Hypermobility Assessment in 1,004 Adult Patients Presenting with Hip Pain: Correlation with Diagnoses and Demographics.

BACKGROUND: The strength of the association between hypermobility and developmental dysplasia of the hip (DDH) in adults is unknown. We sought to analyze this relationship in a prospective, blinded, institutional review board-approved, observational study. The hypothesis was that the prevalence of generalized joint hypermobility (GJH) would be significantly higher in patients with hip dysplasia than in those with other hip diagnoses on the basis of clinical observations of joint laxity. METHODS: One thousand and four consecutive new patients (390 males and 614 females) seen over a 4-year period were evaluated for hypermobility of the hip using 2 criteria: the Beighton 9-point physical examination criteria and the Hakim-Grahame 5-item history questionnaire. Diagnosis, age, sex, and race were tested as predictors of hypermobility. Patient-reported outcome scores from the International Hip Outcome Tool (iHOT-12) and the modified Harris hip score (mHHS) were also assessed. RESULTS: DDH was the primary diagnosis in 33.2% of the patient population. Patients who had dysplasia without osteoarthritis (OA) had a significantly elevated prevalence of GJH (77.9%) compared with those with nondysplastic hips (32.8%; p < 0.0001) or with patients who had dysplasia and OA (35.7%; p < 0.0001) according to either method. The odds ratio (OR) for patients with DDH versus those with other diagnoses was 7.1 (95% confidence interval [CI]: 5.1 to 10.0). The prevalence of hypermobility was significantly greater in females than in males (OR = 4.2 [95% CI: 3.2 to 5.5]; p < 0.0001). The prevalence of GJH was inversely proportional to age. There was a significantly reduced prevalence of GJH observed in Hispanic patients (p < 0.05) compared with other races. GJH was not a predictor of patient-reported outcome scores (p = 0.51 for iHOT-12 and p = 0.44 for mHHS). CONCLUSIONS: To our knowledge, this study is the first to establish a strong association between hypermobility and DDH in adults, confirming the hypothesis. We recommend utilizing both the Beighton and Hakim-Grahame scoring systems together as routine components of the history and physical examination for patients with hip dysplasia. Further research is warranted to explore the genetic basis and potential causal relationships between soft-tissue laxity and skeletal dysplasia, as well as improvements in assessment tools. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity.

BACKGROUND: The prevalence of a cam-type deformity in athletes and its association with vigorous sports activities during and after the growth period is unknown. QUESTIONS/PURPOSES: We therefore compared the prevalence and occurrence of a cam-type deformity by MRI in athletes during childhood and adolescence with an age-matched control group. PATIENTS AND METHODS: We retrospectively reviewed 72 hips in 37 male basketball players with a mean age of 17.6 years (range, 9-25 years) and 76 asymptomatic hips of 38 age-matched volunteers who had not participated in sporting activities at a high level. RESULTS: Eleven (15%) of the 72 hips in the athletes were painful and had positive anterior impingement tests on physical examination. Internal rotation of the hip averaged 30.1° (range, 15°-45°) in the control group compared with only 18.9° (range, 0°-45°) in the athletes. The maximum value of the alpha angle throughout the anterosuperior head segment was larger in the athletes (average, 60.5° ± 9°), compared with the control group (47.4° ± 4°). These differences became more pronounced after closure of the capital growth plate. Overall, the athletes had a 10-fold increased likelihood of having an alpha angle greater than 55° at least at one measurement position. CONCLUSIONS: Our observations suggest a high intensity of sports activity during adolescence is associated with a substantial increase in the risk of cam-type impingement. These patients also may be at increased risk of subsequent development of secondary coxarthrosis. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Protrusio acetabuli: diagnosis and treatment.

Idiopathic protrusio acetabuli is an uncommon disease process with both primary idiopathic and secondary forms. It is important to consider all etiologic possibilities before evaluating treatment options. Diagnosis is made on the basis of an anteroposterior radiograph of the pelvis that demonstrates a center-edge angle greater than 40 degrees and medialization of the medial wall of the acetabulum past the ilioischial line. For the skeletally immature patient, triradiate fusion (occasionally combined with intertrochanteric osteotomy) provides good results. For the young adult, valgus intertrochanteric proximal femoral osteotomy is recommended. In the older adult, this procedure may provide an acceptable result if there is minimal arthritis. For patients with more advanced arthritis, total hip arthroplasty with lateralization of the cup to a normal position provides a predictable long-term solution.

Complications of periacetabular osteotomy.

There was a statistically significant decrease in major complications from 17% to 2.9% when comparing the first 35 cases with the second 35 cases of periacetabular osteotomy performed by one surgeon. There were no cases of intraarticular fracture, conversion to total hip replacement, or deaths in this series. Of considerable significance was that almost all major complications, as defined for disclosure in this report, left the patients with no permanent sequelae after either successful treatment, as in intraoperative bleeding, or with observation with time, as for recovery of sciatic nerve function. The complication rate of periacetabular osteotomy decreases significantly in proportion to increasing experience, as documented in this study. Patients in ongoing studies completed the Western Ontario and McMaster Universities Osteoarthritis Index and the Short Form- 36 preoperatively, which will add to the authors' ability to comment on functional outcomes in future reports.

Tissue expansion prior to revision total knee arthroplasty.

The first case of the use of a tissue expander in revision total knee surgery is reported. A 76-year-old woman presented with extremely adherent scare tissue on the anterior proximal tibia that was the result of multiple debridements and skin grafting for an infected primary total knee arthroplasty. The tissue expander was placed prior to subsequent revision total knee arthroplasty to permit complete excision of the scar and to provide tension-free closure with normal skin at the time of revision. Three years after the surgery, the patient is doing well.

Femoral osteotomy for secondary arthritis of the hip in young adults.

Osteotomy around the hip is a valuable and important treatment option in hip disease. It may be used on either side of the joint or in a combined fashion. The authors review the scientific background to femoral osteotomy and summarize its role in the treatment of developmental dysplasia, nonunion of femoral neck fractures, osteonecrosis, slipped capital femoral epiphysis and Perthes disease. They conclude that it is a most useful tool for the contemporary hip surgeon. The procedure may not be appropriate for elderly patients with arthritic deterioration of the hip, but in carefully selected young adults with clearly defined antecedent developmental conditions, the results can be excellent and long lasting. Careful preoperative planning is emphasized; particular attention must be paid to the possibility of arthroplasty in the future because insertion of the stem of a hip prosthesis can be a problem difficult.

Intertrochanteric osteotomy for osteonecrosis.

Intertrochanteric osteotomy is an effective surgical option in certain well-selected cases of osteonecrosis of the femoral head. The size of the lesion on plain radiographs in the anteroposterior and lateral projections is a critical determinant of success. The best candidates are patients with less than 50% of head involved in the necrotic sector. Collapse of the femoral head is not a contraindication to osteotomy. Location of the necrotic sector determines whether varus, valgus, flexion, or extension are most appropriate alone or in combination.

Mechanics of the normal and osteoarthritic hip. A new perspective.

The mechanism of force transmission in normal and osteoarthritic human hips is interpreted with the aid of the following hypothesis: the essential anatomic requisite for the maintenance of mechanical equilibrium about the hip is a horizontal acetabular weight-bearing surface. Anatomic deviations from this norm result in a disequilibrium of opposing vector forces and may be contributory to the eventual onset of osteoarthritis (OA). The radiographic anatomy of the hip is the temporal record of the biologic response of bone to load transmission. From the analysis of radiographs the magnitude and direction of mechanical forces about the hip can be inferred. Deviations from normal, as in OA, can be understood by such radiographic analyses.

Unicondylar unicompartmental replacement for osteoarthritis of the knee.

Unicompartmental knee replacement is an attractive concept that offers several potential advantages over bicompartmental or tricompartmental replacement, including preservation of bone stock, of the anterior and posterior cruciate ligaments, of the patellofemoral joint, and of the normal opposite compartment. Of our first 100 consecutive knees that had unicompartmental arthroplasty for osteoarthritis and were followed for two to six years (average, three and one-half years), eighty-eight were medial and twelve were lateral replacements. The ages of the patients at the time of operation ranged from forty-six to eighty-five years, with an average age of seventy-one years. At follow-up, pain relief was good to excellent in 92 per cent of the knees. The average amount of flexion was 114 degrees (range, 90 to 140 degrees); one-half of the knees had at least 120 degrees of flexion. The average flexion contracture was 1 degree. There were no infections and no peroneal palsies. At the time of writing, three failures had required revision. Radiolucent lines at the bone-cement interface were present around 8 per cent of the femoral components and 27 per cent of the tibial components. Two femoral components subsided in obese patients. There was no tibial loosening in the series. The most common complications, per anserinus bursitis, occurred in 12 per cent of the knees and was treated satisfactorily by injection of local anesthetics and steroids. Surgical technique must be precise to prevent subluxation of the tibia on the femur due to either improper positioning of the components or too tight a fit (too much pressure) between them. We view unicompartmental replacement as an attractive alternative for the treatment of unicompartmental osteoarthritis in elderly patients. However, we are strong advocates of proximal tibial osteotomy for unicompartmental osteoarthritis associated with a varus deformity in selected patients.