Classifications in Brief: The Hartofilakidis Classification of Developmental Dysplasia of the Hip

Association between physical measures of spinopelvic alignment and physical functioning with patient reported outcome measures (PROMs) after total hip arthroplasty: Protocol for systematic review and meta-analysis

INTRODUCTION

Prevalence of total hip arthroplasty (THA) has trended upwards over past decades and is projected to increase further. Optimizing outcomes after surgery is essential to avoid surgical revision and maximize outcomes. Low back pain is reported as a problem post THA. Patient-reported outcome measures (PROMs) are commonly used to evaluate THA outcomes but have limitations (e.g., ceiling effects). It is therefore important to assess a comprehensive range of outcomes. Physical outcome measures of spinopelvic alignment and physical functioning demonstrate potential value, but no evidence synthesis has investigated their association with PROMs. The objectives of this systematic review are to evaluate the association between spinopelvic alignment and physical outcome measures of physical functioning with PROMs and characteristics of low back pain after THA.

METHODS AND ANALYSIS

This protocol is aligned with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Cross-sectional and longitudinal cohort studies evaluating the association between the physical outcome measures and PROMs (any outcome measures reported) following THA by any approach/implant will be included except surface replacement and revision THA. Studies investigating THA for developmental pathology and inflammatory conditions will be excluded. A systematic search in MEDLINE (Ovid), Embase (Ovid), Scopus, Web of Science, CINAHL, and the grey literature will be carried out from inception to July 31, 2023. Two independent reviewers will evaluate eligibility of retrieved articles, extract data and assess risk of bias (NIH quality assessment tool) of included studies. A third reviewer will mediate disagreements. Random-effects meta-analyses will be conducted if studies are sufficiently homogeneous in design, population, physical measures and PROMs; reporting odds ratios and 95% confidence intervals. Where meta-analyses are not possible, a narrative synthesis will be conducted. Confidence in cumulative evidence will be assessed using a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation).

PROSPERO REGISTRATION NUMBER

PROSPERO Registration number CRD42023412744.

Management of chondral and osteochondral lesions of the hip : A comprehensive review

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

Digital Templating of THA Using PACS and an iPhone or iPad is as Accurate as Commercial Digital Templating Software

BACKGROUND

Digital templating is a standard preoperative planning method in THA. Unfortunately, many hospitals cannot afford the software or have accessibility barriers owing to a limited number of installed computer workstations. We created a templating method using a picture archiving and communication system and the Keynote program on a mobile phone. The method's accuracy and reliability have not been compared with those of commercial digital templating software.

QUESTIONS/PURPOSES

(1) How accurate is this novel method on iPhone and iPad mobile devices compared with a commercially available digital templating software program? (2) Is the method reproducible among users with different levels of experience? (3) Are the results similar for different types of femoral prostheses?

METHODS

Between January 2017 and May 2020, we treated 209 patients for hip disease or trauma with primary cementless THA. We considered patients with a normal contralateral hip as potentially eligible for this retrospective study. Thus, 91% (191 of 209 hips) were eligible; a further 13% (27 hips) were excluded because of postoperative leg length discrepancy > 5 mm, femoral offset discrepancy > 5 mm (9% [18 hips]), intraoperative periprosthetic fracture (4% [eight hips]), and proximal femoral deformity (0.5% [one hip]), leaving 78% (164 hips) for analysis here. Their preoperative radiographs were evaluated by three independent assessors, including one senior orthopaedic surgeon, one senior resident, and one junior resident, using three methods. The first was digital templating using OrthoView software, which is a commercially available digital templating software program used worldwide and known to possess high accuracy. The other two methods were technically similar to one another, with the only difference being the interface: iPhone versus iPad. In both of those approaches, using the picture archiving and communication system measurement tool, we drew a circle on an acetabular radiograph to depict the cup. We took a photograph of the computer display and imported the photograph into slides of the Keynote program, a presentation software application for Mac computers, on both devices. It was then underlaid on transparent digital templates of the femoral stem, which were scanned from plastic templates and positioned at the center of each slide. We scaled the image to the template by adjusting the image size until a 15-cm straight line on the hip photograph was equal to the 15-cm scale markers of the template. All templating results were compared with the actual implanted cementless THA components to assess accuracy. All assessors were blinded to the information about the actual implants, and they were not involved in performing the surgical procedures. The intrarater and interrater reliabilities were analyzed using intraclass correlation coefficients and kappa values. The accuracy for predicting stem size for each type of the four stem designs was compared among the three methods.

RESULTS

We were able to predict the acetabular cup size within one size in 92% of hips (151 of 164) using OrthoView and in 92% (150 of 164) using the novel method (p > 0.99). The accuracies of the three methods were comparable for predicting a femoral stem size within one size (OrthoView: 90% [148 hips], iPhone: 93% [152 hips], and iPad: 91% [149 hips]; p = 0.78), and neck length (OrthoView: 96% [157 hips], iPhone: 96% [158 hips], and iPad: 97% [159 hips]; p = 0.95). Using OrthoView, the neck offset was correctly predicted in 80% (132 hips), compared to 85% (139 hips) when using the iPhone and 82% (134 hips) when using the iPad (p = 0.57). All methods showed substantial or excellent agreement regarding intrarater and interrater reliability. There was no difference in accuracy regarding any of the four femoral stem designs we evaluated (Avenir, Excia, ML taper, and Metha).

CONCLUSION

The digital templating technique for THA using an iPhone or iPad combined with a picture archiving and communication system demonstrated high accuracy, comparable to that of commercial digital templating software. This technique is reliable and reproducible for predicting a cementless prosthesis size, neck length, and offset in different types of femoral stems. It may be useful as an alternative in resource-constrained centers where commercial software programs are too expensive to be used in practice.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Femoral Head Autograft to Manage Acetabular Bone Loss Defects in THA for Crowe III Hips by DAA: Retrospective Study and Surgical Technique

Introduction: The pathologic anatomy of Crowe III is characterized by the erosion of the superior rim of acetabulum, with a typical bone defect in its supero-lateral portion. The performance of a total hip arthroplasty requires the management of the acetabular bone defect, and femoral head autograft can be a valid option to optimize implant coverage. Material and Methods: In all, eight Crowe III patients (nine hips), seven of which having unilateral hip affected, and one with bilateral involvement by secondary osteoarthritis in DDH; maximum limb length discrepancy (LLD) of 3.5 cm in unilateral patients. All were operated on by direct anterior approach. Patients were evaluated in terms of clinical, surgical, and radiological (center-edge, horizontal coverage, cup inclination) parameters. Results: Cup placement was implanted with a mean of 39.5 ± 7.5°. Stem alignment showed average 1.5 ± 2.3° in valgus. LLD showed an overall average preoperative of -29.5 ± 10.5 mm at the affected side, with a significant improvement to -2.5 ± 6.4 mm (p = 0.023). The mean initial coverage evaluated like a percentage of the horizontal bone host was 52.1 ± 7.1%, while the mean final coverage at the last post-operative X-ray from femoral autograft bone was 97.0 ± 4.5% with an average improvement of 44.5%. Average CE improved from -9.5 ± 5.2° (CE I) to the immediate post-operative (CE II) of 40.6 ± 8.2°. At the final follow up, CE III showed a mean of 38.6 ± 6.2°, with an average decrease of 2.0°. Discussion: Acetabular bone defect in Crowe III DDH patients undergoing THA by DAA, can be efficiently managed by massive autograft femoral head, which allowed an adequate and long-lasting coverage of the implant, with cup positioning at the native acetabulum.

Clinical and Radiological Outcomes of Revision Total Hip Arthroplasty for Patients with Prior Hartofilakidis Type C Hip Dysplasia

OBJECTIVE

To investigate the clinical and radiological results of revision total hip arthroplasty (THA) for patients with previously diagnosed Hartofilakidis type C hip dysplasia, which is technically challenging and lacks literature.

METHODS

We enrolled 20 patients with previously diagnosed Hartofilakidis type C hip dysplasia who underwent revision THA between November 2008 and July 2015 at our hospital. Patients were followed up for an average of 87 months. Data pertaining to the Harris hip score (HHS), modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), general satisfaction, and the level of satisfaction related to 16 hip functions or issues experienced after revision THA were collected. The vertical and horizontal center of rotation (COR) of the hips were measured bilaterally based on preoperative and postoperative anteroposterior radiographs. Categorical variables were analyzed by the chi-square test. Continuous variables were analyzed using the student's t test or non-parametric Wilcoxon Rank Sum test.

RESULTS

There were significant postoperative improvements in the HHS (47.4 ± 31.6 vs 70.1 ± 39.0), modified WOMAC (48.5 ± 27.9 vs 75.7 ± 36.8), and the vertical (45.7 ± 33.7 mm vs 21.6 ± 21.8 mm) and horizontal (41.8 ± 17.0 mm vs 31.4 ± 14.7 mm) offset of the COR after revision THA (P < 0.05). Fifteen (75.0%) patients were satisfied with the procedure. The satisfaction rate for each of the 16 items ranged from 45% to 100%. The top three dissatisfactory items were squatting, getting into/out of cars, and leg-length discrepancy. Postoperatively, dissatisfied patients had a significantly higher visual analogue scale pain score and lower WOMAC pain, HHS pain, WOMAC total, and HHS total scores, a lower satisfaction rate for pain relief, and a higher vertical COR.

CONCLUSION

There is a high rate (25%) of dissatisfaction with the outcome after revision THA for patients with prior Hartofilakidis type C hip dysplasia. The most likely reasons for dissatisfaction were inadequate pain relief and a higher vertical COR measured on radiography.

Treatment of symptomatic hip dysplasia by posterolateral small incision assisted Bernese periacetabular osteotomy

Background

For periacetabular osteotomy, traditional approaches usually have a long learning curve. We aimed to evaluate the postoperative results and complications of periacetabular osteotomy under a new double-incision approach.

Methods

The records of 58 consecutive patients (65 hips) who underwent periacetabular osteotomy using the new approach were retrospectively reviewed and evaluated. There were 52 women and 6 men with a mean age of 28.1 years at the time of surgery.

Results

The average follow-up period was 35.2 months, during which no patients were converted to total hip arthroplasty. Complications included 6 hips (9.2%) with nerve dysesthesias and 1 hip (1.5%) with delayed wound healing. The mean operative time and intraoperative blood loss were 88.6 min and 402.8 ml, respectively. The mean modified Harris hip score had improved from 72.2 points preoperatively to 91.3 points at the last follow-up. Fifty-five patients (62 hips, 95.4%) were satisfied to their outcomes, and good preoperative functional score was associated with a satisfactory outcome. Furthermore, the average lateral center–edge angle, anterior center–edge angle and acetabular index angle were corrected well after surgery.

Conclusion

Periacetabular osteotomy using modified Smith-Petersen or Bikini approach with posterolateral assisted small incision can be performed safely and with satisfactory results. In addition, this technique shortens the learning curve, and reduces the operating complexity, especially for beginner.

Direct Anterior Approach in Crowe Type III-IV Developmental Dysplasia of the Hip: Surgical Technique and 2 years Follow-up from Southwest China

OBJECTIVES

To summarize our pioneering surgical practice and clinical outcome of Crowe type III-IV developmental dysplasia of the hip (DDH) with a direct anterior approach total hip arthroplasty in a single teaching hospital in Southwest China.

METHODS

Fourteen patients (15 hips) diagnosed with Crowe type III-IV developmental dysplasia of the hip were involved in this single-center retrospective study between 2016 and 2018. A comprehensive surgical procedure, including preoperative planning and algorithms for leg length equalization, intraoperative stepwise soft tissue release, bone defect reconstruction, and an innovative subtrochanteric osteotomy, was described. Furthermore, advancements in intraoperative CT guidance, computer navigation, and nerve monitoring were available for specific demands. The short-term clinical outcome was evaluated at the endpoint of follow-up by three patient-reported functional scales (Harris, WOMAC, and SF-12 scores), and objective data collected at the clinic, including functional recovery (muscle strength of hip flexor and abductor, correction of the pelvic tilt, leg length discrepancy, and limp), radiographic analysis, and complication occurrence.

RESULTS

The intraoperative variables were carefully recorded. The mean operating times in Crowe type III and IV groups were 115.8 min and 156.2 min, and the median blood loss volumes were 520.5 mL and 810.2 mL, respectively. The general changes in the Harris, SF-12, and WOMAC scores of the two groups were 46.2, 8.7 and 134.3, respectively, at a mean follow-up of 25.4 months. Enhanced recovery of hip abductor muscle strength was identified in 85.7% of the population at the third postoperative month. The equalization of leg length and correction of the pelvic tile were observed at the sixth postoperative month, with a 36-mm decrease in leg length discrepancy. No radiographic evidence of the loosening or migration of the components was observed. A self-innovated subtrochanteric shortening osteotomy was performed in five patients, and they healed after 6 months. Specific complications included two cases of distal femoral cracks and one case of a periprosthetic fracture needing internal fixation. Two patients received a late iliotibial band release at the 3rd month postoperatively due to progressive genu valgum. No records of infection, dislocation, nerve palsy, bone non-union, or revision surgery were identified.

DISCUSSION

The direct anterior approach total hip arthroplasty showed potential advantages, including optimum component positioning, improved hip stability, steerable complication rate, and enhanced functional recovery with Crowe type III-IV DDH. The short-term outcome is comparable to that of the traditional posterolateral approach.