Robert L. Buly

Debridement of the Adult Hip for Femoroacetabular Impingement: Indications and Preliminary Clinical Results

Untreated femoro-acetabular impingement is a common cause of osteoarthrosis of the hip. Surgical debridement of the adult hip with femoro-acetabular impingement recently has been advocated with the aim of relieving symptoms and slowing or halting progression of the arthrosis. At surgery, femoral sources of impingement are relieved by debriding the aspheric peripheral portion of the femoral head and the adjacent femoral neck. Acetabular sources of impingement can be relieved by debridement of the anterior rim. The most fundamental questions concerning these procedures relate to the preoperative and postoperative function, postoperative survivorship of these hips and the incidence of osteonecrosis. The current study assesses a group of 23 hips in 23 patients treated by surgical debridement for impingement. Twenty-two patients were treated by full surgical dislocation and one patient was treated by relief of impingement without dislocation. Followup ranged from a minimum of 2 years to 12 years. At most recent evaluation, seven patients had been converted to total hip arthroplasty, one had arthroscopic debridement of a recurrent labral tear, and 15 patients have had no further surgery. No hips developed osteonecrosis. Of the seven patients who had to have their procedure converted to total hip arthroplasty, three of these hips failed early and four patients’ hips recovered and functioned well and subsequently deteriorated with total hip arthroplasty done between 6.4 and 9.5 years after debridement. Hips at greatest risk of failure have advanced arthrosis or a combination of impingement and instability preoperatively. The procedure effectively treats hips with impingement and without considerable secondary arthrosis or instability.

Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture

The case of a fifty-year-old man who suffered an isolated, associated, both-column fracture of the left acetabulum is presented. He underwent an uncomplicated open reduction and internal fixation through an ilioinguinal approach. A follow-up computed tomographic scan was performed postoperatively, which documented intraarticular fragments. Hip arthroscopy was performed to remove the fragments. During the procedure, arthroscopic fluid extravasated through the fracture site under pump pressure and resulted in an intraabdominal compartment syndrome that presented as cardiopulmonary arrest. An emergent exploratory laparotomy was performed to release the fluid and resume blood flow. Despite prolonged asystole, the patient survived without neurologic sequelae. The literature on compartment syndrome secondary to arthroscopic procedures is reviewed. Because of this previously unreported potentially lethal complication, we do not advocate hip arthroscopic procedures for acute or healing acetabular fractures.

Diagnostic and Therapeutic Use of Sonography-Guided Iliopsoas Peritendinous Injections

OBJECTIVE Our objective was to review our experience performing sonography-guided iliopsoas bursal/peritendinous injections as a diagnostic and therapeutic tool in the workup and treatment of patients with hip pain. CONCLUSION Sonography-guided iliopsoas bursal/peritendinous injections are useful in determining the cause of hip pain. They can provide relief to most patients with iliopsoas tendinosis/bursitis after hip replacement. The results of injection alone are not as successful in cases of idiopathic iliopsoas tendinosis/bursitis, but the technique can help determine which patients may benefit from a surgical tendon release.

Total Hip Arthroplasty for Posttraumatic Arthritis after Acetabular Fracture

Total hip arthroplasty (THA) outcomes for posttraumatic arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA. Recently, improved results have been demonstrated using cementless acetabular reconstruction. Thirty-two patients underwent THA for posttraumatic arthritis after acetabular fracture; 24 were treated with open reduction internal fixation, and 8 were managed conservatively. Time from fracture to THA was 36 months (6-227 months). Average follow-up was 4.7 years (2.0-9.7 years). Harris Hip score increased from 28 (0-56) to 82 points (20-100). Six patients required revision. Five-year survival with revision, loosening, dislocation, or infection as an end point was 79%. Survival for aseptic acetabular loosening was 97%. Revision surgery correlated with nonanatomic restoration of the hip center and a history of infection (P < .05). Despite obvious challenges, advances in fracture management and cementless acetabular fixation in THA demonstrate improved results for posttraumatic arthritis following acetabular fracture.

Rotating hinge total knee arthroplasty in severely affected knees

A consecutive series of 24 knees in 21 patients who received a Finn rotating hinge for primary (nine knees) or revision (15 knees) total knee arthroplasty between August 1993 and January 1997 was reviewed. The average followup was 33 months (range, 21–62 months) for all patients in the study. Seventeen patients (20 knees) were followed up for more than 2 years. Twenty-four knees (21 patients) were categorized according to Knee Society scoring criteria: 37.5% (nine knees) were Category A, 25% (six knees) were Category B, and 37.5% (nine knees) were Category C. Using the Knee Society knee and function scores, clinical and radiographic results were assessed and outcome analysis was determined. The average Knee Society knee score improved from 44 points (range, 5–64 points) before surgery to 83 points (range, 45–95 points) after surgery; the average functional score according to the Knee Society system improved from 10 points (range, 0–35 points) before surgery to 45 points (range, 0–100 points) after surgery. Pain and function markedly improved after surgery. For treatment of the most severely affected knees with compromised bone and ligamentous instability, the Finn total knee replacement appears to be an acceptable option. As a rotating hinge design, the prosthesis at early followup provides excellent pain relief, restoration of walking capacity, and stabilization, without evidence of early mechanical failure.

Hip Arthroscopy in the Athletic Patient: Current Techniques and Spectrum of Disease

Over the last decade, the management of hip injuries has evolved substantially due to the advancement of techniques in arthroscopy and diagnostic tools such as magnetic resonance imaging. Arthroscopy of the hip remains a challenge due to the osseous and soft-tissue constraints of the hip. Currently, various hip lesions, including labral tears, loose bodies, femoroacetabular impingement, coxa saltans (snapping hip syndrome), ligamentum teres injuries, and capsular laxity, can be successfully treated arthroscopically. As continued improvements are made in surgical techniques and in specifically designed instrumentation for the hip, the indications for arthroscopy will continue to increase and arthroscopy of the hip will become a standard procedure performed by an increasing number of orthopaedic surgeons. After reviewing this article, the reader should: (1) have a basic understanding of the intra-articular and extra-articular hip disorders that commonly occur in athletes; (2) be able to generate a differential diagnosis for hip pain; (3) have a basic understanding of the relevant anatomy, patient history, and physical examination findings for an athlete who presents with hip pain; and (4) be able to identify normal and abnormal findings on radiographic and magnetic resonance imaging studies. The differential diagnosis of hip pain in an athletic patient is quite broad (Table I). A complete history and physical examination are necessary in order to determine the source and cause of the pain. It is still common to ascribe hip pain in an athlete to a muscle strain or a soft-tissue contusion. However, hip pain may arise from a number of soft-tissue structures in and around the hip joint, and it is important to be able to differentiate extra-articular from intra-articular abnormalities. The physician should elicit information from the patient with regard to the specific location of the discomfort, the qualitative nature of the discomfort (such as catching, clicking, instability, …

Acetabular revision with the Contour antiprotrusio cage: 2- to 5-year followup.

The Contour cage introduced in 1999 was designed to improve fixation and provide a surface for bone ongrowth. To determine whether the rates of radiographic loosening and/or revision have been reduced with the Contour design, we retrospectively reviewed the medical records and radiographs of 29 patients (average age, 68.1 years) undergoing 31 acetabular revisions with a Contour cage. The minimum followup was 24 months (mean 30 months, range, 24-58 months). Based on the Paprosky classification, two hips were Type 2B, seven were Type 3A, and 22 were Type 3B. Two hips (7%) were revised for loosening; one of these two was also infected. An additional five hips (16%) had signs of radiographic loosening. The mean Harris hip score improved from 45 to 80; functional scores improved less than the pain scores. Only 14 hips (45%) had an excellent or good clinical result and three of these 14 hips had radiographic signs of loosening; presuming these three hips eventually fail, only 35% of the hips had a good or excellent result. We found an association between number of previous surgeries and radiographic loosening and revision. Our data suggest the Contour cage offers little advantage over other antiprotrusio cages and highlight the substantial limitations of current methods available for treating patients with extensive acetabular bone loss.Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum

BACKGROUND Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. METHODS Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). RESULTS All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. CONCLUSIONS Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.BACKGROUND Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. METHODS Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). RESULTS All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. CONCLUSIONS Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.

Corrosion at the Stem-Sleeve Interface of a Modular Titanium Alloy Femoral Component as a Reason for Impaired Disengagement

Modularity in sleeved femoral components allows the exchange of the stem without disruption of the fixation between the sleeve and the surrounding bone at revision surgery. Failure to disengage the stem from the sleeve would represent an unnecessary compromise from the intended usefulness of the modular design. We report the results of an examination of 22 modular titanium alloy femoral components retrieved after 0.0 to 8.8 years in vivo. In 7 implants, the stem-sleeve interface could not be disengaged without cutting through the components or using mechanical force. Moderate to severe corrosion was detected in all 7 of these cases. Corrosive surface changes were observed in an additional 6 interfaces. There was no correlation with the length of time that the devices had been implanted. When only the stem is to be revised, orthopedic surgeons should be aware of difficulties in disengagement and anticipate alternative surgical procedures.

Hip Arthroscopy Update

The management of hip injuries in the athlete has evolved significantly in the past few years with theadvancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in recreational and elite athletes alike. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular pathology that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and thus, left untreated. Current indications for hip arthroscopy include management of labral tears, osteoplasty for femoroacetabular impingement, thermal capsulorrhaphy and capsular plication for subtle rotational instability and capsular laxity, lateral impact injury and chondral lesions, osteochondritis dissecans, ligamentum teres injuries, internal and external snapping hip, removal of loose bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and certain cases of mild to moderate osteoarthritis with associated mechanical symptoms. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation. Patients with reproducible symptoms and physical findings that reveal limited functioning, and who have failed an adequate trial of conservative treatment will have the greatest likelihood of success after surgical intervention. Strict attention to thorough diagnostic examination, detailed imaging, and adherence to safe and reproducible surgical techniques, as described in this review, are essential for the success of this procedure.