Jill A. Erickson

Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults.

BACKGROUND Femoro-acetabular impingement has been associated with acetabular labral and/or articular cartilage damage that may ultimately result in osteoarthritis of the hip. Surgical treatment of femoro-acetabular impingement is directed at restoring a more normal femoral head-neck offset to alleviate femoral abutment against the acetabular rim and treating associated labral and articular cartilage damage. METHODS Thirty hips with femoro-acetabular impingement (in twenty-nine patients) underwent débridement through a greater trochanteric flip osteotomy and anterior dislocation of the femoral head. There were sixteen male patients and thirteen female patients with a mean age of thirty-one years. Cam (femoral based) impingement was noted in fourteen hips; pincer (acetabular based) impingement, in one hip; and combined cam and pincer impingement, in fifteen hips. The mean duration of clinical and radiographic follow-up was thirty-two months. All patients were followed according to a prospective protocol, with Harris hip scores and plain radiographs obtained preoperatively and at six months, one year, and annually for a minimum of two years. RESULTS The mean Harris hip score improved from 70 points preoperatively to 87 points at the time of final follow-up (p < 0.0001). Osteonecrosis did not develop in any hip, and there were no trochanteric nonunions. In eighteen hips, severe damage of the acetabular articular cartilage that had not been appreciated on preoperative plain radiographs or magnetic resonance arthrography was noted on arthrotomy. Eight of these eighteen hips subsequently had radiographic evidence of progression of the osteoarthritis, and four of the eight hips required or were expected to soon require conversion to a total hip arthroplasty to treat progressive pain. CONCLUSIONS At the time of early follow-up, we found that surgical dislocation and débridement of the hip for the treatment of femoro-acetabular impingement in hips without substantial damage to the articular cartilage can reduce pain and improve function. This procedure has a low rate of complications. Radiographic signs of progression of osteoarthritis and clinical failure requiring conversion to a total hip arthroplasty were seen only in patients with severe damage to the acetabular articular cartilage, a finding that emphasizes the need for better imaging methods to assess the extent of damage to the acetabular articular cartilage in patients with this disorder.

Acetabular Cartilage Delamination in Femoroacetabular Impingement: Risk Factors and Magnetic Resonance Imaging Diagnosis

BACKGROUND Delamination of acetabular articular cartilage is a common abnormality in hips with femoroacetabular impingement. The purpose of the present study was to identify clinical and radiographic factors predisposing to delamination and to assess the diagnostic accuracy of magnetic resonance arthrography for the detection of these lesions. METHODS Following a retrospective review of records, we determined that acetabular cartilage delamination had been present in twenty-eight of sixty-four hips that had undergone a surgical dislocation procedure for the treatment of femoroacetabular impingement. Multivariable logistic regression was performed to assess the correlation of radiographic findings (i.e., magnetic resonance imaging and computerized tomography findings) with the status of delamination. The preoperative interpretations of the magnetic resonance arthrograms for twenty-seven hips that underwent surgical dislocation were reviewed to assess the accuracy of detecting delamination. At the time of surgery, nine of these twenty-seven hips were found to have delamination. Magnetic resonance arthrography interpretations that did not correlate with operative findings were subjected to conspicuity assessment and error analysis. RESULTS The rate of delamination of the acetabular cartilage as noted at the time of surgical dislocation was 44% (twenty-eight of sixty-four). Delamination was strongly associated with male sex and femoral sided signs of impingement; however, it was not associated with acetabular overcoverage (center-edge angle, >40 degrees) (odds ratio = 0.16; p < 0.05). While there was no significant difference in the prevalence of labral lesions between groups, whenever labral and delamination lesions were found in the same hip, they were directly adjacent to one another. Preoperative magnetic resonance arthrography had a low sensitivity for delamination (22%) but had a high specificity (100%). Two-thirds of the delamination lesions were visible on retrospective review of these images when the reader was unblinded to the surgical findings. Delamination could most often be identified on the sagittal T1-weighted image and on the proton-density sequences with fat saturation. DISCUSSION There should be a high level of suspicion for articular cartilage delamination in men and in patients with primarily cam-type femoroacetabular impingement. Acetabular overcoverage may be protective against delamination. Preoperative high-quality magnetic resonance arthrograms should be carefully analyzed for evidence of delamination in this patient population.

Arthroscopy for Labral Tears in Patients with Developmental Dysplasia of the Hip: A Cautionary Note

Patients with developmental dysplasia of the hip may present with acetabular rim overloading, labral hypertrophy, and tear. Our hypothesis was that isolated arthroscopic treatment of labral tear is likely to fail in most patients. We investigated 34 patients who underwent at least one arthroscopy of the hip for labral tear. Developmental hip dysplasia or other morphologic abnormalities of the hip were confirmed in all patients. Arthroscopy failed to relieve pain in 24 patients. We observed accelerated arthritis in 14 patients and migration of the femoral head in 13 patients. Sixteen patients underwent further surgery (further surgeries included periacetabular osteotomy [6 patients], femoroacetabular osteoplasty [7 patients], and total hip arthroplasty [3 patients]). At the latest follow-up, all patients but one were pain-free. Patients with evidence of abnormal hip morphologies may not benefit from hip arthroscopy and isolated treatment of the labrum; in fact, the latter may accelerate the process of arthritis in some patients.

Early Results of the Bernese Periacetabular Osteotomy: The Learning Curve at an Academic Medical Center

BACKGROUND Most reports on the results of the Bernese periacetabular osteotomy for the treatment of developmental dysplasia of the hip have been by the originators of the procedure. In 1997, we began to use this osteotomy without direct training from the originators of the procedure. METHODS Seventy-three patients (eighty-three hips) underwent a Bernese periacetabular osteotomy between 1997 and 2003 and were followed prospectively with use of the Harris hip score to assess clinical results and with use of anteroposterior pelvic and false-profile lateral plain radiographs to assess radiographic results. The three-dimensional position of the acetabulum was recorded preoperatively and postoperatively. The mean duration of follow-up was forty-six months. RESULTS The average Harris hip score improved from 54 to 87 points (p < 0.001). Three hips (three patients) had a conversion to total hip arthroplasty at two, three, and four years after the periacetabular osteotomy. Preoperatively, fifty-four of the eighty-three acetabula were anteverted, and twenty-nine were either retroverted or had neutral wall relationships. Postoperatively, sixty-five hips (78%) were anteverted. Radiographically, in preoperatively anteverted hips, the average center-edge angle improved from 3 degrees to 29 degrees (p < 0.0001), the average anterior center-edge angle improved from 5 degrees to 31 degrees (p < 0.0001), and the acetabular index improved from 25 degrees to 5 degrees (p < 0.0001). In preoperatively retroverted or neutral hips, the average center-edge angle improved from 13 degrees to 33 degrees (p < 0.0001), the average anterior center-edge angle improved from 15 degrees to 36 degrees (p < 0.0001), and the acetabular index improved from 19 degrees to 2 degrees (p < 0.0001). Complications included four hematomas, three transient femoral nerve palsies, two deep wound infections, and one transient sciatic nerve palsy. Nine of the ten major complications and all four of the failed osteotomies occurred in the first thirty hips in which the index procedure was performed. CONCLUSIONS In our experience, the early results of the Bernese periacetabular osteotomy have been encouraging, with a 92% survival rate at thirty-six months. The occurrence of complications demonstrates a substantial learning curve. Recognition of the true preoperative acetabular version and reorientation of the acetabulum into an appropriately anteverted position have become important factors in surgical decision-making. LEVEL OF EVIDENCE Therapeutic Level IV.

Patient-specific Total Knee Arthroplasty Required Frequent Surgeon-directed Changes

BackgroundPatient-specific instrumentation potentially improves surgical precision and decreases operative time in total knee arthroplasty (TKA) but there is little supporting data to confirm this presumption.Questions/purposesWe asked whether patient-specific instrumentation would require infrequent intraoperative changes to replicate a single surgeon’s preferences during TKA and whether patient-specific instrumentation guides would fit securely.MethodsWe prospectively evaluated the plan and surgery in 60 patients treated with 66 TKAs performed with patient-specific instrumentation and recorded any changes. A subset of six postoperative radiographic changes to the femoral and tibial components (implant size, coronal and sagittal alignment) was analyzed to determine if surgeon intervention was beneficial. Each guide was evaluated to determine fit. We compared patient demographics and implant sizing in the patient-specific instrumentation group with a control group in which traditional instrumentation was used.ResultsWe recorded 161 intraoperative changes in 66 knee arthroplasties (2.4 changes/knee) performed with patient-specific instrumentation. The predetermined implant size was changed intraoperatively in 77% of femurs and 53% of tibias. We identified a subset of 95 intraoperative changes that could be radiographically evaluated to determine if our changes were an improvement or detriment to reaching goal alignment. Eighty-two of the 95 changes (86%) made by the surgeon were an improvement to the recommended alignment or size of patient-specific instrumentation. The guide did not fit securely on eight femurs (12%) and three tibias (5%). Tourniquet time and blood loss were not improved with patient-specific instrumentation.ConclusionsWe caution surgeons against blind acceptance of patient-specific instrumentation technology without supportive data.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Perioperative Closure-related Complication Rates and Cost Analysis of Barbed Suture for Closure in TKA

BackgroundThe use of barbed suture for surgical closure has been associated with lower operative times, equivalent wound complication rate, and comparable cosmesis scores in the plastic surgery literature. Similar studies would help determine whether this technology is associated with low complication rates and reduced operating times for orthopaedic closures.Questions/purposesWe compared a running barbed suture with an interrupted standard suture technique for layered closure in primary TKA to determine if the barbed suture would be associated with (1) shorter estimated closure times; (2) lower cost; and (3) similar closure-related perioperative complication rates.MethodsWe retrospectively compared two-layered closure techniques in primary TKA with either barbed or knotted sutures. The barbed group consisted of 104 primary TKAs closed with running barbed suture. The standard group consisted of 87 primary TKAs closed with interrupted suture. Cost analysis was based on cost of suture and operating room time. Clinical records were assessed for closure-related complications within the 6-week perioperative period.ResultsAverage estimated closure time was 2.3 minutes shorter with the use of barbed suture. The total closure cost was similar between the groups. The closure-related perioperative complication rates were similar between the groups.ConclusionsBarbed suture is associated with a slightly shorter estimated closure time, although this small difference is of questionable clinical importance. With similar overall cost and no difference in perioperative complications in primary TKA, this closure methodology has led to more widespread use at our institution.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Sequelae of Perthes Disease: Treatment with Surgical Hip Dislocation and Relative Femoral Neck Lengthening

Background Sequelae of Perthes disease commonly manifests as complex hip pathomorphology including coxa magna, coxa brevis, and acetabular dysplasia. These abnormalities contribute to femoroacetabular impingement and early osteoarthritis. This report describes our experience with correction of the proximal femoral deformity associated with Perthes disease through surgical dislocation, osteochondroplasty (SDO), trochanteric advancement, and treatment of intraarticular chondrolabral injury. Methods Between January 2003 and January 2009, 14 patients with Perthes disease (4 female and 10 male patients) with an average age of 19.6 years (range 14 to 28 y) were treated with SDO and trochanteric advancement. One patient had a subsequent staged periacetabular osteotomy to improve acetabular coverage. Patient histories, physical examinations, operative findings, and preoperative and postoperative radiographs were evaluated. Results Operative findings showed 6 acetabular cartilage lesions, 6 labral lesions, and 4 femoral osteochondritis dissecans (OCD) lesions treated with autografts. The mean of center-trochanteric distance improved from −20 mm to −1 mm. Approximately 4 of 14 hips deteriorated to Tönnis grade 1 and 1 of 14 hips deteriorated 2 Tönnis grades. The Harris hip scores improved from an average of 62 preoperatively (range 51 to 72) to 95 postoperatively (range 93 to 97) with OCD lesions versus 71 (range 65 to 76) to 88.6 (range 63 to 100) in the hips without OCD lesions. There was no statistically significant difference in the age, preoperative or postoperative HHSs between the OCD and non-OCD groups. The mean follow-up was 45 months. There were no major perioperative complications, and all the patients in both the groups have their native hip to date. Conclusions The typical adult sequelae of Perthes disease predispose the hip to the development of chondrolabral injury and poor clinical function. Treatment with SDO and trochanteric advancement reduces impingement, improves hip biomechanics, and allows the treatment of intraarticular pathology. This approach is associated with clinical improvement without major perioperative complications. In addition, we have found a high rate of OCD lesions of the femoral head in Perthes hips undergoing surgical dislocation. Osteochondral autograft transfer from the resected femoral head-neck junction been found in the 4 patients treated thus far to be safe and effective with comparable clinical and radiographic outcomes to those hips without OCD lesions. Level of Evidence Level IV (Case series).

Hip-preserving surgery: understanding complex pathomorphology.

Recent evidence suggests that abnormal hip morphology may be the primary cause of osteoarthritis of the hip in young adults1-5. Hip pathomorphology is manifested as acetabular deficiency or malorientation, or as femoral deformity or malorientation, and most commonly as a combination of these problems6,7. Contemporary surgical intervention for hip preservation has been directed toward correction of these malformations and associated chondrolabral injuries and has shown promise as a way of alleviating hip pain and possibly retarding the progression of osteoarthritis8,9. With the increasing number of available surgical methodologies (e.g., surgical dislocation, osteochondroplasty, hip arthroscopy, and redirectional acetabular osteotomy) that are directed at hip preservation, the importance of understanding the pathologic process that results in a painful hip has become paramount. In an effort to augment the basic information obtained from clinical examination, two-dimensional plain radiography, and magnetic resonance arthrography, we have utilized a validated three-dimensional modeling protocol to serve as a diagnostic and surgical planning tool for hip-preservation surgery. Three-dimensional modeling has helped to emphasize the complex pathomorphology that is evident in patients with hip dysplasia and femoroacetabular impingement and may have a future role in the classification and treatment of hip maladies in young adults. The goals of this study were to describe the typical presentation of the young adult with a painful hip and to offer corresponding case examples of the common morphologic abnormalities of the femur and acetabulum. The case examples illustrate the value of a comprehensive imaging protocol to facilitate diagnosis and management of patients who have complex femoroacetabular impingement and dysplasia. In addition, we describe our experience with three-dimensional computational model development as a function of a subset of work focused on the biomechanics of the dysplastic hip, and we outline future streams …

The etiology and treatment of hip pain in the young adult

Interest in the etiology, diagnosis, and treatment of hip pain in young adults has recently heightened. Improved diagnostic techniques with use of physical examination, magnetic resonance arthrography1,2, and three-dimensional computed tomographic imaging better define the diagnoses of femoroacetabular impingement3 and acetabular and/or proximal femoral dysplasia4-6. Newer treatment methods, such as surgical dislocation and debridement7-10 and periacetabular osteotomy11-30, show promise as nonarthroplasty alternatives in young patients6,8,10,11,31. In our experience, femoroacetabular impingement and dysplasia are the main reasons why young adults present with hip pain. Labral pathology may frequently coexist, but it is usually secondary to morphological abnormalities of the hip resulting in abnormal loading and impingement. In our opinion, abnormal morphology of the hip, although sometimes subtle, is the predominant underlying abnormality leading to the development of hip pain in the young adult. We believe that, in most patients, optimum treatment should be directed at normalizing morphology. Fig. 1 The impingement test is performed with the hip in 90° of flexion with additional internal rotation and adduction of the femur. The clinical history in these patients is important. Typically, the pain is described as being located in the anterior part of the groin and sometimes in the lateral aspect of the hip, but without tenderness over the greater trochanter, as the main symptom. The type of pain can vary. When it is described as sharp and catching, worse with sitting or deep flexion, it is likely related to impingement. If it also includes substantial catching or popping, labral pathology may be involved. Pain that occurs with walking and standing, is generalized over the activities of daily living, and possibly involves subluxation sensations may be more related to …

Comparison of Total Knee Arthroplasty With Highly Congruent Anterior-stabilized Bearings versus a Cruciate-retaining Design

BackgroundThe use of a highly conforming, anterior-stabilized bearing has been associated with clinical success in a limited number of studies.Questions/purposesWe compared Knee Society scores, radiographic results, complication rates, and revision rates with the use of anterior-stabilized bearings compared with cruciate-retaining (CR) bearings.MethodsA series of 382 patients with 468 primary total knee arthroplasties (TKAs) between 2003 and 2008 with minimum 2-year followup were reviewed. Anterior-stabilized bearings comprised 49% (n = 228) of the sample and CR bearings consisted of 51% (n = 240). The decision to use an anterior-stabilized bearing was based on integrity of the posterior cruciate ligament (PCL) intraoperatively or after sacrifice of the PCL to achieve soft tissue balance. The tibial and femoral component designs were the same regardless of bearing choice. Outcomes were measured with Knee Society scores, complications, revision TKA, and survival. Radiographs were analyzed for component alignment and evidence of loosening.ResultsThere was no difference in Knee Society knee scores, radiographic alignment, component loosening, manipulation rate, major complications, or time to revision for patients between the two groups. However, the CR group had significantly more revisions than the anterior-stabilized group (21 CR [1.5%] versus seven anterior-stabilized [4.6%], p = 0.03) at a minimum followup of 5 months (mean, 42 months; range, 5–181 months).ConclusionsThe use of a highly congruent anterior-stabilized bearing for PCL substitution has comparable clinical and radiographic results to traditional CR TKA. These results suggest that this approach is an effective method to achieve stability without the PCL in primary TKA.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.