Aims. The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck. Methods. Long-leg standing radiographs of patients undergoing realignment surgery around the knee were used. The hip-knee-ankle angle (HKA) and the vertical orientation of the femoral neck in relation to the floor were measured, prior to surgery and after osteotomy-site-union. Linear regression was performed to determine the influence of knee alignment on the vertical orientation of the femoral neck. Results. The cohort included 147 patients who underwent knee realignment-surgery. The mean age was 51.5 years (SD 11). Overall, 106 patients underwent a valgisation-osteotomy, while 41 underwent varisation osteotomy. There was a significant association between the orientation of the knee and the coronal neck-orientation. In the varus group, the median orientation of the femoral neck was 46.5° (interquartile range (IQR) 49.7° to 50.0°), while in the valgus group, the orientation was 52.0° (IQR 46.5° to 56.7°; p < 0.001). Linear regression analysis revealed that HKA demonstrated a direct influence on the coronal neck-orientation (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p = 0.002). Linear regression also showed that realignment surgery was associated with a significant influence on the change in the coronal femoral neck orientation (β = 5.6 (95% CI 1.5 to 9.8); p = 0.008). Conclusion. Varus or valgus knee alignment is associated with either a more horizontal or a more vertical femoral neck orientation in standing position, respectively. Subsequently, osteotomies around the knee alter the vertical orientation of the femoral neck. These aspects are of importance when planning osteotomies around the knee in order to appreciate the effects on the adjacent hip joint. The concept may be of even more relevance in dysplastic hips. Cite this article: Bone Jt Open 2021;2(12):1057–1061

Mixed Reality has the potential to improve accuracy and reduce required dissection for the performance of peri-acetabular osteotomy. The current work assesses initial proof of concept of MR guidance for PAO. A PAO planning module, based on preoperative computed tomography (CT) imaging, allows for the planning of PAO cut planes and repositioning of the acetabular fragment. 3D files (holograms) of the cut planes and native and planned acetabulum positions are exported with the associated spatial information. The files are then displayed on mixed reality head mounted device (HoloLens2, Microsoft) following intraoperative registration using an FDA-cleared mixed reality application designed primary for hip arthroplasty (HipInsight). PAO was performed on both sides of a bone model (Pacific Research). The osteotomies and acetabular reposition were performed in accordance with the displayed holograms. Post-op CT imaging was performed for analysis. Cutting plane-accuracy was evaluated using a best-fit plane and 2D angles (°) between the planned and achieved supra (SA)- and retroacetabular (RA) osteotomy and retroacetabular and ischial osteotomies (IO) were measured. To evaluate the accuracy of acetabular reorientation, we digitized the acetabular rim and calculated the acetabular opening plane. Absolute errors of planned and achieved operative inclination and anteversion (°) of the acetabular fragment, as well as 3D lateral-center-edge (LCE) angles were calculated. The mean absolute difference between the planned and performed osteotomy angles was 3 ± 3°. The mean absolute error between planned and achieved operative anteversion and inclination was 1 ± 0° and 0 ± 0° respectively. Mean absolute error between planned and achieved 3D LCE angle was 0.5 ± 0.7°. Mixed-reality guidance for the performance of pelvic osteotomies and acetabular fragment reorientation was feasible and highly accurate. This solution may improve the current standard of care by enabling reliable and precise reproduction of the desired acetabular realignment

Aims. The aim of this study was to understand the experience of mature patients who undergo a periacetabular osteotomy (PAO), a major hip-preserving surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to improve our understanding of how the operation affected the lives of patients and their families, with a long-term goal of improving their experience. Methods. We used a phenomenological approach with in-depth, semi-structured interviews to investigate the experience of seven female patients, aged between 25 and 40 years, who underwent a PAO. A modified homogeneity sampling approach coupled with criterion sampling was used. Inclusion criteria involved having at least one child at home and being in a committed relationship with a spouse or partner. Results. Analysis of interview transcripts revealed five major themes: feelings of frustration before having a treatment plan; fear of the operation; the importance of understanding the procedure in order to feel in control of their care; feelings of helplessness, dependence, and depression during recovery; and the need for support during recovery. Conclusion. Our findings suggest that both the physical and psychosocial burdens of undergoing a PAO are great, with a major impact on the patient and their family. Many important issues lie outside the scope of what healthcare teams currently address. Cite this article: Bone Joint J 2022;104-B(7):781–785

The purpose of this study is to understand the lived experience of mature patients who undergo a periacetabular osteotomy (PAO), a major surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to better understand how the PAO impacted the lives of the patients and their families, with a long-term goal of improving the experience. We utilized a phenomenological approach with in-depth, semi-structured interviews to investigate the experience of seven women, ages 25–40, who underwent a PAO. A modified intensity sampling method coupled with criterion sampling was used. Inclusion criteria included raising at least one child and being in a committed relationship with a partner. Analysis of interview transcripts revealed eight themes, each of which falls into one of three chronological periods. From the start of dysplasia symptoms until meeting the PAO surgeon: (1) frustration with symptoms disrupting daily activities, (2) discouragement from misdiagnoses and lack of explanation for symptoms, and (3) fear of the PAO operation. During the PAO decision-making process: (1) the importance of education regarding the PAO procedure and full understanding of its purpose, and (2) the utility of social media to learn from past PAO patients in order to feel more confident about the decision to undergo PAO. Post-operation through recovery: (1) feelings of helplessness, isolation and difficulty asking for help, (2) relying heavily on family and/or close friends for assistance, and (3) desire for more support and communication from the healthcare team. Our findings suggest that the psychosocial burden of PAO surgery is great, with major impact on the patient and family. Many important issues lie outside the scope of what healthcare teams currently address

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Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty.

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The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia.

Tannast has recently shown that safe hip dislocation (SHD) for femoroacetabular impingement treatment does not result in atrophy and degeneration of periarticular hip muscles. In more complex procedures, such as relative neck lengthening for Perthes disease (PD) or modified Dunn procedure for slipped capital epiphysis (SCFE), minimus gluteus femoral insertion is detached to achieve enough mobility of osteotomized trochanter and to fix the latter more distally. Aim of this study was to evaluate MRI appearance of minimus and medius gluteus after relative neck lengthening. Patients treated with SHD and relative neck lengthening eventually associated to epiphyseal realignment for PD or SCFE treatment underwent magnetic resonance imaging (MRI) to study gluteus minimus (MI) and medius (ME) muscles. In the axial T1-weighted sequences, cross sectional area (CSA) and signal intensity were evaluated at acetabular roof level. Statistical comparison was made with the opposite healthy side. Fifteen patients underwent an MRI at an average of 59 months (SD=27.3) after surgery. Average ratio between gluteus minimus CSA (treated/healthy side) was 0.90 (SD=0.2): this reduction in volume was statistically significant (p=0.04) as well as the signal intensity (p=0.04). CSA and signal intensity of gluteus medius did not differ between two sides (respectively p=0.78 and p=0.30). In conclusion, gluteus medius appearance was not influenced by distal fixation of the trochanter. The minimus gluteus was reduced in volume as much as 10% in respect to healty side; increased signal intensity in MRI T1-weighted (fatty infiltration) was found in the minimus gluteus

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Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients.

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Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

We have retrospectively reviewed the clinical and radiological results in 204 consecutive adult patients who had surgical correction of 70 late post-traumatic pelvic nonunions and 134 malalignments. The deformed pelvises were subdivided into united (true), unstable, ununited, and partially stable malalignments with heterotopic bone. The principal complaints were of pain, pelvic instability, sitting imbalance, and apparent limb-length discrepancy. After surgery, 195 patients (96%) achieved a primary union and 144 (71%) had slight, intermittent or no pelvic pain, while pelvic instability was entirely eliminated. Overall, 131 patients (64.2%) were extremely satisfied, 58 (28.4%) were satisfied and 15 (7.4%) were unsatisfied. After reconstruction of the malaligned pelvises, 67 results (50%) were anatomical, 47 (35%) were satisfactory and 20 (15%) were unsatisfactory. For a pelvic nonunion with local osteopenia and malalignment, stabilisation of all three pelvic columns is recommended. True pelvic (united) malunions were the most satisfactorily realigned and had the fewest complications. Ununited and unstable malalignments, especially those with heterotopic bone, had the poorest corrections and the most neurological complications. A therapeutic alternative, by the local resection of a symptomatic bony prominence, and fixation in situ of a posterior pelvic nonunion, gives highly effective symptomatic relief with fewer complications. Despite this, many patients had persistent low back pain

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The aim of this study was to evaluate the long-term clinical and radiographic outcomes of the Birmingham Interlocking Pelvic Osteotomy (BIPO).

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The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE.

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Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA.

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The aim of this study was to evaluate the accuracy of implant placement when using robotic assistance during total hip arthroplasty (THA).

The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.

Cite this article: Bone Joint J 2015;97-B:1017–23.

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE.

Cite this article: Bone Joint J 2013;95-B:445–51.

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001).

We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.

We investigated the wear characteristics and clinical performance of four different total hip joint articulations in 114 patients. Wear and migration was measured by roentgenstereophotogrammetric analysis at five years or at the last follow-up. The mean annual wear was 0.11 mm for a stainless steel/Enduron articulation, 0.34 mm for stainless steel/Hylamer cup, 0.17 mm for zirconium oxide ceramic/Enduron and 0.40 mm for zirconium oxide ceramic/Hylamer. The difference between the groups was significant (p < 0.008) except for stainless steel/Hylamer vs zirconium oxide ceramic/Hylamer (p = 0.26).

At present, 12 patients have undergone a revision procedure, four at five years and eight thereafter. No patient who received a stainless steel/Enduron articulation at their primary replacement required revision.

Conflicting results have been reported about the performance of the zirconium oxide ceramic femoral head, but our findings suggest that it should not be used with a polymethylmethacrylate acetabular component. Hylamer has already been withdrawn from the market.

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes.

This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.