Jaaos 26

Review Article
Natural History of Structural Hip

Abnormalities and the Potential for
Hip Preservation
Abstract
James D. Wylie, MD, MHS Hip osteoarthritis (OA) exerts a significant burden on society, affecting
Christopher L. Peters, MD 3% of Americans aged .30 years. Recent advances in the
understanding of the pathoanatomy and pathomechanics of the hip
Stephen Kenji Aoki, MD
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
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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
From Intermountain Healthcare, Salt in patients with symptomatic hips. However, there is currently limited
Lake City, UT (Dr. Wylie), University of
Utah, Salt Lake City (Dr. Peters), and
evidence that these procedures extend the life of the patient’s natural
University of Utah Hospital, Salt Lake hip. Additional studies are needed to determine protective or
City (Dr. Aoki). adaptive factors in patients with abnormal anatomy who do not
Dr. Peters or an immediate family develop early OA and to determine whether joint preserving hip
member has received royalties from surgery extends the life of the native hip joint.
Zimmer Biomet; is a member of a
speakers’ bureau or has made paid
presentations on behalf of Zimmer
Biomet; serves as a paid consultant to
Zimmer Biomet; has stock or stock
options held in CoNextions Medical;
has received research or institutional
T he prevalence of hip osteoarthritis
(OA) varies by country and eth-
nicity. Symptomatic hip OA affects
174% over the next 15 years as the
US population ages.1
Hip arthritis has been traditionally
support from Zimmer Biomet; and approximately 3% of Americans aged categorized as inflammatory arthritis,
serves as a board member, owner,
officer, or committee member of the
.30 years.1 The burden of OA is posttraumatic OA, septic arthritis,
American Academy of Orthopaedic expected to increase over the next 15 and idiopathic OA, with idiopathic
Surgeons, American Association of years secondary to the obesity epi- OA being the most common.2 It has
Hip and Knee Surgeons, The Hip demic in the United States. In addi- long been postulated that mechanical
Society, and The Knee Society.
Neither of the following authors nor
tion, recent trends have shown an and anatomic factors led to idiopathic
any immediate family member has increase in total hip arthroplasty hip OA.3–5 Wiberg3 was the first to
received anything of value from or has (THA) with a concurrent increase in suggest that a structural hip abnor-
stock or stock options held in a patients aged ,65 years. The costs of mality predisposes the patient to hip
commercial company or institution
related directly or indirectly to the
hip OA to society are staggering. The OA. Murray5 advanced this theory
subject of this article: Dr. Wylie and estimated direct cost of the disease in in the 1960s, reporting that acetab-
Dr. Aoki. patients aged .65 years is approxi- ular dysplasia, epiphysiolysis, and the
J Am Acad Orthop Surg 2018;26: mately $2,000 per year; however, so-called tilt deformity led to what was
515-525 with an estimated prevalence of 51 commonly referred to as idiopathic hip
DOI: 10.5435/JAAOS-D-16-00532
million patients, hip OA accounts for OA. In the 1980s, Harris4 coined the
review-article .$100 billion in direct medical costs term pistol-grip deformity when de-
annually, and indirect costs are up scribing a proximal femoral abnor-
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. to 1.5 times that amount. 1 These mality that predisposed patients to
numbers are projected to increase by hip OA. More recently, Ganz et al6
August 1, 2018, Vol 26, No 15 515
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Natural History of Structural Hip Abnormalities
contributed to the understanding of This phenomenon leads to impinge- pincer FAI is to the capsular margin
a mechanical cause of idiopathic hip ment as the abnormal femoral mor- of the acetabular labrum, with a
OA by describing femoroacetabular phology abuts or enters the acetabulum crushing mechanism against the
impingement (FAI). In addition, Ganz during flexion and internal rotation femoral neck and relative sparing of
and colleagues7,8 described the use of of the femur. This motion conflict the acetabular articular hyaline car-
the Bernese periacetabular osteotomy causes an inside-out chondral injury tilage (at least until late in the dis-
(PAO) to treat hip dysplasia and sur- to the acetabulum starting at the ease process). However, a contracoup
gical dislocation of the hip to allow chondrolabral junction.6 Commonly, articular cartilage injury can develop
surgical access to the hip joint and the anterosuperior articular cartilage posteroinferiorly on the acetabulum
proximal femur without disturbing is detached from the labrum and and is thought to progress to joint
the blood supply to the femoral acetabular subchondral bone while degeneration in some patients.6 Pincer
head. These surgical techniques gave the outer or capsular margin of the FAI morphology can be quantified
surgeons improved ability to treat labrum is spared from direct injury.6 radiographically by lateral and anterior
structural hip joint abnormalities. As the chondral injury progresses, center edge angles (ACEAs) (which
Subsequently, over the past 15 years, this repetitive mechanical injury may typically measure .40°, although
hip arthroscopy has evolved as the lead to global joint degeneration. specific cutoffs have been a topic of
treatment of choice for symptomatic Cam-type FAI can be quantified by debate), a down-sloping or negative
FAI in most centers.9 Here, we review the alpha angle, the degree of head/ acetabular index, the presence of a
the natural history of structural hip neck offset, and the triangular index crossover sign, the presence of ace-
abnormalities and discuss the poten- on imaging studies.10,11 Alpha angles tabular protrusio or profunda, or by
tial for surgical interventions to treat .55° and femoral head/neck ratios the presence of global acetabular
young adult hip pain and preserve the of ,0.17 can indicate cam-type FAI retroversion.10 However, both the
hip joint. morphology. Lateral radiographs crossover sign and acetabular pro-
(45° modified Dunn) are the profunda are commonly found in asymp-
jections most commonly used to tomatic or even dysplastic hips so these
Proposed Pathomechanics
image the anterolateral head-neck may not be reliable signs of Pincer
of Structural Hip
junction that is most commonly FAI.12,13
Abnormalities affected by cam-type FAI. The tri- These two subtypes of FAI are not
angular index is a measure of the exclusive of one another. Mixed-type
Femoroacetabular pistol-grip deformity on the AP pelvis FAI is a combination of cam- and
Impingement radiograph that quantifies the degree pincer-type FAI; typically, these hips
FAI has become the preferred term in which the lateral cortex of the show a combination of chondral and
for describing the motion conflict femoral head/neck junction diverges labral injury patterns of both types.14
phenomenon created by a mismatch from the best-fit circle of the femoral In a large prospective multicenter
between the shape of the proximal head.11 A value of .1 is indicative of study of surgical treatment of FAI, cam
femur and the acetabular socket.6 cam-type FAI morphology. is the most prevalent morphology,
Previous reports of the tilt deformity Pincer-type FAI is caused by focal followed closely by mixed FAI, with
and the pistol-grip fall under the or global acetabular overcoverage. isolated pincer FAI being relatively
umbrella of FAI in that they describe Focal overcoverage is common in the rare (only 8% of cases).15 In addition,
the abnormal shape of the proximal anterosuperior aspect of the acetab- cam-FAI and acetabular dysplasia are
femoral head-neck junction.4,5 FAI ulum, whereas global overcoverage not exclusive of one another and can
has classically been described in the involves a more extensive prominent coexist in the same hip. Similarly, FAI
following fashion: cam-type FAI, acetabular rim or acetabular retro- may occur in some persons with
pincer-type FAI, and mixed-type FAI, version. The overcoverage of the excessive hip range of motion or su-
which constitutes a combination of femoral head leads to early contact of praphysiologic demands (eg, dancing)
cam and pincer impingement. the acetabular rim/labrum with the in the setting of normal bony anatomy.
An abnormally shaped proximal femoral neck during hip motion.6
femur defines cam-type FAI in which Similarly, pincer FAI pathomechanics
there is a lack of offset at the femoral can occur from a retroverted ace- Acetabular Dysplasia
head-neck junction and/or an aspheri- tabulum that causes impingement Although the true definition of dys-
city of the femoral head, most com- between the proximal femur and the plasia refers to any abnormal devel-
monly affecting the anterosuperior prominent anterosuperior rim of the opment, hip dysplasia typically refers
aspect of the head-neck junction. acetabulum. The primary injury in to a shallow acetabulum. Dysplasia is
516 Journal of the American Academy of Orthopaedic Surgeons
James D. Wylie, MD, MHS, et al
a continuum ranging from infantile coverage of the femoral head and an between the rim and the femoral
congenital hip dislocations to milder angle of ,25° is considered to be metaphysis—a mechanism more
adult forms of a shallow acetabulum abnormal, with ,20° representing consistent with pincer-type im-
that can be asymptomatic to severe dysplasia and 20° to 25° represent- pingement. Patients with more severe
forms of the condition with debili- ing borderline dysplasia. The Tönnis residual deformity without remod-
tating symptoms in adults. Here, we angle measures the inclination of the eling provide an impaction injury to
focus on the adolescent and young acetabular sourcil and is abnormal if the acetabular labrum.22 The sever-
adult form of dysplasia. .10°.10 Anterior femoral head cov- ity generally coincides with the initial
Acetabular dysplasia is character- erage can be measured on the false- degree of displacement in which the
ized by a shallow acetabulum that profile radiograph with the ACEA. epiphysis is stabilized, which leads
does not adequately cover and sup- Values ,20° can be indicative of to anterosuperior labral and ace-
port the femoral head. The inade- acetabular dysplasia involving the tabular cartilage damage, decreased
quate bony coverage leads to focal anterior wall.10 function, and subsequent joint de-
overloading of the acetabular rim and generation.20 Some patients have
labrum during weight-bearing activ- minimal symptoms after remodeling,
ities. On radiographs, acetabular Residual Deformities of but this is likely due to remodeling
dysplasia is characterized by an up- Pediatric Hip Disease and patient activity modification.19
sloping acetabular sourcil and un- Conceptually, the residual proximal Because of these pathomechanics,
dercoverage of the femoral head by femoral deformities associated with acute positional reduction or modi-
weight-bearing acetabular cartilage. pediatric hip conditions, such as slipped fied Dunn reorientation are acceptable
The shallow socket and abnormal capital femoral epiphyses (SCFE) and treatment options for preventing
morphology lead to transmission of Perthes disease, present as severe residual deformity in patients with
hip forces through the smaller surface forms of FAI, sometimes with con- acute unstable residual deformity.19
area of weight-bearing cartilage and comitant acetabular abnormalities The rate of osteonecrosis after these
the labrum.3 The upsloping sourcil such as dysplasia or acetabular ret- reorienting procedures must be better
also leads to a shearing force on roversion. However, given their dis- defined but may be similar to those of
the acetabular cartilage with weight tinct etiologies and more severe forms patients with acute SCFE.
bearing. The acetabular abnormality of impingement, the residual proxi- The residual deformity from Perthes
is commonly associated with proximal femoral deformities are discussed disease can range from mild femoral
mal femoral anomalies, including a separately. head abnormalities to severe defor-
more valgus and anteverted femoral The residual SCFE deformity is mities, including coxa magna, coxa
neck and a lateralized hip center.16 defined by the direction and degree vara, and coxa plana and secondary
These anomalies further contribute to of displacement of the epiphysis in acetabular deformities such as dyspla-
abnormal forces at the weight-bearing relation to the femoral metaphysis. sia and/or retroversion.23,24 Perthes
surface that leads to compensatory The epiphysis displaces medial and disease can lead to FAI in multiple
hypertrophy of the acetabular labrum posterior on the femoral metaphysis.19 ways, including intra- and extra-
and hypertrophy of dynamic mus- Common primary treatment involves articular impingement with nota-
cular stabilizers of the hip in some in situ fixation of the epiphysis with ble restrictions in hip motion
patients.17,18 The labral hypertrophy some residual displacement.20 Al- because of the severity of the residual
occurs as a result of the labrum though some remodeling of the deformity. This possibility can lead
becoming a load-bearing structure deformity occurs over time, there to shearing of the articular cartilage
because of the lack of bony acetab- is continued anterior metaphyseal and chondrolabral injury with hip
ular coverage.18 However, the prominence leading to a cam-type motion. In addition, given the eti-
mechanical overload of the cartilage FAI deformity of the proximal femur ology of Perthes disease, there can be
and surrounding soft tissues may that can be severe.21 In patients with residual cartilage and osteochondral
lead to joint degeneration if the joint mild residual deformity or notable lesions of the femoral head from the
tissues cannot fully compensate for remodeling, there is more of a cam- avascular disease process. Along with
the lack of bony support. type FAI mechanism of injury because articular abnormalities, mechanical
Radiographic evaluation of acetab- of the inclusion of the deformity into alterations of hip function from coxa
ular dysplasia begins with the lateral the acetabulum.17 Although some vara, concomitant acetabular dys-
center edge angle (LCEA) of Wiberg would argue that because the pos- plasia, and trochanteric overgrowth
and the acetabular index or Tönnis terior head tilt can become severe, can lead to worsening hip pain and
angle.3,10 The LCEA measures lateral abutment can occur predominantly function over time.24
August 1, 2018, Vol 26, No 15 517
with FAI morphology will develop OA. Kim et al34 found that there was
Natural History of Structural OA. However, given that this was a a correlation between the loss of joint
Hip Abnormalities study of competitive senior athletes, space in the hip and acetabular ret-
it likely has a selection bias for pa- roversion. Similarly, Giori and Trous-
Femoroacetabular tients without radiographic OA. In a dale35 reported a 20% incidence of
Impingement retrospective study, Wyles et al29 radiographic acetabular retroversion
The diagnosis and management of found that in patients who under- in patients with hip OA compared
FAI for young adult hip pain have went THA and had 10 years or with a 5% incidence of retroversion
increased exponentially in recent years. greater radiographic follow-up of in patients without hip OA. Ezoe
Although the mechanical aspects of the contralateral hip had no increase et al36 also reported a 20% incidence
FAI have been well described, the in OA risk in patients with a struc- of retroversion in patients with OA
question of whether FAI leads to OA tural diagnosis of impingement com- compared with 6% in control sub-
remains. The prevalence of cam-FAI pared with normal hips. However, a jects without OA. Compared with
morphology in the asymptomatic gen- similar multicenter study showed the evidence for cam-type impinge-
eral population is thought to be that an increased alpha angle was a ment resulting in OA, the evidence
approximately 15% with higher rates predictor of progression of degen- for pincer-type FAI causing OA is
in males than females, although bet- erative disease in the contralateral less convincing, with at least one
ter studies are needed to truly deter- hip in patients treated with THA.30 study suggesting that acetabular
mine the prevalence.25 Many studies Given all of these studies, reason- overcoverage may protect against
have reported an increased risk of able evidence supports that cam- the development of OA.33
OA progression or prevalence with a type FAI leads to an increased risk of
cam-type or pistol-grip femoral de- developing hip OA over time, but
many hips with FAI morphology will Acetabular Dysplasia
formities (Table 1). In a prospective
never develop OA. Dysplasia has a long history of asso-
cohort study (Cohort Hip and Cohort
Pincer-type FAI has less convinc- ciation with hip OA.3 Most studies
Knee [CHECK]) of 723 patients aged
ing evidence as a cause of hip OA have found an association between
45 to 65 years with a minimum follow-
(Table 2). The proposed primary radiographic dysplasia and hip OA
up period of 5 years, the adjusted
injury in pincer-type FAI is to the (Table 3). The LCEA and ACEA are
odds ratio (OR) for the development
acetabular labrum with secondary the most common radiographic mea-
of end stage OA was 3.67 in patients
injury to the articular cartilage. Some sures used to diagnose acetabular
with an alpha angle .65°.26 In pa-
of the difficulty may be due to the dysplasia. Patients in the CHECK
tients with an alpha angle .83°, the
relatively low incidence of isolated cohort who had an LCEA ,25° had
OR was 9.66. In a 20-year longitudi-
pincer-type FAI. In the CHECK an adjusted OR of 2.83 for incident
nal cohort study of pelvic radiographs
cohort, no association was found OA, an OR of 2.62 in those with an
obtained from 1,003 women at years 2 between an LCEA or ACEA .40° ACEA ,25°, and an OR of 5.45 in
and 20, Thomas et al27 reported that and the development of OA over a those with an LCEA and ACEA
the risk of development of OA in- 5-year period.33 The authors of the ,25°.33 Thomas et al27 reported
creased by 5% for every alpha angle study also found that when both that for every degree the LCEA was
degree .65°, and the risk of THA the LCEA and ACEA were .40°, ,28°, there was a 13% increase in
increased 4%. Similarly, the Co- the adjusted OR for OA was 0.34, the risk of incident OA and an 18%
penhagen Osteoarthritis Substudy or patients were three times less increase in the risk of THA over a
was a cross-sectional investigation likely to develop OA.33 Similarly, 20-year period in a female pop-
that evaluated 3,620 patients in Thomas et al27 found no associa- ulation. The Rotterdam Study was
Denmark aged 21 to 90 years. This tion with LCEA .39° and the another prospective study of the
study found that a triangular index development of OA or the risk of natural history of dysplasia. In 835
.1 had a risk ratio of 2.2 for THA. The Copenhagen Osteo- patients with a mean radiographic
radiographic OA.11 Similar cross- arthritis Substudy did find a rela- follow-up of 6.6 years, an LCEA
sectional studies have had some tive risk for radiographic OA of 2.4 ,25° had an adjusted OR of 4.3 for
differing results. Anderson et al28 eval- in patients with an LCEA .45°.11 joint space narrowing .1 mm and
uated competitive older athletes and Another form of pincer-type FAI is an adjusted OR of 2.4 for incident
found no correlation between alpha acetabular retroversion. Some studies OA.38 An LCEA ,30° had an
angle and radiographic OA. This have suggested an association between adjusted OR of 2.8 for joint space
finding shows that not all patients global acetabular retroversion and narrowing .1 mm and an adjusted
Table 1
Association Between Cam-type Femoroacetabular Impingement and Hip Osteoarthritis
Radiographic
Study Patient Population Study Design Measures Important Findings
Agricola et al26 865 patients (79% female) Prospective cohort Alpha angle on AP and Alpha angle .60° or .83°
(CHECK Cohort) aged 45–65 yr with hip study with 5-yr false-profile leads to increased relative
pain follow-up radiographs risk of developing end-stage
OA over the study period
compared with alpha angle
,60°
Thomas et al27 1,003 female patients Prospective cohort Alpha angle and For every 1° .65° of the alpha
(The Chingford (100% female) study with 20-yr triangular index on angle, 5% increase in the risk
1000 Women follow-up supine AP pelvis of radiographic OA and 4%
Study) increase in risk of THA
Gosvig et al11 3,620 patients (63% Cross-sectional Triangular index on Triangular index .1 indicates
(Copenhagen female) in Copenhagen study standing AP pelvis an increased risk of
Osteoarthritis radiographs radiographic hip OA
Substudy)
Anderson et al28 547 Huntsman senior Cross-sectional Alpha angle on frog-leg No relationship between cam
games participants (45% study lateral radiographs morphology and radiographic
female) OA
Wyles et al29 178 patients who Retrospective Standing AP pelvis The FAI group had the same
underwent unilateral comparative study radiographs; patients rate of OA development as
THA and had no grouped into dysplasia, the normal group. No
contralateral impingement, and differentiation of cam- and
degenerative changes normal groups, as pincer-type FAI.
and minimum 10 yr of reviewed by two hip
radiographic follow-up surgeons.
of the contralateral hip
(56% female)
Clohisy et al30 604 patients (710 hips) Cross-sectional Alpha angle and femoral 93% of hips requiring THA for
treated with THA before study and then head/neck offset on AP unknown etiology had cam-
the age of 50 yr (48% the retrospective and lateral radiographs or mixed-type FAI. The
female) comparative study increased alpha angle and
of the contralateral decreased head/neck offset
hip was a predictor of need for
THA on the contralateral side
in the follow-up period.
Amstutz and 367 patients (20% female) Retrospective Head-to-neck ratio on Lower head-neck ratio
Le Duff31 who underwent THA comparative study standing AP pelvis associated with the
and minimum 2 yr of radiographs development of OA
radiographic follow-up of
the contralateral hip
Nardo et al32 4,140 male patients aged Cross-sectional Impingement angle on No association between
(The Osteoporotic .65 yr study standing AP impingement angle and hip
Fractures in Men radiographs OA
Study)
CHECK = Cohort Hip and Cohort Knee, FAI = femoroacetabular impingement, OA = osteoarthritis, THA = total hip arthroplasty
OR of 1.7 for incident OA.38 Simi- found that dysplasia as measured by increased risk of developing hip OA
larly, an osteoporotic fracture case- a lower LCEA and a higher Tönnis associated with acetabular dysplasia.
control study showed that an LCEA angle were associated with the devel- Although dysplasia is commonly
,30° had an adjusted OR of 3.3 for opment of contralateral hip OA over defined by an LCEA of ,20°, the
incident OA in female patients over time. In a cross-sectional study, An- relative risk of developing OA extends
an 8-year follow-up period.39 Both derson et al28 reported no association into the 25° to 30° LCEA range.
Wyles et al29 and Clohisy et al30 between acetabular dysplasia and hip However, the complexity and vari-
investigated the contralateral hips of OA in an athletic older population. ability of acetabular dysplasia defor-
patients who underwent THA and However, strong evidence supports an mities is increasingly recognized and
August 1, 2018, Vol 26, No 15 519
Table 2
Association Between Pincer-type Femoroacetabular Impingement/Acetabular Retroversion and Hip Osteoarthritis
Radiographic
Agricola et al33 720 patients (79% Prospective cohort LCEA on AP and ACEA No increased risk
(CHECK cohort) female) aged 45–65 yr study with 5-yr on false-profile of developing
with hip pain follow-up radiographs radiographic OA
with LCEA .40°
or ACEA .40°.
Decreased risk
of developing
radiographic OA if
LCEA and ACEA
.40°.
Thomas et al27 1,003 female patients Prospective cohort LCEA on supine AP No relationship
(The Chingford 1,000 study with 20-yr pelvis between
Women Study) follow-up overcoverage and
radiographic OA or the
risk of THA
Gosvig et al11 3,620 patients (63% Cross-sectional study LCEA on standing AP LCEA .45° has an
(Copenhagen female) in pelvic radiographs increased risk of
Osteoarthritis Copenhagen radiographic OA
Substudy)
Anderson et al28 547 Huntsman senior Cross-sectional study LCEA on supine AP No relationship
games participants pelvic radiographs between acetabular
(45% female) overcoverage and
radiographic OA in the
group of older active
patients
Nardo et al32 4,140 male patients aged Cross-sectional study LCEA angle on standing LCEA .39° associated
(The Osteoporotic .65 yr AP radiographs with a small increased
Fractures in Men risk of hip OA
Study)
Kim et al34 118 patients (56% Cross-sectional study Acetabular version and Association between
female) aged ,65 yr joint space narrowing acetabular
underwent virtual on CT images retroversion and
colonoscopy decreased joint space
of the hip
Giori and Trousdale35 131 patients with Retrospective Standing AP pelvic Acetabular retroversion
idiopathic OA requiring comparative study radiographs in 20% of patients
THA compared with 99 undergoing THA
patients (63% female) compared with 5% of
with pelvic radiographs control subjects
for nonorthopaedic
reasons
ACEA = anterior center edge angle, CHECK = Cohort Hip and Cohort Knee, LCEA = lateral center edge angle, OA = osteoarthritis, THA = total hip
arthroplasty
is likely oversimplified by classifica- further migration and stabilize the unstable SCFE, reorientation/reduc-
tion based on a single radiographic epiphysis in a position with some tion has become an accepted man-
parameter. displacement. Therefore, articles agement method and means of
focusing on the outcomes of other preventing deformity.19 Studies on
historical management methods were the natural history of SCFE report
Residual Deformities of excluded from this review. This some osseous remodeling and a de-
Pediatric Hip Disease treatment leaves the residual defor- creased level of activity. Castañeda
The benchmark treatment of stable mity and pathomechanics discussed et al20 reported on the long-term
SCFE is in situ pinning to prevent earlier. In the setting of an acute outcome of in situ pinning with
Table 3
Association Between Acetabular Dysplasia and Hip Osteoarthritis
Radiographic
Murphy et al37 286 patients who Retrospective LCEA, Tonnis angle, Patients who developed OA
underwent contralateral comparative study acetabular depth-to- had lower LCEA, higher
THA width ratio, and femoral Tonnis angle, larger femoral
head extrusion index head extrusion index, and
lower acetabular depth-to-
width ratio.
Agricola et al33 720 patients (79% female) Prospective cohort LCEA on AP and ACEA LCEA ,25° and ACEA ,25°
(CHECK cohort) aged 45–65 yr with hip study with 5-yr on false-profile both increase the risk of OA.
pain follow-up radiographs If both measures are ,25°,
the risk is higher.
Thomas et al27 1,003 female patients Prospective cohort LCEA on supine AP For every 1° ,28° of the
(The Chingford study with 20-yr pelvic radiographs LCEA, there is a 13%
1,000 Women follow-up increased risk of
Study) radiographic OA and an
18% increased risk of THA.
Clohisy et al30 604 patients (48% female; Cross-sectional LCEA on standing AP 48% of hips with OA requiring
710 hips) who had THA study and then the pelvic radiographs THA had LCEA ,20°. Lower
before age 50 yr retrospective LCEA of the contralateral hip
comparative study was a risk factor for
of the contralateral subsequent THA.
hip
Gosvig et al11 3,620 patients (63% Cross-sectional LCEA on standing AP LCEA ,20° did not have an
(Copenhagen female) in Copenhagen study pelvic radiographs increased risk of
Osteoarthritis radiographic OA
Substudy)
Amstutz and Duff31 367 patients (20% female) Retrospective LCEA on standing AP Lower LCEA associated with
who underwent THA comparative study pelvic radiographs the development of OA
with minimum 2-yr
radiographic
follow-up of the
contralateral hip
Wyles et al29 178 patients (56% female) Retrospective LCEA, femoral head Patients with an LCEA ,25°,
who underwent unilateral comparative study lateralization, femoral femoral head lateralization
THA and had no with 20-yr head extrusion, .8 mm, femoral head
contralateral radiographic acetabular depth-to- extrusion .0.20, acetabular
degenerative changes follow-up of the width ratio, and Tonnis depth-to-width index ,0.3,
contralateral hip angle on standing AP and Tönnis angle .8° are at
pelvic radiographs risk of OA
Anderson et al28 547 (45% female) Cross-sectional LCEA on supine AP No relationship between LCEA
Huntsman senior games study pelvic radiographs ,20° and radiographic OA in
participants older active patients
Reijman et al38 835 patients (57% female) Prospective cohort LCEA and acetabular LCEA ,30° or 25° and
(The Rotterdam aged .55 yr with a mean 6.6-yr depth on standing AP acetabular depth ,9 mm
Study) follow-up pelvic radiographs associated with joint
space narrowing during
follow-up
Lane et al39 118 patients without OA Case-control study LCEA and acetabular Diagnosis of dysplasia or
(Study of and 58 patients (all with 8-yr follow-up depth on supine AP LCEA ,30° associated with
Osteoporotic female) with incident OA pelvic radiographs incident OA
Fractures)
ACEA = anterior center edge angle, CHECK = Cohort Hip and Cohort Knee Cohort, FAI = femoroacetabular impingement, LCEA = lateral center
edge angle, OA = osteoarthritis, THA = total hip arthroplasty
capsulotomy in 121 patients. Most hips, respectively), and 107 of 121 Wensaas et al40 reported on the long-
of these patients had mild to mod- patients (88%) had Tönnis grade 2 term outcomes of 36 patients (43
erate residual deformity (34 and 65 or 3 OA at follow-up.20 Similarly, hips) with FAI after slipped upper
August 1, 2018, Vol 26, No 15 521
femoral epiphysis; 19 hips had either fore may not have fully evaluated type FAI or hip dysplasia is elevated,
radiographic OA (ie, joint space patients for cam-type FAI because this the absolute risk is still relatively low.
,2 mm), were treated with THA, or is generally most evident on lateral The absolute risk is the risk of any one
had a poor outcome. The alpha angle views. This scenario may have biased person with the exposure developing
(or the severity of residual proximal the data against finding a relationship the disease over a given period. The
femoral deformity) was strongly that may have otherwise been evident relative risk is defined as the ratio of a
correlated with OA development and if lateral views had been included. disease (ie, development of arthritis)
poor outcomes.20,40 Other studies may have identified occurring in an exposed group (ie,
Perthes and the post-Perthes defor- groups of patients that may possess cam-type FAI) compared with a con-
mity is a heterogeneous mix of pa- some factor that protects them from trol group (ie, normal alpha angle). In
tients with a deformity ranging from developing OA. For example, An- the CHECK cohort, patients with an
relatively mild to severe. Long-term derson et al28 found that older ath- alpha angle .83° had a relative risk
studies on the natural history of letes competing at the Huntsman (adjusted OR) of 9.66 for end-stage
Perthes disease show that the degree Senior Games showed no correlation OA.26 However, end-stage OA de-
of residual deformity correlates with between cam-type FAI or dysplasia veloped in only 14 of 56 patients with
joint degeneration.24,41 Classic studies and hip OA on radiographs. This an alpha angle .83°. Thus, end-stage
from the 1980s showed development study was a cross-sectional analysis OA did not develop in 75% of
of arthrosis at long-term follow-up in of an active group of older persons patients. Of the patients with alpha
most of the patients.23,24 Stulberg and may have been subject to some angles ,83°, 25 of 1,355 patients
et al24 reported on 99 hips with 40- selection bias because patients who developed end-stage OA.26 There-
year follow-up and showed that the had developed arthritis by this stage fore, the relative risk of the patients
amount of OA correlated with the of life may have altered their activity with alpha angles .83° was high
degree of deformity; most patients level. However, this study identifies compared with the control group,
with moderate-to-severe disease an important cohort of patients that but end-stage OA did not develop in
had OA and joint space narrowing may have some resistance to OA 75% of these patients, so the abso-
at follow-up. McAndrew and despite having structural abnormal- lute risk of developing end-stage OA
Weinstein23 reported on 37 hips ities of the hip and a high activity was still relatively low because the
with a mean follow-up of 47 years. level. Further study of this patient disease did not develop in most
Four patients required THA in their cohort is required to understand why patients during the 5-year follow-up
20s and 30s, 11 in their 40s and 50s, hip OA did not develop despite the period.
and eight others had a poor outcome presence of structural abnormalities
or disabling hip pain. More recently, and a high level of activity. This
Larson et al41 reported on a pro- discrepancy demonstrates that a com- Surgical Intervention for
spective cohort of 58 hips with a bination of factors may contribute Preservation of the Native
mean follow-up of 20.4 years. Three to the symptomatic or degenerative Hip
patients had undergone THA, with changes that occur over time in
24 hips showing Tönnis grade 2 or 3 abnormally shaped hips. This com- Although numerous studies exist on
OA and 16 hips having Tönnis grade bination of factors likely includes the outcomes of surgical interven-
1 OA. Only 14 hips had no evidence a structural abnormality, other me- tion, including PAOs for hip dysplasia
of OA at 20-year follow-up, with chanical factors including soft-tissue and open and arthroscopic approaches
most patients being in their late 20s laxity and/or abnormal femoral for cam-type FAI, SCFE, and Perthes
at that time. version, a genetic predisposition (or disease, none of these studies have
lack of a protective factor), injury to involved a nonsurgical control arm
the joint, a high activity level, and and are therefore considered level 3
Discrepancies in the potentially patient luck. The combi- to 4 evidence. Thus, it is difficult to
Natural History Studies nation of these factors initiates joint prove the concept that these inter-
injury, and the degenerative cascade ventions prolong the life of the native
There is some discordance between the progresses. hip joint. Periacetabular osteotomy
studies on the natural history of these Patients with structural hip abnor- is the hip-preserving surgery with
structural abnormalities. Reasons for malities may undergo premature the longest track record (Figure 1).
this are likely many. Some studies hip joint degeneration. However, Steppacher et al42 reported a sur-
relied only on AP radiographs to eval- although the relative risk of joint vival rate of 60% at a mean follow-
uate the patients’ anatomy and there- degeneration in patients with cam- up of 20 years. There have been
multiple other reports of improved Figure 1

pain and function at midterm follow-
up (5 to 10 years).43 Mid-term out-
comes of open and arthroscopic
surgery to correct FAI include a
survival rate of 90% to 93% and
improved patient-reported measures
of pain and function44 (Figure 2).
Treatment of the residual deformity
from SCFE includes arthroscopic
surgery for mild-to-moderate de-
formities to proximal femoral os-
teotomies to realign more severe
deformities. Short- to mid-term A, Preoperative AP pelvic radiograph showing right hip dysplasia in a 20-year-
results of these procedures for the old woman who presented with pain that was recalcitrant to nonsurgical
residual SCFE deformity show measures. She underwent a periacetabular osteotomy (PAO). B,
Postoperative AP pelvic radiograph showing the correction of dysplasia with
improvement in patient reported hip
PAO.
pain and function.45,46 As mentioned
earlier, correction of a post-Perthes
deformity can be a challenging hip
reconstructive procedure. Manage- rate is higher than that for surgical gard to FAI, there are some current
ment options include relative neck correction of other hip deformities.48,49 studies recruiting patients to ran-
lengthening, head reduction, osteo- Studies addressing surgical correc- domized studies comparing surgical
chondroplasty, and PAO or reverse tion of structural hip abnormalities with nonsurgical treatment.50 How-
PAO, depending on the concurrent are limited because they lack control ever, patients undergoing hip-preserving
acetabular deformity.47 Short- and groups to facilitate a comparison of surgeries have generally failed non-
mid-term studies on surgical correc- surgical and nonsurgical treatment surgical measures, and those who
tion of post-Perthes deformity have options. Although a comparison with improve with nonsurgical measures
described patient-reported improve- historic control groups is possible, it do not undergo surgery, making the
ment in hip pain, function, and ab- is not ideal because of the lack of conclusions of these studies difficult
ductor strength; however, the failure systematic data collection. With re- to interpret. In addition, previous
Figure 2
Images from a 22-year-old woman who presented with left hip pain recalcitrant to conservative measures and underwent
arthroscopic surgery for femoroacetabular impingement (FAI). A, Preoperative frog-leg lateral radiograph of the left hip
showing cam-type FAI. B, Arthroscopic image obtained after osteoplasty showing resolution of impingement and restoration
of head-neck offset. C, Postoperative frog-leg lateral radiograph of the left hip showing improved sphericity and restoration of
femoral head-neck offset.
August 1, 2018, Vol 26, No 15 523
surgical studies have had difficulty gress to OA over time. Moreover, osteoarthritis: A population-based survey. J
Bone Joint Surg Am 2010;92:1162-1169.
with large crossover between the although current surgical techniques
surgical and nonsurgical groups, most aimed at correcting structural hip 12. Larson CM, Moreau-Gaudry A, Kelly BT,
et al: Are normal hips being labeled as
notably the Spine Patient Outcomes deformity seem to improve patient Pathologic? A CT-based method for
Research Trial that suffered from pain and function in symptomatic defining normal acetabular coverage. Clin
Orthop Relat Res 2014;473:1247-1254.
approximately a 40% crossover individuals, no evidence to date exists
rate.51 Although short- to mid-term to prove that it preserves the native 13. Anderson LA, Kapron AL, Aoki SK, Peters
CL: Coxa profunda: Is the deep acetabulum
patient-reported outcomes will deter- hip joint over time. overcovered? Clin Orthop Relat Res 2012;
mine whether these interventions im- 470:3375-3382.
prove patient pain and function, these
References 14. Beck M, Kalhor M, Leunig M, Ganz R: Hip
studies are unlikely to ascertain morphology influences the pattern of
whether these interventions are pre- damage to the acetabular cartilage:
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Palm H, Troelsen A: Prevalence of
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25. Dickenson E, Wall PD, Robinson B, et al:
Prevalence of cam hip shape morphology: A 34. Kim WY, Hutchinson CE, Andrew JG, 44. Nwachukwu BU, Rebolledo BJ,
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26. Agricola R, Heijboer MP, Bierma-Zeinstra 727-729. impingement: A systematic review of
SMA, Verhaar JAN, Weinans H, Waarsing medium- to long-term outcomes. Am J
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moderate deformity after slipped capital
27. Thomas GE, Palmer AJ, Batra RN, et al: 36. Ezoe M, Naito M, Inoue T: The prevalence femoral epiphysis: Intra-operative findings
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study. Osteoarthritis Cartilage 2014;22: 37. Murphy SB, Ganz R, Müller ME: The management of healed slipped capital
1504-1510. prognosis in untreated dysplasia of the hip. femoral epiphysis. J Am Acad Orthop Surg
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28. Anderson LA, Anderson MB, Kapron A, the outcome. J Bone Joint Surg Am 1995;
et al: The 2015 Frank Stinchfield Award: 77:985-989. 47. Novais EN, Clohisy JC, Siebenrock KA,
Radiographic abnormalities common in Podeszwa DA, Sucato DJ, Kim YJ: Treatment
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Orthop Relat Res 2016;474:342-352. dysplasia predicts incident osteoarthritis of
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DR, Trousdale RT, Sierra RJ: The John preserving surgery improves pain, range of
Charnley Award: Redefining the natural 39. Lane NE, Lin P, Christiansen L, et al: motion, and abductor strength after Legg-
history of osteoarthritis in patients with hip Association of mild acetabular dysplasia Calvé-Perthes disease. Clin Orthop Relat
dysplasia and impingement. Clin Orthop with an increased risk of incident hip Res 2012;470:2450-2461.
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study of osteoporotic fractures. Arthritis 49. Clohisy JC, Nepple JJ, Ross JR, Pashos G,
30. Clohisy JC, Dobson MA, Robison JF, et al: Rheum 2000;43:400-404. Schoenecker PL: Does surgical hip dislocation
Radiographic structural abnormalities and periacetabular osteotomy improve pain in
associated with premature, natural hip- 40. Wensaas A, Gunderson RB, Svenningsen S, patients with perthes-like deformities and
joint failure. J Bone Joint Surg Am 2011; Terjesen T: Femoroacetabular impingement acetabular dysplasia? Clin Orthop Relat Res
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The radiological diagnosis and clinical
31. Amstutz HC, Le Duff MJ: The natural outcome at long-term follow-up. J Bone 50. FIRST Investigators: A multi-centre
history of Osteoarthritis: What happens to Joint Surg Br 2012;94:1487-1493. randomized controlled trial comparing
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474:1-8. 41. Larson AN, Sucato DJ, Herring JA, et al: A lavage with arthroscopic lavage alone
prospective multicenter study of Legg- on patient important outcomes and
32. Nardo L, Parimi N, Liu F, et al: Calvé-Perthes disease: Functional and quality of life in the treatment of young
Femoroacetabular impingement: Prevalent radiographic outcomes of nonoperative adult (18-50) femoroacetabular
and often asymptomatic in older men: The treatment at a mean follow-up of twenty impingement. BMC Musculoskelet
Osteoporotic Fractures in Men Study. Clin years. J Bone Joint Surg Am 2012;94: Disord 2015;16:64.
Orthop Relat Res 2015;473:2578-2586. 584-592.
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33. Agricola R, Heijboer MP, Roze RH, et al: 42. Steppacher SD, Tannast M, Ganz R, Surgical vs nonoperative treatment for
Pincer deformity does not lead to Siebenrock KA: Mean 20-year follow-up lumbar disk herniation: The spine patient
osteoarthritis of the hip whereas acetabular of Bernese periacetabular osteotomy. outcomes research trial (SPORT): A
dysplasia does: Acetabular coverage and Clin Orthop Relat Res 2008;466: randomized trial. JAMA 2006;296:
development of osteoarthritis in a 1633-1644. 2441-2450.
August 1, 2018, Vol 26, No 15 525
Review Article
Role of Advanced Imaging in the

Diagnosis and Management of
Active Legg-Calvé-Perthes
Disease
Abstract
Jennifer C. Laine, MD Since the first description of Legg-Calvé-Perthes disease a century ago,
Benjamin D. Martin, MD the diagnosis, staging, prognosis, and treatment decisions have been
based on plain radiographs. The goal of treatment is prevention of
Susan A. Novotny, PhD
femoral head deformity, yet radiographic prognostic classifications are
Derek M. Kelly, MD applied in the fragmentation stage, often after deformity occurs. These
classifications are assigned too late in the progression of the disease to
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVA9Bu/kT98wMA1VONGj1wvDrCIBXVNLDeqzNui9RGIb2 on 07/28/2018
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.
From Gillette Children’s Specialty

Healthcare, St. Paul, MN (Dr. Laine
T he diagnosis and treatment of
Legg-Calvé-Perthes disease have
been based on plain radiographs since
published treatment recommenda-
tions, are based on the fragmentation
stage. Initiating treatment after frag-
and Dr. Novotny), the Department of
Orthopaedic Surgery, University of
the disease was first described. Loss of mentation and collapse have occurred
Minnesota, Minneapolis, MN blood flow to the skeletally immature makes obtaining a spherical femoral
(Dr. Laine), the Division of femoral head results in a predictable head at skeletal maturity, the primary
Orthopaedic Surgery and Sports radiographic progression of bone goal of treatment, a challenge.2
Medicine, Children’s National Health
System, Washington, DC (Dr. Martin),
necrosis, resorption, and reossification, Unfortunately, the use of radio-
Campbell Clinic Orthopaedics, first described by Waldenström.1 The graphs in the management of
Memphis, TN (Dr. Kelly), the structural integrity of the femoral head Legg-Calvé-Perthes disease has limi-
Department of Orthopaedic Surgery is most compromised after revascu- tations. A lag occurs between the
and Biomedical Engineering,
University of Tennessee, Memphis,
larization, when blood flow returns physiologic process related to the
TN (Dr. Kelly), and Le Bonheur and osteoclasts resorb necrotic bone, avascular event and the observation
Children’s Hospital, Germantown, TN placing the femoral head at risk of of changes on radiographs. After
(Dr. Kelly). collapse and deformity. Radiographs obvious signs of fragmentation
J Am Acad Orthop Surg 2018;26: are essential for establishing an initial occur, current treatment options
526-536 diagnosis, monitoring the stages of the may not be as effective. In addition,
DOI: 10.5435/JAAOS-D-16-00856 disease, and assessing the shape of the radiographs are static and therefore
femoral head. Current radiographic insufficient to assess the congru-
Academy of Orthopaedic Surgeons. classification systems for Legg-Calvé- ency of the femoral head and ace-
Perthes disease, which drive nearly all tabulum through the arc of motion.
Jennifer C. Laine, MD, et al
Figure 1
Illustrations of the modified Elizabethtown classification by Joseph et al,6 which divides the first three active Waldenström
stages into early and late, resulting in a seven-stage system. This classification is especially useful in determining whether a
patient is in the early (I-IIA) or late (IIB-IV) stages of the disease. A, Stage IA. The epiphysis is avascular and dense, and its
height is maintained. B, Stage IB. The epiphysis is sclerotic with no evidence of fragmentation. There is loss of epiphyseal
height. C, Stage IIA. Early fragmentation. The epiphysis has one to two vertical fissures. D, Stage IIB. Late fragmentation.
Stage of maximal epiphyseal collapse and fissuring. No new bone formation is present. E, Stage IIIA. Early immature bone
formation appears on the periphery of the epiphysis (gray). F, Stage IIIB. New bone covers greater than one-third of the
epiphyseal width and has normal texture. G, Stage IV. Healed.
An arthrogram under fluoroscopy is ström classification that subdivided

Plain Radiographs each original stage into two parts:
a useful dynamic study and is often
used to assess for hinge abduction. Plain radiographs are the preferred early and late (Figure 1). This clas-
However, the procedure uses intra- imaging technique for the diagnosis, sification has high interobserver and
articular contrast to indirectly eval- staging, classification, and assessment intraobserver reliability in dis-
uate the unossified femoral head and of outcomes of Legg-Calvé-Perthes tinguishing among hips that are early
labrum, whereas MRI allows direct disease. Typically, AP and frog-lateral (I-IIA) or late (IIB-IV) in the disease
visualization of these structures. The projections of the pelvis are obtained, process.7
need for general anesthesia in the providing roughly orthogonal views The Catterall and Herring lateral
for assessment of the femoral head. pillar classifications are used to
pediatric patient also makes dynamic
Waldenström1 described four stages describe the extent of disease during
arthrography less desirable, and a
of the disease: initial, fragmentation, the fragmentation stage on radio-
consensus on interpretation has not
reossification, and healed. Serial graphs.3,8 Catterall9 divided patients
been reached.3-5 Newer MRI tech-
radiographs are necessary to deter- into groups I through IV correspond-
niques allow for accurate assessment
mine the maximal extent of disease, ing to an increasing amount of femo-
of femoral head vascularity in earlier ral head involvement and worse
the end of bone resorption, the for-
stages of the disease process. The mation of new bone, and complete prognosis. This classification system
literature evaluating these newer tech- healing of the femoral head. has poor interobserver reliability.8 The
niques and their role in the assessment Joseph et al2 noted that patients Herring lateral pillar classification
and management of Legg-Calvé- treated during the initial stage of the assesses the height of the most lateral
Perthes disease has rapidly expanded. disease, or in early fragmentation, portion of the femoral head during
Whether earlier recognition and had a higher chance of maintaining fragmentation on the AP view8,10
assessment will lead to better prog- femoral head sphericity, compared (Figure 2). The concept is that if the
nostic classifications or improve the with patients treated later in the lateral portion of the femoral head is
treatment outcomes of patients with fragmentation stage. To differentiate preserved, it provides structural sup-
Legg-Calvé-Perthes disease remains these patients, Joseph et al6 devel- port and prevents collapse of the
to be determined. oped a modification of the Walden- centrally located necrotic area. If the
Dr. Laine or an immediate family member serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic
Society of North America. Dr. Martin or an immediate family member serves as a board member, owner, officer, or committee member of the
Pediatric Orthopaedic Society of North America. Dr. Kelly or an immediate family member is a member of a speakers’ bureau or has made
paid presentations on behalf of Medtronic and serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic
Society of North America. Neither Dr. Novotny nor any immediate family member has received anything of value from or has stock or stock
options held in a commercial company or institution related directly or indirectly to the subject of this article.
August 1, 2018, Vol 26, No 15 527
Role of Advanced Imaging in the Diagnosis and Management of Active Legg-Calvé-Perthes Disease
Figure 2
Illustrations depicting the Herring lateral pillar classification.8,10 A, Lateral pillar A. The lateral pillar has no loss of height. B,
Lateral pillar B. The lateral pillar has ,50% collapse of height. C, Lateral pillar B/C border. The lateral pillar has a 50% height
loss or a very thin lateral pillar. D, Lateral pillar C. The lateral pillar has a .50% collapse of height.
Figure 3
Illustrations demonstrating normal containment and normal acetabular contact (A), extrusion, which is defined as the
percentage of the femoral ossific nucleus that lies outside the bony acetabulum (extrusion = A/B · 100; B), and a femoral
head with significant extrusion, abnormal contact with the acetabular rim (arrow), and femoral head deformation (C).11
lateral pillar collapses, the entire fem- articular hypertrophy) is not quanti- femoral head to deformation (Figure
oral head has a high chance of flat- fied in either the Catterall or Herring 3). Patients with extrusion $20% on
tening. This classification has a strong classification system but is frequently plain radiographs have been reported
correlation with the final outcome as well considered prognostic.2 Femoral to have a poor prognosis.11 Although
as high reliability and reproducibility.8 head extrusion results in abnormal the Catterall and Herring classifica-
Lateral extrusion of the femoral contact with the acetabular rim, tions focus on the extent of disease
head (resulting from synovitis and which predisposes the weakened during fragmentation, the Stulberg
classification assesses the shape of the Table 1

femoral head and its congruency with
Stulberg Classification8,12
the acetabulum at skeletal maturity
(Table 1). The sphericity of the Class Description
femoral head is assessed on AP and I Normal femoral head
frog-lateral radiographs in compari-
II Round femoral head that fits within 2 mm of the same circle on the
son with reference concentric circles. AP and frog-lateral radiographs
Three types of congruency are III Ovoid femoral head that does not fit within 2 mm of the same circle
described: spherical congruency on the AP and frog-lateral radiographs
(classes I and II), aspherical con- IV Femoral head that has at least 1 cm of flattening within the weight-
gruency (classes III and IV), and bearing area; flattened acetabulum
aspherical incongruency (class V). V Femoral head collapsed and flattened within a round acetabulum
Historically, class I and II hips
were thought to have good out-
comes; class III, fair outcomes; and chance of a Stulberg I or II femoral graphic outcome and reported that
class IV and V, poor outcomes. head at skeletal maturity is 96%, and if track A hips were more spherical at the
However, Larson et al13 clearly the SDS is 10, the chance is 87%.16 If final follow-up, compared with track B
showed that Stulberg class III hips the SDS is .20, the chance of a good hips. Limitations of bone scintigraphy
have outcomes similar to those of outcome drops substantially. The SDS include poor anatomic detail and
class IV and V hips, with 60% has high reliability.15,16 exposure to ionizing radiation. Bone
having radiographic evidence of scintigraphy is now used infrequently
arthritis at 20 years. in the diagnosis and management of
The major limitation of the Stulberg Advanced Imaging Legg-Calvé-Perthes disease.
classification is that it is applied at
skeletal maturity (ie, after an extensive Bone Scintigraphy
MRI
delay). Nelson et al14 developed a Before the emergence of MRI, bone
continuous outcome tool based on the scintigraphy was the primary diag- The emergence of MRI in the 1980s
AP radiograph to predict the Stulberg nostic tool to detect early changes in allowed multidimensional anatomic
classification during the healing phase vascularity. Conway17 proposed a detail to be visualized without the use of
of the disease with high intraobserver classification system based on serial radiation. Conventional MRI allows
and interobserver agreement. This bone scintigraphy studies and the visualization of epiphyseal and articu-
deformity index accounts for the correlation with plain radiographs. lar cartilage, soft-tissue structures,
height and width differences between These scintigraphic patterns sup- synovitis, extrusion, metaphyseal and
the normal hip and the affected hip, ported theories of revascularization physeal changes, and femoral head
relative to the width of the physis. of the proximal femoral epiphysis. shape. During active stages of the dis-
When measured 2 years after pre- Specifically, track A describes a pattern ease, both hips are commonly imaged
sentation, a deformity index .0.3 in which the femoral head is initially to enable comparison and to detect
correlates with an aspherical femoral revascularized laterally, then anteriorly contralateral involvement. The inclu-
head at skeletal maturity (Stulberg and medially. Track B describes a sion of sagittal images is recom-
class III, IV, or V) with 80% sensitivity process of revascularization more mended because they can show
and specificity.14 This classification centrally through the physis into the greater femoral head collapse and a
can be used only in patients with epiphyseal base. The radioactivity then larger angular span of collapse than
unilateral disease because it requires gradually spreads into the rest of the what coronal images alone can
comparison with the normal side. epiphysis. Conway17 noted that hips demonstrate.19 Compared with bone
Shah et al15 established the sphericity on track A usually revascularized more scintigraphy, MRI better demon-
deviation score (SDS), which uses both quickly than those on track B. He strates the extent of epiphyseal
AP and frog-lateral radiographs to suggested that these patterns likely involvement and more clearly depicts
quantify femoral head sphericity dur- represent different methods of revas- revascularization.20,21
ing the healing stage of the disease. The cularization: relatively rapid recanali-
SDS is derived from a series of calcu- zation in track A and a slower process Comparison of MRI and Plain
lations using the radii of concentric of neovascularization in track B. Tsao Radiography
circles drawn on the AP and frog- et al18 correlated this scintigraphic Lateral extrusion and radiographic
lateral radiographs. If the SDS is 5, the classification system with the radio- medial joint space widening are
August 1, 2018, Vol 26, No 15 529
Figure 4 5.4 years, looking at the extent of

epiphyseal necrosis, lateral extrusion,
physeal involvement, and metaphyseal
change. Although all parameters cor-
related with the final Stulberg classifi-
cation, physeal involvement had the
highest predictive value. This finding
confirmed the work of Jaramillo
et al,25 who reported that physeal
abnormalities, specifically trans-
physeal bone bridging, were strongly
correlated with subsequent growth
arrest. Interestingly, no statistically
significant correlation was found
between epiphyseal cartilaginous
abnormality on conventional MRI
and growth arrest.
Coronal T1-weighted magnetic resonance image (A) and coronal subtraction
magnetic resonance image (B) demonstrating an unaffected right hip and a left
hip in the early stages of Legg-Calvé-Perthes disease. A, Coronal T1-weighted Advanced MRI Techniques
magnetic resonance image showing lipid degradation. B, Coronal subtraction Conventional noncontrast MRI
magnetic resonance image showing hypoperfusion at the epiphyseal area techniques may underestimate femo-
(arrow) without enhancement, which indicates that a substantial portion of the ral head involvement, and occasional
femoral head is involved. The area of low T1 signal intensity on the precontrast
image (A) is more difficult to appreciate. false-negative results in the first 3 to
6 months of the disease have been
reported.28,29 Ischemic findings are
frequent plain radiographic features metaphyseal findings on plain radio- delayed on conventional MRI because
of Legg-Calvé-Perthes disease. Song graphs commonly had physeal, not signal change in the necrotic bone
et al22 reported that the radiographic metaphyseal, irregularities on MRI. marrow relies on lipid degradation.30
appearance of medial joint space in Jaramillo et al25 noted that meta- Gadolinium-enhanced MRI uses con-
the initial stage was found, when as- physeal abnormalities on MRI had a trast to demonstrate the vascularity
sessed on MRI, to be overgrown signal intensity similar to that of the of the femoral head more clearly.
cartilage of the femoral head and physis and likely represented persis- First reported for use in patients
acetabulum, with little or no true tent cartilage in the metaphysis. Song with Legg-Calvé-Perthes disease by
medial joint space widening. In the et al26 used conventional MRI, in Sebag et al,31 dynamic gadolinium-
fragmentation stage, medial joint addition to contrast-enhanced imag- enhanced subtraction (DGS) MRI,
space widening was attributed to ing, to further study metaphyseal or perfusion MRI, delineates femo-
synovitis and synovial fluid, in addi- changes in 85 hips with Legg-Calvé- ral head ischemia and reveals early
tion to cartilaginous overgrowth. In a Perthes disease. They reported both revascularization. The acquisition
more recent study, Kotoura et al23 false and true cysts, with false cysts of postcontrast, fat-suppressed, T1-
reported peak lateral subluxation of consisting of projections of granula- weighted (fast spin-echo or spoiled
the femoral head on MRI at 6 months tion tissue from the epiphysis into the gradient-recalled acquisition) images
after the onset of the disease, followed metaphysis. False cysts were noted makes the lack of normal perfusion
by regression. Severity and persis- more frequently than true cysts were, evident (ie, dark signal because of the
tence of lateral subluxation on MRI and metaphyseal changes in general lack of T1 shortening seen with typical
correlated with a worse radiographic were more commonly noted in Cat- perfusion after gadolinium adminis-
outcome at the final follow-up. terall group III and IV hips than in tration). The precontrast images are
Radiographic findings of meta- Catterall group I and II hips. subtracted from the postcontrast, fat-
physeal change have been correlated Conventional MRI findings have suppressed images, making the per-
with poor prognosis, yet the etiology is been correlated with the radiographic fusion abnormalities substantially
controversial. Hoffinger et al24 found outcome. de Sanctis et al27 evaluated more conspicuous (Figure 4). Stan-
that radiographic and MRI meta- conventional MRI in patients with dard MRI systems can be used to
physeal findings often did not corre- Legg-Calvé-Perthes disease with an obtain dynamic (a series of images
late. They reported that hips with average radiographic follow-up of obtained over time after contrast
injection) or static postcontrast MRI stage perfusion of the whole epiph- were statistically significant indicators
sequences. ysis, as well as of the lateral pillar, of femoral head deformity at 2 years.
Comparisons between DGS MRI has also been shown to correlate Increased ADC in the metaphysis
and bone scintigraphy demonstrated with the lateral pillar classification.36 correlated with increased metaphyseal
that DGS MRI was equivalent to Diffusion-weighted imaging (DWI) contrast enhancement. These authors
bone scintigraphy in the depiction of is an MRI technique first used in regularly obtain both DGS and DWI
epiphyseal necrosis and superior to neuroradiology for assessing post- MRI because perfusion images pro-
bone scintigraphy in the demonstra- ischemic tissue changes after stroke. vide better delineation of perfusion,
tion of lateral and medial pillar revas- DWI is relatively fast and does not whereas DWI allows for a more con-
cularization.32 Kim et al33 reported require contrast. DWI characterizes sistent representation of involvement
revascularization patterns in 29 tissues quantitatively using apparent (Figure 5).
patients who had undergone serial diffusion coefficients (ADCs). ADC After femoral head deformity has
perfusion MRI. The revasculariza- values have been shown to be occurred, assessments of joint con-
tion pattern seen on serial perfusion elevated in the femoral head and gruency and femoral head contain-
MRI resembled the scintigraphic metaphysis affected by Legg-Calvé- ment are important when surgical or
track A described by Conway.17 Perthes disease, compared with the orthotic intervention is considered.
Specifically, initial perfusion findings contralateral, unaffected side.37-39 Static radiographs and MRI provide
were variable, but revascularization Although absolute values of ADCs limited information on how the fem-
seemed to occur in a horseshoe-shaped vary in the literature, the ADC oral head moves and fits within the
pattern, from the lateral, posterior, ratios, which compare the affected acetabulum dynamically. Jaramillo
and medial periphery and then toward side to the unaffected contralateral et al42 and Weishaupt et al43 described
the center region and anteriorly. The hip, are more consistent.40 In unaf- similar techniques using open MRI
rate of revascularization was inde- fected hips, femoral head diffusion for multipositional or dynamic
pendent of age, sex, and lateral pillar decreases with age; this age-related assessment, respectively. They per-
classification. change should be taken into con- formed MRI with the patients in
Kim et al34 reported on 30 patients sideration if serial DWI is used to multiple hip positions to assess for
with Waldenström stage I disease monitor the disease.37 joint congruency and femoral head
who had undergone perfusion MRI. The ADC values in the epiphysis containment. This technique was
The T1-weighted images without fat were found to increase early in the comparable to arthrography for the
suppression were compared with the course of Legg-Calvé-Perthes disease evaluation of congruency and con-
perfusion images to estimate the and to remain elevated as the disease tainment, and no patient in either
extent of femoral head involvement. progresses.37 This finding is in con- study required anesthesia. Kim et al44
The perfusion scans provided a more trast to perfusion MRI findings, used range of motion (ROM) MRI to
reliable assessment of femoral head which continue to change through- assess congruency of the hip in five
involvement, often showing greater out the disease course. Baunin et al38 different positions. This information
femoral head involvement than what found a correlation between high can be used to guide preoperative
was seen on conventional T1- metaphyseal ADC ratios and lateral planning, especially when a varus or
weighted images in patients in early pillar classification but did not find a valgus osteotomy is considered in
stages of the disease. The perfusion statistically significant correlation patients with moderate to severe
images had greater interobserver between a high epiphyseal ADC Legg-Calvé-Perthes disease.
reliability and more clearly demar- ratio and lateral pillar classification.
cated the area of involvement, com- Increased metaphyseal diffusion and
pared with the conventional a high metaphyseal ADC ratio have Limitations and Risks of MRI
T1-weighted images. been associated with transphyseal Despite its numerous benefits, MRI
Du et al35 noted that early perfu- neovascularization, an indicator of likely will not replace plain radio-
sion findings were variable in poor prognosis.37,38 graphs as the standard for serial
patients in stage I Legg-Calvé- Recently, Yoo et al41 correlated both imaging because of its elevated cost,
Perthes disease; however, lower DGS and DWI MRI in the early stages its frequently limited availability, and
perfusion correlated with a worse of Legg-Calvé-Perthes disease in 46 the duration of the study. Young
radiographic outcome at a minimum patients with femoral head deformity children often need sedation or
follow-up of 2 years. The correlation index at 2-year follow-up. Specifically, anesthesia to tolerate the lengthy
was statistically significant only in increased metaphyseal diffusion and scan. In addition to increasing the
patients treated nonsurgically. Early- decreased central epiphyseal perfusion cost of MRI, anesthesia introduces
August 1, 2018, Vol 26, No 15 531
Figure 5
Comparative imaging demonstrating early Legg-Calvé-Perthes disease in the left hip of a boy aged 7 years 3 months (A
through D) and at 12-month follow-up (E). A, Plain AP pelvic radiograph. B, Coronal diffusion-weighted magnetic resonance
image demonstrating a high metaphyseal enhancement ratio. C, Apparent diffusion coefficient (ADC) map demonstrating a
high metaphyseal ADC ratio. D, Coronal contrast-enhanced subtraction magnetic resonance image demonstrating
substantial hypoperfusion. The diffusion-weighted imaging and contrast-enhanced subtraction imaging suggest that this
patient will likely have a poor prognosis. E, Plain AP pelvic radiograph at 12-month follow-up demonstrating the
characteristics of a lateral pillar C hip. (Courtesy of WonJoon Yoo, MD, Seoul, South Korea.)
Table 2
additional risks to the patient. be administered only when indicated
Anesthetic drugs have possible neuro- and that macrocyclic agents, which
Gadolinium-based Contrast
Agents
toxic effects, especially on the devel- have greater stability in vivo, be used
oping brain.45 preferentially over linear agents48
Macrocyclic agents Compared with conventional MRI, (Table 2).
Gadoterate meglumine DGS MRI shows changes earlier in Concerns have been raised regard-
Gadobutrol the disease course, but it exposes ing reactions to GBCA, including
Gadoteridol patients to gadolinium-based con- anaphylaxis and nephrogenic sys-
Linear agents trast agents (GBCAs). Recent reports temic fibrosis. Nephrogenic systemic
Gadofosveset trisodium demonstrate deposition of gadolin- fibrosis is a multisystem fibrosing
Gadoxetate disodium ium in the brains of patients who have disorder associated with gadolinium
Gadopentetate dimeglumine received multiple GBCA doses.46,47 exposure in patients with severe renal
Gadobenate dimeglumine The health implications associated impairment. To evaluate the safety
Gadodiamide with this deposition are currently of perfusion MRI in patients with
Gadoversetamide unknown. The National Institutes of Legg-Calvé-Perthes disease, Sankar
Health recommends that gadolinium et al49 retrospectively reviewed 165
patients in five major centers who and the head begins to hinge at this as the hip moved from neutral to
had undergone 298 perfusion MRI contact point. Hip arthrography maximum abduction was an indica-
scans for the assessment of known or remains the standard of care for tor of hinge abduction, as was a
suspected Legg-Calvé-Perthes dis- dynamic imaging assessment of hip positive impingement sign.
ease. In this study, 31% of patients ROM in patients with Legg-Calvé- Although arthrography provides
required sedation and 16% required Perthes disease. With the patient an excellent dynamic assessment of
general anesthesia. No serious anesthetized, the surgeon can dynam- joint congruency through hip move-
adverse events were reported, and the ically evaluate the hip throughout the ment in all three planes, its limitations
most common complication was entire arc of motion. Anesthesia elim- include the need for general anesthe-
nausea or vomiting (in 1.3% from inates the muscle spasm, anxiety, and sia, invasiveness, and cost. Medial
sedation and in 0.3% from the con- pain that often result from assessment dye pooling can be difficult to quan-
trast agent). The authors concluded of hip motion in an awake and alert tify using fluoroscopy, and the use of
that this imaging technique was safe patient.51 In addition, contrast en- serial arthrograms to follow patients
and recommended routine screening hancement of the unossified portions over time would be unlikely.
for a history of kidney disease. of the femoral head allows for more
complete visualization of points within
the ROM arc where limitations occur. Dynamic Radiography
Dynamic Imaging Three main findings on hip arthrog- In the early 1990s, Kruse et al52 used
raphy can help the surgeon delineate a abduction radiographs to quantify the
Many treatments for patients with
hip with hinge abduction from one increased size of the medial joint space
Legg-Calvé-Perthes disease focus on
with a more fluid ROM. First, when without arthrography. Hinge abduc-
obtaining and maintaining improved
the hip is moved from adduction into tion was defined as widening of the
ROM.50 Dynamic imaging modalities
abduction, the extruded lateral femoral medial joint space by .2 mm with
provide information on hip ROM.
head contacts the lateral edge of the abduction, together with diminished
These imaging modalities include hip
acetabulum on the AP image, and the joint space superolaterally. The
arthrography, dynamic radiography,
extruded lateral portion will not move abduction radiograph provides an
and dynamic MRI.
under the edge of the acetabulum as the attractive alternative to hip arthrog-
leg is further abducted. Second, when raphy because no sedation is required,
Hip Arthrography the leg is brought from adduction into it is relatively inexpensive, and patients
Dynamic assessment of hip ROM can abduction, the center of rotation of the can be followed serially without re-
be achieved with hip arthrography. femoral head moves from a point turning to the operating room. The
This technique, like other imaging within the epiphysis (or a center point weaknesses of the technique are that
modalities, has limitations, risks, and along the physis) to a position at the (1) it assesses only abduction, ignoring
benefits. Much of the literature on hip lateral edge of the acetabulum. Third, internal rotation and flexion, and (2)
arthrography in patients with Legg- the medial dye pool increases as the leg visualization of the unossified portions
Calvé-Perthes disease focuses on the is abducted beyond the hinging point, of the femoral head is limited, making
ability to distinguish patients with which indicates that the femoral head is medial joint space widening or su-
good ROM from those with hinge being levered out of the floor of the perolateral narrowing difficult to
abduction. acetabulum. This medial dye pooling measure.
Catterall3 and Grossbard4 used hip should not be confused with excess dye
arthrography to help define hinge collection superiorly, which can occur
abduction in the 1980s. The AP hip in the absence of hinging when the flat Dynamic MRI
view was used for arthrography, and portion of the femoral head moves Multipositional MRI can assess con-
only the adduction/abduction arc of medially and out of contact with the gruency, ROM, and the presence of
motion was considered. Grossbard4 flat portion of the “remodeled” ace- hinge abduction.42-44 This technique
described hinge abduction as occurring tabulum (Figure 6). has a good correlation with arthrog-
when the unossified part of the femoral Nakamura et al5 enhanced the ar- raphy in the assessment of ROM and
head that extends laterally beyond the thrographic definition of hinge hinge abduction.42,43 Kim et al44
acetabulum impinges against the ace- abduction. They compared the sub- described hinge abduction as medial
tabular rim when abduction is at- luxation index, a ratio of medial joint space widening with elevation of
tempted. This impingement prevents joint space and acetabular width, in the labrum in abduction. In adduction,
the femoral head from rotating further the neutral and abducted positions. congruency was improved, and the
into the acetabulum as the hip abducts, An increase in the subluxation index position of the labrum was restored.
August 1, 2018, Vol 26, No 15 533
Figure 6 short duration of the examination.

Currently, MRI complements the use
of radiographs and is increasingly
used in the management of the dis-
ease, both in the early stages for
diagnostic purposes and in the later
stages to assess intra-articular
pathology and joint congruency.
The definition of hinge abduction is a
topic of debate among pediatric ortho-
paedic surgeons. Although hinge
abduction is uncommon, patients fre-
quently undergo arthrography under
sedation to assess for this phenomenon
because its presence can affect ortho-
paedic management. A minimally
invasive, sedation-free, reliable tech-
nique is needed to better understand
and diagnose hinge abduction.
When treating patients with Legg-
Calvé-Perthes disease, especially those
in the early stage of the disease,
pediatric orthopaedic surgeons lack
sufficient answers. A method of
determining the prognosis early in the
disease course is needed to decrease
the risks of undertreating, surgically
overtreating, or waiting for radio-
graphic change to become evident and
Arthrograms depicting a hip of a patient with Legg-Calvé-Perthes disease and then intervening too late for the
substantial hinge abduction. As the hip is brought from adduction (A) to abduction (B),
the medial dye pool widens, the labrum is upturned, and the lateral edge of the
treatment to be effective. Newer MRI
epiphysis extends beyond the acetabular roof. C and D, Arthrograms of the hip of a techniques, such as DGS and DWI,
different patient depicting femoral head deformity without hinging. D, In the abduction have shown promising early results in
position, a medial dye pool is seen between the flattened portion of the femoral head which early MRI findings were cor-
and the rounded acetabulum. This dye pool should not be confused with the one seen
in a hip with hinging. In the abduction image, the labrum is not upturned when the hip related with the early radiographic
is abducted, and the lateral edge of the epiphysis rotates under the acetabulum. outcome. Further study is needed
to determine the appropriate role of
this imaging modality in the early
management of the disease and to
The center of the femoral head was ease over the last century and is used determine whether a prognostic clas-
noted to move laterally in abduction to diagnose, stage, classify, serially sification based on these techniques
and medially in adduction, compared follow, and predict outcomes of the would be worthwhile. Because of the
with neutral positioning. Because disease. New techniques continue to rarity of the disease, meaningful clin-
patients are typically awake during the be developed, refined, and applied to ical study of these techniques will
examination, the assessment of ROM the study and management of Legg- likely require multicenter enrollment.
using dynamic MRI might be more Calvé-Perthes disease.
physiologic than that obtained by No single imaging modality is the
arthrography. ideal tool for all aspects of the man- Acknowledgment
agement of Legg-Calvé-Perthes dis-
Summary ease. Plain radiographs will likely The authors thank Molly Dempsey,
continue to be the preferred method MD, for contributing her expertise
Imaging has transformed the under- of serial evaluation because of the and for providing critical review of the
standing of Legg-Calvé-Perthes dis- low cost, good accessibility, and MRI sections of the article.
deformation in Perthes disease. Orthop Clin 24. Hoffinger SA, Henderson RC, Renner JB,
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F, et al: Prognosis value of early diffusion 44. Kim HT, Oh MH, Lee JS: MR imaging T, Shore BJ, Kim HK; International Perthes
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Research Article
The Orthopaedic Surgery

Residency Application Process: An
Analysis of the Applicant Experience
Abstract
Prem N. Ramkumar, MD, MBA Introduction: Orthopaedic surgery residency positions are highly
Sergio M. Navarro, BS sought after. The purpose of this survey study was to report the following
components of the applicant experience: (1) the number of programs to
Morad Chughtai, MD
which applicants applied and interviewed, (2) the performance criteria
Heather S. Haeberle, BS associated with receiving interviews, (3) the way applicants respond to
Samuel A. Taylor, MD e-mail interview offers, (4) the pre- and post-interview communication
Michael A. Mont, MD between applicants and programs, (5) the importance of interview day
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVFUKKkwtfKABCUxQWuhYcyW/aQJ+a4ZjI7SUaxa7bf/XT7385xAqIYA= on 08/01/2018
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 6 27 programs, received 17 6 10
interviews, and attended 12 6 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
From Cleveland Clinic, Cleveland, OH
(Dr. Ramkumar, Dr. Chughtai, and location and surgical experience, with research the least important
Dr. Mont), Baylor College of Medicine, factor. The cost of interview season was .$7,000 per applicant,
Houston, TX (Mr. Navarro and
Ms. Haeberle), and the Hospital for
excluding away externships.
Special Surgery, New York, NY Conclusion: Applying to orthopaedic surgery residency is a complex,
(Dr. Taylor). competitive, and costly experience for applicants. The application
Correspondence to Dr. Ramkumar: process may benefit from better expectation management of applicant
premramkumar@gmail.com candidacy and a more prohibitive communication policy between
J Am Acad Orthop Surg 2018;26: applicants and programs after the interview day.
537-544
DOI: 10.5435/JAAOS-D-16-00835

Academy of Orthopaedic Surgeons. A pplication to orthopaedic sur-
gery residency has become an
exceedingly competitive process for
medical students.1 Key factors used
in residency selection include clerk-
ship grades, United States Medical
August 1, 2018, Vol 26, No 15 537
Applying to Orthopaedic Surgery Residency
License Examination (USMLE) board endorses postinterview contact to (5) the importance of interview day
scores, class rank, letters of recom- influence students to rank that pro- activities and the determinants of the
mendation, and interview day perfor- gram higher. In addition to pro- applicant ROL, and (6) the financial
mance.2–4 With an annual unmatched viding more information about what cost of the application process.
rate of 38% despite the growing students prefer, knowledge of ap-
number of residency programs (0.7 plicant activities and perspectives
positions available per applicant), may expose limitations or flaws in Methods
the orthopaedic application process the current system that deserve cor-
itself has demanded more from rection. Bernstein et al5 highlighted Survey Population
medical students than baseline aca- the disconnect between applicants An online survey (SurveyGizmo) was
demic and extracurricular creden- and programs in the residency ap- used to query orthopaedic surgery
tials.1,5–8 As such, applicants perform plication cycle by demonstrating residency applicants during the 2015
away externships to increase their differences in the applicants’ views to 2016 cycle. The survey was avail-
odds of successfully finding a “match” and program directors’ views on able and administered during a
because rotating at a program in- resident selection criteria; specifi- 3-week period between the last
creases the applicant’s chances of cally, students felt letters of recom- interview date of the application cycle
matching at that program by a factor mendation to be more important on February 3, 2016, and the dead-
of 50%.1,9,10 In addition to away than performance on an orthopaedic line for the ROL certification on
externships at the personal financial externship. In an attempt to eluci- February 24, 2016. A link to the
cost of the applicant, students spend date preferences, Huntington et al6 survey was sent to applicants’ e-mail
dedicated time (often a year or more) surveyed 207 applicants and found addresses from the pool of residency
in research to “strengthen” their interpersonal factors, such as per- program applicants to the authors’
application.6 ceived quality of life and resident institutions and made available on-
The literature documenting the camaraderie, to be critical determi- line in the 2015 to 2016 residency
current landscape in the orthopaedic nants in selecting an orthopaedic applicant forum (orthogate.org).
residency application process is residency program. Although data Publicly available historical outcome
dominated by reporting the overall regarding match statistics and selec- data produced by the NRMP and
competitiveness with publicly avail- tion criteria preferences exist,7,11-13 Association of American Medical
able National Residency Matching to our knowledge, no study thus far Colleges were used to validate the
Program (NRMP) data or by selection has evaluated the specific aspects of survey sample pool.8 Data extracted
criteria of residency programs.1-3,5-7 the applicant experience in a chro- included the following: orthopaedic
However, to completely understand nologic fashion, from receiving in- residency positions offered annually;
the process, the perspective of the terviews, to accepting these offers, to total orthopaedic applicant pool;
applicant is saliently absent but nec- finalizing their ROL. mean USMLE Step 1 and Step 2
essary for several reasons. The infor- The purpose of this observational Clinical Knowledge (CK) scores
mation disseminated about programs survey study was to report the follow- both nationally and for orthopaedic
is anecdotal, but for programs tar- ing components of the applicant expe- applicants; and percent of ortho-
geting applicants with mutual goals, rience: (1) the number of programs paedic applicants inducted into the
knowing what applicants tend to to which applicants applied and Alpha Omega Alpha (AOA) Honor
value as they create their final rank interviewed, (2) the performance cri- Medical Society. The historical out-
order list (ROL) submitted to the teria associated with receiving inter- come data extracted from the NRMP
NRMP is critical.5,6 The notion that views, (3) the way applicants respond and Association of American Medi-
program directors want to match the to e-mail interview offers, (4) the pre- cal Colleges were compared with the
applicants they have ranked highest and post-interview communication survey data and validated using the
is supported by a recent study that between applicants and programs, following tests at 95% confidence
Dr. Chughtai serves as a paid consultant to DJ Orthopaedics, Sage Products, and Stryker. Dr. Taylor serves as a paid consultant to DJ
Orthopaedics and Mitek. Dr. Mont has received royalties from MicroPort and Stryker; serves as a paid consultant to Cymedica, DJ
Orthopaedics, Johnson & Johnson, Ongoing Care Solutions, Orthosensor, Orthosensor, Pacira, Performance Dynamics, Sage, Stryker, and
TissueGene; held stock or stock options in PeerWell, DJ Orthopaedics, Johnson & Johnson, National Institutes of Health (NIAMS and
NICHD), Ongoing Care Solutions, Orthosensor, Stryker, and TissueGene; and is a board member or committee member of the American
Academy of Orthopaedic Surgeons. None of the following authors or any of their immediate family members has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr.
Ramkumar, Mr. Navarro, and Ms. Haeberle.
Prem N. Ramkumar, MD, MBA, et al
interval: Student t-test, chi-square Table 1

analysis, and Mann-Whitney U
Baseline Characteristics of Survey Respondents
test. The Student t-test was used to
determine whether the sample stu- Characteristic Data
dent survey population was compa- Sex (%)
rable with the NRMP’s most recent
Male 80
publication of the total orthopaedic
Female 20
applicant pool for USMLE Step 1
Region of medical school (%)
and Step 2 CK scores. Chi-square
Northeast 30
analysis was used to determine
Midwest 27
whether the sample student survey
South 31
population was comparable with the
NRMP’s most recent publication of West 12
the total orthopaedic applicant pool Reapplicants (%) 4
for AOA status. The Mann-Whitney Couples matching (%) 4
U test was used for the sex analysis Orthopaedic subinternships 3.4 6 0.7
to compare whether differences ex- Letter of recommendations from orthopaedic surgeons 3.7 6 0.5
isted between male and female Decision to apply orthopaedic surgery (%)
applicants for Step 1 score, Step 2 Before college 7
CK score, AOA status, and inter- In college 10
views offered. Between college and medical school 16
A total of 1,034 applicants applied MS1 19
in the 2015 to 16 cycle, 315 applicants MS2 17
opened the link, 109 began the survey, MS3 27
and 100 completed the survey in its MS4 1
entirety (ie, 10% of the pool, 32%
response rate, and 92% completion MS = medical school
rate) and were included in the analysis.
Table 1 shows baseline characteristics
of the surveyed applicants. Among Table 2
students surveyed, the mean (6SD)
Notable Attributes of Surveyed Applicants
Step 1 and Step 2 CK scores were 248
6 11 and 255 6 13, respectively, with Characteristic Data
35% receiving AOA Honor Medical Top 25 medical school (%) 24
Society status. Complete data are USMLE scores
shown in Table 2. Step 1 248 6 11
Step 2 CK 255 6 13
Survey Content AOA Honor Medical Society (%) 35
Athlete (collegiate or above) (%) 43
The survey included 45 questions (see
Research year (%) 40
Appendix 1, Supplemental Digital
Other graduate degrees (%) 21
Content 1, http://links.lww.com/
PhD 3
JAAOS/A109). Seven questions were
dedicated to the applicants’ demo- MBA 3
graphics, including medical school MPH 1
region, sex, orthopaedic reapplicant Other 14
status, couples match status, number
AOA = Alpha Omega Alpha, CK = clinical knowledge, USMLE = United States Medical License
of orthopaedic subinternships (includ- Examination
ing both home and away rotations),
number of recommendation letters
from orthopaedic surgeons, and when Seven questions were dedicated to 25, AOA Honor Medical Society
the decision was made to apply to application competitiveness: attend- status, United States Medical Licens-
orthopaedics. ing a medical school ranked in the top ing Step 1 and Step 2 CK scores, other
August 1, 2018, Vol 26, No 15 539
graduate degrees, former collegiate and the Mann-Whitney U test was and 40% received $20 interview
or professional athletes, and any used to determine whether sex differ- offers. Thirty-four percent attended
previous year or years taken off for ences existed between Step scores and #10 interviews, 42% attended 11 to
research. Fifteen questions were dedi- AOA status. The Cochran-Mantel- 15 interviews, and 24% attended
cated to the interaction between Haenszel method was used to adjust $16 interviews.
applicants and programs, including for any confounding effect with respect
the number of programs applied to, to the Step 1 score, Step 2 CK score,
the number of interviews received, the and AOA status when analyzing the Performance Criteria
number of interviews attended, determinants of interview offer analy- Associated With Receiving
the number of programs ranked, the sis. The Fisher exact test was used to Interview Offers
number of interest e-mails sent by the establish the level of importance to Alpha Omega Alpha status (P =
applicant before and after interviews, receiving an interview offer for Step 1 0.00001, .0.01% confidence) was
the time it took to reply to an inter- score, Step 2 CK score, AOA status, the largest differentiator between
view offer (time to reply), the number applying from a top 25 medical school, applicants in receiving interviews,
of people monitoring the applicant’s research year, and other graduate followed by Step 2 CK score (P =
e-mail account, the percent of lost degrees based on increasing confidence 0.000585, .0.1% confidence), Step
interviews because offers were not levels; as such, the analysis was per- 1 score (P = 0.00247, .1% confi-
replied to fast enough, the number of formed at 95%, 99%, 99.9%, and dence), applying from a top 25
programs applicants told would be 99.99% confidence levels. All data, medical school (P = 0.102), research
ranked first, the process of “second analyses, and statistics were performed year (P = 0.104), and other graduate
look” encouragement, and the role using Stata. degrees (P = 0.145). Notably, Step 2
mentors played in applicant advo- CK was found to be a greater
cacy. Fifteen questions used a seven- determinant for interviews if the Step
point Likert14 scale to solicit the
Results
1 score was at least at the level of the
importance of the interview day mean. Step 1 and Step 2 CK scores
Using Student t-test and chi-square
experience and the primary deter- were analyzed for significance if the
analysis, the sample survey pool data
minants affecting the applicant ROL. score was above the median thresh-
were established to be statistically
A final question solicited the approx- old, specifically 250 for Step 1 and
comparable with the total pool of
imate cost of attending each interview, 256 for Step 2 CK. Continuous sig-
orthopaedic applicants in terms of
including accommodations, travel nificance as scores increased was not
Step 1 score (P = 0.58 . 0.05), Step 2
expenses, and food. Appendix 1 (see assessed. Gender was not a statisti-
CK score (P = 0.54 . 0.05), and
Supplemental Digital Content 1, cally significant factor.
AOA status (P = 0.99 . 0.05) based
http://links.lww.com/JAAOS/A109)
on 2014 NRMP outcome data.8 Sex
includes the full list of questions.
analysis revealed no statistically Response to Interview Offers
significant difference between male
A total of 37% of the applicants
Statistical Analysis and female applicants in terms of
had at least one other person (range,
Step 1 score (P = 0.12 . 0.05), Step
The survey responses were collected 1 to 4) monitoring their personal
2 CK score (P = 0.50 . 0.05), AOA
and tabulated anonymously with the e-mail account for interview offers
status (P = 0.19 . 0.05), and the
use of available software (Survey- to minimize time to reply when a
number of interviews offered (P =
Gizmo). Only complete surveys were notification arrived. The mean time
0.19 . 0.05).
analyzed, using five statistical tests to reply to an e-mail interview offer
(ie, Student t-test, chi-square analy- was 17 minutes (range, 1 to 120).
sis, Mann-Whitney U test, Fisher Programs Applied to and Figure 1 shows the distribution of
exact test, and Cochran-Mantel- Interviews response time among applicants.
Haenszel method) to evaluate specific The mean number of residency pro- However, 25% of the applicants
populations and confirm statistical grams applied to was 83 6 27, with a reported losing at least one interview
significance as appropriate. As men- range from 20 to 150. The mean invitation secondary to delayed
tioned earlier, the Student t-test and number of interviews received and response time, with 17 applicants
chi-square analysis were performed to attended was 17 6 10 and 12 6 5, losing one interview, 4 applicants
ensure that the survey data were respectively. Twenty-two percent losing two interviews, and 4 appli-
comparable with previous NRMP received ,10 interview offers, 38% cants losing three interviews. This
orthopaedics applicants from 2014, received 10 to 20 interview offers, subset of 25 applicants who lost an
interview offer self-reported replying ceived reputation, interview day Figure 1

in a mean time of 12 minutes. experience, faculty perception, and
research potential. Only 2% of the
Pre- and Postinterview applicants did not rank every pro-
Communication Between gram where they interviewed; both
Applicants and Programs individuals omitted one program
Applicants contacted a mean of 4.3 from their ROL.
(range, 1 to 40) and 3.3 (range, zero
to 12) programs after submitting Financial Burden
applications and completing inter- The mean cost per interviews,
views, respectively, to express further including accommodations, travel,
interest in particular orthopaedic and food, was $411.29. The appli-
programs. A total of 60% of the cants spent a mean of $5,116.47 for
Diagram showing the distribution of
applicants reported being individually attending interviews throughout the time to reply among applicants
contacted by at least one program season. Using the 2015 to 2016 fees offered interviews.
(range, zero to 8) after interviews rates, applicants applied to a mean of
to explicitly express interest or ask 83 programs and spent a mean of
applicants whether they had further son monitoring their e-mail account.
$1,890 just to submit applications,
questions. According to surveyed The communication between appli-
which amounts to a mean total of
applicants, 14% reported at least one cants and programs outside the inter-
$7,006.47, excluding accommoda-
program explicitly requesting them to view day was extensive and initiated
tions and application fees for the
be ranked first or soliciting where the by both applicants and programs, with
average two to three away extern-
applicant would rank the program. some programs soliciting applicants to
ships completed.
Similarly, 49% of the applicants rerank the program highly or perform a
ported being encouraged by at least second look. The top determinant of
one program to perform a second look Discussion and Summary the ROL was location, whereas
(range, zero to 5) at their institution. A research potential was least important.
total of 86% of the applicants explicitly Our study reports the experience of Also, the orthopaedic applicant
informed a program that they would medical students applying for ortho- incurred a mean of $7,000 of personal
be ranking them first; all applicants paedic residency. Numerous decision- cost to apply, excluding away rota-
informed just one program. making processes are revealed in this tions. Our report represents the first to
report, which summarize how medical study applicant perspectives and pref-
students applying for these positions erences in a chronologic approach to
Importance of Interview Day
optimize their chances for matching examine the current state of the ortho-
Activities and Primary during the preinterview, interview, paedic residency application process.
Determinants of Rank Order and postinterview periods. The deci- This study has several limitations.
List sion to apply to an average of 83 pro- The sample size is a small (10% =
In analyzing the importance of inter- grams is supported by the yield of 12 100/1,034) representation of the
view day activities, applicants prior- interviews attended despite meeting general pool of 2015 to 2016
itized the following aspects as extraordinary criteria that include orthopaedic applicants. However,
“extremely” or “very” important in board scores nearly two SDs greater our response rate was 32%, with a
descending order: interaction with than the national average and unique 92% completion rate, which is
residents, interaction with faculty, experiences that include dedicated higher than other survey studies of
interaction between residents and research years. Predictors of receiving applicants.10,15 Although statistical
faculty, interaction with interviewers, more interviews than peers applying comparison demonstrated that no
organization of the events, tour of the were associated most strongly with statistically significant differences in
facilities and local area, and quality of AOA status, followed by Step 2 CK demographics existed between those
food provided. and Step 1 scores higher than the who did and did not complete the
In forming the final ROL, appli- mean orthopaedic applicant. Despite survey, we compared our results
cants prioritized the following factors accepting interview offers, 25% of the with the publicly available 2014
from most important to least impor- applicants reported that they still lost data, which may be outdated. Our
tant: location, perceived surgical interviews despite a time to reply of analysis was repeated with the
experience, resident perception, per- 17 minutes and at least one other per- recently released 2016 NRMP data,
August 1, 2018, Vol 26, No 15 541
and the survey data of 248 on Step 1, the trimodal distribution of inter- study of 91 orthopaedic residency
255 on Step 2 CK, and 35% AOA views students could attend (ie, #10, programs by Amin et al1 that suggests
rate closely match the 2016 NRMP 11 to 15, or .15). In a survey study a general surgery intern year may be
data of 247 on Step 1, 253 on Step 2, of 408 applicants comparing matched of benefit for most of the programs.
and 34% AOA rate.16 However, the to unmatched applicants, Camp et al15 Although research is viewed favorably
mean number of programs ranked corroborated our findings with data among programs, documented
was 12, which differs from the 17 showing that matched and unmatched research should be carefully evalu-
who responded to this survey, sug- groups applied to 71 and 74 programs, ated because Konstantakos et al28
gesting that those with more com- respectively, and received approxi- have highlighted a growing percent of
petitive odds of matching may have mately 11 interviews on average. The falsification up to 21% of research
preferentially responded to the sur- absence of a gender-based difference in after reviewing 142 publication sec-
vey during the 3-week period. The interview offers confirms the findings tion applicants submitted to residency
outcomes of the applicants studied by Scherl et al and others that any programs. To the point of additional
were not queried. Because the goals potential bias related to the paucity degrees, Bernstein et al5 reported
of applicants are to match, rather of women in orthopaedics is not pre- that additional graduate degrees
than to receive interview offers, sent at the stage of residency interview were found to be the least relevant
there may be differences in scores or invitations.23-26 factors in receiving interviews in a
behavior between applicants who This study also found that the high 2003 survey study of students and
matched versus those who did not, number of programs applied to was program directors.29
which are not accounted for in the not without financial repercussions. Our study demonstrates that com-
analysis. The characterization of Costs from application fees, inter- munication during application is com-
competitiveness may be understated view travel costs, and other associ- plex, from the process of accepting an
because the data include applicants ated expenditures—but not away interview offer in #16 minutes (despite
who did not match; however, the rotations—totaled .$7,000, which 25% still losing at least one interview)
other goals of studying preferences, is supported by a recent study re- to demonstrating interest in a program
cost, interaction, and determinants porting a cost of $5,500 on the entire with personalized e-mails to assessing
of interview offers were unaffected. application and interview process, several programs. The present study
In the same vein, the study does not with a range from $450 to $25,000.10 demonstrated that the interaction
address the applicant features that Previous studies have reported between residency programs and ap-
constitute a residency program’s various selection criteria used to rank plicants in the era of electronic com-
ROL. Although no study has been applicants higher, but none to our munication to be a subtle but powerful
able to report the specific criteria knowledge has ventured to prioritize force that escalates competition for
used by each program director to the which applicant attributes (ie, AOA and between the parties. No study to
authors’ knowledge, other studies status, Step 2 CK greater than the our knowledge has attempted to cap-
have examined various factors from mean, and Step 1 greater than the ture these aspects of communication
valued applicant statistics to per- mean) actually yield the most inter- between applicants and programs. The
sonality similarity bias.17-22 This views to give students the opportunity residency applicant selection process
study also runs the risk of recall bias to make a program’s ROL.2,3,5,18,27 has evolved into a high competition
because applicants may not remem- On the basis of the applicant deter- between applicants as they vie for
ber impressions from the early part minants for receiving interviews, our attention from residency programs,
of application season or may have study also suggests to applicants evidenced by applicants sending nu-
a distorted perspective, given the seeking to match in orthopaedics merous interest letters before the
charged nature of the process. despite suboptimal board scores or interview day, after the interview day,
This study clarifies that the com- not attaining AOA status, that the and finally when the applicant is
petitive landscape of orthopaedic next best recourse would be to com- ranking the program first. In turn,
surgery has coincided with a group of plete a research year and, less likely, programs have only furthered the
applicants applying to a high number an additional degree, although no competition with implicit pressure to
of programs (83 6 27), although this specifics regarding the degrees were attend second looks at the personal
does not necessarily translate to a assessed or reported. The benefits of cost of the applicant, reaching out to
proportionate response in interviews mentorship and publications from a the applicants after interviews to
attended (mean, 12 interviews at- dedicated research year as the next- return the interest, or rewarding the
tended). Applicants tended to fall best modifiable factor an applicant student who replies to e-mail offers
into three distinct echelons based on can have contradict a 2013 survey the fastest. Camp et al10 supported
the notion of postinterview contact other advisors to medical students selection. J Bone Joint Surg Am 2013;95:
e84.
with orthopaedic applicants as a seeking orthopaedic surgery resi-
pressure tactic to influence students dency should take a more active role 5. Bernstein AD, Jazrawi LM, Elbeshbeshy B,
Della Valle CJ, Zuckerman JD: An analysis
to rerank their ROL, with the report in managing student expectations of orthopaedic residency selection criteria.
that 21% of the students moved and providing resources, from access Bull Hosp Joint Dis n.d.;61:49-57.
programs higher after being con- to orthopaedic mentors or applying 6. Huntington WP, Haines N, Patt JC: What
tacted. The authors, however, feel to another subspecialty and (2) the factors influence applicants’ rankings of
orthopaedic surgery residency programs in
that these compensatory behaviors authors recommend a policy similar the National Resident Matching Program?
in communication between pro- to that of the American Council of Clin Orthop Relat Res 2014;472:
grams and applicants portend an Academic Plastic Surgeon by pro- 2859-2866.
unsustainable future for the appli- hibiting the following: (1) communi- 7. Rinard JR, Mahabir RC: Successfully
cation process because the result will cation with faculty and applicants matching into surgical specialties: An
analysis of national resident matching
further degenerate the process into a after the interview, (2) the use of program data. J Grad Med Educ 2010;2:
“numbers game,” with the conse- second looks, and (3) resident com- 316-321.
quence of applicants spending more munication with applicants unless 8. Charting Outcomes in the Match for U.S.
money and programs being inun- initiated by the applicant.30 Such Allopathic Seniors: National Residency
Matching Program. 2014. http://www.
dated with more applications and encouragement by programs to nrmp.org/wp-content/uploads/2014/09/
letters of interest. Although two applicants potentially takes advan- Charting-Outcomes-2014-Final.pdf.
studies examined student preferences tage of a vulnerable population who Accessed July 15, 2017.
in their residency program search, may feel obligated to undertake such 9. Baldwin K, Weidner Z, Ahn J, Mehta S: Are
the present study is the first to a trip for fear of being discounted as away rotations critical for a successful
match in orthopaedic surgery? Clin Orthop
explicitly report the determinants of a serious applicant. Relat Res 2009;467:3340-3345.
the final ROL.5,6 The critical factors
10. Camp CL, Sousa PL, Hanssen AD, et al:
for applicants were desired location, Orthopedic surgery applicants: What they
Conclusion
perceived surgical experience, and want in an interview and how they are
influenced by post-interview contact. J Surg
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suggests that applicants perform senior U.S. medical students, 1996. Acad
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Research Article
Analysis of Femoral Version

in Patients Undergoing
Periacetabular Osteotomy for
Symptomatic Acetabular Dysplasia
Abstract
Wudbhav N. Sankar, MD Introduction: A paucity of information exists on the range of femoral
Eduardo Novais, MD version, its effect on hip stability, clinical examination, and
Denise Koueiter, MS presentation in patients with symptomatic acetabular dysplasia. The
Christian Refakis, MD purpose of this study was to describe the range of version in
Ernest Sink, MD symptomatic acetabular dysplasia, the association between femoral
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVJua3JJgqHHlGTw5fP/IFHLrvbaaK6WB59VHXrMnKGSc6qfBZjgfUto= on 08/01/2018
Michael B. Millis, MD version and proximal femoral morphology and degree of dysplasia,
Young-jo Kim, MD, PhD and the effect of version on clinically measured hip range of motion
John Clohisy, MD and on preoperatively measured hip outcome scores.
Joel Wells, MD, MPH Methods: We reviewed 314 patients prospectively enrolled in a
Jeffrey Nepple, MD longitudinal clinical study on periacetabular osteotomy between
Ira Zaltz, MD January 2014 and August 2015 and measured femoral version,
morphologic characteristics of the upper femur and acetabulum, and
From the Department of Orthopaedic preoperative clinical outcome scores.
Surgery, Children’s Hospital of Results: The average femoral version was 19.7° 6 11.2°
Philadelphia, Philadelphia, PA
(range, 220° to 50°). Femoral version correlated strongly with
(Dr. Sankar and Dr. Refakis), the
Department of Orthopaedic Surgery, clinically measured hip range of motion but did not correlate linearly
Boston Children’s Hospital, Harvard with either radiographic severity of acetabular dysplasia or
Medical School, Boston, MA (Dr. Novais,
Dr. Millis, and Dr. Kim), the Department
preoperative symptomatology.
of Orthopaedic Surgery, William Discussion: Despite concerns that transverse plane femoral
Beaumont Hospital, Oakland University anatomy influences the stability of the hip joint after skeletal
William Beaumont School of Medicine,
Auburn Hills, MI (Ms. Koueiter and
maturity, we did not find a statistical association between femoral
Dr. Zaltz), the Department of version and severity of dysplasia or presenting symptomatology.
Orthopaedic Surgery, the Hospital for This finding suggests that femoral version is not a major influence
Special Surgery, Joan and Sanford I
Weill Medical College of Cornell
on the clinical presentation of acetabular dysplasia.
University, New York, NY (Dr. Sink), the Level of Evidence: Level IIIb
Department of Orthopaedic Surgery,
Washington University School of
Medicine in St. Louis, St. Louis, MO
(Dr. Clohisy and Dr. Nepple), and the
Department of Orthopaedic Surgery, the
University of Texas Southwestern
Medical Center, Dallas, TX (Dr. Wells).
T he field of hip preservation has
evolved considerably over the
past 25 years, as has the recognition
indication for the procedures con-
tinues to expand. With increased
understanding of hip mechanics, the
Correspondence to Dr. Sankar: of the breadth and variability of hip contribution of femoral anatomy,
sankarw@email.chop.edu morphology. With the advent of pro- specifically transverse plane rotational
J Am Acad Orthop Surg 2018;26: cedures such as the periacetabular variations, to the pathologic mechan-
545-551 osteotomy (PAO), surgical dislocation ics of the hip joint has received re-
DOI: 10.5435/JAAOS-D-17-00076 of the hip, and arthroscopic hip sur- newed interest. Recent publications
gery, the mechanics associated with have documented various measure-
Academy of Orthopaedic Surgeons. certain anatomic variations have been ment techniques to more accu-
elucidated. Concurrently, the surgical rately assess transverse plane femoral
August 1, 2018, Vol 26, No 15 545
Analysis of Femoral Version in Patients Undergoing Periacetabular Osteotomy
anatomy.1-3 Clinically, patients who of femoral version on presenting University of California Los Angeles
present with acetabular dysplasia symptomatology. Hip Disability and Osteoarthritis
have varying degrees of femoral Outcome Score Quality-of-Life, and
version (or torsion).4 The important Western Ontario and McMaster Uni-
Methods
contribution of transverse plane fem- versities Arthritis Index scores were
oral anatomy to hip stability in the After approval was obtained from calculated.
newborn with developmental dyspla- each center’s institutional review All patients underwent standard-
sia of the hip has been recognized, and board, five participating Academic ized radiographic evaluation includ-
its assessment and treatment is an Network of Conservational Hip ing at minimum a standing or supine
integral part of managing hip insta- Outcomes Research (ANCHOR) AP pelvis, a false profile, and either a
bility in young children.5-7 The precise investigation sites prospectively en- Dunn or frog lateral view of the
mechanical contribution of transverse rolled a series of patients who were proximal femur.9 From these images,
plane hip anatomy to hip instability in undergoing PAO for the treatment each treating surgeon measured the
adolescents and adults, however, is of symptomatic acetabular dysplasia. lateral center edge angle (LCEA),10
not well understood, although excess Between January 1, 2014, and August the anterior center edge angle
anteversion has been shown to de- 30, 2015, 314 patients underwent (ACEA),11 and the Tönnis acetabu-
crease the abductor moment arm and PAO and had suitable advanced lar inclination angle.12 For all AP
to potentiate anterior hip instability imaging to allow preoperative femoral pelvic radiographs, adequate pelvic
through posterior femoroacetabular version measurements in the trans- tilt and rotation were assessed in a
impingement (FAI).8 Currently, the verse plane (Figure 1). We excluded standardized fashion by evaluating
indications to treat variations of ver- patients who underwent PAO for the vertical distance between the
sion or torsion in young adults have secondary causes of acetabular dys- upper border of the pubic symphysis
not been defined. In addition, the plasia including Legg-Perthes disease, and the center of the sacrococcygeal
spectrum of transverse plane anatomy epiphyseal dysplasia, and post- joint (for pelvic tilt) and the hori-
and its relationship with the clinical traumatic deformity. zontal distance between the same
presentation of symptomatic acetab- After informed consent was ob- landmarks (for pelvic rotation), as
ular dysplasia in the skeletally mature tained from each subject, demo- described by Tannast et al.13 The
are not well understood. graphic data including age, sex, and alpha angle described by Notzli
The main objectives of this study body mass index were prospectively et al14 was measured on all available
were to (1) describe the distribution collected. All patients underwent a radiographic views, and we defined
of femoral version in a large cohort clinical examination of ROM in the absolute alpha (a) angle as the
of patients presenting for PAO, (2) the supine position performed by the largest of these measurements for
determine whether femoral version treating surgeon, who recorded the each patient.
correlates with radiographic severity degree of flexion, internal and exter- Preoperative CT or MRI was used
of acetabular dysplasia and proximal nal rotation at 90° of flexion, and to assess femoral anatomy in the
femoral head-neck morphology, (3) internal and external rotation with transverse plane (Figure 1, B and C).
investigate the effect of transverse the hip in extension. Before surgery, CT was performed using 64- to 256-
plane femoral anatomy on clinically patients completed questionnaires, slice scanners. All MRI studies were
measured hip range of motion and the modified Harris hip score, 12- performed at 1.5 or 3 T. For both
(ROM), and (4) evaluate the effect item Short-Form mental and physical, imaging modalities in all institutions,
Dr. Sankar has received royalties and financial or material support from Wolters Kluwer Health–Lippincott Williams & Wilkins and is a
board member or committee member of the Pediatric Orthopaedic Society of North America. Dr. Sink is a board member or committee
member of the Pediatric Orthopaedic Society of North America. Dr. Millis has received royalties and financial or material support from
Saunders/Mosby-Elsevier. Dr. Kim serves as a paid consultant to Orthopediatics and as an unpaid consultant to Siemens Heath Care
and has received other financial or material support from Siemens Health Care. Dr. Clohisy serves as a paid consultant to MicroPort
Orthopedics and Zimmer; has received research support as a principal investigator from Zimmer; and has received royalties and
financial or material support from Wolters Kluwer Health–Lippincott Williams & Wilkins. Dr. Nepple is a member of a speakers’ bureau
or has made paid presentations on behalf of Ceterix Orthopaedics and Smith & Nephew; serves as a paid consultant to Ceterix
Orthopaedics, Responsive Arthroscopy, and Smith & Nephew; has received research support as a principal investigator from Smith &
Nephew and Zimmer; and is a board member or committee member of the Pediatric Research in Sports Medicine Society. Dr. Zaltz
serves as a paid consultant to Orthopaediatrics. None of the following authors or any of their immediate family members has received
anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the
subject of this article: Dr. Novais, Ms. Koueiter, Dr. Refakis, and Dr. Wells.
Wudbhav N. Sankar, MD, et al
acquisition protocols were similar Figure 1

and included axial and axial oblique
images through the hip and axial
images through the ipsilateral distal
femur, with the patient instructed
not to move in between. In each case,
version was calculated as the angular
difference between the axis of the
femoral neck as measured on the
oblique axial view and the posterior
femoral condylar line as measured
on a transverse image through the
intercondylar plane of the distal
femur.
An a priori sample size analysis was
conducted to determine how many
patients were needed for an ade-
quately powered study. It revealed
that to achieve a power of 0.8, with
a = 0.01 and an effect size of 0.2,
a minimum of 247 patients were
required.
The correlation of femoral version,
ROM, center edge angle (CEA),
Tönnis angle, and a-angle was ana-
lyzed with a Spearman rank-order
correlation. P , 0.05 was considered Case example: Preoperative AP pelvis radiograph (A) in a patient with
symptomatic right-sided acetabular dysplasia (lateral center edge angle = 17°),
statistically significant. A Bonferroni with a Harris hip score of 61 and a University of California Los Angeles activity
correction was used to adjust the P score of 9. Axial oblique magnetic resonance image through the hip (B) and axial
value for family-wise comparisons. To image through the ipsilateral distal femur (C) demonstrate the femoral version of
determine independent predictors of 37°. Postoperative AP pelvis radiograph (D) after right periacetabular
ostetotomy.
ROM, a stepwise linear regression
was used. The effect of independent
variables on internal rotation in flex-
Femoral version was compared
ion and internal and external rotation Results with clinical ROM. We found a sig-
in extension were used. The indepen-
nificant (P , 0.001) trend of in-
dent variables were femoral version, Three hundred fourteen patients
AP a-angle, and absolute a-angle. underwent PAO between January 1, creasing internal rotation in flexion
In addition, to determine the rela- 2014, and August 30, 2015. Of these with increasing version and a statis-
tionship between version outliers and patients, 282 (90%) were women and tically significant (P = 0.008) but
acetabular characteristics, the cohort 31 (10%) were men. The sex was not weak trend of increasing internal
was divided into three groups using recorded for one patient. The average rotation in extension with increasing
the mean femoral version 6 one SD age was 24.7 6 8.5 years (range, 10 femoral version. In addition, we found
as the two cutoffs. Each group was to 53 years), and the average body a significant (P = 0.002) trend of
assessed for normality and then com- mass index was 23.9 6 3.9 kg/m2 decreasing external rotation in flexion
pared in terms of the CEA, Tönnis (range, 16.6 to 40.5 kg/m2). Femoral with increasing femoral version.
angle, a angle, ROM, and preopera- version was measured using MRI Range of motion was compared with
tive functional scores. No variables in 142 patients (45%) and CT in 172 CEAs and a-angles. The AP a-angle
were normal; therefore, a Kruskal- patients (55%). The average calcu- correlated inversely with flexion (P =
Wallis test was used to assess differ- lated femoral version was 19.7° 6 0.002), external rotation in flexion
ences in all variables across groups 11.2° (range, 220° to 50°; 95% (P , 0.001), and external rotation in
with a Dunn-Bonferroni test for pair- confidence interval, 18.43 to 20.91) extension (P = 0.002). Similarly, the
wise comparisons. (Figure 2). absolute a-angle correlated inversely
August 1, 2018, Vol 26, No 15 547
Figure 2 (P , 0.05) for all three measures. In

addition, a significant difference was
noted between groups in internal
rotation in flexion (P , 0.001), with
a significant difference between all
pairwise comparisons (P , 0.05) and
increasing mean values with increas-
ing femoral version. A significant
difference was also noted between
groups in external rotation in flexion
(P = 0.011), with a trend of decreas-
ing mean values and a significant
difference between the low-version
and high-version groups (P = 0.010).
Discussion and Summary
The relationships between transverse

plane femoral anatomy, growth and
development of the hip joint, and
pathologic conditions affecting the
hip in all age groups have been a
subject of some interest for several
Graph showing the distribution of femoral version (in degrees) among patients
undergoing periacetabular osteotomy. decades. The anatomic accuracy of
various measurement techniques has
been well discussed.1-3,15,16 The asso-
with external rotation in flexion (P = and preoperatively measured func- ciation between neonatal hip insta-
0.002), internal rotation in extension tional outcome scores including mod- bility and femoral version has been
(P , 0.001), and external rotation in ified Harris hip score, Western Ontario converted to a formula by McKib-
extension (P = 0.002). and McMaster Universities Arthritis bin.17 The significance of assessing
Stepwise linear regression using Index, Hip Disability and Osteoar- and correcting femoral version during
independent variables for femoral thritis Outcome Score, and University open reductions for developmental hip
version, AP a-angle, and absolute of California Los Angeles activity score dislocations has been previously dis-
a-angle demonstrated a significant 1 (Table 1). cussed by Sankar et al.6 In a landmark
correlation between internal rotation To further investigate the role of review article, Tönnis and Heinecke18
in flexion and femoral version (P , femoral version, the cohort was bro- discussed their clinical experience
0.0001); external rotation in flexion ken into three groups based on the treating patients with different com-
and AP a-angle (P = 0.003) and degree of anteversion. On the basis of binations of femoral and acetabular
femoral version (P = 0.014); and the cohort mean 6 1 SD, the cutoff version and postulated an embryonic/
internal rotation in extension and AP for high version was 30.9°, and the developmental etiology to variations
a-angle (P , 0.0001) and femoral cutoff for low version was 8.5°. The in femoral anatomy with compensa-
version (P = 0.028). three groups did not differ in terms tory acetabular and tibial remodeling.
We did not find any correlation of preoperative functional scores or Despite notable clinical experience
between measures of acetabular dys- a angles. However, we found a sig- and the reported associations be-
plasia (ie, ACEA, LCEA, and Tönnis nificant difference between the three tween femoral version and hip path-
angle) and clinically examined ROM, groups in measures of acetabular omechanics, a paucity of data exists
and we did not find any linear cor- dysplasia ACEA (P = 0.001), LCEA on the distribution of femoral version
relation between femoral version (P = 0.011), and Tönnis angle (P = in patients being treated for symp-
and radiographic measures of the 0.008) (Table 2). Pairwise compari- tomatic acetabular dysplasia, its rela-
ACEA, LCEA, and a-angle. Our sons showed that the average-version tionship with severity of dysplasia,
cohort also did not demonstrate any group varied significantly from the ROM, and presenting symptomatol-
correlations between femoral version low-version and high-version groups ogy. Akiyama et al4 have investigated
Table 1
Femoral Version Versus Preoperative Outcomes Scoresa
Preoperative Preoperative Preoperative
Femoral Preoperative Harris Hip SF-12 Physical SF-12 Mental Preoperative Preoperative
Version UCLA Score Score Score Score HOOS QOL WOMAC
Correlation 0.023 20.066 20.030 0.031 20.015 20.033

coefficient
(Spearman r)
Significance 0.681 0.258 0.601 0.585 0.792 0.574
(two tailed)
N 309 296 308 308 311 287
HOOS = Hip Disability and Osteoarthritis Outcome Score, QOL = Quality-of-Life, SF-12 = 12-item Short-Form, UCLA = University of California Los
Angeles, WOMAC = Western Ontario and McMaster Universities Arthritis Index
a
No significant correlations between femoral version and preoperative outcomes scores
Table 2 and could be associated with certain

morphotypes. In a recent investigation
Mean Acetabular Dysplasia Measures Based on the Version Group
using CT in normal patients, Buller
Group N ACEA LCEA Tönnis Angle et al24 suggested the existence of a
Low version 46 12.4 6 8.5 13.4 6 7.6 17.9 6 6.8 developmental association between
“Average” version 198 17.8 6 10.6 16.0 6 7.0 15.2 6 6.4 a variety of skeletal morphotypes,
High version 49 13.4 6 11.2 11.9 6 10.8 18.7 6 8.6
including between femoral and ace-
P value — 0.001 0.011 0.008
tabulum anteversion. Whether ex-
tremes of femoral version are
ACEA = anterior center edge angle, LCEA = lateral center edge angle responsible for the development of
osteoarthritis has been questioned in
a recent review of the Haman-Todd
femoral version in Asian females with treated arthroscopically for FAI and collection.25
symptomatic acetabular dysplasia and found that patients with ,5° ante- Our study demonstrated, in agree-
found a wider variation of version in version had lower magnitude clinical ment with Akiyama et al,4 the exis-
those with dysplasia than in the gen- outcome score improvement. By con- tence of a wide distribution of femoral
eral population and that increased trast, Jackson et al21 reviewed a version in patients with symptomatic
version correlated only with ante- similar cohort of patients treated acetabular dysplasia. In contrast to
rior and globally deficient acetabula. arthroscopically and found fewer the study by Buller et al,24 our study
With the advent of more powerful labral tears in hips with .25° of an- did not demonstrate a linear associa-
surgical techniques to manage hip teversion but no difference in clinical tion between femoral anteversion and
pathology, furthering our under- outcome scores. Ferro et al22 reviewed other measures of femoral or acetab-
standing regarding the mechanical a similar series of FAI patients treated ular morphology, suggesting that
and clinical effects of femoral version arthroscopically and were unable to there is no clear compensatory devel-
is becoming increasingly important. find a difference in outcome scores opmental association between mea-
Variations in femoral version have between low-, normal-, and high- sures of acetabular dysplasia, femoral
a mechanical effect on the hip joint version groups. head and neck morphology, and
that is clinically notable, which is Femoral version is known to affect transverse plane anatomy. In con-
supported by several recent publica- hip rotation in children, altering gait trast to the findings published by
tions from the field of arthroscopy. parameters and the physical exami- Chadayammuri et al,23 on the basis
Bouma et al19 have demonstrated nation.5-7 Recently, two publications of this study, the primary determi-
that combining femoral and acetab- have documented similar clinical nant of hip ROM is femoral version,
ular morphologic characteristics can findings in adults. Chadayammuri with secondary contributions pro-
be used to identify impingement-free et al23 demonstrated that combined vided by head-neck morphology.
ROM in the hip. Fabricant et al20 measures of acetabular version and In less severe forms of acetabular
reviewed a series of 243 patients femoral version predicted hip ROM dysplasia, greater femoral anteversion
August 1, 2018, Vol 26, No 15 549
has been increasingly considered to be did not analyze the presence of path- quantified using standard CT measures?
an important factor in the production ologic labral and articular cartilage 1309-1314.
of hip instability. However, we did damage that may have been associ-
3. Weiner DS, Cook AJ, Hoyt WA Jr, Oravec
not find a linear association between ated with transverse plane anatomy. CE: Computed tomography in the
femoral version and either acetabular On the basis of this study, we now measurement of femoral anteversion.
Orthopedics 1978;1:299-306.
morphology or presenting symptom- understand the wide variation in
atology assessed using preoperative femoral transverse plane anatomy in 4. Akiyama M, Nakashima Y, Fujii M, et al:
Femoral anteversion is correlated with
clinical outcome scores. These data clinically symptomatic acetabular acetabular version and coverage in Asian
suggest that femoral version may have dysplasia. The degree of femoral women with anterior and global deficient
less influence on clinical presentation version is strongly correlated with subgroups of hip dysplasia: A CT study.
Skeletal Radiol 2012;41:1411-1418.
and that acetabular morphology (and preoperative hip ROM. Depending
5. Staheli LT: Rotational problems in
perhaps associated labral damage) on a patient’s acetabular version, children. Instr Course Lect 1994;43:
may be more influential factors re- this finding suggests that surgeons 199-209.
sponsible for symptom production. may need to consider performing 6. Sankar WN, Neubuerger CO, Moseley CF:
However, we acknowledge that this femoroplasty more frequently in less Femoral anteversion in developmental
contention cannot be definitively con- anteverted femurs to prevent post- dysplasia of the hip. J Pediatr Orthop 2009;
29:885-888.
firmed based on the results of the preoperative impingement.27 Because the
7. Sarban S, Ozturk A, Tabur H, Isikan UE:
sent study. degree of femoral version was not
Anteversion of the acetabulum and femoral
When the overall cohort was statistically associated with symptom neck in early walking age patients with
divided into three version subgroups presentation, it seems that routine developmental dysplasia of the hip. J
Pediatr Orthop B 2005;14:410-414.
based on the cohort mean 6 1 SD, we correction of version is not warranted;
found that the extent of acetabular however, under specific circumstances, 8. Siebenrock KA, Steppacher SD, Haefeli PC,
Schwab JM, Tannast M: Valgus hip with
dysplasia was more severe in both the femoral derotation is indicated to high antetorsion causes pain through
high- and low-version groups com- address gait dysfunction, ROM defi- posterior extraarticular FAI. Clin Orthop
Relat Res 2013;471:3774-3780.
pared with those with “average” cits, or persistent instability after PAO.
femoral version. The significance of Further investigation into the as- 9. Clohisy JC, Carlisle JC, Beaulé PE, et al: A
systematic approach to the plain
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Our study has several limitations. lying groups. In addition, investigation
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12. Tonnis D: Normal values of the hip joint for
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However, a recent study validated the omechanics. Finally, follow-up studies adults. Clin Orthop Relat Res 1976:39-47.
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Relat Res 2005;438:182-190.
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14. Notzli HP, Wyss TF, Stoecklin CH, Schmid
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to consecutive CT measurements and References the femoral head-neck junction as a
consecutive MRI measurements, in- predictor for the risk of anterior
References printed in bold type are impingement. J Bone Joint Surg Br 2002;
dicating that MRI and CT can be used 84:556-560.
interchangeably for the assessment of those published within the past 5 years.
15. Kim HY, Lee SK, Lee NK, Choy WS: An
femoral version. Second, we did not 1. Abel MF, Sutherland DH, Wenger DR, anatomical measurement of medial femoral
measure acetabular version and can- Mubarak SJ: Evaluation of CT scans and 3- torsion. J Pediatr Orthop B 2012;21:
D reformatted images for quantitative 552-557.
not comment whether femoral anat- assessment of the hip. J Pediatr Orthop
omy is associated with acetabular 1994;14:48-53. 16. Murphy SB, Simon SR, Kijewski PK,
Wilkinson RH, Griscom NT: Femoral
version. Third, because not all centers 2. Georgiadis AG, Siegal DS, Scher CE, Zaltz anteversion. J Bone Joint Surg Am 1987;69:
routinely use MRI preoperatively, we I: Can femoral rotation be localized and 1169-1176.
17. McKibbin B: Anatomical factors in the 21. Jackson TJ, Lindner D, El-Bitar YF, Domb 3-dimensional computed tomography. Am
stability of the hip joint in the newborn. J BG: Effect of femoral anteversion on J Sports Med 2012;40:367-375.
Bone Joint Surg Br 1970;52:148-159. clinical outcomes after hip arthroscopy.
Arthroscopy 2015;31:35-41. 25. Weinberg DS, Park PJ, Morris WZ, Liu
18. Tönnis D, Heinecke A: Acetabular and RW: Femoral version and tibial torsion are
femoral anteversion: Relationship with 22. Ferro FP, Ho CP, Briggs KK, Philippon MJ: not associated with hip or knee arthritis in a
osteoarthritis of the hip. J Bone Joint Surg Patient-centered outcomes after hip large osteological collection. J Pediatr
Am 1999;81:1747-1770. arthroscopy for femoroacetabular Orthop 2015;37:e120–e128.
impingement and labral tears are not
19. Bouma HW, Hogervorst T, Audenaert E, different in patients with normal, high, or 26. Hesham K, Carry PM, Feese K, et al:
Krekel P, van Kampen PM: Can combining low femoral version. Arthroscopy 2015;31: Measurement of femoral version by MRI is
femoral and acetabular morphology 454-459. as reliable as reproducible as CT in children
parameters improve the characterization of and adolescents with hip disorders. J
femoroacetabular impingement? Clin 23. Chadayammuri V, Garabekyan T, Bedi A, Pediatr Orthop 2017;37:557–562.
Orthop Relat Res 2015;473:1396-1403. et al: Passive hip range of motion predicts
femoral torsion and acetabular version. J 27. Fabricant PD, Sankar WN, Seeley MA,
20. Fabricant PD, Fields KG, Taylor SA, Bone Joint Surg Am 2016;98:127-134. et al: Femoral deformity may be more
Magennis E, Bedi A, Kelly BT: The effect of predictive of hip range of motion than
femoral and acetabular version on clinical 24. Buller LT, Rosneck J, Monaco FM, Butler severity of acetabular disease in patients
outcomes after arthroscopic R, Smith T, Barsoum WK: Relationship with acetabular dysplasia: An analysis of
femoroacetabular impingement surgery. J between proximal femoral and acetabular the ANCHOR cohort. J Am Acad Orthop
Bone Joint Surg Am 2015;97:537-543. alignment in normal hip joints using Surg 2016;24:465-474.
August 1, 2018, Vol 26, No 15 551
Review Article
Aspiration and Injection

Techniques of the Lower Extremity
Abstract
Christopher P. Chiodo, MD Orthopaedic surgeons frequently use aspirations and injections to
Catherine Logan, MD, MBA, both diagnose and treat disorders of the lower extremity.
MSPT Comprehensive knowledge of regional anatomy, procedural
Cheri A. Blauwet, MD 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
Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVE17rCHCwnx1fETcK+XZ3WkY0TW6/pyAmR9IeCZHCHv5 on 07/28/2018
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.
I ntra-articular and soft-tissue aspi-

rations and injections are common
procedures used by orthopaedic sur-
cated in the setting of noninfectious
effusions that limit range of motion or
cause substantial pain. Such aspiration
geons and other providers to assist also may be indicated to drain a he-
in the diagnosis and management of marthrosis or to drain a septic joint in
lower extremity injuries and disorders. patients with medical comorbidities
Successful outcomes rely on the clini- that preclude surgical irrigation and
cian’s knowledge of pertinent local drainage.
anatomy, appropriate indications, and Joint or soft-tissue injections may be
awareness of evidence-based techniques helpful for both the diagnosis and
that optimize accuracy and outcomes. treatment of several musculoskeletal
Arthrocentesis, or aspiration of conditions. Injections are frequently
synovial joint fluid, is indicated pri- used for targeted delivery of medica-
marily for diagnostic purposes in the tion into joints, bursa, and tendon
setting of acute synovitis, suspected sheaths. Important contraindications
infection, and chronic arthropathy. exist. Injection and aspiration through
From Harvard Medical School,
Repeated aspiration may be used in cellulitic-appearing skin should be
Brigham and Women’s Hospital (Dr. certain settings, such as with chronic, avoided when possible to minimize
Chiodo), Harvard Combined noninfectious effusions. Aspiration bacterial dissemination into the adja-
Orthopaedic Residency Program, should always be performed before cent soft tissues or joint space.3 In
Massachusetts General Hospital (Dr.
Logan), and Harvard Medical School,
injection when clinical suspicion for addition, corticosteroids should not
Spaulding Rehabilitation Hospital and septic arthritis exists. Aspirated syno- be injected into a joint until infection
Brigham and Women’s Hospital, vial fluid should be analyzed for cell has been excluded. Injections in pa-
Boston, MA (Dr. Blauwet). count with differential, Gram stain, tients on anticoagulation or with a
J Am Acad Orthop Surg 2018;26: microbiologic culture, and the pres- known coagulation disorder (ie, a rel-
e313-e320 ence of crystals.1 A preexisting diag- ative contraindication) may be con-
DOI: 10.5435/JAAOS-D-16-00762 nosis of rheumatoid arthritis, gout, or sidered; however, a small-gauge needle
pseudogout does not exclude the pos- should be used along with the appli-
Academy of Orthopaedic Surgeons. sibility of concomitant infection.2 cation of appropriate manual pressure
Therapeutic aspiration may be indi- after the procedure. Furthermore, safe
August 1, 2018, Vol 26, No 15 e313
Aspiration and Injection Techniques
Table 1 ders. The syringe size varies based on Targeted structures may, therefore, be
the joint and effusion size, if present deeper and anatomic landmarks less
Complications of Aspiration and
Injection (range, 5 to 50 mL). distinct, posing a challenge with regard
For certain injections, a growing to accurate needle placement. In our
Allergic reaction
body of evidence has demonstrated experience, the following measures are
Local ecchymosis that image guidance may enhance helpful in patients with obesity. First, a
Bleeding accuracy and outcomes.4-11 Multiple longer 3.5-inch spinal needle should
Local infection modalities are available, including be considered. Second, the provider
Cartilage injury fluoroscopy, US, CT, and MRI. should have a lower threshold for the
Skin changes/atrophy Fluoroscopy with the use of intra- use of image guidance. US imaging
Tendon rupture articular contrast has traditionally may be optimized with use of a lower
Vasovagal reaction been used for therapeutic injections frequency, curvilinear probe as well as
Dry tap and aspirations of deep joints, such optimizing the focal zone to target
as the hip. With this technique, a deeper structures. If image quality
small amount of iodinated contrast remains poor after US optimization,
aspiration or injection can be per- may be administered to confirm an fluoroscopy or CT guidance should
formed on fully anticoagulated patients intra-articular position of the nee- be considered as an alternative.
by using lidocaine with epinephrine as dle. For the purposes of this review, Finally, immediate pain relief with
a local anesthetic. Complications are the use of US will be emphasized, the use of a local anesthetic in the
rare, and when they occur, they are given its growing utility to provide injection solution may help confirm
often minor in severity (Table 1). image guidance in an office setting. the accuracy of needle placement.
Sterile technique is critical to avoid US uses high-frequency sound waves
infection and ensure accurate fluid to image soft tissues and bony
analysis. At minimum, the injection structures and, because of advances in Hip and Knee Regions
site should be prepared with an alco- resolution capabilities, can, in most
hol- or iodine-based skin preparation circumstances, detail tendons, nerves, Hip Joint
solution. A sterile drape may also be ligaments, joint capsules, and mus- Intra-articular hip aspiration is com-
used at the discretion of the clinician. If cles.12 Practitioners may perform both monly used to assist in the diagnosis
ultrasonography (US) guidance is per- static and dynamic US imaging, de- of infection.13,14 Septic hip arthritis is
formed, a sterile probe cover should be pending on the clinical indication. more common in the pediatric patient;
used, followed by cleaning the probe Static US involves precise localization however, the incidence in adults
with antiseptic wipes after each injec- of structures, with the underlying tis- ranges from 2 to 10 per 100,000
tion and before use on subsequent sue in a relaxed position, whereas person-years.15
patients. Sterile gloves should be worn dynamic US is performed during Localizing the hip may be hindered
by the clinician for all injections, provocative testing and/or with the both by body habitus and the inher-
including both palpation and image assistance of the patient moving a ently deep location of the joint. As
guided. The patient position varies by joint or contracting a muscle (eg, to such, image guidance, including fluo-
the intended target (Table 2). The evaluate tendon subluxation).12 The roscopy, CT, or US, is recommended.
needle gauge depends on the joint; advantages of US over other imaging Anterior and lateral approaches have
large joints such as the knee may modalities include the absence of been described (Table 2). Smith et al4
necessitate use of an 18- to 21-gauge radiation and the ability to provide evaluated the accuracy of US-guided
needle, particularly if aspiration is real-time guidance for interventional intra-articular injections performed in
planned, whereas smaller joints may procedures in the office setting.12 30 native adult hips. An anterior
be entered with a 20- to 25-gauge In patients with obesity, the soft-tissue approach was used, and body mass
needle (Table 2). A spinal needle is envelope may be larger, especially with index ranged from 20 to 39 kg/m2.
often used with hips and deep shoul- more central joints such as the hip. The authors reported an accuracy
Dr. Chiodo or an immediate family member has received royalties from Aircast(DJ), Arthrex, Darco, and Zimmer Biomet and serves as a
board member or committee member of the American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society,
and Mass Ortho Association. Dr. Blauwet or an immediate family member serves as a board member or committee member of the American
College of Sports Medicine. Neither Dr. Logan nor any immediate family member has received anything of value from or has stock or stock
options held in a commercial company or institution related directly or indirectly to the subject of this article.
e314 Journal of the American Academy of Orthopaedic Surgeons
Table 2
Palpation-guided Aspiration and Injection Procedures for the Lower Extremity
Needle
Patient Size
Anatomic Area Approach Position Joint Position Landmarks (Gauge) Insertion Direction
Hip Anterior Supine Internal rotation 2-3 cm below the ASIS and 3 cm 22 Needle directed posteromedially
lateral to the femoral artery
pulse
August 1, 2018, Vol 26, No 15

Lateral Supine Internal rotation 1 cm proximal to the greater 22 Needle positioned parallel to the
trochanter patient table
Knee Suprapatellar Supine Extension At the superomedial or 18-21a Needle directed toward the
superolateral border of the intercondylar notch
patella
Midpatellar Supine Extension At the midpoint of the medial or 18-21a Needle directed toward the
lateral border of the patella intercondylar notch
Infrapatellar Seated Flexion to 90° 0.5 cm distal to the inferomedial 18-21a Needle directed toward the
or inferolateral border of the intercondylar notch
patella
Proximal — Side lying Knee flexed 20° Enter the joint deep to the anterior 25 Needle directed inferior to
tibiofibular joint superior proximal tibiofibular superior
ligament
Pes anserine — Side lying Knee flexed 20° Enter the bursa deep to the pes 25 Needle directed inferior to
bursa anserine tendons and superior
superficial to the MCL
Tibiotalar joint Anterolateral Seated or Knee extended or flexed, 1-2 cm proximal and medial to the 25 Needle directed perpendicular to
supine ankle plantarflexed base of the lateral malleolus the fibular shaft
Anteromedial Seated or Knee extended or flexed, ankle 2-3 cm proximal and lateral to the 25 Needle directed perpendicular to
supine plantarflexed base of the lateral malleolus the tibial shaft
Subtalar joint Posterolateral Prone Foot over the edge and ankle Enter at a steep downward angle, 25 Needle directed toward the
dorsiflexed just superficial to the talocalcaneal joint space
posterolateral calcaneus
Peroneal tendon — Supine Hip internally rotated with towel Enter sheath at the level of the 25 Needle directed posterior to
sheath roll under the medial ankle lateral malleolus, where the anterior
Ankle inverted and plantarflexed tendons share a common
sheath
First MTP joint Dorsolateral Supine Knee flexed, foot flat on the Into the dorsal joint space, medial 25 Needle directed toward the MTP
patient table, toe distracted to the extensor tendon joint center
Dorsomedial Supine Knee flexed, foot flat on the Into the dorsal joint space, medial 25 Needle directed toward the MTP
patient table, toe distracted to the extensor tendon joint center
ASIS = anterior superior iliac spine, MCL = medial collateral ligament, MTP = metatarsophalangeal
a
A 25-gauge needle may be used for injection; however, an 18- or 21-gauge needle is recommended for aspiration of the knee.
e315
Christopher P. Chiodo, MD, et al
Figure 1 Figure 2 portals: anteromedial, anterolateral,

and lateral midpatellar. Confirmation
of placement was performed with
fluoroscopy. The authors reported
that a lateral midpatellar injection was
intra-articular 93% of the time and
was more accurate than injections
using either of the other two portals
(71% and 75% for the anterolateral
and anteromedial approaches, re-
spectively). In a systematic review of
429 injections assessing the injection
site, Daley et al7 reported no notable
difference between injection site
approaches, with an average accu-
racy of 84% (range, 70% to 93%).
With regard to imaging, an additional
analysis of 660 knee injections, 75
of which were performed with image
Photograph showing the palpation- Photograph showing the guidance (US), found that the ac-
guided suprapatellar approach to the ultrasonography-guided suprapatellar curacy of image-guided procedures
knee joint at the superolateral border approach to the knee joint at the was 99%, compared with 79% of
of the patella. superolateral border of the patella.
injections performed without guid-
ance.7 Chi-square with Yates correc-
rate of 97%, which was confirmed and therapeutic purposes in a non- tion yielded a P value of ,0.001 and
by contrast-enhanced fluoroscopic infectious, inflammatory process.17 relative risk of 1.246 (confidence in-
examination performed by an inde- Commonly used approaches for knee terval between 1.392 and 1.117),
pendent observer. Meanwhile, Mei- aspiration include the suprapatellar, supporting a statistically significant
Dan et al16 investigated the accuracy midpatellar, and infrapatellar ap- difference in the accuracy of image-
and safety of hip injections without proaches18 (Table 2). guided versus nonguided injections.
image guidance in 55 adults. The The knee joint may be accessed
authors used an anterior approach, using manual palpation alone or with
and the injections were performed image guidance (Figures 1 and 2). Proximal Tibiofibular Joint
before supine hip arthroscopy. The Curtiss et al19 evaluated the accuracy The proximal tibiofibular joint
accuracy of needle insertion was as- of US-guided and palpation-guided (PTFJ) consists of the articulation
sessed with an air arthrogram and by knee injections using the supero- between the medial aspect of the fib-
direct visualization with the arthro- lateral approach in a single-blinded, ular head and the proximal postero-
scope. A 93% success rate was re- prospective study of 20 cadaver lateral tibia. It is a less common and
ported, with female sex correlating specimens. This study also compared potentially overlooked etiology of
with more difficult needle placement the accuracy of a less-experienced cli- lateral knee pain. Pathology at this
(P = 0.06). The proposed reasons nician (ie, orthopaedic fellow) with a location may be due to arthritis,
for misplacement included a high- staff physician in the second decade injury, compression of the common
riding trochanter, increased femoral of practice. US-guided knee injec- peroneal nerve, or a symptomatic
version, thick adipose tissue, and tions were 100% accurate for both ganglion cyst.21,22 Injection of the
ilium morphology. clinicians, whereas palpation-guided joint may be conducted for diag-
injections were markedly less accu- nostic and therapeutic purposes and
rate when comparing the fellow with performed by palpation alone or with
Knee Joint the staff physician (55% versus 100%, image guidance. Positioning the pa-
Aspiration of the knee joint may be respectively). A 2002 investigation by tient in the lateral decubitus position
performed to assist in the diagnosis of Jackson et al20 studied the accuracy of with the knee slightly flexed may
both infectious and noninfectious ef- palpation-guided needle placement in facilitate needle placement (Table 2;
fusions. Corticosteroid injection into 240 consecutive injections through Figure 3). Smith et al23 reported a
the knee is used for both diagnostic three commonly used knee joint comparison of palpation-guided
Figure 3 Figure 4 Figure 5
Photograph showing the Photograph showing the palpation- Photograph showing the
ultrasonography-guided approach to guided anteromedial approach to ultrasonography-guided approach to
aspiration or injection of the proximal aspiration or injection of the ankle aspiration or injection of the first
tibiofibular joint. joint. metatarsophalangeal joint.
injections and US-guided techniques The confluence and its bursa are best is placed just medial to the tibialis
for the PTFJ in a cadaver model. The palpated on the anteromedial aspect of anterior tendon for the anteromedial
authors reported 100% accuracy with the proximal tibia. Alternatively, the approach and just lateral to the per-
image guidance versus 58% with a tendons and bursa may be visualized oneus tertius for the lateral approach.
palpation-guided technique. Inaccurate using US. Patients are placed in the With regard to the use of image
placement was superficial and inferior lateral decubitus position, with the guidance, Wisniewski et al24 found
to the PTFJ in all cases of unsuccessful knee slightly flexed to facilitate needle superior accuracy of US-guided ver-
injection, with extravasation into placement (Table 2). Despite the sus nonguided anteromedial tibiotalar
the adjacent musculature. Only two superficial location of the pes an- joint injections (100% versus 85%,
palpation-guided injections delivered serinus, unguided bursa injections respectively) in a cadaver model.
all the fluid into the PTFJ (17%).23 have proved less accurate than Reach et al25 similarly reported 100%
US-guided injections. In a single- accuracy of US-guided anteromedial
blinded, prospective study, Finnoff injections to the tibiotalar joint; how-
Pes Anserine Bursa et al8 reported a markedly different ever, no comparison group existed.
The pes anserinus is a confluence of the accuracy of 92% versus 17%,
sartorius, gracilis, and semitendinosus respectively, when comparing the
tendons onto the proximal antero- US-guided versus palpation-guided Subtalar Joint
medial tibia. A potential bursa lies technique in adult cadaver specimens. The subtalar (talocalcaneal) joint al-
between the pes anserinus tendons lows for inversion and eversion of the
and the more deeply located medial hindfoot. Three anatomic approaches
collateral ligament and/or medial tibia. Foot and Ankle Region have been described (ie, anterolateral,
Pain in the area of the pes anserine posterolateral, posteromedial), with
bursa is most commonly secondary Tibiotalar Joint the posterolateral often preferred
to an inflammation of the bursa, The tibiotalar joint is a common site of because of its distance from neuro-
tenosynovitis, or tendinopathy as a arthritis, synovitis, osteochondral injury, vascular structures5,9 (Table 2). Reach
result of repetitive overuse or direct and impingement. Both the antero- et al25 reported slightly less accu-
trauma. Injection may be considered lateral and anteromedial approaches to racy (90%) in their investigation of
as a diagnostic tool or as a treatment the tibiotalar joint are useful to access US-guided injection of the subtalar
modality for recalcitrant pain. the joint (Table 2; Figure 4). The needle joint in the cadaver model. Henning
August 1, 2018, Vol 26, No 15 e317
Table 3
Synovial Fluid Analysis
Condition Color Clarity Viscosity WBC (mL) Crystals Culture
Normal Yellow Transparent High ,200 None Negative

Osteoarthritis Yellow Transparent High ,2,000 None Negative
Septic arthritis Purulent Opaque Low .50,000 None Usually positive
Aseptic arthritis Yellow or white Translucent or opaque Low 2,000-100,000 None Negative
WBC = white blood cell
et al9 evaluated the accuracy of three clinical decision-making process and proximal phalanx of the hallux. Pain
US-guided approaches (ie, anterolateral, to assess for surgical appropriateness. at the MTP joint may be acute or
posteromedial, posterolateral) to The patient is positioned supine, with chronic in nature and the result of
inject the posterior subtalar joint and the hip internally rotated and a towel trauma, gout, or other inflammatory
found that all three approaches roll placed under the medial aspect of arthritides. Variation exists in the size
provided accurate needle placement the ankle (Table 2). Injections to the and shape of MTP joints; therefore,
while also minimizing the risk of sheath are performed via palpation or palpation in the setting of conditions
needle entry into adjacent soft-tissue with image-guided assistance. In one such as advanced degenerative ar-
structures. In a comparison of the cadaver study, US-guided peroneal thritis may prove challenging.29 If
palpation-guided anterolateral and tendon sheath injections were mark- necessary, distraction of the joint is
the posterolateral approach in 68 edly more accurate than palpation- helpful during needle placement
cadaver models, 23 (67.7%) of the guided injections (100% versus 60%, (Table 2). Diagnostic aspiration or
anterolateral injections were suc- respectively).27 Accuracy is particu- therapeutic injection may be useful
cessful compared with 31 (91.2%) of larly important in the peritendinous in the management of advanced
the posterolateral injections.26 The injection to minimize the chance of an osteoarthritis, rheumatoid arthritis,
greater accuracy of the posterolat- intratendinous injection, particularly if and gout (Figure 5).
eral approach was statistically sig- corticosteroid is used. Reach et al25 Few data are available on the com-
nificant (P = 0.016). similarly reported 100% accuracy parison between palpation and image-
with US guidance for injections of the guided techniques for injection or
posterior tibialis and flexor hallucis aspiration of the first MTP joint. Reach
Peroneal Tendon Sheath longus tendon sheaths. et al25 report 100% accuracy when
In the supramalleolar region, the per- using US guidance; however, this
oneal tendon complex comprises the analysis was performed without a
peroneus longus tendon and the more Midfoot and Forefoot comparison group. Balint et al10 re-
medial peroneus brevis muscle and Khosla et al28 reported on the accu- ported markedly lower accuracy rates
tendon. As the complex courses dis- racy of intra-articular injections in the conventional, palpation-guided
tally, the peroneus longus courses using palpation versus dynamic US in technique for joint and soft-tissue as-
posterior to the brevis tendon. Trauma a cadaver model and reported 100% piration compared with the US-guided
to the tendons occurs from a forceful accuracy in subtalar and ankle joint technique. In the conventional group,
contraction of the muscles, with the injections in both techniques. How- successful aspiration was achieved in
foot in plantar flexion and inversion. ever, using palpation, the needle was only 32% of the joints, compared
Anatomic variations, such as a shallow correctly placed into the first trans- with 97% of the aspirations in the
or flat retrofibular groove, which metatarsal joint in 3 of 14 cadavers, US-guided group. The mean volume of
houses the tendons as they course compared with 10 of 14 cadavers fluid obtained with successful aspira-
behind the fibula, may contribute to using US. Similar results were ob- tions was similar in both groups.
persistent or recurrent subluxation of tained with placement into the sec-
the tendons. Tenosynovitis or tendinop- ond transmetatarsal joint (ie, four
athy occurs secondary to trauma with palpation versus eight with US). Synovial Fluid Analysis
or repetitive microtrauma. Anes- The first metatarsophalangeal
thetic injections may be used for (MTP) joint comprises the articulation Joint fluid analysis is a useful diag-
diagnostic purposes to assist in the between the first metatarsal and the nostic tool in the management of both
septic arthritis and inflammatory septic arthritis in a prosthetic joint is should be ordered? JAMA 1990;264:
1009-1014.
disease. Analysis of the aspirate is much lower compared with a native
critical in the treatment of adult septic joint. Additional biochemical stud- 2. Yu KH, Luo SF, Liou LB, et al:
Concomitant septic and gouty arthritis: An
arthritis because it guides antibiotic ies, including the analysis of glucose, analysis of 30 cases. Rheumatology
management. It also allows for the protein, and complement level, may (Oxford) 2003;42:1062-1066.
establishment of an accurate diagno- be performed to provide further 3. Courtney P, Doherty M: Joint aspiration
sis in crystalline disease and guides characterization of inflammatory and injection and synovial fluid analysis.
management of inflammatory arthri- arthritides. Best Pract Res Clin Rheumatol 2013;27:
137-169.
tis. The macroscopic appearance of
synovial fluid provides immediate 4. Smith J, Hurdle M-FB, Weingarten TN:
Accuracy of sonographically guided intra-
information to apply toward the dif- Summary articular injections in the native adult hip.
ferential diagnosis. The color, clarity, J Ultrasound Med 2009;28:329-335.
and viscosity can be appreciated on Aspiration and injection of joints and
5. Smith J, Finnoff JT, Henning PT, Turner
gross examination (Table 3). Synovial soft tissues are safe and effective tech- NS: Accuracy of sonographically guided
fluid specimens are placed in speci- niques for the diagnosis and treatment posterior subtalar joint injections:
Comparison of 3 techniques. J Ultrasound
men containers specific to the test of musculoskeletal disorders. Intra- Med 2009;28:1549-1557.
being ordered. A heparinized tube articular aspiration provides invalu-
6. Schmidt-Braekling T, Waldstein W, Renner L,
is preferable for cell counts, sterile able diagnostic information in cases of Valle AGD, Bou Monsef J, Boettner F:
containers for microbiology testing, septic arthritis and inflammatory ar- Ultrasound and fluoroscopy are unnecessary
thritides. Injection of local anesthetic for injections into the arthritic hip. Int Orthop
and plain tubes for chemistry and 2015;39:1495-1497.
immunological testing of the fluid. may be of great utility for diagnostic
purposes, and corticosteroid injections 7. Daley EL, Bajaj S, Bisson LJ, Cole BJ:
The volume aspirated from the joint Improving injection accuracy of the elbow,
may be small, and if only a few mil- may be both diagnostic and therapeu- knee, and shoulder: Does injection site and
liliters of fluid are available, prefer- tic. Although correct needle placement imaging make a difference? A systematic
in most of the peripheral joints of the review. Am J Sports Med 2011;39:
ence should be given for cell count 656-662.
analysis. Normal synovial fluid is lower extremity is routine in the hands
of the experienced clinician, the use of 8. Finnoff JT, Nutz DJ, Henning PT, Hollman
straw-colored, clear, and viscous. JH, Smith J: Accuracy of ultrasound-guided
Increased inflammation changes the image guidance to localize joint and versus unguided pes anserinus bursa
fluid’s macroscopic appearance; the soft-tissue structures may be beneficial. injections. PM R 2010;2:732-739.
color ranges from yellow to greenish Correct needle placement has impor- 9. Henning T, Finnoff JT, Smith J:
yellow, the clarity is more opales- tant implications for the administra- Sonographically guided posterior subtalar
joint injections: Anatomic study and
cent, and the viscosity is decreased. tion of local treatment and underscores validation of 3 approaches. PM R 2009;1:
In the setting of a pyogenic infection, the significance of US as a useful device 925-931.
the aspirate may appear as frank, in clinical practice. 10. Balint PV, Kane D, Hunter J, McInnes IB,
purulent material. Bloody fluid may Field M, Sturrock RD: Ultrasound guided
versus conventional joint and soft tissue
be the result of joint trauma, coex- fluid aspiration in rheumatology practice: A
isting anticoagulation therapy, References pilot study. J Rheumatol 2002;29:
baseline coagulation disorders, or 2209-2213.
Evidence-based Medicine: Levels of
synovial tumors such as pigmented 11. Raza K, Lee CY, Pilling D, et al: Ultrasound
evidence are described in the table of guidance allows accurate needle placement
villonodular synovitis.3 The appear-
contents. In this article, references 1, and aspiration from small joints in patients
ance of particles other than cells may with early inflammatory arthritis.
5, 7-9, 19, 23, and 24 are level II
indicate the presence of crystals. In Rheumatology (Oxford) 2003;42:976-979.
studies. References 4, 11, 13, 16, 26,
rare instances, concomitant septic 12. Smith J, Finnoff JT: Diagnostic and
and 27 are level III studies. Refer-
and gouty arthritis exists;2 therefore, interventional musculoskeletal ultrasound:
ences 2, 6, 10, 14, 20, 22, 25, 28, and Part 1: Fundamentals. PM R 2009;1:64-75.
early diagnosis requires a high level
29 are level IV studies. References 3,
of suspicion because there may be 13. de SA D, Cargnelli S, Catapano M, et al:
12, 15, 17, 18, and 21 are level V Efficacy of hip arthroscopy for the
an absence of fever or leukocytosis. management of septic arthritis: A
expert opinion.
Synovial fluid aspirate should be sent systematic review. Arthroscopy 2015;31:
for cell count and differential, Gram References printed in bold type are 1358-1370.
stain, microbiologic culture, and those published within the past 5 14. Shukla A, Beniwal SK, Sinha S: Outcome of
crystal analysis,1 with results guiding years. arthroscopic drainage and debridement
with continuous suction irrigation
subsequent management (Table 3). 1. Shmerling RH, Delbanco TL, Tosteson AN, technique in acute septic arthritis. J Clin
Of note, the cell count suggestive of Trentham DE: Synovial fluid tests: What Orthop Trauma 2014;5:1-5.
August 1, 2018, Vol 26, No 15 e319
15. Goldenberg DL: Septic arthritis. Lancet intra-articular steroid injections. injections in the foot and ankle. Foot Ankle
1998;351:197-202. J Bone Joint Surg Am 2002;84-A: Int 2009;30:239-242.
1522-1527.
16. Mei-Dan O, McConkey MO, Petersen B, 26. Kraus T, Heidari N, Borbas P, Clement
McCarty E, Moreira B, Young DA: The 21. Stein D, Cantlon M, Mackay B, Hoelscher H, Grechenig W, Weinberg A-M:
anterior approach for a non-image-guided C: Cysts about the knee: Evaluation and Accuracy of anterolateral versus
intra-articular hip injection. Arthroscopy management. J Am Acad Orthop Surg posterolateral subtalar injection. Arch
2013;29:1025-1033. 2013;21:469-479. Orthop Trauma Surg 2011;131:
759-763.
17. Cardone DA, Tallia AF: Diagnostic 22. Ozcan O, Boya H, Oztekin HH: Clinical
and therapeutic injection of the hip evaluation of the proximal tibiofibular joint 27. Muir JJ, Curtiss HM, Hollman J, Smith J,
and knee. Am Fam Physician 2003;67: in knees with severe tibiofemoral primary Finnoff JT: The accuracy of ultrasound-
2147-2152. osteoarthritis. Knee 2009;16:248-250. guided and palpation-guided peroneal
tendon sheath injections. Am J Phys Med
18. Douglas RJ: Aspiration and injection of the 23. Smith J, Finnoff JT, Levy BA, Lai JK: Rehabil 2011;90:564-571.
knee joint: Approach portal. Knee Surg Sonographically guided proximal tibiofibular
Relat Res 2014;26:1-6. joint injection: Technique and accuracy. J 28. Khosla S, Thiele R, Baumhauer JF:
Ultrasound Med 2010;29:783-789. Ultrasound guidance for intra-articular
19. Curtiss HM, Finnoff JT, Peck E, Hollman J, injections of the foot and ankle. Foot Ankle
Muir J, Smith J: Accuracy of ultrasound- 24. Wisniewski SJ, Smith J, Patterson DG, Int 2009;30:886-890.
guided and palpation-guided knee injections Carmichael SW, Pawlina W: Ultrasound-
by an experienced and less-experienced guided versus nonguided tibiotalar joint 29. Mizel MS, Gutmann JM, Ahn U,
injector using a superolateral approach: A and sinus tarsi injections: A cadaveric Temple HT: Lesser metatarsophalangeal
cadaveric study. PM R 2011;3:507-515. study. PM R 2010;2:277-281. joints: Intra-articular distension,
volumetric measurements, and changes
20. Jackson DW, Evans NA, Thomas BM: 25. Reach JS, Easley ME, Chuckpaiwong B, of position. Foot Ankle Int 2003;24:
Accuracy of needle placement of Nunley JA: Accuracy of ultrasound guided 935-937.
On the Horizon From the ORS
Regenerative Rehabilitation of the
Musculoskeletal System
Riccardo Gottardi, PhD
Martin J. Stoddart, PhD R egenerative rehabilitation is
the convergence and integra-
tion of regenerative medicine and
bone defects can be monitored7
and related to vascularization and
repair,8 this would allow us to design
physical rehabilitation sciences.1 fixation strategies that transfer loads9
Physical therapy (PT) is essential to and ambulatory exercises so as to
support the return to function of a promote regeneration and ideally
damaged or repaired tissue. How- accelerate a full patient recovery.
ever, the specific effects of PT down The stability of the fracture fixation
to the cellular level of regeneration has a direct influence on whether
are largely unexplored.2 Conversely, fracture repair is achieved by way
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when thinking of regenerative ap- of endochondral ossification or direct

proaches, the mechanical environ- intramembranous healing, and this
ment that cells and scaffolds must can be modulated by the loads applied
withstand in orthopaedic repair is during the rehabilitation period.
often regarded as a challenge that When stem cells are used to support
needs to be endured or overcome healing of muscle injury, exercise-
rather than as an opportunity that driven mechanical activation
can be leveraged. In tissue engineer- supports proliferation of the trans-
ing, cellular mechanobiology is more planted stem cells and their effective
often studied to promote the matu- repair of the injured muscle.4 For
ration and the three-dimensional larger volumetric muscle loss, in
organization of engineered con- which scaffolds are combined with
From the Department of Orthopaedic structs, ranging from aligned mus- stem cells for repair, exercise regi-
Surgery, Center for Cellular and cled fibers to the zonal organization mens enhance both force production
Molecular Engineering, University of of chondrocytes. Regenerative re- and innervation of the engineered
Pittsburgh, Pittsburgh, PA, and the
habilitation can then be appreci- construct.10 Robotic platforms could
Fondazione Ri.MED, Palermo, Italy
(Dr. Gottardi); and the AO Research ated as an approach to translational then be developed to monitor muscle
Institute Davos, Davos, Switzerland, and mechanobiology, in which the impairment and administer tailored
the Department of Orthopedics and mechanical cues driving cell differ- training during the recovery process
Trauma Surgery, G.E.R.N. Tissue
entiation and function are directed to enhance repair and overall motor
Replacement, Regeneration &
Neogenesis, Medical Faculty, Albert- by rehabilitation routines to pro- performance.11
Ludwigs-University of Freiburg, Freiburg mote repair and regeneration.3,4 Normal cartilage homeostasis is
im Breisgau, Germany (Dr. Stoddart). Bone is well known to respond and reliant on cyclical loading, and this
Dr. Gottardi or an immediate family adapt to changes in load (Wolff’s has been associated in part with
member serves as a board member or law). However, during regeneration mechanical activation of matrix-
committee member of the Orthopaedic after fracture or critical bone defects, associated transforming growth
Research Society and Tissue
Engineering and Regenerative Medicine the picture becomes more complex, factor-b. Within native cartilage,
International Society-Americas. as there is not just the bone to this is thought to be strongly influ-
Dr. Stoddart or an immediate family account for but also a defect with enced mechanically at the su-
member serves as a board member or associated instability, the repair perficial zone12 but enzymically
committee member of the Orthopaedic
Research Society. tissue that bridges the defect, and regulated in the deeper zones.13,14
vascularization that is required for Chondrogenic differentiation of
J Am Acad Orthop Surg 2018;26:
effective healing. Ambulatory loads human bone marrow–derived
e321-e323
have been found to promote frac- mesenchymal stromal cells, such as
DOI: 10.5435/JAAOS-D-18-00220 ture repair5 and to regulate angio- those that would be present during
Copyright 2018 by the American genesis,6 so if the axial loads across microfracture, can be induced
Academy of Orthopaedic Surgeons.
August 1, 2018, Vol 26, No 15 e321
Regenerative Rehabilitation
in vitro by mechanical forces regenerative rehabilitation and the 8. Boerckel JD, Uhrig BA, Willett NJ,
Huebsch N, Guldberg RE: Mechanical
alone,15 and a similar response has delivery of personalized regenerative regulation of vascular growth and
been observed in human articular treatments. tissue regeneration in vivo. Proc
chondroprogenitor cells.16 This is Natl Acad Sci U S A 2011;108:
E674-E680.
due to the production and activation
of endogenous transforming growth Acknowledgments 9. Pobloth AM, Checa S, Razi H, et al:
Mechanobiologically optimized 3D
factor-b, a process that, in part, is titanium-mesh scaffolds enhance bone
regulated by the application of Dr. Gottardi acknowledges support regeneration in critical segmental defects
shear.17-19 Such mechanistic knowl- from the Ri.MED Foundation in sheep. Sci Transl Med 2018;
10:eaam8828.
edge at the protein and cellular level and Alliance for Regenerative Reha-
provides the opportunity to devise bilitation Research & Training 10. Quarta M, Cromie M, Chacon R,
et al: Bioengineered constructs
rehabilitation protocols based on a (AR3T) through NIH Grant no. combined with exercise enhance stem
strong underlying scientific rationale. P2CHD086843. Dr. Stoddart ac- cell-mediated treatment of volumetric
knowledges support from the AO muscle loss. Nat Commun 2017;8:
The joint as a whole, however, 15613.
consists of more than just articular Foundation and Swiss National Science
Foundation Grant 31003A_179438/1. 11. Lai S, Panarese A, Lawrence R,
cartilage. In fact, the joint is an organ Boninger ML, Micera S, Ambrosio F:
comprising multiple tissues—bone, A murine model of robotic training to
evaluate skeletal muscle recovery after
cartilage, synovium, meniscus, liga- injury. Med Sci Sport Exerc 2017;49:
ments, and infrapatellar fat pad—all
References
840-847.
of which interact and influence each
References printed in bold type are 12. Albro MB, Nims RJ, Cigan AD, et al:
other.20,21 More generally, in con- those published within the past 5
Accumulation of exogenous activated
sidering the musculoskeletal system, TGF-b in the superficial zone of articular
years. cartilage. Biophys J 2013;104:
one should not approach it as eval- 1794-1804.
uating each tissue in isolation, but 1. Ambrosio F, Boninger ML, Brubaker CE,
et al: Guest editorial: Emergent themes 13. Madej W, van Caam A, Blaney Davidson EN,
rather should regard it as a contin- from second annual symposium on van der Kraan PM, Buma P: Physiological
uum of components, all tightly con- regenerative rehabilitation, Pittsburgh, and excessive mechanical compression of
Pennsylvania. J Rehabil Res Dev 2013; articular cartilage activates Smad2/3P
nected and transitioning from one to signaling. Osteoarthr Cartil 2014;22:
50:vii-xiv.
the next via the osteochondral junc- 1018-1025.
2. Ambrosio F, Wolf SL, Delitto A, et al: The
tion, the enthesis, and so on.22 The 14. Albro MB, Nims RJ, Cigan AD, et al:
emerging relationship between regenerative
development of proregenerative re- medicine and physical therapeutics. Phys Dynamic mechanical compression of
habilitation regimens should then Ther 2010;90:1807-1814. devitalized articular cartilage does not
activate latent TGF-b. J Biomech 2013;46:
account for load transduction across 3. Rando TA, Ambrosio F: Regenerative 1433-1439.
tissue interfaces20 and for the differ- rehabilitation: Applied biophysics meets
15. Li Z, Kupcsik L, Yao S-J, Alini M,
stem cell therapeutics. Cell Stem Cell 2018;
ent mechanobiological responses of 22:306-309. Stoddart MJ: Mechanical load
each tissue. modulates chondrogenesis of human
4. Ambrosio F, Ferrari RJ, Distefano G, et al: mesenchymal stem cells through the
Overall, PT has been used for years in The synergistic effect of treadmill running TGF-b pathway. J Cel Mol Med 2010;14:
orthopaedics to promote tissue repair on stem-cell transplantation to heal injured 1338-1346.
skeletal muscle. Tissue Eng A 2010;16:
and return to function. However, the 16. Neumann AJ, Gardner OFW, Williams R,
839-849.
cellular signaling and mechanistic Alini M, Archer CW, Stoddart MJ: Human
5. Glatt V, Evans CH, Tetsworth K: A articular cartilage progenitor cells are
relation between exercise and cellular concert between biology and responsive to mechanical stimulation and
responses are still far from being fully biomechanics: The influence of the adenoviral-mediated overexpression of
appreciated. Better understanding of mechanical environment on bone healing. bone-morphogenetic protein 2. PLoS One
Front Physiol 2017;7:678. 2015;10:e0136229.
these underlying mechanisms would
allow us to design the rehabilitation 6. Ruehle MA, Krishnan L, LaBelle SA, 17. Gardner OFW, Fahy N, Alini M,
Willett NJ, Weiss JA, Guldberg RE: Stoddart MJ: Joint mimicking
protocol based on empirical data, Decorin-containing collagen hydrogels as mechanical load activates TGF-b1 in
focusing on the integration with re- dimensionally stable scaffolds to study the fibrin-poly(ester-urethane) scaffolds
effects of compressive mechanical loading seeded with mesenchymal stem cells. J
generative medicine to enhance pa-
on angiogenesis. MRS Commun 2017;7: Tissue Eng Regen Med 2017;11:
tients’ outcomes.3,23 The development 466-471. 2663-2666.
of assistive devices to monitor the 7. Klosterhoff BS, Ghee Ong K, Krishnan L, 18. Schätti O, Grad S, Goldhahn J, et al: A
progression of tissue repair and guide et al: Wireless implantable sensor for combination of shear and dynamic
accordingly the delivery of proregen- noninvasive, longitudinal quantification compression leads to mechanically
of axial strain across rodent long bone induced chondrogenesis of human
erative mechanoactivation stimuli defects. J Biomech Eng 2017;139: mesenchymal stem cells. Eur Cel Mater
could greatly enhance the research in 111004. 2011;22:214-225.
Riccardo Gottardi, PhD and Martin J. Stoddart, PhD
19. Albro MB, Cigan AD, Nims RJ, et al: Shearing 21. Nichols DA, Sondh IS, Litte SR, Zunino osteogenic and chondrogenic systems to
of synovial fluid activates latent TGF-b. P, Gottardi R: Design and validation model osteochondral physiology and
Osteoarthr Cartil 2012;20:1374-1382. of an osteochondral bioreactor for degenerative joint diseases. Exp Biol Med
the screening of treatments for 2014;239:1080-1095.
20. Lozito TP, Alexander PG, Lin H, Gottardi R, osteoarthritis. Biomed Microdevices
Cheng AW-M, Tuan RS: Three-dimensional 2018;20:18. 23. Ambrosio F, Kleim JA: Regenerative
osteochondral microtissue to model rehabilitation and genomics: Frontiers in
pathogenesis of osteoarthritis. Stem Cel Res 22. Alexander PG, Gottardi R, Lin H, Lozito clinical practice. Phys Ther 2016;96:
Ther 2013;4 suppl 1:S6. TP, Tuan RS: Three-dimensional 430-432.
August 1, 2018, Vol 26, No 15 e323
Case Report
Complete Talar Extrusion Treated

With an Antibiotic Cement Spacer
and Staged Femoral Head Allograft
Abstract
Philip Huang, DO Complete talar extrusion is rare and usually associated with a high-
Mary Elizabeth Lundgren, DO, energy mechanism of injury causing complete dissociation of the
PhD talus from the surrounding bony and soft-tissue structures with
Rajeev Garapati, MD enough force to expel the talus out of the body. Treatment can be
complicated by infection, osteonecrosis, posttraumatic
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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.
From Midwestern University,

Olympia Fields, IL (Dr. Huang and
Dr. Lundgren), and the John H.
T he completely extruded talus is a
rare and often devastating injury
that may require a wide variety of
Here, we present a unique case of a
28-year-old woman with a complete
talar extrusion without associated
Stroger Hospital of Cook County, treatment options depending on pa- talar fracture treated with staged
Chicago, IL (Dr. Garapati).
tient factors, associated injuries, time procedures, which included an initial
Correspondence to Dr. Lundgren: to treatment, and other variables débridement and irrigation with im-
mimi.lundgren@gmail.com surrounding the events of the injury. plantation of an antibiotic impreg-
Dr. Garapati or an immediate family Commonly seen associated injuries nated talus-shaped cement spacer and
member is a member of a speakers’ include talar neck fractures, fracture- external fixation. Subsequent serial
bureau or has made paid
dislocations, and substantial soft- débridement was performed with de-
presentations on behalf of Stryker.
Neither of the following authors or any tissue injury. As our understanding finitive management consisting of a
immediate family member has of this injury and associated treat- tibiocalcaneal fusion with interposed
received anything of value from or has ment modalities continue to evolve, femoral head allograft.
stock or stock options held in a
successful functional outcomes with
commercial company or institution
related directly or indirectly to the low infection rates have been re-
subject of this article: Dr. Huang and ported in the literature.1-4 Numerous Case Report
Dr. Lundgren. case reports have identified treat-
J Am Acad Orthop Surg 2018;26: ment options for talar extrusion A 28-year-old woman fell down a
e324-e328 ranging from reimplantation, talec- long flight of stairs sustaining a
DOI: 10.5435/JAAOS-D-16-00748 tomy, and primary arthrodesis;5-12 pronation-type injury to her left
however, because of the rarity of this ankle. She arrived at our facility
Academy of Orthopaedic Surgeons. injury, no consensus exists on a within 2 hours of the injury with a
treatment algorithm. wound over the medial side of her
Philip Huang, DO, et al
ankle measuring approximately 15 Figure 1

cm and radiographs revealing an ab-
sent talus (Figure 1). She was brought
via emergency medical services with
her talus in a separate container,
contaminated with grass and soil,
after it was found at the scene of the
accident. On examination, the pa-
tient reported intact sensation to the
left lower extremity; however, her
motor examination was limited sec-
ondary to the large wound, severe
soft-tissue damage, and gross defor-
mity. She had palpable dorsalis pedis
and posterior tibial pulses, brisk cap-
illary refill, and soft compartments.
The remainder of her preliminary
trauma and orthopaedic examina-
tion were otherwise normal.
Immediately on arrival, the patient’s
wound was copiously irrigated with AP (A) and lateral (B) radiographs demonstrating complete talar extrusion on
several liters of sterile normal saline initial presentation.
solution and she was given intrave-
nous antibiotics consisting of cefa-
zolin and gentamycin with updated Figure 2
tetanus prophylaxis. The talus, which
was initially placed in a sterile saline
solution, was cleansed with serial
bacitracin solutions in preparation
for possible reimplantation.
The patient was presented with all
possible treatment options and the
potential risks, benefits, and compli-
cations. The patient was concerned
about the risk of infection with re-
implantation, especially given the
gross contamination found on her
native talus. After a thorough dis-
cussion, she opted for placement of
an antibiotic impregnated cement
spacer with external fixation and
future tibiocalcaneal fusion.
She was taken to the operating
room for urgent débridement and
irrigation and external fixation within
6 hours of her arrival. A cement spacer A, Photograph showing the native talus (left) and an anatomically
modeled, by hand, talar antibiotic cement spacer for implantation (right).
impregnated with 1 gm vancomycin B, Lateral radiograph of the left ankle with a talar antibiotic spacer and
and 1 gm tobramycin was fashioned external fixator.
by hand in the form of her native talus
and implanted (Figure 2, A). This
procedure was performed to preserve external fixator in a delta frame and a posterior molded splint (Figure
leg length, joint space, and hindfoot arrangement with two tibial pins, a 2, B). The medial wound was loosely
anatomy. The patient was placed in an calcaneal pin, and a first metatarsal pin approximated with nylon sutures. The
August 1, 2018, Vol 26, No 15 e325
Complete Talar Extrusion
Figure 3 Figure 4
Final intraoperative lateral

fluoroscopic image after
tibiocalcaneal fusion with femoral
head allograft interposition.
patient was taken back 48 hours later

for a repeat débridement and external
fixator adjustment. The wound was
again closed primarily with nylon AP (A) and lateral (B) radiographs obtained 2 years after injury demonstrating
sutures. The patient remained neuro- tibiocalcaneal fusion with femoral head allograft interposition.
vascularly intact and had restored
motor function distally in her toes. bearing and followed up at 2 and 6 walking on even surfaces. No sub-
The patient was seen regularly in weeks postoperatively. Her incisions jective or objective leg-length dis-
our clinic over the next 3 months for healed well without complication, crepancy was noted. The AOFAS
serial imaging and wound checks. She and she was advanced to partial ankle-hindfoot score, which is a
was instructed to remain non–weight weight bearing at 12 weeks based on health outcome score for patients
bearing for the entirety of this radiographic evidence of bony fusion. after foot and ankle surgery, was used
follow-up period. Her wound healed Two years after injury, the patient to assess the clinical outcome. An
well without any signs of infection or was seen for repeat radiographs, clini- excellent outcome is scored 90 to 100,
dehiscence. A workup for infection cal examination, and outcome assess- a good outcome 80 to 89, a fair
consisting of erythrocyte sedimenta- ment using the American Orthopaedic outcome 60 to 79, and a poor out-
tion rate, C-reactive protein level, Foot and Ankle Society (AOFAS) come ,60. This patient had a fair
and complete blood count was per- ankle-hindfoot score. Radiographs AOFAS score of 75 2 years post-
formed 2 months postoperatively demonstrated a well-incorporated and operatively. Written informed consent
and all levels were within the normal stable hindfoot fusion with excellent was obtained from the patient for
range. The patient returned 3 alignment and no evidence of loos- research and publication purposes.
months postoperatively, and a ti- ening, subsidence, or pseudarthrosis
biocalcaneal fusion with an intra- (Figure 4). Despite radiographic
medullary nail was performed with a evidence of talonavicular arthritis Discussion
distal fibular osteotomy and inter- and joint incongruence, she did not
position of a femoral head allograft have abnormal physical examination To date, the largest case series by
(Figure 3). The fibula was resected as findings or complaints about the Smith et al5 described 27 talar
part of the lateral approach and to talonavicular joint. The patient was extrusions. Even within this case
use as morcellized bone autograft, working retail part-time and series, extrusion without a talar body
which was placed into areas of bony described pain that did interfere with or neck fracture was rare, three were
defect found anteriorly and laterally. strenuous activities, climbing stairs, associated with minor talar frac-
Intraoperative frozen sections were navigating uneven terrain, and choice tures, and only eight were pure
sent to pathology and did not suggest of shoe wear; these may be related to pantalar dislocations. This phenom-
ongoing infection. The patient was hindfoot incongruity. The pain had enon highlights the even rarer
instructed to remain non–weight no effect on moderate activity or occurrence of the extrusion of a pure
Philip Huang, DO, et al
dislocation. The authors cited an bone stock within the ankle and trauma with significant bone loss. To
equal distribution of medial and subtalar joints and potentially main- our knowledge, no report of initial
lateral extrusions (six of each), tains normal hindfoot anatomy. In talus-shaped antibiotic cement spacer
whereas the remainder were anterior addition to urgent débridement and followed by femoral head allograft
extrusions or undocumented. irrigation of the wound and talus has been the initial treatment plan for
Complications after total talar and antibiotic administration, the talar extrusion. This staged pro-
extrusions have included infection, presence of even a minimal amount of cedure resulted in fair outcomes in
osteonecrosis, posttraumatic osteo- remaining soft-tissue attachment, and terms of AOFAS ankle-hindfoot
arthritis, and leg-length discrep- the absence of an associated talar score and has allowed the patient to
ancy.2 The most recent review in fracture have been suggested as continue with activities of daily
2017 by Boden et al4 documented 18 important factors for successful re- living with minimal interruption
cases of pantalar dislocation without implantation.7,10 In one case report and without the complications of
fractures that were treated with re- of successful reimplantation, the infection or collapse requiring
implantation; osteonecrosis developed talus was reimplanted 8 days after additional unplanned procedures.
in 14 at approximately 1 year of the injury; it was found embedded in Potential complications associated
follow-up, but there were only 2 the wreckage after a motor vehicle with our proposed technique
cases of talar collapse and no inci- accident without associated frac- include late subsidence, nonunion,
dence of deep infection. Chronic ture.3 The patient did not have a allograft fracture, hindfoot stiff-
pain was also highlighted by Boden reported infection but showed signs ness or arthritis, and hardware
et al,4 75% of their cohort continued of osteonecrosis at 3 months after failure. Because of these potential
to take pain medication and 50% injury. The patient later needed a late complications and potential
reported occasional narcotic use when talonavicular and subtalar fusion 3 adjacent joint degeneration, long-
surveyed, on average, 45 months years after injury but required no term follow-up is recommended.
postoperatively. Karampinas et al2 tibiotalocalcaneal fusion for talar
documented nine cases of talar extru- collapse.
sion treated with reimplantation, six Failed reimplantations, whether Summary
without complications at 19 to 25 from talar collapse or infection, have
months of follow-up. Infection and been successfully salvaged with bulk Talar extrusion is a rare and devas-
osteonecrosis are major concerns femoral head allograft or iliac crest tating injury that presents the ortho-
associated with reimplantation. These autograft with accompanying paedic surgeon with a complex and
complications can lead to prolonged arthrodesis.6,8,11 Primary talocalca- difficult approach to management.
treatment and additional procedures, neal arthrodesis is another option; Significant controversy exists re-
including amputation. Talectomy and however, this approach has led to garding the ideal management of
tibiocalcaneal arthrodesis have been limb-length discrepancy in several these injuries, and a variety of treat-
recommended to avoid such compli- case reports ranging from 1.5 to ment options are plausible. The
cations and their sequelae.9 However, 4.0 cm.6,8,10 This alludes to favoring completely extruded talus without
the 88% (8 of 9 extrusion cases) reimplantation if possible, to main- fracture is even more unusual, and
infection rate reported by Detenbeck tain joint space height. Only two relatively good functional outcomes
and Kelly9 does not seem to reflect reports have described femoral and low infection rates can be achieved
the more recent infection rates of head allograft as part of the index with immediate reimplantation. Our
22% (2 of 9 extrusion cases)2 with treatment of talar extrusion. 6,11 case report identifies a unique method
reimplantation and 58% (5 of 12 To date, comparison studies be- in treating this injury with a staged
extrusion cases) independent of tween femoral head allograft and procedure beginning with placement
treatment method (primary talectomy reimplantation are lacking. of a talus modeled antibiotic cement
or reimplantation with primary or This case was unique in that while spacer followed by delayed femoral
late fusion).1 For those patients reimplantation was a viable initial head allograft tibiocalcaneal fusion.
with late osteonecrosis of the talus, treatment option, the patient elected Our patient had no significant early
total talar replacement with custom for an alternative. Cement antibiotic postoperative complications with this
implants has been described with spacers are commonly used in com- treatment approach and reported a
good clinical outcomes.13 plex foot and ankle scenarios such as satisfactory outcome. Our outlined
Reimplantation of the extruded revision ankle arthroplasty with and treatment regimen represents a rea-
talus affords the benefit of maintain- without infection, infected talar body sonable initial approach to this rare
ing the joint space, leg length, and fractures, and complex hindfoot injury.
August 1, 2018, Vol 26, No 15 e327
Complete Talar Extrusion
3. Burston JL, Brankov B, Zellweger R: case reports and review of the literature.
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1-4 are level III studies. References 8 after pantalar dislocation. J Bone Joint Surg Mayehiyo S: Open total dislocation of the
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1. Marsh JL, Saltzman CL, Iverson M, 7. Breccia M, Peruzzi M, Cerbarano L, Galli large allograft interfaces: A report of 3
Shapiro DS: Major open injuries of the M: Treatment and outcome of open cases. J Foot Ankle Surg 2008;47:
talus. J Orthop Trauma 1995;9:371-376. dislocation of the ankle with complete talar 476-482.
extrusion: A case report. Foot (Edinb)
2. Karampinas PK, Kavroudakis E, Polyzois 2014;24:89-93. 13. Taniguchi A, Takakura Y, Tanaka Y, et al:
V, Vlamis J, Pneumaticos S: Open talar An alumina ceramic total talar prosthesis
dislocations without associated fractures. 8. Jaffe KA, Conlan TK, Sardis L, Meyer RD: for osteonecrosis of the talus. J Bone Joint
Foot Ankle Surg 2014;20:100-104. Traumatic talectomy without fracture: Four Surg Am 2015;97:1348-1353.
Case Report
Concomitant Proximal and Distal

Tibiofibular Joint Dislocation
Associated With a Tibial Shaft
Fracture
Abstract
John S. Hwang, MD An association exists between tibial shaft fractures and ankle injuries.
Michael S. Sirkin, MD In addition, although uncommon, an association between tibial shaft
fractures and proximal tibiofibular dislocations has also been
Zachary Gala, BS
established. A review of the previous literature resulted in one case
Mark Adams, MD report of a complete proximal and distal tibiofibular joint dislocation
Mark C. Reilly, MD without fracture of the tibia or fibula. Here, we discuss a case of a
complete proximal and distal tibiofibular syndesmotic complex
From the Department of
dislocation associated with a tibial shaft fracture. To the best of our
Orthopaedics, Carolinas Medical knowledge, this is the first report of this injury pattern associated with a
Center, Charlotte, NC (Dr. Hwang), tibial shaft fracture.
and the Department of Orthopaedics,
Rutgers New Jersey Medical School,
Newark, NJ (Dr. Sirkin, Mr. Gala,
Dr. Adams, and Dr. Reilly).
Correspondence to Dr. Hwang:
jhwang12@gmail.com
D istal tibial shaft fractures have
been found to have a high as-
sociation with concomitant ankle
sensory function, as well as palpable
pulses in the lower extremity.
Initial plain radiographs taken in the
Dr. Sirkin has received royalties and injuries.1-3 In addition, although emergency department showed a distal
financial or material support from rare, cases of proximal tibiofibular tibial shaft fracture with dislocation of
Saunders/Mosby-Elsevier; has served
on the Medical/Orthopaedic publications
dislocation after tibial shaft fractures the proximal and distal tibiofibular
editorial/governing board of the Journal have also been reported.4-6 To our joints(Figure 1). The patient was found
of the American Academy of knowledge, there has never been a to have no other injuries. Review of the
Orthopaedic Surgeons, Journal of reported case of a complete tibio-
Trauma, and Journal of Orthopaedics
lateral ankle radiographs and intra-
and Traumatology; and is a board
fibular dislocation of both the operative fluoroscopy did not reveal a
member or committee member of the proximal and distal joints associated posterior malleolus fracture.
AO Board of Trustees, AONA Education with a tibial shaft fracture. We In the operating room, the patient
Committee, and Orthopaedic Trauma report a unique case of a proximal
Association. Mr. Gala is a paid employee underwent intramedullary nailing of
of Johnson & Johnson. Dr. Reilly is a
and distal tibiofibular joint disloca- his tibia. After completion of the in-
member of a speakers’ bureau or has tion associated with a tibial shaft tramedullary nailing, dislocation of
made paid presentations on behalf or fracture.
Stryker and is a paid consultant to
the proximal and distal tibiofibular
Stryker. None of the following authors or joint was still present (Figure 2, A). A
any of their immediate family members lateral fluoroscopic image of the ankle
has received anything of value from or Case Report
was taken, with the beam parallel to
has stock or stock options held in a
commercial company or institution A 25-year-old man presented to the the distal interlocking screw, to con-
related directly or indirectly to the subject emergency department with a com- firm that the distal interlocking screw
of this article: Dr. Hwang and Dr. Adams. was not in the syndesmosis. Either
plaint of right leg pain after being
J Am Acad Orthop Surg 2018;0:1-4 struck by a car. On initial evaluation, joint, proximal or distal, could have
DOI: 10.5435/JAAOS-D-17-00159 the patient was found to have a been addressed first, but a decision to
deformity of the right leg and diffuse examine and reduce the proximal
Academy of Orthopaedic Surgeons. tenderness throughout the leg. He joint was made. Closed reduction of
demonstrated intact distal motor and the proximal tibiofibular joint was
Month 2018, Vol 0, No 0 1
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Concomitant Proximal and Distal Tibiofibular Joint Dislocation With a Tibial Shaft Fracture
Figure 1
A, AP radiograph of the tibia demonstrating a tibia fracture with widening of the proximal tibiofibular joint. B, Mortise
radiograph of the ankle demonstrating widening of the syndesmosis. C, Lateral radiograph of the proximal tibia
demonstrating the anterior dislocation of the proximal tibiofibular joint. D, Lateral radiograph of the distal tibia demonstrating
a fracture of the distal tibial shaft.
Figure 2
A, Intraoperative image demonstrating continued dislocation of the proximal tibiofibular joint after reduction and
intramedullary nailing of the tibia fracture. B, Intraoperative image demonstrating reduction of the proximal tibiofibular joint
using a bone reduction clamp. C, Intraoperative image demonstrating continued ankle syndemotic joint disruption after
intramedullary nailing of the tibia and reduction of the proximal tibiofibular joint. D, Intraoperative image demonstrating
reduction of the ankle syndemotic joint using a bone reduction clamp.
attempted and unsuccessful. At this the proximal fibula displaced ante- Kirschner wire was placed across the
point, a decision for an open reduc- rolaterally. The devitalized soft tissue joint to further hold the reduction. At
tion of the proximal tibiofibular joint was excised and removed. Once the this point, we held off on definitive
was made. An incision was made joint was cleared of any debris, the fixation of the proximal tibiofibular
directly anterior to the fibula. Soft- proximal tibiofibular joint was easily joint until we confirmed the reduction
tissue disruption was noted within reduced. The reduction was confirmed of the distal joint. With the intact
the anterior compartment of the leg, with both direct visualization and fibula, a malreduction of the proximal
and the proximal joint was visualized fluoroscopic imaging (Figure 2, B). tibiofibular joint would cause diffi-
through the soft-tissue defect. On One tong of the large bone reduction culty in anatomically reducing the
evaluation of the joint, there was forcep was placed on the fibular head, distal tibiofibular joint.
notable soft-tissue and capsular dis- whereas the other was placed on the Even with the proximal joint
ruption around the fibular head, with proximal medial face of the tibia. A reduced, the distal tibiofibular joint
John S. Hwang, MD, et al
Figure 3
AP (A and B) and lateral (C and D) radiographs of the tibia and fibula demonstrating intramedullary nailing of the tibia fracture
with reduction and fixation of the proximal and distal tibiofibular joints.
remained dislocated (Figure 2, C). biofibular screws after 3 months. The tibia and fibula are connected by the
Under fluoroscopic imaging, the patient’s home was out of state; thus, interosseous membrane. The inter-
syndesmosis was identified, and a all subsequent follow-ups were made osseous membrane begins below the
3-cm skin incision was made directly by the patient near his residence. proximal tibiofibular joint and ter-
anterior to the syndesmosis. Blunt minates within the distal syndesmotic
dissection was performed until it was complex. Injuries of the tibiofibular
possible to visualize the joint. The Discussion and Summary syndesmosis may occur in tibial shaft
syndesmosis was found to be dis- fractures with intact fibulas.2,3
rupted, with soft tissue being trapped Tibial shaft fractures and tibiofibular Although uncommon, cases of prox-
within the joint. Once the joint was joint injuries may occur concomi- imal tibiofibular dislocation after tibial
cleaned, we reduced the syndesmosis tantly because of their close anatomic shaft fracture dislocation have been
using large bone reduction forceps. relationship. Proximally, the fibular documented.4-6 One study found that
The clamp was placed with the tongs in head articulates with the undersur- proximal tibiofibular dislocations in
the midaxis of the fibula and tibia, face of the lateral tibial plateau, tibial shaft fractures had an incidence
which was confirmed with both direct forming the proximal tibiofibular of 1.5%.5 A case series of seven
visualization and fluoroscopic imaging joint. A distinct capsule covers this patients by Haupt et al,6 demon-
(Figure 2, D). At this point, we con- joint just below the articular surface strated that two of seven patients
firmed that the proximal joint was still of the tibia. Distally, the fibula artic- experienced anterolateral dislocation,
appropriately reduced. A 3.5-mm cor- ulates within the incisura of the tibia as consistent with our own findings
tical screw was placed into the distal and forms a fibrous joint linked in our patients. In 1974, Ogden7
tibiofibular joint, and we then pro- together with strong ligaments. The described four types of proximal
ceeded to place a 3.5-mm cannulated distal tibiofibular joint, or tibiofibular tibiofibular dislocations: atraumatic
screw across the proximal joint. The syndesmosis, consists of the anterior subluxation, anterolateral disloca-
clamps were removed, and the joints inferior tibiofibular ligament, the pos- tion, posteromedial dislocation, and
were found to be stable (Figure 3). terior inferior tibiofibular ligament, superior dislocation. Of these, an-
Postoperatively, the patient was the transverse ligament, and the inter- terolateral dislocations, or type II
found to be neurovascularly intact osseous ligament. dislocations, were found to be the
and remained non–weight bearing The fibula is farther away from the most common, consisting of up to
for 6 weeks on the right lower tibia in the proximal half and 85% of cases.7,8 These injuries most
extremity. We discussed with the pa- decreases until the fibula again artic- often occur after a rotational injury
tient the possibility of elective removal ulates distally with the tibia. Between to the leg, similar to those seen in
of both the proximal and distal ti- these two articulating surfaces, the spiral tibial shaft fractures.
Month 2018, Vol 0, No 0 3
Concomitant Proximal and Distal Tibiofibular Joint Dislocation With a Tibial Shaft Fracture
Distal tibial fractures have fre- syndesmotic injuries require open 1. Purnell GJ, Glass ER, Altman DT, Sciulli
RL, Muffly MT, Altman GT: Results of a
quently been associated with ankle reduction because of soft-tissue computed tomography protocol
injuries. Stuermer and Stuermer2 entrapment within the joint. evaluating distal third tibial shaft
found that 20% of the 214 tibia When proximal or distal tibio- fractures to assess noncontiguous
malleolar fractures. J Trauma 2011;71:
fractures examined in the study had fibular joint instability is not clearly 163-168.
associated ankle injuries, with three of visible with plain radiographs, 2. Stuermer EK, Stuermer KM: Tibial shaft
these cases having isolated syn- advanced imaging may assist in fracture and ankle joint injury. J Orthop
desmotic injuries without fracture. diagnosing these injuries. CT has Trauma 2008;22:107-112.
Schottel et al found that 49.3% of been shown to be useful in the diag- 3. Schottel PC, Berkes MB, Little MT,
tibial shaft fracture cases had con- nosis of nondisplaced fractures in et al: Predictive radiographic
markers for concomitant ipsilateral
comitant ipsilateral ankle injuries; distal third spiral tibial fractures10 ankle injuries in tibial shaft fractures.
88.6% of these injuries occurred in but not in the assessment of soft- J Orthop Trauma 2014;28:103-107.
spiral tibial fractures. A high index of tissue injury. Magnetic resonance 4. Johnson BA, Amancharla MR, Merk BR:
suspicion of an ankle injury should be images would be useful in diagnos- Dislocation of the proximal
tibiofibular joint in association with a
maintained after spiral tibial fractures. ing occult instability in the proximal tibial shaft fracture: Two case
In isolation, both the proximal ti- and distal tibiofibular joints but are reports and a literature review. Am J
biofibular dislocation and syn- Orthop (Belle Mead NJ) 2007;36:
not typically warranted in cases of 439-441.
desmotic injury require reduction. frank dislocation or subluxation.
5. Herzog GA, Serrano-Riera R, Sagi HC:
Various authors have recommended A single case report of an isolated Traumatic proximal tibiofibular
that irreducible fractures should proximal and distal tibiofibular joint dislocation: A marker of severely
undergo open reduction and pro- dislocation without a tibia or fibula traumatized extremities. J Orthop
Trauma 2015;29:456-459.
visional fixation of the tibia.9 In fracture has been documented. The
conjunction with tibial shaft frac- 6. Haupt S, Frima H, Sommer C: Proximal
injury occurred after a motor vehicle tibiofibular joint dislocation associated
tures, temporary fixation of the accident in which the patient had with tibial shaft fractures: 7 cases. Injury
proximal tibiofibular joint may assist multiple injuries. In this case, open 2016;47:950-953.
in the reduction in the tibia.6 This reduction with internal fixation of 7. Ogden JA: Subluxation and dislocation of
method is particularly useful because both joints was performed.11 the proximal tibiofibular joint. J Bone Jt
Surg Am 1974;56:145-154.
once the proximal joint is reduced, In conclusion, our case represents
the fibula provides a stable base to 8. Van Seymortier P, Ryckaert A,
the first reported case of a proximal Verdonk P, Almqvist KF, Verdonk R:
assist in the reduction of the tibia. In and distal tibiofibular joint dislocation Traumatic proximal tibiofibular
our case, both the proximal and the associated with a tibial shaft fracture. dislocation. Am J Sports Med 2008;36:
distal tibiofibular joints were dis- 793-798.
Although there have been reported
located. Without anatomic reduction cases of proximal or distal tibiofibular 9. Sekiya JK, Kuhn JE: Instability of
the proximal tibiofibular joint.
of both joints, the reduction of the joint dislocation after distal tibial J Am Acad Orthop Surg 2003;11:
tibia fracture would be difficult. The fractures, to our knowledge, this is the 120-128.
fixation is often removed after 6 to first case in which both injuries have 10. Boraiah S, Gardner MJ, Helfet DL, Lorich
12 weeks. Unlike injuries in the occurred after the tibia fracture. DG: High association of posterior
proximal tibiofibular joint, syn- malleolus fractures with spiral distal tibial
fractures. Clin Orthop Relat Res 2008;466:
desmotic injuries require fixation 1692-1698.
after reduction because of the sta- References 11. Corrigan C, Asbury B, Alvarez RG,
bility that this joint provides for the Nowotarski P: Dislocation of the proximal
ankle. Unreduced syndesmotic in- References printed in bold type are and distal tibiofibular syndesmotic
complex without associated fracture: Case
juries can lead to chronic instability those published within the past 5 report. Foot Ankle Int 2011;32:
and posttraumatic arthritis. Irreducible years. 1009-1011.

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Review Article

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August 1, 2018, Vol 26, No 15 515

516 Journal of the American Academy of Orthopaedic Surgeons

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518 Journal of the American Academy of Orthopaedic Surgeons

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520 Journal of the American Academy of Orthopaedic Surgeons

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522 Journal of the American Academy of Orthopaedic Surgeons

multiple other reports of improved Figure 1

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524 Journal of the American Academy of Orthopaedic Surgeons

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Role of Advanced Imaging in the

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An arthrogram under fluoroscopy is ström classification that subdivided

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classification assesses the shape of the Table 1

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Figure 4 5.4 years, looking at the extent of

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532 Journal of the American Academy of Orthopaedic Surgeons

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Figure 6 short duration of the examination.

534 Journal of the American Academy of Orthopaedic Surgeons

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536 Journal of the American Academy of Orthopaedic Surgeons

The Orthopaedic Surgery

Copyright 2018 by the American

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538 Journal of the American Academy of Orthopaedic Surgeons

interval: Student t-test, chi-square Table 1

August 1, 2018, Vol 26, No 15 539

540 Journal of the American Academy of Orthopaedic Surgeons

interview offer self-reported replying ceived reputation, interview day Figure 1

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542 Journal of the American Academy of Orthopaedic Surgeons

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546 Journal of the American Academy of Orthopaedic Surgeons

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Figure 2 (P , 0.05) for all three measures. In

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548 Journal of the American Academy of Orthopaedic Surgeons

Correlation 0.023 20.066 20.030 0.031 20.015 20.033

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I ntra-articular and soft-tissue aspi-

August 1, 2018, Vol 26, No 15 e313

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