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Goh EL, Boughton OR, Donnelly T, Murphy CG, Cashman J, Green C. Do joint-preserving hip procedures compromise subsequent total hip arthroplasty? A meta-analysis of complications, functional outcome and survivorship. SICOT J 2024; 10:25. [PMID: 38847649 PMCID: PMC11160402 DOI: 10.1051/sicotj/2024018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. METHODS MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. RESULTS 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6-11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6-200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2-3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0-3.2], implant loosening [RR: 1.0, 95% CI: 0.7-1.5], or revision surgery [RR: 1.3, 95% CI: 1.0-1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: -5.6, 95% CI: -7.6-(-3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6-6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4-4.7], specifically, with prior femoral osteotomy. CONCLUSION Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.
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Affiliation(s)
- En Lin Goh
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopedics Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford Oxford OX3 9DU United Kingdom
| | - Oliver R. Boughton
- National Orthopedic Hospital Cappagh Cappagh Road, Cappoge Dublin 11 D11 EV29 Ireland
| | - Thomas Donnelly
- National Orthopedic Hospital Cappagh Cappagh Road, Cappoge Dublin 11 D11 EV29 Ireland
| | - Colin G. Murphy
- Department of Trauma and Orthopedics, Merlin Park Hospital EC5, Old Dublin Road Galway Ireland
| | - James Cashman
- National Orthopedic Hospital Cappagh Cappagh Road, Cappoge Dublin 11 D11 EV29 Ireland
| | - Connor Green
- National Orthopedic Hospital Cappagh Cappagh Road, Cappoge Dublin 11 D11 EV29 Ireland
- University College Dublin, School of Medicine Belfield Dublin 4 Ireland
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Comparison between cup implantations during total hip arthroplasty with or without a history of rotational acetabular osteotomy. Arch Orthop Trauma Surg 2022; 142:3539-3547. [PMID: 34799746 DOI: 10.1007/s00402-021-04253-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Total hip arthroplasty (THA) after rotational acetabular osteotomy (RAO) is technically demanding because of the characteristic acetabular morphology after RAO. The present study aimed to investigate the differences in the three-dimensional cup position between THA after RAO and primary THA. MATERIALS AND METHODS We analysed the pre-operative and post-operative computed tomography (CT) data of 120 patients (20 patients after RAO and 100 patients without a history of RAO) who underwent THA between January 2017 and June 2018. We evaluated radiographic parameters, including acetabular anteversion, antero-posterior distance at the level of the femoral head centre, the presence of anterior acetabular osteophyte and/or rotated fragment during RAO from the CT data. Additionally, operative data and clinical scores were also evaluated. RESULTS Although we found no significant differences in any clinical parameters, there were significant differences in radiographic parameters and operative data. The morphology of the acetabulum was significantly retroverted, and the antero-posterior distance was longer in patients after RAO, compared to the implanted cup. Additionally, longer operative time was necessary for such patients. These results reflect the atypical acetabular morphology after RAO, and emphasize that care should be taken to avoid anterior bony impingement and post-operative dislocation. CONCLUSION For cup implantation during THA after RAO, surgeons should acknowledge the atypical morphology of the acetabulum and not be misled by its visual shape.
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Crnogaca K, Sulje Z, Delimar D. Previous corrective osteotomies of femur and pelvis are a risk factor for complications following total hip arthroplasty in hip dysplasia. J Orthop 2022; 33:100-104. [PMID: 35942332 PMCID: PMC9356201 DOI: 10.1016/j.jor.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/13/2022] [Accepted: 07/12/2022] [Indexed: 10/17/2022] Open
Abstract
Background Modified anatomy of dysplastic hips, bone defects and previous operations make THA (total hip arthroplasty) in patients with hip dysplasia a technically challenging procedure. Methods One hundred and ten patients (mean 49.2 years of age, range 19-76, female:103, male:7) underwent 122 subsequent hip arthroplasties from 2012 to 2019. These patients were reviewed at least two years after THA. Plain radiography was used to determine Crowe classification of the affected hips. Fifty-three patients had an operation in childhood before THA was done (mean 47.0 years of age, standard deviation 8.3, range 19-62) and formed the "operated group". Among these patients, there were Chiari pelvic osteotomies, periacetabular osteotomies, femoral osteotomies, greater trochanter distalizations and soft tissue operations. Fifty-seven were not operated in childhood (mean 52.3 years of age, standard deviation 10.9, range 19-76) and formed the "non operated group". The functional status of the patients was assessed with the Oxford Hip Score (OHS). Results 122 total hip arthroplasties were performed using uncemented femoral and acetabular components. There were 13 major complications identified. Ten were in the "operated group", of which 5 needed revision surgery. Only 3 were in the "non operated group", with no need for revision. Aseptic loosenings of the femoral component were seen in the patients that had femoral osteotomy done in childhood. Acetabular component migration and intrapelvic migration occurred due to the initial malposition and lack of osteointegration, thus requiring early revision after just 6 months. Other major complications were peroneal palsy, deep periprosthetic infection, severe trochanteritis and intraoperative femoral fracture. OHS was significantly higher in the "non operated group" 42.3 (10-48), opposed to 39.1 (10-48) in the "operated group" (p 0.017). Conclusion Corrective osteotomies in childhood are a risk factor for complications and lower medium-term survivorship of the THA in hip dysplasia patients.
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Affiliation(s)
- Kresimir Crnogaca
- University Hospital Centre Zagreb, Department of Orthopaedic Surgery, Zagreb, Croatia
| | - Zoran Sulje
- University Hospital Centre Zagreb, Department of Orthopaedic Surgery, Zagreb, Croatia
| | - Domagoj Delimar
- University Hospital Centre Zagreb, Department of Orthopaedic Surgery, Zagreb, Croatia
- University of Zagreb, School of Medicine, University Hospital Centre Zagreb, Department of Orthopaedic Surgery, Zagreb, Croatia
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Influence of shelf acetabuloplasty on the outcomes of total hip arthroplasty in hips with dysplasia: a case-control study. INTERNATIONAL ORTHOPAEDICS 2022; 46:989-997. [PMID: 35113185 DOI: 10.1007/s00264-022-05322-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/26/2022] [Indexed: 10/19/2022]
Abstract
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.
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Zeng Y, Yang J, Wang G, Zhang R, Si H, Wu Y, Shen B. [Effectiveness of total hip arthroplasty in patients with a history of hip preservation surgery with secondary osteoarthritis for developmental dysplasia of the hip]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1537-1542. [PMID: 34913309 DOI: 10.7507/1002-1892.202108062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To evaluate early to medium-term effectiveness of total hip arthroplasty (THA) in patients with a history of hip preservation surgery with secondary severe osteoarthritis for developmental dysplasia of the hip (DDH). Methods The clinical data of 25 DDH patients (31 hips) who had severe osteoarthritis after hip preservation surgery and received THA between September 2009 and March 2021 were retrospectively analyzed. There were 1 male and 24 females; the age ranged from 18 to 65 years, with an average age of 43 years; 8 hips were classified into Crowe type Ⅰ, 9 hips were type Ⅱ, 3 hips were type Ⅲ, and 11 hips were type Ⅳ. The time between osteotomy and THA ranged from 31 to 51 years, with an average of 31.96 years. Preoperative hip flexion range of motion was (69.31±29.72)°, abduction range of motion was (24.00±14.79)°; and Harris hip score was 45.3±15.5. Postoperative Harris hip score, hip range of motion, complications, radiographic findings, and implant survival rate were analyzed. Results Patients in both groups were followed up 2-132 months, with an average of 51 months. During the follow-up, periprosthetic fracture occurred in 1 case; there was no complication such as dislocation, periprosthetic infection, nerve palsy, or deep vein thrombosis. At last follow-up, the hip flexion range of motion was (109.52±11.17)°, abduction range of motion was (41.25±5.59)°, showing significant differences when compared with preoperative values ( t=8.260, P=0.000; t=6.524, P=0.000). The Harris hip score was 91.5±4.1, and the difference was significant when compared with preoperative score ( t=11.696, P=0.000); among them, 13 cases were excellent and 12 cases were good. Radiographic evaluation showed that the center of acetabular rotation moved up 0-18 mm (mean, 6.35 mm). The cup abductor angle was 28°-49° (mean, 37.74°) and the coverage rate was 69.44%-98.33% (mean, 81.04%). All femoral stems were fixed in neutral position without varus or valgus. No osteolysis, radiolucent line, or implant migration was observed. By the end of follow-up, none of the patients underwent revision and the survival rate of prothesis was 100%. Conclusion THA is still the gold standard for the treatment of DDH patients with secondary osteoarthritis after hip preservation surgery. The postoperative joint function can be rapidly restored, the patients' quality of life can significantly improve, and the early to medium-term survival rate of the prosthesis is satisfactory.
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Affiliation(s)
- Yi Zeng
- National Clinical Research Center for Geriatrics, Chengdu Sichuan, 610041, P.R.China.,Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jing Yang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Gang Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Rongying Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Haibo Si
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yuangang Wu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Bin Shen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Saglam N, Gulabi D, Agar A, Erdem AC, Bayam L, Erdem M. Is Obesity Associated with Higher Complication Rates in Total Hip Arthroplasty for High-Riding Dysplastic Hips? Indian J Orthop 2021; 55:987-992. [PMID: 34194656 PMCID: PMC8192644 DOI: 10.1007/s43465-020-00335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/21/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Developmental dysplasia of the hip (DDH) is a disabling pathology leading to hip problems, such as painful arthritic hip, unstable hip, etc. Total hip arthroplasty (THA) is an effective treatment modality for this condition. Obesity has been shown to be associated with increased rates of complications following orthopaedic surgeries (Journal of Arthroplasty 20:46-50). The hypothesis of this study was that patients with a body mass index (BMI) greater than 30 (obese), who undergo total hip arthroplasty for dysplastic hip, are associated with longer operative and anaesthetic times, longer hospital stays and higher re-admission rates within 30 days. METHODS All the cases of total hip arthroplasty in patients with high-riding dysplastic hips were reviewed. Evaluation was made of a total of 68 patients comprising 64 females and 4 males, classified into two groups. Patients with BMI < 30 kg/m2 formed the non-obese group and patients with BMI ≥ 30 kg/m2 the obese group. RESULTS The mean age was 44.67 ± 6.49 years. BMI was < 30 in 44 (64.7%) patients and > 30 in 24 (35.3%) patients. The data analysis showed that mean surgical time, anaesthesia duration and re-admission rate were significantly higher in the group with BMI ≥ 30(obese) as compared to the group with BMI < 30 (non-obese) (p < 0.01). The complication rate was determined to be higher in the obese group (p < 0.05). CONCLUSION Obese patients performed with total hip arthroplasty for high-riding dysplastic hips had more complications and higher rates of re-admission to hospital compared with the non-obese patients.
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Affiliation(s)
- Necdet Saglam
- Umraniye Training and Research Hospital, Saglik Bilimleri University, Elmalikent mah., Adem yavuz cad., Umraniye, 34764 İstanbul, Turkey
| | - Deniz Gulabi
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, Saglik Bilimleri University, Atakent mah, Istanbul cad. No:1, Kucukcekmece, 34303 İstanbul, Turkey
| | - Anil Agar
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, Saglik Bilimleri University, Atakent mah, Istanbul cad. No:1, Kucukcekmece, 34303 İstanbul, Turkey
| | - Ahmet Can Erdem
- Orthopaedic and Traumatology Department, Faculty of Medicine, Bezmialem University, Yali Mah. Sahil yolu sok. No:16, Maltepe, 34844 İstanbul, Turkey
| | - Levent Bayam
- Orthopaedic and Traumatology Department, Faculty of Medicine, Sakarya University, Korucuk Mah. Konuralp Bulvari no: 81, 54290 Adapazarı, Sakarya Turkey
| | - Mehmet Erdem
- Orthopaedic and Traumatology Department, Faculty of Medicine, Sakarya University, Korucuk Mah. Konuralp Bulvari no: 81, 54290 Adapazarı, Sakarya Turkey
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Shapira J, Annin S, Rosinsky PJ, Maldonado DR, Lall AC, Domb BG. Total hip arthroplasty after pelvic osteotomy for acetabular dysplasia: A systematic review. J Orthop 2021; 25:112-119. [PMID: 34017159 PMCID: PMC8113803 DOI: 10.1016/j.jor.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022] Open
Abstract
The purposes were (1) to investigate and compare the findings of patients undergoing total hip arthroplasty (THA) following a corrective pelvic osteotomy (PO), to a control group of patients who underwent THA but not PO and (2) to evaluate the outcomes and complications for secondary THA after PO. Three studies recorded reduced cup anteversion in the osteotomy group. Two studies reported higher PROs for the control group. The most common complication after failed PAO was dislocations. PO may entail challenges on a subsequent THA, illustrated by higher intraoperative blood loss, lower consistency in cup positioning and compromised patients reported outcomes.
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Affiliation(s)
- Jacob Shapira
- American Hip Institute Research Foundation, Chicago, IL, 60018, USA
| | - Shawn Annin
- American Hip Institute Research Foundation, Chicago, IL, 60018, USA
| | | | | | - Ajay C. Lall
- American Hip Institute Research Foundation, Chicago, IL, 60018, USA
- American Hip Institute, Chicago, IL, 60018, USA
- AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, 60169, USA
| | - Benjamin G. Domb
- American Hip Institute Research Foundation, Chicago, IL, 60018, USA
- American Hip Institute, Chicago, IL, 60018, USA
- AMITA Health St. Alexius Medical Center, Hoffman Estates, IL, 60169, USA
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Schneider E, Stamm T, Schinhan M, Peloschek P, Windhager R, Chiari C. Total Hip Arthroplasty after Previous Chiari Pelvic Osteotomy-A Retrospective Study of 301 Dysplastic Hips. J Arthroplasty 2020; 35:3638-3643. [PMID: 32674940 DOI: 10.1016/j.arth.2020.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/05/2020] [Accepted: 06/16/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Controversy exists whether previous pelvic osteotomies have negative effects on total hip arthroplasty (THA). This study evaluates the implant survival and patient-reported outcomes of THA after previous Chiari pelvic osteotomy (CPO). METHODS Data on 301 THAs after CPO were collected through clinical and radiological follow-up examinations and telephone interviews. The Kaplan-Meier survivorship analysis depicts implant survival. RESULTS Of this consecutive series of 1536 CPOs, follow-up was completed in 405 patients with 504 CPOs after a mean time of 36 years (±8; range, 22-54 years). At follow-up, 301 hips (60%) had already undergone THA. The overall survival of THA with revision as an end point after 10, 20, and 25 years was 93%, 76%, and 68%, respectively. The revision rate was 12%. The average period between THA and revision surgery was 9.6 years (±6.1; 4 months-25.4 years). The patient's age at revision was 57.9 years (±10; 33.2-78.5 years). Aseptic loosening was the most common of the known reasons for revision surgery. CONCLUSION This retrospective study supports the hypothesis that prior CPO does not compromise the prerequisites for successful THA at a later stage. Survival rates of the implanted prosthesis are comparable to primary implanted hips, as overall survival was 93% after 10 years.
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Affiliation(s)
- Eleonora Schneider
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Section for Outcome Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Martina Schinhan
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Catharina Chiari
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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Erdoğan F, Can A. The effect of previous pelvic or proximal femoral osteotomy on the outcomes of total hip arthroplasty in patients with dysplastic coxarthrosis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:74-82. [PMID: 32175900 DOI: 10.5152/j.aott.2020.01.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to evaluate whether a history of a pelvic osteotomy or proximal femoral osteotomy compromises the outcomes of total hip arthroplasty in patients with dysplastic coxarthrosis. METHODS The results of total hip arthroplasty in 240 hips of 172 patients without previous pelvic osteotomy or proximal femoral osteotomy were compared to 118 hips of 88 patients with a previous pelvic osteotomy or proximal femoral osteotomy (osteotomy group). Technical difficulties and rates of complications during surgery, operative time, estimated blood loss, rates of postoperative complications, and pre- and postoperative Harris Hip Scores and visual analog scale pain scores were compared between the two groups. RESULTS In the osteotomy, the rate of complications was higher and the operative time was longer. The estimated blood loss was also higher, and the latest follow-up Harris Hip Scores and visual analog scale pain scores were worse in this group. Total hip arthroplasty was more demanding and the revision rate was higher in the osteotomy group (six vs four revisions). CONCLUSION Our data showed that a previous history of pelvic osteotomy or proximal femoral osteotomy compromised the clinical outcomes of subsequent total hip arthroplasty and is related to an increased rate of complications, prolonged operative time, and increased amount of blood loss. LEVEL OF EVIDENCE Level III, Therapeutic Study.
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Affiliation(s)
| | - Ata Can
- Nişantaşı Orthopaedic Center, İstanbul, Turkey
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[Hip arthroplasty after pelvic and femoral osteotomies]. DER ORTHOPADE 2019; 48:308-314. [PMID: 30824969 DOI: 10.1007/s00132-019-03693-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pelvic and femoral osteotomies can be a challenge even for experienced orthopedic surgeons. Residual metal may complicate the insertion of the endoprosthesis in some cases. Sometimes, the anatomical modification of the previous osteotomy complicates the total hip replacement. This may require the use of an acetabular revision system for the primary implantation. Femoral deformities can require additional osteotomies of the femur during the implantation. In every case, accurate preoperative planning should be performed. A preoperative CT with 3D reconstruction is a powerful tool for further information beyond conventional imaging.
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High-Riding Congenital Hip Dislocation: THA With Unilateral vs Bilateral Transverse Femoral Shortening Osteotomy. J Arthroplasty 2018; 33:1432-1436. [PMID: 29289447 DOI: 10.1016/j.arth.2017.11.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We argue that 1-stage bilaterally total hip arthroplasty (THA) could be acceptable in bilateral coxarthrosis because of high-riding developmental dysplasia of the hip (DDH). METHODS Sixty-nine cases (51 patients) of high-riding DDH in patients who underwent THA from 2010 to 2013 were reviewed. Patients were divided into 2 groups: unilateral (group 1) and 1-stage bilateral surgery (group 2). The clinical measurements were the visual analog scale and Harris Hip Score. RESULTS The average follow-up was 37.3 months for group 1 and 38.8 months for group 2. The hospital stay time was 5.2 days in group 1 and 6.2 days in group 2 (P = .334). The mean Harris Hip Score and visual analog scale score were improved significantly after surgery for both groups, and there was no statistically significant difference (P = .988). There was no difference between groups 1 and 2 in terms of complications (P = .137). CONCLUSION Our data confirm that 1-stage bilateral transverse osteotomy with THA is an effective method as unilateral and it does not increase the length of patients' hospital stays and features a low risk of postoperative complications in the treatment of patients with high-riding DDH.
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Amstutz HC, Le Duff MJ. Effects of Previous Osteotomy on Outcome of Hip Resurfacing Arthroplasty. Orthopedics 2017; 40:e609-e616. [PMID: 28418575 DOI: 10.3928/01477447-20170411-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/27/2017] [Indexed: 02/03/2023]
Abstract
The effect of previous conservative surgeries on the outcome of metal-on-metal hip resurfacing arthroplasty (HRA) has not been studied. This study compared postoperative clinical scores and survivorship results of hips with and without previous osteotomies in a population of patients who underwent HRA. A total of 1101 patients (1375 hips) with a mean age of 51.3 years at the time of surgery underwent HRA at a single center. Sixty-nine patients had undergone prior surgery on the operated hip including 14 osteotomies (1 pelvic, 6 femoral, and 7 combined pelvic and femoral osteotomies). Mean follow-up was comparable for patients with prior osteotomy and patients in the control group (101 months vs 96 months, P=.6916); however, patients with prior osteotomies were much younger at the time of surgery (34 years vs 51 years, P=.0001). Kaplan-Meier survival estimates were calculated, and the Cox proportional hazard ratio was used to adjust for the covariates that differed between the 2 groups and affected the survivorship of hip resurfacing. Patients who underwent prior osteotomy showed lower pain and activity scores. In addition, patients who underwent prior osteotomy had a greater chance of revision than the rest of the cohort (hazard ratio, 3.87; 95% confidence interval, 1.54-9.68; P=.004). For patients in whom the natural anatomy or the bone quality of the hip has been severely altered by a prior osteotomy, HRA may be contraindicated if good component fixation cannot be achieved and hip biomechanics restored. [Orthopedics. 2017; 40(4):e609-e616.].
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Molenaers B, Driesen R, Molenaers G, Corten K. The Direct Anterior Approach for Complex Primary Total Hip Arthroplasty: The Extensile Acetabular Approach on a Regular Operating Room Table. J Arthroplasty 2017; 32:1553-1559. [PMID: 28087159 DOI: 10.1016/j.arth.2016.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 11/15/2016] [Accepted: 12/13/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The direct anterior approach on a regular operating room table has been reported with low dislocation rates. This might be beneficial for complex primary total hip arthroplasty (THA) such as in patients with cerebral palsy or following femoral or pelvic osteotomies. Extending the approach is often required to overcome problems such as acetabular deformities or severe contractures. METHODS We retrospectively evaluated the results and complications of 29 patients with 37 complex primary THA in which an extensile approach was used. The extensile approach is described. Functional scores were collected in case the patient was ambulatory independently (n = 17). RESULTS The average age was 35 years (range 15-85) with a mean follow-up of 39 months (range 12-60). There were 3 (8%) intra-operative and 4 (11%) early post-operative complications (<3 months), of which 3 (8%) were anterior dislocations. Late complications (>3 months) consisted of a fibrous ingrown stem, a socket loosening following a pelvic fracture, and a late hematogenous infection (8%). Seventy-one percent of the complications occurred in the first 18 cases (49%) indicating a learning curve. The mean post-operative Harris Hip Score was 79 (range 56-97). CONCLUSION Complex THA can be safely conducted through the extensile anterior approach on a regular operating room table with the use of conventional implants, even in cases with a high risk of dislocation.
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Affiliation(s)
- Ben Molenaers
- Department of Orthopaedic Surgery, University Hospitals Leuven-Pellenberg, Leuven, Belgium; Department of Orthopaedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ronald Driesen
- Department of Orthopaedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Guy Molenaers
- Department of Orthopaedic Surgery, University Hospitals Leuven-Pellenberg, Leuven, Belgium
| | - Kristoff Corten
- Department of Orthopaedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
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Total hip arthroplasty after previous rotational acetabular osteotomy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1057-60. [PMID: 26094826 DOI: 10.1007/s00590-015-1657-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Rotational acetabular osteotomy (RAO) is a joint-conserving surgery in which femoral head coverage is improved using autologous cartilage to stabilize the joint. For advanced coxarthrosis, it has been reported that radical surgery should be selected, compared to the pre- and early stages. The objective of this study was to determine the clinical outcomes of patients in whom coxarthrosis progressed after RAO and came to undergo total hip arthroplasty (THA). METHODS We compared 24 total hip arthroplasties done in dysplastic hips after previous rotational acetabular osteotomy (RAO group) with a well-matched control group of 24 primary arthroplasties (control group) done during the same period at an average follow-up of 85 months (range 15-195). RESULTS RAO group required significantly longer operative times and had more intraoperative blood loss. There was no significant difference between the two groups in terms of Harris Hip Score and radiographic outcome. Revision was performed in four and one joints in the RAO and control groups, respectively, showing no significant difference between the two groups (p = 0.165). CONCLUSION THA after previous RAO leads to midterm results similar to those of other dysplastic hips. RAO does not seem to compromise the midterm clinical and radiographic outcome.
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Does rotational acetabular osteotomy affect subsequent total hip arthroplasty? Arch Orthop Trauma Surg 2015; 135:407-15. [PMID: 25577240 DOI: 10.1007/s00402-015-2154-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Rotational acetabular osteotomy (RAO) has been used successfully in patients with developmental dysplasia of the hip (DDH). However, some patients are forced to undergo total hip arthroplasty (THA) because of the progression of osteoarthritis. We evaluated the effect of previous RAO on the outcome of THA performed for degenerative arthritis secondary to DDH, comparing outcomes for patients with THA and prior RAO versus outcomes for patients with THA and no prior RAO. MATERIALS AND METHODS At an average follow-up point of 8.2 years (range 7-11 years), we compared outcomes in dysplastic hips for 22 hips (group R) in patients who underwent THA after successful RAO with outcomes for a well-matched control group of 30 hips in patients who underwent primary THA (group C) during the same period. RESULTS Both groups had similar midterm results. No acetabular or femoral components exhibited loosening or revision in either group. Harris hip scores (HHSs) at the most recent follow-up had not been compromised by RAO, and there were no significant differences in intraoperative blood loss and operative time between the two groups. Although there was a tendency toward superolateral placement of the acetabular component in group R, there were no significant differences in the mean steady-state linear and volumetric wear rates between the two groups. There were no infections, dislocations, intraoperative fractures, damaged nerves, or deep vein thromboses in either group. CONCLUSIONS Our midterm results demonstrated that RAO does not lead to higher revision rates, compromised HHSs, or shortened survivorship in eventual THA for DDH.
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Pailhé R, Cavaignac E, Murgier J, Cahuzac JP, de Gauzy JS, Accadbled F. Triple osteotomy of the pelvis for Legg-Calve-Perthes disease: a mean fifteen year follow-up. INTERNATIONAL ORTHOPAEDICS 2015; 40:115-22. [DOI: 10.1007/s00264-015-2687-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 01/15/2015] [Indexed: 12/01/2022]
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17
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CORR Insights®: similar clinical outcomes for thas with and without prior periacetabular osteotomy. Clin Orthop Relat Res 2015; 473:692-4. [PMID: 25492568 PMCID: PMC4294895 DOI: 10.1007/s11999-014-4093-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/01/2014] [Indexed: 01/31/2023]
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18
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Duncan S, Wingerter S, Keith A, Fowler SA, Clohisy J. Does previous osteotomy compromise total hip arthroplasty? A systematic review. J Arthroplasty 2015; 30:79-85. [PMID: 25262440 DOI: 10.1016/j.arth.2014.08.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 07/26/2014] [Accepted: 08/17/2014] [Indexed: 02/01/2023] Open
Abstract
Hip osteotomy surgery has increased over the past several years, yet the impact of these procedures on subsequent total hip arthroplasty (THA) remains controversial. The purpose of this study was to perform a systematic review of the literature to determine the clinical results, procedure complications, and survivorship of THA following previous hip osteotomy. Ten studies met inclusion criteria. The operative time and estimated blood loss were higher in the post-osteotomy cohorts; while the clinical results and survivorship between groups were similar. THA following previous pelvic and femoral osteotomy provides pain relief and improved function with similar complication rates, clinical outcomes, and survivorship compared to hips undergoing routine primary THA. These procedures can be technically more demanding with increased operative times and intraoperative blood loss.
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Affiliation(s)
| | - Scott Wingerter
- Washington University School of Medicine, St. Louis, Missouri
| | - Angela Keith
- Washington University School of Medicine, St. Louis, Missouri
| | - Susan A Fowler
- Washington University School of Medicine, St. Louis, Missouri
| | - John Clohisy
- Washington University School of Medicine, St. Louis, Missouri
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Yan F, Chen G, Yang L, He R, Gu L, Wang F. A reduction technique of arthroplasty without subtrochanteric femoral shortening osteotomy for the treatment of developmental high dislocation of hip: a case series of 28 hips. J Arthroplasty 2014; 29:2289-93. [PMID: 24412147 DOI: 10.1016/j.arth.2013.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 09/24/2013] [Accepted: 11/23/2013] [Indexed: 02/01/2023] Open
Abstract
In total hip arthroplasty for the treatment of developmental dysplasia of the hip (DDH) with high hip dislocation, it can be technically challenging to locate the true acetabulum and restore limb length without subtrochantric femoral shortening osteotomy. We explored and described total hip arthroplasty without subtrochanteric femoral shortening osteotomy in 28 hips with Crowe type III and IV dislocation by intravenous injection of rocuronium at 0.9mg/kg 1minute before reduction and hip reduction combined with continuous strong traction of the affected limb with patients in a position with hip and knee flexion. All patients did not show dislocation, prosthesis loosening, and other severe complications. It is thus a safe and feasible reduction technique for arthroplasty of Crowe type III or IV dislocation of DDH.
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Affiliation(s)
- Fei Yan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Guangxing Chen
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Liu Yang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Rui He
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lingchuan Gu
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Fuyong Wang
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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20
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Migaud H, Putman S, Berton C, Lefèvre C, Huten D, Argenson JN, Gaucher F. Does prior conservative surgery affect survivorship and functional outcome in total hip arthroplasty for congenital dislocation of the hip? A case-control study in 159 hips. Orthop Traumatol Surg Res 2014; 100:733-7. [PMID: 25281551 DOI: 10.1016/j.otsr.2014.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 06/26/2014] [Accepted: 07/10/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The results of total hip arthroplasty (THA) in congenital dislocation of the hip (CDH) are well known, but such is not the case for the impact of prior conservative surgery on THA function and survivorship. The present study compared THA in CDH with prior conservative bone surgery (BS group) versus no prior bone surgery (NBS group), to (1) assess the impact of prior conservative surgery on function and survivorship after THA, and (2) determine whether a particular type of conservative surgery affected function or survivorship. HYPOTHESIS Prior conservative surgery for CDH does not affect function or survivorship of subsequent THA. PATIENTS AND METHODS A multicenter retrospective case-control study analyzed 430 THAs in CDH patients (332 patients: 269 female, 63 male; mean age, 56 years [range, 17-80 years]) at a mean 13.2±5.4 years' follow-up (range, 1-29 years). The BS group included 159 hips (37%) (64 pelvic, 81 femoral and 14 combined pelvic and femoral osteotomies), and the NBS group 271 (63%). Groups were comparable for gender, age at surgery, Devane activity score, preoperative Postel Merle d'Aubigné (PMA) functional score and CDH radiographic type following Crowe. RESULTS At follow-up, PMA scores were comparable: BS, 16.8±1.4 (11-18); NBS, 16.9±1.5 (7-18). Fifteen-year survivorship censored for implant revision for whatever reason did not significantly differ: BS, 87% (95% CI: 83-91%); NBS, 89% (95% CI: 86-92%). Ten-year survivorship on the same criterion did not significantly differ according to type of prior surgery: hip shelf arthroplasty, 97% (95% CI: 95-99%); Chiari osteotomy, 100%; femoral osteotomy, 95% (95% CI: 92-98%); and Milch osteotomy 96% (95% CI: 93-99%). DISCUSSION/CONCLUSION Conservative surgery for CDH does not impair the functional results or survivorship of subsequent THA. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- H Migaud
- Service d'orthopédie C, département universitaire de chirurgie orthopédique et de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille, France; Faculté de médecine, université Lille-Nord-de-France, place de Verdun, 589045 Lille, France.
| | - S Putman
- Service d'orthopédie C, département universitaire de chirurgie orthopédique et de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille, France; Faculté de médecine, université Lille-Nord-de-France, place de Verdun, 589045 Lille, France
| | - C Berton
- Faculté de médecine, université Lille-Nord-de-France, place de Verdun, 589045 Lille, France; Service d'orthopédie-traumatologie, centre hospitalier de Valenciennes, avenue Désandrouin, 59322 Valenciennes cedex, France
| | - C Lefèvre
- Service de chirurgie orthopédique et de traumatologie, hôpital Cavale-Blanche, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - D Huten
- Service de chirurgie orthopédique et de traumatologie, CHU de Rennes, 16, boulevard de Bulgarie, BP 90347, 35000 Rennes, France
| | - J-N Argenson
- Institut du mouvement et de l'appareil locomoteur, service de chirurgie orthopédique, hôpital Sainte-Marguerite, université Aix-Marseille, CHU de Marseille, AP-HM, 270, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - F Gaucher
- Service de chirurgie orthopédique et de traumatologie, Hôtel-Dieu, rue Roger-Signor, 29120 Pont l'Abbé, France
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Zhu J, Chen X, Cui Y, Shen C, Cai G. Mid-term results of Bernese periacetabular osteotomy for developmental dysplasia of hip in middle aged patients. INTERNATIONAL ORTHOPAEDICS 2013; 37:589-94. [PMID: 23381611 DOI: 10.1007/s00264-013-1790-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To address the question, compared to having hip replacement with latent revision, does Bernese periacetabular osteotomy (PAO) before primary hip replacement occupy a preferable treatment strategy for middle aged (aged 35-54 years) hip dysplasia patients? We assessed the mid-term functional outcome and survivorship of PAO in those patients. METHODS Forty-one hips in 36 patients at middle age at the time of surgery (mean age, 39.5 years; range, 35-47 years) were retrospectively identified out of a total PAO cohort of 315 patients. Eleven of the 41 PAO hips also underwent osteochondroplasty at the femoral head-neck junction. Radiographic parameters of lateral centre edge angle, anterior centre edge angle and hip joint medialisation were investigated using the Harris Hip Score (HHS). RESULTS The average follow-up was 5.1 years (range, two to ten years). Radiographic parameters postoperatively improved into the normal range, whereas no progression was found from preoperative Tonnis osteoarthritis score. Forty hips survived at the last follow-up, with HHS Score improved from 63.7 to 88.4. Compared to the sole PAO group, both postoperative alpha angle and range of joint motion improved in the PAO combined with osteochondroplasty group. However, no difference in HHS score was found. CONCLUSIONS Good survivorship and improved joint function were identified in middle-aged Chinese patients following PAO with or without osteochondroplasty. We prudently suggest PAO as an alternative strategy for treating DDH in those patients.
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Affiliation(s)
- Junfeng Zhu
- Medical School, Department of Orthopaedics, Xinhua Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
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Sassoon AA, Trousdale RT. Technical considerations in total hip arthroplasty after femoral and periacetabular osteotomies. Orthop Clin North Am 2012; 43:387-93. [PMID: 22819166 DOI: 10.1016/j.ocl.2012.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to outline key technical considerations in the performance of total hip arthroplasty after common osteotomies of both the proximal femur and acetabulum. Attention is called to anatomic variation, both innate and incurred. After a femoral osteotomy, specific focus should be placed on incision selection, residual hardware management, abductor handling, and proper version establishment. After a periacetabular osteotomy, similar concern should be granted to cup position and fixation. Results of total hip arthroplasty after common osteotomies are also reviewed and importance of these issues highlighted.
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Affiliation(s)
- Adam A Sassoon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures. Clin Orthop Relat Res 2011; 469:3351-5. [PMID: 21590485 PMCID: PMC3210276 DOI: 10.1007/s11999-011-1915-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Based on short-term (1 year or less) followup, primary fixation of displaced midshaft clavicle fractures reportedly results in better function compared with that reported for nonoperative methods. Whether better function persists beyond 1 year is unclear. QUESTIONS/PURPOSES For displaced midshaft clavicle fractures, do the better mean Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Shoulder (CSS) scores for operative versus nonoperative treatment at 1 year change between 1- and 2-year followup? PATIENTS AND METHODS We previously reported 132 patients in a randomized prospective trial at 1 year, and here we report a further followup of 95 of the 132 patients (72%) at 2 years after injury. We evaluated all patients with the DASH and CSS scores. RESULTS The mean DASH and CSS scores were similar at 2 years compared with 1 year postinjury for both the nonoperated and operated patients. The mean scores for the operated patients remained higher than those in the nonoperative group (DASH operative 4.1 ± 7.0 versus DASH nonoperative 11.4 ± 19.7, CSS operative 97.1 ± 4.5 versus CSS nonoperative 91.6 ± 14.1) at 2 years postinjury. CONCLUSIONS The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup, suggesting a clinical steady state has been reached whereby outcome is unlikely to change with time. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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