Treatment of Femoroacetabular Impingement with Surgical Dislocation

Background

The authors report the results of femoroacetabular impingement (FAI) treated with a surgical dislocation.

Methods

From April 2005 to May 2007, 15 FAI hips were treated with a surgical dislocation. The male/female ratio, mean age and mean symptom duration was 12/2, 35.8 years and 2.3 years, respectively. Radiographs and MR arthrograms were taken. The clinical evaluation involved changes in the pre- and postoperative Harris hip score (HHS).

Results

There were 12 hips (80%) with at least one structural abnormality in the radiographs, with 11 (79%) labral tears and 8 (73%) abnormally high angles in the MR arthrograms. We performed 15 osteochondroplasties, 12 labral repairs, 12 acetabuloplasty, and 3 debridements. The mean HHS improved from 76 to 93 points. Three non-unions of the trochanteric osteotomy sites were encountered as complications.

Conclusions

Radiographs and MR arthrograms are important for making a proper diagnosis of FAI and planning treatment. A surgical dislocation can be used to treat FAI but further technical improvements will be needed for fixation of the greater trochanteric osteotomy sites.     

No Evidence of Systemic Inflammation in Symptomatic Patients With Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain and represents a major cause of early osteoarthritis. The role of systemic inflammation in pre‐arthritic hip conditions remains largely unknown and uninvestigated. Serum‐free light chains (sFLCs) are inflammatory markers produced by B cells. This study aimed to determine whether there was evidence of systemic inflammation in patients with FAI, defined by sFLCs, and whether this correlated with markers of disease severity. Participants for this study were recruited from a single center (Nuffield Orthopedic Center, Oxford) and were taking part in the Femoroacetabular Impingement Trial. The cohort comprised 115 individuals (38 male, 77 female, mean age 37 years): 57 individuals received surgical intervention and 58 received physiotherapy. All individuals provided patient‐reported outcome measures and serum samples at baseline and follow‐up 8 months post‐randomization. sFLC concentrations were measured in serum samples by immunoturbidimetry. At baseline, for all individuals, mean polyclonal sFLC concentrations were 30.36 mg/l (standard deviation [SD] 9.23). At follow‐up, the mean polyclonal sFLC concentrations were 31.68 mg/l (SD 9.61) in the surgical intervention cohort, and 29.48 mg/l (SD 7.85) in the physiotherapy intervention cohort. There was no significant correlation between sFLC concentrations and any of the patient reported outcome measures, or radiographic measures: average or maximum alpha angle, or center edge angle. In conclusion, in patients with symptomatic FAI there was no systemic inflammation, as defined by sFLC concentrations, and no correlation between sFLC concentrations and measures of disease severity. The lack of inflammation suggests FAI is a mechanical phenomenon. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2189–2196, 2019     

Intraoperative Fluoroscopy for Evaluation of Bony Resection During Arthroscopic Management of Femoroacetabular Impingement in the Supine Position

There is a steep learning curve regarding many aspects of arthroscopic management of femoroacetabular impingement. One of the concerns with regard to this approach is verification of appropriate bony resection for cam- and pincer-type pathology. Dynamic assessment and direct visualization of bony resection are the primary means of evaluating appropriate resection. Intraoperative fluoroscopy, however, can be a helpful adjunct when performing the rim resection or femoral resection osteoplasty. We describe a predictable and reproducible fluoroscopic method for performing and verifying appropriate bony resection of pincer and cam lesions in an attempt to help minimize the risk of under- and over-resection.     

Utility of Ultrasound‐Guided Anesthetic Intra‐articular Injection to Estimate the Outcome of Hip Arthroscopy in Patients with Femoroacetabular Impingement Syndrome

ObjectiveTo investigate the effectiveness of ultrasound (US) guided intra‐hip joint injection to estimate the outcome of hip arthroscopy in patients with femoroacetabular impingement (FAI) syndrome.MethodsPatients with FAI syndrome (n = 60) were prospectively enrolled in our study. Before hip arthroscopy, a mix of 4 mL 2% lidocaine and 4 mL 1% ropivacaine were injected into the hip joint under the guidance of US. The clinical efficacy of the intra‐articular injection was evaluated by comparing the visual analog scale (VAS) and international hip outcome tool 12 (iHOT‐12) results before and after the injection. The outcome of hip arthroscopy was evaluated by iHOT‐12, the modified Harris hip score (MHHS), and the patient''s satisfaction 12 months after the operation. The outcome of intra‐articular injection and hip arthroscopy were compared. Factors related to the outcomes of hip arthroscopy were evaluated. The correlation between the efficacy of intra‐hip joint injection and arthroscopy was evaluated.ResultsThe VAS of patients decreased from 11.3 ± 7.7 to 3.3 ± 4.5, and the iHOT‐12 increased from 52.1 ± 23.2 to 84.1 ± 18.1 after intra‐articular injection (all P < 0.001). The iHOT‐12 score increased from 52.1 ± 23.2 to 78.9 ± 19.2, and the MHHS increased from 66.5 ± 6.8 to 81.6 ± 8.1 after hip arthroscopy (all P < 0.001). The satisfaction rate of arthroscopy, including very satisfied and effective patients, was 93.3%. Multi‐variable logistic regression showed that only iHOT‐12 improved value after injection was included in the regression formula of satisfaction, with the β of −0.154, standard error of 0.071, Wald value of 4.720, and OR of 0.857 (95%CI 0.746–0.985) (P = 0.03). Significant correlation was detected between iHOT‐12 scores after intra‐articular anesthesia and at 12 months after arthroscopy (r = 0.784, P < 0.001). So was the iHOT‐12 improved value (r = 0.781, P < 0.001) and the iHOT‐12 improved ratio (r = 0.848, P < 0.001). If we had performed arthroscopy only on patients with post‐injection iHOT‐12 score improvement ≥10, the satisfaction rate of arthroscopy would have increased to 96.6%.ConclusionsUS‐guided intra‐hip joint injection may provide a feasible way to estimate the outcome of hip arthroscopy in patients with FAI syndrome, and could be used as a method for indication selection of hip arthroscopy.     

Outcomes in Patients with Global Pincer Versus Focal Pincer Femoroacetabular Impingement Treated with Hip Arthroscopy: A Retrospective Study with a Minimum 2‐Year Follow‐Up

ObjectiveGlobal pincer is a relatively rare form of pincer deformity and is typically associated with technical challenges during surgery. So far, controversy remains whether patients with global pincer have equivalent surgical outcomes compared to patients with focal pincer. This study compares the clinical outcomes of arthroscopic treatment between patients with global pincer femoroacetabular impingement (FAI) and focal pincer FAI in the Chinese population.MethodsData were retrospectively collected from patients with global and focal pincer FAI who underwent hip arthroscopy with a minimum two‐year follow‐up between April 2016 and December 2018. Radiographic measurements, arthroscopic procedures, preoperative and postoperative patient‐reported outcomes (PROs) including modified Harris hip score (mHHS), hip outcome score‐activities of daily living (HOS‐ADL), international hip outcome tool–12 (iHOT‐12), and visual analogue scale (VAS) scores, rates of revision surgery and conversion to total hip arthroplasty (THA) were recorded. Achievement of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) was compared for the VAS, mHHS, HOS‐ADL, and iHOT‐12 scores between groups.ResultsThe total of 33 and 167 patients were included in the global and focal group, respectively. There were no intergroup differences in age, gender, body mass index or follow‐up times. Lateral center‐edge angle (LCEA) was reduced in both groups postoperatively. Both groups demonstrated significant improvements in PROs compared with preoperative levels at the final follow‐up. The preoperative scores showed significant differences in terms of mHHS (60.34 vs 62.90, P = 0.031) and HOS‐ADL (61.45 vs 64.74, P = 0.022) scores between two groups, and the improvement of HOS‐ADL score was significantly higher in global group (P = 0.027). However, the postoperative scores, including VAS, mHHS, HOS‐ADL, and iHOT‐12 scores, showed no significant differences between two groups. And there were no significant differences in the rate of meeting the PASS and MCID between groups. One (3.0%) in the global group and six (3.6%) patients in the focal group underwent revision arthroscopy respectively, with no significant difference (P = 0.876). There were no conversions to THA in both groups.ConclusionsArthroscopic management of global pincer FAI can achieve excellent functional scores at minimum 2‐year follow‐up. The outcomes were similar to focal pincer FAI patients with a low rate of secondary procedure.     

Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta‐Analysis of RCTs

To determine the outcome and differences between arthroscopic hip surgery and conservative therapy in patients suffering from femoroacetabular impingement syndrome, we searched articles from PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov using a Boolean search algorithm. Only randomized controlled trials comparing arthroscopic hip surgery and conservative therapy were included in this meta‐analysis of femoroacetabular impingement syndrome management. Two authors determined eligibility, extracted the needed data and assessed the risk of bias of eligible studies independently. Then we meta‐analyzed three articles to assess pooled estimate size (ES) and 95% confidence interval for Hip Outcome Score of activities of daily living (HOS ADL subscale), Hip Outcome Score sport (HOS sports subscale) and International Hip Outcome Tool (iHOT‐33) analyses were performed by using STATA version 14.0 MP (STATA, College Station, TX, USA) with the principal summary measures are mean between group difference, sample size, and standard deviation. We collected 52 articles in total after removing duplicates and screened by titles and abstracts. A total of three RCTs were included finally. There was definite evidence of additional benefit of arthroscopic hip surgery against conservative therapy in the field of improving quality of life (three trials, 575 participants, ES = 2.109, 95% CI: 1.373 to 2.845, I ² = 42.8%, P = 0.000) and activity of daily living (two trials, 262 participants, ES = 9.220, 95% CI: 5.931 to 12.508, I ² = 16.5%, P = 0.000). However, no significant difference could be seen in sports function improvement (two trials, ES = 7.562, 95% CI: −2.957 to 18.082, I ² = 60.1%, P = 0.159). In conclusion, this meta‐analysis suggests that arthroscopic hip surgery provided essential benefit compared with conservative therapy in improving activity of daily living and quality of life.     

不同年龄段髂前下棘的解剖学特点分析

目的比较18~40，41~60，≥61岁不同年龄段髂前下棘形态学解剖参数变化。 方法选择正常半骨盆资料155例，其中男性115例，年龄（48±15）岁，女性40例，年龄（53±14）岁，均无髋臼撞击综合征，通过软件测量髂前下棘的最大长度、宽度、高度以及表面积和体积。 结果41~60岁及≥61岁年龄段男性髂前下棘的最大宽度[（12.0±1.9）mm；（12.0±1.8）mm]、表面积[（444.11±139.24）mm²；（469.03±132.26）mm²]以及体积[（910.19±452.34）mm³；（989.09±442.99）mm³]显著大于女性[宽度：（9.5±1.1）mm，（9.5±1.6）mm；表面积：（328.96±92.64）mm²，（326.26±118.32）mm²；体积：（577.04±259.51）mm³，（482.47±254.34）mm³，均P<0.05）。≥61岁年龄段中，男性髂前下棘的最大高度大于女性[（6.1±1.4）mm VS（4.6±1.4）mm，P=0.007）。不同年龄段之间（18~40岁，41~60岁，≥61岁），男性和女性的解剖学参数均无统计学意义。在三个年龄段中，最常见的髂前下棘分型均是1型（18~40岁，86.05%；41~60岁，71.23%；≥61岁，79%）。年龄与髂前下棘的长度、宽度、高度、体积和表面积均没有相关性（均P>0.05）。 结论髂前下棘的解剖形态相对稳定，与年龄没有显著相关性，但同年龄组不同性别髂前下棘的体积和表面积会有显著差异。此外低位髂前下棘（2型）并不一定导致髋臼撞击综合征的出现。     

Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with External Snapping Hip: A Comparison Study of Matched Case Series

ObjectiveTo determine the effectiveness of hip arthroscopy combined with endoscopic iliotibial band (ITB) release in patients with both femoroacetabular impingement (FAI) syndrome and external snapping hip (ESH).MethodsRetrospectively review the preoperative and minimum of 2‐year follow‐up data of patients with both FAI syndrome and ESH who underwent endoscopic ITB release during hip arthroscopy (FAI + ESH group) from January 2014 to December 2018. The same number of age‐ and gender‐matched FAI syndrome patients without ESH undergoing hip arthroscopy were enrolled in the control group (FAI group). Patient‐reported outcomes (PROs) including international Hip Outcome Tool (iHOT‐33), modified Harris Hip Score (mHHS), visual analog scale for pain (VAS‐pain), and abductive force of affected hip at 3 month and 2 years postoperatively were comparatively analyzed. The VAS‐satisfaction score of two groups at 2 years postoperatively were also analyzed.ResultsThe prevalence of ESH in FAI syndrome patients undergoing hip arthroscopy in our institution was 5.5% (39 of 715 hips), including nine males (10 hips) and 29 females (29 hips). The mean age at the time of surgery was 32.1 ± 6.9 years (range, 22–48 years). According to inclusion and exclusion criteria, 23 patients were enrolled in FAI + ITB group. Twenty‐three age‐ and sex‐matched FAI syndrome patients were enrolled in FAI group. At 24 months postoperatively, no patient still suffered ESH symptoms and painful palpation at lateral region in FAI + ITB group. The iHOT‐33, mHHS, and VAS‐pain score of patients in FAI + ESH group were significantly severer than patients in FAI group preoperatively (41.6 ± 7.5 vs 48.8 ± 7.2, 54.8 ± 7.2 vs 59.2 ± 6.9, 5.5 ± 0.9 vs 4.7 ± 1.0; P < 0.05), while there was no significant difference in these scores between the patients in FAI + ESH group and FAI group at 3‐month and 24‐month follow‐up (73.6 ± 8.5 vs 76.1 ± 6.9, 85.3 ± 7.8 vs 84.2 ± 6.6, 0.8 ± 0.9 vs 0.6 ± 0.9; P > 0.05). At 3 months after surgery, the abductive force of operated hip was significantly smaller than that in FAI group (82.4 ± 12.4 N vs 91.9 ± 16.1 N, P < 0.05), whereas there was no significant difference at 24 months after surgery (101.6 ± 14.9 N vs 106.5 ± 13.7 N, P > 0.05). The VAS‐satisfaction scores of patients in the two groups were at a similarly high level (90.5 ± 6.8 vs 88.8 ± 7.3, P > 0.05). There was no complication and no arthroscopic revision in either group until 2‐year follow‐up.ConclusionAlthough abductive force recovery of the hip was delayed, hip arthroscopy combined with endoscopic ITB release addressed hip snapping in patients with both FAI syndrome and ESH, and could get similar functional improvement, pain relief, recovery speed, as well as patient satisfaction compared with the pure hip arthroscopy in FAI syndrome patients without ESH.     

Operative treatment of avulsion fractures of the anterior inferior iliac spine: a two-case report

Abstract Avulsion fractures of the anterior inferior iliac spine (AIIS) are rare injuries of the pelvic ring. In two male athletes this injury was missed during initial examination and therefore was not treated optimally. Six months after the initial injury, the patients felt constant pain, and there was a lump in the thigh region; they both also had limited range of hip motion. Therefore, radiography and magnetic resonance imaging of the hip were performed. Avulsion fracture of AIIS was diagnosed and treated surgically with excision of the avulsed fragment. Two years later, both athletes have completely recovered and returned to their usual sporting activities. Isokinetic muscle testing disclosed that the extensor muscles of the operated side of the knee were weaker than those on the uninjured side.     

The Evaluation of Sagittal Pelvic‐Femoral Kinematics in Patients with Cam‐Type Femoracetabular Impingement

ObjectiveTo investigate the sagittal hip‐pelvic kinematics in symptomatic cam‐type femoroacetabular impingement (FAI) patients in the process of sitting down and compare their difference between patients with sitting pain complaint and those without.MethodsTwenty‐nine symptomatic cam‐type FAI patients were recruited from our clinic between May 2018 and October 2018. Patients were categorized into two groups depending on whether they complain of pain in prolonged sitting or not. The pelvic‐femoral measurements were assessed with a set of lateral pelvic radiography in sitting and standing respectively. Pelvic incidence (PI), sacral slope (SS), and proximal femoral shaft angle (PFSA) were measured on lateral pelvic radiography, and then pelvic tilting, apparent hip flexion, true hip flexion, and the pelvic‐femoral ratio were calculated to investigate the kinematic change from standing to sitting position. Demographic measurements, hip morphology measurements, functional measurements, visual analog scale (VAS), and pelvic‐femoral measurements were compared between the two groups.ResultsThirteen cases without sitting pain complaint and 16 cases with sitting pain complaint were stratified to Group N and Group P respectively. No was significant difference in age, body mass index (BMI), and gender between the two groups. Hip morphology measurements (α angle and lateral center‐edge angle) and functional measurements (iHOT‐12) showed no significant difference between the two groups. However, the mean VAS of pain while sitting was 0.5 ± 0.4 and 1.6 ± 0.6 in Group N and Group P respectively (P = 0.005). Patients with sitting pain complaint have increased pelvic PI compared to those without (50.1° ± 6.5° and 44.2° ± 7.6°, P = 0. 042). The changes in SS (pelvic tilting) from standing to sitting in Group N was significantly larger than that in Group P (21.8° ± 7.0° and 15.1° ± 6.5°, P = 0.012). Although no significant difference in apparent hip flexion and true hip flexion was found. Patients without sitting pain complaint demonstrated a higher pelvic‐femoral ratio (22.8% ± 7.9% and 16.1% ± 7.5%, P = 0.010) compared to those with sitting pain complaint.ConclusionSagittal pelvic‐femoral kinematics could have an influence on the symptomology of cam‐type FAI. The small PI and insufficient sagittal pelvic tilting in the process of sitting down could be related to the complaint of sitting pain in patients with symptomatic cam‐type FAI.     

Eccentric Rotational Acetabular Osteotomy Using Computed Navigation Guidance for Developmental Dysplasia of the Hip,Sacroiliac Fusion,and Femoroacetabular Impingement Owing to Acetabular Retroversion: A Case Report

BackgroundDevelopmental dysplasia of the hip (DDH) is the main factor that causes secondary osteoarthritis of the hip (hip OA). Acetabular retroversion results in pincer‐type femoroacetabular impingement (FAI), and this is also known to cause secondary hip OA. However, few cases of DDH with acetabular retroversion have been reported, and there is no definite opinion on the optimal treatment. We report a rare case of DDH and FAI owing to acetabular retroversion and dysostosis of the sacroiliac joint that was treated with eccentric acetabular rotational osteotomy (ERAO) using navigation guidance.Case PresentationA 27‐year‐old woman presented with DDH and acetabular retroversion with FAI and dysostosis of the sacroiliac joint on the contralateral side. We performed ERAO using computed navigation guidance and improved the coverage and retroversion of the acetabulum. The acetabular anteversion angle improved from 1° retroversion to 9° anteversion after surgery, the center edge angle improved from 18° to 43°, and the acetabular head index improved from 69% to 93%. The cam lesion of the femur was resected. The Harris Hip Score improved from 55.7 to 100 points at the final examination 2 years after surgery.ConclusionsIn this rare case of DDH and FAI, ERAO using computed navigation guidance accurately improved the coverage and retroversion of the acetabulum.     

Asymptomatic Lacrimal Flow Abnormalities in Patients with Septal Deviations and Turbinate Hypertrophy

Background: This study aimed to investigate the lacrimal flow in patients affected by septal deviations and turbinate hypertrophy and to evaluate changes after rhinoseptoplasty with dacryocystography (DCT) and computed tomographic dacryocystography (CT-DCT). Methods: The study prospectively recruited patients having septal deviations with or without turbinate hypertrophy who underwent surgical evaluation for correction of their respiratory symptoms and were not referred for epiphora. Patients were excluded if they had undergone surgery for cranial vault defects or had experienced septal deviations after traumatic accidents. All patients were studied with DCT and CT-DCT preoperatively and postoperatively. Results: A total of 24 patients (10 men and 14 women) were recruited for the study. Of these patients, 11 (45.8%) had a reduced flow of the medium contrast due to a partial obstruction at the level of the internal ostium. All 11 patients had septal deviations and turbinate hypertrophy, whereas 8 patients had a unilateral obstruction (72.7%), and 3 patients had a bilateral obstruction (27.3%). All flows were corrected after surgery. Conclusions: The safe and well-tolerated radiologic techniques performed in this study provided detailed imaging of the lacrimal outflow system. A high incidence of partial obstruction to the internal ostium was found in patients with septal deviations, turbinate hypertrophy, and no lacrimal symptoms, suggesting a frequent presymptomatic condition.     

In Vivo Pelvic and Hip Joint Kinematics in Patients With Cam Femoroacetabular Impingement Syndrome: A Dual Fluoroscopy Study

Femoroacetabular impingement syndrome (FAIS) may alter the kinematic function of the hip, resulting in pain and tissue damage. Previous motion analysis studies of FAIS have employed skin markers, which are prone to soft tissue artifact and inaccurate calculation of the hip joint center. This may explain why the evidence linking FAIS with deleterious kinematics is contradictory. The purpose of this study was to employ dual fluoroscopy (DF) to quantify in vivo kinematics of patients with cam FAIS relative to asymptomatic, morphologically normal control participants during various activities. Eleven asymptomatic, morphologically normal controls and seven patients with cam FAIS were imaged with DF during standing, level walking, incline walking, and functional range of motion activities. Model-based tracking calculated the kinematic position of the hip by registering projections of three-dimensional computed tomography models with DF images. Patients with FAIS stood with their hip extended (mean [95% confidence interval], −2.2 [−7.4, 3.1]°, flexion positive), whereas controls were flexed (5.3 [2.6, 8.0]°; p = 0.013). Male patients with cam FAIS had less peak internal rotation than the male control participants during self-selected speed level-walking (−0.2 [−6.5, 6.1]° vs. −9.8 [−12.2, −7.3]°; p = 0.007) and less anterior pelvic tilt at heel-strike of incline (5°) walking (3.4 [−1.0, −7.9]° vs. 9.8 [6.4, 13.2]°; p = 0.032). Even during submaximal range of motion activities, such as incline walking, patients may alter pelvic motion to avoid positions that approximate the cam lesion and the acetabular labrum. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:823-833, 2020