Hip joint preservation remains a preferred treatment option for hips with mechanically correctable pathologies prior to the development of significant secondary arthrosis. The pathologies most amenable to joint preservation are hip dysplasia and femoroacetabular impingement. These pathologies sometimes overlap. Untreated acetabular dysplasia of modest severity always leads to arthrosis if uncorrected. Acetabular dysplasia is best treated by periacetabular osteotomy, usually combined with arthrotomy for management of labral pathology and associated cam-impingement if present. Pre-operative variables associated with the best long-term outcomes include less secondary arthrosis, younger age, and concentric articular surfaces. The earlier PAO series show 20 year survivorship of 81% and 65% in Tonnis Grade 0 and 1 hips. Femoroacetabular impingement has become progressively recognised as perhaps the most common cause of secondary arthrosis. The etiology of impingement is multifactorial and includes both genetic factors and stresses experienced by the hip prior to cessation of growth. Cam impingement can be quantified by the alpha angle as measured on plain radiographs and radial MR sequences. Cam impingement can be treated by arthroscopic or open femoral head-neck osteochondroplasty. As with hip dysplasia, prognosis following treatment is correlated with the severity of pre-operative secondary arthrosis but unfortunately impinging hips more commonly have some degree of arthrosis pre-operatively whereas dysplastic hips can become symptomatic with instability in the absence of arthrosis. The scientific basis for the treatment of pincer impingement is less strong. Unlike cam impingement and hip dysplasia, pincer impingement pathology in the absence of coxa profunda has not been correlated with arthrosis and so rim trimming with labral refixation is probably performed more often than is clinically indicated. Overall, joint preserving surgery remains the preferred treatment for hips with mechanically correctable problems prior to the development of significant secondary arthrosis

Hip joint preservation remains a preferred treatment option for hips with mechanically correctable pathologies prior to the development of significant secondary arthrosis. The pathologies most amenable to joint preservation are hip dysplasia and femoroacetabular impingement. These pathologies sometimes overlap. Untreated acetabular dysplasia of modest severity always leads to arthrosis if uncorrected. Acetabular dysplasia is best treated by periacetabular osteotomy, usually combined with arthrotomy for management of labral pathology and associated cam-impingement if present. Preoperative variables associated with the best long-term outcomes include less secondary arthrosis, younger age, and concentric articular surfaces. Femoroacetabular impingement has become progressively recognised as perhaps the most common cause of secondary arthrosis. The etiology of impingement is multifactorial and includes both genetic factors and stresses experienced by the hip prior to cessation of growth. Cam impingement can be quantified by the alpha angle as measured on plain radiographs and radial MR sequences. Cam impingement can be treated by arthroscopic or open femoral head-neck osteochondroplasty. As with hip dysplasia, prognosis following treatment is correlated with the severity of preoperative secondary arthrosis but unfortunately impinging hips more commonly have some degree of arthrosis preop whereas dysplastic hips can become symptomic with instability in the absence of arthrosis. The scientific basis for the treatment of pincer impingement is less strong. Unlike cam impingement and hip dysplasia, pincer impingement pathology in the absence of coxa profunda has not been correlated with arthrosis and so rim trimming with labral refixation is probably performed more often than is clinically indicated. Overall, joint preserving surgery remains the preferred treatment for hips with mechanically correctible problems prior to the development of significant secondary arthrosis

Over the past fifteen years hip preservation surgery has rapidly evolved. Improved understanding of the pathomechanics and associated intra-articular degeneration of both hip instability and femoroacetabular impingement have led to improved surgical indications, refined surgical techniques and more effective joint preservation surgical procedures. The periacetabular osteotomy (PAO) was initially introduced by Ganz and colleagues and has become the preferred treatment in North America for pre-arthritic, symptomatic acetabular dysplasia. Both hip arthroscopy and safe surgical dislocation of the hip have been popularised for the treatment of symptomatic femoroacetabular impingement disorders. Hip arthroscopy is effective for focal and\or accessible impingement lesions while the surgical dislocation approach is reserved for nonfocal disease patterns as seen in complex FAI, and residual Perthes and SCFE deformities. Femoroacetabular impingement from major acetabular retroversion can be managed with the PAO if there is coexistent posterosuperior acetabular insufficiency. Short- to mid-term results of these procedures are generally good to excellent for most patients and the complication rates associated with these procedures are very acceptable. Long-term outcomes are best known for the PAO. Several recent studies have documented survivorship rates of 65–90% at 10–20-year follow-up. Certain factors are associated with long-term success including minimal pre-operative radiographic OA, early symptoms, accurate acetabular correction, and younger age. These data strongly suggest that the PAO can defer THA to an older age for most patients while completely avoiding arthroplasty may only be possible in select patients with excellent congruency, no secondary OA and an ideal surgical correction.

There are a number of progressive conditions that afflict the hip and result in degenerative arthritis. Along the path of progression of the disease and prior to the development of arthritis, some of these conditions may be treatable by joint preservation procedures. Periacetabular osteotomy for developmental dysplasia of the hip (DDH), femoroacetabular osteoplasty for femoroacetabular impingement (FAI), and a variety of surgical procedures for management of early osteonecrosis of the femoral head are some examples of joint preservation of the hip. DDH is characterised by abnormal development of the acetabulum and the proximal femur that leads to suboptimal contact of the articular surfaces and the resultant increase in joint reaction forces. FAI is a condition characterised by an abnormal contact between the femoral neck and the acetabular rim. FAI is believed to exist when a triad of signs (abnormal alpha angle, labral tear, and chondral lesion) can be identified.

The question that remains is whether joint preservation procedures are able to avert the need for arthroplasty or just an intervention along the natural path of progression of the hip disease. There is an interesting study that followed 628 infants born in a Navajo reservation, including 8 infants with severe dysplasia, for 35 years. None of the children with DDH had surgical treatment and all had developed severe arthritis in the interim. The latter study and a few other natural history studies have shown that the lack of administration of surgical treatment to patients with symptomatic DDH results in accelerated arthritis. The situation is not so clear with FAI. Some believe that FAI is a pre-arthritic condition and surgical treatment is only effective in addressing the symptoms and does not delay or defer an arthroplasty. While others believe that restoration of the normal mechanical environment to the hip of FAI patients, by removing the abnormal contact and repair of the labrum, is likely to change the natural history of the disease and at minimum delay the need for an arthroplasty. There is a need for natural history studies or case series to settle the latter controversy.

Surgical invention to preserve the native hip joint remains a preferred treatment option for hips in young patients with mechanically correctable pathologies prior to the development of significant secondary arthrosis. The two most common pathologies most amenable to joint preservation are hip dysplasia and femoroacetabular impingement. These pathologies sometimes overlap. Untreated acetabular dysplasia of modest severity, if left uncorrected, always leads to arthrosis. Acetabular dysplasia is best treated by periacetabular osteotomy, usually combined with arthrotomy for management of labral pathology and associated cam-impingement, if present. Correction of deformities on the femoral side is now less common and reserved for only the more severe combined femoral and acetabular dysplasias or the rare isolated femoral dysplasia. Pre-operative variables associated with the best long-term outcomes include less secondary arthrosis, younger age, and concentric articular surfaces.

Femoroacetabular impingement has become progressively recognised as perhaps the most common cause of secondary arthrosis. The etiology of impingement is multifactorial and includes both genetic factors and stresses experienced by the hip prior to cessation of growth. Cam impingement can be quantified by the alpha angle as measured on plain radiographs and radial MR sequences. Further, significant cam impingement is clearly associated with the development of osteoarthrosis. Treatment can be performed either by arthroscopic or open femoral head-neck osteochondroplasty. As with hip dysplasia, prognosis following treatment is correlated with the severity of pre-operative secondary arthrosis but unfortunately impinging hips more commonly have some degree of arthrosis pre-op whereas dysplastic hips can become symptomatic with the onset of instability in the absence of significant secondary arthrosis. The scientific basis for the treatment of pincer impingement is less strong. Unlike cam impingement and hip dysplasia, pincer impingement pathology in the absence of coxa profunda has not been correlated with arthrosis and so rim trimming with labral refixation is probably performed more often than is clinically indicated. Similarly, caution should be exercised when considering rim-trimming for protrusion since high central contact pressures due to an enlarged acetabular notch are not corrected by rim trimming.

Overall, joint preserving surgery remains the preferred treatment for hips with mechanically correctable problems prior to the development of significant secondary arthrosis.

Aims. The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome. Methods. Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome. Results. At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI. Conclusion. FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes. Cite this article: Bone Jt Open 2022;3(10):804–814

Introduction. Femoroacetabular impingement(FAI) is a relatively common cause causes of hip pain and dysfunction in active young adults. The concept of FAI was popularized by Ganz et al in early 2000s. Surgical treatment for FAI has been widely employed over the last two decades. The long term outcome of femoroacetabular osteoplasty (FAO) and risk factors for long-term failure of FAO is less studied. The goal of this single surgeon series is to identify the long term outcome of FAO (minimum 10-year follow-up) and risk factors for surgical treatment failure in these patients. Methods. The prospective database on hip joint preservation identified 1,120 patients who have undergone FAO between January 2005-June 2019. Of these 164 patients (178 hips) have a minimum 10-year follow-up (range, 10–14). The database collects detailed information on patient demographics, clinical history, radiographic and cross sectional imaging findings, intraoperative findings (site and size of chondral lesion, labral tear, subchondral cyst, size of cam lesion, etc), and patient outcome using the modified HHS, SF-36, and UCLA activity score. Patients are contacted on an annual basis and the functional outcome instruments administered. Of 1,120 patients, 122 patients have been lost to follow-up. Results. The mean age of patients in the cohort is 34.3±10.4 years and 39.6% of patients are female. FAO resulted in an improvement in mean mHHS (58.2±3.9 to 86.4±3.2) and SF-36(60.4±4 to 85±4.1) in 89% of patients. At the latest follow up 8.1% of patients have undergone THA. The study found that older age, longer preoperative symptomatic period, higher preoperative alpha angle, presence of hip dysplasia and acetabular retroversion, inability to repair acetabular labrum, and full thickness acetabular chondral lesion were associated with higher risk of failure of treatment. Conclusion. Patients with symptomatic FAI who undergo surgery experience pain relief and functional improvement that appears to endure over a decade in the majority. This study on a large cohort with long term follow-up has also identified patients who are at higher risk of failure. The study has also shed light on some interesting findings such as labral tear being very common in patients without hip symptoms and others that will be presented. For any tables or figures, please contact the authors directly

Hip joint preservation remains a preferred treatment option for hips with mechanically correctable pathologies prior to the development of significant secondary arthrosis. The pathologies most amenable to joint preservation are hip dysplasia and femoroacetabular impingement. These pathologies sometimes overlap. Untreated acetabular dysplasia of modest severity, if left uncorrected, always leads to arthrosis. Acetabular dysplasia is best treated by periacetabular osteotomy, usually combined with arthrotomy for management of labral pathology and associated cam-impingement if present. Pre-operative variables associated with the best long-term outcomes include less secondary arthrosis, younger age, and concentric articular surfaces. Femoroacetabular impingement has become progressively recognised as perhaps the most common cause of secondary arthrosis. The etiology of impingement is multifactorial and includes both genetic factors and stresses experienced by the hip prior to cessation of growth. Cam impingement can be quantified by the alpha angle as measured on plain radiographs and radial MR sequences. Further, significant cam impingement is clearly associated with the development of osteoarthrosis. Treatment can be performed either by arthroscopic or open femoral head-neck osteochondroplasty. As with hip dysplasia, prognosis following treatment is correlated with the severity of preoperative secondary arthrosis but unfortunately impinging hips more commonly have some degree of arthrosis preop whereas dysplastic hips can become symptomatic with instability in the absence of arthrosis. The scientific basis for the treatment of pincer impingement is less strong. Unlike cam impingement and hip dysplasia, pincer impingement pathology in the absence of coxa profunda has not been correlated with arthrosis and so rim trimming with labral refixation is probably performed more often than is clinically indicated. Similarly, caution should be exercised when considering rim-trimming for protrusion since high central contact pressures due to an enlarged acetabular notch are not corrected by rim trimming. Overall, joint preserving surgery remains the preferred treatment for hips with mechanically correctable problems prior to the development of significant secondary arthrosis

Aims

The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?

Aims

For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis.

We report our early Boston experience with the technique of Ganz, et al., for surgical dislocation of the hip, which provides a safe, powerful approach to certain major intraarticular hip problems. Materials and Methods: Forty-seven hips with various mechanical disorders have been treated using the Ganz technique of trochanteric flip osteotomy and anterior dislocation (JBJS 83-B: 1119-1124, 2001). Diagnoses include slipped epiphysis 14, Perthes 12, aspherical head/ anterior offset 12, dysplasia 14, multiple exostoses 2, other 3.Seven patients had simultaneous femoral oste-otomies; four had subcapital osteotomies for epiphys-iolysis. All patients had pain and limitation of motion preoperatively, and more than fifty percent had severe deformity and/or some arthrosis. Follow-up was six months to five years. Ages at surgery were eight to forty-eight years (mean twenty years). Results: The variety of pathologies render objective analysis difficult, though all patients reported greatly reduced pain and increased motion post operatively. Only five patients were totally pain free and had objectively totally normal hips. No patient felt unimproved. No patient had radiographic signs of osteonecrosis. Conclusion: Paralleling the Bernese experience of more than eight hundred cases, we find the Bernese technique of surgical dislocation to be a safe, effective tool for treating intra-articular hip pathology, increasing treatment possibilities for hip joint preservation. We anticipate greatly expanding its use in the future

The ultimate goal of surgery for acetabular fractures is hip joint preservation for the rest of the patient’s life. However, besides Letournel’s series, long term survi-vorship in this predominantly young patient group has never been published in a very large series. The aim of this study was to determine the cumulative 20-year sur-vivorship of the hip after fixation of acetabular fractures and to identify factors predicting the need for total hip arthroplasty. A Kaplan-Meier survivorship analysis of 1218 consecutive surgically treated acetabular fractures was carried out. 816 fractures were available for analysis with a mean follow up of 10.3 years (range 2–29 years). All the surgeries were performed by a single surgeon in accordance to an established treatment protocol based on Letournel’s principles. Inclusion criteria were a minimum follow-up of two years or failure at any time. Failure was defined as conversion to total hip arthroplasty of hip arthrodesis. A Cox-regression analysis identified significant risk factors predicting the need for total hip arthroplasty. Analyzed parameters comprised data on patient history, preoperative clinical examination, associated injuries, fracture pattern, radiographic and intra-operative features, and the accuracy of reduction. The cumulative 20-years survivorship was 79% (95% CI, 76–81%). Statistically significant factors influencing the need for artificial hip replacement/arthrodesis were: age over 40 years (Hazard ratio [HR] 2.4), femoral head damage (HR 2.6), acetabular impaction (HR 1.5), postoperative incongruence of the acetabular roof (2.9), involvement of the posterior wall (HR 1.6), anterior dislocation (5.9), initial displacement > 20mm (HR 1.6), and a malreduction with residual displacement > 1mm (HR 3.0). There was a significantly different survivorship of the individual fracture types. The worst survivorship occurred in anterior wall fractures (34% at 20 years) and the best survivorship in both column fractures (87% at 20 years). The accuracy of reduction improved significantly over time. In summary, the hip joint can be successfully preserved and prosthetic replacement avoided in 79% of displaced acetabular fractures at 20 years. Many of the factors influencing the long term prognosis are already determined at the time of injury. The factors that can be influenced by the surgeon are anatomic reduction, achievement of congruency of the acetabular roof and correction of marginal impaction. The presented unique results even exceed Letournel’s series in size and follow up. Therefore, they provide benchmark data for any type of comparative evaluation studies dealing with surgical treatment of acetabular fractures in future

Improvement in coverage achieved by double or triple osteotomies is limited by the size of the acetabular fragment and the ligaments connected with the sacrum. Correction is achieved with the notable asymmetry of the pelvis. In periacetabular Ganz osteotomy (PAO) the acetabular fragment has no connection with the sacrum, which creates enormous possibilities for correction, leaving the pelvic ring untouched. The aim of the study is to present our experience and early results of using PAO in the treatment of hip dysplasia in adolescents and young adults who were previously treated operatively in childhood, and to find the technical and clinical impact of previous operations on our Results: In the years 1998–2005 262 periacetaubular osteotomies were performed in our hospital. All the patients were operated by one surgeon (JC). From this group 41 patients (43 hips) had previously been operated in childhood for the treatment of hip dysplasia. The previous treatment consisted of: open reduction in 10 hips, DVO in 14 hips, pelvic osteotomy (Salter, Dega, Chiari) in 8 hips, combined: open reduction+DVO+pelvic osteotomy in 10 hips, greater trochanter transfer in 3 hips, bone lengthening in 4 hips, acetabular cyst removal in 1 hip. The age at the primary operation ranged from 1–20.. The follow-up period ranged from 1–7,5 ys av. 2 ys. In 31 hips the Smith-Petersen, and in 12 hips ilioinguinal approach were performed. Methods. In clinical pre-op, and post-op examination the following factors were considered: pain, limping, Trendelenburg sign, range of motion, length discrepancy. Radiographic pre-op and post-op examination consisted of: AP view of the pelvis, false profile and AP view with the leg in abduction. Classic and anterior CE angle were measured. During the last examination Harris Hip Score was used. Results. Flexion slightly decreased from pre-op. 90–140° (av. 118°) to 80–130° (av. 104°) post-op. abduction remained unchanged 15–60° (av. 40°) and 15–60° (av. 40°) respectively, adduction slightly increased 15–40° (av. 31) and 20–50° (av. 33°). The range of rotation did not change after the operation. The sign of Trendelenburg was found in 27 hips before operation and in 8 hips post-op. Pain (acetabular rim syndrome) was found in 40 hips before operation and in 4 hips after the surgery. Either classic or anterior CE angle increased after the surgery in all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. But in cases previously operated and in males we strongly recommend Smith-Petersen approach extended into the frontal part of the hip for a better exposure in the scarred and hardened tissues. We find the technique of PAO as a safe, and effective tool for treating hip joint pathology increasing treatment possibilities for hip joint preservation

Aims

The follow-up interval of a study represents an important aspect that is frequently mentioned in the title of the manuscript. Authors arbitrarily define whether the follow-up of their study is short-, mid-, or long-term. There is no clear consensus in that regard and definitions show a large range of variation. It was therefore the aim of this study to systematically identify clinical research published in high-impact orthopaedic journals in the last five years and extract follow-up information to deduce corresponding evidence-based definitions of short-, mid-, and long-term follow-up.

As our understanding of hip function and disease improves, it is evident that the acetabular fossa has received little attention, despite it comprising over half of the acetabulum’s surface area and showing the first signs of degeneration. The fossa’s function is expected to be more than augmenting static stability with the ligamentum teres and being a templating landmark in arthroplasty. Indeed, the fossa, which is almost mature at 16 weeks of intrauterine development, plays a key role in hip development, enabling its nutrition through vascularization and synovial fluid, as well as the influx of chondrogenic stem/progenitor cells that build articular cartilage. The pulvinar, a fibrofatty tissue in the fossa, has the same developmental origin as the synovium and articular cartilage and is a biologically active area. Its unique anatomy allows for homogeneous distribution of the axial loads into the joint. It is composed of intra-articular adipose tissue (IAAT), which has adipocytes, fibroblasts, leucocytes, and abundant mast cells, which participate in the inflammatory cascade after an insult to the joint. Hence, the fossa and pulvinar should be considered in decision-making and surgical outcomes in hip preservation surgery, not only for their size, shape, and extent, but also for their biological capacity as a source of cytokines, immune cells, and chondrogenic stem cells.

Cite this article: Bone Joint Res 2020;9(12):857–869.

Introduction. Curved varus intertrochanteric osteotomy of the femur is an excellent and minimally invasive method for the treatment of osteonecrosis of the femoral head or osteoarthritis of the hip for joint preservation. However, the early postoperative complications of this procedure may be due to separation at the osteotomy site and an increase in varus angle due to early partial weight bearing. Methods. We modified the curved varus intertrochanteric osteotomy of the femur by performing an additional rotation. Regarding the surgical technique, curved varus osteotomy is performed at an angle of 30 degrees to the femoral shaft and an additional rotational osteotomy is also performed at an angle of 15 or 20 degrees to the osteotomy plane. Partial weight bearing with one-third body weight is permitted 3 weeks after surgery. Results. Curved varus intertrochanteric osteotomy of the femur was designed for developmental dysplastic hip by Nishio in 1969 and reported to have good outcomes in 1971. An important feature of this method is that the incidence of high riding of the greater trochanter or shortening of leg length is less than that in varus intertrochanteric osteotomy. Moreover, good contact at the osteotomy site and less lateral shift of the femoral shaft is observed. However, we have experienced a case of separation at the osteotomy site and increase of the varus angle in our hospital. Previous reports recommended that partial weight bearing with one-third body weight should be initiated after 5 weeks and full weight bearing after 6 months because the contact area is decreased at the osteotomy site by varus osteotomy. The post-operative recovery of the patients with total hip arthroplasty is rapid, therefore, we must consider important issues such as initiating the rehabilitation program early and reducing the duration of hospitalization. As per our experience, we think that partial weight bearing with one-third body weight should be initiated at 3 weeks. At the osteotomy site, we rotated the nearest bone segment to move it such that it intersects the proximal and distal bone cortex. Therefore, the osteotomy site will be stabilized and will have the ability to endure load. Another feature of this technique is that the partial removal of the necrotic area leads to an increase in the healthy load-bearing area. A limitation of this method is that an angle of an additional rotation is up to 30 degrees, because the joint capsule cannot be incised circumferentially and the short external rotator tendons should also be preserved. Conclusion. Modified curved varus intertrochanteric osteotomy is a useful method for the prevention of increased degree of a varus angle as well as for obtaining more intact area of femoral head in osteonecrosis