A modified periacetabular osteotomy with use of the transtrochanteric exposure

The effect of antifibrinolytic agents in periacetabular osteotomy: A systematic review and meta-analysis

BACKGROUND

Periacetabular osteotomy (PAO) is a major hip preservation surgery for developmental dysplasia of the hip. It is inevitably associated with significant blood loss, so it requires frequent transfusions and could be a cause of perioperative morbidity. However, to date, a large number of studies has not evaluated the effect of antifibrinolytic agents in PAO. Therefore we performed a systematic review and meta-analysis to assess if antifibrinolytics would be effective in reducing blood loss and transfusion rate after PAO surgery.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 4, 2020, that investigated the effect of antifibrinolytic agents in PAO. A pooled analysis was designed to identify differences between antifibrinolytic and control groups focusing on blood loss, transfusion, operation time, postoperative venous thromboembolism (VTE), and length of hospital stay.

RESULTS

We included five studies involving 507 patients (antifibrinolytic group: 256; control group: 251). The pooled analysis showed that the control group had a greater total estimated blood loss (EBL) than the antifibrinolytic group (mean difference [MD]=-257.60mL, 95% confidence interval [CI] -389.68 to -125.53, p=0.0001), but there were no statistical differences in intraoperative EBL (MD=-46.46mL, 95% CI: -192.57 to 99.64, p=0.53). The allogenic transfusion rate was higher in the control group than in the antifibrinolytic group (odds ratio [OR] 0.21, 95% CI: 0.10-0.43, p<0.0001), but there was no difference in the autogenic transfusion rate (OR 0.35, 95% CI: 0.09-1.43, p=0.14). The pooled result showed no difference in operation time (MD=9.13min, 95% CI: -8.54 to 26.80, p=0.31). For the VTE rate, a pooled analysis was not conducted due to the lack of data. The length of hospital stay showed no differences (MD=-0.51 days, 95% CI: -1.17 to 0.16, p=0.13).

CONCLUSIONS

Antifibrinolytic use in PAO has positive effects in terms of reduced total EBL and allogenic transfusion rate.

LEVEL OF EVIDENCE

III; meta-analysis.

Hip survivorship following the Bernese periacetabular osteotomy for the treatment of acetabular dysplasia: A systematic review and meta-analysis

INTRODUCTION

The Bernese periacetabular osteotomy (PAO) is a popular joint-preservation technique aimed at addressing the structural and biomechanical abnormalities associated with acetabular dysplasia. However, the prognostic factors and long-term survivorship of the native hip, with failure defined as conversion to total hip arthroplasty (THA), is poorly understood. Our study aims to address the following: (1) What is the estimated duration of survival of the native hip post-PAO, (2) What are some prognostic factors of functional outcome and (3) What is the complication rate and complications associated with PAO.

HYPOTHESIS

The Bernese PAO is able to result in favourable mid- to long-term outcomes conditional on a stringent patient selection criteria.

MATERIALS AND METHODS

A systematic review was performed using the PRISMA guidelines. All studies that reported on the outcomes of isolated Bernese PAO for the treatment of acetabular dysplasia were included.

RESULTS

A total of 24 studies (3471 patients, 3655 hips) were included at a mean follow-up duration of 54.2months (range: 1-336months). In total, 208 hips (6.03%; 95% CI: 5.25-6.94%) converted to THA at a mean duration of 4.71years (range: 1-240months). Univariate analysis identified advanced age beyond a follow-up duration of 6years (p=0.001) and preoperative Tönnis grade 2 and above (p<0.001) to be the most significant negative prognostic factors. Beyond a follow-up duration of 2years, intraoperative fluoroscopy proved to be a significant positive prognostic factor (p<0.001). Indications for PAO, obesity and gender were not found to be significant predictors of failure. Our study found the complication rate to be 23.5% (95% CI: 21.6-25.6%). The most common complications detailed are transient lateral femoral cutaneous nerve dysesthesia (8.24%; 95% CI: 7.02-9.65%), stress fracture (5.28%; 95% CI: 4.31-6.89%) and the delayed union, non-union or pseudoarthrosis of the ramus not necessitating surgical correction (3.73%, 95% CI: 2.93-4.75%).

DISCUSSION

PAO alters the natural history of the dysplastic hip with a 10- and 20-year survivorship of approximately 75.9% and 36.5% of patients respectively. The ideal patient should be below 40years old, with a preoperative Tönnis grade of 0 or 1. Intraoperative fluoroscopy is able to guide a better precision when re-orientating the acetabulum.

LEVEL OF EVIDENCE

IV; systematic review and meta-analysis.

Periacetabular osteotomy vs. total hip arthroplasty in young active patients with dysplastic hip: Systematic review and meta-analysis

BACKGROUND

In young active patients with hip dysplasia, choosing between periacetabular osteotomy (PAO) and total hip arthroplasty (THA) is challenging.

MATERIALS AND METHODS

We systematically searched Medline, Embase, and Cochrane Library for studies published until October 10, 2019, comparing PAO and THA in patients with dysplastic hip. We compared postoperative complications' incidences, end-stage revisions, and clinical scores.

RESULTS

Five studies with 431 hips (PAO: 235; THA: 196) were included. The incidence of overall and major complications was not different between groups (PAO: OR 2.14; 95% CI, 0.58-7.96; p=0.26; follow-up, 4-7.8 years; THA: OR 2.56; 95% CI, 0.60-10.98; p=0.21; follow-up, 4-7.8 years). There was also no difference in end-stage revision (OR 0.95; 95% CI, 0.33-2.79; p=0.93; follow-up, 4-7.8 years). The standard mean of Western Ontario McMasters Universities (WOMAC) pain score was higher in the THA than in the PAO group (standardized mean difference [SMD] -0.57; 95% CI, -0.93--0.21; p=0.002; follow-up, 4-5.5 years); however, the WOMAC functional score did not differ significantly between groups (SMD -0.16; 95% CI, -1.29-0.97; p=0.78; follow-up, 4-5.5 years). The standard mean UCLA activity index was higher in the PAO than in the THA group (SMD 0.28; 95% CI, 0.02-0.53; p=0.03; follow-up, 5.9-7.3 years).

CONCLUSIONS

The incidence of postoperative complications and revision surgery was not different between THA and PAO groups. However, postoperative pain was less in the THA group and the activity score was higher in the PAO group in the follow-up periods.

LEVEL OF EVIDENCE

III; meta-analysis.

Complications and outcome after periacetabular osteotomy - influence of surgical approach

BACKGROUND

Bernese periacetabular osteotomy (PAO) was introduced by Ganz as a novel surgical technique for hip dysplasia with a congruent hip to reorient the acetabulum in skeletally mature patients. The PAO through a modified Smith-Petersen (Iliofemoral) approach, has been subject to many modifications in order to avoid complications and to minimise risks for failure.

AIM

The aim of this review was to report on the complication rates, functional and radiological outcomes in relation to surgical approaches.

METHODS

A search of NICE healthcare database advanced search, was conducted from the year of inception to May 2018. We included studies that reported complications of PAO. Data extracted from case series was analysed to detect the incidence of complications, relation to surgical approach and temporal trend of complications.

RESULTS

40 studies including 4070 hips with a mean age of 29 years and a mean follow-up of 52.8 month, were analysed. Outcome measures demonstrated good to excellent outcome in 82%. Higher rates of LFCN and sciatic nerve injuries were found to be associated with the ilioinguinal and the 2-incision approach. Minimally invasive (MIS) modified Smith-Petersen (MSP), minimally invasive trans-sartorial and trans-trochanteric approaches were not reported to be associated with any major wound complications. Radiological correction achieved with a mean improvement in acetabular inclination of 17.90 (range 4.5-40), anterior centre-edge correction 25.40 (range 10-51), lateral centre-edge correction 23.30 (range 15-44.6) and medial translation of 6 mm (range 3.2-10).

CONCLUSIONS

The complication rates seem to be lower in this current review (7%) as compared to the previous review performed by Clohisy et al. (6-37%). The MIS trans-sartorial/MIS MSP and intertrochanteric approaches are associated with an even reduced complications rates. This review enables favouring the minimally invasive approaches with regard to reducing nerve injury and wound complications.

Reliability of computer-assisted periacetabular osteotomy using a minimally invasive approach

BACKGROUND

Periacetabular osteotomy (PAO) is the treatment of choice for younger patients with developmental hip dysplasia. The procedure aims to normalize the joint configuration, reduce the peak-pressure, and delay the development of osteoarthritis. The procedure is technically demanding and no previous study has validated the use of computer navigation with a minimally invasive transsartorial approach.

METHODS

Computer-assisted PAO was performed on ten patients. Patients underwent pre- and postoperative computed tomography (CT) scanning with a standardized protocol. Preoperative preparation consisted of outlining the lunate surface and segmenting the pelvis and femur from CT data. The Biomechanical Guidance System was used intra-operatively to automatically calculate diagnostic angles and peak-pressure measurements. Manual diagnostic angle measurements were performed based on pre- and postoperative CT. Differences in angle measurements were investigated with summary statistics, intraclass correlation coefficient, and Bland-Altman plots. The percentage postoperative change in peak-pressure was calculated.

RESULTS

Intra-operative reported angle measurements show a good agreement with manual angle measurements with intraclass correlation coefficient between 0.94 and 0.98. Computer navigation reported angle measurements were significantly higher for the posterior sector angle ([Formula: see text], [Formula: see text]) and the acetabular anteversion angle ([Formula: see text], [Formula: see text]). No significant difference was found for the center-edge ([Formula: see text]), acetabular index ([Formula: see text]), and anterior sector angle ([Formula: see text]). Peak-pressure after PAO decreased by a mean of 13% and was significantly different ([Formula: see text]).

CONCLUSIONS

We found that computer navigation can reliably be used with a minimally invasive transsartorial approach PAO. Angle measurements generally agree with manual measurements and peak-pressure was shown to decrease postoperatively. With further development, the system will become a valuable tool in the operating room for both experienced and less experienced surgeons performing PAO. Further studies with a larger cohort and follow-up will allow us to investigate the association with peak-pressure and postoperative outcome and pave the way to clinical introduction.

Cirrhosis patients have increased risk of complications after hip or knee arthroplasty

BACKGROUND AND PURPOSE

The risk of complications in cirrhosis patients after orthopedic surgery is unclear. We examined this risk after total hip arthroplasty (THA) or total knee arthroplasty (TKA).

PATIENTS AND METHODS

Using Danish healthcare registries, we identified all Danish residents who underwent a THA or TKA for primary osteoarthritis in the period 1995-2011. We compared the risk of complications in patients with or without cirrhosis.

RESULTS

The surgical technique was similar in the 363 cirrhosis patients and in 109,159 reference patients, but cirrhosis patients were more likely to have been under general anesthesia (34% vs. 23%), were younger (median age 66 vs. 69 years), had a predominance of males (54% vs. 41%), had more comorbidity, and had had more hospitalizations preoperatively. Their risk of intraoperative complications was similar to that for reference patients (2.5% vs. 2.0%), but they had greater risk of dying during hospitalization or within 30 days of discharge (1.4% vs. 0.4%; aOR = 3.9, 95% CI: 1.5-10); greater risk of postoperative transfer to an intensive care unit (0.6% vs. 0.06%; aOR = 5.8, CI: 1.3-25) or a medical department (4.4% vs. 2.5%; aOR = 1.7, CI: 0.99-2.9); greater risk of readmission within 30 days of discharge (15% vs. 8%; aOR = 1.8, CI: 1.3-2.4); and greater risk of deep prosthetic infection (3.1% vs. 1.4%) or revision (3.7% vs. 1.7%) within 1 year. The chance of having an uncomplicated procedure was 81.0% (CI: 76.6-85.0) for cirrhosis patients and 90.0% (CI: 89.6-90.0) for reference patients.

INTERPRETATION

Cirrhosis patients had a higher risk of postoperative complications after THA or TKA for primary osteoarthritis than patients without cirrhosis. This may have implications for orthopedic surgeons' postoperative management of cirrhosis patients, and preoperative assessment by a hepatologist may be indicated.

Early weight-bearing after periacetabular osteotomy leads to a high incidence of postoperative pelvic fractures

BACKGROUND

It has not been shown whether accelerated rehabilitation following periacetabular osteotomy (PAO) is effective for early recovery. The purpose of this retrospective study was to compare complication rates in patients with standard and accelerated rehabilitation protocols who underwent PAO.

METHODS

Between January 2002 and August 2011, patients with a lateral center-edge (CE) angle of < 20°, showing good joint congruency with the hip in abduction, pre- or early stage of osteoarthritis, and age younger than 60 years were included in this study. We evaluated 156 hips in 138 patients, with a mean age at the time of surgery of 30 years. Full weight-bearing with two crutches started 2 months postoperatively in 73 patients (80 hips) with the standard rehabilitation protocol. In 65 patients (76 hips) with the accelerated rehabilitation protocol, postoperative strengthening of the hip, thigh and core musculature was begun on the day of surgery as tolerated. The exercise program included active hip range of motion, and gentle isometric hamstring and quadriceps muscle sets; these exercises were performed for 30 minutes in the morning and 30 minutes in the afternoon with a physical therapist every weekday for 6 weeks. Full weight-bearing with two axillary crutches started on the day of surgery as tolerated. Complications were evaluated for 2 years.

RESULTS

The clinical results at the time of follow-up were similar in the two groups. The average periods between the osteotomy and full-weight-bearing walking without support were 4.2 months and 6.9 months in patients with the accelerated and standard rehabilitation protocols (P < 0.001), indicating that the accelerated rehabilitation protocol could achieve earlier recovery of patients. However, postoperative fractures of the ischial ramus and posterior column of the pelvis were more frequently found in patients with the accelerated rehabilitation protocol (8/76) than in those with the standard rehabilitation protocol (1/80) (P = 0.013).

CONCLUSION

The accelerated rehabilitation protocol seems to have advantages for early muscle recovery in patients undergoing PAO; however, postoperative pelvic fracture rates were unacceptably high in patients with this protocol.

Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH

BACKGROUND

Although periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH) provides conceptual advantages compared with other osteotomies and reportedly is associated with joint survivorship of 60% at 20 years, the beneficial effect of proper acetabular reorientation with concomitant arthrotomy and creation of femoral head-neck offset on 10-year hip survivorship remains unclear.

QUESTIONS/PURPOSES

We asked the following questions: (1) Does the 10-year survivorship of the hip after PAO improve with proper acetabular reorientation and a spherical femoral head; (2) does the Merle d'Aubigné-Postel score improve; (3) can the progression of osteoarthritis (OA) be slowed; and (4) what factors predict conversion to THA, progression of OA, or a Merle d'Aubigné-Postel score less than 15 points?

METHODS

We retrospectively reviewed 147 patients who underwent 165 PAOs for DDH with two matched groups: Group I (proper reorientation and spherical femoral head) and Group II (improper reorientation and aspherical femoral head). We compared the Kaplan-Meier survivorship, Merle d'Aubigné-Postel scores, and progression of OA in both groups. A Cox regression analysis (end points: THA, OA progression, or Merle d'Aubigné-Postel score less than 15) was performed to detect factors predicting failure. The minimum followup was 10 years (median, 11 years; range, 10-14 years).

RESULTS

An increased survivorship was found in Group I. The Merle d'Aubigné-Postel score did not differ. Progression of OA in Group I was slower than in Group II. Factors predicting failure included greater age, lower preoperative Merle d'Aubigné-Postel score, and the presence of a Trendelenburg sign, aspherical head, OA, subluxation, postoperative acetabular retroversion, excessive acetabular anteversion, and undercoverage.

CONCLUSIONS

Proper acetabular reorientation and the creation of a spherical femoral head improve long-term survivorship and decelerate OA progression in patients with DDH.

Rotational acetabular osteotomy through an Ollier lateral U approach for early-stage osteoarthritis secondary to acetabular dysplasia

OBJECTIVE

To explore the surgical technique and mid-term results of rotational acetabular osteotomy for early -stage osteoarthritis secondary to acetabular dysplasia.

METHODS

Rotational acetabular osteotomies were performed on 14 hips of 12 patients from May 2000 to May 2006 and the patients followed up. All patients were female and their average age was 28.9 years (range, 13-46 years) at the time of surgery. The mean duration of clinical and roentgenographic follow-up was 6.0 years (range, 3.1-9.1 years). The lateral center-edge (CE) angle, acetabular roof angle and head lateralization index were measured on radiographs taken preoperatively, postoperatively and at the time of final follow-up. Clinical follow-up included use of the Harris hip score. The acetabular osteotomies were performed through an Ollier lateral U transtrochanteric approach and postoperative traction and cast immobilization were not used.

RESULTS

All patients had satisfactory pain relief. The mean preoperative Harris score was 72 points; this had improved to a mean of 91 points at the time of last follow-up (P < 0.05). The mean CE angle improved from 0.9° preoperatively to 27° postoperatively (P < 0.05), the mean acetabular roof angle from 29° to 5° (P < 0.05) and the mean head lateralization index from 0.68 to 0.65. Solid bone-to-bone healing of the osteotomy sites and great trochanters occurred in all patients.

CONCLUSIONS

Rotational acetabular osteotomy through an Ollier lateral U approach, which provides wide exposure and technical ease, for early-stage osteoarthritis secondary to acetabular dysplasia can relieve pain and delay the appearance or reduce the severity of osteoarthritis. Satisfactory mid-term results can be obtained.

Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia

Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term.

We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis.

Comparison of periacetabular osteotomy and total hip replacement in the same patient

We evaluated 31 patients with bilateral dysplastic hips who had undergone periacetabular osteotomy for early (Tönnis grade 0 or 1) or moderate (Tönnis grade 2) osteoarthritis in one hip and total hip replacement for advanced (Tönnis grade 3) osteoarthritis in the other. At a mean follow-up of 5.5 years (2 to 9) after periacetabular osteotomy and 6.7 years (3 to 10) after total hip replacement, there was no difference in the functional outcome in hips undergoing osteotomy for early or moderate osteoarthritis and those with a total hip replacement, as determined by the Merle d’Aubigné and Postel score and the Western Ontario and McMaster Universities osteoarthritis index. More patients preferred the spherical periacetabular osteotomy to total hip replacement (53% vs 23%; p = 0.029). Osteoarthritis secondary to hip dysplasia is often progressive. Given the results, timely correction of dysplasia by periacetabular osteotomy should be considered whenever possible in young patients since this could produce a favourable outcome which is comparable with that of total hip replacement.

Capsular and pericapsular contributions to acetabular and femoral head perfusion

BACKGROUND

Capsular and pericapsular vessels are believed to contribute to acetabular and femoral head perfusion, but, to our knowledge, there is no anatomic study to support this theory. The purpose of this study was to describe the vascular anatomy of the hip with particular reference to the contributions of the capsular and pericapsular vessels.

METHODS

Twenty fresh cadavers were dissected twenty-four hours after intra-arterial injection of colored silicone. The arteries supplying the hip were followed by careful dissection from their origins outside the pelvis to their terminal branches. Particular attention was paid to the vessels traveling between the acetabulum and the capsule and the femoral head.

RESULTS

In all twenty specimens, the hip capsule received blood supply from the superior and inferior gluteal arteries proximally and from the medial and lateral femoral circumflex arteries distally. The contributory vessels entered the capsule peripherally and superficially. The circumflex arteries supplied the anterior capsule. The gluteal arteries supplied the posterior and posterosuperior aspect of the hip capsule, augmented by contributions from the circumflex arteries. Variable anastomoses were found between the gluteal and femoral systems on the capsular surface beneath the gluteus minimus and short hip external rotators. The medial femoral circumflex artery provided the dominant blood supply to the femoral head in eighteen specimens, and the inferior gluteal artery provided the dominant supply in two specimens.

CONCLUSIONS

Capsular and pericapsular vessels that contribute to the blood supply of the acetabulum run on the posterior and posterolateral surface of the capsule. The dominant blood supply to the femoral head comes from vessels that approach the joint posteriorly and penetrate the joint near the femoral attachment of the capsule.

Mean 20-year followup of Bernese periacetabular osteotomy

The goal of the Bernese periacetabular osteotomy is to correct the deficient acetabular coverage in hips with developmental dysplasia to prevent secondary osteoarthrosis. We determined the 20-year survivorship of symptomatic patients treated with this procedure, determined the clinical and radiographic outcomes of the surviving hips, and identified factors predicting poor outcome. We retrospectively evaluated the first 63 patients (75 hips) who underwent periacetabular osteotomy at the institution where this technique was developed. The mean age of the patients at surgery was 29 years (range, 13-56 years), and preoperatively 24% presented with advanced grades of osteoarthritis. Four patients (five hips) were lost to followup and one patient (two hips) died. The remaining 58 patients (68 hips) were followed for a minimum of 19 years (mean, 20.4 years; range, 19-23 years) and 41 hips (60%) were preserved at last followup. The overall mean Merle d'Aubigné and Postel score decreased in comparison to the 10-year value and was similar to the preoperative score. We observed no major changes in any of the radiographic parameters during the 20-year postoperative period except the osteoarthritis score. We identified six factors predicting poor outcome: age at surgery, preoperative Merle d'Aubigné and Postel score, positive anterior impingement test, limp, osteoarthrosis grade, and the postoperative extrusion index. Periacetabular osteotomy is an effective technique for treating symptomatic developmental dysplasia of the hip and can maintain the natural hip at least 19 years in selected patients.

LEVEL OF EVIDENCE

Level III, prognostic study.

Long-term health-related quality of life after surgery for adolescent idiopathic scoliosis and spondylolisthesis

BACKGROUND

The aim of surgical treatment for adolescent idiopathic scoliosis is primarily to prevent progression and secondarily to correct the deformity, whereas the goal of surgical treatment of pediatric spondylolisthesis is mainly to relieve pain and, in patients with a high-grade slip, to prevent progression. The aim of this study was to compare the long-term health-related quality of life after surgery for idiopathic scoliosis and spondylolisthesis in adolescence.

METHODS

One hundred and ninety patients, with a mean age of fifteen years, who were treated surgically for adolescent idiopathic scoliosis and 270 patients, with a mean age of sixteen years, who were treated surgically for low-grade or high-grade spondylolisthesis participated in the present study. The mean duration of follow-up was 14.8 years for the scoliosis group and 17.0 years for the spondylolisthesis group. Radiographs were made preoperatively, at the time of the two-year follow-up, and at the time of the final follow-up. Additionally, a physical examination was performed, and the Scoliosis Research Society-24 and Short Form-36 questionnaires were completed at the final follow-up evaluation.

RESULTS

The median total score on the Scoliosis Research Society questionnaire was 102 (range, 63 to 118) for the scoliosis group and 95 (range, 42 to 115) for the spondylolisthesis group (p < 0.001). After adjusting for age at the time of surgery, gender, and duration of follow-up, the patients with scoliosis had a significantly higher odds ratio for a good total score (> or = 90 points) on the Scoliosis Research Society questionnaire than did patients with spondylolisthesis (odds ratio, 2.65 [95% confidence interval, 1.58 to 4.44]; p = 0.0002). Patients in the scoliosis group had better values for general self-image, postoperative self-image, and postoperative function than did patients in the spondylolisthesis group (p < 0.001). Sixteen patients in both groups reported that they had back pain often or very often at rest. The standardized physical component scale on the Short Form-36 yielded slightly but significantly better values for the scoliosis group (median, 53.8 points; range, 32 to 61 points) compared with the spondylolisthesis group (median, 53.4 points; range, 27 to 59 points) (p = 0.01).

CONCLUSIONS

Patients have good long-term health-related quality of life after surgery for idiopathic scoliosis and spondylolisthesis in adolescence. Patients who have surgery for idiopathic scoliosis are likely to have better long-term outcomes than are patients who have surgery for spondylolisthesis. It is possible that back pain in adolescence may affect quality of life more than spinal deformity does.

Rotational acetabular osteotomy through an ollier lateral u approach

Various methods of periacetabular osteotomy have been described. Since 1990, we have performed rotational acetabular osteotomy through an Ollier lateral U transtrochanteric approach without massive bone graft. This study investigated whether our technique could provide relief from symptoms, whether postoperative hip abductor weakness would be a critical complication, and whether appropriate acetabular coverage could be achieved. We followed in 101 patients (110 consecutive hips) with a mean age at surgery of 32.5 years and a minimum followup of 5 years (mean, 8.3 years; range, 5-16.2 years). Satisfactory results were found in 94 (85%) hips. A positive Trendelenburg sign was observed in eight (7%) hips at last followup. Appropriate postoperative coverage was provided with an average center-edge angle of 35 degrees . We found radiographic evidence of deterioration of osteoarthritic changes in 14 (13%) hips. Complications included deep infection (one patient); pulmonary embolism (one patient); osteonecrosis of the rotated acetabular fragment (two patients); and proximal displacement of the greater trochanter because of breakage of the polylevolactic acid screws (four patients). This procedure allows osseous cuts with good operative exposure and provides relief from symptoms in most painful dysplastic hips.

Perioperative risk of hip arthroplasty in patients with cirrhotic liver disease

We retrospectively reviewed the complete medical records of 30 patients with a diagnosis of liver cirrhosis who had undergone hip arthroplasty at three academic institutions between October 1994 and May 2001. There were 26 males and 4 females with a mean age of 60 yr at index operation. Surgical procedures included 17 primary total hip arthroplasties (THA), 8 bipolar hemiarthroplasties, and 5 revision THAs. According to the Child-Pugh scoring system, 19 cirrhotic patients were categorized as class A, 9 as class B, and 2 as class C. Eight (26.7%) of the 30 patients had one or more perioperative complications. Of these, wound infection was the most common, with a rate of 10% (3 of 30 hips). Other perioperative complications included surgical site bleeding, coagulopathy, encephalopathy, gastrointestinal bleeding, pneumonia, and arrhythmia. Death occurred in 2 (6.7%) of the 30 patients; both were Child-Pugh's C cirrhotics. A higher Child-Pugh score (p=0.0001) and a high level of creatinine (p=0.0499) were associated with significantly increased perioperative complications or death. Our findings suggest that surgeons should be vigilant about perioperative complications in patients with advanced cirrhotic liver disease who undergo hip arthroplasty, albeit the mortality rates are relatively low in less severe cirrhotics.

Image-guided periacetabular osteotomy: computer-assisted navigation compared with the conventional technique: a randomized study of 36 patients followed for 2 years

BACKGROUND

Periacetabular osteotomy (PAO) is an effective but technically demanding surgical procedure. We evaluated the efficiency of computer-assisted navigation in PAO and compared it with the traditional approach.

PATIENTS AND METHODS

We performed a randomized study of 36 patients undergoing PAO using either the CT-based, computer-assisted navigation technique or the conventional approach. The operative details, radiographic results, and functional outcomes were compared between groups.

RESULTS

Patients in the conventional surgery group required an average of 4.4 (2-7) images of intraoperative radiographs, whereas only 0.6 (0-1) images were required in the navigation group. The operation time was 21 min shorter with computer-assisted navigation. No significant difference with regard to operative blood loss, transfusion requirement, correction of deformity, and functional improvement was found. Complications such as intraarticular damage, osteonecrosis, or neurovascular injury were not encountered.

INTERPRETATION

A computer-assisted navigation system is a feasible tool to provide real-time image guidance and facilitate PAO. However, it offers little additional benefit when the surgery is done by an experienced surgeon.

Muscle strength improves after abductor-sparing periacetabular osteotomy

We measured muscle strength after curved periacetabular osteotomy, one form of abductor-sparing periacetabular osteotomy, and then investigated the factors influencing postoperative muscle strength recovery. Curved periacetabular osteotomy was performed for acetabular dysplasia on 24 hips in 22 patients. All patients were females, with a mean age of 34.4 years. We based the severity of hip disease on the Tönnis classification. Isokinetic muscle strengths of the hips were measured preoperatively and 6 months and 12 months postoperatively. At 12 months postoperatively, the mean muscle strength (percentage difference to preoperative value) of the abductor was 42.2 Nm (129.6%), adductor 39.4 Nm (131.4%), flexor 48.4 Nm (121%), and extensor 45.8 Nm (130.5%), all of which exceeded the preoperative values. The 12-month postoperative muscle strength of patients with Grade 0 disease based on the Tönnis classification was greater in all directions than that of patients with Grades 1 and 2 disease. The preoperative stage was thought to be an essential factor in postoperative muscle strength recovery.

LEVEL OF EVIDENCE

Prognostic study, Level II (lesser quality prospective study--eg, patients enrolled at different points in their disease or < 80% followup). See the Guidelines for Authors a complete description of levels of evidence.

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.