Results of hip arthroscopy in patients with MRI diagnosis of subchondral cysts-a case series

Are degenerative findings detected on traction MR arthrography of the hip associated with failure of arthroscopic femoroacetabular impingement surgery?

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.

Editorial Commentary: Preoperative Paralabral Cysts Do Not Have a Detrimental Effect on 2-Year Outcomes After Hip Arthroscopy, but They Can Still Have Predictive Value

The presence of hip paralabral cysts on magnetic resonance imaging is associated with labral tears and more extensive chondral damage. The 2-year follow-up results of patients with paralabral cysts are equivalent to patients who do not have paralabral cysts. However, since paralabral cysts are associated with more prearthritic hip cartilage damage, surgically addressing these hips sooner could yield better outcomes. Further research is needed to see if performing hip arthroscopy on patients with paralabral cysts more urgently yields better long-term outcomes than delaying surgery.

Return to sport after arthroscopic surgery for femoroacetabular impingement

BACKGROUND

Femoroacetabular impingement (FAI) is common among the active and young population. The present study analysed the rate of return to sport, related influencing factors, and the sport activity level according to the Hip Outcome Score - Sport-Specific Subscale (HOS-SSS).

METHODS

The literature search was performed in December 2020. All clinical trials investigating HOS-SSS and/or return to sport after arthroscopic treatment for FAI were considered for inclusion. The outcomes of interest were to analyse the rate of return to sport and the sport activity level according to the HOS-SSS in patients who underwent arthroscopic osteoplasty for FAI.

RESULTS

Data from 41 studies (4063 procedures) were retrieved. A total of 88.75% (581 of 655) of patients returned to sports within a mean of 37.4 ± 16.5 months. The HOS-SSS score improved from 45.0 ± 10.6 to 73.1 ± 9.5 (P < 0.0001) at last follow-up. The following baseline characteristics evidenced positive association with post-operative activity level: lighter weight (P = 0.01), younger age (P = 0.001), Tönnis angle grade I (P = 0.009), greater HHS (P = 0.01), NAHS (P < 0.0001) and HOS-ADL (P = 0.01).

CONCLUSION

Arthroscopic treatment for FAI resulted in excellent results in terms of return to sport. Moreover, lighter weight and younger age, greater HHS, NAHS, HOS-ADL at baseline were positively associated with post-operative sport activity level.

LEVEL OF EVIDENCE

IV, systematic review.

Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.

PURPOSE

To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.

RESULTS

Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

CONCLUSION

Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

Medium-term results of arthroscopic treatment for femoroacetabular impingement

INTRODUCTION

Femoroacetabular impingement (FAI) is a dynamic pathomechanical process of the femoral head-neck junction. Arthroscopic surgery for FAI has increased exponentially in the last decade, and this trend is expected to increase.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

FAI promotes quick rehabilitation and low complication rates in the short-term follow-up.

AREAS OF CONTROVERSY

Despite the growing interest on arthroscopic surgery for FAI, current evidence regarding the medium- and long-term role of arthroscopy are unsatisfactory.

GROWING POINTS

Systematically summarize current evidences, analyse the quantitative available data and investigate the medium- and long-term outcomes of arthroscopic surgery for FAI.

AREAS TIMELY FOR DEVELOPING RESEARCH

Arthroscopic surgery achieves very satisfactory outcomes for patients with FAI at a mean follow-up of 4 years.

Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review

BACKGROUND

A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up.

MATERIAL AND METHODS

This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included.

RESULTS

Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001).

CONCLUSION

Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.

Minimum 5-year follow-up of arthroscopic treatment of symptomatic iliopectineal cyst

INTRODUCTION

We aimed to primarily assess the clinical and functional outcomes of arthroscopic treatment of the symptomatic iliopectineal cyst at a minimum 5-year follow-up. Our secondary objective was to document the technical nuances of our arthroscopic technique.

METHODS

A retrospective review of chart data was performed for 30 patients who underwent arthroscopic treatment of a symptomatic iliopectineal cyst in the period between 1999 and 2015. The mean age of our patients was 57 (33-78) years. All patients completed a minimum follow-up period of 5 years. Our clinical outcomes were assessed by 100 mm VAS for pain, recurrence rate and complications. Functional outcome was evaluated by the modified Harris hip score (mHHS). Patients were asked their level of satisfaction with surgery on a scale of 0-10.

RESULTS

In all patients, the valve mechanism of the iliopectineal cyst could be released arthroscopically and the cyst could be completely evacuated. The preoperative symptoms disappeared within 3-6 weeks after the arthroscopic intervention. Patients showed significant improvement in VAS and mHHS 6 months postoperatively and at final follow-up. The average patient satisfaction was 9.2 at 6 months postoperative and 7.9 at final follow-up. None of our patients experienced any complications. At the final follow-up, there was neither clinical nor radiological evidence of cyst recurrence.

CONCLUSIONS

Arthroscopic treatment of the iliopectineal cyst is a feasible and safe alternative to open surgery resulting in significant improvement of clinical and functional outcomes.

Arthroscopic Bone and Cartilage Grafting of Acetabular Cysts With Autologous Tissue

Repair of acetabular cysts and cartilage defects presents a challenge for the hip-preservation surgeon. Currently, most techniques involve allograft sources or open surgery. We present an arthroscopic technique using autologous graft sources for both bone and cartilage to repair subchondral acetabular cysts and the overlying cartilage defect. This technique uses new technology in combination with familiar arthroscopic instruments to decrease morbidity, hasten rehabilitation, and possibly improve the prognosis of these difficult to treat lesions.

Best Practices: Hip Femoroacetabular Impingement

OBJECTIVE. Imaging plays a critical role in the assessment of patients with femoroacetabular impingement (FAI). With better understanding of the underlying pathomechanics and advances in joint-preserving surgery, there is an increasing need to define the most appropriate imaging workup. The purpose of this article is to provide guidance on best practices for imaging of patients with FAI in light of recent advances in corrective FAI surgery. CONCLUSION. Pelvic radiography with dedicated hip projections is the basis of the diagnostic workup of patients with suspected FAI to assess arthritic changes and acetabular coverage and to screen for cam deformities. Chondrolabral lesions should be evaluated with unenhanced MRI or MR arthrography. The protocol should include a large-FOV fluid-sensitive sequence to exclude conditions that can mimic or coexist with FAI, radial imaging to accurately determine the presence of a cam deformity, and imaging of the distal femoral condyles for measurement of femoral torsion. CT remains a valuable tool for planning of complex surgical corrections. Advanced imaging, such as 3D simulation, biochemical MRI, and MR arthrography with application of leg traction, has great potential to improve surgical decision-making. Further research is needed to assess the added clinical value of these techniques.

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 3: imaging techniques

OBJECTIVES

Imaging diagnosis of femoroacetabular impingement (FAI) remains controversial due to a lack of high-level evidence, leading to significant variability in patient management. Optimizing protocols and technical details is essential in FAI imaging, although challenging in clinical practice. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal consensus techniques driven by relevant literature review. Recommendations on the selection and use of imaging techniques for FAI assessment, as well as guidance on relevant radiographic and MRI classifications, are provided.

METHODS

The Delphi method was used to assess agreement and derive consensus among 30 panel members (musculoskeletal radiologists and orthopedic surgeons). Forty-four questions were agreed on and classified into five major topics and recent relevant literature was circulated, in order to produce answering statements. The level of evidence was assessed for all statements and panel members scored their level of agreement with each statement during 4 Delphi rounds. Either "group consensus," "group agreement," or "no agreement" was achieved.

RESULTS

Forty-seven statements were generated and group consensus was reached for 45. Twenty-two statements pertaining to "Imaging techniques" were generated. Eight statements on "Radiographic assessment" and 12 statements on "MRI evaluation" gained consensus. No agreement was reached for the 2 "Ultrasound" related statements.

CONCLUSION

The first international consensus on FAI imaging was developed. Researchers and clinicians working with FAI and hip-related pain may use these recommendations to guide, develop, and implement comprehensive, evidence-based imaging protocols and classifications.

KEY POINTS

• Radiographic evaluation is recommended for the initial assessment of FAI, while MRI with a dedicated protocol is the gold standard imaging technique for the comprehensive evaluation of this condition. • The MRI protocol for FAI evaluation should include unilateral small FOV with radial imaging, femoral torsion assessment, and a fluid sensitive sequence covering the whole pelvis. • The definite role of other imaging methods in FAI, such as ultrasound or CT, is still not well defined.

Arthroscopic-Assisted Intraosseous Bioplasty of the Acetabulum

Intraosseous bioplasty (IOBP), has been previously described for arthroscopic-assisted treatment of subchondral bone cysts in the proximal tibia associated with early stages of knee osteoarthritis (OA). This technique entails combining bone marrow aspirate concentrate or concentrated platelet-rich plasma with demineralized bone matrix as a bone substitute before injecting into a subchondral bone defect under fluoroscopic guidance. The principles of IOBP as a procedure that combines core decompression with biologic bone substitute augmentation can be extended to treat subchondral bone marrow lesions such as acetabular and femoral cysts in degenerative hip OA. Intraosseous bioplasty of the hip, in particular the acetabulum, when done using this technique, is a useful alternative that can be beneficial in treating young patients with early hip arthritis to achieve successful outcomes while delaying more invasive procedures. The Technical Note described here presents a step-by-step approach, including tips and pearls for arthroscopic-assisted IOBP with decompression of the subchondral cyst in the acetabulum followed by bone substitute injection under fluoroscopic guidance. We believe this method is a safe and reproducible way to treat subchondral defects in young patients with signs of early osteoarthritis of the hip joint.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies