Development and implementation of a roadmap for improving quality of care in prearthritic hip disease: A journey over 20 years.

The understanding and treatment of prearthritic hip disease has evolved remarkably over the past 20 years. The principal investigator and the multicenter Academic Network of Conservational Hip Outcomes Research (ANCHOR) group have had a key role in improving the quality of care for these patients suffering from the three most common prearthritic conditions: femoroacetabular impingement, developmental dysplasia of the hip, and residual Legg-Calve-Perthes Disease. We aim to demonstrate that based on the six quality of care dimensions as defined by Donabedian, our 20-year academic journey has markedly improved the quality of care for young patients with prearthritic hip disease.

Femurs in patients with hip dysplasia have fundamental shape differences compared with cam femoroacetabular impingement.

Femoral deformities are common in developmental dysplasia of the hip (DDH), but decisions about how to treat them are not standardized. Of interest are deformities that may be akin to cam femoroacetabular impingement (FAI). We used three-dimensional and two-dimensional measures to clarify the similarities and differences in proximal femur shape variation among female patients with DDH (n = 68) or cam FAI (n = 60). Three-dimensional measures included femoral head asphericity, as well as shape variation using statistical shape modeling and principal component analysis (PCA). Two-dimensional measures included the α-angle, head-neck offset (HNO) and the neck-shaft angle (NSA). Significant shape variations were captured in the first five PCA modes, with the greatest shared variation between groups being the length from the lesser trochanter to the femoral head and greater trochanter height. Variations unique to DDH were irregularities at different areas of the femoral head, but not at the lateral femoral head-neck junction where variation was strong in FAI. The FAI group also had unique variations in greater trochanter shape. DDH femoral heads were less spherical, as indicated by larger sphere-fitting errors (P < 0.001). Radiographically, the DDH group had significantly smaller α-angles (P < 0.001), larger head-neck offsets (P = 0.02) and larger NSAs (P < 0.001). Both the articular and extra-articular regions of the proximal femur have distinct shape features in DDH and cam FAI that can uniquely affect the biomechanics of each disorder. Accordingly, approaches to addressing each disorder should be unique.

What Is the Carbon Footprint of Adult Spinal Deformity Surgery?

Background/Objectives: While the economic cost of adult spinal deformity (ASD) surgery has been studied extensively, its environmental impact is unknown. The aim of this study is to determine the carbon footprint (CF) associated with ASD surgery. Methods: ASD patients who underwent > four levels of corrective surgery between 2017 and 2021 were included. The open group included a posterior-only, single-stage technique, while the minimally invasive surgery (MIS) group was defined as the use of lateral interbody fusion and percutaneous posterior screw fixation. The two groups were propensity-score matched to adjust for baseline demographic, surgical, and radiographic characteristics. Data on all disposables and reusable instruments, anesthetic gas, and non-gas medications used during surgery were collected from medical records. The CF of transporting, using, and disposing of each product and the footprint of energy use in operating rooms were calculated. The CF produced was evaluated using the carbon dioxide equivalent (CO2e), which is relative to the amount of CO2 with an equivalent global warming potential. Results: Of the 175 eligible patients, 15 pairs (65 ± 9 years, 47% female) were properly matched and analyzed for all variables. The average CF generated per case was 147.7 ± 37.3 kg-CO2e, of which 54% was attributable to energy used to sterilize reusable instruments, followed by anesthetic gas released into the environment (17%) and operating room air conditioning (15%). Conclusions: The CF generated during ASD surgery should be reduced using a multidisciplinary approach, taking into account that different surgical procedures have different impacts on carbon emission sources.

Surgeon Recommendations for Physical Activity in Patients With Pediatric Hip Conditions.

BACKGROUND: While physical activity (PA) is important during youth, it is unclear if children and adolescents with developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), or slipped capital femoral epiphysis (SCFE) are expected or encouraged to return to PA once they have healed. This study examines the orthopaedic surgeons' role in advising pediatric hip patients on the PA they should engage in, assessing their practice, opinions, and consensus when making recommendations. METHODS: Orthopaedic surgeons were invited from member lists of 4 hip study groups. The survey included demographics, opinions regarding PA, and 10 case scenarios that queried respondents on the duration and intensity of PA as well as the restrictions on activity type that they would recommend for DDH, LCPD, or SCFE patients. Consensus was evaluated on a scale ranging from 0 to 1, with a value of 0 indicating no agreement among respondents and a value of 1 indicating complete agreement. RESULTS: A total of 51 orthopaedic surgeons responded. While 94% agreed that it is important for school-aged hip patients to return to PA after they have healed, 53% believed that PA may compromise the hip and contribute to the development of osteoarthritis. Average standardized consensus was 0.92 for suggesting the patient engage in some amount of PA, 0.44 for suggesting the recommended daily minimum of 60 minutes of moderate-to-vigorous physical activity (MVPA), and 0.33 for suggesting restrictions on activity type. The most frequently selected restrictions included avoiding impact activities (93%, 235/254) and contact activities (58%, 147/254), followed by weight-bearing activities (24%, 62/254). Respondents were not aware of existing PA guidelines, although 57% expressed interest in following guidelines and 39% were uncertain. CONCLUSIONS: While there is consensus among orthopaedic surgeons that children with chronic hip conditions should engage in PA, there is considerable variation when recommending the recommended daily MVPA minimum and placing restrictions on activity type. This study suggests interest among orthopaedic surgeons in developing PA guidelines that optimize outcomes for pediatric hip patients. LEVEL OF EVIDENCE: Level II-Survey study.

A Prospective Randomized Pilot Study: One-Year Outcomes of Ligament Reconstruction Tendon Interposition Versus Suture Tape Suspensionplasty for Thumb Carpometacarpal Joint Arthritis.

PURPOSE: We performed a randomized controlled trial assessing patient-reported outcome measures following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) or suture tape suspensionplasty (STS) for treatment of thumb carpometacarpal joint osteoarthritis. METHODS: Patients undergoing surgery for thumb carpometacarpal joint osteoarthritis were prospectively randomized to LRTI or STS. Outcome measures were collected at 2 weeks, 4 weeks, 3 months, and 1 year and included visual analog scale pain, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity, return to work/activity, range of motion, grip/pinch strength, and complications. RESULTS: Thirty-one patients (32 thumbs) were randomized from 51 patients offered participation over two years. One-year follow-up was 97%. Both groups had a decrease in visual analog scale pain scores at all postoperative time points. The trajectory of postoperative Patient-Reported Outcomes Measurement Information System Upper Extremity scores was similar, and both groups achieved the meaningful clinically important difference for improvement in PROMIS Upper Extremity by three months. Grip strength was substantially increased in both groups at one year. Return to work/activity and surgical complications favored the LRTI group. CONCLUSIONS: Our study did not suggest any clinically relevant differences in the postoperative patient-reported outcome measures or objective clinical measurements between LRTI and STS, although LRTI patients had a faster return to work/activity and lower complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Prospective randomized clinical trial, level IIB clinical.

Pain Management for Periacetabular Osteotomy: A Systematic Review.

Background: Early post-operative pain control is essential to facilitate rapid recovery after orthopaedic surgery. Despite periacetabular osteotomy (PAO) being the gold standard treatment of prearthritic hip dysplasia, there is limited evidence assessing efficacy of early post-operative pain management strategies. Recent literature has focused on non-opioid supplemental treatments such as nerve blocks or local wound infiltration. The purpose of this systematic review was to assess efficacy of these interventions to reduce pain, facilitate mobilization, reduce length of stay after PAO surgery. Methods: A systematic review was created under the guidance of PRISMA from databases that included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their creation dates to 12/21/23. These studies were screen based on predetermined inclusion and exclusion criteria. Results: A total of six studies were included in this analysis from independent institutions. Three investigated nerve blocks (fascia iliaca, pericapsular, transversus abdominis), one investigated local wound infiltration with ropivacaine, one investigated high-dose dexamethasone, and the last investigated removal of the epidural catheter on postoperative (POD) 1 compared to POD 2. There were heterogeneous outcomes that were measured from these studies. In general, nerve blocks decreased opioid use, pain, and length of hospital stay. The local wound infiltration decreased pain on POD 3 and 4. Removing the epidural catheter on POD1 compared to POD 2 decreased pain and length of stay. High-dose dexamethasone use decreased opioid use on POD 1, otherwise, there was no difference in pain. Conclusion: In summary, supplemental pain management strategies peri-operatively for PAO surgery can decrease pain, opioid use, and length of hospital stay, though there are few studies assessing these interventions. Limiting opioid use after surgery reduces known negative consequences of the medication and facilitates rapid recovery. Clinical trials are needed that assess efficacy of supplemental pain management strategies after PAO surgery. Level of Evidence: II.

Hip Dysplasia Treated With Periacetabular Osteotomy in Patients Over 40 Years Old: A Systematic Review.

Background: Hip dysplasia is a leading cause of hip osteoarthritis. While periacetabular osteotomy (PAO) is effective for relieving pain and dysfunction caused by hip dysplasia in adolescents and young adults, there is concern that patients over 40 years of age will have an increased risk of persistent dysfunction and need for total hip arthroplasty. Current available evidence for PAO in older adults is limited and there is no systematic review in the literature focusing on this topic. The current systematic review offers insight into the demographics, patient-reported outcome measure (PROM) scores, and hip survivorship from total hip arthroplasty in patients over 40 years older treated for hip dysplasia with PAO. Methods: The review was conducted under the guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Databases that were searched included PubMed, OVID Medline, SCOPUS, Embase, Cochrane Library, and clinicaltrials.gov. Studies were screened based on predetermined inclusion and exclusion criteria. Results: Five studies were included in this systematic review. Enrollment years were 1990-2013. In total, there were 335 hips with mean ages between 43.5-47.2 years. Mean follow up was 4-10.8 years. Most patients that underwent hip preservation had Tonnis osteoarthritis grade 0-1. There was contradicting evidence whether patients >40 years did better or worse compared to <40 years; although, most patients in the >40 years group had good outcomes after PAO. PAO survivorship ranged from 67-100% depending on the study. Complications ranged from 2-36% of cases depending on the study; although, none of these complications had lasting effects. Conclusion: Patients over 40 years old appear to have positive outcomes when treated for hip dysplasia with PAO, though these patients were likely selected for no to minimal osteoarthritis, high functional status, and good health. PAO should be considered for patients with hip dysplasia over 40 years old without hip arthritis, though we recommend very selective indications. Level of Evidence: II.

Prevalence of Radiographic Hip Dysplasia in the General Adult Population: A Systematic Review.

Background: Acetabular dysplasia has a wide range of prevalence reported in the literature. This variation is likely due to differences in the population under investigation and studies focusing on cohorts with hip pain and osteoarthritis. There are reports of radiographic hip dysplasia prevalence for adults without hip pain but there is no systematic review of these studies to document the incidence in the general population. The purpose of this systematic review was to provide a full summary of all studies that report prevalence of hip dysplasia in adults without hip pain. Methods: PRISMA guidelines were utilized as an outline for this systematic review. Articles were pulled from PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their inception dates to 1/7/24. Studies were included if participants were asymptomatic and reported rates of prevalence. Results: Fourteen studies were included in this systematic review. There were 10,998 hips from 5,506 participants included in this analysis. The overall prevalence of radiographic hip dysplasia was 2.3%. Eight studies of 5,930 hips reported the prevalence of hip dysplasia by sex. The prevalence rate in these studies was 3.8% in females and 2.7% in males. Conclusion: Acetabular dysplasia based on radiographic measurements is relatively common in the general adult population. Furthermore, females have a higher prevalence rate when compared to males. It is important to recognize the incidence of hip dysplasia in the asymptomatic adult population as we recommend surgical treatment for patients who present with hip pain and dysplasia. Further studies should investigate the natural history of untreated and treated hip dysplasia. Level of Evidence: III.

Total Hip Arthroplasty After Peri-Acetabular Osteotomy Results in Significant Improvement in Hip Function With Low Revision Rates at Mid-Term Follow-Up.

Background: Bernese periacetabular osteotomy (PAO) improves symptoms and delays degenerative changes in patients with acetabular dysplasia. Yet, eventual total hip arthroplasty (THA) is needed in many of these patients. The impact of PAO on subsequent THA outcomes is not well defined. The purpose of this study is to define: 1) clinical outcomes, 2) post-operative complications and 3) implant survivorship for patients undergoing THA after prior ipsilateral PAO. Methods: A retrospective review was conducted at three institutions to identify individuals undergoing THA after ipsilateral PAO surgery with minimum 1 year follow up. Patient reported outcome measures (PROMs) were collected preoperatively and at final follow-up. Surgical details, radiographic and clinical outcomes, and major complications according to the modified Dindo-Clavien classification system were identified through review of the medical record. Regression analysis and student's t-test were used to compare pre- and post-operative outcome scores. Kaplan-Meier analysis was performed to estimate reoperation-free survivorship. Results: A total of 113 THA in 112 patients were identified with initial review. 103 hips had a minimum of 1-year follow-up and an average follow of 5 ± 4 years (range, 1 to 20). 10 hips (9%) were lost to follow-up leaving 103 (91%) hips available for review with a minimum of 1-year follow-up (mean = 5 years). Mean interval from PAO to THA was 7.7 years (range, 2-15). The average post-operative mHHS improved 37 points (50 to 87, P < 0.001) when compared to pre-operative scores. Eight patients (7.1%) experienced a major grades III-V) surgical complication. These included 2 cases of instability, 2 cases of acetabular loosening, and one case each of periprosthetic fracture, wound dehiscence, periprosthetic infection, acetabular loosening and pneumonia. Failures occurred early at average 3.2 years and survivorship analysis for all-cause revision demonstrated 96% survivorship at both 5 and 10 years. Conclusion: THA after PAO achieves significant clinical improvement and satisfactory survivorship (96%) at mid-term follow-up, with a major complication rate of 7.1%. Level of Evidence: III.

Predictive Factors for Intraoperative Determination for the Need of Femoral Osteochondroplasty After Periacetabular Osteotomy for Acetabular Dysplasia.

Background: Determination of need for osteochondroplasty (OCP) during periacetabular osteotomy (PAO) commonly relies on intraoperative assessment of internal rotation at 90° flexion (IRF). Performing an OCP helps decrease the risk of iatrogenic femoroacetabular impingement from PAO reduction. Avoiding impingement helps decrease risks of accelerated secondary osteoarthritis. The literature is limited for factors that predict need for OCPs during PAOs. The purpose of this study was to (1) define the characteristics of patients needing concurrent OCP and provide OCP rate based on IRF and femoral version and (2) identify predictive factors (clinical, radiographic) associated with need for OCP during PAO. As some surgeons determine need for OCP pre-operatively, predictive factors would aid decision making. Methods: This was a prospective cohort of 224 hips (207 patients) who underwent PAO for symptomatic acetabular dysplasia, of which 154 hips (69%) underwent OCP between years 2013 and 2017. Patients underwent OCP if they had restrictions in motion or impingement intra-operatively. Pre-operative factors such as age, sex, BMI, and CT findings were recorded that underwent univariate and multivariable analyses. Multivariable analysis found predictors that were described using odds ratios and 95% confidence intervals. IRF>30° and femoral version 10°-25° were used as the reference groups during categorical analysis. P-values ≤0.05 were considered significant. Results: Alpha angles >55° (OR= 2.20, CI: 1.08-4.52, p= 0.03), IRF≤20° (OR: 9.52, CI: 3.87-23.40, p<0.001), IRF >20°-30° (OR: 2.68, CI: 1.08-6.62, p=0.03), and femoral version <10° (OR: 5.26, CI: 1.09-25.30, p=0.04) were associated with increased odds of OCP. On continuous modeling, decreasing femoral version (OR: 1.07, CI: 1.02-1.12, p=0.002) and IRF (OR: 1.06, CI: 1.03-1.09, p<0.001) were associated with increased chance of OCP. For 5° changes, the chance of OCP increased by 40% (OR: 1.40, CI: 1.13-1.73, p=0.002) and 35% (OR: 1.35, IC: 1.16-1.57, p<0.001), respectively. Conclusion: Awareness of need for OCP may be valuable in peri-operative planning for these patients especially since some surgeons perform this technique arthroscopically before PAO. Factors associated with increased chances of OCP were alpha angles >55°, decreased IRF, and decreased femoral version. More studies in the future would help determine how OCP affects patient outcomes. Level of Evidence: III.

Post-Operative Hyperextension Bracing Has the Potential to Reduce Proximal Junctional Kyphosis: A Propensity Matched Analysis of Braced versus Non-braced Cohorts.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine effects of bracing on proximal junctional kyphosis (PJK) after adult deformity correction. METHODS: Patients were identified from a single-surgeon dataset of posterior-only fusions for ASD (pelvis to UIV of T9-12) with a minimum of 1-year follow up. Starting in 2021, all lower thoracic fusions were braced using a hyperextension brace. Patients wore the brace at all times (unless in bed) for the first 6 weeks after surgery. A 1:1 propensity-match was performed based on age, number of levels, 3 column osteotomies, and magnitude of correction to identify a comparative non-braced cohort. RESULTS: 141 patients (113 non-brace, 28 brace) were evaluated. After matching, 56 patients were identified to form similar cohorts. Non-matched and matched groups had no statistically significant differences in demographics, comorbid conditions, surgical characteristics (except shorter operative time and lower EBL in the braced group), and preoperative radiographic parameters. For the overall cohort, the change in proximal junctional angle at 1-year was higher in the non-braced group (7.6° vs 8.1°, P = .047), and non-braced patients had a higher incidence of PJK at 1-year in both the overall cohort (36% vs 14%, P = .045) and matched cohort (43% vs 14%, P = .038). There was no difference in proximal junctional failure between groups. CONCLUSION: This pilot study shows that our protocol for extension bracing may reduce rates of PJK. These findings can form the basis for future multi-center trials examining the effect of extension bracing on junctional complications.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Prediction of 3-Dimensional Coverage Surface Area of the Femoral Head in Hip Dysplasia Through Conventional Computed Tomography.

Background: Assessment of 3-dimensional (3D) femoral head coverage is critical in evaluating, preoperative planning, and treating hip dysplasia. Purpose: To (1) propose a mathematical model to establish 3D femoral head coverage using conventional computed tomography (CT), (2) determine the correlation of 2D parameters with 3D coverage, and (3) characterize the patterns of dysplasia based on 3D morphology. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We identified 30 patients (n = hips) with symptomatic dysplasia and 30 patients (n = hips) without dysplasia. Patients with dysplastic hips were matched with regard to sex, age, and body mass index to those with nondysplastic hips. Preoperative CTs were analyzed using 3D software, and 3D femoral head surface area coverage (FHSAC; in %) was assessed in 4 quadrant zones: anteromedial, anterolateral, posteromedial, and posterolateral. To assess lateral coverage of the femoral head, we introduced the anterolateral femoral head coverage angle (ALFC) and the posterolateral femoral head coverage angle (PLFC). Results: Reduced femoral head coverage was more pronounced in dysplastic versus nondysplastic hips in the anterolateral quadrant (18% vs 40.7%, respectively) and posterolateral quadrant (35.8% vs 56.9%, respectively) (P < .0001 for both). Dysplastic hips had smaller ALFC and PLFC (18.4° vs 38.7°; P < .0001; 47.2° vs 72.3°; P = .0002). Anterolateral and posterolateral FHSAC were strongly correlated with the ALFC (r = 0.88; P < .0001) and the PLFC (r = 0.82; P < .0001) along with the lateral center-edge angle (anterolateral, r = 0.75; P < .0001; posterolateral, r = 0.73; P < .0001). Prediction models established for FHSAC had strong agreement with explanatory CT variables (anterolateral: r = 0.91; P < .0001; posterolateral: r = 0.90; P < .0001). The cutoff values for anterolateral and posterolateral FHSAC were 25% and 41%, respectively. In dysplastic hips, global deficiency was most common (15/30 hips), 9 hips showed an anterolateral deficiency, and 4 hips had a posterolateral deficiency pattern. Conclusion: The ALFC and The PLFC were strongly correlated with 3D lateral FHSAC and were able to predict 3D coverage accurately.

Ten Year Outcomes of Contemporary Total Hip Arthroplasty in Adolescent and Young Adult Patients are Favorable.

BACKGROUND: The purpose of this study was to assess 10-year patient-reported outcome measures, complications, polyethylene wear-rates, and implant survivorships in patients ≤30 years of age treated with contemporary total hip arthroplasty (THA). METHODS: We retrospectively assessed 121 patients (144 hips) who underwent THA at age ≤30 years (mean 23 [range, 11 to 30]) at an average follow-up duration of 10.7 years (range, 8 to 17). Highly-crosslinked polyethylene acetabular liners were used in all cases. Femoral heads were ceramic (74%) or cobalt-chrome (26%). There were 52 hips (36%) that had previous surgery and 31 hips (22%) were in patients who had associated major systemic comorbidities. We analyzed the modified Harris Hip scores, University of California Los Angeles Activity Scores, major complications, polyethylene wear-rates, and implant survivorships. RESULTS: At final follow-up, the average modified Harris Hip scores improved from 47 (±15.1) to 81 (±19.5) with an average 34-point improvement. The University of California Los Angeles scores improved from 4.0 (±2.3) to 6.0 (±2.4). The major complication rate was 5.6%. There were 6 hips (4.2%) that were revised. Indications for revision included instability (3, 2.1%), late infection (1, 0.7%), liner dissociation (1, 0.7%), and acetabular loosening (1, 0.7%). Mean linear (0.0438 mm/y) and volumetric (29.07 mm3/y) wear rates were low. No periprosthetic osteolysis was detected in any hip. Survivorship free from revision for any reason was 97.2, 95.8, and 95.8% at 5, 10, and 15 years. CONCLUSIONS: Contemporary THA in patients ≤30 years of age is associated with marked clinical improvements at 10-year follow-up and encouraging survivorship estimates at 15 years.

Comparison Between Movement Pattern Training and Strengthening on Kinematics and Kinetics in Patients With Chronic Hip-Related Groin Pain.

The purpose of this study was to compare the preliminary effects of movement pattern training (MoveTrain) versus strengthening/flexibility (standard) treatment on hip and pelvic biomechanics in patients with chronic hip-related groin pain. This is a secondary analysis of data collected during a pilot randomized clinical trial. Thirty patients with hip pain, between the ages of 15 and 40 years, were randomized to MoveTrain or standard. Both groups completed 10 treatment sessions over 12 weeks along with a daily home exercise program. Three-dimensional motion analysis was used to collect kinematic and kinetic data of the pelvis and hip during a single-leg squat task at pretreatment and immediately posttreatment. Compared with the standard group, the MoveTrain group demonstrated smaller hip adduction angles (P = .006) and smaller hip external adduction moments (P = .008) at posttreatment. The desired changes to hip joint biomechanics, as found in this study, may require specificity in training that could allow health care professionals to better customize the rehabilitation of patients with hip pain. These findings can also be applied to the design and implementation of future clinical trials to strengthen our understanding of the long-term implications of different rehabilitation techniques for patients with hip pain.

Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient.

BACKGROUND: Surgical treatment for adolescent patients with femoroacetabular impingement (FAI) is increasing. The purpose of this study was to determine the clinical outcomes of FAI surgery in a multicenter cohort of adolescent patients and to identify predictors of suboptimal outcomes. METHODS: One hundred twenty-six adolescent hips (114 patients < 18 years of age) undergoing surgery for symptomatic FAI were studied from a larger multicenter cohort. The group included 74 (58.7%) female and 52 male hips (41.3%) with a mean age of 16.1 (range 11.3 to 17.8). Clinical outcomes included the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (5 domains), and University of California Los Angeles activity score. Failure was defined as revision surgery or clinical failure (inability to reach minimally clinical important differences or patient acceptable symptoms state for the mHHS). Statistical analysis was used to identify factors significantly associated with failure. RESULTS: There was clinically important improvement in all patient-reported outcomes for the overall group, but an 18.3% failure rate. This included a revision rate of 8.7%. Females were significantly more likely than males to be classified as a failure (25.7 vs. 7.7%, P =0.01), in part because of lower preoperative mHHS (59.1 vs. 67.0, P < 0.001). Mild cam deformity (alpha angle <55 degrees) was present in 42.5% of female hips compared with 17.3% male hips. Higher alpha angles were inversely correlated with failure. Alpha angles >63 have a failure rate of 8.3%, between 55 and 63 degrees, 12.0% failure rate, and <55 degrees (mild cam) failure rate of 37.5%. Patients who participated in athletics had a 10.3% failure rate compared with nonathletes at 25.0% ( P =0.03, RR (relative risk) 2.4). CONCLUSIONS: Adolescent patients undergoing surgical treatment for FAI generally demonstrate significant improvement. However, female sex, mild cam deformities, and lack of sports participation are independently associated with higher failure rates. These factors should be considered in surgical decision-making and during patient counseling. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Excellent 20-Year Results of Total Hip Arthroplasty With Highly Cross-Linked Polyethylene on Cobalt-Chromium Femoral Heads in Patients ≤50 Years.

BACKGROUND: Highly cross-linked polyethylene (HXLPE) acetabular bearing surfaces have appeared to offer excellent wear resistance, low incidence of wear-related osteolysis, and high implant survivorship at 10-year to 15-year follow-up. However, concerns over potential performance deterioration at longer-term follow-up remain - particularly in younger patients - and outcome data into the third decade have not been available. METHODS: We retrospectively assessed 62 patients (68 hips) who underwent primary total hip arthroplasty (THA) at age ≤50 years with a single manufacturer's cementless components, remelted HXLPE liner, and small diameter (26 and 28 millimeter) cobalt-chromium (CoCr) femoral heads at minimum 18-year follow-up. We assessed clinical outcomes (modified Harris Hip score, University of California Los Angeles Activity Score, polyethylene wear rates, radiographic findings (osteolysis, component loosening), and implant survivorship. RESULTS: At 20.6-year mean follow-up (range, 18 to 23 years) modified Harris Hip scores for surviving hips remained an average of 41 points above preoperative baseline (49 versus 90, P < .001) and UCLA scores 2.8 points above baseline (3.7 versus 6.4, P < .001). Wear analysis revealed a population linear wear rate of 0.0142 mm/y (standard deviation (SD), 0.0471) and volumetric wear rate of 10.14 mm3/y (SD, 23.41). Acetabular lysis was noted in 2 asymptomatic hips at 16.6 and 18.4 years. No components were radiographically loose. Survivorship free from wear-related revision was 100% at 20 years (97% free from any revision). CONCLUSION: The HXLPE-CoCr bearing couple with small femoral heads continues to be extremely effective 20 years after primary THA in the younger patient population.

Revealing a Natural Model of Pre-Osteoarthritis of the Hip Through Study of Femoroacetabular Impingement.

Femoroacetabular impingement (FAI) is considered the mechanical cause of hip osteoarthritis (OA). Surgical intervention involves labrum repair and osteochondroplasty to remove the impingement, alleviating symptoms. Nevertheless, some patients progress to hip OA after surgery, indicating that factors other than mechanical abnormality are contributing to hip OA progression. This review article discusses our laboratory's studies on hip FAI and OA, undertaken to identify key molecular players in the progression of hip OA. Transcriptome analysis identified peroxisome proliferator activated receptor gamma (PPARγ) as a crucial molecule in early hip OA. PPARγ, widely expressed in chondrocytes, has a protective role in preventing OA, but its true mechanism remains unknown. We observed a dysregulation of DNA methyltransferase (DNMT) in the progression of hip OA, with high expression of DNMT1 and 3A and downregulation of DNMT3B. Moreover, we established that DNMT3A is the main molecule that is binding to PPARγ promoter CpG area, and hypermethylation of this area occurs during disease progression. This suggests that epigenetic changes are a main mechanism that regulates PPARγ expression. Finally, we developed a novel rabbit model of hip FAI and OA and are currently performing studies to validate our small-animal model to human FAI.

Personal factors and baseline function in patients undergoing non-operative management for chronic hip-related groin pain: a cross-sectional study.

Aim: Little is known about the relationship between personal factors and perception of hip-related function among patients with chronic hip-related groin pain (HRGP) seeking non-operative management. This analysis was performed to determine if depressive symptoms, central sensitisation, movement evoked pain (MEP), pressure hypersensitivity and activity level were associated with patients' perception of hip-related function, represented by the International Hip Outcome Tool (iHOT-33). Methods: This cross-sectional study used baseline data from a pilot randomised clinical trial. Participants had anterior hip symptoms for at least 3 of the past 12 months reproduced on examination. Depressive symptoms, central sensitisation and activity level were quantified with self-report questionnaires. MEP was assessed during step down and squat. Pain pressure threshold (PPT) was used to assess pressure hypersensitivity. Statistical analysis was performed to assess bivariate association between variables and independent association of variables with iHOT-33. Results: Data from 33 participants (aged 18-40 years) with HRGP were analysed. Greater depressive symptoms (rs=-0.48, p=0.005), higher MEP during step down (rs=-0.36, p=0.040) and squat (rs=-0.39, p=0.024), and greater central sensitisation (rs=-0.33, p=0.058) were associated with lower (worse) iHOT-33 scores. Greater depressive symptoms (ß=-0.47, 95% CI -0.76 to -0.17; p=0.003) and higher MEP during squat (ß=-0.38, 95% CI -0.68 to -0.08; p=0.014) accounted for 37% of variability in iHOT-33. After adjusting for depressive symptoms and MEP, PPT, central sensitisation symptoms and activity level were not associated iHOT-33. Conclusions: In patients with HRGP seeking non-operative management, greater depressive symptoms and MEP are independently associated with worse self-perceived hip function. Trial registration number: NCT03959319.

Team Approach: Hip Preservation Surgery.

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.