Descriptive Epidemiology of Acetabular Dysplasia: The Academic Network of Conservational Hip Outcomes Research (ANCHOR) Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia, which is a well-recognized cause of hip pain, functional limitations, and secondary osteoarthritis. The purpose of this study was to describe the demographics of patients undergoing PAO, the baseline patient-reported outcome measures for this population, and the types of adjunctive procedures performed at the time of PAO surgery. METHODS: Demographics, disease characteristics, and patient-reported functional measures were prospectively collected from all patients who underwent PAO performed by 12 surgeons from 2008 to 2013. RESULTS: We enrolled 950 consecutive patients (982 hips) in the study; 83% were female and 17% were male, with an average age of 25.3 years and an average body mass index (BMI) of 24.6 kg/m. Most patients were Caucasian (87%), and 15% had undergone previous hip surgery. Before PAO was performed, most patients had had symptoms for 1 to 3 years. Baseline modified Harris Hip and University of California Los Angeles activity scores (61.8 and 6.6, respectively) indicated that patients had considerable functional limitations. DISCUSSION: Patients undergoing PAO for symptomatic dysplasia were predominantly young, female, and Caucasian with a normal BMI. Many patients had undergone prior hip surgery, and most had had symptoms for several years before treatment. Baseline patient-reported functional scores demonstrated marked functional limitations. Adjunctive procedures for intra-articular pathology, especially femoral osteochondroplasty and hip arthroscopy, are commonly performed at the time of PAO.

Preoperative Joint Space Width Predicts Patient-Reported Outcomes After Total Hip Arthroplasty in Young Patients.

BACKGROUND: In a new health care economy, there is an emerging need to understand and quantify predictors of total hip arthroplasty (THA) outcomes. We investigated the association between preoperative radiographic disease (as measured quantitatively by joint space width [JSW]) and patient-reported function, activity, pain, and quality of life after THA. METHODS: We retrospectively analyzed 146 patients (146 hips) 55 years or younger with a diagnosis of osteoarthritis who underwent cementless THA between January 2009 and December 2010. Preoperative pelvic radiographs were measured by 1 author blinded to clinical outcomes to establish JSW, defined as the shortest distance between the femoral head margin and the superolateral weight-bearing portion of the acetabulum. The JSW value was treated as a continuous variable when applied to statistical modeling. The relationship between the JSW and the improvement of clinical outcome was examined via a general linear modeling approach with adjustments for patients' age, body mass index, and sex. RESULTS: We identified an inverse relationship between preoperative JSW and improvements in functional, activity, pain, and quality of life. We found that, as JSW decreased by 1 mm, the outcome measure improvements were modified Harris Hip Score of 6.3 (p<0.001); SF-12 physical: 2.1 (p=0.027); WOMAC-pain: 4.8 (p=0.01); and UCLA Activity: 0.44 (p=0.02). CONCLUSIONS: Our results demonstrate that patients with greater preoperative joint space have less predictable improvement in terms of function, pain relief, and activity. These findings suggest that THA in young patients with a JSW less than 1.5 to 2 mm provides more predictable improvements in pain and functional outcomes.

Does Tranexamic Acid Reduce Blood Loss and Transfusion Requirements Associated With the Periacetabular Osteotomy?

BACKGROUND: Tranexamic acid (TXA) has shown safety and efficacy in reducing blood loss associated with various surgical procedures. However, to our knowledge there are no studies evaluating the effect of TXA on blood loss and transfusion requirements associated with periacetabular osteotomy (PAO). QUESTIONS/PURPOSES: The main purpose of this study is to determine whether TXA reduces blood loss and transfusion use in patients undergoing PAO for symptomatic acetabular dysplasia. Our secondary purpose was to compare the frequency of symptomatic thromboembolic events between patients undergoing surgery with and without TXA. METHODS: A consecutive series of 100 periacetabular osteotomies performed by one surgeon was reviewed to compare the groups immediately before and after implementation of routine use of tranexamic acid (two retrospective cohorts). TXA dosing followed an established protocol with a standard dose of 1 g infused intravenously during 10 minutes before skin incision and an additional 1 g intravenously at wound closure. Outcome measures include total estimated blood loss perioperatively and transfusion requirements. Total estimated blood loss was calculated using a formula built from the National Surgical Quality Improvement Program data regarding surgical blood loss. RESULTS: The mean perioperative total estimated blood loss was less in the patients receiving TXA compared with blood loss in patients who did not receive TXA (706 mL versus 1021 mL; p<0.001; 95% CI, -495 to -134). Twenty-six (52%) of the 50 patients who did not receive TXA had postoperative blood transfusions compared with 15 (30%) of 50 who received TXA (odds ratio, 0.395; 95% CI, 0.174-0.899; p=0.0414). No symptomatic deep vein thromboses or symptomatic pulmonary emboli were identified in either group. CONCLUSIONS: TXA reduces estimated blood loss and the frequency of transfusions in patients undergoing PAO for treatment of symptomatic acetabular dysplasia. Future prospective studies should confirm our findings to determine whether patients undergoing PAO should receive routine perioperative TXA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does previous pelvic osteotomy compromise the results of periacetabular osteotomy surgery?

BACKGROUND: As the Bernese periacetabular osteotomy (PAO) has grown in popularity, specific indications and the results in patients treated for those indications need to be evaluated. Currently, although many patients undergo PAO after having had prior pelvic osteotomy, there is limited information regarding the efficacy of the PAO in these patients. QUESTIONS/PURPOSES: The purpose of this study was to compare the (1) early pain, function, activity, and quality of life outcomes; (2) radiographic correction; and (3) major complications and failures between patients who underwent PAO after prior pelvic reconstruction versus those who had a PAO without prior surgery. METHODS: Between February 2008 and January 2012, 39 patients underwent PAO after prior pelvic osteotomy at one of 11 centers and were entered into a collaborative multicenter database. Of those, 34 (87%) were available for followup at a mean of 2.5 years (range 1-5 years). This group was compared with a matched group of 78 subjects, of whom 71 (91%) were available for followup at a similar interval. We compared clinical outcomes including UCLA activity score, SF-12, and Hip Disability and Osteoarthritis Outcome Score (HOOS); radiographic measures-anterior and lateral center-edge angle and acetabular inclination (AI)-and reoperations, major complications, and conversions to total hip arthroplasty. RESULTS: Although both groups reached clinical improvement in all categorical measures, the revision PAO group demonstrated greater pain (HOOS pain, study 74 versus 85, p = 0.03; 95% confidence interval [CI], 18.58 to -0.95) and less function (HOOS activities of daily living, study 80 versus 92, p = 0.002; 95% CI, 018.99-4.45) than the primary cohort. The revision cohort achieved a smaller average radiographic correction than in patients undergoing PAO without prior pelvic surgery. The mean correction in AI was less dramatic when directly comparing the revision and comparison groups (-12° to -17°, p < 0.001, SD 2.3-8.5). Although there was no difference in severe complications requiring further surgery, there were two conversions to hip arthroplasty (p = 0.109; 95% CI, 0.004-2.042) in the study group. CONCLUSIONS: PAO performed after prior pelvic surgery is associated with improvements in pain, function, radiographic correction, and early complication rates, but the improvements observed at short-term followup were smaller and more variable than those seen in patients who had not undergone prior pelvic surgery. We recommend considering PAO for residual deformities after prior osteotomy to improve function and quality life but warning patients of potential ceiling effects with a second periacetabular surgery.

Are younger patients undergoing THA appropriately characterized as active?

BACKGROUND: Surgeons perform THA to address a variety of conditions in younger patients, including osteoarthritis (OA), osteonecrosis, inflammatory arthritis, and congenital deformities. Younger patients aged 50 years or younger have been characterized as active in the literature, but a direct relationship between age and activity level has not been well substantiated. Younger patients with OA may engage in higher activity levels; however, associated medical conditions in patients with other surgical indications may not support a generalization that age is a surrogate for activity level. We recently evaluated these issues in younger patients undergoing total knee arthroplasty (TKA) and noted that the majority would not be considered active. Given this observation, we considered whether younger patients undergoing THA are characterized by high activity levels, which is relevant to understanding the long-term risk of wear-related failures. QUESTIONS/PURPOSES: (1) Do demographic features of younger patients undergoing THA support high activity expectations? (2) Do preoperative or postoperative functional activity measures support projections that younger patients are active after THA? METHODS: We retrospectively compared demographic characteristics and functional activity profiles (as determined by preoperative and postoperative UCLA activity scores, Harris hip scores [HHS], and SF-12 and WOMAC physical function subscores) of 704 patients who had undergone THA and were aged younger than 50 years (822 hips) with those of 484 patients (516 hips) aged between 65 and 75 years, who had undergone THA, with a minimum followup at 1 year after surgery (range, 12-160 months). RESULTS: Compared with patients aged 65 to 75 years, younger patients undergoing THA were more often men (51%, 95% confidence interval [CI], 48.8%-53.2% versus 40%, 95% CI, 37.1%-42.9% women; p < 0.01) or had undergone surgery for osteonecrosis (29% versus 4%; 95% CI, 2.8%-5.2%; p < 0.001). Postoperative HHS, SF-12, and WOMAC scores were not appreciably different between the two patient groups. Compared with older patients, younger patients with OA had higher preoperative (5.0 ± 2.5 versus 3.9 ± 2.0, p < 0.001) and postoperative UCLA activity scores (6.8 ± 2.1 versus 5.3 ± 1.9, p < 0.001). Younger patients with diagnoses other than OA had slightly higher mean postoperative UCLA activity scores than older patients (6.0 ± 2.3 versus 5.3 ± 1.9; p < 0.001). Two hundred fifty-nine of 704 younger patients undergoing THA (37%; 95% CI, 34.9%-39.1%) returned to impact activity compared with 75 of 484 older patients undergoing THA (15.5%; 95% CI, 13.3%-17.7%) (p < 0.001). CONCLUSIONS: Younger patients with OA are likely to return to high levels of activity after surgery, which may impact long-term wear-related implant survivorship. High activity levels are less common among younger patients with diagnoses other than OA. Age is not the ideal surrogate for activity level in patients considering THA; instead, specific activity-level measures should be used when discussing patient expectations pertaining to postoperative activity levels after arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery.

Outcome measures may be simple questions or complex measures that assess multiple interrelated domains affecting treatment outcomes. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. Joint and disease-specific outcome measures have been developed for the hip, knee, and foot and ankle. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability. General health measures and activity level scores should be included in outcome assessments after treatment for orthopaedic conditions.