Hip Arthroscopy of a Painful Hip with Borderline Dysplasia

The Everted Acetabular Labrum: Outcomes of Surgical Management

BACKGROUND

An everted acetabular labrum (EL) is a pathologic variant in which the labrum is flipped to the capsular side of the acetabular rim. An iatrogenic EL is a known complication of a poorly executed labral repair, and a recent study described the native acetabular EL.

PURPOSE

To analyze surgical outcomes after advancement or reconstruction of an EL in a native hip.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a multicenter retrospective review of prospectively collected data on primary hip arthroscopic surgeries performed between 2013 and 2023. An EL was identified arthroscopically as a labrum-femoral head gap while off traction in the native hip. All patients with EL who were analyzed in this study underwent arthroscopic labral repair and advancement or labral augmentation or reconstruction. Patients with hip dysplasia also underwent periacetabular osteotomy with or without a derotational femoral osteotomy. Patient-reported outcomes (PROs) were assessed using the 12-item International Hip Outcome Tool (iHOT-12) and the Nonarthritic Hip Score. PROs were obtained preoperatively and up to 24 months after surgery. PROs were compared with those of a case-matched control cohort in a 1:2 ratio. Only patients with PROs available at ≥1 year postoperatively were included in the outcome analysis.

RESULTS

A total of 111 patients (129 hips) with EL during the study period were identified, with PROs available in 96 hips. The mean age of patients with EL was 30.5 years, and women made up 87% of the cohort. Of the 129 hips with an EL, an isolated diagnosis of an EL was present in 11.6% of hips. Deficient acetabular coverage (lateral center-edge angle <25°) was seen in 40.6% of EL hips. No difference was seen in iHOT-12 scores between EL and control groups at 12- or 24-month follow-up (P = .18 and .94, respectively). Patients with EL reported a significant improvement of PROs at latest follow-up (P < .001 for iHOT-12 and Nonarthritic Hip Score).

CONCLUSION

Surgical management of a native EL with restoration of the labral seal on the femoral head and correction of concomitant pathologies resulted in significant clinical improvement, with postoperative outcome scores comparable to those of patients without an EL. These findings provide evidence supporting surgical intervention for a native EL.

Patient-Reported Outcomes and Factors Impacting Success of the Periacetabular Osteotomy

Hip dysplasia is a condition affecting both infants and adults, characterized by a shallow acetabulum that does not sufficiently cover the head of the femur. This leads to instability of the hip and elevated levels of mechanical stress around the acetabular rim. A popular procedure for the correction of hip dysplasia is the periacetabular osteotomy (PAO), in which fluoroscopically guided osteotomies around the pelvis are made to allow for repositioning of the acetabulum to fit properly on the femoral head. This systematic review aims to analyze patient factors that impact outcomes, as well as patient-reported outcomes such as the Harris Hip Score (HHS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The patients in this review did not undergo any prior intervention for acetabular hip dysplasia, allowing for an unbiased reporting of outcomes from all included studies. Of studies reporting HHS, the mean preoperative HHS was 68.92 and the mean postoperative HHS was 89.1. Of the study that reported mHHS, the mean preoperative mHHS was 70, and the mean postoperative mHHS was 91. Of the studies reporting WOMAC, the mean preoperative WOMAC was 66, and the mean postoperative WOMAC was 63. Key findings of this review are that of the seven included studies, six achieved a minimally important clinical difference (MCID) based on patient-reported outcomes, and factors impacting outcome are preoperative Tönnis osteoarthritis (OA) grade, pre and postoperative lateral-center edge angle (LCEA), preoperative hip joint congruency, postoperative Tönnis angle, and age. In patients with no prior intervention for hip dysplasia, the PAO is a successful procedure with significant improvement in postoperative patient-reported outcomes. Despite the reported success of the PAO, proper patient selection is vital to avoid early conversions to total hip arthroplasty (THA) and prolonged pain. However, further investigation is prompted regarding the long-term survivorship of the PAO in patients with no prior intervention for hip dysplasia.

Hip arthroscopy and T-shaped capsular plication for the treatment of borderline dysplasia: a minimum 2-year follow-up

PURPOSE

The aim of the study was to evaluate the clinical outcomes of patients treated arthroscopically for symptomatic borderline dysplasia of the hip (BHD) with a T-shaped capsular plication, with a minimum follow-up of 24 months.

METHODS

Twenty-seven patients who had undergone hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All patients were clinically evaluated prior to surgery (T₀) and at two consecutive follow-ups (T₁: 12 ± 1.2 months; T₂: 52.0 ± 23.2 months) using the visual analogue scale (VAS) pain score, the Hip Outcome Score in activities of daily living (HOS-ADL) and sport-specific subscale (HOS-SSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-12 in its physical (PCS) and mental component scores (MCS). We also evaluated the presence of correlations and analysed the possible differences between subgroups.

RESULTS

We found a significant difference for HOS-ADL, HOS-SSS, VAS and WOMAC with the Friedman test for repeated measures through time points (p < 0.0001), but not for MCS. All clinical scores reported a significant improvement compared to the previous time point (p < 0.05), with the exception of HOS-SSS, for which p = 0.2570 between T₁ and T₂. The body mass index was positively correlated with preoperative VAS (R = 0.42857; p = 0.0257) and negatively correlated with PCS at T₀ (R = - 0.40999; p = 0.0337) and with PCS (R = - 0.40491; p = 0.0362), MCS (R = - 0.45939; p = 0.0159) and WOMAC (R = - 0.40573; p = 0.0216) at T₂. No complications were reported in our cohort.

CONCLUSIONS

The results of the current study confirm that patients with intra-articular hip pathology and concomitant BHD (LCEA 20°-25°) can benefit from arthroscopic treatment and that T-shaped capsular plication is one of the available options. Orthopaedic surgeons specialising in hip arthroscopy should consider arthroscopy for the treatment of symptomatic BHD for stabilising and strengthening the joint. Future studies should focus on finding out which type of patients can benefit most from this procedure.

LEVEL OF EVIDENCE IV

Prospective Case Series.

Comparison Between Hip Arthroscopic Surgery and Periacetabular Osteotomy for the Treatment of Patients With Borderline Developmental Dysplasia of the Hip: A Systematic Review

Background:

The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH.

Purpose:

To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH.

Results:

A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures.

Conclusion:

There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.

Successful return to sport in patients with symptomatic borderline dysplasia following hip arthroscopy and T-shaped capsular plication

PURPOSE

This study aims to evaluate the return to sport and correlations of patients with symptomatic borderline hip dysplasia (BHD) after hip arthroscopy and T-shaped capsular plication at a minimum follow-up of 24 months.

METHODS

Twenty-five patients who underwent hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All the patients were evaluated clinically prior to surgery (T₀) and at two consecutive follow-ups (T₁:15 ± 1.2 months and T₂: 53.9 ± 23.2 months) using the visual analogue scale (VAS) pain score, whereas sports activity was assessed by the Hip Outcome Score Sport Specific Subscale (HOS-SSS), the University of California, Los Angeles (UCLA) activity scale, the Tegner score and the physical component (PCS) of the Short Form-12 (SF-12). Furthermore, the presence of correlations and the possible differences between subgroups were evaluated and analysed.

RESULTS

A significant difference was found for HOS-SSS, VAS, Tegner, UCLA and PCS with the Friedman test for repeated measures through time points (p < 0.0001). Moreover, all the scores reported significant improvement compared to the previous time point (p < 0.0001) except the HOS-SSS between T₁ and T₂ (n.s.). Body Mass Index (BMI) was negatively correlated with HOS-SSS at T₀ (rho = - 0.526 p = 0.006) and T₁ (rho = - 0.425; p = 0.034), with Tegner at each follow-up (T₀: rho = - 0470 p = 0.017; T₁: rho = - 0.450; p = 0.024; T₂: rho = - 0.448; p = 0.024), with UCLA at T₁ (rho = - 0.396 p = 0.049), with pre-operative PCS (rho = - 0.413 p = 0.0401), and positively correlated with pre-operative VAS (rho = 0.436 p = 0.0291).

CONCLUSIONS

Hip arthroscopy and T-shaped capsular plication in young patients with symptomatic BHD demonstrates a significant increase in return to sport and physical activity and low risk of complications. T-shaped capsular plication procedure may be considered in young and active patients for whom non-operative treatment failed and who have a significant limitation in sports activity; in these patterns of patients, the ideal treatment should reliably allow fast recovery in combination with very low invasiveness which will prevent osteoarthritis. The results of this study provide more accurate information regarding return to sport in patients with BHD after hip arthroscopy and T-shaped capsular plication.

LEVEL OF EVIDENCE

Level IV.

Outcomes of arthroscopic femoroplasty in patients with cam lesions: Minimum 2-year follow-up

PURPOSE

Successful arthroscopic femoroplasty in patients with cam lesions have been reported in Western countries in the last two decades. However, the outcomes after arthroscopic femoroplasty in Asia have thus far only been reported in patients with borderline dysplasia and in the military population. This retrospective study was designed to evaluate the short-term clinical outcomes and radiologic outcomes after hip arthroscopy in patients with cam-type femoroacetabular impingement (FAI) at a minimum postoperative follow-up of 2 years.

METHODS

From January 2013 to December 2016, 204 hip arthroscopy procedures were performed. Of these cases, 62 patients (73 hips) underwent hip arthroscopy for cam-type FAI.

RESULTS

Of the 73 hips, 65 (89.0%) achieved gratified reduction or elimination of preoperative pain. The clinical outcomes showed improvement in scores from before surgery to the last follow-up: 67.1 ± 15.0 to 90.2 ± 6.3 for the modified Harris hip score (p < 0.001), 4.7 ± 2.5 to 7.1 ± 1.4 for the University of California Los Angeles score (p < 0.001), and 7.4 ± 1.9 to 1.8 ± 1.5 for the visual analog scale score (p < 0.001). In radiologic assessments, significant improvement was observed in the alpha angle from a mean 60.9° to 49.5° (p < 0.001) and in the head-neck offset from a mean of 3.3 mm to 6.3 mm (p < 0.001). Of the 73 hips, 65 (89.0%) achieved satisfactory reduction or elimination of preoperative pain. In subgroup analysis for the sufficiency of femoroplasty (alpha angle < 55°), the clinical outcomes were not different between the two groups.

CONCLUSION

Arthroscopic femoroplasty resulted in an 89% satisfaction at the 2-year follow-up. Therefore, hip arthroscopic femoroplasty might be an excellent alternative to open surgery and offers a greater probability of good to excellent results.

Ultrasound-guided hydrodilatation for adhesive capsulitis of the hip is a safe and effective treatment

Purpose

Adhesive capsulitis of the hip (ACH) is likely that this condition had been previously encountered, but easily unrecognised. We investigated the clinical features of patients with ACH, the efficacy of ultrasound-guided intra-articular hydrodilatation, and the patients’ prognosis.

Methods

We enrolled 84 patients (93 hips) who visited the outpatient clinic from August 2018 to November 2019. ACH was diagnosed by restricted range of motion and sharp pain when turning with the affected leg fixed on the ground. We evaluated patient demographics and associated intra-articular pathologies found on magnetic resonance angiography (MRA) images. Injections were performed twice at two week intervals with a mixture of 0.5% lidocaine (25 mL) and triamcinolone (40 mg; 1 mL) with capsular distension under ultrasound guidance. Patients were assessed before and after treatment using a visual analogue scale (VAS), hip disability and osteoarthritis outcome score (HOOS), hip range of motion (ROM), and distance from floor to knee (DFK) when sitting in the cross-legged position.

Results

On MRA, 18 patients had abnormal findings (eight labral tears, seven abductor tendinosis, three primary arthrosis). The mean VAS decreased from 7.1 ± 1.1 to 0.8 ± 0.9 after the last injection, and the HOOS improved in all subsets. The mean DFK decreased from 17.9 ± 4.8 to 9.7 ± 2.8 cm, and passive ROM showed improvement, especially in flexion and rotation. In seven patients, symptom recurrence was reported a mean of 4.1 months after the latest injection, but no independent risk factor for recurrence was identified.

Conclusion

Based on these current observations, patients with ACH may receive relief from hip joint pain and experience improved function with a timely diagnosis and effective treatment.

Time taken to resume driving following hip arthroscopy

Background

Resuming driving is a common concern among patients undergoing hip arthroscopy. The present study aimed to assess whether patients who had undergone right hip arthroscopy presented with poorer driving performance than patients with normal hips and to analyze the time required to regain preoperative driving performance.

Methods

Forty-seven patients who had undergone right hip arthroscopy and consented to our test protocol were included in this study. Using an immersive driving simulator, the patients were tested for their brake reaction time (BRT), total brake time (TBT), and brake pedal depression (BPD) preoperatively and postoperatively. The first postoperative assessments were conducted when the patients could comfortably sit on the driving seat, and the follow-up assessments were conducted for 6 consecutive weeks at weekly intervals. The patients were divided into the following two groups based on the type of surgery that they underwent: the femoroacetabular impingement (FAI) surgery group and the simple hip arthroscopy (SA) group. Twenty healthy volunteers underwent driving assessments thrice at weekly intervals and constituted the control group. The braking parameters were compared between preoperative and postoperative measurements and among the FAI surgery, SA, and control groups.

Results

The preoperative braking parameters of the patients who underwent arthroscopy did not differ significantly from those of the controls (p = 0.373, 0.763, and 0.447 for the BRT, TBT, and BPD, respectively). All braking parameters returned to normal in 2 weeks in the FAI surgery group and in 1 week in the SA group.

Conclusions

Our study suggests that the driving performance of patients who underwent right hip arthroscopy is comparable to that of individuals with normal hips and that the braking parameters may normalize to the preoperative state at 1 week after SA and 2 weeks after FAI surgery.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum two year follow-up

PURPOSE

The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia.

METHODS

Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB).

RESULTS

Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50 months in the borderline hip dysplasia cohort, and 52 months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts.

CONCLUSION

With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Editorial Commentary: Arthroscopy for Borderline Developmental Dysplasia of the Hip: Selection Determines the Outcomes

Although the literature has presented results that favored arthroscopic procedures in treating borderline developmental dysplasia of the hip (BDDH), it remains controversial whether arthroscopic surgery would be better than periacetabular osteotomy for BDDH. Instead of a debate on the application of arthroscopy, the issue worthy of discussion should be distinguishing suitable BDDH candidates for hip arthroscopy. First, identification of patients with real BDDH is critical for making management choices. Second, it should be distinguished whether the major symptoms result from mechanical lesions or functional hip instability. Third, once hip arthroscopy is suggested for BDDH patients, relative contraindications such as advanced age and osteoarthritis should be taken into consideration, in addition to labral repair and capsular closure or plication intraoperatively. In conclusion, more long-term and high-grade evidence is still demanded to end the debate, but we believe that an individualized management strategy based on an accurate diagnosis and comprehensive assessment will bring optimal outcomes for BDDH patients.

Hip Arthroscopy and Borderline Developmental Dysplasia of the Hip: A Systematic Review

PURPOSE

To provide an up-to-date evidence-based review of hip arthroscopy for patients with borderline developmental dysplasia of the hip (BDDH).

METHODS

Literature describing hip arthroscopy in patients with BDDH was systematically identified from PubMed, EMBASE, and Cochrane Library using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All studies that involved BDDH and not just those reporting their clinical outcomes were included. Methodological Index for Non Randomized Studies criteria and Newcastle-Ottawa Scale were used to assess the quality of studies. The definition of BDDH, operative technique, correlation with labrum and/or cartilage lesions, outcome, and factors associated with poor outcome were collected and analyzed.

RESULTS

Assessment of the articles yielded 28 studies involving 1502 hips that were included for final analysis. There were no studies with a high risk of bias. BDDH was defined as lateral center-edge angle of 20° to 25° in most studies. Hip arthroscopy for BDDH showed an improvement in the weighted mean postoperative modified Harris Hip Score, from 60.2 to 81.7, a relatively high rate of acquisition of minimal clinically important difference of 79.5% to 87%, and had 1.0% rate of complications. Eleven studies reported on all the patients undergoing a capsular plication. Four studies reported that BDDH was associated with cartilage damage on the femoral head. Age older than 35 or 42 years and ≥20° of femoral anteversion were reported as risk factors for poor outcomes.

CONCLUSIONS

Hip arthroscopy for BDDH with capsular plication provides improvement in patient-reported outcome measures and a relatively high rate of acquisition of minimal clinically important difference with a low rate of complications in the shorter term. BDDH may be associated with cartilage damage on the femoral head. Female sex is a factor related to good outcomes, whereas older age, excessive femoral anteversion, and anterior undercoverage of acetabulum are risk factors related to poorer outcomes.

LEVEL OF EVIDENCE

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

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With a Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.

PURPOSE

To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m²) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.

CONCLUSION

The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.