Prevalence and impact of pain at the greater trochanter after open surgery for the treatment of femoro-acetabular impingement

Femoro-acetabular impingement can cause pain and degenerative changes of the hip joint. Traditionally, surgical dislocation of the hip joint has been performed for correction of pathologic abnormalities in the proximal part of the femur and the acetabulum. Failures of surgical treatment are often related to postoperative pain in the groin or in the area of the greater trochanter, associated with this surgical approach. The aim of our study was to determine the prevalence and functional impact of pain at the greater trochanter after surgical dislocation of the hip.

Long-term outcome after traumatic anterior dislocation of the hip

Traumatic anterior dislocation of the hip joint is rare. Additional injuries to the hip due to dislocation are even more infrequent. Outcome is limited by osteoarthritic joint degeneration or the occurrence of avascular necrosis of the femoral head.

Delayed gadolinium-enhanced magnetic resonance imaging of hip joint cartilage: pearls and pitfalls

With the increasing advances in hip joint preservation surgery, accurate diagnosis and assessment of femoral head and acetabular cartilage status is becoming increasingly important. Magnetic resonance imaging (MRI) of the hip does present technical difficulties. The fairly thin cartilage lining necessitates high image resolution and high contrast-to-noise ratio (CNR). With MR arthrography (MRA) using intraarticular injected gadolinium, labral tears and cartilage clefts may be better identified through the contrast medium filling into the clefts. However, the ability of MRA to detect varying grades of cartilage damage is fairly limited and early histological and biochemical changes in the beginning of osteoarthritis (OA) cannot be accurately delineated. Traditional MRI thus lacks the ability to analyze the biological status of cartilage degeneration. The technique of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) is sensitive to the charge density of cartilage contributed by glycosaminoglycans (GAGs), which are lost early in the process of OA. Therefore, the dGEMRIC technique has a potential to detect early cartilage damage that is obviously critical for decision-making regarding time and extent of intervention for joint-preservation. In the last decade, cartilage imaging with dGEMRIC has been established as an accurate and reliable tool for assessment of cartilage status in the knee and hip joint.This review outlines the current status of dGEMRIC for assessment of hip joint cartilage. Practical modifications of the standard technique including three-dimensional (3D) dGEMRIC and dGEMRIC after intra-articular gadolinium instead of iv-dGEMRIC will also be addressed.

Hip arthroscopy after surgical hip dislocation: is predictive imaging possible?

Our purpose was to study the sensitivity, specificity, and predictive values for hip adhesions, labral tears, and articular cartilage lesions in patients who had open treatment for femoroacetabular impingement, had persistent symptoms, and had both magnetic resonance arthrography (MRA) with radial slices and hip arthroscopy.

Rationales for the Bernese approaches in acetabular surgery

PURPOSE: To present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures. METHOD: The trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described. RESULTS: Full exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head-neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches. CONCLUSIONS: Utilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approaches.

Joint-preserving surgery improves pain, range of motion, and abductor strength after Legg-Calvé-Perthes disease

Patients after Legg-Calvé-Perthes disease (LCPD) often develop pain, impaired ROM, abductor weakness, and progression of osteoarthritis (OA) in early adulthood. Based on intraoperative observations during surgical hip dislocation, we established an algorithm for more detailed characterization of the underlying pathomorphologies with a proposed joint-preserving surgical treatment.

Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures

The aims of the study were (1) to determine the cumulative two to twenty-year survivorship of the hip after open reduction and internal fixation of displaced acetabular fractures, (2) to identify factors predicting conversion to total hip arthroplasty or hip arthrodesis, and (3) to create a predictive model that calculates an individual's probability of early need for total hip arthroplasty or hip arthrodesis.

Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery

PURPOSE: To evaluate selective and superselective catheter therapy of serious arterial damage associated with orthopedic surgery of the pelvis, hip joint, femur, and knee. MATERIALS AND METHODS: Between 1989 and 2005, 16 consecutive patients with arterial damage after orthopedic surgery (seven women, nine men; mean age, 62 years; age range, 21-82 y) underwent angiographic exploration. Seven patients were in hemodynamically unstable condition. Initial orthopedic procedures were iliac crest internal fixation (n = 1); total hip prosthesis (n = 3); revision of total hip prosthesis (n = 4); revision of acetabular cup prosthesis (n = 1); gamma-nailing, nail-plate fixation, or intramedullary nailing (n = 3); and total knee prosthesis (n = 4). RESULTS: Angiography showed pseudoaneurysms (n = 11), vascular lacerations with active extravasation (n = 3), and arteriovenous fistulas with extravasation (n = 2). After angiographic documentation of serious arterial injury, 14 patients were treated with a single or coaxial catheter technique in combination with coils alone, coils and polyvinyl alcohol particles, coils and Gelfoam pledgets, or Gelfoam pledgets; or balloon occlusion with isobutyl cyanoacrylate and coils. Two patients were treated with covered stents. In all, bleeding was effectively controlled in a single session in 16 patients, with immediate circulatory stabilization. Major complications included death, pulmonary embolism, and postprocedural hematoma. CONCLUSION: Selective and superselective catheter therapy may be used for effective, minimally invasive management of rare but potentially life-threatening vascular complications after orthopedic surgery.

Patient-related risk factors leading to aseptic stem loosening in total hip arthroplasty: a case-control study of 5,035 patients

BACKGROUND: We hypothesized that certain patient characteristics have different effects on the risk of early stem loosening in total hip arthroplasty (THA). We therefore conducted a case-control study using register-database records with the aim of identifying patient-specific risk factors associated with radiographic signs of aseptic loosening of the femoral component in THA. METHOD: Data were derived from a multinational European registry and were collected over a period of 25 years. 725 cases with radiographic signs of stem loosening were identified and matched to 4,310 controls without any signs of loosening. Matching criteria were type of implant, size of head, date of operation, center of primary intervention, and follow-up time. The risk factors analyzed were age at operation, sex, diagnosis and previous ipsilateral operations, height, weight, body mass index and mobility based on the Charnley classification. RESULTS: Women showed significantly lower risk of radiographic loosening than men (odds ratio (OR) 0.64). Age was also a strong factor: risk decreased by 1.8% for each additional year of age at the time of surgery. Height and weight were not associated with risk of loosening. A higher body mass index, however, increased the risk of stem loosening to a significant extent (OR 1.03) per additional unit of BMI. Charnley Class B, indicating restricted mobility, was associated with lower risk of loosening (OR 0.78). INTERPRETATION: An increased activity level, as seen in younger patients and those with unrestricted mobility, is an important factor in the etiology of stem loosening. If combined with high BMI, the risk of stem loosening within 10 years is even higher. A younger person should not be denied the benefits of a total hip arthroplasty but must accept that the risk of future failure is increased.

[Conventional vs minimally invasive total hip arthroplasty. A prospective study of rehabilitation and complications]

BACKGROUND: In a prospective, nonrandomized study the outcome in terms of rehabilitation and complications of total hip arthroplasty (THA) through a superior capsulotomy exposure (study group) was compared to THA performed through a direct lateral exposure (control group). PATIENTS AND METHODS: The study group (106 THA) and the control group (107 THA) were controlled for complexity and had no significant differences in age, sex, diagnosis, or body mass index. RESULTS: The study group had improved recovery at 6 weeks after surgery which was statistically significant (p<0.001). In addition, the study group had a lower incidence of perioperative complications. CONCLUSION: The current study demonstrates the potential that less-invasive surgical techniques with the philosophy of maximally preserving the abductors, posterior capsule, and short rotators may result in a safer operation with an accelerated recovery.

Accuracy considerations in navigated cup placement for total hip arthroplasty

Computer assisted orthopaedic surgery (CAOS) technology has recently been introduced to overcome problems resulting from acetabular component malpositioning in total hip arthroplasty. Available navigation modules can conceptually be categorized as computer tomography (CT) based, fluoroscopy based, or image-free. The current study presents a comprehensive accuracy analysis on the computer assisted placement accuracy of acetabular cups. It combines analyses using mathematical approaches, in vitro testing environments, and an in vivo clinical trial. A hybrid navigation approach combining image-free with fluoroscopic technology was chosen as the best compromise to CT-based systems. It introduces pointer-based digitization for easily assessable points and bi-planar fluoroscopy for deep-seated landmarks. From the in vitro data maximum deviations were found to be 3.6 degrees for inclination and 3.8 degrees for anteversion relative to a pre-defined test position. The maximum difference between intraoperatively calculated cup inclination and anteversion with the postoperatively measured position was 4 degrees and 5 degrees, respectively. These data coincide with worst cases scenario predictions applying a statistical simulation model. The proper use of navigation technology can reduce variability of cup placement well within the surgical safe zone. Surgeons have to concentrate on a variety of error sources during the procedure, which may explain the reported strong learning curves for CAOS technologies.

Computed tomography-based surgical navigation for hip arthroplasty

Component malpositioning and postoperative leg length discrepancy are the most common technical problems associated with total hip arthroplasty (THA). Surgical navigation offers the potential to reduce the incidence of these problems. We reviewed 317 patients (344 hips) that underwent THA using computed tomography-based surgical navigation, including 112 THAs using a simplified method of measuring leg length. Guided by the navigation system, cups were placed in 40.8 degrees +/- 2 degrees of operative abduction (range, 35 degrees -50 degrees) and 30.8 degrees +/- 3.2 degrees (range, 19 degrees -43 degrees) of operative anteversion. We subsequently measured radiographic abduction on plain anteroposterior pelvic radiographs and calculated abduction and anteversion. Radiographically, 97.1 % of the cups were in the safe zone for abduction and 92.4% for anteversion. The mean incision length was less than 8 cm for 327 of the 344 hips. Leg length change measured intraoperatively was 6.6 +/- 4.1 mm (range, -2-22), similar to measurements from the pre- and postoperative magnification-corrected radiographs. Computer assistance during THA increased the consistency of component positioning and allowed reliable measurement of leg length change during surgery.

Minimum ten year results of total hip arthroplasty with the acetabular reinforcement ring in avascular osteonecrosis

Total hip arthroplasty (THA) still carries a higher failure rate in patients with avascular necrosis of the femoral head (AVN) than in a similar patient population with THA for other reasons. This is particularly true for the acetabular component. One of the major factors accounting for this is the compromised acetabular bone quality with structural defects subsequent to collapsing of the femoral head in high-grade AVN. In this study we implanted an acetabular reinforcement ring with hook (ARRH), which had been used successfully for other indications with acetabular bone stock deficiency, in 32 consecutive THA's in 29 patients with AVN. Five patients died during the observation period of causes unrelated to the surgery, one patient was lost to follow-up and one patient could not be followed up due to chronic illness, leaving 25 hips (23 patients) with a minimum follow-up of ten years (mean: 11.8; range: 10-15). The mean Merle d'Aubigne score increased significantly from 7.7 preoperatively to 16.6 postoperatively (p < 0.001). One revision was performed for aseptic stem loosening. Of the unrevised hips, one acetabular component was classified as definitively loose. The cumulative 12-year survivorship for THA with ARRH in AVN was 95.2% (confidence interval: 86.1-100%) for both components, 100% for the cup and 95.2% for the stem (86.1-100%).

Hip arthroscopy after previous surgical hip dislocation for femoroacetabular impingement

PURPOSE: The purpose of this study was to examine whether arthroscopic adhesiolysis can relieve symptoms of patients with persistent pain after open surgical hip dislocation for femoroacetabular impingement syndrome without osseous or cartilaginous alterations. METHODS: This study comprised 16 consecutive patients (6 men and 10 women; mean age, 33.5 years [range, 19 to 60 years]) with persistent pain without osseous or cartilaginous alterations after surgical hip dislocation for the treatment of femoroacetabular impingement. At index surgery, all patients had osteochondroplasty of the head-neck junction and resection of the acetabular rim with reattachment of the labrum in 9 cases. All patients had preoperative magnetic resonance imaging-arthrogram and were treated with arthroscopy of the hip. RESULTS: At arthroscopy, all reattached labra were stable. In the cases without preservation of the labrum at the index operation, the joint capsule was attached at the level of the acetabular rim and synovitis was noticed. All patients had adhesions between the neck of the femur and joint capsule or between the labrum and capsule. In 3 patients the arthroscopic procedure was technically limited by massive thickening of the capsule. Overall, 81% of patients (13/16) showed less pain or were pain-free. The Merle d'Aubigné score improved from 13 points preoperatively to 16 points at the last follow-up. CONCLUSIONS: Persistent pain after surgical dislocation of the hip without evidence of cartilaginous and osseous alterations could result from intra-articular adhesions. Hip arthroscopy after previous surgery can be demanding because of scarring. If the adhesions can be released, good results can be achieved. LEVEL OF EVIDENCE: Level IV, therapeutic case series.