Hip arthroscopy for challenging deformities: global pincer femoroacetabular impingement

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage

BACKGROUND

Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS).

PURPOSE

To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups.

RESULTS

In total, 94 patients (mean age, 41.9 ± 14.2 years) were included with a mean follow-up duration of 6.1 ± 0.9 years. Of these patients, 40.4% had no acetabular overcoverage, 36.2% had lateral overcoverage, and 23.4% had global overcoverage. There was no difference between groups with respect to percentage of patients who underwent reoperation for either revision arthroscopy or conversion to total hip arthroplasty (28.9% for the normal acetabular coverage group, 29.4% for the lateral overcoverage group, and 31.8% for the global overcoverage group; P = .971). Among patients for whom primary hip arthroscopy did not fail, there was no difference in 5-year functional outcomes between groups. Postoperative LCEA >40° (β = -13.3; 95% CI, -24.1 to -2.6; P = .016), female sex (β = -14.5; 95% CI, -22.7 to -6.2; P = .001), and higher body mass index (β = -1.9; 95% CI, -2.8 to -1.0; P < .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score.

CONCLUSION

There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.

T, Maniar A, Mitrasinovic S, Menta SV, Ranawat A. Intraoperative traction has a negligible time-dependent influence on patient-reported outcomes after hip arthroscopy: a cohort study

The aim of this study is to determine if post-operative patient-reported outcome measures (PROMs) are influenced by hip arthroscopy traction duration. Patients from a local prospective hip arthroscopy database were retrospectively analyzed. Four hip-specific PROMs were utilized: modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS), and international Hip Outcome Tool (iHOT). PROMs were collected pre-operatively and 6 months, 1 year and 2 years post-operatively. Two cohorts were created based on a cut-off corresponding to the 66th percentile for our patient cohort. Analyses were completed for each PROM at each post-operative interval with univariable statistics. Multivariable statistics were examined to identify the variables that were predictive of achieving post-operative minimal clinically important difference (MCID) at the 2-year follow-up. Overall, 222 patients met the inclusion criteria. The mean age was 32.4 ± 9.4 years, and 116 (52.3%) were female. The average traction time of the study population was 46.1 ± 12.9 min. A total of 145 patients were included in the short traction cohort (65%) with traction times of <50 min (66th percentile). No significant differences were found regarding PROM scores or MCID achievement rates between both cohorts at any post-operative period. In multivariable analyses, achievement of MCID was predicted by a decrease in traction time for all PROMs and pincer-type resection for mHSS, HOS-ADL and iHOT. There was no difference in PROMs and MCID achievement between longer and shorter traction time cohorts. On multivariable analysis, a decrease in traction time is predictive of MCID for all PROM scores and pincer-type resection was predictive of MCID for most PROM scores. Level of evidence: Level III, cohort study.

Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes

» Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.» Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.» Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.» Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology.

Treatment of Severe Pincer-Type Femoroacetabular Impingement With Arthroscopic Significant Acetabular Rim Correction and Circumferential Labral Reconstruction Improves Patient-Reported Outcome Measures

PURPOSE

To validate an arthroscopic approach for performing significant acetabular rim correction and circumferential labral reconstruction required to treat severe pincer-type femoroacetabular impingement.

METHODS

Using a minimum of 2-year follow-up, data from 48 hips, including 47 patients (11 male, 36 female; mean age of 42 years) having undergone significant arthroscopic acetabuloplasty for severe pincer impingement (center edge angle >45°) with concomitant circumferential allograft labral reconstruction were analyzed to determine improvements in patient-reported outcomes and degree of radiographic correction.

RESULTS

Findings demonstrated a 98% success rate, including substantial improvements on all radiographic measurements and patient-reported outcomes. Minimal clinically important differences were met with extremely strong measures of effect. The mean center edge angle improved from 49° to 36° (MΔ = 13.96, P ≤ .001, standard deviation [SD] = 55.97, confidence interval [CI] 12.17- 15.62, d = 2.33) and the mean Tönnis angle improved from -6° to 0° (MΔ = 6.2, P ≤ .001, SD = 2.76 CI -7.1 to -5.39, d = 2.29). Modified Hip Harris Scores improved by a mean of 34.45 points (P ≤ .001, SD = 20.64, 95% CI 28.45-40.44, d = 1.66). Lower extremity functional scale scores improved by a mean of 27.35 points (P ≤ .001, SD = 18.37, 95% CI 22.02-32.69, d =1.48). No complications were reported. One case converted to a total hip arthroplasty (2%).

CONCLUSIONS

Findings validated that the significant acetabular rim correction required to treat severe pincer morphology is safe and feasible via an arthroscopic approach. This, in addition to concomitant circumferential allograft labral reconstruction, resulted in improvement in patient-reported outcomes and radiographic measurements.

LEVEL OF EVIDENCE

Level IV, therapeutic case-series.

Outcomes in Patients with Global Pincer Versus Focal Pincer Femoroacetabular Impingement Treated with Hip Arthroscopy: A Retrospective Study with a Minimum 2-Year Follow-Up

OBJECTIVE

Global pincer is a relatively rare form of pincer deformity and is typically associated with technical challenges during surgery. So far, controversy remains whether patients with global pincer have equivalent surgical outcomes compared to patients with focal pincer. This study compares the clinical outcomes of arthroscopic treatment between patients with global pincer femoroacetabular impingement (FAI) and focal pincer FAI in the Chinese population.

METHODS

Data were retrospectively collected from patients with global and focal pincer FAI who underwent hip arthroscopy with a minimum two-year follow-up between April 2016 and December 2018. Radiographic measurements, arthroscopic procedures, preoperative and postoperative patient-reported outcomes (PROs) including modified Harris hip score (mHHS), hip outcome score-activities of daily living (HOS-ADL), international hip outcome tool-12 (iHOT-12), and visual analogue scale (VAS) scores, rates of revision surgery and conversion to total hip arthroplasty (THA) were recorded. Achievement of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) was compared for the VAS, mHHS, HOS-ADL, and iHOT-12 scores between groups.

RESULTS

The total of 33 and 167 patients were included in the global and focal group, respectively. There were no intergroup differences in age, gender, body mass index or follow-up times. Lateral center-edge angle (LCEA) was reduced in both groups postoperatively. Both groups demonstrated significant improvements in PROs compared with preoperative levels at the final follow-up. The preoperative scores showed significant differences in terms of mHHS (60.34 vs 62.90, P = 0.031) and HOS-ADL (61.45 vs 64.74, P = 0.022) scores between two groups, and the improvement of HOS-ADL score was significantly higher in global group (P = 0.027). However, the postoperative scores, including VAS, mHHS, HOS-ADL, and iHOT-12 scores, showed no significant differences between two groups. And there were no significant differences in the rate of meeting the PASS and MCID between groups. One (3.0%) in the global group and six (3.6%) patients in the focal group underwent revision arthroscopy respectively, with no significant difference (P = 0.876). There were no conversions to THA in both groups.

CONCLUSIONS

Arthroscopic management of global pincer FAI can achieve excellent functional scores at minimum 2-year follow-up. The outcomes were similar to focal pincer FAI patients with a low rate of secondary procedure.

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Acetabular Rim Disorders/Pincer-type Femoroacetabular Impingement and Hip Arthroscopy

Femoroacetabular impingement (FAI) can lead to acetabular impaction, chondral injury, and labral pathology secondary to deformities of the proximal femur (CAM-type FAI), acetabulum (pincer-type FAI), or with combined FAI. While the majority of cases are of the combined type, this paper focuses on acetabular overcoverage/pincer-type deformities. Various pincer subtypes include focal anterior overcoverage, global retroversion, global overcoverage/profunda, protrusio, subspine impingement, and os acetabuli/rim fracture variants. A thorough history and physical examination, plain radiographs, magnetic resonance imaging, 3-dimensional computerized tomography, and diagnostic injections can lead to an accurate assessment of pincer-type variants. Appropriately indicated arthroscopic management techniques and pearls for the various pincer subtypes can lead to improved patient-related outcome measures and a high rate of return to athletic activity for the majority of these patients.

Outside-In Capsulotomy of the Hip for Arthroscopic Pincer Resection

Hip surgical techniques have evolved significantly, transitioning from open techniques to arthroscopic techniques. Hip arthroscopy has many advantages over open techniques, including reduced trauma to surrounding tissues, reduced risk of infection, and improved patient-reported outcome measures. Hip arthroscopic techniques are now commonly used for pathologies such as femoroacetabular impingement (FAI). FAI can include cam, pincer, or mixed impingement. Through hip arthroscopy, FAI may be treated with a femoroplasty and acetabuloplasty along with addressing any labral pathology that may exist. Owing to the capsule playing an integral role in hip stability, surgeons are now mindful of the initial approach and closure on completion of the intra-articular procedure. The most common approach for capsulotomy is the inside-out approach. However, this approach can be difficult in patients with a large pincer deformity. The authors describe an outside-in approach to arthroscopic hip capsulotomy. This capsular approach helps protect the labrum and articular cartilage while preserving capsular tissue.

Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome, Labral Tear, and Acetabular Overcoverage: Minimum 5-Year Outcomes With a Subanalysis Against Patients Without Overcoverage

BACKGROUND

Improvement in patient-reported outcomes (PROs) has been reported in the short term after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear in the setting of acetabular overcoverage. Yet, there is a paucity of information in the literature on midterm PROs.

PURPOSE

To (1) report minimum 5-year PROs in patients who underwent primary hip arthroscopy for FAIS and acetabular labral tears in the context of acetabular overcoverage and (2) compare outcomes with those of a propensity-matched control group without acetabular overcoverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively analyzed on all patients who underwent hip arthroscopy for FAIS and labral tears between February 2008 and November 2013. Inclusion criteria were lateral center-edge angle >40° and minimum 5-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the Hip Outcome Score-Sports-Specific Subscale (HOS-SSS). Exclusion criteria were previous ipsilateral hip surgery or conditions, active workers' compensation claims, or lack of minimum 5-year outcomes. A 1:1 propensity-matched comparison was made between the study group and a control group without acetabular overcoverage (lateral center-edge angle, 25°-40°) based on age at surgery, sex, body mass index, Tönnis grade, laterality, and follow-up time. The minimal clinically important difference (MCID) was calculated for the mHHS, HOS-SSS, and NAHS. Secondary surgical procedures were recorded.

RESULTS

A total of 54 patients satisfied the inclusion criteria for the study group, of whom 45 (83.3%; 45 hips) had a minimum 5-year follow-up and were matched without differences in age at surgery, sex, body mass index, or follow-up time. The study and control groups demonstrated significant and comparable improvements for the mHHS (mean ± SD Δ, 24.06 ± 24.19 vs 26.33 ± 17.27; P = .625), NAHS (Δ, 31.22 ± 25.31 vs 27.15 ± 17.61; P = .399), and HOS-SSS (Δ, 33.16 ± 34.73 vs 34.75 ± 26.15; P = .557). The rates for achieving the MCID were similar for the study and control groups for the mHHS (76.7% vs 84.2%; P = .399), HOS-SSS (79.1% vs 75.8%; P = .731), and NAHS (81.4% vs 84.2%; P = .738). Need for revision surgery was similar (P = .748). A lower conversion rate to total hip arthroplasty was reported for the study than for the control group (2.2% vs 15.6%; P = .026).

CONCLUSION

In the context of FAIS, labral tears, and acetabular overcoverage, patients who underwent hip arthroscopy reported significant improvement in several PROs at minimum 5-year follow-up. Moreover, outcomes were comparable with those of a propensity-matched control group without acetabular overcoverage. Furthermore, the rate of achieving the MCID for the mHHS, HOS-SSS, and NAHS was similar between these groups.

Hip Arthroscopy With Initial Access to the Peripheral Compartment: A Detailed Step-by-Step Technique Description

Hip arthroscopy with initial access to the peripheral compartment represents a specific technique to approach the hip that can be particularly useful. This technique is suitable for both the arthroscopic treatment of femoroacetabular impingement syndrome and other pathologies that can be addressed by classic arthroscopy with central compartment initial access. Minimal capsulotomies preserve the fluid pressure in the peripheral compartment, which allows the "ballooning" of the capsule and improved joint exposure with decreased risk of fluid extravasation. In the vast majority of cases, the hip joint can be accessed by any technique depending on the surgeon preference/expertise. Interestingly, access to the central compartment under direct arthroscopic visualization decreases the risk of iatrogenic labral and chondral damage. This is particularly important when access to the central compartment is technically challenging (e.g., acetabular overcoverage, labral hypertrophy, and limited joint distraction). Such a technique is also preferable if the pathology is mainly located in the peripheral compartment. Despite several advantages, hip arthroscopy with initial access to the peripheral compartment is not a commonly performed technique. Our purpose is to perform a step-by-step explanation of a previously described technique.

Hip Arthroscopy for Diffuse Idiopathic Skeletal Hyperostosis Using a Capsulotomy-First Approach

Diffuse idiopathic skeletal hyperostosis (DISH) is a systematic disease of unknown etiology characterized by ossification at the site of spine and major joints entheses, including the hip. Ossified connective tissue may cause pain and joint stiffness, which may require surgical intervention. The purpose of this study was to investigate the clinical, radiographic, and arthroscopic presentation and surgical outcomes of patients with DISH involving the hips. Fourteen hips in 9 patients (mean±SD age, 63±14 years; range, 35-76 years) with overcoverage of the femoral head by DISH were retrospectively reviewed. For all joints, a transverse, capsulotomy-first approach was performed due to an inability to access the central compartment by traction of the lower extremity. After arthroscopic resection of the ossified lesion, labral reconstruction was performed with an iliotibial band autograft. For clinical evaluation, patient-reported outcome scores (modified Harris Hip Score [mHHS], Nonarthritic Hip Score [NAHS], International Hip Outcome Tool-12 [iHot-12], visual analog scale [VAS] pain score, and VAS satisfaction score) were obtained. Arthroscopically, circumferential labral damage with no or mild articular cartilage damage was observed. Mean NAHS, iHot-12 score, and VAS satisfaction score improved significantly (47 to 56, 43 to 71, and 21 to 72, respectively; P<.05). Mean mHHS and VAS pain score did not reach significance but did improve (65 to 92 and 45 to 78, respectively). Using a transverse, capsulotomy-first approach for arthroscopic hip surgery for patients with DISH yields successful outcomes in patient-reported outcome measures and satisfaction, despite minor gains in hip range of motion. [Orthopedics. 2020;43(5):e369-e377.].

Importance of Retaining Sufficient Acetabular Depth: Successful 2-Year Outcomes of Hip Arthroscopy for Patients With Pincer Morphology as Compared With Matched Controls

BACKGROUND

Patients with pincer-type femoroacetabular impingement are commonly treated with arthroscopic reduction of acetabular depth as measured by the lateral center-edge angle (LCEA). The optimal amount of rim reduction has not been established, although large resections may increase contact pressures through the hip. A recent publication demonstrated inferior surgical outcomes in patients with acetabular overcoverage as compared with normal acetabular coverage. Casual observation of our database suggested equivalent improvements, prompting a similar analysis.

PURPOSE

To analyze patient-reported outcomes after hip arthroscopy for femoroacetabular impingement in patients with acetabular overcoverage who were matched with controls with normal coverage, as well as to analyze associations with reduction in LCEA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected prospectively from patients with a minimum 2-year follow-up after receiving hip arthroscopy for femoroacetabular impingement by a single surgeon. Cases were reviewed to identify those with pincer-type morphology (LCEA >40°) and matched according to sex, age, chondral damage, and surgery date in a 1:1 ratio with controls with an LCEA of 25° to 40°. The surgical goal was to reduce the LCEA to the upper end of the normal range with minimal rim resection, usually 35° to 37°. Radiographic measurements of coverage, intraoperative findings, procedures, and patient-reported outcomes were recorded, including the 12-Item International Hip Outcome Tool, Non-arthritic Hip Score, Hip Disability and Osteoarthritis Outcome Score, visual analog scale for pain, rates of revision or reoperation, and conversion to total hip arthroplasty.

RESULTS

A total of 114 hips (93 patients) for the pincer group were matched 1:1 from 616 hips (541 patients) for the control group. The pincer group (mean ± SD age, 34.5 ± 12.2 years) did not differ in age, body mass index, or follow-up from controls. LCEA was reduced in both groups pre- to postoperatively: the pincer group from 44.0° ± 2.8° to 34.2° ± 3.5° and the controls from 32.9° ± 3.9° to 31.0° ± 3.0°. No differences in improvement were observed: iHOT-12 improved by 35.7 points in both groups (P = .9 for analysis of variance interaction) and Nonarthritic Hip Score by 22.3 points (P = .6). From all eligible surgical procedures, 2-year follow up rates were 2.5% and 2.6% for the pincer and control cohorts, respectively, and 1.2% and 0.3% for conversion to total hip arthroplasty.

CONCLUSION

Arthroscopic management of acetabular overcoverage can achieve excellent results, equivalent to arthroscopy for other causes of symptomatic femoroacetabular impingement. A key finding was smaller rim resections producing a mean postoperative LCEA of 34.2° with a small standard deviation.

Arthroscopic Outcomes as a Function of Acetabular Coverage From a Large Hip Arthroscopy Study Group

PURPOSE

To report comparative hip arthroscopic outcomes of patients with low (borderline dysplasia), normal, and high (global pincer femoroacetabular impingement [FAI]) lateral acetabular coverage.

METHODS

A retrospective analysis of prospectively collected data from a multicenter registry was performed. Primary hip arthroscopy patients were assigned to 1 of 3 groups based on preoperative lateral center-edge angle: borderline dysplasia (≤25°), normal (25.1°-38.9°), and pincer (≥39°). Repeated-measures analysis of variance compared preoperative with 2-year minimum postoperative International Hip Outcome Tool (iHOT-12) scores. Subsequent analysis of variance determined the effect of acetabular coverage on magnitude of change in scores.

RESULTS

Of 437 patients, the only statistical difference between groups was a lower prevalence of acetabuloplasty in the borderline dysplasia group (P = .001). A significant improvement in the preoperative to postoperative iHOT-12 scores for patients with normal acetabular coverage, acetabular undercoverage, and acetabular overcoverage was observed: F(1, 339) = 311.06; P <.001, with no statistical differences in preoperative (P = .505) and postoperative (P <.488) iHOT-12 scores when comparing the groups based on acetabular coverage. Mean iHOT-12 scores increased from 37.3 preoperatively to 68.7 postoperatively (P <.001) in the borderline dysplasia group, from 34.4 to 72 (P <.001) in the normal coverage group, and from 35.3 to 69.4 (P <.001) in the pincer group. These preoperative scores increased by 31.4, 37.8, and 34.1, respectively, with no effect for acetabular coverage on the magnitude of change from preoperative to postoperative iHOT-12 scores: F(2,339) = 1.18; P = .310. Ten patients (2.3%) underwent conversion arthroplasty, and 19 patients (4.4%) underwent revision arthroscopy with no significant effect of acetabular coverage on the incidence of revision or conversion surgery: χ² (6,433) = 11.535; P = .073.

CONCLUSIONS

Lateral acetabular coverage did not influence outcomes from primary hip arthroscopy when performed in patients with low (borderline dysplasia), normal, and high (global pincer FAI) lateral center-edge angle. Borderline dysplasia and moderate global pincer FAI with no or minimal osteoarthritis do not compromise successful 2-year minimum outcomes or survivorship following primary hip arthroscopy when performed by experienced surgeons.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic trial.

Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade >1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m², Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively (P = 0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91-17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group.

Forget the Greater Trochanter! Hip Joint Access With the 12 O'clock Portal in Hip Arthroscopy

Most surgeons rely on the greater trochanter as the reference point to establish the anterolateral portal. Nevertheless, we believe that the anterosuperior iliac spine is a more reliable landmark. Unlike the greater trochanter, it is unaffected by leg rotation and is more easily identified by palpation. Abiding by the central tenet of medicine to "do no harm," the technique described herein presents in detail the concept of the 12 o'clock portal placement, a hip joint access method based on identifying specific anatomic points under fluoroscopy and by palpation. To accomplish this goal, this Technical Note presents a step-by-step approach, including tips and pearls for patient positioning and fluoroscopic guidance. We believe this method ensures a reproducible and safe way to start hip arthroscopy in the supine position.

Use of Air Arthrograms to Aid in Joint Distraction During Hip Arthroscopic Surgery Decreases Postoperative Pain and Opioid Requirements

BACKGROUND

Positive-pressure air arthrography and venting of the hip capsule are techniques used to decrease the traction forces needed for joint distraction during hip arthroscopic surgery. Little is known about the effects that these techniques have on postoperative pain.

HYPOTHESIS

Positive-pressure air arthrography and venting during hip arthroscopic surgery will decrease patient-reported pain and narcotic requirements in the acute postoperative setting.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort analysis was conducted to analyze 35 patients who underwent positive-pressure air arthrography and venting to aid joint distraction during hip arthroscopic surgery versus a group with similar demographics, pathologies, and treatments who did not undergo air arthrography. Numeric pain rating scale (NPRS) scores and medication administration including narcotic and nonnarcotic analgesia in the postanesthesia care unit (PACU) were tracked and compared.

RESULTS

The maximum (7.17 vs 4.97, respectively), minimum (2.43 vs 1.09, respectively), and mean (5.15 vs 3.11, respectively) NPRS scores were all higher in the control group compared with the air arthrogram group (P < .001, P = .007, and P < .001, respectively). The administration of oral morphine equivalents (OMEs) during the PACU stay was significantly lower in the air arthrogram group, with a mean of 36.75 ± 11.37 OMEs, compared with 44.53 ± 16.06 OMEs in the control group (P = .023). There was no difference in postoperative nonopioid medications, such as ketorolac or acetaminophen, given between groups.

CONCLUSION

Patients undergoing hip arthroscopic surgery with air arthrography and venting used to aid distraction had significantly less postoperative pain and required a lower total dosage of opioids during their PACU stay when compared with patients who underwent hip arthroscopic surgery without air arthrography.

[Mid-term effectiveness of arthroscopic surgery for femoroacetabular impingement]

Objective

To assess the mid-term effectiveness of arthroscopic surgery in treatment of femoroacetabular impingement (FAI).

Methods

Between July 2014 and December 2015, 131 patients (132 hips) with FAI were enrolled in this study. There were 68 males and 63 females with an average age of 42.5 years (range, 17-68 years). The FAI was located at left hip in 72 cases, right hip in 58 cases, and bilateral hips in 1 case. The mean disease duration was 35 months (range, 3-120 months). Under arthroscopy, the femoral neck osteoplasty and/or acetabular rim trimming were performed, then the torn labrum was repaired. At the same time, the iliopsoas tendon was divided and the torn round ligament was debrided. The effectiveness was assessed by the visual analogue scale (VAS) and the Harris hip score (HHS).

Results

After operation, the perineum nerve palsy and numbness of dorsal feet occurred in 2 cases and 3 cases, respectively. There was no other complication. All patients were followed up 20-36 months (mean, 27.7 months). There were significant differences in the VAS scores and HHS scores between pre-operation, post-operative 3 months, and the last follow-up ( P<0.05). Imaging examination showed that joint interspace of the involved hip was normal, and there was no sign of impingement and osteoarthritis in the femoral neck or acetabulum.

Conclusion

Arthroscopic labral repair and osteoplasty is an effective and safe management for FAI in the mid-term follow-up.

Minimum 2-Year Outcomes of Hip Arthroscopic Surgery in Patients With Acetabular Overcoverage and Profunda Acetabulae Compared With Matched Controls With Normal Acetabular Coverage

BACKGROUND

Advancements in instrumentation and techniques have extended the scope of hip arthroscopic surgery to treat complex osseous deformities that were previously best addressed with an open approach. Global pincer-type femoroacetabular impingement is an example of an abnormality requiring osseous correction with a technically challenging access point.

PURPOSE

To report on the patterns of clinical presentation and intra-articular derangements, radiological associations, and minimum 2-year outcomes after hip arthroscopic surgery in patients with a lateral center edge angle (LCEA) >40° and profunda acetabulae in comparison with matched controls with normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected on all patients undergoing hip arthroscopic surgery during the study period from April 2008 to April 2013. All patients who had undergone hip arthroscopic surgery for symptomatic labral tears not responsive to a minimum of 3 months of physical therapy with both an LCEA >40° and profunda acetabulae, as defined by the ilioischial line lateral to the medial border of the teardrop, and without a history of hip surgery or hip conditions were included. This group was matched in a 1-to-1 ratio with a control group that had also undergone the arthroscopic management of symptomatic labral tears refractory to a minimum of 3 months of physical therapy with an LCEA between 25° and 40° according to age within 3 years, sex, body mass index category, Tönnis grade, labral treatment, and capsular treatment. Range of motion, impingement signs, and radiographic indices of coverage and version were recorded for each group. Four patient-reported outcome (PRO) scores, the visual analog scale (VAS) for pain, patient satisfaction, revision hip arthroscopic surgery, and conversion to total hip arthroplasty (THA) were also recorded.

RESULTS

Thirty-nine patients met the inclusion criteria for the study (overcoverage) group, of which 36 (92.3%) patients had a minimum 2-year follow-up; 215 patients satisfied the inclusion criteria for the control (normal coverage) group, of which 183 (85.1%) had a minimum 2-year follow-up. Thirty-six patients were matched in each group using the above criteria. There was no difference with respect to range of motion and impingement signs between the groups. The study group had significantly higher radiological markers of overcoverage but not retroversion compared with the control group. The study group had a significantly higher incidence of Seldes type 2 tears compared with the control group: 50.0% versus 19.4%, respectively ( P = .013). Both groups demonstrated significant improvements in the mean scores of all PROs, but the study group had a lower magnitude of improvement for all the PROs compared with the control group, with the modified Harris Hip Score (mHHS) achieving statistical significance: 13.5 versus 21.7 points, respectively ( P = .032). The study group had a significantly lower mean patient satisfaction score compared with the control group: 6.61 versus 7.91, respectively ( P = .019). The study group also had a significantly higher incidence of conversion to THA compared with the control group: 4 versus 0, respectively ( P = .040).

CONCLUSION

Hip arthroscopic surgery for the management of symptomatic labral tears in patients with combined overcoverage and coxa profunda is associated with improvements in patient outcomes and pain at a minimum 2-year follow-up. However, the degree of improvement is of lower magnitude compared with a matched cohort with normal coverage undergoing the arthroscopic management of symptomatic labral tears. While hips with lateral overcoverage combined with coxa profunda may have a smaller potential for improvement compared with hips with normal coverage, this type of osseous morphology is still repairable with arthroscopic treatment.

Minimum 2-Year Outcomes of Arthroscopic Management of Symptomatic Hip Labrum Tears in Patients With Global Acetabular Overcoverage

PURPOSE

To report minimum 2-year patient-reported outcomes (PROs) after hip arthroscopy (HA) for symptomatic labral tears in patients with global acetabular overcoverage.

METHODS

This study was a retrospective case series of patients who underwent HA from April 2008 to April 2013. The inclusion criteria were patients with global acetabular overcoverage, defined as a lateral center-edge angle greater than 40°, and with coxa profunda, defined radiologically by the ilioischial line lateral to the acetabular floor. Only patients with minimum 2-year follow-up and no history of hip conditions or surgery were included. We recorded demographic, examination, radiologic, and intraoperative findings; intraoperative procedures performed; and the following PROs: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), visual analog scale, and patient satisfaction.

RESULTS

The inclusion criteria were met by 39 patients, of whom 35 (89.7%) had 2-year follow-up. There was no distinct pattern of examination findings. The study population had a mean acetabular inclination of -1.19° and an anterior center-edge angle of 35°. There was no association with measures of acetabular retroversion. Intrasubstance tearing of the labrum occurred in 75% of patients (mean tear size, 2.68 hours on acetabular clock face; mean location, 11.5 to 3 on acetabular clock face). There were significant improvements in the mean scores for all PROs: mHHS, 13.5 ± 17.7 points (P < .01); Non-Arthritic Hip Score, 14.3 ± 21.3 (P < .001); HOS-ADL, 11.6 ± 19.7 (P < .001); HOS-SSS, 17.1 ± 35.1 (P < .001); and visual analog scale, -2.77 ± 2.58 (P < .001). The mean patient satisfaction rating was 6.61. The improvements in mHHS, HOS-ADL, and HOS-SSS did not reach the minimal clinically important difference. The incidence of secondary procedures was 17% (4 patients underwent conversion to total hip arthroplasty and 2 required revision HA).

CONCLUSIONS

HA in patients with global acetabular overcoverage was associated with improvements in PROs and pain at minimum 2-year follow-up. However, these improvements did not reach the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS. The incidence of secondary procedures was 17%. The pattern of labral injury is predominantly intrasubstance labral damage with a narrow rim of adjacent chondral injury.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic treatment of global pincer-type femoroacetabular impingement

PURPOSE

Few studies have evaluated the role of hip arthroscopy in patients with coxa profunda. The purposes of this study are to (1) report functional hip outcomes after arthroscopic treatment of patients with femoroacetabular impingement (FAI) associated with radiographic coxa profunda and (2) evaluate factors associated with poor hip function at minimum 2 years following surgery in this specific cohort.

METHODS

This retrospective review included patients with radiographic sign of coxa profunda who underwent hip arthroscopy to treat FAI. Preoperative and post-operative radiographs were reviewed to determine changes in lateral centre-edge angle (CEA), the presence and correction of Cam deformity, and Tönnis grade of osteoarthritis. Hip functional scores, including modified Harris Hip Score, Hip Outcome Score, and IHOT score, were obtained at a minimum of 2 years following surgery.

RESULTS

The study cohort included 46 patients with a mean preoperative CEA of 39.9 (±2.4)° which decreased to a mean of 30.8 (±1.8)° post-operatively. At a mean follow-up of 2.5 years (±0.5), the mean mHHS and IHOT scores were 79.5 (±20.2) and of 69.7 (±28.3), respectively. Increased preoperative (p = 0.02) and post-operative (p = 0.001) Tönnis Osteoarthritis Grade was associated with a lower mHHS.

CONCLUSIONS

Patients with coxa profunda can achieve similar functional scores to more traditional FAI cohorts after arthroscopic treatment. Baseline osteoarthritis is predictive of lower hip function after hip arthroscopy. This study demonstrates that patients with global over-coverage can benefit from hip arthroscopy and may influence surgeons to treat these patients with less invasive arthroscopic techniques which avoid the morbidity of open surgical procedures.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Avoiding Failure in Hip Arthroscopy: Complications, Pearls, and Pitfalls

Although most patients have successful outcomes after hip arthroscopy, a minority of patients experience complications that may impact their recovery and long-term benefit. As most of these complications can be minimized by appropriate surgical technique, many tips have been recommended. Additionally, the reasons behind clinical failure postoperatively have been scrutinized, which include, most commonly, incomplete correction of osseous pathomorphology, underappreciated preexisting hip osteoarthritis, and/or an incorrect preoperative diagnosis. Meticulous preoperative planning, evaluation of advanced imaging studies, and proper patient selection will help to reduce the number of postoperative failures and increase the chance of a successful outcome following hip arthroscopy.

Arthroscopic treatment of femoroacetabular impingement shows persistent clinical improvement in the mid-term

INTRODUCTION

The concept of femoroacetabular impingement (FAI) and the indication for surgical intervention have been established in the last decade. Despite promising short-term results and emerging arthroscopic techniques, it remains unclear whether patients benefit from surgical correction in the mid- to long-term and whether progressive joint degeneration can be prevented.

MATERIALS AND METHODS

A retrospective study of our first 50 consecutive patients who underwent arthroscopic correction for FAI was conducted. The modified Harris hip score (mHHS) was assessed preoperatively and at final follow-up. In addition, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and a subjective hip value (SHV) were added at final follow-up. Degenerative changes according to Kellgren and Lawrence scale and the α angle were analyzed preoperatively and on the most recent radiograph.

RESULTS

Of a total of 50 patients, 44 (24 male, 20 female) with a mean age of 34.3 years (17-65) were available with complete follow-up. Of these 44 patients, 39 were treated with correction of the femoral offset for isolated cam deformity, 5 with additional focal pincer correction and partial labral resection. After a mean follow-up of 66.3 ± 14.5 months the mHHS had improved significantly from 67.2 ± 6.4 preoperatively to 86.4 ± 13.5 (p < 0.001). The WOMAC score (converted to 0 = best/100 = worst) resulted in mean indices for the subcategories pain, stiffness and function of 11.8 ± 16.5, 12.2 ± 17.8 and 9.1 ± 16.1. The SHV was reported with a mean of 77.7 ± 21.8 % at final follow-up. The α angle was reduced significantly from 57.2° ± 10.1° to 46.3° ± 7.4° (p < 0.001). The Kellgren and Lawrence score showed a non-significant trend from 2.0 ± 0.8 preoperatively to 2.2 ± 0.9 in the most recent radiograph (p = 0.46). 5 patients had been converted to a total hip arthroplasty a mean of 28 ± 7.1 months postoperatively. These patients were significantly (p < 0.01) older with a mean age of 49.8 ± 7.8 years and showed significantly higher present osteoarthritic changes with an average Kellgren and Lawrence score of 2.6 ± 2.5 before FAI correction (p < 0.01).

CONCLUSIONS

Arthroscopic correction of femoroacetabular impingement results in a persistent clinical improvement without significant progression of degenerative changes in the majority of patients. The indication for surgery should be established cautiously when degenerative changes are present.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

Open and Arthroscopic Surgical Treatment of Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain, and when indicated, can be successfully managed through open surgery or hip arthroscopy. The goal of this review is to describe the different approaches to the surgical treatment of FAI. We present the indications, surgical technique, rehabilitation, and complications associated with (1) open hip dislocation, (2) reverse periacetabular osteotomy, (3) the direct anterior “mini-open” approach, and (4) arthroscopic surgery for FAI.

Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review

PURPOSE

To identify the indications and outcomes in patients undergoing revision hip arthroscopy.

METHODS

The electronic databases Embase, Medline, HealthStar, and PubMed were searched from 1946 to July 19, 2014. Two blinded reviewers searched, screened, and evaluated the data quality of the studies using the Methodological Index for Non-Randomized Studies scale. Data were abstracted in duplicate. Agreement and descriptive statistics are presented.

RESULTS

Six studies were included (3 prospective case series and 3 retrospective chart reviews), with a total of 448 hips examined. The most common indications for revision hip arthroscopy included residual femoroacetabular impingement (FAI), labral tears, and chondral lesions. The mean interval between revision arthroscopy and the index procedure was 25.6 months. Overall, the modified Harris Hip Score improved by a mean of 33.6% (19.3 points) from the baseline score at 1-year follow-up. In 14.6% of patients, further surgical procedures were required, including re-revision hip arthroscopy (8.0%), total hip replacement (5.6%), and hip resurfacing (1.0%). Female patients more commonly underwent revision hip arthroscopy (59.7%).

CONCLUSIONS

The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (modified Harris Hip Score) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Discrepancies in measuring acetabular coverage: revisiting the anterior and lateral center edge angles

The lateral center edge angle (LCEA) and the anterior center edge angle (ACEA) are commonly used to assess acetabular coverage of the femoral head. There are two distinct methods found in the literature to obtain these angles, specifically, measuring to the most lateral bone edge versus the sclerotic lateral sourcil edge. A difference between these two methods may contribute to inconsistent estimates of acetabular coverage, and potentially lead to clinical misdiagnosis and treatment mismanagement. The objectives of this study were to quantify the difference between bone edge and sourcil edge measurements and to determine how the difference influences the classification of acetabular coverage in adult patients with suspected hip pathomorphology. Two observers completed the measurements independently using preoperative anteroposterior and false profile radiographs. Bland-Altman plots and paired t-tests were used to compare measurement methods. Bone and sourcil measurements of the LCEA and ACEA were significantly different (both P < 0.001). On average, the bone LCEA was 4° (95% limits of agreement = -2° to 10°) greater than the sourcil LCEA. The bone ACEA was, on average, 10° (95% limit of agreement = -2° to 22°) greater than the sourcil ACEA. The differences often led to different clinical classifications for the same hip. With a statistically and clinically significant difference in the quantification of acetabular coverage using bone edge versus sourcil edge methods for measuring the LCEA and ACEA in adult patients, it should be mandatory to clearly identify which method was used in each study.

Arthroscopy of the nondistractable hip: a novel extracapsular approach

Adequate traction to achieve hip joint distraction is essential for avoiding iatrogenic injury to the joint during hip arthroscopy. An inability to distract the joint is a relative contraindication for hip arthroscopy. This report describes a novel technique involving an extracapsular approach to gain safe access to a hip joint that fails a trial of traction during positioning for hip arthroscopy. The anterolateral portal is established under fluoroscopic guidance. The arthroscope is positioned on the lateral rim of the acetabulum. A shaver, introduced through a modified anterior portal, is used to facilitate capsular exposure. An arthroscopic capsular incision is made proximal to the lateral acetabular rim and extended anteriorly with a radiofrequency probe. Osteoplasty of the anterolateral acetabular rim is carried out with a burr while protecting the labrum. Distraction of the hip is then possible, allowing safe central-compartment access and subsequent chondrolabral procedures.

The modified mid-anterior portal for hip arthroscopy

The modified mid-anterior portal is a utilitarian hip arthroscopy working portal that permits dual-portal comprehensive surgery for femoroacetabular impingement and related chondrolabral procedures without the need for interportal exchange. Its distal location facilitates labral reparative and reconstructive procedures while minimizing iatrogenic acetabular chondral damage. The relatively lateral location permits instrument navigation not only along the anterosuperior acetabular rim and anterolateral proximal femur typically required for acetabuloplasty and femoroplasty but even to the posterior regions of the hip in cases of global pincer femoroacetabular impingement and posterior extensions of cam morphology and the anteromedial proximal femur while avoiding direct injury to the lateral femoral cutaneous nerve.