Hermès Howard Miozzari

Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement in High-Level Athletes:

Background: Midterm outcome studies show that symptomatic femoroacetabular impingement (FAI) can be successfully treated by addressing the underlying pathomorphology with open or arthroscopic surgery. Although athletes may be vulnerable to hip injury from impingement, limited information is available regarding the results of open surgery in this group. Hypothesis: High-level athletes with FAI can resume their sports after surgical hip dislocation and continue professional careers for a significant period. Study Design: Case series; Level of evidence, 4. Methods: Twenty-two professional male athletes (19.7 ± 2.2 years) were evaluated by postal survey at a mean of 45.1 months (range, 12 to 79) after treatment by surgical hip dislocation (30 hips, cam- or mixed-type FAI; mean α angle, 69.3°; 14 ice hockey players). Evaluation included types and level of sports, subjective ratings, and clinical outcomes: Hip Outcome Score, SF-12, UCLA (University of California, Los Angeles) activity scale, Hip Sports Activity Scale, visual analog scale for pain. The primary outcome variable was return to professional sports; the clinical result was the secondary outcome variable. Results: At follow-up, 21 of 22 patients (96%) were still competing professionally: 19 at their previous level and 2 in minor leagues. Eighteen (82%) were satisfied with their hip surgery and 19 (86%) with their sports ability. Mean activity levels were 9.8 per the UCLA scale and 7.6 per the Hip Sports Activity Scale. Mean scores of the Hip Outcome Score–Activities of Daily Living and Sport subscales were 94.5 and 89.1. Mean scores of the SF-12 physical and mental component summaries were 51.1 and 54.3. Pain levels during sports were 1.8 per the visual analog scale. Conclusion: Surgical hip dislocation for the treatment of FAI allows athletes to resume sports and continue professional careers at the same level for several years. Clinical outcomes in terms of subjective ratings and scores were favorable.

Midterm Results of Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement

Background: Surgical treatment of femoroacetabular impingement (FAI) includes both open and arthroscopic procedures. Encouraging results have been reported for the majority of patients after surgical hip dislocation; however, most of these reports were short term and included only small cohorts. Purpose: To determine the results of surgical hip dislocation in a large cohort of FAI patients at a midterm follow-up. Study Design: Case series; Level of evidence, 4. Methods: A retrospective study including 185 consecutive patients (mean age, 30 years; 40% female) with 233 hips treated was conducted. We determined clinical outcomes in terms of range of motion and analyzed radiographs for several criteria including the alpha angle preoperatively and at 1 year postoperatively. At latest follow-up, on average 61 months postoperatively, patient satisfaction, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Hip Outcome Score, SF-12, and University of California, Los Angeles (UCLA) activity scale scores were determined. All revisions and conversions to total hip arthroplasty (THA) were recorded. Results: Both hip flexion and internal rotation improved from preoperatively to postoperatively. Alpha angles decreased from 65.1° ± 14.2° to 42.4° ± 4.9°. At 5 years, 82% of the patients were satisfied or very satisfied with the results of surgery, and 81% would undergo the same surgery again. There were 83% who rated their overall hip function as normal or nearly normal. Mean scores for the WOMAC pain, stiffness, and function subscales were 10.3 ± 15.8, 15.9 ± 17.4, and 9.6 ± 13.0 points; for Hip Outcome Score activities of daily living and sport subscales were 89.0 ± 13.1 and 75.6 ± 23.0 points; and for the SF-12 Physical Component Scale and Mental Component Scale were 47.4 ± 6.3 and 52.3 ± 7.4 points, respectively. The mean UCLA activity level was 7.7 ± 1.9. Conversion to THA was performed in 7 hips (3%). Seven hips (3%) underwent other major revisions, and 11 (4.7%) underwent minor revisions. Female patients had a significantly increased risk for conversion to THA (odds ratio, 13.3; 95% confidence interval [CI], 1.3-92.6) and major revision (odds ratio, 19.2; 95% CI, 2.4-152.9). The mean body mass index was significantly lower in those patients who underwent conversion to THA. The need for microfracture because of residual full-thickness cartilage defects after rim trimming was a significant (P = .04) predictor of subjective dissatisfaction. Conclusion: This study demonstrates that surgical hip dislocation is a successful procedure for the treatment of FAI. A majority of patients were satisfied with the results of surgery at a midterm follow-up. Older and slim female patients were at an increased risk for a less successful outcome in terms of conversion to THA and revision surgery.

Late repair of abductor avulsion after the transgluteal approach for hip arthroplasty

The abductor release sometimes does not heal after a transgluteal approach for hip arthroplasty. Factors influencing the success of subsequent repair are unclear. We used magnetic resonance imaging (MRI) to compare the condition of the gluteus medius with clinical outcome after late repair of abductor dehiscence in 12 total hip patients. Evaluation included a pain rating, gait evaluation, Trendelenburg test, strength grading, and Harris Hip Score. Most had both prerepair and postrepair MRI studies to assess the repair and to grade abductor muscle fatty degeneration. Two repairs without MRI were explored surgically. Although average pain, limp, and strength scores improved significantly, rerupture occurred in 4 subjects and fatty degeneration in the gluteus medius did not improve, even with intact repair. Nine patients were satisfied; 7 of these had an intact repair. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair.

The German Hip Outcome Score: Validation in Patients Undergoing Surgical Treatment for Femoroacetabular Impingement

PURPOSE To cross-culturally adapt and validate the Hip Outcome Score (HOS) for use in German-speaking patients undergoing surgical treatment for femoroacetabular impingement. METHODS After cross-cultural adaptation (German-language version of the HOS [HOS-D]), the following metric properties of the questionnaire were assessed in 85 consecutive patients (mean age, 33.4 years; 36 women) undergoing hip arthroscopy or surgical hip dislocation: feasibility, reliability, internal consistency, and construct validity (correlation with Western Ontario and McMaster Universities Arthritis Index, Oxford Hip Score, Short Form 12, and University of California, Los Angeles activity scale). We calculated floor and ceiling effects taking the minimal detectable change into account. RESULTS The activities of daily living subscale of the HOS-D could be scored in all cases and the sport subscale in all but one. The HOS-D scores were highly reproducible with intraclass correlation coefficients of 0.94 for the activities of daily living subscale and 0.89 for the sport subscale. Internal consistency was confirmed by Cronbach α values >0.90 for both subscales. Correlation coefficients with the other measures ranged from -0.08 (Mental Component Scale of Short Form 12) to -0.90 (Western Ontario and McMaster Universities Arthritis Index function subscale). CONCLUSIONS The HOS-D is a reliable and valid self-assessment tool for patients undergoing surgical femoroacetabular impingement treatment. By use of the HOS, comparisons between studies and treatment regimens involving either German- or English-speaking patients are now possible. LEVEL OF EVIDENCE Level I, testing of previously developed diagnostic criteria in a series of consecutive patients with universally applied gold standard.

The Hip Sports Activity Scale (HSAS) for patients with femoroacetabular impingement

Purpose To develop and validate a sports activity scale for patients with a diagnosis of femoroacetabular impingement (FAI). Methods A nine level Hip Sports Activity Scale (HSAS) was constructed both in German and English languages. Fifty-nine consecutive patients undergoing surgical treatment for FAI at two centers in Switzerland and in the US completed a questionnaire set consisting of the HSAS, the University of California at Los Angeles (UCLA) activity scale and different hip joint-specific and generic outcome tools. For reliability assessment, the HSAS was completed twice about nine days apart. Evidence of reliability, validity and responsiveness was investigated by classical psychometric analyses. Results Reliability was excellent for both the German and the English versions with intraclass correlation coefficients of 0.94 and 0.96, respectively. Evidence of convergent validity was supported by moderate to high correlations with the UCLA activity scale and with the joint-specific measures used. Evidence of divergent validity was supported by low correlations with the SF-12 Mental Component Scale and the WOMAC stiffness subscale. The standardised response mean was 0.69. Conclusions The HSAS is a reliable and valid tool to determine sports levels in patients suffering from FAI. Its use in future studies investigating outcomes in young patients with hip disease can be recommended. Level of Evidence Level III, Diagnostic Studies – An independent, masked comparison with an appropriate population of patients, but reference standard not applied to all study patients.

Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement

Background: Several studies indicate that professional athletes can successfully return to competition after surgical treatment of femoroacetabular impingement (FAI). However, little is known about sports and activity levels after FAI surgery in the general patient population. Hypothesis/Purpose: The purpose was to determine the sports behavior, satisfaction with sports ability, and activity levels in a consecutive cohort of patients with FAI who were treated by surgical hip dislocation. The hypothesis was that the majority of patients (>75%) would be active in sports at follow-up. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study included 153 patients (mean age, 30.0 years; 40.5% female) with 192 hips treated. Sports behavior and satisfaction were determined at a mean follow-up of 59.4 months with the use of a questionnaire. Activity levels at follow-up were assessed by the Hip Sports Activity Scale (HSAS) and the University of California, Los Angeles (UCLA) activity scale. Results: Of 126 patients who were regularly active in sports before surgery, 107 (85%) were so at follow-up. Nineteen patients (12.4%) stopped participating in regular sports, and 8 (5.2%) commenced with sports after the operation. The most popular activities before surgery were skiing (22%), cycling (22%), jogging (20%), and soccer (13%). At follow-up, most patients were engaged in cycling (23%), fitness/weight training (20%), skiing (18%), and jogging (11%). Of all patients, 75% were satisfied with their sports ability, and 25% were not. Moreover, 60.3% stated that their sports ability had improved after surgery, 20.5% declared no change, and 19.2% were subjectively deteriorated. The mean pain level during sports was rated to be 2.1 according to the visual analog scale. The mean HSAS score was 3.5 (range, 0-8), and the mean UCLA score was 7.7 (range, 3-10); male patients reported significantly higher scores than did female patients on the HSAS (4.1 vs 2.7, respectively) and UCLA scale (8.2 vs 7.0, respectively). Conclusion: The vast majority of patients with FAI who are treated by surgical hip dislocation return to sports activities, and most patients are satisfied with their sports ability at midterm follow-up. Activity levels are significantly higher in male patients, but this does not yield higher satisfaction rates.

Body mass and weight thresholds for increased prosthetic joint infection rates after primary total joint arthroplasty

Background and purpose — Obesity increases the risk of deep infection after total joint arthroplasty (TJA). Our objective was to determine whether there may be body mass index (BMI) and weight thresholds indicating a higher prosthetic joint infection rate. Patients and methods — We included all 9,061 primary hip and knee arthroplasties (mean age 70 years, 61% women) performed between March 1996 and December 2013 where the patient had received intravenous cefuroxime (1.5 g) perioperatively. The main exposures of interest were BMI (5 categories: < 24.9, 25–29.9, 30–34.9, 35–39.9, and ≥ 40) and weight (5 categories: < 60, 60–79, 80–99, 100–119, and ≥ 120 kg). Numbers of TJAs according to BMI categories (lowest to highest) were as follows: 2,956, 3,350, 1,908, 633, and 214, respectively. The main outcome was prosthetic joint infection. The mean follow-up time was 6.5 years (0.5–18 years). Results — 111 prosthetic joint infections were observed: 68 postoperative, 16 hematogenous, and 27 of undetermined cause. Incidence rates were similar in the first 3 BMI categories (< 35), but they were twice as high with BMI 35–39.9 (adjusted HR = 2.1, 95% CI: 1.1–4.3) and 4 times higher with BMI ≥ 40 (adjusted HR = 4.2, 95% CI: 1.8–9.7). Weight ≥ 100 kg was identified as threshold for a significant increase in infection from the early postoperative period onward (adjusted HR = 2.1, 95% CI: 1.3–3.6). Interpretation — BMI ≥ 35 or weight ≥ 100 kg may serve as a cutoff for higher perioperative dosage of antibiotics.

Administration of antibiotic agents before intraoperative sampling in orthopedic infections alters culture results

UNLABELLED Many physicians and surgeons think that prescribing antibiotics before intraoperative sampling does not alter the microbiological results. METHODS Case-control study of adult patients hospitalized with orthopedic infections. RESULTS Among 2740 episodes of orthopedic infections, 1167 (43%) had received antibiotic therapy before surgical sampling. Among these, 220 (19%) grew no pathogens while the proportion of culture-negative results in the 2573 who had no preoperative antibiotic therapy was only 6%. By multivariate analyses, pre-operative antibiotic exposure was associated with significantly more culture-negative results (odds ratio 2.8, 95% confidence interval 2.1-3.7), more non-fermenting rods and skin commensals (odds ratio 2.8 and 3.0, respectively). Even a single pre-operative dose of antibiotic was significantly associated with subsequent culture-negative results (19/93 vs. 297/2350; χ²-test, p = 0.01) and skin commensals (17/74 vs. 274/2350; p = 0.01) compared to episodes without preceding prophylaxis. CONCLUSIONS Prior antibiotic use, including single-dose prophylactic administrations, is three-fold associated with culture-negative results, non-fermenting rods and resistant skin commensals.

Acute, exertional medial compartment syndrome of the foot in a high-level athlete: a case report

matic event, typically in association with a fracture, but also from a soft tissue injury such as a direct blow or crush. There are, however, a number of reports in the literature of acute exertional compartment syndrome in which unaccustomed exertion leads to abnormal intramuscular pressure. Acute compartment syndrome may also occur as an acute complication of a pre-existing chronic exertional compartment syndrome. Symptoms of chronic exertional compartment syndrome rapidly subside with cessation of exercise, while symptoms of acute exertional compartment syndrome tend to worsen after exercise, and pain is often completely out of proportion to the apparent degree of injury. Acute, isolated, medial compartment syndrome of the foot without a specific major trauma is very uncommon; we found only 4 cases in the literature, 3 of which were exertional compartment syndrome and 1 that developed as a complication of spinal surgery (Table 1). Most compartment syndromes of the foot occur in the setting of a clear soft-tissue or bone injury. We report the case of a marathon runner who developed an isolated medial compartment syndrome of the foot, documented by physical examination, compartment pressure measurements, and MRI. He was treated by open fasciotomy, and follow-up at 6 months showed full recovery. CASE HISTORY

Associations of diabetes mellitus with orthopaedic infections

Background: Clinical experience suggests that a high proportion of orthopaedic infections occur in persons with diabetes. Methods: We reviewed several databases of adult patients hospitalized for orthopaedic infections at Geneva University Hospitals from 2004 to 2014 and retrieved 2740 episodes of infection. Results: Overall, diabetes was noted in the medical record for 659 (24%) of these cases. The patients with, compared with those without, diabetes had more than five times more foot infections (274/659 [42%] vs 155/2081 [7%]; p < 0.01) and a significantly higher serum C-reactive protein level at admission (median 96 vs 70 mg/L; p < 0.01). Diabetic patients were older (median 67 vs 52 years; p < 0.01), more often male (471 [71%] vs 1398 [67%]; p = 0.04), and had more frequent polymicrobial infections (219 [37%] vs 353 [19%]; p < 0.01), including more gram-negative non-fermenting rods (90 [15%] vs 168 [9%]; p < 0.01). Excluding foot infections from these analyses did not change the statistically significant differences. Diabetes was present in 17% of all infected orthopaedic patients without foot involvement. In Geneva canton, the overall prevalence of diabetes is estimated at 5.1%, while we have found that the prevalence is 13% in our hospitalized adults. Conclusions: Diabetes is present in 24% of all adult patients hospitalized for surgery for an orthopaedic infection, a prevalence that is several times higher than for the general population and twice as high as that for the population of hospitalized patients. Compared with non-diabetics, patients with diabetes have significantly more infections that are polymicrobial, including gram-negative non-fermenting rods.