The Anterior Modified San Diego Acetabuloplasty Does Not Increase Superior-Anterior Coverage in Patient-Specific 3D-Printed Models.

BACKGROUND: Patients with developmental dysplasia of the hip may require pelvic osteotomies to improve acetabular coverage. The purpose of this study was to compare the changes in acetabular version, tilt, and regional coverage angles following the San Diego acetabuloplasty (SDA), the modified San Diego acetabuloplasty (mSDA), and the Pemberton acetabuloplasty (PA). METHODS: Fourteen patients with developmental dysplasia of the hip and computed tomography (CT) imaging were identified. From CT images, 2 identical pelvises were 3-dimensional-printed for each patient. Bone was printed with rigid material, and cartilage with flexible material. For each model pair, the SDA was performed on one and the PA was performed on the other. CT scans were obtained before and after acetabuloplasties. Next, the bone graft in the SDA model was moved anteriorly, representing the mSDA, and the model was rescanned. Acetabular version, tilt, and coverage angles (posterior, superior-posterior, superior, superior-anterior, and anterior) were calculated. Preoperative to postoperative differences were compared (repeated measures analysis of variance or Wilcoxon signed rank test). The significance was set to P <0.05. RESULTS: The mean age at CT was 5.8±1.2 years (range: 3.9 to 7.5 y). All 3 procedures (SDA, mSDA, and PA) significantly increased acetabular tilt; P <0.045), with a similar change observed for all 3 ( P =0.868). PA was the only procedure to significantly decrease relative acetabular version (6.5±6.5 degrees, preoperative: 12.9±5.3 degrees; P =0.004). Both the SDA and mSDA procedures significantly increased coverage in the superior-posterior octant (SDA: 92.6±9.3 degrees, mSDA: 92.3±9.8 degrees, preoperative: 81.9±9.5 degrees; P <0.02), with a similar percent change among the 2 ( P =1.0). All 3 procedures significantly increased superior coverage ( P <0.04); the increase was similar among the 3 ( P =0.205). The PA was the only procedure to produce a significant increase in coverage in the superior-anterior octant (91.0±16.7 degrees, preoperative: 74.0±12.1 degrees; P =0.005) or the anterior octant (50.7±11.7 degrees, preoperative: 45.8±8.9 degrees; P =0.012). CONCLUSIONS: The SDA and mSDA procedures produced similar postoperative changes, primarily in the superior and superior-posterior acetabular octants. Placing the graft more anteriorly did not increase anterior coverage in the mSDA, and only the PA increased coverage in the superior and superior-anterior acetabular octants.

Twelve to Twenty-year Follow-up of Dega Acetabuloplasty in Patients With Developmental Dysplasia of the Hip: Is it as Effective as Expected?

BACKGROUND: Although Dega acetabuloplasty is widely used for the treatment of developmental dysplasia of the hip, there is a paucity of data on long-term outcomes. The purpose of the study was to evaluate the rate of residual acetabular dysplasia after Dega acetabuloplasty. METHODS: Patients of a previously reported consecutive series of 35 patients (43 hips) operated by a single surgeon were recontacted for long-term follow-up. Of these, 25 patients (32 hips) consented, with a follow-up rate of 71% (74% of hips). The mean age at the time of surgery was 35 (18 to 65) months. The presence of residual dysplasia was noted according to the lateral center-edge angle of Wiberg, femoral head extrusion index, and Tönnis angle. The latest radiographic outcome was evaluated according to the Severin classification and patients were clinically evaluated according to the modified McKay criteria. RESULTS: The mean follow-up duration of 16.5 (12 to 20) years yielded an average age of 19.2 (14 to 23) years at the time of analysis. According to lateral center-edge angle, femoral head extrusion index, and Tönnis angle, 5 (15.6%) hips were dysplastic and 2 (6.3%) hips were reoperated for resubluxation. Thus, a total of 7 hips (21.9%) were considered to have residual dysplasia. With the exception of 2 hips that underwent further osteotomies, no other hips were re-subluxated or redislocated. Overcoverage was noted in 6 (18.7%) hips. There were 26 Severin group I and II (81.3%), 4 Severin group III (12.5%), and 2 Severin group IV (6.2%) hips. According to modified McKay criteria, 20 (62.5%) hips were excellent, 7 (21.9%) hips were good, and 5 (15.6%) were fair. Severin classification and modified McKay criteria were correlated with dysplasia ( P < 0.05). CONCLUSIONS: Seventy-eight percent of the hips treated by Dega acetabuloplasty for developmental dysplasia of the hip did not have acetabular dysplasia at a mean follow-up of 16 years. Even in well-treated asymptomatic hips, patients should be followed regularly, especially for residual dysplasia. LEVEL OF EVIDENCE: Level IV.

Fixation strength in arthroscopic labral repair of the hip: A head-to-head comparison of the biomechanical performance of a biocompatible vs. all-suture anchor in the setting of acetabuloplasty.

Much is known about the biomechanical performance of various types of suture anchors commonly used for labral fixation in the shoulder; however, similar studies in the hip are less common. We sought to compare all-suture and polyether ether ketone small-diameter anchors in the setting of labral repair during hip arthroscopy, with and without acetabuloplasty. We hypothesized that the biomechanical properties of the all-suture group when compared to polyether ether ketone anchors would be similar amongst native acetabula and significantly less following acetabuloplasty and that pullout forces would be reduced in the anterior and inferior regions of the acetabulum compared to the superior region. Bone density was measured in nine matched pairs of fresh-frozen cadaveric acetabula in the superior, anterosuperior, and anterior regions. Acetabuloplasty was performed in all three regions, while the contralateral acetabulum was left in situ as a control. Suture anchors were placed such that one each of two different types was placed within each region. Specimens were tested in cyclic fatigue and loaded to failure. The all-suture group had significantly higher cyclic displacement compared to the polyether ether ketone, but there was no significant difference in ultimate load, regardless of acetabuloplasty. Amongst all non-resected specimens, the lowest bone density was observed consistently in the inferior region. Our results indicate that, with or without acetabuloplasty, a small-diameter polyether ether ketone anchor appears to be more stable than an all-suture anchor, which needs to be set first.

Relationship between the Depth of Acetabuloplasty and Outcomes of Hip Arthroscopy in Patients with Global Pincer Femoroacetabular Impingement: Study with a Minimum Follow-Up Period of 2 Years.

OBJECTIVE: There has been no definite consensus on the ideal depth of acetabuloplasty, especially in cases of global pincer femoroacetabular impingement (FAI). This study aims to determine whether the depth of acetabuloplasty influences postoperative outcomes in cases of global pincer FAI. METHODS: Data were retrospectively collected from patients with global pincer FAI who underwent hip arthroscopy with a minimum follow-up period of 2 years from May 2014 to December 2018. Patients with global pincer FAI were subdivided into low or high resection depth groups based on whether the intraoperative acetabular rim was resected by more than 3 mm. Radiographic measurements; arthroscopic procedures; preoperative and postoperative PROs were recorded. Achievement of MCID and PASS was compared for the VAS, mHHS, HOS-ADL, and iHOT-12. A paired Student t-test was used to evaluate the significance of preoperative and postoperative PROs and two-tailed unpaired Student t-test was used to compare demographic data and PROs between different groups. MCID and PASS were evaluated using the chi-square test or the Fisher's exact test. RESULTS: A total of 41 hips with global pincer FAI (15 and 26 patients in low or high resection depth groups, respectively) were included in this study. Both groups showed significant postoperative improvements in the scores of all PROs (p < 0.001). Compared to the low resection depth group, the high resection depth group had a lower degree of improvement through hip arthroscopy, which manifested as lower postoperative mHHS scores (94.29 vs. 85.08, p = 0.006), higher VAS scores (0.93 vs. 2.54, p = 0.002), and lower improvements in VAS (-5.00 vs. -3.35, p = 0.028), HOS-ADL (34.99 vs. 23.90, p = 0.017) and iHOT-12 (39.89 vs. 29.27, p = 0.036). Patients in high resection depth group were less likely to achieve the MCID for the VAS score compared to low resection depth group in significant (73.3 vs. 26.9%, p = 0.004). CONCLUSIONS: For patients with global pincer, the outcomes in high resection depth group were slightly worse than the the low resection depth group. It is indicated that excessive resection of the acetabular rim during the procedure should be avoided.

Salter osteotomy has lower fluoroscopy exposure time compared to Tonnis lateral acetabuloplasty.

Salter osteotomy and Tonnis lateral acetabuloplasty (TLA) are pelvic osteotomies with similar indications and clinical results used in the treatment of developmental dysplasia of the hip (DDH). The aim of our study was to compare the intraoperative fluoroscopy exposure time (FET) in patients with DDH treated with the Salter osteotomy and TLA. In this study, data were collected prospectively and compared after the study was completed. The patients were evaluated in three groups: pelvic osteotomy (group 1), open reduction with pelvic osteotomy (group 2) and open reduction + pelvic osteotomy + femoral shortening (group 3). Pelvic osteotomy techniques in each group were further analyzed in two subgroups as Salter osteotomy and TLA. Age, sex, surgery side, degree of dysplasia according to the Tönnis classification, duration of anesthesia and intraoperative FET (seconds) were recorded. A total of 109 patients (93 girls and 16 boys) were included in the study; 29 patients in group 1, 50 in group 2 and 30 in group 3. Although the patients who underwent Salter osteotomy and TLA were similar in all three groups in terms of age, sex, surgery side, Tönnis classification and duration of anesthesia, FET was longer in the patients who underwent TLA (group 1, P < 0.001; group 2, P < 0.001; group 3, P = 0.005). The use of the Salter osteotomy technique in the treatment of acetabular dysplasia in patients with DDH seems to be more advantageous in terms of FET than TLA osteotomy. It would be beneficial to consider this result in terms of radiation safety. Level of Evidence: II.

Arthroscopic labral repair combined with less invasive open-shelf acetabuloplasty for patients with developmental dysplasia of the hip.

Hip arthroscopy has become widely used for intra-articular lesions, such as labral tears and femoral acetabular impingement. However, its use in patients with developmental dysplasia of the hip (DDH) has been controversial and has historically demonstrated mixed results, as acetabular dysplasia may cause instability due to insufficient bony coverage of the femoral head, thus causing excessive stress on the repaired labrum and cartilage. We devised a combined hip arthroscopic labral repair and a less invasive open-shelf procedure using a small skin incision as an anterolateral portal in hip arthroscopy. This novel procedure may improve the stability of the repaired labrum with a bony covering in a minimally invasive manner. Moreover, the shelf procedure can be performed under direct vision in a comparatively safe and precise manner. In total, 13 hips with DDH underwent the procedure for labral tears. All patients were females, with a mean age of 30 years. The mean follow-up period was 33 months. The mean Harris hip score improved from 74.2 to 93.6, and Oxford Hip score improved from 32.4 to 19.3. According to the Tönnis classification, the grade of arthritis preoperatively was grade 0 for nine hips and grade I for four hips. No radiographic progression of osteoarthritis was observed. It is possible that this novel procedure could be an effective treatment for labral tears with DDH and may prevent the early onset of secondary osteoarthritis. In this technical tip, we describe hip arthroscopic labral repair combined with a less invasive open-shelf acetabuloplasty in further detail.

Dega transiliac osteotomy in the treatment of advanced forms of Perthes' disease: a literature review.

The work aims to revise the current views on the effectiveness of Dega's pelvic osteotomy in preventing femoral head deformity in the course of Perthes' disease in patients with late symptoms >8 years of age and withsignificant changes in the radiographic image (Catterall III/IV or Herring B, B/C, C). We did a literature review. Four articles from six found in 'PubMed' which combine Dega acetabuloplasty and Perthes' disease words were fully read and analyzed. Kamegaya (2018), with a 9.5-year follow-up period, described differences comparing the group treated with femoral varus osteotomy with the group that was treated with a combined Dega acetabuloplasty and femoral varus osteotomy. A series of papers by Napiontek from 2004, with an average 8-year follow-up, also describes satisfactory results after Dega's osteotomy, with 27 hips in groups I/II according to Stulberg. Another paper in the series, which analyzed operatively and non-operatively treated patients, shows no differences in the period of time of Perthes disease treatment between the analyzed groups. The last paper in the series from 2001, describes 10 patients treated primarily due to hip dysplasia, who was diagnosed with Perthes disease. Five of them underwent Dega acetabuloplasty obtaining a Stulberg score of I/II in the long-term follow-up. We think it seems reasonable to return to the treatment planning of Perthes' disease using Dega acetabuloplasty as a method to improve the hip congruence in late-diagnosed and advanced forms of the disease.

The Vascularization Course of Labral Autograft and Its Effect on Tissue Healing: Acetabular Labral Augmentation Versus Labral Reconstruction in a Porcine Model.

BACKGROUND: The preservation of the native labral vascularization is assumed to be the potential advantage of acetabular labral augmentation, the effect of which remains unknown. PURPOSE: To identify the vascular distribution within the labral autograft and its effect on the healing process between labral augmentation (AUG) and reconstruction (RECON) in a porcine model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 36 pigs randomly underwent unilateral labral augmentation or reconstruction (AUG group, n = 18; RECON group, n = 18). The pigs were randomly sacrificed at 6, 12, and 24 weeks postoperatively. The labral autografts were harvested for macroscopic evaluation and histologic assessment. The labral autograft was zoned into 2 halves to observe the vascular distribution: the capsular half (zone I) and the articular half (zone II). Each zone was divided into 2 parts: the peripheral part (IA and IIA) and the part attached to the acetabulum (IB and IIB). RESULTS: At 6 weeks, there existed more vascular ingrowth in zone I, whereas zone IIB appeared nearly avascular in both groups. At 12 weeks, the area with the greatest vascularity was zone II in the RECON group and zone IA in the AUG group. The vascularity was concentrated at zones IA and IIA in both groups at 24 weeks. The labral autografts were hypertrophic with sufficient filling of the labral defect in both groups at 6 weeks. At 12 weeks, an insufficient volume of the articular half was observed in 3 of 6 labral autografts in the RECON group, while all autografts remained well integrated with the chondrolabral junction in the AUG group. At 24 weeks, unsatisfactory merging of the labral autograft with the cartilage at the articular side was found in 2 of 6 labral autografts in the RECON group, which was not observed in the AUG group despite the sufficient volume of autografts labrum in both groups. CONCLUSION: Slow vascular ingrowth within the articular half might account for the poor healing of the reconstructed labral autograft. Labral augmentation provides the possibility of better tissue healing because of the preservation of the original chondrolabral junction compared with labral reconstruction. CLINICAL RELEVANCE: Labral augmentation might be a feasible alternative to labral reconstruction under the condition of viable labral remnants.

Early and mid-term results of Tönnis lateral acetabuloplasty for the treatment of developmental dysplasia of the hip.

OBJECTIVES: This study aimed to present the clinical and radiological results of a large patient group operated by Tönnis lateral acetabuloplasty (TLA) for developmental dysplasia of the hip (DDH). PATIENTS AND METHODS: The retrospective study was conducted with 66 hips of 41 patients (5 males, 36 females; mean age: 32.3±18 months; range, 11 to 132 months) operated for DDH using the TLA technique in a single center between February 2012 and December 2016. Adductor tenotomy was performed on 52 (79%) hips. There was a need for additional femoral shortening and derotation-varization osteotomy in 14 (21%) hips. Clinical outcomes were evaluated with modified McKay criteria. The acetabular index and lateral migration index for the subluxated hip were calculated, and the femoral head position was evaluated according to Perkin's line and Shenton's line. The Severin classification was used to assess the outcome of the hips. RESULTS: The mean follow-up period was 27±11 months. According to the modified McKay criteria for DDH, 77.3% of hips were classified as excellent, 16.6% as good, and 6.1% as fair. The mean acetabular index decreased from 36.1° preoperatively to 18.6° postoperatively. The mean postoperative improvement for the acetabular index was 17.5±5. The lateral migration index improved from 89.7 to 10.6%. A statistically significant difference was determined between the preoperative and postoperative measurements of the acetabular index and lateral migration index (p<0.001). CONCLUSION: Tönnis lateral acetabuloplasty was found to be safe and effective with a low learning curve, and successful treatment decreases the duration of follow-up required in patients with DDH.

Influence of shelf acetabuloplasty on the outcomes of total hip arthroplasty in hips with dysplasia: a case-control study.

INTRODUCTION: Total hip arthroplasty (THA) in young adults, especially in those with hip dysplasia, is affected by wear and acetabular fixation problems. Shelf acetabuloplasty is performed to delay THA in patients with acetabular dysplasia. Thus, we conducted a retrospective, continuous case-control study at a single healthcare facility to analyze (1) the influence of prior shelf acetabuloplasty on the survival of a subsequent THA and (2) the functional outcomes. MATERIALS AND METHODS: We evaluated 105 patients (124 THA) who underwent THA due to hip dysplasia: 54 patients (61 THA) were included in the THA post-shelf acetabuloplasty group (case group) and 51 patients (63 THA) in the THA for dysplasia group (control group). RESULTS: At 15 years' follow-up, 89% of patients (95% CI: 84-91%) in the shelf group and 83% (95% CI: 81-90%) in the dysplasia group had not undergone surgical revision. This difference between groups was not statistically significant (p = 0.566). The functional outcomes were satisfactory in both groups; however, they were significantly better in the dysplasia group than in the shelf group based on the Merle d'Aubigne and Postel score (16.9 vs 16.0 min-max: 14-18 vs 3-18) (p = 0.01), Harris Hip score (90.0 vs 84.7, min-max: 62-100 vs 22-100) (p = 0.017), and the Oxford-12 (18/60 vs 21/60, min-max: 45-12 vs 51-12) (p = 0.04). CONCLUSION: Shelf acetabuloplasty before THA does not negatively affect THA survivorship. The functional outcomes appear to be better in the hips that did not undergo shelf acetabuloplasty, although the results were good in both groups.

Incidence and risk factors of preoperative deep venous thrombosis following pelvic and acetabular fractures: a retrospective case-control study.

The objective of this study was to investigate the prevalence of preoperative deep venous thrombosis (DVT) in the pelvic cavity and lower extremities following pelvic and acetabular fractures and to identify the risk factors of the occurrence of DVT. Duplex ultrasound (DUS) screening and blood tests were conducted in patients admitted from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. Univariate analyses were performed on data of demographics, comorbidities, time from injury to surgery, injury mechanism, accompanied injury, and laboratory results. The optimal cutoff values of continuous variables with statistical significance were obtained by using the receiver operating characteristic (ROC) curve. A multivariate logistic regression analysis was then employed to examine the independent values in terms of predicting preoperative DVT. A total of 607 patients with pelvic and acetabular fractures were included, among whom 82 (13.5%) patients sustained preoperative DVTs. Specifically, 31.7% (26/82) were diagnosed with proximal DVTs. Fifty-two (63.4%) patients had DVT within 7 days after injury, and 67 (81.7%) patients within 10 days. The multivariate logistic regression analysis identified 6 factors independently associated with the presence of preoperative DVT, including age > 46 years (odds ratio [OR] = 2.94), BMI > 26.73 kg/m2 (OR = 3.91), time from injury to surgery > 9 days (OR = 5.39), associated injury (OR = 7.85), ALB < 32.8 g/L (OR = 2.71) and FIB > 3.095 g/L (OR = 3.34). Despite the modern prophylactic regimen, the preoperative DVT in patients with pelvic and acetabular fractures still draws the attention of orthopaedic surgeons. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.

Acetabular remodeling after graft extrusion, rotation or impaction in Dega and Pemberton acetabuloplasties for developmental dysplasia of the hip.

Traditionally graft displacement following Pemberton and Dega acetabuloplasties involves internal fixation for treatment of developmental dysplasia of hip (DDH). This study was performed to assess the acetabular remodeling by conservative management of graft displacement among patients with DDH. This was a retrospective study of 20 patients 17 (85%) women and 3 (15%) men; mean age 22.90 ± 6.96 months with DDH who underwent Pemberton and Dega acetabuloplasties at King Khalid University Hospital, Riyadh between January 2013 and January 2018. All patients after losing acetabular correction during immediate postoperative period were treated by conservative management. The management involved application of Spica cast for 6 weeks that was trimmed to broomstick cast for an extended period of time and finally replaced by nocturnal abduction brace until normal acetabular index (AI) was achieved. The patients were followed up for a mean period of 44.60 ± 12.36 months. Out of the total, 18 (90%) patients with DDH were successfully treated by conservative management. The mean preoperative AI of 43.70° ± 5.91° improved to 21.35o ± 6.32o at the final follow-up (P < 0.001) which was no different when compared to the mean of unaffected hips (19.70o ± 2.96o; P < 0.44). The mean preoperative CEA of all the patients was negative that improved during the conservative treatment to 29.20° ± 10.0° which was no different when compared with the mean of unaffected (31.70° ± 4.64o; P = 0.32) hips at the final follow-up. doption of less aggressive approach for management of displaced, rotated or impacted autograft following acetabuloplasties among children with DDH was not only a useful conservative approach for remodeling of hips but also obviated the need for additional surgical intervention.

3-D acetabular morphology of the neuromuscular hip: implications for preoperative planning.

The importance of precisely understanding the pathoanatomy of acetabular dysplasia prior to surgical treatment has long been recognized. Acetabuloplasties for neuromuscular hip dysplasia have typically aimed to improve the acetabulum by increasing posterior-superior coverage, as previous three-dimensional (3-D) computed tomography (CT) studies have shown that acetabular dysplasia in neuromuscular hips is primarily in the direction of posterior-superior subluxation or dislocation. The purpose of this study was to identify differences in 3-D morphology between normal hips and dysplastic neuromuscular hips, specifically to identify areas of acetabular deficiency to guide preoperative decision-making. Patients treated for neuromuscular hip dysplasia at a single institution between 2009 and 2017 with a preoperative high-resolution pelvic CT scan (28 hips) were evaluated with custom software to measure acetabular morphology. Acetabuli were divided into equal octants; coverage angles were measured for each octant of interest. Variables were compared with age- and sex-matched normal controls (56 hips). We found a wide range of hip pathology in our study cohort. Five hips had no sectors with abnormal coverage. One hip (4%) was overcovered anteriorly. The remaining pathology was undercoverage located anteriorly [n = 7 (25%)], superiorly [n = 6 (21%)], posteriorly [n = 4 (14%)] or globally [n = 5 (18%)]. Our findings indicate that individual patients with neuromuscular acetabular dysplasia have unique deformities that do not uniformly conform to a specific area of acetabular deficiency. It is imperative to define the specific 3-D acetabular deficiency location and magnitude for accurate preoperative planning. Level of evidence: Level III.

Isolated Acetabuloplasty for Femoroacetabular Impingement: Favorable Patient-Reported Outcomes and Sustained Survivorship at Minimum 5-Year Follow-Up.

PURPOSE: To evaluate minimum 5-year outcomes and conversion rate to total hip arthroplasty (THA) for the treatment of femoroacetabular impingement (FAI) syndrome with an isolated acetabular osteoplasty. METHODS: Patients undergoing hip arthroscopy with an isolated acetabular osteoplasty from March 2009 to June 2014 for FAI syndrome with pincer and/or cam morphology and a labral tear were identified. Those who underwent femoroplasty or prior ipsilateral hip surgery or who had previous hip conditions, ipsilateral hip dysplasia, or a Tönnis grade higher than 2 were excluded. Patient-reported outcomes (PROs) collected included Patient-Reported Outcomes Measurement Information System (PROMIS) scores specific to physical functioning and pain interference, modified Harris Hip Score, International Hip Outcome Tool 12, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, and Numeric Pain Rating Scale. Patients were also queried about secondary surgical procedures and conversion to THA. RESULTS: We identified 86 patients at minimum 5-year follow-up (average, 7.4 years). The average patient age was 39.8 ± 12.3 years, 70.9% of patients were female, and 7% of patients had Tönnis grade 2. The mean PRO scores were 52.0 ± 8.9 for the PROMIS physical functioning score, 39.6 ± 7.5 for the PROMIS pain interference score, 78.7 ± 12.0 for the modified Harris Hip Score, 73.3 ± 23.1 for the International Hip Outcome Tool 12 score, 89.9 ± 12.0 for the Hip Outcome Score-Activities of Daily Living, and 81.4 ± 21.0 for the Hip Outcome Score-Sport-Specific Subscale. Of the patients, 72.1% achieved the patient acceptable symptomatic state (PASS) according to previously established PASS scores for FAI syndrome treated with hip arthroscopy at minimum 5-year follow-up. The overall rate of revision arthroscopy was 3.5%, and the rate of conversion to THA was 5.8%. CONCLUSIONS: An isolated acetabular osteoplasty can provide sustained clinical benefits for the treatment of FAI syndrome with labral tears, with good to excellent PROs and PASS rates and a low rate of conversion to THA at minimum 5-year follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Does Adding Femoral Lengthening at the Time of Rotation Hip Transposition After Periacetabular Tumor Resection Allow for Restoration of Limb Length and Function? Interim Results of a Modified Hip Transposition Procedure.

BACKGROUND: Reconstruction after pelvic tumor resection of the acetabulum is challenging. Previous methods of hip transposition after acetabular resection have the advantages of reducing wound complications and infections of the allograft or metal endoprosthesis but were associated with substantial limb length discrepancy. We therefore developed a modification of this procedure, rotation hip transposition after femur lengthening, to address limb length, and we wished to evaluate its effectiveness in terms of complications and functional outcomes. QUESTIONS/PURPOSES: In this study, we asked: (1) What were the Musculoskeletal Tumor Society scores after this reconstruction method was used? (2) What complications occurred after this reconstruction method was used? (3) What proportion of patients achieved solid arthrodesis (as opposed to pseudarthrosis) with the sacrum and solid union of the femur? (4) What were the results with respect to limb length after a minimum follow-up of 2 years? METHODS: From 2011 to 2017, 83 patients with an aggressive benign or primary malignant tumor involving the acetabulum were treated in our institution. Of those, 23% (19 of 83) were treated with rotation hip transposition after femur lengthening and were considered for this retrospective study; 15 were available at a minimum follow-up of 2 years (median [range], 49 months [24 to 97 months]), and four died of lung metastases before 2 years. No patients were lost to follow-up before 2 years. During the period in question, the general indications for this approach were primary nonmetastatic malignant bone tumor or a locally aggressive benign bone tumor that could not be treated adequately with curettage. There were seven men and 12 women with a median age of 43 years. Nine patients underwent Zones I + II resection, eight patients had Zones I + II + III resection, and two received Zones II + III resection. After tumor resection, rotation hip transposition after femur lengthening reconstruction was performed, which included two steps. The first step was to lengthen the femur with the insertion of an allograft. Two methods were used to achieve limb lengthening: a "Z" osteotomy and a transverse osteotomy. The second step was to take the hip transposition and rotate the femoral head posteriorly 10° to 20°. The median (range) operative time was 510 minutes (330 to 925 minutes). The median intraoperative blood loss was 4000 mL (1800 to 7000 mL). We performed a chart review on the 15 available patients for clinical and radiographic assessment of functional outcomes and complications. Arthrodesis and leg length discrepancy were evaluated radiographically. RESULTS: The median (range) Musculoskeletal Tumor Society score was 21 points (17 to 30). Eleven of 19 patients developed procedure-related complications, including six patients with allograft nonunion, two with deep infection, two with delayed skin healing, and one with a hematoma. Two patients had minor additional surgical interventions without the removal of any implants. Local recurrences developed in four patients, and all four died of disease. All seven patients treated with a Z osteotomy had bone union. Among the eight patients with transverse osteotomy, bone union did not occur in six patients. After hip transposition, stable iliofemoral arthrodesis was achieved in seven patients. Pseudarthrosis developed in the remaining eight patients. The median (range) lower limb length discrepancy at the last follow-up visit or death was 8 mm (1 to 42 mm). CONCLUSION: Although complex and challenging, rotation hip transposition after femur lengthening reconstruction with a Z osteotomy provides acceptable functional outcomes with complications that are within expectations for resection of pelvic tumors involving the acetabulum. Because of the magnitude and complexity of this technique, we believe it should be used primarily for patients with a favorable prognosis, both locally and systemically. This innovative procedure may be useful to other surgeons if larger numbers of patients and longer-term follow-up confirm our results. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Hip arthroscopy with initial access to the peripheral compartment provides significant improvement in FAI patients.

PURPOSE: This study was designed to evaluate the clinical and radiographic results of arthroscopic treatment of femoroacetabular impingement (FAI) using the technique of initial access to the peripheral compartment. It is based on a single surgeon large case series with a minimum of 2 years follow-up. METHODS: Prospective longitudinal study with consecutive patients. Inclusion criteria were the presence of FAI syndrome that had failed non-operative treatment and had a hip arthroscopy with initial access to the peripheral compartment. Exclusion criteria were previous hip surgery, patients younger than 16 or older than 60 years, Tönnis grade ≥ 2 osteoarthritis, hip dysplasia based on radiographic evidence of LCEA less than 25° and workers compensation cases. One hundred and sixty hips met the inclusion criteria, 84 were female and 70 were male patients (six bilateral cases), with a median age of 36 years (range 16-59). RESULTS: The median alpha angle correction was 22.6º (range 5.9-46.7) (p < 0.01) and the average LCEA correction when acetabuloplasty was undertaken was 6.5º (range - 1.4-20.8) (p < 0.01). The mean NAHS at baseline was 56.1 (range 16-96) and improved to 83.2 at the last follow up (range 44-100) for the patients that had no additional procedure (p < 0.01). The mean average improvement was 27.7º points (range - 16-73). No iatrogenic labral perforation and no full-thickness chondral damage were recorded during the arthroscopic procedures. CONCLUSIONS: Favourable outcomes are reported for the arthroscopic treatment of FAI with initial access to the peripheral compartment. The technique is protective against iatrogenic chondral and labral damage, more conservative to the joint capsule, but the mean traction time was relatively long when suture anchors were used. The results are comparable to the classic initial central compartment approach. LEVEL OF EVIDENCE: Level IV.

No Correlation Between Depth of Acetabuloplasty or Postoperative Lateral Center-Edge Angle on Midterm Outcomes of Hip Arthroscopy With Acetabuloplasty and Labral Repair.

BACKGROUND: The treatment of pincer deformity in hip arthroscopy remains controversial, with some authors advocating that over resection may risk early joint deterioration. The role of acetabular resection depth and postoperative acetabular morphology on postoperative outcomes has yet to be defined. PURPOSE/HYPOTHESIS: This study measures the influence of acetabular resection depth and postoperative lateral center-edge angle (LCEA) on minimum 5-year patient-reported outcomes (PROs), revision rates, and conversion to total hip arthroplasty using a single surgeon's prospective database. We hypothesized that patients with acetabular resections >10°, as measured by LCEA, or patients with postoperative LCEA outside the normal range of 25° to 35° would have lower PROs, higher revision rates, and higher conversion to total hip arthroplasty at midterm follow-up. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 192 patients who underwent primary hip arthroscopy with acetabuloplasty and labral repair by a single surgeon with a minimum 5-year follow-up met the inclusion criteria. Preoperative and postoperative LCEAs were measured on supine anteroposterior radiographs, and patients were divided into cohorts based on LCEA and acetabular resection depth. Cohorts for postoperative LCEA were <20° (dysplasia), 20° to 25° (borderline dysplasia), 25° to 35° (normal), and >35° (borderline overcoverage). Cohorts for acetabular resection depth were <5°, 5° to 10°, and >10° difference from preoperative to postoperative LCEA. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short Form Health Survey, modified Harris Hip Score, Hip Outcome Score, satisfaction scores, revision rates, and conversion to arthroplasty rates. RESULTS: Patients significantly improved in all outcome score measures at final follow-up. There were no statistically significant differences in PRO scores or conversion to total hip arthroplasty between any cohorts in the postoperative LCEA group. There were more revisions in the 25° to 35° cohort than the other cohorts (P = .02). The 5-10° resection depth cohort demonstrated a higher postoperative WOMAC score (P = .03), but otherwise no statistically significant differences were seen between resection depth cohorts in the remaining postoperative outcomes scores, revision rates, or conversion to total hip arthroplasty rates. CONCLUSION: Patients with postoperative LCEA values outside the normal reference range and with large resections perform similar to those with normal postoperative LCEA values and smaller resections at a minimum 5-year follow-up.

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis.

INTRODUCTION: Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques. METHODS: Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models. RESULTS: From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results. CONCLUSIONS: Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.