Multiple deep tissue cultures in primary total hip arthroplasty: prognostic value for periprosthetic infection.

BACKGROUND: The risk of infection after total hip replacement (THR) is significant, with negative impact on quality of life and high costs. Bacteria can contaminate the surgical site despite aseptic techniques; however, there is debate regarding the benefit of identifying bacteria during the primary procedure. Although taking multiple samples for culture is a well-established practice in revision arthroplasty, doing so in primary cases remains controversial. We aimed to investigate whether there is a prognostic value in the culture of samples taken during primary THR, seeking a correlation between the positivity of the cultures and subsequent prosthetic joint infection (PJI). METHODS: Deep samples (capsule, femoral and acetabular bone) were collected from 426 patients undergoing elective primary THR. Follow-up was at least 3 years. Microbiological profiles of cultures were analysed. Patient data were reviewed for the identification of risk factors presumably associated with a higher risk of PJI. RESULTS: 54 surgeries (12.6%) had positive cultures. 16 cases (3.8%) developed infection, of which 5 had a positive culture in the primary surgery. Infection rate was 9.3% in patients with positive culture and 3% in those with negative culture (p < 0.05), with an odds ratio of 3.34 (95% CI, 1.09-10.24). Patients with previous hip surgery had an infection rate of 8.5%, compared to 2.9% in patients with no previous surgery (p < 0.05). CONCLUSIONS: Routinely harvesting microbiologic samples in primary THR is not justified, as it has no consequence in clinical decision for most patients. It might be recommended in selected cases that are suspected to be at high risk for infection, especially previously operated patients (conversion arthroplasty).

Iliopsoas Bursitis Managed with Endoscopic Bursectomy and Lesser Trochanter Decompression: A Case Report.

CASE: A 32-year-old woman presented with worsening right anterior hip pain, reduced hip flexion strength, and passive range of motion during hip flexion. Magnetic resonance imaging of the hip demonstrated a prominent lesser trochanter and localized fluid signal intensity at the iliopsoas bursa. The patient underwent endoscopic iliopsoas bursectomy and lesser trochanterplasty, reporting improvement in all clinical outcome scores at 1-year follow-up. CONCLUSION: Lesser trochanter morphology should be evaluated in patients presenting with iliopsoas bursitis. In patients failing to respond to conservative management, endoscopic iliopsoas bursectomy and lesser trochanterplasty may address pain and functional limitations.

Clinically Significant Outcome Improvement After Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome and Severe Femoral Torsion.

BACKGROUND: The influence of femoral torsion on clinically significant outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has not been well-studied. PURPOSE: To quantify femoral torsion in FAIS patients using magnetic resonance imaging (MRI) and explore the relationship between femoral torsion and clinically significant outcome improvement after hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were patients who underwent hip arthroscopy for FAIS between January 2012 and August 2018 and had 2-year follow-up and preoperative MRI scans containing transcondylar slices of the knee. Participants were categorized as having severe retrotorsion (SR; <0°), normal torsion (NT; 0°-25°), and severe antetorsion (SA; >25°) as measured on MRI. Patient-reported outcomes (PROs) included the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score, 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. Achievement of Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were analyzed among cohorts. RESULTS: Included were 183 patients (SR, n = 13; NT, n = 154; SA, n = 16) with a mean age, body mass index, and femoral torsion of 30.6 ± 12.1 years, 24.0 ± 4.4 kg/m2, and 12.55° ± 9.58°, respectively. The mean torsion was -4.5° ± 2.6° for the SR, 12.1° ± 6.8° for the NT, and 31.0° ± 3.6° for the SA group. There were between-group differences in the proportion of patients who achieved PASS and SCB on the iHOT-12, pain VAS, and any PRO (P < .05). Post hoc analysis indicated that the SA group achieved lower rates of PASS and SCB on the iHOT-12 and pain VAS, and lower rates of PASS on any PRO versus the SR group (P < .05); the SR group achieved higher rates of PASS and SCB on pain VAS scores versus the NT group (P = .003). CONCLUSION: The orientation and severity of femoral torsion during hip arthroscopy influenced the propensity for clinically significant outcome improvement. Specifically, patients with femoral retrotorsion and femoral antetorsion had higher and lower rates of clinically significant outcome improvement, respectively.

Association Between Orientation and Magnitude of Femoral Torsion and Propensity for Clinically Meaningful Improvement After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Computed Tomography Analysis.

BACKGROUND: Femoral torsion imaging measurements and classifications are heterogeneous throughout the literature, and the influence of femoral torsion on clinically meaningful outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has not been well studied. PURPOSE: To (1) perform a computed tomography (CT)-based analysis to quantify femoral torsion in patients with FAIS and (2) explore the relationship between the orientation and magnitude of femoral torsion and the propensity for clinically meaningful outcome improvement after hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Consecutive patients who underwent hip arthroscopy for FAIS between January 2012 and April 2018 were identified. Inclusion criteria were the presence of preoperative CT imaging with transcondylar slices of the knee and minimum 2-year outcome measures. Exclusion criteria were revision hip arthroscopy, Tönnis grade >1, congenital hip condition, hip dysplasia (lateral center-edge angle <20°), and concomitant gluteus medius or minimus repair. Torsion groups were defined as severe retrotorsion (SR; <0°), moderate retrotorsion (MR; 0°-5°), normal torsion (N; 5°-20°), moderate antetorsion (MA; 20°-25°), and severe antetorsion of antetorsion (SA; >25°). Treatment did not differ based on femoral torsion. Patient characteristics and clinical outcomes were analyzed, including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and VAS for satisfaction. Achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) by torsion stratification was analyzed using the chi-square test. Inter- and intrarater reliabilities for CT measurements were 0.980 (P < .001) and 0.974 (P < .001), respectively. RESULTS: The study included 573 patients with a mean ± SD age and body mass index of 32.6 ± 11.8 years and 25.6 ± 10.6, respectively. The mean ± SD femoral torsion for the study population was 12.3°± 9.3°. After stratification, the number of patients within each group and the mean ± SD torsion for each group were as follows: SR (n = 36; -6.5°± 7.1°), MR (n = 80; 2.8°± 1.4°), N (n = 346; 12.3°± 4.1°), MA (n = 64; 22.2°± 1.4°), and SA (n = 47; 30.3°± 3.7°). No significant differences in age, body mass index, sex, tobacco use, workers' compensation status, or participation in physical activity were observed at baseline. No significant differences were seen in pre- and postoperative VAS pain, mHHS, HOS-ADL, HOS-SS, iHOT-12, or postoperative VAS satisfaction among the cohorts. Furthermore, no statistically significant differences were found in the proportion of patients who achieved the MCID or the PASS for any outcome among the groups. CONCLUSION: The orientation and severity of femoral torsion at the time of hip arthroscopy for FAIS did not influence the propensity for clinically significant outcome improvement.

Indications and Outcomes for Arthroscopic Hip Labral Reconstruction With Autografts: A Systematic Review.

Background: The acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include iliotibial band (ITB), semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts. Questions/Purposes: As allografts are not always readily available and have some inherent disadvantages, the aims of this systematic review were to assess (1) indications for labral reconstruction and (2) summarize outcomes, complications, and reoperation rates after arthroscopic labral reconstruction with autografts. Methods: A systematic review of the literature was performed using six databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, reoperation rates, conversion to arthroplasty, and patient reported outcomes were extracted and reported. Results: Seven studies were identified for inclusion with a total of 402 patients (173 females, age range 16-72, follow-up range 12-120 months). The most commonly reported functional outcome score was the modified Harris Hip Score (mHHS), which was reported in six of seven studies. Preoperative mHHS ranged from 56 to 67.3 and improved postoperatively to a range of 81.4-97.8. Conversion to total hip arthroplasty and reoperation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of rectus femoris, and capsular tissue. Conclusions: Arthroscopic autograft reconstruction of the acetabular labrum results in significant improvement in the short- and mid-term patient reported outcomes, for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.

No Differences in Hip Joint Space Measurements Between Weightbearing or Supine Anteroposterior Pelvic Radiographs.

PURPOSE: To to assess whether there are any significant differences in hip joint space width (JSW) between weight-bearing versus supine pelvic radiographs. METHODS: Standing and supine anteroposterior pelvic radiographs of 86 patients (146 hips) were included. Sample size was sufficiently powered to assess for equivalence between standing and supine films for JSW measurements made at the medial, lateral, and central aspects of the sourcil line. Measurements were made by 2 independent reviewers blinded to patient positioning. Each reviewer repeated a subset of the measurements to assess intra-rater reproducibility. Mean differences in joint space measurements between standing and supine radiographs were reported for each point of the sourcil. Intraclass correlation coefficients (ICCs) for inter and intra-rater reliability were also calculated. RESULTS: There were no significant differences between JSW measurements made on standing and supine pelvic radiographs (P = .468). Furthermore, equivalence testing demonstrated statistical equivalence between standing and supine JSW measurements made based on an equivalence threshold of ±0.5 mm. Inter-rater reliability demonstrated good agreement with an overall ICC of 0.775 (95% confidence interval [CI] 0.734-0.809). Intra-rater reliability also demonstrated good agreement with ICCs of 0.84 (95% CI 0.758-0.889) and 0.798 (95% CI 0.721-0.851) for the 2 reviewers, respectively. CONCLUSIONS: JSW measurements on standing and supine pelvic radiographs were not significantly different, and their inter-rater agreement and intra-rater reproducibility demonstrated good reliability and repeatability. Therefore, either may be used to assess JSW, including measurements that may impact treatment decisions for hip arthroscopy. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Arthroscopic bullet removal from the hip joint and concurrent treatment of associated full-thickness chondral defects: A case report.

The diagnosis of a bullet inside the hip joint is a rare finding. The usual method to treat this condition has been open surgery, with its associated complications and morbidity. The arthroscopic approach has been increasingly utilized for the diagnosis and treatment of several hip conditions, and the number of indications for this technique has been steadily rising. We report the case of a 35-year-old man who suffered a gunshot wound and was operated on for abdominal perforation. He later presented with groin pain that worsened with weight-bearing on his right leg and then underwent arthroscopic removal of a bullet located inside his right hip joint. After a 2-year follow-up, the patient had an excellent clinical outcome, with no radiologic signs of arthritis. The removal of an intra-articular projectile is necessary to avoid complications such as synovitis, osteoarthritis, septic arthritis, and saturnism. The best access to the hip joint remains a topic of debate. Arthroscopy has the advantage of less soft-tissue damage and quicker recovery. The treatment of associated chondral lesions can be done with several techniques, including microfracture, autologous chondrocyte implantation, mosaicplasty, and fresh osteochondral allograft transplantation. There is no consensus as to the best course of treatment for associated chondral lesions in such cases. Hip arthroscopy can be a safe and effective technique for the removal of intra-articular bullets in the hip.