Rapidly Progressive Osteoarthritis After Arthroscopic Labral Repair in Patients With Hip Dysplasia

Recent reports of poor clinical outcomes after arthroscopic surgery in hips with marked dysplasia have emerged. Arthroscopic resection of the hypertrophic labrum in cases of dysplasia, especially in the absence of periacetabular osteotomy (PAO), has been implicated. Some patients will refuse PAO because it is a major open procedure, opting for a less invasive arthroscopic procedure. We present the cases of 2 young adults with marked dysplasia who had rapidly progressive osteoarthrosis despite arthroscopic labral repair. Though perhaps beneficial as an isolated procedure in borderline or mild dysplasia cases, arthroscopic hip surgery, even labral repair, may best be performed with PAO in cases with more severe dysplasia. Albeit attractive as a less invasive labral-preserving surgery, arthroscopic labral repair not only may fail to provide symptomatic improvement but may compromise or preclude a later PAO if rapidly progressive osteoarthrosis ensues. Hip arthroscopy may best be performed concurrently with or after PAO but not proceeding PAO in patients requiring both procedures.     

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement in Patients With Borderline Dysplasia Does Not Result in Inferior Outcomes Compared With Outcomes in Patients Without Dysplasia: Do Not Fear

The treatment of adult borderline hip dysplasia remains challenging and continues to be a subject of controversy. The preferred treatment for hip instability and acetabular undercoverage is periacetabular osteotomy. However, patients with painful hips and associated femoroacetebular impingement, microinstability, or no instability may benefit from arthroscopic surgery. Short-term studies have reported favorable clinical outcomes. Traditionally, the lateral center-edge angle was used to determine hip dysplasia. More recently the femoro-epiphyseal acetabular roof (FEAR) index was introduced as a measure for borderline dysplasia. In general, a FEAR index of less than 5° indicates hip instability. When using a FEAR index of more than 2° as a cut-off for hip instability and borderline dysplasia, arthroscopic hip surgery can achieve very similar clinical outcomes to patients with a FEAR index of less than 2°. However low and unequal sample sizes have potentially resulted in both type I and II errors, reducing internal study validity. Although this may be a step in the right direction, further high-quality studies are required to understand patients’ characteristics on diagnosis, prognosis, outcomes of surgical interventions, and long-term disease progression for adult borderline hip dysplasia.     

Body Composition in Ambulatory Patients With Multiple Sclerosis

The aim of this study was to compare between ambulatory patients with multiple sclerosis (MS) and control subjects, bone mineral density (BMD), and body composition, that is, percent of bone minerals (M%), fat (F%), and remaining substances (L%). Total body composition and BMD were measured by dual-energy X-ray absorptiometry in 68 patients with definite MS and Expanded Disability Status Scale (EDSS) score ≤6.5 (41 females and 27 males) and 114 control individuals (72 females and 42 males). The amount of F%, L%, M%, and BMD in the whole body, arms, and trunk was not statistically different between MS patients (males and females) and controls, except in the lower extremities of female patients where there was increased F% and reduced L% compared with controls. There were no correlations between F%, L%, M%, and BMD at any anatomic region with EDSS or the cumulative corticosteroid dose. The reduced L% in the lower extremities of female patients suggests a possible increased subsequent risk of osteoporosis in the legs. Brief steroid courses administered during disease exacerbations in ambulatory MS patients did not result in obvious adverse consequences.     

Three Patterns of Acetabular Deficiency Are Common in Young Adult Patients With Acetabular Dysplasia

Background

Detailed recognition of the three-dimensional (3-D) deformity in acetabular dysplasia is important to help guide correction at the time of reorientation during periacetabular osteotomy (PAO). Common plain radiographic parameters of acetabular dysplasia are limited in their ability to characterize acetabular deficiency precisely. The 3-D characterization of such deficiencies with low-dose CT may allow for more precise characterization.

Questions/purposes

The purposes of this study were (1) to determine the variability in 3-D acetabular deficiency in acetabular dysplasia; (2) to define subtypes of acetabular dysplasia based on 3-D morphology; (3) to determine the correlation of plain radiographic parameters with 3-D morphology; and (4) to determine the association of acetabular dysplasia subtype with patient clinical characteristics including sex, range of motion, and femoral version.

Methods

Using our hip preservation database, we identified 153 hips (148 patients) that underwent PAO from October 2013 to July 2015. Among those, we noted 103 hips in 100 patients with acetabular dysplasia (lateral center-edge angle < 20°) and who had a Tönnis grade of 0 or 1. Eighty-six patients (86%) underwent preoperative low-dose pelvic CT scans at our institution as part of the preoperative planning for PAO. It is currently our standard to obtain preoperative low-dose pelvic CT scans (0.75–1.25 mSv, equivalent to three to five AP pelvis radiographs) on all patients before undergoing PAO unless a prior CT scan was performed at an outside institution. Hips with a history of a neuromuscular disorder, prior trauma, prior surgery, radiographic evidence of joint degeneration, ischemic necrosis, or Perthes-like deformities were excluded. Fifty hips in 50 patients met inclusion criteria and had CT scans available for review. These low-dose CT scans of 50 patients with symptomatic acetabular dysplasia undergoing evaluation for surgical planning of PAO were then retrospectively studied. CT scans were analyzed quantitatively for acetabular coverage, relative to established normative data for acetabular coverage, as well as measurement of femoral version. The cohort included 45 females and five males with a mean age of 26 years (range, 13–49 years).

Results

Lateral acetabular deficiency was present in all patients, whereas anterior deficiency and posterior deficiency were variable. Three patterns of acetabular deficiency were common: anterosuperior deficiency (15 of 50 [30%]), global deficiency (18 of 50 [36%]), and posterosuperior deficiency (17 of 50 [34%]). The presence of a crossover sign or posterior wall sign was poorly predictive of the dysplasia subtype. With the numbers available, males appeared more likely to have a posterosuperior deficiency pattern (four of five [80%]) compared with females (13 of 45 [29%], p = 0.040). Hip internal rotation in flexion was significantly greater in anterosuperior deficiency (23° versus 18°, p = 0.05), whereas external rotation in flexion was significantly greater in posterosuperior deficiency (43° versus 34°, p = 0.018). Acetabular deficiency pattern did not correlate with femoral version, which was variable across all subtypes.

Conclusions

Three patterns of acetabular deficiency commonly occur among young adult patients with mild, moderate, and severe acetabular dysplasia. These patterns include anterosuperior, global, and posterosuperior deficiency and are variably observed independent of femoral version. Recognition of these distinct morphologic subtypes is important for diagnostic and surgical treatment considerations in patients with acetabular dysplasia to optimize acetabular correction and avoid femoroacetabular impingement.

     

Headache and Its Management in Patients With Multiple Sclerosis

Purpose of review

The purpose of this review was to discuss the prevalence, impact, pathophysiology, and treatment of headaches (H/As) in patients with multiple sclerosis (MS).

Recent findings

Headaches and multiple sclerosis are more common in women than in men with the ratio of female to male being 3:1. It is not entirely clear if there is a correlation or an incidental comorbidity of two neurological conditions. A review of the literature shows a variable prevalence of H/As in MS patients. Using the International Classification of Headache Disorders (ICHD) criteria, the primary type of H/As, especially migraine, is the most common type seen in patients with MS. One of the theories of the pathophysiologic mechanisms of migraine in MS patients is inflammation leading to demyelinating lesions in the pain-producing centers in the midbrain. Secondary H/As due to MS medications such as interferons are also frequently present.

Summary

H/As can be a cause for significant comorbidity in patients with MS. The treatment of H/As in patients with MS should be addressed in the same fashion as in the non-MS population, which is a combination of pharmacological and non-pharmacological methods. Preventive medicines for the H/As should be carefully selected because of their side effect profiles. Acute attacks of migraines can be treated with medications such as triptans. Patients with MS who have migraine H/As should be educated about the phenomenon of overuse H/As, keeping headache journals, avoiding stress, and monitoring sleeping habits. The presence of depression in patients with MS and migraine affects quality of life (QOL) and should also be addressed for better outcomes.

     

Size of Medial Knee Osteophytes Correlates With Knee Alignment But Not With Coronal Laxity in Patients With Medial Knee Osteoarthritis

The severity of osteoarthritis (OA) has been related to osteophyte size. However, the effects on osteophyte size of repeated and increased loading associated with joint laxity and varus misalignment remain unclear. We investigated these relationships in patients with medial knee OA and compared the performances of computed tomography (CT) and radiography for assessing osteophyte parameters. We examined knee joint alignment on radiographs and knee laxity using arthrometry in 191 patients with medial knee OA who were undergoing total knee arthroplasty. We also measured femur and tibia osteophyte distance (largest perpendicular distance from the cortical line to outer margin of the osteophyte) using radiography and CT, osteophyte areas (largest area surrounded by the outer margin of an osteophyte) by CT and determined the locations of the osteophytes in the femur and tibia by CT. We then analyzed the correlations between the variables using Spearman's rank correlation tests. Osteophyte sizes in the femur and tibia as determined by radiography (distance) or CT (distance and area) were positively correlated with the degree of varus alignment but not with medial or lateral laxity. There was also a significant correlation between maximum osteophyte distances measured by radiography and CT. The greatest number and the largest osteophytes were located in the posterior third of the femur and middle third of the tibia, respectively. Osteophyte size was correlated with preoperative knee alignment but not with knee laxity in patients with medial knee OA. Osteophyte size can be evaluated using conventional radiography, without the need for CT. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:639–644, 2020     

Risk of Periprosthetic Joint Infection in Patients With Multiple Arthroplasties

Background

Risk of subsequent periprosthetic joint infection (PJI) in a second prosthetic joint following initial PJI has been shown to be 19%-20%. We sought to identify (1) the risk of developing a second PJI for our patients with multiple prosthetic joints and (2) the effect of bacteremia on development of a subsequent PJI.

Posterior Pelvic Tilt From Supine to Standing in Patients With Symptomatic Developmental Dysplasia of the Hip

Pelvic sagittal inclination (PSI) significantly affects the femoral head coverage by the acetabulum in patients with developmental dysplasia of the hip (DDH), while no reports have quantified PSI in DDH patients in the supine and standing positions. Furthermore, little is known about how PSI changes after periacetabular osteotomies. Herein, PSI in the supine and standing positions was quantified in DDH patients preoperatively and postoperatively. Twenty-five patients with DDH who had undergone periacetabular osteotomies were analyzed. The preoperative PSI and the PSI 2 years after surgery were measured in the supine and standing positions using the image registration technique between radiographs and computed tomographic images. The percentage of patients who showed PSI changes of more than 10° from the supine to the standing position was quantified. PSI changed 8.2 ± 5.0° posteriorly from the supine to the standing position during the preoperative period. Posterior pelvic tilt of more than 10° was found in nine cases (36%). Two years after periacetabular osteotomies, the postural PSI change was 7.1 ± 3.9° posteriorly. When the preoperative and postoperative PSI values were compared, PSI in the standing position did not differ (p = 0.20). Similarly, the amount of PSI change from the supine to standing position was not significantly different (p = 0.26). In conclusion, posterior pelvic tilt in the standing position was found preoperatively in symptomatic DDH patients, and it remained for 2 years after periacetabular osteotomies. This postural change in PSI does not seem to influence the outcome of periacetabular osteotomy. However, during preoperative planning, surgeons should recognize that acetabular anteversion or anterior acetabular coverage differs between the supine and standing positions in some patients with DDH. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:578–587, 2020     

Relationship Between Coronal Alignment and Rotational Profile of Lower Extremity in Patients With Knee Osteoarthritis

Background

We aimed at determining whether the coronal alignment of lower extremity was related to rotational geometry of distal femur, femoral anteversion, and tibial torsion in patients with knee osteoarthritis.

The Use of Combined Anteversion in Total Hip Arthroplasty for Patients With Developmental Dysplasia of the Hip

The combined anteversion technique has been proposed recently and proved to be an applicable technique in general THA. The corresponding author routinely applied this approach to DDH patients in clinical practice. The current study aimed to provide clinical evidence for this approach. We studied 35 DDH patients (47 hips). Every patient underwent pelvic CT scans before and after surgery and the HHs was recorded. The data indicate a high accuracy of controlling components orientation and satisfactory clinical outcomes. Using this approach, we reduced dislocation risk and got better impingement free range of motion. Therefore, we conclude that combined anteversion is effective for DDH patients who receive a THA. This approach could guarantee stable and functioning joints for DDH patients receiving THA.     

Radiographic Measurements of Patients With Juvenile Hallux Valgus Compared With Age-Matched Controls: A Cohort Investigation

The purpose of this study was to investigate radiographic measurements in a cohort of patients with juvenile hallux valgus (with a hallux valgus angle > 15 degrees ) using standardized weightbearing x-rays compared with an age-matched control group. First metatarsal protrusion distance, metatarsus primus adductus angle, metatarsus adductus, first metatarsal cuneiform angle, calcaneal inclination angle, and talocalcaneal angles were assessed with discriminant functional analysis. A total of 37 sets of data were analyzed from patients with a mean age of 13.45 +/- 1.75 years. The study identified 2 significant components of juvenile hallux valgus: a positive first metatarsal protrusion distance (P <.001) and metatarsal primus adductus angle (P = .002). Discriminant functional analysis was then used to determine the best predictors of juvenile hallux valgus. This analysis allowed only 1 variable, metatarsal protrusion distance, as a predictor of whether juvenile hallux valgus was present (P < .001), with 94.3% accuracy. This study showed that a positive metatarsal protrusion distance is a significant component of juvenile hallux valgus.     

Polyethylene Wear and Osteolysis Is Associated With High Revision Rate of a Small Sized Porous Coated THA in Patients With Hip Dysplasia

The outcome of 25 primary THAs in patients with hip dysplasia using the AML Bantam femoral stem (DePuy) is reported. Age at operation averaged 43 ± 10 years. Twenty-two of 25 stems were cementless. All cementless acetabular components had conventional or cross-linked polyethylene and screws. Follow-up averaged 11 ± 5 years (range 4–18). Four cementless stems were revised after 3, 4, 8, and 9 years; 2/3 cemented stems were revised at 8 and 18 years. Femoral revisions demonstrated extensive conventional polyethylene wear, periprosthetic osteolysis and loosening. Five entire cups were revised for wear and loosening; four liners were replaced. Harris Hip Scores for patients with retained stems went from 43 ± 12 to 85 ± 13. High revision rates with the proximally porous coated Bantam stem are due to loss of fixation, often associated with polyethylene wear and osteolysis.