Vincent Y. Ng

Efficacy of Surgery for Femoroacetabular Impingement A Systematic Review

Background Recent case studies on the surgical treatment of femoroacetabular impingement (FAI) have introduced a large amount of clinical data. However, there has been no clear consensus on its efficacy. Hypothesis The current literature can be clarified to address 4 questions: (1) Does treatment for FAI succeed in improving symptoms? (2) In which subset of patients should treatment for FAI be avoided? (3) Is labral refixation superior to simple resection? (4) Does treatment for FAI alter the natural progression of osteoarthritis in this group of typically young patients? Study Design Systematic review. Methods Twenty-three reports of case studies on the surgical treatment of FAI were identified and a systematic review was conducted. Data from each study were collected to answer each of the 4 focus questions. Results This review of 970 cases included 1 level II evidence trial, 2 level III studies, and 20 level IV studies. Based on patient outcome scores and effect size, all studies demonstrated improvement of patient symptoms. Up to 30% of patients will eventually require total hip arthroplasty; those patients with Outerbridge grade III or IV cartilage damage seen intraoperatively or with preoperative radiographs showing greater than Tonnis grade I osteoarthritis will have worse outcomes with treatment for FAI. Only 2 studies directly compared labral refixation with labral debridement. Several studies reported postoperative osteoarthritis findings; only a minority of these patients had progression of their osteoarthritis. Conclusion Surgical treatment for FAI reliably improves patient symptoms in the majority of patients without advanced osteoarthritis or chondral damage. Early evidence supports labral refixation. It is too soon to predict whether progression of osteoarthritis is delayed. Clinical Relevance These results may be used to help predict the outcome of surgical treatment of FAI in different patient populations and to assess the need for labral refixation.

Efficacy of treatment of trochanteric bursitis: a systematic review.

Objective:Trochanteric bursitis (TB) is a self-limiting disorder in the majority of patients and typically responds to conservative measures. However, multiple courses of nonoperative treatment or surgical intervention may be necessary in refractory cases. The purpose of this systematic review was to evaluate the efficacy of the treatment of TB. Data Sources:A literature search in the PubMed, MEDLINE, CINAHL, and ISI Web of Knowledge databases was performed for all English language studies up to April 2010. Terms combined in a Boolean search were greater trochanteric pain syndrome, trochanteric bursitis, trochanteric, bursitis, surgery, therapy, drug therapy, physical therapy, rehabilitation, injection, Z-plasty, Z-lengthening, aspiration, bursectomy, bursoscopy, osteotomy, and tendon repair. Study Selection:All studies directly involving the treatment of TB were reviewed by 2 authors and selected for further analysis. Expert opinion and review articles were excluded, as well as case series with fewer than 5 patients. Twenty-four articles were identified. According to the system described by Wright et al, 2 studies, each with multiple arms, qualified as level I evidence, 1 as level II, 1 as level III, and the rest as level IV. More than 950 cases were included. Data Extraction:The authors extracted data regarding the type of intervention, level of evidence, mean age of patients, patient gender, number of hips in the study, symptom duration before the study, mean number of injections before the study, prior hip surgeries, patient satisfaction, length of follow-up, baseline scores, and follow-up scores for the visual analog scale (VAS) and Harris Hip Scores (HHS). Data Synthesis:Symptom resolution and the ability to return to activity ranged from 49% to 100% with corticosteroid injection as the primary treatment modality with and without multimodal conservative therapy. Two comparative studies (levels II and III) found low-energy shock-wave therapy (SWT) to be superior to other nonoperative modalities. Multiple surgical options for persistent TB have been reported, including bursectomy (n = 2), longitudinal release of the iliotibial band (n = 2), proximal or distal Z-plasty (n = 4), osteotomy (n = 1), and repair of gluteus medius tears (n = 4). Conclusions:Efficacy among surgical techniques varied depending on the clinical outcome measure, but all were superior to corticosteroid therapy and physical therapy according to the VAS and HHS in both comparison studies and between studies. This systematic review found that traditional nonoperative treatment helped most patients, SWT was a good alternative, and surgery was effective in refractory cases.

Neutral Mechanical Alignment: A Requirement for Successful TKA: Affirms

Restoration of an overall neutral mechanical axis has been a long-held tenet in total knee arthroplasty (TKA). Numerous biomechanical, finite element, and clinical studies have demonstrated that coronal malalignment, particularly varus, is associated with increased strain, higher failure rates, and, in some cases, poorer outcomes. With advances in computer-assisted navigation, 3-dimensional imaging, and patient-specific positioning guides, the potential for greater precision in bone resection and component positioning has rekindled interest in this important issue. Several recently published studies demonstrating no difference in survivorship for malaligned TKAs have challenged the concept of an alignment safe zone. Some surgeons have discussed a paradigm shift in defining optimal alignment. While we agree that compared to several decades ago, there is greater understanding of TKA kinematics and that broad targets for alignment may not impart significant benefit as a dichotomous variable, there are multiple reasons why neutral alignment and classic bone cuts remain valid and important in delivering a successful TKA. In comparison to the preponderance of evidence advocating a neutral mechanical axis and approximately 5° to 7° valgus anatomic alignment, there is insufficient support for reasonably choosing any other target. Although technology has improved surgical precision, it has not eliminated the human factor, and aiming for neutral provides the safest margin for error. The foremost objective of TKA is a durable and well-functioning joint, not necessarily one that replicates normal or the patients native condition. While the latter goal is certainly desirable, the priority of the former should never be overlooked.

Femoroacetabular impingement: a common cause of hip pain in young adults.

Objective:Femoroacetabular impingement (FAI) is a common cause of hip discomfort in young adults. Recently, a better understanding of the pathomechanics and morphologic abnormalities in the hip has implicated FAI as a possible factor in early osteoarthrosis. The clinical presentation, physical examination findings, and radiographic features are discussed in this article. Data Sources:PubMed was searched using words and terms including femoacetabular impingement, hip osteoarthritis, hip arthroscopy, early osteoarthrosis, and hip dislocation. References of relevant studies were searched by hand. Study Selection:All studies directly involving the treatment of FAI were reviewed by 3 authors and selected for further analysis, including expert opinion and review articles. Data Synthesis:The quality of each study was assessed, and the results were summarized. Conclusions:Conservative measures, including physical therapy, restriction of activities, core strengthening, improvement of sensory-motor, and control and nonsteroidal anti-inflammatories are the mainstays of nonsurgical treatment. However, surgical management is often necessary to allow full return to activity with options including surgical dislocation of the hip, hip arthroscopy, periacetabular and rotational osteotomies, and combined hip arthroscopy with a limited open exposure. Although the literature is replete with short-term evidence to support surgical treatment, there are currently no long-term prospective data or natural history studies examining the implications of FAI and effects of early intervention.

Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction: AAOS Exhibit Selection.

Demand for primary total hip arthroplasty and demand for total knee arthroplasty in the United States are anticipated to grow by 174% and 673%, respectively, over the next twenty years1. Satisfaction rates are good to excellent in most patients2-4. Modern techniques and perioperative care have reduced systemic and local complications5-7. Nevertheless, the risks of major adverse outcomes (2.2% to 7.4%)8-10 and death (0.1% to 0.8%)5,7-9,11-19 remain real. Careful preoperative clearance and targeted therapeutic interventions are necessary to minimize complications. Studies have demonstrated total joint arthroplasty to be a highly cost-effective procedure. Nevertheless, many payers, especially the U.S. Centers for Medicare & Medicaid Services (CMS), have targeted total joint arthroplasty for cost control20. Adoption of a pay-for-performance program by CMS21 has created a zero-sum game to reward overachievers and penalize underachievers. The current literature lacks a detailed, comprehensive approach for risk-stratifying total joint arthroplasty patients and a systematic method for preoperatively allaying these risks. Popular tools such as the American Society of Anesthesiologists (ASA) classification system may be effective in predicting the overall outcome of surgery, but they cannot predict specific complications22 and they do not facilitate further preparatory action23-25. Although medical evaluation should be performed in collaboration with the internist, evidence-based guidelines provide standardization and comprehensiveness. Conditions necessitating postponement or cancellation of total joint arthroplasty are present in approximately 4% of patients26. Complications related to the cardiovascular system represent 42% to 75% of major systemic adverse events and deaths following total joint arthroplasty7,13,27,28, and cardiovascular comorbidities are a significant risk factor for these events14,29. Intramedullary instrumentation …

Limb-length discrepancy after hip arthroplasty.

➤ Limb-length discrepancy is a common condition found in the general population and elderly individuals with osteoarthritis. ➤ All aspects of total hip arthroplasty are interconnected, and making adjustments in one can affect several others. ➤ Intraoperative imaging with trial or final components in place is helpful to rule out excessive limb-length discrepancy and to confirm proper component sizing and position in difficult primary total hip arthroplasty or revision situations.

Perspectives in managing an implant recall: revision of 94 Durom Metasul acetabular components.

The Metasul LDH Large Diameter Head with Durom Acetabular Component (Zimmer, Warsaw, Indiana) was launched in Europe in 20031 and was approved by the United States Food and Drug Administration (FDA) in April 20062. The Durom acetabular component was designed as a monoblock, truncated hemispherical cup with a 165° arc, and had performed well in the Swedish Arthroplasty Registry and in early European studies3,4. The senior author (M.A.M.), a fellowship-trained surgeon specializing in adult reconstruction who had more than twenty years’ experience with total hip arthroplasty, performed approximately 400 primary total hip arthroplasties annually during the past five years and 100 to 150 annually during the preceding years. Prior to October 2006, he utilized the Trabecular Metal Modular Acetabular System (Zimmer) with good success. Utilization of the Durom cup began in October 2006 because of the good results that had been reported internationally and the purported benefits of increased range of hip motion, enhanced stability, and greater durability. The senior author implanted 297 Durom acetabular cups during the subsequent two years. All procedures were performed at a large community hospital with a company representative present in the operating room. None of the patients was part of a clinical trial, and the surgeon had no current industry ties. All cups were inserted according to the manufacturers instructions. The learning curve was rapid, and no obvious intraoperative complications developed. A minority of patients (seventy-six of 297, 26%) progressed slowly with therapy, reporting vague symptoms of groin discomfort, mild pain with initial weight-bearing, and difficulty with ambulation. Furthermore, several patients who had a non-Durom cup on the contralateral side reported worse performance on the side with the Durom cup. Nevertheless, there was little objective evidence to support the existence of a widespread problem. Because there were …

Risk of Disease Transmission With Bone Allograft

Why is the risk of disease transmission with bone allograft an important topic? Approximately 1 million bone allografts are implanted every year in the United States. Although safety measures to prevent disease transmission have improved significantly over the past 2 decades, infectious complications remain a relevant concern. During informed consent, patients invariably take pause at the prospect of potentially contracting a serious and incurable condition from surgery. Although many are adequately reassured with the proverbial “1 in a million” estimated risk, astute clinicians should be prepared to provide the more incisive individuals a deeper understanding of the real and theoretical risks of allograft.

Calcium phosphate cement to prevent collapse in avascular necrosis of the femoral head

Subchondral and articular collapse following nontraumatic osteonecrosis of the femoral head is an important cause of osteoarthritis in patients between ages 20 and 40. Because hip arthroplasty in the younger population is prone to early wear and failure, it is paramount to prevent collapse once osteonecrosis is detected. Natural remodeling of the osteonecrotic areas by adjacent normal bone is predominated by osteoclastic resorption, which weakens the cancellous bone and allows microfractures to occur before full healing can take place. Current treatment modalities include core decompression and various adjuncts such as bone graft, mesenchymal stem cells and tantalum implants to provide structural integrity and to speed bony creeping substitution. Calcium phosphate cement has been reported in the treatment of fractures, especially depressed tibial plateau fractures. It is slow to resorb and is gradually replaced by bone, allowing prolonged support of periarticular fractures during healing. We hypothesize that calcium phosphate cement in conjunction with standard decompression of osteonecrotic femoral head lesions can prevent collapse.

The Effect of Surgery With Radiation on Pelvic Ewing Sarcoma Survival

Pelvic Ewing sarcoma (ES) has poorer outcomes than extremity‐based lesions and the method of local control is controversial.