Periacetabular Osteotomy in United States Military Personnel: Results From an Interservice Hip Preservation Practice.

BACKGROUND: Untreated or residual developmental dysplasia of the hip may cause significant morbidity. Periacetabular osteotomy (PAO) allows for surgical reorientation of the acetabulum but requires a significant recovery period. Because of the physical demands of active military service, hip dysplasia or its treatment with PAO may cause a significant impact on the careers of affected personnel. PURPOSE: To measure the impact of symptomatic acetabular dysplasia and its treatment with PAO on the physical readiness of personnel in the United States Armed Forces. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Records from an interservice hip-preservation practice were reviewed for all patients who underwent PAO while on active duty from January 2014 through April 2017. Collected information included branch of service, military occupation, preoperative duty restrictions related to the hip, and concomitant surgical procedures. Patients were evaluated for a minimum of 24 months and assessed for their time to return to duty, continued duty restrictions, and referrals to the medical evaluation board. RESULTS: Twenty patients (15 female, 5 male) underwent a PAO while on active duty during the period assessed. The mean patient age at surgery was 25.9 years, and the mean follow-up was 3.3 years (range, 2.3-5.4 years). In the 6 months preceding surgery, 94% of the 17 patients with available records were on duty restrictions specific to their hip (14 temporary, 2 permanent). After PAO, 35% of patients (n = 7) returned to full duty and 85% were able to remain on active duty (n = 12) or complete their military service commitments (n = 5) without noted medical disability. Three patients were medically discharged after PAO, with 1 patient referred due to hip pathology. CONCLUSION: Acetabular dysplasia significantly affects physical readiness in affected servicemembers, with 94% requiring duty restrictions. PAO allowed 85% of patients to return to military service, and 1 in 3 were able to return to full duty.

Acetabular labral tears in the adolescent athlete: results of a graduated management protocol from therapy to arthroscopy.

This study sought to determine outcomes of a graduated management protocol from therapy to arthroscopy for adolescents presenting with hip pain and an associated acetabular tear. Thirty-seven hips with an MRI confirmed labral tear were prospectively enrolled in a graduated management protocol created for adolescents. The protocol began with activity modification and focused physical therapy. Patients with persistent symptoms were offered an intraarticular corticosteroid injection. Those with continued symptoms were treated with arthroscopic surgery. The modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were recorded at the initial visit. Patients were contacted by telephone at 1, 2, and 5 years from enrollment for repeat assessment with mHHS and NAHS. At presentation, the mean mHHS and NAHS for the entire cohort was 66.4 ± 11.4 and 70.2 ± 12.6, and these values improved significantly to 89.3 ± 10.6 and 87.0 ± 11.4 at a mean follow-up of 35.7 ± 18.3 months (range 11.7-64.4 months). Forty-two percent of hips were managed with physical therapy and activity modifications alone, 28% of hips progressed to a steroid injection but did not require surgery, and 31% required arthroscopic intervention. Seventy-three percent of hips treated with activity modification alone, 80% treated with an injection, and 82% of hips treated with arthroscopic repair met the minimal clinically significant difference (MCID) (P = 0.859). At an average of 36 months follow-up, the majority (78%) of adolescent patients with an acetabular labral tear will achieve the MCID utilizing a graduated management protocol.

Developmental Dysplasia of the Hip in Adolescents and Young Adults.

Developmental dysplasia of the hip (DDH) in adolescents and young adults can cause notable pain and dysfunction and is a leading cause of progressive hip osteoarthritis in affected patients. Recognition of the clinical symptoms and radiographic presentation of DDH in adolescents and young adults are paramount for early management. Plain radiographs are critical for making proper diagnosis, whereas three-dimensional imaging including MRI and/or CT detects intra-articular pathology and better characterizes hip morphology. Management of early, symptomatic DDH includes nonsurgical modalities and open joint preservation techniques. Arthroscopic management can be used as an adjunct for symptomatic treatment and for addressing intra-articular pathology, but it alone does not correct the underlying osseous dysplasia and associated instability. The periacetabular osteotomy has become the mainstay of efforts to redirect the acetabulum and preserve the articular integrity of the hip; however, the proximal femur is also a potential source of pathology that should be considered. Open hip procedures are technically demanding yet provide the opportunity for pain relief, improved function, and preservation of the hip joint.

Osteoid Osteoma at the Lesser Trochanter: A Lesson in Mimicry.

A 16-year-old female soccer player presented with an eight-month-old, insidious right-hip pain. The imaging workup demonstrated a cortically based lytic lesion at the level of the lesser trochanter with surrounding sclerosis, adjacent periosteal reaction, and a small soft-tissue mass. A biopsy revealed findings related to an osteoid-forming lesion with features of nuclear atypia. The patient's pathology referral returned a diagnosis of osteoid osteoma, and she was treated with CT-guided cryoablation. She had an excellent response and returned to full activities through nearly two years of surveillance. In similar patients approaching skeletal maturity, the differential diagnosis for bone lesions involving the lesser trochanter ranges from post-traumatic to primary oncologic processes. Given the implications of a missed malignancy, vigilance is required when treating young and active patients.

Analysis of References Used in Orthopaedic Self-Assessment Exams.

Orthopaedic surgery board certification and maintenance of certification requires success on standardized tests and ongoing continuing medical education. This study aims to identify the most impactful resources for preparation for and maintenance of board certification. Questions included in the Orthopaedic Self-Assessment Exams (SAEs) from 2009 to 2014 were examined with the type and age of reference materials cited for each question. There were 4479 total citations. There were 289 journals and 95 textbooks identified. The Journal of Bone and Joint Surgery (15% of citations), Journal of the American Academy of Orthopaedic Surgeons (11%), and Clinical Orthopaedic and Related Research (6%) were the most frequently cited journals. The average age of cited articles was 8.2 years. These data demonstrate that certain orthopaedic journals are consistently the most commonly cited references for SAEs and could also be expected to be the highest yield references for knowledge acquisition and exam preparation. (Journal of Surgical Orthopaedic Advances 27(2):92-97, 2018).

An Impaled Potential Unexploded Device in the Civilian Trauma Setting: A Case Report and Review of the Literature.

BACKGROUND: The management of patients with impaled unexploded devices is rare in the civilian setting. However, as the lines of the traditional battlefield are blurred by modern warfare and terrorist activity, emergency providers should be familiar with facility protocols, plans, and contact information of their local resources for unexploded devices. CASE REPORT: A 44-year-old male sustained a close-proximity blast injury to his lower extremities while manipulating a mortar-type firework. He presented to the regional trauma center with an open, comminuted distal femur fracture and radiographic evidence of a potential explosive device in his thigh. His management was coordinated with the local Explosive Ordinance Disposal and the fire department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Explosive devices pose a grave threat when encountered. Familiarization with protocols to manage these patients can mitigate disaster. Emergency providers should expect and be prepared to coordinate care for these patients.

An Analysis of the Most Commonly Tested Topics and Their Taxonomy From Recent Self-Assessment Examinations.

OBJECTIVE: The purpose of this study is to determine the most commonly tested topics and the question taxonomy of the American Academy of Orthopaedic Surgeons Self-Assessment Examinations (SAE) from 2009 through 2014. DESIGN: All SAEs were analyzed from 2009 through 2014. The SAEs were separated by subject and the questions of each SAE were analyzed for topic, taxonomic classification, and question type. RESULTS: A total of 2107 questions were reviewed from 10 different subjects. In all, 6 of the 9 subjects had roughly 1/3 of their questions composed of the 3 most commonly tested topics. Each subject had at least 1 trauma-related question within its top 5 most commonly tested topics. Almost half (47%) of all questions were of taxonomy 1 classification and 29% were taxonomy 3. The Basic Science SAEs had the greatest percentage of taxonomy 1 questions of any subject (83%) whereas Trauma contained the highest percentage of taxonomy 3 questions (47%). CONCLUSIONS: Certain topics within each subject are consistently tested more often than other topics. In general, the 3 most commonly tested topics comprise about one-third of total questions and orthopedic surgeons should be very familiar with these topics in order to best prepare for standardized examinations.

Total knee arthroplasty for posttraumatic osteoarthritis in military personnel under age 50.

United States military personnel frequently suffer knee injuries. The resulting progressive posttraumatic osteoarthritis (PTOA) causes significant disability in these young high-demand patients for which total knee arthroplasty (TKA) is the only effective treatment of their pain and impairment. Yet the use of this option for treatment of PTOA has not been studied. This retrospective review identified 74 knees in 64 U.S. military personnel who underwent TKA at ≤50 years of age during an 8-year period at a tertiary-care, academic, military medical center. Fifty-five knees (74.3%) experienced one or more prior ligamentous, meniscal, or chondral injuries prior to arthroplasty. Only one subject had a history of osteochondral intra-articular fracture. The average at injury was 29.2 years (95%CI of ±2.50) with an average age at arthroplasty of 44.3 years (±1.11). The most common injury was anterior cruciate ligament rupture (n = 19) with a mean time to TKA of 23.1 (±10.54) and 18.8 years (±7.01) when concomitant meniscal pathology was noted. Nineteen patients were noted to have radiographic and symptomatic end-stage osteoarthritis without a specified etiology at 41.4 years (±1.47) and underwent subsequent TKA. This is the first study to evaluate treatment of end-stage PT OA in young people treated with TKA, finding that the incidence of PTOA as an indication for arthroplasty is significantly higher than among civilians. In this otherwise healthy, high-demand patient population, the rate of OA progression following knee injury is accelerated and the long term implications can be career and life altering. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:677-681, 2017.

Thin-Walled Cross-Linked Acetabular Liners Need Not Exhibit Reduced Locking Strength.

Use of larger diameter femoral heads has emerged as a promising strategy to reduce the risk of dislocation after total hip arthroplasty, but thinning the walls of cross-linked ultra-high-molecular-weight polyethylene (UHMWPE) acetabular liners to accommodate these larger heads may compromise the locking mechanism of the liner. The purpose of this study was to test the mechanical integrity of the locking mechanism in cross-linked and re-melted UHMWPE acetabular components with reduced wall thickness. The locking mechanism of cross-linked (100 kGy/re-melted) acetabular liners in sizes 50/28, 50/36, and 52/36 mm of 1 design was evaluated by lever-out tests and torsion tests. Torsion tests were performed at 2 angles to isolate the liner's locking tabs independent of the contribution of its central post. Lever-out testing demonstrated nominally reduced failure strength in 50/36-mm liners (13.3 N · m) compared with 50/28-mm liners (12.3 N · m; P=.0502), whereas the lever-out strength of 52/36-mm liners was 12.2±0.94 N · m. Failure torques were similar between 50/28- and 50/36-mm liners at 45° and 90°, but the failure torque of size 52/36-mm liners was significantly higher at each angle. The use of larger diameter femoral heads does not compromise the locking mechanism of thinned MicroSeal (Signal Medical Corp, Marysville, Michigan) acetabular liners. Use of a cross-linked UHMWPE acetabular liner, with a locking mechanism that is not compromised when the liner is thinned to a thickness of at least 2.86 mm, appears to be a biomechanically sound construct when articulated with large diameter femoral heads.