How to prevent graft resorption or breakage in shelf acetabuloplasty for Perthes disease with hinge abduction – A modified Staheli technique successful in 31 hips in midterm results

BACKGROUND: Shelf acetabuloplasty covers the hip and allows remodeling in hips with Legg-Calv-Perthes disease and hinge abduction. Graft resorption or breakage is a bad complication that necessitate another surgical procedure. AIM: Our report evaluates a modified Staheli technique for graft resorption or breakage. MATERIALS AND METHODS: Case series study of 31 hips (29 patients) with mean age at operation was 8.1 (range 6-14 years). Duration of complaint ranged between one year and up to three years with the mean duration 1.52 0.76 years. The different parameters evaluating the hip as: Tnnis angle, Sharp angle, center-edge angle, and acetabular coverage percentage were measured. For unilateral cases only, medial joint space ratio and epiphyseal height ratio were evaluated. RESULTS: The mean postoperative follow-up was 47.8 9.8 months. All studied joints had Catterall type IV, Salter-Thompson classification type B. Seven joints were in Fragmentation stage whereas 24 joints were in re-ossification stage. Based on Lateral Pillar classification; only two joints were classified as B/C and 29 joints were classified as C. Final follow up internal rotation, abduction, center-edge angle, and acetabular coverage percentage were found to be significantly higher. In contrast, Tnnis angle and Sharps angle were significantly decreased. For unilateral cases, it was found that medial joint space ratio and epiphyseal height ratio were significantly decreased. None of the hips had resorbed or broken graft till final follow up. CONCLUSIONS: This modified Staheli technique prevent graft resorption or breakage. Shelf provides a good acetabular coverage for the deformed aspherical head with Legg-Calv-Perthes disease and hinge abduction to improve hip clinical and radiological outcome.

PREOPERATIVE 3D MODELING AND PRINTING FOR GUIDING PERIACETABULAR OSTEOTOMY

Background: Achieving adequate acetabular correction in multiple planes is essential to the success of Periacetabular Osteotomy (PAO). Three-dimensional (3D) modeling and printing has the potential to improve preoperative planning by accurately guiding intraoperative correction. Hypothesis/Purpose: We, therefore, asked the following questions: 1) For a patient undergoing a PAO, does 3D-modeling with intraoperative 3D-printed models create a reproducible surgical plan to obtain predetermined parameters of correction including lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), Tonnis angle, and femoral head extrusion index (FHEI), 2) Can 3D computer modeling accurately predict when a normalized FHEI can be achieved without the need for a concomitant femoral sided osteotomy? Methods: A retrospective review was conducted on forty-two (42) consecutive patients that underwent a PAO. 3D-modeling software was utilized to simulate a PAO in order to achieve normal LCEA, ACEA, Tonnis angle, and FHEI. If adequate FHEI was not achieved, a femoral osteotomy was simulated. 3D-models were printed as intraoperative guides. Preoperative, simulated, and postoperative ACEA, LCEA, Tonnis angle, and FHEI were measured and compared statistically. Results: 40 patients had a traditional PAO, and 2 had an anteverting-PAO. The simulated LCEA, ACEA, Tonnis angle, and FHEI were within a median difference of 3º, 1º, 1°, and 0% of postoperative values, respectively and showed no statistical difference. Of those that had a traditional PAO, all thirty-four (34) patients were correctly predicted to need a traditional acetabular sided correction alone and the other six (6) were correctly predicted to need a concomitant femoral osteotomy for a correct prediction in 100% of patients. Conclusion: This study demonstrated that in PAO, 3D-modeling and printing allow the surgeon to accurately create a reproducible surgical plan to obtain predetermined postoperative hip coverage parameters. This new technology has the potential to improve preoperative/intra-operative decision making for hip dysplasia and other complex disorders of the hip.

Achieving Successful Outcomes in High-Level Athletes With Borderline Hip Dysplasia Undergoing Hip Arthroscopy With Capsular Plication and Labral Preservation: A Propensity-Matched Controlled Study

Background: Return to sports (RTS) rates and patient-reported outcomes (PROs) after hip arthroscopy in athletes with borderline dysplasia (BD) have not been established. Purpose: (1) To report minimum 2-year PROs and RTS rates in high-level athletes with BD who underwent hip arthroscopy for labral pathology in the setting of microinstability and (2) to compare clinical results with those of a matched control group of athletes with normal acetabular coverage. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reviewed for surgery performed between January 2012 and July 2018. Patients were considered eligible if they received a primary hip arthroscopy in the setting of BD (lateral center-edge angle, 18°-25°) and competed in professional, collegiate, or high school sports. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score–Sport Specific Subscale, and visual analog scale for pain. Athletes with BD were matched to a control group of athletes with normal acetabular coverage (lateral center-edge angle, 25°-40°). Results: A total of 65 patients with BD were included in the study with a mean ± standard deviation follow-up of 47.5 ± 20.4 months. Athletes with BD showed significant improvement in all outcome measures recorded, demonstrated high RTS rates (80.7%), and achieved the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the Hip Outcome Score–Sport Specific Subscale at high rates (MCID, 90.8%; PASS, 75.4%). When compared with a propensity-matched control group with normal acetabular coverage, capsular plication was performed more commonly in the BD group (93.8% vs 82.7%; P = .037). PROs and RTS, PASS, and MCID rates were similar between the BD and control groups ( P > .05). Conclusion: High-level athletes with BD who undergo primary hip arthroscopy for labral pathology in the setting of microinstability may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a control group of athletes with normal coverage.

Use of Younger Patient Age and Greater Anterior Center-Edge Angle to Predict the Need for Bilateral Hip Arthroscopy in Patients With Bilateral Femoroacetabular Impingement–Related Hip Pain

Background: In patients with symptomatic femoroacetabular impingement syndrome, bilateral hip pain has been reported to occur in high frequency. However, not all patients require bilateral hip arthroscopy. Purpose: To determine the incidence, patient-specific variables, and postoperative outcomes in patients who presented with bilateral hip pain at the time of index hip arthroscopy and underwent subsequent contralateral arthroscopic hip surgery. Study Design: Case series; Level of evidence, 4. Methods: Patients who presented with bilateral hip pain, underwent primary hip arthroscopy between January 2012 and June 2018 for indication of femoroacetabular impingement syndrome, and had minimum 2-year follow-up were retrospectively analyzed. Baseline descriptive data, preoperative hip range of motion, and radiographic measurements were recorded with pre- and postoperative patient-reported outcomes (PROs). Independent samples t test was used to compare continuous variables, and chi-square test was used to compare categorical variables between patients undergoing unilateral and bilateral surgery. Bivariate correlations and a multivariable binary logistic regression were performed to determine factors predictive of the need for future contralateral hip arthroscopy. Results: In total, 108 patients were identified who reported bilateral hip pain during the index evaluation, underwent primary hip arthroscopy, and had 2-year follow-up. Among these, 42% (n = 45) elected to undergo hip arthroscopy on the contralateral hip at a mean of 6.0 months (range, 1-17 months) after the index surgery. Patients requiring bilateral surgery were significantly younger ( P = .004) and had a larger preoperative anterior center-edge angle (ACEA; P = .038) when compared with patients who had unilateral surgery. There were no significant differences in alpha angle measurements between patients who had unilateral and bilateral surgery. On bivariate analysis, younger age at the time of the index surgery ( r = −0.272; P = .005) and preoperative ACEA ( r = 0.249; P = .016) were significantly correlated with the need for bilateral surgery. On multivariate analysis, younger age remained a significant predictor for bilateral surgery (odds ratio, 0.95; 95% CI, 0.91-0.99). Patients who underwent bilateral hip arthroscopy reported significant improvement in all PROs ( P < .001), with a significantly greater mean Hip Outcome Score− Sports Specific Subscale score when compared with patients undergoing unilateral surgery ( P = .037). Conclusion: Subsequent contralateral hip arthroscopy was performed in 42% of patients who presented with bilateral hip pain. Younger age at the time of the index surgery and greater ACEA were predictive of the need for contralateral surgery. Patients undergoing bilateral surgery reported significantly improvement in PROs at minimum 2-year follow-up.

Short-term patient-reported outcomes following concomitant hip arthroscopy and the endoscopic modified shelf procedure for the treatment of acetabular dysplasia and intra-articular pathology

The shelf procedure is a treatment of acetabular dysplasia, with the aim of increasing weight-bearing acetabular coverage. Although several shelf techniques have been described, the endoscopic procedure with concomitant hip arthroscopy is a new, less invasive alternative. Outcomes following this procedure are scarce. The purpose of this study was to report short-term patient-reported outcomes (PROs) following concomitant hip arthroscopy and endoscopic modified shelf procedure in the setting of acetabular dysplasia and labral tears. Patients that met extraordinarily selective surgical indications and underwent the abovementioned surgery between February 2016 and October 2019 and had minimum 1-year follow-up were included. There were five females with a mean age of 40.18 ± 5.05 years and follow-up of 21.55 ± 8.68 months. The lateral center-edge angle increased from 15.80° to 23.20° (P = 0.003), and vertical center-edge angle increased from 16.60° to 23.60° (P &lt; 0.001). The Tönnis angle decreased from 15.40° to 3.74° (P &lt; 0.001). The alpha angle decreased from 58.46° to 40.70° (P &lt; 0.001). PROs demonstrated significant improvement at latest follow-up (modified Harris Hip Score, P = 0.042; Non-Arthritic Hip Score, P &lt; 0.001; Hip Outcome Score–Sports Specific Subscale, P = 0.035; Visual Analog Scale, P &lt; 0.001; International Hip Outcome Tool-12, P = 0.043), and satisfaction was 8.60 ± 0.89. No secondary surgeries were reported. Concomitant hip arthroscopy and endoscopic modified shelf procedure appears to be a safe and effective procedure for patients with acetabular dysplasia and labral tears yielding favorable outcomes and satisfaction at short-term follow-up.

Comparison Between Hip Arthroscopic Surgery and Periacetabular Osteotomy for the Treatment of Patients With Borderline Developmental Dysplasia of the Hip: A Systematic Review

Background: The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH. Purpose: To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH. Study Design: Systematic review; Level of evidence, 4. Methods: Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH. Results: A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures. Conclusion: There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.