Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients.

PURPOSE: Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography. METHODS: A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. RESULTS: A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness. CONCLUSION: Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

Arthroscopic surgery for femoroacetabular impingement has limited effect in patients with Tönnis grade-2 at 4-year follow-up.

INTRODUCTION: This study evaluated intraoperative findings and outcomes in Tönnis grade-2 patients after hip arthroscopy and compared these results with patients with Tönnis grade-0 and grade-1. MATERIALS AND METHODS: Retrospective cohort study of patients undergoing hip arthroscopy between January 2013 and December 2017. Patients were divided into either Tönnis grade-2, grade-1, and grade-0 osteoarthritis groups. Labral and chondral status were evaluated. Radiographic analysis, modified Harris hip score (mHHS), a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (IHOT-12) were assessed at 6, 12 months, and then yearly. Clinical meaningful outcomes were measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for mHHS, HOS-ADL and HOS-SSS, and IHOT-12. RESULTS: A total of 264 hip arthroscopic procedures met the inclusion criteria. There were 38 patients Tönnis grade-2, 91 patients Tönnis grade-1, and 135 patients Tönnis grade-0. Mean follow-up was 48.7 months in Tönnis grade-2 group, 48.6 months in Tönnis grade-0 group, and 48.1 months in Tönnis grade-1 group. Tönnis grade-2 patients had more extensive rim chondral damage, and a higher rate of labral debridement was performed in this group. There were no statistically significant differences in preoperative PROs among the groups. Tönnis grade-2 group had statistically significant improvement in mHHS, but not in HOS-AVD, HOS-SSS and IHOT-12. Between T1 and T2 groups there were no statistically significant differences in outcomes. Lower significant percentage values of Tönnis grade-2 patients achieved MCID, PASS, and SCB threshold. CONCLUSION: Improvements in PROs and rates of achieving clinical meaningful outcomes were limited for patients with Tönnis grade-2 after HA at 4-year follow-up. The outcomes of the Tönnis grade-2 cohort deteriorate over mid-term follow-up. Our results could be used in orthopedic practice to inform patients about the limited role of hip arthroscopy as a joint preservation procedure in these selected patients. LEVEL OF EVIDENCE: Cohort study, level 3.

Significant improvement after hip arthroscopy for femoroacetabular impingement in women.

PURPOSE: This study was designed to evaluate outcomes in women after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and compare these results with men. METHODS: Retrospective study of a prospective database of patients undergoing hip arthroscopy between 2015 and 2018. Inclusion criteria were patients between 18 and 50 years of age, diagnosis of FAIS, complete clinical patient-reported outcomes (PROs), radiographic measurements, and underwent at least a 2-year HA follow-up. For each woman, two men underwent HA were matched in a 1:2 ratio based on age within 5 years, and date of surgery within 6 months. Diagnostic arthroscopy was performed to evaluate labral and chondral status. Radiographic evaluation, a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (iHOT-12) were assessed at 6 months, 12 months, and then yearly. Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for HOS-ADL, HOS-SSS, and iHOT-12. RESULTS: One hundred and eighty-five patients met the inclusion criteria. Fifty-two women were matched with 104 men. Significant differences in terms of demographics, radiographic results, intraoperative findings and arthroscopic procedures were found between women and men. Mean follow-up was 48.4 months in women and 50.2 months in men. Both groups showed significant improvement from preoperative PROs to the latest follow-up. There were no significant differences between groups in preoperative PROs, latest follow-up PROs and PROs improvements. The difference in frequency of patients achieving MCID, PASS, and SCB was only significant greater for iHOT-12 PASS in women compared with men. CONCLUSION: Significant improvements in PROs in women after HA for FAIS at 4-year follow-up were found. Differences between women and men in PROs and rates of achieving MCID, SCB and PASS were only significant for iHOT-12 PASS. LEVEL OF EVIDENCE: IV.

Benefits of a Specific and Supervised Rehabilitation Program in Femoroacetabular Impingement Patients Undergoing Hip Arthroscopy: A Randomized Control Trial.

(1) To assess the efficacy of a specific rehabilitation protocol for femoroacetabular impingement syndrome (FAIS), patients who underwent hip arthroscopy (HA) were compared with a control group. (2) Patients with symptomatic FAIS who were scheduled for HA were randomized either to a control group (n = 45, 66.6% men, 41.8 ± 12.4 years) following a general post-surgical treatment protocol or to an experimental group (n = 45, 71.2% men, 40.9 ± 7.6 years) following a specific rehabilitation protocol supervised by a physiotherapist. Range of motion (ROM), orthopedic tests and pain were assessed immediately before surgery and at 4 and 14 weeks after surgery. The hip functional status was assessed by the modified Harris Hip Score (mHHS) before surgery and at the end of follow-up. (3) At 14 weeks after surgery and compared with the control group, the experimental group showed a lower percentage of positives for hip provocation tests (15.6% vs. 46.6% on Faber test; 15.6% vs. 77.8% on Fadir test; 2.2% vs. 20% on Ober test, experimental vs. control group, p < 0.001), a greater improvement in mHHS (27.2 vs. 10.7 points, p < 0.001) and higher ROM for all the movements evaluated: flexion (99.6 ± 12.2 vs. 89.6 ± 4.5, p < 0.001), extension (20.6 ± 5.8 vs. 13.3 ± 2.6, p < 0.001), adduction (30.6 ± 5.7 vs. 23.4 ± 8.4, p < 0.001), abduction (43.4 ± 10.7 vs. 32.8 ± 8.4, p < 0.001) and both internal (28.2 ± 8.5 vs. 18.7 ± 6.1, p < 0.001) and external hip rotation (36.8 ± 9.3 vs. 27.4 ± 5.6. p < 0.001). The pain decreased after surgery for both groups, although the reduction was greater in the experimental group at the end of intervention (13.8 ± 16.1 vs. 34.9 ± 16.3 mm, experimental vs. control group, p < 0.001). (4) The specific and supervised rehabilitation program in patients with FAIS undergoing HA showed better benefits at 14 weeks of treatment than the benefits achieved by a care protocol in terms of pain reduction and recovery of hip motion.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: We aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome. METHODS: A retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports' independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed. RESULTS: Patients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)10 questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively. CONCLUSIONS: Rotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum two year follow-up.

PURPOSE: The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia. METHODS: Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB). RESULTS: Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50 months in the borderline hip dysplasia cohort, and 52 months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts. CONCLUSION: With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Severe Weakness of Hip Flexor after Iliopsoas Tenotomy: Two Case Reports.

Hip arthroscopies are becoming a standard surgical technique, with psoas tenotomy being a relatively common procedure during this operation. A 37-year-old male and a 42-year-old female with internal hip snapping came to our department. Arthroscopic partial psoas tenotomy of the iliopsoas portion of the conjoint tendon was performed, but its results were bad. Patients reported preoperative unilateral low-back pain and weakness when flexing the hip. Unilateral atrophy of the lumbar psoas and fatty multifidus were detected in both cases. Patients at risk of unsatisfactory outcomes after psoas tenotomy should be ideally identified prior to surgery. Warning symptoms, physical examination, and imaging studies should be considered to avoid unsatisfactory results.

Topical tranexamic acid in cemented primary total knee arthroplasty without tourniquet: a prospective randomized study.

PURPOSE: Tranexamic acid (TXA) has been shown to be effective in reducing blood loss after total knee replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use, to reduce blood loss after primary total knee replacement without tourniquet, and to compare these outcomes with a control group that did not receive tranexamic acid. METHODS: This is a prospective, randomized study to assess the effect of a 2-g topical tranexamic acid in 50 mL physiological saline solution in total knee replacement without tourniquet and drain. Primary outcomes were total blood loss. Secondary outcomes were hemoglobin and hematocrit level, hemoglobin and hematocrit drop, transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: Preoperative and intraoperative data were similar between the two groups. The mean total blood loss was 620 mL in the topical tranexamic acid group and 1094 mL in the control group with significant differences (p = 0.001), which meant 43% reduction in total blood loss. The hemoglobin and hematocrit postoperative value was significantly higher in the topical tranexamic acid group than in the control group (p = 0.002). Transfusion rates were 0% in the topical tranexamic group and 4.3% in the control group. The length of stay was significantly lower in the topical tranexamic acid group (p = 0.01). There were no DVT or PE in any group. CONCLUSION: A single dose of 2-g TXA in 50 mL topical administration significantly reduces blood loss and improves postoperative blood chemistries in patients undergoing unilateral primary cemented TKA without tourniquet and drain compared to a control group, without increasing the risk of thromboembolic complications.

Plantar pressure improvement in moderate hallux valgus with modified chevron osteotomy: Clinical and radiographic outcomes.

BACKGROUND: Hallux valgus (HV) is widely treated by Chevron osteotomy (CO); however, a modified CO may improve patient outcomes and recovery. METHODS: A prospective study was designed to analyze plantar pressure measurements and clinical and radiographic outcomes of a modified CO for HV. Recruitment was between February 2016 and February 2017. INCLUSION CRITERIA: diagnosis of moderate HV; an indication for surgical correction due to discomfort, pain or difficulty with shoe wear; and age over 18 years. Clinical and radiographic outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) guidelines and a visual analog scale (VAS). RESULTS: Forty-four patients met inclusion criteria. After surgery, the highest percentage in mean pressure was in the first and fifth metatarsal heads. At 12 months' follow-up, the AOFAS score improved, but differences in VAS scale were only significant at baseline. CONCLUSIONS: Modified CO is a good option for people with HV, improving foot activity compared to preoperative levels while limiting the time needed for recovery.

Femoroacetabular impingement: prospective study of rate and factors related for nerve injury after hip arthroscopy.

Prospective, longitudinal, descriptive study was conducted from January 2016 to January 2018 to detect nerve dysfunction after hip arthroscopy. A total of 110 patients were included. Twenty-four hours after surgery, 62.7% reported symptoms of abnormal sensation at least in one area. The most common was the perineal area. Three weeks after hip arthroscopy, 42.6% still experienced abnormal sensation. Six months after hip arthroscopy, only one patient remained with symptoms. Nerve dysfunction after HA was more common than has been reported in the literature within large populations. Traction time was a significant factor for the development of perineal nerve dysfunction.

Indirect Scapholunate Ligament Repair: All Arthroscopic.

The arthroscopic technique most frequently used in acute scapholunate instability is reduction and fixation with Kirschner wires. To repair the injured ligament, open surgery and dorsal capsular plication are recommended, but this procedure has the risk of damaging secondary dorsal stabilizers, the dorsal blood supply, and the proprioceptive innervation of the posterior interosseous nerve. In this report, we present an all-arthroscopic technique of a dorsal reconstruction of the scapholunate interosseous ligament for scapholunate instability using a tape by tethering the scaphoid to the lunate.

Matched cohort study of topical tranexamic acid in cementless primary total hip replacement.

PURPOSE: Tranexamic acid has been shown to be effective in reducing blood loss after total hip replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use to reduce blood loss after primary total hip replacement and to compare these outcomes with those of a matched control group from a similar cohort that did not have received tranexamic acid. METHODS: This is a prospective matched control study to assess the effect of a 2 g topical tranexamic acid in 50 mL physiological saline solution in total hip replacement. Primary outcomes were hemoglobin and hematocrit drop, and total blood loss. Secondary outcomes were transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: We could match 100 patients to a control group. There were no statistical significantly differences between the two groups. The hemoglobin and hematocrit postoperative values were significantly higher in topical tranexamic acid group than in control group (P < 0.001). The mean total blood loss was 769 in topical tranexamic acid group and 1163 in control group with significant differences (P = 0.001), which meant 34% reduction in total blood loss. Length of stay was lower in topical tranexamic acid group. The risk of deep vein thrombosis and pulmonary events did not increase. CONCLUSIONS: A single dose of 2 g tranexamic acid in 50 mL physiological saline solution topical administration was effective and safe in reducing bleeding in patients undergoing unilateral primary non-cemented total hip replacement compared to a matched control group.

Chondrolysis after hip arthroscopy.

We report the case of a 58-year-old woman who presented with left hip pain and was diagnosed with femoroacetabular impingement. She underwent hip arthroscopy to repair a degenerative labral tear, as well as radiofrequency debridement and microfracture of the exposed chondral defect, and femoral osteoplasty. Two months after hip arthroscopy, hip pain and limping began. Hip radiography showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis. Revision surgery 4 months after hip arthroscopy showed that the cartilage of the femoral head was soft and separated from the subchondral bone.

Cementless total knee arthroplasty in obese patients: a prospective matched study with follow-up of 5-10 years.

A prospective matched cohort study was performed to compare outcomes of cementless total knee arthroplasties between 171 knees in obese patients (BMI ≥ 30) and 171 non-obese patients (BMI < 30). Mean follow-up was 7 years. There were no significant differences in overall functional outcomes or components alignment. In the obese group, there were 14 perioperative complications, 9 revisions, and 5 other patients were considered clinical failures, whereas in the non-obese group there were 3, 5, and 7, respectively. There were no significant differences between obese class I-II and class III (morbid) subgroups. The obese and non-obese groups had similar implant survivorship at 7 years. Although TKA outcome in obese was satisfactory, these patients should be informed of the perioperative risks, and advised to lose weight prior to surgery.

Cementless acetabular reconstruction after acetabular fracture: a prospective, matched-cohort study.

BACKGROUND: Total hip arthroplasty (THA) is a common surgical treatment when significant joint changes and pain are present after acetabular fracture. Few series have been reported in the literature with cemented and uncemented acetabular components. The aim of this study was to analyze the long-term results of cementless acetabular components inserted in acetabula that had been altered with previous fracture and to compare these results to those of routine THA. METHODS: Twenty-four uncemented total hip arthroplasties were performed for the treatment of posttraumatic arthritis after acetabular fracture. The mean age and follow-up was 56 years and 8.4 years, respectively. The results were compared with 48 primary uncemented total hip arthroplasties in patients with nontraumatic arthritis. Clinical assessment with Harris hip score and radiologic with special interest in the socket was made. RESULTS: No significant difference between the two cohorts was found with regard to postoperative follow-up, perioperative transfusion requirements, reoperations, and acetabular survival. Between both cohorts, there were significant differences with regard to operative time and postoperative Harris score. CONCLUSIONS: Cementless THA is a suitable treatment for posttraumatic arthritis after acetabular fracture. LEVEL OF EVIDENCE: Therapeutic study, level III.

Outcomes in nonagenarians after hemiarthroplasty for femoral neck fracture. A prospective matched cohort study.

A prospective cohort of 33 nonagenarians with hemiartroplasty for femoral neck fracture was matched with 33 patients aged between 70 and 89, using preoperative and postoperative data, and the following were studied; epidemiological data, physical dependence, and SF-12 and WOMAC questionnaires. The mortality rate at one year was 24.2%, influenced by the presence of 3 or more comorbidities, dementia, and previous dependence. The perioperative period was the most vulnerable time, and in some cases delaying surgery should be considered to stabilise the patient's medical condition in very elderly patients. Mortality and functional outcomes were worse than in younger patients, but the surgical complication rate was similar. Prognostic factors for a decline in quality of life were dementia and previous dependence.

Cementless total hip arthroplasty using titanium, plasma-sprayed implants: a study with 10 to 15 years of follow-up.

PURPOSE: To evaluate long-term outcomes of total hip arthroplasty (THA) using the Perfecta cementless system. METHODS: 73 men and 76 women aged 65 to 88 (mean, 71) years underwent 168 THAs using the Perfecta cementless system and were followed up for a mean of 13 (10 to 15) years. 19 patients had bilateral THA. The diagnoses were idiopathic osteoarthritis (n=121), osteonecrosis of the femoral head (n=25), rheumatoid arthritis (n=14), and post-traumatic osteoarthritis (n=8). Patients were evaluated clinically and radiographically before and after THA. RESULTS: The mean Harris hip score improved from 40 to 84 (p<0.001); the score was excellent or good in 130 hips, fair in 17, and poor in 21. The mean Merle D'Aubigne score improved from 4 to 10 (p<0.001); the score was excellent or good in 138 hips, fair in 9, and poor in 21. Poor results were due to aseptic revision of the cup (n=16) or stem (n=3) or deep infection (n=2). Thigh pain that limited activities of daily living was noted in 3 hips. 142 patients could walk without a limp, 5 had a slight limp, and 3 had a moderate limp and used a cane. The mean Short Form-12 score for the physical function was 49 and for the mental health was 56; the mean Western Ontario and McMaster Universities Osteoarthritis Index was 39; the mean visual analogue scale score for satisfaction was 8. Two patients developed deep infection at postoperative months 8 and 50 and were treated with 2-staged revision. Five patients had hip dislocation within 2 months; 3 of whom endured recurrent dislocation and underwent revision surgery; they had acetabular malposition with excessive anteversion despite a correct acetabular angle. 13 other cups were revised because of loosening or extensive osteolysis (n=10) and polyethylene wear (n=3) after a mean interval of 6 (range, 4-10) years. Three stems were revised because of aseptic loosening after a mean interval of 7 (range, 6-9) years. The survivorship at 14 years was 99% for stems and 91% for cups. CONCLUSION: The long-term outcome of the Perfecta cementless stem was good; most major complications occurred in the cup.