The Chitranjan S. Ranawat Award Young, Simon W.; Walker, Matthew L.; Bayan, Ali ...
Clinical orthopaedics and related research,
01/2017, Volume:
475, Issue:
1
Journal Article
Peer reviewed
Open access
Background
Neutral mechanical alignment (MA) in total knee arthroplasty (TKA) aims to position femoral and tibial components perpendicular to the mechanical axis of the limb. In contrast, kinematic ...alignment (KA) attempts to match implant position to the prearthritic anatomy of the individual patient with the aim of improving functional outcome. However, comparative data between the two techniques are lacking.
Questions/purposes
In this randomized trial, we asked: (1) Are 2-year patient-reported outcome scores enhanced in patients with KA compared with an MA technique? (2) How does postoperative component alignment differ between the techniques? (3) Is the proportion of patients undergoing reoperation at 2 years different between the techniques?
Methods
Ninety-nine primary TKAs in 95 patients were randomized to either MA (n = 50) or KA (n = 49) groups. A pilot study of 20 TKAs was performed before this trial using the same patient-specific guides positioning in kinematic alignment. In the KA group, patient-specific cutting blocks were manufactured using individual preoperative MRI data. In the MA group, computer navigation was used to ensure neutral mechanical alignment accuracy. Postoperative alignment was assessed with CT scan, and functional scores (including the Oxford Knee Score, WOMAC, and the Forgotten Joint Score) were assessed preoperatively and at 6 weeks, 6 months, and 1 and 2 years postoperatively. No patients were lost to followup. We set sample size at a minimum of 45 patients per treatment arm based on a 5-point improvement in the mean Oxford Knee Score (OKS; the previously reported minimum clinically significant difference for the OKS in TKA), a pooled SD of 8.3, 80% power, and a two-sided significance level of 5%.
Results
We observed no difference in 2-year change scores (postoperative minus preoperative score) in KA versus MA patients for the OKS (mean 21, SD 8 versus 20, SD 8, least square means 1.0, 95% confidence interval CI, −1.4 to 3.4, p = 0.4), WOMAC score (mean 38, SD 18 versus 35, SD 8, least square means 3, 95% CI, −3.2 to 8.9, p = 0.3), or Forgotten Joint score (28 SD 37 versus 28, SD 28, least square means 0.8, 95% CI, −9.1–10.7, p = 0.8). Postoperative hip-knee-ankle axis was not different between groups (mean KA 0.4° varus SD 3.5 versus MA 0.7° varus SD 2.0), but in the KA group, the tibial component was a mean 1.9° more varus than the MA group (95% CI, 0.8°−3.0°, p = 0.003) and the femoral component in 1.6° more valgus (95% CI, −2.5° to −0.7°, p = 0.003). Complication rates were not different between groups.
Conclusions
We found no difference in 2-year patient-reported outcome scores in TKAs implanted using the KA versus an MA technique. The theoretical advantages of improved pain and function that form the basis of the design rationale of KA were not observed in this study. Currently, it is unknown whether the alterations in component alignment seen with KA will compromise long-term survivorship of TKA. In this study, we were unable to demonstrate an advantage to KA in terms of pain or function that would justify this risk.
Level of Evidence
Level I, therapeutic study.
Background
Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) ...reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice.
Questions/purposes
Which graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity?
Methods
We performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000™ testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months.
Results
Two hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84).
Conclusions
In this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection.
Level of Evidence
Level III, therapeutic study.
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FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Both acetabular undercoverage (hip dysplasia) and overcoverage (pincer-type femoroacetabular impingement) can result in hip osteoarthritis. In contrast to undercoverage, there is a lack of ...information on radiographic reference values for excessive acetabular coverage.
Questions/purposes
(1) How do common radiographic hip parameters differ in hips with a deficient or an excessive acetabulum in relation to a control group; and (2) what are the reference values determined from these data for acetabular under- and overcoverage?
Methods
We retrospectively compared 11 radiographic parameters describing the radiographic acetabular anatomy among hip dysplasia (26 hips undergoing periacetabular osteotomy), control hips (21 hips, requiring no rim trimming during surgical hip dislocation), hips with overcoverage (14 hips, requiring rim trimming during surgical hip dislocation), and hips with severe overcoverage (25 hips, defined as having acetabular protrusio). The hips were selected from a patient cohort of a total of 593 hips. Radiographic parameters were assessed with computerized methods on anteroposterior pelvic radiographs and corrected for neutral pelvic orientation with the help of a true lateral radiograph.
Results
All parameters except the crossover sign differed among the four study groups. From dysplasia through control and overcoverage, the lateral center-edge angle, acetabular arc, and anteroposterior/craniocaudal coverage increased. In contrast, the medial center-edge angle, extrusion/acetabular index, Sharp angle, and prevalence of the posterior wall sign decreased. The following reference values were found: lateral center-edge angle 23° to 33°, medial center-edge angle 35° to 44°, acetabular arc 61° to 65°, extrusion index 17% to 27%, acetabular index 3° to 13°, Sharp angle 38° to 42°, negative crossover sign, positive posterior wall sign, anterior femoral head coverage 15% to 26%, posterior femoral head coverage 36% to 47%, and craniocaudal coverage 70% to 83%.
Conclusions
These acetabular reference values define excessive and deficient coverage. They may be used for radiographic evaluation of symptomatic hips, may offer possible predictors for surgical outcomes, and serve to guide clinical decision-making.
Level of Evidence
Level III, diagnostic study.
Full text
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Transplantation of mesenchymal stem cells (MSCs) is one possible strategy to achieve articular cartilage repair. We previously reported that synovial MSCs were highly proliferative and ...able to undergo chondrogenesis. We also found that placing a suspension of synovial MSCs on a cartilage defect for 10 minutes promoted cartilage repair in rabbit and pig models. However, the in vivo efficacy of this approach has not been tested clinically.
Questions/purposes
We asked whether transplantation of synovial MSCs improves (1) MRI features, (2) histologic features, and (3) clinical evaluation scores in patients with cartilage defects in the knee?
Methods
Patients with a symptomatic single cartilage lesion of the femoral condyle were indicated for inclusion in our study, and between April 2008 and April 2011, 10 patients were enrolled in this study. All patients completed followups of 3 years or more. The average followup period was 52 months (range, 37–80 months). Synovial MSCs were expanded with 10% autologous human serum for 14 days after digestion. For transplantation, the patient was positioned so that the cartilage defect was facing upward, and synovial MSC suspension was placed on the cartilage defect with a syringe under arthroscopic control. The defect with the applied suspension then was held in the upward position for 10 minutes. Five patients underwent concomitant ACL reconstructions, among whom two had meniscus suturing performed simultaneously. For MRI quantification, the cartilage defect was scored from 0 to 5. Second-look arthroscopy was performed for four patients and biopsy specimens were evaluated histologically. Clinical outcome was assessed using the Lysholm score and Tegner Activity Level Scale at final followup. Comparisons of MRI and Lysholm scores before and after treatment for each patient were analyzed using the Wilcoxon signed-rank test.
Results
MRI score (median ± 95% CI) was 1.0 ± 0.3 before and 5.0 ± 0.7 after, and increased after treatment in each patient (p = 0.005). Second-look arthroscopy in four patients showed that the cartilage defect appeared to be qualitatively better in all cases. Histologic analyses showed hyaline cartilage in three patients and fibrous cartilage in one at the deep zone. The Lysholm score (median ± 95% CI) was 76 ± 7 before and 95 ± 3 after, and increased after treatment in each patient (p = 0.005). The Tegner Activity Level Scale did not decrease after treatment in each patient.
Conclusions
For this small initial case series, transplantation of synovial MSCs was effective in terms of MRI score, qualitative histology, and Lysholm score. The use of synovial MSCs has an advantage in that the cells can be prepared at passage 0 in only 14 days. Transplantation of synovial MSCs may be less invasive than mosaicplasty and autologous chondrocyte implantation. To conclusively show the effectiveness of this treatment requires comparative studies, especially with more established arthroscopic procedures, such as marrow stimulation techniques.
Level of Evidence
Level IV, therapeutic study.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Where Are the Women in Orthopaedic Surgery? Rohde, Rachel S.; Wolf, Jennifer Moriatis; Adams, Julie E.
Clinical orthopaedics and related research,
09/2016, Volume:
474, Issue:
9
Journal Article
Peer reviewed
Open access
Background
Although women account for approximately half of the medical students in the United States, they represent only 13% of orthopaedic surgery residents and 4% of members of the American ...Academy of Orthopaedic Surgeons (AAOS). Furthermore, a smaller relative percentage of women pursue careers in orthopaedic surgery than in any other subspecialty. Formal investigations regarding the gender discrepancy in choice of orthopaedic surgery are lacking.
Questions/purposes
(1) What reasons do women orthopaedic surgeons cite for why they chose this specialty? (2) What perceptions do women orthopaedic surgeons think might deter other women from pursuing this field? (3) What role does early exposure to orthopaedics and mentorship play in this choice? (4) What professional and personal choices do women in orthopaedics make, and how might this inform students who are choosing a career path?
Methods
A 21-question survey was emailed to all active, candidate, and resident members of the Ruth Jackson Orthopaedic Society (RJOS, n = 556). RJOS is the oldest surgical women’s organization incorporated in the United States. An independent orthopaedic specialty society, RJOS supports leadership training, mentorship, grant opportunities, and advocacy for its members and promotes sex-related musculoskeletal research. Although not all women in orthopaedic practice or training belong to RJOS, it is estimated that 42% of women AAOS fellows are RJOS members. Questions were formulated to determine demographics, practice patterns, and lifestyle choices of women who chose orthopaedic surgery as a specialty. Specifically, we evaluated the respondents’ decisions about their careers and their opinions of why more women do not choose this field. For the purpose of this analysis, the influences and dissuaders were divided into three major categories: personal attributes, experience/exposure, and work/life considerations.
Results
The most common reasons cited for having chosen orthopaedic surgery were enjoyment of manual tasks (165 of 232 71%), professional satisfaction (125 of 232 54%), and intellectual stimulation (123 of 232 53%). The most common reasons indicated for why women might not choose orthopaedics included perceived inability to have a good work/life balance (182 of 232 78%), perception that too much physical strength is required (171 of 232 74%), and lack of strong mentorship in medical school or earlier (161 of 232 69%). Respondents frequently (29 of 45 64%) commented that their role models, mentors, and early exposure to musculoskeletal medicine were influential, but far fewer (62 of 231 27%) acknowledged these in their top five influences than they did the more “internal” motivators.
Conclusions
To our knowledge, this is the largest study of women orthopaedic surgeons regarding factors influencing their professional and personal choices. Our data suggest that the relatively few women currently practicing orthopaedics were attracted to the field because of their individual personal affinity for its nature despite the lack of role models and exposure. The latter factors may impact the continued paucity of women pursuing this field. Programs designed to improve mentorship and increase early exposure to orthopaedics and orthopaedic surgeons may increase personal interest in the field and will be important to attract a diverse group of trainees to our specialty in the future.
Full text
Available for:
FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The alpha-defensin test has been previously demonstrated to be highly accurate in the diagnosis of prosthetic joint infection (PJI), nearly matching the Musculoskeletal Infection Society ...definition for PJI. However, the relationship between alpha-defensin levels and differing infecting organism has not yet been investigated.
Questions/purposes
The purpose of this study is to describe the breadth of organisms that can trigger a positive synovial fluid alpha-defensin test result in the setting of PJI and also to assess the magnitude of the alpha-defensin result in terms of various pathogen characteristics.
Methods
Between December 2012 and March 2014, one laboratory processed 2319 synovial fluid samples for alpha-defensin testing. The present study reviewed the results of the 1937 samples that simultaneously had a synovial fluid culture performed; these came from 418 surgeons in 42 states. The overall culture-positive rate was 49% (244 of 498) among alpha-defensin-positive synovial fluids and 1% (19 of 1439) among alpha-defensin-negative synovial fluids. The organisms recovered from 244 alpha-defensin-positive, culture-positive fluids were recorded and grouped based on various characteristics, including Gram type, species, virulence, oral pathogenicity, and source joint. Alpha-defensin-negative samples served as uninfected controls. Median alpha-defensin levels were calculated for each group, and Dunn’s multiple comparison test for nonparametric data was used to identify any statistically significant (p < 0.05) organism-specific differences in the alpha-defensin level.
Results
The alpha-defensin test for PJI was positive in the setting of a wide spectrum of organisms typically causing PJI. The median alpha-defensin level for all 244 alpha-defensin-positive, culture-positive samples (4.7 interquartile range {IQR}, 3.7–5.3) was higher than negative controls (0.26 IQR, 0.22–0.33) with a median difference of 4.4 (p < 0.001). There were no differences in the median alpha-defensin levels when performing a multiple comparison test among Gram-positive organisms (4.7 IQR, 3.6–5.3), Gram-negative organisms (4.8 IQR, 4.2–5.3), yeast (4.1 IQR, 2.2–5.1), virulent organisms (4.7 IQR, 3.8–5.2), less virulent organisms (4.8 IQR, 3.6–5.4), oral pathogens (4.5 IQR, 3.2–5.2), knees (4.7 IQR, 3.7–5.3), hips (4.9 IQR, 4.1–5.8), or shoulders (5.3 IQR, 4.0–10.7) with all comparisons having a p > 0.999.
Conclusions
The alpha-defensin test provides consistent results regardless of the organism type, Gram type, species, or virulence of the organism and should be seriously considered to be a standard diagnostic tool in the evaluation for PJI. Future research should focus on the performance of this test in specific clinical scenarios such as the immediate postoperative period in the setting of severe immunocompromise and in the setting of a native joint.
Level of Evidence
Level III, diagnostic study.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Background
A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. ...Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation.
Questions/purposes
We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results?
Methods
Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI.
Results
The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval CI, 92%–99%), the specificity was 97% (95% CI, 92%–99%), the positive predictive value was 88% (95% CI, 81%–92%), and the negative predictive value was 99% (95% CI, 96%–99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative.
Conclusions
Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result.
Level of Evidence
Level I, diagnostic study.
Falls in Older Adults are Serious Vaishya, Raju; Vaish, Abhishek
Indian journal of orthopaedics,
02/2020, Volume:
54, Issue:
1
Journal Article
Peer reviewed
Open access
Background
Falls in older adults are a reasonably common occurrence and about 10% of these experience multiple falls annually. These falls may be serious and may cause significant morbidity and ...mortality. These can also threaten the independence of older people and may be responsible for an individual’s loss of independence and socioeconomic consequences. These falls may add extra burden to the health care and to direct and indirect costs.
Methodology
An extensive search of literature was done on the important data bases of PubMed, SCOPUS, and Google Scholar on this topic and all the useful information was derived from the relevant articles for this review.
Results
We found that the falls in older individuals are often multi factorial and hence a multidisciplinary approach is required to prevent and manage these falls. The risk factors leading to the falls could be divided into extrinsic, intrinsic and situational factors. The commonest and serious injuries are to the head and fractures, due to fragility of bones.
Discussion
The falls in elderly are on rise and taking the shape of an epidemic. Prevention of these falls is far better than the management. Safe living environment of the elderly people helps in prevention of these falls. The management of the falls should focus on the causative factors, apart from treating the injuries caused by the falls.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The diagnosis of periprosthetic joint infection (PJI) continues to pose a challenge. While many diagnostic criteria have been proposed, a gold standard for diagnosis is lacking. Use of ...multiple diagnostic criteria within the joint arthroplasty community raises concerns in patient treatment and comparison of research pertaining to PJI.
Questions/purposes
We (1) determined the variation in existing diagnostic criteria, (2) compared the existing criteria to a proposed new set of criteria that incorporates aspirate cell count analysis, and (3) investigated the variations between the existing criteria and the proposed criteria.
Patients and Methods
We retrospectively identified 182 patients undergoing 192 revision knee arthroplasties who had a preoperative joint aspiration analysis at our institution between April 2002 and November 2009. We excluded 20 cases due to insufficient laboratory parameters, leaving 172 cases for analysis. We applied six previously published sets of diagnostic criteria for PJI to determine the variation in its incidence using each set of criteria. We then compared these diagnostic criteria to our proposed new criteria and investigated cases where disagreement occurred.
Results
We identified 41 cases (24%) in which at least one established criteria set classified the case as infected while at least one other criteria set classified the case as uninfected. With our proposed criteria, the infected/uninfected ratio was 92/80. The proposed criteria had a large variance in sensitivity (54%–100%), specificity (39%–100%), and accuracy (53%–100%) when using each of the established criteria sets as the reference standard.
Conclusions
The discrepancy between definitions of infection complicates interpretation of the literature and the treatment of failed TKAs owing to PJI. Based on our findings, we suggest establishing a common set of diagnostic criteria utilizing aspirate analysis to improve the treatment of PJI and facilitate interpretation of the literature.
Level of Evidence
Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Background
Since its first description in 1984, periacetabular osteotomy (PAO) has become an accepted treatment for hip dysplasia. The 30-year survivorship with this procedure has not been reported. ...Because these patients are often very young at the time of surgery, long-term followup and identification of factors associated with poor outcome could help to improve patient selection.
Questions/purposes
Looking at the initial group of patients with hip dysplasia undergoing PAO at the originator’s institution, we asked: (1) What is the cumulative 30-year survival rate free from conversion to THA, radiographic progression of osteoarthritis, and/or a Merle d’Aubigné-Postel score < 15? (2) Did hip function improve and pain decrease? (3) Did radiographic osteoarthritis progress? (4) What are the factors associated with one or more of the three endpoints: THA, radiographic progression of osteoarthritis, and/or Merle d’Aubigné-Postel score < 15?
Methods
We retrospectively evaluated the first 63 patients (75 hips) who underwent PAO for hip dysplasia between 1984 and 1987. At that time, hip dysplasia was the only indication for PAO and no patients with acetabular retroversion, the second indication for a PAO performed today, were included. During that period, no other surgical treatment for hip dysplasia in patients with closed triradiate cartilage was performed. Advanced osteoarthritis (≥ Grade 2 according to Tönnis) was present preoperatively in 18 hips (24%) and 22 patients (23 hips 31%) had previous femoral and/or acetabular surgery. Thirty-nine patients (42 hips 56%) were converted to a THA and one patient (one hip 1%) had hip fusion at latest followup. Two patients (three hips 4%) died from a cause unrelated to surgery 6 and 16 years after surgery with an uneventful followup. From the remaining 21 patients (29 hips), the mean followup was 29 years (range, 27–32 years). Of those, five patients (six hips 8%) did not return for the most recent followup and only a questionnaire was available. The cumulative survivorship of the hip according to Kaplan-Meier was calculated if any of the three endpoints, including conversion to THA, progression of osteoarthritis by at least one grade according to Tönnis, and/or a Merle d’Aubigné-Postel score < 15, occurred. Hip pain and function were assessed with Merle d’Aubigné-Postel score, Harris hip score, limp, and anterior and posterior impingement tests. Progression of radiographic osteoarthritis was assessed with Tönnis grades. A Cox regression model was used to calculate factors associated with the previously defined endpoints.
Results
The cumulative survivorship free from conversion to THA, radiographic progression of osteoarthritis, and/or Merle d’Aubigné-Postel score < 15 was 29% (95% confidence interval, 17%-42%) at 30 years. No improvement was found for either the Merle d’Aubigné-Postel (15 ± 2 versus 16 ± 2, p = 0.144) or Harris hip score (83 ± 11 versus 85 ± 17, p = 0.602). The percentage of a positive anterior impingement test (39% versus 14%, p = 0.005) decreased at 30-year followup, whereas the percentage of a positive posterior impingement test (14% versus 3%, p = 0.592) did not decrease. The percentage of positive limp decreased from preoperatively 66% to 18% at 30-year followup (p < 0.001). Mean osteoarthritis grade (Tönnis) increased from preoperatively 0.8 ± 1 (0–3) to 2.1 ± 1 (0–3) at 30-year followup (p < 0.001). Ten factors associated with poor outcome defined as THA, radiographic progression of osteoarthritis, and/or Merle d’Aubigné-Postel score < 15 were found: preoperative age > 40 years (hazard ratio HR 4.3 3.7–4.9), a preoperative Merle d’Aubigné-Postel score < 15 (HR 4.1 3.5–4.6), a preoperative Harris hip score < 70 (HR 5.8 5.2–6.4), preoperative limp (HR 1.7 1.4–1.9), presence of a preoperative positive anterior impingement test (HR 3.6 3.1–4.2), presence of a preoperative positive posterior impingement test (HR 2.5 1.7–3.2), a preoperative internal rotation of < 20° (HR 4.3 3.7–4.9), a preoperative Tönnis Grade > 1 (HR 5.7 5.0–6.4), a postoperative anterior coverage > 27% (HR 3.2 2.5–3.9), and a postoperative acetabular retroversion (HR 4.8 3.4–6.3).
Conclusions
Thirty years postoperatively, 29% of hips undergoing PAO for hip dysplasia can be preserved, but more than 70% will develop progressive osteoarthritis, pain, and/or undergo THA. Periacetabular osteotomy is an effective technique to treat symptomatic hip dysplasia in selected and young patients with closed triradiate cartilage. Hips with advanced joint degeneration (osteoarthritis Tönnis Grade ≥ 2) should not be treated with PAO. Postoperative anterior acetabular overcoverage or postoperative acetabular retroversion were associated with decreased joint survival.
Level of Evidence
Level III, therapeutic study.
Full text
Available for:
FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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