Hip instability treated with arthroscopic capsular plication.

PURPOSE: Atraumatic microinstability of the hip is felt to be a cause of intra-articular pathology, particularly tears of the anterior labrum. The purpose of this study is to evaluate a consecutive series of patients with atraumatic hip microinstability that resulted in anterior labral and cartilage pathology, treated with hip arthroscopy and capsular plication without any associated bony procedures. METHODS: Thirty-two patients underwent hip arthroscopy and suture capsular plication for the treatment of hip instability without concomitant bony resections of the acetabulum or proximal femur between November 2009 and November 2012 and were followed for a minimum of 12 months. Patients were clinically evaluated preoperatively and again at 3, 6, 12, 24, and 36 months postoperatively with the modified Harris hip score (mHHS) and iHOT score in some patients (as this was introduced late in the study). Comparison was made evaluating centre-edge angle, Tönnis angle, physical examination findings, and demographics on outcome. RESULTS: There was significant improvement in the mean mHHS from 67 (SD = 8.7) to 97 (SD = 4.7) and iHOT score from 41 (SD = 18.3) to 85 (SD = 10.1) at final follow-up. When comparing patients with mild hip dysplasia to patients without hip dysplasia, there was no significant difference in clinical outcome at any point in follow-up. There was no significant association between patient age, duration of preoperative symptoms, previous ipsilateral hip arthroscopy, nature of onset of symptoms, centre-edge angle, Tönnis angle, or preoperative physical examination findings with clinical outcome at final follow-up. CONCLUSION: Isolated arthroscopic suture capsular plication performed for the treatment of hip instability resulted in improved patient pain and function at a minimum of 1-year follow-up.

Microinstability of the hip-it does exist: etiology, diagnosis and treatment.

Symptomatic hip microinstability is now recognized as a potential cause of pain and disability in young patients. Causes of hip microinstability include underlying bony or soft tissue abnormalities and iatrogenic injuries of the hip capsule; however, many patients lack a clear underlying etiology. Treatment usually begins with an extensive course of non-operative management with an emphasis on activity modification and physical therapy. Surgical intervention should focus on treatment of the underlying cause as well as any associated intra-articular pathology. In many cases, arthroscopic suture plication can be considered when bony deficiency is not the cause. In this article, we will review the spectrum of symptomatic hip microinstability with a focus on the relevant anatomy, etiology, diagnosis and various treatment options.

Reliability of hip internal rotation range of motion measurement using a digital inclinometer.

PURPOSE: Assessment of hip internal rotation (IR) is a critical element in the evaluation of a painful hip, yet there currently exists no consistent method of determining this measurement. The purpose of this study is to report the intra-rater and inter-rater reliability of active and passive hip IR measurement using a digital inclinometer. METHODS: Twenty-five subjects (8 men, 17 women) with asymptomatic hip joints, and no known pathology between the ages of 22 and 42 participated. Two examiners measured hip IR for each subject using a digital inclinometer while visually monitoring pelvic motion. Measurements included passive IR, active IR, and active IR while internally rotating both legs simultaneously. Statistical analysis was performed including intra-rater and inter-rater reliability. RESULTS: There was no significant difference in measured IR values. Mean range of motion values for all techniques and both examiners ranged from 30.7° to 32.8°. Intra-rater reliability for examiner 1 ranged from 0.84 to 0.92. Inter-rater reliability ranged from 0.89 to 0.93. Of the methods utilized, active IR of a single leg was the most responsive technique with a minimal detectable change value of 5.4°. CONCLUSIONS: Clinical assessment of hip IR range of motion can be performed efficiently and reliably with a digital inclinometer along with visual monitoring of the pelvis for unwanted motion. Findings from this study support unilateral active hip IR in a seated position as a reliable and responsive technique for obtaining hip IR measurements.

Patellofemoral arthroplasty: outcomes and factors associated with early progression of tibiofemoral arthritis.

PURPOSE: The purpose of this study was to review the results of patellofemoral arthroplasty (PFA) performed by a single surgeon at a single institution in order to determine factors associated with clinical outcomes and progression of tibiofemoral degenerative joint disease. METHODS: Sixty-one patients with isolated patellofemoral osteoarthritis were treated with a PFA by a single surgeon between 2003 and 2009. Fifty-nine patients were available for analysis with a mean follow-up of 4 years (range 2-6 years). Patients were evaluated by measuring range of motion and with the use of the Knee Society clinical rating system, the Tegner Activity Level Scale, and the UCLA Activity Score. In addition, preoperative radiographs were evaluated for patellofemoral and tibiofemoral compartment osteoarthritis and presence of trochlear dysplasia, and post-operative radiographs were reviewed for progression of tibiofemoral degenerative arthritis. Furthermore, multivariate statistical methods were applied to study factors that had potential to influence the final outcome. RESULTS: There was no statistically significant association between age, gender, history of prior knee surgery, patellar height, patellofemoral osteoarthritis severity, patellar and femoral component size, or performance of lateral release with patient pain and function (as measured by the Knee Society scores) or progression of tibiofemoral joint osteoarthritis at final follow-up. Increased preoperative body mass index (BMI) was associated with lower post-operative Knee Society function scores (p=0.03). Patients with preoperative trochlear dysplasia had significantly less radiographic evidence of tibiofemoral joint osteoarthritis progression compared with patients without trochlear dysplasia at final follow-up (p<0.0001). CONCLUSION: In this study, patients with preoperative radiographic evidence of trochlear dysplasia experienced less progression of tibiofemoral degenerative joint disease than patients without trochlear dysplasia at a mean follow-up of 4 years. LEVEL OF EVIDENCE: IV.

Randomized clinical trial of rotating-platform and fixed-bearing total knee arthroplasty: no clinically detectable differences at five years.

BACKGROUND: For some surgeons, rotating-platform total knee designs are an intellectually appealing option to use for total knee arthroplasty because of the contention that they can self-align and accommodate small mismatches in the rotational position of the tibial and femoral components. We carried out a randomized clinical trial to determine if a posterior-stabilized, rotating-platform knee design provided better maximum knee flexion, better function, or better durability at five years of follow-up when compared with a fixed-bearing design. METHODS: This randomized clinical trial of 240 primary total knee arthroplasties involved a single type of distal femoral implant (posterior-stabilized) and three different types of tibial implant (all-polyethylene fixed-bearing, modular-metal-backed fixed-bearing, and rotating-platform). The three tibial implant groups were balanced dynamically with a computerized randomization process that accounted for patient age, sex, and body mass index; surgeon; and implant type. Patients returned for examination and radiographs at three months, one year, two years, and five years postoperatively. RESULTS: Knee range of motion was not significantly different among the all-polyethylene, modular-metal-backed, and rotating-platform tibial component groups at two years (mean, 111°, 111°, and 110°, respectively) or five years (mean, 110°, 109°, and 109°, respectively). Function, as measured with Knee Society scores, was not significantly different among the all-polyethylene, modular-metal-backed, and rotating-platform groups at two years (mean, 90, 91, and 91 points, respectively) or five years (mean, 88, 89, and 88 points, respectively). Stair-climbing scores were not significantly different among the three groups at two years (mean, 39, 40, and 39 points, respectively) or five years (mean, 37, 40, and 36 points, respectively). There were four revisions: one in the all-polyethylene group (patellar fracture), two in the modular-metal-backed group (aseptic loosening), and one in the rotating-platform group (deep infection). CONCLUSIONS: In this randomized clinical trial, the rotating-platform total knee design was reliable and durable but did not provide better maximum knee flexion, better function, or better durability at five years postoperatively when compared with a posterior-stabilized, fixed-bearing design incorporating either an all-polyethylene or a modular-metal-backed tibial component.

Effects of preoperative gait analysis on costs and amount of surgery.

BACKGROUND: The purpose of this study was to determine the effects of clinical gait analysis (GA) on the costs of care in ambulatory children with cerebral palsy (CP) and the amount of surgery these children undergo. METHODS: A retrospective review identified all ambulatory patients with CP who had undergone lower extremity orthopaedic surgery at our hospital from 1991 to 2005 with at least a 6-month follow-up. The patients were grouped into those who had undergone GA before their index surgery (GA group, N=313) and those who had not (NGA group, N=149). The groups were compared in terms of the number of procedures during index surgery and subsequent surgeries and the direct costs associated with these surgeries. Costs were calculated in US dollars by using a standardized protocol including fees for the surgeon, anesthesia, operating room, hospital stay, physical therapy, and GA. RESULTS: Patients in the GA group were significantly older and less functionally involved, had their first surgery in later years, and had a shorter follow-up than patients in the NGA group (P<0.001). Adjusting for these differences, patients in the GA group had more procedures (GA: 5.8, NGA: 4.2; P<0.001) and higher cost (GA: $43,006, NGA: $35,215; P<0.001) during index surgery, but less subsequent surgery. A higher proportion of patients went on to additional surgery in the NGA group (NGA: 32%, GA: 11%; P<0.001), with more additional surgeries per person-year (NGA: 0.3/person-year, GA: 0.1/person-year; P<0.001) resulting in higher additional costs (NGA: $3009/person-year, GA: $916/person-year; P<0.001). The total number of procedures (GA: 2.6/person-year, NGA: 2.3/person-year; P=0.22) and cost (GA: $20,448/person-year, NGA: $19,535/person-year; P=0.58) did not differ significantly between the 2 groups. CONCLUSIONS: Clinical GA is associated with a lower incidence of additional surgery, resulting in lesser disruption to patients' lives. This finding has not been shown before and may assist patients, physicians, policy makers, and insurance companies in assessing the role of GA in the care of ambulatory children with CP. LEVEL OF EVIDENCE: Level III, retrospective comparative study.