Journal club on Surgical Management of the Problematic hip in adolescent and young adult

1. Journal club on Surgical
Management of the Problematic
Hip in Adolescent and Young
Adult Patients
Presenter - Dr. Shubhanshu Singh
Guide – Dr. John Mukhopadhaya sir

2. Introduction
• In < 40 years patients, pathologic condition
can lead to permanent hip OA.
• Primary cause – Damage to articular cartilage,
chondrolabral complex, acetabular rim,
labrum
• Secondary – Instability, Impingement or both
• Dysplasia instability spectrum and femoro-
acetabular impingement most problematic hip
disorders.

3. Femoro-acetabular Impingement
• Alpha angle assesed by Dunn or Frog Leg
lateral xrays.
• Cam FAI - femur origin (Abnormal shape of femoral head)
Posterior tilt of femur head as in SCFE, coxa magna, LCPD
Femoral retroversion coxa vara
Jamming into anterolateral acetabulan in flexion and/or
internal rotation

5. Femoro-acetabular Impingement
• Pincer FAI- Acetabular origin
– Overcoverage
– Acetabular retroversion
– Hip flexion adduction internal rotated
– Seen in deep acetabulum coxa profunda protrusio
acetabuli acetabular retroversion

6. Femoro-acetabular Impingement
• Symtomatic reported in some non surgically
managed dysplastic hip
• Retroversion can be seen in single, triple
innominate osteotomy or PAO.
• High prevalance of retroversion in LCPD, SCFE,
Proximal Femoral Focal Deficiency and bladder
exstrophy.

7. Hip Instability
• Obliquity of acetabular weight bearing zone
• Acetabular deficiency
• Intracapsular changes: labrum injury, rim
fracture, deficient anterolateral head neck
offset
• Acetabular retroversion, coxa valga, excessive
femoral anteversion, ligamentous laxity

8. Hip Instability
• Severity assesed by measuring center-edge
angle (normal>25 degree) on AP
• Tonnis angle of inclination of acetabulum
weight bearing zone (i.e. sourcil) on AP (0-10)
• Hip joint lateralization assesed by distance
between medial border of femur head and
ilioischial line(<10mm)

10. Joint preserving techniques
• Goal is to restore stability and reduce
pathologic stress on acetabular rim without
creating joint incongruity and impingement
• Acetabular redirectional osteotomy
Immature skeletal – triple innominate osteotomy
Skeletal mature- Bernese periacetabular osteotomy (PAO)
Rotational osteotomy
• Proximal femoral realignment osteotomy

11. Bernese periacetabular osteotomy
• Management of choice in symptomatic hip
instability
• Patient should be negative for advanced OA,
painless ROM flexion >90 abduction >30
• Four osteotomies
1. Anterior ischium
below the acetabulum
2. Superior pubic ramus
3. Supra-acetabular ilium
4. Posterior column joining cut number one

12. Bernese PAO
• Acetabular fragment
– Tilted laterally
– Rotated inward
– Medialized
– Extended
• Correction of the superolateral pathologic slope of the
sourcil to horizontal position and correction of
lateralization.
• The anterior and posterior edges of the acetabulum are
identified to assess for retroversion.
• Retroversion avoided by using an inward rotation maneuver
(around an AP axis) and avoiding excessive extension of the
acetabular fragment.

13. BPAO
• 90° of flexion and 25° to 30° of abduction
should be seen.
• Anterior arthrotomy is performed before or
after acetabular reorientation to examine the
labrum and the head-neck junction.
• In the patient with deficient offset, head-neck
junction osteochondroplasty is performed.

14. BPAO
• PAO, the lateral extrusion index should be <20%.
• Proximal femoral osteotomy (PFO)(flexion/valgus) to
achieve lateral coverage.
• Limited hip abduction following PAO is likely to occur
when acetabular dysplasia is corrected in association
with an LCPD-like femoral head deformity.
• Increased hip abduction may be achieved by reducing
the lateral acetabular coverage, performing a proximal
femoral head-neck osteochondroplasty, and/or
performing a valgus-producing PFO.

15. Proximal Femoral Osteotomy
• Correct posterior slip deformity at intertrochanteric level
– Flexion
– Internal rotation
– Valgus at osteotomy site sometimes
• Intertrochanteric osteotomy is performed just proximal to
the lesser trochanter and is fixed with a blade plate.
• Non-wedge end-to-side apposition
• Distal fragment is flexed, internally rotated, and translated
anteriorly on the proximal fragment
• Anterolateral osteochondroplasty in conjunction with
osteotomy restores a more normal anterior head-neck
offset, thereby minimizing anterolateral FAI

17. • Osteonecrosis about in 15%
• Delayed union
• Anterolateral Impingement

18. PFO and osteochondroplasty via
surgical dislocation
• Surgical dislocation allows for optimal
visualization of the femoral head and acetabulum
• Medial anterior & lateral osteochondroplasty of
the proximal femur
• labrum and acetabular articular cartilage are
inspected, debrided or repaired
• Ganz et al 36 have performed the osteotomy
through the true surgical neck; they noted
osteonecrosis in just 1 of 21 patients

19. PFO and osteochondroplasty via
surgical dislocation
• Dunn procedure is resection of the neck through
the proximal femoral open physis and reduction
of the displaced proximal femoral capital
epiphysis
• Critical retinacular blood supply to the epiphysis
must be preserved during dissection, reduction,
and stabilization
• Chen et al reported a 13% rate of osteonecrosis
following emergent closed reduction combined
with joint decompression.

21. • Osteonecrosis high incidence if delays
between onset of symptoms and treatment
• Parsch et al performed open reduction of
unstable slips in 64 with rate of 4.7%
osteonecrosis

22. Slipped Capital Femoral Epiphysis
• Residual deformity
• Femoral head is posteriorly positioned on the femoral neck
• Displaced femoral anterolateral metaphyseal prominence
(cam impingement)
• Degenerative wear of anterior acetabular labrum and
articular cartilage
• Goodwin et al demonstrated the potential for similar
screw-head impingement following in situ stabilization of
SCFE.
• Redirectional
• PFO combined with anterolateral osteochondroplasty
improves hip flexion, internal rotation, and abduction.

23. Legg-Calvé-Perthes Disease
• Residual deformity
• symptomatic in adolescence
• heals with coxa magna or asphericity
• Acetabulum dysplastic (acetabular angle >10°)
• Surgical management
– Proximal femoral valgus osteotomy
– Osteochondroplasty of the head-neck junction
– Relative neck lengthening
– Distal trochanteric transfer
– Transtrochanteric surgical hip dislocation provides optimal
exposure for proximal femoral deformity

24. Hip Arthroscopy
• Hip arthroscopy for mild forms includes
– Labral debridement
– Labral repair, partial synovectomy, chondroplasty
– Microfracture
– Removal of loose bodies
– Debridement of the ligamentum teres
– Osteochondroplasty of the acetabular rim
– Femoral head neck junction

25. Hip Replacement , Arthrodesis
• Goals of management
– Provide pain relief
– Improve function
– Avoid complications
• Young patients with end-stage joint disease and severe
symptoms
• Hip is fused in a functional position of 20° to 30°
flexion, zero to 5° adduction, and 10° external rotation.
• The fusion is fixed with a large fragment plate over the
anterior femur, anterior hip joint, and inner aspect of
the ilium.

26. Take Home Message
• Articular damage at hip joint permanent even
in young patients
• Early diagnosis to prevent mechanical OA
• Management depends on stage of condition
and age of patient

27. THANK YOU