Operative findings and complications associated with adjunctive hip arthroscopy in 95 hips undergoing periacetabular osteotomy.

PURPOSE: to report our initial experience with adjunctive hip arthroscopy and periacetabular osteotomy (PAO). METHODS: Retrospective review of patients who underwent PAO and ipsilateral hip arthroscopy between 2003 and 2013. Indications for arthroscopy were mechanical symptoms and/or positive magnetic resonance imaging to suggest intra-articular pathology including chondrolabral lesions, ligamentum teres tears and hypertrophy, and synovitis. Preoperative Tönnis arthritis grades, age, sex, operative findings and treatment, complications, and, if available, hip survival were recorded. RESULTS: Of 78 patients (95 hips) included, 64 (82%) were female and 14 (18%) male, average age was 30.6 (14-63) years. Tönnis grades were 0 in 40 hips (42%), 1 in 45 hips (47%), and 2 in 10 hips (11%). No Tönnis 3 hips were included. 84% of hips demonstrated labral pathology. 92% had chondromalacia, which was severe enough in 4 patients to warrant cancellation of PAO; all 4 have subsequently required total hip replacement at short-term follow-up. Labral debridement was performed in 73 hips and refixation in 7. 5 postoperative complications occurred - none major, including 1 fluid extravasation, 1 case of heterotopic ossification, and 3 transient neuropraxias. CONCLUSIONS: Intraarticular pathology is highly prevalent in patients undergoing PAO with mechanical symptoms, and can be safely managed by adjunctive arthroscopy. Complications were minimal in our series and are comparable to reports of PAO without arthroscopy. Arthroscopy can treat pathology that is inaccessible during standalone PAO and permits avoidance of routine arthrotomy, surgical dislocation, rectus release, and futile PAO in cases with severe articular damage.

Does neck/liner impingement increase wear of ultrahigh-molecular-weight polyethylene liners?

We explore the hypothesis that repetitive impingement increases wear of ultrahigh-molecular-weight polyethylene inserts. During revision total hip arthroplasty, 113 acetabular components were retrieved and examined for impingement, backside wear, and articular wear. Sixty percent of acetabular liners showed evidence of prosthetic impingement, with moderate or severe damage to the rim in 32%. Moderate or severe backside damage was present in 31%. Backside wear was found in 61% (22/36) of liners exhibiting impingement vs 16% (12/73) of liners without impingement (P < .0001). The average articular wear rate of liners with moderate/severe impingement damage was 159 +/- 42 mm(3)/y, compared with 70 +/- 21 mm(3)/y for liners with no/mild impingement damage (P = .02). Repetitive impingement frequently occurs after total hip arthroplasty and leads to a multitude of adverse events, including motion between the liner and the acetabular shell.

Pelvic and femoral osteotomy in the treatment of hip disease in the young adult.

Osteotomies of the pelvis and upper femur play a useful and enduring role in the overall management of posttraumatic and developmental conditions of the hip. Rotational osteotomies of the pelvis have supplanted intertrochanteric osteotomies for treatment of most dysplasia-related conditions. In particular, the Bernese (Ganz) periacetabular osteotomy with lateral muscle sparing has emerged as the most effective and widely used pelvic osteotomy. Other methods, such as the Tönnis juxta-articular and triple innominate, also can be successful. These procedures have a risk profile that demands respect for the possible occurrence of significant complications and outcomes that are not uniformly excellent. Once significant arthritis is present, total hip arthroplasty is the procedure of choice in most instances. On the femoral side, the effectiveness of valgus osteotomy for femoral neck nonunion is unquestioned. Precollapse osteonecrosis is not a contraindication. Limb-length inequalities, malrotations, and displacements of posttraumatic deformities can be uniquely benefited by intertrochanteric osteotomy. Grade II slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and osteonecrosis sometimes can be effectively treated with intertrochanteric osteotomy. All osteotomies should be planned and performed in a manner that anticipates the possible need for future conversion to total hip replacement.

The role of acetabular and femoral osteotomies in reconstructive surgery of the hip: 2005 and beyond.

Femoral and acetabular osteotomies have enduring and useful roles in the ongoing surgical treatment of patients with various hip conditions. The classic indication for intertrochanteric valgus osteotomy is to induce healing of femoral neck nonunions. Additional indications include posttraumatic deformity, limb-length inequality, certain cases of osteonecrosis, and adult sequelae of Legg-Calve-Perthes disease, and slipped capital femoral epiphysis. Isolated intertrochanteric osteotomy is only occasionally indicated for the treatment of arthritis secondary to dysplasia. Rotational osteotomies of the pelvis have overtaken the role once historically played by intertrochanteric osteotomy in the treatment of dysplasia-related hip anomalies. Ideal candidates have prearthritic, activity-related pain associated with radiographic dysplasia. It is imperative that the hip joint be congruous, free of fixed subluxation, and located in the natural acetabulum. Surgical treatment of associated acetabular labral tears and/or detachments and impingement lesions can be done at the same time through antecedent hip arthroscopy (same anesthetic) or open arthrotomy. The direction and magnitude of correction need to be customized to fit the nature of the dysplasia. A standard method of correction likely is to result in unwanted iatrogenic retroversion in some cases. Intertrochanteric osteotomy now is used as a complement to rotational osteotomy for the indications outlined above.

Intertrochanteric femoral osteotomies for developmental and posttraumatic conditions.

Despite the numerous advances in technology and techniques for total hip arthroplasty, this surgery is often not the procedure of choice for all patients or for all hip conditions. Originally described as a treatment for femoral neck nonunions, the intertrochanteric femoral osteotomy retains an enduring role in the treatment of various posttraumatic and developmental hip conditions including femoral neck nonunions, iatrogenic or postsurgical deformities, leg-length inequality, osteonecrosis, slipped capital femoral epiphysis, deformities occurring after Legg-Calvé-Perthes desease, and for certain patients with dysplasia and secondary arthritis. By correcting deformity (either acquired or developmental), the intertrochanteric osteotomy can restore a more normal biomechanical geometry to the hip joint, which can increase the likelihood of improved longevity of the articulation. Excellent results have been reported by numerous authors using this procedure alone or in association with simultaneous or staged osteotomy of the pelvis. Factors that are common to most successful series are an emphasis on proper patient selection, detailed preoperative step-by-step planning, and meticulous intraoperative technique. Surgical intervention prior to the development of irreversible articular deterioration may result in dramatic short-term relief of pain because of improvements in biomechanics and relief of impingement. Long-term results include elimination of the need for total hip arthroplasty or postponement o f the need for this surgery for a meaningful number of years (such as 10 years or more).