Indications for hip arthroscopy in pediatric patients a systematic review

Total Hip Arthroplasty in the Ultrayoung

Background

Total hip arthroplasty (THA) procedures provide a surgical option for "ultrayoung" patients ≤30 years old with end-stage hip arthropathy. This has historically been coupled with concerns over early component failure and challenging surgical technique leading to increased risk of overall morbidity. The purpose of this study is to better elucidate the poorly defined indications and outcomes for THA in ultrayoung patients with end-stage hip disease.

Methods

A total of 40 THAs in 35 patients ≤30 years old performed at our institution from 2009 to 2016 were retrospectively followed for an average of 2 years (median 11 months, interquartile range 1-31.25). Primary outcome measure was THA revision. Patient demographics were compared against outcomes. The effects on revision rate of hip joint pathology and type of bearing surface were investigated. T-test, chi-square test, and bivariate correlation were performed to determine statistical significance (P < .05). Machine learning was used to determine the normalized important factor leading to THA revision.

Results

Fifteen male and 25 female patients were included. Median patient age was 23 (interquartile range 19-27) years, with an average body mass index of 27.0 ± 7.9. A majority of THAs were indicated for osteonecrosis (32) and bearing surface type was predominantly metal-on-highly cross-linked polyethylene (36). The overall revision rate was 7.5%, without a correlation between revision and demographic characteristics. Revision surgery was significantly correlated with bearing surface type (P = .028). Important factors for revision were age (100%), bearing surface type (84.7%), and body mass index (52.1%).

Conclusions

In patients ≤30 years old, THAs performed with the use of modern implants and surgical methods show satisfactory survivorship and functional outcomes with short-term follow-up.

Hip Arthroscopy in Adolescents Through an Extra-Capsular Approach

Hip arthroscopic treatment for femoroacetabular impingement syndrome and labral tears is the gold standard in the adult and adolescent population, as we all know the most common surgical approach to the hip is entering the central compartment with fluoroscopy and with continuous distraction. A periportal capsulotomy in traction must be done to have visibility and instrument maneuverability. These maneuvers avoid scuffing the femoral head cartilage. In adolescents, extreme care must be taken in hip distraction, as the force used can cause iatrogenic neurovascular lesions, avascular necrosis, and lacerations of the genitals and foot/ankle. Experienced surgeons around the world have developed an extracapsular approach to the hip with smaller capsulotomies with a low complication rate. This approach to the hip has brought attention in the adolescent population because it is more secure and simple. Less force of distraction is needed because the capsulotomy is done first. This surgical technique allows observation of the cam morphology while entering to the hip without distraction. We describe an extracapsular approach as an option to treat femoral acetabular impingement syndrome and labral tears in the pediatric and adolescent population.

THE STATE OF HIP ARTHROSCOPY IN RUSSIA: ASSESSMENT BASED ON A SOCIOLOGICAL SURVEY OF DOCTORS

Background.Hip arthroscopy is a minimally invasive surgical technique most commonly performed to correct femoroacetabular impingement (FAI). The number of hip arthroscopy performed in Russia is unknown. Information about this surgical technique is also very limited in our country.The aim of the study was to assess the level of hip arthroscopy in Russia.Methods.A sociological survey of orthopaedic surgeon with experience in performing hip arthroscopy was conducted. The questionnaire was posted on the Google Forms platform. The survey included 54 surgeons from Russian clinics, 45 people filled out the questionnaire.Results.The majority of specialists (73,30,06%) were trained in hip arthroscopy. More than half of the respondents (68,80,06%) are currently engaged in this surgical area, however, in 45,160,07% of them, the number of operations does not exceed 5 per year. For surgeons who have completed two or more training courses, the volume of operations performed is higher (p0,05). 51,110,07% of doctors perform arthroscopy using an alternative technique. There are 2,5 time more specialists doing just bone resection, than surgeons who apply any kind of reconstruction technique while treating FAI (p0,05). Fifteen respondents (48,390,08%) perform debridement as an attempt to delay arthroplasty. The most common difficulties faced by surgeon are problems with the diagnosis of FAI (400,02%), lack of the necessary tools (400,02%) and sufficient time to master the technique (33,30,07%). Only three (6,60,07%) respondents believed to achieve planned results, 93,30,03% of surgeons said that it is not always possible to achieve the desired outcomes.Conclusion. Hip arthroscopy in Russia is not very common, the volume of such interventions is insignificant. Doctors not skilled in arthroscopic hip surgery predominate. Factors impeding the development of this area in our country are related to teaching methods, FAI diagnostics, the lack of necessary instruments for performing operations, and the lack of time for specialists to master surgical techniques.

Peripheral Nerve Block for Hip Arthroscopy Does Not Have any Clinical Advantage Compared With Local Anesthetic Regarding Pain Management: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To evaluate the efficacy of peripheral nerve block on reduction in opioid consumption and pain control after hip arthroscopy.

METHOD

To identify studies evaluating the effects of peripheral nerve block on pain control and reduction in opioid consumption in hip arthroscopy, we searched all records in the PubMed, Embase, and Cochrane Library databases until May 2021. Studies with the following characteristics were considered eligible: 1) patients who underwent a hip arthroscopy (population); 2) patients who received peripheral nerve block (intervention); 3) patients who did not receive peripheral nerve block (comparator); 4) record of total opioid consumption as a primary outcome and pain level at 1, 3 to 6, and 24 hours after surgery, patient satisfaction, and incidence of nausea and vomiting as secondary outcomes (outcomes); and 5) randomized controlled trial (study design). Data were independently extracted by two reviewers and synthesized using a random or fixed-effects model, according to the heterogeneity.

RESULTS

Eight RCTs were finally included in the meta-analysis. There were no significant differences in postoperative opioid consumption at 24 hours (standardized mean difference [SMD] = -0.091, 95% confidence interval [CI] [-0.270, 0.089]) or in visual analog scale (VAS) score at 1 (SMD = 0.299, 95% CI [-0.758, 0.160]), 3 to 6 (SMD = -0.304, 95% CI [-0.655, 0.047]), and 24 (SMD = -0.230, 95% CI [-0.520, 0.060]) hours postoperatively between the peripheral nerve block and control groups. Moreover, no significant differences were observed in patient satisfaction (SMD < 0.001, 95% CI [-0.284, 0.284]) or the incidence of nausea and vomiting (SMD = 0.808, 95% CI [0.311, 2.104]) between the two groups.

CONCLUSION

Peripheral nerve block for hip arthroscopy has no clinical advantage regarding pain management after surgery when compared with the group that received the local infiltration of analgesics without peripheral nerve block.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II randomized controlled trials (RCTs).

Repair versus Debridement for Acetabular Labral Tears-A Systematic Review

Purpose

The purpose of this study was to systematically review the evidence in the literature to ascertain whether acetabular labral repair (ALR) or debridement (ALD) resulted in superior patient outcomes.

Methods

The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed studies comparing ALR and ALD published in English with full text available were included. Patients undergoing both open and arthroscopic surgery in randomized controlled trials, prospective cohort studies, retrospective cohort studies, and case-control studies were included. Studies were quantified for methodological quality using the MINORS criteria. Clinical outcomes were compared, with qualitative analysis, and quantitative analyses were performed using GraphPad Prism version 7. A P value <.05 was considered to be statistically significant.

Results

There were 8 studies included (level of evidence [LOE] I = 1; LOE II = 2; LOE III = 5). The 7 studies compared 364 patients (369 hips) with ALR to 318 patients (329 hips) with ALD, with a mean follow-up time ranging between 32-120 months. Five studies found significantly improved patient reported outcomes with ALR (Harris Hip Score, Merle d'Aubigné, Pain, SF-12). Several studies compared the outcomes after ALR and ALD and found statistical significance in all investigated metrics in favor of ALR. One study found a significant improvement in abduction but no other study found any difference in range of motion. No study found any difference in complication rate, revision rate or conversion to total hip arthroplasty. Although, 2 studies found ALR reduced the rate of osteoarthritic progression.

Conclusion

Current literature suggests that acetabular labral repair may result in superior patient reported outcomes. However, there appears to be no significant difference in the rate of progression to total hip arthroplasty at up to 10-year follow-up.

Level of Evidence

Level III, systematic review of Level I, II, and III studies.

How does former Salter innominate osteotomy in patients with Legg–Calvé–Perthes disease influence acetabular orientation? An MRI-based study

Salter innominate osteotomy (SIO) has been successfully used in the treatment of Legg–Calvé–Perthes disease (LCPD). Recent studies that have raised concerns about acetabular retroversion after SIO have been based on plain radiographs. In order to assess the true acetabular orientation, the present study uses a specific magnetic resonance imaging (MRI) technique. In addition, the association between acetabular morphology and clinical function as well as health-related quality of life was assessed. Twenty-three patients with 24 operated hips who underwent SIO for LCPD between January 2004 and November 2014 were included. Mean age was 8.5 ± 2.2 years at surgery and 18.5 ± 2.9 years at follow-up. MRIs were conducted at 1.5 T using radial sequences. The analysis included the acetabular version, acetabular sector angles (ASAs) and alpha angles. Plain radiographs were used in order to obtain the Stulberg classification. Patient-related outcome measures included the international Hip Outcome Tool and Euroqol-5 dimensions scores. In comparison to the non-operated side, the MRI of previously operated hips showed no difference of version at the center of the femoral head but significantly decreased version just below the roof level. As a marker for posterior acetabular coverage, the ASAs between 9 and 11 o’clock were significantly decreased when compared with non-operated hips. In hips with a mild acetabular retroversion (<15°), the function was significantly decreased when compared with non-retroverted hips. The SIO is an effective tool in order to restore acetabular containment in LCPD. When compared with the non-operated hips, our collective displays only moderate changes of acetabular orientation and coverage.

Simultaneous Morscher's osteotomy and arthroscopic debridement in the management of Legg-Calvé-Perthes disease: a case report and literature review

There is a lack of consensus around optimal surgical management for Legg–Calvé–Perthes Disease (LCPD). This case report discusses the benefits of combining arthroscopic femoral neck osteochondroplasty and labral repair with Morscher’s Osteotomy (MO) for LCPD. S.A. is a 17-year-old female diagnosed with LCPD at the age of 6 years and has long-standing right hip symptoms. An arthroscopic femoral neck osteochondroplasty and labral repair followed by MO was performed. The pre-operative and 8 months post-operative International Hip Outcome Tool (iHOT-12) scores were 16.3 and 79.8 out of 100, respectively, indicating better quality-of-life. Also, the femoral neck-shaft-angle (NSA) changed from 120 pre-operative to 138.7 post-operative to represent the correction of coxa vara. The literature review revealed no published reports describing combined MO with hip arthroscopic interventions in managing LCPD. Combined arthroscopic femoral neck osteochondroplasty (with labral repair) and MO provides high patient satisfaction and improves radiographic parameters in patients with LCPD.

Hip Arthroscopy for Sequelae of Legg-Calve-Perthes Disease: A Systematic Review

There is no clear evidence on indications and outcomes of hip arthroscopy in sequelae of Legg-Calve-Perthes disease (LCPD). The aim of the current study was to evaluate current literature on the role and outcome of hip arthroscopy in LCPD. A literature search using four databases was conducted in April 2020, focusing on the role of hip arthroscopy in sequelae of LCPD. A systematic search was carried out in confirmation with the Cochrane Collaboration, Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of nine studies were included in the systematic review. The total number of hip arthroscopies performed for LCPD was 109. The mean age of included patients was 34.8±7.88 years (7-58 years). Recalcitrant hip pain was the main indication for surgery, followed by pain and stiffness. The most common finding in arthroscopy was labral tears, followed by osteochondral lesions of femoral head or acetabulum and intra-articular loose bodies. Consequently, debridement of labrum tears chondroplasty for cartilage defects and osteoplasty for impingement from deformed femoral head (hinged abduction) were commonly performed. A significant improvement in hip function was seen in all studies. Pooled data of Harris hip score showed significant improvement after surgery was conducted. Hip arthroscopy may be beneficial in patients having symptoms of impingement secondary to changes in labrum, femoral head or acetabulum. Limited evidence shows improved function and range of motion after surgery. This treatment has been found to be safe in terms of complication rates and improvement may persist for years.