Low Rate of AVN and Complications in Unstable SCFE With Epiphyseal-metaphyseal Discontinuity After Treatment With a Modified Dunn Procedure.

BACKGROUND: The risk of developing avascular necrosis (AVN) in the setting of an unstable slipped capital femoral epiphysis (SCFE) that is undergoing treatment with the modified Dunn procedure is not well understood. In addition, since the Loder classification of unstable is reportedly different than actual intraoperatively observed instability (that is, discontinuity between the femoral head epiphysis and proximal femoral metaphysis), the overall risk of developing AVN, as well as the potential complications of treatment of these patients with the modified Dunn procedure, are unknown. QUESTIONS/PURPOSES: To evaluate the modified Dunn procedure for the treatment of patients with epiphyseal-metaphyseal discontinuity, we asked: (1) What was the survivorship free from AVN at 10 years? (2) What was the survivorship free from subsequent surgery and/or complications at 10 years? (3) What were the clinical and patient-reported outcome scores? METHODS: In a retrospective analysis, we identified 159 patients (159 hips) treated with a modified Dunn procedure for SCFE between 1998 and 2020, of whom 97% (155 of 159) had documentation about intraoperatively observed epiphyseal-metaphyseal stability. Of those, 37% (58 of 155) of patients were documented to have intraoperatively observed epiphyseal-metaphyseal discontinuity and were considered eligible for inclusion, whereas 63% (97 of 155) had documented epiphyseal-metaphyseal stability and were excluded. No patients were lost to follow-up before the 2-year minimum. All patients were assessed for survival, but 7% (4 of 58) did not fill out our outcomes score questionnaire. This resulted in 93% (54 of 58) of patients who were available for outcome score assessment. Additionally, 50% (29 of 58) of patients had not been seen within the last 5 years; they are included, but we note that there is uncertainty about their status. The median (range) age at surgery was 13 years (10 to 16), and the sex ratio was 60% (35 of 58) male and 40% (23 of 58) female patients. Sixty-four percent (37 of 58) of patients were classified as acute-on-chronic, and 17% (10 of 58) of patients were classified as acute. Forty-seven percent (27 of 58) of patients presented with severe slips and 43% (25 of 58) of patients with moderate slips based on radiographic classification. All patients underwent surgical hip dislocation with the modified Dunn procedure to correct the slip deformity and provide stabilization. Complications and reoperations were assessed from a review of electronic medical records, and a Kaplan-Meier estimator was used to estimate survivorship free from complications and reoperations at 10 years. Clinical examination results and questionnaire responses were evaluated at minimum 2-year follow-up. RESULTS: Kaplan-Meier survivorship free from AVN was 93% (95% CI 87% to 100%) at 10 years. Survivorship free from any reoperation was 75% (95% CI 64% to 88%) at 10 years. In addition, survivorship free from complications, defined as development of AVN, reoperation, or a Sink Grade II complication or higher, was 57% (95% CI 45% to 73%) at 10 years. The median (range) Merle D'Aubigne Postel score was 18 (14 to 18) for the patients who did not develop AVN, and 12 (6 to 16) for the four patients who developed AVN (p < 0.001). The median modified Harris hip score was 100 (74 to 100) in the non-AVN cohort and 65 (37 to 82) in the AVN cohort (p = 0.001). Median HOOS total score was 95 (50 to 100) in the non-AVN cohort and 53 (40 to 82) in the AVN cohort (p = 0.002). CONCLUSION: Although the modified Dunn procedure is technically challenging, this study shows that in experienced hands, patients with who have demonstrated epiphyseal-metaphyseal discontinuity can be treated with a low risk of AVN and subsequent surgery. Referral of these patients to specialists who have substantial expertise in this procedure is recommended to improve patient outcomes. Prospective, long-term observational studies will help us identify these high-risk patients preoperatively and determine the long-term success of this procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Do Osteochondroplasty Alone, Intertrochanteric Derotation Osteotomy, and Flexion-Derotation Osteotomy Improve Hip Flexion and Internal Rotation to Normal Range in Hips With Severe SCFE? - A 3D-CT Simulation Study.

BACKGROUND: Severe slipped capital femoral epiphysis (SCFE) leads to femoroacetabular impingement and restricted hip motion. We investigated the improvement of impingement-free flexion and internal rotation (IR) in 90 degrees of flexion following a simulated osteochondroplasty, a derotation osteotomy, and a combined flexion-derotation osteotomy in severe SCFE patients using 3D-CT-based collision detection software. METHODS: Preoperative pelvic CT of 18 untreated patients (21 hips) with severe SCFE (slip-angle>60 degrees) was used to generate patient-specific 3D models. The contralateral hips of the 15 patients with unilateral SCFE served as the control group. There were 14 male hips (mean age 13±2 y). No treatment was performed before CT. Specific collision detection software was used for the calculation of impingement-free flexion and IR in 90 degrees of flexion and simulation of osteochondroplasty, derotation osteotomy, and combined flexion-derotation osteotomy. RESULTS: Osteochondroplasty alone improved impingement-free motion but compared with the uninvolved contralateral control group, severe SCFE hips had persistently significantly decreased motion (mean flexion 59±32 degrees vs. 122±9 degrees, P <0.001; mean IR in 90 degrees of flexion -5±14 degrees vs. 36±11 degrees, P <0.001). Similarly, the impingement-free motion was improved after derotation osteotomy, and impingement-free flexion after a 30 degrees derotation was equivalent to the control group (113± 42 degrees vs. 122±9 degrees, P =0.052). However, even after the 30 degrees derotation, the impingement-free IR in 90 degrees of flexion persisted lower (13±15 degrees vs. 36±11 degrees, P <0.001). Following the simulation of flexion-derotation osteotomy, mean impingement-free flexion and IR in 90 degrees of flexion increased for combined correction of 20 degrees (20 degrees flexion and 20 degrees derotation) and 30 degrees (30 degrees flexion and 30 degrees derotation). Although mean flexion was equivalent to the control group for both (20 degrees and 30 degrees) combined correction, the mean IR in 90 degrees of flexion persisted decreased, even after the 30 degrees combined flexion-derotation (22±22 degrees vs. 36 degrees±11, P =0.009). CONCLUSIONS: Simulation of derotation-osteotomy (30 degrees correction) and flexion-derotation-osteotomy (20 degrees correction) normalized hip flexion for severe SCFE patients, but IR in 90 degrees of flexion persisted slightly lower despite significant improvement. Not all SCFE patients had improved hip motion with the performed simulations; therefore, some patients may need a higher degree of correction or combined treatment with osteotomy and cam-resection, although not directly investigated in this study. Patient-specific 3D-models could help individual preoperative planning for severe SCFE patients to normalize the hip motion. LEVEL OF EVIDENCE: III, case-control study.

High prevalence of hip lesions secondary to arthroscopic over- or undercorrection of femoroacetabular impingement in patients with postoperative pain.

OBJECTIVES: To compare the prevalence of pre- and postoperative osseous deformities and intra-articular lesions in patients with persistent pain following arthroscopic femoroacetabular impingement (FAI) correction and to identify imaging findings associated with progressive cartilage damage. METHODS: Retrospective study evaluating patients with hip pain following arthroscopic FAI correction between 2010 and 2018. Pre- and postoperative imaging studies were analyzed independently by two blinded readers for osseous deformities (cam-deformity, hip dysplasia, acetabular overcoverage, femoral torsion) and intra-articular lesions (chondro-labral damage, capsular lesions). Prevalence of osseous deformities and intra-articular lesions was compared with paired t-tests/McNemar tests for continuous/dichotomous data. Association between imaging findings and progressive cartilage damage was assessed with logistic regression. RESULTS: Forty-six patients (mean age 29 ± 10 years; 30 female) were included. Postoperatively, 74% (34/46) of patients had any osseous deformity including 48% (22/46) acetabular and femoral deformities. Ninety-six percent (44/46) had an intra-articular lesion ranging from 20% (9/46) for femoral to 65% (30/46) for acetabular cartilage lesions. Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of cam-deformity decreased (83 to 28%, p < 0.001). Progressive cartilage damage was detected in 37% (17/46) of patients and was associated with extensive preoperative cartilage damage > 2 h, i.e., > 60° (OR 7.72; p = 0.02) and an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04). CONCLUSION: Prevalence of osseous deformities secondary to over- or undercorrrection was high. Extensive preoperative cartilage damage and higher postoperative alpha angles increase the risk for progressive degeneration. KEY POINTS: • The majority of patients presented with osseous deformities of the acetabulum or femur (74%) and with intra-articular lesions (96%) on postoperative imaging. • Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of a cam deformity decreased (83 to 28%, p < 0.001). • Progressive cartilage damage was present in 37% of patients and was associated with extensive preoperative cartilage damage > 2 h (OR 7.72; p = 0.02) and with an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04).

Limited Hip Flexion and Internal Rotation Resulting From Early Hip Impingement Conflict on Anterior Metaphysis of Patients With Untreated Severe SCFE Using 3D Modelling.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescent patients that can result in complex 3 dimensional (3D)-deformity and hip preservation surgery (eg, in situ pinning or proximal femoral osteotomy) is often performed. But there is little information about location of impingement.Purpose/Questions: The purpose of this study was to evaluate (1) impingement-free hip flexion and internal rotation (IR), (2) frequency of impingement in early flexion (30 to 60 degrees), and (3) location of acetabular and femoral impingement in IR in 90 degrees of flexion (IRF-90 degrees) and in maximal flexion for patients with untreated severe SCFE using preoperative 3D-computed tomography (CT) for impingement simulation. METHODS: A retrospective study involving 3D-CT scans of 18 patients (21 hips) with untreated severe SCFE (slip angle>60 degrees) was performed. Preoperative CT scans were used for bone segmentation of preoperative patient-specific 3D models. Three patients (15%) had bilateral SCFE. Mean age was 13±2 (10 to 16) years and 67% were male patients (86% unstable slip, 81% chronic slip). The contralateral hips of 15 patients with unilateral SCFE were evaluated (control group). Validated software was used for 3D impingement simulation (equidistant method). RESULTS: (1) Impingement-free flexion (46±32 degrees) and IRF-90 degrees (-17±18 degrees) were significantly ( P <0.001) decreased in untreated severe SCFE patients compared with contralateral side (122±9 and 36±11 degrees).(2) Frequency of impingement was significantly ( P <0.001) higher in 30 and 60 degrees flexion (48% and 71%) of patients with severe SCFE compared with control group (0%).(3) Acetabular impingement conflict was located anterior-superior (SCFE patients), mostly 12 o'clock (50%) in IRF-90 degrees (70% on 2 o'clock for maximal flexion). Femoral impingement was located on anterior-superior to anterior-inferior femoral metaphysis (between 2 and 6 o'clock, 40% on 3 o'clock and 40% on 5 o'clock) in IRF-90 degrees and on anterior metaphysis (40% on 3 o'clock) in maximal flexion and frequency was significantly ( P <0.001) different compared with control group. CONCLUSION: Severe SCFE patients have limited hip flexion and IR due to early hip impingement using patient-specific preoperative 3D models. Because of the large variety of hip motion, individual evaluation is recommended to plan the osseous correction for severe SCFE patients. LEVEL OF EVIDENCE: Level III.

Minimal Out-Toeing and Good Hip Scores of Severe SCFE Patients Treated With Modified Dunn Procedure and Contralateral Prophylactic Pinning at Minimal 5-year Follow up.

BACKGROUND: Slipped capital femoral epiphyses (SCFE) is associated with out-toeing of the foot and external rotation gait. But it is unknown if SCFE patients treated with the modified Dunn procedure have out-toeing at follow up.Therefore, we used instrumented gait analysis and questioned (1) do severe SCFE patients treated with a modified Dunn procedure have symmetrical foot progression angle (FPA) compared with contralateral side and compared with asymptomatic volunteers (2) what is the prevalence of out-toeing gait and what are the outcome socres at follow up. METHODS: Gait analysis of 22 patients (22 hips) treated with an unilateral modified Dunn procedure for severe SCFE (slip angle >60 degrees, 2002 to 2011) was retrospectively evaluated. Of 38 patients with minimal 5-year follow up, 2 hips (4%) had avascular necrosis of the femoral head and were excluded for gait analysis. Twenty-two patients were available for gait analysis at follow up (mean follow up of 9±2 y). Mean age at follow up was 22±3 years. Mean preoperative slip angle was 64±8 degrees (33% unstable slips) and decreased postoperatively (slip angle of 8±4 degrees). Gait analysis was performed with computer-based instrumented walkway system (GAITRite) to measure FPA with embedded pressure sensors. Patients were compared with control group of 18 healthy asymptomatic volunteers (36 feet, mean age 29±6 y). RESULTS: (1) Mean FPA of SCFE patients (3.6±6.4 degrees) at follow up was not significantly different compared with their contralateral side (5.6±5.5 degrees) and compared with FPA of controls (4.0±4.5 degrees). (2) Of the 22 SCFE patients, most of them (19 hips, 86%) had normal FPA (-5 to 15 degrees), 2 patients had in-toeing (FPA<-5 degrees) and 1 had out-toeing (FPA >15 degrees) and was not significantly different compared with control group. (3) Mean modified Harris hip score (mHHS) was 93±11 points, mean Hip Disability and Osteoarthritis Outcome Score (HOOS) score was 91±10 points. Three patients (14%) had mHHS <80 points and walked with normal FPA. The 2 patients with in-toeing and one patient with out-toeing had mHHS >95 points. CONCLUSIONS: Patients with severe SCFE treated with modified Dunn procedure had mostly symmetrical FPA and good hip scores at long term follow up. This is in contrast to previous studies. Although 1 patient had out-toeing and 2 patients had in-toeing at follow up, they had good hip scores. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Revision of a Failed Primary Total Hip Arthroplasty following Excessive Reaming with a Medial Cup Protrusion.

Background and Objectives: Atraumatic intrapelvic protrusion of the acetabular component following excessive reaming of the acetabulum with a far medial positioning of the cup is a rare, but serious complication of a total hip arthroplasty (THA). This study analyzes the factors contributing to this uncommon complication and presents the outcome after the revision surgery using the Ganz reinforcement ring combined with a bone graft and plating of the posterior column and/or screws for the anterior column. Materials and Methods: A retrospective case series study with seven patients (four males, mean age 76 ± 10 years (60−86)) that underwent a revision THA within 24 ± 17 days (5−60) after an atraumatic periprosthetic acetabular fracture with a medial cup protrusion was performed. All fractures were reconstructed with a Ganz reinforcement ring and bone graft with a mean follow-up of 1.7 ± 1.7 years (0.5−5). Radiographs were evaluated for the following: (i) cup positioning immediately after the primary THA and the revision surgery, (ii) cup migration in the follow-up, and (iii) fracture healing. Results: The position of the acetabular component as assessed on the postoperative radiographs after the index surgery and before the complete medial cup protrusion showed a cup placement beyond the ilioischial line indicative of a fracture of the medial wall. The revision surgery with the reconstruction of the medial wall with a Ganz reinforcement ring combined with a bone graft restored in the presented cases the center of rotation in the horizontal direction with a statistical significance (p < 0.05). During the follow-up, there was no aseptic loosening with the relevant cup migration or significant change in the position of the acetabular cup at the final follow-up (p > 0.05) after the revision. All seven fractures and bone grafts realized a bone union until the latest follow-up. Conclusions: Following excessive reaming, the acetabular component was placed too far medially and resulted in an intrapelvic cup protrusion. An unstable cup following a fracture of the medial wall was evident on the immediate postoperative radiographs. In the case of the medial wall perforation with an intrapelvic cup protrusion after the primary THA, the reconstruction with a Ganz reinforcement ring was a successful treatment option resulting in the fracture healing and a stable cup positioning. Surgeons should be aware of that rare and probably underreported complication and restore the anatomic center of rotation by treating the defect intraoperatively.

Magnetization-prepared 2 Rapid Gradient-Echo MRI for B1 Insensitive 3D T1 Mapping of Hip Cartilage: An Experimental and Clinical Validation.

Background Often used for T1 mapping of hip cartilage, three-dimensional (3D) dual-flip-angle (DFA) techniques are highly sensitive to flip angle variations related to B1 inhomogeneities. The authors hypothesized that 3D magnetization-prepared 2 rapid gradient-echo (MP2RAGE) MRI would help provide more accurate T1 mapping of hip cartilage at 3.0 T than would 3D DFA techniques. Purpose To compare 3D MP2RAGE MRI with 3D DFA techniques using two-dimensional (2D) inversion recovery T1 mapping as a standard of reference for hip cartilage T1 mapping in phantoms, healthy volunteers, and participants with hip pain. Materials and Methods T1 mapping at 3.0 T was performed in phantoms and in healthy volunteers using 3D MP2RAGE MRI and 3D DFA techniques with B1 field mapping for flip angle correction. Participants with hip pain prospectively (July 2019-January 2020) underwent indirect MR arthrography (with intravenous administration of 0.2 mmol/kg of gadoterate meglumine), including 3D MP2RAGE MRI. A 2D inversion recovery-based sequence served as a T1 reference in phantoms and in participants with hip pain. In healthy volunteers, cartilage T1 was compared between 3D MP2RAGE MRI and 3D DFA techniques. Paired t tests and Bland-Altman analysis were performed. Results Eleven phantoms, 10 healthy volunteers (median age, 27 years; range, 26-30 years; five men), and 20 participants with hip pain (mean age, 34 years ± 10 [standard deviation]; 17 women) were evaluated. In phantoms, T1 bias from 2D inversion recovery was lower for 3D MP2RAGE MRI than for 3D DFA techniques (mean, 3 msec ± 11 vs 253 msec ± 85; P < .001), and, unlike 3D DFA techniques, the deviation found with MP2RAGE MRI did not correlate with increasing B1 deviation. In healthy volunteers, regional cartilage T1 difference (109 msec ± 163; P = .008) was observed only for the 3D DFA technique. In participants with hip pain, the mean T1 bias of 3D MP2RAGE MRI from 2D inversion recovery was -23 msec ± 31 (P < .001). Conclusion Compared with three-dimensional (3D) dual-flip-angle techniques, 3D magnetization-prepared 2 rapid gradient-echo MRI enabled more accurate T1 mapping of hip cartilage, was less affected by B1 inhomogeneities, and showed high accuracy against a T1 reference in participants with hip pain. © RSNA, 2021.

A Cam Morphology Develops in the Early Phase of the Final Growth Spurt in Adolescent Ice Hockey Players: Results of a Prospective MRI-based Study.

BACKGROUND: Cam morphologies seem to develop with an increased prevalence in adolescent boys performing high-impact sports. The crucial question is at what age the cam morphology actually develops and whether there is an association with an aberration of the shape of the growth plate at the cam morphology site. QUESTIONS/PURPOSES: (1) What is the frequency of cam morphologies in adolescent ice hockey players, and when do they appear? (2) Is there an association between an extension of the physeal growth plate and the development of a cam morphology? (3) How often do these players demonstrate clinical findings like pain and lack of internal rotation? METHODS: A prospective, longitudinal MRI study was done to monitor the proximal femoral development and to define the appearance of cam morphologies in adolescent ice hockey players during the final growth spurt. Young ice hockey players from the local boys' league up to the age of 13 years (mean age 12 ± 0.5 years) were invited to participate. From 35 players performing on the highest national level, 25 boys and their parents consented to participate. None of these 25 players had to be excluded for known disease or previous surgery or hip trauma. At baseline examination as well as 1.5 and 3 years later, we performed a prospective noncontrast MRI scan and a clinical examination. The three-dimensional morphology of the proximal femur was assessed by one of the authors using radial images of the hip in a clockwise manner. The two validated parameters were: (1) the alpha angle for head asphericity (abnormal > 60°) and (2) the epiphyseal extension for detecting an abnormality in the shape of the capital physis and a potential correlation at the site of the cam morphology. The clinical examination was performed by one of the authors evaluating (1) internal rotation in 90° of hip and knee flexion and (2) hip pain during the anterior impingement test. RESULTS: Cam morphologies were most apparent at the 1.5-year follow-up interval (10 of 25; baseline versus 1.5-year follow-up: p = 0.007) and a few more occurred between 1.5 and 3 years (12 of 23; 1.5-year versus 3-year follow-up: p = 0.14). At 3-year follow-up, there was a positive correlation between increased epiphyseal extension and a high alpha angle at the anterosuperior quadrant (1 o'clock to 3 o'clock) (Spearman correlation coefficient = 0.341; p < 0.003). The prevalence of pain on the impingement test and/or restricted internal rotation less than 20° increased most between 1.5-year (1 of 25) and the 3-year follow-up (6 of 22; 1.5-year versus 3-year follow-up: p = 0.02). CONCLUSION: Our data suggest that a cam morphology develops early during the final growth spurt of the femoral head in adolescent ice hockey players predominantly between 13 to 16 years of age. A correlation between an increased extension of the growth plate and an increased alpha angle at the site of the cam morphology suggests a potential underlying growth disturbance. This should be further followed by high-resolution or biochemical MRI methods. Considering the high number of cam morphologies that correlated with abnormal clinical findings, we propose that adolescents performing high-impact sports should be screened for signs of cam impingement, such as by asking about hip pain and/or examining the patient for limited internal hip rotation. LEVEL OF EVIDENCE: Level I, prognostic study.

The Acetabular Wall Index Is Associated with Long-term Conversion to THA after PAO.

BACKGROUND: Periacetabular osteotomy (PAO) has been shown to be a valuable option for delaying the onset of osteoarthritis in patients with hip dysplasia. Published studies at 30 years of follow-up found that postoperative anterior overcoverage and posterior undercoverage were associated with early conversion to THA. The anterior and posterior wall indices are practical tools for assessing AP coverage on standard AP radiographs of the pelvis pre-, intra-, and postoperatively. However, no study that we know of has evaluated the relationship between the postoperative anterior and posterior wall indices and survivorship free from arthroplasty. QUESTIONS/PURPOSES: In a study including patients after PAO for developmental dysplasia of the hip (DDH), we evaluated whether the acetabular wall index is associated with conversion to THA in the long-term after PAO. We asked: (1) Is an abnormal postoperative anterior wall index associated with conversion to THA after PAO? (2) Is an abnormal postoperative posterior wall index associated with conversion to THA after PAO? (3) Are there other factors associated with joint replacement after PAO? METHODS: This retrospective study involved pooling data of PAO for DDH from two previously published sources. The first series (1984-1987) comprised the very first 75 PAOs for symptomatic DDH performed at the inventor's institution. The second (1997-2000) comprised a series of PAOs for symptomatic DDH completed at the same institution 10 years later. No patient was lost to follow-up. Fifty hips (44 patients) were excluded for predefined reasons (previous surgery, substantial femoral pathomorphologies, poor-quality radiographs), leaving 115 hips (102 patients, mean age 29 ± 11 years, 28% male) for analysis with a mean follow-up of 22 ± 6 years. One observer not involved in patient treatment digitally measured the anterior and posterior wall indices on postoperative AP pelvic radiographs of all patients. All patients were contacted by mail or telephone to confirm any conversion to THA and the timing of that procedure relative to the index procedure. We performed univariate and multivariate Cox regression analyses using conversion to THA as our endpoint to determine whether the anterior and posterior wall indices are associated with prosthetic replacement in the long-term after PAO. Thirty-one percent (36 of 115) of hips were converted to THA within a mean of 15 ± 7 years until failure. The mean follow-up duration of the remaining patients was 22 ± 6 years. RESULTS: A deficient anterior wall index was associated with conversion THA in the long-term after PAO (adjusted hazard ratio 10 [95% CI 3.6 to 27.9]; p < 0.001). Although observed in the univariate analysis, we could not find a multivariate association between the posterior wall index and a higher conversion rate to THA. Grade 0 Tönnis osteoarthritis was associated with joint preservation (adjusted HR 0.2 [95% CI 0.07 to 0.47]; p = 0.005). Tönnis osteoarthritis Grades 2 and 3 were associated with conversion to THA (adjusted HR 2.3 [95% CI 0.9 to 5.7]; p = 0.08). CONCLUSION: A deficient anterior wall index is associated with a decreased survivorship of the native hip in the long-term after PAO. Intraoperatively, in addition to following established radiographical guidelines, the acetabular wall indices should be measured systematically to ascertain optimal acetabular fragment version to increase the likelihood of reconstructive survival after PAO for DDH. LEVEL OF EVIDENCE: Level III, therapeutic study.

Return to Sports After Total Hip Arthroplasty: A Survey Among Members of the European Hip Society.

BACKGROUND: The study's aim was to summarize the recommendations given by members of the European Hip Society (EHS) regarding sport activities after total hip arthroplasty (THA). METHODS: Members of the EHS were invited to complete an online web-based questionnaire including recommendations for 47 sports disciplines. The questions regarding the specific sports were also divided into 4 subcategories: "allowed," "allowed when experienced," "not allowed", and "no opinion." Four intervals for resuming the sports activities after THA were evaluated: within 6 weeks after THA, 6 to 12 weeks after THA, 12 weeks to 6 months after THA, and more than 6 months after THA. Consensus on resuming sports was analyzed. RESULTS: A total of 150 (32.9%) EHS members participated in the survey. Agreement was found for 5 sports activities in the first 6 weeks after THA, for 10 activities, 6 to 12 weeks after surgery, for 26 activities, 3 to 6 months after THA, and for 37 of 47 activities, 6 months after surgery. Sports activities which were not allowed after THA were handball, soccer and football, basketball, full contact sports, and martial arts. CONCLUSION: This is the first report describing the recommendations of European hip arthroplasty surgeons on resuming sport activity after THA. Most physical activities were allowed for the patients 6 months after THA. The experience of the patient in performing a distinct sport activity did not influence the recommendations to return to former sports activities. European surgeons are progressively mitigating restrictions to sports after THA. Further studies should evaluate the effects of this trend on patients' outcome and implant survival.

[Torsional deformities of the femur in patients with femoroacetabular impingement : Dynamic 3D impingement simulation can be helpful for the planning of surgical hip dislocation and hip arthroscopy]. / Femorale Torsionsfehler bei Patienten mit femoroazetabulärem Impingement : Die dynamische 3D Impingementsimulation kann bei der Planung der chirurgischen Hüftluxation und der Hüftarthroskopie behilflich sein.

BACKGROUND: Torsional deformities of the femur include femoral retrotorsion and increased femoral torsion, which are possible causes for hip pain and osteoarthritis. For patients with femoroacetabular impingement (FAI), torsional deformities of the femur represent an additional cause of FAI in addition to cam and pincer-type FAI. OBJECTIVES: The aim of this article is to provide an overview of measurement techniques and normal values of femoral torsion. The clinical presentation, possible combinations and surgical therapy of patients with torsional deformities of the femur will be discussed. METHODS: For measurement of femoral torsion, CT or MRI represent the method of choice. The various definitions should be taken into account, because they can lead to differing values and misdiagnosis. This is the case especially for patients with high femoral torsion. Dynamic 3D impingement simulation using 3D-CT can help to differentiate between intra und extra-articular FAI. RESULTS AND DISCUSSION: Femoral retrotorsion (< 5°) can lead to anterior intra- and extraarticular (subspine) FAI, between the anterior iliac inferior spine (AIIS) and the proximal femur. Increased femoral torsion (> 35°) can lead to posterior intra- and extra-articular ischiofemoral FAI, between the lesser/greater trochanter and the ischial tuberosity. During clinical examination, a patient with femoral retrotorsion exhibits loss of internal rotation and a positive anterior impingement test. Hips with increased femoral torsion show high internal rotation if examined in prone position and have a positive FABER and posterior impingement test. During surgical therapy for patients with torsional deformities, intra and extra-articular causes for FAI in addition to cam and pincer-deformities should be considered. In addition to hip arthroscopy and surgical hip dislocation, also femoral rotational or derotational osteotomies should be evaluated during surgical planning of these patients.

Differences in Femoral Torsion Among Various Measurement Methods Increase in Hips With Excessive Femoral Torsion.

BACKGROUND: Correct quantification of femoral torsion is crucial to diagnose torsional deformities, make an indication for surgical treatment, or plan the amount of correction. However, no clear evaluation of different femoral torsion measurement methods for hips with excessive torsion has been performed to date. QUESTIONS/PURPOSES: (1) How does CT-based measurement of femoral torsion differ among five commonly used measurement methods? (2) Do differences in femoral torsion among measurement methods increase in hips with excessive femoral torsion? (3) What is the reliability and reproducibility of each of the five torsion measurement methods? METHODS: Between March and August 2016, we saw 86 new patients (95 hips) with hip pain and physical findings suggestive for femoroacetabular impingement at our outpatient tertiary clinic. Of those, 56 patients (62 hips) had a pelvic CT scan including the distal femur for measurement of femoral torsion. We excluded seven patients (seven hips) with previous hip surgery, two patients (two hips) with sequelae of Legg-Calvé-Perthes disease, and one patient (one hip) with a posttraumatic deformity. This resulted in 46 patients (52 hips) in the final study group with a mean age of 28 ± 9 years (range, 17-51 years) and 27 female patients (59%). Torsion was compared among five commonly used assessment measures, those of Lee et al., Reikerås et al., Jarrett et al., Tomczak et al., and Murphy et al. They differed regarding the level of the anatomic landmark for the proximal femoral neck axis; the method of Lee had the most proximal definition followed by the methods of Reikerås, Jarrett, and Tomczak at the base of the femoral neck and the method of Murphy with the most distal definition at the level of the lesser trochanter. The definition of the femoral head center and of the distal reference was consistent for all five measurement methods. We used the method described by Murphy et al. as our baseline measurement method for femoral torsion because it reportedly most closely reflects true anatomic femoral torsion. With this method we found a mean femoral torsion of 28 ± 13°. Mean values of femoral torsion were compared among the five methods using multivariate analysis of variance. All differences between two of the measurement methods were plotted over the entire range of femoral torsion to evaluate a possible increase in hips with excessive femoral torsion. All measurements were performed by two blinded orthopaedic residents (FS, TDL) at two different occasions to measure intraobserver reproducibility and interobserver reliability using intraclass correlation coefficients (ICCs). RESULTS: We found increasing values for femoral torsion using measurement methods with a more distal definition of the proximal femoral neck axis: Lee et al. (most proximal definition: 11° ± 11°), Reikerås et al. (15° ± 11°), Jarrett et al. (19° ± 11°), Tomczak et al. (25° ± 12°), and Murphy et al. (most distal definition: 28° ± 13°). The most pronounced difference was found for the comparison between the methods of Lee et al. and Murphy et al. with a mean difference of 17° ± 5° (95% confidence interval, 16°-19°; p < 0.001). For six of 10 possible pairwise comparisons, the difference between two methods increased with increasing femoral torsion and decreased with decreasing femoral torsion. We observed a fair-to-strong linear correlation (R range, 0.306-0.622; all p values < 0.05) for any method compared with the Murphy method and for the Reikerås and Jarrett methods when compared with the Tomczak method. For example, a hip with 10° of femoral antetorsion according Murphy had a torsion of 1° according to Reikerås, which corresponds to a difference of 9°. This difference increased to 20° in hips with excessive torsion; for example, a hip with 60° of torsion according to Murphy had 40° of torsion according to Reikerås. All five methods for measuring femoral torsion showed excellent agreement for both intraobserver reproducibility (ICC, 0.905-0.973) and interobserver reliability (ICC, 0.938-0.969). CONCLUSIONS: Because the quantification of femoral torsion in hips with excessive femoral torsion differs considerably among measurement methods, it is crucial to state the applied methods when reporting femoral torsion and to be consistent regarding the used measurement method. These differences have to be considered for surgical decision-making and planning the degree of correction. Neglecting the differences among measurement methods to quantify femoral torsion can potentially lead to misdiagnosis and surgical planning errors. LEVEL OF EVIDENCE: Level IV, diagnostic study.

What Is the Prevalence of Cam Deformity After Prophylactic Pinning of the Contralateral Asymptomatic Hip in Unilateral Slipped Capital Femoral Epiphysis? A 10-year Minimum Followup Study.

BACKGROUND: Prophylactic pinning of the asymptomatic and normal-appearing contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) remains controversial. Understanding the minimal 10-year clinical, functional, and radiographic outcomes of the contralateral asymptomatic hip in unilateral SCFE may be helpful in the decision regarding whether the benefits associated with potentially preventing a SCFE are outweighed by the risk of additional surgery. QUESTIONS/PURPOSES: Among patients with SCFE treated with prophylactic pinning of the asymptomatic and contralateral hip, we sought (1) to determine the complications and reoperations; (2) to evaluate the development of cam deformities and the frequency and severity of osteoarthritis progression; and (3) to characterize hip pain and function as measured by the Harris hip score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) at minimal 10-year followup. METHODS: Between 1998 and 2005 all patients with SCFE seen at our institution were treated with the modified Dunn procedure and all were offered prophylactic pinning of the contralateral asymptomatic hip. Of the 41 patients who underwent the unilateral modified Dunn procedure and who had an asymptomatic contralateral hip, 37 patients (90%) underwent pinning of that contralateral hip. Of those, 33 patients (80%) were available for clinical and radiographic evaluation for this retrospective study at a minimum of 10 years (mean followup 12 ± 2 years) after surgery. Three patients of the 37 patients only had 10-year clinical followup, including questionnaires sent by mail and telephone, because they refused further radiographic followup and one patient was lost to followup. The group included 19 males and 17 females whose age at surgery was a mean of 13 ± 2 years. Medical charts were reviewed and patients were asked about complications and additional surgical procedures. Most recent postoperative radiographs were evaluated for measurement of the alpha angle, head-neck offset, epiphysis orientation, and osteoarthritis grading according to Tönnis classification and minimum joint space width. The presence of a cam deformity was defined by an alpha angle measurement > 60° on the AP radiograph and/or > 55° on the lateral radiograph. Hip function and pain were assessed by the HHS and HOOS outcome measures. RESULTS: No complications with prophylactic in situ pinning were recorded. Four of 36 (11%) patients underwent subsequent surgical treatment for cam-type femoroacetabular impingement (FAI), and hardware removal was performed in four hips (11%). The mean alpha angle was 53° ± 8° on the AP radiograph and 49° ± 8° on the lateral view at followup. In total, 10 of 33 hips (30%) had a cam morphology at the femoral head-neck junction and four (12%) were symptomatic and underwent FAI surgery. Six of 33 patients (18%) developed an asymptomatic cam morphology at the femoral head-neck junction; in three of 33 hips (9%), the cam deformity instead of lesion were visible only on the lateral projection, and 9% were visible on both the AP and lateral projections. The preoperative offset of the femoral head-neck junction was 10 ± 3 mm on the AP view and 11 ± 4 mm on the lateral view. At followup, the AP offset was 7 ± 3 mm and the lateral offset was 6 ± 3 mm, and on the lateral view, the offset was < 10 mm in eight hips (22%). No patient had radiographic signs of hip osteoarthritis (Tönnis Grade 0). The mean minimum joint space width was 4 ± 0.4 mm. The mean HHS for the 32 patients who did not undergo subsequent surgery was 97 ± 5 at latest followup. The mean postoperative HOOS was 94 ± 8 for the 32 patients at latest followup. CONCLUSIONS: At a minimum followup of 10 years after prophylactic pinning of a contralateral asymptomatic hip, most patients achieve excellent hip scores; however, a substantial proportion will develop a symptomatic cam deformity despite prophylactic pinning. No patient had signs of osteoarthritis at a minimum of 10 years, but almost one-third of the patients who underwent prophylactic pinning developed a cam deformity. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Automatic MRI-based Three-dimensional Models of Hip Cartilage Provide Improved Morphologic and Biochemical Analysis.

BACKGROUND: The time-consuming and user-dependent postprocessing of biochemical cartilage MRI has limited the use of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). An automated analysis of biochemical three-dimensional (3-D) images could deliver a more time-efficient and objective evaluation of cartilage composition, and provide comprehensive information about cartilage thickness, surface area, and volume compared with manual two-dimensional (2-D) analysis. QUESTIONS/PURPOSES: (1) How does the 3-D analysis of cartilage thickness and dGEMRIC index using both a manual and a new automated method compare with the manual 2-D analysis (gold standard)? (2) How does the manual 3-D analysis of regional patterns of dGEMRIC index, cartilage thickness, surface area and volume compare with a new automatic method? (3) What is the interobserver reliability and intraobserver reproducibility of software-assisted manual 3-D and automated 3-D analysis of dGEMRIC indices, thickness, surface, and volume for two readers on two time points? METHODS: In this IRB-approved, retrospective, diagnostic study, we identified the first 25 symptomatic hips (23 patients) who underwent a contrast-enhanced MRI at 3T including a 3-D dGEMRIC sequence for intraarticular pathology assessment due to structural hip deformities. Of the 23 patients, 10 (43%) were male, 16 (64%) hips had a cam deformity and 16 (64%) hips had either a pincer deformity or acetabular dysplasia. The development of an automated deep-learning-based approach for 3-D segmentation of hip cartilage models was based on two steps: First, one reader (FS) provided a manual 3-D segmentation of hip cartilage, which served as training data for the neural network and was used as input data for the manual 3-D analysis. Next, we developed the deep convolutional neural network to obtain an automated 3-D cartilage segmentation that we used as input data for the automated 3-D analysis. For actual analysis of the manually and automatically generated 3-D cartilage models, a dedicated software was developed. Manual 2-D analysis of dGEMRIC indices and cartilage thickness was performed at each "full-hour" position on radial images and served as the gold standard for comparison with the corresponding measurements of the manual and the automated 3-D analysis. We measured dGEMRIC index, cartilage thickness, surface area, and volume for each of the four joint quadrants and compared the manual and the automated 3-D analyses using mean differences. Agreement between the techniques was assessed using intraclass correlation coefficients (ICC). The overlap between 3-D cartilage volumes was assessed using dice coefficients and means of all distances between surface points of the models were calculated as average surface distance. The interobserver reliability and intraobserver reproducibility of the software-assisted manual 3-D and the automated 3-D analysis of dGEMRIC indices, thickness, surface and volume was assessed for two readers on two different time points using ICCs. RESULTS: Comparable mean overall difference and almost-perfect agreement in dGEMRIC indices was found between the manual 3-D analysis (8 ± 44 ms, p = 0.005; ICC = 0.980), the automated 3-D analysis (7 ± 43 ms, p = 0.015; ICC = 0.982), and the manual 2-D analysis.Agreement for measuring overall cartilage thickness was almost perfect for both 3-D methods (ICC = 0.855 and 0.881) versus the manual 2-D analysis. A mean difference of -0.2 ± 0.5 mm (p < 0.001) was observed for overall cartilage thickness between the automated 3-D analysis and the manual 2-D analysis; no such difference was observed between the manual 3-D and the manual 2-D analysis.Regional patterns were comparable for both 3-D methods. The highest dGEMRIC indices were found posterosuperiorly (manual: 602 ± 158 ms; p = 0.013, automated: 602 ± 158 ms; p = 0.012). The thickest cartilage was found anteroinferiorly (manual: 5.3 ± 0.8 mm, p < 0.001; automated: 4.3 ± 0.6 mm; p < 0.001). The smallest surface area was found anteroinferiorly (manual: 134 ± 60 mm; p < 0.001, automated: 155 ± 60 mm; p < 0.001). The largest volume was found anterosuperiorly (manual: 2343 ± 492 mm; p < 0.001, automated: 2294 ± 467 mm; p < 0.001). Mean average surface distance was 0.26 ± 0.13 mm and mean Dice coefficient was 86% ± 3%. Intraobserver reproducibility and interobserver reliability was near perfect for overall analysis of dGEMRIC indices, thickness, surface area, and volume (ICC range, 0.962-1). CONCLUSIONS: The presented deep learning approach for a fully automatic segmentation of hip cartilage enables an accurate, reliable and reproducible analysis of dGEMRIC indices, thickness, surface area, and volume. This time-efficient and objective analysis of biochemical cartilage composition and morphology yields the potential to improve patient selection in femoroacetabular impingement (FAI) surgery and to aid surgeons with planning of acetabuloplasty and periacetabular osteotomies in pincer FAI and hip dysplasia. In addition, this validation paves way to the large-scale use of this method for prospective trials which longitudinally monitor the effect of reconstructive hip surgery and the natural course of osteoarthritis. LEVEL OF EVIDENCE: Level III, diagnostic study.

The Ganz acetabular reinforcement ring shows excellent long-term results when used as a primary implant: a retrospective analysis of two hundred and forty primary total hip arthroplasties with a minimum follow-up of twenty years.

PURPOSE: The acetabular reinforcement ring with a hook (ARRH) has been designed for acetabular total hip arthroplasty (THA) revision. Additionally, the ARRH offers several advantages when used as a primary implant especially in cases with altered acetabular morphology. The implant facilitates anatomic positioning by placing the hook around the teardrop and provides a homogenous base for cementing the polyethylene cup. Therefore, the implant has been widely used in primary total hip arthroplasty at our institution. The present study reports the long-term outcome of the ARRH after a minimum follow-up of 20 years. METHODS: Two hundred and ten patients with 240 primary THAs performed between April 1987 and December 1991 using the ARRH were retrospectively reviewed after a minimum follow-up of 20 years. Twenty-three of 240 hips were lost to follow-up, 110 patients with 124 THAs had deceased without having a revision surgery performed. This left 93 hips for final evaluation. Of those, 75 hips were assessed clinically and radiographically after a mean follow-up of 23.1 years (range 21.1-26.1 years). In 18 cases, clinical and radiographic assessment was omitted because implant revision had been performed prior to the follow-up investigation. The primary endpoint was defined as revision for aseptic loosening. RESULTS: Out of the 93 hips available for final evaluation, 14 hips were revised for aseptic loosening; another four were revised for other reasons (deep infection n = 2, recurrent dislocation n = 2). The survival probability of the cup was 0.96 (95% confidence interval 0.93-0.99) after 20 years with aseptic loosening as endpoint. Radiographic analysis of the surviving 75 hips showed at least one sign of radiographic loosening in 24 hips. The mean Merle d'Aubigne score increased from 8 points pre-operatively to 15 points at final follow-up (7.5 ± 1.8 vs 15.0 ± 2.3, p < 0.001). The mean HHS was 85 ± 14 at final follow-up. Radiographic loosening did not correlate with the clinical outcome. CONCLUSIONS: The long-term results of the ARRH in primary THA are comparable to results with standard cemented cups and modern cementless cups. We believe that the ARRH is a versatile implant for primary THA, especially in cases with limited acetabular coverage and altered acetabular bone stock where the ARRH provides sufficient structural support for a cemented cup.

Correction to: Reconstruction of AAOS type III and IV acetabular defects with the Ganz reinforcement ring: high failure in pelvic discontinuity.

The author would like to correct the errors in the publication of the original article. The corrected details are given below for your reading.

Labral Reattachment in Femoroacetabular Impingement Surgery Results in Increased 10-year Survivorship Compared With Resection.

BACKGROUND: Since the importance of an intact labrum for normal hip function has been shown, labral reattachment has become the standard method for open or arthroscopic treatment of hips with femoroacetabular impingement (FAI). However, no long-term clinical results exist evaluating the effect of labral reattachment. A 2-year followup comparing open surgical treatment of FAI with labral resection versus reattachment was previously performed at our clinic. The goal of this study was to report a concise followup of these patients at a minimum of 10 years. QUESTIONS/PURPOSES: We asked if patients undergoing surgical hip dislocation for the treatment of mixed-type FAI with labral reattachment compared with labral resection had (1) improved hip pain and function based on the Merle d'Aubigné-Postel score; and (2) improved survival at 10-year followup. METHODS: Between June 1999 and July 2002, we performed surgical hip dislocation with femoral neck osteoplasty and acetabular rim trimming in 52 patients (60 hips) with mixed-type FAI. In the first 20 patients (25 hips) until June 2001, a torn labrum or a detached labrum in the area of acetabular rim resection was resected. In the next 32 patients (35 hips), reattachment of the labrum was performed. The same indications were used to perform both procedures during the periods in question. Of the 20 patients (25 hips) in the first group, 19 patients (95%) (24 hips [96%]) were available for clinical and/or radiographic followup at a minimum of 10 years (mean, 13 years; range, 12-14 years). Of the 32 patients (35 hips) in the second group, 29 patients (91%) (32 hips [91%]) were available for clinical and/or radiographic followup at a minimum of 10 years (mean, 12 years; range, 10-13 years). We used the anterior impingement test to assess pain. Function was assessed using the Merle d'Aubigné- Postel score and ROM. Survivorship calculation was performed using the method of Kaplan-Meier with failure defined as conversion to THA, progression of osteoarthritis (of one grade or more on the Tönnis score), and a Merle d'Aubigné-Postel score < 15. RESULTS: At the 10-year followup, hip pain in hips with labral reattachment was slightly improved for the postoperative Merle d'Aubigné-Postel pain subscore (5.0 ± 1.0 [3-6] versus 3.9 ± 1.7 [0-6]; p = 0.017). No difference existed for the prevalence of hip pain assessed using the anterior impingement test with the numbers available (resection group 52% [11 of 21 hips] versus reattachment group 27% [eight of 30 hips]; odds ratio, 3.03; 95% confidence interval [CI], 0.93-9.83; p = 0.062). Function was slightly better in the reattachment group for the overall Merle d'Aubigné-Postel score (16.7 ± 1.5 [13-18] versus 15.3 ± 2.4 [9-18]; p = 0.028) and hip abduction (45° ± 13° [range, 30°-70°] versus 38° ± 8° [range, 25°-45°]; p = 0.001). Hips with labral reattachment showed a better survival rate at 10 years than did hips that underwent labral resection (78%; 95% CI, 64%-92% versus 46%, 95% CI, 26%-66%; p = 0.009) with the endpoints defined as conversion to THA, progression of osteoarthritis, and a Merle d'Aubigné-Postel score < 15. With isolated endpoints, survival at 10 years was increased for labral reattachment and the endpoint Merle d'Aubigné score < 15 (83%, 95% CI, 70%-97% versus 48%, 95% CI, 28%-69%; p = 0.009) but did not differ for progression of osteoarthritis (83%, 95% CI, 68%-97% versus 81%, 95% CI, 63%-98%; p = 0.957) or conversion to THA (94%, 95% CI, 86%-100% versus 87%, 95% CI, 74%-100%; p = 0.366). CONCLUSIONS: The current results suggest the importance of preserving the labrum and show that resection may put the hip at risk for early deterioration. At 10-year followup, hips with labral reattachment less frequently had a decreased Merle d'Aubigné score but no effect on progression of osteoarthritis or conversion to THA could be shown. LEVEL OF EVIDENCE: Level III, therapeutic study.

What MRI Findings Predict Failure 10 Years After Surgery for Femoroacetabular Impingement?

BACKGROUND: Magnetic resonance arthrogram (MRA) with radial cuts is presently the best available preoperative imaging study to evaluate chondrolabral lesions in the setting of femoroacetabular impingement (FAI). Existing followup studies for surgical treatment of FAI have evaluated predictors of treatment failure based on preoperative clinical examination, intraoperative findings, and conventional radiography. However, to our knowledge, no study has examined whether any preoperative findings on MRA images might be associated with failure of surgical treatment of FAI in the long term. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify the preoperative MRA findings that are associated with conversion to THA, any progression of osteoarthritis, and/or a Harris hip score of < 80 points after acetabuloplasty and/or osteochondroplasty of the femoral head-neck junction through a surgical hip dislocation (SHD) for FAI at a minimum 10-year followup; and (2) identify the age of patients with symptomatic FAI when these secondary degenerative findings were detected on preoperative radial MRAs. METHODS: We retrospectively studied 121 patients (146 hips) who underwent acetabuloplasty and/or osteochondroplasty of the femoral head-neck junction through SHD for symptomatic anterior FAI between July 2001 and March 2003. We excluded 35 patients (37 hips) with secondary FAI after previous surgery and 11 patients (12 hips) with Legg-Calvé-Perthes disease. All patients underwent preoperative MRA to further specify chondrolabral lesions except in 19 patients (32 hips) including 17 patients (20 hips) who presented with an MRI from an external institution taken with a different protocol, 10 patients with no preoperative MRA because the patients had already been operated on the contralateral side with a similar appearance, and two patients (two hips) refused MRA because of claustrophobia. This resulted in 56 patients (65 hips) with idiopathic FAI and a preoperative MRA. Of those, three patients (three hips) did not have minimal 10-year followup (one patient died; two hips with followup between 5 and 6 years). The remaining patients were evaluated clinically and radiographically at a mean followup of 11 years (range, 10-13 years). Thirteen pathologic radiographic findings on the preoperative MRA were evaluated for an association with the following endpoints using Cox regression analysis: conversion to THA, radiographic evidence of any progression of osteoarthritis, and/or a Harris hip score of < 80. The age of the patient when each degenerative pattern was found on the preoperative MRA was recorded. RESULTS: The following MRI findings were associated with one or more of our predefined failure endpoints: cartilage damage exceeding 60° of the circumference had a hazard ratio (HR) of 4.6 (95% confidence interval [CI], 3.6-5.6; p = 0.003) compared with a damage of less than 60°, presence of an acetabular rim cyst had a HR of 4.1 (95% CI, 3.1-5.2; p = 0.008) compared with hips without these cysts, and presence of a sabertooth osteophyte had a HR of 3.2 (95% CI, 2.3-4.2; p = 0.013) compared with hips without a sabertooth osteophyte. The degenerative pattern associated with the youngest patient age when detected on preoperative MRA was the sabertooth osteophyte (lower quartile 27 years) followed by cartilage damage exceeding 60° of the circumference (28 years) and the presence of an acetabular rim bone cyst (31 years). CONCLUSIONS: Preoperative MRAs with radial cuts reveal important findings that may be associated with future failure of surgical treatment for FAI. Most of these factors are not visible on conventional radiographs or standard hip MRIs. Preoperative MRA evaluation is therefore strongly recommended on a routine basis for patients undergoing these procedures. Findings associated with conversion to arthroplasty, radiographic evidence of any progression of osteoarthritis, and/or a Harris hip score of < 80 points should be incorporated into the decision-making process in patients being evaluated for joint-preserving hip surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

How Does the dGEMRIC Index Change After Surgical Treatment for FAI? A Prospective Controlled Study: Preliminary Results.

BACKGROUND: Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) allows an objective, noninvasive, and longitudinal quantification of biochemical cartilage properties. Although dGEMRIC has been used to monitor the course of cartilage degeneration after periacetabular osteotomy (PAO) for correction of hip dysplasia, such longitudinal data are currently lacking for femoroacetabular impingement (FAI). QUESTIONS/PURPOSES: (1) How does the mean acetabular and femoral dGEMRIC index change after surgery for FAI at 1-year followup compared with a similar group of patients with FAI treated without surgery? (2) Does the regional distribution of the acetabular and femoral dGEMRIC index change for the two groups over time? (3) Is there a correlation between the baseline dGEMRIC index and the change of patient-reported outcome measures (PROMs) at 1-year followup? (4) Among those treated surgically, can dGEMRIC indices distinguish between intact and degenerated cartilage? METHODS: We performed a prospective, comparative, nonrandomized, longitudinal study. At the time of enrollment, the patients' decision whether to undergo surgery or choose nonoperative treatment was not made yet. Thirty-nine patients (40 hips) who underwent either joint-preserving surgery for FAI (20 hips) or nonoperative treatment (20 hips) were included. The two groups did not differ regarding Tönnis osteoarthritis score, preoperative PROMs, or baseline dGEMRIC indices. There were more women (60% versus 30%, p = 0.003) in the nonoperative group and patients were older (36 ± 8 years versus 30 ± 8 years, p = 0.026) and had lower alpha angles (65° ± 10° versus 73° ± 12°, p = 0.022) compared with the operative group. We used a 3.0-T scanner and a three-dimensional dual flip-angle gradient-echo technique for the dGEMRIC technique for the baseline and the 1-year followup measurements. dGEMRIC indices of femoral and acetabular cartilage were measured separately on the initial and followup radial dGEMRIC reformats in direct comparison with morphologic radial images. Regions of interest were placed manually peripherally and centrally within the cartilage based on anatomic landmarks at the clockface positions. The WOMAC, the Hip disability and Osteoarthritis Outcome Score, and the modified Harris hip score were used as PROMs. Among those treated surgically, the intraoperative damage according to the Beck grading was recorded and compared with the baseline dGEMRIC indices. RESULTS: Although both the operative and the nonoperative groups experienced decreased dGEMRIC indices, the declines were more pronounced in the operative group (-96 ± 112 ms versus -16 ± 101 ms on the acetabular side and -96 ± 123 ms versus -21 ± 83 ms on the femoral side in the operative and nonoperative groups, respectively; p < 0.001 for both). Patients undergoing hip arthroscopy and surgical hip dislocation experienced decreased dGEMRIC indices; the decline in femoral dGEMRIC indices was more pronounced in hips after surgical hip dislocation (-120 ± 137 ms versus -61 ± 89 ms, p = 0.002). In the operative group a decline in dGEMRIC indices was observed in 43 of 44 regions over time. In the nonoperative group a decline in dGEMRIC indices was observed in four of 44 regions over time. The strongest correlation among patients treated surgically was found between the change in WOMAC and baseline dGEMRIC indices for the entire joint (R = 0.788, p < 0.001). Among those treated nonoperatively, no correlation between baseline dGEMRIC indices and change in PROMs was found. In the posterosuperior quadrant, the dGEMRIC index was higher for patients with intact cartilage compared with hips with chondral lesions (592 ± 203 ms versus 444 ± 205 ms, p < 0.001). CONCLUSIONS: We found a decline in acetabular, femoral, and regional dGEMRIC indices for the surgically treated group at 1-year followup despite an improvement in all PROMs. We observed a similar but less pronounced decrease in the dGEMRIC index in symptomatic patients without surgical treatment indicating continuous cartilage degeneration. Although treatment of FAI is intended to alter the forces acting across the hip by eliminating impingement, its effects on cartilage biology are not clear. dGEMRIC provides a noninvasive method of assessing these effects. Longer term studies will be needed to determine whether the matrix changes of the bradytrophic cartilage seen here are permanent or clinically important. LEVEL OF EVIDENCE: Level II, therapeutic study.

Acetabular Version Increases After Closure of the Triradiate Cartilage Complex.

BACKGROUND: Although the etiology of primary femoroacetabular impingement (FAI) is considered developmental, the underlying pathogenic mechanisms remain poorly understood. In particular, research identifying etiologic factors associated with pincer FAI is limited. Knowledge of the physiologic growth patterns of the acetabulum during skeletal maturation might allow conclusions on deviations from normal development that could contribute to pincer-related pathomorphologies. QUESTIONS/PURPOSES: In a population of healthy children, we asked if there were any differences related to skeletal maturation with regard to (1) acetabular version; (2) acetabular depth/width ratio; and (3) femoral head coverage in the same children as assessed by MRIs obtained 1 year apart. METHODS: We prospectively compared 129 MRIs in 65 asymptomatic volunteers without a known hip disorder from a mixed primary/high school population (mean age, 12.7 years; range, 7-16 years). All participants underwent two MRI examinations separated by a minimum interval of 1 year. Based on the status of the triradiate cartilage complex (open versus closed [TCC]), all hips were allocated to the following groups: "open-open" = open TCC at both MRIs (n = 45 hips [22 bilateral]); "open-closed" = open TCC at initial and closed TCC at followup MRI (n = 26 hips [13 bilateral]); and "closed-closed" group = closed TCC at both MRIs (n = 58 hips [29 bilateral]). We assessed acetabular version in the axial plane at five different locations (5, 10, 15, 20 mm below the acetabular dome and at the level of the femoral head) as well as three-dimensional (3-D) acetabular depth/width ratio and 3-D femoral head coverage on six radial MRI sequences oriented circumferentially around the femoral neck axis. Using analysis of variance for multigroup comparisons with Bonferroni adjustment for pairwise comparisons, we compared the results between the initial and followup MRI examinations and among the three groups. RESULTS: Acetabular version was increased in hips of the "open-closed" group at the followup MRI compared with the initial MRI at 5 mm (-6 ± 4.6 [95% confidence interval {CI}, -7.6 to -3.6] versus -1 ± 5.0 [95% CI, -3.3 to 0.7]; p < 0.001), 10 mm (0 ± 4.0 [95% CI, -1.6 to 2.1] versus 7 ± 4.6 [95% CI, 4.4-8.7]; p < 0.001), and 15 mm (8 ± 5.0 [95% CI, 6.1-10.2] versus 15 ± 4.6 [95% CI, 13.3-17.4]; p < 0.001) below the acetabular dome. Acetabular version did not change between the initial and followup MRI in the "open-open" and "closed-closed" groups. Independently of the groups, acetabular version was increased in all hips with a fused TCC compared with hips with an open TCC (mean difference measured at 5 mm below the acetabular dome at initial MRI examination: 2° ± 5.9° [95% CI, 0.2°-3.4°] versus -9° ± 4.4° [95% CI, -9.9° to -7.8°]; p < 0.001; at followup MRI examination: 1° ± 5.7° [95% CI, 0.1°-2.7°] versus -9° ± 3.8° [95% CI, -10° to -7.6°]; p < 0.001). Both acetabular depth/width ratio and femoral head coverage did not differ among the groups or between the initial and followup MRI examinations within each group. CONCLUSIONS: Although acetabular depth/width ratio and femoral head coverage remain relatively constant, acetabular version increases with advancing skeletal maturity. There seems to be a relatively narrow timeframe near physeal closure of the TCC within which acetabular orientation changes to more pronounced anteversion. Further studies with greater numbers and longer followup periods are required to support these findings and determine whether such version changes may contribute to pincer-type pathomorphologies. LEVEL OF EVIDENCE: Level II, prospective study.