Long-term results of rotational acetabular osteotomy in young patients with advanced osteoarthrosis of the hip

Minimum 10-Year Clinical Outcomes After Periacetabular Osteotomy for Advanced Osteoarthritis Due to Hip Dysplasia

The purpose of this study was to examine the minimum 10-year clinical outcomes, including patient-reported and functional outcomes, of periacetabular osteotomy in patients with advanced osteoarthritis. A total of 46 hips in 44 patients with advanced osteoarthritis who underwent periacetabular osteotomy between 1992 and 2006 were retrospectively reviewed. Mean age at surgery was 47.5 years, and mean follow-up was 16.9±4.7 years. Survivorship was determined using the Kaplan-Meier method, and the associated risk factors for the endpoint-conversion to total hip arthroplasty less than 15 years after surgery-were evaluated. The Oxford Hip Score and the University of California, Los Angeles activity score were evaluated at final follow-up. The survival rates at 15 and 20 years after surgery were 80% and 59%, respectively. Multivariate analysis indicated that body mass index greater than 24 kg/m² (P=.034; odds ratio, 1.72) was significantly associated with the endpoint as an independent risk factor. For 32 hips of 31 patients with preserved native joints at final follow-up, the Oxford Hip Score and the University of California, Los Angeles score averaged 41±5 and 5.2±1.8, respectively, equivalent (P=.28 and P=.215, respectively) to the scores of 14 hips of 13 patients with conversion to total hip arthroplasty (38±8.7 and 5.8±1.4, respectively). The results of this mid-term study may be useful for surgical decision-making among patients with advanced osteoarthritis who want to preserve native hip joints. [Orthopedics. 2018; 41(5):300-305.].

Sports activity after treatment of residual hip dysplasia with triple pelvic osteotomy using the Tönnis and Kalchschmidt technique

BACKGROUND

Pelvic osteotomies are performed to prevent the progression of osteoarthritis and its associated pain due to adult hip dysplasia, particularly for young patients with no or low-grade osteoarthritis. No data are available concerning levels of sporting activity before and after triple pelvic osteotomy (TPO). Therefore, the aim of this study was to provide comprehensive data on levels of sporting activity and the subjective outcome of patients after this complex operation.

HYPOTHESIS

Patients can return to a higher level of sports activity after TPO compared with their preoperative level.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2003 and 2011, a total of 116 triple pelvic osteotomies were performed at a single institution; the Tönnis and Kalchschmidt technique was used on 91 patients. After exclusion criteria for this study were applied, 77 patients remained (59 females and 18 males); the mean ± SD age at operation was 26 ± 3.9 years. To study outcomes, patients were asked to complete both the Harris hip score (HHS) and the Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and at postoperative follow-up. Their level of activity was determined according to the University of California, Los Angeles (UCLA) activity score. Patients rated their hip movement and overall satisfaction preoperatively and at postoperative follow-up using a visual analog scale for sporting activity, physical fitness level, and level of pain experienced while performing their sport.

RESULTS

The mean ± SD follow-up time was 6.2 ± 1.4 years. The mean HHS changed significantly from 63.3 ± 15.6 preoperatively to 90.1 ± 10.8 at follow-up (P < .001), and the mean HOOS changed significantly from 52.9 ± 20.1 to 82 ± 17.1 at follow-up (P < .001). The mean UCLA activity score changed significantly from 4.8 ± 2.1 to 7.7 ± 1.4 at follow-up (P < .001).

CONCLUSION

Patients achieved a higher level of sports activity postoperatively. The postoperative level of participation in sports was superior, with a shift from low- to high-impact activities.

Relationship of acetabular dysplasia in females with osteoarthritis of the hip to the distance between both anterior superior iliac spines

BACKGROUND

Acetabular dysplasia (AD) is the main cause of hip osteoarthritis in Japan. A simple method to evaluate acetabular dysplasia would be helpful for early treatment or prevention of hip osteoarthritis. Acetabular dysplasia is reported to be associated with pathological transverse growth of the pelvis, indicating that the distance between the 2 anterior superior iliac spines might be useful for screening and detection of acetabular dysplasia. The purpose of this study was to determine if the acetabular dysplasia radiographic parameters are related to the distance between the 2 anterior superior iliac spines in patients with hip osteoarthritis.

MATERIAL AND METHODS

In this study, data obtained in a previous multi-institutional examination of patients with hip osteoarthritis in Japan were evaluated. The anterior superior iliac spine distances of 176 female patients (mean age, 54 years; range, 18-85 years) were measured by physical examination. The relationship between the anterior superior iliac spine distance and acetabular dysplasia was analyzed, and the anterior superior iliac spine distances of the patients with acetabular dysplasia who were at relatively high risk for hip osteoarthritis were compared with that of the patients at lower risk.

RESULTS

A statistically significant relationship between the anterior superior iliac spine distance and all of the acetabular dysplasia parameters was observed. The anterior superior iliac spine distances of the acetabular dysplasia patients with a relatively high risk for radiographic acetabular dysplasia parameters were significantly smaller than those of patients at lower risk. Even after adjustment for age, height, and weight, significantly increased relative risk for having high risk AD was found in patients with an ASIS distance of less than 24.5 cm.

CONCLUSIONS

There was a significant relationship between the anterior superior iliac spine distance and the degree of acetabular dysplasia.

Rotational acetabular osteotomy with resection of the capital drop and double floor for advanced osteoarthritis of the hip

Rotational acetabular osteotomy (RAO) is an established joint preservation technique for early stage osteoarthritis (OA). To extend the application of RAO for advanced OA with significant osteophyte formation, we added intraarticular procedures including removal of the double floor and the capital drop to create medialisation and better coverage of the femoral head.
The procedures were performed for seven joints with advanced OA. The average age of patients at surgery was 39 years. The follow-up periods ranged from five to 23 years. The capital drop was resected in five joints and both the capital drop and the double floor were removed in the other two joints.
The Japanese Orthopaedic Association Hip Score improved from 53 points before surgery to 69 at the latest follow-up. The range of flexion was decreased. The centre-edge angle, Sharp angle and acetabular head index were significantly improved. The femoral head was medialised 5 mm by surgery. Three joints (43%) showed progression of osteoarthritis. One joint (14%) needed replacement at seven years after RAO. Resection of the capital drop and curtain osteophyte with RAO improved joint congruity and medialisation of the femoral head, but decreased the range of motion of the joint due to increased bony coverage. Progression of degeneration of the joint is not preventable. We abandoned these procedures for advanced osteoarthritis of the hip joint especially in older patients who were suitable for replacement arthroplasty.

A comparison of biomechanical changes on femoral head following rotational acetabular osteotomy and eccentric rotational acetabular osteotomy in normal cadaveric hip

PURPOSE

Both rotational acetabular osteotomy (RAO) and eccentric rotational acetabular osteotomy (ERAO) are effective procedures for young patients with developmental dysplasia of the hip. However, no comparative study of biomechanical changes has been reported following these two procedures. We therefore explored the stress changes on femoral head after RAO and ERAO under different load conditions.

MATERIALS AND METHODS

Twelve female cadaveric hips without deformity were divided into RAO group and ERAO group. Stress value on femoral head was measured preoperatively and postoperatively after the vertical force was loaded on the cadaveric spine from 0 to 500 N. Stress change value was then calculated base on the measurements.

RESULTS

In the RAO group, preoperative stress increased when loading on spine became larger, but postoperative stress changed its increasing trend into decreasing when the load was greater than 200 N (turning point). Same phenomenon was found in the ERAO group (turning point was 300 N). However, the difference between preoperative and postoperative stress was not statistically significant in both RAO and ERAO groups. Stress change value from each procedure showed similar trends. With the load growth, stress change increased firstly and then decreased, but the difference between RAO and ERAO was not statistically significant.

CONCLUSIONS

Both RAO and ERAO could correct the abnormal biomechanical effect of dysplastic hip; moreover, they may have similar biomechanical effects on femoral head, obtaining the same clinical outcomes. Non-biomechanical factors (surgical trauma, technical complexity, etc.) also play important roles in procedure selection.

Patient selection criteria for periacetabular osteotomy or rotational acetabular osteotomy

BACKGROUND

Hip dysplasia is the most common cause of secondary osteoarthritis (OA). Periacetabular osteotomy (PAO) or rotational acetabular osteotomy (RAO) has been used as a joint-preserving procedure. However, the patient selection criteria are not clearly defined.

QUESTIONS/PURPOSES

Based on a systematic review, we identified reported patient selection criteria for PAO or RAO.

METHODS

We performed a systematic review of RAO and 18 studies met our inclusion criteria. For the PAO, the systemic review performed by Clohisy et al. was used. WHERE ARE WE NOW?: For patients with symptomatic hip dysplasia, lateral center-edge angle less than 10° to 30°, radiographic pre- or early OA, mean age at the time of surgery of 18 to 45 years, and improvement in joint congruency on AP radiograph with hip abduction, radiographic deformity correction consistently improved hip function in all studies. Radiographic OA progression was noted in 5% to 33% at 3.2 to 20 years postoperatively. Clinical score and prevention of radiographic OA progression of patients 50 years or older or with advanced stage were worse in younger patients or those with early stage. WHERE DO WE NEED TO GO?: The key challenges are (1) preoperative evaluation of articular cartilage; (2) indication for older patients; (3) prevention of secondary femoroacetabular impingement; and (4) intraarticular treatment combined with PAO or RAO. HOW DO WE GET THERE?: Future prospective, longitudinal cohort studies need to determine optimal patient selection criteria, risk factors for clinical failure, optimal deformity correction parameters, and the role of adjunctive surgical procedures.

Joint congruency as an indication for rotational acetabular osteotomy

Long-term results of periacetabular osteotomy for advanced-stage osteoarthritis secondary to developmental dysplasia of the hip are reportedly unsatisfactory compared with results for early-stage osteoarthritis. Other preoperative information that can be used to determine indications for periacetabular osteotomy is therefore important to avoid performing osteotomy in young patients with advanced-stage osteoarthritis who would not likely achieve substantial benefit. We retrospectively reviewed 47 patients (49 hips) with advanced-stage osteoarthritis who underwent rotational acetabular osteotomy (RAO) using preoperative congruency in abduction. The minimum postoperative followup was 8 years (mean, 12.3 years; range, 8-20 years) and mean age at surgery was 43.1 years (range, 30-59 years). At followup, osteoarthritic stage was improved in 12 hips, unchanged in 24 hips, and had progressed in 13 hips. Preoperative joint congruency in abduction was good in 13 hips, poor in 32 hips, and narrowed in four hips. Patients with better congruency in abduction had better results. We believe osteoarthritis with good congruency in abduction preoperatively remains a good indication for RAO even in advanced stages of disease.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Triple pelvic osteotomy as treatment for osteoarthritis secondary to developmental dysplasia of the hip

Joint-preserving osteotomies are an established treatment for adult hip pain secondary to developmental dysplasia of the hip. However, their value for advanced osteoarthritis is unclear. Therefore this study addresses the question of long-term results of triple pelvic osteotomy in patients with second grade osteoarthritis. Thirty-two patients with second grade osteoarthritis secondary to developmental dysplasia of the hip before triple pelvic osteotomy were clinically and radiographically assessed 11.5 years postoperatively. Five patients required conversion to total hip replacement. Kaplan-Meier survivorship analysis predicted a survival rate of 85.3%. The mean Harris hip score increased significantly with more than 56% good or very good results. A preoperative BMI > 25 and Harris hip score < 70 resulted in worse outcome or early conversion into total hip arthroplasty. The results indicate that developmental dysplasia of the hip even in second grade osteoarthritis can be treated with triple pelvic osteotomy.

Rotational acetabular osteotomy with excision of the capital drop for advanced osteoarthritis secondary to developmental dysplasia of the hip

INTRODUCTION

Advanced-stage osteoarthritis may occasionally be associated with capital drop of the femoral head. In such cases, excision of the capital drop is performed to obtain good congruency with sufficient coverage of the femoral head by rotational acetabular osteotomy (RAO). In the present study, we examined the outcome of RAO with excision of the capital drop.

MATERIALS AND METHODS

Rotational acetabular osteotomy (RAO) with excision of the capital drop was performed in 17 hips of 16 patients with a mean follow-up of 12.6 years (excision group), while only RAO was performed in 42 hips of 41 patients with a mean follow-up of 12.3 years (non-excision group). All 57 patients indicated radiographic evidence of advanced-stage osteoarthritis. Clinical follow-up was performed using the Merle d'Aubigné and Postel system. The clinical and radiological results were compared between the two groups.

RESULTS

The mean Merle d'Aubigne and Postel's total hip-joint scores at follow up significantly (p < 0.001) improved compared with the mean pre-operative scores only in the non-excision group. While the numbers of hips in excision group (17 hips) showing progressive and non-progressive osteoarthritic changes were 10 and 7, those in the non-excision group (42 hips) were 11 and 20, respectively. Although none (0/17) in the excision group showed any improvement in osteoarthritic stage at follow up, 11 of 42 hips indicated a favorable outcome in the non-excision group. There were significantly (p = 0.0077) higher improvements in osteoarthritis stage in the non-excision than excision group. Three patients each of the excision group (18%) and non-excision group (7%) underwent total hip arthroplasty during the follow-up period.

CONCLUSION

Excision of capital drop of the femoral head is not a useful adjunct to the RAO procedure for the treatment of advanced osteoarthritis. Based on results from a previous study, Chiari pelvic osteotomy may serve as a more favorable alternative.

Radiographic joint space width in patients with Crowe Type-I dysplastic hips

Radiographic evaluation of preoperative joint space width is believed important to predict the long-term results of osteotomy. We asked whether joint space width differs in the supine and standing positions in patients with Crowe Type-1 osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH). Joint space width was measured in the supine and standing positions in 146 women and 16 men (231 hips) with OA. Subjects had a mean age of 46.7 years (range, 22-59 years). Differences were seen on radiographs in joint space width between supine (2.35 +/- 1.65 mm; range, 0.1-6.2 mm) and standing (2.04 +/- 1.78 mm; range, 0.0-5.9 mm). In 27 of 172 hips with greater than 1 mm joint space in the supine position, joint space width was decreased by greater than 1 mm in the standing position. To evaluate preoperative joint space width in patients scheduled for osteotomy, radiographs should be obtained with the patient in the standing position.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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.

Rotational acetabular osteotomy for advanced osteoarthritis secondary to developmental dysplasia of the hip

We evaluated the results of rotational acetabular osteotomy in 44 hips (42 patients) with advanced osteoarthritis secondary to developmental dysplasia. The mean age of the patients at surgery was 43.4 years (30 to 59) and the mean follow-up was 12.1 years (8 to 19). The mean Merle d'Aubigné clinical score improved from 10.8 points (8 to 15) pre-operatively to 13.5 points (6 to 18) at follow-up. Radiologically, this procedure produced adequate improvement regarding cover of the femoral head. At follow-up, the osteoarthritic stage assessed using the Japanese Orthopaedic Association grading, was improved in 11 hips (25%), unchanged in 22 (50%) and had progressed in 11 (25%). The mean pre-operative roundness index of the femoral head was significantly different in the 33 hips which had improved or maintained their osteoarthritic stage compared with the 11 which had progressed (53.7% vs 63.7%; p < 0.001). Osteoarthritis with a round femoral head is considered to be an indication for rotational acetabular osteotomy, even in advanced stages of the disease.

Rotational acetabular osteotomy with a resection of the lateral edge of the acetabulum for the treatment of advanced coxarthrosis

INTRODUCTION

We compared the functional and radiological results of a rotational acetabular osteotomy (RAO) with and without a resection of the lateral edge of the acetabulum. The purpose of the resection was to obtain good joint congruency.

MATERIALS AND METHODS

RAO was performed on 71 hips to treat advanced coxarthrosis caused by acetabular dysplasia. RAO without a resection (non-resection group) was performed in 54 patients (57 hips) with a median age of 43.1 years. The remaining 14 patients (14 hips), who had a median age of 44.6 years, received RAO with a resection of the lateral edge of the acetabulum (resection group).

RESULTS

The average postoperative total hip joint score was better than the average preoperative score in the non-resection group (P < 0.001), but not in the resection group. In the resection group, all hips displayed progressive osteoarthritic change and ten hips had chondrolysis of the hip joint and a collapse of the transferred acetabulum within 3 years. In the non-resection group, 15 hips showed progressive osteoarthritic change, 24 hips had no change, and 18 hips showed a decrease in the osteoarthritic stage.

CONCLUSION

Our findings demonstrated that resection of the lateral edge of the acetabulum is not a useful adjunct to the RAO procedure for the treatment of advanced coxarthrosis.

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.

Acetabular centre-edge angles revisited: applications and limitations in patients with acetabular dysplasia undergoing periacetabular osteotomy

This study evaluates the application and limitations of the acetabular centre-edge angles as described by Wiberg (LCE) and Lequesne (VCA) in a group of adult patients with acetabular dysplasia that were treated with periacetabular osteotomy. Fifty hips in patients with a mean age of 30 years (range, 17-45) were identified and a number of radiographic indices were compared pre and post osteotomy. The potential for measurement variation in both the LCE and VCA angle was evaluated and relationships between the centre-edge angles and other radiographic indices were determined. While all hips displayed some degree of lateral deficiency only 19 (40%) of these cases displayed a ''classic'' lateral and anterior deficiency while 12 (20%) were in fact retroverted. The mean VCA in hips with primarily anterior and lateral deficiency (-6.712.5) was significantly lower (p<0.01) than those with uniform deficiency (5.18.3) or those with retroverted acetabuli (8.913.3). Overall the mean VCA angle of 2.3 (SD12.7) and LCE angle of 3.4 (SD9.3) was corrected to 25.8 (SD11.6) and 28.6 (SD8.7) following osteotomy. The VCA and LCE angles were not correlated (r=0.35) and the LCE angle showed no significant correlation to other lateral coverage indices (Tnnis, Sharp). No correlation was seen either in the post osteotomy values, or in the absolute degree of correction. An alternate VCA (aVCA), identifying the most anterior aspect of the acetabular margin as the reference point, was significantly larger (p<0.001) but did correlate (r=0.77) with the traditional VCA. Potential sources of error in measurement were identified and are reviewed.

EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To develop evidence based recommendations for the management of hip osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale.

RESULTS

Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.