JAAOS

JAAOS, Volume 26, No. 15


Analysis of Femoral Version in Patients Undergoing Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia

Introduction: A paucity of information exists on the range of femoral version, its effect on hip stability, clinical examination, and presentation in patients with symptomatic acetabular dysplasia. The purpose of this study was to describe the range of version in symptomatic acetabular dysplasia, the association between femoral version and proximal femoral morphology and degree of dysplasia, and the effect of version on clinically measured hip range of motion and on preoperatively measured hip outcome scores.

Methods: We reviewed 314 patients prospectively enrolled in a longitudinal clinical study on periacetabular osteotomy between January 2014 and August 2015 and measured femoral version, morphologic characteristics of the upper femur and acetabulum, and preoperative clinical outcome scores.

Results: The average femoral version was 19.7° ± 11.2° (range, −20° to 50°). Femoral version correlated strongly with clinically measured hip range of motion but did not correlate linearly with either radiographic severity of acetabular dysplasia or preoperative symptomatology.

Discussion: Despite concerns that transverse plane femoral anatomy influences the stability of the hip joint after skeletal maturity, we did not find a statistical association between femoral version and severity of dysplasia or presenting symptomatology. This finding suggests that femoral version is not a major influence on the clinical presentation of acetabular dysplasia.

Level of Evidence: Level IIIb

      • Subspecialty:
      • Adult Reconstruction,

      • Foot and Ankle,

    Aspiration and Injection Techniques of the Lower Extremity

    Orthopaedic surgeons frequently use aspirations and injections to both diagnose and treat disorders of the lower extremity. Comprehensive knowledge of regional anatomy, procedural indications, and appropriate techniques are essential. Clinicians must be well versed in a range of musculoskeletal aspiration and injection techniques, including patient positioning, equipment needs, injectable solutions, aspirate analysis, and potential complications. Safe and effective aspiration and injection techniques for the lower extremity, including the hip, knee, foot, and ankle, are reviewed. Image guidance modalities include fluoroscopy, ultrasonography, CT, and MRI.

        • Subspecialty:
        • Ankle,

        • Knee,

        • Adult Reconstruction,

        • Foot,

        • Foot and Ankle,

        • Leg,

      Complete Talar Extrusion Treated With an Antibiotic Cement Spacer and Staged Femoral Head Allograft

      Complete talar extrusion is rare and usually associated with a high-energy mechanism of injury causing complete dissociation of the talus from the surrounding bony and soft-tissue structures with enough force to expel the talus out of the body. Treatment can be complicated by infection, osteonecrosis, posttraumatic osteoarthritis, and leg length discrepancy, which may require multiple subsequent surgeries for improved outcome and quality of life. Reimplantation of the native talus affords maintenance of joint height and favorable outcomes have been reported. Failed reimplantations have been successfully managed with arthrodesis with or without a bone allograft. We report a case of talar extrusion initially treated with a talus-shaped impregnated antibiotic spacer, followed by femoral head allograft and tibiocalcaneal fusion. This treatment resulted in radiographic evidence of bony fusion at 12 weeks without subsequent infection and good clinical outcome at 2-year follow-up.

          • Subspecialty:
          • Ankle,

          • Foot,

          • Foot and Ankle,

        Concomitant Proximal and Distal Tibiofibular Joint Dislocation Associated With a Tibial Shaft Fracture

        An association exists between tibial shaft fractures and ankle injuries. In addition, although uncommon, an association between tibial shaft fractures and proximal tibiofibular dislocations has also been established. A review of the previous literature resulted in one case report of a complete proximal and distal tibiofibular joint dislocation without fracture of the tibia or fibula. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. To the best of our knowledge, this is the first report of this injury pattern associated with a tibial shaft fracture.

            • Subspecialty:
            • Foot,

            • Foot and Ankle,

          Natural History of Structural Hip Abnormalities and the Potential for Hip Preservation

          Hip osteoarthritis (OA) exerts a significant burden on society, affecting 3% of Americans aged >30 years. Recent advances in the understanding of the pathoanatomy and pathomechanics of the hip have led to treatment options for young adults with hip pain. Femoroacetabular impingement, specifically cam-type femoroacetabular impingement, hip dysplasia, and the sequelae of pediatric hip disease can predispose the hip to early OA. However, many patients with abnormal anatomic findings do not develop early OA, suggesting that there exist other patient characteristics that are protective despite abnormal bony anatomy. Outcome studies show that arthroscopic and open hip procedures improve pain and function in patients with symptomatic hips. However, there is currently limited evidence that these procedures extend the life of the patient's natural hip. Additional studies are needed to determine protective or adaptive factors in patients with abnormal anatomy who do not develop early OA and to determine whether joint preserving hip surgery extends the life of the native hip joint.

              • Subspecialty:
              • Hip,

              • Adult Reconstruction,

            Role of Advanced Imaging in the Diagnosis and Management of Active Legg-Calvé-Perthes Disease

            Since the first description of Legg-Calvé-Perthes disease a century ago, the diagnosis, staging, prognosis, and treatment decisions have been based on plain radiographs. The goal of treatment is prevention of femoral head deformity, yet radiographic prognostic classifications are applied in the fragmentation stage, often after deformity occurs. These classifications are assigned too late in the progression of the disease to maximize the effects of intervention. Thus, alternative mechanisms to determine femoral head involvement earlier in the disease course are warranted. Increasingly, MRI has been used in the study of the disease. Gadolinium-enhanced and diffusion-weighted MRI has shown promising results that correlate with radiographic classifications and the early radiographic outcome. Advanced imaging has improved the assessment of hinge abduction, yet the exact definition remains controversial. The role of imaging in the management of Legg-Calvé-Perthes disease is rapidly evolving. New or refined imaging techniques may eventually allow earlier prognosis and treatment.

                • Subspecialty:
                • Hip,

                • Adult Reconstruction,

              The Orthopaedic Surgery Residency Application Process: An Analysis of the Applicant Experience

              Introduction: Orthopaedic surgery residency positions are highly sought after. The purpose of this survey study was to report the following components of the applicant experience: (1) the number of programs to which applicants applied and interviewed, (2) the performance criteria associated with receiving interviews, (3) the way applicants respond to e-mail interview offers, (4) the pre- and post-interview communication between applicants and programs, (5) the importance of interview day activities and the determinants of the applicant rank order list (ROL), and (6) the financial cost of the application process.

              Methods: An online survey was administered and entirely completed by a representative sample of 100 orthopaedic surgery residency applicants for the 2015 to 2016 cycle during the 3-week period between the last interview of the application season and the deadline for ROL certification. The survey included 45 questions: 7 for background, 7 for competitiveness, 15 for the interaction between applicants and programs, 15 for the importance of interview day experience and the determinants of the applicant ROL, and 1 for the cost of attending each interview.

              Results: Students applied to 83 ± 27 programs, received 17 ± 10 interviews, and attended 12 ± 5 interviews. Interview offers correlated with, in descending order, Alpha Omega Alpha status, Step 2 Clinical Knowledge, and Step 1. The mean time to reply of interview offer was 17 minutes, yet 25% of the applicants lost at least one interview despite having at least one other person monitor the applicant's e-mail account. Applicants and programs frequently contacted each other to express interest. Although evaluating current residents was the most valuable aspect of interview day to applicants, the strongest determinants for applicants' ROLs were location and surgical experience, with research the least important factor. The cost of interview season was >$7,000 per applicant, excluding away externships.

              Conclusion: Applying to orthopaedic surgery residency is a complex, competitive, and costly experience for applicants. The application process may benefit from better expectation management of applicant candidacy and a more prohibitive communication policy between applicants and programs after the interview day.

                  • Subspecialty:
                  • General Orthopaedics,

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