Trousdale, Robert T.

Background: The natural history of femoroacetabular impingement (FAI) remains incompletely understood. In particular, there is limited documentation of joint damage in adolescent patients with limited range of motion (LROM) of the hip, which is commonly associated with FAI. Purpose: To evaluate changes in magnetic resonance imaging (MRI), radiographs, and clinical examinations over 5 years in a group of athletes from a wide variety of sports with asymptomatic LROM of the hip compared with matched controls. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: The authors screened 226 male and female athletes aged 12 to 18 years presenting for preparticipation sports physical examinations. Using a goniometer, we identified 13 participants with at least one hip having internal rotation <10° with the hip flexed to 90°. Overall, 21 of 26 hips (81%) had internal rotation <10°. These participants were age- and sex-matched to 13 controls with internal rotation >10°. At the time of enrollment, all participants were asymptomatic and underwent a complete hip examination and radiographic imaging with radiographs (anteroposterior [AP] and von Rosen views) and non-arthrogram MRI. Participants returned at 5-year follow-up and underwent repeat hip examinations, imaging (AP and lateral radiographs and non-arthrogram MRI), and hip function questionnaires. MRI scans were classified as “normal” versus “abnormal” based on the presence of any of 13 scored chondral, labral, or osseous abnormalities. Comparisons between the LROM group and control group were performed using generalized linear models (either linear, logistic, or log-binomial regression as appropriate for the outcome) with generalized estimating equations to account for the within-participant correlation due to patients having both hips included. Relative risk (RR) estimates are reported with 95% CIs. Results: At the time of study enrollment, 16 of 26 hips (62%) in the LROM group had abnormal MRI findings within the acetabular labrum or cartilage compared with 8 of 26 hips (31%) in the control group (RR, 2.0; 95% CI, 0.95-4.2; P = .067). The mean alpha angle measured from radial MRI sequences was 58° in the LROM group versus 44° in the control group ( P < .0001). In the LROM group, 13 of 26 hips (50%) had a positive anterior impingement sign, whereas 0 of 26 hips (0%) had a positive anterior impingement sign in the control group. At 5-year follow-up, 18 of 19 hips (95%) in the LROM group had abnormal MRI findings compared with 14 of 26 hips (54%) in the control group (RR, 1.7; 95% CI, 1.1-2.7; P = .014). New or progressive findings were documented on MRI in 15 of 20 hips in the LROM group compared with 8 of 26 hips in the control group (RR, 2.4; 95% CI, 1.2-4.8; P = .011). Six of 22 hips (27%) in the LROM group progressed from Tönnis grade 0 to Tönnis grade 1 in degenerative changes, whereas all 26 hips in the control group remained at Tönnis grade 0 on hip radiographs. In the LROM group, 11 of 22 hips (50%) had a positive anterior impingement sign, whereas 1 of 26 hips (4%) had a positive anterior impingement sign in the control group. A cam deformity (alpha angle >55° on lateral radiographs) was present in 20 of 22 hips (91%) in the LROM group and 12 of 26 hips (46%) in the control group ( P = .0165). The following variables at baseline were associated with an increased risk of degenerative changes at 5-year follow-up for the entire cohort: decreased hip internal rotation, positive anterior impingement sign, decreased hip flexion, increased alpha angle, and presence of a cam lesion. Conclusion: At 5 years, young athletes with LROM of the hip showed increased progressive degenerative changes on MRI and radiographs compared with matched controls. Although the majority of these participants remained asymptomatic, those with features of FAI had radiographic findings consistent with early osteoarthritis. These outcomes suggest that more aggressive screening and counseling of young active patients may be helpful to prevent hip osteoarthritis in those with FAI.

Background: A potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoas tendon. Treatment options include conservative management, tenotomy, and acetabular revision, but the literature, to our knowledge, has been limited to small case series on each technique. We present a series of patients with iliopsoas impingement after total hip arthroplasty and evaluate efficacy and risk factors for success or failure of each treatment strategy. Methods: Forty-nine patients treated at one institution for a diagnosis of iliopsoas impingement after primary total hip arthroplasty with hemispherical acetabular component and polyethylene bearing were retrospectively reviewed. Twenty-one patients underwent acetabular revision, 8 patients underwent tenotomy, and 20 patients had nonoperative management. The mean follow-up was 4 years. Anterior acetabular component prominence was measured on true lateral hip radiographs. Results: At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution compared with 22 patients (76%) in the operative group (p = 0.06). In patients with <8 mm of component prominence, tenotomy provided resolution of groin pain in 5 (100%) of 5 patients and a mean Harris hip score of 89 points. In patients with ≥8 mm of prominence, acetabular revision led to groin pain resolution in 12 (92%) of 13 patients compared with 1 (33%) of 3 patients treated with tenotomy (p = 0.07). Conclusions: Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. In patients with minimal acetabular component prominence, iliopsoas release provided a high rate of success. Acetabular revision was more predictable for groin pain resolution in patients with ≥8 mm of anterior component prominence. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: The spasticity and increased muscle tone observed in patients with cerebral palsy can lead to hip degeneration, subluxation, and pain. Currently, there is hesitation to perform total hip arthroplasty in patients with cerebral palsy because of fears of early wear and dislocation. The purpose of this study was to review the outcomes of total hip arthroplasty in patients with cerebral palsy and to compare outcomes with those of matched patients with a diagnosis of osteoarthritis. Methods: Over a 24-year period, 39 patients undergoing a total hip arthroplasty with a diagnosis of cerebral palsy were identified. The cohort included 26 male patients (67%), and the mean patient age was 49 years. The mean follow-up was 7 years. Patients with cerebral palsy were matched 1:2 with a group of patients undergoing total hip arthroplasty for osteoarthritis. Results: There was no difference in the rate of reoperation, implant survival, or complications, specifically dislocation. Prior to the surgical procedure, all patients had severe or moderate pain, and postoperatively no patient had moderate or severe pain. Twenty-three patients had an improvement in their ability to independently walk, and all preoperative hip flexion contractures were corrected (n = 9). There was also a significant improvement (p < 0.0001) in functional Harris hip scores. Conclusions: This study refutes previous evidence showing increased risk of complications following total hip arthroplasty in patients with cerebral palsy. Total hip arthroplasty is a durable treatment option and provides clinically important pain relief and functional improvement in patients with cerebral palsy. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: There is debate regarding the role of single-anesthetic versus staged bilateral total hip arthroplasty (THA) for patients with end-stage bilateral osteoarthritis. Studies have shown that single-anesthetic bilateral THA is associated with systemic complications, but there are limited data comparing patient outcomes in a matched setting of bilateral THA. Methods: We identified 94 patients (188 hips) who underwent single-anesthetic bilateral THA. Fifty-seven percent of the patients were male. Patients had a mean age of 52.2 years and body mass index of 27.1 kg/m 2 . They were matched 1:1 on the basis of sex, age (±1 year), and year of surgery (±3 years) to a cohort of patients undergoing staged bilateral THA. In the staged group, there was <1 year between procedures (range, 5 days to 10 months). Mean follow-up was 4 years for each group. Results: Patients in the single-anesthetic group experienced shorter total operating room time and length of stay. There was no difference (hazard ratio [HR] = 0.73, p = 0.50) in the overall revision-free survival in patients undergoing single-anesthetic or staged bilateral THA. The risks of reoperation (HR = 0.69, p = 0.40), complications (HR = 0.83, p = 0.48), and mortality (HR = 0.47, p = 0.10) were similar. Single-anesthetic bilateral THA reduced the total cost of care (by 27%, p = 0.0001). Conclusions: In this matched cohort analysis, single-anesthetic bilateral THA was not associated with an increased risk of revision, reoperation, or postoperative complications, while decreasing cost. In our experience, single-anesthetic bilateral THA is a safe procedure that, for certain patients, offers an excellent means to deal with bilateral hip osteoarthritis. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Current literature describing the periacetabular osteotomy (PAO) is mostly limited to retrospective case series. Larger, prospective cohort studies are needed to provide better clinical evidence regarding this procedure. The goals of the current study were to (1) report minimum 2-year patient-reported outcomes (pain, hip function, activity, overall health, and quality of life), (2) investigate preoperative clinical and disease characteristics as predictors of clinical outcomes, and (3) report the rate of early failures and reoperations in patients undergoing contemporary PAO surgery. Methods: A large, prospective, multicenter cohort of PAO procedures was established, and outcomes at a minimum of 2 years were analyzed. A total of 391 hips were included for analysis (79% of the patients were female, and the average patient age was 25.4 years). Patient-reported outcomes, conversion to total hip replacement, reoperations, and major complications were documented. Variables with a p value of ≤0.10 in the univariate linear regressions were included in the multivariate linear regression. The backward stepwise selection method was used to determine the final risk factors of clinical outcomes. Results: Clinical outcome analysis demonstrated major clinically important improvements in pain, function, quality of life, overall health, and activity level. Increasing age and a body mass index status of overweight or obese were predictive of improved results for certain outcome metrics. Male sex and mild acetabular dysplasia were predictive of lesser improvements in certain outcome measures. Three (0.8%) of the hips underwent early conversion to total hip arthroplasty, 12 (3%) required reoperation, and 26 (7%) experienced a major complication. Conclusions: This large, prospective cohort study demonstrated the clinical success of contemporary PAO surgery for the treatment of symptomatic acetabular dysplasia. Patient and disease characteristics demonstrated predictive value that should be considered in surgical decision-making. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

IntroductionHaemostatic assessments of patients with von Willebrand disease (VWD) who undergo total knee arthroplasty (TKA) and total hip arthroplasty (THA) have mainly relied on subjective parameters.AimsTo compare objective haemostatic outcomes of TKA/THA in VWD patients and controls without bleeding disorders.MethodsWe retrospectively analysed haemostatic outcomes in VWD patients undergoing TKA/THA from 1993 to 2011 and compared them with two matched controls per operation. Using one‐way analysis of variance, we tested the effect of VWD on bleeding risk after TKA and THA.ResultsTwelve VWD patients (6 type 1, 3 type 2M, 1 each of types 2A/2B/3) undergoing 19 operations (12 TKA, 7 THA) were matched to 38 controls. One (5%) of 19 operations in VWD patients and none of the control operations met clinical criteria for major bleeding. Baseline and postoperative day 1 haemoglobin levels, postoperative blood loss, transfused red blood cells (RBCs) and mean hospitalization days were not significantly different. More VWD patients than controls received RBC transfusions [12 (63%) vs. 12 (32%)]. Only 9 (47%) VWD patients vs. 38 (100%) controls received pharmacologic VTE prophylaxis. No postoperative symptomatic VTE occurred in either group.ConclusionIn this largest, single‐institutional study, von Willebrand factor replacement based on daily levels resulted in low frequency of major bleeding in VWD patients after TKA/THA. RBC transfusion was more frequent compared with matched controls, but other objective measures of haemostasis were similar. Lack of sufficient details in published reports precluded comparison of haemostatic outcomes.

Background: There is a paucity of data on the results of reverse (anteverting) periacetabular osteotomy (RPAO) for treatment of femoroacetabular impingement (FAI) secondary to acetabular retroversion. Purpose: To evaluate the midterm outcomes of RPAO for FAI secondary to acetabular retroversion in those with and without hip dysplasia. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review identified RPAOs performed on patients with acetabular retroversion in isolation or in the setting of dysplasia (lateral center-edge angle [LCEA] ≤19°). Acetabular retroversion with FAI was diagnosed clinically and radiographically, with a positive crossover and posterior wall signs on pelvic radiographs. Twenty-three patients (30 hips) met the inclusion criteria; 20 hips with isolated retroversion and 10 hips with retroversion and hip dysplasia. The average age at the time of the procedure was 26 years (range, 13-45 years). The average length of follow-up was 5 years (range, 2-19 years). Harris Hip Score (HHS) and radiographs were evaluated preoperatively and at last follow-up. Results: The mean preoperative LCEA was 31° (range, 22°-49°) in the isolated retroversion group and 9° (range, –4° to 17°) in the dysplastic group. Postoperatively, the LCEA in the dysplastic group increased to 35° (range, 15°-46°) ( P = .0001). The crossover sign corrected in 55% (11/20) of the isolated retroversion group and 80% (8/10) of the dysplastic group. The acetabular index (mean ± SD) improved from 1.3 ± 0.3 to 1.7 ± 0.6 ( P = .0001), indicating improved anteversion. At the latest follow-up, the average HHS in the isolated retroversion group increased from 58 preoperatively (range, 23-77) to 93 (range, 68-100) ( P = .0001); the HHS in the dysplastic group improved from 49 (range, 20-74) to 92 (range, 77-100) ( P < .0001). Complication rates were similar in both groups. Excluding hardware removal, additional surgeries were performed in 13% (4/30). Conclusion: RPAO performed for FAI in the young patient with isolated acetabular retroversion or retroversion in the setting of dysplasia successfully improved clinical and radiographic results at mid- to long-term follow-up.

When fracture of an extensively porous-coated femoral component occurs, its removal at revision total hip arthroplasty (THA) may require a femoral osteotomy and the use of a trephine. The remaining cortical bone after using the trephine may develop thermally induced necrosis. A retrospective review identified 11 fractured, well-fixed, uncemented, extensively porous-coated femoral components requiring removal using a trephine with a minimum of two years of follow-up.The mean time to failure was 4.6 years (1.7 to 9.1, standard deviation (sd) 2.3). These were revised using a larger extensively porous coated component, fluted tapered modular component, a proximally coated modular component, or a proximal femoral replacement. The mean clinical follow-up after revision THA was 4.9 years (2 to 22, sd 3.1). The mean diameter of the femoral component increased from 12.7 mm (sd 1.9) to 16.2 mm (sd 3.4; p > 0.001). Two revision components had radiographic evidence of subsidence that remained radiographically stable at final follow-up. The most common post-operative complication was instability affecting six patients (54.5%) on at least one occasion.A total of four patients (36.4%) required further revision: three for instability and one for fracture of the revision component. There was no statistically significant difference in the mean Harris hip score before implant fracture (82.4; sd 18.3) and after trephine removal and revision THA (81.2; sd 14.8, p = 0.918).These findings suggest that removal of a fractured, well-fixed, uncemented, extensively porous-coated femoral component using a trephine does not compromise subsequent fixation at revision THA and the patient’s pre-operative level of function can be restored. However, the loss of proximal bone stock before revision may be associated with a high rate of dislocation post-operatively.Cite this article: Bone Joint J 2015;97-B:1192–6.

Revision total hip arthroplasty (THA) is challenging when there is severe loss of bone in the proximal femur. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with severe proximal femoral bone loss treated with a fluted, tapered, modular femoral component. Between January 1998 and December 2004, 92 revision THAs were performed in 92 patients using a single fluted, tapered, modular femoral stem design. Pre-operative diagnoses included aseptic loosening, infection and peri-prosthetic fracture. Bone loss was categorised pre-operatively as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic fracture. The mean clinical follow-up was 6.4 years (2 to 12). A total of 47 patients had peri-operative complications, 27 of whom required further surgery. However, most of these further operations involved retention of a well-fixed femoral stem, and 88/92 femoral components (97%) remained in situ. Of the four components requiring revision, three were revised for infection and were well fixed at the time of revision; only one (1%) was revised for aseptic loosening. The most common complications were post-operative instability (17 hips, 19%) and intra-operative femoral fracture during insertion of the stem (11 hips, 12%). Diaphyseal stress shielding was noted in 20 hips (22%). There were no fractures of the femoral component. At the final follow-up 78% of patients had minimal or no pain.Revision THA in patients with extensive proximal femoral bone loss using the Link MP fluted, tapered, modular stem led to a high rate of osseointegration of the stem at mid-term follow-up.Cite this article: Bone Joint J 2015; 97-B:312–17.

The treatment of hip dysplasia should be customised for patients individually based on radiographic findings, patient age, and the patient’s overall articular cartilage status. In many patients, restoration of hip anatomy as close to normal as possible with a PAO is the treatment of choice. Cite this article: Bone Joint J 2013;95-B, Supple A:21–5.