Surgical treatment for young adult hip dysplasia: joint-preserving options

Roles of combined femoral and acetabular anteversion in pathological changes of hip dysplasia and hip reconstructive surgery

Combined femoral and acetabular anteversion is the sum of femoral and acetabular anteversion, representing their morphological relationship in the axial plane. Along with the increasing understanding of hip dysplasia in recent years, numerous scholars have confirmed the role of combined femoral and acetabular anteversion in the pathological changes of hip dysplasia. At present, the reconstructive surgery for hip dysplasia includes total hip replacement and redirectional hip preservation surgery. As an important surgery index, combined femoral and acetabular anteversion have a crucial role in these surgeries. Herein, we discuss the role of combined femoral and acetabular anteversion in pathological changes of hip dysplasia, total hip replacement, and redirectional hip preservation surgery.

Bilateral hip dysplasia in a South African male: A case study from the 17-18th century

OBJECTIVE

To identify, critically analyse and describe severe bilateral skeletal pathology involving the ossa coxae of an individual from historic era Cape Town.

MATERIALS

A single individual from the University of Cape Town's Human Skeletal Repository was analysed under research approval (HREC# 035/2021).

METHODS

An osteobiography was constructed, radiocarbon dating and isotopic analyses were conducted. Pathological description and contextualised disability analyses followed, along with differential diagnosis. The pelvis and femora were visualised macroscopically and radiographically.

RESULTS

This individual was a non-European middle-aged adult male who lived in the 17-18th centuries CE. Morphological changes showed hypoplastic hips with collapsed femoral heads and neoacetabulae. A diagnosis of developmental dysplasia of the hips (DDH) was made. Then a contextualised disability analysis including consideration of the clinical and functional impacts of the condition were applied. No signs of maltreatment, physiological stress or persistent infections were present. His bones were well developed, illustrating mobility and use.

CONCLUSIONS

He developed DDH early in life and lived through adulthood, and his strong, healthy bones suggest resilience, some mobility and contribution to society through less physically demanding tasks.

SIGNIFICANCE

Value for palaepathological analyses to inform and understand disability and culturally significant health mediation to offer a more objective interpretation and improve understanding of past people. It expands our understanding of the presence of DDH globally and in Africa and provides insight into disease impact for individuals with bilateral expression.

SUGGESTIONS FOR FUTURE RESEARCH

Further contextual research is required.

LIMITATIONS

Poor scene recovery hindered in-depth care analysis and interpretation of the condition.

Effects of different pelvic osteotomies on acetabular morphology in developmental dysplasia of hip in children

Developmental dysplasia of hip seriously affects the health of children, and pelvic osteotomy is an important part of surgical treatment. Improving the shape of the acetabulum, preventing or delaying the progression of osteoarthritis is the ultimate goal of pelvic osteotomies. Re-directional osteotomies, reshaping osteotomies and salvage osteotomies are the three most common types of pelvic osteotomy. The influence of different pelvic osteotomy on acetabular morphology is different, and the acetabular morphology after osteotomy is closely related to the prognosis of the patients. But there lacks comparison of acetabular morphology between different pelvic osteotomies, on the basis of retrospective analysis and measurable imaging indicators, this study predicted the acetabular shape after developmental dysplasia of the hip pelvic osteotomy in order to help clinicians make reasonable and correct decisions and improve the planning and performance of pelvic osteotomy.

The economics of patients undergoing periacetabular osteotomy for hip dysplasia: the financial relationship between physicians and hospitals

Periacetabular osteotomy (PAO) is the gold standard for treating hip dysplasia in patients with preserved articular cartilage. The aim of this study is to evaluate the financial relationship between facility and professional revenue for patients undergoing PAO for hip dysplasia and acetabular version abnormalities. All patients who underwent PAO for hip dysplasia by a single surgeon at a tertiary academic medical center between December 2016 and November 2020 were identified. Financial records for facility and professional services were reviewed and analyzed. The orthopedic charge multiplier, the dollars of facility charge created by a single dollar of orthopedic professional charge, and orthopedic net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopedic surgeon, were calculated. A total of 36 patients were included in the study. The mean total charge for all patients was $144 939.35 ± $23 726.48 (range $109 002.71 to $227 290.20), and the average total revenue for all patients was $44 218.79 ± $12 352.97 (range $29 397.39 to $90,830.62). The mean orthopedic charge multiplier was 2.47 ± 1.32 (range 0.78-6.53), and the net revenue collection multiplier was 8.62 ± 10.69 (range, 1.20-57.80). The majority of charges and revenue related to care of patients undergoing PAO return to the hospital. The significant mean orthopedic charge multiplier for this procedure increases the value of the service and the surgeon to hospital profitability. This information can help shape the relationship between the hospital and the surgeon and create a firm platform to advocate for program advancement.

Appropriate Surgical Timing of Salter Innominate Osteotomy for Residual Acetabular Dysplasia in Children

BACKGROUND

Salter innominate osteotomy (SIO) provides favorable results for treating residual acetabular dysplasia in young children. In this study, we examined the midterm results of SIO according to the age at surgery to determine the optimal timing of this procedure.

METHODS

We retrospectively examined 50 hips of 42 patients (8 boys and 34 girls) with acetabular dysplasia who underwent SIO and were followed up until skeletal maturity. The center-edge angle (CEA) was measured based on the anteroposterior radiographs of the hip obtained before surgery, 5 weeks after surgery, and at the latest follow-up. Severin classification was evaluated at the latest follow-up. Patients were categorized into 3 groups according to age at surgery: younger than 7 years of age (group A), 7 to 8 years of age (group B), and 9 years of age or older (group C).

RESULTS

The mean preoperative CEA level of 0.9 degrees improved to 17.1 degrees postoperatively, which was increased to 28.1 degrees at the latest examination. Overall, 45 hips (90%) were classified as Severin I or II, with 96% in group A, 94% in group B, and 57% in group C. In group C, postoperative acetabular coverage was similar to that in the other groups (16.6 degrees in group A, 14.8 degrees in group B, and 18.1 degrees in group C), although the final outcome was unsatisfactory. The average improvement in CEA from postoperative to skeletal maturity was significantly smaller in group C than in the other groups (12.7 degrees in group A, 11.3 degrees in group B, and 3.0 degrees in group C).

CONCLUSIONS

SIO showed favorable outcomes with satisfactory acetabular coverage at skeletal maturity. However, satisfactory acetabular coverage could not be obtained in some older patients because of limited postoperative remodeling capacity and smaller secondary improvement of CEA. We recommend that SIO should be performed in patients aged 8 years or younger.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Application Value of Combined Diagnosis of Ultrasound, MRI, and X-Ray in Developmental Dysplasia of the Hip in Children

Objective

To explore the application value of the combined diagnosis of ultrasound, MRI, and X-ray in developmental dysplasia of the hip (DDH) in children.

Methods

Ninety children with suspected DDH admitted to our hospital from June 2017 to June 2020 were selected as the research objects to conduct a retrospective study. According to the age of the children, they were divided into a group with 0-6 months (group X), a group with 7-12 months (group Y), and a group older than 12 months (group Z), with 30 cases in each group. X-ray and high-frequency ultrasound were performed in all groups, and MRI examination was added to the children in groups Y and Z to compare the diagnostic value of the three imaging examinations in DDH children.

Results

No obvious differences in the general data and maternal risk factors were observed among the three groups (P < 0.05). The final comprehensive diagnostic results were taken as the gold standard, including 23 cases with acetabular dysplasia, 28 cases with subluxation of the femoral head, 31 cases with complete dislocation of the femoral head, and 8 non-DDH cases. The diagnostic accuracy of the three methods from high to low was MRI, high-frequency ultrasound, and X-ray, with obviously higher diagnostic accuracy of MRI than that of X-ray (P < 0.05). The ROC curves showed that the diagnostic efficacy from high to low was MRI + high-frequency ultrasound + X-ray, high-frequency ultrasound + X-ray, MRI, high-frequency ultrasound, and X-ray.

Conclusion

Ultrasound combined with X-ray has obvious advantages in the diagnosis of children at low months of age, while MRI has outstanding advantages in the diagnosis of children at high months of age. MRI combined with ultrasound and X-ray can significantly improve the diagnostic accuracy of DDH and provide objective data support for the clinical treatment of children.

Analysis of Factors Affecting Early Functional Recovery of Bernese Periacetabular Osteotomy

OBJECTIVES

To explore factors affecting the efficacy of Bernese periacetabular osteotomy for the treatment of hip dysplasia.

METHODS

A retrospective study was conducted on 44 patients with hip dysplasia who underwent Bernese periacetabular osteotomy with a modified Smith-Peterson approach between January 2017 and November 2019. Among them, 40 were women and four were men. The average age was 31.2 ± 9.4. Preoperative and postoperative imaging parameters were measured. The acetabular top tilt angle, lateral central edge angle, acetabular abduction angle, femoral head extrusion index, sphericity index of femoral head, Shenton line, Tonnis grade of osteoarthritis, joint congruency, p/a ratio, acetabular anteversion angle, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale scores, and modified Harris hip score (MHHS) were observed. MHHS were divided into three clinically relevant categories: poor (<70 points), good (70-85 points), and excellent (86-91 points). Patient demographic data, as well as preoperative and postoperative radiographic parameters, were subjected to univariate logistic regression analysis. Multiple regression analysis was used to determine factors influencing postoperative MHHS.

RESULTS

The follow-up time was 1.0-3.9 years after surgery, with an average of 1.6 years. By the last follow-up, MHHS increased from 70 points before surgery to 91 points after surgery (P < 0.001), WOMAC pain score decreased from 4 points before surgery to 0 points after surgery (P < 0.001). WOMAC functional score decreased (Preoperative: 18.0 [4.0]; Postoperative: 4.0 [0], P = 0.004). Six patients had sensory disturbance of the lateral femoral cutaneous nerve, four of which recovered completely during follow-up. No other complications related to surgical approach, osteotomy, acetabular displacement, acetabular fixation, and postoperative stage were found. There was no significant vascular, nerve, or visceral injuries in any of the patients. On multiple regression analysis, the probability of the postoperative modified Harris hip score of a hip joint with a preoperative lateral center edge angle ≥4.5° being classified as excellent was six times that of angles <4.5° (Exp[β]: 6.249, 95% CI: 1.03-37.85, P = 0.046). Regression analysis of other factors found no significant correlation with postoperative functional scores.

CONCLUSION

Overall functional scores post-PAO significantly improved, and pain symptoms were significantly reduced. Patients with a preoperative lateral center edge angle ≥4.5° had better joint function after surgery.

Costs of open, arthroscopic and combined surgery for developmental dysplasia of the hip

A variety of options exist for management of patients with developmental dysplasia of the hip (DDH). Most studies to date have focused on clinical outcomes; however, there are currently no data on comparative cost of these techniques. The purpose of this study was to evaluate in-hospital costs between patients managed with periacetabular osteotomy, hip arthroscopy or a combination for DDH. One hundred and nine patients were included: 35 PAO + HA, 32 PAO and 42 HA. There were no significant differences in the demographic parameters. Operative times were significantly different between groups with a mean of 52 min for PAO, 100 min for HA and 155 min for PAO + HA, (P < 0.001). Total direct medical costs were calculated and adjusted to nationally representative unit costs in 2017 inflation-adjusted dollars. Total in-hospital costs were significantly different between each of the three treatment groups. PAO + HA was the most expensive with a median of $21 852, followed by PAO with a median of $15 124, followed by HA with a median of $11 582 (P < 0.001). There was a significant difference between outpatient median costs of $11 385 compared with $24 320 for inpatients (P < 0.001). Procedures with greater complexity were more expensive. However, a change from outpatient to inpatient status with HA moved that group from the least expensive to similar to PAO and PAO + HA. These data provide an important complement to clinical outcomes reports as surgeons and policymakers aim to provide optimal value.

Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip combined with intertrochanteric fracture: a case report and literature review

BACKGROUND

Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip (DDH) is a complex procedure. Crowe type IV DDH combined with intertrochanteric frature is very rare.

CASE PRESENTATION

A 75-year-old patient suffering from left hip pain after a fall was sent to our hospital. Plain radiographs and computed tomography scans were used to diagnose this patient with DDH combined with an intertrochanteric fracture. We conducted a total hip arthroplasty using an S-rom prosthesis following subtrochanteric shortening osteotomy in this patient, after which steel wires were used to fix the intertrochanteric fracture. The patient did not suffer any significant intraoperative or postoperative complications, and treatment was sufficient to overcome lower leg abnormalities. The patient was encouraged to resume walking with support at 3 days post-surgery, and at 6-month postoperatively he had regained the majority of his original range of motion. At 10-month postoperatively, the intertrochanteric fracture and subtrochanteric osteotomy of left femur had healed effectively,and the patient's VAS and mHSS scores had improved significantly.

CONCLUSIONS

Total hip arthroplasty is an effective approach to treat patients suffering from Crowe type IV DDH combined with an intertrochanteric fracture, and can achieve satisfactory clinical outcomes.

Capsular arthroplasty for neglected developmental dysplasia of hip

INTRODUCTION

Treatment of developmental dysplasia of hip (DDH) diagnosed after 10 years of age is extremely difficult because of the soft tissue and bone deformities. In this study, we evaluated short-term results of a single-stage procedure performed with surgical hip dislocation, femoral shortening and capsular arthroplasty.

PATIENTS AND METHODS

A retrospective review of charts of five patients with DDH, older than 10 years, who underwent capsular arthroplasty at Ghurki Trust Teaching Hospital between 2013 and 2015 was performed. Post-operative functional evaluation was performed using modified McKay's scoring system and radiographic assessment using Severin's scoring method at a minimum of 2-year follow-up.

RESULTS

We present results of five patients (six hips) with a mean age of 18.16 years. All patients had limping gait and International Hip dysplasia Institute classification (IHDI) class 4 hip dislocation. Harris hip score showed a significant improvement (53.13 vs 84.16; p = 0.0001). Femoral shortening of 2-2.5 cm was done. Additional shelf procedure was required in one patient. This patient persistently has post-operative hip subluxation. All patients had good to excellent outcomes according to McKay classification. Post-operative Severin classification was 1A in all patients. No case of avascular necrosis of the femoral head was noted during the follow-up.

CONCLUSION

Capsular arthroplasty with subtrochanteric shortening is a useful procedure for neglected cases of DDH in patients older than 10 years.

Can Salter osteotomy correct late diagnosed hip dysplasia: A retrospective evaluation of 49 hips after 6.7 years?

BACKGROUND

Surgical treatment of late diagnosed development dysplasia of the hip (DDH) remains challenging with several methods being described. We therefore retrospectively evaluated the outcome of Salter innominate osteotomy (SIO) in patients with fully-grown bone, to evaluate whether this surgical procedure allows sufficient acetabular correction.

MATERIAL AND METHODS

Between 2004-2012 SIO had been performed in 45 patients (49 hips) with late diagnosed DDH. The evaluation included pre- and postoperative radiographs (n=49), the complication rate (n=49) and the clinical outcome (WOMAC, HHS, UCLA) (n=34).

RESULTS

Mean age at surgery was 27.6 (16-51) with a follow-up of 6.7±2.7 (0.9-11.0) years. Radiologically, a good acetabular correction with a significant improvement of the Center Edge angle (15.4° to 34.9°), sharps angle (45.7° to 32.0°) and migration percentage (33.2% to 14.4%) (p<0.001) was found. Clinical results revealed a WOMAC of 13.9±13.3, UCLA of 7.8±2.1 and HHS of 85.0±11.8. Complications were noted for 10 patients (20%) with 7 (14%) requiring revision.

CONCLUSION

The results demonstrated that SIO achieved a satisfying acetabular correction and good clinical results in late diagnosed DDH. It therefore might be an option in some cases, although periacetabular osteotomy techniques are currently preferable used as they allow a wider range of acetabular correction.

LEVEL OF EVIDENCE

IV, retrospective observational study.