Does Cartilage Degenerate in Asymptomatic Hips With Cam Morphology?

The critical importance of recognition, evaluation, and management of mental health on outcomes following hip arthroscopy - A synthetic narrative review: Current concepts

Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most orthopaedic surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single centre and single surgeon at short-term follow-up. Although hip preservation surgeons are orthopaedic surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.

Femurs in patients with hip dysplasia have fundamental shape differences compared with cam femoroacetabular impingement

Femoral deformities are common in developmental dysplasia of the hip (DDH), but decisions about how to treat them are not standardized. Of interest are deformities that may be akin to cam femoroacetabular impingement (FAI). We used three-dimensional and two-dimensional measures to clarify the similarities and differences in proximal femur shape variation among female patients with DDH (n = 68) or cam FAI (n = 60). Three-dimensional measures included femoral head asphericity, as well as shape variation using statistical shape modeling and principal component analysis (PCA). Two-dimensional measures included the α-angle, head-neck offset (HNO) and the neck-shaft angle (NSA). Significant shape variations were captured in the first five PCA modes, with the greatest shared variation between groups being the length from the lesser trochanter to the femoral head and greater trochanter height. Variations unique to DDH were irregularities at different areas of the femoral head, but not at the lateral femoral head-neck junction where variation was strong in FAI. The FAI group also had unique variations in greater trochanter shape. DDH femoral heads were less spherical, as indicated by larger sphere-fitting errors (P < 0.001). Radiographically, the DDH group had significantly smaller α-angles (P < 0.001), larger head-neck offsets (P = 0.02) and larger NSAs (P < 0.001). Both the articular and extra-articular regions of the proximal femur have distinct shape features in DDH and cam FAI that can uniquely affect the biomechanics of each disorder. Accordingly, approaches to addressing each disorder should be unique.

Progression of Osteoarthritis at Long-term Follow-up in Patients Treated for Symptomatic Femoroacetabular Impingement With Hip Arthroscopy Compared With Nonsurgically Treated Patients

BACKGROUND

Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA.

PURPOSE

To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes.

RESULTS

A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years [range, 6.5-41.0 years]) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort (P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients (P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio [HR], 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01).

CONCLUSION

At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.

Ten-year outcome following surgical treatment of femoroacetabular impingement

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Methods

Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome.

Results

At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI.

Conclusion

FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes.

Cite this article: Bone Jt Open 2022;3(10):804–814.

FAI morphology increases the risk for osteoarthritis in young people with a minimum follow-up of 25 years

INTRODUCTION

The mechanical conflict in symptomatic femoroacetabular impingement can lead to early osteoarthritis. However, radiographic impingement morphology is often seen in asymptomatic individuals. Long-term observation regarding the risk of developing osteoarthritis in these individuals is lacking. Our study addressed the following questions: Does femoroacetabular impingement morphology increase the risk for development of osteoarthritis after at least 25 years? If yes, which radiographic parameter is the most predictive? Does the level of activity influence the risk for development of osteoarthritis? Are PROM influenced by the grade of osteoarthritis in this population?

METHODS

We investigated 51 (32 male, 19 female) patients for whom AP pelvis and Dunn view radiographs were available with a minimum follow-up of 25 years. Alpha angle in AP pelvis and Dunn view radiographs, femoral torsion in Dunn view, lateral center edge angle, cross-over sign, posterior wall sign and prominence of ischial spine sign in AP pelvis radiographs were determined. On the follow-up radiographs, osteoarthritis was graded. Tegner Score for the time of the index radiograph was evaluated. Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index were assessed at latest follow-up.

RESULTS

The mean follow-up was 43 years (range 25-58). Cam impingement morphology showed to increase the risk for development of osteoarthritis: Alpha angles of ≥ 55° on AP pelvis and Dunn view radiographs were associated risk factors and showed an OR of 1.05 (p = 0.002) and 1.10 (p = 0.001), respectively. Abnormal femoral torsion and acetabular retroversion were not risk factors for osteoarthritis. Tegner Score at index presentation, HHS and WOMAC Score did not correlate with the grade of osteoarthritis.

CONCLUSION

This study showed that cam impingement morphology in young patients raises the risk for development of hip osteoarthritis by 5-10% in a long-term follow-up with a minimum of 25 years, thus its contribution was small.

What Is the Correlation Among dGEMRIC, T1p, and T2* Quantitative MRI Cartilage Mapping Techniques in Developmental Hip Dysplasia?

BACKGROUND

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) is a validated technique for evaluating cartilage health in developmental dysplasia of the hip (DDH), which can be a helpful prognosticator for the response to surgical treatments. dGEMRIC requires intravenous injection of gadolinium contrast, however, which adds time, expense, and possible adverse reactions to the imaging procedure. Newer MRI cartilage mapping techniques such as T1 rho (ρ) and T2* have been performed in the hip without the need for any contrast, although it is unknown whether they are equivalent to dGEMRIC.

QUESTION/PURPOSE

In this study, our purpose was to determine the correlation between the relaxation values of three cartilage mapping techniques, dGEMRIC, T1ρ, and T2*, in patients with DDH.

METHODS

Fifteen patients with DDH (three male, 12 female; mean age 29 ± 9 years) scheduled for periacetabular osteotomy underwent preoperative dGEMRIC, T1ρ, and T2* MRI at 3T with quantitative cartilage mapping. The outcomes of dGEMRIC, T1ρ, and T2* mapping were calculated for three regions of interest (ROI) to analyze the weightbearing cartilage of the hip: global ROI, anterior and posterior ROI, and further subdivided into medial, intermediate, and lateral to generate six smaller ROIs. The correlation between the respective relaxation time values was evaluated using the Spearman correlation coefficient (rS) for each ROI, categorized as negligible, weak, moderate, strong, or very strong. The relaxation values within the subdivided ROIs were compared for each of the three cartilage mapping techniques using the Kruskal-Wallis test.

RESULTS

There was a moderate correlation of T1ρ and T2* relaxation values with dGEMRIC relaxation values. For the global ROI, there was a moderate correlation between dGEMRIC and T2* (moderate; rS = 0.63; p = 0.01). For the anterior ROI, a moderate or strong correlation was found between dGEMRIC and both T1ρ and T2*: dGEMRIC and T1ρ (strong; rS = -0.71; p = 0.003) and dGEMRIC and T2* (moderate; rS = 0.69; p = 0.004). There were no correlations for the posterior ROI. The mean dGEMRIC, T1ρ, and T2* relaxation values were not different between the anterior and posterior ROIs nor between the subdivided six ROIs.

CONCLUSION

Quantitative T1ρ and T2* cartilage mapping demonstrated a moderate correlation with dGEMRIC, anteriorly and globally, respectively. However, the clinical relevance of such a correlation remains unclear. Further research investigating the correlation of these two noncontrast techniques with clinical function and outcome scores is needed before broad implementation in the preoperative investigation of DDH.

LEVEL OF EVIDENCE

Level II, diagnostic study.

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.