Relative femoral neck lengthening improves pain and hip function in proximal femoral deformities with a high-riding trochanter

Treatment of Symptomatic Residual Deformity in Legg-Calvé-Perthes Disease: Mid-Term Outcomes and Predictors of Failure After Surgical Hip Dislocation with Femoral-Head Reshaping and Relative Neck Lengthening

BACKGROUND

Treating patients with symptomatic hips after healed Legg-Calvé-Perthes disease (LCPD) is challenging, mainly because of the complexity of the deformity. We performed a retrospective study to evaluate clinical and radiographic outcomes, measure the survival rate, and identify predictors of failure following a surgical hip dislocation (SHD) with femoral-head reshaping and relative femoral-neck lengthening for the treatment of symptomatic residual hip deformity after healed LCPD.

METHODS

We identified 60 patients undergoing SHD for the treatment of symptomatic residual LCPD deformity. Fifty-one (85%) of the patients (mean age, 16.3 ± 4.7 years; 21 male patients [41%]), were followed ≥4 years after surgery. We defined surgical failure as conversion to, or recommendation for, total hip arthroplasty (THA) or a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of ≥10 at the most recent follow-up. We used a multivariable Cox proportional hazards model to identify factors that were predictive of failure. The rate of survival free from failure was estimated using a Kaplan-Meier curve.

RESULTS

Twenty (39%) of the patients met 1 of the end-point criteria for surgical failure, while the hips of the remaining 31 (61%) of the patients were successfully preserved at a median follow-up of 10.2 years (interquartile range, 5.7 to 12.9 years). The estimated survival was 80% (95% confidence interval [CI] = 70% to 92%) at 5 years and 66% (95% CI = 53% to 81%) at 10 years. Independent factors associated with surgical failure were the severity of preoperative pain as assessed by the WOMAC pain score (hazard ratio [HR] = 1.16; 95% CI = 1.03 to 1.30; p = 0.01) and the severity of the deformity as assessed by the anteroposterior alpha angle (HR = 1.06; 95% CI = 1.01 to 1.11; p = 0.01).

CONCLUSIONS

We found that SHD with relative femoral-neck lengthening and osteochondroplasty of the femoral head-neck junction was associated with improved deformity as assessed radiographically and decreased pain and symptoms of stiffness among patients with symptomatic residual LCPD deformity. Preoperative pain and deformity were identified as predictors of surgical failure. Further research is needed to establish the role of SHD and other procedures in preserving the hip over the long term.

LEVEL OF EVIDENCE

Therapeutic L evel IV . See Instructions for Authors for a complete description of levels of evidence.

Short-Term Complications of Relative Femoral Neck Lengthening Combined with Extra-Articular Osteotomies of the Proximal Femur

Purpose

Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO.

Methods

All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1 week, 6 weeks, 3 months, 6 months, 12 months and 24 months.

Results

Seventy two patients (31 males, 41 females, 6-52 years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union.

Conclusion

RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections.

Significance

The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.

Surgical hip dislocation with relative femoral neck lengthening and retinacular soft-tissue flap for sequela of Legg–Calve–Perthes disease

Objective

Correction of post-LCP (Legg–Calve–Perthes) morphology using surgical hip dislocation with retinacular flap and relative femoral neck lengthening for impingent correction reduces the risk of early arthritis and improves the survival of the native hip joint.

Indications

Typical post-LCP deformity with external and internal hip impingement due to aspherical enlarged femoral head and shortened femoral neck with high riding trochanter major without advanced osteoarthritis (Tönnis classification ≤ 1) in the younger patient (age < 50 years).

Contraindications

Advanced global osteoarthritis (Tönnis classification ≥ 2).

Surgical technique

By performing surgical hip dislocation, full access to the hip joint is gained which allows intra-articular corrections like cartilage and labral repair. Relative femoral neck lengthening involves osteotomy and distalization of the greater trochanter with reduction of the base of the femoral neck, while maintaining vascular perfusion of the femoral head by creation of a retinacular soft-tissue flap.

Postoperative management

Immediate postoperative mobilization on a passive motion device to prevent capsular adhesions. Patients mobilized with partial weight bearing of 15 kg with the use of crutches for at least 8 weeks.

Results

In all, 81 hips with symptomatic deformity of the femoral head after healed LCP disease were treated with surgical hip dislocation and offset correction between 1997 and 2020. The mean age at operation was 23 years; mean follow-up was 9 years; 11 hips were converted to total hip arthroplasty and 1 patient died 1 year after the operation. The other 67 hips showed no or minor progression of arthrosis. Complications were 2 subluxations due to instability and 1 pseudarthrosis of the lesser trochanter; no hip developed avascular necrosis.

Ellipsoidal Process of the Femoral Head in Legg-Calvé-Perthes Disease: Effect of Prophylactic Hemiepiphysiodesis

PURPOSE

Legg-Calvé-Perthes disease (LCPD) often causes the residual deformity, typically appearing as an ellipsoidal shape. In some cases, this ovalization is related to the asymmetric growth of the femoral head physis, which presents a growth-inhibiting necrotic area in the anterosuperior quadrant. The objective of the present study is to evaluate the effectiveness of selective hemiepiphysiodesis of the healthy physis in the posteroinferior quadrant as a means of disrupting femoral head ovalization in cases of LCPD with the previous onset of ovalization.

METHODS

We performed a prospective study of 39 LCPD hips operated on consecutively by selective hemiepiphysiodesis of the posteroinferior portion of the head during the reossification phase.Surgical indication was based on a progressive increase in the ellipsoidal index (EI), the presence of a double epiphyseal nucleus of reossification, physeal narrowing, and physeal angulation. Hemiepiphysiodesis was performed at the mean patient age of 8.8 years (SD 1.5) and a mean of 4.7 years (SD 1.4) following disease onset.

RESULTS

Preoperative EI was 1.80 (SD 0.2), which was reduced to 1.72 (SD 0.2) postoperatively (P > 0.05). Physeal angulation increased from 50° preoperatively (SD 9.3) to 54.29° (SD 9.7) at the end of growth (P > 0.05). The final result according to the Stulberg classification revealed 20 class-II cases, 16 class III, and 3 class IV, and SDS was 25.97 (SD 9.95), range: 9.36-51.67.

CONCLUSION

As revealed by the EI, the ellipsoidal process may be stopped by selective hemiepiphysiodesis in the posteroinferior quadrant of the femoral head.

LEVEL OF EVIDENCE

II.

Relative Femoral Neck Lengthening in Legg-Calvé-Perthes Total Hip Arthroplasty

Background

Total hip replacement (THR) in patients with a history of Legg-Calvé-Perthes disease can be a technically challenging procedure due to the distorted hip morphology. We propose a technique in which THR is preceded by a modified relative femoral neck lengthening (RFNL) procedure. Hereby, we aim to restore the biomechanical parameters.

Methods

Twenty-eight patients underwent RFNL in preparation of a second-stage THR between December 2011 and September 2019. The mean age was 38.1 ± 11.4 years. Radiographs were analyzed for centrotrochanteric distance, lateral displacement of the greater trochanter, and leg length discrepancy to assess the biomechanical restoration. Complication rate, reoperation rate, and patient-reported outcome measures were measured.

Results

Mean centrotrochanteric distance increased from −18.7 ± 6.7 mm preoperatively to 1.9 ± 9.0 mm (P < .001) after RFNL and to 11.4 ± 10.4 mm after THR (P < .001). Mean lateral displacement of the greater trochanter increased from 34.2 ± 8.1 mm preoperatively to 42.4 ± 5.2 mm (P < .001) after RFNL and to 49.9 ± 8.3 mm after THR (P < .001). Leg length discrepancy decreased from 17.5 ± 10.5 mm to 2.7 ± 2.2 mm after THR (P < .001). Mean Harris Hip Score improved from 56.9 ± 17.6 preoperatively to 89.4 ± 10.7 at the latest follow-up (P < .001). Eight patients (8 hips) postponed THR because of sufficient clinical improvement, at a mean follow-up of 4.2 ± 2.1 years. Two hips needed a revision RFNL due to non-union (7.1%), and 1 hip replacement was revised due to a deep infection (5.0%).

Conclusions

RFNL prior to THR in patients with end-stage osteoarthritis following Legg-Calvé-Perthes disease allows for utilizing regular implants with straight access to the femoral canal, with restored biomechanics and restoration of leg length. The prominent overhanging greater trochanter is reduced to prevent postoperative extra-articular impingement.

Combined Surgical Dislocation and Periacetabular Osteotomy for Complex Residual Legg-Calvé-Perthes Deformities: Intermediate-Term Outcomes

BACKGROUND

Residual Legg-Calvé-Perthes (LCP) deformities represent one of the most challenging disorders in hip reconstructive surgery. In complex cases, both instability (acetabular dysplasia) and multifocal femoroacetabular impingement (FAI) (proximal femoral deformities) require correction. We assessed intermediate-term patient-reported outcome measures, radiographic correction, complications, and survivorship for combined surgical dislocation (SD) and periacetabular osteotomy (PAO) for the treatment of complex LCP deformities.

METHODS

A retrospective cohort study was performed on 31 hips with complex LCP deformities undergoing combined SD and PAO for concurrent instability and FAI. Treatment included femoral head reshaping, trochanteric advancement and relative femoral neck lengthening, management of intra-articular lesions, and PAO. Twenty-seven hips (87%) had a minimum follow-up of 5 years. The mean age was 19.8 years, 56% of patients were female, and 44% of patients had undergone a previous surgical procedure.

RESULTS

At a mean of 8.4 years, 85% of hips (23 of 27) remained preserved (no conversion to total hip arthroplasty). The survivorship estimates were 93% at 5 years and 85% at 10 years. The median (and interquartile range) increased from 64 points (55, 67 points) to 92 points (70, 97 points) (p < 0.001) for the modified Harris hip score (mHHS) and from 60 points (45, 75 points) to 86 points (75, 100 points) (p = 0.001) for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Symptoms (mHHS < 70 points) were reported for an additional 19% of hips (n = 5) at the final follow-up. The University of California Los Angeles (UCLA) activity score increased from a median of 8 points (6, 10 points) to 9 points (7, 10 points) (p = 0.207). Structural correction included mean improvement (and standard deviation) of 15.3° ± 7.6° for acetabular inclination, 20.7° ± 10.8° for the lateral center-edge angle, 23.4° ± 16.3° for the anterior center-edge angle, and 18 ± 10 mm for trochanteric height (p < 0.001 for all). Complications occurred in 2 hips (7%), including 1 deep wound infection and 1 superficial wound infection. There was 1 reoperation due to complication, but there were no nerve palsies, thromboembolic events, fractures, or nonunions.

CONCLUSIONS

At an intermediate follow-up of combined SD and PAO for complex LCP deformities, 85% of hips were preserved. This procedure provides reliable deformity correction, major pain relief, improved function, and acceptable complication and failure rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Is combined surgical dislocation and proximal femoral osteotomy a safe procedure for correction of complex hip deformities?

Complex deformities of the hip requiring intra-articular and proximal femoral correction are challenging with regard to surgical access and complication risk. Combined surgical dislocation and proximal femoral osteotomy (SD/PFO) is a surgical strategy that provides unrestricted access to the joint with the capability for adjunctive PFO. Although providing excellent surgical access, concerns over a potentially high risk of postoperative complications remain, and published information on the safety of this technique remain scarce. In this study, we defined the early complication profile of combined surgery across 48 hips with a variety of complex deformities using a standardized, validated complication grading scheme for hip preservation surgery. Patients were mean age 19.1 years 13–33 years and 60% had previous surgery. At the early mean follow-up of 2.9 years, considerable improvement was seen across all outcome scores. Major complications (Grade III or higher) occurred at a rate of 4.2% (n = 2). Both were osteotomy non-unions, and both were treated successfully with revision PFO and bone grafting at mean 1.1 years. To our knowledge, the current series of combined SD-PFO surgeries represents the largest to date for which detailed complication data have been reported. Given the complexity of these disorders, a major complication rate of 4.2% is acceptable. Our complication rates were comparable to those reported for isolated SD and PFO procedures. These rates did not vary significantly across morphologic variants or patient-specific characteristics. Additionally, our complication risk profile is consistent with previous, smaller reports, which supports the generalizability of these results among appropriately experienced surgeons.

Morscher's femoral neck lengthening osteotomy through surgical hip dislocation approach for preservation of Perthes and Perthes-like deformities

Background

Typical sequelae of Perthes disease and Perthes-like deformities comprise a short femoral neck, aspherical femoral head, and greater trochanteric overgrowth. Morscher's osteotomy aims at restoring the normal extra-articular anatomy, but incapable of restoring a normal head-neck contour with residual impingement. Femoral neck lengthening osteotomy combined with osteochondroplasty through surgical hip dislocation approach was not previously described in the literature. We hypothesized that this technique is capable of near-normal restoration of the proximal femoral anatomy, increasing limb length, restoring abductor power, and simultaneous management of intra-articular chondro-labral disease.

Methods

A prospective series of 21 consecutive patients with sequelae of Perthes disease and Perthes-like deformity (Stulberg II and III) were treated by Morscher's osteotomy through surgical hip dislocation approach. The mean age was 14.9 years (9-30 years) and the mean follow-up was 4.5 years (2-8 years).

Results

The mean Harris hip score improved significantly from 66.5 to 89.5 points (p < 0.001), and the mean limb length discrepancy improved from 2.5 to 0.6 cm (p < 0.001). The mean alpha angle improved from 81.8° to 49.5°, the mean neck-shaft angle increased from 117.8° to 129.8°, and the articulo-trochanteric distance has improved from -6.7 to 20.8 mm. Six out of 21 patients required staged periacetabular osteotomy for residual acetabular dysplasia. No cases of chondrolysis or osteonecrosis were identified.

Conclusion

Femoral neck lengthening osteotomy through surgical hip dislocation appraoch has proven to be safe and effective for preservation of symptomatic hips with Perthes and Perthes-like deformities and mild to moderate femoral head deformities (Stulberg II and III). A staged periacetabular osteotomy may be required in those patients with significant acetabular dysplasia.

Level of evidence

Level IV.

External snapping hip syndrome is associated with an increased femoral offset

Background

External snapping hip syndrome (ESH) is postulated to be one of the causes of greater trochanteric pain syndrome, which also includes greater trochanteric bursitis and tendinopathy or tears of the hip abductor mechanism. However, it was not yet described what kind of bony morphology can cause the snapping and whether symptomatic and asymptomatic individuals have different imaging features.

Purpose

It was the purpose of this study to look for predisposing morphological factors for ESH and to differentiate between painful and asymptomatic snapping.

Methods

A consecutive cohort with ESH and available magnetic resonance imaging (MRI) between 2014 and 2019 was identified. The control group consisted of patients that underwent corrective osteotomies around the knee for mechanical axis correction and never complained of hip symptoms nor had undergone previous hip procedures. The following parameters were blindly assessed for determination of risk factors for ESH: CCD (corpus collum diaphysis) angle; femoral and global offset; femoral antetorsion; functional femoral antetorsion; translation of the greater trochanter (GT); posterior tilt of the GT; pelvic width/anterior pelvic length; intertrochanteric width. Hip and pelvic offset indexes were calculated as ratios of femoral/global offset and intertrochanteric/pelvic width, respectively. For the comparison of symptomatic and asymptomatic snapping, the following soft-tissue signs were investigated: presence of trochanteric bursitis or gluteal tendinopathy; presence of surface bony irregularities on trochanter major and ITB (Iliotibial band) thickness.

Results

A total of 31 hips with ESH were identified. The control group (n = 29) consisted of patients matched on both age (± 1) and gender. Multiple regression analysis determined an increased hip offset index to be independent predictor of ESH (r =  + 0.283, p = 0.025), most likely due to the higher femoral offset in the ESH group (p = 0.031). Pearson correlation analysis could not identify any significant secondary factors. No differences were found between painful and asymptomatic snapping on MRI.

Conclusions

A high hip offset index was found as an independent predictor for external snapping hip in our cohort, mainly due to increased femoral offset. No imaging soft-tissue related differences could be outlined between symptomatic and asymptomatic external snapping.

Level of evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00590.

Growth modulation with tension-band plates for the correction of paediatric lower limb angular deformity: current concepts and indications for a rational use

Growth modulation (GM) with tension-band plates (TBPs) by tethering part of the growth plate is an established technique for the correction of angular deformities in children, and it has increasingly supplanted more invasive osteotomies.Growth modulation with TBPs is a safe and effective method to correct a variety of deformities in skeletally immature patients with idiopathic and pathological physes. The most common indication is a persistent deformity in the coronal plane of the knee exceeding 10°, with anterior and/or lateral joint pain, patellofemoral instability, gait disturbance, or cosmetic concerns. GM has also shown good results in patients with fixed flexion deformity of the knee and ankle valgus.This paper reviews the history of the procedure, current indications, and recent advances underlying physeal manipulation with TBPs. Cite this article: EFORT Open Rev 2021;6:658-668. DOI: 10.1302/2058-5241.6.200098.

Hip arthroscopy following slipped capital femoral epiphysis fixation: chondral damage and labral tears findings

PURPOSE

This study investigated the association between chondrolabral damage and time to arthroscopic surgery for slipped capital femoral epiphysis (SCFE).

METHODS

This was a descriptive retrospective study that enrolled patients with SCFE who underwent hip arthroscopy for femoral osteochondroplasty after SCFE fixation. SCFE type, time from SCFE symptom onset or slip fixation surgery to hip arthroscopy and intraarticular arthroscopic findings were recorded. Acetabular chondrolabral damage was evaluated according to the Konan and Outerbridge classification systems. Nested analysis of variance and the chi-squared test were used for statistical analyses.

RESULTS

We analyzed 22 cases of SCFE in 17 patients (five bilateral). The mean age at the time of hip arthroscopy was 13.6 years-old (8-20), and mean time from SCFE fixation to arthroscopy was 25.1 months (3 weeks to 8 years). Labral frying was present in 20 cases, labral tears in 16 and acetabular chondral damage in 17. The most frequent lesion was type 3 (41%) (Konan classification). Two cases had a grade III and 1 had a grade II acetabular chondral lesion (Outerbridge classification). Positive associations were observed between time from SCFE to hip arthroscopy and hip intraarticular lesions evaluated using Konan (p = 0.004) and Outerbridge (p = 0.000) classification systems. There was no association between SCFE severity (chi-squared = 0.315), stability (chi-squared = 0.558) or temporality (chi-squared = 0.145) type and hip intraarticular lesions.

CONCLUSION

A longer time from SCFE symptom onset and fixation to hip arthroscopy is associated with greater acetabular chondrolabral damage.

LEVEL OF EVIDENCE

IV.

Hip preservation

Classical indications for hip preserving surgery are: femoro-acetabular impingement (FAI) (intra- and extra-articular), hip dysplasia, slipped capital femoral epiphysis, residual deformities after Perthes disease, avascular necrosis of the femoral head.

Pre-operative evaluation of the pathomorphology is crucial for surgical planning including radiographs as the basic modality and magnetic resonance imaging (MRI) and/or computed tomography (CT) to evaluate further intra-articular lesions and osseous deformities.

Two main mechanisms of intra-articular impingement have been described:

(1) Inclusion type FAI (‘cam type’).

(2) Impaction type FAI (‘pincer type’).

Either arthroscopic or open treatment can be performed depending on the severity of deformity.

Slipped capital femoral epiphysis often results in a cam-like deformity of the hip. In acute cases a subcapital re-alignment (modified Dunn procedure) of the femoral epiphysis is an effective therapy.

Perthes disease can lead to complex femoro-acetabular deformity which predisposes to impingement with/without joint incongruency and requires a comprehensive diagnostic workup for surgical planning.

Developmental dysplasia of the hip results in a static overload of the acetabular rim and early osteoarthritis. Surgical correction by means of periacetabular osteotomy offers good long-term results.

Cite this article: EFORT Open Rev 2020;5:630-640. DOI: 10.1302/2058-5241.5.190074

Morscher Osteotomy Through Surgical Dislocation Approach for True Femoral Neck Lengthening with Greater Trochanter Transposition

BACKGROUND

Young adults presenting with hip pain can be affected by proximal femoral growth disturbances as seen in Legg-Calvé-Perthes disease (LCPD) or as a complication of surgical treatment of developmental dysplasia of the hip (DDH). In 1988, Morscher proposed a novel femoral neck lengthening osteotomy to address these issues. The purpose of this study was to evaluate the effectiveness and safety of the Morscher osteotomy as a procedure to complement the well-documented surgical hip dislocation, to increase femoral offset, to distalize the greater trochanter, and to increase the overall limb length.

METHODS

This study was a retrospective case series from 3 hip-preservation-expert surgeons. Morscher osteotomies performed through a surgical dislocation approach by 3 surgeons between January 2008 and September 2019 were reviewed. Fifteen patients with a median age at surgery of 17 years (range, 13 to 28 years) and a minimum follow-up of 3 months (until union) were included. Surgical indications, clinical findings, comparative radiographic analyses including the change in horizontal femoral offset and the position of the greater trochanter, and complications were assessed.

RESULTS

Surgical indications included DDH and LCPD. The horizontal femoral offset improved in all patients, to a median of 32.5 mm (range, 4 to 46.4 mm). The articular-trochanteric distance increased to >5 mm in all patients. Limb length improved by a median of 11.5 mm (range, 3 to 30 mm). Complementary periacetabular osteotomy was performed in 14 patients. The lateral center-edge angle and the acetabular index improved in patients with an associated periacetabular osteotomy, to a median of 28.2° (range, 9° to 37.7°) and 7.9° (range, 0° to 20°), respectively. Two patients demonstrated osteoarthritis progression from Tönnis stage 0 to stage 1, and 6 patients had a decrease of the joint space. Complications included 1 pulmonary embolism, 1 case of asymptomatic fibrous union of the greater trochanter, and 1 transient sciatic nerve palsy.

CONCLUSIONS

The time-tested Morscher osteotomy indicated for complex proximal femoral reconstruction is effective in increasing horizontal femoral offset, distalization of the greater trochanter, and limb length. Combining the Morscher osteotomy with the versatility of surgical hip dislocation and the improved coverage capacity of periacetabular osteotomy proved complementary in the arsenal of hip preservation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A review of outcomes associated with femoral neck lengthening osteotomy in patients with coxa brevis

PURPOSE

Double and triple femoral neck lengthening osteotomies have been described to correct coxa brevis deformity. Only small studies reported the results. Our aim was to provide an overview of the outcomes of double and triple femoral neck lengthening.

METHODS

After an extensive search of different online databases, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

After evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported.

CONCLUSIONS

Double and triple femoral neck lengthening osteotomies in coxa brevis show good results with few complications in the literature, especially in young patients with non-arthritic hips.

LEVEL OF EVIDENCE

III.

Surgical hip dislocation with femoral osteotomy and bone grafting prevents head collapse in hips with advanced necrosis

QUESTIONS

Does surgical hip dislocation with drilling or bone grafting, cartilage treatment and femoral osteotomy in avascular necrosis of the femoral head (AVN) result in: (1) progression of osteonecrosis or osteoarthritis; (2) pain relief and improved function; and (3) subsequent surgery and complications?

METHODS

We retrospectively reviewed 12 patients (13 hips, mean age 29 ± 9 years) undergoing surgical hip dislocation for AVN. Preoperative ARCO stages were: 1 hip ARCO II, 8 hips ARCO III early, 4 hips ARCO III late. Drilling was performed in 4 hips, 9 hips underwent curettage, drilling and autologous bone grafting. Cartilage was sutured in 5 hips, autologous matrix-induced chondrogenesis was performed in 3 hips, an osteochondral autograft was used in 1 hip. Femoral osteotomy was performed in 10 hips. Mean follow-up was 3 ± 2 years. Progression of AVN and osteoarthritis was assessed preoperatively and at latest follow-up using Tönnis and ARCO staging. Pain and function were assessed with the Merle d'Aubigné-Postel score. Complications were graded according to Sink et al.

RESULTS

1 hip had AVN progression and converted to THA. 9 hips showed no AVN- or advanced osteoarthritis progression and 3 hips improved at least 1 ARCO stage. The Merle d'Aubigné-Postel score increased from preoperatively 14.1 ± 3.2 to 16.6 ± 1.2 (p = 0.012). Subsequent surgery were performed in 3 hips, complications occurred in 3 hips.

CONCLUSION

Although the first results are promising a longer follow-up with more patients is needed to draw a definite conclusion regarding the joint preserving potential in AVN.

Femoral osteotomies for the treatment of avascular necrosis of the femoral head

OBJECTIVE

Unloading of the area of necrosis out of the weight-bearing region by shifting healthy bone in the main weight-bearing area, which may delay the progression of the necrosis and enable healing.

INDICATIONS

Circumscribed osteonecrosis of the femoral head without advanced degenerative signs (Tönnis grade ≤ 1) in the relatively young patient (age < 50 years).

CONTRAINDICATIONS

Radiographic joint degeneration (> Tönnis grade 1); extensive avascular necrosis (Kerboul angle > 240°); advanced lesions (≥ Association Research Circulation Osseous [ARCO] classification 3b).

SURGICAL TECHNIQUE

By performing a surgical hip dislocation, full access to the hip joint is gained. A femoral varus osteotomy is used to turn the necrotic lesion of the femoral head out of the central weight-bearing area and more medially. Osteosynthesis is performed with an angular stable screw or a blade plate. Via a trapdoor procedure, direct debridement and autologous bone grafting from the trochanter major is possible. The cartilage flap is preserved whenever possible or supplanted by an autologous matrix-induced chondrogenesis (AMIC).

POSTOPERATIVE MANAGEMENT

A passive motion device is installed during hospital stay beginning immediately after surgery to prevent capsular adhesions. After surgery, patients are mobilized with partial weight-bearing of 15 kg with the use of crutches for at least 8 weeks. Forced abduction and adduction as well as flexion of more than 90° are restricted to protect the trochanteric osteotomy. After radiographic confirmation of healing at the 8‑week follow-up, stepwise return to full weight-bearing is allowed and abductor training is initiated.

RESULTS

Nine patients (10 hips) with osteonecrosis of the femoral head were treated with surgical hip dislocation and varus osteotomy. Six hips were treated with autologous bone grafting, four hips with antegrade drilling. Chondral lesions were sutured in four cases, whereas two cases needed an AMIC treatment. The mean age at operation was 29 ± 9 years (20-49), and the mean follow-up time for all patients was 3 ± 2 years (1-7). Conversion to a total hip prosthesis was required for one hip with progressing arthrosis. The other nine hips showed no progression of necrosis and an improved clinical outcome. Complications were pseudarthrosis of the femoral osteotomy and pseudarthrosis of the greater trochanter.

Extra-articular hip impingement: clinical presentation, radiographic findings and surgical treatment outcomes

Femoroacetabular impingement syndrome is classically thought of as either a cam or pincer deformity causing abnormal bony contact resulting in labral pathology. However, alternate patterns of hip impingement can occur, but tend to be less commonly recognized or studied. Collectively termed 'extra-articular impingement', four subgroups of impingement can contribute to non-arthritic hip pain and disability: iliopsoas impingement, subspine impingement, ischiofemoral impingement and trochanteric-pelvic impingement. The purpose of this review article is to highlight the pertinent points to aid in proper clinical and radiographic evaluation to allow appropriate diagnosis. Additionally, a review of potential surgical treatment options and resultant outcomes will also be provided.

Greater Trochanter Apophysiodesis in Legg-Calve-Perthes Disease: Which Implant to Choose?

BACKGROUND

Greater trochanter apophysiodesis (GTA) is relatively minimal invasive technique for the treatment of trochanteric overgrowth. Various types of implants can be used in each procedure. The purpose of this study was to compare outcomes of three different types of implants that were used in treatment of trochanteric overgrowth in Legg-Calve-Perthes disease.

MATERIALS AND METHODS

We retrospectively studied radiological results of three implants (screw, screw washer, and EP) on inhibiting trochanteric growth in 32 patients. Articulo-trochanteric and trochanter-trochanter distances (TTDs) were measured on radiographs. Embedding of implant evaluated on final radiographs.

RESULTS

The mean of age at the surgery was 10 ± 2.3 years, and the mean of follow up period was 50.0 ± 16.7 months. In all groups, articulo-trochanteric distance was decreased on final radiographs. In screw and screw washer group, increase of TTD was not statistically significant (P < 0.05). Twelve, one, and two implants were embedded, respectively, in screw, screw washer, and EP groups. Two patients in EP group had revision surgery due to loosening.

CONCLUSIONS

In this study group, GTA using screw and screw washer methods could slow down but did not restore trochanteric overgrowth. We suggest using washer to reduce embedding of the screw.

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery

Background

There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases.

Methods

The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively.

Results

The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group.

Conclusions

The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Impingement around the hip: beyond cam and pincer

In this review, we bring to the attention of the reader three relatively unknown types of hip impingement. We explain the concept of low anterior inferior iliac spine (AIIS) impingement, also known as sub-spine impingement, ischio-femoral impingement (IFI) and pelvi-trochanteric impingement. For each type of impingement, we performed a search of relevant literature.We searched the PubMed, Medline (Ovid) and Embase databases from 1960 to March 2016. For each different type of impingement, a different search strategy was conducted.In total, 19 studies were included and described. No data analysis was performed since there was not much comparable data between studies.An overview of symptoms, clinical tests and possible surgical treatment options for the three different types of extra-articular impingement is provided.Several disorders around the hip can cause similar complaints. Therefore, we plead for a standardized classification. In young and athletic patients, in particular, there is much to gain if hip impingement is diagnosed early. Cite this article: EFORT Open Rev 2018;3:30-38. DOI: 10.1302/2058-5241.3.160068.

Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement

INTRODUCTION

The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI.

METHODS

Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis.

RESULTS

International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found.

CONCLUSIONS

Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.

Innovations in Joint Preservation Procedures for the Dysplastic Hip "The Periacetabular Osteotomy"

The Bernese periacetabular osteotomy is an effective treatment for symptomatic developmental dysplasia in the prearthritic young adult hip. Refinements in the periacetabular osteotomy technique and perioperative management have markedly improved the clinical outcomes and recovery in these patients. We will review the clinical presentation of acetabular dysplasia, indications for surgery, perioperative management, and contemporary refinements in technique including refined acetabular reduction, adjunctive hip arthroscopy, femoral head-neck osteochondroplasty, femoral procedures, and rapid recovery protocols. In well-selected patients, this reconstructive osteotomy should be considered safe and effective in alleviating pain and improving hip function in patients with symptomatic acetabular dysplasia.

Double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in adolescents

PURPOSE

To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents.

METHODS

Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120º or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospıtal Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs.

RESULTS

The mean follow-up duration was 61 (range, 28-86) months. The ATD improved from 16±11.5 mm to -6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112º±24.4º to 131º±16º (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis.

CONCLUSION

Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

Imaging of femoroacetabular impingement-current concepts

Following the recognition of femoroacetabular impingement (FAI) as a clinical entity, diagnostic tools have continuously evolved. While the diagnosis of FAI is primarily made based on the patients' history and clinical examination, imaging of FAI is indispensable. Routine diagnostic work-up consists of a set of plain radiographs, magnetic resonance imaging (MRI) and MR-arthrography. Recent advances in MRI technology include biochemically sensitive sequences bearing the potential to detect degenerative changes of the hip joint at an early stage prior to their appearance on conventional imaging modalities. Computed tomography may serve as an adjunct. Advantages of CT include superior bone to soft tissue contrast, making CT applicable for image-guiding software tools that allow evaluation of the underlying dynamic mechanisms causing FAI. This article provides a summary of current concepts of imaging in FAI and a review of the literature on recent advances, and their application to clinical practice.

Open and Arthroscopic Surgical Treatment of Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain, and when indicated, can be successfully managed through open surgery or hip arthroscopy. The goal of this review is to describe the different approaches to the surgical treatment of FAI. We present the indications, surgical technique, rehabilitation, and complications associated with (1) open hip dislocation, (2) reverse periacetabular osteotomy, (3) the direct anterior “mini-open” approach, and (4) arthroscopic surgery for FAI.

The Anthropoid Crista Trochanterica and the Hip Joint Capsule

The tubercle on the posterior aspect of the femoral neck (the crista trochanterica) has been repeatedly remarked upon because of its presence in early fossil apes, yet the function of this tubercle has eluded researchers. The prevailing explanation for the tubercle is that it relates to a strong ischiofemoral ligament, although none of the hypotheses for this bony projection have been systematically evaluated. This study surveyed 41 extant anthropoid species (n = 267 individuals) for the presence of a crista trochanterica. The soft tissue structures of the hip joint were then dissected and described for a sample of anthropoid cadavers (n = 14) in order to evaluate different hypotheses related to function of this tubercle. This study confirmed that the crista trochanterica is found in most cercopithecoids and platyrrhines, and is not present in great apes. The tubercle is rarely present in hylobatids, contrary to prior reports. The ischiofemoral ligament is not usually well-developed in anthropoids and does not fully explain the crista trochanterica morphology, although all cadavers displayed a well-developed zona orbicularis running along the posterior aspect of the joint capsule. The hip joint capsule itself inserted along the crista trochanterica in some individuals, typically those with an elongate crista trochanterica, but was highly variable in regards to the position of the tubercle. The hypotheses for the crista trochanterica are considered within the context of these findings, although the exact function of the tubercle remains unresolved.

Hip impingement: beyond femoroacetabular

In the last 20 years, femoroacetabular impingement has been at the forefront of clinical practice as a cause of hip pain in young adults. As arthroscopic techniques for the hip continue to evolve, the possible presence of a new group of conditions creating mechanical conflict in and around the hip joint (ischiofemoral, subspine and iliopsoas impingement) has recently been elucidated whilst interest in already known 'impingement' syndromes (pelvic-trochanteric and pectineofoveal impingement) is now revived. This article attempts to increase awareness of these relatively uncommon clinical entities by describing their pathomorphology, contact mechanics, treatment and published results available to present. It is hoped that such knowledge will diversify therapeutic options for the clinician, thereby improving outcomes in a small but not negligible portion of patients with previously unexplained persistent symptoms.

Treatment of Arthritis Associated With Legg-Calve-Perthes Disease With Modular Total Hip Arthroplasty

Legg-Calve-Perthes (LCP) disease can result in morphological deformities and associated adult hip arthritis. Thirty-five consecutive total hip arthroplasties (THA) were performed in 28 patients with a history of LCP using a non-cemented modular femoral component. There was one revision for late hematogenous infection and no evidence of prosthesis failure. Harris hip scores, on average, improved from 49.8 (26-73) to 93.9 (82-100) (P<0.05) after a minimum of 2 years follow-up (average, 8.2 years, range 2-14 years). Clinically, patients demonstrated diminished or no limping (94%, 33/35) and improved leg length equality post-operatively (100%, 35/35). This style of stem accommodated metaphyseal/diaphyseal size mismatch in 80% (28/35), allowed for abnormal anteversion in 71% (25/35), and resulted in radiographic improvements in trochanteric height (P<0.05), body weight lever arm (P<0.05), and leg length (P<0.05).

Trochanteric impingement: is it a source of pain after THR?

While uncommon, trochanteric-pelvic impingement may lead to significant lateral hip pain. We defined “impingement distance” as the radiographic distance from the medial aspect of the greater trochanter and the corresponding lateral edge of the acetabular bone or component and compared this to the contralateral normal hip. We present two painful total hip replacement (THR) cases, each featuring a patient with severe lateral hip pain when walking and sitting. Both patients had diminished femoral offset and trochanteric-pelvic clearance, compared to the contralateral normal hip. The impingement distance was increased an average of 10 mm with the exchange to a longer femoral head. Both patients had immediate and complete pain relief with operative treatment to increase the impingement distance.