Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 473 | Issue 4 | Apr, 2015

Editorial: Estimating Survivorship in the Face of Competing Risks

M. Daniel Wongworawat MD, Matthew B. Dobbs MD, Mark C. Gebhardt MD, Terence J. Gioe MD, Seth S. Leopold MD, Paul A. Manner MD, Clare M. Rimnac PhD, Raphaël Porcher PhD

Most American Academy of Orthopaedic Surgeons’ Online Patient Education Material Exceeds Average Patient Reading Level

Adam E. M. Eltorai BA, Pranav Sharma BS, Jing Wang BS, Alan H. Daniels MD

Advancing health literacy has the potential to improve patient outcomes. The American Academy of Orthopaedic Surgeons’ (AAOS) online patient education materials serve as a tool to improve health literacy for orthopaedic patients; however, it is unknown whether the materials currently meet the National Institutes of Health/American Medical Association’s recommended sixth grade readability guidelines for health information or the mean US adult reading level of eighth grade.

What Ape Proximal Femora Tell Us About Femoroacetabular Impingement: A Comparison

Joost T. Fikkers MSc, Heinse W. Bouma MD, Stefan F. Boer MD, Paul A. Toogood MD, Paulien M. Kampen PhD, Tom Hogervorst MD, PhD

Human hip morphology is variable, and some variations (or hip morphotypes) such as coxa profunda and coxa recta (cam-type hip) are associated with femoroacetabular impingement and the development of osteoarthrosis. Currently, however, this variability is unexplained. A broader perspective with background information on the morphology of the proximal femur of nonhuman apes is lacking. Specifically, no studies exist of nonhuman ape femora that quantify concavity and its variability.

Twelve Percent of Hips With a Primary Cam Deformity Exhibit a Slip-like Morphology Resembling Sequelae of Slipped Capital Femoral Epiphysis

Christoph E. Albers MD, Simon D. Steppacher MD, Pascal C. Haefeli MD, Stefan Werlen MD, Markus S. Hanke MD, Klaus A. Siebenrock MD, Moritz Tannast MD

In some hips with cam-type femoroacetabular impingement (FAI), we observed a morphology resembling a more subtle form of slipped capital femoral epiphysis (SCFE). Theoretically, the morphology in these hips should differ from hips with a primary cam-type deformity.

How Do Acetabular Version and Femoral Head Coverage Change With Skeletal Maturity?

Andreas M. Hingsammer MD, Sarah Bixby MD, David Zurakowski PhD, Yi-Meng Yen MD, PhD, Young-Jo Kim MD, PhD

Normal changes in acetabular version over the course of skeletal development have not been well characterized. Knowledge of normal version development is important because acetabular retroversion has been implicated in several pathologic hip processes.

What Are the Radiographic Reference Values for Acetabular Under- and Overcoverage?

Moritz Tannast MD, Markus S. Hanke MD, Guoyan Zheng PhD, Simon D. Steppacher MD, Klaus A. Siebenrock MD

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.

Are Normal Hips Being Labeled as Pathologic? A CT-based Method for Defining Normal Acetabular Coverage

Christopher M. Larson MD, Alexandre Moreau-Gaudry MD, PhD, Bryan T. Kelly MD, J. W. Thomas Byrd MD, Jérôme Tonetti MD, PhD, Stephane Lavallee PhD, Laurence Chabanas MS, Guillaume Barrier MS, Asheesh Bedi MD

Plain radiographic measures of the acetabulum may fail to accurately define coverage or pathomorphology such as impingement or dysplasia. CT scans might provide more precise measurements for overcoverage and undercoverage. However, a well-defined method for such CT-based measurements and normative data regarding CT-based acetabular coverage is lacking.

Which Radiographic Hip Parameters Do Not Have to Be Corrected for Pelvic Rotation and Tilt?

Moritz Tannast MD, Stefan Fritsch MD, Guoyan Zheng PhD, Klaus A. Siebenrock MD, Simon D. Steppacher MD

Acetabular anatomy on AP pelvic radiographs depends on pelvic orientation during radiograph acquisition. However, not all parameters may change to a clinically relevant degree with differences in pelvic orientation. This issue may influence the diagnosis of acetabular pathologies and planning of corrective acetabular surgery (reorientation or rim trimming). However, to this point, it has not been well characterized.

Functional Acetabular Orientation Varies Between Supine and Standing Radiographs: Implications for Treatment of Femoroacetabular Impingement

James R. Ross MD, Eric P. Tannenbaum MD, Jeffrey J. Nepple MD, Bryan T. Kelly MD, Christopher M. Larson MD, Asheesh Bedi MD

Often, anteroposterior (AP) pelvic radiographs are performed with the patient positioned supine. However, this may not represent the functional position of the pelvis and the acetabulum, and so when assessing patients for conditions like femoroacetabular impingement (FAI), it is possible that standing radiographs better incorporate the dynamic influences of periarticular musculature and sagittal balance. However, this thesis remains largely untested.

Head Reduction Osteotomy With Additional Containment Surgery Improves Sphericity and Containment and Reduces Pain in Legg-Calvé-Perthes Disease

Klaus A. Siebenrock MD, Helen Anwander MD, Corinne A. Zurmühle MD, Moritz Tannast MD, Theddy Slongo MD, Simon D. Steppacher MD

Severe femoral head deformities in the frontal plane such as hips with Legg-Calvé-Perthes disease (LCPD) are not contained by the acetabulum and result in hinged abduction and impingement. These rare deformities cannot be addressed by resection, which would endanger head vascularity. Femoral head reduction osteotomy allows for reshaping of the femoral head with the goal of improving head sphericity, containment, and hip function.

What Is the Impingement-free Range of Motion of the Asymptomatic Hip in Young Adult Males?

Brian Larkin MD, Marnix Holsbeeck MD, Denise Koueiter MS, Ira Zaltz MD

Femoroacetabular impingement is a recognized cause of chondrolabral injury. Although surgical treatment for impingement seeks to improve range of motion, there are very little normative data on dynamic impingement-free hip range of motion (ROM) in asymptomatic people. Hip ultrasound demonstrates labral anatomy and femoral morphology and, when used dynamically, can assist in measuring range of motion.

Patient-Specific Anatomical and Functional Parameters Provide New Insights into the Pathomechanism of Cam FAI

K. C. Geoffrey Ng MASc, Mario Lamontagne PhD, Andrew P. Adamczyk MSc, Kawan S. Rahkra MD, Paul E. Beaulé MD

Femoroacetabular impingement (FAI) represents a constellation of anatomical and clinical features, but definitive diagnosis is often difficult. The high prevalence of cam deformity of the femoral head in the asymptomatic population as well as clinical factors leading to the onset of symptoms raises questions as to what other factors increase the risk of cartilage damage and hip pain.

What Are the Demographic and Radiographic Characteristics of Patients With Symptomatic Extraarticular Femoroacetabular Impingement?

Benjamin F. Ricciardi MD, Peter D. Fabricant MD, MPH, Kara G. Fields MS, Lazaros Poultsides MD, MS, PhD, Ira Zaltz MD, Ernest L. Sink MD

Extraarticular femoroacetabular impingement (FAI) can result in symptomatic hip pain, but preoperative demographic, radiographic, and physical examination findings have not been well characterized.

Can Femoral Rotation Be Localized and Quantified Using Standard CT Measures?

Andrew G. Georgiadis MD, Daniel S. Siegal MD, Courtney E. Scher DO, Ira Zaltz MD

The terms “femoral anteversion” and “femoral torsion” have often been used interchangeably in the orthopaedic literature, yet they represent distinct anatomical entities. Anteversion refers to anterior tilt of the femoral neck, whereas torsion describes rotation of the femoral shaft. Together, these and other transverse plane differences describe what may be considered rotational deformities of the femur. Assessment of femoral rotation is now routinely measured by multiple axial CT methods. The most widely used radiographic technique (in which only two CT-derived axes are made, one through the femoral neck and one at the distal femoral condyles) may not accurately quantify proximal femoral anatomy nor allow identification of the anatomic locus of rotation.

Biochemical MRI Predicts Hip Osteoarthritis in an Experimental Ovine Femoroacetabular Impingement Model

Klaus A. Siebenrock MD, Karl-Philipp Kienle MD, Simon D. Steppacher MD, Moritz Tannast MD, Tallal C. Mamisch MD, Brigitte Rechenberg MD

Cam-type femoroacetabular impingement (FAI) resulting from an abnormal nonspherical femoral head shape leads to chondrolabral damage and is considered a cause of early osteoarthritis. A previously developed experimental ovine FAI model induces a cam-type impingement that results in localized chondrolabral damage, replicating the patterns found in the human hip. Biochemical MRI modalities such as T2 and T2* may allow for evaluation of the cartilage biochemistry long before cartilage loss occurs and, for that reason, may be a worthwhile avenue of inquiry.

Is the T1ρ MRI Profile of Hyaline Cartilage in the Normal Hip Uniform?

Kawan S. Rakhra MD, Arturo Cárdenas-Blanco PhD, Gerd Melkus PhD, Mark E. Schweitzer MD, Ian G. Cameron PhD, Paul E. Beaulé MD

T1ρ MRI is an imaging technique sensitive to proteoglycan (PG) content of hyaline cartilage. However, normative T1ρ values have not been established for the weightbearing cartilage of the hip, and it is not known whether it is uniform or whether there is topographic variation. Knowledge of the T1ρ profile of hyaline cartilage in the normal hip is important for establishing a baseline against which comparisons can be made to experimental and clinical arthritic subjects.

Eighty Percent of Patients With Surgical Hip Dislocation for Femoroacetabular Impingement Have a Good Clinical Result Without Osteoarthritis Progression at 10 Years

Simon D. Steppacher MD, Helen Anwander MD, Corinne A. Zurmühle MD, Moritz Tannast MD, Klaus A. Siebenrock MD

We previously reported the 5-year followup of hips with femoroacetabular impingement (FAI) that underwent surgical hip dislocation with trimming of the head-neck junction and/or acetabulum including reattachment of the labrum. The goal of this study was to report a concise followup of these patients at a minimum 10 years.

Does the Nature of Chondrolabral Injury Affect the Results of Open Surgery for Femoroacetabular Impingement?

Christopher L. Peters MD, Lucas A. Anderson MD, Claudio Diaz-Ledezma MD, Mike B. Anderson MS, ATC, Javad Parvizi MD

The degree to which patient characteristics, clinical outcomes, and the nature, severity, and corresponding treatment of chondrolabral injury in femoroacetabular impingement (FAI) is associated with failure after surgery is incompletely understood.

No Regeneration of the Human Acetabular Labrum After Excision to Bone

Hermes H. Miozzari MD, Marco Celia MD, John M. Clark MD, PhD, Stefan Werlen MD, Florian D. Naal MD, Hubert P. Nötzli MD

Treatment options for a symptomatic, torn, irreparable, or completely ossified acetabular labrum are limited to either excision and/or reconstruction with grafts. In a previous animal model, regeneration of the acetabular labrum after excision to the bony rim has been shown. In humans, less is known about the potential of regeneration of the labrum. Recent studies seem to confirm labral regrowth, but it is still unclear if wide excision might be a surgical option in cases where repair is not possible.

What Clinimetric Evidence Exists for Using Hip-specific Patient-reported Outcome Measures in Pediatric Hip Impingement?

Agnes G. d’Entremont PhD, Anthony P. Cooper FRCS, Ashok Johari FAMS, Kishore Mulpuri MS(Ortho)

Patient-reported outcomes (PROs) are an increasingly popular research tool used to evaluate the outcomes of surgical intervention. If applied appropriately, they can be useful both for disease monitoring and as a method of assessing the efficacy of treatment. Many disorders can lead to impingement in children and adolescents, but it is not clear if any PROs have been validated to evaluate outcomes in these populations.

Does Surgical Hip Dislocation and Periacetabular Osteotomy Improve Pain in Patients With Perthes-like Deformities and Acetabular Dysplasia?

John C. Clohisy MD, Jeffrey J. Nepple MD, James R. Ross MD, Gail Pashos BS, Perry L. Schoenecker MD

Patients with symptomatic residual Perthes-like deformities may present with a combination of structural abnormalities including a large aspheric femoral head, short and wide femoral neck, high greater trochanter, and acetabular dysplasia. Sometimes, the hip is further compromised by concurrent symptomatic femoroacetabular impingement (FAI) (proximal femoral deformities) and structural instability (acetabular dysplasia).

Relative Femoral Neck Lengthening Improves Pain and Hip Function in Proximal Femoral Deformities With a High-riding Trochanter

Christoph E. Albers MD, Simon D. Steppacher MD, Joseph M. Schwab MD, Moritz Tannast MD, Klaus A. Siebenrock MD

Complex proximal femoral deformities, including an elevated greater trochanter, short femoral neck, and aspherical head-neck junction, often result in pain and impaired hip function resulting from intra-/extraarticular impingement. Relative femoral neck lengthening may address these deformities, but mid-term results of this approach have not been widely reported.

Residual Deformity Is the Most Common Reason for Revision Hip Arthroscopy: A Three-dimensional CT Study

James R. Ross MD, Christopher M. Larson MD, Olusanjo Adeoyo MD, Bryan T. Kelly MD, Asheesh Bedi MD

Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. An awareness of the most frequent locations of the residual deformities may be critical to minimize these failures.

Can Combining Femoral and Acetabular Morphology Parameters Improve the Characterization of Femoroacetabular Impingement?

Heinse W. Bouma MD, Tom Hogervorst MD, PhD, Emmanuel Audenaert MD, PhD, Peter Krekel PhD, Paulien M. Kampen PhD

Femoroacetabular impingement (FAI) presupposes a dynamic interaction of the proximal femur and acetabulum producing clinical symptoms and chondrolabral damage. Currently, FAI classification is based on alpha angle and center-edge angle measurements in a single plane. However, acetabular and femoral version and neck-shaft angle also influence FAI. Furthermore, each of these parameters has a reciprocal interaction with the others; for example, a shallow acetabulum delays impingement of the femoral head with the acetabular rim.

Periacetabular Osteotomy Restores the Typically Excessive Range of Motion in Dysplastic Hips With a Spherical Head

Simon D. Steppacher MD, Corinne A. Zurmühle MD, Marc Puls PhD, Klaus A. Siebenrock MD, Michael B. Millis MD, Young-Jo Kim MD, PhD, Moritz Tannast MD

Residual acetabular dysplasia is seen in combination with femoral pathomorphologies including an aspherical femoral head and valgus neck-shaft angle with high antetorsion. It is unclear how these femoral pathomorphologies affect range of motion (ROM) and impingement zones after periacetabular osteotomy.

Does Previous Pelvic Osteotomy Compromise the Results of Periacetabular Osteotomy Surgery?

Jeffrey B. Stambough MD, John C. Clohisy MD, Geneva R. Baca BA, Ira Zaltz MD, Robert Trousdale MD, Michael Millis MD, Daniel Sucato MD, MS, Young-Jo Kim MD, PhD, Ernest Sink MD, Perry L. Schoenecker MD, Rafael Sierra MD, David Podeszwa MD, Paul Beaulé MD

As the Bernese periacetabular osteotomy (PAO) has grown in popularity, specific indications and the results in patients treated for those indications need to be evaluated. Currently, although many patients undergo PAO after having had prior pelvic osteotomy, there is limited information regarding the efficacy of the PAO in these patients.

No Sex Differences Exist in Posterior Condylar Offsets of the Knee

Pramod B. Voleti MD, Jason W. Stephenson MD, Paul A. Lotke MD, Gwo-Chin Lee MD

Restoration of posterior condylar offset during TKA is believed to be important to improving knee kinematics, maximizing ROM, and minimizing flexion instability. However, controversy exists regarding whether there are important anatomic differences between sexes and whether a unisex knee prosthesis can restore the anatomy of knees in males and females.

Are There Sex-dependent Differences in Acetabular Dysplasia Characteristics?

Stephen T. Duncan MD, Ljiljana Bogunovic MD, Geneva Baca BA, Perry L. Schoenecker MD, John C. Clohisy MD

Many patients who undergo periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia experience decreased pain and improved function, yet some experience inadequate clinical improvement. The etiologies of treatment failure have not been completely defined, and sex-dependent disease characteristics that may be associated with less pain relief are not understood.

What Are the Functional Results and Complications From Allograft Reconstruction After Partial Hemipelvectomy of the Pubis?

S. Mohammed Karim MD, Matthew W. Colman MD, Santiago A. Lozano-Calderón MD, PhD, Kevin A. Raskin MD, Joseph H. Schwab MD, Francis J. Hornicek MD, PhD

In patients undergoing hemipelvectomies including resection either of a portion of the pubis or the entire pubis from the symphysis to the lateral margin of the obturator foramen while sparing the hip (so-called Dunham Type III hemipelvectomies), reconstructions typically are not performed given the preserved continuity of the weightbearing axis and the potential complications associated with reconstruction. Allograft reconstruction of the pelvic ring may, however, offer benefits for soft tissue reconstruction of the pelvic floor and hip stability, but little is known about these reconstructions.

Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study

Gijs I. T. Iordens MD, Dennis Hartog PhD, Esther M. M. Lieshout PhD, Wim E. Tuinebreijer PhD, Jeroen Haan PhD, Peter Patka PhD, Michael H. J. Verhofstad PhD, Niels W. L. Schep PhD

After a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM.

Synthetic Mesh Improves Shoulder Function After Intraarticular Resection and Prosthetic Replacement of Proximal Humerus

Xiaodong Tang MD, Wei Guo MD, PhD, Rongli Yang MD, Shun Tang MD, Tao Ji MD

Shoulder function often is limited after tumor resection and endoprosthetic replacement of the proximal humerus. This is partly attributable to the inability to reliably reattach rotator cuff tendons to the prosthesis and achieve adequate shoulder capsule repair with a metallic prosthesis. An option to attain these goals is to use synthetic mesh for the reconstruction, although the value of this method has not been well documented in the literature.

Is Neuraxial Anesthesia Safe in Patients Undergoing Surgery for Treatment of Periprosthetic Joint Infection?

Mohammad R. Rasouli MD, Priscilla K. Cavanaugh MS, Camilo Restrepo MD, Hasan Huseyin Celyan MD, Mitchell G. Maltenfort PhD, Eugene R. Viscusi MD, Javad Parvizi MD

There is concern that neuraxial anesthesia in patients undergoing surgery for treatment of a periprosthetic joint infection (PJI) may increase the risk of having a central nervous system infection develop. However, the available data on this topic are limited and contradictory.

Patients With Greater Symptom Intensity and More Disability are More Likely to be Surprised by a Hand Surgeon’s Advice

Joost A. Strooker MD, Sjoerd P. F. T. Nota MD, Michiel G. J. S. Hageman MD, David C. Ring MD, PhD

A clash between a patient’s assumptions and a doctor’s advice can feel adversarial which might influence satisfaction ratings and compliance with treatment recommendations. A better understanding of sources of patients’ bewilderment might lead to improved strategies for conveying counterintuitive information that improve patient comfort and wellbeing.

Development of a Mouse Model of Ischemic Osteonecrosis

Nobuhiro Kamiya MD, PhD, Ryosuke Yamaguchi MD, PhD, Olumide Aruwajoye MS, Naga Suresh Adapala PhD, Harry K. W. Kim MD, MS

Availability of a reliable mouse model of ischemic osteonecrosis could accelerate the development of novel therapeutic strategies to stimulate bone healing after ischemic osteonecrosis; however, no mouse model of ischemic osteonecrosis is currently available.

Intramedullary Nailing of Femoral Diaphyseal Metastases: Is it Necessary to Protect the Femoral Neck?

Bryan Moon MD, Patrick Lin MD, Robert Satcher MD, PhD, Justin Bird MD, Valerae Lewis MD

Intramedullary nailing is the accepted form of treatment for impending or pathologic fractures of the femoral diaphysis. Traditional teaching promotes the use of a cephalomedullary nail so that stabilization is provided for the femoral neck in the event that a future femoral neck metastasis develops. However, that approach may add cost, surgical time, blood loss, and added radiation exposure to staff members, and there is limited evidence in the literature that supports this practice.

Hydroxyapatite-coated Collars Reduce Radiolucent Line Progression in Cemented Distal Femoral Bone Tumor Implants

Melanie J. Coathup BSc, PhD, Anish Sanghrajka MBBS, BS, William J. Aston BSc, MBBS, Panagiotis D. Gikas MBBS, BSc, MD, PhD, Robin C. Pollock MBBS, BSc, Stephen R. Cannon MA, MCh Orth, John A. Skinner MBBS, Timothy W. R. Briggs MBBS, MChOrth, Gordon W. Blunn BSc, PhD

Aseptic loosening of massive bone tumor implants is a major cause of prosthesis failure. Evidence suggests that an osteointegrated hydroxyapatite (HA)-coated collar would reduce the incidence of aseptic loosening around the cemented intramedullary stem in distal femoral bone tumor prostheses. Because these implants often are used in young patients with a tumor, such treatment might extend the longevity of tumor implants.We asked whether (1) HA-coated collars were more likely to osteointegrate; (2) HA collars were associated with fewer progressive radiolucent lines around the stem-cement interface; and (3) HA-coated collars were associated with less bone loss at the bone-shoulder implant junction?

A Dedicated Research Program Increases the Quantity and Quality of Orthopaedic Resident Publications

Daniel Torres MD, Zbigniew Gugala MD, PhD, Ronald W. Lindsey MD

Programs seek to expose trainees to research during residency. However, little is known in any formal sense regarding how to do this effectively, or whether these efforts result in more or better-quality research output.

Correlations Between a Dedicated Orthopaedic Complications Grading System and Early Adverse Outcomes in Joint Arthroplasty

Dorothy Y. Harris MD, Jillian K. McAngus MS, Yong-Fang Kuo PhD, Ronald W. Lindsey MD

Reliable classification of postoperative complications is important for quality improvement efforts. In 2014, The Knee Society proposed a grading system for complications after TKA, but to our knowledge, a relationship between complication grades and surgical outcomes has not yet been established.

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