Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 470 | Issue 12 | Dec, 2012

Hip Ontogenesis: How Evolution, Genes, and Load History Shape Hip Morphotype and Cartilotype

Tom Hogervorst MD, PhD, Wouter Eilander MD, Joost T. Fikkers MSc, Ingrid Meulenbelt PhD

Developmental hip disorders (DHDs), eg, developmental dysplasia of the hip, slipped capitis femoris epiphysis, and femoroacetabular impingement, can be considered morphology variants of the normal hip. The femoroacetabular morphology of DHD is believed to induce osteoarthritis (OA) through local cumulative mechanical overload acting on genetically controlled patterning systems and subsequent damage of joint structures. However, it is unclear why hip morphology differs between individuals with seemingly comparable load histories and why certain hips with DHD progress to symptomatic OA whereas others do not.

Pelvic Morphology Differs in Rotation and Obliquity Between Developmental Dysplasia of the Hip and Retroversion

Moritz Tannast MD, Peter Pfannebecker MD, Joseph M. Schwab MD, Christoph E. Albers MD, Klaus A. Siebenrock MD, Lorenz Büchler MD

Developmental dysplasia of the hip (DDH) and acetabular retroversion represent distinct acetabular pathomorphologies. Both are associated with alterations in pelvic morphology. In cases where direct radiographic assessment of the acetabulum is difficult or impossible or in mixed cases of DDH and retroversion, additional indirect pelvimetric parameters would help identify the major underlying structural abnormality.

Hip Capsule Dimensions in Patients With Femoroacetabular Impingement: A Pilot Study

Jan Weidner MD, Lorenz Büchler MD, Martin Beck MD

Joint-preserving hip surgery, either arthroscopic or open, increasingly is used for the treatment of symptomatic femoroacetabular impingement (FAI). As a consequence of surgery, thickening of the joint capsule and intraarticular adhesions between the labrum and joint capsule and between the femoral neck and the joint capsule have been observed. These alterations are believed to cause persistent pain and reduced range of motion. Because the diagnosis is made with MR arthrography, knowledge of the normal capsular anatomy and thickness on MRI in patients is important. To date there is no such information available.

Do Plain Radiographs Correlate With CT for Imaging of Cam-type Femoroacetabular Impingement?

Jeffrey J. Nepple MD, John M. Martel MD, Young-Jo Kim MD, Ira Zaltz MD, John C. Clohisy MD

Three-dimensional imaging (CT and MRI) is the gold standard for detecting femoral head-neck junction malformations in femoroacetabular impingement, yet plain radiographs are used for initial diagnostic evaluation. It is unclear, however, whether the plain radiographs accurately reflect the findings on three-dimensional imaging.

MRI of Hip Cartilage: Joint Morphology, Structure, and Composition

Stephanie L. Gold BA, Alissa J. Burge MD, Hollis G. Potter MD

Accurate, reproducible, and noninvasive assessment of hip cartilage is clinically relevant and provides a means by which to assess the suitability of candidates for arthroscopic or open surgical procedures and the response to such interventions over time. Given the relatively thin cartilage of the hip and the complex spherical anatomy, however, accurately assessing the cartilage poses a challenge for traditional MRI techniques.

Anterior Delayed Gadolinium-enhanced MRI of Cartilage Values Predict Joint Failure After Periacetabular Osteotomy

Sang Do Kim MD, Rebecca Jessel MD, David Zurakowski PhD, Michael B. Millis MD, Young-Jo Kim MD, PhD

Several available compositional MRIs seem to detect early osteoarthritis before radiographic appearance. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) has been most frequently used in clinical studies and reportedly predicts premature joint failure in patients undergoing Bernese periacetabular osteotomies (PAOs).

Patient Selection Criteria for Periacetabular Osteotomy or Rotational Acetabular Osteotomy

Yuji Yasunaga MD, Takuma Yamasaki MD, Mitsuo Ochi MD

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.

The Acetabular Wall Index for Assessing Anteroposterior Femoral Head Coverage in Symptomatic Patients

Klaus A. Siebenrock MD, Lea Kistler, Joseph M. Schwab MD, Lorenz Büchler MD, Moritz Tannast MD

Understanding acetabular pathomorphology is necessary to correctly treat patients with hip complaints. Existing radiographic parameters classify acetabular coverage as deficient, normal, or excessive but fail to quantify contributions of anterior and posterior wall coverage. A simple, reproducible, and valid measurement of anterior and posterior wall coverage in patients with hip pain would be a clinically useful tool.

Can the Alpha Angle Assessment of Cam Impingement Predict Acetabular Cartilage Delamination?

Paul E. Beaulé MD, FRCSC, Kelly Hynes MD, Gillian Parker BSc, Kyle A. Kemp MSc

Substantial acetabular cartilage damage is commonly present in patients suffering from femoral acetabular impingement (FAI). A better understanding of which patient is at risk of developing substantial cartilage damage is critical for establishing appropriate treatment guidelines.

Radiographic Features Associated With Differing Impinging Hip Morphologies With Special Attention to Coxa Profunda

Gregory Boone BS, Michael R. Pagnotto MD, Justin A. Walker MD, Robert T. Trousdale MD, Rafael J. Sierra MD

Combined with clinical examination and MRI, radiographs have been mainstays in the management femoroacetabular impingement (FAI). Because hip morphology often portends intraoperative damage, radiographic features should inform surgical management.

Coxa Profunda: Is the Deep Acetabulum Overcovered?

Lucas A. Anderson MD, Ashley L. Kapron BS, Stephen K. Aoki MD, Christopher L. Peters MD

Coxa profunda, or a deep acetabular socket, is often used to diagnose pincer femoroacetabular impingement (FAI). Radiographically, coxa profunda is the finding of an acetabular fossa medial to the ilioischial line. However, the relative position of the acetabular fossa to the pelvis may not be indicative of acetabular coverage.

Parafoveal Chondral Defects Associated with Femoroacetabular Impingement

Ira Zaltz MD, Michael Leunig MD

Cam-type, pincer, and mixed femoroacetabular impingement (FAI) are accepted causes of labral and acetabular rim injury; however, the abnormal contact stresses associated with motion may damage other areas of the hip. Although cartilage damage to the femoral head has been reported previously in athletes, FAI-associated focal parafoveal chondral defects differ from previously reported lesions and represent a rare manifestation of the complex pathomechanics associated with FAI.

Is Posterior Hip Instability Associated with Cam and Pincer Deformity?

Aaron J. Krych MD, Matt Thompson MD, Christopher M. Larson MD, J. W. Thomas Byrd MD, Bryan T. Kelly MD

Posterior hip instability is an increasingly recognized injury in athletes; however, the function of patients after these injuries and an understanding of the pathoanatomy and underlying mechanism are currently unclear.

The Biomechanical Case for Labral Débridement

Ira Zaltz MD

Labral repair is increasingly performed in conjunction with open and arthroscopic surgical procedures used to treat patients with mechanically related hip pain. The current rationale for labral repair is based on restoring the suction-seal function and clinical reports suggesting improved clinical outcome scores when acetabular rim trimming is accompanied by labral repair. However, it is unclear whether available scientific evidence supports routine labral repair.

Save the Torn Labrum in Hips With Borderline Acetabular Coverage

Niraj V. Kalore MD, William A. Jiranek MD

Hip arthroscopy for labral tears improves short-term function, but reoperations occur in 5% to 47% of patients. The effect of borderline acetabular coverage on reoperation rate has been debated. Labral repair rather than débridement has been proposed to improve function, but the effect on reoperation rate is unclear.

Preliminary Pain and Function After Labral Reconstruction During Femoroacetabular Impingement Surgery

Justin A. Walker MD, Michael Pagnotto MD, Robert T. Trousdale MD, Rafael J. Sierra MD

Labral refixation rather than resection provides better pain relief and function after femoroacetabular impingement (FAI) surgery. When the labrum is absent, degenerated, or is irreparable, reconstruction may provide a favorable biomechanical environment for the hip. However, it is unclear whether labral reconstruction relieves pain and restores function.

Surgical Technique: Second-generation Bone Marrow Stimulation via Surgical Dislocation to Treat Hip Cartilage Lesions

Michael Leunig MD, Lisa M. Tibor MD, Florian D. Naal MD, Reinhold Ganz MD, Matthias R. Steinwachs MD

Compared to knees, hips have more bony constraint and soft tissue coverage. Thus, repair of focal cartilage defects in hips requires more invasive and technically complex surgeries than simple arthroscopy or arthrotomy. Autologous matrix-induced chondrogenesis (AMIC) is a second-generation bone marrow stimulation technique. Improvement in Tegner, Lysholm, International Cartilage Repair Society (ICRS), and Cincinnati scores has been reported at 1 and 2 years after AMIC in knees. AMIC is potentially useful to repair defects in hips, but it is unknown whether it relieves symptoms or results in a durable construct.

Slipped Capital Femoral Epiphysis: Prevalence, Pathogenesis, and Natural History

Eduardo N. Novais MD, Michael B. Millis MD

Obesity is a risk factor for developing slipped capital femoral epiphysis (SCFE). The long-term outcome after SCFE treatment depends on the severity of residual hip deformity and the occurrence of complications, mainly avascular necrosis (AVN). Femoroacetabular impingement (FAI) is associated with SCFE-related deformity and dysfunction in both short and long term.

What Are the Factors Associated With Acetabular Correction in Perthes-like Hip Deformities?

John C. Clohisy MD, James R. Ross MD, Joshua D. North MD, Jeffrey J. Nepple MD, Perry L. Schoenecker MD

Perthes-like hip deformities encompass variable proximal femoral abnormalities and associated acetabular dysplasia that can be reconstructed with contemporary hip preservation procedures. Nevertheless, the necessity and indications for surgical correction of associated acetabular dysplasia have not been established.

Early Experience With a Comprehensive Hip Preservation Service Intended to Improve Clinical Care, Education, and Academic Productivity

Christopher L. Peters MD, Stephen K. Aoki MD, Jill A. Erickson PA-C, Lucas A. Anderson MD, Andrew E. Anderson PhD

The field of hip preservation surgery has grown substantially over the past decade. Although open hip procedures reportedly relieve pain and restore function, arthroscopic treatment has increasingly become a reasonable alternative. In 2008, we formed a comprehensive hip preservation service (HPS) to address clinical, educational, and research needs.

Report of Breakout Session: Strategies to Improve Hip Preservation Training

Christopher L. Peters MD, Paul E. Beaulé MD, Martin Beck MD, Moritz Tannast MD, William Jiranek MD, Rafael J. Sierra MD

To What Degree do Shoulder Outcome Instruments Reflect Patients’ Psychologic Distress?

Young Hak Roh MD, Jung Ho Noh MD, Joo Han Oh MD, Goo Hyun Baek MD, Hyun Sik Gong MD

Psychologic distress contributes to symptom severity in patients with several musculoskeletal disorders. While numerous shoulder outcome instruments are used it is unclear whether and to what degree psychologic distress contributes to the scores.

The Natural Progression of Adult Elbow Osteonecrosis Related To Corticosteroid Treatment

Charles-Henri Flouzat-Lachaniette MD, Chaib Younes MD, William Delblond MD, Nicolas Dupuy MD, Philippe Hernigou MD

In patients with corticosteroid treatment, the elbow is a rare site of osteonecrosis; there is little information about the rate and risk factors of disease progression in symptomatic and asymptomatic elbows.

Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial

Harm W. Boons MD, Jon H. Goosen MD, PhD, Susan Grinsven MSc, Job L. Susante MD, PhD, Corné J. Loon MD, PhD

Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function.

Quantitative 3D-CT Anatomy of Hamate Osteoarticular Autograft for Reconstruction of the Middle Phalanx Base

Paul Berg MSc, David Ring MD, PhD

Hamate osteoarticular autografts are difficult to obtain and it is unclear to what degree the graft matches the joint surface to be replaced and whether a direct ulnar approach might provide a more reliable graft than the standard proximal to distal approach.

Reliability of Bucholz and Ogden Classification for Osteonecrosis Secondary to Developmental Dysplasia of the Hip

Andreas Roposch MD, MSc, FRCS, John H. Wedge OC, MD, FRCS(C), Georg Riedl MD

Osteonecrosis is perhaps the most important serious complication after treatment of developmental dysplasia of the hip (DDH). The classification by Bucholz and Ogden has been used most frequently for grading osteonecrosis in this context, but its reliability is not established and unreliability could affect the validity of studies reporting the outcome of treatment.

Do Fluoroscopy and Postoperative Radiographs Correlate for Periacetabular Osteotomy Corrections?

Charles L. Lehmann MD, Jeffrey J. Nepple MD, Geneva Baca BA, Perry L. Schoenecker MD, John C. Clohisy MD

The Bernese periacetabular osteotomy (PAO) can relieve pain and restore function in patients with symptomatic acetabular dysplasia. Accurate acetabular correction is fundamental to achieving these clinical goals and presumably enhancing survivorship of the reconstruction. Fluoroscopy is used by some surgeons to assess intraoperative acetabular correction but it is unclear whether the features observed by fluoroscopy accurately reflect those on postoperative radiographs.

Acetabular Component Positioning Using Anatomic Landmarks of the Acetabulum

Yong-Chan Ha MD, Jeong Joon Yoo MD, PhD, Young-Kyun Lee MD, Jin Young Kim MD, Kyung-Hoi Koo MD

The acetabular cup should be properly oriented to prevent dislocation and to reduce wear. However, achieving proper cup placement is challenging with potentially large variations of cup position. We propose a new technique to position the acetabular cup.

Anterior Impingement Test for Labral Lesions Has High Positive Predictive Value

Takehito Hananouchi MD, PhD, Yukihiko Yasui MD, Kengo Yamamoto MD, Yukiyoshi Toritsuka MD, PhD, Kenji Ohzono MD, PhD

The anterior impingement test is intended to detect anterosuperior acetabular labral lesions. In patients treated for labral lesions its sensitivity is reportedly 95% to 100%, and in a small group of patients undergoing periacetabular osteotomy, its sensitivity was 59% and specificity 100%. However, the sensitivity, specificity, positive predictive value, and negative predict value of this test to detect these labral lesions in unselected patients with hip pain are unknown.

Alumina-on-alumina THA Performed in Patients Younger Than 30 Years: A 10-year Minimum Followup Study

Hyeong Jo Yoon MD, Jeong Joon Yoo MD, Kang Sup Yoon MD, Kyung-Hoi Koo MD, Hee Joong Kim MD

THA in patients younger than 30 years presents challenges because of uncertainties regarding the long-term survivorship of prostheses. Alumina-on-alumina bearings, which exhibit little long-term wear, may be a reasonable option but the long-term survivorship is unknown.

Cross-sectional Anatomy of the Ilium: Implications for Acetabular Component Placement in Total Hip Arthroplasty

John Antoniades MD, Vincent D. Pellegrini MD

High hip center reconstructions, used in revision and complex primary THAs, rely on pelvic bone stock at least 35 mm above the anatomic teardrop. However, the technique does not restore normal hip biomechanics and controversy exists regarding acetabular implant survival. Previous reports document a wide range of implant positioning above the teardrop. There is no anatomic guidance in the literature regarding the amount of bone stock available for initial implant stability in this area of the ilium.

A Dual-mobility Cup Reduces Risk of Dislocation in Isolated Acetabular Revisions

Roberto Civinini MD, Christian Carulli MD, Fabrizio Matassi MD, Lorenzo Nistri MD, Massimo Innocenti MD

Isolated acetabular revisions using standard cups are at risk of dislocation. The introduction of a nonconstrained dual-mobility cup was designed to improve prosthetic stability without increasing loosening rates, but it is unclear whether the risk of dislocation is reduced.

All-polyethylene Tibial Components are Equal to Metal-backed Components: Systematic Review and Meta-regression

Klaas Auke Nouta MD, Wiebe C. Verra MD, Bart G. Pijls MD, Jan W. Schoones MA, Rob G. H. H. Nelissen MD, PhD

Less than 1% of all primary TKAs are performed with an all-polyethylene tibial component, although recent studies indicate all-polyethylene tibial components are equal to or better than metal-backed ones.

Sagittal Cutting Error Changes Femoral Anteroposterior Sizing in Total Knee Arthroplasty

Hiroyuki Nakahara MD, Shuichi Matsuda MD, PhD, Ken Okazaki MD, PhD, Yasutaka Tashiro MD, PhD, Yukihide Iwamoto MD, PhD

Prosthetic alignment and size are important factors in achieving a long-term survival in TKA. Although two-dimensional and three-dimensional (3-D) planning for component sizing has been introduced, it sometimes is difficult to cut the bones accurately according to preoperative planning. It is unclear whether changing sagittal alignment of the distal femur affects the AP dimension and sizing of the prepared bone.

Reliability of Lower-limb Alignment Measurements in Patients With Multiple Epiphyseal Dysplasia

Bekhzad Akhmedov MD, Ki Hyuk Sung MD, Chin Youb Chung MD, Kyoung Min Lee MD, Moon Seok Park MD

Although radiographic measurements are used in multiple epiphyseal dysplasia (MED) during correction of lower-limb alignment, the reliabilities of the measurements are unclear.

Surgical Technique: Unicondylar Osteoallograft Prosthesis Composite in Tumor Limb Salvage Surgery

Hongbin Fan MD, Zheng Guo MD, Zhen Wang MD, Jing Li MD, Xiangdong Li MD

After resecting tumors confined to one femoral condyle, a unicondylar osteoarticular allograft can be used for reconstruction without sacrificing the uninvolved condyle. However, unicondylar osteoarticular allografts have been associated with a high rate of joint degeneration. We describe a unicondylar osteoallograft prosthesis composite reconstruction replacing only one side of the joint to reduce compartment degeneration and avoid contamination of the tibia, but the survival, function, and complications of a unicondylar osteoallograft prosthesis composite are unclear.

Widespread Osteonecrosis in Children With Leukemia Revealed by Whole-body MRI

Paivi Maria Miettunen MD, Lucie Lafay-Cousin MD, Gregory M. T. Guilcher MD, Alberto Nettel-Aguirre PhD, Vijay Moorjani MD

Confirmation of early long-bone epiphyseal osteonecrosis in pediatric patients with leukemia allows for medical and surgical intervention before articular surface collapse. MRI detects early osteonecrosis, but multiple focused MR images are required to capture all lesions.

Do Concomitant Fractures With Hip Fractures Influence Complication Rate and Functional Outcome?

Benjamin Buecking MD, Christina Wack MD, Ludwig Oberkircher MD, Steffen Ruchholtz MD, Daphne Eschbach MD

Owing to the aging population, the incidence of hip fractures is increasing. While concomitant fractures are not uncommon, it is unclear how they influence subsequent function.

VEGF Improves Skeletal Muscle Regeneration After Acute Trauma and Reconstruction of the Limb in a Rabbit Model

Soenke Percy Frey MD, Hendrik Jansen MD, Michael J. Raschke MD, Rainer H. Meffert MD, Sabine Ochman MD

Complicated tibial fractures with severe soft tissue trauma are challenging to treat. Frequently associated acute compartment syndrome can result in scarring of muscles with impaired function. Several studies have shown a relationship between angiogenesis and more effective muscle regeneration. Vascular endothelial growth factor (VEGF) is associated with angiogenesis but it is not clear whether it would restore muscle force, reduce scarring, and aid in muscle regeneration after acute musculoskeletal trauma.

Case Report: Osteochondral Avulsion Fracture of the Posteromedial Bundle of the PCL in Knee Hyperflexion

Zhihong Xu MD, Dongyang Chen MD, Dongquan Shi MD, Qing Jiang PhD

Injury of the PCL of the knee in adults usually results in rupture rather than avulsion fracture and avulsions usually occur at the tibial insertion.

Erratum to: Giant Cell Tumor With Pathologic Fracture: Should We Curette or Resect?

Lizz Heijden MSc, P. D. Sander Dijkstra MD, PhD, Domenico A. Campanacci MD, PhD, C. L. Max H. Gibbons MA, FRCS(Orth), Michiel A. J. Sande MD, PhD

Complications In Brief: Osteotomy for Lower Extremity Malalignment

Loukas Koyonos MD, Nick Slenker MD, Steven Cohen MD When performing an osteotomy for lower extremity malalignment, several complications can occur. These can include introducing iatrogenic malalignment, intraoperative fracture or vascular injury, postoperative recurrence of deformity, patella baja, and challenges when performing subsequent total knee replacement in the future. Likewise, a poor functional result can occur secondary to poor preoperative planning and patient selection. In this article, we review the complications that can occur as a result of errors made before, during, and after surgery. This article pertains to opening and closing wedge osteotomies of the distal femur and proximal tibia.

Orthopaedic Case of the Month: Painless Right Knee Mass in 32-year-old Man

Michael K. Merz MD, Mansooreh Eghtesadghalati MD, Michael E. Bresler MD, Yasser R. Farid MD, PhD
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