Periacetabular Osteotomy in Athletes With Symptomatic Hip Dysplasia Allows for Participation in Low-, Moderate-, and High-Impact Sports, With Greater Than 70% Return to Sport for Competitive Athletes: A Systematic Review

Predicting early return to sport after periacetabular osteotomy : a machine-learning approach

Aims

Periacetabular osteotomy (PAO) is the primary surgical treatment for developmental dysplasia of the hip (DDH), providing considerable pain relief and improved joint function. Return to sport (RTS) is a key outcome for young, active patients. This study aimed to identify preoperative predictors of RTS timing and develop a machine-learning-based prediction model to optimize patient counselling.

Methods

This retrospective analysis of prospectively collected data included 235 patients who underwent PAO between January 2019 and December 2023. Preoperative variables, including demographic, functional, and psychological assessments, were analyzed. RTS was assessed at three, six, and 12 months postoperatively. Logistic regression with recursive feature elimination and a conditional inference tree (ctree) model were used to identify predictors of RTS.

Results

At three months, 102 patients (43%) had returned to sports, increasing to 182 (77%) at six months and 223 (95%) at 12 months. Key predictors of early RTS included the minimally invasive surgical approach, higher preoperative physical activity (≥ two sessions/week), lower anxiety scores, and higher Hip disability and Osteoarthritis Outcome Score (HOOS) pain scores. Male sex and older age were associated with delayed RTS. The ctree model stratified patients based on their likelihood of early RTS, providing an individualized prognosis.

Conclusion

PAO enables early RTS in over 90% of patients within the first year. The use of a minimally invasive approach allowing immediate active hip flexion, higher preoperative activity levels, and lower anxiety scores significantly improves RTS timing. The machine-learning model provides precise, individualized RTS predictions, offering a valuable tool for patient counselling and rehabilitation planning.

Activity Level Maintenance at 10-Year Minimum Follow-up Among Active Patients Undergoing Periacetabular Osteotomy

BACKGROUND

Periacetabular osteotomy (PAO) can treat pain, dysfunction, and decreased activity secondary to hip dysplasia. Patients' pre- and postoperative activity can be measured using the University of California Los Angeles (UCLA) activity score, a validated questionnaire. Understanding return to and maintenance of activity at long-term follow-up after PAO is a priority for active patients.

PURPOSE

To provide long-term follow-up of a previously published cohort that will help examine maintenance of activity after PAO, guide treatment decision-making, and inform patient counseling.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This prospective longitudinal cohort consisted of patients undergoing PAO between 2006 and 2013. Inclusion criteria included lateral center-edge angle <25°, highly active individuals (UCLA score ≥7), and 10-year minimum follow-up. UCLA, modified Harris Hip Score, and Western Ontario and McMaster Universities Osteoarthritis Index scores and descriptive information were obtained. P values <.05 were considered significant.

RESULTS

The cohort included 68 hips (86.1% follow-up; 61 patients), with 7 (10.3%) having additional surgery (4 total hip arthroplasty, 3 osteochondroplasty) at a mean 9.8 years (range, 6.0-15.8). Reoperated hips were excluded; the remaining 61 were analyzed. Mean age at PAO was 24.7 years (range, 14.7-44.8) with female predominance (74.1%). Mean follow-up was 12.5 years (range, 10.2-17.1). Of 61 hips, 54 (88.5%) either maintained high activity with a UCLA score ≥7 (n = 43; 70.5%) or had lower activity unrelated to the surgical hip (n = 11; 18.0%). When compared with preoperative values, the mean UCLA score decreased from 8.9 to 8.1 (P = .009); the modified Harris Hip Score improved from 64.6 to 88.8 (P < .001), with 49 of 61 hips (80.3%) achieving the minimal clinically important difference; and the Western Ontario and McMaster Universities Osteoarthritis Index pain score improved from 68.2 to 89.0 (P < .001), with 35 of 51 hips (68.7%) achieving the minimal clinically important difference. Hips with PAO before age 25 years were more likely to be in higher activity groups at follow-up (P = .030).

CONCLUSION

Patients with hip dysplasia can be treated with PAO to help maintain activity and preserve the native hip. At long-term follow-up (mean, 12.5 years), 54 of 68 (79.4%) hips did not have additional surgery and either remained in the high activity group or had lower activity levels unrelated to the hip. PAO appears to be a durable hip preservation technique at 12.5-year follow-up for highly active patients.

Evaluating Return to Sports Following Total Hip Arthoplasty With Custom Stems in Professional and Recreational Table Tennis Players

Background

Table tennis players execute short explosive movements, along with continuous hip flexion, abduction, and rotation, increasing their risk of injury. Previous studies reported a rate of return to sports (RTS) of 20% to 80% in athletes following total hip arthroplasty (THA). There are no studies reporting RTS in table tennis players following THA.

Purpose

To evaluate the clinical outcomes and RTS following custom THA in professional, ex-professional, and recreational table tennis players.

Study design

Case series; Level of evidence, 4.

Methods

Patients who underwent primary THA between April 2013 and January 2022 were retrospectively reviewed (n = 2977). Table tennis players of any level that received a custom femoral stem were included in the study (N = 17). At a minimum follow-up of 2 years, all players were assessed using the Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and the University of California Los Angeles (UCLA) activity score, as well as with a sports-specific questionnaire that included questions related to their table tennis practice. Descriptive statistics, including medians and interquartile ranges, were used to summarize the data.

Results

All 17 players (22 hips) were available at ≥2 years, of which 3 were professional (5 hips), 4 were ex-professional (6 hips), and 10 were recreational (11 hips). The median OHS was 44.0 (IQR, 44.0-48.0) in professional, 48.0 (IQR, 48.0-48.0) in ex-professional, and 48.0 (IQR, 45.0-48.0) in recreational players. The median FJS was 92.0 (IQR, 88.0-98.0) in professional, 98.0 (IQR, 98.0-98.0) in ex-professional, and 100.0 (IQR, 93.0-100.0) in recreational players. The median UCLA activity score was 10.0 (IQR, 9.0-10.0) in professional, 9.0 (IQR, 9.0-9.8) in ex-professional, and 8.0 (IQR, 5.5-9.0) in recreational players. The rate of RTS was 100% for professional and ex-professional players, and 80% for recreational players. The hours played before onset of symptoms was higher than following surgery for professional (30.0 [IQR, 25.0-30.0] vs 20.0 [IQR, 16.0-22.5] h/week) and ex-professional players (19.5 [IQR, 11.0-29.3] vs 3.0 [IQR, 2.0-5.5] h/week), while it was constant for recreational players (4.0 [IQR, 2.3-4.0] vs 4.0 [IQR, 3.8-4.5] h/week).

Conclusion

Our retrospective analysis demonstrated that at a minimum follow-up of 2 years THA using custom stems provided good to excellent clinical outcomes in professional, ex-professional, and recreational table tennis players. All professional and ex-professional players, as well as 80% of recreational players, were able to return to play table tennis, although both professional and ex-professional players reduced their number of hours of play compared with before surgery. These findings could be used to help set expectations for table tennis players who are scheduled to undergo THA.

Favorable Early Outcomes and High Clinical Benefit Achievement Rate With Concomitant Hip Arthroscopy and Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip

PURPOSE

To report minimum 2-year follow-up patient-reported outcomes (PROs), clinical benefit, and survivorship in patients who underwent concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the surgical treatment of the developmental dysplasia of the hip (DDH).

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent hip arthroscopy with concomitant PAO between December 2015 and September 2022. Patients with baseline and minimum 2-year PROs were included. Exclusion criteria included those who underwent an isolated PAO or had a history of ipsilateral prior surgery. The PROs collected were Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The minimal clinically important difference (MCID) was reported. Survivorship was defined as nonconversion to total hip arthroplasty (THA).

RESULTS

Thirty patients were included (29 females and 1 male). The average age at the time of surgery was 27.48 ± 8.57 years, and the average body mass index was 23.97 ± 4.05. Further, 86.67%, 73.33%, and 100% underwent labral treatment, femoroplasty, and capsular closure, respectively. The preoperative lateral center-edge angle increased from 17.07° ± 4.40 to 33.24° ± 3.40 postoperatively (P < .001). At a minimum of 2-year follow-up, all PROs significantly improved from baseline (P < .001): HOS-ADL improved from 62.68 ± 16.18 to 91.66 ± 15.13, HOS-SSS from 38.96 ± 21.39 to 86.82 ± 19.56. Moreover, 90% and 93.33% achieved MCID for the HOS-ADL and HOS-SSS, respectively. No conversions to THA were reported.

CONCLUSIONS

At a minimum 2-year follow-up, the surgical management of DDH with PAO and concomitant hip arthroscopy demonstrated significant improvement in all PROs collected, with a high achievement rate for the MCID, and survivorship of 100%. These results suggest that, at short-term follow-up, this surgical approach seems to be safe and effective.

LEVEL OF EVIDENCE

Level IV, retrospective case-series.

Periacetabular osteotomy with and without concomitant arthroscopy: a systematic review of evidence on post-operative activity levels and return to sport

The purpose of this systematic review is to (i) compare post-operative activity levels after periacetabular osteotomy (PAO) versus PAO + HA (concomitant PAO and hip arthroscopy) using patient-reported outcomes that specifically assess activity and sports participation [Hip Disability and Osteoarthritis Outcome Score-Sport and Recreation subscale (HOOS-SR), University of California Los Angeles (UCLA) activity score, Hip Outcome Score-Sport-Specific Subscale (HOS-SSS)] and (ii) compare post-operative return to sport (RTS) data between PAO and PAO + HA groups. A systematic review of literature was conducted on 1 June 2023, utilizing PubMed, Cochrane and Embase (OVID). Articles were screened for inclusion using specific inclusion and exclusion criteria. Twenty-six out of 1610 articles met all inclusion criteria, without meeting any exclusion criteria. In the 12 studies containing only subjects who underwent PAO alone, 11 demonstrated an average score improvement in UCLA, HOOS-SR or HOS-SSS post-operatively (P < 0.05). In the three studies containing subjects who underwent PAO with concomitant HA, significant improvements were seen in the HOS-SS and UCLA scores (P < 0.05). In the five studies that directly compared UCLA, HOS-SSS and HOOS-SSS scores between PAO groups and PAO + HA groups, all demonstrated statistically significant improvement post-operatively (P < 0.05). The rate of RTS ranged from 63% to 90.8% among PAO studies and was found to be 81% in the single PAO + HA study that assessed RTS. When performed in patients with intra-articular pathology, concomitant PAO + HA may provide similar sport-related outcomes to PAO alone in patients without intra-articular pathology.

Noninterportal capsulotomy of hip arthroscopy showed improved outcomes in borderline hip dysplasia: A retrospective study with minimum 2-year follow-up

PURPOSE

The present study aimed to evaluate the functional outcomes of hip arthroscopy using a noninterportal capsulotomy technique to address labral tears in patients with borderline hip dysplasia (BHD). Additionally, we also compared these outcomes with those of patients with BHD who underwent the standard repaired interportal capsulotomy (RIPC) arthroscopy.

METHODS

Data from patients with BHD were retrieved from a database of patients who underwent arthroscopic hip surgery with noninterportal capsulotomy or RIPC to treat labral tears between January 2014 and December 2020. Data collected included both pre- and postoperative patient-reported outcomes (PROs).

RESULTS

A total of 58 patients (noninterportal capsulotomy, n = 37; RIPC, n = 21) with a mean age of 30.9 ± 5.6 and 28.6 ± 5.5 years, respectively, met the inclusion criteria. All of the patients underwent a minimal 2-year follow-up. The mean lateral centre-edge angle was 23.3 ± 1.2° in the noninterportal capsulotomy group and 23.7 ± 1.0° in the RIPC group, with no significant difference. The PROs improved from the preoperative to the latest follow-up, with a p < 0.001. There were no differences between the groups.

CONCLUSION

Using strict patient selection criteria, hip arthroscopy with noninterportal capsulotomy demonstrated significant pre- to postoperative improvements in patients with BHD and achieved results comparable to those from hip arthroscopy with RIPC.

LEVEL OF EVIDENCE

Level III.

Excellent Clinical Outcomes and Return to Dance of 6 Active, Professional Ballet Dancers Aged Younger Than 40 Years at Total Hip Arthroplasty Through Direct Anterior Approach With a Custom Stem: A Case Report

OBJECTIVE

To report clinical outcomes and return to dance after total hip arthroplasty (THA) by direct anterior approach (DAA) using custom stems in young, active, professional ballet dancers.

DESIGN

Case report.

SETTING

Tertiary.

PATIENTS

Six active, professional ballet dancers younger than 40 years who intended to resume ballet after THA.

INTERVENTIONS

Primary THA by muscle-sparing DAA using custom stems.

MAIN OUTCOME MEASURES

Return to dance, Oxford hip score (OHS), forgotten joint score (FJS), and satisfaction with surgery and pain using numeric rating scale (NRS). CTs were acquired 2 days after surgery to assess implant position. Descriptive statistics were used.

RESULTS

The cohort comprised 4 women and 2 men aged 15 to 39 years. At 2.5 to 5.1 years of follow-up, all patients returned to professional ballet dance. Time to return to dance was 3 to 4 months for 3 patients and 12 to 14 months for 3 patients. Clinical scores were excellent, except for FJS in 1 patient who had considerable pain at her spine and ipsilateral foot. All patients were satisfied with surgery (NRS = 10). There were no complications, reoperations, or revisions. CTs confirmed that stems and cups were correctly positioned.

CONCLUSIONS

All 6 young, active, professional ballet dancers who underwent THA by muscle-sparing DAA using custom stems returned to professional ballet dance and were completely satisfied with surgery. At >2 years of follow-up, 5 patients had excellent clinical outcomes and reported their dancing level to be as expected or better, whereas 1 patient had a lower FJS and was unable to return to her expected dance level.

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision

The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.

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.