Hip arthroscopy in the setting of hip arthroplasty

What happens to endoscopic/arthroscopic tenotomies with iliopsoas impingement in the medium term? Review of a prospective cohort of 64 patients with a minimum follow-up of 5 years

INTRODUCTION

The occurrence of iliopsoas impingement (IPI) after total hip arthroplasty (THA) is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective multicenter series. We carried out a review of the patients at more than 5 years of follow-up in order to assess the stability of the results over time.

HYPOTHESIS

Our main hypothesis was that endoscopic/arthroscopic tenotomies allow stable medium-term resolution of the painful symptoms of IPI. Our secondary hypothesis was that medium-term survival was satisfactory.

MATERIAL AND METHOD

This study is a continuation of a multicenter prospective series. Patients were contacted through multiple channels in order to: obtain an Oxford score, assess for satisfaction, psoas irritation, and daily pain on a visual analogue scale (VAS).

RESULTS

Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7±7.7 [12-48]. There was a significant difference between the Oxford scores preoperatively, at 8 months and at the last follow-up. The mean satisfaction out of 10 was 8.0±2.1 [1-10]. We found 84% satisfaction at 5 years against 83% at 8 months. The VAS was 2.1±2.3 [0-10]. A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in four cases, while it reappeared during the interval in six cases. Survival was 91.2% (95% CI: 80.2-96.3) at 5 years.

CONCLUSION

Endoscopic/arthroscopic iliopsoas tenotomies represent a permanent medium-term solution to treat IPI after THA. The existence of a force differential or an acetabular overhang does not seem, within a certain limit, to impact the results in the medium term.

LEVEL OF EVIDENCE

IV; prospective series without control group.

Iliopsoas impingement after total hip arthroplasty: Does the CT-scan have any role? Our Algorithm proposal

Introduction

The first surgical option considered in managing iliopsoas impingement following THA is endoscopic/arthroscopic iliopsoas tenotomy, because of its low risk and minimal invasiveness. Acetabular revision is a much more aggressive surgery, recommended only in cases of substantial cup malposition. However, there are no clear indications for this procedure. The purpose of this article is to analyse the role of CT-scan measurement of acetabular cup positioning in a therapeutic algorithm for iliopsoas impingement.

Methods

In this retrospective observational study, we reviewed 25 patients treated for iliopsoas impingement following THA between 2011 and 2019. We studied acetabular cup positioning using CT-scan. We compared radiological parameters of patients who presented with significant clinical improvement with conservative treatment and with tenotomy against those who did not. Finally, we developed a proposed therapeutic algorithm.

Results

Forty-eight percent of patients presented a significant clinical improvement following conservative treatment. Patients who did not improve were found to have greater acetabular cup axial and sagittal overhang (p-values 0.016 and 0.003). These patients were considered for tenotomy. Of this group, those who did not improve with surgery (38%) showed greater axial overhang (p-value 0.005).

Conclusions

Conservative management should be the first line of treatment. In cases of non-operative treatment failure, axial acetabular cup overhang measured by CT-scan can be a useful tool in choosing between iliopsoas tenotomy or cup-revision surgery in selected cases of very severe acetabular malposition. A cut-off point of 10 mm of axial overhang is a reliable predictor of higher failure risk with iliopsoas tenotomy.

Endoscopic treatment of iliopsoas impingement after total hip arthroplasty: a minimum 2-year follow-up and comparison of tenotomy performed at the acetabular rim versus lesser trochanter

Iliopsoas impingement is an underdiagnosed cause of groin pain after total hip arthroplasty (THA), being responsible for 4.4% of cases. Non-surgical treatment may be effective in ∼50% of cases. Endoscopic surgery has gained popularity as an option for non-responsive patients because of its non-invasive characteristics, faster recovery and encouraging results. This study compares two different sites of endoscopic psoas tenotomy performed following THA: at the edge of the acetabulum (AR) versus at the lesser trochanter (LT). This is a retrospective review of prospectively collected data from a single-surgeon case series. Thirty-five iliopsoas tenotomy cases which had >24-month follow-up were identified. There were 21 tenotomies at the lesser trochanter. Demographic data, preop and postop pain, mHHS and NAHS scores, strength and patient satisfaction data were collected and analysed. Average age at the time of surgery was 62. Mean follow-up for the LT group was 49.11 months and 42.42 months for the AR group. Pain decreased significantly for both groups (P < 0.001). Both mHHS and NAHS showed superiority in the LT group, but this difference did not reach significance (P = 0.06). LT patients showed better strength with 71.42% of them having normal strength at latest follow-up, compared with 41.6% in the AR group. There were no complications in either group. Endoscopic tenotomy is a safe and reliable surgical option, giving significant pain relief and good functional outcomes. Tenotomy at the level of the lesser trochanter might be preferable since it shows better outcomes. Larger studies are necessary to achieve statistically significant results.

Hip arthroscopy in France: An epidemiological study of postoperative care and outcomes involving 3699 patients

BACKGROUND

Hip arthroscopy is a surgical procedure that is becoming more and more prevalent in France. Even though indications are now well-established little is still known about patient outcomes. Therefore, the purpose of our retrospective study was to: (1) describe the circumstances in which hip arthroscopies are being performed; (2) study arthroscopy and arthroplasty reoperation rates; (3) assess the incidence of readmissions for complications.

HYPOTHESIS

Hip arthroscopy in France produced similar results to those observed in other countries.

MATERIALS AND METHODS

We conducted a cohort study from January 2008 to December 2014 in the French population using the national hospital discharge database called "Programme de médicalisation des systèmes d'information (PMSI)." We included all admissions that had a hip arthroscopy code and analyzed readmissions for conversion to hip arthroplasty, revision hip arthroscopy and complications (without being able to provide detailed descriptions). Risk factors associated with conversion, revision and readmission for complications were studied after performing a population analysis.

RESULTS

A total of 3,699 patients were included over a period of seven years. The mean age was 40 years, with women being significantly older (mean age of 43 years) than men (38 years) (p<0.05). The number of procedures increased from 240 in 2008 to 702 in 2014. Synovectomies (67.9%; 2514/3699) and surgical bone procedures (acetabuloplasty or femoroplasty) (47.3%; 1751/3699) were the main procedures performed during the primary arthroscopy. In total, 410 patients underwent a conversion to arthroplasty, 231 patients had a revision arthroscopy, and 126 patients suffered a complication. Five years after the index procedure, the conversion rate was 16.3%, revision rate was 8.2%, and readmission rate for a postoperative complication was 5%. The main risk factor associated with conversions was [Hazard ratio (HR) and 95% Confidence Index (CI)] an age between 40 and 79 years during the first arthroscopy [3.04 (2.40; 3.87) compared with the reference class of 25-39 years]. Patients between ages 16 to 24 years during the first arthroscopy (0.35 [0.20; 0.61] compared with the reference class of 25-39 years) had a decreased risk of conversion (HR and 95% CI). The main risk factors associated with revisions were: synovectomies [1.90 (1.34; 2.70)] and surgical bone procedures on the femoral neck and/or the acetabulum [1.82 (1.36; 2.4)]. The risk factor associated with complication-related readmissions was an age greater than 40 years [2.23 (1.43; 3.49)].

CONCLUSION

Unlike the international literature, our study population was largely male. The rates of revision (8.2% after five years) and conversion to arthroplasty (16.3% after five years) were relatively low and comparable to the different international studies. This procedure, which is not widely performed, is growing in popularity, has low morbidity and remains an interesting approach given the revision and conversion rates after five years. The implementation of specific coding for arthroscopic hip procedures and the pathologies to be treated seems warranted.

LEVEL OF EVIDENCE

IV; descriptive epidemiological study.

Arthroscopic Evaluation and Treatment of Complications That Arise Following Prosthetic Shoulder Arthroplasty

Arthroscopy may be used to diagnose symptomatic glenoid loosening following anatomic total shoulder arthroplasty (aTSA), and arthroscopic glenoid component removal may suffice as treatment for some patients. Arthroscopy may be used to diagnose shoulder prosthetic joint infection (PJI) following aTSA and reverse shoulder arthroplasty (RSA). Tissues are biopsied from multiple sites within the joint and the subdeltoid or subacromial space, and they are cultured for a minimum of 14 days. Postoperative adhesions arising after prosthetic shoulder arthroplasty (PSA) may be released arthroscopically. However, other problems contributing to shoulder stiffness such as component malpositioning or shoulder PJI require additional intervention. Arthroscopy may be used to repair select rotator cuff tears that arise acutely following aTSA, but chronic attritional tears do not heal after repair; therefore, revision to RSA often is needed. Many complications following PSA, such as infection, fixed instability, humeral component loosening, and major humeral or glenoid bone loss, are not adequately treated using arthroscopic techniques. However, arthroscopy following PSA may help to diagnose and treat other complications, even as the precise indications following aTSA and RSA remain unclear.

Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty

BACKGROUND

Iliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks.

METHODS

A consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort.

RESULTS

At last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P = .005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P = .002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series.

CONCLUSION

Endoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA.

Arthroscopic Diagnosis and Treatment of Chronic Hip Pain After Total Hip Arthroplasty and the Role of Anterior Capsule Disruption in Iliopsoas Tendinopathy

Background:

The use of hip arthroscopic surgery in patients suffering from chronic hip pain after total hip arthroplasty (THA) has a limited presence in the literature, with most studies having limited follow-up.

Purpose:

The first goal of this study was to evaluate hip arthroscopic surgery in the diagnosis and management of patients with chronic hip pain after THA. The second goal was to describe a new cause of iliopsoas tendinopathy (IPT) involving disruption of the anterior capsule.

Study Design:

Case series; Level of evidence, 4.

Methods:

We conducted a retrospective analysis with prospectively collected clinical outcomes of patients after THA who underwent hip arthroscopic surgery for chronic hip pain without an identifiable cause. The patients were at least 18 years old and had a minimum follow-up of 24 months.

Results:

The retrospective analysis found that hip arthroscopic surgery led to new diagnostic information in 8 patients (80%). Of the 10 patients diagnosed with IPT, 4 (40%) lacked an anatomic cause; however, these patients had a history of difficult exposure of the anterior capsule and/or a lack of capsular repair during index THA. The mean modified Harris Hip Score (mHHS) was 71.9 ± 15.6, and the mean 6-month postoperative visual analog scale (VAS) pain score was 0.8 ± 2.2, which was significantly lower than preoperatively (P = .0055). There was also significantly improved forward flexion range of motion (P = .0183) and straight leg raise (SLR) strength test results (P = .0263). Hip arthroscopic surgery resulted in 8 patients (80%) continuing to be pain-free at a mean follow-up of 6.8 ± 1.4 years, while 2 patients (20%) progressed to revision arthroplasty. There were no major or minor complications.

Conclusion:

Hip arthroscopic surgery was found to have an important role in the diagnostic and therapeutic management of patients with chronic hip pain after THA, with good clinical outcomes at a mean follow-up of 6.8 years and no complications. We believe that disruption of the anterosuperior acetabular capsule, including the reflected head of the rectus femoris, can allow the iliopsoas tendon to move intra-articularly and precipitate IPT. This disruption may be appreciated on the SLR strength test. Although this study presents a small sample size that cannot substantiate a cause-effect relationship, orthopaedic surgeons performing THA should consider minimizing disruption and/or ensuring repair of the anterior capsule to decrease this potential cause of IPT.

Arthroscopic treatment of iliopsoas impingement syndrome after hip arthroplasty

BACKGROUND AND AIM OF THE WORK

Groin pain after hip arthroplasty (HA) ranges from 0.4% to 18.3%. Defining the cause of groin pain after HA can be difficult. Iliopsoas impingement (IPI) has been reported to be the underlying cause of groin pain in up to 4.4% of cases. The purpose of this study is to present arthroscopic surgical outcomes in the treatment of IPI after HA.

METHODS

Between September 2013 and March 2018, 13 patients, 11 total hip arthroplasty (THA), 1 hip endoprosthesis and 1 total hip resurfacing affected by groin pain due to unceasing iliopsoas tendinopathy for impingement after HA were treated arthroscopically. The patients underwent to physical examination, blood analysis, hip X-rays, bone scintigraphy and CT assessment. We performed the arthroscopic OUT-IN access to hip joint in all patients. VAS scale, Harris Hip Score (HHS) and Medical Research Council (MRC) scale were performed before surgery and during follow up at 1-3-6-12 months.

RESULTS

After 10 months of mean follow-up, average HHS and MRC scale improved significantly from preoperatively to postoperatively. No complications arose in our case series.

CONCLUSIONS

Hip arthroscopy after hip arthroplasty is supported in the literature for a variety of indications. Hip arthroscopy is a viable and reproducible technique in treatment of IPI, being less invasive than the classic open technique. This simple arthroscopic release provides satisfactory results and preserves HA function. Moreover an arthroscopic OUT-IN access proves good clinical outcomes, few complications and iatrogenic lesions.

A Systematic Review of Arthroscopic Versus Open Tenotomy of Iliopsoas Tendonitis After Total Hip Replacement

PURPOSE

To conduct a systematic review of the literature comparing patient outcomes following arthroscopic and open operative management of iliopsoas tendonitis (IPT) following total hip replacement (THR).

METHODS

This review study was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Inclusion criteria were as follows: outcome studies following open or arthroscopic iliopsoas tendon release after THR with at least 6 months of follow-up, English language, and human studies. The exclusion criteria included case reports, articles evaluating nonsurgical management or cup revision, and articles without a specific diagnosis of IPT or in which results between open and arthroscopic treatment were reported in conjunction.

RESULTS

A total of 131 studies were initially retrieved, with 7 satisfying all inclusion criteria (4 studies on arthroscopic tenotomy and 3 studies on open tenotomy). The review included a total of 88 patients with IPT-61 patients treated arthroscopically and 27 patients treated with open tenotomy. In total, 77 of the 88 patients demonstrated successful outcomes following surgery. In the group treated with arthroscopy, 91.8% (56/61) of patients had successful outcomes, whereas in those treated with open tenotomy, 77.8% (21/27) of patients had successful outcomes. Of patients with signs of mechanical impingement from acetabular component overhang, those who underwent open tenotomy had complete pain relief in 6/8 patients (75%) compared to arthroscopic tenotomy in which there was relief in 40/43 patients (93%).

CONCLUSIONS

Arthroscopic iliopsoas release for management of IPT is suggested to be an effective minimally invasive operative technique that may also yield a lower complication rate in comparison to open tenotomy. Tenotomy, both arthroscopic and open, are successful treatment options for IPT, including those with signs of mechanical impingement, and are recommended prior to cup revision.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

[Hip arthroscopy]

Hip arthroscopy represents an important component in the treatment of diseases of the hip joint and is nowadays an indispensible tool in modern hip-preserving surgery. This article provides a review of the basic technical principles, typical indications and complications of hip arthroscopy. Furthermore, current developments as well as possibilities and limitations of the arthroscopic technique are reviewed.

Aggressive Early Debridement in Treatment of Acute Periprosthetic Joint Infections After Hip and Knee Replacements

BACKGROUND

Periprosthetic Joint Infection Remains a Dreaded Complication After Hip and Knee Replacement Surgery. Treatment Options for Acute Postoperative and Acute Hematogenous Infections Include Arthroscopic or Open Debridement With Retention or Exchange of the Prostheses. This Review Article Aims to Summarize the Evidence for Management of Acute Postoperative And Acute Hematogenous Infections.

METHODS

A Systematic Literature Search Was Performed Using a Computer-based Search Engine Covering Medline (OvidSP), PubMed Database (U.S. National Library of Medicine, National Institutes of Health), Embase, Web of Science, Cochrane and Google Scholar for Relevant Articles.

RESULTS

Common Themes Around Treatment of Acute Postoperative and Acute Hematogenous Infections Discussed in this Review Include the Timing of Intervention, Description of the Optimal Procedure and How we Perform it at our Institution, the Role of Arthroscopic Debridement, Most Commonly Isolated Micro-organisms and Prognostic Factors for Infection Control.

CONCLUSION

Success in Treating Acute Postoperative and Acute Hematogenous Infections Depends on Early Diagnosis and Aggressive Surgical Debridement Combined With Effective Antibiotic Therapy.

Indications and outcomes of shoulder arthroscopy after shoulder arthroplasty

BACKGROUND

Arthroscopy is a widely used intervention in the treatment of a variety of shoulder conditions. Arthroscopy has also been selectively used in symptomatic patients after shoulder arthroplasty. The purpose of this systematic review was to determine indications for shoulder arthroscopy in patients after shoulder arthroplasty and to report patient outcomes after these procedures.

MATERIALS AND METHODS

The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for studies involving shoulder arthroscopy in shoulder arthroplasty patients. A full-text review of eligible studies was conducted in duplicate, and references were searched using predetermined inclusion and exclusion criteria.

RESULTS

The review included 11 studies containing 84 patients. All were Level IV evidence. The most common indications for shoulder arthroscopy in the setting of shoulder arthroplasty were pain or loss of range of motion without a clear diagnosis, suspected periprosthetic infection, and rotator cuff assessment. Although 92% of patients were satisfied with the procedure and standardized shoulder scores increased in all studies that reported them, 44% of patients still went on to additional revision surgery after arthroscopy.

CONCLUSIONS

Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies. Despite the low sample size and quality of evidence in our review, patient satisfaction after arthroscopy is high because standardized outcome scores improve, and the risk of complications is low. However, a high percentage of patients who receive arthroscopy later require further surgery.

Safety and efficacy of arthroscopy in the setting of shoulder arthroplasty

Shoulder arthroplasty has become a reliable and reproducible method of treating a range of shoulder pathologies including fractures, osteoarthritis, and rotator cuff arthropathy. Although most patients experience favorable outcomes from shoulder arthroplasty, some patients suffer from persistent symptoms post-arthroplasty and it is these patients who present a unique diagnostic and therapeutic challenge. The role of arthroscopy in assessing and treating patients with symptomatic prosthetic joints elsewhere in the body has been established in recent literature. However, the range of pathology that can affect a prosthetic shoulder is distinct from the knee or the hip and requires careful and considered assessment if an accurate diagnosis is to be made. When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty.