Arthroscopic treatment for symptomatic bilateral cam-type femoroacetabular impingement

Arthroscopic femoral osteochondroplasty improves clinical outcome in patients with unilateral cam-type femoroacetabular impingement. The goal of this study was to evaluate the clinical outcome and pathological similarities in patients who have had bilateral arthroscopic femoral osteochondroplasy for cam-type femoroacetabular impingement. The study group included 82 patients who had sequential bilateral hip arthroscopies for symptomatic cam-type femoroacetabular impingement with a minimum of 12 months follow-up. All patients had bilateral restricted hips at presentation. We differentiated between patients who had bilateral painful hips and those with unilateral pain at presentation. Scores and surgical findings were compared between the 2 study groups and between bilateral surgeries in each group. Pre- and postoperative Modified Harris Hip Scores and Non-Arthritic Hip Scores were undertaken prospectively by an independent observer. Mean patient age at the first surgery was 29 years (range, 14-63 years). The average time difference between arthroscopies was 5 months (range, 0.3-30 months). Postoperative scores improved significantly in both study groups in the first and second (contralateral) surgeries. Intra-articular pathologies between sides were linearly correlated for both groups. The time interval between surgeries had a linear correlation to age, reverse correlation to chondral damage, and reverse correlation to postoperative scores at the first surgery. Our results suggest that symptomatic patients with cam-type femoroacetabular impingement have similar accompanied pathologies on both sides and can benefit from sequential arthroscopic osteochondroplasty.     

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。     

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.     

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.     

Does Surgical Hip Dislocation and Periacetabular Osteotomy Improve Pain in Patients With Perthes-like Deformities and Acetabular Dysplasia?

BackgroundPatients with symptomatic residual Perthes-like deformities may present with a combination of structural abnormalities including a large aspheric femoral head, short and wide femoral neck, high greater trochanter, and acetabular dysplasia. Sometimes, the hip is further compromised by concurrent symptomatic femoroacetabular impingement (FAI) (proximal femoral deformities) and structural instability (acetabular dysplasia).Questions/purposesWe therefore sought to characterize (1) the intraoperative findings; (2) radiographic correction; and (3) early patient-reported outcomes, complications, and failures of treating complex Perthes-like hip deformities with combined surgical dislocation and periacetabular osteotomy (PAO).MethodsWe performed 694 hip preservation procedures between November 2006 and August 2010. Of these, 46 had residual Perthes-like hip deformities, defined as proximal deformity consistent with residual Perthes and a history of Perthes disease or treatment of pediatric hip dysplasia. Of these, we report on 16 patients (16 hips) with residual Perthes-like hip deformities and associated acetabular dysplasia (structural instability, defined as radiographic evidence of acetabular dysplasia with intraoperative confirmation of instability). These 16 patients were treated with a combined surgical hip dislocation to comprehensively address intraarticular and extraarticular sources of FAI and PAO to address structural instability and were analyzed at a minimum 24-month followup (median, 40 months; range, 24–78 months). No patients in this series were lost to followup. Ten patients’ hips had previous surgical treatment, including six with previous osteotomy. Operative findings were extracted from standardized prospectively collected intraoperative data collection forms. Radiographic correction was evaluated with established methods (lateral center-edge angle, anterior center-edge angle, acetabular inclination, center-to-trochanter distance) and clinical outcomes were measured with the modified Harris hip score (mHHS) as well as by prospectively recorded data on patient complications and followup.ResultsAcetabular labrochondral abnormalities included labral hypertrophy in all hips and labral and/or articular cartilage lesions requiring treatment in 13 hips. Radiographic analysis demonstrated consistent radiographic correction. The median preoperative mHHS improved from 64 to 92 at a median followup of 40 months (p < 0.001). Fourteen patients (14 hips) had a good or excellent clinical result. Two patients (two hips) were classified as failures based on mHHS less than 70 (n = 1) or conversion to total hip arthroplasty (n = 1).ConclusionsCombined surgical hip dislocation and PAO provides major deformity correction in Perthes-like hip deformities with associated acetabular dysplasia. Early clinical results suggest this technique is safe and effective. Long-term studies are needed to determine if improved long-term outcomes are associated with comprehensive deformity correction.

Level of Evidence

Level IV, therapeutic study.     

髋关节外科脱位治疗股骨髋臼撞击综合征合并盂唇损伤

[目的]介绍髋关节外科脱位治疗股骨髋臼撞击综合征合并盂唇损伤的手术技术与初步临床疗效。[方法]2015年8月~2018年4月,采用髋关节外科脱位治疗股骨髋臼撞击综合征合并盂唇损伤23例(23侧),"凸轮"型6例,"钳夹"型2例,混合型15例。患者取健侧卧位,采用髋关节后外侧入路,在大转子下方1.5 cm处截骨,"Z"形切开关节囊,剪断圆韧带,脱出股骨头。去除部分骨性髋臼缘和股骨头颈部多余的骨质,修整盂唇用2.8 mm的带线锚钉缝合固定,大转子骨折块并用2枚7.3 mm的空心钉固定。[结果]23例患者均顺利完成手术并获随访,随访时间12~24个月,平均(15.92±4.63)个月。术后12个月Harris、WOMAC、SF-36和Merle D’Aubignéand Postel评分与术前比较均显著改善,差异均有统计学意义(P<0.05)。末次随访时未出现大转子截骨不愈合和股骨头缺血性坏死的现象。[结论]髋关节外科脱位治疗股骨髋臼撞击综合征合并盂唇损伤,临床疗效满意,并发症少。     

Protrusio Acetabuli: Contraindication or Indication for Hip Arthroscopy? And the Case for Arthroscopic Treatment of Global Pincer Impingement

Protrusio acetabuli has been considered a contraindication for hip arthroscopy. We present the case of a 33-year-old man with bilateral symptomatic protrusio acetabuli—the most extreme form of global pincer femoroacetabular impingement—and cam femoroacetabular impingement. We demonstrate the feasibility of the arthroscopic correction of severe deformities and describe key surgical steps permitting central compartment access, subtotal acetabuloplasty, labral reconstruction, and femoroplasty of the right hip, followed by later subtotal acetabuloplasty, labral refixation, and femoroplasty of the left hip, with improved outcomes at 2 and 1 years, respectively, as measured by the nonarthritic hip score. Though challenging, global pincer impingement, even acetabular protrusion, may be successfully treated with dual-portal outpatient hip arthroscopy. The modified midanterior portal enables central compartment access and extended posterior “reach” in the arthroscopic treatment of major global pincer femoroacetabular impingement, potentially making this contraindication a historical one while respectfully challenging the “global” recommendation for open surgery in this setting.     

Arthroscopic treatment of labral tears in femoroacetabular impingement: a comparative study of refixation and resection with a minimum two-year follow-up

Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (T?nnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection.     

髋臼盂唇损伤的关节镜手术

目的 探讨髋臼盂唇损伤的诊断方法和关节镜治疗结果.方法 2008年11月至2009年12月收治单侧髋臼盂唇损伤行关节镜手术且随访时间超过半年的患者21例,男9例,女12例;年龄17～65岁,平均37.1岁.术前行体格检查、X线和MR关节造影明确诊断.于髋关节镜下行盂唇清理术14例、盂唇清理及股骨头颈区成形术5例、盂唇修复及股骨头颈区成形术2例.结果 Fadir试验阳性21例(100%,21/21),Fabir试验阳性15例(71%,15/21),McCarthy试验阳性9例(43%,9/21).X线片显示11例存在凸轮型撞击(其中6例合并钳夹型撞击),2例为单纯钳夹型撞击.MR关节造影均显示前上象限不同程度的盂唇损伤信号,阳性率100%;所有盂唇损伤均经关节镜证实,准确率100%.全部病例随访6～19个月,平均11.6个月.术后症状明显缓解,疼痛视觉模拟评分由术前(5.3±1.3)分降至术后6个月(1.4±0.9)分,Harris髋关节评分由术前(63±9)分提高至术后6个月(84±10)分,差异均有统计学意义.结论 髋臼盂唇损伤与股骨髋臼撞击有关.撞击试验和MR关节造影具有较高的诊断阳性率和准确率.关节镜下髋臼盂唇损伤的清理、修复与骨成形术可获得满意的早期临床效果.     

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement in Systemic Inflammatory Disease: Pirates Gold in Uncharted Waters

Hip pain in patients with systemic inflammatory diseases may arise from synovitis, cartilage degeneration or bony abnormalities like femoroacetabular impingement or acetabular dysplasia. With advances in early diagnosis and medical management of the autoimmune response, these often-young patients may benefit from correction of underlying bony abnormalities like femoroacetabular impingement. Short-term improvement in patients’ pain and function can be achieved with hip arthroscopic treatment. However, the long-term efficacy of hip arthroscopy in systemic inflammatory disease needs further research. Careful selection of patients with nondysplastic hips without significant cartilage degradation, correction of underlying bony abnormalities, collaboration with rheumatologist, and use of evidence-based perioperative management of anti-rheumatic drugs are keys to success.