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

BackgroundAs 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.Questions/purposesThe purpose of this study was to compare the (1) early pain, function, activity, and quality of life outcomes; (2) radiographic correction; and (3) major complications and failures between patients who underwent PAO after prior pelvic reconstruction versus those who had a PAO without prior surgery.MethodsBetween February 2008 and January 2012, 39 patients underwent PAO after prior pelvic osteotomy at one of 11 centers and were entered into a collaborative multicenter database. Of those, 34 (87%) were available for followup at a mean of 2.5 years (range 1–5 years). This group was compared with a matched group of 78 subjects, of whom 71 (91%) were available for followup at a similar interval. We compared clinical outcomes including UCLA activity score, SF-12, and Hip Disability and Osteoarthritis Outcome Score (HOOS); radiographic measures—anterior and lateral center-edge angle and acetabular inclination (AI)—and reoperations, major complications, and conversions to total hip arthroplasty.ResultsAlthough both groups reached clinical improvement in all categorical measures, the revision PAO group demonstrated greater pain (HOOS pain, study 74 versus 85, p = 0.03; 95% confidence interval [CI], 18.58 to −0.95) and less function (HOOS activities of daily living, study 80 versus 92, p = 0.002; 95% CI, 018.99–4.45) than the primary cohort. The revision cohort achieved a smaller average radiographic correction than in patients undergoing PAO without prior pelvic surgery. The mean correction in AI was less dramatic when directly comparing the revision and comparison groups (−12° to −17°, p < 0.001, SD 2.3–8.5). Although there was no difference in severe complications requiring further surgery, there were two conversions to hip arthroplasty (p = 0.109; 95% CI, 0.004–2.042) in the study group.ConclusionsPAO performed after prior pelvic surgery is associated with improvements in pain, function, radiographic correction, and early complication rates, but the improvements observed at short-term followup were smaller and more variable than those seen in patients who had not undergone prior pelvic surgery. We recommend considering PAO for residual deformities after prior osteotomy to improve function and quality life but warning patients of potential ceiling effects with a second periacetabular surgery.

Level of Evidence

Level III, therapeutic study.     

Does Trochanteric Step Osteotomy Provide Greater Stability Than Classic Slide Osteotomy? A Preliminary Study

The use of a trochanteric slide osteotomy needs a partial weightbearing period to allow safe healing of the osteotomy. We compared the initial rigidity of fixation of the trochanteric slide osteotomy with that of a newly developed technique, the trochanteric step osteotomy. The slide and step osteotomies were tested on six bilateral pairs of cadaveric femora with cyclic shear load of constant amplitude for 100 cycles in both a superior direction to represent standing and 60° of hip flexion to represent a squat stance. Translational and rotational migration and cyclic amplitude were measured with an optoelectronic camera system. During superior loading, translational migration of the slide osteotomy was greater than for the step osteotomy (slide median, 1.7 mm; step median, 0.3 mm), but rotational migration was not (slide median, 1.9°; step median, 0.2°). Translational amplitude was greater for the slide osteotomy in the superior direction (median slide, 0.3 mm; median step, 0.16 mm), but not in rotational amplitude. Similar trends in migration and amplitude were observed for the squat loading configuration. The data suggest the trochanteric step osteotomy is a more stable construct than the commonly performed slide osteotomy. One or more of the authors (RG, ML) have received funding from the German Osteoarthritis Foundation. Each author certifies that his or her institution has approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.     

Box Osteotomy — a New Technique of Proximal Tibial Osteotomy for Osteoarthritis of the Knee

Objective Stable correction of a varus knee with osteoarthritis of the medial and patellofemoral compartments through a high tibial valgization osteotomy. Indications Painful osteoarthritis of the medial compartment with or without patellofemoral involvement in patients with varus knee. Contraindications Osteoarthritis of the lateral compartment. Varus exceeding 15° and flexion deformity exceeding 10°. Severe limitation of movement. Instability of knee. Uncooperative patient. Surgical Technique Transverse lateral approach. Resection of proximal tibiofibular joint. Lateral wedge resection osteotomy, leaving an anterior bony ledge at the distal and a posterior ledge at the proximal fragment (box osteotomy). Anterior translation of distal fragment. Fixation with stepped staple. Cylinder cast for 6 weeks. Results Report on 16 patients (nine women, seven men, age 48-64 years) with a minimum follow-up of 30 months (maximum 6 years). Using the Hospital for Special Surgery (HSS) knee-score, 93.75 of the patients had either an excellent or good result. The outcome was fair in one patient only. A longitudinal assessment using the HSS score showed a reduction in the mean score over the period of reporting.     

Tibial Tubercle Osteotomy vs the Extensile Medial Parapatellar Approach in Revision Total Knee Arthroplasty: Is Tibial Tubercle Osteotomy a Harmful Approach?

BackgroundAs the frequency of total knee arthroplasty (TKA) is increasing, long-term follow-up of patients has become essential, and the frequency of revision total knee arthroplasty (R-TKA) due to the occurrence of various complications has also increased. There is controversy regarding which approach has minimal complications and an adequate visual field in R-TKA. Therefore, we compared the clinical and radiological results between the extensile medial parapatellar (EMP) approach and tibial tubercle osteotomy (TTO) for R-TKA.MethodsBetween March 1, 2000, and December 31, 2015, we compared 35 patients who underwent the EMP approach and 31 who underwent the TTO approach for R-TKA. In this study, the preoperative range of motion (ROM) was an important criterion for the choice of approach in R-TKA. The EMP approach was applied to patients with a ROM above 60°. The TTO approach was applied to patients with knee flexion limited to 0°-30°. We clinically assessed knee ROM, Knee Society scores, and Hospital for Special Surgery scores at the time of the last follow-up. We radiographically measured femorotibial alignment and patellar height. We also examined the complication rates. The average length of the TTO was 1.0 × 2.5 cm × 10 cm. We used 3 or more 3.5-mm half-threaded screws.ResultsThe mean postoperative ROM of the knee joint at the time of the last follow-up was 103° (flexion contracture 5° and further flexion 108°) in the group that underwent the EMP approach and 101° (flexion contracture 4° and further flexion 109°) in the group that underwent the TTO approach. The mean Knee Society scores were 86 (71-96) and 85 (72-94), and the mean Hospital for Special Surgery scores were 82 (70-93) and 83 (68-92) for the 2 groups, respectively, with no statistically significant difference. The mean femorotibial angles were 0.6° (±3.3°) and 0.1° (±2.9°), and the mean Insall-Salvati ratios were 1.0 (±0.34) and 0.8 (±0.14), respectively, with no statistically significant difference. The group that underwent TTO achieved bone union at an average of 11.8 weeks after surgery. In the group that underwent the EMP approach, 2 patients had extensor lag of more than 10°. In the group that underwent TTO, 2 subjects had skin necrosis at the operative site.ConclusionThe clinical and radiological outcomes were similar in the 2 groups after R-TKA. To increase the ROM and obtain adequate exposure, TTO is also considered a useful surgical approach. However, complications related to TTO should be minimized.Level of EvidenceTherapeutic level III, retrospective comparative study.     

Distal Femoral Osteotomy: Is Internal Fixation Better than External?

Background  

Distal femoral osteotomies (DFO) can be used to correct deformities around the knee. Although osteotomies can be fixed with either internal or external fixation techniques, the advantages of one over the other are unclear.     

Benefit of Adding Fibular Osteotomy to Open-Wedge,Valgus, Distal Tibial Osteotomy for Correcting Varus Ankle Arthritis: An In Vitro Study

Early-stage varus ankle arthritis can usually be treated with a medial, open-wedge, valgus, distal tibial osteotomy; however, the value of adding a fibular osteotomy has been debated. We sought to determine the increase in the maximum medial osteotomy gap and correction angle provided by fibular osteotomy. In 3 sequential experiments on 12 fresh cadaveric legs, we first performed a medial open-wedge, valgus, distal tibial osteotomy alone. Second, we added a transverse fibular osteotomy. Finally, we added a blocked fibular osteotomy. In each experiment, we measured the maximum corrected osteotomy gap and the maximum correction angle. Correction was defined as the absence of lateral cortex diastasis and talocrural joint incongruity. The mean ± standard deviation maximum osteotomy gaps and correction angles were 8.40 ± 1.6 mm and 10.70° ± 3.3° for the tibial osteotomy alone, 15.70 ± 4.6 mm and 20.20° ± 5.6° for the tibial plus transverse fibular osteotomy, and 16.67 ± 3.7 mm and 20.56° ± 4.6° for the tibial plus transverse plus blocked fibular osteotomies, respectively. The corresponding median maximum correction angles were 10° (range 8° to 18°), 19.5° (range 14° to 30°), and 20° (range 14° to 28°). The osteotomy gap and correction angle in the distal tibial and transverse fibular osteotomy were significantly greater than those in the distal tibial osteotomy alone (p < .001 for both) but not in the distal tibial and blocked fibular osteotomy (p = .62 for the gap and p = .88 for the correction angle). Our data support the clinical use of adjunct transverse fibular osteotomies. The blocked fibular osteotomy provided no additional benefit.     

Do Fluoroscopy and Postoperative Radiographs Correlate for Periacetabular Osteotomy Corrections?

Background

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.

Questions/Purposes

We therefore determined whether the parameters of acetabular correction of PAO correlated on intraoperative fluoroscopic imaging and postoperative radiography.

Methods

We retrospectively reviewed the imaging of 48 patients (50 hips) who underwent PAO. Intraoperative fluoroscopic AP and false profile images were obtained after final PAO correction. The intraoperative deformity correction as measured on the two fluoroscopy views was compared with the correction determined with postoperative standing plain AP pelvis and false profile radiographs using common measurements of acetabular position.

Results

Of all radiographic parameters, lateral center-edge angle had the highest correlation between intraoperative fluoroscopy and the postoperative radiograph with an intraclass correlation coefficient (ICC) of 0.80 (0.68–0.88). Similarly, acetabular inclination and anterior center-edge angle also correlated with ICCs of 0.76 (0.61–0.85) and 0.71 (0.54–0.82), respectively. Extrusion index and medial offset distance had lower correlations with ICCs of 0.66 (0.46–0.79) and 0.46 (0.21–0.65), respectively.

Conclusions

Intraoperative fluoroscopic assessment of PAO correction correlated with that from the postoperative radiographic assessment. Measurement of lateral center-edge angle shows the highest correlation with the fewest outliers. Acetabular inclination and anterior center-edge angle also correlated; extrusion index and medial offset distance should be used with more caution.     

The “Scarf” Osteotomy for the Correction of Hallux Valgus

Objective

Correction of symptomatic valgus deformities.

Indications

A hallux valgus in which the pathologic intermetatarsal angle I–II can be fully corrected by a lateral shift of the metatarsal head not exceeding two thirds of its width.

Contraindications

Hypermobility of the first ray. Osteoporosis. Osteoarthritis of the first metatarsophalangeal joint.

Surgical Technique

Medial longitudinal incision extending from the first metatarsophalangeal joint to the midportion of the metatarsal. Tenotomy of the abductor hallucis longus tendon, and lateral longitudinal incision of the metatarsophalangeal joint capsule to allow complete repositioning of the metatarsal head over the sesamoid bones. Z-shaped osteotomy in the mediolateral plane of the distal two thirds of the first metatarsal. Lateral shift of the distal fragment to reduce the intermetatarsal angle to a physiologic one. A pathologic distal metatarsal articular angle can be corrected simultaneously by rotating the distal fragment medially. Medial metatarsophalangeal capsulorrhaphy.

Results

Between October 1995 and July 1998, 73 Scarf osteotomies were performed in 57 patients and followed up clinically and radiologically for an average of 23 (12–45) months. The average intermetatarsal angle I–II was reduced from 12° to 6° and the first metatarsophalangeal angle from 27° to 11°. Patient’s satisfaction assessed in a visual 0–10 analog scale (10 points representing complete satisfaction) reached a mean value of 9.2 points. Three patients would not undergo the operation again (one bilateral severe undercorrection, one painful osteoarthritis of the first metatarsophalangeal joint, and one overcorrection).     

Effect of Combined Fibular Osteotomy on the Pressure of the Tibiotalar and Talofibular Joints in Supramalleolar Osteotomy of the Ankle: A Cadaveric Study

We investigated the effect of combined fibular osteotomy on the pressure of the tibiotalar and talofibular joints in medial opening-wedge supramalleolar osteotomy. Three different tibial osteotomy gaps (6, 8, and 10 mm) were created in 10 cadaveric models, and the pressure in the tibiotalar and talofibular joints was measured under axial load before and after fibular osteotomy. The heel alignment angle and talar translation ratio were evaluated radiographically. An increase in osteotomy gap led to increases in hindfoot valgus (p = .001) and the contact and peak pressures in the talofibular joint (p = .03 and p = .004). In contrast, the contact and peak pressures in the tibiotalar joint were unchanged with an increasing osteotomy gap (p = .52 and p = .76). Fibular osteotomy reduced the contact and peak pressures in the talofibular joint (p < .001 and p = .001, respectively), and it did not influence the contact and peak pressures in the tibiotalar joint (p = .46 and p = .14, respectively). Therefore, fibular osteotomy might be necessary in supramalleolar osteotomy for medial ankle arthritis to minimize the increase in pressure in the talofibular joint, especially when the osteotomy gap is large.     

End-Stage Ankle Arthritis: Arthrodiastasis,Supramalleolar Osteotomy,or Arthrodesis?

End-stage ankle arthritis is a debilitating condition that leads to pain and swelling in the ankle joint, with symptoms aggravated by standing and ambulation. Ankle arthritis commonly results from a history of trauma, or a series of recurrent injuries to the ankle. However, it may develop from other causes such as uneven loading of the ankle joint caused by an alignment deformity or from inflammatory arthritis such as rheumatoid arthritis, gout, or secondary to a serious joint infection. Patients with severe ankle arthritis often have limited ankle motion with an antalgic gait.     

Is Cup Positioning Challenged in Hips Previously Treated With Periacetabular Osteotomy?

After periacetabular osteotomy (PAO), some patients develop osteoarthritis with need of a total hip arthroplasty (THA). We evaluated the outcome of THA following PAO and explored factors associated with inferior cup position and increased polyethylene wear. Follow-up were performed 4 to 10 years after THA in 34 patients (38 hips) with previous PAO. Computer analysis evaluated cup position and wear rates. No patient had dislocations or revision surgery. Median scores were: Harris hip 96, Oxford hip 38 and WOMAC 78. Mean cup anteversion and abduction angles were 22^o (range 7°–43°) and 45° (range 28°–65°). Outliers of cup abduction were associated with persisting dysplasia (CE < 25°). THA after PAO can produce excellent clinical results. Persisting acetabular dysplasia following PAO may lead surgeons to place the acetabular component in excessive cup abduction, and this tendency should be recognized at the time of the PAO.     

What Factors Predict Failure 4 to 12 Years After Periacetabular Osteotomy?

Background  

The goal of periacetabular osteotomy (PAO) is to delay or prevent osteoarthritic development in dysplastic hips. However, it is unclear whether the surgical goals are achieved and if so in which patients. This information is essential to select appropriate patients for a durable PAO that achieves its goals.     

Does Salter Innominate Osteotomy Predispose the Patient to Acetabular Retroversion in Adulthood?

Background

Salter innominate osteotomy has been identified as an effective additional surgery for the dysplastic hip. However, because in this procedure, the distal segment of the pelvis is displaced laterally and anteriorly, it may predispose the patient to acetabular retroversion. The degree to which this may be the case, however, remains incompletely characterized.

Questions/purposes

We asked, in a group of pediatric patients with acetabular dysplasia who underwent Salter osteotomy, whether the operated hip developed (1) acetabular retroversion compared with contralateral unaffected hips; (2) radiographic evidence of osteoarthritis; or (3) worse functional scores. (4) In addition, we asked whether femoral head deformity resulting from aseptic necrosis was a risk factor for acetabular retroversion.

Methods

Between 1971 and 2001, we performed 213 Salter innominate osteotomies for unilateral pediatric dysplasia, of which 99 hips (47%) in 99 patients were available for review at a mean of 16 years after surgery (range, 12–25 years). Average patient age at surgery was 4 years (range, 2–9 years) and the average age at the most recent followup was 21 years (range, 18–29 years). Acetabular retroversion was diagnosed based on the presence of a positive crossover sign and prominence of the ischial spine sign at the final visit. The center-edge angle, acetabular angle of Sharp, and acetabular index were measured at preoperative and final visits. Contralateral unaffected hips were used as controls, and statistical comparison was made in each patient. Clinical findings, including Harris hip score (HHS) and the anterior impingement sign, were recorded at the final visit.

Results

Patients were no more likely to have a positive crossover sign in the surgically treated hips (20 of 99 hips [20%]) than in the contralateral control hips (17 of 99 hips [17%]; p = 0584). In addition, the percentage of positive prominence of the ischial spine sign was not different between treated hips (22 of 99 hips [22%]) and contralateral hips (18 of 99 hips [18%]; p = 0.256). Hips that had a positive crossover or prominence of the ischial spine sign in the operated hips were likely also to have a positive crossover sign or prominence of the ischial spine sign in the unaffected hips (16 of 20 hips [80%] crossover sign, 17 of 22 hips [77%] prominence of the ischial spine sign). At the final visit, five hips (5%) showed osteoarthritic change; one of the five hips (20%) showed positive crossover and prominence of the ischial spine signs, and the remaining four hips showed negative crossover and prominence of the ischial spine signs. There was no significant difference in HHS between the crossover-positive and crossover-negative patient groups nor in the prominence of the ischial spine-positive and prominence of the ischial spine-negative patient groups (crossover sign, p = 0.68; prominence of the ischial spine sign, p = 0.54). Hips with femoral head deformity (25 of 99 hips [25%]) were more likely to have acetabular retroversion compared with hips without femoral-head deformity (crossover sign, p = 0.029, prominence of the ischial spine sign, p = 0.013).

Conclusions

Our results suggest that Salter innominate osteotomy does not consistently cause acetabular retroversion in adulthood. We propose that retroversion of the acetabulum is a result of intrinsic development of the pelvis in each patient. A longer-term followup study is needed to determine whether retroverted acetabulum after Slater innominate osteotomy is a true risk factor for early osteoarthritis. Femoral head deformity is a risk factor for subsequent acetabular retroversion.

Level of Evidence

Level III, therapeutic study.     

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Background

Bernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established.

Questions/purposes

(1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance?

Methods

We retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10–36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon’s experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the initial and the experienced intervals, a multivariate logistic regression analysis was performed and the adjusted risk of a complication between the two intervals was calculated. Linear regression analyses were used to test the association between surgeon level of experience and operative time.

Results

The overall incidence of major (Grade III or Grade IV) complications was 6% (95% confidence interval [CI], 2%–14%). These included deep infection (3% [three of 81]), intraoperative posterior column fracture (1% [one of 81]), and pulmonary embolism (1% [one of 81]). With the numbers available, the risk of a complication did not decrease with increasing surgeon experience. After controlling for body mass index and surgeon, the frequency of a complication did not decrease in the experienced interval relative to the initial interval (odds ratio, 0.78; 95% CI, 0.25–2.4; p = 0.6623). The adjusted risk difference between the experienced interval relative and the initial interval was 6% (95% CI, −11% to 23%). When experience was modeled as a continuous variable (number of PAOs performed), increasing experience was not associated with a lower likelihood of a complication (odds ratio per one PAO increase in experience, 0.99; 95% CI, 0.94–1.04; p = 0.5478). However, after adjusting for body mass index and surgeon, increased experience was associated with a reduction in operative time (slope [change in log operative time per one procedure increase in experience], −0.005; 95% CI, −0.009 to −0.0005; p = 0.0292). For every one additional PAO increase in experience, there was a 0.45% decrease in operative time (95% CI, 0.05%–0.86% decrease].

Conclusions

With a case exposure greater than 40 PAOs and progressive surgical responsibility during contemporary structured training, two young surgeons were able to perform PAO with a low risk of complications. However, even with that surgical experience before independent practice, surgical time decreased over the first 40 PAOs they performed independently. Our data may help guide orthopaedic residency and hip preservation fellowship programs in establishing training requirements and assessing competency in PAO.

Level of Evidence

Level III, therapeutic study.