Search

Background: The incidence of developmental dysplasia of the hip (DDH) in Japanese newborns has reduced drastically following a primary prevention campaign initiated around 1972 to 1973; this perinatal education campaign promoted maintaining the hips of newborns in the naturally flexed-leg position. The purpose of the present study was to describe the life course epidemiology of hip osteoarthritis (OA) in adolescent and adult patients and to assess its association with exposure to the primary prevention campaign for DDH. Methods: We included new patients with hip OA diagnosed from January 1, 2022, to December 31, 2022, at 12 core hospitals (8 special-function hospitals and 4 regional medical care support hospitals). The trend in the percentage of hips with a history of DDH treatment in childhood was estimated with use of a centered moving average using the birth year of the patient. We compared the prevalence of severe subluxation (Crowe type II, III, or IV) between patients with secondary hip OA due to hip dysplasia who were born in or before 1972 and those who were born in or after 1973. Results: Overall, 1,095 patients (1,381 hips) were included. The mean age at the time of the survey was 63.5 years (range, 15 to 95 years). A total of 795 patients (1,019 hips; 73.8% of hips) were diagnosed with secondary OA due to hip dysplasia. Approximately 13% to 15% of hips among patients born from 1963 to 1972 had a history of DDH treatment in childhood; however, the percentage decreased among patients born in or after 1973. The prevalence of severe subluxation (Crowe type II, III, or IV) among patients born in or after 1973 was 2.4%, which was significantly less than that among patients born in or before 1972 (11.1%; odds ratio, 0.20; p < 0.001). Conclusions: As of 2022, secondary hip OA due to hip dysplasia is still responsible for most new cases of adolescent and adult hip OA seen in core hospitals in Japan. However, the perinatal education campaign initiated 50 years ago, which utilized a population approach and advocated for maintaining the hips of newborns in the naturally flexed-leg position, may have improved the environmental factors of DDH, as indicated by the apparently reduced need for treatment of DDH in childhood and the associated severe subluxation. This may result in a reduced need for challenging hip surgery later in life. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background No single graft type has been shown to have a benefit in acetabular labral reconstruction. The native labrum and lateral meniscus share many similarities, suggesting that the meniscus may be a promising source of graft material in labral reconstruction. Questions/purposes Using a pig model, we sought to evaluate the healing process of fresh-frozen meniscus allograft for acetabular reconstruction by assessing (1) MRI and macroscopic observations of the meniscus allograft; (2) histologic appearance and immunohistologic evaluation of the meniscus allograft, native meniscus, and labrum; (3) microscopic assessment of the native labrum and meniscus via scanning electron microscopy; and (4) biomechanical assessment of tensile properties. Methods Twelve skeletally mature male miniature Bama pigs (24 hips) were randomly divided into two groups: labral defect group (control) and lateral meniscus allograft group. The selection of Bama pig specimens was based on the similarity of their acetabular labrum to that of the human acetabular labrum, characterized by the presence of fibrocartilage-like tissue lacking blood vessels. The pigs underwent bilateral hip surgery. Briefly, a 1.5-cm-long section was resected in the anterior dorsal labrum, which was left untreated or reconstructed using an allogeneic lateral meniscus. The pigs were euthanized at 12 and 24 weeks postoperatively, and then evaluated by macroscopic observations and MRI measurement to assess the extent of coverage of the labral defect. We also performed a histologic analysis and immunohistologic evaluation to assess the composition and structure of meniscus allograft, native labrum, and meniscus, as well as scanning electron microscopy assessment of the microstructure of the native labrum and meniscus and biomechanical assessment of tensile properties. Results Imaging measurement and macroscopic observations revealed that the resected area of the labrum was fully filled in the lateral meniscus allograft group, whereas in the control group, the labral defect remained at 24weeks. The macroscopic scores of the meniscus allograft group (8.260.8) were higher than those of the control groups (4.8 6 1.0) (mean difference 3.3 [95% CI 1.6 to 5.0]; p < 0.001). Moreover, in themeniscus allograft group, histologic assessment identified fibrocartilage-like cell cluster formation at the interface between the graft and acetabulum; cells and fibers arranged perpendicularly to the acetabulum and tideline structure that were similar to those of native labrum could be observed at 24 weeks. Immunohistochemical results showed that the average optical density value of Type II collagen at the graft-acetabulum interface was increased in the meniscus allograft group at 24 weeks compared with at 12 weeks (0.259 6 0.031 versus 0.228 6 0.023, mean difference 0.032 [95% CI 0.003 to 0.061]; p = 0.013). Furthermore, the tensile modulus of the lateral meniscus allograft was near that of the native labrum at 24 weeks (54.7 6 9.9 MPa versus 63.2 6 11.3 MPa, mean difference -8.4 MPa [95% CI -38.3 to 21.4]; p = 0.212). Conclusion In a pig model, lateral meniscus allografts fully filled labral defects in labral reconstruction. Regeneration of a fibrocartilage transition zone at the graftacetabulum interface was observed at 24 weeks. Clinical Relevance The use of an autograft meniscus for labral reconstruction may be a viable option when labral tears are deemed irreparable. Before its clinical implementation, it is imperative to conduct a comparative study involving tendon grafts, which are extensively used in current clinical practice. [ABSTRACT FROM AUTHOR]

The article offers information on recent research in hip surgery. Topics include the management of hip pathology in young adults; hip fracture management; and nonoperative management of osteoarthritis. The research includes studies on arthroscopic and nonoperative management of femoroacetabular impingement; the impact of sarcopenia on hip fracture patients; and the efficacy of intra-articular corticosteroid injection for symptomatic hip osteoarthritis.

Ballet dancers may be predisposed to hip injuries because of the unique demands placed on the hips during dance training and performance. Hip arthroscopy can be used to address several of these symptomatic disorders, including hip instability and femoroacetabular impingement syndrome (FAIS). After hip arthroscopy, ballet dancers undergo a rehabilitation program to allow for healing, range of motion restoration, and progressive strengthening. Once patients complete the standard postoperative therapy program, a paucity of information is available to guide dancers back to the advanced hip movements involved in ballet. Therefore, the purpose of this clinical commentary is to present a stepwise rehabilitation protocol with return to ballet progression for dancers undergoing hip arthroscopy for instability or FAIS. Particular emphasis is placed on movement-specific exercises for ballet performers, and objective clinical metrics, to guide return to dance progression. [ABSTRACT FROM AUTHOR]

Abstract: Recovery from surgery is quicker in the postpartum period, and this may reflect oxytocin action in the spinal cord. We hypothesized that intrathecal injection of oxytocin would speed recovery from pain and disability after major surgery. Ninety-eight individuals undergoing elective total hip arthroplasty were randomized to receive either intrathecal oxytocin (100 μg) or saline. Participants completed diaries assessing pain and opioid use daily and disability weekly, and they wore an accelerometer beginning 2 weeks before surgery until 8 weeks after. Groups were compared using modelled, adjusted trajectories of these measures. The study was stopped early due to the lack of funding. Ninety patients received intrathecal oxytocin (n = 44) or saline (n = 46) and were included in the analysis. There were no study drug-related adverse effects. Modelled pain trajectory, the primary analysis, did not differ between the groups, either in pain on day of hospital discharge (intercept: -0.1 [95% CI: -0.8 to 0.6], P = 0.746) or in reductions over time (slope: 0.1 pain units per log of time [95% CI: 0-0.2], P = 0.057). In planned secondary analyses, postoperative opioid use ended earlier in the oxytocin group and oxytocin-treated patients walked nearly 1000 more steps daily at 8 weeks (P < 0.001) and exhibited a clinically meaningful reduction in disability for the first 21 postoperative days (P = 0.007) compared with saline placebo. Intrathecal oxytocin before hip replacement surgery does not speed recovery from worst daily pain. Secondary analyses suggest that further study of intrathecal oxytocin to speed functional recovery without worsening pain after surgery is warranted. [ABSTRACT FROM AUTHOR]

The utility of preoperative transthoracic echocardiogram (TTE) before hip fracture repair remains controversial. This is a retrospective chart review study of adult patients admitted with hip fractures from multiple sites, including tertiary and community hospitals, with teaching and nonteaching services. The study compared the length of stay, time to surgery, in-hospital mortality, and postoperative complications between TTE and non-TTE groups. TTE patients were risk stratified using the Revised Cardiac Risk Index to compare TTE indications according to contemporary guidelines. Objectives: Preoperative transthoracic echocardiograms (TTE) before hip fracture repairs are controversial. This study aimed to quantify the frequency of ordering TTE, the appropriateness of testing based on current guidelines, and the impact of TTE on in-hospital morbidity and mortality outcomes. Methods: This retrospective chart review of adult patients admitted with hip fracture compared the length of stay (LOS), time to surgery, in-hospital mortality, and postoperative complications between TTE and non-TTE groups. TTE patients were risk stratified using the Revised Cardiac Risk Index (RCRI) to compare TTE indication according to current guidelines. Results: Of the 490 patients included in this study, 15% received preoperative TTE. The median LOS of the TTE and non-TTE groups was 7.0 and 5.0 d, respectively, whereas the median time to surgery was 34 and 14 h, respectively. The odds of in-hospital mortality remained significantly higher in the TTE group after adjusting for RCRI but not when adjusted for the Charlson Comorbidity Index. Significantly more patients in the TTE groups had postoperative heart failure and up triage in the intensive care unit. Furthermore, 48% of patients with an RCRI score of 0 received preoperative TTE, with cardiac history as the most typical indication. TTE changed perioperative management in 9% of patients. Conclusions: Patients subjected to TTE before hip fracture surgery had a longer LOS and time to surgery, with higher mortality and intensive care unit up triage rates. TTE evaluations were typically conducted for inappropriate indications, which rarely made meaningful changes to patient management. [ABSTRACT FROM AUTHOR]

Cochrane in CORR ®: Interventions for Improving Mobility After Hip Fracture Surgery in Adults One recent estimate found that more than 14 million people experience a hip fracture every year. Delivery and outcomes of a yearlong home exercise program after hip fracture: a randomized controlled trial exercise program after hip fracture: a randomized controlled trial. [Extracted from the article]

Studies of reduced time to surgery among older adult patients with hip fractures have demonstrated outcome improvement and fewer complications. The purpose of this study was to explore the association between preoperative wait times among older adult patients (aged 65 years and older) who underwent hip fracture surgery and mortality. This retrospective cohort study examined the potential relationship(s) between time to surgery and 30-day outcomes and mortality rates. Objective: This retrospective study explored the impact of time to surgery in acute hip fractures and outcomes in patients with acute hip fractures at a level I trauma center within an academic medical center in the southeastern United States. The objective was to explore the association between time to surgery and 30-day mortality and outcomes in adults 65 years and older undergoing hip fracture surgery for traumatic injuries in 2014–2019. Methods: The population of this study consisted of patients who presented with a hip fracture and required operative measures. The research team conducted a secondary data analysis of medical records among patients who experienced a hip fracture and subsequent hip surgery to address the injury. Results: Results from this study demonstrated a statistically significant relationship between a delay in surgery and an increase in postoperative complications and morbidity, as well as increased morbidity among male patients. Conclusions: Incidence of hip fractures is increasing among older adult patients and is cause for concern because of an associated high mortality rate and risk of postoperative complications. The existing body of literature indicates earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality. The results of this study affirm these findings and suggest further examination specifically among males. [ABSTRACT FROM AUTHOR]

Background: Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. Questions/purposes: (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? Methods: In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. Results: After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. Conclusion: In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. Level of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning. Questions/purposes: (1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR? Methods: This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI). Results: Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR. Conclusion: Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures. Level of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Surgical repair of hip fracture carries substantial short-term risks of mortality and complications. The risk-reward calculus for most patients with hip fractures favors surgical repair. However, some patients have low prefracture functioning, frailty, and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult. The importance of high-quality informed consent and shared decision-making for frail patients with hip fracture has recently been demonstrated. A tool to accurately estimate patient-specific risks of surgery could improve these processes. Questions/purposes: With this study, we sought (1) to develop, validate, and estimate the overall accuracy (C-index) of risk prediction models for 30-day mortality and complications after hip fracture surgery; (2) to evaluate the accuracy (sensitivity, specificity, and false discovery rates) of risk prediction thresholds for identifying very high-risk patients; and (3) to implement the models in an accessible web calculator. Methods: In this comparative study, preoperative demographics, comorbidities, and preoperatively known operative variables were extracted for all 82,168 patients aged 18 years and older undergoing surgery for hip fracture in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2011 and 2017. Eighty-two percent (66,994 of 82,168) of patients were at least 70 years old, 21% (17,007 of 82,168) were at least 90 years old, 70% (57,260 of 82,168) were female, and 79% (65,301 of 82,168) were White. A total of 5% (4260 of 82,168) of patients died within 30 days of surgery, and 8% (6786 of 82,168) experienced a major complication. The ACS-NSQIP database was chosen for its clinically abstracted and reliable data from more than 600 hospitals on important surgical outcomes, as well as rich characterization of preoperative demographic and clinical predictors for demographically diverse patients. Using all the preoperative variables in the ACS-NSQIP dataset, least absolute shrinkage and selection operator (LASSO) logistic regression, a type of machine learning that selects variables to optimize accuracy and parsimony, was used to develop and validate models to predict two primary outcomes: 30-day postoperative mortality and any 30-day major complications. Major complications were defined by the occurrence of ACS-NSQIP complications including: on a ventilator longer than 48 hours, intraoperative or postoperative unplanned intubation, septic shock, deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, sepsis, intraoperative or postoperative myocardial infarction, intraoperative or postoperative cardiac arrest requiring cardiopulmonary resuscitation, acute renal failure needing dialysis, pulmonary embolism, stroke/cerebral vascular accident, and return to the operating room. Secondary outcomes were six clusters of complications recently developed and increasingly used for the development of surgical risk models, namely: (1) pulmonary complications, (2) infectious complications, (3) cardiac events, (4) renal complications, (5) venous thromboembolic events, and (6) neurological events. Tenfold cross-validation was used to assess overall model accuracy with C-indexes, a measure of how well models discriminate patients who experience an outcome from those who do not. Using the models, the predicted risk of outcomes for each patient were used to estimate the accuracy (sensitivity, specificity, and false discovery rates) of a wide range of predicted risk thresholds. We then implemented the prediction models into a web-accessible risk calculator. Results: The 30-day mortality and major complication models had good to fair discrimination (C-indexes of 0.76 and 0.64, respectively) and good calibration throughout the range of predicted risk. Thresholds of predicted risk to identify patients at very high risk of 30-day mortality had high specificity but also high false discovery rates. For example, a 30-day mortality predicted risk threshold of 15% resulted in 97% specificity, meaning 97% of patients who lived longer than 30 days were below that risk threshold. However, this threshold had a false discovery rate of 78%, meaning 78% of patients above that threshold survived longer than 30 days and might have benefitted from surgery. The tool is available here: https://s-spire-clintools.shinyapps.io/hip%5fdeploy/. Conclusion: The models of mortality and complications we developed may be accurate enough for some uses, especially personalizing informed consent and shared decision-making with patient-specific risk estimates. However, the high false discovery rate suggests the models should not be used to restrict access to surgery for high-risk patients. Deciding which measures of accuracy to prioritize and what is "accurate enough" depends on the clinical question and use of the predictions. Discrimination and calibration are commonly used measures of overall model accuracy but may be poorly suited to certain clinical questions and applications. Clinically, overall accuracy may not be as important as knowing how accurate and useful specific values of predicted risk are for specific purposes. Level of Evidence Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Joint arthroplasty registries traditionally report survivorship outcomes mainly on primary joint arthroplasty. The outcome of first revision procedures is less commonly reported, because large numbers of primary procedures are required to analyze a sufficient number of first revision procedures. Additionally, adequate linkage of primary procedures to revisions and mortality is required. When undertaking revision hip surgery, it is important for surgeons to understand the outcomes of these procedures to better inform patients.Questions/purposes: Using data from a large national joint registry, we asked: (1) What is the overall rate of revision of the first aseptic revision procedure for a primary THA? (2) Does the rate of revision of the first revision vary by the diagnosis for the first revision? (3) What is the mortality after the first revision, and does it vary by the reason for first revision?Methods: The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The analyses for this study were performed on primary THA procedures in patients with a diagnosis of osteoarthritis up to December 31, 2020, who had undergone subsequent revision. We excluded all primary THAs involving metal-on-metal and ceramic-on-metal bearing surfaces and prostheses with exchangeable necks because these designs may have particular issues associated with revisions, such as extensive soft tissue destruction, that are not seen with conventional bearings, making a comparative analysis of the first revision involving these bearing surfaces more complicated. Metal-on-metal bearing surfaces have not been used in Australia since 2017. We identified 17,046 first revision procedures from the above study population and after exclusions, included 13,713 first revision procedures in the analyses. The mean age at the first revision was 71 ± 11 years, and 55% (7496 of 13,713) of the patients were women. The median (IQR) time from the primary procedure to the first revision was 3 years (0.3 to 7.3), ranging from 0.8 years for the diagnosis of dislocation and instability to 10 years for osteolysis. There was some variation depending on the reason for the first revision. For example, patients undergoing revision for fracture were slightly older (mean age 76 ± 11 years) and patients undergoing revision for dislocation were more likely to be women (61% [2213 of 3620]). The registry has endeavored to standardize the sequence of revisions and uses a numerical approach to describe revision procedures. The first revision is the revision of a primary procedure, the second revision is the revision of the first revision, and so on. We therefore described the outcome of the first revision as the cumulative percent second revision. The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the second revision. Hazard ratios from Cox proportional hazards models, adjusting for age and gender, were performed to compare the revision rates among groups. When possible, the cumulative percent second revision at the longest follow-up timepoint was determined with the available data, and when there were insufficient numbers, we used appropriate earlier time periods.Results: The cumulative percent second revision at 18 years was 26% (95% confidence interval [CI] 24% to 28%). When comparing the outcome of the first revision by reason, prosthesis dislocation or instability had the highest rate of second revision compared with the other reasons for first revision. Dual-mobility prostheses had a lower rate of second revision for dislocation or instability than head sizes 32 mm or smaller and when compared to constrained prostheses after 3 months. There was no difference between dual-mobility prostheses and head sizes larger than 32 mm. There were no differences in the rate of second revision when first revisions for loosening, periprosthetic fracture, and osteolysis were compared. If cemented femoral fixation was performed at the time of the first revision, there was a higher cumulative percent second revision for loosening than cementless fixation from 6 months to 6 years, and after this time, there was no difference. The overall mortality after a first revision of primary conventional THA was 1% at 30 days, 2% at 90 days, 5% at 1 year, and 40% at 10 years. A first revision for periprosthetic fracture had the highest mortality at all timepoints compared with other reasons for the first revision.Conclusion: Larger head sizes and dual-mobility cups may help reduce further revisions for dislocation, and the use of cementless stems for a first revision for loosening seems advantageous. Surgeons may counsel patients about the higher risk of death after first revision procedures, particularly if the first revision is performed for periprosthetic fracture.Level of Evidence Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Classic and reverse Bernese periacetabular osteotomy (PAO) have been shown to be effective for the treatment of developmental dysplasia of the hip (by classic PAO), severe acetabular retroversion (by reverse PAO), and some protrusio acetabuli (by reverse PAO). Especially in severe cases with higher degrees of correction, a relevant overlap between the osteotomized fragment and the pelvis might occur, leading to necessary fragment translation. The aim of the present study was to analyze the necessary translation as a function of the degree of correction using a statistical mean model of the pelvis according to the technique (classic PAO or reverse PAO).Methods: A mean statistical shape model of the pelvis and 2 extreme models were used to simulate rotation of the osteotomized fragment during a classic or reverse PAO and to calculate rotations from -20° to 20° in the frontal, sagittal, and transverse planes and a combination thereof. The depth and volume of the intersection between the mobilized fragment and the pelvis were calculated, and the minimum translation of the fragment necessary to avoid segment overlap was determined.Results: The maximum intersection distances between the pelvis and the 20° rotated fragment were 6.7 and 15.3 mm for adduction and abduction (frontal plane), 6.4 and 4.5 mm for internal and external rotation (transverse plane), and 27.8 and 9.2 mm for extension and flexion (sagittal plane). The necessary translations for 20° of fragment rotation were 7.0 and 12.8 mm for adduction and abduction (frontal plane), 4.8 and 5.0 mm for internal and external rotation (transverse plane), and 18.5 mm and 8.8 mm for extension and flexion (sagittal plane).Conclusions: Acetabular reorientation with the classic or reverse PAO results in translation of the fragment and in a consequent change in the rotational center. This finding is more pronounced with higher degrees of fragment reorientation in abduction and extension; it becomes especially pronounced in reverse PAO for acetabular retroversion or protrusio acetabuli, and might limit the ability to achieve the intended improvement in overall hip biomechanics. [ABSTRACT FROM AUTHOR]

Background: Hip microinstability is an increasingly recognized source of pain and dysfunction but has no agreed upon diagnostic criteria and the pathophysiology remains unclear. It has been suggested that pain associated with microinstability is caused by excess translation of the femoral head. Recent research indicates that single-plane femoral head translation can be reliably measured using dynamic ultrasonography during a supine clinical examination; however, the overall accuracy of that technique has not been established, and the range of femoral head translation values that are found in individuals with no history of surgery or symptomatic pathology is unknown.Questions/purposes: (1) How much femoral head translation is present in native, uninjured hips during a weightbearing apprehension position for females and males? (2) How large is the side-to-side difference in hip translation and rotation within the same individual in females and males with no history of surgery or pain during the weightbearing apprehension position? (3) What differences exist in femoral head translation and rotation when comparing females to males?Methods: Twenty-two young adults (11 males, 11 females; mean age 22 ± 2 years; BMI 22 ± 5 kg/m2) with no history of hip pain, no known hip injury, and who never had hip surgery participated in this study. High-resolution CT images of the femur and pelvis were acquired for each participant, and the bone tissue was segmented from the CT volume. Synchronized biplane radiographs were collected during a neutral standing trial and during a static weightbearing apprehension position in which the participant extended, externally rotated, and abducted at their back hip while standing with their feet split in the AP direction. A validated volumetric model-based tracking technique was used to match the patient-specific bone models to the biplane radiographs with an accuracy of 0.3 mm for translation and 0.8° for rotation. Translation of the center of the femoral head relative to the center of the acetabulum and rotation of the femur relative to the pelvis from neutral to the weightbearing apprehension position were calculated. Sex-based differences in hip kinematics were assessed by bivariate linear regression.Results: The median (range) translation during the weightbearing apprehension position in females was 0.9 mm (0.2 to 2.7 mm), which was less than in the 1.3 mm (0.2 to 2.6 mm) translation found in males (median difference of 0.5 mm; p = 0.04). The median absolute side-to-side difference in translation during the pivot was 1.4 mm (0.1 to 3.8 mm) in females and 1.3 mm (0.1 to 4.4 mm) in males.Conclusion: These findings demonstrate that the femoral head translates the same under bodyweight loading as previously observed during supine exam, showing the inherent stability of the hip with no history of surgery or symptomatic pathology. This study also provides normal values for comparison with individuals who have suspected microinstability. Future directions for research include directly comparing biplane radiography to alternative imaging techniques, such as dynamic ultrasound, for identifying hip microinstability and identifying threshold values for symptomatic hip microinstability.Level Of Evidence: Level III, prognostic study. [ABSTRACT FROM AUTHOR]

Background: Because of the unique theoretical surgical risks, including osteonecrosis, acute iatrogenic slipped capital femoral epiphysis, and epiphyseal injury, the optimal treatment strategy for femoroacetabular impingement (FAI) in growing adolescents has yet to be established. The aim of this study was to compare the clinical outcomes of primary arthroscopic treatment of FAI in growing adolescents with a matched adult group.Methods: Patients with FAI who underwent arthroscopic treatment with a minimum follow-up of 2 years were included. Patients with previous ipsilateral hip surgery, an Outerbridge grade of ≥3, a preoperative Tönnis grade of ≥2, or evidence of dysplasia (lateral center-edge angle of <25°) were excluded. Eligible patients who were ≤19 years old and whose proximal femoral physis had not yet closed were matched to adult (20 to 40-year-old) counterparts in a 1:1 ratio by sex, body mass index, and time of surgery. For the adolescents, cam resection was performed with a physeal-sparing approach. Outcome scores, including the modified Harris hip score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and HOS-Sports-Specific Subscale (HOS-SSS), were prospectively collected.Results: Of the 196 eligible adolescents, 157 (80%) were pair-matched to adult controls, with a median postoperative follow-up of 8.9 and 6.6 years, respectively. Fourteen (9%) of the adolescents required revision hip arthroscopy compared with 18 adults (11%) (p = 0.46). No patient in the adolescent group had conversion to a total hip arthroplasty (THA), while 3 in the adult group had a THA (p = 0.25). For adolescents without subsequent hip surgery, the median mHHS improved from 59 preoperatively to 96 postoperatively; the HOS-ADL, from 71 to 98; and the HOS-SSS, from 44 to 94 (p < 0.001), which were significantly higher postoperative scores than those of the matched adults (p < 0.05) despite similar or inferior baseline scores. No complications were found during the office visit or at the final follow-up.Conclusions: Hip arthroscopy performed with a physeal-sparing approach for FAI in growing adolescents is safe and effective and yields superior clinical outcomes compared with those in a matched adult group.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Residual Legg-Calvé-Perthes (LCP) deformities represent one of the most challenging disorders in hip reconstructive surgery. In complex cases, both instability (acetabular dysplasia) and multifocal femoroacetabular impingement (FAI) (proximal femoral deformities) require correction. We assessed intermediate-term patient-reported outcome measures, radiographic correction, complications, and survivorship for combined surgical dislocation (SD) and periacetabular osteotomy (PAO) for the treatment of complex LCP deformities.Methods: A retrospective cohort study was performed on 31 hips with complex LCP deformities undergoing combined SD and PAO for concurrent instability and FAI. Treatment included femoral head reshaping, trochanteric advancement and relative femoral neck lengthening, management of intra-articular lesions, and PAO. Twenty-seven hips (87%) had a minimum follow-up of 5 years. The mean age was 19.8 years, 56% of patients were female, and 44% of patients had undergone a previous surgical procedure.Results: At a mean of 8.4 years, 85% of hips (23 of 27) remained preserved (no conversion to total hip arthroplasty). The survivorship estimates were 93% at 5 years and 85% at 10 years. The median (and interquartile range) increased from 64 points (55, 67 points) to 92 points (70, 97 points) (p < 0.001) for the modified Harris hip score (mHHS) and from 60 points (45, 75 points) to 86 points (75, 100 points) (p = 0.001) for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Symptoms (mHHS < 70 points) were reported for an additional 19% of hips (n = 5) at the final follow-up. The University of California Los Angeles (UCLA) activity score increased from a median of 8 points (6, 10 points) to 9 points (7, 10 points) (p = 0.207). Structural correction included mean improvement (and standard deviation) of 15.3° ± 7.6° for acetabular inclination, 20.7° ± 10.8° for the lateral center-edge angle, 23.4° ± 16.3° for the anterior center-edge angle, and 18 ± 10 mm for trochanteric height (p < 0.001 for all). Complications occurred in 2 hips (7%), including 1 deep wound infection and 1 superficial wound infection. There was 1 reoperation due to complication, but there were no nerve palsies, thromboembolic events, fractures, or nonunions.Conclusions: At an intermediate follow-up of combined SD and PAO for complex LCP deformities, 85% of hips were preserved. This procedure provides reliable deformity correction, major pain relief, improved function, and acceptable complication and failure rates.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Objective: There is no information about surfing after hip resurfacing arthroplasty (HRA). We did a retrospective study aiming to evaluate the safety and feasibility to resume surfing-an extreme sport with high-impact physical activity-after HRA. Design: Retrospective case series. Setting: Specialist Orthopaedic Group, Mater Hospital Sydney, NSW, Australia. Patients: We evaluated 45 patients who practiced surfing before the onset of pain and hip surgery. Complete clinical and radiographical follow-up and a completed questionnaire were available for 37 (82%) patients. Interventions: Hip resurfacing arthroplasty. Main outcome measures: Postel-Merle d'Aubigne score, the Oxford hip score, the Harris hip score, and the University of California at Los Angeles activity score. Radiographical evaluation at 6 weeks, 3, and 12 months after surgery and yearly thereafter. Return to surf rates using a specific questionnaire. Complications and failures during follow-up. Results: All clinical scores improved significantly after HRA. Eight of 37 (22%) patients stopped surfing after their HRA. More than 80% of patients commenced surfing within the first 6 months after surgery. During surfing, 21 patients (72%) were completely pain free. Conclusion: No literature exists regarding the return to a high-impact sport as surfing after HRA. Most of our patients (71%) were able to return at least to their preoperative level of surfing after surgery. No complications related to this sport activity were observed during short-term follow-up. We believe that surfing is compatible with HRA, but long-term studies are necessary to assess the influence of this extreme sport on loosening and revision rates. [ABSTRACT FROM AUTHOR]

Background: Torsional hip deformities are common among patients undergoing hip arthroscopy. However, recent studies have suggested conflicting outcomes following arthroscopy in the setting of abnormal hip version. The purpose of this study was to systematically evaluate the literature and determine the impact of femoral and acetabular version on patient-reported outcomes following primary arthroscopic hip surgery.Methods: This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies investigating femoral and acetabular version in primary hip arthroscopy with clinical outcomes were identified, and data were extracted in duplicate.Results: Overall, 11 studies met inclusion criteria and comprised 1,297 hips (726 femora and 571 acetabulae), with a mean patient age of 29.2 years (range, 14 to 74.7 years). In patients with acetabular retroversion, there was no significant difference, when compared with the normal acetabular version group, in the modified Harris hip score (mHHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) pain scores postoperatively. Among patients with femoral retroversion, in 2 of 3 studies, the authors reported no difference in mHHS postoperatively compared with patients with normal femoral version. In patients with high femoral anteversion, in 2 of 3 studies, the authors reported a significant difference in postoperative mHHS favoring patients with normal femoral version. Studies examining high femoral anteversion included patients with borderline hip dysplasia and patients who underwent concurrent psoas-lengthening procedures.Conclusions: Although the definition of the normal version of the hip varied within the literature, hip arthroscopy in patients with acetabular retroversion resulted in no difference in functional outcomes compared with patients with normal version. Postoperative functional outcomes in patients with femoral retroversion and high femoral anteversion were mixed, although the procedure was possibly less effective in high femoral anteversion combined with specific clinical scenarios. Further prospective studies based on standardized definitions and version analysis techniques would be useful in identifying the precise surgical indications for safe arthroscopic surgical procedures in patients with version abnormalities of the femur and acetabulum, particularly those with high femoral anteversion and retroversion.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Dislocation is the most common reason for early revision following total hip arthroplasty (THA). More than 40 years ago, Lewinnek et al. proposed an acetabular "safe zone" to avoid dislocation. While novel at the time, their study was substantially limited according to modern standards. The purpose of this study was to determine optimal acetabular cup positioning during THA as well as the effect of surgical approach on the topography of the acetabular safe zone and the hazard of dislocation.Methods: Primary THAs that had been performed at a single institution from 2000 to 2017 were reviewed. Acetabular inclination and anteversion were measured using an artificial intelligence neural network; they were validated with performance testing and comparison with blinded grading by 2 orthopaedic surgeons. Patient demographics and dislocation were noted during follow-up. Multivariable Cox proportional-hazards regression, including multidimensional analysis, was performed to define the 3D topography of the acetabular safe zone and its association with surgical approach.Results: We followed 9,907 THAs in 8,081 patients (4,166 women and 3,915 men; 64 ± 13 years of age) for a mean of 5 ± 3 years (range: 2 to 16); 316 hips (3%) sustained a dislocation during follow-up. The mean acetabular inclination was 44° ± 7° and the mean anteversion was 32° ± 9°. Patients who did not sustain a dislocation had a mean anteversion of 32° ± 9° (median, 32°), with the historic ideal anteversion of 15° observed to be only in the third percentile among non-dislocating THAs (p < 0.001). Multivariable modeling demonstrated the lowest dislocation hazards at an inclination of 37° and an anteversion of 27°, with an ideal modern safe zone of 27° to 47° of inclination and 18° to 38° of anteversion. Three-dimensional analysis demonstrated a similar safe-zone location but significantly different safe-zone topography among surgical approaches (p = 0.03) and sexes (p = 0.02).Conclusions: Optimal acetabular positioning differs significantly from historic values, with increased anteversion providing decreased dislocation risk. Additionally, surgical approach and patient sex demonstrated clear effects on 3D safe-zone topography. Further study is needed to characterize the 3D interaction between acetabular positioning and spinopelvic as well as femoral-sided parameters.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Hip fractures are common, and most patients with hip fractures treated operatively will have better outcomes than those treated nonoperatively [[2]]. 7 Holt G,, Smith R,, Duncan K,, Hutchison JD,, Gregori A. Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. But because patients with hip fractures present with a variety of demographic and comorbid characteristics, a patient-individualized risk assessment or decision tool would be useful. [Extracted from the article]

Background: The evaluation of the natural history prevalence of adverse local tissue reactions (ALTRs) using MRI has focused only on metal-on-metal (MoM) bearing surfaces without comparison to nonMoM bearing surfaces.Questions/purposes: To determine (1) the longitudinal changes and differences in blood metal ion levels in patients with hip resurfacing arthroplasty (HRA), ceramic-on-ceramic (CoC) THA, and metal-on-polyethylene (MoP) THA compared with those undergoing ceramic-on-polyethylene (CoP) THA; (2) how the longitudinal change of synovial reaction classification in patients with HRA, CoC THA, and MoP THA compares with those undergoing CoP THA, and whether there is an association between the presence of an ALTR or metallosis on MRI with corresponding patient-reported outcomes, or the presence of capsular dehiscence; and (3) differences in blood metal ion levels between patients undergoing HRA with an ALTR or metallosis on MRI and those with HRA without these conditions.Methods: Between March 2014 and February 2019, 22,723 patients underwent primary HRA and THA at one center. Patients received an HRA based on their desired athletic level after surgery and the presence of normal acetabular and proximal femoral bone morphology without osteopenia or osteoporosis. Two percent (342 of 22,723) of patients were contacted to participate, and 71% (243 of 342 hips in 206 patients) were enrolled for analysis at baseline. The patients underwent arthroplasty for degenerative joint disease, and 25 patients withdrew over the course of the study. We included patients who were more than 1 year postarthroplasty. All participants had an MRI examination and blood serum ion testing and completed a Hip Disability and Osteoarthritis Outcome Score survey annually for four years (baseline, year 1, year 2, year 3). Morphologic and susceptibility-reduced MR images were evaluated by a single radiologist not involved in the care of patients for the presence and classification of synovitis (Gwet AC1: 0.65 to 0.97), synovial thickness, and volume (coefficient of repeatability: 1.8 cm3). Linear mixed-effects models were used to compare the mean synovial thickness, synovial volume, and Hip Disability and Osteoarthritis Outcome Score subscales between bearing surfaces at each timepoint and within each bearing surface over time. Marginal Cox proportional hazards models were used to compare the time to and the risk of developing ALTR only, metallosis only, and ALTR or metallosis between bearing surfaces. All models were adjusted for age, sex, BMI, and length of implantation based on known confounders for hip arthroplasty. Adjustment for multiple comparisons was performed using the Dunnett-Hsu method.Results: Patients with unilateral HRA had higher cobalt and chromium serum ion levels (baseline: 1.8 ± 0.8 ppb, year 1: 2.0 ± 1.5 ppb, year 2: 2.1 ± 1.2 ppb, year 3: 1.6 ± 0.7 ppb) than those with unilateral CoP bearings (baseline: 0.0 ± 0.1 ppb, year 1: 0.1 ± 0.3 ppb, year 2: 0.0 ± 0.2 ppb, year 3: 0.0 ± 0.0 ppb) at all timepoints (p < 0.001 for each time point). More patients who received an HRA developed ALTR or metallosis on MRI than did patients with CoP bearings (hazard ratio 4.8 [95% confidence interval 1.2 to 18.4]; p = 0.02). There was no association between the longitudinal change of synovial reaction to ALTR or metallosis on MRI with patient-reported outcomes. In addition, there was no association between the presence of dehiscence at baseline and the subsequent development of ALTR or metallosis, as seen on MRI. There were elevated cobalt (4.7 ± 3.5 ppb) and chromium (4.7 ± 2.6 ppb) serum levels in patients with unilateral HRA who had an ALTR or metallosis present on MRI at year 1 compared with patients without an ALTR or metallosis on MRI (cobalt: 1.8 ± 1.0 ppb, mean difference 4.7 ppb [95% CI 3.3 to 6.0]; p < 0.001; chromium: 2.3 ± 0.5 ppb, mean difference 3.6 ppb [95% CI 2.2 to 5.0]; p < 0.001) as well as for chromium at year 3 (3.9 ± 2.4 ppb versus 2.2 ± 1.1 ppb, mean difference 1.3 ppb [95% CI 0.3 to 2.4]; p = 0.01).Conclusion: We found a higher proportion of ALTR or metallosis on MRI in patients with HRA compared with patients with CoP, even when patient self-assessed symptomatology of those with an ALTR or metallosis on MRI was not different than the absence of these features. MRI detected ALTRs in high-function patients, emphasizing that an annual clinical assessment dependent on survey or blood ion testing alone may not detect soft tissue complications. The results of this study are in line with prior consensus recommendations of using MRI as part of a routine follow-up protocol for this patient population.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Time-driven activity-based costing (TDABC) has been suggested as the cost-accounting arm of value-based care organizations seeking to address costing challenges from the bottom up by studying the actual processes used in patient care. Lean methodology is a system in which the care pathway is understood at a granular level. In the current study, we attempt to combine these 2 methodologies, providing a robust mechanism to detect meaningful variation. First, we used data from a single surgeon and examined differences in time and cost for patients released on postoperative days 1 or 2. Next, we compared the data from patients discharged on postoperative day 1 with those of patients who underwent an operation by a different surgeon and were also discharged on postoperative day 1. Methods: Consecutive patients who underwent an anterior hip arthroplasty performed by 1 of 2 surgeons and who had degenerative pathology of the hip, an inpatient stay of 1 or 2 days, discharge to home, and no readmission within 30 days of the surgical procedure were identified. We obtained data on patient demographic characteristics and time spent on activities for each personnel role in 15-minute increments occurring during 4 time points of a surgical episode of care (preoperative bay, surgical procedure, post-anesthesia care unit, and inpatient). Personnel costs were set as a ratio relative to the cost of a registered nurse (RN). Results: Consistent with our hypotheses, both RNs and nursing assistants-certified (NA-Cs) spent more time with patients released on postoperative day 2 compared with those released on postoperative day 1. Also consistent with our hypotheses, we only found significant differences for the time that personnel spent in the surgical procedures. Conclusions: For patients undergoing total hip arthroplasty for degenerative conditions, we demonstrate that, in the setting of lean methodology, TDABC can detect variability in a meaningful and predictable way. This combination may further enable clinicians and administrators to improve processes, to allocate appropriate resources to specific process steps, and to optimize various treatments across episodes of care. Level of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels.Methods: Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters.Results: A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm.Conclusions: This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism is a common complication after hip fractures. However, there are no reliable laboratory assays to identify patients at risk for venous thromboembolic (VTE) events after major orthopaedic surgery.Question/purposes: (1) Are rotational thromboelastometry (ROTEM) findings associated with the presence or development of symptomatic VTE after hip fracture surgery? (2) Were any other patient factors associated with the presence or development of symptomatic VTE after hip fracture surgery? (3) Which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE?Methods: This retrospective study was conducted over a 13-month period. In all, 354 patients with femoral neck and peritrochanteric fractures who underwent hip hemiarthoplasty or cephallomedullary nailing were assessed for eligibility. Of those, 99% (349 of 354) were considered eligible for the study, 1% (3 of 354) of patients were excluded due to coagulation disorders, and another 1% (2 of 354) were excluded because they died before the postoperative ROTEM analysis. An additional 4% (13 of 354) of patients were lost before the minimum study follow-up of 3 months, leaving 95% (336 of 354) for analysis. A ROTEM analysis was performed in all patients at the time of their hospital admission, within hours of the injury, and on the second postoperative day. The patients were monitored for the development of symptoms indicative of VTE, and the gold standard tests for diagnosing VTE, such as CT pulmonary angiography or vascular ultrasound, were selectively performed only in symptomatic patients and not routinely in all patients. Therefore, this study evaluates the association of ROTEM with only clinically evident VTE events and not with all VTE events. ROTEM results did not affect the clinical surveillance of the study group and the decision for further work up. To determine whether ROTEM findings were associated with the presence or development of symptomatic VTE, ROTEM parameters were compared between patients with and without symptomatic VTE. To establish whether any other patient factors were associated with the presence or development of symptomatic VTE after hip fracture surgery, clinical parameters and conventional laboratory values were also compared between patients with and without symptomatic VTE. Finally, to determine which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE, the area under the curve (AUC) for certain cut off values of ROTEM parameters was calculated.Results: We found several abnormal ROTEM values to be associated with the presence or development of symptomatic VTE. The preoperative maximum clot firmness was higher in patients with clinically evident VTE than in patients without these complications (median [interquartile range] 70 mm [68 to 71] versus 65 mm [61 to 68]; p < 0.001). The preoperative clot formation time was lower in patients with clinically evident VTE than those without clinically evident VTE (median 61 seconds [58 to 65] versus 70 seconds [67 to 74]; p < 0.001), and also the postoperative clot formation time was lower in patients with clinically evident VTE than those without these complications (median 52 seconds [49 to 59] versus 62 seconds [57 to 68]; p < 0.001). Increased BMI was also associated with clinically evident VTE (odds ratio 1.26 [95% confidence interval 1.07 to 1.53]; p < 0.001). We found no differences between patients with and without clinically evident VTE in terms of age, sex, smoking status, comorbidities, and preoperative use of anticoagulants. Lastly, preoperative clot formation time demonstrated the best performance for detecting the association of hypercoagulability with symptomatic VTE (AUC 0.89 [95% CI 0.81 to 0.97]), with 81% (95% CI 48% to 97%) sensitivity and 86% (95% CI 81% to 89%) specificity for clot formation time ≤ 65 seconds.Conclusion: ROTEM's performance in this preliminary study was promising in terms of its association with symptomatic VTE. This study extended our earlier work by demonstrating that ROTEM has a high accuracy in detecting the level of hypercoagulability that is associated with symptomatic VTE. However, until its performance is validated in a study that applies a diagnostic gold standard (such as venography, duplex/Doppler, or chest CT) in all patients having ROTEM to confirm its performance, ROTEM should not be used as a regular part of clinical practice.Level Of Evidence: Level IV, diagnostic study. [ABSTRACT FROM AUTHOR]

➤: The proper diagnosis and treatment of patients with concurrent hip and spine pathological processes can be challenging because of the substantial overlap in symptomatology.➤: There is no consensus on which pathological condition should be addressed first.➤: Factors such as advanced spinal degeneration, deformity, and prior fusion alter the biomechanics of the spinopelvic unit. Attention should be paid to recognizing these issues during the work-up for a total hip arthroplasty as they can result in an increased risk of dislocation.➤: In patients with concurrent spine and hip degeneration, the surgeon must pay close attention to appropriate implant positioning and have consideration for implants with enhanced stability to minimize the risk of dislocation.➤: A proper understanding of sagittal balance and restoration of this balance is integral to improving patient outcomes following spinal surgery.➤: The advent of new imaging modalities, increased awareness of spinopelvic mobility, as well as a better understanding of sagittal alignment will hopefully improve our treatment of patients with hip-spine syndrome. [ABSTRACT FROM AUTHOR]

Objective: Although many rehabilitation protocols after hip arthroscopy have been described, there is still significant variability about duration, goals, restrictions, and techniques to apply by the physical therapy after the surgical procedure. The aim of the study was to systematically review rehabilitation after hip arthroscopy. Design: The data sources were PubMed, Scopus, and Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for the systematic review. Level I-IV evidence clinical studies and clinical reviews that focused on rehabilitation protocols after hip arthroscopy have been used as study eligibility criteria. Major limitations include the retrospective nature of most of the studies selected (level IV evidence) and the use of different clinical scores to report the outcomes. Results: This review showed that although a standardized guideline on rehabilitation after hip arthroscopy is still missing, the most recent studies and clinical trials are focusing on a four-phase program, which includes goals, recommendations, and a progression of exercises. Conclusions: Rehabilitation after hip arthroscopy is strongly suggested, but different authors recommended different rehabilitation programs. There is not a defined program, but as of today, the current standard of care is composed of phase-based programs. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic treatment of symptomatic femoroacetabular impingement (FAI) has promising short-term to mid-term results. In addition to treating acute pain or impaired function, the goal of hip-preserving surgery is to achieve a lasting improvement of hip function and to prevent the development of osteoarthritis. Long-term results are necessary to evaluate the effectiveness of surgical treatment and to further improve results by identifying factors associated with conversion to THA.Questions/purposes: (1) How do the Merle d'Aubigné-Postel scores change from before surgery to follow-up of at least 10 years in patients undergoing hip arthroscopy for the treatment of FAI? (2) What is the cumulative 10-year survival rate of hips with the endpoints of conversion to THA or a Merle d'Aubigné-Postel score less than 15? (3) Which factors are associated with conversion to THA?Methods: Between 2003 and 2008, we treated 63 patients (65 hips) for symptomatic FAI with hip arthroscopy at our institution. During that period, the indications for using arthroscopy were correction of anterior cam morphology and anterolateral rim trimming with debridement or reattachment of the labrum. We excluded patients who were younger than 16 years and those who had previous trauma or surgery of the hip. Based on that, 60 patients (62 hips) were eligible. A further 17% (10 of 60) of patients were excluded because the treatment was purely symptomatic without treatment of cam- and/or pincer-type morphology. Of the 50 patients (52 hips) included in the study, 2% (1) of patients were lost before the minimum study follow-up of 10 years, leaving 49 patients (51 hips) for analysis. The median (range) follow-up was 11 years (10 to 17). The median age at surgery was 33 years (16 to 63). Ninety percent (45 of 50) of patients were women. Of the 52 hips, 75% (39 of 52) underwent cam resection (femoral offset correction), 8% (4 of 52) underwent acetabular rim trimming, and 17% (9 of 52) had both procedures. Additionally, in 35% (18 of 52) of hips the labrum was debrided, in 31% (16 of 52) it was resected, and in 10% (5 of 52) of hips the labrum was reattached. The primary clinical outcome measurements were conversion to THA and the Merle d'Aubigné-Postel score. Kaplan-Meier survivorship and Cox regression analyses were performed with endpoints being conversion to THA or Merle d'Aubigné-Postel score less than 15 points.Results: The clinical result at 10 years of follow-up was good. The median improvement of the Merle d'Aubigné-Postel score was 3 points (interquartile range 2 to 4), to a median score at last follow-up of 17 points (range 10 to 18). The cumulative 10-year survival rate was 92% (95% CI 85% to 99%) with the endpoints of conversion to THA or Merle d'Aubigné-Postel score less than 15. Factors associated with conversion to THA were each year of advancing age at the time of surgery (hazard ratio 1.1 [95% CI 1.0 to 1.3]; p = 0.01) and preoperative Tönnis Grade 1 compared with Tönnis Grade 0 (no sign of arthritis; HR 17 [95% CI 1.8 to 166]; p = 0.01).Conclusion: In this series, more than 90% of patients retained their native hips and reported good patient-reported outcome scores at least 10 years after arthroscopic treatment of symptomatic FAI. Younger patients fared better in this series, as did hips without signs of osteoarthritis. Future studies with prospective comparisons of treatment groups are needed to determine how best to treat complex impingement morphologies.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated.Question/purpose: Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era?Methods: A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%.Results: The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days.Conclusion: Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: Previous CT and cadaver studies have suggested that the external obturator footprint might be used as a landmark for stem depth in direct anterior THA. Instructions on where to template this structure with small variability in height have been developed but have not been tested in daily clinical practice.Questions/purposes: In this study we sought to investigate the (1) usability, (2) accuracy, and (3) reliability of the external obturator footprint as a landmark for stem depth in direct anterior THA.Methods: The distance between the superior border of the external obturator tendon and the shoulder of the stem was measured intraoperatively in all patients (n = 135) who underwent primary THA via a direct anterior approach performed by the senior author between November 2019 and October 2020. The landmark was considered useful when two of thre`e evaluators agreed that the intersection of the vertical line comprised of the lateral wall of the trochanteric fossa and the oblique line formed by the intertrochanteric crest was clearly visible on the preoperative planning radiograph, and when the landmark was furthermore identified with certainty during surgery. Accuracy was defined as the degree of agreement (categorical for thresholds of 2 and 5 mm, the latter representing the threshold for developing unphysiological gait parameters) between the intraoperative distance and radiographic distance as measured on intraoperative fluoroscopy images or postoperative radiographs, which were calibrated based on femoral head sizes in a software program commonly used for templating. Intrarater reliability was defined as the degree of agreement (categorical for thresholds of 1 mm, which we considered an acceptable measurement error) between the ratings of one observer, who measured the radiographic distance on two different occasions separated by a washout period of at least 2 weeks. Interrater reliability was defined as the degree of agreement (categorical for thresholds of 1 mm, which we considered an acceptable measurement error) between the ratings of three observers with varying levels of experience (a fellowship-trained hip surgeon, a hip surgery fellow, and a medical student).Results: The landmark was considered useful in 77% (104 of 135) of patients who underwent direct anterior THA based on the observations that the trochanteric fossa was clearly visible on the planning radiograph in 117 patients and that the tendon was identified with certainty during surgery in 118 patients. There was good-to-excellent accuracy (intraclass correlation coefficient 0.75-087), and intrarater reliability (ICC 0.99) and interrater reliability (ICC 0.99) were both excellent.Conclusion: This clinical study showed that the external obturator footprint is a useful, accurate, and reliable landmark for stem depth in direct anterior THA.Clinical Relevance: The external obturator landmark allows the surgeon to position the stem within a range of the templated depth that is beneath the threshold for the development of unphysiological gait parameters. Although strictly speaking it was found useful in 77% of patients in this study, we found that this percentage of usability can easily be improved to around 90% by providing the radiology lab technician with instructions to correct external rotation of the foot during the taking of the planning radiograph. Future studies could compare the established (in)equality in leg length in patients using the external obturator landmark with computer-assisted surgery. [ABSTRACT FROM AUTHOR]

Objective: To investigate clinical outcomes after arthroscopic labral preservation surgery for femoroacetabular impingement (FAI) in the presence of osteoarthritis (OA) compared with FAI without significant OA. Design: Retrospective case--control study. Setting: Department of Orthopaedic Surgery and Sports Medicine, Hospital of Academic Institute. Patients: Femoroacetabular impingement patients (n = 97; ≥35 years) undergoing arthroscopic FAI correction with labral preservation surgery from March 2009 to April 2014 were enrolled in this study. Interventions: Patients were divided into 2 groups: FAI group (79 patients), with Tonnis grade 0 or 1, and FAI + OA group (18 patients), with Tonnis grade 2 or 3. Main OutcomeMeasures: We examined the clinical outcomes using the Modified Harris Hip Score (MHHS), Nonarthritic Hip Score (NAHS), and the conversion rate to total hip arthroplasty (THA). Results: No significant differences existed between the 2 groups with respect to age, sex, follow-up period, or preoperative MHHS or NAHS. The mean MHHS and NAHS at the final follow-up were significantly lower in the FAI + OA group than in the FAI group. There was a significant difference in the rate of conversion to THA and failure between the 2 groups (THA 5% vs 50%) (failure 15% vs 67%). Conclusion: Patients with FAI in the presence of OA did not improve after arthroscopic labral preservation surgery and had a high conversion rate to THA. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Supplemental digital content is available in the text. A 36-yr-old man with a history of industrial accident causing traumatic left hip disarticulation, pubic symphysis, and right sacroiliac joint fractures presented with a 3-yr history of left-sided lower back pain radiating down the amputated limb. Computed tomography lumbar spine showed osteophytes surrounding the sacroiliac joint bilaterally with reduced left L4–L5 foraminal space. A fluoroscopically guided left sacroiliac steroid injection led to mild improvement in low back pain. Magnetic resonance imaging of the lumbar spine without contrast showed transitional type L5 vertebral body with left-sided flowing osteophytes abutting the extraforaminal L4 and L5 nerves. Ultimately, multilevel left fluoroscopically guided transforaminal epidural steroid injection at L4–L5 and L5–S1 significantly improved symptoms. Although phantom radiculopathy is a rare entity, clinical suspicion of degenerative spine disease or other pathology contributing to nerve impingement in patients with amputations should remain; this unique case discusses bony osteophyte complex as the cause for phantom radiculopathy instead of previously described disc herniation. Magnetic resonance imaging remains a key tool in delineating causes of low back pain among patients with lower limb amputations. [ABSTRACT FROM AUTHOR]

Background: Fusion of a joint reportedly increases force in the adjacent joints and leads to progression of arthritis. Whether lumbar spinal fusion increases force in the hip joint and promotes wear of the joint space is unclear. The purpose of this study was to evaluate the rate of joint-space narrowing in the hip following spinal fusion and to examine the effects of the number of levels fused on the joint-narrowing rate.Methods: We retrospectively reviewed data for patients who underwent lumbar spinal fusion from 2011 to 2018 at our institute. Patients with a previous hip surgery, Kellgren-Lawrence grade ≥II hip osteoarthritis, hip dysplasia, and rheumatoid arthritis were excluded. The rate of joint-space narrowing in the hip was measured in 205 eligible patients (410 hips) following spinal fusion, and the effects of sex, age, body mass index, indication for spinal fusion, laterality, sacral fixation, and number of levels fused on the narrowing rate were examined.Results: The rate of joint-space narrowing for all patients was 0.114 ± 0.168 mm/year. The narrowing rate for single-level fusion was 0.062 ± 0.087 mm/year, whereas that for fusion of ≥7 levels was 0.307 ± 0.254 mm/year. In the multivariate regression analysis, only the length of fusion (standardized coefficient [SC] = 0.374, p < 0.0001) was associated with an increased narrowing rate. When the narrowing rate was normalized by height, female sex was another risk factor for increased narrowing (SC = 0.109, p = 0.023). Secondary regression modeling performed with patients who underwent spinal fusion for degenerative disc disease showed that the length of fusion (SC = 0.454, p < 0.0001) and female sex (SC = 0.138, p = 0.033) were associated with increased joint-space narrowing.Conclusions: Longer spinal fusion was associated with the progression of hip joint narrowing following spinal fusion. Surgeons should be aware of the possible increased risk of hip degeneration following spinal fusion and should inform patients of this risk.Level Of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Schizophrenia impairs a patient's self-care abilities, which are crucial after a hip fracture. Studies on the outcomes of patients with schizophrenia after a hip fracture are dated. This study aims to investigate the complication rates, 1-year mortality, and functional outcomes of surgically managed hip fractures in elderly patients with schizophrenia.Methods: This is a retrospective, single-institution cohort study based on a prospectively maintained registry of patients with hip fracture. In this study, 3,056 patients who were ≥60 years of age were treated under a geriatric-orthopaedic hip fracture pathway from January 2014 to December 2018. Baseline demographic characteristics and the Modified Barthel Index (MBI) scores were obtained at admission and at 6 months and 1 year after the fracture. Complications from the fracture and the surgical procedure were recorded during a minimum follow-up period of 2 years. A matching process (based on age, sex, and the MBI at admission) of up to 6 patients without schizophrenia per 1 patient with schizophrenia was utilized to increase power. Differences in perioperative, 6-month, and 1-year outcomes were compared for significance among surgically managed patients with schizophrenia and patients without schizophrenia.Results: Thirty-eight patients with schizophrenia were compared with 170 geriatric patients without schizophrenia who underwent a surgical procedure for a hip fracture. Patients with schizophrenia were more likely to be institutionalized postoperatively (26.3% compared with 4.7%; p < 0.001). Patients with schizophrenia had poorer MBI scores at 12 months (76 compared with 90 points; p = 0.006). The 1-year mortality rate was comparable (p = 0.29) between patients with schizophrenia (5.7%) and those without schizophrenia (2.4%). Similar trends in MBI were observed in the conservatively managed group of patients.Conclusions: There was no increase in postoperative complications after a surgical procedure for a hip fracture in elderly patients with schizophrenia. The 1-year mortality after a surgical procedure for hip fracture is similar in both patients with schizophrenia and those without schizophrenia. Patients with schizophrenia and hip fracture who were surgically managed had poorer 1-year functional outcomes compared with patients without schizophrenia matched for age, sex, and MBI at admission. This information will be useful in shared decision-making discussions with patients and families.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Femoroacetabular impingement (FAI) is a recognized cause of hip pain and decreased quality of life and has been linked to primary idiopathic hip osteoarthritis (OA). Although the operative indications for FAI have expanded to include older patients, we do not know whether there is an increased risk of conversion to THA after femoroacetabular osteoplasty (FAO) via the mini-open approach for FAI in patients older than 40 years compared with younger patients, after controlling for other confounding variables.Questions/purposes: (1) After matching for gender, BMI, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of chondral lesion, are patients older than 40 years who undergo FAO for FAI more likely to be revised to THA at a minimum of 2 years' follow-up than are patients younger than 40? (2) Is there a difference in delta (postoperative minus preoperative) improvement in functional outcome scores in those patients who did not go on to THA between patients older than and younger than 40 years?Methods: Between 2003 and 2017, one surgeon performed 281 FAOs via the mini-open approach in patients older than 40 years and 544 of the same procedure in patients younger than 40 years. During that period, the general indications for FAO were the same in both age groups: (1) history and physical exam consistent with FAI, (2) radiographic evidence of focal impingement (cam, pincer, or both), (3) evidence of labral or chondrolabral tears, and (4) minimal to no arthritic changes (all four criteria required). In general, age was not used as a contraindication for surgery. A total of 86% (241 of 281) of patients older than 40 and 91% (494 of 544) of those younger than 40 were available for minimum of 2 years' follow-up, had complete datasets (radiographs as well as preoperative and most recent patient-reported outcomes scores) at a minimum of 2 years after surgery, and were considered eligible for the match. Propensity score matching was used to match for BMI, gender, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of intraoperative chondral lesion. We matched at a 1:2 ratio 130 patients older than age 40 with 260 patients younger than age 40. The mean ± SD follow-up duration for both groups was 5 ± 2 years. The mean age of the cohort of interest was 47 ± 5 years compared with 28 ± 7 years in the control. Fifty-four percent (70 of 130) of patients older than 40 years were women and 46% (60 of 130) were men; for those younger than 40, 51% (133 of 260) of participants were women and 49% (127 of 260) were men. Tönnis grade distribution for patients older than 40 was as follows: 46% (60 of 130) had Grade 0, 42% (55 of 130) had Grade 1, and 12% (15 of 130) had Grade 2. In comparison, Tönnis grade for patients younger than 40 was as follows: 52% (136 of 260) had Grade 0, 38% (100 of 260) had Grade 1, and 9% (24 of 260) had Grade 2 (p = 0.49). Chondral lesion degree was determined intraoperatively as none, a partial-thickness tear, or a full-thickness tear. Tönnis grade was determined based on preoperative plain AP hip radiographs. We then compared the percentage of patients who converted to THA during the surveillance period (our primary study outcome). We also compared the difference in delta (preoperative minus postoperative) improvement in functional outcome scores using the modified Harris Hip Score (mHHS) between the groups, excluding those who had already been converted to THA.Results: In patients older than 40 years, 16% (21 of 130) converted to THA at a mean time to conversion of 2 ± 1 years compared with 7% (17 of 260) at a mean time of 2 ± 2 years in patients younger than 40 years (p = 0.01). At a mean of 5 ± 2 years after FAO, among those patients who had not undergone conversion to THA, the mean delta mHHS score for patients older than 40 was 11 ± 17, compared with 20 ± 26 for patients younger than 40 (p = 0.04).Conclusion: Since approximately 1 in 6 patients older than 40 years in this series who underwent FAO for FAI opted for early conversion to THA at a mean time of 2 years after the osteoplasty procedure, and the remaining patients who did not undergo THA reported lower improvement in functional outcomes, we recommend surgeons avoid this procedure in patients in this age group until or unless we can better refine our indications. This is especially true because loss to follow-up causes us to believe that, if anything, our estimates of the risk of conversion to THA are conservative.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Several classification systems have been used to describe early lesions of hip cartilage and the acetabular labrum in young adults with hip pain. Some of them were introduced before the concept of femoroacetabular impingement was proposed. Others were developed for other joints (such as the patellofemoral joint). However, these often demonstrate inadequate reliability, and they do not characterize all possible lesions. Therefore, we developed a novel classification system.Question/purpose: We asked: What is the (1) intraobserver reliability, (2) interobserver reproducibility, and (3) percentage of nonclassifiable lesions of the new classification system for damage to the hip cartilage and labrum compared with six established classification systems for chondral lesions (Beck et al. [4], Konan et al. [10], Outerbridge et al. [14]) and labral lesions (Beck et al. [3], Lage et al. [12], Peters and Erickson [15])?Methods: We performed a validation study of a new classification system of early chondrolabral degeneration lesions based on intraoperative video documentation taken during surgical hip dislocations for joint-preserving surgery in 57 hips (56 patients) performed by one surgeon with standard video documentation of intraarticular lesions. The exclusion criteria were low-quality videos, inadequate exposure angles, traumatic lesions, and incomplete radiographic documentation. This left 42 hips (41 patients) for the blinded and randomized analysis of six raters, including those with cam-pincer-type femoroacetabular impingement (FAI) (19 hips in 18 patients), isolated cam-type FAI (10 hips), extraarticular FAI due to femoral anteversion (seven hips), isolated pincer-type FAI (two hips), focal avascular necrosis (two hips), localized pigmented villonodular synovitis (one hip), and acetabular dysplasia as a sequelae of Perthes disease (one hip). The raters had various degrees of experience in hip surgery: Three were board-certified orthopaedic fellows and three were orthopaedic residents, in whom we chose to prove the general usability of the classification systems in less experienced readers. Every rater was given the original publication of all existing classification systems and a visual guide of the new Bern classification system. Every rater classified the lesions according the existing classifications (cartilage: Beck et al. [4], Konan et al. [10], and Outerbridge et al. [14]; labrum: Beck et al. [3], Peters and Erickson [15], and Lage et al. [12]) and our new Bern chondrolabral classification system. The intraclass correlation coefficient with 95% confidence interval was used to assess the intraobserver reliability and interobserver reproducibility. The percentage of nonclassifiable lesions was calculated as an absolute number and percentage.Results: The intraobserver intercorrelation coefficients (ICCs) for cartilage lesions were as follows: the Bern classification system (0.68 [95% CI 0.61 to 0.70]), Beck (0.44 [95% CI 0.34 to 0.54]), Konan (0.39 [95% CI 0.29 to 0.49]), and the Outerbridge classification (0.57 [95% CI 0.48 to 0.65]). For labral lesions, the ICCs were as follows: the Bern classification (0.70 [95% CI 0.63 to 0.76]), Peters (0.42 [95% CI 0.31 to 0.51]), Lage (0.26 [95% CI 0.15 to 0.38]), and Beck (0.59 [95% CI 0.51 to 0.67]). The interobserver ICCs for cartilage were as follows: the Bern classification system (0.63 [95% CI 0.51 to 0.75), the Outerbridge (0.14 [95% CI 0.04 to 0.28]), Konan (0.58 [95% CI 0.40 to 0.76]), and Beck (0.52 [95% CI 0.39 to 0.66]). For labral lesions, the ICCs were as follows: the Bern classification (0.61 [95% CI 0.49 to 0.74]), Beck (0.31 [95% CI 0.19 to 0.46]), Peters (0.28 [95% CI 0.16 to 0.44]), and Lage (0.20 [95% CI 0.09 to 0.35]). The percentage of nonclassifiable cartilage lesions was 0% for the Bern, 0.04% for Beck, 17% for Konan, and 25% for the Outerbridge classification. The percentage of nonclassifiable labral lesions was 0% for Bern and Beck, 4% for Peters, and 25% for Lage.Conclusion: We have observed some shortcomings with currently used classification systems for hip pathology, and the new classification system we developed seems to have improved the intraobserver reliability compared with the Beck and Konan classifications in cartilage lesions and with the Peters and Lage classifications in labral lesions. The interrater reproducibility of the Bern classification seems to have improved in cartilage lesions compared with the Outerbridge classification and in labral lesions compared with the Beck, Peters, and Lage classifications. The Bern classification identified all present cartilage and labral lesions. It provides a solid clinical basis for accurate descriptions of early degenerative hip lesions independent of etiology, and it is reproducible enough to use in the reporting of clinical research. Further studies need to replicate our findings in the hands of nondevelopers and should focus on the prognostic value of this classification and its utility in guiding surgical indications.Level Of Evidence: Level II, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: Periacetabular osteotomy (PAO) increases acetabular coverage of the femoral head and medializes the hip's center, restoring normal joint biomechanics. Past studies have reported data regarding the degree of medialization achieved by PAO, but measurement of medialization has never been validated through a comparison of imaging modalities or measurement techniques. The ilioischial line appears to be altered by PAO and may be better visualized at the level of the inferior one-third of the femoral head, thus, an alternative method of measuring medialization that begins at the inferior one-third of the femoral head may be beneficial.Questions/purposes: (1) What is the true amount and variability of medialization of the hip's center that is achieved with PAO? (2) Which radiographic factors (such as lateral center-edge angle [LCEA] and acetabular inclination [AI]) correlate with the degree of medialization achieved? (3) Does measurement of medialization on plain radiographs at the center of the femoral head (traditional method) or inferior one-third of the femoral head (alternative method) better correlate with true medialization? (4) Are intraoperative fluoroscopy images different than postoperative radiographs for measuring hip medialization?Methods: We performed a retrospective study using a previously established cohort of patients who underwent low-dose CT after PAO. Inclusion criteria for this study included PAO as indicated for symptomatic acetabular dysplasia, preoperative CT scan, and follow-up between 9 months and 5 years. A total of 333 patients who underwent PAO from February 2009 to July 2018 met these criteria. Additionally, only patients who were between 16 and 50 years old at the time of surgery were included. Exclusion criteria included prior ipsilateral surgery, femoroacetabular impingement (FAI), pregnancy, neuromuscular disorder, Perthes-like deformity, inadequate preoperative CT, and inability to participate. Thirty-nine hips in 39 patients were included in the final study group; 87% (34 of 39) were in female patients and 13% (5 of 39 hips) were in male patients. The median (range) age at the time of surgery was 27 years (16 to 49). Low-dose CT images were obtained preoperatively and at the time of enrollment postoperatively; we also obtained preoperative and postoperative radiographs and intraoperative fluoroscopic images. The LCEA and AI were assessed on plain radiographs. Hip medialization was assessed on all imaging modalities by an independent, blinded assessor. On plain radiographs, the traditional and alternative methods of measuring hip medialization were used. Subgroups of good and fair radiographs, which were determined by the amount of pelvic rotation that was visible, were used for subgroup analyses. To answer our first question, medialization of all hips was assessed via measurements made on three-dimensional (3-D) CT hip reconstruction models. For our second question, Pearson correlation coefficients, one-way ANOVA, and the Student t-test were calculated to assess the correlation between radiographic parameters (such as LCEA and AI) and the amount of medialization achieved. For our third question, statistical analyses were performed that included a linear regression analysis to determine the correlation between the two radiographic methods of measuring medialization and the true medialization on CT using Pearson correlation coefficients, as well as 95% confidence intervals and standard error of the estimate. For our fourth question, Pearson correlation coefficients were calculated to determine whether using intraoperative fluoroscopy to make medialization measurements differs from measurements made on radiographs.Results: The true amount of medialization of the hip center achieved by PAO in our study as assessed by reference-standard CT measurements was 4 ± 3 mm; 46% (18 of 39 hips) were medialized 0 to 5 mm, 36% (14 hips) were medialized 5 to 10 mm, and 5% (2 hips) were medialized greater than 10 mm. Thirteen percent (5 hips) were lateralized (medialized < 0 mm). There were small differences in medialization between LCEA subgroups (6 ± 3 mm for an LCEA of ≤ 15°, 4 ± 4 mm for an LCEA between 15° and 20°, and 2 ± 3 mm for an LCEA of 20° to 25° [p = 0.04]). Hips with AI ≥ 15° (6 ± 3 mm) achieved greater amounts of medialization than did hips with AI of < 15° (2 ± 3 mm; p < 0.001). Measurement of medialization on plain radiographs at the center of the femoral head (traditional method) had a weaker correlation than using the inferior one-third of the femoral head (alternative method) when compared with CT scan measurements, which were used as the reference standard. The traditional method was not correlated across all radiographs or only good radiographs (r = 0.16 [95% CI -0.17 to 0.45]; p = 0.34 and r = 0.26 [95% CI -0.06 to 0.53]; p = 0.30), whereas the alternative method had strong and very strong correlations when assessed across all radiographs and only good radiographs, respectively (r = 0.71 [95% CI 0.51 to 0.84]; p < 0.001 and r = 0.80 [95% CI 0.64 to 0.89]; p < 0.001). Measurements of hip medialization made on intraoperative fluoroscopic images were not found to be different than measurements made on postoperative radiographs (r = 0.85; p < 0.001 across all hips and r = 0.90; p < 0.001 across only good radiographs).Conclusion: Using measurements made on preoperative and postoperative CT, the current study demonstrates a mean true medialization achieved by PAO of 4 mm but with substantial variability. The traditional method of measuring medialization at the center of the femoral head may not be accurate; the alternate method of measuring medialization at the lower one-third of the femoral head is a superior way of assessing the hip center's location. We suggest transitioning to using this alternative method to obtain the best clinical and research data, with the realization that both methods using plain radiography appear to underestimate the true amount of medialization achieved with PAO. Lastly, this study provides evidence that the hip center's location and medialization can be accurately assessed intraoperatively using fluoroscopy.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: Acetabular overcoverage is associated with pincer-type femoroacetabular impingement (FAI). A subtype of acetabular overcoverage is caused by a deep acetabulum with a negatively tilted acetabular roof, in which acetabular reorientation may be a preferable alternative to rim trimming to uncover the femoral head. We introduced the true reverse periacetabular osteotomy (PAO) in 2003, which in contrast to an anteverting PAO, also flexes and abducts the acetabulum relative to the intact ilium to decrease anterior and lateral femoral head coverage and correct negative tilt of the acetabular roof. To our knowledge, the clinical results of the true reverse PAO have not been evaluated.Questions/purposes: For a group of patients who underwent reverse PAO, (1) Do patients undergoing reverse PAO demonstrate short-term improvement in pain, function, and hip ROM, and decreased acetabular coverage, as defined by lateral and anterior center-edge angle and Tönnis angle? (2) Are there identifiable factors associated with success or adverse outcomes of reverse PAO as defined by reoperation, conversion to THA, or poor patient-reported outcome scores? (3) Are there identifiable factors associated with early complications?Methods: Between 2003 and 2017, two surgeons carried out 49 reverse PAOs in 37 patients. Twenty-five patients had unilateral reverse PAO and 12 patients had staged, bilateral reverse PAOs. To ensure that each hip was an independent data point for statistical analysis, we chose to include in our series only the first hip in the patients who had bilateral reverse PAOs. During the study period, our general indications for this operation were symptomatic lateral and anterior acetabular overcoverage causing FAI that had failed to respond to previous conservative or surgical treatment. Thirty-seven hips in 37 patients with a median (range) age of 18 years (12 to 41; interquartile range 16 to 21) were included in this retrospective study at a minimum follow-up of 2 years (median 6 years; range 2 to 17). Thirty-four patients completed questionnaires, 24 patients had radiographic evaluation, and 23 patients received hip ROM clinical examination. However, seven patients had not been seen in more than 5 years. The clinical and radiographic parameters of all 37 hips that underwent reverse PAO in 37 patients from a longitudinally maintained institutional database were retrospectively studied preoperatively and postoperatively. Adverse outcomes were considered conversion to THA or a WOMAC pain score greater than 10 at least 2 years postoperatively. Patient-reported outcomes, radiographic measurements, and hip ROM were evaluated preoperatively and at most recent follow-up using a paired t-test or McNemar test, as appropriate. Linear regression analysis was used to assess for identifiable factors associated with clinical outcomes. Logistic regression analysis was used to assess for identifiable factors associated with adverse outcomes and surgical complications. All tests were two-sided, and p values less than 0.05 were considered significant.Results: At a minimum of 2 years after reverse PAO, patients experienced improvement in WOMAC pain (-7 [95% CI -9 to -5]; p < 0.001), stiffness (-2 [95% CI -3 to -1]; p < 0.001), and function scores (-18 [95% CI -24 to -12]; p < 0.001) and modified Harris Hip Score (mHHS) (20 [95% CI 13 to 27]; p < 0.001). The mean postoperative hip ROM improved in internal rotation (8° [95% CI 2° to 14°]; p = 0.007). Acetabular coverage, as defined by lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), and Tönnis angle, improved by -8° (95% CI -12° to -5°; p < 0.001) for LCEA, -12° (95% CI -15° to -9°; p < 0.001) for ACEA, and 9° (95% CI 6° to 13°; p < 0.001) for Tönnis angle. The postoperative severity of radiographic arthritis was associated with worse WOMAC function scores such that for each postoperative Tönnis grade, WOMAC function score increased by 12 points (95% CI 2 to 22; p = 0.03). A greater postoperative Tönnis grade was also correlated with worse mHHS, with an average decrease of 12 points (95% CI -20 to -4; p = 0.008) in mHHS for each additional Tönnis grade. Presence of a positive postoperative anterior impingement test was associated with a decrease in mHHS score at follow-up, with an average 23-point decrease in mHHS (95% CI -34 to -12; p = 0.001). Nineteen percent (7 of 37) of hips had surgery-related complications. Four hips experienced adverse outcomes at final follow-up, with two patients undergoing subsequent THA and two with a WOMAC pain score greater than 10. We found no factors associated with complications or adverse outcomes.Conclusion: The early clinical and radiographic results of true reverse PAO compare favorably to other surgical treatments for pincer FAI, suggesting that reverse PAO is a promising treatment for cases of pincer FAI caused by global acetabular overcoverage. However, it is a technically complex procedure that requires substantial training and preparation by a surgeon who is already familiar with standard PAO, and it must be carefully presented to patients with discussion of the potential risks and benefits. Future studies are needed to further refine the indications and to determine the long-term outcomes of reverse PAO.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: The anterior inferior iliac spine (AIIS) prominence is increasingly recognized in the setting of femoroacetabular impingement (FAI). The AIIS prominence may contribute to decreased hip flexion after acetabular reorientation in patients with acetabular dysplasia. AIIS morphologies have been characterized in numerous populations including asymptomatic, FAI, and athletic populations, but the morphology of the AIIS in patients with symptomatic acetabular dysplasia undergoing periacetabular osteotomy (PAO) has not been studied. In acetabular dysplasia, deficiency of the anterosuperior acetabular rim is commonly present and may result in the AIIS being positioned closer to the acetabular rim. Understanding morphological variation of the AIIS in patients with symptomatic dysplasia, and its relationship to dysplasia subtype and severity may aid preoperative planning, surgical technique, and evaluation of postoperative issues after PAO.Questions/purposes: In this study, we sought to determine: (1) the variability of AIIS morphology types in hips with symptomatic acetabular dysplasia and (2) whether the differences in the proportion of AIIS morphologies are present between dysplasia pattern and severity subtypes.Methods: Using our hip preservation database, we identified 153 hips (148 patients) who underwent PAO from October 2013 to July 2015. Inclusion criteria for the current study were (lateral center-edge angle [LCEA] < 20°), Tönnis Grade of 0 or 1 on plain AP radiographs of the pelvis, preoperative low-dose CT scan, and no prior surgery, trauma, neuromuscular, ischemic necrosis, or Perthes-like deformity. A total of 50 patients (50 hips) with symptomatic acetabular dysplasia undergoing evaluation for surgical planning of PAO remained for retrospective evaluation; we used these patients' low-dose CT scans for analysis. The median (range) age of patients in the study was 24 years (13 to 49). Ninety percent (45 of 50) of the hips were in female patients, whereas 10% (5 of 50) were in male patients. The morphology of the AIIS was classified on three-dimensional CT reconstructions according to a previously published classification to define the relationship between the AIIS and the acetabular rim. The morphology of the AIIS was classified as Type I (AIIS well proximal to acetabular rim), Type II (AIIS extending to level of acetabular rim), or Type III (AIIS extending distal to acetabular rim). Acetabular dysplasia subtype was characterized according to a prior protocol as either predominantly an anterosuperior acetabular deficiency, a posterosuperior acetabular deficiency, or a global acetabular deficiency. Acetabular dysplasia severity was distinguished as mild (LCEA 15° to 20°) or moderate/severe (LCEA < 15°). To answer our first question, regarding the proportions of each AIIS morphology in the dysplasia population, we calculated proportions and 95% CI estimates. To answer our second question, regarding the proposition of AIIS type between subtypes of dysplasia type and severity, we used a chi-square test or Fisher's exact test to compare categorical variables. A p value of < 0.05 was considered significant.Results: Seventy-two percent (36 of 50; 95% CI 58% to 83%) of patients had a Type II or III AIIS morphology. Type I AIIS morphology was found in 28% of patients (14 of 50; 95% CI 18% to 42%), Type II AIIS morphology in 62% (31 of 50; 95% CI 48% to 74%), and Type III AIIS/morphology in 10% (5 of 50; 95% CI 4% to 21%). A Type I AIIS was seen in seven of 15 of patients with anterosuperior acetabular deficiency, three of 18 of patients with global deficiency, and four of 17 patients with posterosuperior deficiency (p = 0.08). There was no difference in the variability of AIIS morphologies between the different subtypes of acetabular dysplasia pattern and no difference in AIIS morphology variability between patients with mild versus moderate/severe dysplasia.Conclusions: The morphology of the AIIS in patients with acetabular dysplasia is commonly prominent, with 72% of hips having Type II or Type III morphologies.Clinical Relevance: The AIIS is often prominent in patients with acetabular dysplasia undergoing PAO, regardless of dysplasia pattern or severity. Prominent AIIS morphologies may affect hip flexion ROM after acetabular reorientation. AIIS morphology is a variable that should be considered during preoperative planning for PAO. Future studies are needed to assess the clinical significance of a prominent AIIS on intraoperative findings and postoperative status after PAO. [ABSTRACT FROM AUTHOR]

Background: Assessment of AP acetabular coverage is crucial for choosing the right surgery indication and for obtaining a good outcome after hip-preserving surgery. The quantification of anterior and posterior coverage is challenging and requires either other conventional projections, CT, MRI, or special measurement software, which is cumbersome, not widely available and implies additional radiation. We introduce the "rule of thirds" as a promising alternative to provide a more applicable and easy method to detect an excessive or deficient AP coverage. This method attributes the intersection point of the anterior (posterior) wall to thirds of the femoral head radius (diameter), the medial third suggesting deficient and the lateral third excessive coverage.Question/purpose: What is the validity (area under the curve [AUC], sensitivity, specificity, positive/negative likelihood ratios [LR(+)/LR(-)], positive/negative predictive values [PPV, NPV]) for the rule of thirds to detect (1) excessive and (2) deficient anterior and posterior coverages compared with previously established radiographic values of under-/overcoverage using Hip2Norm as the gold standard?Methods: We retrospectively evaluated all consecutive patients between 2003 and 2015 from our institutional database who were referred to our hospital for hip pain and were potentially eligible for joint-preserving hip surgery. We divided the study group into six specific subgroups based on the respective acetabular pathomorphology to cover the entire range of anterior and posterior femoral coverage (dysplasia, overcoverage, severe overcoverage, excessive acetabular anteversion, acetabular retroversion, total acetabular retroversion). From this patient cohort, 161 hips were randomly selected for analysis. Anterior and posterior coverage was determined with Hip2Norm, a validated computer software program for evaluating acetabular morphology. The anterior and posterior wall indices were measured on standardized AP pelvis radiographs, and the rule of thirds was applied by one observer.Results: The detection of excessive anterior and posterior acetabular wall using the rule of thirds revealed an AUC of 0.945 and 0.933, respectively. Also the detection of a deficient anterior and posterior acetabular wall by applying the rule of thirds revealed an AUC of 0.962 and 0.876, respectively. For both excessive and deficient anterior and posterior acetabular coverage, we found high specificities and PPVs but low sensitivities and NPVs.Conclusion: We found a high probability for an excessive (deficient) acetabular wall when this intersection point lies in the lateral (medial) third, which would qualify for surgical correction. On the other hand, if this point is not in the lateral (medial) third, an excessive (deficient) acetabular wall cannot be categorically excluded. Thus, the rule of thirds is very specific but not as sensitive as we had expected.Level Of Evidence: Level II, diagnostic study. [ABSTRACT FROM AUTHOR]

Background: The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology.Questions/purposes: (1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls?Methods: After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI.Results: After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side.Conclusion: Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning.Level Of Evidence: Level III, prognostic study. [ABSTRACT FROM AUTHOR]

Background: Short-length stems were developed to reduce bone loss of the proximal femur and potentially decrease the incidence of thigh pain after cementless THA. However, it remains unknown whether short stems indeed reduce bone loss or the frequency of thigh pain.Questions/purposes: Is there a difference between short- and standard-length stems in terms of: (1) the frequency or severity of thigh pain, (2) modified Harris hip scores, (3) implant loosening, or (4) bone mineral density as measured by dual-energy x-ray absorptiometry?Methods: Between March 2013 and January 2014, three surgeons performed 205 primary THAs. To be eligible, patients needed to be at least 20 years of age, have not undergone previous history of hip surgery, and have no metabolic bone disease. A total of 100 patients were randomized to receive THA either with a short stem (n = 56) or with a standard-length stem (n = 44). Both stems were proximally coated, tapered, cementless stems. Compared with standard stems, short stems typically were 30- to 35-mm shorter. A total of 73% (41 of 56) and 77% (34 of 44) of those groups, respectively, were accounted for at a minimum of 5 years and were analyzed. The presence of thigh pain during activity was evaluated using a 10-point VAS, and the modified Harris hip score was calculated by research assistants who were blinded to the treatment groups. Plain radiographs were taken at 6 weeks, 6 months, and 12 months postoperatively, and every 1 year thereafter; loosening was defined as subsidence > 3 mm or a position change > 3° on serial radiographs. Radiological assessment was performed by two researchers who did not participate in the surgery and follow-up evaluations. Bone mineral density of the proximal femur was measured using dual-energy x-ray absorptiometry at 4 days, 1 year, 2 years, and 5 years postoperatively. The primary endpoint of our study was the incidence of thigh pain during 5-year follow-up. Our study was powered at 80% to detect a 10% difference in the proportion of patients reporting thigh pain at the level of 0.05.Results: With the numbers available, we found no difference between the groups in the proportion of patients with thigh pain; 16% (9 of 56) of patients in the short-stem group and 14% (6 of 44) of patients in the standard-stem group experienced thigh pain during the follow-up period (p = 0.79). In all patients, the pain was mild or moderate (VAS score of 4 or 6 points). Among the 15 available patients who reported thigh pain, there was no difference between the implant groups in mean severity of thigh pain (4.3 ± 0.8 versus 4.2 ± 0.7; p = 0.78). There were no between-group differences in the short versus standard-length stem groups in terms of mean modified Harris hip score by 5 years after surgery (89 ± 13 versus 95 ± 7 points; p = 0.06). No implant was loose and no hip underwent revision in either group. Patients in the short-stem group showed a slightly smaller decrease in bone mineral density in Gruen Zones 2, 3, and 5 than those in the standard-stem group did; the magnitude of the difference seems unlikely to be clinically important.Conclusion: We found no clinically important differences (and few differences overall) between short and standard-length THA stems 5 years after surgery in a randomized trial. Consequently, we recommend that clinicians use standard-length stems in general practice because standard-length stems have a much longer published track record in other studies, and short stems can expose patients to the uncertainty associated with novelty, without any apparent offsetting benefit.Level Of Evidence: Level I, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Ceramic-on-ceramic (CoC) is a durable bearing with excellent wear characteristics, but squeaking remains a concern. The proportion of patients who report squeaking varies widely between studies performed at short- and mid-term follow-up.Questions/purposes: (1) What proportion of patients treated with CoC THA bearings report squeaking at a minimum of 10 years of follow-up? (2) Are patient, implant, or radiographic factors associated with squeaking? (3) Are THAs that squeak more likely to be revised than those that do not? (4) Are patient-reported functional outcome scores lower between THAs that squeak and THAs that do not squeak at long-term follow-up?Methods: Between January 1, 2003 and August 31, 2008 a total of 80 patients received THAs with third-generation alumina-on-alumina bearings at one center. Of the original 80 patients, 1% (1 of 80) had died, and 21% (17 of 80) were lost to follow-up before 10 years, leaving 62 patients for analysis at a median (range) of 14 years (11 to 16). Ceramic-on-ceramic THA represented 23% (80 of 343) of all primary THAs performed during the study period. Ceramic-on-ceramic THA was used preferentially in patients younger than 50 years of age. The mean (range) age of patients in the cohort was 44 ± 11 years (18 to 65). Sixty-eight percent (42 of 62) were men. Two separate manufacturers' implants were included. There were uncemented acetabular and femoral components included in this study. All CoC bearings were third-generation alumina-on-alumina. Squeaking was determined through a mailed questionnaire or telephone interview. The 10-question survey developed by the researchers queried patients whether audible "squeaking" could be heard from their hip replacement. Patients were asked to write in their description of the noise to distinguish squeaking from other noises not relevant to the current study. Implant information, component position, and patient demographics were obtained via chart review and postoperative radiographs reviewed by one of the investigators not involved with the index operative procedure. Using revision for any reason as an endpoint, a Kaplan-Meier analysis was performed to compare survivorship between THAs that squeaked versus those that did not. Patient-reported outcomes were surveyed using the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), which comprises six items regarding patient pain and function, raw summed scores range from 0 (perfect hip health) to 24 (total hip disability).Results: Squeaking was self-reported by 53% (33 of 62) of patients in this group. Squeaking was more common in patients who received the titanium-molybdenum-zirconium-iron stem than in patients with the titanium-aluminum-vanadium stem (63% [29 of 46] versus 31% [4 of 13]; odds ratio 3.8 [95% CI 1.02 to 14.4]; p = 0.046). We found no differences in the likelihood a patient would report squeaking based on component position, component size, patient age, sex, or BMI. Ten-year survivorship free from revision was not lower in patients who reported squeaking (91% [95% CI 74 to 97] versus 90% [95% CI 71 to 96]; p = 0.69). Patient-reported outcome scores (HOOS JR) were not lower in those who reported squeaking (3 ± 3 [95% CI 1.5 to 4.0] versus 3 ± 5 [95% CI 1.5 to 5.5]; p = 0.59).Conclusion: At long-term follow-up, we found that CoC bearing squeaking in patients who underwent THA is more common than previously reported. Survivorship was lower than expected in this cohort, and most revisions in this series were for squeaking. Although implant-dependent, surgeons should counsel patients about the potential for squeaking in CoC THA, which may occur years after index procedure.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: The introduction of stem cell transplantation has improved life expectancy and cognitive outcome in patients with mucopolysaccharidosis I, but this condition remains associated with substantial residual disease in several parts of the body. Many patients have hip dysplasia with progressive medial flattening of the femoral head. Quantitative evidence on the effect of surgery on remodeling to sphericity of flattened femoral heads is lacking. In the present study, we used statistical shape modeling to quantify the effect of hip surgery on the sphericity of the femoral head in patients with mucopolysaccharidosis I.Methods: We performed a retrospective case control study involving a series of 23 patients with hip dysplasia due to mucopolysaccharidosis I. Surgery was not offered to the first 11 children (control group). Following a change in treatment protocol, the next 12 children underwent bilateral proximal femoral varus derotation osteotomy and Pemberton osteotomy for the treatment of acetabular dysplasia with progressive femoral head flattening (surgery group). The surgery and control groups were compared with a reference group of patients with normal hips. Statistical shape modeling was used to quantify the shape of the femoral head (i.e., flattening and/or roundness of the epiphysis).Results: The mean age at the time of stem cell transplantation in the surgery and control groups was comparable (1.2 years). The mean age at the time of surgical intervention was 5.5 years, and mean duration of postoperative follow-up was 3.3 years. Statistical shape modeling showed variations within the total group in terms of medial indentation, width, height, and sphericity of the femoral heads. In contrast to the progressive femoral head flattening in the control group, the surgery group showed improvement of the sphericity of the femoral head after surgery. The overall shape characteristics of the femoral head in the surgery group were similar to those of the reference group of patients with normal hips.Conclusions: To our knowledge, this is the first study in patients with mucopolysaccharidosis I that has shown quantitative remodeling of the dysplastic, flattened femoral head to normal sphericity after increasing containment of the femoral head.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Studiesthathavebeenpublishedin The Lancethavereporteda survivorship of 82% for total knee arthroplasty and 77% for total hip arthroplasty (with older bearing surfaces) at 25 years 4-6. Fixation methods and tribology 12, including improved cementing techniques 13, biological fixation 14, or just an awareness of implantation technique and choice of implants, have greatly advanced for both hip and knee arthroplasty, resulting in better survivorship 15. Current Situation Hip and knee arthroplasty remain the fastest growing 1 and most successful 2 surgical procedures. Total hip arthroplasty has historically been named the "operation of the century", 3 with outcome scores that suggest that not only is function rapidlyrestored,butlongevityoftheprocedureischaracterized by a high percentage that continues into the third decade 4-6. [Extracted from the article]

Background: Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates.Methods: Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively.Results: Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes.Conclusions: Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation.Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Well-validated data from arthroplasty registries provide an opportunity to understand contemporary use of revision hip replacement at a national level. Such information can underpin health-care resource allocation and surgical workforce planning. The purposes of the present study were to describe the demographic characteristics of patients managed with revision hip replacement surgery in Australia and to examine changes in the lifetime risk of revision hip replacement over a decade.Methods: Deidentified individual-level data on all revision hip replacement procedures performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Life tables and population data were sourced from the Australian Bureau of Statistics. The lifetime risk of revision surgery each year was estimated with use of a standardized approach, with separate calculations for males and females.Results: A total of 46,086 revision hip replacement procedures were performed from 2007 to 2017. The median age at the time of surgery was 72 years (interquartile range, 63 to 80 years). While loosening or lysis became less frequent reasons for revision over time (from 51% in 2007 to 28% in 2017), revision hip replacement for infection became increasingly common (from 14% in 2007 to 25% in 2017). Revisions for metal-related pathology peaked in 2011. Utilization rates were highest for males ≥80 years of age (127.9 procedures per 100,000 population in 2017). Although a small rise was evident in 2011 and 2012 (to 2.39% and 2.22%, respectively), the lifetime risk of revision hip replacement in females decreased from 1.90% (95% confidence interval [CI], 1.82% to 1.99%) in 2007 to 1.74% (95% CI, 1.66% to 1.82%) in 2017. A similar pattern was evident for males; the lifetime risk was 1.78% (95% CI, 1.69% to 1.86%) in 2007 and 1.57% (95% CI, 1.49% to 1.65%) in 2017.Conclusions: These data enable us to understand the epidemiology of revision hip replacement in Australia, including the shifting clinical indications for this procedure. At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. These methods can be utilized for population-level surveillance of revision burden and to enable between-country benchmarking.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip. [ABSTRACT FROM AUTHOR]

Femoral version is extremely variable between patients presenting with femoroacetabular impingement (FAI). Careful and routine measurement of femoral anteversion is essential in comprehensive preoperative planning. In general, low degrees of femoral version can lead to anterior impingement (especially on the subspine and distal medial femoral neck). High degrees of anteversion can be seen in the setting of acetabular dysplasia and can lead to anterior hip instability and or posterior impingement. In this article, the authors will discuss the role of routine femoral version management for optimal outcomes after hip arthroscopy for FAI. [ABSTRACT FROM AUTHOR]

There has been an increased emphasis on capsular management during hip arthroscopy in the literature in recent years. The capsule plays a significant role in the hip joint stability and studies have demonstrated that capsular closure can restore the biomechanics of the hip back to the native state. Capsular management also affects functional outcomes with capsular repair resulting in better clinical outcomes in some studies. Management of the capsule has evolved in recent years with more surgeons performing routine capsular closure. Management techniques and degree of capsular closure, however, can be quite variable between surgeons. This review will discuss hip capsular anatomy, the importance of the capsule in hip biomechanics, management of the capsule during arthroscopy, and functional outcomes as it relates to the various capsular closure techniques versus leaving the capsulotomy unrepaired. [ABSTRACT FROM AUTHOR]