Head reduction osteotomy with additional containment surgery improves sphericity and containment and reduces pain in Legg-Calvé-Perthes disease

Femoral Head Reduction Osteotomy for Legg-Calvé-Perthes Disease Sequelae: Case Report

Legg-Calvé-Perthes disease (LCPD) commonly causes sequelae in the hip joint morphology. A common variant is an oversized, nonspherical femoral head, associated with a short femoral neck and elevated greater trochanter, which leads to femoroacetabular impingement (FAI). The innovative Ganz technique for surgical hip dislocation opened up new treatment possibilities for FAI, including LCPD sequelae, without increasing the risk of avascular necrosis of the femoral head. In the ellipsoid coxa magna resulting from LCPD, joint wear is more accentuated in the central portion of the femoral head; the lateral third remains intact as it does not articulate with the acetabulum. A femoral head reduction osteotomy technique developed for such cases resects the damaged portion of the femoral head and restores its sphericity. Short-term outcomes are encouraging. The present case report presents a patient with LCPD sequelae submitted to a femoral head reduction osteotomy.

Ganz femoral head reduction associated with coverage and containment procedures improve radiological and functional outcomes in Perthes' disease

Aims

Ganz's studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes' disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach.

Methods

From September 2015 to December 2021, 13 FHROs were performed on 11 patients for Perthes' disease in two centres. Of these, 11 hips had an associated PAO. A specific CT- and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiological parameters (sphericity index, extrusion index, integrity of the Shenton's line, lateral centre-edge angle (LCEA), Tönnis angle), and clinical parameters (range of motion, visual analogue scale (VAS) for pain, Merle d'Aubigné-Postel score, modified Harris Hip Score (mHHS), and EuroQol five-dimension five-level health questionnaire (EQ-5D-5L)). Early and late complications were reported.

Results

The mean follow-up was 39.7 months (standard deviation (SD) 26.4). The mean age at surgery was 11.4 years (SD 1.6). No major complications were recorded. One patient required a total hip arthroplasty. Mean femoral head sphericity increased from 46.8% (SD 9.34%) to 70.2% (SD 15.44; p < 0.001); mean LCEA from 19.2° (SD 9.03°) to 44° (SD 10.27°; p < 0.001); mean extrusion index from 37.8 (SD 8.70) to 7.5 (SD 9.28; p < 0.001); and mean Tönnis angle from 16.5° (SD 12.35°) to 4.8° (SD 4.05°; p = 0.100). The mean VAS improved from 3.55 (SD 3.05) to 1.22 (1.72; p = 0.06); mean Merle d'Aubigné-Postel score from 14.55 (SD 1.74) to 16 (SD 1.6; p = 0.01); and mean mHHS from 60.6 (SD 18.06) to 81 (SD 6.63; p = 0.021). The EQ-5D-5L also showed significant improvements.

Conclusion

FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease. The newly introduced simulation and planning algorithm may help to further refine the technique.

Inhibition of Toll-Like Receptor 4 Signaling Pathway Accelerates the Repair of Avascular Necrosis of Femoral Epiphysis through Regulating Macrophage Polarization in Perthes Disease

BACKGROUND

Legg-Calvé-Perthes disease (LCPD) is still a refractory disease in children's orthopedics. With the introduction of the concept of "osteoimmunology", the immune-inflammatory mechanisms between bone and immune system have become a research focus of LCPD. However, few studies have reported on the pathological role of inflammation-related receptors such as toll-like receptors (TLRs) as well as immune cells such as macrophages in LCPD. This study was for investigating the mechanism of TLR4 signaling pathway on the direction of macrophage polarization and the repair of avascular necrosis of femoral epiphysis in LCPD.

METHODS

With GSE57614 and GSE74089, differentially expressed genes were screened. Through enrichment analysis and protein-protein interaction network, the functions of TLR4 were explored. Furthermore, immunohistochemistry, enzyme-linked immunosorbent assay (ELISA), hematoxylin & eosin (H&E) staining, micro-CT, tartrate-resistant acid phosphatase (TRAP) dyeing and western blotting were performed for determining the influences of TAK-242 (a TLR4 inhibitor) on the repair of avascular necrosis of femoral epiphysis in rat models.

RESULTS

Totally 40 co-expression genes were screened as well as enriched in TLR4 signaling pathway. Immunohistochemistry and ELISA analyses certified that TLR4 facilitated macrophage polarization toward the M1 phenotype and prevented macrophage polarization toward the M2 phenotype. Besides, the results of H&E and TRAP staining, micro-CT, and western blotting showed that TAK-242 can inhibit osteoclastogenesis and promote osteogenesis.

CONCLUSION

Inhibition of TLR4 signaling pathway accelerated the repair of avascular necrosis of femoral epiphysis by regulating macrophage polarization in LCPD.

Effects of different pelvic osteotomies on acetabular morphology in developmental dysplasia of hip in children

Developmental dysplasia of hip seriously affects the health of children, and pelvic osteotomy is an important part of surgical treatment. Improving the shape of the acetabulum, preventing or delaying the progression of osteoarthritis is the ultimate goal of pelvic osteotomies. Re-directional osteotomies, reshaping osteotomies and salvage osteotomies are the three most common types of pelvic osteotomy. The influence of different pelvic osteotomy on acetabular morphology is different, and the acetabular morphology after osteotomy is closely related to the prognosis of the patients. But there lacks comparison of acetabular morphology between different pelvic osteotomies, on the basis of retrospective analysis and measurable imaging indicators, this study predicted the acetabular shape after developmental dysplasia of the hip pelvic osteotomy in order to help clinicians make reasonable and correct decisions and improve the planning and performance of pelvic osteotomy.

Surgical Hip Dislocation in Pediatric and Adolescent Patients

LEVEL OF EVIDENCE

V, Expert opinion.

Simultaneous femoral head reduction osteotomy (FHRO) combined with periacetabular osteotomy (PAO) for the treatment of severe femoral head asphericity in Perthes disease

BACKGROUND

The purpose of this study is to describe the midterm clinical and radiologic outcomes of concurrent femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO) in Legg-Calvé-Perthes disease (LCPD) patients with major aspherical femoral head deformities.

METHODS

The study included four Perthes patients in Stage IV of Waldenstrom's classification with a mean age of 10.5 and severe femoral head asphericity. They were treated with a combination of FHRO + PAO and followed for at least 2 years. An evaluation of the radiological outcome of the surgery was carried out based on the lateral center to edge angle (LCEA), the anterior center to edge angle (ACEA), the Tönnis angle, the head sphericity index, the Stulberg classification, the extrusion index, and Shenton's line integrity. An evaluation of the clinical outcome was made by evaluating hip range of motion (ROM), Harris hip score (HHS), and Merle d'Aubigne´-Postel score.

RESULTS

All radiographic measures improved; three patients were classified as Stulberg class II and one as class III. The LCEA, ACEA, and Tönnis angle improved by 29° (from 3° to 32°), 16° (from 14° to 30°), and - 10° (from 18° to 8°), respectively. The mean femoral head sphericity index and extrusion index improved by 12% (from 83 to 95%) and - 33% (from 40 to 7%). No disruption was observed in the postoperative Shenton's line. According to HHS, all patients have shown excellent hip function, which improved by 27 points (from 69 to 96). Moreover, the hip ROM was increased from 222° to 267°. The follow-up period did not reveal any serious postoperative complications, such as osteonecrosis or conversion to arthroplasty.

CONCLUSIONS

Combined FHRO with PAO may improve the hip joint's morphology and function in patients with residual femoral head deformity and acetabular dysplasia due to LCPD. Despite being considered a complex and demanding hip surgery, these results suggest a more widespread implication of the salvage procedure.

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.

Femurkopfreduktionsosteotomie zur Verbesserung des femoroazetabulären Containments bei Morbus Perthes

Operationsziel

Wiederherstellung der Hüftkongruenz und des Containments durch zentrale Hüftkopfresektion/Reduktion über eine erweiterte chirurgische Hüftluxation unter Erhaltung/Respektierung der Hüftkopfdurchblutung. Eine gleichzeitige oder spätere Reorientierung des Acetabulums durch Triple-Osteotomie oder PAO bei instabiler Hüfte kann in speziellen Fällen notwendig werden.

Indikationen

Die Indikation zur chirurgischen Hüftkopfreduktion ist praktisch unabhängig vom Alter bei jeglicher inkongruenten, asphärischen Hüftkopfsituation mit „hinged abduction“ (zu erwartende Endsituation wie Stulberg IV und V) gegeben. Dies kann noch bei aktivem wie auch bei bereits ausgeheiltem Morbus Perthes der Fall sein. Zudem kann bei einer Stulberg-V-Situation selbst im adulten Alter noch eine Verbesserung erziel werden. Nach Resektion muss noch ein tragfähiger Resthüftkopf vorhanden bleiben, d. h. mindestens noch 50 % des ausgeweiteten Hüftkopfes. Die dafür beste Planung erfolgt in der „vergleichenden“ 3‑D-Rekonstruktion.

Kontraindikationen

Völlig zerstörter Knorpel oder Hüftkopf.

Operationstechnik

Identisches Operationsvorgehen wie für die klassische chirurgische Hüftluxation. Präparation der retinakulären Flaps. Unter Respektierung und in Kenntnis der Gefäßversorgung Spaltung des Hüftkopfes gemäß dem zu entfernenden, nekrotischen Kopfanteil. Bildung eines möglichst sphärischen Hüftkopfes und Verschraubung der beiden Kopfanteile auf Schenkelhalsniveau. Distalisation und Fixierung des großen Trochanters. Je nach Kongruenz und Stabilität des Hüftkopfs in der Hüftpfanne kann eine primäre oder sekundäre Triple-OT oder PAO notwendig werden.

Weiterbehandlung

Die intraoperative Stabilität des Femurkopfes im Acetabulum muss erzielt worden sein, um eine beckengipsfreie, funktionelle Nachbehandlung zu gewährleisten: Stockentlastung mit Bodenkontakt ist erlaubt; keine aktive Rotation; Flexion aktiv und passiv bis 90 Grad ist erlaubt; vorerst keine spezifische Physiotherapie; je nach Heilungsverlauf sind diese Maßnahmen 8 bis 10 Wochen einzuhalten.

Ergebnisse

Gemäß unseren publizierten Nachuntersuchungen (aktuell 21 Jahre) sehen wir bei technisch korrekt durchgeführter Operation und korrekter Indikation sowie adäquater Nachbehandlung durchwegs gute Ergebnisse. Nekrosen des reduzierten Hüftkopfs haben wir nie beobachtet. Alle gespaltenen Hüftköpfe, respektive Schenkelhälse sind primär geheilt.

Avascular femoral head necrosis in young gymnasts: a pursuit of aetiology and management

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

Methods

Outcome of hip-preserving head reduction osteotomy combined with periacetabular osteotomy was good in one and moderate in the other up to three years after surgery; based on the pronounced hip destruction, the third received initially a total hip arthroplasty.

Results

The described pathology is quite devastating, and extensive joint preserving surgery (which has been shown successful in Perthes’ cases) was less successful in this patient cohort.

Conclusion

Supraselective angiography may be helpful to improve pathomechanical understanding and surgical decision making.

Cite this article: Bone Jt Open 2022;3(9):666–673.

3D Mapping of Bone Channel of Blood Supply to Femoral Head in Proximal Femur

Background

A detailed depiction of nutrient foramina is useful for defining guidelines and minimising iatrogenic damage during hip surgery. Therefore, this study aimed to define the location and frequency of nutrient foramina in the proximal femur using mapping techniques.

Methods

One hundred dry human cadaveric proximal femurs, comprising 56 left and 44 right femurs, were scanned using a three-dimensional scanner, with scanning distance 200 mm, precision 0.01 mm, and measuring point 0.04 mm. The image resolution of 1,310,000 pixels was obtained. Digital imaging models were acquired from the proximal femur surface. All the nutrient foramina in each model were identified and marked. The nutrient foramina models were superimposed on one another and oriented to fit a standard template of the femur’s proximal aspect. Three-dimensional mapping in the proximal femur’s nutrient foramina was performed.

Results

The nutrient foramina’s location and dense zones were identified. The dense zones were distributed along the vascular course and gaps between the muscle attachment sites. Eighteen dense zones were identified and found to be location-dependent. They were located in the central part of the fovea capitis femoris, subcapital and basicervical areas of the femoral neck, and muscle attachment gaps of the femoral trochanter.

Conclusions

The terminal branch of the nutrient vessels entering the nutrient foramina is at risk for iatrogenic damage during hip surgeries, especially in cases of close bone exposures. There are 18 dense zones that need to be considered for a safer approach to the proximal femur. To minimise iatrogenic damage to the nutrient vessels entering the nutrient foramina, the dense areas should be avoided when technically possible.

Is a Femoro-Acetabular Impingement Type Cam Predictable after Slipped Capital Femoral Epiphysis?

(1) Background: Previous studies have proven a high incidence of a femoro-acetabular impingement (FAI) type cam in patients sustaining a slipped capital femoral epiphysis (SCFE). Thus, the current study analyzed, if a cam deformity is predictable after SCFE treatment; (2) Methods: 113 cases of SCFE were treated between 1 January 2005 and 31 December 2017. The radiological assessment included the slip angle after surgery (referenced to the femoral neck (epiphyseal tilt) and shaft axis as Southwick angle) and the last available lateral center edge angle (LCEA), the acetabular- and alpha angle. A correlation was performed between these parameters and the last alpha angle to predict a FAI type cam; (3) Results: After a mean follow-up of 4.3 years (±1.9; 2.0-11.2), 48.5% of the patients showed a FAI type cam and 43.2% a dysplasia on the affected side. The correlation between the epiphyseal tilt and alpha angle was statically significant (p = 0.017) with a medium effect size of 0.28; (4) Conclusions: The postoperative posterior epiphyseal tilt was predictive factor to determine the alpha angle. However, the cut-off value of the slip angle was 16.8° for a later occurrence of a FAI type cam indicating a small range of acceptable deviations from the anatomical position for SCFE reconstruction.

Treatment Options for End-Stage Hip Disease in Adolescents: To Replace, Fuse, or Reconstruct?

INTRODUCTION

This paper aims to review the indications criteria for the surgical treatment of adolescents with hip osteoarthritis and summarize the contemporary techniques that orthopaedic surgeons can apply for hip reconstruction.

DISCUSSION

Hip osteoarthritis remains a concerning burden to North American society. While the rate of total hip replacement (THR) in younger patients has increased in the last decades, younger patients may have a higher risk of revision hip replacement because of their increased level of activity and expected patient longevity compared with the elderly. Increased demand for multiple revision surgeries is a concern for the adolescent patient. Although in general THR has been increasingly recommended for the treatment of end-stage osteoarthritis secondary to pediatric hip disorders, hip arthrodesis remains a beneficial alternative for the treatment of severe hip disease secondary to infection and for patients who desire to engage in a very active lifestyle. Hip preservation procedures are ideally performed in the prearthritic stage or in hips with minimal degeneration to preserve the joint and achieve the most optimal outcomes. However, adolescents and young adults with moderate and rarely advanced arthritis may benefit from surgical treatment using hip preservation techniques.

CONCLUSIONS

Treatment of adolescents with pain and dysfunction because of end-stage hip disease is challenging and controversial. THR and arthrodesis are the 2 principal alternatives. However, in particular circumstances, hip reconstruction may be recommended.

Bilateral femoral head reshaping and mosaicplasty in Legg-Calvé-Perthes disease residual deformity

Residual hip deformity secondary to Perthes disease may lead to early symptomatic joint degeneration. The altered anatomy results in biomechanical and biological problems that can be surgically addressed in adolescents or young adults with hip preservation procedures. This case report aims to demonstrate a customized surgical treatment performed on a 15-year-old male who developed painful hips with significant intra- and extra-articular impingement, secondary to bilateral Leg–Calvé–Perthes disease residual deformity. Intra-articular procedures were executed through a safe surgical dislocation of the hip, with a mosaicplasty using osteochondral autografts from the exceeding peripheral ipsilateral femoral head, a femoral head–neck osteochondroplasty and a labrum repair. A relative lengthening of the femoral neck was also carried out with a trochanteric advancement to solve the extra-articular issues. On follow-up, he referred to a substantial improvement in pain and function, being his radiographic studies satisfactory. At 4 and 5 years from surgery, the patient was able to exercise regularly with minimal complaints, with a Harris Hip Score of 85.85% and a Hip Outcome Score of 94.1% for activities of daily life and 86.1% for sports. In patients with hip deformity after healed Perthes disease, treatment strategies that address both the morphological disturbance of coxa magna, plana and breva, as well as the biological concerns arising from osteochondral injuries or labral tears, and mechanical dysfunctions lead to improvements in symptomatology, function and medium-term prognosis. Further procedures to address residual adaptative acetabular dysplasia would favor outcomes of conservative hip surgery in the sequelae of LCPD.

Best Practices: Hip Femoroacetabular Impingement

OBJECTIVE. Imaging plays a critical role in the assessment of patients with femoroacetabular impingement (FAI). With better understanding of the underlying pathomechanics and advances in joint-preserving surgery, there is an increasing need to define the most appropriate imaging workup. The purpose of this article is to provide guidance on best practices for imaging of patients with FAI in light of recent advances in corrective FAI surgery. CONCLUSION. Pelvic radiography with dedicated hip projections is the basis of the diagnostic workup of patients with suspected FAI to assess arthritic changes and acetabular coverage and to screen for cam deformities. Chondrolabral lesions should be evaluated with unenhanced MRI or MR arthrography. The protocol should include a large-FOV fluid-sensitive sequence to exclude conditions that can mimic or coexist with FAI, radial imaging to accurately determine the presence of a cam deformity, and imaging of the distal femoral condyles for measurement of femoral torsion. CT remains a valuable tool for planning of complex surgical corrections. Advanced imaging, such as 3D simulation, biochemical MRI, and MR arthrography with application of leg traction, has great potential to improve surgical decision-making. Further research is needed to assess the added clinical value of these techniques.

Remodelling of femoral head deformity after hip reconstructive surgery in patients with cerebral palsy

Aims

Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP.

Methods

We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement.

Results

A total of 108 patients were enrolled. The mean preoperative MP was 58.3% (SD 31.7%), which improved to 9.1% (SD 15.6%) at the last follow-up. NSA and MHR improved from 156.5° (SD 11.5°) and 82.3% (SD 8.6%) to 126.0° (SD 18.5°) and 89.1% (SD 9.0%), respectively. Factors affecting the postoperative MHR were preoperative MP (p = 0.005), immediate postoperative MP (p = 0.032), and history of Dega osteotomy (p = 0.046).

Conclusion

We found that hip sphericity improves with HRS. Preoperative MP, reduction quality, and acetabular coverage influence femoral head remodelling. We recommend that surgeons should consider intervention early before hip displacement progresses and that during HRS, definite reduction and coverage of the femoral head should be obtained.

Cite this article: Bone Joint J 2021;103-B(1):198–203.

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

Computer-assisted femoral head reduction osteotomies: an approach for anatomic reconstruction of severely deformed Legg-Calvé-Perthes hips. A pilot study of six patients

BACKGROUND

Legg-Calvé-Perthes (LCP) is a common orthopedic childhood disease that causes a deformity of the femoral head and to an adaptive deformity of the acetabulum. The altered joint biomechanics can result in early joint degeneration that requires total hip arthroplasty. In 2002, Ganz et al. introduced the femoral head reduction osteotomy (FHRO) as a direct joint-preserving treatment. The procedure remains one of the most challenging in hip surgery. Computer-based 3D preoperative planning and patient-specific navigation instruments have been successfully used to reduce technical complexity in other anatomies. The purpose of this study was to report the first results in the treatment of 6 patients to investigate whether our approach is feasible and safe.

METHODS

In this retrospective pilot study, 6 LCP patients were treated with FHRO in multiple centers between May 2017 and June 2019. Based on patient-specific 3D-models of the hips, the surgeries were simulated in a step-wise fashion. Patient-specific instruments tailored for FHRO were designed, 3D-printed and used in the surgeries for navigating the osteotomies. The results were assessed radiographically [diameter index, sphericity index, Stulberg classification, extrusion index, LCE-, Tönnis-, CCD-angle and Shenton line] and the time and costs were recorded. Radiologic values were tested for normal distribution using the Shapiro-Wilk test and for significance using Wilcoxon signed-rank test.

RESULTS

The sphericity index improved postoperatively by 20% (p = 0.028). The postoperative diameter of the femoral head differed by only 1.8% (p = 0.043) from the contralateral side and Stulberg grading improved from poor coxarthrosis outcome to good outcome (p = 0.026). All patients underwent acetabular reorientation by periacetabular osteotomy. The average time (in minutes) for preliminary analysis, computer simulation and patient-specific instrument design was 63 (±48), 156 (±64) and 105 (±68.5), respectively.

CONCLUSION

The clinical feasibility of our approach to FHRO has been demonstrated. The results showed significant improvement compared to the preoperative situation. All operations were performed by experienced surgeons; nevertheless, three complications occurred, showing that FHRO remains one of the most complex hip surgeries even with computer assistance. However, none of the complications were directly related to the simulation or the navigation technique.

Preoperative planning of femoral head reduction osteotomy using 3D printing model: A report of two cases

The deformed and enlarged femoral head secondary to hip diseases such as Legg Calve Perthes and Developmental Dysplasia usually causes impingement between the aspherical head and the acetabulum. To restore and reduce the size of enlarged femoral head, a femoral head reduction technique has been described previously. The goal is to obtain a spherical femoral head and to cover the gliding surface with best available cartilage. Planning of osteotomy to achieve spherical head is the crucial point of surgery. It is usually done intra-operatively and dependent on experience of surgeon. Preoperative 3- Dimension (D) modeling of femoral head is commonly preferred to minimize this risk. In this technical note, preoperative planning with 3-D printing was demonstrated in two separate patients with Legg-Calve-Perthes Disease and developmental hip dysplasia. Surgical time was approximately 150 and 120 min, respectively. Blood loss was 230 and 300 cc, respectively. Patients were followed up 9 months and 12 months, respectively. None of the patients in this study developed avascular necrosis; however, the follow-up period is very limited. Moreover, none of the patients developed post-operative complications or required additional surgery. With a more detailed preoperative planning done on computer model and printed in 3-D, one can mimic the surgical procedure before the procedure. Finally, this technique is advantageous both for the patient and surgeon.

Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities

AIMS

The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities.

PATIENTS AND METHODS

Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle.

RESULTS

The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty.

CONCLUSION

FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities.

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.

Acetabular morphology in slipped capital femoral epiphysis: comparison at treatment onset and skeletal maturity

PURPOSE

To investigate changes in acetabular morphology during the follow-up of slipped capital femoral epiphysis (SCFE) and search for factors associated with acetabular dysplasia at skeletal maturity.

METHODS

We evaluated 108 patients with unilateral SCFE (mean age at slip, 12.3 years sd 1.7) to skeletal maturity, with a minimum follow-up of two years (median 4.5 years; interquartile range 3.2 to 6.2). Acetabular parameters obtained from initial and most recent radiographs included the lateral centre-edge angle (LCEA), Tönnis angle (TA) and acetabular depth-width ratio (ADR). Acetabular dysplasia was considered for LCEA < 20° or TA > 10°. Femoral parameters consisted of the most recent head diameter, neck-shaft angle, neck length, articulotrochanteric distance and alpha angle.

RESULTS

At SCFE onset, the affected hip showed a slightly lower LCEA (26.4° sd 6.1° versus 27.3° sd 5.7°; p = 0.01) and ADR (330 sd 30 versus 340 sd 30; p < 0.001) compared with the uninvolved hip. At final follow-up, the affected hip showed lower LCEA (24.5° sd 7.6° versus 28.8°sd 6.6°; p < 0.001) and ADR (330 sd 40 versus 350 sd 40; p < 0.001), and TA was larger (5.5° sd 5.4° versus 2.3° sd 4.2°; p < 0.001) compared with the uninvolved hip. Acetabular dysplasia was observed in 27 (25%) of 108 hips with SCFE. Femoral head overgrowth, age at slip and SCFE severity were independent factors associated with acetabular dysplasia (p < 0.05).

CONCLUSION

Acetabular coverage and depth are not increased in SCFE, and the acetabular coverage tends to decrease up to skeletal maturity. A potential disturbance in the acetabular growth and remodelling exists mainly for young children with severe SCFE, and a potential for acetabular insufficiency may be observed at the diagnosis and follow-up of SCFE.

LEVEL OF EVIDENCE

Prognostic Level IV.

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.

Hip Vascularity: A Review of the Anatomy and Clinical Implications

Throughout development, the vascular supply to the proximal femur and acetabulum undergoes a series of changes during which it is susceptible to injury. Before age 3 months, the ligamentum teres and lateral epiphyseal arteries are the dominant supply to the developing head. The dominant supply shifts to the lateral epiphyseal vessels by age 18 months. The distinct metaphyseal and epiphyseal circulations of the adult proximal femur form in adolescence when an increasingly rich metaphyseal circulation supplies the subphyseal region, terminating at the physeal plate. The acetabular blood supply derives from two independent systems, with the dominance of each changing throughout maturity. Most descriptions of the vascular contributions to the proximal femur and acetabulum have been gross anatomic and histologic studies. Advanced imaging studies (eg, CT angiography, perfusion MRI) have added to our understanding of the vascular anatomy of the proximal femur and acetabulum, its changes throughout development, and its clinical implications.