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Lerch TD, Nanavati AK, Heimann AF, Meier MK, Steppacher SD, Wagner M, Brunner A, Vavron P, Schmaranzer E, Schwab JM, Tannast M, Schmaranzer F. Are degenerative findings detected on traction MR arthrography of the hip associated with failure of arthroscopic femoroacetabular impingement surgery? Eur Radiol 2024; 34:3555-3565. [PMID: 37982837 PMCID: PMC11166863 DOI: 10.1007/s00330-023-10419-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/04/2023] [Accepted: 10/15/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES To identify preoperative degenerative features on traction MR arthrography associated with failure after arthroscopic femoroacetabular impingement (FAI) surgery. METHODS Retrospective study including 102 patients (107 hips) undergoing traction magnetic resonance arthrography (MRA) of the hip at 1.5 T and subsequent hip arthroscopic FAI surgery performed (01/2016 to 02/2020) with complete follow-up. Clinical outcomes were assessed using the International Hip Outcome Tool (iHOT-12) score. Clinical endpoint for failure was defined as an iHOT-12 of < 60 points or conversion to total hip arthroplasty. MR images were assessed by two radiologists for presence of 9 degenerative lesions including osseous, chondrolabral/ligamentum teres lesions. Uni- and multivariate Cox regression analysis was performed to assess the association between MRI findings and failure of FAI surgery. RESULTS Of the 107 hips, 27 hips (25%) met at least one endpoint at a mean 3.7 ± 0.9 years follow-up. Osteophytic changes of femur or acetabulum (hazard ratio [HR] 2.5-5.0), acetabular cysts (HR 3.4) and extensive cartilage (HR 5.1) and labral damage (HR 5.5) > 2 h on the clockface were univariate risk factors (all p < 0.05) for failure. Three risk factors for failure were identified in multivariate analysis: Acetabular cartilage damage > 2 h on the clockface (HR 3.2, p = 0.01), central femoral osteophyte (HR 3.1, p = 0.02), and femoral cartilage damage with ligamentum teres damage (HR 3.0, p = 0.04). CONCLUSION Joint damage detected by preoperative traction MRA is associated with failure 4 years following arthroscopic FAI surgery and yields promise in preoperative risk stratification. CLINICAL RELEVANCE STATEMENT Evaluation of negative predictors on preoperative traction MR arthrography holds the potential to improve risk stratification based on the already present joint degeneration ahead of FAI surgery. KEY POINTS • Osteophytes, acetabular cysts, and extensive chondrolabral damage are risk factors for failure of FAI surgery. • Extensive acetabular cartilage damage, central femoral osteophytes, and combined femoral cartilage and ligamentum teres damage represent independent negative predictors. • Survival rates following hip arthroscopy progressively decrease with increasing prevalence of these three degenerative findings.
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Affiliation(s)
- Till D Lerch
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Andreas K Nanavati
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Alexander F Heimann
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Chemin Des Pensionnats 2-6, 1700, Fribourg, Switzerland
| | - Malin K Meier
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Moritz Wagner
- Department of Orthopaedic Surgery and Traumatology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Alexander Brunner
- Department of Orthopaedic Surgery and Traumatology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Peter Vavron
- Department of Orthopaedic Surgery and Traumatology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Ehrenfried Schmaranzer
- Department of Radiology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Joseph M Schwab
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Chemin Des Pensionnats 2-6, 1700, Fribourg, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Chemin Des Pensionnats 2-6, 1700, Fribourg, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Department of Radiology, Balgrist University Hospital, Faculty of Medicine, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
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Dean MC, Cherian NJ, McBroom TJ, Eberlin CT, Torabian KA, Dowley KS, LaPorte ZL, Kucharik MP, Martin SD. Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair. Arthroscopy 2024; 40:1475-1487.e1. [PMID: 37865131 DOI: 10.1016/j.arthro.2023.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging/arthrography predict 2-year functional outcomes after arthroscopic acetabular labral repair. METHODS Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis > 1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on magnetic resonance imaging/arthrography. Primary outcomes were International Hip Outcome Tool and modified Harris Hip Score. Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics. RESULTS Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of International Hip Outcome Tool scores (weighted difference = 1.60; 95% confidence interval [CI], -5.09, 8.28; P = .64), modified Harris Hip Scores (weighted difference = 0.56; 95% CI, -4.16, 5.28; P = .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference = -11.85; 95% CI, -22.85, -0.84; P = .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P > .99), or conversion to total hip arthroplasty between cohorts (P > .99). These results held across all sensitivity analyses. CONCLUSIONS Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Michael C Dean
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A..
| | - Nathan J Cherian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University of Nebraska, Omaha, Nebraska, U.S.A
| | | | - Christopher T Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - Kaveh A Torabian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Kieran S Dowley
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Zachary L LaPorte
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Michael P Kucharik
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; Harvard Medical School, Boston, Massachusetts, U.S.A
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Ramkumar PN, Berrier AS, Helm JM, Koolmees DS, Pareek A, Krych AJ, Makhni EC, Harris JD, Nwachukwu BU. Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis. Orthop J Sports Med 2023; 11:23259671221144776. [PMID: 36655021 PMCID: PMC9841845 DOI: 10.1177/23259671221144776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 01/13/2023] Open
Abstract
Background Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design Cohort study; Level of evidence, 3. Methods Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.
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Affiliation(s)
- Prem N. Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Prem N. Ramkumar, MD, MBA, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA () (Twitter: @prem_ramkumar)
| | - Ava S. Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - J. Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, USA
| | - Dylan S. Koolmees
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric C. Makhni
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua D. Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, USA
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Larson CM. Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers. Arthroscopy 2022; 38:3020-3022. [PMID: 36344059 DOI: 10.1016/j.arthro.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 11/06/2022]
Abstract
Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.
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