David A. Podeszwa

Magnetic Resonance Arthrography of Labral Disorders in Hips with Dysplasia and Impingement

Despite the fact that classic studies on osteoarthritis of the hip have shown the periphery of the hip to be prone to degeneration, it was not until recently that an abnormal acetabular labrum has been associated with osteoarthritis. This study was designed to determine whether magnetic resonance arthrography can show differences in disorders of the labrum (tears, size, ganglion formation) expected in symptomatic patients with developmental dysplasia of the hip and anterior femoroacetabular impingement. Fourteen patients in each group were evaluated preoperatively not only clinically but also with conventional radiographs and magnetic resonance arthrographs. In both conditions, disorders of the labrum localized identically with a predilection to the anterosuperior quadrant of the acetabulum. Labral tears were observed in nine hips of each group. The labrum was enlarged in 12 hips with dysplasia but in none of the hips with impingement. Ganglion formation in the periacetabular area was seen in 10 hips with dysplasia and three hips with impingement. These findings provide evidence that the anterosuperior acetabulum represents the initial fatiguing site of the hip under both conditions. Based on these data, the size of the labrum and the presence of soft tissue ganglia seem to be good predictors for the presence of developmental dysplasia, whereas the presence of tears did not differentiate between conditions. The capability of magnetic resonance arthrography to show these differences in labral disorders suggests this method is a helpful diagnostic tool that can aid in defining the most appropriate treatment strategy.

Descriptive Epidemiology of Femoroacetabular Impingement: A North American Cohort of Patients Undergoing Surgery

Background: Symptomatic femoroacetabular impingement (FAI) is associated with hip pain, functional limitations, and secondary osteoarthritis. There is limited information from large patient cohorts defining the specific population affected by FAI. Establishing a large cohort will facilitate the identification of “at-risk” patients and will provide a population for ongoing clinical research initiatives. The authors have therefore established a multicenter, prospective, longitudinal cohort of patients undergoing surgery for symptomatic FAI. Purpose: To report the clinical epidemiology, disease characteristics, and contemporary surgical treatment trends in North America for patients with symptomatic FAI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Upon approval of the institutional review boards at 8 institutions, 12 surgeons enrolled consecutive patients undergoing surgical intervention for symptomatic FAI. Patient demographics, physical examination data, radiographic data, diagnoses, operative data, and standardized patient-reported outcome measures were collected. The first 1130 cases are summarized in this study. Results: A total of 1076 consecutive patients (1130 hips) were enrolled; 55% (n = 622) were female, and 45% (n = 508) were male, with an average age of 28.4 years and average body mass index (BMI) of 25.1. Demographics revealed that 88% of patients who were predominantly treated for FAI were white, 19% reported a family history of hip surgery, 47.6% of hips had a diagnosis of cam FAI, 44.5% had combined cam/pincer FAI, and 7.9% had pincer FAI. Preoperative clinical scores (pain, function, activity level, and overall health) indicated a major dysfunction related to the hip. Surgical interventions were arthroscopic surgery (50.4%), surgical dislocation (34.4%), reverse periacetabular osteotomy (9.4%), limited open osteochondroplasty with arthroscopic surgery (5.8%), and limited open by itself (1.5%). More than 90% of the hips were noted to have labral and articular cartilage abnormalities at surgery; femoral head-neck osteochondroplasty was performed in 91.6% of the surgical procedures, acetabular rim osteoplasty in 36.7%, labral repair in 47.8%, labral debridement in 16.3%, and acetabular chondroplasty in 40.1%. Conclusion: This multicenter, prospective, longitudinal cohort is one of the largest FAI cohorts to date. In this cohort, FAI occurred predominantly in young, white patients with a normal BMI, and there were more female than male patients. The disease pattern of cam FAI was most common. Contemporary treatment was predominantly arthroscopic followed by surgical hip dislocation.

Complications associated with the Bernese periacetabular osteotomy for hip dysplasia in adolescents

BACKGROUND The Bernese (Ganz) periacetabular osteotomy is an effective surgical procedure to reorient the acetabulum, allowing restoration of anatomic femoral head coverage and medial translation of the hip in adults with hip dysplasia. However, it is a challenging surgical procedure, and we know of no study that has specifically analyzed the complications and associated factors seen with this procedure in adolescent patients. METHODS A retrospective clinical and radiographic review of a consecutive series of adolescent patients who underwent a Bernese periacetabular osteotomy for hip dysplasia was conducted. RESULTS Eighty-three osteotomies were performed in seventy-six patients with an average age (and standard deviation) of 15.6 +/- 2.4 years. Significant improvement from the preoperative to the two-year follow-up evaluation was seen radiographically with regard to the lateral center-edge angle (-0.14 degrees to 35.5 degrees), the ventral center-edge angle (-5.13 degrees to 31.3 degrees), and the femoral head extrusion index (38.4% to 7.7%) (p < 0.0001 for all). There were three major complications, including excessive arterial bleeding requiring embolization in a patient with a prior acetabuloplasty, osteonecrosis of the acetabular fragment in a patient with severe dysplasia and subluxation of the hip, and osteonecrosis of the femoral head following combined periacetabular and femoral osteotomies in a patient with Charcot-Marie-Tooth disease. Eighteen hips (22%) had minor complications, including nonunion of the superior pubic ramus osteotomy (five hips), a superficial stitch abscess (four), and transient lateral femoral cutaneous nerve palsy (four). Nine hips (11%) underwent removal of symptomatic screws, and two required a second operation to reposition the acetabular fragment. An underlying diagnosis other than developmental dysplasia increased the prevalence of minor complications (p = 0.0017), while a major complication was more likely with longer surgery time, greater blood loss, and proximal femoral osteotomy. CONCLUSIONS The Bernese periacetabular osteotomy is a joint-preserving procedure that very effectively corrects acetabular dysplasia in adolescent patients, providing improved radiographic results and a low rate of complications. Although the rate of minor complications is increased when there is an underlying diagnosis other than developmental dysplasia, no other predictors were identified. However, a major complication is more likely with a longer duration of surgery and with a concomitant femoral varus osteotomy.

Comparison of Pavlik harness application and immediate spica casting for femur fractures in infants.

This retrospective study compares Pavlik harness application versus spica casting for the treatment of children under 1 year of age with a femoral shaft fracture. The clinical and radiographic outcomes of 24 patients treated in a Pavlik harness were compared with 16 patients treated in a spica cast. The average age and weight of the two groups were significantly different, but there were no differences in radiographic outcomes between the Pavlik and spica cast groups. Approximately one third of all spica patients had a skin complication that added an additional risk to the patient. There were no similar complications in the Pavlik group. There were no differences in the outcome of the fractures in the two groups. The authors believe that all children under 1 year of age with a femoral shaft fracture are candidates for treatment with a Pavlik harness.

Evaluation of process fractures of the talus using computed tomography.

Summary: Coronal computed tomography (CT) scan was used in the evaluation of a fractured process of the talus in 10 patients. Because routine radiographs failed to determine either the size or comminution of the fractured process, CT imaging was used to accurately assess the size, displacement, and comminution of the fractured process. CT scans also showed the extent of subtalar joint involvement, any associated tendon pathology, or additional fractures. In two patients the nature of the injury was initially missed, and CT scan diagnosed a nonunion of the lateral process. In all patients, CT scan altered the management of the fracture or helped in selecting the surgical approach. The authors recommend that coronal CT scans be used in the evaluation of a fractured process of the talus

Evaluation and treatment of young adults with femoro-acetabular impingement secondary to Perthes' disease.

Hip pain and loss of motion in young adults with previous Legg-Calve-Perthes-Disease may be caused by anterior femoro-acetabular impingement. Eleven patients (12 hips) with the chief complaint of groin pain and significant proximal femoral deformity were treated. Gadolinium-enhanced magnetic resonance arthrography in ten patients indicated labral injury and adjacent acetabular cartilage lesions in nine hips. A surgical dislocation of each hip confirmed that there was impingement induced intra-articular injury consistent with the pathology indicated on the MRI. Reshaping of the femoral head, with correction of the femoral head/neck offset, and treatment of the acetabular rim pathology was performed for each hip in conjunction with other procedures for the proximal femur. Correction of the impingement and increased range of motion could be visualized intra-operatively. At a mean follow-up of 33 months, half of all patients were pain-free and all had improvement in pain compared with preoperatively. Ten patients had an improved range of motion and two a slight decrease. No additional necrosis following the dislocation of the femoral head was seen.;

Complications associated with the periacetabular osteotomy: a prospective multicenter study.

BACKGROUND The purpose of this prospective multicenter study was to determine and categorize all complications associated with the periacetabular osteotomy performed by experienced surgeons. METHODS We prospectively analyzed perioperative complications in 205 consecutive unilateral periacetabular osteotomies performed at seven institutions by ten surgeons. All perioperative complications were recorded at an average of ten weeks and one year after surgery in standardized fashion using a validated complication grading scheme applied to hip preservation procedures. The mean patient age was 25.4 years. There were 143 female and sixty-two male patients. The most common diagnosis was developmental acetabular dysplasia, and concomitant procedures most commonly included femoral osteochondroplasty (58%) or hip arthroscopy (20%), which could include labral repair or resection. RESULTS Major complications (grade III or IV) occurred in twelve patients (5.9%). Seven complications were evident at the ten-week visit and five at the one-year visit. Nine of the complications required a second surgical intervention, including repair for acetabular migration or implant adjustment (four patients), incision and drainage for a deep infection (two patients), and heterotopic bone resection, contralateral peroneal nerve decompression, and posterior column fixation (one patient each). Three thromboembolic complications were managed medically. There were no vascular injuries, permanent nerve palsies, intra-articular osteotomies and/or fractures, or acetabular osteonecrosis. The most common grade-I or II complication was asymptomatic heterotopic ossification. CONCLUSIONS For surgeons experienced with the periacetabular osteotomy, it is a safe procedure but is associated with a 5.9% risk of grade-III or IV complications beyond the learning curve. The majority of these complications are resolved without permanent disability. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Incidence of deep vein thrombosis and pulmonary embolus following periacetabular osteotomy

BACKGROUND Venous thromboembolism, a known complication of orthopaedic procedures, is thought to be more prevalent following hip surgery. Venous thromboembolism risk assessment and appropriate prophylaxis according to the American College of Chest Physicians guidelines has become the standard of care. However, it is accepted that venous thromboembolism prophylaxis is associated with potential adverse sequelae including hematoma, wound drainage, and infection. Little is known regarding the incidence of venous thromboembolism following periacetabular osteotomy and the necessity for and method of routine prophylaxis. METHODS A total of 1067 periacetabular osteotomies performed at six North American centers utilizing different methods of prophylaxis against venous thromboembolism were analyzed for type of prophylaxis and incidence of clinically symptomatic venous thromboembolism. RESULTS There were four cases of pulmonary embolus and seven cases of deep vein thrombosis. There were no reported deaths. The crude incidence of clinically symptomatic venous thromboembolism was 9.4 per 1000 procedures. CONCLUSIONS The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy.

Danger zones associated with fibular osteotomy.

Summary: Anatomic dissections were performed on five cadaveric lower extremities. Measurements of important neurovascular structures in relation to the fibula were obtained at 1-cm intervals along the length of the fibula with the tip of the fibular head as the reference point. Neurovascular structures adjacent to the fibula in danger of injury with fibular osteotomy were identified. At the proximal one-third of the fibula, the peroneal nerves and their muscular branches are at primary risk. The anterior tibial artery is vulnerable where it penetrates the interosseous membrane and where it runs adjacent to the fibula with the deep peroneal nerve. In the middle one-third of the fibula, the peroneal artery and vein are the major structures at risk. In the distal one-third of the fibula the peroneal vessels are at less risk because they branch and enter the region of the syndesmosis curving anteriorly. The other neurovascular structures are not adjacent to the fibula. Based on these data, general recommendations for fibular osteotomy include (a) placement of the osteotomy as distally along the shaft as is feasible, commensurate with the surgical goal; (b) direction of the osteotomy blade along a line connecting the axis of the fibula with the midpoint of the subcutaneous tibial surface in the proximal and middle one-third of the fibula; and (c) direction of the osteotomy blade from the axis of fibula to the anterior subcutaneous border of the tibia in the distal one-third of the fibula.

Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, III, and IV fractures).

Physeal fractures of the distal tibia and fibula are common and can be seen at any age, although most are seen in the adolescent. An understanding of the unique anatomy of the skeletally immature ankle in relation to the mechanism of injury will help one understand the injury patterns seen in this population. A thorough clinical exam is critical to the diagnosis and treatment of these injuries and the avoidance of potentially catastrophic complications. Nondisplaced physeal fractures of the distal tibia and fibula can be safely treated nonoperatively. Displaced fractures should undergo a gentle reduction with appropriate anesthesia while multiple reduction attempts should be avoided. Gapping of the physis >3 mm after reduction should raise the suspicion of entrapped periosteum that will increase the risk of premature physeal closure. Open reduction of displaced Salter-Harris type III and IV fractures is critical to maintain joint congruity and minimize the risk of physeal arrest.