Long-term results of arthroscopic labral debridement: predictors of outcomes

Limited data exist regarding the long-term results of labral debridement and the effect of coexisting pathology on outcomes. Our hypothesis was that untreated coexisting hip pathologies such as femoroacetabular impingement and arthritis significantly affect the outcomes of arthroscopic labral debridement. Between 1996 and 2003, fifty consecutive patients who underwent hip arthroscopy and labral debridement with a mean follow-up of 8.4 years were included in our study. Patients' preoperative Harris Hip Scores and coexisting pathologies such as femoroacetabular impingement, dysplasia, or arthritis were recorded as variables. Postoperative Harris Hip Score and satisfaction at final follow-up were recorded as outcomes. Good or excellent results were achieved in 62% of cases (58% in patients with untreated femoroacetabular impingement and 19% in patients with arthritis). Failures included 2 cases that were converted to total hip replacement (4.5 and 5.2 years after index procedure) due to advancement of arthritis and 1 case of repeat arthroscopy for cam decompression. Patients with no coexisting pathology had significantly higher satisfaction and Harris Hip Scores. Almost all of the patients with low postoperative Harris Hip Scores had arthritic changes. Arthritis had a significant correlation with low postoperative Harris Hip Scores and satisfaction. Coexisting pathology, especially arthritis and untreated femoroacetabular impingement, can result in inferior outcomes. Arthroscopic labral debridement of symptomatic tears in selected patients with no coexisting pathology can result in favorable long-term results. Arthritis is the strongest independent predictor of poor outcomes.     

An algorithmic approach to surgical decision making in acetabular retroversion

The optimum treatment for the young adult patient with symptomatic femoroacetabular impingement due predominately to acetabular retroversion remains unknown. The retroversion deformity can be associated with a volumetrically deficient or sufficient acetabulum based on the adequacy of lateral and posterior coverage. We prospectively collected clinical data from 2001 to 2006 on 60 hips with symptomatic femoroacetabular impingement that had radiographic evidence of acetabular retroversion defined as a crossover sign on an adequate anteroposterior radiograph or retroversion on magnetic resonance imaging or computed tomography. Our treatment algorithm for acetabular retroversion used measurements of acetabular coverage (lateral center edge angle and the posterior wall sign) and condition of acetabular cartilage to direct treatment of acetabular retroversion. The algorithm directed the surgeon to perform a periacetabular osteotomy in 30 hips and a surgical dislocation and osteochondroplasty of the femoral head-neck junction and acetabular rim in 30 hips. Harris Hip Score improved from 52 to 90 in the hips treated with surgical dislocation and osteochondroplasty and 72 to 91 in the hips treated with periacetabular osteotomy, with an overall survivorship of 96% at 4 years. Patient follow-up averaged 46 months (range, 24-75 months). Elimination of the crossover sign and correction of the posterior wall sign occurred in >90% of all patients when present. The results indicate that hips with acetabular retroversion, deficient posterior and/or lateral acetabular coverage, and intact hyaline cartilage can be effectively treated with acetabular reorientation, while retroverted hips with anterior overcoverage but sufficient posterior coverage are effectively treated with osteochondroplasty of the acetabulum and proximal femur.     

Editorial Commentary: Prolonged Delays in Staging Bilateral Hip Arthroscopic Surgery for Femoroacetabular Impingement May Result in Inferior Patient Outcomes: Two Halves of One Problem

Patients with symptomatic femoroacetabular impingement frequently have contralateral symptoms and, thus, alterations to the biomechanics of both hips. It has become increasingly clear that prolonged delays in staging bilateral hip arthroscopic surgery may result in inferior patient outcomes. There is an interchange between primary surgical recovery and altered biomechanics stemming from the untreated hip. At a certain point, the persistence of microinstability and/or femoroacetabular impingement in one hip becomes a limitation to the recovery of the other. Still, individual patient variability remains a critical factor when considering bilateral surgeries. Some patients cannot tolerate 2 surgeries in proximity. The time frame for bilateral surgery should be based on individual patient factors and functional goals.     

Imageless versus image-based registration in navigated arthroscopy of the hip: a cadaver-based assessment

The aim of this study was to determine the accuracy of registration and the precision of the resection volume in navigated hip arthroscopy for cam-type femoroacetabular impingement, using imageless and image-based registration. A virtual cam lesion was defined in 12 paired cadaver hips and randomly assigned to either imageless or image-based (three-dimensional (3D) fluoroscopy) navigated arthroscopic head-neck osteochondroplasty. The accuracy of patient-image registration for both protocols was evaluated and post-operative imaging was performed to evaluate the accuracy of the surgical resection. We found that the estimated accuracy of imageless registration in the arthroscopic setting was poor, with a mean error of 5.6 mm (standard deviation (sd) 4.08; 95% confidence interval (CI) 4.14 to 7.19). Because of the significant mismatch between the actual position of the probe during surgery and the position of that probe as displayed on the navigation platform screen, navigated femoral osteochondroplasty was physically impossible. The estimated accuracy of image-based registration by means of 3D fluoroscopy had a mean error of 0.8 mm (sd 0.51; 95% CI 0.56 to 0.94). In terms of the volume of bony resection, a mean of 17% (sd 11; -6% to 28%) more bone was resected than with the virtual plan (p = 0.02). The resection was a mean of 1?mm deeper (sd 0.7; -0.3 to 1.6) larger than on the original virtual plan (p = 0.02). In conclusion, given the limited femoral surface that can be reached and digitised during arthroscopy of the hip, imageless registration is inaccurate and does not allow for reliable surgical navigation. However, image-based registration does acceptably allow for guided femoral osteochondroplasty in the arthroscopic management of femoroacetabular impingement.     

Editorial Commentary: Fracture Risk After Arthroscopic Osteochondroplasty for Femoroacetabular Impingement—How Can We Become Better?

There is an increased risk of fracture following osteochondroplasty at the femoral head–neck junction for cam-type femoroacetabular impingement. The amount of safe resection has previously been investigated through several biomechanical models, including composite bone, cadaver, animal, and finite element models. Translation of ex vivo results regarding safe resection to an arthroscopic procedure on an actual patient remains a research and clinical challenge.     

Use of Intraoperative Computed Tomography Scanning in Determining the Magnitude of Arthroscopic Osteochondroplasty

Femoroacetabular impingement has recently become a recognized cause of disability and hip arthritis. Hip arthroscopy and femoroacetabular reshaping have been performed to treat this condition. Quantification of the excess femoral and acetabular bone requiring resection has been challenging with the less invasive arthroscopic technique. We describe the use of intraoperative computed tomography assessing osteochondroplasty during arthroscopic surgery to treat cam- and pincer-type femoroacetabular impingement. We also describe the technical steps and present the important radiologic findings we have been able to visualize. We found intraoperative computed tomography scanning to be a reliable and reproducible method of assessing the quality of femoroacetabular impingement surgery. We believe that femoroacetabular impingement surgery can be assessed intraoperatively by use of computed tomography scanning where corrections can be made if necessary.     

Treatment of failed arthroscopic acetabular labral debridement by femoral chondro-osteoplasty: a case series of five patients

Femoroacetabular impingement is recognised as being a cause of labral tears and chondral damage. We report a series of five patients who presented with persistent pain in the hip after arthroscopy for isolated labral debridement. All five had a bony abnormality consistent with cam-type femoroacetabular impingement. They had a further operation to correct the abnormality by chondro-osteoplasty of the femoral head-neck junction. At a mean follow-up of 16.3 months (12 to 24) all had symptomatic improvement.     

Editorial Commentary: The Competitive Dancer’s Hip—An Acquired Flexible Attitude to a High-Performance Hip

Competitive dancers have a high prevalence of hip injuries. The dancer’s hip is a unique scenario in which hip impingement is associated with compensatory soft-tissue laxity. Particularly in these athletes, normal osseous hip morphology with symptomatic femoroacetabular impingement may be observed. The repetitive training, including extreme daily hip range of motion, results in compensatory soft-tissue laxity and secondary impingement-induced subluxation. Peculiarly, hip impingement in dancers occurs in the posterosuperior aspect of the hip and extra-articularly between the anterior inferior iliac spine and the distal femoral neck (subspinous impingement). Normal or even dysplastic hips might impinge during extreme range of motion. An atypical osteochondroplasty, including a subtle distal-based femoral resection, anterior inferior iliac spine decompression, and excellent management of the capsule, should be considered in this population for a successful outcome. Hip dysplasia should always be ruled out in these athletes, and if present, a periacetabular osteotomy should be indicated.     

Current concepts in the treatment of adolescent femoroacetabular impingement

There is growing evidence that symptomatic femoroacetabular impingement leads to intra-articular damage and the development of early-onset osteoarthritis. Symptoms of femoroacetabular impingement often do not manifest until adulthood, but have been increasingly recognised in the paediatric and adolescent population. The surgical treatment of femoroacetabular impingement is aimed at restoring a more normal femoral head–neck offset in order to increase the clearance and prevent femoral abutment against the acetabular edge. Current methods include open and arthroscopic techniques. The latter has been combined with an open approach to gain access to the head–neck junction for osteochondroplasty. Proximal femoral and/or periacetabular osteotomies are used to treat femoroacetabular impingement associated with deformity secondary to childhood hip conditions, such as slipped capital femoral epiphysis and Legg–Calvé–Perthes disease. Some adolescents have severe degenerative joint disease at the time of presentation and may require arthroplasty or arthrodesis. The aim of this review is to identify the major trends and advancements in the management of femoroacetabular impingement in adolescents, including the outcome of studies of the surgical treatment modalities used.     

Why large-head metal-on-metal hip replacements are painful: the anatomical basis of psoas impingement on the femoral head-neck junction

Large-head metal-on-metal total hip replacement has a failure rate of almost 8% at five years, three times the revision rate of conventional hip replacement. Unexplained pain remains a feature of this type of arthroplasty. All designs of the femoral component of large-head metal-on-metal total hip replacements share a unique characteristic: a subtended angle of 120° defining the proportion of a sphere that the head represents. Using MRI, we measured the contact area of the iliopsoas tendon on the femoral head in sagittal reconstruction of 20 hips of patients with symptomatic femoroacetabular impingement. We also measured the articular extent of the femoral head on 40 normal hips and ten with cam-type deformities. Finally, we performed virtual hip resurfacing on normal and cam-type hips, avoiding overhang of the metal rim inferomedially. The articular surface of the femoral head has a subtended angle of 120° anteriorly and posteriorly, but only 100° medially. Virtual surgery in a normally shaped femoral head showed a 20° skirt of metal protruding medially where iliopsoas articulates. The excessive extent of the large-diameter femoral components may cause iliopsoas impingement independently of the acetabular component. This may be the cause of postoperative pain with these implants.     

Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age

We reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54). The mean modified Harris hip score improved by 19.2 points (95% confidence interval 13.6 to 24.9; p < 0.001) while the mean non-arthritic hip score improved by 15.0 points (95% confidence interval 10.9 to 19.1, p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The overall level of satisfaction was high with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred. Arthroscopic femoral osteochondroplasty performed in selected patients over 60 years of age, who have hip pain and mechanical symptoms resulting from cam femoroacetabular impingement, is beneficial with a minimal risk of complications at a mean follow-up of 30 months.     

Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable?

Background

Magnetic resonance arthrography (MRA) is commonly used to demonstrate injury to the labrum and hyaline cartilage in patients with femoroacetabular impingement (FAI). The purpose of this study was to assess the diagnostic correlation between MRA and findings at arthroscopic and open surgery.

Materials and methods

MRA reports of 41 hips with symptomatic FAI were reviewed and compared with subsequent intraoperative findings (n = 21 surgical dislocations and n = 20 therapeutic hip arthroscopies). Each case was assessed for the presence of a cam deformity, a cartilage lesion of the femoral head, an os acetabuli, an injury to the labrum and injury to the acetabular cartilage. Results were collected prospectively in a cross-table and analysed retrospectively for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results

The sensitivity, specificity, PPV and NPV in the presence of reported cam-type deformity or an os acetabuli were 100 %. In the presence of cartilage lesions of the femoral head, the values were 46, 81, 55 and 73 %, respectively. For labral tears, the values were 91, 86, 97 and 67 %. In the presence of acetabular cartilage injuries, the values were 69, 88, 78 and 81 %, respectively.

Conclusions

MRA appears to be an efficacious imaging modality in the evaluation of labral tears, cam-type impingement lesions and os acetabuli of the hip. MRA is less efficacious in the diagnosis of cartilage abnormalities in the hip, both femoral and acetabular. Researchers should focus on further improvements in imaging techniques in order to give reliable preoperative information to the surgeon.     

Surgical management of healed slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) results in posterior and inferior displacement of the epiphysis on the femoral neck. In most centers, the recommended initial management of stable SCFE is in situ pinning. Minimal reduction with in situ pinning is recommended for unstable SCFE. This approach does not restore the normal anatomy of the hip joint, and the resulting proximal femoral deformity may cause femoroacetabular impingement. Patients with femoroacetabular impingement experience reduced hip range of motion as well as hip pain, and they are at risk of early-onset hip osteoarthritis. Techniques for managing this deformity include arthroscopic femoral neck osteochondroplasty, a limited anterior hip approach or surgical hip dislocation, and flexion intertrochanteric osteotomy. These surgical techniques should be considered for patients with healed SCFE deformity who present with hip pain at an early age.     

Clinical and radiological outcomes following surgical hip dislocation for paediatric hip pathologies,a prospective cohort study

BackgroundSurgical Hip Dislocation (SHD) is a powerful tool in the armamentarium of any surgeon treating conditions affecting the hips of children presenting with sequelae of a number of common conditions including Legg-CalvéPerthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). Risks associated with the procedure are well described. We investigated to assess if SHD is associated with significant surgical risk and if it improved clinical outcomes for patients.MethodsWe conducted a prospective cohort study. We reviewed 18 (11 males and 7 females; mean age 13.7 years (6–17) with symptomatic hip pathology, secondary to femoroacetabular impingement (FAI) between 2017 and 2021. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty, Head Split osteotomy or both. Clinical improvement was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. The minimum follow-up was 6 months (mean, 22 months; range, 6–42 months).ResultsWOMAC scores improved at final follow-up from 10 to 3 for pain, 33 to 10 for function, and 4 to 2 for the stiffness subscales. All radiographic measures improved significantly of the postoperative X-rays. No patients developed osteonecrosis, implant failure, deep infection, or nonunion.ConclusionSurgical Hip Dislocation, in the short term, we found improvement in WOMAC scores and radiographic indices with a low complication rate.     

Arthroscopic treatment of femoroacetabular impingement secondary to paediatric hip disorders

Open reduction of the prominence at the femoral head-neck junction in femoroacetabular impingement has become an established treatment for this condition. We report our experience of arthroscopically-assisted treatment of femoroacetabular impingement secondary to paediatric hip disease in 14 hips in 13 consecutive patients (seven women, six men) with a mean age of 30.6 years (24 to 39) at the time of surgery. The mean follow-up was 2.5 years (2 to 4). Radiologically, 13 hips had successful restoration of the normal geometry and only one had a residual deformity. The mean increase in the Western Ontario McMasters Osteoarthritis Index for the series at the last follow-up was 9.6 points (4 to 14). No patient developed avascular necrosis or sustained a fracture of the femoral neck or any other complication. These findings suggest that femoroacetabular impingement associated with paediatric hip disease can be treated safely by arthroscopic techniques.     

关节镜下股骨头颈成形术治疗凸轮型股骨髋臼撞击症

 目的 探讨髋关节镜下股骨头颈成形术治疗凸轮（Cam）型股骨髋臼撞击症的可行性及临床疗效。方法 2007年10月至2009年4月收治Cam型股骨髋 臼撞击症患者31例,男12例,女19例;年龄18～45岁,平均34.1岁。术前行体格检查、X线摄片和三维CT明确诊断。所有病例均行髋关节镜下关节清理术和股骨 头颈成形术。术后1个月、3个月、6个月、1年及以后每年1次随访。比较术前和末次随访时的撞击试验结果、髋关节活动度、α角、疼痛视觉模拟评分（visual analogue scale,VAS）和改良Harris髋关节评分。结果 所有患者均得到随访,随访时间18~36个月,平均22.7个月。末次随访时撞击试验均为阴性,髋关节屈 曲活动度和屈曲90°位内旋活动度分别达到121.0°±11.7°和30.1°±12.7°,α角由术前74.2°±10.7°降至44.7°±8.3°,疼痛VAS由术前（6.1±1.1） 分降至（0.9±0.7）分,改良Harris髋关节评分由术前（41.2±5.7）分提高至（73.6±4.1）分,差异均有统计学意义（P<0.05）。结论 髋关节镜下股骨头颈 成形术能够切除股骨头颈结合部骨性隆起,恢复股骨头颈结合部的自然弧度,有效缓解Cam型股骨髋臼撞击症的症状和改善髋关节活动度。