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Oca Pernas R, Fernández Cantón G. Direct MR arthrography without image guidance: a practical guide, joint-by-joint. Skeletal Radiol 2024:10.1007/s00256-024-04709-0. [PMID: 38801542 DOI: 10.1007/s00256-024-04709-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/10/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024]
Abstract
Direct MR arthrography (dMRA) is a fundamental technique in diagnosing pathology in major peripheral joints, allowing for precise evaluation of intra-articular structures. Although injection guidance is typically performed using imaging techniques such as ultrasound or fluoroscopy, puncture via anatomical landmarks may be useful in certain circumstances where it has been proven to be a safe and effective procedure. This paper describes the indications and injection technique of dMRA, joint by joint, focusing on the different technical details, from the most common locations, like the shoulder or hip, to those with more restricted clinical indications, such as the wrist, knee, elbow, or ankle. The most relevant anatomical landmarks are detailed for each joint, aiding in the intra-articular introduction of diluted contrast, highlighting the most accessible trajectories and structures to avoid when inserting the needle. Additionally, tips are provided to facilitate proper joint distension. With all this information, this paper aims to serve as a suitable reference guide for performing dMRA without image guidance if needed.
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Affiliation(s)
- Roque Oca Pernas
- Osakidetza - Basque Health Service, MRI Department, OSATEK, Osatek Deusto, Luis Power, 18, 48014, Bilbao, Spain.
- Department of Radiology, Mutualia, Bilbao, Spain.
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Keogh JAJ, Keng I, Ifabiyi M, Patel M, Duong A, Malviya A, Wuerz TH, Ayeni OR. Adhesions After Hip Arthroscopy Are Associated With Revision But Show Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review. Arthroscopy 2024:S0749-8063(24)00303-7. [PMID: 38697325 DOI: 10.1016/j.arthro.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions that developed after hip arthroscopy (HA). METHODS A systematic search of the MEDLINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was designed and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Eligible studies included patients with confirmed adhesions after HA that reported one or more of the following: (1) diagnostic procedures and criteria used; (2) indications for and details surrounding surgical management; and (3) clinical outcomes after the operative management of adhesions (e.g., patient-reported outcome measures). RESULTS Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female sex) were included in this review. The quality of evidence was found to be fair for both comparative studies (mean, 17; range, 13-21) and noncomparative studies (mean, 10; range, 5-12) according to the Methodological Index for Non-randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intraoperatively at the time of revision surgery (10 of 19 studies, 53%), with only 3 studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (9 of 19, 47%), but this was often grossly stated for revision HA rather than being specific to adhesions. Patient-reported outcome measures were the most reported postoperative outcomes (9 of 19, 47%) and generally showed significant improvement from preoperative assessment across the short-term follow-up period (range, 24.5-38.1 months). There was a paucity of objective measures of clinical improvement (3 of 19, 16%) and of mid- and long-term follow-up (i.e., 5-7 years and ≥10 years, respectively). CONCLUSIONS Despite the growing body of evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, although the operative management of adhesions after HA has shown satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid- to long-term outcomes, as well as minimal use of objective assessment of clinical improvement (e.g., biomechanics). LEVEL OF EVIDENCE Level IV, systematic review of Level II to IV studies.
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Affiliation(s)
- Joshua A J Keogh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada; Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Isabelle Keng
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada; Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Muyiwa Ifabiyi
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Mansi Patel
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Ajay Malviya
- Department of Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, England
| | - Thomas H Wuerz
- Boston Sports & Shoulder Center, Waltham, Massachusetts, U.S.A
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada.
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Pernas RO, Cantón GF, Aguirre NH, Arroita MA. Direct MR arthrography of the hip joint: anterior approach without imaging guidance. Skeletal Radiol 2024; 53:753-759. [PMID: 37872371 DOI: 10.1007/s00256-023-04482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE The purpose of this study is to describe the anterior injection approach, with anatomical landmark guidance, for direct MR arthrography (dMRA) of the hip joint, and to evaluate the effectiveness in joint distension and the security of the technique. MATERIAL AND METHODS Retrospective review of hip dMRAs was conducted on patients with suspected intra-articular pathology from two MR outpatient centers, performed by two radiologists with 25 and 5 years of experience, respectively. The analysis included assessing the presence of intra-articular contrast material (gadolinium-based solution), the number of injections performed, the degree of joint distension, and the degree of contrast extravasation. A multi-variant analysis was carried out to determine if the procedure success depend on any of the demographic variants or on the radiologist experience. Additionally, the presence of immediate and medium-term post-puncture complications was evaluated. RESULTS One hundred patients with 104 hip dMRA were included; 60 were men, with mean age of 38 years (16-63 years). Contrast material was successfully introduced intra-articularly in 100% of patients, being necessary a second puncture only in 6% of procedures. The capsular distension was considered optimal for diagnosis in 97% of cases. Different degrees of contrast extravasation were found in 30% of dMRA. There was no statistically significant relationship observed between patient variables and the performance of dMRA, nor did it show any correlation with the experience of the radiologists. No puncture-derived complications were found. CONCLUSION Hip dMRA through anterior injection guided by anatomical references is an effective and safe alternative for patients with suspected intra-articular pathology.
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Affiliation(s)
- Roque Oca Pernas
- MRI Department, Osakidetza - Basque Health Service, OSATEK, Deusto, Bilbao, Spain.
| | | | - Nerea Hormaza Aguirre
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Radiology Department, Osakidetza - Basque Health Service, Cruces University Hospital, Barakaldo, Spain
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Flores DV, Foster RCB, Sampaio ML, Rakhra KS. Hip Capsulolabral Complex: Anatomy, Disease, MRI Features, and Postoperative Appearance. Radiographics 2024; 44:e230144. [PMID: 38300815 DOI: 10.1148/rg.230144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
The hip is a uniquely constrained joint with critical static stability provided by the labrum, capsule and capsular ligaments, and ligamentum teres. The labrum is a fibrocartilaginous structure along the acetabular rim that encircles most of the femoral head. Labral tears are localized based on the clock-face method, which determines the extent of the tear while providing consistent terminology for reporting. Normal labral variants can mimic labral disease and can be differentiated by assessment of thickness or width, shape, borders, location, and associated abnormalities. The Lage and Czerny classification systems are currently the most well-known arthroscopic and imaging systems, respectively. Femoroacetabular impingement is a risk factor for development of labral tears and is classified according to bone dysmorphisms of the femur ("cam") or acetabulum ("pincer") or combinations of both (mixed). The capsule consists of longitudinal fibers reinforced by ligaments (iliofemoral, pubofemoral, ischiofemoral) and circular fibers. Capsular injuries occur secondary to hip dislocation or iatrogenically after capsulotomy. Capsular repair improves hip stability at the expense of capsular overtightening and inadvertent chondral injury. The ligamentum teres is situated between the acetabular notch and the fovea of the femoral head. Initially considered to be inconsequential, recent studies have recognized its role in hip rotational stability. Existing classification systems of ligamentum teres tears account for injury mechanism, arthroscopic findings, and treatment options. Injuries to the labrum, capsule, and ligamentum teres are implicated in symptoms of hip instability. The authors discuss the labrum, capsule, and ligamentum teres, highlighting their anatomy, pathologic conditions, MRI features, and postoperative appearance. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6; and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ryan C B Foster
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6; and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marcos Loreto Sampaio
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6; and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kawan S Rakhra
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6; and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Chang EY, Bencardino JT, French CN, Fritz J, Hanrahan CJ, Jibri Z, Kassarjian A, Motamedi K, Ringler MD, Strickland CD, Tiegs-Heiden CA, Walker REA. SSR white paper: guidelines for utilization and performance of direct MR arthrography. Skeletal Radiol 2024; 53:209-244. [PMID: 37566148 PMCID: PMC10730654 DOI: 10.1007/s00256-023-04420-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion. MATERIALS AND METHODS The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations. RESULTS Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus. CONCLUSION Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.
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Affiliation(s)
- Eric Y Chang
- Radiology Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Jenny T Bencardino
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Cristy N French
- Department of Radiology, Penn State Hershey Medical Center, Hummelstown, PA, USA
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Zaid Jibri
- GNMI in Mississauga, Greater Toronto Area, Toronto, ON, Canada
| | - Ara Kassarjian
- Department of Radiology, Division of Musculoskeletal Imaging, Olympia Medical Center, Elite Sports Imaging, Madrid, Spain
| | - Kambiz Motamedi
- Department of Radiology, University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Colin D Strickland
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Richard E A Walker
- McCaig Institute for Bone and Joint Health, Calgary, Canada.
- Cumming School of Medicine, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
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Ruzbarsky JJ, Comfort SM, Ernat JJ, Day HK, Philippon MJ. Magnetic Resonance Imaging Approximates Labral Width at the 9-, 12-, and 3-O'Clock Positions in the Setting of Revision Hip Arthroscopy. Arthroscopy 2024; 40:320-327. [PMID: 37355193 DOI: 10.1016/j.arthro.2023.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To compare preoperative magnetic resonance imaging (MRI) and intraoperative measurements of labral width and determine whether MRI can reliably predict labral width in the setting of revision surgery. METHODS Patients who underwent revision hip arthroscopy with labral repair performed by a single surgeon from January 2008 to December 2015 were identified retrospectively from a prospectively collected database. The width of the labrum was measured intraoperatively at the time of surgery. Two orthopaedic surgeons performed labral width measurements on MRI scans at 3 standardized locations using the clock-face method. Interobserver and intraobserver reliabilities were calculated, and comparisons between intraoperatively measured labral widths and MRI measurements were performed. RESULTS Fifty-eight patients who underwent revision hip arthroscopy were enrolled in the study. The average labral width measurements at the 3-, 12-, and 9-o'clock positions were 7.4 mm (standard deviation [SD], 1.2 mm), 7.5 mm (SD, 1.4 mm), and 6.6 mm (SD, 1.2 mm), respectively, on MRI compared with 6.7 mm (SD, 2.1 mm), 6.5 mm (SD, 2.5 mm), and 7.0 mm (SD, 1.9 mm), respectively, when measured intraoperatively. The average intraoperative measurements were smaller than the MRI measurements at the 3-o'clock (P = .03) and 12-o'clock (P = .01) positions. The inter-rater intraclass correlation coefficients between the 2 surgeons exhibited good agreement (0.612) at the 3-o'clock position, fair agreement (0.498) at the 12-o'clock position, and poor agreement (0.171) at the 9-o'clock position. The positive predictive values of the MRI measurements were 72% at the 3-o'clock position, 68% at the 12-o'clock position, and 88% at the 9-o'clock position for identifying a labral width of 6 mm or greater. CONCLUSIONS The results of this study show that MRI-measured labral width and actual labral width measured at the time of revision arthroscopy are usually within 1 mm of each other. LEVEL OF EVIDENCE Level II, diagnostic study investigating diagnostic test.
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Affiliation(s)
- Joseph J Ruzbarsky
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | | | - Justin J Ernat
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | - Hannah K Day
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A..
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Particularities on Anatomy and Normal Postsurgical Appearances of the Hip. Radiol Clin North Am 2023; 61:167-190. [PMID: 36739140 DOI: 10.1016/j.rcl.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Detailed knowledge of anatomy helps to understand pathologic processes. This article focuses on the anatomy and functionality of the hip, with emphasis on recently studied concepts and anatomic features that have an association with the development of symptoms. The most common anatomic variants posing a challenge for diagnosis and other common findings in asymptomatic patients are reviewed. Good understanding of the different surgical procedures helps in providing as much information as possible to guarantee a favorable outcome, improving prognosis. We review what are the commonly expected postsurgical appearances and the most common postsurgical complications.
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Matthewson G, Williams A, Macciacchera M, Shahabinezhad A, Duong A, Ayeni OR. Effective Management Options for Treatment of Microinstability of the Hip: a Scoping Review. Curr Rev Musculoskelet Med 2022; 16:9-18. [PMID: 36472785 PMCID: PMC9839911 DOI: 10.1007/s12178-022-09808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To review the recent literature identifying and summarizing the research involving management of microinstability of the hip and highlight new and evolving techniques in its treatment. RECENT FINDINGS Recent updates in the understanding of capsular management hip arthroscopy will likely lead to less revision surgery and a decreased incidence of persistent post-operative pain. Repair of residual capsular defects has shown good outcomes with high patient satisfaction. Capsular plication remains the gold standard for hips with increased pain that show signs of capsular laxity/deficiency on exam or imaging. Capsular reconstruction has shown equivalent results to other revision hip arthroscopy procedures with low rates of complications. Ligamentum teres pathology, although rare, should be considered a source of pain, particularly in patients with laxity on exam. In cases where CAM over-resection has occurred, remplissage using allograft is an effective option for restoring the capsular suction seal and stability. Microinstability is increasingly being recognized as a source of post-operative hip pain. Patients with collagen disorders remain a challenging clinical entity with increased rates of complications and post-operative pain. CAM resection should be performed carefully and not disrupt the suction seal but be sufficient to not cause further impingement. Improved evidence including well-designed prospective studies with large sample sizes will determine the future management of this complex problem.
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Affiliation(s)
- Graeme Matthewson
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Allison Williams
- grid.28046.380000 0001 2182 2255Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Matthew Macciacchera
- grid.4912.e0000 0004 0488 7120Faculty of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ali Shahabinezhad
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Andrew Duong
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Olufemi R. Ayeni
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
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Kassarjian A, Isern-Kebschull J, Tomas X. Postoperative Hip MR Imaging. Magn Reson Imaging Clin N Am 2022; 30:673-688. [DOI: 10.1016/j.mric.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Ruzbarsky JJ, Seiter MN, Comfort SM, Soares RW, Briggs KK, Philippon MJ. Arthroscopic Hip Capsular Reconstruction Using Iliotibial Band Allograft as a Salvage Option for Unrepairable Capsular Defects Demonstrates Good Survivorship and Improved Patient-Reported Outcomes. Arthroscopy 2022; 38:2219-2226. [PMID: 34990758 DOI: 10.1016/j.arthro.2021.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe patient outcomes 3 to 5 years after arthroscopic hip capsule reconstruction. METHODS Between January 2007 and December 2016, patients aged 18 to 50 years who underwent arthroscopic hip capsular reconstruction using an Iliotibial band allograft by the senior author and had minimum of 3-year follow-up were identified. Patients were excluded if they had previous open hip surgery, advanced osteoarthritis (Tönnis grade >2), significant acetabular dysplasia (lateral center edge angle <20°), avascular necrosis, or Legg-Calve-Perthes disease. Outcome scores including the Hip Outcome Score (HOS)-Activities of Daily Living scale, modified Harris Hip Score, HOS-Sports scale, SF-12, and Western Ontario & McMaster Universities Osteoarthritis Index were compared in addition to failure rate, revision rate, and patient satisfaction rate with the outcome (range, 1-10). All patients were assessed by the senior author pre- and postoperatively. RESULTS Thirty-nine patients met the inclusion criteria. The mean age of the cohort was 32 ± 10 years, with 6 male and 33 female patients. The average number of previous hip arthroscopy surgeries was 2 ± 1. Six patients (15%) converted to total hip arthroplasty at an average of 2.1 years (range 7 months to 6 years) following capsular reconstruction. Four patients required revision hip arthroscopy after the arthroscopic capsular reconstruction. All arthroscopic revisions occurred in female patients with the primary intraoperative finding of capsulolabral adhesions at the time of revision. At mean follow-up of 4.3 years (range 3-6.8 years), the 29 patients who did not require subsequent surgery had significant improvements from preoperatively to postoperatively in HOS-Activities of Daily Living and HOS-Sport with 90% reaching minimal clinically important difference. All other scores showed significant improvement. Survival for patients not requiring total hip arthroplasty was 86% at 3 years, with a mean survival of 5.7 years (95% confidence interval 4.97-6.4). CONCLUSIONS Arthroscopic hip capsular reconstruction with iliotibial band allograft is a successful treatment option for patients with symptomatic capsular defects, demonstrating improved patient-reported outcomes maintained at mean follow-up time of 4 years. This technique offers restoration of the anatomic structure and function of the capsular ligaments to improve pain and instability. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Joseph J Ruzbarsky
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | - Max N Seiter
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | | | - Rui W Soares
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Karen K Briggs
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A..
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Mortensen AJ, Metz AK, Froerer DL, Aoki SK. Hip Capsular Deficiency-A Cause of Post-Surgical Instability in the Revision Setting Following Hip Arthroscopy for Femoroacetabular Impingement. Curr Rev Musculoskelet Med 2021; 14:351-360. [PMID: 34786635 PMCID: PMC8733039 DOI: 10.1007/s12178-021-09732-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW To characterize current concepts in capsular repair and hip instability, and examine findings from biomechanical and clinical studies on hip capsular management strategies as they pertain to hip stability, patient outcomes, and hip arthroscopy failure. Further, we discuss the clinical evaluation and treatment of capsular deficiency. RECENT FINDINGS There remains debate regarding the optimal capsular management strategies in hip arthroscopy, particularly concerning the necessity of routine capsular repair. A variety of capsulotomy techniques exist and may be used to access the hip joint. Additionally, a wide variety of techniques are employed to repair the hip capsule. Biomechanical evidence supports capsular closure restores hip joint stability to that of the intact, native state. Several clinical studies in both primary and revision hip arthroscopy settings have demonstrated improved pain and functional outcomes in patients who underwent capsular repair or capsular reconstruction. Studies have shown capsular repair may be especially important in patients with ligamentous laxity and hip dysplasia, and in competitive athletes. Post-surgical hip instability secondary to capsular insufficiency is increasingly recognized as a cause of hip arthroscopy failure. Capsular closure restores native biomechanical stability to the hip joint, and several clinical studies report improved pain and functional outcomes following capsular repair or capsular reconstruction in both the primary and revision hip arthroscopy settings. There remains much to learn regarding capsular hip instability as it relates to optimal capsular management surgical technique, intra-operative capsular management decision-making, clinical diagnosis, and related advanced imaging findings.
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Affiliation(s)
- Alexander J Mortensen
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Allan K Metz
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Devin L Froerer
- University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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Schmaranzer F, Haefeli PC, Liechti EF, Hanke MS, Tannast M, Büchler L. Improved Cartilage Quality on Delayed Gadolinium-Enhanced MRI of Hip Cartilage after Subchondral Drilling of Acetabular Cartilage Flaps in Femoroacetabular Impingement Surgery at Minimum 5-Year Follow-Up. Cartilage 2021; 13:617S-629S. [PMID: 32686503 PMCID: PMC8808901 DOI: 10.1177/1947603520941241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To assess whether subchondral drilling of acetabular cartilage flaps during femoroacetabular impingement (FAI) surgery improves (1) acetabular dGEMRIC indices and (2) morphologic magnetic resonance imaging (MRI) scores, compared with hips in which no additional treatment of cartilage lesions had been performed; and (3) whether global dGEMRIC indices and MRI scores correlate. DESIGN Prospective cohort study of consecutive patients with symptomatic FAI treated with open surgery between 2000 and 2007. Patients with subchondral drilling of acetabular cartilage flaps were allocated to the study group, those without drilling to the control group. All patients underwent indirect 3-T MR arthrography to assess cartilage quality by dGEMRIC indices and a semiquantitative morphologic MRI score at minimum 5 years after surgery. dGEMRIC indices and morphologic MRI scores were compared between and among groups using analysis of covariance/paired t tests. RESULTS No significant difference was found between the global dGEMRIC indices of the study group (449 ± 147 ms, 95% CI 432-466 ms) and the control group (428 ± 143 ms, 95% CI 416-442 ms; P = 0.235). In regions with cartilage flaps, the study group showed higher dGEMRIC indices (472 ± 160 ms, 95% CI 433-510 ms) compared with the control group (390 ± 122 ms, 95% CI 367-413 ms; P < 0.001). No significant differences were found for the morphologic MRI scores. A strong inversely linear correlation between the dGEMRIC indices and the morphologic MRI scores (r = -0.727, P < 0.001) was observed. CONCLUSIONS Treatment of acetabular cartilage flaps with subchondral drilling leads to better cartilage quality in regions with cartilage flaps at minimum 5 years of follow-up.
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Affiliation(s)
- Florian Schmaranzer
- Department of Diagnostic, Interventional
and Pediatric Radiology, Inselspital Bern, University of Bern, Bern,
Switzerland,Department of Orthopaedic Surgery and
traumatology, inselspital Bern, University of Bern, Bern, Switzerland,Florian Schmaranzer, University of Bern,
Freiburgstraße, Bern, 3010, Switzerland.
| | - Pascal C. Haefeli
- Department of Orthopaedic Surgery,
Kantonsspital Luzern, Luzern, Switzerland
| | - Emanuel F. Liechti
- Department of Orthopaedic Surgery and
traumatology, inselspital Bern, University of Bern, Bern, Switzerland
| | - Markus S. Hanke
- Department of Orthopaedic Surgery and
traumatology, inselspital Bern, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and
Traumatology, Kantonsspital Fribourg, University of Fribourg Faculty of Science and
Medicine, Fribourg, Switzerland
| | - Lorenz Büchler
- Department of Orthopaedic Surgery and
Traumatology, Kantonsspital Aarau AG, Aarau, Switzerland
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Meier MK, Lerch TD, Steppacher SD, Siebenrock KA, Tannast M, Vavron P, Schmaranzer E, Schmaranzer F. High prevalence of hip lesions secondary to arthroscopic over- or undercorrection of femoroacetabular impingement in patients with postoperative pain. Eur Radiol 2021; 32:3097-3111. [PMID: 34842955 PMCID: PMC9038890 DOI: 10.1007/s00330-021-08398-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/28/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
Objectives To compare the prevalence of pre- and postoperative osseous deformities and intra-articular lesions in patients with persistent pain following arthroscopic femoroacetabular impingement (FAI) correction and to identify imaging findings associated with progressive cartilage damage. Methods Retrospective study evaluating patients with hip pain following arthroscopic FAI correction between 2010 and 2018. Pre- and postoperative imaging studies were analyzed independently by two blinded readers for osseous deformities (cam-deformity, hip dysplasia, acetabular overcoverage, femoral torsion) and intra-articular lesions (chondro-labral damage, capsular lesions). Prevalence of osseous deformities and intra-articular lesions was compared with paired t-tests/McNemar tests for continuous/dichotomous data. Association between imaging findings and progressive cartilage damage was assessed with logistic regression. Results Forty-six patients (mean age 29 ± 10 years; 30 female) were included. Postoperatively, 74% (34/46) of patients had any osseous deformity including 48% (22/46) acetabular and femoral deformities. Ninety-six percent (44/46) had an intra-articular lesion ranging from 20% (9/46) for femoral to 65% (30/46) for acetabular cartilage lesions. Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of cam-deformity decreased (83 to 28%, p < 0.001). Progressive cartilage damage was detected in 37% (17/46) of patients and was associated with extensive preoperative cartilage damage > 2 h, i.e., > 60° (OR 7.72; p = 0.02) and an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04). Conclusion Prevalence of osseous deformities secondary to over- or undercorrrection was high. Extensive preoperative cartilage damage and higher postoperative alpha angles increase the risk for progressive degeneration. Key Points • The majority of patients presented with osseous deformities of the acetabulum or femur (74%) and with intra-articular lesions (96%) on postoperative imaging. • Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of a cam deformity decreased (83 to 28%, p < 0.001). • Progressive cartilage damage was present in 37% of patients and was associated with extensive preoperative cartilage damage > 2 h (OR 7.72; p = 0.02) and with an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04). Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08398-4.
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Affiliation(s)
- Malin K Meier
- Department of Orthopedic Surgery and Traumotology, Inselspital Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Till D Lerch
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery and Traumotology, Inselspital Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopedic Surgery and Traumotology, Inselspital Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Fribourg Cantonal Hospital, University of Fribourg, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| | - Peter Vavron
- Department of Orthopaedic Surgery, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Ehrenfried Schmaranzer
- Department of Radiology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Florian Schmaranzer
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland. .,Department of Radiology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria.
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O'Neill DC, Tomasevich KM, Mortensen AJ, Featherall J, Ohlsen SM, Aoki SK. Capsular Repair During Hip Arthroscopy Demonstrates Restoration of Axial Distraction Resistance in an in Vivo Intraoperative Testing Model. J Bone Joint Surg Am 2021; 103:1977-1985. [PMID: 34314401 DOI: 10.2106/jbjs.20.01932] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels. METHODS Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters. RESULTS A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm. CONCLUSIONS This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time.
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Affiliation(s)
- Dillon C O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Kelly M Tomasevich
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Joseph Featherall
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Aichmair A, Sutter R, Dietrich TJ, Dora C, Zingg PO. Magnetic Resonance Arthrographic Findings After Hip Labrum Resection Versus Refixation. Orthopedics 2021; 44:e607-e613. [PMID: 34292826 DOI: 10.3928/01477447-20210618-25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to evaluate whether new tissue formation occurs after labral debridement/excision, and, if so, which morphological features are typical for a neo-labrum. The authors further compared the findings after labrum resection with those seen after labrum refixation. Patients with femoroacetabular impingement who underwent hip arthroscopy or surgical hip dislocation to address a labrum pathology were retrospectively included, and postoperative magnetic resonance arthrography studies were assessed. Forty-two patients had undergone either labrum resection (n=25) or refixation (n=17), performed arthroscopically (47.6%) or via surgical hip dislocation (52.4%). In the subgroup of patients after debridement/resection, there was anterosuperior/superior scar tissue in 83.5%, with amorphous configuration in 92%, irregular surface in approximately two-thirds of the cases, and a mean±SD thickness of 7.0±2.7 mm. A labrum-like shape of the scar plate was seen in 7.7%. Regarding the subgroup of patients who had undergone labral refixation, an irregular or rounded labrum shape was noted in 26.5% and 51.3% of cases, respectively, with a triangular shape in less than one-fourth of cases. Labrum re-tears (35.7%) were mainly observed at the base (71.7%), rather than within the labral substance (28.4%). New tissue formation can be observed in the majority of cases after excision of the hip labrum, with amorphous and irregular surface configuration compared with a native labrum. This new tissue should therefore be referred to as scar tissue rather than as neo-labrum. Whether scar tissue is inferior to a refixed labrum needs to be further elucidated in follow-up studies. [Orthopedics. 2021;44(4):e607-e613.].
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Abstract
Preoperative evaluation of the pathomorphology is crucial for surgical planning, including radiographs as the basic modality and magnetic resonance imaging (MRI) and case-based additional imaging (e.g. 3D-CT, abduction views). Hip arthroscopy (HAS) has undergone tremendous technical advances, an immense increase in use and the indications are getting wider. The most common indications for revision arthroscopy are labral tears and residual femoroacetabular impingement (FAI). Treatment of borderline developmental dysplastic hip is currently a subject of controversy. It is paramount to understand the underlining problem of the individual hip and distinguish instability (dysplasia) from FAI, as the appropriate treatment for unstable hips is periacetabular osteotomy (PAO) and for FAI arthroscopic impingement surgery. PAO with a concomitant cam resection is associated with a higher survival rate compared to PAO alone for the treatment of hip dysplasia. Further, the challenge for the surgeon is the balance between over- and undercorrection. Femoral torsion abnormalities should be evaluated and evaluation of femoral rotational osteotomy for these patients should be incorporated to the treatment plan.
Cite this article: EFORT Open Rev 2021;6:472-486. DOI: 10.1302/2058-5241.6.210019
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Affiliation(s)
- Markus S Hanke
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Till D Lerch
- Department of Diagnostic, Interventional and Pediatric Radiology University Hospital of Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology University Hospital of Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Malin K Meier
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
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Ross JR, Clohisy JC, Bedi A, Zaltz I. Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success. Sports Med Arthrosc Rev 2021; 29:44-51. [PMID: 33395230 DOI: 10.1097/jsa.0000000000000300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.
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Affiliation(s)
- James R Ross
- BocaCare Orthopedics-Boca Raton Regional Hospital, Florida Atlantic University College of Medicine, Boca Raton, FL
| | - John C Clohisy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Ira Zaltz
- Department of Pediatric Orthopaedics, William Beaumont Hospital, Royal Oak, MI
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Prospective and longitudinal evolution of postoperative periprosthetic findings on metal artifact-reduced MR imaging in asymptomatic patients after uncemented total hip arthroplasty. Skeletal Radiol 2021; 50:1177-1188. [PMID: 33169220 PMCID: PMC8035088 DOI: 10.1007/s00256-020-03666-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To prospectively assess the evolution of postoperative MRI findings in asymptomatic patients after total hip arthroplasty (THA) over 24 months (mo). METHODS This prospective cohort study included 9 asymptomatic patients (56.7 ± 15.0 years) after THA. Metal artifact-reduced 1.5-T MRI was performed at 3, 6, 12, and 24 mo after surgery. The femoral stem and acetabular cup were assessed by two readers for bone marrow edema (BME), periprosthetic bone resorption, and periosteal edema in addition to periarticular soft tissue edema and joint effusion. RESULTS BME was common around the femoral stem in all Gruen zones after 3 mo (range: 50-100%) and 6 mo (range: 33-100%) and in the acetabulum in DeLee and Charnley zone II after 3 mo (100%) and 6 mo (33%). BME decreased substantially after 12 mo (range: 0-78%) and 24 mo (range: 0-50%), may however persist in particular in Gruen zones 1 + 7. Periosteal edema along the stem was common 3 mo postoperatively (range: 63-75%) and rare after 24 mo: 13% only in Gruen zones 2 and 5. Twelve months and 24 mo postoperatively, periprosthetic bone resorption was occasionally present around the femoral stem (range: 11-33% and 13-38%, respectively). Soft tissue edema occurred exclusively along the surgical access route after 3 mo (100%) and 6 mo (89%) and never at 12 mo or 24 mo (0%). CONCLUSION Around the femoral stem, BME (33-100%) and periosteal edema (0-75%) are common until 6 mo after THA, decreasing substantially in the following period, may however persist up to 24 mo (BME: 0-50%; periosteal edema: 0-13%) in few non-adjoining Gruen zones. Soft tissue edema along the surgical access route should have disappeared 12 mo after surgery.
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O'Neill DC, Mortensen AJ, Cannamela PC, Aoki SK. Clinical and Radiographic Presentation of Capsular Iatrogenic Hip Instability After Previous Hip Arthroscopy. Am J Sports Med 2020; 48:2927-2932. [PMID: 32877211 DOI: 10.1177/0363546520949821] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The clinical and radiographic features of iatrogenic hip instability following hip arthroscopy have been described. However, the prevalence of presenting symptoms and associated imaging findings in patients with hip instability has not been reported. PURPOSE To detail the prevalence of clinical and magnetic resonance arthrogram (MRA) findings in a cohort of patients with isolated hip instability and to determine midterm patient-reported outcomes in this patient population. STUDY DESIGN Case series; Level of evidence, 4. METHODS We retrospectively reviewed patients from 2014 to 2016 who underwent an isolated capsular repair in the revision hip arthroscopy setting. Patients were excluded if they underwent any concomitant procedures, such as labral repair, reconstruction, femoral osteoplasty, or any other related procedure. Several clinical data points were reviewed, including painful activities, mechanical symptoms, subjective instability, Beighton scores, axial distraction testing (pain, toggle, and apprehension), and distractibility under anesthesia. Patient-reported outcomes-including modified Harris Hip Score, Hip Outcome Score-Sports Subscale, Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function Computer Adaptive Test, and a return patient hip questionnaire-were collected pre- and postoperatively. Pre-revision radiographs were obtained, and lateral center-edge angle and alpha angle were measured on anteroposterior and frog-leg lateral views, respectively. Pre-revision MRAs were reviewed and evaluated for capsular changes. Capsular changes were defined as follows: 0, normal; 1, capsular redundancy; 2, focal capsular rent; and 3, gross extravasation of fluid from the capsule. RESULTS A total of 31 patients met inclusion criteria (5 male, 26 female; 14 right and 17 left hips). The mean age of patients was 36 years (range, 20-58 years). Overall, 27 (87%) reported hip pain with activities of daily living, and 31 (100%) experienced pain with sports or exercise. In addition, 24 (77%) had at least 1 positive finding on axial distraction testing. All patients had evidence of capsular changes on review of pre-revision MRAs. Out of 31 patients, 23 (74%) were available for follow-up at a minimum of 3.3 years and a mean ± SD of 4.6 ± 0.8 years. On average, modified Harris Hip Score improved by 20.3, Hip Outcome Score-Sports Subscale by 25.1, and PROMIS Physical Function Computer Adaptive Test by 6.4. Additionally, 20 (87%) patients reported improved or much improved physical ability, and 18 (78%) reported improved or much improved pain. CONCLUSION The current study suggests that patients with hip instability demonstrate high rates of pain with activities of daily living and exercise, positive findings on axial distraction testing, and evidence of capsular changes on magnetic resonance imaging. Furthermore, these patients improve with revision surgery for capsular repair at midterm follow-up.
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Affiliation(s)
- Dillon C O'Neill
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | | | | | - Stephen K Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
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Filli L, Jungmann PM, Zingg PO, Rüdiger HA, Galley J, Sutter R, Pfirrmann CWA. MRI with state-of-the-art metal artifact reduction after total hip arthroplasty: periprosthetic findings in asymptomatic and symptomatic patients. Eur Radiol 2019; 30:2241-2252. [PMID: 31863147 DOI: 10.1007/s00330-019-06554-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/07/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess the spectrum of periprosthetic MRI findings after primary total hip arthroplasty (THA). METHODS This multi-center cohort study analyzed 31 asymptomatic patients (65.7 ± 12.7 years) and 27 symptomatic patients (62.3 ± 11.9 years) between 6 months and 2 years after THA. 1.5-T MRI was performed using Compressed Sensing SEMAC and high-bandwidth sequences. Femoral stem and acetabular cup were assessed for bone marrow edema, osteolysis, and periosteal reaction in Gruen zones and DeLee and Charnley zones. Student t test and Fisher's exact test were performed. RESULTS The asymptomatic and symptomatic groups showed different patterns of imaging findings. Bone marrow edema was seen in 19/31 (61.3%) asymptomatic and 22/27 (81.5%) symptomatic patients, most commonly in Gruen zones 1, 7, and 8 (p ≥ 0.18). Osteolysis occurred in 14/31 (45.2%) asymptomatic and 14/27 (51.9%) symptomatic patients and was significantly more common in Gruen zone 7 in the symptomatic group (8/27 (29.6%)) compared to the asymptomatic group (2/31 (6.5%)) (p = 0.03). Periosteal reaction was present in 4/31 asymptomatic (12.9%) and 9/27 symptomatic patients (33.3%) and more common in Gruen zones 5 and 6 in the symptomatic group (p = 0.04 and 0.02, respectively). In the acetabulum, bone marrow edema pattern was encountered in 3/27 (11.1%) symptomatic patients but not in asymptomatic patients (p ≥ 0.21). Patient management was altered in 8/27 (29.6%) patients based on MRI findings. CONCLUSIONS Periprosthetic bone marrow edema is common after THA both in asymptomatic and symptomatic patients. Osteolysis and periosteal reaction are more frequent in symptomatic patients. MRI findings led to altered patient management in 29.6% of patients. KEY POINTS • Bone marrow edema pattern was frequent in both asymptomatic and symptomatic patients after THA, particularly around the proximal femoral stem in Gruen zones 1, 7, and 8. • Osteolysis was significantly more frequent in symptomatic patients in Gruen zone 7. • Periosteal reaction occurred more frequently in symptomatic patients in Gruen zones 5 and 6.
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Postoperative MRI Findings and Associated Pain Changes After Arthroscopic Surgery for Femoroacetabular Impingement. AJR Am J Roentgenol 2019; 214:177-184. [PMID: 31691612 DOI: 10.2214/ajr.19.21421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this study is to describe postoperative MRI findings after femoroacetabular impingement surgery in correlation with pain changes and surgical findings. SUBJECTS AND METHODS. We prospectively enrolled 42 patients (43 hips) who were scheduled for FAI surgery. Pre- and postoperative MR images were obtained using a 3-T MRI system. Changes in pain scores were assessed using the hip dysfunction and osteoarthritis outcome score. MR images were evaluated for the presence of acetabuloplasty or femoroplasty, presence of chondral and labral repair surgery, bone marrow edema, subchondral cysts, chondral defects, labral tears, capsular defects, and effusion. The optimal orientation to detect these changes was noted. Imaging findings were compared with pain score changes using linear regression analysis. Sensitivity and specificity were assessed using surgical correlation as the reference standard. RESULTS. Increased acetabular bony débridement length was associated with decreased improvement in pain scores (coefficient, -2.07; 95% CI, -3.53 to -0.62; p = 0.008), whereas other imaging findings were not significantly different. Femoroplasty and capsular alterations were best detected on oblique axial sequences; acetabuloplasty and cartilage and labral repair were best seen on sagittal sequences. MRI showed excellent sensitivity (100%) and specificity (100%) for detecting labral repair and excellent sensitivity for detecting femoroplasty (98%). Sensitivity and specificity were lower for detecting acetabuloplasty (83% and 80%, respectively) and chondral repair (75% and 54%, respectively). CONCLUSION. Arthroscopic acetabuloplasty showed a greater association with postoperative pain than did other aspects of surgical correction for femoroacetabular impingement. Femoroplasty and labral repair were reliably diagnosed on 3-T MRI; however, limitations were found in the evaluation of acetabular chondral repair.
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Early Outcomes After Arthroscopic Hip Capsular Reconstruction Using Iliotibial Band Allograft Versus Dermal Allograft. Arthroscopy 2019; 35:778-786. [PMID: 30733039 DOI: 10.1016/j.arthro.2018.10.110] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/16/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical outcomes between 2 groups of patients who underwent arthroscopic hip capsular reconstruction with the same surgical technique with an iliotibial band (ITB) allograft versus dermal allograft tissue. METHODS From March 2013 to October 2015, patients who were 18 years of age or older and who underwent revision arthroscopic hip surgery with capsular reconstruction by the senior author were identified. Patients who were younger than 18 years old, had a lateral center-edge angle <20° or Tonnis osteoarthritis grade 2 or 3, or refused to participate were excluded. Patients were assigned to 2 groups based on whether an ITB (ITB group) or a dermal allograft (dermal group) was used to reconstruct the capsule. The ITB graft was used initially, then the dermal graft was used when it was available. The dimensions were based on the intraoperative measurement of the capsular defect, and the thickness was 3 mm. Other treatments included labral debridement, repair, or reconstruction; treatment of residual femoroacetabular impingement; and treatment of cartilage damage. Clinical outcome scores including the Hip Outcome Score (HOS)-Activity of Daily Living scale (primary outcome measure), modified Harris Hip Score, HOS-Sports scale, SF-12, and Western Ontario & McMaster Universities Osteoarthritis Index were compared between the groups in addition to the failure rate (conversion to total hip arthroplasty, revision hip arthroscopy) and patient satisfaction rate with the outcome (range, 1-10). RESULTS Thirty-six patients (9 men and 27 women) met the inclusion criteria. Each group consisted of 18 patients (18 hips) with a mean age of 30.9 ± 9.4 years in the ITB group and a mean age of 29.8 ± 9.4 years in the dermal group (P = .718). There were no differences in patient demographics, physical examination findings, or imaging characteristics. The procedure failed for 8 patients (4 in the ITB group and 4 in the dermal group), and another surgery was required (P = 1.0). Additional surgeries included 3 total hip arthroplasties, 1 periarticular osteotomy, and 4 revision arthroscopies. The mean follow-up time was 25 months (range, 18-38 months) in both groups (P = .881). At follow-up, the HOS-Activity of Daily Living scale, SF-12, modified Harris Hip Score, and HOS-Sports scale measures were significantly higher in the ITB group than in the dermal group (P < .05). A greater percentage of patients reached minimum clinically important difference in the ITB group for Western Ontario & McMaster Universities Osteoarthritis Index and HOS scales with the minimum clinically important difference for HOS-Sports scale being significantly higher in the ITB group (P = .04). Patient satisfaction scores were 8 and 6 in the ITB and dermal groups, respectively. CONCLUSIONS At a mean follow-up time of 25 months, hip capsular reconstruction with an ITB allograft results in improved clinical outcomes compared with the dermal allograft. A similar failure rate was noted in both groups, but a greater percentage of patients in the ITB group achieved clinical improvement.
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Fagotti L, Kemler BR, Utsunomiya H, Storaci HW, Krob JJ, Brady AW, Turnbull TL, Philippon MJ. Effects of Capsular Reconstruction With an Iliotibial Band Allograft on Distractive Stability of the Hip Joint: A Biomechanical Study. Am J Sports Med 2018; 46:3429-3436. [PMID: 30382750 DOI: 10.1177/0363546518802841] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The capsular ligaments and the labral suction seal cooperatively manage distractive stability of the hip. Capsular reconstruction using an iliotibial band (ITB) allograft aims to address capsular insufficiency and iatrogenic instability. However, the extent to which this procedure may restore hip distractive stability after a capsular defect is unknown. PURPOSE To evaluate the biomechanical effects of capsular reconstruction on distractive stability of the hip joint. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric hip specimens were dissected to the level of the capsule and axially distracted in 3 testing states: intact capsule, partial capsular defect, and capsular reconstruction with an ITB allograft. Each femur was compressed with 500 N of force and then distracted 6 mm relative to the neutral position at 0.5 mm/s. Distractive force was continuously recorded, and the first peak delineating 2 phases of hip distractive stability in the force-displacement curve was analyzed. RESULTS The median force at maximum distraction in the capsular reconstruction state (156 N) was significantly greater than that in the capsular defect state (89 N; P = .036) but not significantly different from that in the intact state (218 N; P = .054). Median values for distractive force at first peak (60 N, 72 N, and 61 N, respectively; P = .607), distraction at first peak (2.3 mm, 2.3 mm, and 2.5 mm, respectively; P = .846), and percentage decrease in distractive force (35%, 78%, and 63%, respectively; P = .072) after the first peak were not significantly different between the intact, defect, and reconstruction states. CONCLUSION Capsular reconstruction with an ITB allograft significantly increased the force required to distract the hip compared with a capsular defect in a cadaveric model. To our knowledge, this is the first study to report an initial peak distractive force and to propose 2 distinct phases of hip distractive stability. CLINICAL RELEVANCE The consequences of a capsular defect on distractive stability of the hip may be underappreciated among the orthopaedic community; with that said, capsular reconstruction using an ITB allograft provided significantly increased distractive stability and should be considered an effective treatment option for patients with symptomatic capsular deficiency.
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Affiliation(s)
| | | | | | | | - Joseph J Krob
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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24
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Woodward RM, Philippon MJ. Persistent or recurrent symptoms after arthroscopic surgery for femoroacetabular impingement: A review of imaging findings. J Med Imaging Radiat Oncol 2018; 63:15-24. [DOI: 10.1111/1754-9485.12822] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/26/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rebecca M Woodward
- Steadman Philippon Research Institute Vail Colorado USA
- Auckland Radiology Group Auckland New Zealand
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25
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Haefeli PC, Schmaranzer F, Steppacher SD, Cullmann JL, Tannast M, Büchler L. Imaging appearance and distribution of intra-articular adhesions following open FAI surgery. Eur J Radiol 2018; 104:71-78. [DOI: 10.1016/j.ejrad.2018.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/21/2018] [Accepted: 04/24/2018] [Indexed: 11/24/2022]
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26
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Shin JJ, de SA DL, Burnham JM, Mauro CS. Refractory pain following hip arthroscopy: evaluation and management. J Hip Preserv Surg 2018; 5:3-14. [PMID: 29423245 PMCID: PMC5798041 DOI: 10.1093/jhps/hnx047] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 11/21/2017] [Accepted: 12/12/2017] [Indexed: 01/11/2023] Open
Abstract
With increased knowledge and understanding of hip pathology, hip arthroscopy is rapidly becoming a popular treatment option for young patients with hip pain. Despite improved clinical and radiographic outcomes with arthroscopic treatment, some patients may have ongoing pain and less than satisfactory outcomes. While the reasons leading to failed hip arthroscopy are multifactorial, patient selection, surgical technique and rehabilitation all play a role. Patients with failed hip arthroscopy should undergo a thorough history and physical examination, as well as indicated imaging. A treatment plan should then be developed based on pertinent findings from the workup and in conjunction with the patient. Depending on the etiology of failed hip arthroscopy, management may be nonsurgical or surgical, which may include revision arthroscopic or open surgery, periacetabular osteotomy or joint arthroplasty. Revision surgery may be appropriate in settings including, but not limited to, incompletely treated femoroacetabular impingement, postoperative adhesions, heterotopic ossification, instability, hip dysplasia or advanced degeneration.
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Affiliation(s)
- Jason J Shin
- Department of Orthopaedics and Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15203, USA
| | - Darren L de SA
- Department of Orthopaedics and Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15203, USA
| | - Jeremy M Burnham
- Department of Orthopaedics and Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15203, USA
| | - Craig S Mauro
- Department of Orthopaedics and Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15203, USA
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27
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Crim J. Imaging evaluation of the hip after arthroscopic surgery for femoroacetabular impingement. Skeletal Radiol 2017; 46:1315-1326. [PMID: 28466104 PMCID: PMC5559574 DOI: 10.1007/s00256-017-2665-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/14/2017] [Accepted: 04/18/2017] [Indexed: 02/02/2023]
Abstract
Arthroscopic surgery for femoroacetabular impingement (FAI) is increasingly frequently performed. Initial reports were that complications were very low, but as experience has increased, a number of long-term complications, in addition to factors related to poor clinical outcomes, have been identified. This review describes the normal and abnormal postoperative imaging appearance of the hip after arthroscopy for FAI. Abnormalities discussed include incomplete resection or over-resection of the impingement lesion, heterotopic ossification, cartilage damage, chondrolysis, instability and dislocation, recurrent labral tear, adhesions, psoas atrophy, infection, and avascular necrosis.
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Affiliation(s)
- Julia Crim
- University of Missouri at Columbia, Columbia, MO USA
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