Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia

Primary Hip Arthroscopy in Patients With Acetabular Dysplasia: A Systematic Review of Published Clinical Outcomes at Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy in patients with borderline hip dysplasia has satisfactory outcomes at short-term follow-up; however, the data on midterm outcomes are inconsistent, and failure rates are high in some studies, limiting understanding of the role and utility of hip arthroscopy in this patient cohort.

PURPOSE

To provide an up-to-date, evidence-based review of the clinical outcomes of primary hip arthroscopy in patients with frank or borderline hip dysplasia at ≥5-year follow-up and report the failure rate and progression to total hip arthroplasty in this cohort.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A comprehensive literature search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated outcomes of primary hip arthroscopy in patients with lateral center-edge angle (LCEA) <25° at ≥5-year follow-up. Risk of bias assessment was performed using the methodological index for non-randomized studies scoring system. Level of evidence was determined using criteria from the Oxford Centre for Evidence-Based Medicine.

RESULTS

Nine studies were included in this review. Patients with LCEA <25° demonstrated satisfactory clinical outcomes, high patient satisfaction, and significant postoperative improvements in patient-reported outcomes (PROs) at follow-up ranging from a ≥5 to 10 years. Studies comparing patients with dysplasia to those without did not demonstrate significant differences in preoperative, postoperative, or delta PROs or in failure, reoperation, or revision rates. There was no overall significant correlation between outcomes and LCEA stratification.

CONCLUSION

Hip arthroscopy in carefully selected patients with LCEA <25° can be successful at mid- to long-term follow-up and may provide clinical outcomes and failure rates comparable with patients with normal LCEA, understanding that this is a singular, 2-dimensional radiographic measure that does not differentiate instability from impingement or combinations thereof, warranting future studies delineating these differences. These findings suggest that hip dysplasia may not be an absolute contraindication for isolated hip arthroscopy and may serve as a viable intervention with consideration of staged future periacetabular osteotomy (PAO). Importantly, this review does not suggest that hip arthroscopy alters the natural history of dysplasia; therefore, patients with dysplasia should be counseled on the potential utility of PAO by appropriate hip preservation specialists.

Staged Hip Arthroscopy with Labral Repair, Femoroplasty, and Capsular Plication Followed by Periacetabular Osteotomy for Hip Dysplasia Results in Improved Outcomes and 100% Survivorship at Minimum 2-Year Follow-Up

PURPOSE

To assess patient-reported outcomes (PROs), clinically significant outcomes (CSOs), and survivorship following staged hip arthroscopy with labral repair, femoroplasty, and capsular plication followed by periacetabular osteotomy (PAO) for the management of femoroacetabular impingement syndrome (FAIS) and hip dysplasia (lateral center edge angle ≤25°).

METHODS

A prospectively maintained database was queried to retrospectively identify patients who underwent staged primary hip arthroscopy and PAO between 1/2018-10/2021 and had a minimum 2-year follow-up. PROs collected included, Hip Outcome Score Activities of Daily Living/Sports Subscale (HOS-ADL/SS), international Hip Outcome Tool-12 item questionnaire (iHOT-12), and Visual Analog Scale for Pain (VAS Pain). CSO achievement for minimal clinical important difference (MCID) and patient acceptable symptom state (PASS) were determined through cohort specific thresholds. Rates of reoperation, including, revision hip arthroscopy and conversion to total hip arthroplasty (THA) were evaluated to determine short-term survivorship.

RESULTS

Thirty-nine hips met criteria for inclusion, of which 35 hips had minimum 2-year follow up (89.7% compliance). Mean age was 25±9.1 years and 91.7% of patients were female. Respective pre- and postoperative radiographic outcomes were: Alpha angle 59.8±5.9 to 39.7±2.6°, Tönnis angle 14.6±5.6° to -1.0±2.9°, lateral center-edge angle 16.6±5.5° to 36.6±4.6°, and anterior center-edge angle 15.6±9.1° to 36.1±3.8°, with statistically significant differences pre- to postoperatively for all (P<0.001). Patients demonstrated significant improvement in all PROs pre- to postoperatively (P ≤0.004). MCID and PASS achievement rates for any PRO were 93.9% and 78.8%, respectively. There were no revision hip surgeries or conversion to THA at a mean 2.7±1.0-year follow-up. Four patients (11.1%) underwent hardware removal. One patient (2.8%) experienced a postoperative infection treated with incision and drainage.

CONCLUSIONS

Staged hip arthroscopy and PAO for the management of hip dysplasia demonstrated improvement in PROs, high CSO achievement rates, and 100% survivorship at minimum 2-year follow-up.

Improved Functional Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy at Minimum 2-Year Follow-Up

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at minimum 2-year follow-up after combined hip arthroscopy and periacetabular osteotomy (PAO) performed in the setting of a single anesthetic event.

METHODS

Patients who underwent combined hip arthroscopy (M.J.P.) and PAO (J.M.M.) between January 2017 and June 2020 were identified. Preoperative and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport, modified Harris Hip Score (mHHS), Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form Survey Mental Component Scores (SF-12 MCS), and 12-Item Short Form Survey Physical Component Score were collected and compared in addition to revision rate, conversion to total hip arthroplasty (THA), and patient satisfaction.

RESULTS

Twenty-four of 29 patients (83%) eligible for the study were available for 2-year minimum follow-up with a median follow-up time of 2.5 years (range, 2.0-5.0). There were 19 females and 5 males with mean age of 31 ± 12 years. Mean preoperative lateral center edge angle was 20° ± 5° and alpha angle was 71° ± 11°. One patient underwent reoperation for removal of a symptomatic iliac crest screw at 11.7 months after operation. Two patients, a 33-year-old woman and a 37-year-old man, were converted to THA at 2.6 and 1.3 years, respectively, following the combined procedure. Both patients had a Tönnis grade of 1 on radiographs, as well as bipolar Outerbridge grade III/IV defects requiring microfracture of the acetabulum. For patients who did not convert to THA (n = 22), there was significant improvement from before to after surgery for all scores (P < .05) except SF-12 MCS. The minimal clinically significant difference and patient-acceptable symptom state rates for HOS-ADL, HOS-Sport, and mHHS were 72%, 82%, 86%, and 95%, 91%, and 95%, respectively. Median patient satisfaction was 10 (range, 4 to 10).

CONCLUSIONS

Single-stage combined hip arthroscopy with periacetabular osteotomy for patients with symptomatic hip dysplasia results in improvement in PROs and arthroplasty free survivorship of 92% at median 2.5 year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Functional outcome and athletic level after arthroscopic repair followed by triple pelvic osteotomy in patients with labral tears resulting from acetabular dysplasia

BACKGROUND

Patients with acetabular dysplasia are at a higher risk of developing symptomatic labral tears. Isolated treatments that address these pathologies are well established. Combined treatment with hip reorientation osteotomy using Bernese periacetabular osteotomy in addition to arthroscopic labral repair show good results. Studies that report the outcome in patients who received both arthroscopic labral repair and a triple pelvic osteotomy (TPO) are lacking. The aim of this study is to investigate the short to midterm functional outcome and activity level in these patients.

METHODS

This case series retrospectively included 8 patients (2 male, 6 female) with acetabular dysplasia (lateral center-edge angle [LCEA] ≤ 25°) and a labral tear on magnetic resonance arthrography (MRA). All patients underwent arthroscopic labral repair followed by TPO after an average period of 3 months (range 2-6). Average age at the time of surgery was 25 years (range 15-37). Patients were followed up and the following main parameters were assessed: LCEA, modified Harris hip score (mHSS), Tegner score, UCLA score, patient satisfaction on a scale of 1-4.

RESULTS

The mean follow-up was 19 months (range 15-25). The mean LCEA increased from 18° to 37° (p < 0.0001). The mHSS improved from a mean of 79 to 94 on final follow-up (p = 0.00123). The Tegner and UCLA scores had a median of 4 and 5, respectively. The mean LCEA increased from 18° to 37° (p < 0.0001). The mean patient satisfaction was 3.6.

CONCLUSION

Patients with evidence of a labral tear resulting from acetabular dysplasia benefit from arthroscopic repair followed by a TPO. The literature still lacks evidence that labral repair and reorientation osteotomy produce superior outcome compared to osteotomy alone. Treatment should consider clinical presentation in addition to radiological findings with emphasis on MRA.

Outcomes After Concomitant Hip Arthroscopy and Periacetabular Osteotomy: A Systematic Review

Background

Despite several studies' reports on outcomes of concomitant hip arthroscopy and periacetabular osteotomy (PAO), there is a paucity of aggregate data in the literature.

Purpose

To evaluate outcomes and survivorship after concomitant hip arthroscopy and PAO.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed, Cochrane, and Scopus databases were searched in April 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following keywords were used: (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (periacetabular osteotomy or rotational osteotomy) AND (outcomes OR follow-up). Of 270 articles initially identified, 10 studies were ultimately included. The following information was recorded for each study if available: publication information; study design; study period; patient characteristics; follow-up time; indications for hip arthroscopy; patient-reported outcomes (PROs); rates of secondary hip preservation surgeries; and rates of conversion to total hip arthroplasty (THA). Survivorship was defined as nonconversion to THA.

Results

The study periods for the 10 included articles ranged from 2001 to 2018. Three studies were level 3 evidence, and 7 studies were level 4 evidence. This review included 553 hips with a mean follow-up of 1 to 12.8 years. All 10 studies listed dysplasia as an indication for surgery. Of 9 studies that reported PRO scores, 7 reported significant improvement after surgery. Studies with a <5-year follow-up reported conversion to THA rates of 0% to 3.4% and overall secondary surgery rates of 0% to 10.3%. Similarly, studies with >5-year follow-up reported conversion to THA rates of 0% to 3% and overall secondary surgery rates of 0% to 10%.

Conclusion

Patients who underwent concomitant hip arthroscopy and PAO reported favorable outcomes, with 7 of the 9 studies that provided PRO scores indicating significant preoperative to postoperative improvement.

High-Level Athletes With Borderline Hip Dysplasia Achieve Favorable Outcomes and Return to Sport Rates Following Primary Hip Arthroscopy: Minimum 5-Year Outcomes Comparison to a Propensity-Matched Control Group

PURPOSE

(1) To report minimum 5-year patient-reported outcomes (PROs) and return to sport (RTS) rates in high-level athletes with borderline hip dysplasia (BHD) following primary hip arthroscopy for labral pathology and femoroacetabular impingement syndrome and (2) to compare results to a propensity-matched control group of athletes with normal acetabular coverage.

METHODS

Data were reviewed for surgeries performed between February 2009 and February 2016. Patients were eligible if they underwent primary hip arthroscopy in the setting of BHD (lateral center-edge angle [LCEA] 18-25°) and competed in professional, collegiate, or high school sports. Inclusion criteria were preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Non-Arthritis Hip Score, Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale for pain. Rates of achieving the minimal clinically importance difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold (MOIST) were recorded in addition to RTS. BHD athletes were matched by age at the time of surgery, sex, body mass index, Tönnis grade, follow-up time, sport type, and competition level to a control group of 58 athletes with normal acetabular coverage (LCEA 25°-40°) for comparison.

RESULTS

A total of 34 BHD athletes were included with a mean follow-up of 73.6 ± 10.7 months. BHD athletes showed significant improvements in all PROs, demonstrated high RTS rates (90.0%), and achieved PASS/MCID/MOIST for mHHS (MCID: 80.0%, PASS: 93.3%, MOIST: 80.0%) and HOS-SSS (MCID: 76.7%, PASS: 73.3%) at high rates. When compared to a propensity-matched group with normal acetabular coverage, BHD athletes demonstrated similar postoperative PROs, rates of achieving psychometric thresholds, and RTS rates (P > .05). Additionally, by the latest follow-up, no athlete in either group required conversion to total hip arthroplasty.

CONCLUSIONS

High-level athletes with BHD undergoing primary hip arthroscopy for labral pathology and femoroacetabular impingement syndrome may expect favorable midterm outcomes and high RTS rates. These results were comparable to a control group of athletes with normal coverage.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Athletes Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy Demonstrate Greater Than 80% Return-to-Sport Rate at 2-Year Minimum Follow-Up

PURPOSE

To report minimum 2-year follow-up patient-reported outcomes and return-to-sport (RTS) rates in athletes undergoing concomitant hip arthroscopy and periacetabular osteotomy (PAO) to treat acetabular dysplasia and intra-articular pathologies such as cam deformity and labral tears.

METHODS

We reviewed the data of consecutive athletes undergoing concomitant primary hip arthroscopy and PAO for acetabular dysplasia and cam deformity from November 2010 to December 2018. Patients were included in the study if they had the following preoperative and minimum 2-year postoperative scores: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The percentage of patients who achieved the minimal clinically important difference was recorded, in addition to RTS status.

RESULTS

A total of 29 athletes (29 hips) were included, with a mean follow-up time of 34.1 ± 7.9 months, mean age of 26.0 ± 8.7 years, and mean body mass index of 23.7 ± 3.4. These athletes showed significant improvements in the mHHS, NAHS, and HOS-SSS from baseline to latest follow-up (P < .001). The minimal clinically important difference was achieved at high rates for the mHHS (82.8%), NAHS (86.2%), and HOS-SSS (79.3%). Athletes who attempted to RTS successfully returned at a rate of 81.8%.

CONCLUSIONS

Athletes undergoing concomitant hip arthroscopy and PAO showed significant improvements in patient-reported outcomes at minimum 2-year follow-up and had an RTS rate of 81.8%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[Treatment of hip dysplasia in young adults]

Developmental dysplasia of the hip (DDH) is one of the most common disorders of hips in children. The deformity can remain asymptomatic into adolescence and adulthood; however, it is considered to be a form of prearthritis and is the main cause of premature osteoarthritis of the hip. The deformity affects the acetabulum but can also be accompanied by changes in the shape of the proximal femur. If conservative treatment for mild DDH is insufficient, or in cases of moderate to severe DDH, operative treatment should be carried out, for example by corrective osteotomy of the pelvis and/or the proximal femur and hip arthroscopy may be considered adjunctively in order to resolve the prearthritis and prevent premature osteoarthritis of the hip. This manuscript elucidates the deformity, the diagnostic measures required to make the diagnosis and the treatment options available for prevention of arthritis.

Hip arthroscopy after periacetabular osteotomy for acetabular dysplasia - incidence and clinical outcome

Background

The periacetabular osteotomy (PAO) is the treatment of choice for acetabular dysplasia and has demonstrated improvement in patient reported outcomes measures (PROMs) as well as acceptable long-term survival. However, acetabular dysplasia is also associated with intra-articular lesions that can negatively impact clinical outcome. This study aimed to analyse the incidence, operative findings, and outcomes of hip arthroscopy after PAO.

Methods

This is a single center retrospective study by querying our hip preservation prospectively collected database from 2006 to 2020. All patients having undergone hip arthroscopy after a PAO, with a minimal follow-up of one year, were identified. 202 PAOs were done with a mean age of 28.3 years (12.7 – 53.6) including 39 males and 167 females. Failure was defined as conversion to hip replacement. Demographics, surgical findings, reoperations, and PROMs (pre and post operatively at the last follow-up point only for hips not converted to hip replacement).

Results

Fifteen hips in 15 patients (7.4%) out of 202 PAOs underwent a hip arthroscopy at a mean time of 3.9 years (0.3–10.3) after PAO. There were 2 males, 13 females and the mean age was 29.8 years (18.5–45). 12 hips had no radiological osteoarthritis (Tönnis 0) and 3 hips had early osteoarthritis (Tönnis 1). At time of arthroscopy, all hips had a labral tear, 9 had a chondral damage ≥ Beck 4. Eight hips had labral debridement, 7 had labral repair, 2 had resection of adhesions and 4 underwent a femoral osteochondroplasty. Four hips (27%) were converted to a hip replacement at a mean time of 1.8 years(0.5–3.2) after hip arthroscopy. Patients converted to hip replacement were significantly older (p = 0.01), had a lower post-PAO LCEA (p = 0.01) and a higher post-PAO Tönnis angle (p = 0.02). There were no significant improvements in PROMs.

Conclusion

This study reports a hip arthroscopy reoperation rate after PAO of 7.4%. All three types of dysplasia (uncovered anteriorly, posteriorly, or globally) were present in this cohort. Twenty seven percent of patients were converted to hip replacement and PROMs were not significantly improved by hip arthroscopy. Therefore, this procedure should be approached with some caution.

A comparison of 6-month outcomes between periacetabular osteotomy with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement

PURPOSE

To compare early outcomes of periacetabular osteotomy (PAO) with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement (FAI) and chondrolabral pathology using patient-reported outcomes measurement information system (PROMIS).

MATERIALS AND METHODS

Consecutive patients scheduled for PAO with concomitant hip arthroscopy (PAO + HA) or isolated hip arthroscopy (HA) between the ages of 15 and 30 years old were prospectively included in the study. Based on power analysis, subjects were recruited until there were 22 subjects in the PAO + HA group. These subjects were then gender matched to the HA group. The PROMIS, with six subscales and two global health measures, were completed during preoperative and 6-month follow-up visits. One-way ANOVA was performed to compare intake information of age, symptom duration, body mass index, and Beighton scores as well as preoperative and 6-month postoperative PROMIS scores between the PAO + HA and HA.

RESULTS

22 consecutive subjects undergoing PAO + HA were all females (average age 20.0 years) and matched to 22 consecutive females (average age 22.6) in the HA group. ANOVA did not find a significant difference between the two groups when comparing intact information, with exception of age (p = 0.04). A significant difference was also not identified (p ≥ 0.05) between the two groups on preoperative or 6-month postoperative PROMIS scores. The largest difference in 6-month postoperative scores between the two groups was 4.4 points on physical function subscale.

CONCLUSION

Outcomes at 6 months were not significantly different when comparing PAO + HA to HA for FAI and chondrolabral pathology in females under 30 years of age. The more extensive surgery with a prolonged protective period associated with PAO do not seem to negatively impact outcomes at 6 months when compared to HA. These finding support the use of PAO + HA, particularly if the patient and/or surgeon were concerned about prolonged disability, metal health issues, and/or higher pain levels that might be associated with the PAO procedure.

Short-term Outcomes of Concomitant Femoral Derotation Osteotomy and Hip Arthroscopy

The goal of this study is to report the short-term outcomes of concomitant hip arthroscopy and femoral derotational osteotomy (FRO) to treat femoral malrotation and intra-articular pathology. Data were retrospectively reviewed for patients undergoing concomitant hip arthroscopy and FRO between March 2013 and January 2017. Patients were included if they had a minimum of 1 year of follow-up for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12) score, 12-item Short Form Health Survey Physical component and Mental component (SF-12 P and SF-12 M, respectively) scores, Veterans RAND 12-item Health Survey Physical and Mental (VR-12 P and VR-12 M, respectively) scores, visual analog scale (VAS) score for pain, and patient satisfaction ratings. Rates for meeting the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) were also recorded. Nine hips were included, and mean follow-up was 36.9 months. Mean preoperative femoral version was 33.0°. Patients underwent 1 or more concomitant procedures, such as labral treatment, capsular plication, acetabuloplasty, or femoroplasty. At latest follow-up, significant improvement was seen for mHHS, NAHS, HOS-SSS, and VAS score. Additionally, rates of meeting the PASS for mHHS, iHOT-12 score, and HOS-SSS were 100%, 88.9%, and 55.6%, respectively. Rates of achieving MCID for mHHS and HOS-SSS were 77.8% and 66.7%, respectively. One hip required revision derotational osteotomy to treat overcorrection, and 3 hips underwent secondary surgery for hardware removal. Concomitant hip arthroscopy and FRO may yield improved outcomes for patients with concurrent intra-articular pathology and excessive femoral anteversion. Considering that no major complications were diagnosed, this procedure is also relatively safe. [Orthopedics. 2021;44(6):e739-e746.].

What Mid-term Patient-reported Outcome Measure Scores, Reoperations, and Complications Are Associated with Concurrent Hip Arthroscopy and Periacetabular Osteotomy to Treat Dysplasia with Associated Intraarticular Abnormalities?

BACKGROUND

Periacetabular osteotomy (PAO) is a well-accepted treatment for acetabular dysplasia, but treatment success is not uniform. Concurrent hip arthroscopy has been proposed for select patients to address intraarticular abnormalities. The patient-reported outcomes, complications, and reoperations for concurrent arthroscopy and PAO to treat acetabular dysplasia remain unclear.

QUESTIONS/PURPOSES

(1) What are the functional outcome scores among select patients treated with PAO plus concurrent hip arthroscopy at mid-term follow-up? (2) What factors are associated with conversion to THA or persistent symptoms (modified Harris hip score ≤ 70 or WOMAC pain subscore ≥ 10)? (3) What proportion of patients underwent further hip preservation surgery at mid-term follow-up? (4) What are the complications associated with the procedure?

METHODS

Between November 2005 and December 2012, 78 patients (81 hips) who presented with symptomatic acetabular dysplasia-defined as a lateral center-edge angle less than 20° with hip pain for more than 3 months that interfered with daily function-had undergone unsuccessful nonsurgical treatment, had associated intraarticular abnormalities on MRI, and underwent combined hip arthroscopy and PAO. Eleven patients did not have minimum 4-year follow-up and were excluded, leaving 67 patients (70 hips) who met our inclusion criteria and had a mean follow-up duration of 6.5 ± 1.6 years. We retrospectively evaluated patient-reported outcomes at final follow-up using the University of California Los Angeles (UCLA) activity score, the modified Harris Hip Score (mHHS), and the WOMAC pain subscore. Conversion to THA or persistent symptoms were considered clinical endpoints. Repeat surgical procedures were drawn from a prospectively maintained database, and major complications were graded according to the validated Clavien-Dindo classification (Grade III or IV). Student t-tests, chi-square tests, and Fisher exact tests identified the association of patient factors, radiographic measures, and surgical details with clinical endpoints. For patients who underwent bilateral procedures, only the first hip was included in our analyses.

RESULTS

At final follow-up, the mean mHHS for all patients improved from a mean ± SD of 55 ± 19 points to 85 ± 17 points (p < 0.001), the UCLA activity score improved from 6.5 ± 2.7 points to 7.5 ± 2.2 points (p = 0.01), and the WOMAC pain score improved from 9.1 ± 4.3 points to 3.2 ± 3.9 points (p < 0.001). Three percent (2 of 67) of patients underwent subsequent THA, while 21% (15 of 70) of hips were persistently symptomatic, defined as mHHS less than or equal to 70 or WOMAC pain subscore greater than or equal to 10. Univariate analyses indicated that no patient demographics, preoperative or postoperative radiographic metrics, or intraoperative findings or procedures were associated with subsequent THA or symptomatic hips. Worse baseline mHHS and WOMAC pain scores were associated with subsequent THA or symptomatic hips. Seven percent (5 of 67) of patients underwent repeat hip preservation surgery for recurrent symptoms, and 4% (3 of 67) of patients had major complications (Clavien-Dindo Grade III or IV).

CONCLUSION

This study demonstrated that concurrent hip arthroscopy and PAO to treat symptomatic acetabular dysplasia (with intraarticular abnormalities) has good clinical outcomes at mid-term follow-up in many patients; however, persistent symptoms or conversion to THA affected almost a quarter of the sample. We noted an acceptable complication profile. Further study is needed to directly compare this approach to more traditional techniques that do not involve arthroscopy. We do not use isolated hip arthroscopy to treat symptomatic acetabular dysplasia.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Long-Term Results of Periacetabular Rotational Osteotomy Concomitantly With Arthroscopy in Adult Acetabular Dysplasia

BACKGROUND

Although the long-term results of periacetabular osteotomy in acetabular dysplasia have been well documented, there is paucity in reports on the long-term outcomes of periacetabular osteotomy with simultaneous hip arthroscopy. This study aimed to assess the cumulative 10-year outcomes of periacetabular rotational osteotomy with concomitant hip arthroscopy.

METHODS

Through an arthroscopic procedure, the status of the labrum was assessed, and torn labrum was debrided. Evaluations on survival from conversion to total hip arthroplasty and success in radiographic and clinical long-term results were completed in 39 hips (36 patients). Acetabular parameters (center-edge angle, Sharp angle, acetabular-head index, and head lateralization index), Tönnis grades on radiograph, Harris Hip Score, and range of motion of the hip were evaluated. Survivorship analyses were evaluated with the Kaplan-Meier method.

RESULTS

Thirty-eight hips (97.4%, 95% confidence interval 0.832-0.996) were preserved for 12.8 ± 1.7 years on average, and only 1 hip was converted to total hip arthroplasty at 7.8 years. All the acetabular parameters were improved (P < .001). Twenty-eight hips (71.8%) showed unchanged or improved Tönnis grades at the latest follow-up. The average Harris Hip Score was significantly better than the preoperative value (P < .001), and range of motion was not significantly different until the latest follow-up.

CONCLUSION

Sufficient acetabular reorientation, such as periacetabular rotational osteotomy, with concomitant arthroscopic debridement showed successful long-term outcomes for acetabular dysplasia in adults.

Periacetabular osteotomy with or without arthroscopic management in patients with hip dysplasia: study protocol for a multicenter randomized controlled trial

Background

Hip dysplasia is one of the most common causes of hip arthritis. Its incidence is estimated to be between 3.6 and 12.8% (Canadian Institute for Health Information, Hip and knee replacements in Canada, 2017–2018: Canadian joint replacement registry annual report, 2019; Jacobsen and Sonne-Holm, Rheumatology 44:211–8, 2004). The Periacetabular Osteotomy (PAO) has been used successfully for over 30 years (Gosvig et al., J Bone Joint Surg Am 92:1162–9, 2010), but some patients continue to exhibit symptoms post-surgery (Wyles et al., Clin Orthop Relat Res 475:336–50, 2017). A hip arthroscopy, performed using a small camera, allows surgeons to address torn cartilage inside the hip joint. Although both procedures are considered standard of care treatment options, it is unknown whether the addition of hip arthroscopy improves patient outcomes compared to a PAO alone. To delay or prevent future joint replacement surgeries, joint preservation surgery is recommended for eligible patients. While previous studies found an added cost to perform hip arthroscopies, the cost-effectiveness to Canadian Health care system is not known.

Methods

Patients randomized to the experimental group will undergo central compartment hip arthroscopy prior to completion of the PAO. Patients randomized to the control group will undergo isolated PAO. Patient-reported quality of life will be the primary outcome used for comparison between the two treatment groups as measured by The International Hip Outcome Tool (iHOT-33) (Saberi Hosnijeh et al., Arthritis Rheum 69:86–93, 2017). Secondary outcomes will include the four-square step test and sit-to-stand (validated in patients with pre-arthritic hip pain) and hip-specific symptoms and impairment using the HOOS; global health assessment will be compared using the PROMIS Global 10 Score; health status will be assessed using the EQ-5D-5L and EQ VAS questionnaires (Ganz et al., Clin Orthop Relat Res 466:264–72, 2008) pre- and post-operatively. In addition, operative time, hospital length of stay, adverse events, and health services utilization will be collected. A sub-group of patients (26 in each group) will receive a T1rho MRI before and after surgery to study changes in cartilage quality over time. A cost-utility analysis will be performed to compare costs and quality-adjusted life years (QALYs) associated with the intervention.

Discussion

We hypothesize that (1) concomitant hip arthroscopy at the time of PAO to address central compartment pathology will result in clinically important improvements in patient-reported outcome measures (PROMs) versus PAO alone, that (2) additional costs associated with hip arthroscopy will be offset by greater clinical improvements in this group, and that (3) combined hip arthroscopy and PAO will prove to be a cost-effective procedure.

Trial registration

ClinicalTrials.gov NCT03481010. Registered on 6 March 2020. Protocol version: version 3.

Is hip arthroscopy useful in the treatment of borderline dysplasia?: a case-control study

INTRODUCTION

Since arthroscopy remains a controversial treatment of hip dysplasia, our objective was to analyse its clinical and radiological results in a cohort of patients with dysplasia and compare them to controls with femoroacetabular impingement (FAI).

MATERIAL AND METHODS

We retrospectively analysed a series of patients who underwent hip arthroscopy for the treatment of labral pathology; 29 of them with borderline hip dysplasia and 197 with FAI, comparing reoperations and joint survival. The diagnosis of borderline dysplasia was made with a lateral centre-edge angle greater than 18° but less than 25°. The average follow-up was 43 months. We performed a multivariate regression analysis to evaluate the association of reoperations with different demographic, radiological and intraoperative variables.

RESULTS

Seven complications were registered in the FAI group (1 medically treated superficial wound infection, 3 pudendal nerve paraesthesias, 1 deep vein thrombosis and 2 heterotopic ossifications) and none in the dysplasia group. While 5 patients from the FAI group required a new surgery, none of the dysplasia group was re-operated (p=.38). After adjusting for confounders, reoperation showed a very strong association with the finding of osteochondral lesions during index surgery, with a coefficient of .12 (p<.001, 95%CI=.06-.17).

CONCLUSION

Hip arthroscopy was useful in the treatment of borderline dysplasia, without non-inferior survival compared to the FAI group. We suggest indicating it carefully in dysplasia cases, whenever the symptoms of femoroacetabular friction prevail over those of instability.

Outcomes of Hip Arthroscopy With Concomitant Periacetabular Osteotomy, Minimum 5-Year Follow-Up

PURPOSE

To report minimum 5-year follow-up results of concomitant hip arthroscopy followed by periacetabular osteotomy (PAO) to treat acetabular dysplasia and intra-articular pathology, such as femoroacetabular impingement syndrome and labral tears.

METHODS

Data were prospectively collected from October 2010 to December 2012. Patients were included in this study if they underwent concomitant hip arthroscopy and PAO and if they had preoperative scores documented for the following measures: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and pain on a visual analog scale (VAS). Patients who underwent reverse PAO to address acetabular retroversion were excluded. Follow-up was considered complete with these outcomes collected after surgery, as well as the abbreviated International Hip Outcome Tool and patient satisfaction on a 0-10 scale. Significance was set at P = .05.

RESULTS

Sixteen patients were eligible, all of whom had complete follow-up at a minimum of 5 years after surgery. There were 13 female subjects. The average age of the patients was 23.5 ± 6.8 years (range, 12.3-35.3 years), and the average body mass index was 24.3 ± 5.6 (range, 14.8-34.2). The mean lateral center-edge angle increased from 14.2° to 31.8° (P < .0001), and the anterior center-edge angle increased from 11.9° to 28.6° (P < .0001). The Tönnis angle of acetabular inclination decreased from 19.3° to 2.6° (P < .0001). The alpha angle decreased from 55.7° to 41.0° (P < .0001). All preoperative radiographs were Tönnis ≤1, and there was no progression of arthritis in radiographs taken at the latest clinical visit. All patient-reported outcomes scores demonstrated significant improvement from preoperative baseline to the minimum 5-year follow-up scores (mHHS, P < .001; NAHS, P < .001; HOS-SSS, P = .001). The VAS score decreased from a preoperative mean of 5.8 to 3.1 at the latest follow-up (P = .007). No conversion to total hip arthroplasty was reported.

CONCLUSIONS

Concomitant hip arthroscopy and PAO appears to be a safe and effective procedure with favorable mid-term outcomes that are durable compared to the short-term.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Hip Arthroscopy in Dysplastic Hip Population? A Must, a Maybe, or a No Go?

Treating symptomatic patients with dysplasia involves a controversy in therapy. The question is whether to obtain osseous correction with the help of pelvic reorientation osteotomy or to address intra-articular pathology with an arthroscopic approach. Neither isolated therapy nor the other method seems to be sufficient, but conducting both treatment options simultaneously has also not proved to be superior and carries the risk of additional complications. Different treatment options have been presented on this topic over the years and should be considered on a case-by-case basis. Pelvic reorientation osteotomy in patients with moderate to severe acetabular dysplasia remains uncontested, but it lacks the ability to obtain visualization of the central hip compartment. The isolated arthroscopic approach seems to be favorable for treatment of intra-articular pathologies in patients with mild to borderline dysplasia, whereas collateral arthroscopy in pelvic reorientation osteotomy may achieve better clinical outcomes in patients with more complex cases.

The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review

PURPOSE

To compare patient-reported outcomes, progression of osteoarthritis, and conversion to total hip replacement in a dysplastic population when hip arthroscopy was used as an isolated treatment or as an adjunct to pelvic reorientation osteotomy.

METHODS

An exhaustive search of the existing literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Embase) were searched for studies from January 1930 through January 2018 published in the English language concerning the use of hip arthroscopy with diagnostic and therapeutic intentions in individuals with acetabular dysplasia. We excluded studies that presented ambiguous data sets or in which clear identification of the strategy for arthroscopy was absent.

RESULTS

The selection criteria were defined, and 33 studies (1,368 hip arthroscopies) were included in the final analysis. Studies that met the inclusion criteria were classified within 5 different categories: (1) hip arthroscopy for screening, chondral mapping, and planning (9 studies, 729 hip arthroscopies); (2) isolated arthroscopic treatment (13 studies, 434 hip arthroscopies); (3) outcomes of hip arthroscopy after previous reorientation pelvic osteotomy for acetabular dysplasia (4 studies, 52 hip arthroscopies); (4) arthroscopy followed by unplanned hip-preservation surgery (3 studies, 48 hip arthroscopies); and (5) combined arthroscopy and periacetabular osteotomy (4 studies, 106 hip arthroscopies). A risk-of-bias analysis showed a moderate to high risk of bias (level 3 or 4) within and across the included studies.

CONCLUSIONS

Although hip arthroscopy can be used to accurately grade the severity of chondral injuries in the native hip and provide zone-specific geographic mapping that may aid in subsequent surgical planning, there is insufficient evidence to conclude that arthroscopic characterization alone has any bearing on the ultimate clinical outcomes after osseous structural correction. Isolated arthroscopic treatment is not recommended in the setting of moderate to severe dysplasia, given the inferior clinical outcomes and risk of iatrogenic instability reported for this group. However, there is limited evidence to suggest that the isolated use of hip arthroscopy may be considered in cases of borderline acetabular dysplasia when careful attention is paid to labral and capsular preservation. Limited evidence supports the conclusion that after prior reorientation pelvic osteotomy for acetabular dysplasia, hip arthroscopy leads to improved clinical and functional outcomes and should be considered in this setting. Furthermore, there is insufficient evidence to conclude that failed hip arthroscopy compromises or challenges the ultimate clinical outcomes in patients undergoing subsequent reorientation pelvic osteotomy. Last, there is insufficient evidence to conclude that the adjunctive use of hip arthroscopy with reorientation pelvic osteotomy produces superior clinical outcomes compared with pelvic osteotomy alone. In summary, arthroscopic techniques may provide a useful complement to the correction of acetabular dysplasia and should be thoughtfully considered on a case-by-case basis when designing a comprehensive treatment strategy in dysplastic populations.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Arthroscopic Capsular Plication in Patients With Labral Tears and Borderline Dysplasia of the Hip: Analysis of Risk Factors for Failure

BACKGROUND

Hip arthroscopy for the treatment of instability in the setting of borderline dysplasia is controversial. Capsular management in such cases is an important consideration, and plication has been described as a reliable technique, with good midterm outcomes reported when indications are appropriate.

HYPOTHESIS

Patients with borderline dysplasia who have a lower lateral center-edge angle (LCEA) and greater age will be at a higher risk of failure after arthroscopic capsular plication.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were retrospectively reviewed for all patients between 15 and 40 years of age who underwent hip arthroscopy from November 2008 to January 2015. Inclusion criteria were an LCEA between 18° and 25°, Tönnis grade ≤1, primary case with capsular plication, and minimum 2-year follow-up. Patients were excluded if they had any history of ipsilateral hip procedure or conditions such as Legg-Calve-Perthes disease, slipped capital femoral epiphysis, rheumatologic disease, and Tönnis grade ≥2. Age, sex, and body mass index data were retrieved for each patient. Patient-reported outcomes (PROs)-including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, and a visual analog scale (VAS) for pain (0-10)-were obtained preoperatively and at a minimum of 2 years postoperatively, in addition to the postoperative International Hip Outcome Tool-12. The "success" group consisted of all patients who achieved the patient acceptable symptomatic state of mHHS ≥74 and had no ipsilateral hip surgery subsequent to their index arthroscopy. The "failure" group was composed of patients who were below the patient acceptable symptomatic state at latest follow-up or required secondary arthroscopy or conversion to total hip arthroplasty. Patient satisfaction and minimal clinically important difference were also calculated. Mean age for the failure group was applied as a cutoff age for subanalysis, and relative risk for failure was determined.

RESULTS

Ninety patients (97 hips; 79.5%) met criteria for the success group, and 25 patients (25 hips) met criteria for the failure group. No significant differences in preoperative baseline scores or VAS were found. However, there did appear to be a trend that the failure group had lower mean preoperative scores for all PRO measures and a higher VAS score. The differences in preoperative mHHS and NAHS closely approached significance ( P = .053). Postoperative PRO, VAS, and patient satisfaction scores of the success group were significantly higher than the failure group. The failure group was significantly older than the success group (28.5 ± 7.8 vs 23.5 ± 7.5 years, P = .005). Patients >35 years old were 2.25 times more likely to fail according to relative risk (95% CI, 1.10-4.60; P = .0266). LCEA did not differ between the groups, and no other risk factors for failure were identified.

CONCLUSION

Stringent criteria for patient selection and meticulous repair or augmentation of the static stabilizers of the hip yielded favorable clinical outcomes in this study cohort with borderline dysplasia. Within this carefully selected group, the analysis revealed that increased age was the main risk factor for failure in the management of borderline hip dysplasia via isolated primary arthroscopic hip surgery with capsular plication.

Previous failed hip arthroscopy negatively impacts early patient-reported outcomes of the periacetabular osteotomy: an ANCHOR Matched Cohort Study

Surgical treatment of hip dysplasia by arthroscopic procedures remains controversial. The aim of this study was to compare outcomes of periacetabular osteotomy (PAO) after failed hip arthroscopy to a matched-control group without previous arthroscopy. Fifty-two patients who underwent PAO after failed hip arthroscopy were matched to two subjects without arthroscopy based on age, sex, BMI and radiographic severity. Pre- and post-operative patient self-reported outcomes and radiographic parameters were compared at minimum 1-year follow-up. Prior to PAO the failed hip arthroscopy group exhibited lower modified Harris hip scores (mHHS; 57 versus 62; P = 0.04), WOMAC (59.9 versus 66.3; P = 0.08), UCLA activity (5 versus 7; P = 0.001) and SF12 physical scores (34 versus 40; P = 0.001) compared with the non-arthroscopy group. At minimum 1-year follow-up, the failed hip arthroscopy group had lower mHHS (78 versus 87; P = 0.003); worse WOMAC (84.1 versus 90.8; P = 0.02) and SF-12 physical component (46 versus 50; P = 0.02) with similar UCLA (7 versus 8; P = 0.21) compared with the non-arthroscopy group. No differences were detected regarding radiographic parameters or in patient-reported outcomes from preoperative to follow up. PAO achieved the desired radiographic correction and significant improvement in pain and function after a failed previous hip arthroscopy, however, the patient-reported outcomes were inferior to those of PAO without previous failed arthroscopy.

Concomitant Arthroscopy With Labral Reconstruction and Periacetabular Osteotomy for Hip Dysplasia

In the setting of true hip dysplasia, the high prevalence of intra-articular pathology may lead to recurrent symptoms and failure after periacetabular osteotomy (PAO). Femoral neck osteochondroplasty, microfracture, removal of loose bodies, and labral repair are examples of procedures that are performed with concomitant arthroscopy. When damage to the labrum is too severe to repair, reconstruction instead of extensive debridement before PAO can be more effective in restoring the labral seal to maintain joint lubrication and chondral protection. This Technical Note describes a method for concomitant hip arthroscopy with circumferential labral reconstruction with allograft and PAO.

Atraumatic Hip Instability

Atraumatic hip instability is an increasingly recognized source of pain and hip dysfunction. It can result from numerous causes, including femoroacetabular impingement, prior trauma, injury to the capsuloligamentous structures, and idiopathic etiologies. Occult hip instability can be a challenging diagnosis that requires careful attention to, and interpretation of, history, physical examination, and radiographic imaging findings. Iatrogenic hip instability is a potential complication of both open and arthroscopic hip-preserving surgical procedures that can have catastrophic results. Atraumatic hip instability is a pathologic entity that can be successfully addressed with open and arthroscopic procedures.

Hip Arthroscopy for Femoroacetabular Impingement

Background

The first recorded attempt at arthroscopic visualization of the hip can be attributed to Dr. Michael Burman in 1931. Since then, hip arthroscopy has become widely used for the management of femoroacetabular impingement (FAI) because of its clear benefits, including a low complication rate and limited patient morbidity as compared with traditional open approaches.

Description

Arthroscopic management of FAI begins with arthroscopy of the central compartment, where the intra-articular damage is identified. Standard portal placement provides optimal access for surveying and accessing intra-articular injury. The pathological findings identified preoperatively and confirmed during diagnostic arthroscopy dictate the necessary arthroscopic procedures. Correction of acetabular overcoverage and repair of the labrum to the acetabular rim can correct pincer lesions. Femoral-sided cam lesions require removal of traction and application of hip flexion in order to perform a femoral osteoplasty to recreate a normal anatomic femoral head-neck offset. Finally, capsular management is performed as clinically indicated.

Alternatives

Appropriate management of FAI typically begins with nonoperative care consisting of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy¹. Intra-articular corticosteroid injections can also provide relief². Open procedures involving surgical hip dislocation can be utilized to address pathological conditions not accessible arthroscopically. Additionally, a "mini-open" procedure in which intra-articular disorders are treated arthroscopically and cam lesions are resected via a small anterior exposure can be employed^3,4.

Rationale

Hip arthroscopy offers a minimally invasive technique that can be effective for treating intra-articular hip disorders and is usually favored over open surgical dislocation. Hip arthroscopy has been shown to result in higher functional outcome scores than open procedures, with lower rates of complications⁵. Hip arthroscopy is playing an increasingly important role as an adjunct diagnostic and therapeutic tool in conjunction with open femoral and/or periacetabular osteotomy for complex hip deformities.

Modified Shelf Acetabuloplasty Endoscopic Procedure With Allograft for Developmental Hip Dysplasia Treatment

Hip dysplasia has been identified as one of the leading causes of osteoarthritis. However, hip arthroscopy alone, in the setting of hip dysplasia, remains controversial. In borderline hip dysplasia, with lateral center-edge angle (LCEA) between 18° and 25°, good outcomes have been reported with appropriate capsular and labral management. However, in severe hip dysplasia, with LCEA below 18°, there is an acetabular bony structural deficiency that must be addressed. Even with the potential benefit of hip arthroscopy in addressing intra-articular injuries related to the instability, it cannot be used for soft-tissue procedures. Periacetabular osteotomy remains the gold standard to address that matter; however, its invasive nature along with the long recovery time leaves some patients unwilling to undergo this procedure. New minimally invasive endoscopic procedures, derived from open techniques, describe acetabular autologous bone grafting as an alternative. Donor-side morbidity is always a concern when using autografts; we believe that the use of bone allograft will decrease this potential issue and make the procedure itself less invasive. This Technical Note will describe a type of endoscopic shelf acetabuloplasty using an allograft iliac bone graft.

Arthroscopy and arthrotomy to address intra-articular pathology during PAO for hip dysplasia demonstrates similar short-term outcomes

Periacetabular osteotomy (PAO) remains the gold standard procedure for joint preservation in symptomatic developmental dysplasia of the hip (DDH). Hip arthroscopy (HA) and open arthrotomy have been used to correct intra-articular pathology at the time of PAO, but there is limited data regarding differences in outcomes between these techniques when performed at the time of PAO. The aim of this study was to determine if short-term clinical outcomes differed between patients managed with HA versus arthrotomy to evaluate and treat intra-articular pathology at the time of PAO to discern if one technique is associated with better pain and functional results. Data were retrospectively reviewed from two surgeons at one institution managing DDH patients from September 2013 to December 2015. One surgeon treated patients with PAO and arthrotomy (N = 32), while the other performed PAO and HA (N = 39). There were 87% women, median age was 28 years and mean BMI was 25. Seventy-five percent of all patients received an intra-articular intervention. Patients completed 13 PROs at the pre-operative and 1-year post-operative clinical visits. Pre-operatively, there were no differences in any of the 13 PROs between patients treated with HA versus arthrotomy (P ≥ 0.076). Patients treated with PAO and arthrotomy experienced greater mean improvement in two out of the 13 PROs; the other 11 showed no differences. No treatment effect was observed for any of the 13 PROs using multivariable modelling that accounted for severity of dysplasia and degree of arthritis. Few differences were shown in short-term clinical outcomes between HA and arthrotomy at the time of PAO. This work highlights the need for a high quality randomized clinical trial to provide definitive guidance on whether hip preservation surgeons should address intra-articular pathology at the time of PAO for DDH and which technique best serves this purpose.

Operative findings and complications associated with adjunctive hip arthroscopy in 95 hips undergoing periacetabular osteotomy

PURPOSE

to report our initial experience with adjunctive hip arthroscopy and periacetabular osteotomy (PAO).

METHODS

Retrospective review of patients who underwent PAO and ipsilateral hip arthroscopy between 2003 and 2013. Indications for arthroscopy were mechanical symptoms and/or positive magnetic resonance imaging to suggest intra-articular pathology including chondrolabral lesions, ligamentum teres tears and hypertrophy, and synovitis. Preoperative Tönnis arthritis grades, age, sex, operative findings and treatment, complications, and, if available, hip survival were recorded.

RESULTS

Of 78 patients (95 hips) included, 64 (82%) were female and 14 (18%) male, average age was 30.6 (14-63) years. Tönnis grades were 0 in 40 hips (42%), 1 in 45 hips (47%), and 2 in 10 hips (11%). No Tönnis 3 hips were included. 84% of hips demonstrated labral pathology. 92% had chondromalacia, which was severe enough in 4 patients to warrant cancellation of PAO; all 4 have subsequently required total hip replacement at short-term follow-up. Labral debridement was performed in 73 hips and refixation in 7. 5 postoperative complications occurred - none major, including 1 fluid extravasation, 1 case of heterotopic ossification, and 3 transient neuropraxias.

CONCLUSIONS

Intraarticular pathology is highly prevalent in patients undergoing PAO with mechanical symptoms, and can be safely managed by adjunctive arthroscopy. Complications were minimal in our series and are comparable to reports of PAO without arthroscopy. Arthroscopy can treat pathology that is inaccessible during standalone PAO and permits avoidance of routine arthrotomy, surgical dislocation, rectus release, and futile PAO in cases with severe articular damage.

Incidence of deep venous thrombosis following periacetabular and derotational femoral osteotomy: a case for mechanical prophylaxis

There are currently no established guidelines for appropriate antithrombotic prophylaxis following periacetabular osteotomy (PAO) or derotational femoral osteotomy (DFO). The purpose of this study was to determine the incidence of clinical deep venous thrombosis (DVT) following PAO and/or DFO wherein a portable, mechanical device and low-dose aspirin were used postoperatively for DVT prophylaxis. Patients who had undergone staged hip arthroscopy and primary PAO and/or DFO were prospectively reviewed. Following PAO/DFO, patients were prophylactically treated for thromboembolic disease with a portable, mechanical compression device for 3 weeks and low-dose aspirin for 4 weeks. Patients were followed in clinic until 24 months postoperatively. During the study period, 145 hips (124 patients) underwent surgery (PAO: 109, DFO: 24, PAO + DFO: 12). Overall, the incidence of clinically apparent DVT was 0% in the study cohort. Average estimated blood loss during surgery was 601 mL and five cases required blood transfusions of 1 or 2 units. Ten patients were seen in the emergency room 10–20 days after surgery presenting with calf tenderness and DVT was ruled out in all cases with ultrasound. There were no postoperative bleeding or wound complications. A portable, mechanical compression device and low-dose aspirin effectively lessens the risk of DVT following staged hip arthroscopy and PAO/DFO without an increased risk of bleeding complications.

Hip Arthroscopic Surgery With Labral Preservation and Capsular Plication in Patients With Borderline Hip Dysplasia: Minimum 5-Year Patient-Reported Outcomes

BACKGROUND

The arthroscopic management of hip dysplasia has been controversial and has historically demonstrated mixed results. Studies on patients with borderline dysplasia, emphasizing the importance of the labrum and capsule as secondary stabilizers, have shown improvement in patient-reported outcomes (PROs). Purpose/Hypothesis: The purpose was to assess whether the results of hip arthroscopic surgery with labral preservation and concurrent capsular plication in patients with borderline hip dysplasia have lasting, positive outcomes at a minimum 5-year follow-up. It was hypothesized that with careful patient selection, outcomes would be favorable.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected and retrospectively reviewed for patients aged <40 years who underwent hip arthroscopic surgery for intra-articular abnormalities. Inclusion criteria included lateral center-edge angle (LCEA) between 18° and 25°, concurrent capsular plication and labral preservation, and minimum 5-year follow-up. Exclusion criteria were severe dysplasia (LCEA ≤18°), Tönnis grade ≥2, pre-existing childhood hip conditions, or prior hip surgery. PRO scores including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) and the visual analog scale (VAS) score for pain were collected preoperatively, at 3 months, and annually thereafter. Complications and revisions were recorded.

RESULTS

Twenty-five hips (24 patients) met the inclusion criteria. Twenty-one hips (19 patients, 84%) were available for follow-up. The mean age at surgery was 22.9 years. The mean preoperative LCEA and Tönnis angle were 21.7° (range, 18° to 24°) and 6.9° (range, -1° to 16°), respectively. The mean follow-up was 68.8 months. The mean mHHS increased from 70.3 to 85.9 ( P < .0001), the mean NAHS from 68.3 to 87.3 ( P < .0001), and the mean HOS-SSS from 52.1 to 70.8 ( P = .0002). The mean VAS score improved from 5.6 to 1.8 ( P < .0001). Four hips (19%) required secondary arthroscopic procedures, all of which resulted in improved PRO scores at latest follow-up. No patient required conversion to total hip arthroplasty.

CONCLUSION

While periacetabular osteotomy remains the standard for treating true acetabular dysplasia, hip arthroscopy may provide a safe and durable means of managing intra-articular abnormalities in the setting of borderline acetabular dysplasia at midterm follow-up. These procedures should be performed by surgeons with expertise in advanced arthroscopic techniques, using strict patient selection criteria, with emphasis on labral preservation and capsular plication.

Periacetabular osteotomy for developmental hip dysplasia with labral tears: is arthrotomy or arthroscopy required?

Patients with developmental dysplasia of the hip (DDH) who undergo periacetabular osteotomy (PAO) often have labral tears. The objective of this retrospective study was to compare PAO alone with PAO combined with arthrotomy or arthroscopy in DDH patients who had a full-thickness labral tear on magnetic resonance imaging. In total, 47 hips in the PAO group (PAO) were compared with 60 hips in the PAO with concomitant arthrotomy or arthroscopy (PAO-A) with respect to Hip Disability and Osteoarthritis Outcome Score (HOOS), modified Harris Hip Score (mHHS), Visual Analog Scale (VAS), clinical and radiographic outcomes at a median of 29 months. Reoperation rate and complications were compared between two groups of treatment. The PAO group was younger than the PAO-A group (25.2 ± 9.7 versus 31.3 ± 8.3). The PAO group was more likely to have worse dysplasia: lateral center edge angle (7.6°±9.63° versus 10.8°±6.85°) and anterior center edge angle (4°±12.92° versus 10.8°±9.92°). The PAO group had a higher preoperative mHHS (65.2 ± 15.3 versus 57.8 ± 14.8) and HOOS (66.3 ± 17.5 versus 55.8 ± 20.1). There were no significant differences in final functional outcome scores across treatment groups: mHHS (PAO; 86.8 ± 12.4 versus PAO-A, 83.3 ± 17.2), HOOS (86.5 ± 13.3 versus 82.5 ± 16.8) and VAS (2.5 ± 2.8 versus 2.5 ± 3.1). There was no difference in reoperation rate between two groups (6.4% versus 11.6%, P = 0.51). The overall complication rate was lower in the PAO group (26% versus 68%), but major complications were comparable. On the basis of our data, we were not able to conclusively demonstrate a clear benefit for the routine treatment of all labral tears; however, arthrotomy or arthroscopy may play a role in some conditions.

Does Hip Arthroscopy Have a Role in the Treatment of Developmental Hip Dysplasia?

BACKGROUND

Indications for hip arthroscopy in mildly dysplastic patients with a symptomatic hip remain controversial.

METHODS

This article provides a concise review of the available literature evaluating the role of hip arthroscopy in treating symptomatic dysplasia. Potential indications for hip arthroscopy in isolation are reviewed. Emerging evidence on the role of hip arthroscopy based on patient-specific pathomorphology is highlighted.

RESULTS

Hip arthroscopy in isolation may be helpful for select dysplastic patients with dynamic impingement or microinstability. Isolated arthroscopic treatment of intra-articular pathology resulting from static overload is unlikely to be successful in the long term and may be detrimental.

CONCLUSION

Arthroscopic procedures for individuals with mild dysplasia in the absence of frank instability may be effective; however, great caution should be exercised when approaching dysplastic patients with symptomatic hips.

The Birmingham Interlocking Pelvic Osteotomy for acetabular dysplasia: 13- to 21-year survival outcomes

AIMS

The aim of this study was to evaluate the long-term clinical and radiographic outcomes of the Birmingham Interlocking Pelvic Osteotomy (BIPO).

PATIENTS AND METHODS

In this prospective study, we report the mid- to long-term clinical outcomes of the first 100 consecutive patients (116 hips; 88 in women, 28 in men) undergoing BIPO, reflecting the surgeon's learning curve. Failure was defined as conversion to hip arthroplasty. The mean age at operation was 31 years (7 to 57). Three patients (three hips) were lost to follow-up.

RESULTS

Survivorship was 76% at ten years and 57% at a mean of 17 years. Younger patients (< 20 years) had the best survivorship (20 hips at risk; 90% at 17 years; 95% confidence interval 65 to 97). Post-operative complications occurred after 12 operations (10.4%) over the duration of the study. Increasing patient age and hip arthritis grade were primary determinants of surgical failure.

CONCLUSION

BIPO provides good to excellent survivorship in appropriately selected patients, with a relatively low rate of complications. Our results are comparable with other established methods of periacetabular osteotomy (PAO), such as the Bernese PAO, even during the surgeon's initial learning curve. Cite this article: Bone Joint J 2017;99-B:724-31.

Open treatment of dysplasia-other than PAO: does it have to be a PAO?

Hip dysplasia is a developmental disorder that results in anatomic abnormalities in which the acetabular coverage is insufficient. In the absence of severe degenerative changes, younger active patients with these symptomatic structural abnormalities are increasingly managed with joint-preserving operations. Historically there have been numerous reconstructive pelvic osteotomies. In recent years, the Bernese periacetabular osteotomy (PAO) has become the preferred osteotomy by many surgeons. Even so, as our understanding of the hip advances and new diagnostic and treatment techniques are developed, we sought to put a focus on the long-term results of augmental osteotomies and pelvic osteotomies other than the PAO, to see if any of these surgeries still have a place in the current algorithm of treatment for the dysplastic hip. As the longevity of the treatment is the focal point for joint preservation surgeries for the dysplastic hip, these authors have searched databases for articles in the English literature that reported results of long-term follow-up with a minimum of 11-year survivorship after surgical treatment of developmental dysplasia of the hip. Reconstruction osteotomies for the dysplastic hip are intended to restore normal hip anatomy and biomechanics, improve symptoms and prevent degenerative changes, in this manuscript each procedure is independently assessed on the ability to achieve these important characteristics.

Outcome after arthroscopic labral surgery in patients previously treated with periacetabular osteotomy: a follow-up study of 43 patients

To identify factors predicting failure after hip arthroscopy in patients with previous periacetabular osteotomy (PAO) defined as a conversion to total hip replacement (THR) and to evaluate the patient reported outcome scores. Of 55 hips treated with hip arthroscopy after PAO from Aug 2008 to 2012 at Aarhus University Hospital, 43 hips were included (median age: 36.1 yrs, range 16.3-56.9 yrs). Indications were unacceptable pain, a positive FABER and impingement test and signs of labral damage on MR-arthrography. Outcomes were evaluated with mHHS and HOS. Failure was defined as conversion to a THR. Nine hips were converted to a THR. Kaplan-Meier survival rate was 52.8% (95% CI, 10%-83.8%) at 6.5 years follow-up. Statistically significant predictors of failure: joint space width after PAO <3.0 mm and Tönnis grade of 2. Fourteen hips needed revision hip arthroscopy. Labral damage was present in 84% of the hips. In 42% of the hips cartilage lesions of Becks grade >3 were found. Mean mHHS and HOS were 65.7 and 68.8 respectively at follow-up. A NRS pain score of >3 in rest and during activity were present in respectively, 43% and 62% of the patients. Hip arthroscopy after PAO demonstrated limited clinical benefit with no decrease in pain levels and 21% of patients needing reoperation to THR. Radiographic signs of joint degeneration after PAO are predictors of faiElure. Further studies are needed to clarify what role hip arthroscopy should play in this patient group.

Evaluation of repair of the hip labrum under simulated full weight-bearing

INTRODUCTION

Repairs of labral tears are performed for unstable tears, hip instability, and after detachment concomitant to the treatment of femoroacetabular impingement (FAI), but limited data is known about the strength of repair. This study evaluated the effect of simulated axial weight-bearing on suture anchor based repair of the acetabular labrum.

METHODS

3 cadaveric pelvises underwent creation of a 1.5 cm anterior-superior labral tear in each hip. The tears were then repaired using 2 suture anchors per hip. Following repair, the hip joint underwent axial cyclic loading to 756 N, and were inspected for separation of the labrum from the acetabulum. The strength of the suture anchor repair was evaluated by testing load to failure, in-line with insertion.

RESULTS

Upon visual examination, all 6 repairs remained fully intact following loading with no visible gap formation or damage at the repair site. In all cases an arthroscopic probe could not be inserted under the edge of the repair. The mean failure force of the 12 suture anchors, in-line with insertion, was 154 N ± 44 N.

CONCLUSIONS

Acetabular labral suture anchor repairs may be able to immediately withstand the physiological loads of axial weight-bearing. Labral repair may be able to tolerate axial weight-bearing immediately after repair, preserving the strength and integrity of muscles and soft tissues.

The role of arthroscopy in the dysplastic hip-a systematic review of the intra-articular findings, and the outcomes utilizing hip arthroscopic surgery

Acetabular dysplasia is one of the most common sources of hip arthritis. With the recent innovation in hip arthroscopy, the question has been raised whether arthroscopy can be used to treat dysplastic hip conditions. The purposes of this systematic review are (i) describe the prevalence of intra-articular pathologies and (ii) report the outcomes of dysplastic hip treatment with hip arthroscopy as a sole treatment. Medical databases were searched for articles including arthroscopic findings and treatment of dysplastic hip with predetermined criteria. PubMed, Ovid database and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched up until 7 January 2015. Two reviewers independently assess the eligibility of retrieved studies using titles, abstracts and full-text articles. Thirteen studies were eligible to be included for the systematic review. Overall, labral tear was the most common pathology with a prevalence rate of 77.3%. All of the four studies describing arthroscopic treatment for only borderline dysplasia reported favorable outcome. With regard to more severely dysplastic hips, two out of three studies reported acceptable outcomes while one study reported negative results. This review indicates that intra-articular pathology is commonly observed in symptomatic dysplastic hips with a labral tear being the most common pathology. Arthroscopic treatment of borderline dysplasia could provide benefits whereas treatment of more dysplastic hips is controversial. Nevertheless, there is a lack of evidence for using arthroscopy alone in hips with a center edge angle <20°. Level IV, systematic review of Level IV studies.

The use of hip arthroscopy in the management of the pediatric hip

Arthroscopy of the pediatric hip began in 1977 with a publication by Gross. Interest was relatively slow to develop in the 1980s and 1990s. Coupled with the success of hip arthroscopy in the adult, interest heightened in applying the procedure to a variety of pediatric hip disorders, given that the alternative was an open surgical hip dislocation. The success of this initial group of pediatric hip arthroscopist's has further expanded the application of hip arthroscopy as the primary or adjunct procedure for the management of intra-articular problems of the pediatric hip.

Hip arthroscopy in the setting of hip dysplasia: A systematic review

Objective

Hip arthroscopy in the setting of hip dysplasia is controversial in the orthopaedic community, as the outcome literature has been variable and inconclusive. We hypothesise that outcomes of hip arthroscopy may be diminished in the setting of hip dysplasia, but outcomes may be acceptable in milder or borderline cases of hip dysplasia.

Methods

A systematic search was performed in duplicate for studies investigating the outcome of hip arthroscopy in the setting of hip dysplasia up to July 2015. Study parameters including sample size, definition of dysplasia, outcomes measures, and re-operation rates were obtained. Furthermore, the levels of evidence of studies were collected and quality assessment was performed.

Results

The systematic review identified 18 studies investigating hip arthroscopy in the setting of hip dysplasia, with 889 included patients. Criteria used by the studies to diagnose hip dysplasia and borderline hip dysplasia included centre edge angle in 72% of studies but the range of angles were quite variable. Although 89% of studies reported improved post-operative outcome scores in the setting of hip dysplasia, revision rates were considerable (14.1%), with 9.6% requiring conversion to total hip arthroplasty.

Conclusion

The available orthopaedic literature suggests that although improved outcomes are seen in hip arthroscopy in the setting of hip dysplasia, there is a high rate of re-operation and conversion to total hip arthroplasty. Furthermore, the criteria used to define hip dysplasia vary considerably among published studies.

Cite this article: M. Yeung, M. Kowalczuk, N. Simunovic, O. R. Ayeni. Hip arthroscopy in the setting of hip dysplasia: A systematic review. Bone Joint Res 2016;5:225–231. DOI: 10.1302/2046-3758.56.2000533.

Do labral tears influence poor outcomes after periacetabular osteotomy for acetabular dysplasia?

AIMS

Acetabular dysplasia is frequently associated with intra-articular pathology such as labral tears, but whether labral tears should be treated at the time of periacetabular osteotomy (PAO) remains controversial. The purpose of this study was to compare the clinical outcomes and radiographic corrections of PAO for acetabular dysplasia between patients with and without labral tears pre-operatively.

PATIENTS AND METHODS

We retrospectively reviewed 70 hips in 67 patients with acetabular dysplasia who underwent PAO. Of 47 hips (45 patients) with labral tears pre-operatively, 27 (25 patients) underwent PAO alone, and were classified as the labral tear alone (LT) group, and 20 (20 patients) underwent combined PAO and osteochondroplasty, and were classified as the labral tear osteochondroplasty (LTO) group. The non-labral tear (NLT) group included 23 hips in 22 patients.

RESULTS

There were no significant differences between groups for post-operative Harris hip scores, degree of progression of osteoarthritis or rate of reoperation. The pre-operative alpha angle was significantly larger in the LTO group compared with the other groups (p < 0.0001).

CONCLUSION

PAO provides equivalent short-term relief of pain and functional outcome in patients with or without labral tears. The rate of progression of osteoarthritis and reoperation was not significantly increased in patients with labral tears.

TAKE HOME MESSAGE

PAO provides equivalent short-term pain relief and functional outcomes in patients with acetabular dysplasia with and without labral tears. We did not find significantly increased risks of progression of osteoarthritis or re-operation in those with labral tears. Cite this article: Bone Joint J 2016;98-B:741-6.

Endoscopic hip osteotomies: less invasive approaches to peri-acetabular, proximal femoral and pubic symphyseal procedures

Beyond the recent expansion of extra-articular hip arthroscopy into the peri-trochanteric and subgluteal space, this instructional course lecture introduces three innovative procedures: endoscopy-assisted periacetabular osteotomy, closed derotational proximal femoral osteotomy and endoscopic pubic symphysectomy. Supportive rationale, evolving indications, key surgical techniques and emerging outcomes are presented for these innovative less invasive procedures.

Open and Arthroscopic Treatment of Adult Hip Dysplasia: A Systematic Review

PURPOSE

To compare patient-reported outcome (PRO) and rates of conversion to total hip arthroplasty (THA) after hip arthroscopy, Bernese periacetabular osteotomy (PAO), and a combined approach for the management of patients with different grades of hip dysplasia.

METHODS

We searched MEDLINE and PubMed databases for articles published since 2000 using the following terms: (((("hip dysplasia") or "dysplastic") and "arthroscopy")) or ((("hip dysplasia") or "dysplastic") and "osteotomy"). Two authors independently reviewed the literature. Inclusion criteria were English language, relevance to hip dysplasia, surgical outcomes, and sample size of 10 patients or more. We excluded articles that were reviews or techniques; articles that included overlapping populations, patients with a mean age less than 18 years, patients with other hip conditions, patients with genetic or neuromuscular causes of hip dysplasia, and patients with Tonnis grade 2 or greater arthritis; articles on femoral osteotomy, and articles on previous surgical intervention, except hip arthroscopy. Articles were analyzed for PRO scores and rates of conversion to THA.

RESULTS

Ten of 759 articles reviewed met the inclusion and exclusion criteria. Of 834 hips treated for dysplasia with a mean age of 31 years, 114 were treated with arthroscopy alone, 703 were treated with PAO alone, and 17 were treated with both procedures. Mean follow-up was 3.2 years, 6.5 years, and 5.6 years, respectively. Conversion rates to THA were 4.8%, 12.0%, and 17.7%, respectively. In studies reporting pre- and postoperative PRO scores, all but one reported improvement.

CONCLUSIONS

The management of hip dysplasia may entail hip arthroscopy, PAO, or a combined approach. Arthroscopy has resulted in improved outcomes in borderline dysplastic cases (lateral center edge angle between 18° and 25°). PAO has primarily been used in true dysplasia with continued success. There were too few combined procedures of arthroscopy with PAO to reach a reliable conclusion in this subgroup.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy

PURPOSE

To detail our early experience using concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of acetabular dysplasia.

METHODS

We prospectively collected and retrospectively reviewed the surgical and outcome data of 17 patients who underwent concomitant hip arthroscopy and PAO between October 2010 and July 2013. Preoperative and postoperative range of motion, outcome and pain scores, and radiographic data were collected. Intraoperative arthroscopic findings and postoperative complications were recorded.

RESULTS

The group consisted of 3 male and 14 female patients with a mean follow-up period of 2.4 years. Three patients had undergone previous surgery on the affected hip. Chondrolabral pathology was identified in all 17 patients. Twelve patients underwent labral repair, and five patients underwent partial labral debridement. No patient was converted to total hip arthroplasty or required revision surgery at short-term follow-up. All 4 patient-reported outcome scores showed statistically significant changes from baseline to latest follow-up (P < .001). An excellent outcome was obtained in 82% of patients (13 of 16). The lateral center-edge angle averaged 11° preoperatively and 29° postoperatively. The acetabular inclination averaged 18° preoperatively and 3° postoperatively. The anterior center-edge angle averaged 7° preoperatively and 27° postoperatively. At most recent radiographic follow-up, 1 patient had progression of arthritic changes but remained asymptomatic. No other patient showed any radiographic evidence of progression of arthritis. Complications included 3 superficial wound infections, 1 pulmonary embolism, and 1 temporary sciatic neurapraxia.

CONCLUSIONS

Our initial experience with concomitant hip arthroscopy and PAO has been favorable. We noted that all our patients have evidence of chondrolabral damage at the time of PAO when the joint is distracted and evaluated. All patients in this series had intra-articular pathology treated arthroscopically and showed satisfactory mean clinical improvement. Hip arthroscopy with PAO did not appear to introduce complications beyond the PAO alone.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopy of the hip for patients with mild to moderate developmental dysplasia of the hip and femoroacetabular impingement

The purpose of this study was to determine patient-reported outcomes of patients with mild to moderate developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) undergoing arthroscopy of the hip in the treatment of chondrolabral pathology. A total of 28 patients with a centre-edge angle between 15° and 19° were identified from an institutional database. Their mean age was 34 years (18 to 53), with 12 female and 16 male patients. All underwent labral treatment and concomitant correction of FAI. There were nine reoperations, with two patients requiring revision arthroscopy, two requiring periacetabular osteotomy and five needing total hip arthroplasty.

Patients who required further major surgery were more likely to be older, male, and to have more severe DDH with a larger alpha angle and decreased joint space.

At a mean follow-up of 42 months (24 to 89), the mean modified Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p < 0.001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to 43; p < 0.001). Median patient satisfaction was 9.0/10 (1 to 10). Patients reported excellent improvement in function following arthroscopy of the hip.

This study shows that with proper patient selection, arthroscopy of the hip can be successful in the young patient with mild to moderate DDH and FAI.

Cite this article: Bone Joint J 2015;97-B:1316–21.

Risk factors for the need of hip arthroscopy following periacetabular osteotomy

Despite the frequency of labral tears in symptomatic developmental dysplasia of the hip, no consensus exists regarding the treatment of coexisting dysplasia of the hip and tearing of the acetabular labrum. The purpose of this prospective, MR arthrography (MRA) based 2-year follow-up study was to identify risk factors predicting the need for a hip arthroscopy (HA) after periacetabular osteotomy (PAO). Ninety-nine patients (104 hips) scheduled for PAO were evaluated preoperatively and at 2-year follow-up. MRA was performed in all patients prior to PAO. At follow-up, patients were divided into a non-arthroscopy and arthroscopy group. The two groups were compared clinical and radiological, and risk factors for HA after PAO were calculated. Patient reported outcome measures (WOMAC, Oxford Hip and SF36) were filled out before PAO and at follow-up. Ninety-five hips (91.3%) were evaluated. Twenty-six hips (27%) required an arthroscopy within 2 years of the PAO. Risk factors were preoperative borderline dysplasia, acetabular retroversion and complete labral detachment. Labral tearing, degeneration or hypertrophy did not negatively affect the outcome of PAO. Patients not requiring an arthroscopy had a statistically significant better outcome measured by patients reported outcome measures. After PAO, 27% of the hips needed intra-articular assessment. Conventional radiographs and MRA analysis can be used to identify predictors for patients requiring HA after PAO. At 2-year follow-up, the clinical outcome improved in all patients. However, those patients who had no need of a HA after their PAO had superior results.

Surgical treatment for young adult hip dysplasia: joint-preserving options

Developmental dysplasia of the hip (DDH) is a spectrum of disorders that results in anatomic abnormalities leading to increased contact stress in the joint and, eventually, secondary osteoarthritis. However, many patients with DDH become symptomatic before the severe degenerative changes of the hip because of abnormal hip biomechanics, mild hip instability, impingement, or associated intra-articular pathology. Early diagnosis and appropriate treatment for DDH are of the utmost importance. With the modification of techniques like pelvic osteotomy and capsular arthroplasty, and the introduction of intracapsular procedures such as arthroscopy and femoral head-neck junction osteochondroplasty, many young patients with symptomatic hip dysplasia may benefit from joint preservation procedures. We review the current development of these concepts and the associated surgical techniques.

Hip arthroscopy in patients with recurrent pain following Bernese periacetabular osteotomy for acetabular dysplasia: operative findings and clinical outcomes

To report the operative findings and outcomes of hip arthroscopy for recurrent pain following periacetabular osteotomy (PAO) for acetabular dysplasia. A departmental database was used to identify patients who underwent hip arthroscopy following PAO between 2000 and 2009. Demographic data, arthroscopic findings, functional outcome scores and patient satisfaction were analysed. Of 556 PAO patients, 17 hips in 16 patients (3.1%) underwent post-PAO hip arthroscopy. Mean age at PAO was 23.8 years, and mean age at arthroscopy was 27.0 years. Common hip arthroscopy findings included labral tears (13 hips, 81.3%), significant (≥grade 2) chondral changes (12 hips, 75%), cam impingement (7 hips, 43.8%) and pincer impingement (6 hips, 37.5%). At mean follow-up 2.8 years after arthroscopy, additional procedures had been performed in six hips (37.5%), including total hip arthroplasty in one hip. Post-PAO arthroscopy questionnaire revealed 85.7% of patients with improved hip pain, 57.1% improved hip stiffness and 57.1% improved hip function. There was no significant difference in functional outcome measures. Common post-PAO hip arthroscopy findings include labral tears, chondral changes and femoroacetabular impingement. Many patients reported subjective hip improvement from post-PAO arthroscopy, but hip outcome scores were unchanged and one-third of patients had further surgery.

Current possibilities for hip arthroplasty

Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra-articular conditions and endoscopy for extra-articular procedures can be used in diagnosing or treating different conditions. This updated article has the objective of presenting the various current possibilities for hip arthroscopy.