2026年4月 保髋进展 JCRQ1

Periacetabular osteotomy has been shown to be a powerful hip preservation procedure for over 4 decades. The advances in hip arthroscopy have revolutionized intra-articular hip preservation procedures, and combining the 2 operations is a deeply debated topic among hip preservation surgeons. The exact role of hip arthroscopy in the face of hip dysplasia and borderline hip dysplasia continues to be defined in our literature. The addition of hip arthroscopy to osteotomy patients has shown safety and improved patient outcomes. Clinical identification of combined impingement and dysplasia is imperative to potentially improve our patient outcomes.

BACKGROUND: Although periacetabular osteotomy (PAO) is a commonly used procedure with generally good intermediate and long-term outcomes, complications such as stress fractures of the ischium or pubis have been reported. A limited number of studies have investigated stress fracture after PAO, but the results lack consensus and do not thoroughly explore lifestyle factors or patient-reported outcome measures (PROMs). QUESTIONS/PURPOSES: Among patients treated with PAO: (1) What percentage of patients and hips developed a stress fracture after PAO? (2) What preoperative and intraoperative factors were associated with stress fractures? (3) Did PROMs or the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) achievement differ between patients with stress fractures and patients without at most recent follow-up? METHODS: Six hundred seventy-five hips (546 patients) were treated with PAO with or without hip arthroscopy for symptomatic acetabular dysplasia between February 2016 and October 2024 by one surgeon in a mature hip preservation practice. Patients were excluded if the index procedure for those who had bilateral PAOs occurred before the study period. Patients who underwent concomitant femoral osteotomy, surgical hip dislocation, or relative neck lengthening were also excluded, yielding 90% (608 of 675) of hips from 487 patients as potentially eligible for analysis. Ninety-four percent (574 of 608) of PAOs were performed in women, and 65% (396 of 608) were performed without concomitant hip arthroscopy. The mean ± SD age was 26 ± 8 years, and the mean BMI was 23.2 ± 3.9 kg/m 2 . All hips had 6-week, 3-month, and 6-month postoperative radiographs available for review. Two patients with stress fractures and one without converted to THA, leaving 81% (393 of 484) of patients with available minimum 1-year PROMs after their most recent PAO surgery. Stress fracture diagnoses were tallied by hip and by patient to establish the percentages. Exploratory analyses included age, BMI, preoperative vitamin D levels, magnitude of lateral center-edge angle (LCEA) correction, magnitude of anterior center-edge angle correction, Tönnis grade, sex, marijuana use, nicotine use, screw type, prior ipsilateral surgery, PAO with or without concomitant hip arthroscopy, initial PAO versus subsequent contralateral PAO, and diagnoses of Ehlers-Danlos syndrome (EDS) or hypermobility. Factors with p < 0.1 were considered in the multivariate analysis. To determine the association between stress fractures and postoperative outcomes, univariate regression was performed with the presence of stress fractures as the independent variable. Multivariate regressions were performed to determine whether stress fractures were associated with modified Harris hip score (mHHS) and International Hip Outcome Tool-12 (iHOT-12) improvement after controlling for factors identified in the previous analysis. Similarly, regression models were used to determine whether stress fractures were associated with achievement of the MCID and PASS. RESULTS: Stress fractures occurred in 8% (37 of 487) of patients and in 7% (40 of 608) of hips. For patients who underwent bilateral PAOs, 11% (13 of 121) experienced a stress fracture after the second surgery. Bilateral stress fractures occurred in 2% (3 of 121) of patients. After controlling for potential confounding variables such as age, BMI, LCEA correction, substance use, and EDS or hypermobility, we found that several factors were associated with developing stress fractures. Increasing age was associated with higher odds of stress fracture (OR 1.05 [95% confidence interval (CI) 1.01 to 1.09] for each year of increasing age; p = 0.03). Higher BMI was associated with greater odds of stress fracture (OR 1.09 [95% CI 1.002 to 1.19] for each kg/m 2 increase in BMI; p = 0.046). Greater magnitude of LCEA correction was associated with higher odds of stress fracture (OR 1.05 [95% CI 1.01 to 1.10] for each degree of correction; p = 0.02). Current marijuana users had greater odds of stress fracture compared with nonusers (OR 3.06 [95% CI 1.2 to 8.0]; p = 0.02), as did current nicotine users (OR 6.41 [95% CI 1.2 to 34]; p = 0.03). Patients with EDS or hypermobility diagnoses also had higher odds of stress fracture (OR 2.88 [95% CI 1.3 to 6.0]; p = 0.01). Although the proportion was higher, no difference was found between stress fracture occurrence after the first PAO and second PAO in patients who underwent bilateral procedures (OR 2 [95% CI 1 to 4]; p = 0.07). After controlling for factors found to be associated with stress fractures, preoperative PROM scores, and time since most recent PAO, stress fractures were found to be associated with lower preoperative to postoperative improvements in mHHS and iHOT-12 scores, along with decreased odds of achieving the PASS for iHOT-12 and the MCID for mHHS. Patients with stress fractures had mean 6 points less improvement in mHHS than patients without (95% CI -11.6 to -0.84; p = 0.02). Patients with stress fractures had mean 12 points less improvement in iHOT-12 scores than patients without (95% CI -20.6 to -2.45; p = 0.01). Patients with stress fractures had lower odds of achieving the PASS for iHOT-12 (OR 0.36 [95% CI 0.15 to 0.86]; p = 0.02) and lower odds of achieving the MCID for mHHS (OR 0.33 [95% CI 0.13 to 0.83]; p = 0.02). Stress fractures were not associated with achieving the PASS for mHHS (OR 0.52 [95% CI 0.18 to 1.53]; p = 0.24) or the MCID for iHOT-12 (OR 0.86 [95% CI 0.33 to 2.24]; p = 0.76). CONCLUSION: Increasing age, higher BMI, greater LCEA correction, marijuana use, nicotine use, and EDS or hypermobility were associated with increased risk of stress fracture development after PAO for symptomatic acetabular dysplasia. At minimum 1-year follow-up, stress fractures were associated with smaller improvements in mHHS and iHOT-12, as well as lower odds of achieving the PASS for iHOT-12 and the MCID for mHHS. Rather than serving as barriers to surgery, these factors can guide surgeon-patient discussions to provide personalized counseling and rehabilitation, including guidance on potential substance cessation, the use of extended nonweightbearing periods, and realistic expectations for early functional gains. With larger samples of stress fractures, potentially through multicenter registries, future studies should aim to establish clinically meaningful thresholds for associated factors and evaluate the long-term relationship between stress fractures and PROMs, including the influence of fracture healing and fracture location. LEVEL OF EVIDENCE: Level III, therapeutic study.

BACKGROUND: Gluteus medius tears are an increasingly recognized cause of lateral hip pain in active individuals, yet no gold standard repair technique has been established, and failure and retear rates remain high. Iliotibial band (ITB) graft augmentation is a validated option in rotator cuff and hip labral repairs for stronger repair construct, but its biomechanical utility in gluteus medius repairs has not been investigated. HYPOTHESIS: It was hypothesized that ITB-augmented gluteus medius repairs would demonstrate superior ultimate load to failure and increased repair stiffness as compared with nonaugmented repairs. STUDY DESIGN: Controlled laboratory study. METHODS: Fourteen unpaired fresh-frozen cadaveric hemipelvises with intact gluteus medius tendons were randomized into ITB-augmented and nonaugmented groups and tested biomechanically with a tensile testing machine. Native stiffness was assessed as follows: 10-N preload for 2 minutes, 150 cycles at 0.8 Hz from 10 to 125 N to simulate early partial weightbearing, followed by a quasistatic load to 60 N at 1 mm/s. Tendons were then elevated from their anatomic footprint on the greater trochanter and repaired using double-row suture bridge configurations, with augmented repair incorporating ITB graft fixation. After preconditioning (10 N for 2 minutes, 150 cycles at 0.8 Hz from 10 to 125 N to simulate early partial weightbearing), specimens were loaded to failure at a constant displacement rate of 31 mm/min. Failure load, repair stiffness, and mode of failure were recorded. Data analysis included Shapiro-Wilk test, independent samples 2-tailed RESULTS: ITB-augmented repairs demonstrated a 98% stronger failure load (mean ± SD, 294.6 ± 87.9 N) than nonaugmented repairs (149.0 ± 40.4 N; CONCLUSION: Gluteus medius repairs augmented with ITB grafts led to greater failure load than nonaugmented repairs and were less stiff than the native state. CLINICAL RELEVANCE: Utilization of ITB-augmented double-row repairs when treating tears of the gluteus medius tendon can potentially reduce high failure rates.

BACKGROUND: Differences in outcomes between primary and revision hip arthroscopy are well documented; however, specific comparisons between revision and primary labral reconstruction are limited, especially regarding midterm outcomes. PURPOSE: To evaluate whether revision arthroscopic labral reconstruction achieves minimum 5-year patient-reported outcomes (PROs) and survivorship comparable to primary labral reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was conducted of patients undergoing labral reconstruction between June 2008 and December 2019. Inclusion required a minimum 5-year follow-up for PROs, including the Nonarthritic Hip Score, International Hip Outcome Tool-12, and Hip Outcome Score-Sports Specific Subscale. Exclusion criteria included Tönnis grade >1, preexisting hip conditions, lateral center-edge angle <20°, active workers' compensation claims, and intraoperative gluteus medius repair. Revision cases (n = 36) were matched 1:1 with primary reconstruction cases (n = 36) based on age, sex, body mass index, lateral center-edge angle, and capsular treatment strategy. RESULTS: Preoperatively, the primary reconstruction cohort had greater cartilage damage but higher baseline scores for the Nonarthritic Hip Score, International Hip Outcome Tool-12, and Hip Outcome Score-Sports Specific Subscale ( CONCLUSION: Labral reconstruction during primary and revision hip arthroscopy showed significant, durable clinical improvements over a minimum 5-year follow-up. Midterm outcomes were comparable, highlighting the efficacy of revision reconstruction in appropriately selected patients.

BACKGROUND: Periacetabular osteotomy (PAO) is a common procedure for the treatment of symptomatic acetabular dysplasia in adolescent patients. Despite concerns regarding surgical outcomes and complications in patients with hypermobility spectrum disorders (HSD), the outcomes of PAO in such patients are not well documented. METHODS: We conducted a retrospective cohort review of patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Radiographic parameters including the lateral center edge angle of Wiberg (LCEA), medial center edge angle (MCEA), anterior wall index (AWI), posterior wall index (PWI), and Tönnis angle were measured. Patient-reported outcomes (PROs) were also collected. RESULTS: The mean duration of follow-up of non-HSD and HSD patients was 2.86 ± 0.73 years and 3.00 ± 1.11 years, respectively. No significant differences were found in mean age ( P = 0.289), sex, body mass index ( P = 0.125), laterality ( P = 0.192), or the duration of follow-up ( P = 0.636). Postoperatively, LCEA and AWI in patients with HSD were higher than those in non-HSD patients ( P = 0.002, P = 0.007, respectively). No notable differences were observed in Modified Harris Hip Score, Nonarthritic Hip Score, International Hip Outcome Tool, Hip Dysfunction and Osteoarthritis Outcome Score, or mean changes in PROs between the non-HSD and HSD groups at preoperative, 1-year postoperative, and most recent follow-up timepoints. However, patient-reported satisfaction with surgery in the HSD group (9.39 ± 1.04) was significantly higher than the non-HSD group (8.35 ± 1.95; P = 0.047). CONCLUSION: Patients with HSD exhibited similar outcomes to patients without HSD after PAO for symptomatic acetabular dysplasia. Postoperative AWI and LCEA were markedly greater in patients with HSD consistent with our technical bias toward increased correction in such hips, suggesting greater anterolateral coverage of the femoral head after PAO may be a promising strategy to achieve improved outcomes in patients with HSD.

Secondary osteoarthritis, a degenerative joint disease, is often precipitated by well‑characterized etiological factors, with developmental dysplasia of the hip (DDH) emerging as a leading contributor. Despite its clinical importance, the intricate molecular and cellular cascades triggered by the biomechanical perturbations associated with DDH remain poorly understood. In the present study, a swaddling‑induced rat model of DDH was successfully developed, which recapitulated key pathological features including acetabular labral tears and cartilage degeneration. Through comprehensive mRNA‑sequencing analysis of acetabular cartilage samples from rats with DDH, a notable upregulation of dual‑specificity phosphatase 26 (DUSP26) was identified, a protein with previously unreported roles in joint homeostasis. Subsequently, in an

Patients with acetabular dysplasia frequently develop early-onset osteoarthritis due to insufficient femoral head coverage and hip instability, leading to compensatory gait adaptation. This study aimed to elucidate three-dimensional gait kinematics of the pelvis and lower limbs in these patients by analyzing the peak range of motion, as well as the timing and duration of joint movement throughout the gait cycle, using statistical parametric mapping. We examined 25 patients with acetabular dysplasia (mean age: 27.4 years) and compared them with 25 healthy controls (mean age: 29.4 years). Gait was assessed using a motion capture system, and pelvis and lower-limb joint angles (hip, knee, and ankle) in the sagittal and coronal planes were evaluated using a rigid-body model. Compared with controls, patients exhibited increased anterior pelvic tilt, reduced pelvic hike on the non-weight-bearing side, decreased hip extension, and increased hip and knee flexion. Ankle motion showed reduced plantarflexion and significantly increased eversion. These findings highlight characteristic compensatory gait patterns in acetabular dysplasia, especially involving pelvic and ankle movements. Understanding kinematic adaptations may facilitate effective surgical planning and postoperative rehabilitation protocols to improve functional outcomes.

PURPOSE: Focal labral ossification is a recognized radiographic finding in developmental dysplasia (DDH) and is typically regarded as a chronic lesion resulting from excessive stress on the chondro-labral junction. The necessity for direct surgical intervention at the time of periacetabular osteotomy (PAO) for these ossifications remains a subject of debate. This study aimed to explore the natural course of pre-existing focal labral ossifications following isolated PAO in adolescents and adults, hypothesizing that biomechanical correction alone would facilitate the spontaneous resolution of this focal labral metaplasia. METHODS: A retrospective observational subgroup analysis of an institutional database identified a single treatment group who underwent isolated PAO for symptomatic DDH in adolescents and adults between January 2022 and November 2024. Pre- and 1-year postoperative radiographs were independently assessed for the status of the labral ossification. Radiographic parameters of acetabular coverage and validated patient-reported outcome measures (PROMs) were compared between hips with and without ossification. Multivariable regression analysis was performed to identify factors associated with labral ossification. RESULTS: Of 389 hips undergoing PAO, 41 (10%) demonstrated preoperative labral ossification. Baseline PROMs and most radiographic parameters were comparable between hips with and without ossification, although posterior coverage was significantly reduced in the ossification group. At 1-year follow-up, 37 of 41 hips (90%) showed complete radiographic resolution of labral ossification, two hips (5%) demonstrated partial regression and two hips (5%) remained unchanged. Multivariable analysis identified a mild association between posterior coverage and the presence of ossification, while no associations were found with activity level or PROMs. CONCLUSION: Isolated PAO was found to be strongly associated with spontaneous remission of focal rim ossification in the vast majority of dysplastic hips within 1 year after surgery. These findings challenge the concept that focal rim ossifications represent irreversible degenerative pathology and instead suggest that they are a more appropriately interpreted as a metaplastic adaptation, indicating a remodeling potential of the chondro-labral junction following biomechanical correction alone. Routine surgical treatment of chronic labral ossifications at the time of PAO may therefore be unnecessary. LEVEL OF EVIDENCE: Level III.

Steroid-induced osteonecrosis of the femoral head (SONFH) is a challenging orthopedic disease worldwide. Previous research has long focused on bone structure repair; however, bone and muscle are now recognized as functionally interconnected units coupled through biomechanics throughout the lifespan. Recent studies suggest that SONFH is not an isolated single-organ disorder but rather aligns with a systemic comorbid state characterized by the synergistic decline of bone and muscle function. Understanding the pathophysiology of bone and muscle crosstalk in SONFH is essential for its prevention and treatment. In this review, we propose an integrated pathological framework-the four-axis pathological mechanism of bone and muscle crosstalk in SONFH. We elaborate in detail on the mechanisms of bone and muscle crosstalk along four pathological axes-blood supply, lipid metabolism homeostasis, inflammation-immune regulation, and mechanical transduction-as well as the cross-tissue signaling-mediated synergistic damage among these axes: Imbalance in the blood supply axis may contribute to parallel ischemia in bone and muscle via shared pathways such as decreased HIF-1α/VEGF and inhibited NO/eNOS, which has been associated with endothelial dysfunction and impaired angiogenesis; Dysregulation of the lipid metabolism axis promotes bone marrow adiposity and muscular lipid accumulation by modulating key factors such as PPARγ and PGC-1α, as well as signaling pathways including PI3K/Akt/mTOR; Activation of the inflammation-immune axis exacerbates bone resorption and muscle atrophy through pathways such as NF-κB and STAT3, along with imbalanced immune cell polarization; Abnormalities in the mechanical axis create a vicious cycle of bone-muscle co-deterioration due to reduced bone load-bearing capacity and diminished muscular support function. This review further highlights current research gaps, including the insufficient systematic analysis of multi-axis interactive mechanisms, the lack of in-depth verification of bone-muscle crosstalk via multi-dimensional technologies, and the limited research on multi-target combined interventions targeting the bone-muscle unit. It proposes that future studies should strengthen systematic investigation into the interactive mechanisms among multiple pathological axes and develop combined intervention strategies targeting both bone and muscle. This will provide important insights for establishing an integrated diagnostic and therapeutic model addressing both structure and function, as well as for developing future hip-preserving treatment strategies for SONFH.

AIMS: Periacetabular osteotomy (PAO) is technically demanding with an assumed steep learning curve. This systematic review and meta-analysis evaluated how surgeon experience influences operative efficiency, perioperative morbidity, radiological correction, and conversion to total hip arthroplasty (THA) in developmental dysplasia of the hip (DDH). METHODS: A systematic search of five databases identified studies comparing early with late PAO experience phases. Random-effects meta-analyses (Sidik-Jonkman with Hartung-Knapp adjustment) were performed for continuous (mean difference (MD)) and binary (odds ratios (ORs)) outcomes. Risk of bias was assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I), and certainty of evidence with Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS: In all, seven studies (499 patients, 556 hips) were included. Late-phase PAOs had significantly shorter operative times (MD -74.58 minutes, 95% CI -136.52 to -12.65). No significant differences were found for blood loss, complications, THA conversion, or radiological correction. Heterogeneity was high for operating time and blood loss, and most studies showed moderate risk of bias. CONCLUSION: Surgeon experience substantially improves operative efficiency in PAO, while complications, blood loss, radiological accuracy, and early THA conversion appear largely unaffected, likely reflecting structured supervision and high-volume training environments. The lack of significant differences in complications and radiological correction suggests that structured mentorship and centralized hip preservation programmes may mitigate early-phase risk. Standardized, prospective studies are needed to define proficiency thresholds and optimize training in hip preservation surgery.

BACKGROUND: Periacetabular osteotomy (PAO) is a well-established surgical intervention for symptomatic acetabular dysplasia in young, active patients. While radiographic and clinical outcomes are well documented, less is known about functional return to daily and athletic activities postoperatively. This study aimed to assess post-PAO return to activity, including sport, school, work, driving, and sexual activity. METHODS: A survey was distributed to 276 patients (348 hips) who underwent PAO in the last 10 years at a single institution, with 85 respondents (118 hips), and a response rate of 31%. Patients were asked about their activity levels and daily life preoperatively and postoperatively. RESULTS: The average age at surgery was 25 years (SD = 6.5), with a mean follow-up of 5.1 years (range, 0.4 to 11.2). Return to school (n = 35) and work (n = 62) occurred within 12 weeks for the majority of patients. Driving (n = 54) resumed within 6 weeks for 55% of patients. Sexual activity (n = 49) resumed within 9 weeks for 61.3% of patients, with hip pain (94.6%) and muscle weakness (54.1%) being the most common challenges. Among preoperative athletes, 70.1% returned to sport, primarily at a recreational level, while 27.3% of those who did not play sports preoperatively initiated a sport postoperatively. CONCLUSIONS: Most patients successfully returned to daily activities following PAO within 3 months, though many experienced moderate difficulties, particularly due to hip pain and muscle weakness. While return to sport was less frequent and often at a lower level of competitiveness, improvements in physical function were evident through patient-reported outcomes. These findings offer valuable guidance on expected recovery following PAO for both patients and providers, while underscoring the importance of targeted rehabilitation to address persistent functional limitations and promote return to daily life.

PURPOSE: Periacetabular osteotomy (PAO) is an established treatment for DDH with generally favourable outcomes. Although developmental hip dysplasia (DDH) is more prevalant in females, it remains unclear whether male patients achieve comparable patient reported outcome, with some studies suggesting inferior outcome in men. The aim of this study was to evaluate short-term outcomes of PAO in male versus female hips. METHODS: A prospective PAO registry was utilized and predefined inclusion criteria applied. A total of 282 hips (44 male, 238 female) that had undergone PAO surgery between 2022 and 2024 by a single surgeon were included. Radiographic measures and patient-reported outcome measures (PROMs), including the University of California, Los Angeles activity scale (UCLA), Hip Disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), international hip outcome tool-12 (iHOT-12), Harris hip score (HHS), modified Harris Hip Score (mHHS) and Postel-Merle d'Aubigné (PMA) score, were assessed preoperatively and at final follow-up and compared between sexes. RESULTS: Preoperatively, male patients had higher BMI (27.07 vs. 25.01, CONCLUSION: The findings of this study demonstrate that there are no significant sex-related differences in the clinical burden of DDH or in short-term outcomes after PAO in patients with this diagnosis. Both males and females showed substantial improvement after PAO, indicating that the procedure provides similarly favourable outcomes for both sexes. Based on these results, gender should not influence decision-making in PAO surgery. LEVEL OF EVIDENCE: Level III.