Extracapsular approach for arthroscopic treatment of femoroacetabular impingement: clinical and radiographic results and complications

Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis

PURPOSE

This scoping review aims to map and summarise the available literature on heterotopic ossification (HO) following hip arthroscopy, with particular focus on incidence, distribution as per Brooker classification, efficacy of prophylactic measures and factors that may influence the likelihood of production of HO.

METHODS

A computer-based search was performed on PubMed, Embase, Emcare, Cinahl, ISI web of science and Scopus using the terms 'heterotopic ossification' and 'hip arthroscopy'. Articles reporting heterotopic ossification following hip arthroscopy for any condition were included after two-stage title/abstract and full-text screening.

RESULTS

Of the 663 articles retrieved, 45 studies were included. The proportion of patients with HO ranged from 0 to 44%. The majority of the cases were either Brooker grade I or II. Of the six studies investigating the effect of NSAID prophylaxis, five reported a significantly lower incidence of heterotopic ossification associated with its use. Weak evidence suggests that an outside-in arthroscopic approach, no capsular closure, male sex and mixed cam and pincer resection may be associated with an increased risk of HO.

CONCLUSION

Although there is a large variation in rates of HO following hip arthroscopy in the current literature, the majority of studies report a low incidence. Evidence exists advocating the administration of post-operative NSAIDs to reduce the incidence of HO following hip arthroscopy. This, combined with the low risk of complications, means there is a favourable risk-benefit ratio for prophylactic NSAID used in HA. Future research should work to identify patient clinical and demographic factors which may increase the risk of development of HO, allowing clinicians to risk stratify and select only specific patients who would benefit from receiving NSAID prophylaxis.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Anterior inferior iliac spine avulsion fracture post hip arthroscopy for Femoroacetabular impingement

FAI (Femoroacetabular Impingement) is an uncommon yet reported pathology of the hip joint, especially in the young athletic population. If left untreated, it predisposes for premature osteoarthritis of the hip. FAI treatment modalities consists of either open or arthroscopic surgery, the latter becoming the most adapted modality. We present a case of a young male athlete found to have FAI, treated arthroscopically. His post operative follow up was complicated by anterior inferior iliac spine avulsion fracture due to post op protocol non compliance which was treated with ORIF, with satisfactory non symptomatic outcome.

A systematic review-meta-analysis of venous thromboembolic events following primary hip arthroscopy for FAI: clinical and epidemiologic considerations

The purpose of this study was to report the proportion of venous thromboembolic events (VTE) in patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) and present a critical overview of the literature to aid in better result interpretation. MedLine, Scopus and Web of Science databases were searched from January 2000 to March 2017. Four thousand-five-hundred and seventy-seven hip cases were included in the meta-analysis of 38 studies. The mean age of patients was 36 ± 1.8 years and the mean follow-up time was 20.6 months. The meta-analysed rate of deep vein thrombosis (DVT) in patients undergoing primary hip arthroscopy for FAI syndrome was 1.18%; 95%CI [0.8–1.74%]; The meta-analysed rate of pulmonary embolism (PE) in patients undergoing primary hip arthroscopy for FAI syndrome was 0.59%; 95%CI [0.38–0.92%]. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria the Quality in Prognostic Studies (QUIPS) tool. Sensitivity analysis was conducted to assess for publication bias and its influence on the results. The corrected for publication bias proportion of DVT was 2.02%; 95%CI [1.36–2.99%]. The DVT rate was double following the correction of bias while additional types of bias were detected. Attention must be paid when considering the outcomes of observational studies to make clinical decisions. Insufficient evidence exists to support whether anti-VTE chemoprophylaxis should be administered to patients undergoing primary hip arthroscopy for FAI. Due to the life-threatening character of this complication, the results should serve as starting point to design clinical trials and establish guidelines. Until then, the application of preventive measures against VTE should be decided on a case-by-case basis.

Open versus arthroscopic approach in the treatment of femoroacetabular impingement: a case-control study with two-years follow up

Objective

To compare clinical and imaging results and complications between patients treated for femoroacetabular impingement (FAI) who underwent either anterior open surgery or an arthroscopic approach, with a minimum follow-up of two years.

Methods

This retrospective case–control study included patients submitted to FAI surgical treatment between November 2007 and March 2012. Patients treated with open surgery were compared with those treated with arthroscopy. Patients were clinically assessed by the modified Harris Hip Score, Non-Arthritic Hip Score, and internal hip rotation. Patients were radiographically assessed by the center-edge angle, joint space width, alpha angle, neck-head index, degree of arthrosis, and presence of heterotopic ossification of the hip.

Results

In the study period, 56 patients (58 hips) with FAI were included; 16 underwent open surgery and 40 underwent arthroscopy. The 40 patients treated by the arthroscopic route had a mean follow-up of 29.1 months, and 75.6% presented good or excellent clinical results. The radiographic evaluation parameters progressed to normal levels. The 16 patients who underwent open surgery had a mean follow-up of 52 months, and 70.58% presented good or excellent clinical results. The radiographic evaluation parameters progressed to normal levels. Postoperative clinical and radiographic results were considered similar in both groups.

Conclusions

Arthroscopy and open surgery treatments for FAI provided comparable clinical and radiographic results. However, a higher rate of complications was observed in the open surgery group.

Arthroscopic subcapital realignment osteotomy in chronic and stable slipped capital femoral epiphysis: early results

OBJECTIVE

This study aimed to evaluate the clinical and radiographic outcomes, as well as the complications of arthroscopic subcapital realignment osteotomy in chronic and stable slipped capital femoral epiphysis (SCFE). As indicated by the literature review, this is the first time this type of arthroscopic osteotomy was described.

METHODS

Between June 2012 and December 2014, seven patients were submitted to arthroscopic subcapital realignment osteotomy in chronic and stable SCFE. The mean age was 11 years and 4 months, and the mean follow-up period was 16.5 months (6-36). Clinical results were evaluated using the Modified Harris Hip Score (MHHS), which was measured pre- and postoperatively. Radiographs were evaluated using the Southwick quantitative classification and the epiphysis-diaphysis angle (pre- and postoperatively). Complications were assessed.

RESULTS

The mean preoperative MHHS was 35.8 points, and 97.5 points post-operatively (p < 0.05). Radiographically, five patients were classified as Southwick classification grade II and two as grade III. The mean correction of the epiphysis-diaphysis angle was 40°. No immediate postoperatively complications were observed. One patient presented femoral head avascular necrosis, without collapse or chondrolysis at the most recent follow-up (22 months).

CONCLUSION

The arthroscopic technique presented for subcapital realignment osteotomy in chronic and stable SCFE showed satisfactory clinical and radiographic outcomes in a 16.5 months follow-up period.

Femoroacetabular impingement

The femoroacetabular impingement (FAI) is as condition recently characterized that results from the abnormal anatomic and functional relation between the proximal femur and the acetabular border, associated with repetitive movements, which lead labrum and acetabular cartilage injuries. Such alterations result from anatomical variations such as acetabular retroversion or decrease of the femoroacetabular offset. In addition, FAI may result from acquired conditions as malunited femoral neck fractures, or retroverted acetabulum after pelvic osteotomies. These anomalies lead to pathological femoroacetabular contact, which in turn create impact and shear forces during hip movements. As a result, there is early labrum injury and acetabulum cartilage degeneration. The diagnosis is based on the typical clinical findings and images. Treatment is based on the correction of the anatomic anomalies, labrum debridement or repair, and degenerate articular cartilage removal. However, the natural evolution of the condition, as well as the outcome from long-term treatment, demand a better understanding, mainly in the asymptomatic individuals.