Open and Arthroscopic Surgical Treatment of Femoroacetabular Impingement

[Arthroscopic assisted mini-open arthrotomy for the treatment of the femoroacetabular impingement]

OBJECTIVES

Treatment of pathologies of the central and peripheral compartment of the hip using arthroscopic assisted mini-open arthrotomy via the Smith-Petersen approach.

INDICATIONS

Cam- and pincer-type femoroacetabular impingement (FAI), labral tear, loose bodies.

(RELATIVE) CONTRAINDICATIONS

Osteoarthritis of the hip with Tönnis classification grade ≥ 2.

SURGICAL TECHNIQUE

After mini-open approach to the hip joint via direct anterior muscular gap, the anterior capsule is split with protection of the labrum. Decompression allows the joint to be inspected using an arthroscope. Depending on the intra-articular findings, additional procedures can be performed (e.g., curettage of the cartilage, microfracturing, matrix-induced autologous chondrocyte implantation [MACI]). Cases with pincer-type FAI or labral tear can also be addressed. After partial release, the cam-type FAI can be resected using a surgical burr.

POSTOPERATIVE MANAGEMENT

Partial weightbearing for 2-6 weeks with 10-20 kg or half body weight using crutches depending on the intraoperative treatment.

RESULTS

Radiological analysis of the pre- and postoperative X‑rays (n = 69) prove that this surgical technique is suitable to address pathologies especially FAI syndromes. The α‑angle according to Nötzli could be reduced from a mean preoperative value of 72.8° to 49.4° postoperative. In combined cam-type and Pincer-type FAI syndrome (n = 16), the lateral center-edge angle could be reduced from a mean preoperative value of 50.2° to 37.6° postoperatively. The clinical follow-up (n = 29) revealed good midterm outcomes after arthroscopic assisted mini-open arthrotomy (modified Harris Hip Score [mHHS] 84.8 points after 4.9 years [range 4.2-5.7; ±0.43]).

Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review

BACKGROUND

A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up.

MATERIAL AND METHODS

This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included.

RESULTS

Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001).

CONCLUSION

Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.

Treatment of femoroacetabular impingement by arthroscopy versus anterior mini-open approach: Case-control study of a continuous series of 91 cases at a mean 4.6 years' follow-up

INTRODUCTION

Femoroacetabular impingement is a frequent cause of hip pain, and can be managed by conservative surgery. Many studies assessed postoperative course, but none compared operative techniques within a given population. We therefore conducted a retrospective case-control study comparing the minimally invasive anterior Hueter approach versus arthroscopy, assessing difference in 1) functional gain and 2) complications and 3) analyzing the impact of labral or cartilage lesions on functional scores.

HYPOTHESIS

Clinical results do not differ between the mini-open and arthroscopic approach.

MATERIAL AND METHOD

Between 2007 and 2018, 91 hips in 84 patients were treated for femoroacetabular impingement: 69/91 (75.8%) cam effect, 6/91 pincer effect (6.6%) and 16/91 mixed (17.6%). Fifty-five were treated by arthroscopy and 36 by the Hueter mini-open approach. There were 20 female and 71 male hips. Mean age at surgery was 32 years (range, 17-55 years). Potential predictive factors comprised Nötzli alpha angle, labral/cartilage lesion and type of surgery.

RESULTS

Mean follow-up was 4.6 years (range, 1-16 years), with no loss to follow-up. The arthroscopy and Hueter groups showed no differences in functional improvement on Oxford-12 score (gain, -6.7±5.9 versus -6.2±8.1 (p=0.73), Postel Merle d'Aubigné (PMA) score (gain, 1.3±1 versus 1.1±0.9; p=0.41), operative time (75 versus 67min; p=0.16), or alpha angle correction (-10.9±12.9 versus -9.8±7.1; p=0.22). Complications did not differ: 1/55 severe complications after arthroscopy (1 definitive femoral nerve palsy) versus 4/36 non-severe complications after Hueter (3 cases of dysesthesia in the lateral cutaneous nerve of the thigh, 1 rectus femoris enthesopathy) (p=0.15). Labral lesions (37/91) did not affect clinical outcome: gain, 1.2±1 versus 1.3±0.9 on PMA (p=0.514) and -7.3±6 versus -6±7.3 on Oxford-12 (p=0.366). Cartilage lesions (27/91) were associated with poorer outcome on PMA (gain, 1±1.1 versus 1.3±0.9; p=002) but not on Oxford-12 (gain, -6.1±7.3 versus -6.7±6.6; p=0.288).

CONCLUSION

Impingement correction by the minimally invasive anterior Hueter approach gave clinical results comparable to those of hip arthroscopy in terms of Oxford and PMA scores, alpha angle correction, operative time and complications. Cartilage lesions were associated with poorer clinical results.

LEVEL OF EVIDENCE

III; retrospective case-control study.

Comparison of the open versus the arthroscopic approach in the treatment of femoroacetabular shock

OBJECTIVE

To compare clinical and imaging results and complications between patients treated for femoroacetabular impingement who underwent either open surgery or an arthroscopic approach.

METHODS

This retrospective study included patients who underwent femoroacetabular impingement surgical treatment between June 2009 and January 2018. Patients treated with open surgery were compared with those treated with arthroscopy. Patients were radiographically and clinically assessed by alpha angle, degree of arthritis, Harris Hip Score, hospital stay and complications, as well as progression to total hip arthroplasty.

RESULTS

57 patients with FAI were included; 27 (45.6%) underwent open surgery and 31 (54.4%) underwent arthroscopy. Statistically significant differences were observed in hospital stay, where the patients who underwent arthroscopic surgery showed better outcomes. There were no other statistically significant differences, the results were similar in both groups.

CONCLUSIONS

Arthroscopy and open surgery treatments for femoroacetabular impingement provided comparable clinical and radiographic results. However, the latter surgery provides better results in surgery time, hospital stay and postoperative recovery.

Treatment for Post-Slipped Capital Femoral Epiphysis Deformity

In situ pinning of slipped capital femoral epiphysis (SCFE) is a safe and effective treatment modality, but often results in residual deformity leading to femoroacetabular impingement, which may limit patient activities and predispose to early onset arthritis. Enhanced understanding of the implications of femoroacetabular impingement and new surgical techniques have prompted interest in treating post-slipped capital femoral epiphysis deformity to both improve current symptoms and delay or prevent hip arthrosis.

Vertical Extension of the T-Capsulotomy Incision in Hip Arthroscopic Surgery Does Not Affect the Force Required for Hip Distraction: Effect of Capsulotomy Size, Type, and Subsequent Repair

BACKGROUND

Interportal and T-capsulotomies are popular techniques for exposing femoroacetabular impingement deformities. The difference between techniques with regard to the force required to distract the hip is currently unknown.

PURPOSE

To quantify how increasing interportal capsulotomy size, conversion to T-capsulotomy, and subsequent repair affect the force required to distract the hip.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric hip specimens were dissected and fixed in a materials testing system, such that pure axial distraction of the iliofemoral ligament could be achieved. The primary outcome measure was the load required to distract the hip to a distance of 6 mm at a rate of 0.5 mm/s. Each hip was tested in the intact state and then sequentially under varying capsulotomy conditions: 2-cm interportal, 4-cm interportal, half-T (4-cm interportal and 2-cm T-capsulotomy), and full-T (4-cm interportal and 4-cm T-capsulotomy). After serial testing, isolated T-limb repair and then subsequent complete repair were performed. Repaired specimens underwent distraction testing as previously stated to assess the ability to restore hip stability to the native profile. Distraction force as well as the relative distraction force (percentage normalized to the intact capsule) were compared between all capsulotomy and repair conditions.

RESULTS

Increasing interportal capsulotomy size from 2 to 4 cm resulted in significantly less force required to distract the hip ( P < .001). The largest relative decrease in force was seen between the intact state (274.6 ± 71.2 N; 100%) and 2-cm interportal (209.7 ± 73.2 N; 76.4% ± 15.6%; P = .0008). There was no significant mean difference in distraction force when 4-cm interportal (160.4 ± 79.8 N) was converted to half-T (140.7 ± 73.5 N; P = .270) and then full-T (112.0 ± 70.2 N; P = .204). When compared with the intact state, isolated T-limb repair partially restored stability (177.3 ± 86.3 N; 63.5% ± 19.8%; P < .0001), while complete repair exceeded native values (331.7 ± 103.7 N; 122.7% ± 15.1%; P = .0008).

CONCLUSION

The conversion of interportal capsulotomy to T-capsulotomy did not significantly affect the force required to distract the hip in a cadaveric model. However, larger interportal capsulotomies resulted in significant stepwise decreases in distraction force. When performing interportal or T-capsulotomy, the iliofemoral ligament strength is significantly decreased, but complete capsular repair demonstrated the ability to restore joint stability to the native, intact hip.

CLINICAL RELEVANCE

Increasing interportal capsulotomy size decreases the force required to distract the hip. In an effort to maximize visualization and minimize the magnitude of iliofemoral ligament fibers cut, many surgeons have moved from extended interportal capsulotomy to T-capsulotomy. Interportal and T-capsulotomies result in equivalent hip distraction, partial capsular repair marginally improves hip stability, and only complete repair has the ability to restore the hip to its native biomechanical profile.

Multicentre study on capsular closure versus non-capsular closure during hip arthroscopy in Danish patients with femoroacetabular impingement (FAI): protocol for a randomised controlled trial

INTRODUCTION

Hip arthroscopy has become a standard procedure in the treatment of hip joint pain not related to osteoarthritis or dysplasia in the young and active patient. There has been increasing focus on the contribution of the hip capsule to function and on stability following hip arthroscopy. It has been suggested that capsular closure after hip arthroscopy may prevent microinstability and macroinstability of the hip joint and reduce revision rate. However, it remains unknown whether capsular closure should be performed as a standard procedure when performing hip arthroscopies, especially in patients without additional risk factors for instability such as hypermobility or dysplasia of the hip. We hypothesised that capsular closure will lead to a superior outcome in hip arthroscopy for femoroacetabular impingement syndrome (FAIS) compared with non-capsular closure.

METHODS AND ANALYSIS

In this randomised controlled, multicentre trial, 200 patients scheduled for hip arthroscopy for FAIS will be cluster randomised into one of two groups (group I: hip arthroscopy without capsular closure, group II: hip arthroscopy combined with capsular closure). Inclusion criteria are: age between 18 years and 50 years and FAIS according to the Warwick agreement. Exclusion criteria are: previous hip surgery in either hip, previous conditions of Legg-Calvé-Perthes or slipped capital femoral epiphysis, malignant disease, recent hip or pelvic fractures, arthritis, Ehlers-Danlos or Marfan disease, recent (within 6 weeks) application of intra-articular corticosteroids, language problems of any kind, and radiological signs of osteoarthritis, acetabular dysplasia or acetabular retroversion. Surgery will be performed in Denmark at four centres by four surgeons, all performing an interportal capsulotomy and closure with at least two absorbable sutures. Patients in both groups, who are blinded for the intervention, will receive the same standardised rehabilitation programme. As primary outcome scores, HAGOS (sport) will be used with HAGOS (symptoms, pain, function in daily living, participation in physical activities and hip and/or groin-related quality of life), Hip Sports Activity Scale, short validated version of the International Hip Outcome Tool, EQ-5D, Visual Analogue Scale for pain, complications and reoperation rate as secondary outcome tools. Using HAGOS (sport) as primary outcome parameter the power analysis required a minimum of 84 individuals per group. Together with a clinical examination performed by the patient's surgeon 1 year after surgery, patient reported outcome measures will be completed preoperatively, as well as at 3 months, 1 year, 2 years and 5 years postoperatively. In addition, adverse effects will be recorded.

ETHICS AND DISSEMINATION

The study is approved by the Central Denmark Region Committee on Biomedical research ethics. The results of this study will be presented at national and international congresses and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03158454; Pre-results.

Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Prospective Analysis of the Relationship Between Surgeon Experience and Patient Outcomes

BACKGROUND

Hip arthroscopic surgery is a rapidly growing procedure, but it may be associated with a steep learning curve. Few studies have used patient-reported outcome (PRO) surveys to investigate the relationship between surgeon experience and patient outcomes after the arthroscopic treatment of femoroacetabular impingement (FAI).

HYPOTHESIS

Patients undergoing hip arthroscopic surgery for the treatment of FAI in the early stages of a surgeon's career will have significantly worse outcomes and longer procedure times compared with patients treated after the surgeon has gained experience.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients undergoing hip arthroscopic surgery for FAI and labral injuries were prospectively enrolled during a sports medicine fellowship-trained surgeon's first 15 months of practice. Patients were stratified into an early group, consisting of the first 30 consecutive cases performed by the surgeon, and a late group, consisting of the second 30 consecutive cases. Radiographic and physical examinations were performed preoperatively and postoperatively. PRO surveys, including the 12-item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), were administered preoperatively and at a minimum of 1 year postoperatively.

RESULTS

There was no difference between the early and late groups for patient age (37.2 ± 11.5 vs 35.3 ± 10.8 years, respectively; P = .489), body mass index (25.6 ± 4.0 vs 25.1 ± 4.5 kg/m2, respectively; P = .615), or sex (P = .465). There was a significantly increased procedure time (119.3 ± 21.0 vs 99.0 ± 28.6 minutes, respectively; P = .002) and traction time (72.7 ± 21.4 vs 59.0 ± 16.7 minutes, respectively; P = .007) in the early group compared with the late group. Mean postoperative PRO scores significantly improved in both groups compared with preoperative values for all surveys except for the SF-12 mental component summary. No differences were found in PRO score improvements or complication rates between the early and late groups.

CONCLUSION

The total procedure time and traction time decrease after a surgeon's first 30 hip arthroscopic surgery cases for FAI and labral tears, but patient outcomes can similarly improve regardless of surgeon experience in the early part of his or her career.

Surgical hip dislocation for removal of retained intra-articular bullets

INTRODUCTION

Surgical hip dislocation with trochanteric osteotomy was introduced for the treatment of femoroacetabular impingement and other intra-articular pathologies of the hip. We expanded the indications to include removal of retained bullets in the hip joint as an alternative to hip arthroscopy.

PATIENTS AND METHODS

We present a prospective case series of ten patients that were treated with a surgical hip dislocation for removal of retained bullets in the hip joint between January 2014 and October 2015 in a Level 1 trauma centre. The main outcome measurements were successful bullet removal, blood loss, surgical time and intraoperative complications.

RESULTS

There were 8 males and 2 females with a mean age of mean age 27.3 years (range 20-32). All patients had one whole retained bullet for removal (right side: 8; left side: 2). In all cases the bullet could be removed in its entirety. The average surgical time was 73min (range 55-125) and the average blood loss 255ml (range 200-420).

CONCLUSIONS

Surgical hip dislocation provides an unlimited view of the acetabulum and femoral head and neck and it therefore allows for easy removal of retained bullets. Osteocartilaginous lesions and concomitant fractures of the femoral head can be simultaneously evaluated and treated.