Perry L Schoenecker

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (151)264.86 Total impact

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    ABSTRACT: The Bernese periacetabular osteotomy (PAO) is frequently used to treat symptomatic acetabular dysplasia in the adolescent age group. Despite encouraging results, factors predictive of the development of postoperative complications remain poorly understood. The purpose of this study was to investigate whether obesity is a risk factor for complications following PAO in adolescents.
    Journal of pediatric orthopedics 11/2014; · 1.23 Impact Factor
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    ABSTRACT: Some patients opt to undergo conversion to a THA for continued pain or progression of hip arthritis after periacetabular osteotomy. Whether patients are at greater risk for postoperative complications, revision THA, poor clinical outcomes, or compromised radiographic results after periacetabular osteotomy is debatable.
    Clinical Orthopaedics and Related Research 10/2014; · 2.79 Impact Factor
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    ABSTRACT: Periacetabular osteotomy is a well-described surgical intervention for symptomatic acetabular deformities in skeletally mature patients. Data regarding return to athletic activity or sport after this procedure are still limited.
    The American journal of sports medicine. 06/2014;
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    ABSTRACT: The periacetabular osteotomy has become a common procedure for treating symptomatic acetabular dysplasia. Like other major hip procedures, there is concern regarding the risk of associated venous thromboembolic disease. Nevertheless, there is limited information regarding the need for screening, and optimal prophylactic measures have not been established. We sought to determine the frequency of thromboembolic events (deep vein thrombosis [DVT] and symptomatic pulmonary embolism [PE]) associated with the periacetabular osteotomy in in patients receiving aspirin and mechanical compression prophylaxis. We performed a retrospective review of 134 adult patients (149 hips) treated with the periacetabular osteotomy during an 8-year period. During this period, 136 (91%) of the hips treated with a periacetabular osteotomy were screened within 1 week for DVT, whereas 13 (9%) could not be evaluated for various reasons. The mean age of the patients at the time of surgery was 30 years (range, 18-60 years), and no patients were lost to followup during the 4 to 6 months after surgery. The same thromboembolic prophylactic regimen was used for all patients. This consisted of 325 mg aspirin twice a day and compression stockings for 6 weeks and lower extremity pneumatic compression devices while hospitalized. Screening bilateral lower extremity ultrasonography was performed within 1 week (mean, 4 days) of the procedure to detect asymptomatic DVTs. Of the 134 patients, two patients (two hips) with negative postoperative screening ultrasounds presented at 14 and 38 days postoperatively with clinical symptoms of DVT. Repeat ultrasound confirmed this diagnosis in both cases. There were no symptoms of PE. Screening venous ultrasonography did not identify any DVTs during the early postoperative period before discharge. These two patients were treated with 3 to 6 months of warfarin anticoagulation. Neither patient had persistent symptoms related to the DVT. These data indicate that the risk of symptomatic DVT associated with periacetabular osteotomy is low (1%) with use of aspirin and mechanical compression prophylaxis. Furthermore, routine postoperative screening did not detect any patients with an asymptomatic DVT. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 04/2014; · 2.79 Impact Factor
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    ABSTRACT: Purpose: To look at the rates of compartment syndrome (CS) occurs after intramedullary (IM) nailing of pediatric diaphyseal forearm fractures. Methods: In this retrospective case series, we reviewed the charts of all patients treated operatively for radius and ulnar shaft fractures from 2000-2009 at our institution and identified 113 patients who underwent IM fixation of both bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, seven grade II fractures, one grade IIIA fracture. We compared patients who did and did not develop CS to identify variables associated with post-operative CS. Indications for IM fixation included inability to obtain an acceptable reduction, loss of reduction, or the presence of an open fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. Results: CS occurred in three of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared to none of 74 closed fractures (p=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS post-operatively (168 vs 77 min, p<0.001). CS occurred within the first 24 post-operative hours in all three cases. Each patient required three subsequent operations until final wound coverage or closure. Conclusion: CS was an uncommon complication following IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. Prior literature has reported as increased risk of CS in patients treated with IM nailing within 24 hours of injury, but this was not corroborated in our study. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS, however 51% of these patients required a small open approach to aid reduction and nail passage. No closed fracture treated with IM fixation in this series developed CS, compared with up to 10% in other series. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.
    2013 American Academy of Pediatrics National Conference and Exhibition; 10/2013
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    ABSTRACT: Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. Level IV-Case Series.
    Journal of pediatric orthopedics 07/2013; · 1.23 Impact Factor
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    ABSTRACT: There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.
    Journal of pediatric orthopedics 06/2013; · 1.23 Impact Factor
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    ABSTRACT: Background: Symptomatic femoroacetabular impingement (FAI) is associated with hip pain, functional limitations, and secondary osteoarthritis. There is limited information from large patient cohorts defining the specific population affected by FAI. Establishing a large cohort will facilitate the identification of ‘‘at-risk’’ patients and will provide a population for ongoing clinical research initiatives. The authors have therefore established a multicenter, prospective, longitudinal cohort of patients undergoing surgery for symptomatic FAI. Purpose: To report the clinical epidemiology, disease characteristics, and contemporary surgical treatment trends in North America for patients with symptomatic FAI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Upon approval of the institutional review boards at 8 institutions, 12 surgeons enrolled consecutive patients undergoing surgical intervention for symptomatic FAI. Patient demographics, physical examination data, radiographic data, diagnoses, operative data, and standardized patient-reported outcome measures were collected. The first 1130 cases are summarized in this study. Results: A total of 1076 consecutive patients (1130 hips) were enrolled; 55% (n = 622) were female, and 45% (n = 508) were male, with an average age of 28.4 years and average body mass index (BMI) of 25.1. Demographics revealed that 88% of patients who were predominantly treated for FAI were white, 19% reported a family history of hip surgery, 47.6% of hips had a diagnosis of cam FAI, 44.5% had combined cam/pincer FAI, and 7.9% had pincer FAI. Preoperative clinical scores (pain, function, activity level, and overall health) indicated a major dysfunction related to the hip. Surgical interventions were arthroscopic surgery (50.4%), surgical dislocation (34.4%), reverse periacetabular osteotomy (9.4%), limited open osteochondroplasty with arthroscopic surgery (5.8%), and limited open by itself (1.5%). More than 90% of the hips were noted to have labral and articular cartilage abnormalities at surgery; femoral head-neck osteochondroplasty was performed in 91.6% of the surgical procedures, acetabular rim osteoplasty in 36.7%, labral repair in 47.8%, labral debridement in 16.3%, and acetabular chondroplasty in 40.1%. Conclusion: This multicenter, prospective, longitudinal cohort is one of the largest FAI cohorts to date. In this cohort, FAI occurred predominantly in young, white patients with a normal BMI, and there were more female than male patients. The disease pattern of cam FAI was most common. Contemporary treatment was predominantly arthroscopic followed by surgical hip dislocation. Keywords: FAI; hip arthroscopic surgery; surgical hip dislocation; epidemiology
    The American journal of sports medicine 05/2013; · 3.61 Impact Factor
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    ABSTRACT: Coxa profunda is commonly viewed as a radiographic parameter that is indicative of pincer-type femoroacetabular impingement, and this finding can impact diagnostic and surgical decision-making. Validation of coxa profunda as a measure of pincer-type femoroacetabular impingement has not been rigorously analyzed. Our hypothesis was that coxa profunda is a very common radiographic finding in females and is not a finding that is specifically associated with pincer-type femoroacetabular impingement. A retrospective review was performed to determine the prevalence of coxa profunda in four groups of hips: those with acetabular dysplasia (fifty-eight hips), femoroacetabular impingement (fifty hips), symptomatic residual Legg-Calvé-Perthes deformities (sixteen hips), and asymptomatic hips (thirty-three). Coxa profunda was present when the floor of the acetabular fossa touched or was medial to the ilioischial line. The association between coxa profunda and hip disorder diagnosis, lateral center-edge angle, acetabular inclination, patient age, and sex was analyzed. Coxa profunda was seen in 55% of the 157 hips and was slightly less common in the hips with acetabular dysplasia or residual Legg-Calvé-Perthes deformities (41% and 31%, respectively). Coxa profunda was evident in 76% of the thirty-three asymptomatic hips compared with 64% of the fifty hips with femoroacetabular impingement. Coxa profunda was more common in females than males (70% compared with 24%; p < 0.001). Acetabular overcoverage (a lateral center-edge angle of >40° or acetabular inclination of <0°) was seen in only 22% of hips with coxa profunda. Coxa profunda should be considered a normal radiographic finding, at least in females. Coxa profunda is a nonspecific radiographic finding, seen in a variety of hip disorders and asymptomatic hips. The presence of coxa profunda is neither necessary nor sufficient to support a diagnosis of pincer-type femoroacetabular impingement. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 03/2013; 95(5):417-23. · 3.23 Impact Factor
  • Margaret M Rich, Perry L Schoenecker
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    ABSTRACT: : Containment treatment is widely accepted in the management of Legg-Calvé-Perthes disease. Many reports indicate the need to regain hip motion before pelvic or femoral osteotomy, but have not indicated how osteotomy affected motion. Recent studies have suggested that osteotomy treatment of lateral pillar B hips may result in a higher proportion of spherical hips than those managed nonoperatively; however, outcomes for children older than 8 years of age or with pillar C involvement remain unsatisfactory. : The records of all patients with a diagnosis of Legg-Calvé-Perthes disease seen at our facility from 1985 through 2001 were reviewed. Two hundred and thirteen patients (175 males, 38 females), average age 6.4 years (range, 2.6 to 11.3 y), with 240 involved hips in the necrotic or the fragmentation stage were managed under a protocol to restore and maintain satisfactory hip abduction with an adductor tenotomy and abduction cast, followed by daily hip range-of-motion exercises and an A-frame orthosis to facilitate the concentric position of the epiphysis within the acetabulum. Assessment included measurement of hip abduction, femoral head sphericity and congruence, presence of femoral neck deformity, limb-length inequality, and later reconstructive surgical procedures. Hips were grouped by lateral pillar class (12A, 113B, 115C) and evaluated at maturity using a modified Stulberg grade. : All pillar A hips were spherically congruent. Of pillar B hips, 101 were spherically congruent, 8 were aspherical but congruent, and 4 were aspherical and incongruent. Of pillar C hips, 77 were spherically congruent, 26 were aspherical but congruent, and 12 were aspherical and incongruent. Age did not correlate with outcome. Hip abduction improved and was maintained in all groups. : Treatment that restored and maintained hip range of motion along with the use of an A-frame orthosis resulted in a high proportion of spherically congruent hips for patients of all ages irrespective of the extent of disease. Seventy-eight percent of pillar B and C hips were spherically congruent hips at maturity; overall, 93% of hips were congruent. This regimen has supplanted all other methods of treatment at our institution. : Level IV-case series.
    Journal of pediatric orthopedics 03/2013; 33(2):112-9. · 1.23 Impact Factor
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    ABSTRACT: Proximal femoral deformities and overcorrection of the acetabulum both can result in secondary femoroacetabular impingement and suboptimal clinical results after periacetabular osteotomy. The purpose of the present study was to determine the rate of complications, the need for reoperations, radiographic correction, and hip function among patients who underwent periacetabular osteotomy and combined femoral head-neck osteochondroplasty as compared with those who underwent periacetabular osteotomy alone. Patients who underwent periacetabular osteotomy with or without osteochondroplasty of the femoral head-neck junction were evaluated retrospectively after a minimum duration of follow-up of two years. We compared the two groups with regard to the modified Harris hip score, radiographic correction, complications, and reoperations. Forty patients (forty hips) who underwent periacetabular osteotomy in conjunction with a femoral head-neck osteochondroplasty were compared with forty-eight patients (forty-eight hips) who underwent an isolated periacetabular osteotomy. Patients were evaluated after a mean duration of follow-up of 3.4 years (range, 2.0 to 9.7 years). Preoperatively, the modified Harris hip score (and standard deviation) was 64.3 ± 13.2 for the study group and 63.2 ± 13.4 for the comparison group. At the time of the latest follow-up, the modified Harris hip score was not significantly different between the study group and the comparison group (p = 0.17). Patients demonstrated equivalent preoperative deformities and postoperative acetabular radiographic parameters. There was a significant decrease in the alpha angle and improvement in head-neck offset in the study group. There was one reoperation for secondary impingement and/or labral pathology in the study group, compared with four reoperations in the comparison group. There were no adhesions requiring surgery, femoral neck fractures, instances of osteonecrosis, or increases in heterotopic ossification in the study group. Femoral head-neck junction osteochondroplasty performed concurrently with a periacetabular osteotomy for the treatment of symptomatic acetabular dysplasia and associated femoral head-neck junction deformities is not associated with an increased complication rate. This combined procedure provides effective correction of associated femoral head-neck deformities and produces similar early functional outcomes when compared with isolated periacetabular osteotomy. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 11/2012; 94(21):1959-66. · 3.23 Impact Factor
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    ABSTRACT: BACKGROUND: The Bernese periacetabular osteotomy (PAO) can relieve pain and restore function in patients with symptomatic acetabular dysplasia. Accurate acetabular correction is fundamental to achieving these clinical goals and presumably enhancing survivorship of the reconstruction. Fluoroscopy is used by some surgeons to assess intraoperative acetabular correction but it is unclear whether the features observed by fluoroscopy accurately reflect those on postoperative radiographs. QUESTIONS/PURPOSES: We therefore determined whether the parameters of acetabular correction of PAO correlated on intraoperative fluoroscopic imaging and postoperative radiography. METHODS: We retrospectively reviewed the imaging of 48 patients (50 hips) who underwent PAO. Intraoperative fluoroscopic AP and false profile images were obtained after final PAO correction. The intraoperative deformity correction as measured on the two fluoroscopy views was compared with the correction determined with postoperative standing plain AP pelvis and false profile radiographs using common measurements of acetabular position. RESULTS: Of all radiographic parameters, lateral center-edge angle had the highest correlation between intraoperative fluoroscopy and the postoperative radiograph with an intraclass correlation coefficient (ICC) of 0.80 (0.68-0.88). Similarly, acetabular inclination and anterior center-edge angle also correlated with ICCs of 0.76 (0.61-0.85) and 0.71 (0.54-0.82), respectively. Extrusion index and medial offset distance had lower correlations with ICCs of 0.66 (0.46-0.79) and 0.46 (0.21-0.65), respectively. CONCLUSIONS: Intraoperative fluoroscopic assessment of PAO correction correlated with that from the postoperative radiographic assessment. Measurement of lateral center-edge angle shows the highest correlation with the fewest outliers. Acetabular inclination and anterior center-edge angle also correlated; extrusion index and medial offset distance should be used with more caution.
    Clinical Orthopaedics and Related Research 08/2012; · 2.79 Impact Factor
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    ABSTRACT: BACKGROUND: Perthes-like hip deformities encompass variable proximal femoral abnormalities and associated acetabular dysplasia that can be reconstructed with contemporary hip preservation procedures. Nevertheless, the necessity and indications for surgical correction of associated acetabular dysplasia have not been established. QUESTIONS/PURPOSES: We determined whether patient-specific factors (sex, age, BMI, previous surgery, hip pain and function) and/or structural deformity characteristics (radiographic parameters of acetabular morphology) were associated with our indications for acetabular reorientation in surgical reconstruction of Perthes-like hip deformities. METHODS: We compared patient-specific characteristics and radiographic parameters of acetabular morphology in 94 patients (97 hips) with residual Perthes deformities who underwent joint preservation surgery without or with a periacetabular osteotomy (PAO) as part of the reconstruction. RESULTS: Patient sex, BMI, preoperative Harris hip score, and previous hip surgery were not associated with our indications for a combined femoral and PAO procedure. Radiographic parameters associated with the indication for a PAO included the lateral center-edge angle, anterior center-edge angle, acetabular inclination, and acetabulum-head index. No or mild secondary osteoarthritis and joint congruency were associated with the indication for a PAO as part of the reconstruction. CONCLUSIONS: Contemporary hip preservation surgery for residual Perthes deformities covers a wide spectrum of procedures. We believe a PAO should be considered in the surgical treatment plan for symptomatic patients having radiographic parameters indicating acetabular dysplasia, no or mild secondary osteoarthritis, and adequate joint congruity. LEVEL OF EVIDENCE: Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 08/2012; · 2.79 Impact Factor
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    ABSTRACT: Residual Perthes and Perthes-like hip deformities are complex and may encompass proximal femoral deformity, secondary acetabular dysplasia, and associated intraarticular abnormalities. These intraarticular abnormalities have not been well characterized but may influence surgical technique and treatment outcomes. We (1) determined the characteristics of intraarticular disease associated with residual Perthes-like hip deformities; and (2) correlated these intraarticular abnormalities with clinical characteristics and radiographic parameters of hip morphology. We retrospectively reviewed 35 patients (36 hips) with residual Perthes or Perthes-like deformities and hip symptoms treated using a surgical dislocation. There were 24 males and 11 females; mean age was 18.5 years (range, 10-36 years). We prospectively documented all intraoperative findings and comprehensively reviewed all radiographs. Labral abnormalities and acetabular and femoral head cartilage abnormalities were present in 76%, 59%, and 81% of hips, respectively. Male sex was associated with severe chondromalacia (64% versus 27%), femoral head chondromalacia (92% versus 55%), and advanced radiographic osteoarthritis (44% versus 9%). Stulberg classification of 3 or greater was associated with moderate to severe acetabular chondromalacia (71% versus 30%). Lateral center-edge angle > 20° and acetabular inclination < 15° correlated with severe chondromalacia (73% versus 38%; 23% versus 70%). Center-trochanteric distance < -1.7 was associated with labral tears (90% versus 57%). Chondral lesions and labral tears are common in symptomatic patients with residual Perthes or Perthes-like deformities. Male sex, a high trochanter, and joint incongruity are associated with more advanced intraarticular disease. Secondary acetabular dysplasia seems to protect the articular cartilage in that hips with acetabular dysplasia had less chondromalacia.
    Clinical Orthopaedics and Related Research 05/2012; 470(11):2968-77. · 2.79 Impact Factor
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    ABSTRACT: Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.
    Journal of pediatric orthopaedics. Part B / European Paediatric Orthopaedic Society, Pediatric Orthopaedic Society of North America 03/2012; 21(5):482-8. · 0.66 Impact Factor
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    ABSTRACT: We retrospectively analyzed cases of intra-articular medial malleolar fractures in skeletally-immature patients (Salter-Harris III and IV) with suboptimal outcomes at St. Louis Children's Hospital and Shriner's Hospital for Children. Common causes of poor outcome were frac­ture malunion or malreduction and physeal damage. Malreductions of only 2 mm does not appear to be toler­ated and the concept of "remodeling" does not apply to these fracture patterns. Based on this study, we "recom­mend" fracture reduction and fixation if there is greater than 1 mm of fracture step-off..
    American journal of orthopedics (Belle Mead, N.J.) 03/2012; 41(3):113-6.
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    ABSTRACT: The Bernese periacetabular osteotomy (PAO) is commonly used to surgically treat residual acetabular dysplasia. However, the degree to which function and radiographic deformity are corrected in patients with more severe deformities that have undergone previous reconstructive pelvic or femoral osteotomies is unclear. We evaluated hip pain and function, radiographic deformity correction, complications, reoperations, and early failures (conversion to THA) associated with PAO in hips treated with previous reconstructive hip surgery. We retrospectively reviewed 63 patients who had undergone 67 PAOs after a previous reconstructive hip procedure. We compared preoperative hip scores and radiographic parameters with postoperative values at most recent followup. We recorded complications, need for nonarthroplasty revision surgery, and failures. Minimum followup was 2 years. Five of the 67 hips (8%) were converted to THA between 24 and 118 months. The average followup for the remaining 62 hips was 60 months (range, 24-147 months). The average Harris hip score improved 11 points, and postoperatively, 83% of the hips had pain component scores of greater than 30 (none, slight, or mild pain). Radiographically, there were improvements in lateral center-edge angle (25°), anterior center-edge angle (23°), Tönnis angle (17°), and medialization of the hip center (8 mm). Complications occurred in 13 hips (19%). Seven hips (10%) underwent a subsequent surgical procedure to address residual pain or deformity. PAO performed after previous reconstructive hip surgery improves hip function and corrects residual dysplasia deformities. These procedures are inherently more complex than primary PAO and are associated with a considerable risk of perioperative complications, reoperations, and early treatment failures. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 02/2012; 470(2):516-24. · 2.79 Impact Factor
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    ABSTRACT: Treatment of hip dysplasia has focused on corrective osteotomy surgery, while hip arthroscopy remains controversial. Improved understanding of intra-articular disease patterns associated with hip dysplasia will help delineate the role of arthroscopy as an adjunct to osteotomy surgery for dysplastic hips. The authors set out to describe the intra-articular disease patterns of patients undergoing combined hip arthroscopy and periacetabular osteotomy for the treatment of symptomatic acetabular dysplasia with associated mechanical symptoms. Secondly, they wanted to identify the potential role for arthroscopy in treating intra-articular problems as an adjunct to acetabular reorientation surgery. Case series; Level of evidence, 4. Seventy-three hips in 71 patients undergoing arthroscopy for mechanical symptoms before a redirectional osteotomy of the acetabulum were reviewed. Radiographic findings of acetabular dysplasia were compared with intraoperative labral and chondral disease patterns. Arthroscopic interventions were recorded. Labral tears and acetabular cartilage lesions were present in 65.8% and 68.5% of hips, respectively. Combined acetabular articular cartilage lesions and labral disease were observed in 58.9% of hips. When disease was present, acetabular labrum and chondral lesions were primarily located at the anterior (81.0%, 76.0%) and superolateral (66.7%, 84.0%) labrochondral junctions. A lateral center-edge angle <15° was associated with an increased likelihood of acetabular chondromalacia, as well as moderate to severe acetabular cartilage disease. An acetabular inclination of >20° was associated with an increased risk of larger labral tears (>2 cm). Sixty-three percent had at least 1 arthroscopic treatment of central compartment disease, most commonly acetabular chondroplasty (30.1%), partial labral resection (26.0%), and labral repair (16.4%). Acetabular rim disease is common in symptomatic acetabular dysplasia, and 63% of cases have a central compartment abnormality amenable to arthroscopic treatment. Lateral center-edge angle <15° and acetabular inclination >20° are associated with more severe labrochondral disease.
    The American journal of sports medicine 07/2011; 39 Suppl:72S-8S. · 3.61 Impact Factor
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    ABSTRACT: Surgical hip dislocation enables complete exposure of the hip joint for treatment of various hip disorders.There is limited information regarding the complications associated with this procedure. Our purpose is to report the incidence of complications associated with surgical dislocation of the hip in a large, multicenter patient cohort. A retrospective, multicenter analysis of patients who had undergone surgical hip dislocation was performed.Patients who had undergone a simultaneous osteotomy were excluded. Complications were recorded, with specific assessment for osteonecrosis, trochanteric nonunion, femoral neck fracture, nerve injury, heterotopic ossification, and thromboembolic disease. We graded complications with a validated classification scheme that includes five grades based on the treatment required to manage the complication and any long-term morbidity. With this classification, a Grade-I complication is one that requires no change in the routine postoperative course, Grade II requires a change in outpatient management, Grade III requires invasive surgical or radiologic management, Grade IV is associated with long-term morbidity or is life-threatening,and Grade V results in death. The study included 334 hips in 302 patients seen at eight different North American centers. There were eighteen complications (5.4%) that were classified as Grade I (not clinically relevant and required no deviation from routine postoperative care). There were six complications (1.8%) classified as Grade II (treated on an outpatient basis or with close observation and resolved). There were nine complications (2.7%) classified as Grade III (treatable and resolved with surgery or inpatient management). There was one complication (0.3%) classified as Grade IV (resulting in a long-term deficit). A total of thirty hips had one or more complications, for an overall incidence of 9%. Excluding heterotopic ossification, the complication rate was sixteen (4.8%) of 334. Surgical hip dislocation is a safe procedure with a low complication rate. Many of the complications were clinically unimportant heterotopic ossification. There were no cases of femoral head osteonecrosis or femoral neck fracture, and, with the exception of one sciatic neurapraxia that partially resolved, no other complication resulted in long-term morbidity.
    The Journal of Bone and Joint Surgery 05/2011; 93(12):1132-6. · 3.23 Impact Factor
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    ABSTRACT: Acetabular dysplasia is recognized as a cause of early degenerative hip osteoarthritis. The purpose of this study was to prospectively determine the early clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. Fifty-seven consecutive skeletally mature patients with a total of sixty-five symptomatic hips were diagnosed with symptomatic acetabular dysplasia on the basis of the history, physical examination, and radiographs. These fifty-seven patients were enrolled in this study and were followed prospectively for a minimum of twenty-four months postoperatively. The study group included forty-one female patients (72%) and sixteen male patients (28%) with a mean age of twenty-four years. All were treated with a periacetabular osteotomy and were followed for a minimum of twenty-four months. The initial presentation was insidious in 97% of the hips, and the majority (77%) of the hips were associated with moderate-to-severe pain on a daily basis. Pain was most commonly localized to the groin (72%) and/or the lateral aspect of the hip (66%). Activity-related hip pain was common (88%), and activity restriction frequently diminished hip pain (in 75% of the cases). On examination, thirty-one hips (48%) were associated with a limp; twenty-five (38%), with a positive Trendelenburg sign; and sixty-three (97%), with a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of hip dysplasia was 61.5 months. The mean number of health-care providers seen prior to the definitive diagnosis was 3.3. The mean Harris hip score improved from 66.4 points preoperatively to 91.7 points at a mean of 29.2 months after the periacetabular osteotomy. The diagnosis of symptomatic acetabular dysplasia is commonly delayed, and procedures other than a pelvic reconstructive osteotomy are frequently recommended. The diagnosis of developmental dysplasia of the hip should be suspected and investigated when a skeletally mature, young, active patient has a predominant complaint of insidious activity-related groin pain and/or lateral hip pain. Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 05/2011; 93 Suppl 2:17-21. · 3.23 Impact Factor

Publication Stats

2k Citations
264.86 Total Impact Points

Institutions

  • 1986–2014
    • Washington University in St. Louis
      • • Department of Orthopaedic Surgery
      • • Department of Medicine
      • • Department of Surgery
      San Luis, Missouri, United States
  • 1991–2012
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
  • 2011
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
  • 2009
    • St. Luke's Hospital (MO, USA)
      Saint Louis, Michigan, United States
    • Boston Children's Hospital
      Boston, Massachusetts, United States
  • 1989–2007
    • Shriners Hospitals for Children
      Tampa, Florida, United States
  • 2002
    • University of Missouri - St. Louis
      Saint Louis, Michigan, United States
  • 1995
    • Government of the People's Republic of China
      Peping, Beijing, China
  • 1990–1991
    • University of Washington Seattle
      • Department of Surgery
      Seattle, WA, United States