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Kraeutler MJ, Hernandez E, Samuelsson K, Mei-Dan O. The Principles of Hip Joint Preservation. Arthroscopy 2024; 40:1958-1960. [PMID: 38960506 DOI: 10.1016/j.arthro.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/05/2024] [Indexed: 07/05/2024]
Abstract
The 3 primary factors involved with preservation of the hip joint are femoroacetabular impingement (FAI), hip dysplasia, and femoral torsion abnormalities. Each of these factors affects the health of the acetabular labrum and femoroacetabular cartilage. The appropriate surgical treatments for each of these factors include arthroscopic or open femoroplasty or acetabuloplasty for FAI, periacetabular osteotomy (PAO) for acetabular dysplasia, and de-rotational femoral osteotomy for femoral torsion abnormalities. When evaluating patients with prearthritic hip conditions, orthopaedic surgeons should be aware of the various factors involved in hip joint preservation and, if surgery is indicated, surgeons should be sure to address all factors that need surgical treatment rather than focusing on the most obvious issue or injury (e.g., a labral tear). The purpose of this infographic is to illustrate the importance of the factors involved in hip joint preservation and the appropriate treatments for pathology in any of these factors.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora Colorado, U.S.A.; Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden.
| | - Evan Hernandez
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, Lubbock, Texas, U.S.A
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora Colorado, U.S.A
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Gillinov SM, Lee JS, Siddiq BS, Dowley KS, Torabian KA, Dean MC, Cherian NJ, Cote MP, Martin SD. Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears. Am J Sports Med 2024; 52:2295-2305. [PMID: 38872427 DOI: 10.1177/03635465241255950] [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] [Indexed: 06/15/2024]
Abstract
BACKGROUND Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored. PURPOSE To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared. RESULTS In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score-Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250). CONCLUSION Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.
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Affiliation(s)
- Stephen M Gillinov
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan S Lee
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bilal S Siddiq
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kieran S Dowley
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kaveh A Torabian
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael C Dean
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathan J Cherian
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, Nebraska, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kraeutler MJ, Samuelsson K, Mei-Dan O. The Principles of Hip Joint Preservation. J Am Acad Orthop Surg 2024:00124635-990000000-01024. [PMID: 38968611 DOI: 10.5435/jaaos-d-24-00340] [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: 03/24/2024] [Accepted: 05/19/2024] [Indexed: 07/07/2024] Open
Abstract
The three primary factors involved in preservation of the hip joint include femoroacetabular impingement (FAI), hip dysplasia/instability, and femoral torsion abnormalities. Each of these factors affects the health of the acetabular labrum and femoroacetabular cartilage. The appropriate surgical treatments for each of these factors include arthroscopic or open femoroplasty/acetabuloplasty for FAI, periacetabular osteotomy for hip dysplasia/instability, and derotational femoral osteotomy for femoral torsion abnormalities. When evaluating patients with prearthritic hip conditions, orthopaedic surgeons should be aware of the various factors involved in hip joint preservation and, if surgery is indicated, the surgeon should be sure to address all factors that need surgical treatment rather than focusing on the commonly diagnosed issue or visible injury, for example, a labral tear. If any of these factors is ignored, the hip joint may not thrive. The purpose of this review was to explain the importance of the most common factors involved in hip joint preservation and the appropriate surgical treatments for pathology in these factors.
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Affiliation(s)
- Matthew J Kraeutler
- From the Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO (Dr. Kraeutler, and Dr. Mei-Dan), and the Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, MöIndal, Sweden (Dr. Kraeutler, and Dr. Samuelsson)
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Jan K, Vogel MJ, Alvero AB, Wright-Chisem J, Nho SJ. Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up. Am J Sports Med 2024; 52:1554-1562. [PMID: 38590189 DOI: 10.1177/03635465241239874] [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] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD. PURPOSE To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups. RESULTS In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835). CONCLUSION Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.
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Affiliation(s)
- Kyleen Jan
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael J Vogel
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander B Alvero
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Joshua Wright-Chisem
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Bardakos NV. CORR Insights®: What Is the Influence of Femoral Version on Size, Tear Location, and Tear Pattern of the Acetabular Labrum in Patients With FAI? Clin Orthop Relat Res 2024:00003086-990000000-01531. [PMID: 38489554 DOI: 10.1097/corr.0000000000003042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Nikolaos V Bardakos
- Centre Hospitalier de Figeac, Chirurgie Orthopédique et Traumatologique, Figeac, France
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Wu JY, Li W, Xu LY, Zheng G, Chen XD, Shen C. Ligamentum Teres Tears and Increased Combined Anteversion Are Associated With Hip Microinstability in Patients With Borderline Dysplasia. Arthroscopy 2024; 40:745-751. [PMID: 37419221 DOI: 10.1016/j.arthro.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 06/17/2023] [Accepted: 06/17/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE To investigate the differences in the prevalence of ligamentum teres (LT) tears and other radiographic measurements in borderline dysplasia of the hip (BDDH) with/without microinstability and to evaluate the associations between these imaging findings and the prevalence of microinstability in patients with BDDH. METHODS This was a retrospective study of symptomatic patients with BDDH (18° ≤ lateral center-edge angle <25°) treated with arthroscopy in our hospital between January 2016 and December 2021. These patients were divided into the BDDH with microinstability (mBDDH) group and the stable BDDH (nBDDH) group. The radiographic parameters associated with hip joint stability, such as the state of LT, acetabular versions, femoral neck version, Tönnis angle, combined anteversions, and anterior/posterior acetabular coverage, were reviewed and analyzed. RESULTS There were 54 patients (49 female/5 male, 26.7 ± 6.9 years) in the mBDDH group and 81 patients (74 female/7 male, 27.2 ± 7.7 years) in the nBDDH group. The mBDDH group had greater LT tear (43/54 vs 5/81) and general laxity rates, increased femoral neck version, acetabular version and combined anteversion (52.4 ± 5.9 vs 41.5 ± 7.1 at 3-o'clock level) than the nBDDH group. Binary logistic regression showed that LT tears (odds ratio 6.32, 95% confidence interval 1.38-28.8; P = .02; R2 = .458) and combined anteversion at the 3-o'clock level (odds ratio 1.42, 95% confidence interval 1.09-1.84; P < .01; R2 = .458) were independent predictors of microinstability in patients with BDDH. The cutoff value of combined anteversion at 3-o'clock level was 49.5°. In addition, LT tear was correlated with increased combined anteversion at 3-o'clock level in patients with BDDH (P < .01, η2 = 0.29). CONCLUSIONS LT tears and increased combined anteversion at the 3-o'clock level on the acetabular clockface were associated with hip microinstability in patients with BDDH, suggesting that patients with BDDH and LT tears might have a greater prevalence of anterior microinstability. LEVEL OF EVIDENCE Level III, case‒control study.
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Affiliation(s)
- Jin-Yan Wu
- Department of Orthopedics, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai
| | - Wei Li
- Department of Joint Surgery, Weifang People's Hospital, Shandong, China
| | - Liu-Yang Xu
- Department of Orthopedics, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai
| | - Guoyan Zheng
- Institute of Medical Robotics, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Dong Chen
- Department of Orthopedics, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai
| | - Chao Shen
- Department of Orthopedics, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai.
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Kraeutler MJ, Garabekyan T, Mei-Dan O. We Need Better Classification of Patients With Borderline Hip Dysplasia: Shifting the Focus From Dysplasia to Instability. Arthroscopy 2024; 40:653-654. [PMID: 38206250 DOI: 10.1016/j.arthro.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/12/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | | | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, Boulder, Colorado, U.S.A
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Dhillon J, Orozco E, Keeter C, Scillia AJ, Harris JD, Kraeutler MJ. Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review. Arthroscopy 2024; 40:602-611. [PMID: 37355179 DOI: 10.1016/j.arthro.2023.05.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes. RESULTS Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies. CONCLUSIONS The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome. LEVEL OF EVIDENCE Level III, systematic review of level III studies.
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Affiliation(s)
- Jaydeep Dhillon
- Rocky Vista University College of Osteopathic Medicine, Parker, Colorado, U.S.A
| | - Erin Orozco
- Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Carson Keeter
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, U.S.A.; Academy Orthopaedics, Wayne, New Jersey, U.S.A
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Heimann AF, Todorski IAS, Schmaranzer F, Viganò M, Lerch TD, Schwab JM, Steppacher SD, Tannast M. What Is the Influence of Femoral Version on Size, Tear Location, and Tear Pattern of the Acetabular Labrum in Patients With FAI? Clin Orthop Relat Res 2024:00003086-990000000-01466. [PMID: 38231022 DOI: 10.1097/corr.0000000000002961] [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: 08/31/2023] [Accepted: 12/01/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Femoral version deformities have recently been identified as a major contributor to femoroacetabular impingement (FAI). An in-depth understanding of the specific labral damage patterns caused by femoral version deformities may help to understand the underlying pathomorphologies in symptomatic patients and select the appropriate surgical treatment. QUESTIONS/PURPOSES We asked: (1) Is there a correlation between femoral version and the mean cross-sectional area of the acetabular labrum? (2) Is there a difference in the location of lesions of the acetabular labrum between hips with increased femoral version and hips with decreased femoral version? (3) Is there a difference in the pattern of lesions of the acetabular labrum between hips with increased femoral version and hips with decreased femoral version? METHODS This was a retrospective, comparative study. Between November 2009 and September 2016, we evaluated 640 hips with FAI. We considered patients with complete diagnostic imaging including magnetic resonance arthrography (MRA) of the affected hip with radial slices of the proximal femur and axial imaging of the distal femoral condyles (allowing for calculation of femoral version) as eligible. Based on that, 97% (620 of 640 hips) were eligible; a further 77% (491 of 640 hips) were excluded because they had either normal femoral version (384 hips), incomplete imaging (20 hips), a lateral center-edge angle < 22° (43 hips) or > 39° (16 hips), age > 50 years (8 hips), or a history of pediatric hip disease (20 hips), leaving 20% (129 of 640 hips) of patients with a mean age of 27 ± 9 years for analysis, and 61% (79 of 129 hips) were female. Patients were assigned to either the increased (> 30°) or decreased (< 5°) femoral version group. The labral cross-sectional area was measured on radial MR images in all patients. The location-dependent labral cross-sectional area, presence of labral tears, and labral tear patterns were assessed using the acetabular clockface system and compared among groups. RESULTS In hips with increased femoral version, the labrum was normal in size (21 ± 6 mm2 [95% confidence interval 20 to 23 mm2]), whereas hips with decreased femoral version showed labral hypotrophy (14 ± 4 mm2 [95% CI 13 to 15 mm2]; p < 0.01). In hips with increased femoral version, labral tears were located more anteriorly (median 1:30 versus 12:00; p < 0.01). Hips with increased femoral version exhibited damage of the anterior labrum with more intrasubstance tears anterosuperiorly (17% [222 of 1322] versus 9% [93 of 1084]; p < 0.01) and partial tears anteroinferiorly (22% [36 of 165] versus 6% [8 of 126]; p < 0.01). Hips with decreased femoral version showed superior labral damage consisting primarily of partial labral tears. CONCLUSION In the evaluation of patients with FAI, the term "labral tear" is not accurate enough to describe labral pathology. Based on high-quality radial MR images, surgeons should always evaluate the combination of labral tear location and labral tear pattern, because these may provide insight into associated femoral version abnormalities, which can inform appropriate surgical treatment. Future studies should examine symptomatic patients with normal femoral version, as well as an asymptomatic control group, to describe the effect of femoral version on labral morphology across the entire spectrum of pathomorphologies. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Alexander F Heimann
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Inga Almut Senta Todorski
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martino Viganò
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Till D Lerch
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joseph M Schwab
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital Bern, University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, HFR - Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Domb BG, Owens JS, Glein RM, Jimenez AE, Maldonado DR. Borderline Dysplasia After Primary Hip Arthroscopy with Capsular Plication and Labral Preservation: Ten-Year Survivorship and Patient-Reported Outcomes. J Bone Joint Surg Am 2023; 105:687-699. [PMID: 37083686 DOI: 10.2106/jbjs.22.00340] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND The arthroscopic management of borderline hip dysplasia (BHD) is controversial, and long-term follow-up data are scarce. The purpose of this study was to report prospectively collected survivorship and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up following primary hip arthroscopy with capsular plication and labral preservation in patients with BHD. METHODS Data were prospectively collected on all patients who underwent primary hip arthroscopy between September 2008 and September 2011. Patients with BHD (defined by a lateral center-edge angle [LCEA] between 18° and 25°) were included. Preoperative and minimum 10-year follow-up scores for the modified Harris hip score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were collected. Exclusion criteria were prior ipsilateral hip surgery, Workers' Compensation status, Tönnis grade of >1, previous hip conditions, or LCEA of <18°. Survivorship was defined as no conversion to total hip arthroplasty (THA). The risk factors for THA conversion were analyzed. The achievement rate for the minimal clinically important difference (MCID) was reported. A propensity-matched comparison with a control group without BHD was performed. RESULTS Forty-five (80%) of 56 eligible hips were included in this study: 38 hips (84%) of female patients and 7 hips (16%) of male patients. The mean patient age was 31.0 ± 12.9 years, and the mean patient body mass index (BMI) was 24.5 ± 5.4 kg/m2. The 10-year survivorship was 82.2%, and there was significant improvement in all PROMs and VAS pain from baseline to the minimum 10-year follow-up (p < 0.001). The odds of undergoing conversion to THA were 4.4 times higher for patients with a BMI of ≥23 kg/m2 and 7.1 times higher for patients who were ≥42 years of age. The MCID was achieved at high rates for the mHHS (79%), NAHS (79%), HOS-SSS (70%), and VAS pain (76%). The minimum 10-year survivorship, PROMs, and MCID achievement rates for the BHD group were comparable with those for the control group. CONCLUSIONS Patients with BHD who underwent primary hip arthroscopy with capsular plication and labral preservation demonstrated an overall survivorship of 82.2% and significant improvement in all PROMs and achieved the MCID at high rates at a minimum 10-year follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois
- American Hip Institute, Chicago, Illinois
| | - Jade S Owens
- American Hip Institute Research Foundation, Chicago, Illinois
| | - Rachel M Glein
- American Hip Institute Research Foundation, Chicago, Illinois
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Heimann AF, Zurmühle CA, Stetzelberger VM, Galley J, Schwab JM, Tannast M. [Definition of hip dysplasia in 2023 : Signs of macro and micro instability]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:261-271. [PMID: 36881127 PMCID: PMC10063496 DOI: 10.1007/s00132-023-04353-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Hip dysplasia is a complex static-dynamic pathology leading to chronic joint instability and osteoarthritis. Because our understanding of the underlying pathomorphologies of hip dysplasia, both on the macro and micro levels, has evolved, an updated definition is needed. QUESTION What is the definition of hip dysplasia in 2023? METHODS By summarizing and reviewing relevant literature, we provide an up-to-date definition of hip dysplasia with a guide to appropriately making the diagnosis. RESULTS In addition to the pathognomonic parameters, supportive and descriptive indicators, as well as secondary changes are used to fully characterize instability inherent in hip dysplasia. The primary diagnostic tool is always the plain anteroposterior pelvis radiograph, which can be supplemented by additional investigations (MRI of the hip with intraarticular contrast agent; CT) if necessary. CONCLUSION The complexity, subtlety, and diversity of the pathomorphology of residual hip dysplasia requires careful, multilevel diagnosis and treatment planning in specialized centers.
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Affiliation(s)
- Alexander Frank Heimann
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Corinne Andrea Zurmühle
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Vera Marie Stetzelberger
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Julien Galley
- Klinik für Radiologie, HFR Kantonsspital Freiburg, Universität Freiburg, Freiburg, Schweiz
| | - Joseph M Schwab
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Moritz Tannast
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz.
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12
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Kraeutler MJ. Editorial Commentary: Most Patients With Borderline Hip Dysplasia Do Well After Hip Arthroscopy: Could Instability Be the Problem for Those Who Do Poorly? Arthroscopy 2023; 39:283-284. [PMID: 36603997 DOI: 10.1016/j.arthro.2022.10.005] [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: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 01/04/2023]
Abstract
Borderline hip dysplasia (BHD) is often defined based on the lateral center edge angle. While patients with frank hip dysplasia often require bony realignment with periacetabular osteotomy and/or derotational femoral osteotomy, patients with BHD represent an "in-between" group of patients. While many, perhaps even most, patients with BHD will have successful outcomes after hip arthroscopy alone, some will be unresponsive to an arthroscopic-only approach and require the same surgical treatments as those with frank dysplasia. A variety of radiographic and arthroscopic parameters can be used to assess the degree of instability in patients with BHD. It may be that patients with "borderline" hip dysplasia combined with hip instability are more likely to fail an arthroscopic-only approach but to date we still do not have a great algorithm for determining which patients with BHD should undergo bony treatment with periacetabular osteotomy. It is important for future studies to continue to seek out characteristics of BHD patients that predict failure of an arthroscopic-only approach. This will not only allow for optimal initial surgical treatment in "at-risk" patients with BHD but will also improve success rates in BHD patients selected for hip arthroscopy as initial surgical treatment.
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Welton KL, Kraeutler MJ, Garabekyan T, Mei-Dan O. Radiographic Parameters of Adult Hip Dysplasia. Orthop J Sports Med 2023; 11:23259671231152868. [PMID: 36874050 PMCID: PMC9983115 DOI: 10.1177/23259671231152868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/08/2022] [Indexed: 03/04/2023] Open
Abstract
As knowledge about the origin and morphologic characteristics of hip pain in the young adult has evolved, so too has the clinician's ability to assess for various pathologies of the hip on radiographs, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA), and computed tomography (CT). Because there is no algorithm at this time directly indicating what to do in more subtle hip morphologies, such as microinstability and borderline hip dysplasia (BHD), a skilled hip preservation specialist must use multiple imaging sources and know how to interpret them correctly. Imaging parameters used in the workup for hip dysplasia and BHD include the lateral center-edge angle, Tönnis angle, iliofemoral line, and presence of an upsloping lateral sourcil or everted labrum, among many others. The purpose of this narrative review was to detail various established criteria and parameters on anteroposterior pelvis plain radiographs, MRI/MRA, and CT that assist in defining the nature and severity of instability present in a dysplastic hip, thereby aiding in the development of patient-specific surgical treatment plans.
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Affiliation(s)
- K Linnea Welton
- MultiCare Orthopedics & Sports Medicine, Auburn, Washington, USA
| | - Matthew J Kraeutler
- Houston Methodist Hospital, Department of Orthopedics & Sports Medicine, Houston, Texas, USA
| | | | - Omer Mei-Dan
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
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Kuhns BD, Reuter JM, Hansen VL, Soles GL, Jonason JH, Ackert-Bicknell CL, Wu CL, Giordano BD. Whole-genome RNA sequencing identifies distinct transcriptomic profiles in impingement cartilage between patients with femoroacetabular impingement and hip osteoarthritis. J Orthop Res 2022. [PMID: 36463522 DOI: 10.1002/jor.25485] [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: 09/30/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022]
Abstract
Femoroacetabular impingement (FAI) has a strong clinical association with the development of hip osteoarthritis (OA); however, the pathobiological mechanisms underlying the transition from focal impingement to global joint degeneration remain poorly understood. The purpose of this study is to use whole-genome RNA sequencing to identify and subsequently validate differentially expressed genes (DEGs) in femoral head articular cartilage samples from patients with FAI and hip OA secondary to FAI. Thirty-seven patients were included in the study with whole-genome RNA sequencing performed on 10 gender-matched patients in the FAI and OA cohorts and the remaining specimens were used for validation analyses. We identified a total of 3531 DEGs between the FAI and OA cohorts with multiple targets for genes implicated in canonical OA pathways. Quantitative reverse transcription-polymerase chain reaction validation confirmed increased expression of FGF18 and WNT16 in the FAI samples, while there was increased expression of MMP13 and ADAMTS4 in the OA samples. Expression levels of FGF18 and WNT16 were also higher in FAI samples with mild cartilage damage compared to FAI samples with severe cartilage damage or OA cartilage. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. We independently validated the results of the sequencing analysis and found increased expression of anabolic markers in patients with FAI and minimal histologic cartilage damage, suggesting that anabolic signaling may be increased in early FAI with a transition to catabolic and inflammatory gene expression as FAI progresses towards more severe hip OA. Clinical significance:Cam-type FAI has a strong clinical association with hip OA; however, the cellular pathophysiology of disease progression remains poorly understood. Several previous studies have demonstrated increased expression of inflammatory markers in FAI cartilage samples, suggesting the involvement of these inflammatory pathways in the disease progression. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. In addition to differences in inflammatory gene expression, we also identified differential expression in multiple pathways involved in hip OA progression.
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Affiliation(s)
- Benjamin D Kuhns
- Center for Regenerative and Personalized Medicine, Steadman-Philippon Research Institute, Vail, Colorado, USA
| | - John M Reuter
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Victoria L Hansen
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Gillian L Soles
- Department of Orthopedic Surgery, University of California Davis Health System, Sacramento, California, USA
| | - Jennifer H Jonason
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Cheryl L Ackert-Bicknell
- Colorado Program for Musculoskeletal Research, Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Chia-Lung Wu
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
| | - Brian D Giordano
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA
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15
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Criteria for the Operating Room Confirmation of the Diagnosis of Hip Instability: The Results of an International Expert Consensus Conference. Arthroscopy 2022; 38:2837-2849.e2. [PMID: 35378192 DOI: 10.1016/j.arthro.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/20/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish an international expert consensus on operating room findings that aid in the diagnosis of hip instability. METHODS An expert panel was convened to build an international consensus on the operating room diagnosis/confirmation of hip instability. Seventeen surgeons who have published or lectured nationally or internationally on the topic of hip instability were invited to participate. Fifteen panel members completed a pre-meeting questionnaire and agreed to participate in a 1-day consensus meeting on May 15, 2021. A review of the literature was performed to identify published intraoperative reference criteria used in the diagnosis of hip instability. Studies were included for discussion if they reported and intraoperative findings associated with hip instability. The evidence for and against each criteria was discussed, followed by an anonymous voting process. For consensus, defined a priori, items were included in the final criteria set if at least 80% of experts agreed. RESULTS A review of the published literature identified 11 operating room criteria that have been used to facilitate the diagnosis of hip instability. Six additional criteria were proposed by panel members as part of the pre-meeting questionnaire. Consensus agreement was achieved for 8 criteria, namely ease of hip distraction under anesthesia (100.0% agreement), inside-out pattern of chondral damage (100.0% agreement), location of chondral damage on the acetabulum (93.3% agreement), pattern of labral damage (93.3% agreement), anteroinferior labrum chondral damage (86.7% agreement), perifoveal cartilage damage (97.6% agreement), a capsular defect (86.7% agreement), and capsular status (80.0% agreement). Consensus was not achieved for 9 items, namely ligamentum teres tear (66.7% agreement), arthroscopic stability tests (46.7% agreement), persistent distraction after removal of traction (46.7% agreement), findings of examination under anesthesia (46.7% agreement), the femoral head divot sign (40.0% agreement), inferomedial synovitis (26.7% agreement), drive-through sign (26.7% agreement), iliopsoas irritation (26.7% agreement) and ligamentum teres-labral kissing lesion (13.3% agreement). All experts agreed on the final list of 8 criteria items reaching consensus. CONCLUSION This expert panel identified 8 criteria that can be used in the operating room to help confirm the diagnosis of hip instability. LEVEL OF EVIDENCE Level V expert opinion.
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16
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Lee JH, Houck DA, Gruizinga BA, Garabekyan T, Jesse MK, Kraeutler MJ, Mei-Dan O. Correlation of Delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) Value With Hip Arthroscopy Intraoperative Findings and Midterm Periacetabular Osteotomy Outcomes. Orthop J Sports Med 2022; 10:23259671221117606. [PMID: 36081408 PMCID: PMC9445473 DOI: 10.1177/23259671221117606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is an advanced imaging technique that is purported to quantify cartilage damage in acute and chronic joint disease and predict periacetabular osteotomy (PAO) outcomes. There is a paucity of literature relating dGEMRIC values to arthroscopic findings before PAO and postoperative outcomes after PAO. Purpose: To assess the utility and validity of dGEMRIC as a preoperative and prognostic assessment tool of cartilage status and integrity as it relates to intraoperative findings and midterm postoperative outcomes after PAO. Study Design: Case series; Level of evidence, 4. Methods: We analyzed a cohort of 58 patients (70 hips) with a median age of 30.1 years (range, 15-50) with hip dysplasia who underwent hip arthroscopy, followed by a PAO with preoperative dGEMRIC. The primary outcome measures were intraoperative assessment and correlation with cartilage damage (presence of cartilage flap, Outerbridge grade of the acetabulum and femoral head). Secondary outcome measures were postoperative patient-reported outcome (PRO) scores, including the International Hip Outcome Tool and Non-arthritic Hip Score. Correlation analyses were performed to determine the relationship between dGEMRIC values and (1) PROs and (2) intraoperative assessment of cartilage damage. Results: There were significant negative linear relationships between dGEMRIC values and the primary outcome measures: presence of a cartilage flap (coronal, P = .004; sagittal, P < .001), Outerbridge grade of acetabular articular cartilage lesion (coronal, P = .002; sagittal, P = .003), and Outerbridge grade of femoral head articular cartilage lesion (coronal, P = .001; sagittal, P < .001). Despite significant overall improvement in all patients, there was no significant correlation between preoperative dGEMRIC values and improvement in PROs from presurgery to latest postoperative follow-up (median, 2.2 years; range, 1.0-5.0 years). Conclusion: Although dGEMRIC values (sagittal and coronal) were significant predictors of the intraoperative presence of cartilage flaps and overall cartilage integrity, they were not associated with midterm outcomes after PAO.
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Affiliation(s)
- Jessica H. Lee
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Darby A. Houck
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Brandt A. Gruizinga
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | | | - Mary K. Jesse
- Department of Radiology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Matthew J. Kraeutler
- Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Omer Mei-Dan
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
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Cho YJ, Rhyu KH, Chun YS, Kim MS. Patterns of labral tears and cartilage injury are different in femoroacetabular impingement and dysplasia. J Hip Preserv Surg 2022; 9:151-157. [PMID: 35992029 PMCID: PMC9389910 DOI: 10.1093/jhps/hnac026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/09/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to assess injury patterns and risk factors of the acetabular labrum and associated cartilage in patients with femoroacetabular impingement (FAI) versus dysplasia. We retrospectively reviewed 137 patients diagnosed with labral tears and FAI or dysplasia (74 or 63 cases, respectively) through an arthroscopic procedure. Labral and concomitant cartilage injuries were evaluated. Demographics and radiological variables [lateral center-edge angle (LCEA), anterior center-edge angle, acetabular index (AI), acetabular version and alpha angle] were evaluated as risk factors for labral and cartilage injuries. Detachment of acetabular cartilage with intact labro-cartilaginous junction was the most common in dysplasia, whereas cartilage delamination from the labro-cartilaginous junction was more common in FAI (P < 0.001). A higher body mass index was significantly associated with delamination injury in FAI (odds ratio 1.226; 95% CI 1.043–1.441; P = 0.013). A significant correlation was evident between detachment injury and a larger AI in dysplasia (odds ratio 1.127; 95% CI 1.000–1.270; P = 0.049). In addition, symptom duration was positively correlated with the extent of labral tearing in FAI (P = 0.013), whereas the smaller LCEA was correlated with the larger extent of labral tearing in dysplasia (P = 0.044). FAI and dysplasia patients exhibited different labral and cartilage injury patterns. Increased body mass index was correlated with delamination injury in FAI, whereas an increased AI was associated with detachment injury in dysplasia. Greater tearing was associated with a longer symptom duration in FAI, and a decreased LCEA was a risk factor for the extent of tearing in dysplasia.
Level of evidence
Level III. Case–control study.
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Affiliation(s)
- Yoon-Je Cho
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital, 23 Kyung Hee Dae-ro, Dongdaemoon-ku, Seoul 02447, Republic of Korea
| | - Kee-Hyung Rhyu
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital, 23 Kyung Hee Dae-ro, Dongdaemoon-ku, Seoul 02447, Republic of Korea
| | - Young-Soo Chun
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-ku, Seoul 05278, Republic of Korea
| | - Myung-Seo Kim
- Department of Orthopaedic Surgery, College of Medicine , Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-ku, Seoul 05278, Republic of Korea
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Atzmon R, Safran MR. Arthroscopic Treatment of Mild/Borderline Hip Dysplasia with Concomitant Femoroacetabular Impingement-Literature Review. Curr Rev Musculoskelet Med 2022; 15:300-310. [PMID: 35708882 PMCID: PMC9276885 DOI: 10.1007/s12178-022-09765-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review This literature review aims to survey the current knowledge about the management FAI in the setting of borderline hip dysplasia. Recent Findings With better understanding, hip arthroscopy has recently been advocated for treating mild or borderline hip dysplasia (BDH) with concomitant femoroacetabular impingement (FAI) despite early studies that condemned its use. Recent outcome data have demonstrated that hip arthroscopy is a viable option in BDH, with and without FAI, and has been gaining wider acceptance. Hip arthroscopy can address the concomitant soft tissue and bony intra-articular pathologies and obviate the necessity for other surgeries. Moreover, hip arthroscopy may be used as an adjuvant treatment to other procedures such as a periacetabular osteotomy (PAO). Summary Hip arthroscopy for BDH is an evolving procedure with promising short- and mid-term outcomes. The combination of BDH and FAI is becoming recognized as a problem in its own right, requiring dedicated treatment.
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Affiliation(s)
- Ran Atzmon
- Department of Orthopaedics Surgery, Stanford University, 450 Broadway, Redwood City, CA 94063 USA
| | - Marc R Safran
- Department of Orthopaedics Surgery, Stanford University, 450 Broadway, Redwood City, CA 94063 USA
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Foissey C, Abid H, Martinot P, Cazor A, Thaunat M. Predictive radiological parameters of failure following surgical management of femoroacetabular impingement associated with borderline acetabular dysplasia. Orthop Traumatol Surg Res 2022; 109:103349. [PMID: 35688380 DOI: 10.1016/j.otsr.2022.103349] [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: 09/04/2021] [Revised: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The role of arthroscopic treatment of femoroacetabular impingement (FAI) in mild or borderline hip dysplasia (lateral center edge angle=18-25) is controversial. It is recommended to combine capsular plication with femoral neck osteoplasty and suture repair of the labrum. Few studies have investigated which radiological parameters are associated with failure of this procedure. HYPOTHESIS A larger number of radiological signs of mild or borderline hip dysplasia than radiological signs of FAI negatively influence the outcomes of arthroscopic treatment. METHODS This was a retrospective study done with data collected prospectively after a minimum of 2 years' follow-up in patients who underwent arthroscopic treatment of FAI due to cam impingement combined with mild to moderate hip dysplasia. Patients with hip osteoarthritis graded as ≥ Tönnis 2 were excluded. Functional outcome scores (mHHS and NAHS) were determined along with the need for reoperation. Three groups were defined based on the outcomes: success (mHHS ≥ Patient Acceptable Symptomatic State [PASS]); moderate improvement (improvement in mHHS + mHHS<PASS) and failure (worsening of the mHHS). Demographic data, radiographic parameters (LCEA, Tönnis angle, alpha angle, offset, FEAR index, Shenton's line, Cliff sign, anterior wall index [AWI], posterior wall index [PWI]) and intraoperative findings were compared between these three groups. The area under the curve (AUC) for the most relevant data identified during the univariate analysis were then modeled to define which factors were the best at predicting failed arthroscopic treatment a posteriori. RESULTS The study analyzed 39 patients. The mean mHHS was 76±15 [40-92]. The "success" group consisted of 21 patients (56%, 21/39), the "moderate improvement" group of 12 patients (31%, 12/39) and the failure group of 6 patients (13%, 6/39) (2 subsequently underwent total hip replacement, 4 underwent shelf acetabuloplasty). The FEAR index was significantly higher and the AWI and VCE were significantly lower in the "failure" group. The FEAR index was the best predictive factor; an index ≥ 4° detected 100% of failures with 96% specificity. The patients in the "moderate improvement" group were significantly older (37 years±8 [18-45]<p= 0.04) with a significantly higher offset (2mm±3 [-5-5]<p=0.004); an offset ≥ 2mm could detect 73% of them with a specificity of 72%. CONCLUSION A FEAR index ≥ 4° and offset ≥ 2mm is best able to detect patients at risk of failure and unsatisfactory results, respectively, in the mild clinical cam-type impingement in a population of FAI patients. LEVEL OF EVIDENCE IV, retrospective series.
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Affiliation(s)
- Constant Foissey
- Centre Orthopédique Santy, Lyon, France-Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.
| | - Hichem Abid
- Centre Orthopédique Santy, Lyon, France-Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Pierre Martinot
- Service d'orthopédie, Hôpital Salengro, CHU de Lille, place de Verdun, 59000 Lille, France
| | - Antoine Cazor
- Centre Orthopédique Santy, Lyon, France-Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Lyon, France-Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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20
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De Lucas Villarrubia JC, Méndez Alonso MÁ, Sanz Pérez MI, Trell Lesmes F, Panadero Tapia A. Acellular Matrix-Induced Chondrogenesis Technique Improves the Results of Chondral Lesions Associated With Femoroacetabular Impingement. Arthroscopy 2022; 38:1166-1178. [PMID: 34437943 DOI: 10.1016/j.arthro.2021.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The study's main objective was to evaluate, in the short-term, the result of the autologous acellular matrix-induced chondrogenesis (AMIC) technique in a selected group of patients with 2-4 cm2 full-thickness chondral lesions, undergoing hip arthroscopy for femoroacetabular impingement (FAI). METHODS A retrospective single-center Level IV case series of 25 patients (28 hips) who underwent an arthroscopic hip surgery with a liquid acellular collagen matrix. Inclusion criteria for implantation were FAI diagnosis (cam or pincer type), grade IV chondral lesions (Outerbridge size 2-4 cm2); Tönnis stage 0-II, minimum follow-up of 24 months, and 1 year (12-15 months) evaluation with very high field 3-T MRI arthrography. Exclusion criteria were Tönnis III, joint space <2 mm, center-edge angle <20°, and <24 months of follow-up. Clinical assessments involved symptoms duration until surgery, changes in physical and work activity and range of motion, modified Harris Hip Score, reporting percentages of patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID), pain with a VAS, and level of satisfaction. Radiological assessments: Tönnis stage, articular space, alpha and lateral center edge angle (Wiberg), and generated tissue characteristics at 1 year (based on the MOCART score), through 3-T MRI. RESULTS 25 patients (28 hips) treated; 19 men and 6 women (mean age: 40.5 years; range: 25-55). Two women underwent joint replacement surgery. Thus, 23 patients (26 hips) were analyzed. At 29 months following surgery (range: 24-48), a significant improvement was obtained in all parameters assessed, focusing on the characteristics of the generated tissue in the MRI (MOCART scores). 95% of the patients met the MCID (improvement >12 points in the modified Harris Hip Score), and 100% scored >74 points, achieving the PASS. Patients' satisfaction was 86.6% (SD 16.4). All patients who practiced sports resumed them. CONCLUSIONS The liquid AMIC is a safe technique that shows good clinical and radiological outcomes in a 2-year follow-up in patients with femoroacetabular impingement and grade IV acetabular 2-4 cm2 chondral defects. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | - Marta Isabel Sanz Pérez
- Traumatology and Orthopedic Surgery Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Fernando Trell Lesmes
- Traumatology and Orthopedic Surgery Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Alberto Panadero Tapia
- Department of Radiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
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21
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Ortiz-Declet V, Maldonado DR, Annin S, Yuen LC, Kyin C, Kopscik MR, Lall AC, Domb BG. Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity. Am J Sports Med 2022; 50:40-49. [PMID: 34825837 DOI: 10.1177/03635465211056086] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. PURPOSE To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. RESULTS A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively(P = .6288). The average body mass index was significantly higher in the male group (P < .0001). GLL was more common in women (38.6%) than men (13.6%) (P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) (P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° (P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). CONCLUSION In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.
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Affiliation(s)
- Victor Ortiz-Declet
- Kayal Orthopaedic Center, Westwood, New Jersey, USA.,American Hip Institute Research Foundation, Chicago, Illinois, USA
| | | | - Shawn Annin
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Leslie C Yuen
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Cynthia Kyin
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Michael R Kopscik
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,American Hip Institute, Chicago, Illinois, USA.,AMITA Health St Alexius Medical Center, Hoffman Estates, Illinois, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,American Hip Institute, Chicago, Illinois, USA.,AMITA Health St Alexius Medical Center, Hoffman Estates, Illinois, USA
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22
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Kucharik MP, Abraham PF, Nazal MR, Varady NH, Eberlin CT, Meek WM, Naessig SA, Martin SD. Treatment of Full-Thickness Acetabular Chondral Flaps During Hip Arthroscopy: Bone Marrow Aspirate Concentrate Versus Microfracture. Orthop J Sports Med 2021; 9:23259671211059170. [PMID: 34901293 PMCID: PMC8655470 DOI: 10.1177/23259671211059170] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The optimal treatment strategy for patients with full-thickness chondral flaps undergoing hip arthroscopy is controversial. Purpose: To compare functional outcomes of patients who underwent bone marrow aspirate concentrate (BMAC) application with those of patients who underwent microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by 1 surgeon between June 2014 and April 2020. The inclusion criteria for this study were age ≥18 years, preoperative radiographs of the pelvis, arthroscopic acetabular labral repair, exposed subchondral bone with overlying chondral flap seen at the time of hip arthroscopy, microfracture or BMAC to address this lesion, and completed patient-reported outcome measures (PROMs) (International Hip Outcome Tool–33 [iHOT-33], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports Subscale [HOS-Sport], modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) at enrollment and 12-month follow-up. Clinical outcomes were assessed using PROM scores. Results: A total of 81 hips with full-thickness chondral flaps were included in this study: 50 treated with BMAC and 31 treated with microfracture. There were no significant differences between groups in age, sex, body mass index, tear size, radiographic osteoarthritis, or radiographic femoroacetabular impingement. In the BMAC cohort, all PROM scores improved significantly from preoperatively to follow-up: 41.7 to 75.6 for iHOT-33, 67.6 to 91.0 for HOS-ADL, 41.5 to 72.3 for HOS-Sport, 59.4 to 87.2 for mHHS, and 6.2 to 2.2 for VAS pain (P < .001 for all). In the microfracture cohort, the score improvements were 48.0 to 65.1 for iHOT-33 (P = .001), 80.5 to 83.3 for HOS-ADL (P = .275), 59.2 to 62.4 for HOS-Sport (P = .568), 70.4 to 78.3 for mHHS (P = .028), and 4.9 to 3.6 for VAS pain (P = .036). Regarding clinically meaningful outcomes, 77.6% of the BMAC group and 50.0% of the microfracture group met the minimal clinically important difference for iHOT-33 at the 12-month follow-up (P = .013). Conclusion: Patients with full-thickness chondral flaps at the time of hip arthroscopy experienced greater improvements in functional outcome scores at the 12-month follow-up when treated with BMAC as opposed to microfracture.
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Affiliation(s)
- Michael P Kucharik
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts, USA
| | - Paul F Abraham
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - Mark R Nazal
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Christopher T Eberlin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts, USA
| | - Wendy M Meek
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts, USA
| | - Sara A Naessig
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts, USA
| | - Scott D Martin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, Massachusetts, USA
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23
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Kraeutler MJ, Mei-Dan O, Dávila Castrodad IM, Talishinskiy T, Milman E, Scillia AJ. A proposed algorithm for the treatment of core muscle injuries. J Hip Preserv Surg 2021; 8:337-342. [PMID: 35505804 PMCID: PMC9052413 DOI: 10.1093/jhps/hnab084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, USA
| | - Iciar M Dávila Castrodad
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Toghrul Talishinskiy
- Department of Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Edward Milman
- Department of Radiology, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
- New Jersey Orthopaedic Institute, 504 Valley Rd, Wayne, NJ 07470, USA
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24
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Shimodaira H, Hatakeyama A, Suzuki H, Takada S, Murata Y, Sakai A, Uchida S. The prevalence and risk factors of pubic bone marrow edema in femoroacetabular impingement and hip dysplasia. J Hip Preserv Surg 2021; 8:318-324. [PMID: 35505801 PMCID: PMC9052425 DOI: 10.1093/jhps/hnab081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/28/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Femoroacetabular impingement syndrome (FAIS) has been associated with osteitis pubis; however, it is still unclear whether hip dysplasia is associated with osteitis pubis. This study aimed to investigate (i) the incidence of pubic bone marrow edema (BME) on magnetic resonance imaging in symptomatic patients with FAIS, borderline developmental dysplasia of the hip (BDDH) and developmental dysplasia of the hip (DDH) undergoing hip arthroscopic surgery with labral preservation and (ii) the demographic and radiographic factors associated with pubic BME. A total of 259 symptomatic patients undergoing hip arthroscopic surgery between July 2016 and April 2019 were retrospectively reviewed and divided into three groups: FAIS (180 patients), BDDH (29 patients) and DDH (50 patients). Diffuse changes in the pubic bone adjacent to the pubic symphysis were labeled pubic BME, and the prevalence of their occurrence was examined. Multivariate logistic regression analysis was performed to identify factors involved in pubic BME, and odds ratios (ORs) for relevant factors were calculated. There was no significant difference in the prevalence of pubic BME among the three groups (20 [11.1%] of 180 FAIS patients, 6 [20.6%] of 29 BDDH patients and 7 [14%] of 50 DDH patients, P = 0.325). Multivariate logistic regression analysis showed that acetabular coverage was not associated with pubic BME, whereas younger age and greater alpha angle were still independent associated factors [age ≤26 years (OR, 65.7) and alpha angle ≥73.5° (OR, 4.79)]. Determining the possible association of osteitis pubis with cam impingement in dysplastic hips may provide insights toward a more accurate understanding of its pathophysiology.
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Affiliation(s)
- Hiroki Shimodaira
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Akihisa Hatakeyama
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Hitoshi Suzuki
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Shinichiro Takada
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Yoichi Murata
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Akinori Sakai
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
| | - Soshi Uchida
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu-ku, Kitakyushu, Fukuoka 808-0024, Japan
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25
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Zurmühle CA, Kuner V, McInnes J, Pfluger DH, Beck M. The crescent sign—a predictor of hip instability in magnetic resonance arthrography. J Hip Preserv Surg 2021; 8:164-171. [PMID: 35145713 PMCID: PMC8826156 DOI: 10.1093/jhps/hnab067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/12/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022] Open
Abstract
Currently, much is debated on the optimal treatment of borderline hips, being in the continuum between stable and unstable hips. The diagnosis of stability is often difficult but is a prerequisite for further treatment. Analysis includes a variety of radiographic parameters. We observed that unstable hips often had a crescent-like gadolinium collection in the postero-inferior joint space. We therefore questioned if the ‘crescent sign’ could be an indicator for hip instability? A retrospective comparative study was conducted including 56 hips in the instability group (treated with PAO) and 70 hips with femoroacetabular impingement (FAI) as control group. Based on standard radiographic parameters and magnetic resonance imaging (MRI), the association between hip instability and the ‘crescent sign’ was analyzed. For univariate group comparisons, the non-parametric Wilcoxon two sample test was used. Association between discrete variables was examined by means of chi-square tests. To examine predictive variables, logistic regression models were carried out. Most hips with a crescent sign belong to the instability group. A crescent sign has a sensitivity of 73.3% and specificity of 93% for instability. Based on our results, the crescent sign is a factor that is more prevalent in unstable hips. However, its absence does not exclude instability of the hip. If present, the specificity speaks strongly in favor for instability of the hip.
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Affiliation(s)
- Corinne A Zurmühle
- Department of Orthopaedic Surgery and Traumatology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Orthopaedic Surgery and Traumatology, HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Valerie Kuner
- Department of Orthopaedic Surgery and Traumatology, Luzerner Kantonsspital, Luzern, Switzerland
| | - James McInnes
- Department of Orthopaedic Surgery, ReBalanceMD, Victoria, British Columbia, Canada
| | | | - Martin Beck
- Department of Orthopaedic Surgery and Traumatology, Luzerner Kantonsspital, Luzern, Switzerland
- Orthopaedic Clinic Lucerne, Hirslanden St. Anna Hospital, Luzern, Switzerland
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26
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Abstract
Acetabular dysplasia represents a structural pathomorphology associated with hip pain, instability, and osteoarthritis. The wide spectrum of dysplasia anatomically refers to a 3-dimensional volumetric- and surface area-based insufficiency in coverage and is classified based on the magnitude and location of undercoverage. Borderline dysplasia has been variably defined and leads to management challenges. In symptomatic dysplasia, treatment addresses coverage with periacetabular osteotomy. Concomitant simultaneous or staged hip arthroscopy has significant advantages to address intra-articular pathology. In nonarthritic individuals, there is evidence PAO alters the natural history of dysplasia and decreases the risk of hip arthritis and total hip arthroplasty.
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Affiliation(s)
- Joshua D Harris
- The Houston Methodist Hip Preservation Program, Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX 77030, USA; Houston Methodist Academic Institute; Houston Methodist Orthopedics & Sports Medicine, Houston, TX, USA; Weill Cornell Medical College, New York, NY, USA; Texas A&M University, College Station, TX, USA.
| | - Brian D Lewis
- Department of Orthopedics, Duke University Medical Center, Box 3389, Durham, NC 27710, USA
| | - Kwan J Park
- The Houston Methodist Hip Preservation Program, Houston Methodist Orthopedics and Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX 77030, USA
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27
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Woodward RM, Vesey RM, Bacon CJ, White SG, Brick MJ, Blankenbaker DG. Microinstability of the hip: a systematic review of the imaging findings. Skeletal Radiol 2020; 49:1903-1919. [PMID: 32583134 DOI: 10.1007/s00256-020-03516-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To undertake a systematic review of the morphologic features associated with hip microinstability and determine whether there are suggestive or diagnostic imaging findings. METHODS Four electronic databases were searched up to September 2019 to identify original research reporting morphologic features in individuals with either a clinical diagnosis of hip microinstability (instability without overt subluxation/dislocation) or those with symptomatic laxity demonstrated on imaging (increased femoral head translation/distraction or capsular volume). Studies focussing on individuals with pre-existing hip conditions (including definite dysplasia (lateral centre edge angle < 20°), significant trauma, previous dislocation or surgery were excluded. Methodological quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS Twenty-two studies met inclusion criteria (clinical diagnosis of microinstability n = 15 and demonstration of laxity n = 7). Imaging information gathered from the studies includes radiographs (n = 14), MRI (n = 6), MR arthrography (n = 4), CT (n = 1) and intraoperative examination. Most studies exhibited design features associated with an overall high or unclear risk of bias. Some dysplastic features are associated with microinstability or laxity reference measures; however, microinstability is frequently diagnosed in those with a lateral centre edge angle > 25°. Other associated imaging findings reported include impingement morphology, anterior labral tearing, femoral head chondral injury, ligamentum teres tears and capsular attenuation. CONCLUSIONS The current literature does not provide strong evidence for imaging features diagnostic of microinstability. In the appropriate clinical context, dysplastic morphology, anterior labral tears and ligamentum teres tears may be suggestive of this condition although further research is needed to confirm this. PROSPERO REGISTRATION CRD42019122406.
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Affiliation(s)
- Rebecca M Woodward
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.,Auckland Radiology Group, Auckland, New Zealand
| | - Renuka M Vesey
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Catherine J Bacon
- Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.,Orthosports North Harbour Ltd., Millennium Institute of Sport & Health, Auckland, New Zealand
| | - Steve G White
- Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.,Department of Physiotherapy, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Matthew J Brick
- Orthosports North Harbour Ltd., Millennium Institute of Sport & Health, Auckland, New Zealand
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28
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Kraeutler MJ, Safran MR, Scillia AJ, Ayeni OR, Garabekyan T, Mei-Dan O. A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia. Am J Sports Med 2020; 48:2314-2323. [PMID: 31725329 DOI: 10.1177/0363546519881411] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO. PURPOSE To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD. STUDY DESIGN Narrative review. METHODS A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia. RESULTS The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented. CONCLUSION Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.
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Affiliation(s)
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, California, USA
| | - Anthony J Scillia
- St Joseph's University Medical Center, Paterson, New Jersey, USA.,New Jersey Orthopaedic Institute, Wayne, New Jersey, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Omer Mei-Dan
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
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