2026年7月 保髋进展 JCR Q3+Q4

BACKGROUND: In Japan, secondary screening for developmental hip dysplasia has expanded. However, the capacity of screening programs has outpaced the availability of ultrasonography and the number of clinicians who perform and interpret examinations outside tertiary centers. Plain radiography is widely accessible; however, interpreting images in infants can be challenging. This study developed and validated a deep learning-based system to support radiographic diagnosis and test a prespecified two-step triage strategy for clinical use.

METHODS: Overall, 1188 anteroposterior pelvic radiographs of infants aged 2-12 months were retrospectively analyzed. Three non-overlapping test subsets (50 images each) represented routine screening, images without a visible femoral-head ossification center, and images from external hospitals; the remainder were used for training and internal validation. The system generates measurements and the International Hip Dysplasia Institute grades for each radiograph. All test images were independently graded by two pediatric orthopedic surgeons, and the consensus served as a categorical reference. The agreement was summarized using the intraclass correlation coefficient for measurements and quadratic-weighted kappa for grades. The triage strategy was as follows: (1) no further imaging or referral when both hips were grade 1, and (2) high-priority alert when either hip was grade ≥2 and/or the acetabular angle was at least 25°.

RESULTS: Agreement for the principal measurement between the system and each reader was 0.83-0.84 by intraclass correlation, comparable to inter-reader agreement (0.81), with small biases and acceptable limits of agreement. For grades, quadratic-weighted kappa was 0.63-0.75 across subsets, with disagreements mainly between adjacent categories. With a 25-degree cutoff, the triage strategy achieved sensitivities of 0.75-0.93 and specificities of 0.62-0.95 across subsets.

CONCLUSIONS: The system supported radiographic screening decisions across diverse images typical of this age range, achieving comparable agreement with clinicians. Therefore, a prospective multicenter evaluation with thresholds adjusted for age and location is required.

BACKGROUND: Femoral varus osteotomy (FVO) is a common treatment for Legg-Calve-Perthes disease (LCPD). Due to concerns of decreased hip abductor strength, neck-shaft angle (NSA), and articular-trochanteric distance (ATD), concomitant greater trochanteric apophysiodesis (GTA) is often performed. While abductor strength remains a concern, no studies have quantified hip strength following FVO+GTA. The purpose of this study was to objectively quantify hip strength in patients treated with FVO+GTA using isokinetic testing and analyze contributors to abductor weakness.

METHODS: A retrospective review was conducted for 26 patients who underwent unilateral FVO+GTA at Waldenström stages 1b-3a, and hip strength testing in stages 3b-4 using an isokinetic dynamometer. The strength of the operated side was compared with the contralateral side. Clinically significant abductor weakness between the contralateral and operated side was set at ≥25% based on previous data.

RESULTS: The mean age at diagnosis was 7.7±1.2 years (range: 5.9 to 9.6) and the time from surgery to testing was 3.3±1.3 years (range: 1.8 to 6.1). While the operated side showed significant decreases in NSA ( P <0.001) and ATD ( P =0.002) compared with the contralateral side, no significant difference in the abduction strength between sides was observed with a paired t test ( P =0.15). However, when patients were grouped by those who did only home exercises (n=11, 42%) versus outpatient physiotherapy (n=15, 58%), the home exercise group showed significantly weaker abduction strength on the operated side compared with the contralateral side with a paired t test ( P =0.027), whereas the outpatient physiotherapy group was insignificant ( P =0.93). In addition, all 4 patients who had abductor weakness ≥25% on the operated side were in the home exercise group.

CONCLUSIONS: Following FVO+GTA, only 4 out of 26 patients (15%) had clinically significant abductor weakness, all of whom did only home exercises. We recommend outpatient physiotherapy after FVO+GTA to obtain more symmetrical abduction strength.

LEVEL OF EVIDENCE: Level III.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder that is often missed on initial presentation due to subtle radiographic findings, leading to significant complications. Traditional diagnostic methods like Klein's line are subjective and prone to inter-observer variability. This study aimed to develop and validate an attention-guided deep learning model to automatically identify SCFE on pediatric pelvic radiographs.

METHODS: A total of 174 pelvic radiographs (139 training, 35 testing) were retrospectively collected. A two-stage model was developed: first, a U-Net++ model segmented the femoral head to define an anatomic region of focus (ROF). Second, an attention-guided EfficientNet B1 model, trained to focus specifically within the ROF, classified radiographs as "SCFE" or "no SCFE." Model performance was evaluated on the testing set using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity.

RESULTS: The SCFE detection model demonstrated an AUC of 0.893, accuracy of 91.4%, sensitivity of 93.3%, and specificity of 90.0%. Gradient-weighted Class Activation Mapping (Grad-CAM) visualizations confirmed that the model's predictions were based on the anatomically relevant ROF.

CONCLUSIONS: The attention-guided deep learning model detected SCFE with high diagnostic accuracy. The anatomically informed attention mechanism provides interpretability, improving its utility within clinical settings. This automated tool demonstrates potential as a clinical decision-support system to reduce diagnostic delays and improve the consistency of SCFE detection.

LEVEL OF EVIDENCE: Level III.

BACKGROUND: Periacetabular osteotomy (PAO) has historically been contraindicated in children with hip dysplasia and open triradiate cartilage because of concerns that osteotomy through the triradiate might disrupt acetabular development. This preliminary study reports early outcomes of PAO for hip dysplasia in patients approaching skeletal maturity (aged 8 to 12 y or younger) with open triradiate cartilage.

METHODS: We performed a retrospective review of patients with hip dysplasia and open triradiate cartilage who underwent PAO between 1994 and 2019. Primary outcomes included changes in lateral center edge angle (LCEA), anterior center edge angle (ACEA), and acetabular index (AI), discontinuity along Shenton's line, extrusion index, triradiate width, and Tonnis grade preoperatively, postoperatively, and at final follow-up. Secondary outcomes included comparisons of radiographic parameters between the operative hip and the contralateral nonoperative hip, preoperative and postoperative patient-reported outcomes, and complications, including intraoperative intra-articular fractures, osteotomy nonunion, and premature triradiate closure. Descriptive statistics characterized the study population. Linear mixed-effects regression models and Cochran Q tests compared clinical and radiographic outcomes preoperatively, postoperatively, and at final follow-up. Differences between operative hips and contralateral nonoperative hips were analyzed using paired t tests or Wilcoxon signed-rank tests.

RESULTS: Thirteen patients were included. The mean age was 11.04 years (range: 8.05 to 12.82 y), and the mean follow-up was 3.79 years (range: 0.51 to 8.39 y). The mean LCEA increased 21.08 degrees immediately after PAO (preoperative 5.61±10.41 degrees; postoperative 26.69±8.82 degrees; P <0.01). This change was maintained at final follow-up (23.14±9.14 degrees; P <.01). Premature triradiate closure occurred in 5/13 patients (38.5%). No hips progressed in Tonnis Grade during the study period. Neither intra-articular fracture nor osteotomy nonunion was noted.

CONCLUSIONS: This preliminary study demonstrates that PAO can safely treat hip dysplasia in young adolescents with open triradiate cartilage, with good short-term outcomes. Despite premature triradiate closure in 38%, immediate postoperative correction of acetabular dysplasia remained satisfactory at final follow-up. Further studies are warranted to determine long-term outcomes.

LEVEL OF EVIDENCE: Level IV-case series.

BACKGROUND: Avascular necrosis (AVN) is associated with poor outcomes in pediatric hip disorders, including developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE), and Legg-Calve-Perthes disease (LCPD). Perfusion MRI (pMRI), a dynamic assessment of femoral head perfusion, and contrast-enhanced MRI (CE-MRI), a static assessment of femoral head perfusion, might be able to predict femoral head hypoperfusion, particularly before the onset of irreversible structural change, and the progression of structural changes once perfusion has been compromised, improving therapeutic options and outcomes.

METHODS: A systematic review was conducted in accordance with the Cochrane Handbook for Diagnostic Test Accuracy and PRISMA guidelines. MEDLINE, Embase, Web of Science, and Cochrane databases were searched from inception to October 2025. Studies assessing pMRI or CE-MRI as a diagnostic or prognostic tool for AVN of the femoral head in patients under 18 years were included. Diagnostic accuracy for AVN screening, prognostic associations with femoral head deformity, and validated radiographic scoring systems were included as outcomes. The risk of bias was assessed using the QUADAS-2 and QUIPS tools.

RESULTS: Thirteen studies comprising 538 patients (567 hips) met the inclusion criteria. Nine evaluated pMRI or CE-MRI as screening tools for AVN in DDH and SCFE, and 4 assessed prognostic value in LCPD. Analysis using weighted averages demonstrated a sensitivity of 90%, specificity of 60%, positive predictive value (PPV) of 58%, and a negative predictive value (NPV) of 90% for pMRI. Prognostic studies consistently showed associations between femoral head hypoperfusion and adverse radiographic outcomes, including higher lateral pillar class, increased deformity index, and worse sphericity deviation scores.

CONCLUSION: Perfusion MRI has potential as a screening tool for early detection of AVN in pediatric hip disorders and as a prognostic indicator in LCPD. However, heterogeneity in the data and a limited number of included studies mandate cautious interpretation of the results. High-quality prospective studies are necessary to validate clinical utility.

LEVEL OF EVIDENCE: Level III-systematic review of level-III studies.

The purpose of this study is to report outcomes of patients with Diabetes Mellitus (DM) who underwent hip arthroscopy for femoroacetabular impingement (FAI) at short- to mid-term timepoints comparing these results to a control group of non-DM patients. Data were retrospectively analyzed for patients who underwent primary hip arthroscopy for FAI with a history of DM. Patients had completed pre- and postoperative patient-reported outcomes (PROs) at a minimum 2-year follow-up, including clinically important thresholds for hip arthroscopy, revision surgery, and conversion to arthroplasty. Subanalysis was conducted based on glycemic control. Patients were propensity matched to a control group of nondiabetic patients in a 1:3 ratio. A total of 116 patients were included, with 29 DM patients matched to 87 control patients. DM patients displayed significant improvements across all PROs and high patient satisfaction. No significant differences were observed in the sub-analysis. When compared to a control group, DM patients had lower preoperative PROs and reached similar postoperative scores. DM patients had significantly lower patient satisfaction (7.70 ± 2.43 compared to 8.63 ± 1.57 in the control group P < .05.) at the latest follow-up and had a higher relative risk for revision hip arthroscopy (P < .05). Hip arthroscopy for the treatment of FAI in DM patients resulted in significant short- to mid-term improvements in PROs, comparable to a matched control group. DM patients had an overall 2.63-fold increased relative risk of revision hip arthroscopy compared to non-DM patients, with a trend toward more uncontrolled DM patients undergoing revision hip arthroscopy. Perioperative diabetic control is recommended.

Hip dysplasia is currently diagnosed with two-dimensional radiographic measurements that may not adequately describe the aetiology of pain and dysfunction associated with dysplastic deformity and future osteoarthritis progression. This study aimed to assess how accurately two-dimensional radiographic measurements represent the three-dimensional mechanical joint environment. Spearman ρ correlation was used to determine associations between radiographic measurements of hip dysplasia made on pre-operative and 6-month post-operative standing AP pelvis radiographs, and hip contact stress calculated based on pre- and post-operative pelvis CT scans for a series of 100 patients (125 dysplastic hips) treated with periacetabular osteotomy using discrete element analysis. Only moderate correlations were observed between radiographic measurements and contact mechanics. Pre-operative lateral centre edge angle of Wiberg had the highest, though moderate, correlation with mean cumulative contact stress-time exposure (ρ = -0.5112, P < .0001). Tönnis angle (ρ = 0.4898, P < .0001) and extrusion index (ρ = 0.4579, P < .0001) also had moderate correlations with pre-operative mean cumulative contact stress-time exposure. Only weak correlations were found post-operatively and when comparing change in radiographic measurements to computational contact mechanics metrics before and after surgery. These findings indicate the mechanical environment of the hip joint is more complex than simple radiographic measurements that quantify coverage of the femoral head by the acetabulum. Evaluation of three-dimensional contact mechanics in dysplastic hips should be used in combination with two-dimensional radiographic evaluation for guiding clinical care for patients with hip dysplasia.

Recent studies for acetabular dysplasia (AD) have revealed its complex morphology and biomechanical implications. In this context, range of motion (ROM) assessment could provide insight into early functional changes not captured by static imaging. This retrospective study aimed to determine whether radiographic features of AD are associated with alterations in passive ROM among asymptomatic individuals. Participants (200 hips from 100 asymptomatic Asian volunteers aged 18 to 50 years) underwent standardized physical and radiological examinations to assess passive hip ROM and AD. Passive ROM comparisons were made between AD and non-AD groups. Subgroup analyses for posterior signs and coxa profunda were performed within the AD group. Compared to the non-AD group (n = 148), the AD group (n = 52) demonstrated significantly greater passive ROM in forward flexion (FF), abduction, adduction, and external rotation (P < .05 for all), with FF independently associated with AD presence (OR, 1.06; 95% CI, 1.01-1.11). In the AD group, sharp angle positively correlated with FF, abduction, and internal rotation (IR). Subgroup analysis revealed that posterior sign was associated with reduced FF, while coxa profunda was linked to increased FF and IR. Multivariate analysis confirmed that FF and IR were independently associated with these morphological features. Additionally, participants with coxa profunda exhibited significantly higher sharp angles. Hips with AD demonstrated greater ROM compared to non-dysplastic hips, with sharp angle showing the strongest correlation with hip joint ROM. Subgroup analysis revealed distinct motion patterns: posterior sign was associated with reduced FF, while coxa profunda correlated with increased IR.

Patients electively undergo the treatment of symptomatic acetabular dysplasia by periacetabular osteotomy (PAO). Increasing evidence suggests that a patient's perception of success following orthopaedic surgery is influenced by their preoperative expectations. In response, the Hip Preservation Surgery Expectations Survey (HPSES) was developed to quantify improvement expected and received in domains of pain, function, and psychological well-being. This instrument has not yet been evaluated in a hip preservation sample postoperatively, consistent with a paucity in the literature regarding patient-derived goals. Therefore, the purpose of this study was to describe the fulfilment of expectations following PAO through the HPSES and collection of preoperative personal goals. Preoperatively and at 1-year, 80 participants undergoing PAO (mean age 27.5 ± 9.2 years, 98.8% female) completed the HPSES and/or personal goals surveys. A proportion was calculated as the amount of improvement received versus the amount of improvement expected. The average expectations proportional score was 0.97 with 51.6% achieving a proportional score ≥ 1.0. The average goals proportional score was 0.91 with 50.0% achieving a proportional score ≥ 1.0. Expectations and goals related to day-to-day function, social activity, routine exercise, and relieving stress and anxiety were met most often and correlated to improvement and satisfaction scores. Goals related to high-level physical activity and pregnancy were met less often. Higher preoperative expectations and less attainable goals were associated with lower fulfilment. The appraisal and management of appropriate and realistic goals hold considerable value in achieving patient-perceived satisfaction. PAO is successful in fulfilling expectations related to routine function, social activity, and psychological well-being.

Acetabular labral reconstruction has proven to be a good option for treatment of irreparable labral tears. The purpose of this manuscript is to demonstrate the graft integration in patients who undergo acetabular labral reconstruction with use of allograft. Data were prospectively collected on patients undergoing hip arthroscopy between September 2008 and June 2023 and retrospectively reviewed. The inclusion criteria were patients who underwent hip arthroscopy with labral reconstruction and subsequently underwent a second look arthroscopy for revision surgery. The quality of the integration of the graft used in the previous labral reconstruction was examined by analysing pictures taken during the revision arthroscopy procedure. Three different characteristics of the labral graft were assessed: graft integrity, chondrolabral junction restoration, and anastomosis. There were 12 hips (11 patients) who had labral reconstruction performed in the index surgery with either labral debridement or no labral treatment performed in the revision surgery. There were six females and five males with a mean age of 35.3 years. The mean body mass index was 25.7. The average time between surgeries was 29.5 months. Ten out of 12 hips (83%) were found to have good quality of the graft integrity, with 11 out of 12 labral reconstructions (92%) achieving chondrolabral junction restoration and good anastomosis. Acetabular labral reconstruction demonstrated graft integration at a very high rate. Based on these results, labral reconstruction seems to be a biologically reliable option for irreparable labra with the ability to restore the labral anatomy.

Periacetabular osteotomy (PAO) has demonstrated favourable outcomes for the treatment of acetabular dysplasia. Minimally invasive (MI) PAO uses a smaller incision to preserve soft tissue, minimize complications, and accelerate recovery; however, the outcomes of MI PAO are still being established. The purpose of this study was to conduct a systematic review to assess the reoperation rates and patient-reported outcomes following MI PAO. A systematic review of the literature was conducted in PubMed, CENTRAL, and Scopus in April 2024 with the following keywords: (mini*) AND (periacetabular osteotomy"). The PRISMA criteria were used. Only studies that reported on patient-reported outcome measures (PROMs) of MI PAO techniques were included. Eight studies with study periods ranging between 2004 and 2021 including a total of 2247 hips were included in this review. Mean follow-up ranged from 12 to 60 months. The mean age at the time of surgery ranged from 20.0 to 38.7 years, and 85.6% of included hips were from female patients. Seven out of 8 included studies reported significant improvement in preoperative vs postoperative PROMs. The mean Non-Arthritic Hip Score ranged from 49.8 to 58.7 preoperatively compared to 77.2-89.4 postoperatively. Mean UCLA scores ranged from 3.9 to 4.67 preoperatively to 6.3-6.97 postoperatively. Mean Harris Hip Scores ranged from 50.8 to 66 preoperatively compared to 87.4-93 postoperatively. Conversion to THA rates ranged from 0% to 5.3% at a mean of 4.9 years (0.6-14). Patients undergoing MI PAO surgery for the treatment of acetabular dysplasia demonstrated low rates of conversion to THA and significant improvement in PROMs at short- to mid-term follow-up.

PURPOSE: This study aims to determine differences in joint space width (JSW) between hips with femoroacetabular syndrome (FAIS) and instability, and to investigate the influence of several hip morphological measures on JSW.

METHODS: A retrospective review of symptomatic female hips, which used standing anterior-posterior x-rays to measure JSW at the medial, superior, and lateral acetabular sourcil, was conducted. Hips were grouped by radiographic indices, collected from 3D-reconstructed models, into cam-femoroacetabular impingement (FAI), pincer-FAI, mixed-FAI, mild instability, instability, and combined FAIS-instability. Associations between JSW and hip morphology measures, including lateral centre edge angle (LCEA), acetabular coverage, Tönnis angle, and femoral neck shaft angle (FNSA), were analysed.

RESULTS: In 493 symptomatic female hips, JSW at all locations was significantly lower in pincer hips compared to all other pathology groups (P < .05), with the exception of mixed-FAI hips (P > .4). Hips with isolated instability and combined instability-FAI morphology had significantly greater JSW than pincer- and mixed-FAI groups (P < .05). There were no significant JSW differences between instability and combined FAI-instability groups at any location (P > .1). Acetabular coverage, LCEA, Tönnis angle, and FNSA were significantly associated with JSW (P < .001). No significant associations were observed for acetabular version (P > .05) or femoral torsion (P > .05).

CONCLUSION: Differences in JSW across groups highlight the influence of femoroacetabular morphology and orientation in pre-arthritic hips. In patients with naturally decreased JSW and no other findings of osteoarthritis, attention should be given to evaluation for pincer-FAI. In contrast, in patients with naturally increased JSW, instability findings should be thoroughly evaluated.

The supraacetabular fossa (SAF) is a bony fossa in the acetabular roof's load-bearing region. Its role in acetabular development and hip morphology remains unclear, with potential implications for hip preservation procedures. We aimed to (i) determine the prevalence of SAF by age, (ii) measure its dimensions in patients with hip pain undergoing magnetic resonance (MR) arthrogram, and (iii) assess associations between SAF and acetabular or femoral morphologies. We performed a retrospective analysis of patients with hip pain who underwent MR arthrograms. SAF were classified as type 1 (unfilled) or type 2 (cartilage-filled), and its dimensions measured. Acetabular and femoral morphology were assessed on radiographs, and hips were categorized into 13 morphology groups. 697 hips from 615 patients were included. SAF was present in 10.9% (76/697) of hips, with affected patients being younger (24.3 ± 7.6 years) than those without SAF (31.8 ± 11.2 years, P < 0.001). Type 1 SAF had a mean depth of 3.1 mm versus 4.8 mm for type 2 (P < 0.001). SAF prevalence was 30.8% in acetabular protrusion and 5.2% in dysplasia (P = 0.0135). Acetabular protrusion (OR 3.78, P = 0.03) were risk factors for SAF, but no associations were found with femoral morphology. SAF occurs predominantly in patients under 25 years and is nearly six times more common in acetabular protrusion than dysplasia. Future studies should investigate the implications of SAF on acetabular rim trimming and reorientation procedures, particularly focusing on their effect on residual joint contact forces.

The study aims to evaluate our experience of the Bernese periacetabular osteotomy (PAO) in patients with neurogenic hip dysplasia. Retrospective data were collected for patients with neurogenic hip dysplasia, managed with PAO over a 10-year period. Data were collected for 20 consecutive patients (23 hips). Mean age at the time of surgery was 15 years (range 12-31). 85% had a diagnosis of cerebral palsy (GMFCS 1(18%), 2(18%), 3(35%), 4(12%), 5(18%)). Mean follow up was 47 months. Electronic records were reviewed for outcomes. Pre- and post-operative radiographs were evaluated separately by two independent assessors using TraumaCad software. Post-operative radiographic evaluation was available for 20 patients (21 hips). The median lateral centre edge angle was corrected from -1° pre-operatively (range: -58° to 25°) to 42° post operatively (range: 15° to 65°). Tönnis angle was corrected from an average of 26° pre-operatively (range: 10° to 37°) to 9° post-operatively (range: -19 to 29). Reimer's index decreased from an average of 50% (range: 27% to 93%) to 7% (range 0% to 25%) post-operatively. At the latest follow there was absence of pain in 16 patients. Our experience has demonstrated safe use of the PAO, in conjunction with soft tissue procedures and femoral osteotomy, in the management of neuromuscular patients. In this cohort there was stable reduction of the hip in all but two patients (three hips), and effective pain management for this challenging patient group.

The fovea capitis anchors the ligamentum teres on the femoral head. In normal hips, it resides within the acetabular fossa. However, clinical observations suggest that its position and morphology vary in pathological hips, potentially contributing to joint degeneration through fossa-foveolar mismatch (FFM). Understanding the fovea's morphology is essential to clarifying its role in hip pathomechanics. We asked: (i) what is the proportion of the femoral head occupied by the fovea; (ii) what is the position of the fovea relative to the acetabular fossa; and (iii) what is the FFM index in a defined neutral position for different pathological and normal hips. Using three-dimensional models from computed tomography scans, we analysed 183 hips with femoroacetabular impingement or dysplasia and 22 with normal morphology. Using a standardized medial view of the fovea through the fossa, we determined: (i) the proportion of the fovea surface area on the femoral head; (ii) the positioning of the fovea relative to the fossa; and (iii) FFM indices in all study groups. (i) In normal hips, the fovea accounted for a median of 7% of the femoral head surface. (ii) While the fovea was positioned centrally in normal hips, dysplastic hips demonstrated an anterosuperior displacement of the fovea. (iii) Dysplastic hips had the highest FFM indices (median 0.13; P < .001). This study highlights variations in foveal morphology across different hip pathomorphologies. Foveal size was generally consistent. Foveal position differed markedly, with dysplastic hips showing anterosuperior displacement and the highest FFM indices. These results suggest that altered foveal morphology may contribute to pathological contact and degenerative lesions.

Femoral osteotomy is an effective surgical intervention for correcting torsional deformities that contribute to hip instability and femoroacetabular impingement. However, traditional osteotomy techniques require extensive soft tissue dissection, disrupt the femoral canal, and complicate future total hip arthroplasty. Additionally, traditional approaches frequently involve multiple incisions when combined with other procedures, prolonging recovery and increasing morbidity. The direct anterior approach (DAA) offers a minimally invasive alternative that preserves the femoral anatomy while enabling simultaneous intra-articular interventions. This technique provides access to the femoral neck for varisation, valgisation, and rotational osteotomies while preserving critical vascular structures. Moreover, the DAA facilitates concurrent hip arthroscopy, periacetabular osteotomy, and cartilage restoration procedures. We describe the DAA for femoral neck osteotomy to correct torsional deformities and discuss its potential benefits in optimizing surgical outcomes.

INTRODUCTION: Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle.

METHODS: A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles.

RESULTS: After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery.

CONCLUSIONS: Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.

The spectrum of hip pathology treated by hip preservation surgery ranges from femoroacetabular impingement to hip dysplasia. Borderline hip dysplasia (BHD) represents a challenging diagnosis where the surgical indication is not always clear. BHD is a complex pathology which presents challenges in surgical decision-making between hip arthroscopy and open surgery, specifically periacetabular osteotomy. Research has shown efficacy for both isolated hip arthroscopy and/or periacetabular osteotomy as a treatment option in the appropriately selected patients.

INTRODUCTION: Avascular necrosis (AVN), chondrolysis, and or trauma to the femoral head with acetabular labrum involvement leads to predictable end-stage osteoarthritis of the hip. A hip preservation procedure that restores articular integrity and delays osteoarthritis is needed. Osteochondral allograft transplantation (OCAT) is a potential solution but may fail if other intra-articular pathology is not addressed. We describe our detailed surgical technique that addresses femoral head osteochondral lesions and irreparable acetabular labral pathology, through OCAT and fresh meniscus allograft transplantation (MAT) as a follow-up to our previously published clinical series.

MATERIALS AND METHODS: The surgical technique described is to address femoral head article cartilage defects >2 cm2 (grade III or IV). Via open surgical hip dislocation, fresh OCAT was used to address the femoral head articular cartilage defects and fresh MAT was used for irreparable acetabular labral deficiency. Femoral head OCAT was performed using either cylindrical grafts or custom-cut patient-specific shell grafts preserved with the Missouri Osteochondral Preservation System (MOPS). For acetabular labral reconstruction, standard recipient site preparation was performed. MOPS-preserved medial or lateral meniscus allografts were used based on the recipient labrum's radius of curvature. Suture anchor fixation was used to secure the graft. Labral allograft fixation was performed with the hip reduced from anterior to posterior using the preplaced knotless anchors. A posterior junctional suture was used to fix the graft to the native labrum.

CONCLUSIONS: A surgical technique combining fresh OCAT and fresh MAT is presented to provide a hip preservation surgery option that addresses femoral head and acetabular labrum pathology to minimise the risk of disease progression.

Developmental dysplasia of the hip (DDH) represents a wide range of abnormalities affecting the acetabulum and femoral head. Traditional diagnostic tools such as anteroposterior pelvic radiographs are limited in evaluating the three-dimensional morphology of the acetabulum, especially in pediatric populations. This study introduces novel measurement parameters that include both angular and dimensional metrics for a comprehensive assessment of acetabular morphology. It also compares these parameters between normal and dysplastic hips in pediatric population. Computed tomography scans of 35 children with unilateral DDH, aged between four and 48 months, were analyzed, comparing dysplastic and normal hips. Parameters measured included anterior and posterior acetabular indexes and lengths, anterior and posterior coverage angles, lengths, and posterior coverage area, dome length and dome coverage. Statistical analyses evaluated differences between groups. Dysplastic hips exhibited higher anterior and posterior acetabular index values and reduced anterior and posterior acetabular lengths, reflecting global elongation and shallowness. Anterior coverage angle was significantly greater, while posterior coverage angle and posterior coverage parameters were reduced, highlighting posterior wall deficiencies. Dome coverage was also significantly decreased. All measurements showed good to excellent interobserver and intraobserver reliability (0.68-0.94 and 0.76-0.92, respectively). Our findings suggest that DDH involves global acetabular deficiencies, including posterior insufficiency, challenging the traditional focus on anterolateral deficiencies. The introduced parameters provide a reproducible method for evaluating pediatric acetabular morphology, offering valuable insights for diagnosis and treatment planning. Future studies should validate these findings and explore MRI for enhanced diagnostic accuracy.

Adolescent neuromuscular hip dysplasia involves abnormal acetabular morphology with insufficient coverage, femoral containment, and depth. The triple pelvic osteotomy (TPO) corrects acetabular orientation, while acetabuloplasty improves containment, but they are insufficient on their own for severe deformities where both coverage and depth are compromised; combining both procedures allows simultaneous correction of orientation and morphology. In this study, the feasibility and safety of this combined approach were evaluated in adolescents with steep acetabula and dysplasia. Between 2020 and 2023, patients with adolescent neuromuscular hip dysplasia underwent combined TPO-Dega acetabuloplasty. The radiographic outcomes included Sharp's angle, acetabular depth-width ratio, center-edge angle, migration index, and neck-shaft angle. The surgical time, blood loss, and complications were recorded. Five patients with cerebral palsy (mean age: 14.4, 11.5-16 years) underwent combined TPO-acetabuloplasty. The mean follow-up was 15.6 (12-24) months, mean surgical time was 294 (225-360) min, and mean blood loss was 469 (375-600) ml. Sharp's angle improved from 54° to 36° (51°-57° to 24°-42°), depth-width ratio from 0.12 to 0.24 (0.09-0.15 to 0.22-0.27), center-edge angle from -31.4° to 36.2° (-54.0° to 46.0°), and migration index from a mean of 83% (68-100%) to 0%, and neck- shaft angle from 165° to 125° (158°-170° to 121°-134°). No acetabular avascular necrosis or iliac nonunion was observed. Combined TPO-Dega acetabuloplasty appears to be a safe surgical option for adolescents with steep acetabula and dysplasia.