Description and mid-term results of the 'over the top' technique for the treatment of the pincer deformity in femoroacetabular impingement

Editorial Commentary: Reach Over the Top and Preserve the Hip Labrum

There is increasing interest in fine tuning of hip arthroscopy to improve the long-term outcomes of femoroacetabular impingement (FAI) surgery. Recently, some advocated for rim trimming and labral refixation without taking down the labrum, using a so-called over-the-top technique. Although some studies have already reported on the outcomes of this procedure, very few have focused on how maintaining an unharmed chondrolabral junction may decrease cartilage wear over time. Preserving labral attachment should be the standard of care in the treatment of FAI, to keep the suction seal working normally.

Portal enlargement in hip arthroscopy preserving the iliofemoral ligament: a novel access technique protecting soft tissue restraints

Capsulotomy in different modalities has been used to provide adequate exposure to access both the central and peripheral compartment in hip arthroscopy. Even though the hip joint has inherent bony stability, soft tissue restraints may be important in patients with ligaments hyperlaxity or in some cases with diminished bony stability. Biomechanical studies and clinical outcomes have shown the relevant role of the capsule in hip stability, mainly the role of the iliofemoral ligament. Although is not very common, iatrogenic post-arthroscopy subluxation and dislocation have been reported and many surgeons are concerned about the role aggressive capsulotomy or capsulectomy in this situation, thus capsule repair has become very popular. We present a novel technique to access the hip without cutting the iliofemoral ligament. With this technique we can obtain adequate arthroscopic access to the hip joint in order to treat adequately the central compartment pathologies reducing the risk of iatrogenic post-operative hip instability.

Teamwork in hip preservation: the ISHA 2019 Annual Scientific Meeting

Hip preservation surgery is now an established part of orthopedic surgery and sports medicine. This report describes the key findings of the 11th Annual Scientific Meeting of International Society for Hip Arthroscopy-the International Hip Preservation Society-in Madrid, Spain from 16 to 19 October 2019. Lectures, seminars and debates explored the most up-to-date and expert views on a wide variety of subjects, including: diagnostic problems in groin pain, buttock pain and low back pain; surgical techniques in acetabular dysplasia, hip instability, femoroacetabular impingement syndrome, labral repair and reconstruction, cartilage defects, adolescent hips and gluteus medius and hamstring tears; and new ideas about femoral torsion, hip-spine syndrome, hip capsule surgery, impact of particular sports on hip injuries, registries, robotics and training for hip preservation specialists. Surgeons, sports physicians, radiologists and physiotherapists looking after young people with hip problems have an increasingly sophisticated armoury of ideas and techniques with which to help their patients. The concept of hip preservation has developed incredibly fast over the last decade; now it is clear that the best results can only be achieved by a multidisciplinary team working together. The 2020s will be the decade of 'Teamwork in Hip Preservation'.

The clinical outcome of chondrolabral-preserving arthroscopic acetabuloplasty for pincer- or mixed-type femoroacetabular impingement: A systematic review

While preservation and repair of the acetabular labrum are increasingly being recognized as important goals in hip arthroscopy, controversies still exist regarding the clinical outcome of arthroscopic acetabuloplasty with chondrolabral preservation. A systematic review was conducted and implemented by two independent reviewers, who used the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews for their search. These databases were queried with the terms "arthroscopic acetabuloplasty" and "chondrolabral preservation" and "arthroscopic acetabular recession." From the 55 initial studies the reviewers finally chose and assessed five clinical studies which were eligible to their inclusion-exclusion criteria. The reviewed studies included in total 444 patients, mainly young, between 30 and 40 years old. The follow-up evaluation varied between 24 and 41 months, while all studies utilized at least a 24-month final end-point assessment. All five studies illustrated improved outcome with the use of chondrolabral preservation acetabuloplasty without labral detachment. The rate of complications was very low. The different techniques of arthroscopic acetabuloplasty combined with chondrolabral preservation illustrated encouraging results in patients suffering from pincer-type or mixed-type FAI. However, the available clinical evidence was limited and insufficient to establish any superiority of these techniques over the traditional labral detachment and sequential reattachment. In relation to the optimal treatment of FAI without isolated CAM, further research of higher quality is recommended to be conducted in order to lead to definitive conclusions.

Quality Assessment of Prospective Cohort Studies Evaluating Arthroscopic Treatment for Femoroacetabular Impingement Syndrome: A Systematic Review

Background

Femoroacetabular impingement (FAI) syndrome is a cause of pain and reduced range of motion in the hip joint. Given the limited number of randomized controlled trials, prospective cohort studies constitute the dominant part of the available prospective evidence evaluating relevant clinical outcomes after arthroscopic hip surgery for FAI.

Purpose

To assess the methodological quality of prospective cohort studies evaluating arthroscopic surgery for FAI and to determine whether there has been an improvement in methodological quality over time.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic literature search was performed in PubMed, Embase (OvidSP), and the Cochrane Library. Included studies were clinical prospective cohort studies of primary arthroscopic surgery for cam and/or pincer morphology FAI. Methodological quality was assessed with the Methodological Index for Non-randomized Studies (MINORS). The mean MINORS score for studies published during the first 5 years of the period was compared with those published during the last 5 years to evaluate methodological improvement over time. The methodological quality of randomized controlled trials was also assessed with the Coleman Methodology Score.

Results

The search yielded 53 studies. There were 34 noncomparative studies, 15 nonrandomized comparative studies, and 4 randomized controlled trials. The included studies were published between 2008 and 2017. The mean ± SD MINORS score for noncomparative and comparative studies was 10.4 ± 1.4 of 16 possible and 18.7 ± 2.0 of 24 possible, respectively. The mean Coleman Methodology Score for randomized controlled trials was 79.0 ± 7.0 of 100 possible.

Conclusion

The methodological quality of prospective cohort studies evaluating arthroscopic surgery for FAI is moderate for comparative and noncomparative studies. Common areas for improvement include unbiased assessment of study endpoints and prospective sample-size calculations. Despite an increase in the number of published studies, an improvement in methodological quality over time was not observed.

Acetabular retroversion: Diagnosis and treatment

Acetabular retroversion (AR) consists of a malorientation of the acetabulum in the sagittal plane. AR is associated with changes in load transmission across the hip, being a risk factor for early osteoarthrosis. The pathophysiological basis of AR is an anterior acetabular hyper-coverage and an overall pelvic rotation.

The delay or the non-diagnosis of AR could have an impact in the overall management of femoroacetabular impingement (FAI). AR is a subtype of (focal) pincer deformity.

The objective of this review was to clarify the pathophysiological, diagnosis and treatment fundaments inherent to AR, using a current literature review.

Radiographic evaluation is paramount in AR: the cross-over, the posterior wall and ischial spine signs are classic radiographic signs of AR. However, computed tomography (CT) evaluation permits a three-dimensional characterization of the deformity, being more reliable in its recognition.

Acetabular rim trimming (ART) and periacetabular osteotomy (PAO) are the best described surgical options for the treatment of AR.

The clinical outcomes of both techniques are dependent on the correct characterization of existing lesions and adequate selection of patients.

Cite this article: EFORT Open Rev 2018;3:595-603. DOI: 10.1302/2058-5241.3.180015

Arthroscopic acetabuloplasty without labral detachment for focal pincer-type impingement: a minimum 2-year follow-up

In order to access and resect the acetabular rim, arthroscopic acetabuloplasty was described with labral detachment. When the chondrolabral junction remains intact, acetabuloplasty and labral refixation can be performed maintaining an unharmed labrum. We aimed to evaluate the outcome of a group of patients treated with arthroscopic acetabuloplasty without labral detachment. During the study period, we retrospectively analysed 44 patients with pincer-type o combined impingement and an intact chondroblabral junction, with an average follow-up of 32 months (range: 27-38). We excluded patients with isolated CAM-type impingement and previous hip pathology. Radiographs were analysed to define impingement and classify grade of osteoarthritis. Clinical evaluation consisted of pre-operative and post-operative modified Harris hip score (mHHS) and WOMAC as well as post-operative visual analogue scale (VAS) of pain and satisfaction. Reoperations were considered surgical failures for purposes of survival analysis. Mean mHHS changed from 51.06 (SD 4.81) pre-operatively to 84.97 (SD 12.79) post-operatively. Pre-operative WOMAC was 29.18 (SD 8) and post-operative, 13.10 (SD 11). Post-operative VAS was 7.5 and 2.27 for satisfaction and pain, respectively. When comparing patients with Tönnis 0 to those with Tönnis 1, the former showed better results regarding post-operative mHHS (89.9 s versus 77.85, P = 0.03), pain VAS (1.5 versus 6.3, P = 0.03) and satisfaction VAS (8.2 versus 6.3, P = 0.01). Survival was 100% at 24 months and 76% at 40 months (95% CI: 35-98%). Arthroscopic acetabuloplasty without labral detachment achieved good clinical outcomes. Slight degenerative changes on radiographs correlated with poorer clinical outcomes.

The current situation in hip arthroscopy

Hip arthroscopy is an evolving surgical technique that has recently increased in popularity.

Although femoroacetabular impingement was an important launch pad for this technique, extra-articular pathology has been described through hip endoscopy.

Good clinical results in the medium term will allow improvements in this technique and increase its indications.

Cite this article: EFORT Open Rev 2017;2:58-65. DOI: 10.1302/2058-5241.2.150041

Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion

BACKGROUND

Acetabular retroversion can cause impaction-type femoroacetabular impingement leading to hip pain and osteoarthritis. It can be treated by anteverting periacetabular osteotomy (PAO) or acetabular rim trimming with refixation of the labrum. There is increasing evidence that acetabular retroversion is a rotational abnormality of the entire hemipelvis and not a focal overgrowth of the anterior acetabular wall, which favors an anteverting PAO. However, it is unknown if this larger procedure would be beneficial in terms of survivorship and Merle d'Aubigné scores in a midterm followup compared with rim trimming.

QUESTIONS/PURPOSES

We asked if anteverting PAO results in increased survivorship of the hip compared with rim trimming through a surgical hip dislocation in patients with symptomatic acetabular retroversion.

METHODS

We performed a retrospective, comparative study evaluating the midterm survivorship of two matched patient groups with symptomatic acetabular retroversion undergoing either anteverting PAO or acetabular rim trimming through a surgical hip dislocation. Acetabular retroversion was defined by a concomitantly present positive crossover, posterior wall, and ischial spine sign. A total of 279 hips underwent a surgical intervention for acetabular retroversion at our center between 1997 and 2012 (166 periacetabular osteotomies, 113 rim trimmings through surgical hip dislocation). A total of 99 patients (60%) were excluded from the PAO group and 56 patients (50%) from the rim trimming group because they had any of several prespecified conditions (eg, dysplasia or pediatric conditions 61 [37%] for the PAO group and two [2%] for the rim trimming group), matching (10 [6%]/10 [9%] hips), deficient records (10 [6%]/13 [12%] hips), or the patient declined or was lost to followup (18 [11%]/31 [27%] hips). This left 67 hips (57 patients) that underwent anteverting PAO and 57 hips (52 patients) that had acetabular rim trimming. The two groups did not differ in terms of age, sex, body mass index, preoperative ROM, preoperative Merle d'Aubigné-Postel score, radiographic morphology of the acetabulum (except total and anterior acetabular coverage), alpha angle, Tönnis grade of osteoarthritis, and labral and chondral lesions on the preoperative MRI. During the period in question, we generally performed PAO from 1997 to 2003. With the availability of surgical hip dislocation and labral refixation, we generally performed rim trimming from 2004 to 2010. With growing knowledge of the underlying pathomorphology, anteverting PAOs became more common again around 2007 to 2008. A minimum followup of 2 years was required for this study. Failures were included at any time. The median followup for the anteverting PAO group was 9.5 years (range, 2-17.4 years) and 6.8 years (range, 2.2-10.5 years) for the rim trimming group (p < 0.001). Kaplan-Meier survivorship analysis was performed using the following endpoints at 5 and 10 years: THA, radiographic progression of osteoarthritis by one Tönnis grade, and/or Merle d'Aubigné-Postel score < 15 points.

RESULTS

Although the 5-year survivorship of the two groups was not different with the numbers available (86% [95% confidence interval {CI}, 76%-94%] for anteverting PAO versus 86% [95% CI, 76%-96%] for acetabular rim trimming), we found increased survivorship at 10 years in hips undergoing anteverting PAO for acetabular retroversion (79% [95% CI, 68%-90%]) compared with acetabular rim trimming (23% [95% CI, 6%-40%]) at 10 years (p < 0.001). The drop in the survivorship curve for the acetabular rim trimming through surgical hip dislocation group started at Year 6. The main reason for failure was a decreased Merle d'Aubigné score.

CONCLUSIONS

Anteverting PAO may be the more appropriate treatment for hips with substantial acetabular retroversion. This may be the result of reduction of an already smaller lunate surface of hips with acetabular retroversion through rim trimming. However, rim trimming may still benefit hips with acetabular retroversion in which only one or two of the three signs are positive. Future randomized studies should compare these treatments.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Arthroscopic Decompression of a Type III Subspine Impingement

Extra-articular hip impingement refers to a variety of hip disorders causing pain and limited function in young, non-arthritic patients. Recently, there has been an increased focus on analyzing the degree of anterior inferior iliac spine (AIIS) dysmorphism and its correlation with subspine impingement (SSI), defined as abutment between a prominent distal aspect of the AIIS and the anterior aspect of the femoral head-neck junction. Arthroscopic decompression of the AIIS is recognized as an effective treatment for SSI. However, there may be some inherent risks of performing this procedure arthroscopically that require further investigation.