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1.  Guided growth of the trochanteric apophysis combined with soft tissue release for Legg–Calve–Perthes disease 
During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3–9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14–78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up. The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton’s line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28–69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.
PMCID: PMC3951627  PMID: 24563149
Legg–Calve–Perthes disease; Trochanteric arrest; Guided growth; Coxa brevis; Containment
2.  Success of torsional correction surgery after failed surgeries for patellofemoral pain and instability 
Torsional deformities of the femur and/or tibia often go unrecognized in adolescents and adults who present with anterior knee pain, and patellar maltracking or instability. While open and arthroscopic surgical techniques have evolved to address these problems, unrecognized torsion may compromise the outcomes of these procedures. We collected a group of 16 consecutive patients (23 knees), with mean age of 17, who had undergone knee surgery before torsion was recognized and subsequently treated by means of rotational osteotomy of the tibia and/or femur. By follow-up questionnaire, we sought to determine the role of rotational correction at mean 59-month follow-up. We reasoned that, by correcting torsional alignment, we might be able to optimize long-term outcomes and avert repeated knee surgery. Knee pain was significantly improved after torsional treatment (mean 8.6 pre-op vs. 3.3 post-op, p < 0.001), while 70 % of patients did have some continued knee pain postoperatively. Only 43 % of patients had continued patellar instability, and 57 % could trust their knee after surgery. Activity level remained the same or increased in 78 % of patients after torsional treatment. Excluding planned rod removal, subsequent knee surgery for continued anterior knee pain was undertaken on only 3 knees in 2 patients. We believe that malrotation of the lower limb not only raises the propensity for anterior knee symptoms, but is also a under-recognized etiology in the failure of surgeries for anterior knee pain and patellar instability. Addressing rotational abnormalities in the index surgery yields better clinical outcomes than osteotomies performed after other prior knee surgeries.
PMCID: PMC3951618  PMID: 24338661
Pan genu torsion; Miserable malalignment; Tibial torsion; Femoral anteversion; Osteotomy
3.  Early Experience With a Comprehensive Hip Preservation Service Intended to Improve Clinical Care, Education, and Academic Productivity 
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.
We compared (1) volume, type, and corresponding improvement in pain and function of open and arthroscopic treatments; (2) orthopaedic resident test performance; and (3) academic productivity before and after creation of the HPS.
We retrospectively reviewed 212 patients undergoing 220 open procedures from 1996 to 2007 (Group 1) and 260 patients undergoing 298 procedures (153 open, 145 arthroscopic) from 2008 to May 2010 (Group 2). At each clinic visit, we recorded Harris hip score (HHS) and conversion to THA. Minimum followup was 1 year for Group 1 (mean, 4 years; range, 1–13 years) and Group 2 (mean, 1.5 years; range, 1–3 years). We compared orthopaedic resident performance on two standardized tests and the number of academic works (publications, book chapters, electronic media) and peer-reviewed grants funded before and after creation of the HPS.
Mean HHS improved from 63 to 90 in Group 1 and from 76 to 91 in Group 2. Rate of conversion to THA was similar between groups despite expansion of surgical volume. Standardized orthopaedic resident test performance improved. Academic productivity as measured by publications and grant funding was facilitated by the HPS.
Early experience with a multidisciplinary HPS was positive; it facilitated clinical volume expansion while maintaining improvement in pain and function in young adults. Additional benefits included educational and academic productivity gains.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3492621  PMID: 22926493
4.  Coxa Profunda: Is the Deep Acetabulum Overcovered? 
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.
We therefore determined the incidence of coxa profunda and evaluated associations between coxa profunda and other radiographic parameters of acetabular coverage commonly used to diagnose pincer FAI and acetabular dysplasia.
We evaluated the radiographs of three cohorts for coxa profunda, lateral center edge (LCE) angle, acetabular index, posterior wall sign, and crossover sign. Data from 67 collegiate football players were collected prospectively (Cohort 1). We identified two patient cohorts through retrospective review of all 179 hips undergoing hip preservation surgery from 2002 to 2008 (83 periacetabular osteotomies [Cohort 2] and 96 surgical dislocation and osteochondroplasties [Cohort 3]).
In all three cohorts, we detected no difference in the LCE angle or acetabular index between hips with and without coxa profunda. Coxa profunda existed in hips representing the spectrum of acetabular coverage measured by LCE angle (−18° to 60°) and acetabular orientation determined by the crossover sign.
Coxa profunda was a common radiographic finding in both symptomatic patients and asymptomatic football players. Coxa profunda existed in hips representing the spectrum of acetabular coverage and was not associated with an overcovered acetabulum. We conclude coxa profunda is unrelated to overcoverage and suggest its use in diagnosis of pincer FAI be abandoned in favor of other determinants of focal or general overcoverage.
Level of Evidence
Level III, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3492622  PMID: 22898988
5.  Mean 5-Year Clinical and Radiographic Outcomes of Cementless Total Hip Arthroplasty in Patients under the Age of 30 
BioMed Research International  2013;2013:649506.
We performed a retrospective review of 40 consecutive modern cementless THAs with 65-month mean followup in 34 patients under the age of 30 primarily for diagnoses other than inflammatory arthritis. We found acceptable functional improvement and radiographic outcomes at mean 5-year followup. We found a high transfusion rate, dislocation rate (10%), and midterm overall aseptic revision rate (17%). Twenty-eight (67.5%) of hips in this series were metal on metal, with a large percentage of aseptic revisions related to metallosis (57%). When revisions due to metallosis were excluded, the aseptic revision rate was 7.5%. The high prevalence of prior pediatric hip surgery in these patients (50%) may predispose to increased technical difficulty resulting in increased complications and higher revision rates. Although our revision rate was high in these young patients, it is favorable compared to older techniques and consistent with the limited data available with modern cementless techniques in patients of similar age. Cementless THA with modern designs remains a viable option for the treatment of arthritis in the young patient.
PMCID: PMC3707213  PMID: 23865060
6.  Perioperative Closure-related Complication Rates and Cost Analysis of Barbed Suture for Closure in TKA 
The use of barbed suture for surgical closure has been associated with lower operative times, equivalent wound complication rate, and comparable cosmesis scores in the plastic surgery literature. Similar studies would help determine whether this technology is associated with low complication rates and reduced operating times for orthopaedic closures.
We compared a running barbed suture with an interrupted standard suture technique for layered closure in primary TKA to determine if the barbed suture would be associated with (1) shorter estimated closure times; (2) lower cost; and (3) similar closure-related perioperative complication rates.
We retrospectively compared two-layered closure techniques in primary TKA with either barbed or knotted sutures. The barbed group consisted of 104 primary TKAs closed with running barbed suture. The standard group consisted of 87 primary TKAs closed with interrupted suture. Cost analysis was based on cost of suture and operating room time. Clinical records were assessed for closure-related complications within the 6-week perioperative period.
Average estimated closure time was 2.3 minutes shorter with the use of barbed suture. The total closure cost was similar between the groups. The closure-related perioperative complication rates were similar between the groups.
Barbed suture is associated with a slightly shorter estimated closure time, although this small difference is of questionable clinical importance. With similar overall cost and no difference in perioperative complications in primary TKA, this closure methodology has led to more widespread use at our institution.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3237999  PMID: 21952745
7.  An Algorithmic Approach to Surgical Decision-making in Acetabular Retroversion 
Orthopedics  2011;34(1):10.
We prospectively collected clinical data during the period 2001–2006 on 60 hips with symptomatic femoroacetabular impingement that had radiographic evidence of acetabular retroversion defined as a crossover sign on an adequate anteroposterior radiograph or retroversion on magnetic resonance imaging or computed tomography. Our treatment algorithm for acetabular retroversion used measurements of acetabular coverage (lateral center edge angle and the posterior wall sign) and condition of acetabular cartilage to direct treatment of acetabular retroversion. The algorithm directed the surgeon to perform a periacetabular-osteotomy (PAO) in 30 hips and in 30 hips a surgical-dislocation and osteochondroplasty (SDO) of the femoral head-neck junction and acetabular rim. HHS and Tönnis radiographic grading were collected preoperatively and at latest followup. The HHS improved from 52 to 90 in the hips treated with SDO and 72 to 91 in the hips treated with PAO, with an overall survivorship of 96% at four years. Patient follow-up averaged 46 months (range 24–75). Elimination of the crossover sign and correction of the posterior wall sign occurred in over 90% of all patients when present. The results indicate that hips with acetabular retroversion, deficient posterior and/or lateral acetabular coverage and intact hyaline cartilage can be effectively treated with acetabular reorientation while retroverted hips with anterior over-coverage but sufficient posterior coverage are effectively treated with osteochondroplasty of the acetabulum and proximal femur.
PMCID: PMC3399593  PMID: 21210626
8.  Correlation between radiographic measures of acetabular morphology with 3D femoral head coverage in patients with acetabular retroversion 
Acta Orthopaedica  2012;83(3):233-239.
Background and purpose
Acetabular retroversion may result in anterior acetabular over-coverage and posterior deficiency. It is unclear how standard radiographic measures of retroversion relate to measurements from 3D models, generated from volumetric CT data. We sought to: (1) compare 2D radiographic measurements between patients with acetabular retroversion and normal control subjects, (2) compare 3D measurements of total and regional femoral head coverage between patients and controls, and (3) quantify relationships between radiographic measurements of acetabular retroversion to total and regional coverage of the femoral head.
Patients and methods
For 16 patients and 18 controls we measured the extrusion index, crossover ratio, acetabular angle, acetabular index, lateral center edge angle, and a new measurement termed the “posterior wall distance”. 3D femoral coverage was determined from volumetric CT data using objectively defined acetabular rim projections, head-neck junctions, and 4 anatomic regions. For radiographic measurements, intra-observer and inter-observer reliabilities were evaluated and associations between 2D radiographic and 3D model-based measures were determined.
Compared to control subjects, patients with acetabular retroversion had a negative posterior wall distance, increased extrusion index, and smaller lateral center edge angle. Differences in the acetabular index between groups approached statistical significance. The acetabular angle was similar between groups. Acetabular retroversion was associated with a slight but statistically significant increase in anterior acetabular coverage, especially in the anterolateral region. Retroverted hips had substantially less posterior coverage, especially in the posterolateral region.
We found that a number of 2D radiographic measures of acetabular morphology were correlated with 3D model-based measures of total and regional femoral head coverage. These correlations may be used to assist in the diagnosis of retroversion and for preoperative planning.
PMCID: PMC3369147  PMID: 22553905
9.  Sequelae of Perthes Disease 
Journal of pediatric orthopedics  2010;30(8):758-766.
Sequelae of Perthes disease commonly manifests as complex hip pathomorphology including coxa magna, coxa brevis, and acetabular dysplasia. These abnormalities contribute to femoroacetabular impingement and early osteoarthritis. This report describes our experience with correction of the proximal femoral deformity associated with Perthes disease via surgical dislocation, osteochondroplasty (SDO), trochanteric advancement, and treatment of intra-articular chondrolabral injury.
Between January 2003 and January 2009, 14 patients with Perthes disease (4 female and 10 male patients) with an average age of 19.6 years (range 14 – 28) were treated with SDO and trochanteric advancement. One patient had a subsequent staged periacetabular osteotomy to improve acetabular coverage. Patient histories, physical exams, operative findings, and pre and postoperative radiographs were evaluated.
Operative findings demonstrated 6 acetabular cartilage lesions, 6 labral lesions, and 4 femoral osteochondritis dissecans (OCD) lesions treated with autografts. Mean center trochanteric distance improved from −20 mm to −1 mm. 4/14 hips deteriorated 1 Tönnis grade and 1/14 hips 2 grades. The Harris hip scores improved from an average of 62 preoperatively (range 51–72) to 95 postoperatively (range 93–97) versus 71 (range 65–76) to 88.6 (range 63–100) in the hips without OCD lesions. There was no statistically significant difference in the age, pre or postoperative HHS between the OCD and non-OCD groups. Mean follow up was 45 months. There were no major perioperative complications and all patients in both groups have their native hip to date.
The typical adult sequelae of Perthes disease predispose the hip to the development of chondrolabral injury and poor clinical function. Treatment with SDO and trochanteric advancement reduces impingement, improves hip biomechanics and allows treatment of intra-articular pathology. The described approach is associated with clinical improvement without major perioperative complication. Additionally, we have found a high rate of OCD lesions of the femoral head in Perthes hips undergoing surgical dislocation. Osteochondral autograft transfer from the resected femoral head-neck junction been found in the 4 patients treated thus far to be safe and effective with comparable clinical and radiographic outcomes to those hips without OCD lesions.
PMCID: PMC3031125  PMID: 21102198
10.  Open Treatment of Femoroacetabular Impingement is Associated with Clinical Improvement and Low Complication Rate at Short-term Followup 
Since the modern description of femoroacetabular impingement (FAI) a decade ago, surgical treatment has become increasingly common. Although the ability of open treatment of FAI to relieve pain and improve function has been demonstrated in a number of retrospective studies, questions remain regarding predictability of clinical outcome, the factors associated with clinical failure, and the complications associated with treatment.
We therefore described the change in clinical pain and function after open treatment, determined whether failure of treatment and progression of osteoarthritis was associated with Outerbridge Grade IV hyaline cartilage injury, and described the associated complications.
We retrospectively reviewed all 94 patients (96 hips) (55 males and 39 females; mean age, 28 years) who underwent surgical dislocation for femoroacetabular impingement between 2000 and 2008. Seventy-two of the 96 hips had acetabular articular cartilage lesions treated with a variety of methods, most commonly resection of damaged hyaline cartilage and labral advancement. Patients were followed for a minimum of 18 months (mean, 26 months; range, 18–96 months).
Mean Harris hip scores improved from 67 to 91 at final followup. Six of the 96 hips (6%) were converted to arthroplasty or had worse Harris hip score after surgical recovery. Four of these six had Outerbridge Grade IV acetabular cartilage lesions and two had Legg-Calvé-Perthes disease or slipped capital epiphysis deformities. Two hips (2%) had refixation of the greater trochanter.
At short-term followup, open treatment for femoroacetabular impingement in hips without substantial acetabular hyaline cartilage damage reduced pain and improved function with a low complication rate. Treatment of Outerbridge Grade IV acetabular cartilage delamination remains the major challenge.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2806994  PMID: 19885709

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