The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multi-Center 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 endpoint being the International Hip Outcome Tool-33 (iHOT-33) at one year. METHODS: In a multi-center study, two hundred and three 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 (BMI) 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 BMI 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 significant improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months post-surgery on all scores: pre-operative iHot-33 score of 31.2 (SD [standard deviation] 16.0) versus 36.4 (SD 15.9), and 12 months post-operative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6)]. The pre-operative Hip disability and Osteoarthritis Outcome (HOOS)-pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0)] and 12 months post-operative [88.2 (SD 15.8) versus 88.4 (SD 18.3)]. The mean pre-operative physical health Patient-Reported Outcomes Measurement Information System (PROMIS) score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months post-operative [48.7 (SD 8.5) versus 52.0 (SD 10.6)]. There were four patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and one patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSION: This Randomized Controlled Trial (RCT) has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at one-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Can Patients Who Have Low-Grade Hip Osteoarthritis Expect the Same Outcome After Total Hip Arthroplasty Compared to Those Who Have End-Stage Osteoarthritis? - A Matched Case-Control Study.

BACKGROUND: Total hip arthroplasty (THA) is an effective procedure for patients with end-stage hip osteoarthritis (OA). In addition, when hip preservation surgery is no longer indicated due to the presence of early or mild arthritic changes, THA can also be considered. Whether these patients can expect the same outcome after THA as patients who have end-stage OA remains unclear. The goal of this study was to compare the clinical outcomes after THA of patients who have low-grade OA versus a matched cohort with end-stage OA. METHODS: This is a retrospective, single-center, multisurgeon case-control study in a high-volume referral center. Based on a cohort of 2,189 primary anterior approach THAs (1,815 patients), 50 low-grade OA cases were matched 1:1 by age, sex, and body mass index to 50 controls who have end-stage OA. Patient-reported outcome measures (PROMs) were Hip Disability and Osteoarthritis Outcome Scores and Short Form-36. RESULTS: No significant differences in preoperative PROMs between low-grade and end-stage OA patients were found, except for 36-item Short Form Survey pain (33.0 versus 41.0; P = .045). In both groups a significant improvement of all PROMs was found postoperatively. However, all Hip Disability and Osteoarthritis Outcome Scores were significantly lower in the low-grade OA group compared to the end-stage OA group. In the group with low-grade OA, a significantly lower percentage of patients achieved the minimal clinically important difference and substantial clinical benefit after THA compared to the group with end-stage OA. CONCLUSIONS: Patients who have low-grade OA can expect substantial clinical improvement after THA. However, the improvement is lower compared to patients who have end-stage OA. A thorough understanding of the factors that may lead to inferior clinical outcomes is imperative to improving the indications for THA in individuals who have low-grade OA.

What patient parameters influence lumbar stiffness in patients with hip pathology?

Lumbar stiffness leads to greater hip dependence to achieve sagittal motion and increases instability after total hip arthroplasty (THA). We aimed to determine parameters that influence lumbar stiffness among patients with hip pathology. We hypothesized that modifiable (degenerative changes, spinal canal stenosis, facet orientation) and nonmodifiable factors (muscle condition) would be associated with lumbar spine stiffness. In this retrospective case-cohort study from a tertiary referral center, consecutive patients presenting at a hip specialist clinic underwent standing and deep-seated radiographic assessment to measure lumbar lordosis (∆LL) (stiffness: ∆LL < 20°), hip flexion (∆PFA: pelvic femoral angle), and degree of degenerative-disc-disease (DDD) (facet osteoarthritis, disc height, endplate proliferative changes). Of these, 65 patients were selected with previous lumbar spine magnetic resonance imaging, allowing to determine lumbar facet orientation, spinal canal stenosis (Schizas classification), and flexor- and extensor-muscle atrophy (Goutallier classification). Mean ∆LL was 45° (range: 11°-72°) and four patients (6%) exhibited spine stiffness. Patients with multilevel DDD (n = 22) had less ∆LL than those with no/single level (n = 43) DDD (34° [range: 11°-53°] vs. 51° [21°-72°]; p < 0.001). Number of DDD levels correlated strongly with ∆LL (ρ = -0.642; p < 0.001). Spinal stiffness was only seen in patients with ≥4 DDD levels. There was no correlation between ∆LL and facet orientation (p > 0.05). ∆LL correlated strongly with extensor atrophy at L3-L4 (ρ = -0.473), L4-L5 (ρ = -0.520), and L5-S1 (ρ = -0.473) and poorly with flexors at L4-L5 (ρ = -0.134) and L5-S1 (ρ = -0.227). Lumbar stiffness is dependent on modifiable (muscle atrophy) and nonmodifiable (extend of DDD) factors. This can guide nonoperative management of hip pathology, emphasizing the relevance of core muscle rehabilitation to improve posture and stiffness. Identification ≥4 DDD levels should alert surgeons of increased THA instability risk. Level of evidence: level IV, cohort series.

Periprosthetic fracture following anterior approach or dislocation after posterior approach: which one is the lesser evil?

INTRODUCTION: The most common approaches in total hip arthroplasty (THA) have different complication profiles; anterior-approach (AA-THA) has an increased risk of periprosthetic fractures (PPF); posterior-approach (PA-THA) is associated with higher dislocation risk. However, the relative severity of one versus the other is unknown. This study aims to compare outcome of patients who suffered PPF after AA-THA with those that sustained dislocation after PA-THA. METHODS: This is a retrospective, single-center, multi-surgeon, consecutive case-series of primary THA patients. In a cohort of 9867 patients who underwent THA, 79 fulfilled the approach-specific, post-operative complication criteria, of which 44 were PPF after AA-THA and 35 with dislocation after PA-THA (age 67.9 years (range: 38.0-88.1), 58.2% women). Outcome included complication- and revision- rates, and patient-reported outcomes including Oxford Hip Score (OHS). RESULTS: At 5.8 years follow-up (range: 2.0-18.5), reoperation was more common in the dislocation after PA-THA group (23/35 vs. 20/44; p = 0.072). Change of surgical approach occurred in 15/20 of patients with PPF after AA-THA, but none in those with dislocation after PA-THA. Following re-operation, complication rate was greater in the PPF group (9/20 vs. 4/23; p = 0.049). At latest follow-up, OHS were superior in the PPF after AA-THA group [42.6 (range: 25.0-48.0) vs. 36.6 (range: 21.0-47.0); p = 0.006]. CONCLUSION: Dislocation following PA-THA is more likely to require revision. However, PPF following AA-THA requires more often a different surgical approach and is at higher risk of complications. Despite the increased surgical burden post-operative PROMs are better in the peri-prosthetic fracture group, especially in cases not requiring reoperation. LEVEL OF EVIDENCE: III, case-control study.

Which Acetabular Measurements Most Accurately Differentiate Between Patients and Controls? A Comparative Study.

BACKGROUND: Acetabular morphology is an important determinant of hip biomechanics. To identify features of acetabular morphology that may be associated with the development of hip symptoms while accounting for spinopelvic characteristics, one needs to determine acetabular characteristics in a group of individuals older than 45 years without symptoms or signs of osteoarthritis. Previous studies have used patients with unknown physical status to define morphological thresholds to guide management. QUESTIONS/PURPOSES: (1) To determine acetabular morphological characteristics in males and females between 45 and 60 years old with a high Oxford hip score (OHS) and no signs of osteoarthritis; (2) to compare these characteristics with those of symptomatic hip patients treated with hip arthroscopy or periacetabular osteotomy (PAO) for various kinds of hip pathology (dysplasia, retroversion, and cam femoroacetabular impingement); and (3) to assess which radiographic or CT parameters most accurately differentiate between patients who had symptomatic hips and those who did not, and thus, define thresholds that can guide management. METHODS: Between January 2018 and December 2018, 1358 patients underwent an abdominopelvic CT scan in our institution for nonorthopaedic conditions. Of those, we considered 5% (73) of patients as potentially eligible as controls based on the absence of major hip osteoarthritis, trauma, or deformity. Patients were excluded if their OHS was 43 or less (2% [ 28 ]), if they had a PROMIS less than 50 (1% [ 18 ]), or their Tönnis score was higher than 1 (0.4% [ 6 ]). Another eight patients were excluded because of insufficient datasets. After randomly selecting one side for each control, 40 hips were left for analysis (age 55 ± 5 years; 48% [19 of 40] were in females). In this comparative study, this asymptomatic group was compared with a group of patients treated with hip arthroscopy or PAO. Between January 2013 and December 2020, 221 hips underwent hip preservation surgery. Of those, eight were excluded because of previous pelvic surgery, and 102 because of insufficient CT scans. One side was randomly selected in patients who underwent bilateral procedure, leaving 48% (107 of 221) of hips for analysis (age 31 ± 8 years; 54% [58 of 107] were in females). Detailed radiographic and CT assessments (including segmentation) were performed to determine acetabular (depth, cartilage coverage, subtended angles, anteversion, and inclination) and spinopelvic (pelvic tilt and incidence) parameters. Receiver operating characteristics (ROC) analysis was used to assess diagnostic accuracy and determine which morphological parameters (and their threshold) differentiate most accurately between symptomatic patients and asymptomatic controls. RESULTS: Acetabular morphology in asymptomatic hips was characterized by a mean depth of 22 ± 2 mm, with an articular cartilage surface of 2619 ± 415 mm 2 , covering 70% ± 6% of the articular surface, a mean acetabular inclination of 48° ± 6°, and a minimal difference between anatomical (24° ± 7°) and functional (22° ± 6°) anteversion. Patients with symptomatic hips generally had less acetabular depth (20 ± 4 mm versus 22 ± 2 mm, mean difference 3 mm [95% CI 1 to 4]; p < 0.001). Hips with dysplasia (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 0% to 12%]; p = 0.03) or retroversion (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 1% to 12%]; p = 0.04) had a slightly lower relative cartilage area compared with asymptomatic hips. There was no difference in acetabular inclination (48° ± 6° versus 47° ± 7°, mean difference 0.5° [95% CI -2° to 3°]; p = 0.35), but asymptomatic hips had higher anatomic anteversion (24° ± 7° versus 19° ± 8°, mean difference 6° [95% CI 3° to 9°]; p < 0.001) and functional anteversion (22° ± 6° versus 13°± 9°, mean difference 9° [95% CI 6° to 12°]; p < 0.001). Subtended angles were higher in asymptomatic at 105° (124° ± 7° versus 114° ± 12°, mean difference 11° [95% CI 3° to 17°]; p < 0.001), 135° (122° ± 9° versus 111° ± 12°, mean difference 10° [95% CI 2° to 15°]; p < 0.001), and 165° (112° ± 9° versus 102° ± 11°, mean difference 10° [95% CI 2° to 14°]; p < 0.001) around the acetabular clockface. Symptomatic hips had a lower pelvic tilt (8° ± 8° versus 11° ± 5°, mean difference 3° [95% CI 1° to 5°]; p = 0.007). The posterior wall index had the highest discriminatory ability of all measured parameters, with a cutoff value of less than 0.9 (area under the curve [AUC] 0.84 [95% CI 0.76 to 0.91]) for a symptomatic acetabulum (sensitivity 72%, specificity 78%). Diagnostically useful parameters on CT scan to differentiate between symptomatic and asymptomatic hips were acetabular depth less than 22 mm (AUC 0.74 [95% CI 0.66 to 0.83]) and functional anteversion less than 19° (AUC 0.79 [95% CI 0.72 to 0.87]). Subtended angles with the highest accuracy to differentiate between symptomatic and asymptomatic hips were those at 105° (AUC 0.76 [95% CI 0.65 to 0.88]), 135° (AUC 0.78 [95% CI 0.70 to 0.86]), and 165° (AUC 0.77 [95% CI 0.69 to 0.85]) of the acetabular clockface. CONCLUSION: An anatomical and functional acetabular anteversion of 24° and 22°, with a pelvic tilt of 10°, increases the acetabular opening and allows for more impingement-free flexion while providing sufficient posterosuperior coverage for loading. Hips with lower anteversion or a larger difference between anatomic and functional anteversion were more likely to be symptomatic. The importance of sufficient posterior coverage was also illustrated by the posterior wall indices and subtended angles at 105°, 135°, and 165° of the acetabular clockface having a high discriminatory ability to differentiate between symptomatic and asymptomatic hips. Future research should confirm whether integrating these parameters when selecting patients for hip preservation procedures can improve postoperative outcomes.Level of Evidence Level III, prognostic study.

The quest for optimal femoral torsion angle measurements: a comparative advanced 3D study defining the femoral neck axis.

PURPOSE: There is high variability in femoral torsion, measured on two-dimensional (2D) computed tomography (CT) scans. The aim of this study was to find a reliable three-dimensional (3D) femoral torsion measurement method, assess the influence of CAM deformity on femoral torsion measurement, and to promote awareness for the used measurement method. METHODS: 3D models of 102 dry femur specimens were divided into a CAM and non-CAM group. Femoral torsion was measured by one 2D-CT method described by Murphy et al. (method 0) and five 3D methods. The 3D methods differed in strategies to define the femoral neck axis. Method 1 is based on an elliptical least-square fit at the middle of the femoral neck. Methods 2 and 3 defined the centre of mass of the entire femoral neck and of the most cylindrical part, respectively. Methods 4 and 5 were based on the intersection of the femoral neck with a 25% and 40% enlarged best fit sphere of the femoral head. RESULTS: 3D methods resulted in higher femoral torsion measures than the 2D method; the mean torsion for method 0 was 8.12° ± 7.30°, compared to 9.93° ± 8.24° (p < 0.001), 13.21° ± 8.60° (p < 0.001), 8.21° ± 7.64° (p = 1.00), 9.53° ± 7.87° (p < 0.001) and 10.46° ± 7.83° (p < 0.001) for methods 1 to 5 respectively. In the presence of a CAM, torsion measured with method 4 is consistently smaller than measured with method 5. CONCLUSION: 2D measurement might underestimate true femoral torsion and there is a difference up to 5°. There is a tendency for a higher mean torsion in hips with a CAM deformity. Methods 4 and 5 are the most robust techniques. However, method 4 might underestimate femoral torsion if a CAM deformity is present. Since method 5 is independent of a CAM deformity, it is the preferred technique to define expected values of torsion.

Prevalence of Lumbosacral Transitional Vertebral Anomalies Among Healthy Volunteers and Patients with Hip Pathology: Association with Spinopelvic Characteristics.

A lumbosacral transitional vertebra (LSTV) has been reported to be prevalent among patients with hip dysplasia. The aims of this study were to determine the (1) prevalence of an LSTV in young patients presenting with hip pain and a group of asymptomatic volunteers, (2) effect of an LSTV on spinopelvic characteristics, and (3) presence of low back pain among patients with an LSTV. Methods: This cross-sectional study included 102 patients with hip pathology and 51 asymptomatic volunteers (mean age, 33.9 ± 7.3 years; mean body mass index, 26.0 ± 5.0 kg/m2; 57.5% female). Participants underwent radiographic assessment of the lumbar spine and pelvis in standing and deep-seated positions. LSTV occurrence was classified according to the Castellvi system. Spinopelvic characteristics included lumbar lordosis (including segmental lumbar angles), pelvic tilt, and hip flexion (pelvic-femoral angle). Differences between standing and deep-seated values were calculated. Low back pain was assessed using the Oswestry Disability Index. Results: The prevalence of LSTV type ≥II was 8.5%, with no difference between patients and volunteers (p = 0.386). Individuals with an LSTV had a greater standing L1-L5 angle (mean, 51.6° ± 11.7° versus 38.9° ± 9.3°; p < 0.001). The overall spinal flexion (change in L1-S1 angle between the standing and deep-seated positions) in individuals with an LSTV was similar to that in individuals without an LSTV; restricted L5-S1 mobility was compensated for at L1-L2 (10.2° ± 5.8° in those with versus 8.4° ± 4.1° in those without an LSTV; p = 0.070). No significant difference in the presence of low back pain was found (p = 0.250). Conclusions: An LSTV was found in 8.5% of young adults, with no difference between patients with hip pathology and controls. Individuals with an LSTV have greater standing lumbar lordosis, with altered mechanics at the cephalad adjacent level, which may predispose these individuals to degenerative changes at this level. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acetabular Sector Angles in Asymptomatic and Dysplastic Hips: Defining Dysplasia and Thresholds to Guide Management.

BACKGROUND: Radiographic evaluation plays an important role in detecting and grading hip dysplasia. Acetabular sector angles (ASAs) measure the degree of femoral head coverage provided by the acetabulum on computed tomographic (CT) scans. In this study, we aimed to determine ASA values at different axial levels in a control cohort with asymptomatic, high-functioning hips without underlying hip pathology and a study group with symptomatic, dysplastic hips that underwent periacetabular osteotomy (PAO), thereby defining the ASA thresholds for hip dysplasia. METHODS: This was a cross-sectional study evaluating a control group of 51 patients (102 hips) and a study group of 66 patients (72 hips). The control group was high-functioning and asymptomatic, with an Oxford Hip Score of >43, did not have osteoarthritis (Tönnis grade ≤1), underwent a pelvic CT scan, had a mean age (and standard deviation) of 52.1 ± 5.5 years, and was 52.9% female. The study group had symptomatic hip dysplasia treated with PAO, had a mean age of 29.5 ± 7.3 years, and 83.3% was female. Anterior ASA (AASA) and posterior ASA (PASA) were measured at 3 axial CT levels to determine equatorial, intermediate, and proximal ASA. The thresholds for dysplasia were determined using receiver operating characteristic (ROC) curve analysis, including the area under the curve (AUC). RESULTS: Patients with dysplasia had significantly smaller ASAs compared with the control group; the differences were most pronounced for proximal AASAs and proximal and intermediate PASAs. The control group had a mean proximal PASA of 162° ± 17°, yielding a threshold for dysplasia of 137° (AUC, 0.908). The mean intermediate PASA for the control group was 117° ± 11°, yielding a threshold of 107° (AUC, 0.904). The threshold for anterior dysplasia was 133° for proximal AASA (AUC, 0.859) and 57° for equatorial AASA (AUC, 0.868). The threshold for posterior dysplasia was 102° for intermediate PASA (AUC, 0.933). CONCLUSIONS: Measurement of ASA is a reliable tool to identify focal acetabular deficiency with high accuracy, aiding diagnosis and management. A proximal PASA of <137° or an intermediate PASA of <107° should alert clinicians to the presence of dysplasia. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The effect of ethnicity on the age-related changes of spinopelvic characteristics: a systematic review.

Spinopelvic characteristics influence the hip's biomechanical behaviour. However, to date there is little knowledge defining what 'normal' spinopelvic characteristics are. This study aims to determine how static spinopelvic characteristics change with age and ethnicity among asymptomatic, healthy individuals. This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify English studies, including ≥ 18-year-old participants, without evidence of hip or spine pathology or a history of previous surgery or interventional treatment, documenting lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). From a total of 2,543 articles retrieved after the initial database search, 61 articles were eventually selected for data extraction. When all ethnicities were combined the mean values for LL, SS, PT, and PI were: 47.4° (SD 11.0°), 35.8° (SD 7.8°), 14.0° (SD 7.2°), and 48.8° (SD 10°), respectively. LL, SS, and PT had statistically significant (p < 0.001) changes per decade at: -1.5° (SD 0.3°), -1.3° (SD 0.3°), and 1.4° (SD 0.1°). Asian populations had the largest age-dependent change in LL, SS, and PT compared to any other ethnicity per decade at: -1.3° (SD 0.3°) to -0.5° (SD 1.3°), -1.2° (SD 0.2°) to -0.3° (SD 0.3°), and 1.7° (SD 0.2°) versus 1.1° (SD 0.1°), respectively. Ageing alters the orientation between the spine and pelvis, causing LL, SS, and PT to modify their orientations in a compensatory mechanism to maintain sagittal alignment for balance when standing. Asian populations have the largest degree of age-dependent change to their spinopelvic parameters compared to any other ethnicity, likely due to their lower PI.

Selective THA-approach use amongst junior surgeons improves safety of introducing the anterior approach: a prospective, multi-surgeon, comparative, study.

BACKGROUND: Learning curves associated with independent practice and anterior approach total hip arthroplasty (AA-THA) has been associated with inferior outcome. This study compared outcome of junior, fellowship-trained, surgeons who perform THA through both anterior and posterior (PA) approach, with senior surgeons who perform either AA or PA, to determine whether: 1. Fellowship training and selective practice allows for safe introduction of AA into practice; and 2. Whether selective approach-use influences outcome. METHODS: This is a prospective, consecutive study comparing the first 800 THAs of two junior, dual-approach, surgeons (AA/PA: 455/345), with 400 THAs cases of two senior, single-approach, surgeons (AA/PA: 200/200), between 2018 and 2020. Most patients were female (54.4%), mean age was 65 years-old (range 19-96) and mean BMI was 29 kg/m2 (range 16-66). Outcome included radiologic measurements (inclination/anteversion and leg-length), complication- and revision rates, and patient-reported outcomes including Oxford Hip Score (OHS). RESULTS: At 3.1 years (range 2.0-6.8) follow-up, there were 43 complications (3.6%), including 27 re-operations (2.3%); with no difference between junior and senior surgeons for AA-THA (Junior: 8/455 vs. Senior: 3/200; p = 0.355) or PA-THA (Junior: 11/345 vs. Senior: 5/200; p = 0.400). Amongst juniors, there was no difference in complications (AA:8/455 vs. PA:11/345; p = 0.140) and in ΔOHS (AA:20.5 ± 7.7 vs. PA:20.5 ± 8.0; p = 0.581) between approaches. CONCLUSION: Contemporary training and selective approach-use minimizes the learning curve, allowing junior staff to have equivalent outcome to established, senior surgeons in both AA and PA. We would advocate for selective approach use amongst junior arthroplasty surgeons when introducing the AA into independent practice.

Is Outcome of Total Hip Arthroplasty for Hip Fracture Inferior to That of Arthritis in a Contemporary Arthroplasty Practice?

BACKGROUND: Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS: This was a retrospective, multisurgeon study from an academic center. Of FNFs treated between 2010 and 2020, 177 received THA by an arthroplasty surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score. RESULTS: Postoperative mean leg-length difference was 0 mm (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26°, respectively. There was no difference in radiological measurements between FNF and OA patients (P = .3). At a 5-year follow-up, mortality rate was significantly higher in the FNF-THA group compared to the OA-THA group (15.3 versus 1.1%; P < .001). There was no difference in complications (7.3 versus 4.2%; P = .098) or reoperation rates (5.1 versus 2.9%; P = .142) between the groups. Dislocation rate was 1.7%. Oxford Hip Score at the final follow-up was similar [43.7 points (range, 10 to 48) versus 43.6 points (range, 10 to 48); P = .030]. CONCLUSION: THA for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2 years, similar clinical and radiographic outcomes with low rates of revision can be expected compared to elective THA for OA. LEVEL OF EVIDENCE: III, case-control study.

Risk Factors for Iliopsoas Tendinopathy After Anterior Approach Total Hip Arthroplasty.

BACKGROUND: Iliopsoas tendinopathy is a cause of groin pain following total hip arthroplasty (THA). With the anterior approach becoming increasingly popular, our aim was to determine the prevalence of iliopsoas tendinopathy following anterior approach THA, to identify risk factors and to determine an influence on patient-reported outcomes. METHODS: This is a retrospective case-control study of prospectively recorded data on 2,120 primary anterior approach THA (1,815 patients). The diagnosis of iliopsoas tendinopathy was based on (1) persistent postoperative groin pain, triggered by hip flexion; (2) absence of dislocation, infection, loosening, or fracture; and (3) decrease of pain after fluoroscopy-guided iliopsoas tendon sheet injection with xylocaine and corticosteroid. Outcomes included hip reconstruction (inclination/anteversion and leg-length), complication rates, reoperation rates, and patient-reported outcomes including Hip disability and Osteoarthritis Outcome Score. RESULTS: Forty four patients (46 THAs) (2.2%) were diagnosed with iliopsoas tendinopathy. They were younger than patients who did not have iliopsoas tendinopathy (51 years [range, 27-76] versus 62 years [range, 20-90]; P < .001). Logistic regression analyses demonstrated that younger age (P < .001) and presence of a spine fusion (P = .008) (odds ratio 4.6) were the significant predictors of iliopsoas tendinopathy. These patients had lower Hip disability and Osteoarthritis Outcome scores, reported more often low back pain (odds ratio 4.8), and greater trochanter pain (odds ratio 5.4). CONCLUSION: We found an incidence of 2.2% of iliopsoas tendinopathy patients after anterior approach THA that compromised outcomes. Younger age and previous spine fusion were identified as most important risk factors. These patients were 5 times more likely to report low back pain and greater trochanter pain post-THA.

The Safety and Efficacy of the Anterior Approach Total Hip Arthroplasty as per Body Mass Index.

BACKGROUND: Obesity is associated with component malpositioning and increased revision risk after total hip arthroplasty (THA). With anterior approaches (AAs) becoming increasingly popular, the goal of this study was to assess whether clinical outcome post-AA-THA is affected by body mass index (BMI). METHODS: This multicenter, multisurgeon, consecutive case series used a prospective database of 1,784 AA-THAs (1,597 patients) through bikini (n = 1,172) or standard (n = 612) incisions. Mean age was 63 years (range, 20-94 years) and there were 57.5% women, who had a mean follow-up of 2.7 years (range, 2.0-4.1 years). Patients were classified into the following BMI groups: normal (BMI < 25.0; n = 572); overweight (BMI: 25.0-29.9; n = 739); obese (BMI: 30.0-34.9; n = 330); and severely obese (BMI ≥ 35.0; n = 143). Outcomes evaluated included hip reconstruction (inclination/anteversion and leg-length, complications, and revision rates) and patient-reported outcomes including Oxford Hip Scores (OHS). RESULTS: Mean postoperative leg-length difference was 2.0 mm (range: -17.5 to 39.0) with a mean cup inclination of 34.8° (range, 14.0-58.0°) and anteversion of 20.3° (range, 8.0-38.6°). Radiographic measurements were similar between BMI groups (P = .1-.7). Complication and revision rates were 2.5% and 1.7%, respectively. The most common complications were fracture (0.7%), periprosthetic joint infection (PJI) (0.5%), and dislocation (0.5%). There was no difference in dislocation (P = .885) or fracture rates (P = .588) between BMI groups. There was a higher rate of wound complications (1.8%; P = .053) and PJIs (2.1%; P = .029) among obese and severely obese patients. Wound complications were less common among obese patients with the 'bikini' incision (odds ratio 2.7). Preoperative OHS was worse among the severely obese (P < .001), which showed similar improvements (Change in OHS; P = .144). CONCLUSION: AA-THA is a credible option for obese patients, with low dislocation or fracture risk and excellent ability to reconstruct the hip, leading to comparable functional improvements among BMI groups. Obese patients have a higher risk of PJIs. Bikini incision for AA-THA can help minimize the risk of wound complications.

Does pelvic tilt change with a peri-acetabular osteotomy?

Change in pelvic tilt (PT) during and after peri-acetabular osteotomy (PAO) is important for surgical planning. The aims of this study were to (i) determine how PT varies throughout the course of treatment in patients undergoing PAO, (ii) test what factors influence the change in PT and (iii) assess whether changes in PT influenced achieved correction. This is an retrospective, single-centre, consecutive case series of 111 patients treated with PAO for global (n = 79), posterior (n = 49) or anterior dysplasia (n = 6) (mean age: 27.3 ± 7.7 years; 85% females). PT was determined on supine, anteroposterior pelvic radiographs pre-, intra-, 1 day, 6 weeks and 1 year post-operatively, using the sacro-femoral-pubic (SFP) angle, a validated, surrogate marker of PT. An optimal acetabular correction was based on the lateral centre-edge angle (25°-40°), acetabular index (-5° to 10°) and cross-over ratio (<20%). There was a significant difference across pre- (70.1° ± 4.8°), 1-day (71.7° ± 4.3°; P < 0.001) and early post-operative SFP (70.6° ± 4.7°; P = 0.004). The difference in SPF between pre-operative and 1-year post-operative was -0.5° ± 3.1° (P = 0.043), with 9% of cases having a difference of >5°. The difference in SFP did not correlate with age, sex, body mass index, type of dysplasia or achievement of optimal acetabular correction (P = 0.1-0.9). In the early post-operative period, PT is reduced, leading to a relative appearance of acetabular retroversion, which gradually corrects and is restored by annual follow-up. The degree of change in PT during PAO did not adversely affect fragment orientation. PT does not significantly change in most patients undergoing PAO and therefore does not appear to be a compensatory mechanism.

Perioperative Operating Room Efficiency Can Make Simultaneous Bilateral Total Hip Arthroplasty Cost-effective: A Proposal for a Value-sharing Model.

Background: Increasing demand for total hip arthroplasty (THA) and rising health-care costs have led hospitals to improve operating room (OR) efficiency. We compare the cost-effectiveness of a simultaneous bilateral THA to that of staged unilateral procedures following the implementation of OR efficiency strategies. Methods: Between 2017 and 2019, 446 simultaneous and 238 staged bilateral primary THA patients (mean age 61.3 ± 12.0 years; 41.8% males/58.2% females; mean body mass index 27.2 ± 4.8 kg/m2) were treated by a single surgeon using an efficient, standardized workflow for efficient direct anterior approach THA on a standard operating table. There were no differences in inclusion criteria between both groups. From this cohort, 16 simultaneous bilateral THAs and 34 unilateral THAs were prospectively compared for cost-effectiveness using detailed timestamp measurements and data on personnel and material usage. Outcome was assessed based on complication and reoperation rate and patient-reported outcome measures. Results: There was a complication rate of 1.2%, without a difference between patients who underwent a simultaneous THA vs those who underwent a staged primary THA (5/446; 1.1% vs 3/238; 1.3% P = .386). The mean OR time (patient in/out and turnover time) was 109.4 ± 19.8 minutes for bilateral THAs and 133.8 ± 12.8 minutes for 2 unilateral THAs (P < .001). An 18% time-saving and 14% cost-saving was achieved per procedure. Sharing 5% of the cost-saving with the surgeon brings benefit to both the hospital and surgeon. Conclusions: Implementing OR efficiency improves cost-effectiveness of simultaneous bilateral THA compared to unilateral procedures. A new value-sharing model could be a solution to align incentives.

Cup orientation following posterior approach THA - the effect of different visual aids and pelvic supports.

INTRODUCTION: This study aims to compare cup inclination achieved (1) Using two orientation guides, whilst using the same 3-point pelvic positioner and (2) Using two types of pelvic positioners, whilst measuring intra-operative cup inclination with an inclinometer. MATERIALS AND METHODS: This is a prospective, diagnostic cohort study of a consecutive series of 150 THAs performed through a posterior approach. Two types of 3-point pelvic positioners were used (Stulberg and modified Capello Hip Positioners) and the cup was positioned freehand using one of two orientation guides (mechanical guide or digital inclinometer). Intra-operative inclination was recorded, radiographic cup inclination and anteversion were measured from radiographs. The differences in inclination due to pelvic position (ΔPelvicPosition) and orientation definitions (ΔDefinition) were calculated. Target radiographic inclination and anteversion was 40/20° ± 10°. RESULTS: There was no difference in radiographic cup inclination/ (p = 0.63) using a mechanical guide or digital inclinometer. However, differences were seen in ΔPelvicPosition between the positioners ((Stulberg: 0° ± 5 vs. Capello: 3° ± 6); p = 0.011). Intra-operative inclination at implantation was different between positioners and this led to equivalent cases within inclination/anteversion targets (Stulberg:84%, Capello:80%; p = 0.48). CONCLUSIONS: With the pelvis securely positioned with 3-point supports, optimum cup orientation can be achieved with both alignment guides and inclinometer. Non-optimal cup inclinations were seen when intra-operative inclinations were above 40° and below 32°, or the ΔPelvicPosition was excessive (> 15°; n = 2). We would thus recommend that the intra-operative cup inclination should be centered strictly between 30° and 35° relative to the floor. Small differences exist between different type of pelvic positioners that surgeons need to be aware off and account for.

A novel technique with Dacron vascular graft augmentation for knee extensor mechanism repairs: Technical note.

Ruptures of the extensor apparatus can have different etiologies and be complicated by underlying situations. Direct repair is not always possible, and reconstruction procedures can be insufficient, which leads to the appearance of multiple augmentation techniques to improve the strength of these constructs. Despite the proven results of these techniques, numerous procedures are described without any gold standard. We present our augmentation method for repairing the knee extensor apparatus with a vascular prosthesis that facilitates healing, does not interfere with the primary procedure, has no donor morbidity or rejection risk, and allows earlier mobilization and rehabilitation. The technique was used in different cases with multiple etiologies that needed reinforcement, with promising results.

Defining "Normal" Static and Dynamic Spinopelvic Characteristics: A Cross-Sectional Study.

Spinopelvic characteristics influence the hip's biomechanical behavior. However, there is currently little knowledge regarding what "normal" characteristics are. This study aimed to determine how static and dynamic spinopelvic characteristics change with age, sex, and body mass index (BMI) among well-functioning volunteers. Methods: This was a cross-sectional cohort study of 112 asymptomatic volunteers (age, 47.4 ± 17.7 years; 50.0% female; BMI, 27.3 ± 4.9 kg/m2). All participants underwent lateral spinopelvic radiography in the standing and deep-seated positions to determine maximum hip and lumbar flexion. Lumbar flexion (change in lumbar lordosis, ∆LL), hip flexion (change in pelvic-femoral angle, ∆PFA), and pelvic movement (change in pelvic tilt, ΔPT) were determined. The hip user index, which quantifies the relative contribution of the hip to overall sagittal movement, was calculated as (∆PFA/[∆PFA + ∆LL]) × 100%. Results: There were decreases of 4.5° (9%) per decade of age in lumbar flexion (rho, -0.576; p < 0.001) and 3.6° (4%) per decade in hip flexion (rho, -0.365; p < 0.001). ∆LL could be predicted by younger age, low standing PFA, and high standing LL. Standing spinopelvic characteristics were similar between sexes. There was a trend toward men having less hip flexion (90.3° ± 16.4° versus 96.4° ± 18.1°; p = 0.065) and a lower hip user index (62.9% ± 8.2% versus 66.7% ± 8.3%; p = 0.015). BMI weakly correlated with ∆LL (rho, -0.307; p = 0.011) and ∆PFA (rho, -0.253; p = 0.039). Conclusions: Spinopelvic characteristics were found to be age, sex, and BMI-dependent. The changes in the lumbar spine during aging (loss of lumbar lordosis and flexion) were greater than the changes in the hip, and as a result, the hip's relative contribution to overall sagittal movement increased. Men had a greater change in posterior pelvic tilt when moving from a standing to a deep-seated position in comparison with women, secondary to less hip flexion. The influence of BMI on spinopelvic parameters was low.

Spinopelvic Characteristics Normalize 1 Year After Total Hip Arthroplasty: A Prospective, Longitudinal, Case-Controlled Study.

BACKGROUND: The presence of hip osteoarthritis is associated with abnormal spinopelvic characteristics. This study aimed to determine whether the preoperative, pathological spinopelvic characteristics normalize at 1 year after total hip arthroplasty (THA). METHODS: This was a prospective, longitudinal, case-control, matched cohort study. Forty-seven patients undergoing THA underwent preoperative and 1-year postoperative assessments. This group was matched with regard to age, sex, and body mass index with 47 controls (volunteers) with well-functioning hips. All participants underwent clinical and radiographic assessments including lateral radiographs in standing, relaxed-seated, and deep-flexed-seated positions. Spinopelvic characteristics included change in lumbar lordosis (ΔLL), change in pelvic tilt (ΔPT), and hip flexion (change in pelvic-femoral angle, ΔPFA) when moving from a standing position to either of the seated positions. Spinopelvic hypermobility was defined as ΔPT > 30° between the standing and upright-seated positions. RESULTS: Patients who underwent THA, compared with the control group, preoperatively demonstrated less mean change in hip flexion (ΔPFA, -54.8° ± 17.1° compared with -68.5° ± 9.5°; p < 0.001), greater mean change in pelvic tilt (ΔPT, 22.0° ± 13.5° compared with 12.7° ± 8.1°; p < 0.001), and greater mean lumbar movement (ΔLL, -22.7° ± 15.5° compared with -15.4° ± 10.9°; p = 0.015) transitioning from a standing position to an upright-seated position. After THA, these differences were no longer present between the THA group and the control group: the mean postoperative changes were -65.8° ± 12.5° (p = 0.256) for ΔPFA, 14.3° ± 9.5° (p = 0.429) for ΔPT, and -15.3° ± 10.6° (p = 0.966) for ΔLL. The higher prevalence of spinopelvic hypermobility in the THA group compared with the control group that was observed preoperatively (21% compared with 0%; p = 0.009) was no longer present after THA (6% compared with 0%; p = 0.194). Similar results were found moving from a standing position to a deep-seated position after THA. CONCLUSIONS: Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion. This leads to patients having the expected hip, pelvic, and spinal flexion as demographically matched controls, thus potentially eliminating abnormal mechanics that contribute to the development or exacerbation of hip-spine syndrome. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is a periacetabular osteotomy as efficacious in retroversion as it is in dysplasia? : The role of femoral anteversion on outcome.

AIMS: Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia. It has also been proposed as a treatment for patients with acetabular retroversion. By reviewing a large cohort, we aimed to test whether outcome is equivalent for both types of morphology and identify factors that influenced outcome. METHODS: A single-centre, retrospective cohort study was performed on patients with acetabular retroversion treated with PAO (n = 62 hips). Acetabular retroversion was diagnosed clinically and radiologically (presence of a crossover sign, posterior wall sign, lateral centre-edge angle (LCEA) between 20° and 35°). Outcomes were compared with a control group of patients undergoing PAO for dysplasia (LCEA < 20°; n = 86 hips). Femoral version was recorded. Patient-reported outcome measures (PROMs), complications, and reoperation rates were measured. RESULTS: The mean Non-Arthritic Hip Score (NAHS) preoperatively was 58.6 (SD 16.1) for the dysplastic hips and 52.5 (SD 12.7) for the retroverted hips (p = 0.145). Postoperatively, mean NAHS was 83.0 (SD 16.9) and 76.7 (SD 17.9) for dysplastic and retroverted hips respectively (p = 0.041). Difference between pre- and postoperative NAHS was slightly lower in the retroverted hips (18.3 (SD 22.1)) compared to the dysplastic hips (25.2 (SD 15.2); p = 0.230). At mean 3.5 years' follow-up (SD 1.9), one hip needed a revision PAO and no hips were converted to total hip arthroplasty (THA) in the retroversion group. In the control group, six hips (7.0%) were revised to THA. No differences in complications (p = 0.106) or in reoperation rate (p = 0.087) were seen. Negative predictors of outcome for patients undergoing surgery for retroversion were female sex, obesity, hypermobility, and severely decreased femoral anteversion. CONCLUSION: A PAO is an effective surgical intervention for acetabular retroversion and produces similar improvements when used to treat dysplasia. Femoral version should be routinely assessed in these patients and when extremely low (< 0°), as an additional procedure to address this abnormality may be necessary. Females with signs of hypermobility should also be consulted of the likely guarded improvement. Cite this article: Bone Jt Open 2021;2(9):757-764.