Satisfactory mid-term clinical outcomes of endoscopic tenotomy for iliopsoas tendinopathy following total hip arthroplasty

PURPOSE

To report 5-year outcomes of endoscopic iliopsoas tenotomy in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether clinical scores are associated with cup position.

METHODS

Patients who underwent endoscopic iliopsoas tenotomy for iliopsoas tendinopathy following THA (2014-2017) were contacted. Indications for endoscopic iliopsoas tenotomy after THA were groin pain during active hip flexion, exclusion of other causes of groin pain, and no pain relief after 6 months of conservative treatment. Pretenotomy cup inclination and anteversion were measured on radiographs; axial and sagittal cup overhang were measured on computed tomography (CT) scans. Oxford hip score (OHS), modified Harris hip score (mHHS), and groin pain were assessed.

RESULTS

The initial cohort comprised 16 men (17 hips) and 31 women (32 hips), aged 60.7 ± 10.6 years. Cup inclination and anteversion were, respectively, 46.2 ± 6.2° and 14.6 ± 8.4°, while axial and sagittal cup overhang were, respectively, 4.4 ± 4.0 mm and 6.9 ± 4.5 mm. At ≥5 years follow-up, four hips underwent cup and stem revision, two underwent isolated cup revision and one underwent secondary iliopsoas tenotomy. OHS improved by 23 ± 10 and mHHS improved by 31 ± 16. Posttenotomy groin pain was slight in 20.0%, mild in 17.5% and moderate in 12.5%. Regression analyses revealed that net change in mHHS decreased with sagittal cup overhang (β = -3.1; 95% confidence interval [CI] = -4.6 to -1.7; p < 0.001), but that there were no associations between cup position and net change in OHS.

CONCLUSIONS

Endoscopic iliopsoas tenotomy provides good mid-term clinical outcomes in patients with iliopsoas tendinopathy following THA. Furthermore, improvements in mHHS were found to decrease with increasing sagittal cup overhang, in cases for which adequate preoperative imaging was available.

LEVEL OF EVIDENCE

Level IV.

No Differences in Clinical Outcomes Between Hip Arthroscopy With Versus Without Capsular Closure in Patients With Cam- or Mixed-Type Femoroacetabular Impingement: A Randomized Controlled Trial

PURPOSE

To compare 2-year clinical outcomes of primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in patients with cam- or mixed-type femoroacetabular impingement (FAI).

METHODS

Patients with cam- or mixed-type FAI undergoing primary hip arthroscopy with interportal capsulotomy were prospectively enrolled in this randomized controlled trial (RCT) and allocated into either capsular closure or no capsular closure groups. Patients were blinded to group allocation. Clinical outcomes were assessed preoperatively and at 2-year follow-up using the 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and 6 subsections of the Copenhagen Hip and Groin Outcome Score (HAGOS). Complications and reoperations were noted.

RESULTS

Eighty-four patients (100 hips) were enrolled, 49 hips in the capsular closure group and 51 in the no capsular closure group, with no significant differences in age (28.5 ± 7.5 vs 30.4 ± 8.4, P = .261), body mass index (23.5 ± 3.0 vs 23.4 ± 1.9, P = .665), and sex distribution (female: 10.2% vs 13.7%, P = .760). Four patients were lost to follow-up (2.0% vs 5.9%, P = .618) and 6 had reoperations (6.1% vs 5.9%, P = 1.000), which left 45 hips per group for clinical assessment. There were no significant differences between groups in the net change of iHOT-12 (28.3 ± 19.6 vs 32.5 ± 22.7, P = .388), mHHS (7.6 ± 13.1 vs 7.5 ± 10.2, P = .954), and subsections of HAGOS (P > .05). Complication rates were also similar between groups (P > .05).

CONCLUSIONS

The present RCT compared primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in a male-dominated, non-dysplastic, non-arthritic cohort with cam- or mixed-type FAI and found no significant differences in patient-reported clinical outcomes, complication rates, or reoperation rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

No significant differences in 60-day postoperative complication rates between conventional and shortened stems

PURPOSE

To compare 60-day complication rates, radiographic outcomes, and clinical outcomes following primary THA with conventional versus shortened stems, in a large cohort study.

METHODS

The authors reviewed a consecutive series of 800 primary THAs, of which 781 met the inclusion/exclusion criteria: 395 received a conventional stem and 386 received a shortened stem. Intraoperative and postoperative complications were noted. Radiographic and clinical assessments were performed preoperatively and 60 days after surgery.

RESULTS

Compared to conventional stems, shortened stems had significantly less intraoperative complications (2.8% vs 0.3%, p = 0.006), but no significant differences in complications that did not require reoperation (1.0% vs 1.3%, p = 0.620), complications that required reoperation without stem revision (2.0% vs 1.0%, p = 0.384), and complications that required stem revision (0.5% vs 0.5%, p = 1.000). Four hips (two from each group) required stem revision and were thus excluded from 60-day assessment. There were no significant differences between groups in subsidence ≥ 3 mm (1.0% vs 0.5%, p = 0.686), alignment (90.3%vs 86.7%, p = 0.192), net change in offset (within 3 mm, 32.3% vs 30.5%, p = 0.097), and limb length discrepancy (3.0 ± 2.6 mm vs 2.9 ± 2.4 mm, p = 0.695). Compared to conventional stems, shortened stems had significantly better preoperative mHHS (56.5 ± 18.5 vs 64.5 ± 13.5, p < 0.001), and significantly lower net improvement in mHHS (29.9 ± 17.1 vs 24.4 ± 15.0, p < 0.001), but no significant differences in postoperative mHHS (87.3 ± 11.9 vs 89.4 ± 9.6, p = 0.109).

CONCLUSIONS

There were no significant differences between conventional and shortened stems in terms of postoperative complication rates, radiographic outcomes, and postoperative mHHS. However, patients implanted with shortened stems had less intraoperative complications, but lower net improvement in mHHS.

LEVEL OF EVIDENCE

Level IV, Retrospective comparative cohort study.

What happens to endoscopic/arthroscopic tenotomies with iliopsoas impingement in the medium term? Review of a prospective cohort of 64 patients with a minimum follow-up of 5 years

INTRODUCTION

The occurrence of iliopsoas impingement (IPI) after total hip arthroplasty (THA) is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective multicenter series. We carried out a review of the patients at more than 5 years of follow-up in order to assess the stability of the results over time.

HYPOTHESIS

Our main hypothesis was that endoscopic/arthroscopic tenotomies allow stable medium-term resolution of the painful symptoms of IPI. Our secondary hypothesis was that medium-term survival was satisfactory.

MATERIAL AND METHOD

This study is a continuation of a multicenter prospective series. Patients were contacted through multiple channels in order to: obtain an Oxford score, assess for satisfaction, psoas irritation, and daily pain on a visual analogue scale (VAS).

RESULTS

Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7±7.7 [12-48]. There was a significant difference between the Oxford scores preoperatively, at 8 months and at the last follow-up. The mean satisfaction out of 10 was 8.0±2.1 [1-10]. We found 84% satisfaction at 5 years against 83% at 8 months. The VAS was 2.1±2.3 [0-10]. A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in four cases, while it reappeared during the interval in six cases. Survival was 91.2% (95% CI: 80.2-96.3) at 5 years.

CONCLUSION

Endoscopic/arthroscopic iliopsoas tenotomies represent a permanent medium-term solution to treat IPI after THA. The existence of a force differential or an acetabular overhang does not seem, within a certain limit, to impact the results in the medium term.

LEVEL OF EVIDENCE

IV; prospective series without control group.

The influence of the sacral slope on pelvic kinematics and clinical manifestations in femoroacetabular impingement

INTRODUCTION

The radiological study of the sagittal alignment of the spine in static and dynamic positions has allowed a better understanding of the clinical results of total hip prostheses. According to the Roussouly classification, the sacral slope in a standing position characterizes the patient with a stiff spine (less than 35̊) or a flexible spine (greater than 35̊). The objectives of this study were to compare, in a population of patients operated on for femoroacetabular impingement (FAI), firstly, the kinematics of the lumbar-pelvic-femoral complex and secondly, the clinical presentation depending on whether the spine is stiff or flexible.

HYPOTHESIS

Patients with stiff spines (SS<35̊) were "hip users" and had less ability to compensate for their hip pathology.

MATERIAL AND METHOD

This prospective and comparative multicenter study was conducted with patients operated on arthroscopically for FAI between 2020 and 2021. All patients included received preoperative EOS imaging of the lower limbs and spine, in standing and seated positions. The following parameters were measured: pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and sacral slope (SS), as well as dynamic parameters (intrinsic mobility of the hip: delta standing/sitting femoral sacral angle, and of the pelvis: delta standing/sitting sacral slope). The functional result was evaluated at 1 year.

RESULTS

In the stiff spine group, 62 patients were included versus 138 in the flexible spine group. The mean follow-up was 15.1±3.3 months (9.2-24.3). Nineteen patients were lost to follow-up and there were 2 revisions for iterative arthroscopy. Intrinsic pelvic mobility and intrinsic hip mobility were 16̊±13.5 (-12; 44) and 44.5̊±28.5 (-9; 99) respectively in the stiff spine group. In the flexible spine group, these same measurements were 22̊±11.5 (-30; 45) and 29.7̊±22.7 (-33; 82) respectively. In the stiff spine group, the symptoms occurred at a significantly younger age: 28.3 years±9.5 (18-51) versus 31 years±8 (18-54) (p=0.017).

DISCUSSION

The sacral slope is a determining factor in the kinematics of impingement and the appearance of symptoms. The sacral slope helps define the concept of a "hip user" in symptomatic FAI.

LEVEL OF EVIDENCE

IV.

Radiological signs of femoroacetabular impingement are linked to pelvic version in asymptomatic subjects

INTRODUCTION

With the recent interest in hip-spine relationship, the link between femoroacetabular impingement (FAI) and the lumbar-pelvic-femoral complex (LPFC) appears decisive. The objectives of this study were (1) to compare the pelvic version, as well as (2) all the parameters of the LPFC between two populations of healthy subjects, comparing those with radiological signs of FAI to those without and finally, (3) to evaluate the LPFC parameters according to the type of FAI.

HYPOTHESIS

Asymptomatic subjects with radiological signs of FAI had superior pelvic anteversion.

MATERIALS AND METHOD

This retrospective study was based on a prospective cohort of 118 voluntary asymptomatic patients including 62 men (52.5%) with a mean age of 25.6 years±4.4 (19-39). The following parameters: pelvic version (PV), pelvic incidence (PI), lumbar lordosis (LL), sacral slope (SS), hip flexion, intrinsic (IER) and extrinsic (EER) extension reserve were measured using EOS imaging™ in the reference standing position and the lunge position. The radiological signs of FAI (cam, pincer, mixed) were identified on these acquisitions then separated into 2 groups. The first was the group presenting with one or more images of FAI (FAI+) and the second group with no images of FAI (FAI-).

RESULTS

There were 143 hips in the FAI+ group compared to 93 hips in the FAI- group. There were 36.4% cams and 45% pincers. With an average of 9.08°±7.81 (-11.0; 27.0) versus 12.33°±8.94 (-5.0; 55.0), the PV was significantly lower (p=0.022) in the FAI+ group compared to the FAI- group. A post-hoc power analysis on the primary outcome (PV) confirmed sufficient power (1-β=0.809). Compared to the FAI- group, the cam group presented a significantly lower IER and EER (respectively p=0.014 and p=0.047). The comparative analysis between the FAI- and pincer groups found a significant difference in PI (p=0.001), PV (p<0.001), IER (p=0.017) and hip flexion (p<0.001), SS in lunge position (p=0.031) and EER (p=0.039).

CONCLUSION

Asymptomatic subjects with radiographic signs of FAI present with weak pelvic version when standing. This pelvic hyper-anteversion is mainly found in the event of a radiological pincer sign.

LEVEL OF EVIDENCE

III, retrospective comparative study.

The 2022 International Society for Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS): an international consensus statement

The 2022 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of greater trochanteric pain syndrome (GTPS) was intended to present a physiotherapy consensus on the assessment and surgical and non-surgical physiotherapy management of patients with GTPS. The panel consisted of 15 physiotherapists and eight orthopaedic surgeons. Currently, there is a lack of high-quality literature supporting non-operative and operative physiotherapy management. Therefore, a group of physiotherapists who specialize in the treatment of non-arthritic hip pathology created this consensus statement regarding physiotherapy management of GTPS. The consensus was conducted using a modified Delphi technique to guide physiotherapy-related decisions according to the current knowledge and expertise regarding the following: (i) evaluation of GTPS, (ii) non-surgical physiotherapy management, (iii) use of corticosteroids and orthobiologics and (iv) surgical indications and post-operative physiotherapy management.

Diagnosing Hip Microinstability: an international consensus study using the Delphi methodology

PURPOSE

Hip microinstability is a relatively new diagnosis which is increasingly being discussed in the literature and yet there are no clear guidelines for making a diagnosis. Microinstability has generally been defined as persistent excessive hip motion that has become symptomatic especially with pain. This aim of this Delphi study was to seek expert opinion to formulate a diagnostic criteria for hip microinstability.

METHODS

A Delphi methodology was used for this consensus study. A literature search was conducted on PubMed up to March 2019 using the keywords ((hip) and (microinstability)) to identify relevant articles on this topic. All relevant criteria used for diagnosing hip microinstability were collated to create a questionnaire and further criterion suggested by the experts were included as well. Four rounds of questionnaires were delivered via an online survey platform. Between each round the authors acted as administrating intermediaries, providing the experts with a summary of results and synthesising the next questionnaire. The expert panel was comprised of 27 members: 24 (89%) orthopaedic surgeons and 3 (11%) physiotherapists from around the world.

RESULTS

Expert panel participation in rounds 1-4 was: 27 (100%), 20 (74%), 21 (78%) and 26 (96%) respectively. A literature review by the authors identified 32 diagnostic criteria to populate the first questionnaire. Experts suggested amending three criteria and creating five new criteria. The panel converged on ranking 3 (8%) of criteria as "Not important", 20 (54%) as "Minor Factors" and 14 (38%) as "Major Factors". No criteria was ranked as "Essential". Criteria were subcategorised into patient history, examination and imaging. Experts voted for a minimum requirement of four criteria in each subcategory, including at least six "Major factors". The final diagnostic tool was approved by 20 (77%) of the final round panel.

CONCLUSION

This study describes the first known expert consensus on diagnosing hip microinstability. The relative complexity of the final diagnostic tool is illustrative of the difficulty clinicians' face when making this diagnosis.

LEVEL OF EVIDENCE

V.

Validation of the French version of the Self-Administered International Hip Outcome Tool-12 Questionnaire and determination of the Minimal Clinically Important Difference (MCID) in the French speaking population

BACKGROUND

Patient-Reported Outcomes tools are becoming the gold standard in the evaluation of results in orthopaedic surgery. In 2012, the International Hip Outcome Tool-12 (iHOT-12) was developed. This self-administered questionnaire was designed to address the day-to-day clinical setting with faster completion and easier patient flow. In 2021, a French translation of the iHOT-33 questionnaire, from which the iHOT-12 is derived, proved to be valid. Since there is not data in French regarding iHOT-12, we performed a prospective study aiming to answer: (1) is this French version of the iHOT-12 questionnaire as valid, (2) can the minimal clinically important difference (MCID) value for patients undergoing hip arthroscopy for femoro-acetabular impingement (FAI) be defined?

HYPOTHESIS

It is hypothesized that the iHOT-12-Fr would be valid and responsive to change in a cohort treated for FAI.

PATIENTS AND METHODS

Using the COSMIN recommendations, a multicentric prospective cohort study was conducted to evaluate the reliability, validity, responsiveness and MCID of the iHOT-12-Fr.

RESULTS

In total, 101 patients were recruited for participation in the project. The reliability of the iHOT-12-Fr questionnaire was assessed with the intraclass correlation coefficient (ICC=0.84) and the internal consistency with a Cronbach's alpha (α=0.86). The standard error of measurement (SEM=6.7) and the smallest detectable change (SDC=1.8) were calculated. Construct validity was evaluated with Pearson's correlation coefficients (r) by comparing the iHOT-12-Fr with the iHOT-33-Fr (r=0.96), the Hip disability and Osteoarthritis Outcome Score-Fr (r=0.68) and Nonarthritic Hip Score-Fr (r=0.82). Responsiveness was shown with a standardized effect size of 1.18, standardized response mean of 0.73, responsiveness ratio of 1.4 and an MCID of 11 points.

DISCUSSION

Metrological qualities of the iHOT-12-Fr are comparable to the original version and other versions translated into different languages. This study proves that the French translation of the iHOT-12 is valid, reliable and compares to the original iHOT-12.

LEVEL OF EVIDENCE

IV prospective study.

Endoscopic Tenotomy for Iliopsoas Tendinopathy Following Total Hip Arthroplasty Can Relieve Pain Regardless of Acetabular Cup Overhang or Anteversion

PURPOSE

To report outcomes of endoscopic iliopsoas tenotomy (EIT) in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether improvements in clinical scores are associated with acetabular cup anteversion measured on plain radiographs or overhang measured using established and alternative computed tomography (CT)-based methods.

METHODS

We evaluated patients who underwent EIT for iliopsoas tendinopathy after THA (2014-2017), performed between the lesser trochanter and psoas valley. Indications were groin pain during active hip flexion, exclusion of other complications, and no pain relief after 6 months of conservative treatment. Pretenotomy inclination and anteversion were measured on radiographs; sagittal and axial overhang were measured on CT scans on slices passing through: (Method 1) prosthetic head center and (Method 2) anterior margin of acetabular cup. Modified Harris hip score (mHHS), Oxford Hip Score (OHS), and level of groin pain were recorded at 12 or more months. Wilcoxon signed-rank tests were used to compare pre- and post-tenotomy scores, and intraclass correlation coefficients (ICCs) to assess intermethod agreement.

RESULTS

The cohort comprised 16 men (17 hips) and 32 women (33 hips), aged 60.8 ± 10.5 years at EIT. For the 30 (60%) hips that had pretenotomy CT scans, axial and sagittal overhang were, respectively, 3.4 ± 3.7 mm and 4.6 ± 4.6 mm, using Method 1, compared with 3.9 ± 3.9 mm and 6.9 ± 5.0 mm using Method 2. Intermethod agreement was good for axial (ICC, 0.67; P < .001) and sagittal (ICC, 0.68; P < .001) overhang. At a minimum 1 year after EIT, 3 hips had cup and stem revision and 1 hip had isolated cup revision, leaving 46 hips for clinical assessment. No complications were noted. mHHS improved by 26 ± 19 (P < .001) and OHS improved by 20 ± 11 (P < .001). Twenty-six hips (57%) achieved the patient acceptable symptom state for mHHS, whereas 42 hips (91%) achieved the patient acceptable symptom state for OHS. Post-tenotomy groin pain was slight in 15%, mild in 17%, and moderate in 11%. Regression analyses revealed no associations between clinical scores and overhang/anteversion.

CONCLUSIONS

For patients with iliopsoas tendinopathy following THA, endoscopic iliopsoas tenotomy granted clinically important improvements of mHHS in 76% and OHS in 89%, despite moderate residual groin pain in 11%. Improvements in clinical scores did not seem to be associated with the extent of cup overhang or anteversion in the cases for which adequate preoperative imaging was available.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Unusual apical femoral head deformity treated by hip arthroscopy and tunnel drilling through femoral head: a case report

Femoro-acetabular impingement (FAI), is the result of an abnormal morphology of the hip joint. On the femoral side, asphericity of the head can be highlighted by an alpha angle measurement >50° on computed tomography or MRI. However, some particular cephalic asphericities can make it difficult to measure the alpha angle, leading to a diagnostic pitfall. While in the classic cam effect, the deformity is peripheral and can be treated by arthroscopic femoroplasty, an apical head deformity remains a therapeutic challenge. We present the case of a 17-year-old male patient with a femoral head deformity, corresponding to an ISHA zone 6 overhang, significantly improved in everyday and sports life by arthroscopic trapdoor technique to resect the focal central deformity while enabling concomitant treatment of central compartment pathology, in this case, a hypertrophic ligamentum teres and femoral head chondral flap. Etiology of this femoral head deformity remains uncertain but could be a particular cam deformity, sequelae to pediatric disease or instability with repeated traction of the ligament teres on the femoral head apical insertion during cephalic growth.

Total Hip Arthroplasty Using a Hemispherical Uncemented Dual-Mobility Cup Results in Satisfactory Clinical Outcomes and No Dislocations at 2 years

BACKGROUND

The authors performed total hip arthroplasty (THA) using a novel hemispherical dual-mobility (DM) acetabular cup without a protrusive cylindro-spherical rim, intended to reduce risks of iliopsoas impingement without requiring changes to conventional intraoperative positioning as with unipolar cups. We aim to determine clinical scores and rates of dislocations, complications, and revisions of this hemispherical DM cup, with the hypothesis that this novel design would result in clinical scores and dislocation rates comparable to other contemporary DM cups with protrusive cylindro-spherical rims.

METHODS

We assessed 332 consecutive uncemented THAs performed using a hemispherical DM cup, at a minimum 2-year follow-up, using modified Harris Hip Score (mHHS) and Oxford Hip Score (OHS), and noting complications and revisions. Regression analyses were conducted to determine if mHHS and OHS depended on any independent factors.

RESULTS

At 2.8 ± 0.5 years (range, 2-5), 2 patients (0.6%) had stem and cup revisions, 3 patients (1%) had isolated stem revisions, 13 patients (4%) died, and none were lost to follow-up. No dislocations occurred. For the final cohort of 305 patients (314 hips) with their original implants in place, mHHS was 92 ± 12 (range, 46-100), and OHS was 57 ± 5 (range, 34-60). Multivariable analyses revealed that mHHS and OHS decreased significantly with age (β = -0.35, P < .001, and β = -0.15, P < .001, respectively).

CONCLUSIONS

With no dislocations and satisfactory clinical scores, this sizable cohort confirms that the novel hemispherical DM cup studied is effective at preventing dislocations, although longer-term follow-up remains necessary to ascertain the longevity of clinical outcomes and radiographic stability.

LEVEL OF EVIDENCE

Level IV, multicentric retrospective case series.

Validation of the French version of the self-administered international hip outcome tool-33 questionnaire

INTRODUCTION

To evaluate the effectiveness of new treatments, whether conservative or surgical, a self-administered questionnaire for hip pain targeted at physically active patients 18 to 60 years of age, named the international Hip Outcome Tool-33 (iHOT-33), was developed and validated in 2012. Since there is no French version available and we are acutely aware of transcultural variations, we conducted a prospective study to: 1) translate, and then 2) validate this questionnaire into international French.

HYPOTHESIS

The iHOT-33-Fr questionnaire is a valid and reliable tool for evaluating hip pain in a young, francophone population.

MATERIALS AND METHODS

Translation of the questionnaire was done according to the standardized method described by Beaton and the final version of the iHOT-33-Fr was validated using the COSMIN methodology. The data were collected prospectively at multiple sites. The reliability of the iHOT-33-Fr questionnaire was evaluated using the intraclass correlation coefficient (ICC) and its internal consistency using Cronbach's alpha. The standard error of measurement and minimum detectable change were calculated. The construct validity was evaluated using Pearson's correlation coefficient by comparing the iHOT-33-Fr with the Hip disability and Osteoarthritis Outcome Score (HOOS-Fr) and Nonarthritic Hip Score (NAHS-Fr).

RESULTS

In all, 101 patients filled out the questionnaires. The ICC was 0.87. The Cronbach alpha was 0.95. The standard error of measurement was 6.4 and the minimum detectable change was 1.8. The correlation between the iHOT-33-Fr and the HOOS-Fr was 0.86, while the correlation between the iHOT-33-Fr and the NAHS-Fr was 0.75.

DISCUSSION

Our results show that the metrological qualities of the iHOT-33-Fr are comparable to those of the original version and the versions translated into other languages. This study demonstrates that the iHOT-33-Fr is valid, reproducible and comparable to the original iHOT-33. It can be used by francophone surgeons treating symptomatic hip disease in young, active patients.

LEVEL OF EVIDENCE

IV.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program

INTRODUCTION

Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol.

HYPOTHESIS

The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol.

METHODS

This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months.

RESULTS

Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA.

DISCUSSION

The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed.

LEVEL OF EVIDENCE

IV; Prospective cohort study without control group.

Fast track protocol for primary total hip arthroplasty in non-trauma cases reduces the length of hospital stay: Prospective French multicenter study

BACKGROUND

Fast-track (FT) procedures continue to evolve; however, their benefits are still controversial. This led us to conduct a prospective study of FT procedures for total hip arthroplasty (THA) on a national scale in France with historical control data. The aims were to (1) evaluate the effectiveness of FT procedures after THA on the length of hospital stay (LOS) in a multicenter analysis, (2) measure the immediate return to home, rehospitalization and reoperation rates.

HYPOTHESIS

FT procedures reduce the LOS after primary THA for non-traumatic indications relative to national historical data.

METHODS

A prospective observational study was done at 11 hospital facilities throughout France. Patients who underwent primary THA for a non-traumatic condition and FT procedures were followed for 3 months. The average LOS, discharge to home, unexpected readmissions, and reoperation rate were compared to 2016 figures from the French national database of 104,745 procedures on the same population.

RESULTS

The study included 1,110 patients, 499 men (45%) and 611 women (55%), with a mean age of 67.5±11.9 years. The average LOS was 3.3±2.9 days versus 7.5±5.3 days in the national database (p<0.001). Eight hundred eighty patients (79%) were discharged directly to home versus 72,577 (69%) in the national database (p<0.001). Forty-two patients (4%) were readmitted to the hospital within 90 days of the THA versus 11,092 (11%) in the national database (p<0.001). Eighteen patients (1.6%) were reoperated within 90 days of the THA procedure versus 2100 (2.0%) in the national database (p=0.72).

DISCUSSION

FT procedures help to significantly reduce the average LOS and rehospitalization rate after primary THA for non-traumatic conditions and significantly increased the percentage of patients being discharged directly to home relative to national historical data, without altering the risk of reoperation. FT procedures should become the standard of care after THA.

LEVEL OF EVIDENCE

III; prospective case-control study.

Correction to: Clinical and radiographic predictors of failed hip arthroscopy in the management of dysplasia: a systematic review and proposal for classification

Unfortunately, the author name was incorrectly published in the original publication as Sochi Uchida insted of Soshi Uchida. The author name is corrected here by this Erratum. The ​original ​article ​has ​been ​corrected.

Clinical and radiographic predictors of failed hip arthroscopy in the management of dysplasia: a systematic review and proposal for classification

PURPOSE

As indications for hip arthroscopy continue to expand, its efficacy in patients with more complex deformities of the hip, such as those with acetabular dysplasia, remains controversial. The purpose of this systematic review is to identify the predictors of failed hip arthroscopy in dysplastic hips and to propose a standardize prognostic sub-classification of dysplasia.

METHODS

This systematic review was performed in accordance with the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA guidelines. Three databases [EMBASE, PubMed, and Ovid (MEDLINE)] were searched using terms including "hip arthroscopy" and "dysplasia". Studies were screened and data extracted in duplicate. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Due to the non-uniform nature of study data, findings were presented in descriptive summary form.

RESULTS

Thirteen studies were included in this systematic review, comprising 712 dysplastic patients (773 hips) with mean age 34.2 years and 74.1% females. Most studies defined hip dysplasia by a lateral centre-edge angle (LCEA) of 20°-25° (borderline) or 15°-20° (moderate). Failure was defined as progression to revision arthroscopy, peri-acetabular osteotomy, or total hip arthroplasty. Overall, failure rate was 192/743 (25.8%) at an average of 28.1 months following index arthroscopy. Smaller LCEA, larger Tönnis angle, broken Shenton line, and decreased joint space (≤ 2 mm) were radiographic predictors of failure. Severe cartilage lesions to the femoral head or acetabulum were associated with failure in five studies. Labral debridement led to more failures than labral repair.

CONCLUSION

Overall, hip arthroscopy yielded good outcomes in mildly dysplastic hips without severe chondral damage. Hip arthroscopy is expected to result in a failed outcome in individuals with moderate-to-severe hip dysplasia (LCEA < 15°), severe cartilage lesions, larger Tönnis angle (> 20°), broken Shenton line, and decreased joint space (≤ 2 mm). Arthroscopic surgery may be more effective in individuals with borderline-to-mild (LCEA 15°-25°) acetabular dysplasia in the absence of severe cartilaginous lesions (7-year survival: 89.6%). A standardized prognostic classification of hip dysplasia based on the LCEA and Tönnis angle is proposed.

LEVEL OF EVIDENCE

Systematic review of non-randomized studies, Level IV.

Promising outcomes of hip mosaicplasty by minimally invasive anterior approach using osteochondral autografts from the ipsilateral femoral head

PURPOSE

Recent studies demonstrated promising results of mosaicplasty for femoral head osteochondral lesions using posterior and lateral approaches. This study aimed to evaluate outcomes of mosaicplasty using ipsilateral femoral head autografts by minimally invasive anterior approach. The hypothesis was that this surgical technique would grant satisfactory clinical outcomes with considerable improvement of clinical scores.

METHODS

A consecutive series of 27 mosaicplasties, to treat osteochondral lesions of the femoral head measuring 1.6 ± 0.7 cm² (range 0.8-4.0) in patients aged 28.7 ± 7.4 years (range 19-44), was evaluated using the mHHS and WOMAC scores at minimum follow-up of 12 months. All patients were operated by minimally invasive anterior (Hueter) approach and osteochondral plugs were harvested from the non-weight-bearing portion of the femoral head. Adjuvant osteoplasty was necessary for some patients at the acetabulum (n = 3), femur (n = 14) or both (n = 2).

RESULTS

Three patients were excluded due to concomitant periacetabular osteotomies or shelf procedures, one patient could not be reached, and another was revised to THA. This left 22 patients for clinical assessment at 39.4 ± 23.2 months (12.0-90.2). Their mHHS improved from 56.3 ± 12.6 to 88.4 ± 9.9, and WOMAC improved from 45.1 ± 16.9 to 80.6 ± 13.0. Two patients (8.4%) underwent arthroscopy at 13 and 30 months to remove painful residual cam-type deformities. Regression analyses revealed that net improvement in WOMAC decreased with lesion size (p = 0.002) and increased with follow-up (p = 0.004).

CONCLUSIONS

Hip mosaicplasty using autografts from the ipsilateral femoral head, performed by minimally invasive anterior approach, granted satisfactory outcomes and functional improvements. Caution is, however, advised for lesions > 2 cm² (diameter > 16 mm) which may be a threshold limit for this procedure.

LEVEL OF EVIDENCE

Level IV, Case series.

Evaluating the cost-consequence of a standardized strategy for the etiological diagnosis of uveitis (ULISSE study)

MAIN OBJECTIVE

To prospectively assess the cost-consequence of a standardized diagnostic strategy as to compared to an open one for the etiological diagnosis of uveitis.

DESIGN

This was a prospective, non-inferiority, multicentre, randomized controlled trial.

METHODS

We included all consecutive patients with uveitis who had visited at least one of the Departments of Ophthalmology. In the standardized group, patients had a minimal work-up regardless of the type of uveitis (including evaluation of the CBC, ESR, C-reactive protein, tuberculin skin test, syphilis serology and chest X-ray). Depending on ophthalmological findings, further investigations could be performed. In the open strategy, ophthalmologists were free to order any kind of investigation. The main outcome was the mean cost per patient of each strategy.

RESULTS

903 uveitis patients were included from January, 2010 to May, 2013. The mean cost per patient of the standardized strategy was 182.97 euros [CI 95% (173.14; 192.80)], and the mean cost per patient of the open strategy was 251.75 euros [CI 95% (229.24; 274.25)]. Therefore, the mean cost per patient of the standardized strategy was significantly lower than the mean cost per patient of the open strategy (p<0.001). There were significantly fewer visits (p<0.001), fewer radiological procedures (p<0.004) and fewer laboratory investigations (p<0.001) in the standardized group.

CONCLUSION

A standardized strategy is a cost-saving approach for the etiological diagnosis of uveitis.

A shortened uncemented stem offers comparable positioning and increased metaphyseal fill compared to a standard uncemented stem

BACKGROUND

Shortened stems are increasingly used in uncemented total hip arthroplasty (THA) as they represent a compromise between the metaphyseal anchorage of short stems and the facilitated axial alignment of standard stems. The purpose of this study was to compare the metaphyseal canal-fill ratio (CFR) and axial alignment of a shortened double-tapered stem with those of a standard stem. The hypothesis was that the shortened stem would achieve greater metaphyseal fill and comparable axial alignment.

METHODS

The authors reviewed routine follow-up anteroposterior radiographs taken 2 months after THA to evaluate metaphyseal fill and axial alignment of a shortened stem (n = 96) and a standard stem (n = 101). The CFR was calculated at the level of the tip and superior margin of the lesser trochanter. Stem alignment was defined as the angle between the stem axis and the proximal anatomic femoral axis. Stems were classified as being in varus or valgus alignment if they deviated by more than 3° from the anatomic axis of the femur.

RESULTS

Hips implanted with shortened and standard stems had comparable demographics and axial alignment (1.1° ± 1.7° vs 0.8° ± 1.2°; p = 0.331). However, varus alignment was observed in 5% of shortened stems compared to only 1% of standard stems, though this difference was not significant (p = 0.111). The femoral CFR was greater using shortened stems than using standard stems, both at the level of the tip of the lesser trochanter (0.91 ± 0.05 vs 0.85 ± 0.08; p < 0.001) and at its superior margin (0.76 ± 0.06 vs 0.72 ± 0.07; p < 0.001).

CONCLUSIONS

Compared to the standard stem, the shortened stem had increased metaphyseal filling and equivalent alignment. These findings suggest that shortened stems could provide adequate metaphyseal fixation and correct alignment. Further studies remain necessary to evaluate how shortened stems perform in terms of osseointegration, clinical outcomes and survival.

Does acetabular dysplasia affect outcome in arthroscopic treatment of cam femoroacetabular impingement? Case-control study with and without acetabular dysplasia

BACKGROUND

Arthroscopic management of femoroacetabular impingement (FAI) is classically contraindicated when acetabular dysplasia is associated, although this is controversial in case of moderate dysplasia or isolated cam effect. A case-control study was therefore conducted comparing borderline (center-edgeangle (CEA), 20-24°), moderate (15-19°) and severe dysplasia (<15°) (group D) versus a control group with normal acetabular cover (CEA, 25-30°). The aims were 1) to determine functional results and satisfaction, and 2) to correlate functional results with severity of dysplasia and of cam effect.

HYPOTHESIS

Improvement in functional scores and satisfaction is lower in group D than in controls, due to non-correction of dysplasia.

MATERIAL AND METHOD

A single-center, single-surgeon retrospective comparative case-control study included all patients with isolated cam-effect FAI and dysplasia but without osteoarthritis (group D) or with isolated cam-effect FAI without dysplasia (controls) operated on during the study period. Cases of mixed impingement were excluded. Preoperative and last-follow-up functional variables included McCarthy's modified Harris Hip Score (mHHS) and Christensen's Non-Arthritic Hip Score (NAHS).

RESULTS

Between 2011 and 2014, details of 407 patients operated on by arthroscopy were entered in a data-base. Twenty patients (22 hips) were included in group D, with CEA<25° (mean, 19±3.1; range, 10-23°). The control group comprised 23 patients (25 hips) with CEA>25° (mean, 29±2.1°; range, 25-30°) matched for gender, age and body-mass index. Mean follow-up was 29.6±14.1 months (range, 14-58 months) in group D and 31.4±10.6 months (range, 15-57 months) in the control group (p=0.66). For functional scores, the two groups showed respectively 9.9 (-34 to +47) (p=0.038) and 10.4 (-20 to +48) (p=0.0038) gain in mHHS (non-significant: p=0.943). Mean gain in NAHS was 16.6 (-19 to +33) (p=0.0001) and 13.7 (-11 to +47) (p=0.0002), respectively (non-significant: p=0.56) CONCLUSION: Short-term functional results for cam FAI treatment were equivalent with<25° acetabular cover (mean, 19°; range, 13-24°) or normal cover. Longer-term assessment is indispensable to determine the impact of dysplasia and its severity.

LEVEL OF EVIDENCE

III, case-control study.

Outcomes of cup revision for ilio-psoas impingement after total hip arthroplasty: Retrospective study of 46 patients

BACKGROUND

Impingement of the ilio-psoas tendon on the acetabular component is a cause of pain after total hip arthroplasty (THA). Studies of cup revision for ilio-psoas impingement (IPI) are scarce and limited in size. We therefore conducted a large multicentre retrospective study with the following objectives: to assess the effectiveness of cup replacement in resolving the impingement syndrome, to determine the frequency and nature of complications after cup revision for IPI, and to identify pre-operative factors associated with good outcomes of cup revision for IPI.

HYPOTHESIS

Cup revision is effective in resolving the pain due to IPI in selected patients.

METHODS

This retrospective multicentre study included 46 patients who underwent cup revision because of IPI. Before the revision, 38 (83%) patients had prominence of the anterior cup rim (mean, 9.9±4.5mm (range, 2-22mm) by radiography and 35 (76%) had cup malposition (anteversion<10° and/or inclination>50°). Mean follow-up was 21months (range, 6months to 6 years) and no patient was lost to follow-up. Outcomes at last follow-up were assessed based on the Oxford Hip Score (OHS), patient satisfaction index, complications, and revisions.

RESULTS

At last follow-up, 39 (85%) patients were satisfied with the revision procedure, a significant improvement versus baseline was noted in the OHS (mean, 43±6; range, 25-48; P<0.001), and 41 patients were free of pain during hip flexion (P<0.001 versus baseline). Complications occurred in 3 (6.5%) patients, but only one complication was severe (deep infection). Recurrent groin pain was reported by 4 (8.7%) patients at last follow-up. None of the factors studied predicted the outcome of revision surgery.

DISCUSSION

Cup revision for IPI after THA is effective in relieving the groin pain in 80% of patients with anterior cup rim prominence and/or cup malposition. However, complications can occur. Tenotomy may be preferable when the diagnosis is in doubt and/or cup position is acceptable.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Proximal femoral anatomy and collared stems in hip arthroplasty: is a single collar size sufficient?

Background

Even if the benefits of collars are unclear, they remain widely used, in several femoral stem designs. This study aimed to determine whether collar size should be proportional to hip dimensions and morphology. The hypothesis was that the collar should be larger for greater stem sizes and for varus femoral necks.

Methods

Computed Tomography scans of 204 healthy hips were digitally analysed and manually templated to determine principle dimensions, appropriate stem size and model, as well as cortical distance at the femoral calcar (ideal collar size).

Results

Univariable analysis revealed that cortical distance was moderately correlated with mediolateral offset (r = 0.572; p < 0.0001) and stem model (r = 0.520; p < 0.0001). Cortical distance was weakly correlated with head diameter (r = 0.399; p < 0.0001), stem size (r = 0.200; p = 0.017), and patient gender (r = 0.361; p < 0.0001). Multivariable analysis confirmed that stem model (p < 0.0001) and head diameter (p = 0.0162) are directly correlated to cortical distance.

Conclusion

We found that cortical distance along the femoral calcar is directly correlated with the model of the stem implanted (‘standard’ or ‘varus’) and with the head diameter. This cortical distance indicates optimal collar size, which would grant maximum calcar coverage without prosthetic overhang. Collar size should be proportional to the size of the operated hip, and should be larger for ‘varus’ stem models than for ‘standard’ stem models.

What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips

INTRODUCTION

Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors.

HYPOTHESIS

Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study.

PATIENTS AND METHODS

A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup).

RESULTS

The patients with unstable THAs were 67±12 [37-73]years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5years after in 20 cases (16%), 5 to 10years after in 17 cases (13%) and more than 10years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4-2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15-7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0-3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3-7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2-15.9), and cup inclination outside Lewinnek's safe zone (30°-50°) with OR of 2.4 (95% CI: 1.4-4.0).

DISCUSSION

This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation.

LEVEL OF EVIDENCE

Level III; case-control study.

Reasons for and functional results of repeated hip arthroscopy: A continuous prospective study of 17 revisions out of 295 primary hip arthroscopies at mean 28months' follow-up

INTRODUCTION

The rate of iterative arthroscopy has been increasing over the last decade as the technique has grown. The results of and reasons for these revision procedures, however, are not exactly known. We therefore conducted a prospective study to shed light on: 1) functional results and patient satisfaction following repeated arthroscopy, and 2) the relevant indications.

HYPOTHESIS

Functional scores and patient satisfaction increase following repeated arthroscopy. MATERIALS AND METHOD: A single-center continuous prospective study without control group included patients undergoing repeated hip arthroscopy between September 2010 and September 2014, with a mean 28months' follow-up (median, 23.3months; range, 12-62months). Preoperative and follow-up functional assessment used the modified Harris hip, WOMAC and Christensen (NHAS) questionnaires, and a satisfaction scale. On etiological analysis, repeated arthroscopy was indicated if a cause of recurrent or persistent pain accessible to arthroscopic treatment was identified.

RESULTS

Seventeen patients were included out of 295 primary arthroscopies (5.7%): 9 male, 8 female; median age, 29.6years (range, 16-48years). Indications for primary arthroscopy comprised 13 cases of femoroacetabular impingement, 3 labrum lesions with instability, 1 chondromatosis and 1 case of osteoarthritis. Eleven of the 17 primary lesions showed persistence, including 9 of the 13 cases of femoroacetabular impingement. There were 3 failures in 17 repeated arthroscopies. All functional scores improved, with a gain of 7 points (P<0.06) on modified Harris hip score, 25 points (P<0.0006) on WOMAC score, and 27 points (P<0.001) on NHAS score. Ten of the 17 patients were satisfied or very satisfied with the repeated arthroscopy (59%).

CONCLUSION

Although less good than on primary arthroscopy, functional results on repeated hip arthroscopy were satisfactory in the short term. The main reason for repeated arthroscopy was persistence of initial abnormality due to insufficient treatment.

Randomized Controlled Trial Evaluating a Standardized Strategy for Uveitis Etiologic Diagnosis (ULISSE)

PURPOSE

To prospectively assess the efficiency of a standardized diagnostic approach, compared to an open strategy, for the etiologic diagnosis of uveitis.

DESIGN

Noninferiority, prospective, multicenter, clustered randomized controlled trial.

METHODS

Consecutive patients with uveitis, who visited 1 of the participating departments of ophthalmology, were included. In the standardized group, all patients had a minimal evaluation regardless of the type of uveitis (complete blood count, erythrocyte sedimentation rate, C-reactive protein, tuberculin skin test, syphilis serology, and chest radiograph) followed by more complex investigations according to ophthalmologic findings. In the open group, the ophthalmologist could order any type of investigation. Main outcome was the percentage of etiologic diagnoses at 6 months.

RESULTS

Nine hundred and three patients with uveitis were included from January 2010 to May 2013 and the per-protocol population comprised 676 patients (open 373; standardized 303). Mean age at diagnosis was 46 years. Anatomic distribution of uveitis was as follows: anterior (60.8% and 72.3%, P = .0017), intermediate (11.7% and 12.3%, P = .8028), posterior (17.8% and 8.2%, P = .0004), and panuveitis (15.3% and 15.2%, P = .9596). An etiologic diagnosis was established in 54.4% of cases in the open group and 49.5% in the standardized group (P = .2029). The difference between both strategies (standardized minus open) was -4.9% (95% CI [-12.5%; 2.6%]). There were more investigations in the open group than in the standardized group (5371 vs 3759, P < .0001).

CONCLUSION

The standardized strategy appears to be an efficient diagnostic approach for the etiologic diagnosis of uveitis, although its noninferiority cannot be proved.

Hip arthroscopy protocol: expert opinions on post-operative weight bearing and return to sports guidelines

The objectives of this study are to survey the weight-bearing limitation practices and delay for returning to running and impact sports of high volume hip arthroscopy orthopedic surgeons. The study was designed in the form of expert survey questionnaire. Evidence-based data are scares regarding hip arthroscopy post-operative weight-bearing protocols. An international cross-sectional anonymous Internet survey of 26 high-volume hip arthroscopy specialized surgeons was conducted to report their weight-bearing limitations and rehabilitation protocols after various arthroscopic hip procedures. The International Society of Hip Arthroscopy invited this study. The results were examined in the context of supporting literature to inform the studies suggestions. Four surgeons always allow immediate weight bearing and five never offer immediate weight bearing. Seventeen surgeons provide weight bearing depending on the procedures performed: 17 surgeons allowed immediate weight bearing after labral resection, 10 after labral repair and 8 after labral reconstruction. Sixteen surgeons allow immediate weight bearing after psoas tenotomy. Twenty-one respondents restrict weight bearing after microfracture procedures for 3–8 weeks post-operatively. Return to running and impact sports were shorter for labral procedures and bony procedures and longer for cartilaginous and capsular procedures. Marked variability exists in the post-operative weight-bearing practices of hip arthroscopy surgeons. This study suggests that most surgeons allow immediate weight bearing as tolerated after labral resection, acetabular osteoplasty, chondroplasty and psoas tenotomy. For cartilage defect procedures, 6 weeks or more non-weight bearing is suggested depending on the area of the defect and lateral central edge angle. Delayed return to sports activities is suggested after microfracture procedures. The level of evidence was Level V expert opinions.

Microinstability of the hip: A review

With the development of conservative hip surgery techniques, new entities such as microinstability have been identified. Microinstability is a painful supra-physiological mobility of the hip. It results from the association of architectural and functional abnormalities impairing joint stability. These risk factors concern hip joint bone architecture or peri-articular soft tissues. Bone abnormalities are identified on hip assessment parameters. Soft tissues also play a key role in the static and dynamic stability of the hip: the joint capsule, labrum, ligamentum teres and adjacent myotendinous structures affect joint coaptation; any abnormality or iatrogenic lesion concerning these structures may constitute a risk factor for microinstability. Diagnosis is based on interview, clinical examination and imaging. Findings of labral lesions or femoro-acetabular impingement do not rule out microinstability; they may be associated. Treatment is based first on physiotherapy for muscle reinforcement to improve joint coaptation. In case of failure, arthroscopic surgery is indicated for femoro-acetabular impingement and capsular plicature which is being evaluated. Periacetabular osteotomy or shelf acetabuloplasty may be indicated, according to the severity of joint bone architecture abnormality. Microinstability is a multifactorial entity. Lesions induced by microinstability may in turn become risk factors for aggravation. Diagnosis and indications for surgery are thus difficult to establish. Only full clinical examination and exhaustive imaging assessment allow microinstability and associated lesions to be identified.

How to best measure femoral length and lateralisation after total hip arthroplasty on antero-posterior pelvic radiographs

PURPOSE

Various methods exist for measuring limb length and lateralisation after total hip arthroplasty. Most of them utilise standard anteroposterior (AP) pelvic radiographs, but their results can be affected by patient position during imaging and thus the position of the lower limb on the coronal plane. The aim of this study is to evaluate how commonly used measuring methods of limb lengthening and femoral offset are affected by the position of the lower limb in the coronal plane.

METHODS

A standing pelvic AP radiograph post implantation of a right total hip prosthesis was digitised. The right femur and its femoral stem were digitally segmented, such that they could be positioned orthogonal to the pelvis horizontal reference, with 10° of adduction, and with 10° of abduction, with respect to the centre of rotation. Various limb lengths and implant lateralisation were also digitised. We obtained nine x-rays differing one to three variables. Twice four independent surgeons performed three femoral length measurement methods and femoral offset measurement methods. Intra and inter-observer error as well as the effect of the femoral position on the measurements were studied.

RESULTS

With respect to length measurements, the distance between the centre of rotation (C) and the tip of the lesser trochanter (LT) increased by 3 mm per cm of lateralisation. This measurement was not affected by the hip position in abduction or adduction. The distance between the tip of the lesser or greater trochanter (GT) and the horizontal passing through the centre of rotation was strongly affected by the hip position in abduction or adduction. With respect to offset, the distance between the centre of rotation and the greater trochanter (C-GT) was the most consistent and was not affected by variations in lengths or femoral axis. At the level of the lesser trochanter, the distance of the femoral anatomical axis and to Perkin's line was heavily influenced by the femoral position.

CONCLUSION

The C-LT distance was consistent in measuring limb length and the C-GT distance was reliable in determining femoral offset regardless of the relative position of the femur.

Evolution of slipped capital femoral epiphysis after in situ screw fixation at a mean 11 years' follow-up: a 222 case series

INTRODUCTION

Slipped capital femoral epiphysis (SCFE) can lead to hip impingement, more or less rapidly depending on initial slippage severity and on surgical technique. Various surgical options are applicable, including in situ fixation (ISF). The aim of the present study was to look for long-term signs of radiological impingement in hips treated for SCFE by IFS, in order to identify a slip threshold beyond which impingement more regularly appears.

MATERIAL AND METHODS

A multicenter retrospective study assessed the clinical and radiological evolution of patients operated on by ISF for SCFE, with a minimum 10 year's follow-up. Coxometric analysis of postoperative and last follow-up radiographs was performed. Functional outcome was assessed on Oxford hip score and radiographic osteoarthritis on the Tönnis classification. Alpha angle was measured on lateral views to highlight hip impingement.

RESULTS

Two hundred and twenty-two hips were included, with a mean 11.2 years' follow-up. Mean age at diagnosis was 12.8 years. Mean preoperative Southwick angle was 38.8°, with 43% of hips at stage I, 42% at stage II and 15% at stage III. At latest follow-up, mean Oxford score was 14.86, with 88% of hips rated Tönnis 0 or I. Only 15 cases of impingement were diagnosed. There seemed to be a non-significant trend for hip impingement in SCFE exceeding 35°.

CONCLUSION

ISF led to hip impingement in moderate to severe initial epiphyseal displacement. However, in smaller displacement, the consequences were milder, with perfectly satisfactory function scores and no clinical or radiological evidence of impingement. The threshold seemed to be around 35° slippage, beyond which other surgical options than ISF should be considered. Thus, it seems reasonable to propose isolated ISF in SCFE<35° and to treat symptomatic impingement by surgery in stage II slips.

"Femoroacetabular impingement". Legg-Calve-Perthes disease: from childhood to adulthood

OBJECTIVES

The objective of this study was to investigate cases of femoroacetabular impingement (FAI) and analyze the risk factors for a painful hip at skeletal maturity after Perthes disease. We hypothesized that FAI occurs as a sequela of Perthes disease and that coxa plana and triple osteotomy of the pelvis (TOP) may be risk factors.

METHODS

Ninety-five hips were included from 1981 to 2011, 56 of which were operated on with TOP (53) or shelf acetabuloplasty (3). The results were evaluated at a mean 13years of follow-up (range, 2-23years) with Oxford score and hip radiograph analysis including the Stulberg grade, coxometry, and presence of a femoral bump. FAI was characterized by positional hip pain with preserved joint space and aspherical/nonspherical femoral head.

RESULTS

The Oxford score was optimal (12) in 79 hips (75%) and 20 or above in nine hips (9.5%). Seventeen hips were rated Stulberg I (18%), 36 Stulberg II (38%), 27 Stulberg III (28%), and 15 Stulberg IV or V (16%). The average acetabular angle was 10° (range, -4 to 25), VCE 41.5° (range, 18-80), and VCA 38.5° (range, 13-70). A femoral bump was noted in 31 hips (33%). Five cases of FAI were managed operatively with at least pain relief. Hip pain at the latest follow-up correlated with coxa plana (P=0.0003) and femoral bump (P=0.007). No significant correlation was found with a history of hip surgery or coxometry parameters.

CONCLUSION

Perthes hips bear risk for later FAI. Risk factors include coxa plana and femoral bump. In case of TOP, it is advocated to avoid excessive tilt, which may cause FAI.

LEVEL OF EVIDENCE

IV.

Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement

PURPOSE

Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management.

METHODS

We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented.

RESULTS

Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P = .008), Hip Outcome Score-Activities of Daily Living (P = .02), and Hip Outcome Score-Sport (P = .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5° improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported.

CONCLUSIONS

This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes.

LEVEL OF EVIDENCE

Systematic review of Level IV and V (case report) studies.

The incidence of trochlear dysplasia in anterior cruciate ligament tears

PURPOSE

The purpose of the present epidemiologic study is to record the radiographic presence of trochlear dysplasia and patella alta in patients who undergo anterior cruciate ligament (ACL) reconstruction as a potential underlying factor for post-operative anterior knee pain (AKP).

METHODS

All consecutive cases of skeletally-mature ACL-deficient knees that would undergo ACL reconstruction in three different hospitals were prospectively included during a six-month period. Inclusion criteria were acute and sub-acute ACL injury with no previous ipsilateral knee operation. Patients with chronic ACL tears, prior-to-ACL-injury history of patellar instability or other PF disorders were excluded from the study.

RESULTS

A total of 299 knees were included (mean age 32 ± ten years). Forty-four (14.7 %) knees had a positive 'crossing sign' in the lateral X-rays and 255 (85.3 %) had no sign of trochlear dysplasia (p < 0.01). Among the cases with trochlear dysplasia, 41 (93 %) had type A trochlear dysplasia with the presence only of the 'crossing sign' and three (7 %) had type C trochlear dysplasia. Patellar height results included a mean Caton-Deschamps index of 1.0 ± 0.14 (0.5-1.4). Twenty (6.6 %) knees had an index of less than 0.8, and two (0.6 %) knees had an index less than 0.6. In contrast, 15 (5.0 %) knees had an abnormal value of more than 1.2, indicating patella alta.

CONCLUSIONS

The most important finding of the study is the increased prevalence of trochlear dysplasia and patella alta in patients with ACL injury, when compared to the incidence of trochlear dysplasia and patella alta in the general population in the literature. This finding could sound as an alert of a possible additional risk factor for post-operative anterior knee pain after ACL reconstruction.

Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction

PURPOSE

The aim of the study was to compare three different procedures performed by the same surgeon: mono-bundle patellar tendon reconstruction (bone-patellar tendon-bone, BPTB), double-bundle hamstring reconstruction (DBH) and mono-bundle patellar tendon combined with extra-articular reconstruction (Lemaire) (BPTB + L).

METHODS

A total of 75 patients (25 in each group) were evaluated at a mean follow-up of 25 months. Laxity was assessed pre- and post-operatively with Telos™ stress radiographs (15 kg). The amount of anterior tibial translation (ATT) corrected by the surgery was quantified. Secondary outcomes were International Knee Documentation Committee (IKDC) scores, pivot shift grading, pain complaints, sensory deficits, subsequent surgical procedures, return to sports and patients' ability to kneel or squat on their affected knee.

RESULTS

Absolute correction of ATT for the internal compartment was not statistically significant [analysis of variance (ANOVA), p=0.377]. For the external compartment BPTB + L (8.2 mm) showed superiority over DBH (5.6 mm) and BPTB (4.1 mm) (ANOVA, p=0.0001, Tukey's test). Kneeling was better in the DBH group (ANOVA, p=0.0001, Tukey's test). In 22 patients it felt normal, while only in seven in the BPTB and eight in the BPTB + L groups. Sensory deficits were present in 11 patients from the DBH group, while in 17 in the BPTB and 19 in the BPTB + L groups (ANOVA, p=0.052). Mean IKDC values, presence of anterior knee pain, subsequent operations, ability to squat and return to sports were not statistically different between groups.

CONCLUSIONS

Absolute correction of ATT was not statistically different for the medial compartment, but the patellar tendon reconstruction combined with the extra-articular procedure achieved the best lateral compartment ATT correction. Sensory deficits and kneeling seem to be worse in the groups where the patellar tendon is harvested.

Double-bundle bone-patellar tendon-bone and gracilis in ACL reconstruction

An original technique for the reconstruction of the anterior cruciate ligament is explained. Two bundles are reconstructed using the central third of the patellar tendon and the gracilis tendon, passed through four tunnels but requiring only two interference screws for fixation. Level of evidence V.

Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study

INTRODUCTION

Surgical treatment of femoroacetabular impingement can be performed under arthroscopic control, to limit associated morbidity. Encouraged by recent good reports, arthroscopy is replacing alternative techniques for this indication.

HYPOTHESIS

Arthroscopy enables femoroacetabular impingement to be corrected with a low rate of associated morbidity.

AIM OF STUDY

To assess the indications for and quality of the technique and its impact on preliminary results and complications. To investigate preoperative prognostic factors.

PATIENT AND METHODS

One hundred and eleven hips in 110 patients (78 male, 32 female; mean age, 31 years) were operated on under arthroscopic control for femoroacetabular impingement, by six senior surgeons. Sixty-five patients showed no radiographic sign of osteoarthritis, and 36 showed grade-1 early osteoarthritis on the Tönnis scale.

RESULTS

Mean WOMAC score rose from 60.3 preoperatively to 83 (p<0.001) at a mean 10 months' FU (range, 6-18 mo). Seventy-seven percent of patients were satisfied or very satisfied with their result. Patients with early osteoarthritis had significantly lower WOMAC and satisfaction scores than those free of osteoarthritis. Operative crossover to open surgery occurred in only one case. Five patients (4%) had revision: total hip replacement or resurfacing. There were seven complications (6%): three cases of heterotopic ossification, one of crural palsy, one of pudendal palsy, one of labium majus necrosis, and one non-displacement stress fracture of the femoral head/neck junction (managed by non-weight-bearing). There was no palsy of the territory of the lateral cutaneous nerve of the thigh.

DISCUSSION

Results confirmed the efficacy and low associated morbidity of arthroscopy in the management of femoroacetabular impingement. Short-term functional results matched those of the literature. Planning and assessment seem not yet to be fully standardized. Preoperative osteoarthritis on X-ray was associated with poorer functional results. This attitude does not seem to be indicated for hips showing evolved osteoarthritis (>grade 1).

Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review

Two hundred and ninety-two patients, aged between 16 and 50 years and presenting with mechanical hip pathology, were included in a prospective multicenter study. The descriptive study concerned the clinical examination and analysis of three X-ray views (AP pelvic, Lequesne false profile and lateral axial view). The series comprised 62% males, mean age 35 years, with 53% right side and 22% bilateral involvement. Initial trauma was reported in 19% of cases, and direct familial history of hip pathology in 20%. Seventy percent of the patients played sports, 30% were high-level athletes, and 17% played combat sports. The physical impingement sign was present in 18% to 65% of cases depending on the variant studied. On imaging (n=241), 62% of hips showed osteoarthritis, with 25% at the evolved stage. In the series, as a whole, there was a 35% rate of dysplasia, 63% of impingement and 5% of normal X-ray results. The radiologic impingement aspects were 58% cam-type, 19% pincer-type and 23% mixed. Twenty-two percent of dysplasia cases showed signs of associated impingement. Pain experienced exclusively in flexion/internal rotation/adduction on examination showed little sensitivity (20%) but considerable specificity (86%) for the main diagnosis of impingement. The links between impingement and dysplasia are discussed, and an integrative schema of all risk factors is put forward.

Adult tibial eminence fracture fixation: arthroscopic procedure using K-wire folded fixation

The purpose of this article is to describe a new and simple technique for arthroscopic fixation of tibial intercondylar eminence avulsion fractures using folded surgical pin. This technique allows reduction and fixation of the bone fragment without using special equipment. After standard arthroscopic procedure to explore the knee and to remove fracture debris and blood clot, the bone block is reduced and advanced with the spike of the anterior cruciate ligament tibial drill guide. A 1.8-mm K-wire is drilled through the guide from the proximal tibia into the reduced fragment. It is bent on its end into the joint with a strong needle case. The K-wire is then pulled back until good fragment compression to the tibia appears with the wire starting unbending. Next, the other side is bent on the anterior tibial cortex and cut. This arthroscopic fixation allows elastic compression fragment stabilization that authorizes early weight bearing and rehabilitation programs. The material is extracted by traction after 6 months.

Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up

A retrospective review of 29 patients (30 knees) was carried out who had previously undergone a single-stage combined ACL reconstruction with valgus upper tibial osteotomy for chronic ACL rupture coupled with early medial tibio-femoral arthritis. Of the 30 knees, 19 (63%) had had a previous medial meniscectomy. Major complications occurred in two knees resulting in stiffness. At a mean of 12 years follow-up (6-16 years) only five knees (17%) had progressed one arthritis grade. Fourteen patients (47%) returned to intensive sports, and a further 11 (37%) played moderate sports. The mean difference in anterior tibial translation with the opposite normal knee was 3 mm at review. It was concluded that the combined operation has a low morbidity, controls anterior laxity, allows many patients to return to sports, and does not result in a rapid progression of osteoarthritis.

Kniegelenknahe Flexions- und Extensionsosteotomien beim Erwachsenen

The present review analyzes the rare indications for sagittal knee osteotomies either for some complex cases of capsular and ligamentous laxities in combination with or without bony deformities in the sagittal plane. A thorough clinical and radiological analysis of the patients' knees is mandatory. We routinely recommend lateral standing X-rays to assess not only the bony structures, but also an abnormal knee laxity in the sagittal plane. We present different surgical options and preliminary results of these technically demanding procedures.

Réinsertion du tendon fléchisseur par ancre de suture : étude prospective continue avec mobilisation active précoce

INTRODUCTION

The aim of this study was to evaluate subjective and functional results of a prospective continuous series of immediate tendon-to-bone repair of the F.D.L. using a miniaturized anchor.

METHOD

Seven patients have been operated by the same surgeon in emergency for a section of the FDL in zone one. Distal tendon-to-bone re-attachment has been realized using a mini-G II Mitek anchor suture. Five of the patient were male, four of them being manual workers. Only one had a work accident. According to Leddy and Packer's classification one patient had a stage 1 lesion and the six others had stage two lesions. The injured fingers showed associated lesions in four cases. Rehabilitation consisted of early active mobilization protected by a Duran-type splint. All the patients had been examined by an independent surgeon at 10 months follow-up. Mean age at that time was 32 years.

RESULTS

One patient was very satisfied with his results while the six others were satisfied. Two minor complications were encountered, one of them being directly in relation to the implant. Total Active Motion (TAM) summed up to 92% of the arch of motion of the normal controlateral finger. Pinch-force reached 81% compared to that of the controlateral finger. Two patients described no pain. Mean eviction from work was 70 days.

DISCUSSION

Tendon-to-bone repair of the FDL using an anchor seems to give good results on pain, TAM and on force. The only complication due to the implant did not have any functional incidence. The series of Marin Braun on 77 cases of such repairs using a barb-wire show similar results compared to the implant used in our series. However, anchor sutures have several advantages compared to a transcutaneous device: they reduce the risk of infection, of nail dystrophy and they offer a better comfort to the patient.

Effect of somatostatin on diarrhea and on small intestinal water and electrolyte transport in a patient with pancreatic cholera

The effects of somatostatin on diarrhea and on small intestinal flow of water and electrolytes (slow-marker perfusion technique) in a patient with pancreatic cholera are reported. Continuous intravenous infusion of somatostatin (8 micrograms/kg/hr) suppressed the diarrhea, but a rebound was observed after somatostatin. Infusion of somatostatin at the same dosage decreased the ileal fluid flow rate to within control values. This effect was mainly due to a sharp reduction in the rate fluid entered the jejunum, but was also due to a suppression of the abnormal water and electrolyte secretion in the proximal jejunum. Secretion in the rest of the small bowel remained unchanged. Somatostatin did not noticeably alter the high preinfusion plasma level of prostaglandin E1, but decreased the initially high plasma concentration of vasoactive intestinal peptide to normal values. These results suggest that long-acting somatostatin analogs could be of value in the symptomatic treatment of diarrhea in pancreatic cholera.