Developmental dysplasia of the hip (DDH) in adolescents and young adults can cause notable pain and dysfunction and is a leading cause of progressive hip osteoarthritis in affected patients. Recognition of the clinical symptoms and radiographic presentation of DDH in adolescents and young adults are paramount for early management. Plain radiographs are critical for making proper diagnosis, whereas three-dimensional imaging including MRI and/or CT detects intra-articular pathology and better characterizes hip morphology. Management of early, symptomatic DDH includes nonsurgical modalities and open joint preservation techniques. Arthroscopic management can be used as an adjunct for symptomatic treatment and for addressing intra-articular pathology, but it alone does not correct the underlying osseous dysplasia and associated instability. The periacetabular osteotomy has become the mainstay of efforts to redirect the acetabulum and preserve the articular integrity of the hip; however, the proximal femur is also a potential source of pathology that should be considered. Open hip procedures are technically demanding yet provide the opportunity for pain relief, improved function, and preservation of the hip joint.
United States military personnel frequently suffer knee injuries. The resulting progressive posttraumatic osteoarthritis (PTOA) causes significant disability in these young high-demand patients for which total knee arthroplasty (TKA) is the only effective treatment of their pain and impairment. Yet the use of this option for treatment of PTOA has not been studied. This retrospective review identified 74 knees in 64 U.S. military personnel who underwent TKA at ≤50 years of age during an 8-year period at a tertiary-care, academic, military medical center. Fifty-five knees (74.3%) experienced one or more prior ligamentous, meniscal, or chondral injuries prior to arthroplasty. Only one subject had a history of osteochondral intra-articular fracture. The average at injury was 29.2 years (95%CI of ±2.50) with an average age at arthroplasty of 44.3 years (±1.11). The most common injury was anterior cruciate ligament rupture (n = 19) with a mean time to TKA of 23.1 (±10.54) and 18.8 years (±7.01) when concomitant meniscal pathology was noted. Nineteen patients were noted to have radiographic and symptomatic end-stage osteoarthritis without a specified etiology at 41.4 years (±1.47) and underwent subsequent TKA. This is the first study to evaluate treatment of end-stage PT OA in young people treated with TKA, finding that the incidence of PTOA as an indication for arthroplasty is significantly higher than among civilians. In this otherwise healthy, high-demand patient population, the rate of OA progression following knee injury is accelerated and the long term implications can be career and life altering. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:677-681, 2017.
This study sought to determine outcomes of a graduated management protocol from therapy to arthroscopy for adolescents presenting with hip pain and an associated acetabular tear. Thirty-seven hips with an MRI confirmed labral tear were prospectively enrolled in a graduated management protocol created for adolescents. The protocol began with activity modification and focused physical therapy. Patients with persistent symptoms were offered an intraarticular corticosteroid injection. Those with continued symptoms were treated with arthroscopic surgery. The modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were recorded at the initial visit. Patients were contacted by telephone at 1, 2, and 5 years from enrollment for repeat assessment with mHHS and NAHS. At presentation, the mean mHHS and NAHS for the entire cohort was 66.4 ± 11.4 and 70.2 ± 12.6, and these values improved significantly to 89.3 ± 10.6 and 87.0 ± 11.4 at a mean follow-up of 35.7 ± 18.3 months (range 11.7-64.4 months). Forty-two percent of hips were managed with physical therapy and activity modifications alone, 28% of hips progressed to a steroid injection but did not require surgery, and 31% required arthroscopic intervention. Seventy-three percent of hips treated with activity modification alone, 80% treated with an injection, and 82% of hips treated with arthroscopic repair met the minimal clinically significant difference (MCID) (P = 0.859). At an average of 36 months follow-up, the majority (78%) of adolescent patients with an acetabular labral tear will achieve the MCID utilizing a graduated management protocol.
Use of larger diameter femoral heads has emerged as a promising strategy to reduce the risk of dislocation after total hip arthroplasty, but thinning the walls of cross-linked ultra-high-molecular-weight polyethylene (UHMWPE) acetabular liners to accommodate these larger heads may compromise the locking mechanism of the liner. The purpose of this study was to test the mechanical integrity of the locking mechanism in cross-linked and re-melted UHMWPE acetabular components with reduced wall thickness. The locking mechanism of cross-linked (100 kGy/re-melted) acetabular liners in sizes 50/28, 50/36, and 52/36 mm of 1 design was evaluated by lever-out tests and torsion tests. Torsion tests were performed at 2 angles to isolate the liner's locking tabs independent of the contribution of its central post. Lever-out testing demonstrated nominally reduced failure strength in 50/36-mm liners (13.3 N · m) compared with 50/28-mm liners (12.3 N · m; P=.0502), whereas the lever-out strength of 52/36-mm liners was 12.2±0.94 N · m. Failure torques were similar between 50/28- and 50/36-mm liners at 45° and 90°, but the failure torque of size 52/36-mm liners was significantly higher at each angle. The use of larger diameter femoral heads does not compromise the locking mechanism of thinned MicroSeal (Signal Medical Corp, Marysville, Michigan) acetabular liners. Use of a cross-linked UHMWPE acetabular liner, with a locking mechanism that is not compromised when the liner is thinned to a thickness of at least 2.86 mm, appears to be a biomechanically sound construct when articulated with large diameter femoral heads.
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