Gail Pashos

Why Do Hip Arthroscopy Procedures Fail

BackgroundDespite the successes of hip arthroscopy, clinical failures do occur, and identifying risk factors for failure may facilitate refinement of surgical indications and treatment. Knowledge regarding the reasons for treatment failures may also improve surgical decision making.Questions/purposesWe (1) characterized patients whose symptoms recurred after hip arthroscopy necessitating a revision hip preservation procedure or hip arthroplasty, (2) determined the etiologies of failure, (3) and reported the profile of revision surgical procedures.MethodsIn a prospective database of 1724 consecutive hip surgeries, we identified 58 patients (60 hips) with a history of failed hip arthroscopy. Thirty-seven patients (38 hips) underwent revision hip preservation and 21 (22) hip arthroplasty. Thirty-nine (67%) were female. Demographics, etiology of failure, and type of revision surgery were analyzed.ResultsPatients treated with revision hip preservation were younger, had a lower BMI, and lower Tönnis osteoarthritis grade at the time of revision surgery compared to patients treated with hip arthroplasty. Common etiologies of failure were residual femoroacetabular impingement (68%) and acetabular dysplasia (24%) in patients treated with revision hip preservation and advanced osteoarthritis in patients treated with hip arthroplasty. The revision preservation procedures included arthroscopy in 16 (42%), arthroscopy with limited open capsulorraphy in two (5.3%), periacetabular osteotomy in nine (24%), and surgical dislocation in 12 (32%).ConclusionsResidual or unaddressed structural deformity of the hip and underlying osteoarthritis are commonly associated with failure after hip arthroscopy. Thorough patient evaluation with detailed characterization of structural hip anatomy and articular cartilage integrity are critical to the selection of proper surgical intervention and successful patient outcome.Level of EvidenceLevel IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement

BACKGROUND A variety of surgical techniques have been introduced for the treatment of femoroacetabular impingement, but clinical outcome studies of less-invasive treatment with a minimum duration of follow-up of two years are limited. The purpose of this study was to evaluate the early clinical and radiographic outcomes of combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction for the treatment of cam femoroacetabular impingement. METHODS We performed a retrospective review of our first thirty-five patients (thirty-five hips) in whom cam femoroacetabular impingement had been treated with combined hip arthroscopy and limited open osteochondroplasty. Thirty-five patients (twenty-eight men and seven women) with an average age of thirty-four years and a minimum duration of follow-up of two years were analyzed. The modified Harris hip score was utilized to assess hip function. The Tönnis osteoarthritis grade and the alpha angle were determined to assess osteoarthritis progression and deformity correction, respectively. RESULTS The average modified Harris hip score improved from 63.8 points preoperatively to 87.4 points at the time of the last follow-up. Twenty-nine (83%) of the thirty-five patients had at least a 10-point improvement in the Harris hip score, and 71% had a score of >80 points. The average alpha angle was reduced from 58.6 degrees preoperatively to 37.1 degrees at the time of follow-up when measured on cross-table lateral radiographs, from 63.9 degrees to 37.8 degrees when measured on frog-leg lateral radiographs, and from 63.1 degrees to 44.8 degrees when measured on anteroposterior radiographs. Two patients had osteoarthritis progression from Tönnis grade 0 to grade 1. Minor complications included one superficial wound infection, one deep vein thrombosis, and four cases of asymptomatic Brooker grade-I heterotopic ossification. There were no femoral neck fractures or cases of femoral head osteonecrosis, and no hip was converted to an arthroplasty. CONCLUSIONS Early results indicate that combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction is a safe and effective treatment for femoroacetabular impingement. In our small series, most patients had symptomatic relief, improved hip function, and enhanced activity after two years of follow-up.

What is the Evidence for Total Knee Arthroplasty in Young Patients?: A Systematic Review of the Literature

BackgroundTKA is commonly performed to treat advanced inflammatory and degenerative knee arthritis. With increasing use in younger patients, it is important to define the best practices to enhance clinical performance and implant longevity.Questions/purposesWe systematically reviewed the literature to assess: (1) how TKAs perform in young patients; (2) whether the TKA is a durable procedure for young patients, and (3) what guidance the literature outlines for TKA in young patients.MethodsWe searched the literature between 1950 and 2009 for all studies reporting on TKAs for patients younger than 55 years that documented clinical and radiographic assessments with a minimum 2-year followup. Thirteen studies, reporting on 908 TKAs performed for 671 patients, met these criteria.ResultsMean Knee Society clinical and functional scores increased by 47 and 37 points, respectively. Implant survivorship was reported between 90.6% and 99% during the first decade and between 85% and 96.5% during the second decade of followup. The literature does not direct specific techniques for TKA for young patients.ConclusionsTKA provides surgeon-measured clinical and functional improvements with a moderate increase in second-decade implant failures. Improvements in study design and reporting will be beneficial to guide decisions regarding implant selection and surgical technique.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Long-Term Results of Total Hip Arthroplasty with 28-Millimeter Cobalt-Chromium Femoral Heads on Highly Cross-Linked Polyethylene in Patients 50 Years and Less

Highly cross-linked polyethylene (HXLPE) is the most commonly used bearing surface in total hip arthroplasty (THA) because of its superior wear properties, but long-term results in young patients are limited. We report on the clinical outcome, radiographic wear patterns and survivorship of 72 patients ≤50 years old who had a 28-millimeter cobalt-chromium femoral head on HXLPE acetabular liner. Mean and median true linear wear rates at average ten-year follow-up were 0.0104 and 0.01 mm per year ± 0.07 mm. Mean and median two-dimensional volumetric wear rates were 12.79 mm(3) and 5.834 mm(3) per year ± 26.1mm(3) as determined by Martell analysis. As a result of the minimal wear profile, there was no evidence of radiographic osteolysis and no wear-related revisions.

Highly cross-linked polyethylene improves wear and mid-term failure rates for young total hip arthroplasty patients

We compared clinical outcomes and polyethylene wear for 2 young primary THA patient cohorts (<50 years of age) at mid-term follow-up. In total, 72 patients (84 hips) received a coventional polyethylene liner (CPE) and 84 patients (89 hips) received a highly cross-linked polyethylene liner (HXLPE). Mean Harris Hip Score improved to 81 points for both groups. UCLA activity scores were higher for HXLPE patients (6.0 vs 5.3, p = 0.03), with lower mean linear wear (0.02 vs 0.13 mm/year, p<0.001) and lower mean volumetric wear (75.1 vs 229.8 mm3, p<0.001) at an average of 70 months follow-up. No HXLPE patient required revision for wear related concerns, compared to 5 CPE patients with revision for aseptic loosening or impending radiographic failure (0% vs 5.9%, p = 0.02). HXLPE is associated with reduced wear among young, active THA patients without increased risk of early mechanical failure.

Total Hip Arthroplasty in Patients 50 Years or Less: Do We Improve Activity Profiles?

The primary objective of this study was to use step activity monitoring to quantify activity changes after total hip arthroplasty in patients 50 years or less. Secondly, we investigated whether step activity measurements correlated with the Harris hip and UCLA scores. We prospectively analyzed 37 patients (age ≤ 50) treated with primary THA. Patient activity was recorded with a step activity monitor. Harris hip and UCLA scores were analyzed. Total daily stride counts increased by an average of 30.0%. Increases were noted in the percent of daily time spent at high, moderate and low activity. Increases in daily time spent at high activity moderately correlated with the UCLA activity score but did not correlate with the HHS. Both the UCLA score and the HHS did not correlate with mean daily strides. Following THA, patients ≤ 50 years of age increase their activity by taking more daily strides and improve their activity profile by spending more time at higher activity. Improvements in step activity moderately correlate with improvements in UCLA scores.

Do Radiographic Parameters of Dysplasia Improve to Normal Ranges After Bernese Periacetabular Osteotomy

BackgroundThe goal of periacetabular osteotomy (PAO) is to improve the insufficient coverage of the femoral head and achieve joint stability without creating secondary femoroacetabular impingement. However, the complex tridimensional morphology of the dysplastic acetabulum presents a challenge to restoration of normal radiographic parameters. Accurate acetabular correction is important to achieve long-term function and pain improvement. There are limited data about the proportion of patients who have normal radiographic parameters restored after PAO and the factors associated with under- and overcorrection.Questions/purposes(1) What is the proportion of patients undergoing PAO in which the acetabular correction as assessed by the lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), acetabular inclination (AI), and extrusion index (EI) is within defined target ranges? (2) What patient and preoperative factors are associated with undercorrection of the acetabulum as defined by a LCEA < 22°, a factor that has been reported to be associated with PAO failure at 10-year followup?MethodsBetween January 2007 and December 2011 we performed 132 PAOs in 116 patients for treatment of symptomatic acetabular dysplasia. One patient with Legg-Calvé-Perthes disease, one with multiple osteochondromatosis, and two with concomitant femoral osteotomy were excluded. A total of 128 hips (112 patients) were included. The hip cohort was 76% (97 of 128) female and the mean age at surgery was 28.5 years (SD 8.7 years). Correction of LCEA between 25° and 40°, ACEA between 18° and 38°, Tönnis angle between 0° and 10°, and EI ≤ 20% were defined as adequate based on normative values. Values lower than the established parameters were considered undercorrection for the LCEA and ACEA and those higher than the established values were considered overcorrection. Because postoperative LCEA < 22o has been previously associated with PAO failure at a minimum of 10-year followup, in this study we sought to measure whether demographic factors including age, gender, body mass index, and severity of acetabular dysplasia assessed by preoperative LCEA, ACEA, AI, and EI were associated with undercorrection. Postoperative radiographs were obtained at minimum of 1 month after surgery (mean, 7 months; range, 1–44 months) and were measured by a professional research assistant and a hip reconstruction fellow not involved in the clinical care of the patients. No patient was lost to followup.ResultsOf the 128 hips, the proportion of hips with radiographic parameters within the established range was 78% (100 hips) for the LCEA, 86% (110 hips) for the ACEA, 89% (114 hips) for the AI, and 80% (102 hips) for the EI. For hips with an inadequate correction, the LCEA was more often undercorrected than overcorrected (20% versus 2%; 95% confidence interval [CI], 11%–27%; p < 0.001), whereas the ACEA was more often overcorrected than undercorrected (11% versus 3%; 95% CI, 1%–15%; p = 0.03) After adjusting for age, sex, body mass index, and preoperative radiographic parameters including ACEA, AI, and EI, we found that the preoperative LCEA was the only independent factor associated with a postoperative LCEA < 22° (odds ratio, 0.92; 95% CI, 0.87–0.97; p = 0.003), indicating that hips with lower preoperative LCEA were more likely to have a LCEA < 22°. For each additional degree of preoperative LCEA, the odds of LCEA < 22° were reduced by 15%.ConclusionsAcetabular correction after PAO performed by two experienced surgeons was adequate for individual radiographic parameters in most but not all hips. Hips with more severe dysplasia preoperatively are at higher risk for undercorrection as assessed by the LCEA. This intuitive information may help surgeons performing PAO in severely dysplastic hips plan for possible combined procedures including a femoral osteotomy if PAO alone does not allow for adequate correction of femoral head coverage and a congruous concentric hip. Further studies are planned to determine whether the long-term hip function and pain in patients whose hips were corrected within these established parameters will be improved in comparison to those that were under- or overcorrected.Level of EvidenceLevel III, therapeutic study.

Stride activity level in young and middle-aged adults with hip disorders.

Objectives To determine the activity level, represented by total daily strides (TDS), of young and middle-aged adults with hip disorders and asymptomatic controls and to assess the association between TDS and self-report functional measures. Methods: Patients (age 15–50) with deep hip or groin pain (n = 202) and controls (n = 20) wore an accelerometer that recorded TDS. Symptomatic subjects completed self-report questionnaires. Symptomatic subjects were classified into subgroups: femoroacetabular impingement (FAI), developmental dysplasia of the hip (DDH), isolated labral tear (LT) and osteoarthritis (OA) based on intraoperative findings. Between-group comparisons of TDS were performed and correlations between TDS and questionnaires were determined. Results: Overall, controls recorded greater TDS than symptomatic subjects; however, between-group comparisons showed that FAI and DDH were similar to controls. OA demonstrated fewer TDS than FAI (4327 [2075] vs. 5095 [2354]). In symptomatic subjects, TDS had a low correlation with modified Harris Hip Score (r = 0.33) and the University of California Los Angeles Activity Score (ρ = 0.30), but no correlation with the Marx Activity Rating Scale. Conclusions: Subjects with hip disorders demonstrate reduced TDS compared with controls; however, some subgroups demonstrated TDS similar to controls. In addition, symptomatic subjects demonstrated relatively high TDS while reporting poor function. Accelerometers can be used in clinical populations to provide additional information about activity not represented by traditional functional measures.

A Prospective Analysis of the Contralateral Hip Among Patients With Femoroacetabular Impingement: What Are the Risk Factors for Disease Progression?

Background: The pathophysiology of femoroacetabular impingement (FAI) remains to be better understood, including factors affecting symptom development and disease progression. Purpose: (1) To determine rates of initial and subsequent symptom development in the contralateral hip of patients with symptomatic FAI and (2) to identify predictors of the development of symptomatic contralateral FAI. Study Design: Case-control study; Level of evidence, 3. Methods: This prospective study cohort included the contralateral hip of 179 consecutive patients undergoing primary surgical treatment of FAI. At presentation and follow-up time points, patients recorded the presence of symptoms in the contralateral hip. Patients with a minimum 1-year follow-up were included in the final cohort. Univariate analysis compared the patient characteristics and FAI imaging characteristics (cam and pincer) of initially asymptomatic patients who developed symptoms and those who remained asymptomatic. Kaplan-Meier survival curves were calculated to demonstrate symptom development over time. Results: A total of 148 patients (83%) were followed for at least 1 year (mean, 2.9 years). Thirty-four (23%) patients had symptoms in the contralateral hip at the time of the initial presentation. An additional 27 hips (24% of the initially asymptomatic) developed symptoms during the follow-up period at a mean 2.0 years from presentation. Head-neck offset ratio on the anteroposterior pelvis radiograph was significantly lower among hips that developed symptoms (0.153 vs 0.163 asymptomatic group, P = .027). Maximum alpha angle (P = .503), lateral center edge angle (P = .975), and crossover sign (P = .865) were not predictive of the development of symptoms. Patients developing contralateral hip symptoms were less likely to have a UCLA (University of California, Los Angeles) activity score of 9 or 10 at presentation (18.2% vs 43.8%, P = .032). The total arc of rotation in flexion (internal rotation in 90° of flexion + external rotation in flexion) was significantly decreased in hips developing symptoms (39.4º vs 50.4º, P = .012). Kaplan-Meier survival analysis demonstrated that 72%, 67%, 56%, and 48% of all patients remained asymptomatic at 1, 2, 3, and 4 years, respectively. Conclusion: Approximately 1 in 4 patients with FAI presents with symptoms in the contralateral hip, and an additional 1 in 4 patients develops significant symptoms in the following 4 years. Several factors, including low activity level, less hip rotational motion, and decreased head-neck offset ratio, were significantly associated with the development of symptoms, while the alpha angle and crossover sign were not.

Early Clinical and Radiographic Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy.

Objectives: Modern treatment of hip dysplasia has focused on the correction of the structural deformity with the periacetabular osteotomy (PAO), which addresses the deformity by redirecting the acetabulum into an improved mechanical position. Hip arthroscopy has allowed an increased awareness of the intra-articular pathology associated with acetabular dysplasia. The combination of hip arthroscopy with periacetabular osteotomy allows for treatment of both intra-articular and structural abnormalities associated with hip dysplasia. However, there is limited information regarding this combined approach for treating symptomatic acetabular dysplasia. The purpose of this study was to report the early clinical and radiographic outcomes of combining hip arthroscopy with PAO compared to PAO alone. Methods: We retrospectively reviewed 48 hips (46 patients) who underwent hip arthroscopy combined with periacetabular osteotomy (HS-PAO) and compared them to a control group of 62 hips (54 patients) who underwent PAO alone. The minimum clinical follow-up of the HS-PAO group was 12 months (mean, 31.4 months; range, 12-79 months), which was not significantly different from the control group (mean, 28.7 months; range, 12-71 months; p = 0.39). Pre-operative and post-operative standardized radiographs were analyzed for findings of acetabular dysplasia, including lateral center-edge angle (LCEA), acetabular inclination, anterior-center edge angle (ACEA), and Tönnis osteoarthritis grade. Clinical outcomes were evaluated with the UCLA activity score, modified Harris hip score (mHHS), short form-12 (SF-12), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Perioperative complications were graded and compared between the two groups. Results: The mean age of the patients in the HS-PAO group was 28.0 years (range, 12 to 47 years), which was not significantly different from the control group (p = 0.35). Forty-four hips (91.7%) were in female patients, and 58% were right-sided. There was significant change in the mean LCEA (15.1° vs. 29.7°; p < 0.0001), acetabular inclination (15.0° vs. 2.8°; p < 0.0001), and ACEA (16.5° vs. 33.7°; p <0.0001). The preoperative UCLA, mHHS, and SF-12 scores were not significantly different between groups. The HS-PAO group had a significantly higher pre-operative total WOMAC score (40.6 vs. 30.8; p = 0.03). The HS-PAO and control groups both saw significant improvement in the mHHS (23.5 vs. 21.3), SF-12 physical (7.5 vs. 9.1) scores, which were not significantly different from each other (all p-values > 0.3). The PAO-HS group, however, experienced a 0.9 improvement in the UCLA score, which was significantly different from the control group (-0.2; p = 0.03). The PAO-HS group also experienced a significantly greater improvement in the total WOMAC score (27.0 vs. 17.8; p = 0.03). There were no significant differences in the complication between the groups. Within the PAO-HS group, there were 16 lateral femoral cutaneous nerve palsies (33.3%) that resolved with outpatient management. There was 1 posterior column fracture that was treated nonoperatively. Conclusion: At short-term follow-up, hip arthroscopy with PAO shows equal to improved clinical outcomes with similar radiographic changes when compared to PAO alone without an increase in major complications. Patients that underwent hip arthroscopy combined with PAO also experienced a larger increase in activity level when compared to PAO alone.