141 patients were performed. Associations with EBL (log-transformed) and lowest postoperative haematocrit (post-HCT, <26 vs. ≥26) were assessed by regression analysis, adjusting for surgeon and for within-patient correlations. Results Geometric mean EBL was 925 mL (range 200–3900mL; 95% CI: 851.3, 1005.1). There was 11.1% greater blood loss per hour of surgery (p = 0.02). Pre-Operative HCT averaged (±SD) 36.1 (±3.3). In 119 cases (71%), the post-HCT was <26. Lower pre-operative HCT correlated with post-HCT <26 (p<0.001); the median ratio of the lowest postoperative HCT to the pre-operative HCT was 0.687 (5th, 95th percentiles: 0.538, 0.781). Age, body mass index (BMI), arthrotomy, and anaesthesia-type showed no association with EBL or post-HCT. Conclusions Longer duration of surgery correlated with increased blood loss during PAO. Current guidelines recommend considering transfusion at haemoglobin ≤8 g/dL for postoperative patients. The median nadir post-HCT was 31% lower than the pre-operative value, a ratio that may help determine the need for pre-operative blood donation. This information facilitates future investigation of blood management with PAO.

Imaging Hip Dysplasia in the Skeletally Mature

Hip disorders in the young adult manifest along a continuum that ranges from an excessively constrained, impinging joint, to an overly shallow, unstable hip. Knowledge of simple measures on plain radiographs can aid in efficient and accurate identification of mechanically compromised hips that may be at risk for premature OA. Improvements in joint-preserving surgery have shown promise in delaying or preventing progression of articular degeneration; thus, timely diagnosis is important. Once a diagnosis is established, specialized imaging can be individualized to supplement surgical planning, assess the degree of cartilage damage, and facilitate discussion regarding the prognosis of hip-preserving procedures.

Special Patients and Conditions: Acetabular Dysplasia

Acetabular dysplasia is a common hip condition that can cause pain, restrict function, and lead to premature osteoarthritis. Pelvic osteotomy techniques have evolved in an effort to preserve the native hip in symptomatic young patients with minimal joint degeneration. These procedures reorient the dysplastic acetabulum to correct deformity and improve the mechanical environment of the hip. This chapter outlines the physical examination and imaging parameters that confirm a diagnosis of acetabular dysplasia. In addition, it reviews the surgical techniques and results of pelvic osteotomies that are currently used to treat symptomatic dysplasia in adolescents and adults around the world.

Surgical innovation and safety: femoroacetabular impingement and the IDEAL collaborative framework

Operative treatment of femoroacetabular impingement (FAI) is a relatively new, yet rapidly expanding surgical innovation. Although the practice of surgery is inherently innovative, there is no clear distinction between minor technical variation and true modification that warrants testing. This raises important questions about how new procedures should be evaluated before being broadly disseminated. The IDEAL Collaborative is a consortium that promotes safe and responsible translation of research into clinical practice. The collaborative has delineated the typical stages of evolution of new interventional technologies, and the type of study designs appropriate for each stage. This report examines the surgical treatment of FAI as a case study of the IDEAL framework and discusses both missed and future opportunities for critical assessment.