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Migliorini F, Maffulli N, Baroncini A, Eschweiler J, Tingart M, Betsch M. Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review. Am J Sports Med 2022; 50:1146-1156. [PMID: 34081552 PMCID: PMC8980457 DOI: 10.1177/03635465211011744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear. PURPOSE To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient. RESULTS Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA. CONCLUSION Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany,Filippo Migliorini, MD, MBA, Orthopaedics and Trauma Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany ()
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke on Trent, UK
| | - Alice Baroncini
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Medical Centre Mannheim of the University Heidelberg, Mannheim, Germany
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Migliorini F, Liu Y, Eschweiler J, Baroncini A, Tingart M, Maffulli N. Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review. Surgeon 2021; 20:194-208. [PMID: 33731304 DOI: 10.1016/j.surge.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/10/2021] [Accepted: 01/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up. MATERIAL AND METHODS This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included. RESULTS Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001). CONCLUSION Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Yu Liu
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Alice Baroncini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Markus Tingart
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.
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Youngman TR, Wagner KJ, Montanez B, Johnson BL, Wilson PL, Morris WZ, Sucato DJ, Podeszwa DA, Ellis HB. The Association of α Angle on Disease Severity in Adolescent Femoroacetabular Impingement. J Pediatr Orthop 2021; 41:88-92. [PMID: 33208669 PMCID: PMC7803481 DOI: 10.1097/bpo.0000000000001703] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoroacetabular Impingement (FAI) is a common cause of hip pain in adolescent patients. Clinical exam and radiographic markers, such as α angle and lateral center edge angle (LCEA), are commonly used to aid in the diagnosis of this condition. The purpose of this study was to correlate preoperative α angle and LCEA with preoperative symptoms, intraoperative findings, and preoperative and postoperative patient reported outcomes (PROs) in the adolescent patient. METHODS A retrospective analysis of prospectively collected data was conducted for all patients who underwent operative intervention for FAI at an academic institution over an 11-year period. Preoperative imaging was obtained and measured for LCEA and α angle. PROs (modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA score) were collected preoperatively, as well as 1, 2, and 5 years postoperatively. Operative intervention was either open surgical hip dislocation or arthroscopic, and intraoperative disease was graded using the Beck Classification system. Patients with minimum 1-year follow-up were included in statistical analysis. RESULTS There were 86 hips (64 female hips) included with an average age of 16.3 years (range, 10.4 to 20.5 y), with an average of 37 months of follow-up. There was no correlation between severity of preoperative symptoms or difference between pre and postoperative PROs for both α angle and LCEA. Overall, significant improvement was noted in modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA Score (P<0.001 for each). Independent of preoperative symptoms, increased α angle correlated with more severe intraoperative labral disease (P<0.001), and longer length of labral tear (Corr 0.295, P<0.01). Femoral head and acetabular articular cartilage damage did not correlate with α angle or LCEA, nor did overall severity of disease. CONCLUSIONS In adolescent patients with FAI, increased α angle was found to significantly correlate with labral pathology, including increased length of tear and severity of disease, irrespective of preoperative symptoms or postoperative patient reported outcomes. LEVEL OF EVIDENCE Level III-retrospective.
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Affiliation(s)
- Tyler R. Youngman
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | | | - Phillip L. Wilson
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | - William Z. Morris
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | - Daniel J. Sucato
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | - David A. Podeszwa
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | - Henry B. Ellis
- University of Texas Southwestern Medical Center
- Texas Scottish Rite Hospital for Children, Dallas, TX
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Block AM, Minaie A, Ross JR, Clohisy JC, Nepple JJ. Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence? THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:145-154. [PMID: 34552417 PMCID: PMC8259176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020. METHODS Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies. RESULTS Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23). CONCLUSION Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.
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Affiliation(s)
- Andrew M. Block
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arya Minaie
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - James R. Ross
- Broward Orthopedic Specialists, Fort Lauderdale, FL, USA
| | - John C. Clohisy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jeffrey J. Nepple
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Kim HT, Kim UJ, Cho YJ. Anterolateral Approach in the Treatment of Femoroacetabular Impingement of the Hip. Clin Orthop Surg 2019; 11:337-343. [PMID: 31475056 PMCID: PMC6695336 DOI: 10.4055/cios.2019.11.3.337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 11/22/2022] Open
Abstract
Background Ganz surgical hip dislocation via a posterior (Kocher-Langenbeck) approach is a popular procedure in the management of femoroacetabular impingement (FAI). We report the results of surgery performed through an anterolateral (Watson-Jones) approach in the management of anterolateral FAI. Methods Twenty-one hips in 20 patients (mean age at the time of operation, 17.3 years) were treated surgically using an anterolateral approach: 12 hips with Legg-Calvé-Perthes disease, three septic hips, three hips with avascular necrosis (combined with slipped capital femoral epiphysis [SCFE], femoral neck fracture, and developmental dislocation of the hip), two hips with epiphyseal dysplasia, and one hip with SCFE. All patients had anterolateral FAI. Surgical hip dislocation was performed in four hips with trochanteric osteotomy. Combined osteotomies were for neck lengthening in 11 hips, varus or valgus osteotomy in the proximal femur in four hips, and pelvic osteotomy in four hips. Clinical results were evaluated using a modified Harris hip score (mHHS). Results Range of hip flexion and abduction showed statistically significant improvement after surgery; however, the improvement in mean mHHS was not statistically significant. Conclusions An anterolateral approach can be used as an alternative to a posterior approach in the management of anterolateral FAI with or without hip dislocation while safely preserving the blood supply to the femoral head and allowing simultaneous procedures in the proximal femur.
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Affiliation(s)
- Hui Taek Kim
- Department of Orthopedic Surgery, Pediatric Orthopedics and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Um Ji Kim
- Department of Orthopedic Surgery, Pediatric Orthopedics and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Simultaneous Bilateral Hip Arthroscopy in Adolescent Athletes With Symptomatic Femoroacetabular Impingement. J Pediatr Orthop 2019; 39:193-197. [PMID: 30839478 DOI: 10.1097/bpo.0000000000000987] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes. METHODS Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests. RESULTS In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up. CONCLUSIONS Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery. LEVEL OF EVIDENCE Level II-therapeutic study.
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Acetabular Chondral Lesions Associated With Femoroacetabular Impingement Treated by Autologous Matrix-Induced Chondrogenesis or Microfracture: A Comparative Study at 8-Year Follow-Up. Arthroscopy 2018; 34:3012-3023. [PMID: 30266548 DOI: 10.1016/j.arthro.2018.05.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this retrospective study was to investigate, at 8 years, the clinical follow-up and failure rate (revision rate/conversion to arthroplasty) of patients with hip chondral lesions associated with femoroacetabular impingement and to compare over time the treatment by microfracture (MFx) and autologous matrix-induced chondrogenesis (AMIC). METHODS Patients aged between 18 and 55 years, with acetabular grade III and IV chondral lesions (Outerbridge), measuring 2 to 8 cm2 operated on at least 8 years before enrollment. Exclusion criteria were rheumatoid arthritis, dysplasia, or axial deviation of the femoral head. There were no arthritic lesions, Tonnis < 2, or joint space of at least 2 mm. MFx was performed with an awl, and the Chondro-Gide membrane used for the AMIC procedure was placed without glue. Outcomes used modified Harris hip score (mHHS) at 6 months and yearly for 8 years and patient acceptable symptomatic state. RESULTS Among 130 patients, 109 fulfilled inclusion criteria. Fifty were treated by MFx and 59 by AMIC. The mHHS significantly improved in both groups from 46 ± 6.0 to 78 ± 8.8 for mHHS at 6-12 months, even for lesions > 4 cm2. From 2 to 8 years, mHHS in the AMIC group was better than in the MFx group (P < .005). This mHHS improvement in the AMIC group was maintained through the 8-year follow-up period, whereas it deteriorated after 1 year in the MFx group (P < .005). Eleven patients (22%) in the MFx group required total hip arthroplasty (THA); none in the AMIC group did. Patient acceptable symptomatic state analysis confirmed similar short-term improvement, but a significant (P < .007) degradation after 2-8 years in MFx patients. CONCLUSIONS MFx and AMIC techniques led to marked clinical short-term improvement in patients with chondral defects resulting from femoroacetabular impingement in the first 2 years. However, AMIC gave significantly better results as measured by mHHS, which were maintained after 8 years, the results of MFx in the hip deteriorated over time with 22% of patients undergoing conversion to THA. No patient in the AMIC group was converted to THA; the results of AMIC appeared stable over time and independent of lesion size. LEVEL OF EVIDENCE III, retrospective patient group study.
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Dodwell ER, Pathy R, Widmann RF, Green DW, Scher DM, Blanco JS, Doyle SM, Daluiski A, Sink EL. Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery. JB JS Open Access 2018; 3:e0020. [PMID: 30882054 PMCID: PMC6400510 DOI: 10.2106/jbjs.oa.18.00020] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases. Methods The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively. Results The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group. Conclusions The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.
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Affiliation(s)
| | - Rubini Pathy
- Shriners Hospitals for Children-Springfield, Springfield, Massachusetts
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Reiman MP, Peters S, Sylvain J, Hagymasi S, Ayeni OR. Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review. Arthroscopy 2018; 34:1319-1328.e9. [PMID: 29402587 DOI: 10.1016/j.arthro.2017.11.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies. METHODS A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors. RESULTS Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies. CONCLUSIONS Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Michael P Reiman
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A..
| | - Scott Peters
- Toronto Blue Jays Baseball Club, Toronto, Ontario, Canada
| | | | | | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Local Infiltration Analgesia Compared With Epidural and Intravenous PCA After Surgical Hip Dislocation for the Treatment of Femoroacetabular Impingement in Adolescents. J Pediatr Orthop 2018; 38:9-15. [PMID: 26840273 PMCID: PMC4970959 DOI: 10.1097/bpo.0000000000000725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Open treatment of femoroacetabular impingement (FAI) through a surgical hip dislocation (SHD) approach has been reported to allow for improvement in pain and function. However, the approach require a trochanteric osteotomy and may be associated with high level of pain after surgery. Currently, there is no systematic approach for pain management after SHD for treatment of FAI. METHODS A retrospective chart review was used to collect data from 121 subjects (12 to 21 y and below) who received periarticular local infiltration analgesia (LIA, n=20), epidural analgesia (n=72), or intravenous patient-controlled analgesia (PCA, n=29) after SHD from January 2003 to June 2014. Verbal pain scores, opioid consumption, incidence of side effects/complications, and length of hospital stay (LOS) were recorded. All nonopioid medications with analgesic potential were included in the statistical models as potential confounding variables RESULTS:: Twelve hours after surgery, the odds of moderate/severe pain were higher in the PCA group (odds ratio, 20.5; 95% confidence interval (CI), 1.7-243.8; P=0.0166] and epidural group (odds ratio, 5.2; 95% CI, 0.7-92.0; P=0.3218) compared with the LIA group. There was no difference in pain scores across all groups 1 hour (P=0.0675) or 24 hours (P=0.3473) postoperatively. Total opioid consumption in the LIA group was 59.8% (95% CI, 15.0%-81.0%; P=0.0175) lower than the total opioid consumption in the epidural group and 60.7% (95% CI, 17.3-81.3; P=0.0144) lower than the total opioid consumption in the PCA group. LOS was increased in the epidural (mean difference, 22.1; 95% CI, 6.8-37.4 h; P=0.0051) and PCA (mean difference, 16 h; 95% CI, 1-31.5 h; P=0.0367) groups relative to the LIA group. There was 0 (0%) complication in the LIA group compared with 11 (15.3%) in the epidural group. CONCLUSIONS LIA was more effective at controlling pain 12 hours after surgery in comparison with PCA with similar pain control to epidural. LIA was associated with significantly lower need for opioids and shorter LOS compared with the PCA and epidural protocols. Periarticular infiltration should be considered for pain management after SHD for treatment of FAI in adolescents. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement. Hip Int 2017; 27:599-607. [PMID: 28605002 DOI: 10.5301/hipint.5000506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI. METHODS Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis. RESULTS International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found. CONCLUSIONS Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.
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Ricciardi BF, Fields KG, Wentzel C, Kelly BT, Sink EL. Early Functional Outcomes of Periacetabular Osteotomy After Failed Hip Arthroscopic Surgery for Symptomatic Acetabular Dysplasia. Am J Sports Med 2017; 45:2460-2467. [PMID: 28617619 DOI: 10.1177/0363546517710011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Persistent acetabular dysplasia is a common reason for the failure of hip arthroscopic surgery; however, the effect of prior hip arthroscopic surgery on functional outcomes after subsequent periacetabular osteotomy (PAO) is unknown. Hypothesis/Purpose: The purpose of this study was to (1) compare demographic and radiological findings in patients who had and had not undergone previous hip arthroscopic surgery before PAO for symptomatic acetabular dysplasia and (2) compare the short-term, hip-specific patient-reported outcomes in these same patient populations. It was hypothesized that prior hip arthroscopic surgery is associated with worse early functional outcomes in PAO. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective cohort study design was utilized. Patients undergoing PAO were enrolled from a single-center, prospective hip preservation registry from March 2011 to April 2015. Patients with a minimum of 1-year clinical follow-up with preoperative and postoperative outcome scores undergoing PAO were eligible for inclusion (n = 93 patients; mean clinical follow-up, 24 months [range, 11-58 months]). The study group consisted of patients undergoing PAO for symptomatic hip dysplasia after prior hip arthroscopic surgery (PREVSCOPE group; 22 patients, 25 hips). Patients undergoing PAO without prior hip arthroscopic surgery (PAOALONE group; 71 patients, 85 hips) were included as a comparison group. Demographic and radiological variables were recorded. Postoperative functional outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score [HOS], and International Hip Outcome Tool [iHOT-33]) were recorded at 6 months and annually postoperatively. RESULTS There were no demographic differences between the 2 groups at baseline. Acetabular version, femoral version, Tönnis grade, preoperative lateral center edge angle, and intraoperative procedures were not different between the 2 groups. At 1-year follow-up from the last hip surgical procedure, the mean (±SD) mHHS (73 ± 14 vs 86 ± 14, respectively; P < .001), HOS-Activities of Daily Living (84 ± 12 vs 93 ± 11, respectively; P = .007), HOS-Sport (62 ± 25 vs 85 ± 18, respectively; P < .001), and iHOT-33 (62 ± 21 vs 79 ± 20, respectively; P = .004) were decreased in the PREVSCOPE group versus the PAOALONE group. At last follow-up (mean, 18 months from the last hip surgical procedure), the mHHS and HOS-Sport were lower in the PREVSCOPE group versus the PAOALONE group. There was no difference in complication or reoperation rates between the 2 groups. CONCLUSION Failed hip arthroscopic surgery before PAO for symptomatic hip dysplasia is associated with lower hip-specific functional outcomes within the first 1 year of follow-up despite similar baseline demographic and radiological characteristics. These differences persisted in certain outcome scores (mHHS, HOS-Sport) at last follow-up but were less pronounced than at 1 year.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Kara G Fields
- Healthcare Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Catherine Wentzel
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Ernest L Sink
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
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Complications and short-term patient outcomes of periacetabular osteotomy for symptomatic mild hip dysplasia. Hip Int 2017; 27:42-48. [PMID: 27791238 DOI: 10.5301/hipint.5000420] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purpose of our study is to identify complications and early functional outcome scores in patients treated with periacetabular osteotomy (PAO) for mild acetabular dysplasia. METHODS The study population consisted of patients from a single centre prospective hip registry undergoing PAO with mild acetabular dysplasia (LCEA ≥18° and ≤25°; n = 27 patients; Mild Dysplasia group). A comparison group of patients undergoing PAO with more severe acetabular dysplasia (lateral centre-edge angle [LCEA] ≤17°; n = 50 patients; Severe Dysplasia group) were included as a comparison cohort. Demographics, radiographic findings, complications, and functional outcome scores were recorded at 6 months, 1 year, and 2 years postoperatively (mean 15 months [range 6-30]). RESULTS Demographic characteristics were similar in patients with mild dysplasia undergoing PAO compared with more severe dysplasia. Achievement of radiological correction and complication rates were not different between the 2 groups. Functional outcome scores showed similar improvements in modified Harris Hip Score (mHHS), hip outcome score (HOS) activities of daily living (ADL), HOS Sport, and the international Hip Outcome Tool-33 (iHOT-33) at all time points between the 2 groups with over 90% of patients in the mild dysplasia group achieving a minimum important change (MIC) in functional outcome scores at final follow-up. DISCUSSION Patients with symptomatic mild acetabular dysplasia undergoing PAO have similar complication rates and functional outcomes as a cohort of patients with more severe dysplasia.
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Skowronek P, Synder M, Polguj M, Marczak D, Sibiński M. Treatment of Femoroacetabular Impingement with a Mini-open Direct Anterior Approach. Indian J Orthop 2017; 51:677-680. [PMID: 29200484 PMCID: PMC5688861 DOI: 10.4103/ortho.ijortho_248_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The opinion about best methods of femoroacetabular impingement (FAI) treatment are not consistent. Operative treatment of this condition may be arthroscopic, but open procedures with osteotomy of the greater trochanter and hip dislocation has been used. The present study evaluates the benefits of the mini-open direct anterior approach (DAA) in treating patients with FAI, with is a procedure available for most orthopedic surgeons. MATERIALS AND METHODS 39 patients treated for FAI (25 men and 14 women) at an average age of 29.3 years (range 18-46 years) were reviewed in this retrospective study. The mean followup was 45 months, (range 24-55 months). The hip impingement test was positive in all patients. The diagnosis of FAI was confirmed on anteroposterior and lateral hip view radiographs. All patients were operated with mini-open DAA. The outcomes were assessed with the Harris Hip Score, Short-Form 36 Health Survey and VAS score. Preoperative osteoarthritis was assessed according to Tönnis score. RESULTS At the final followup, improvement was noted compared to preoperative status in Harris Hip Score (P < 0.00001), visual analog scale score (P < 0.001), and Short-Form-36 score (P < 0.001). Nineteen patients returned to their previous sports activities. No major complications occurred. One patient developed heterotopic ossification and three patients developed temporary postoperative meralgia paresthetica. Five patients from the treatment group required total hip arthroplasty for severe osteoarthritis. CONCLUSIONS Mini-open DAA is a safe and effective procedure for the treatment of FAI that gives good relief of symptoms and allows a successful return to preoperative activity levels. Further research with a longer followup period is needed to evaluate the influence of surgery on natural history of FAI.
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Affiliation(s)
- Paweł Skowronek
- Department of Orthopaedics and Traumatology, The Jan Kochanowski University, Grunwaldzka, Kielce, Poland
| | - Marek Synder
- Clinic of Orthopaedics and Paediatric Orthopaedics, Medical University of Łódź, Łódź, Poland
| | - Michał Polguj
- Department of Angiology, Chair of Anatomy, Medical University of Łódź, Łódź, Poland
| | - Dariusz Marczak
- Department of Orthopeadic, Postgraduate Medical Education Center, Otwock, Poland
| | - Marcin Sibiński
- Clinic of Orthopaedics and Paediatric Orthopaedics, Medical University of Łódź, Łódź, Poland,Address for correspondence: Prof. Marcin Sibiński, Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Pomorska 251, 92-213 Łodź, Poland. E-mail:
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Radiographic predictors of femoroacetabular impingement treatment outcomes. Knee Surg Sports Traumatol Arthrosc 2017; 25:36-44. [PMID: 26387126 DOI: 10.1007/s00167-015-3794-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 09/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To review the literature on femoroacetabular impingement (FAI) treatment outcomes, specifically focusing on potential pre-operative radiographic parameters that may provide prognostic information regarding outcomes following surgical management. METHODS A comprehensive review of computerized literature databases (Medline Ovid and PubMed) was performed, searching for articles reporting on FAI treatment outcomes. A single reviewer screened titles, abstracts and performed full-text reviews of eligible studies. The references of these studies were further screened for additional potentially relevant studies. A total of 243 studies were reviewed, with 18 meeting inclusion criteria. RESULTS Thirteen arthroscopic studies reported on 1556 patients, with clinical improvement in 35-92 % of patients and associated failure rates of 12-71 %. Five open surgical studies reported on 238 patients with clinical improvement in 65-95 % of patients and associated failure rates of 0-35 %. Both arthroscopic and open studies identified inferior outcomes with pre-operative radiographic findings of an elevated Tönnis grade (grade 2 or higher), joint space <2 mm, lateral centre-edge angle (LCEA) <20° and incomplete femoral osteoplasty. CONCLUSION Pre-operative radiographic findings of osteoarthritis (Tönnis grade 2/3, <2 mm joint space) or dysplasia (LCEA < 20°) should be considered relative contraindications to joint preservation surgery as outcomes are worse among these patients and associated with a higher risk of conversion to total hip arthroplasty. Care should also be taken to perform a thorough femoral osteoplasty to reduce the risk of failure and need for revision surgery. LEVEL OF EVIDENCE III.
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Return to Play Following Open Treatment of Femoroacetabular Impingement in Adolescent Athletes. J Am Acad Orthop Surg 2016; 24:872-879. [PMID: 27855130 DOI: 10.5435/jaaos-d-16-00110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION After treatment of femoroacetabular impingement (FAI) in adolescent competitive athletes, the rate, timing, and level of return to play have not been well reported. METHODS Adolescent athletes who underwent open FAI treatment were assessed at a minimum 1-year follow-up. Patients completed a self-reported questionnaire centered on the time and level of return to play. Pain and functional outcomes were assessed using the modified Harris Hip Score (mHHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS). RESULTS Among the 24 athletes included, 21 (87.5%) (95% confidence interval [CI], 67.6% to 97.3%) successfully returned to play after open FAI treatment. The median time to return to play was 7 months (95% CI, 6 to 10 months). Of the 21 who returned to play, 19 (90%) returned at a level that was equivalent to or greater than their level of play before surgery. Three athletes (12.5%) did not return to play and indicated that failure to return to play was unrelated to their hip. There was significant improvement in the mHHS (P < 0.0001), HOOS (P < 0.0001), α angle (P < 0.0001), and offset (P < 0.0001). DISCUSSION Most adolescent athletes can expect to return to the same or better level of sports participation during the first year after open treatment of FAI.
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Ricciardi BF, Mayer SW, Fields KG, Wentzel C, Kelly BT, Sink EL. Patient Characteristics and Early Functional Outcomes of Combined Arthroscopic Labral Refixation and Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia. Am J Sports Med 2016; 44:2518-2525. [PMID: 27416990 DOI: 10.1177/0363546516651829] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Symptomatic labral tears are common in patients with acetabular dysplasia; however, optimal treatment of the labrum remains controversial. PURPOSE To present patient characteristics and early functional outcomes associated with combined arthroscopic labral refixation and Bernese periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia with a displaced labral tear from the acetabular rim. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients undergoing PAO from a single-center prospective hip preservation registry were eligible (N = 73 patients; mean clinical follow-up, 23 months). Indications for combined arthroscopic labral refixation included symptomatic labral injury and MRI findings suggestive of labral detachment from the acetabular rim indicating a repairable tear. The study group consisted of patients undergoing combined arthroscopic labral refixation and PAO (scope/PAO group: n = 21 patients). Patients undergoing PAO alone (PAO group: n = 52 patients) were included as a comparison. Demographic characteristics, pre- and postoperative radiographic findings, and hip-specific functional outcome scores were recorded. RESULTS The scope/PAO group was older relative to PAO alone (27 vs 23 years; P = .047). Preoperative computed tomography showed increased acetabular version at the 3-o'clock position in the scope/PAO group relative to PAO alone (median [quartile 1, quartile 3]: 24° [20°, 25°] vs 19° [14°, 24°]; P = .026). PAO operative time, achievement of radiographic correction, or postoperative complications did not differ between groups. Improvements by minimum important change for modified Harris Hip Score, Hip Outcome Score (HOS)-ADL, HOS-Sport, and International Hip Outcome Tool (iHOT-33) were seen in 90%, 79%, 74%, and 100% of patients, respectively, undergoing scope/PAO at most recent follow-up. There was greater improvement from baseline in the iHOT-33 at most recent follow-up in the scope/PAO versus PAO group after adjusting for age and Tönnis grade (mean change ± SD: 48 ± 22 [scope/PAO] vs 37 ± 24 [PAO]; P = .03). CONCLUSION Patients undergoing combined arthroscopic labral refixation and PAO were older and had increased acetabular anteversion versus patients undergoing PAO alone. Combined arthroscopic labral refixation and PAO was safe, did not affect PAO operative time or radiographic correction achievement, and may benefit clinical outcomes in this patient subset.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Stephanie W Mayer
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Kara G Fields
- Healthcare Research Institute, Hospital for Special Surgery, New York, New York, USA
| | - Catherine Wentzel
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Ernest L Sink
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
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Abstract
PURPOSE OF REVIEW The present review discusses the etiology, clinical presentation, and management of femoroacetabular impingement (FAI) in the pediatric population, including etiologic and diagnostic controversies, management options, and outcomes. RECENT FINDINGS New evidence demonstrates conflicting results regarding how and when primary FAI develops in relation to skeletal maturity. Recent studies also discuss the effects of sex, race, and sports on FAI development and radiographic considerations in the pediatric population. Recent literature demonstrates good to excellent outcomes in the operative management of FAI in children and adolescents. SUMMARY FAI is a source of pediatric hip pain and can occur primarily or secondarily. It is characterized by anterior hip pain, made worse with flexion activities, decreased hip internal rotation, and a positive impingement sign. Pathologic values for radiographic measures of FAI are not clearly defined in the pediatric population. As FAI is a risk factor for osteoarthritis, early intervention in specific patients may be indicated. Hip arthroscopy, surgical hip dislocation, or combined mini-open and arthroscopic approaches are utilized, with good to excellent short, and mid-term functional results. Further study is required in the pediatric population to identify potential preventive strategies, to delineate the pathologic radiographic values of FAI, to define specific indications for operative management, and to examine long-term outcomes to determine optimal management.
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Sim Y, Horner NS, de Sa D, Simunovic N, Karlsson J, Ayeni OR. Reporting of non-hip score outcomes following femoroacetabular impingement surgery: a systematic review. J Hip Preserv Surg 2015; 2:224-41. [PMID: 27011844 PMCID: PMC4765302 DOI: 10.1093/jhps/hnv048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/08/2015] [Accepted: 05/19/2015] [Indexed: 01/02/2023] Open
Abstract
This systematic review was designed to evaluate the reporting of non-hip score outcomes following surgical management of femoroacetabular impingement (FAI). MEDLINE, EMBASE and PubMed were searched and screened in duplicate for studies involving non-hip score outcomes following the surgical management of FAI. A full-text review of eligible studies was conducted and references were searched using pre-determined inclusion and exclusion criteria. Thirty-three studies involving 3198 patients were included in this review. The most common non-hip score outcomes reported included: patient satisfaction (72.7%), symptom improvement (24.7%), pain improvement (12.4%), hip range of motion (12.3%) and return to sport (6.8%). The most frequently reported standardized hip outcome scores used were the modified Harris Hip Score (mHHS) (41.2%), Non-Arthritic Hip Score (NAHS) (29.4%), Hip Outcome Score—Activities of Daily Living (HOS-ADL) (26.5%), the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC) (17.6%), the HOS Sport-Specific Subscale (SSS) (17.6%). The most commonly reported non-hip score outcomes are patient satisfaction, symptom improvement and pain improvement. Patients report high levels of satisfaction when surveyed post-operatively. A discrepancy exists between what outcomes the literature suggests should be reported and what outcomes are actually reported. Return to sport is often held as a major patient-important outcome yet it is seldom reported in studies assessing the efficacy of FAI surgery. Second, despite emerging evidence that outcome measures such as the HOS or IHOT evaluate the FAI patient population precisely, other standardized hip score outcomes (mHHS and NAHS) are still more commonly reported.
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Affiliation(s)
- Yan Sim
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nolan S Horner
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jon Karlsson
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- 1. Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
Surgical hip dislocation (SHD) is a versatile approach used to address both intra-articular and extra-articular pathology around the hip joint in both pediatric and adult patients. It allows anterior dislocation of the femoral head for direct visualization of the hip joint while preserving femoral head vascularity and minimizing trauma to the abductor musculature. Previously described indications for SHD include femoroacetabular impingement, deformity resulting from Legg-Calve-Perthes disease, slipped capital femoral epiphysis, periarticular trauma, benign lesions of the hip joint, and osteochondral lesions. In this review, we will describe current surgical techniques, indications, and clinical outcomes for SHD.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, NY
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Ricciardi BF, Fabricant PD, Fields KG, Poultsides L, Zaltz I, Sink EL. What are the demographic and radiographic characteristics of patients with symptomatic extraarticular femoroacetabular impingement? Clin Orthop Relat Res 2015; 473:1299-308. [PMID: 25344401 PMCID: PMC4353520 DOI: 10.1007/s11999-014-4001-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extraarticular femoroacetabular impingement (FAI) can result in symptomatic hip pain, but preoperative demographic, radiographic, and physical examination findings have not been well characterized. QUESTIONS/PURPOSES The purposes of this study were to (1) define the demographic characteristics of patients with symptomatic extraarticular FAI; and (2) identify relevant radiographic and physical examination findings that are associated with intraoperative locations of extraarticular FAI. METHODS For purposes of this study, we defined extraarticular FAI as abnormal contact between the extraarticular regions of the proximal femur (greater trochanter, lesser trochanter, extracapsular femoral neck) and the ilium or ischium. The diagnosis was suspected preoperatively, but it was confirmed at the time of surgery by direct visualization of extraarticular impingement after surgical hip dislocation. A prospective single-center hip preservation registry was used to retrospectively characterize patients presenting between October 2010 and November 2013 with symptomatic hip pain and intraoperative findings of extraarticular FAI (N = 75 patients, 86 hips). Detailed demographic data were recorded. Radiographs, CT, and MRI scans were reviewed for all patients by two of the authors (BFR, ELS). Outcome instruments including modified Harris hip score (mHHS), Hip Outcome Score (HOS), and International Hip Outcome Tool (iHOT-33) were assessed preoperatively. A comparison group of all patients (N = 1690 patients, 1989 hips) undergoing surgery for intraarticular FAI over the study period were included for demographic comparisons. Cases with extraarticular FAI accounted for 4% (75 of 1765 patients) of our cohort over the study time period. RESULTS Patients with extraarticular FAI were more likely to be younger (mean ± SD, 24 ± 7 years versus 30 ± 11 years; difference [95% confidence interval {CI}], -7 [-9 to -4]; p < 0.001), female (85% versus 49%; odds ratio [95% CI], 6 [3 to 12]; p < 0.001), to have undergone prior hip surgery (44% versus 10%; odds ratio [95% CI], 9 (6 to 15); p < 0.001), and have lower preoperative outcome scores after adjustment for age, sex, and revision status (mHHS 55 ± 15 versus 63 ± 15; adjusted difference [95% CI], -4 (-8 to -1); p = 0.017; HOS ADL 64 ± 19 versus 73 ± 18; adjusted difference [95% CI], -7 (-11 to -3); p = 0.002) than patients undergoing surgery for intraarticular FAI. Within the extraarticular FAI group, preoperative femoral version on CT was different among patients with anterior versus posterior extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 21° [20, 30], respectively; p = 0.005) and anterior versus complex extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 20° [10, 30], respectively; p = 0.007]. Preoperative external rotation in extension was increased in patients with anterior versus complex extraarticular FAI (median [first quartile, third quartile], 70° [55, 75] versus 40° [20, 60]; p < 0.001). CONCLUSIONS Extraarticular FAI is an uncommon source of impingement symptoms. We suspect the diagnosis often is missed, because many of these patients had prior hip surgery before the procedure that diagnosed the extraarticular impingement source. This diagnosis seems more common in younger, female patients. Radiographic and physical examination findings correspond to locations of intraoperative extraarticular impingement. Future studies will need to determine whether surgical treatment of extraarticular impingement pathology improves pain and function in this subset of patients.
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Affiliation(s)
- Benjamin F. Ricciardi
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Peter D. Fabricant
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Kara G. Fields
- />Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | - Lazaros Poultsides
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
| | - Ira Zaltz
- />Department of Orthopedic Surgery, William Beaumont Hospital-Royal Oak, Royal Oak, MI USA
| | - Ernest L. Sink
- />Center for Hip Pain and Preservation, Hospital for Special Surgery, 541 East 71th Street, New York, NY 10021 USA
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de Sa D, Cargnelli S, Catapano M, Bedi A, Simunovic N, Burrow S, Ayeni OR. Femoroacetabular impingement in skeletally immature patients: a systematic review examining indications, outcomes, and complications of open and arthroscopic treatment. Arthroscopy 2015; 31:373-84. [PMID: 25262968 DOI: 10.1016/j.arthro.2014.07.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/14/2014] [Accepted: 07/24/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI. METHODS The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented. RESULTS There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were "abnormally" or "severely abnormally" impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported. CONCLUSIONS Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Stephanie Cargnelli
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Catapano
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Asheesh Bedi
- MedSport at Domino's Farms, MedSport, Ann Arbor, Michigan, U.S.A
| | - Nicole Simunovic
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Burrow
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada.
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23
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Ricciardi BF, Fields K, Kelly BT, Ranawat AS, Coleman SH, Sink EL. Causes and risk factors for revision hip preservation surgery. Am J Sports Med 2014; 42:2627-33. [PMID: 25139303 DOI: 10.1177/0363546514545855] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying causes and risk factors for failure of hip preservation surgery is critical to properly address residual pathological abnormalities in the revision setting and improve outcomes in this subset of patients. PURPOSE To identify the structural causes of failure in both open and arthroscopic hip preservation procedures and to identify demographic and radiographic risk factors that correlate with the need for revision surgery. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A single-center hip preservation registry was reviewed (N = 1898 procedures in 1600 patients) to identify 147 patients (n = 152 procedures) who had undergone previous pelvic surgery. Exclusion criteria included residual deformity from pediatric hip disease (n = 5 patients). Preoperative demographics, intraoperative findings, radiographic data, and clinical outcome scores were compared between cohorts with and without revision surgery in the registry. Postoperative, short-term patient-reported outcome scores for the revision cohort were described. RESULTS The most common reason for revision was residual intra-articular femoroacetabular impingement (74.8%), followed by extra-articular impingement (9.5%). The majority of revision cases (78.9%) could be addressed with arthroscopic surgery, with the exception of extra-articular impingement or residual acetabular dysplasia, which necessitated open approaches. Patients who underwent revision were more likely to be female, were younger in age, and had worse preoperative outcome scores than did those in the primary cohort. Abnormal femoral version and the presence of acetabular dysplasia were not significantly different between the revision and primary cohorts. Short-term improvements in patient-reported outcome scores were found in the revision cohort at a mean of 15.0 months from the last revision surgery. CONCLUSION Residual intra- and extra-articular impingement were the most common reasons for revision in this cohort. Patients who underwent revision tended to be younger in age, were female, and had worse preoperative hip functional outcomes than did those in the primary cohort. Abnormal femoral version or acetabular coverage was not increased in our revision cohort.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Kara Fields
- Department of Biostatistics, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Anil S Ranawat
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Struan H Coleman
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Ernest L Sink
- Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA
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24
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Hellman MD, Riff AJ, Frank RM, Haughom BD, Nho SJ. Operative treatment of femoroacetabular impingement. PHYSICIAN SPORTSMED 2014; 42:112-9. [PMID: 25295773 DOI: 10.3810/psm.2014.09.2082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Femoroacetabular impingement is a common pathologic disorder of the hip that causes pain and has been implicated in the development of early osteoarthritis in young adults. This disorder includes 2 different subtypes: cam impingement and pincer impingement. When nonsurgical treatment methods fail, surgical options are indicated. These options have been increasingly investigated over recent years and show promising results. Several surgical techniques have been described, including surgical dislocation of the hip, mini-open procedures, hip arthroscopy, and periacetabular osteotomies. Nevertheless, the preferred mode of surgical management of femoroacetabular impingement remains a source of controversy. Only short-term and midterm outcome data are available regarding the efficacy of these surgical techniques. This review details 5 approaches for surgical management of femoroacetabular impingement: open surgical dislocation, a combined arthroscopic and open approach, hip arthroscopy, a mini-open anterior approach, and periacetabular osteotomy. It focuses specifically on surgical technique, outcomes, and their efficacy in treatment of femoroacetabular impingement.
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Affiliation(s)
- Michael D Hellman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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25
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Chu CR, Millis MB, Olson SA. Osteoarthritis: From Palliation to Prevention: AOA Critical Issues. J Bone Joint Surg Am 2014; 96:e130. [PMID: 25100783 PMCID: PMC4116563 DOI: 10.2106/jbjs.m.01209] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Osteoarthritis is a leading cause of disability. The traditional focus on late-stage osteoarthritis has not yielded effective disease-modifying treatments. Consequently, current clinical care focuses on palliation until joint replacement is indicated. A symposium format was used to examine emerging strategies that support the transformation of the clinical approach to osteoarthritis from palliation to prevention. Central to this discussion are concepts for diagnosis and treatment of pre-osteoarthritis, meaning joint conditions that increase the risk of accelerated development of osteoarthritis. The presentation of translational and clinical research on three common orthopaedic conditions-anterior cruciate ligament tear, intra-articular fracture, and hip dysplasia-were used to illustrate these ideas. New information regarding the use of novel quantitative magnetic resonance imaging (MRI) in the form of ultrashort echo time enhanced T2* (UTE-T2*) mapping to evaluate the potential for articular cartilage to heal subsurface damage in a mechanically sound environment was presented. These data indicate that improved diagnostics can both identify cartilage at risk and evaluate the effectiveness of early treatment strategies. With use of a new mouse model for intra-articular fracture, it was shown that inflammation correlated to fracture severity and that super-healer mice avoided early posttraumatic osteoarthritis in part through an enhanced ability to dampen inflammation. These findings suggest that there is a role for acute and sustained anti-inflammatory treatment in the prevention of osteoarthritis. For long-term treatment, contemporary gene-therapy approaches may offer an effective means for sustained intra-articular delivery of anti-inflammatory and other bioactive agents to restore joint homeostasis. To illustrate the potential of early treatment to prevent or delay the onset of disabling osteoarthritis, the positive clinical effects on articular cartilage and in long-term clinical follow-up after operative correction of structural abnormalities about the hip highlight the role for targeting mechanical factors in delaying the onset of osteoarthritis. Given that orthopaedic surgeons treat the full spectrum of joint problems, ranging from joint trauma to pre-osteoarthritic conditions and end-stage osteoarthritis, an awareness of the paradigm shift toward the prevention of osteoarthritis is critical to the promotion of improved clinical care and participation in clinical research involving new treatment strategies.
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Affiliation(s)
- Constance R. Chu
- Department of Orthopaedic Surgery, Stanford University,
450 Broadway Street, MC 6342, Redwood City, CA 94063. E-mail address:
| | - Michael B. Millis
- Child and Adult Hip Program, Boston Children’s
Hospital, 300 Longwood Avenue, Hunnewell 213, Boston, MA 02215
| | - Steven A. Olson
- Hip Preservation and Orthopaedic Trauma, Department of
Orthopaedic Surgery, Duke University Health System, DUMC 3389, Durham, NC 27710
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26
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Surgical treatment of femoroacetabular impingement: what are the limits of hip arthroscopy? Arthroscopy 2014; 30:99-110. [PMID: 24384276 DOI: 10.1016/j.arthro.2013.10.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 02/02/2023]
Abstract
The variety of hip pathology that can be addressed in a minimally invasive fashion in the young, pre-arthritic patient has rapidly grown in parallel with technical advances in hip arthroscopy. However, the indications and limits of arthroscopy must be carefully defined and indications must evolve correspondingly to avoid an increase in failure rates and unsatisfactory clinical outcomes. Some diagnoses may be better and more comprehensively addressed with open procedures or combined surgical approaches. The purpose of this article is to provide an unbiased and evidence-based review of conditions of the pre-arthritic hip to define our current understanding of the advantages, disadvantages, and limitations of an arthroscopic approach.
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