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Approach to the Patient With Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement. J Am Acad Orthop Surg 2020; 28:538-545. [PMID: 32574474 DOI: 10.5435/jaaos-d-16-00928] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery. The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon, and the postoperative physical therapy. This review highlights common causes of failure, including those related to residual bony deformity as well as capsular deficiency, and provides a framework for diagnosis and treatment of these patients.
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Atkins PR, Aoki SK, Whitaker RT, Weiss JA, Peters CL, Anderson AE. Does Removal of Subchondral Cortical Bone Provide Sufficient Resection Depth for Treatment of Cam Femoroacetabular Impingement? Clin Orthop Relat Res 2017; 475:1977-1986. [PMID: 28342138 PMCID: PMC5498381 DOI: 10.1007/s11999-017-5326-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Residual impingement resulting from insufficient resection of bone during the index femoroplasty is the most-common reason for revision surgery in patients with cam-type femoroacetabular impingement (FAI). Development of surgical resection guidelines therefore could reduce the number of patients with persistent pain and reduced ROM after femoroplasty. QUESTIONS/PURPOSES We asked whether removal of subchondral cortical bone in the region of the lesion in patients with cam FAI could restore femoral anatomy to that of screened control subjects. To evaluate this, we analyzed shape models between: (1) native cam and screened control femurs to observe the location of the cam lesion and establish baseline shape differences between groups, and (2) cam femurs with simulated resections and screened control femurs to evaluate the sufficiency of subchondral cortical bone thickness to guide resection depth. METHODS Three-dimensional (3-D) reconstructions of the inner and outer cortical bone boundaries of the proximal femur were generated by segmenting CT images from 45 control subjects (29 males; 15 living subjects, 30 cadavers) with normal radiographic findings and 28 nonconsecutive patients (26 males) with a diagnosis of cam FAI based on radiographic measurements and clinical examinations. Correspondence particles were placed on each femur and statistical shape modeling (SSM) was used to create mean shapes for each cohort. The geometric difference between the mean shape of the patients with cam FAI and that of the screened controls was used to define a consistent region representing the cam lesion. Subchondral cortical bone in this region was removed from the 3-D reconstructions of each cam femur to create a simulated resection. SSM was repeated to determine if the resection produced femoral anatomy that better resembled that of control subjects. Correspondence particle locations were used to generate mean femur shapes and evaluate shape differences using principal component analysis. RESULTS In the region of the cam lesion, the median distance between the mean native cam and control femurs was 1.8 mm (range, 1.0-2.7 mm). This difference was reduced to 0.2 mm (range, -0.2 to 0.9 mm) after resection, with some areas of overresection anteriorly and underresection superiorly. In the region of resection for each subject, the distance from each correspondence particle to the mean control shape was greater for the cam femurs than the screened control femurs (1.8 mm, [range, 1.1-2.9 mm] and 0.0 mm [range, -0.2-0.1 mm], respectively; p < 0.031). After resection, the distance was not different between the resected cam and control femurs (0.3 mm; range, -0.2-1.0; p > 0.473). CONCLUSIONS Removal of subchondral cortical bone in the region of resection reduced the deviation between the mean resected cam and control femurs to within a millimeter, which resulted in no difference in shape between patients with cam FAI and control subjects. Collectively, our results support the use of the subchondral cortical-cancellous bone margin as a visual intraoperative guide to limit resection depth in the correction of cam FAI. CLINICAL RELEVANCE Use of the subchondral cortical-cancellous bone boundary may provide a method to guide the depth of resection during arthroscopic surgery, which can be observed intraoperatively without advanced tooling, or imaging.
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Affiliation(s)
- Penny R. Atkins
- 0000 0001 2193 0096grid.223827.eDepartment of Orthopaedics, University of Utah, 590 Wakara Way, Room A100, Salt Lake City, UT 84108 USA ,0000 0001 2193 0096grid.223827.eDepartment of Bioengineering, University of Utah, Salt Lake City, UT USA
| | - Stephen K. Aoki
- 0000 0001 2193 0096grid.223827.eDepartment of Orthopaedics, University of Utah, 590 Wakara Way, Room A100, Salt Lake City, UT 84108 USA
| | - Ross T. Whitaker
- 0000 0001 2193 0096grid.223827.eDepartment of Bioengineering, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eScientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eSchool of Computing, University of Utah, Salt Lake City, UT USA
| | - Jeffrey A. Weiss
- 0000 0001 2193 0096grid.223827.eDepartment of Orthopaedics, University of Utah, 590 Wakara Way, Room A100, Salt Lake City, UT 84108 USA ,0000 0001 2193 0096grid.223827.eDepartment of Bioengineering, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eScientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eSchool of Computing, University of Utah, Salt Lake City, UT USA
| | - Christopher L. Peters
- 0000 0001 2193 0096grid.223827.eDepartment of Orthopaedics, University of Utah, 590 Wakara Way, Room A100, Salt Lake City, UT 84108 USA ,0000 0001 2193 0096grid.223827.eDepartment of Bioengineering, University of Utah, Salt Lake City, UT USA
| | - Andrew E. Anderson
- 0000 0001 2193 0096grid.223827.eDepartment of Orthopaedics, University of Utah, 590 Wakara Way, Room A100, Salt Lake City, UT 84108 USA ,0000 0001 2193 0096grid.223827.eDepartment of Bioengineering, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eScientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT USA ,0000 0001 2193 0096grid.223827.eDepartment of Physical Therapy, University of Utah, Salt Lake City, UT USA
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