Publisher: Oxford University Press (Total: 368 journals)
Journal of Hip Preservation Surgery
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Open Access journal
ISSN (Print) 2054-8397
Published by Oxford University Press [368 journals]
- Surgery for hip preservation—let the patient decide
Authors: Villar R.
Abstract: I got to thinking the other day. Thinking what might have happened had hip arthroscopy never existed. Around the world I see colleagues being threatened by Governments, insurers, even departmental heads who should know better. The basic tenet of the threats is that impingement is unproven surgery and, as a consequence, should not be undertaken until proof exists. So, my first question is simple—what do we (or they) mean by proof' Readers of JHPS may have read a recent Editorial,1 which addressed this very issue. There appears to be a view that only the procedure with the most successful result is the one that should be offered. Yet how valid a position is this' It must surely depend on the patient; patients, as many might agree, are at best unpredictable.
- Lateral acetabular coverage as a predictor of femoroacetabular cartilage
Authors: Ashwell Z; Flug J, Chadayammuri V, et al.
Abstract: To investigate the correlation between femoroacetabular cartilage thickness and lateral acetabular coverage in patients undergoing hip arthroscopy for a variety of indications. Articular cartilage at the hip is hypothesized to undergo adaptive change secondary to unique patterns of pathomechanical loading which results in a direct relationship between acetabular coverage and femoroacetabular cartilage thickness. A cohort of 252 patients presenting to our dedicated hip preservation service between June 2013 and June 2015 were retrospectively analysed. Preoperative radiographs and MRI studies were obtained for all symptomatic hips and classified according to radiographic lateral center edge angle (LCEA) as follows: normal acetabular coverage (25–40°), acetabular overcoverage (≥40°), borderline dysplasia (20–24.9°) and frank dysplasia (
- Outcomes of joint preservation surgery: comparison of patients with
developmental dysplasia of the hip and femoroacetabular impingement
Authors: Belzile EL; Beaulé PE, Ryu J, et al.
Abstract: Femoroacetabular impingement (FAI) and developmental dysplasia of the hip (DDH) are fundamentally and structurally different hip abnormalities yet their clinical presentation can often be very similar. We asked whether adult patients surgically treated for DDH when compared with FAI patients achieve (i) better outcome as reflected by the WOMAC Osteoarthritis Index, (ii) higher physical activity as reflected by the UCLA physical activity scale. Five hundred fifty-six patients treated by periacetabular osteotomy for DDH and 540 patients treated for FAI (cam, pincer, or combined) in nine high-volume centers, between 2008 and 2011 were matched using propensity analysis, based on age and BMI. After exclusions, 144 pairs were evaluated on WOMAC, SF-12 Health Survey, modified Harris Hip Score (mHHS) and UCLA scale at pre and post-operations. At pre-operative evaluation, FAI patients showed lower scores on WOMAC (total, stiffness, function) and SF-12 physical. Statistically significant improvements in the outcome scores were observed from pre to post-operative time points in both treatment groups. Once FAI and DDH patients were compared, FAI patients showed lower scores on most of the outcome measures. However, these differences diminished in time, with only SF-12 mental and mHHS scores remaining significantly lower at 2-year follow-up. Because of more advanced disease at presentation, patients with FAI had an inferior clinical outcome compared with patients with DDH after surgical correction. Further prospective studies are required to better describe the long-term clinical benefits of hip joint preservation surgery.
- Prospective study of nerve injuries associated with hip arthroscopy in the
lateral position using the modified portals
Authors: Salas A; O’Donnell JM.
Abstract: To access the central compartment of the hip, distraction is essential in hip arthroscopy (HA); nerve injuries have long been accepted as a complication of this surgical procedure, with an incidence ranging from 0 to 46%. Only one previous article collected data prospectively, and the authors utilized a supine technique, with a modified mid-anterior portal. Our study also used prospectively collected data, from a group of 200 consecutive patients who had HA performed in the lateral position using the paratrochanteric portals. Our results were that four patients (2%) reported symptoms of neurological deficits after surgery, three patients with traction times ranging from 20 to 41 min, their neurological deficits resolved completely over a time from 6 to 9 weeks. The fourth patient who had the longest traction time of 73 min, and also greater than usual traction, his neurological deficit resolved at 12 weeks. Our hypothesis of 200 hip arthroscopies, performed in the lateral position by the modified paratrochanteric portals, the incidence of nerve injuries would be lower than 46%. We found an incidence of 2%, all affecting the perineum and genitals and all occurring in men, no differences between the age, surgery side or type of surgery performed on the patient were found to have statistical differences. Traction times with
- The feasibility of conducting a randomised controlled trial comparing
arthroscopic hip surgery to conservative care for patients with
femoroacetabular impingement syndrome: the FASHIoN feasibility study
Authors: Griffin DR; Dickenson EJ, Wall PH, et al.
Abstract: To determine whether it was feasible to perform a randomized controlled trial (RCT) comparing arthroscopic hip surgery to conservative care in patients with femoroacetabular impingement (FAI). This study had two phases: a pre-pilot and pilot RCT. In the pre-pilot, we conducted interviews with clinicians who treated FAI and with FAI patients to determine their views about an RCT. We developed protocols for operative and conservative care. In the pilot RCT, we determined the rates of patient eligibility, recruitment and retention, to investigate the feasibility of the protocol and we established methods to assess treatment fidelity. In the pre-pilot phase, 32 clinicians were interviewed, of which 26 reported theoretical equipoise, but in example scenarios 7 failed to show clinical equipoise. Eighteen patients treated for FAI were also interviewed, the majority of whom felt that surgery and conservative care were acceptable treatments. Surgery was viewed by patients as a ‘definitive solution’. Patients were motivated to participate in research but were uncomfortable about randomization. Randomization was more acceptable if the alternative was available at the end of the trial. In the pilot phase, 151 patients were assessed for eligibility. Sixty were eligible and invited to take part in the pilot RCT; 42 consented to randomization. Follow-up was 100% at 12 months. Assessments of treatment fidelity were satisfactory. An RCT to compare arthroscopic hip surgery with conservative care in patients with FAI is challenging but feasible. Recruitment has started for a full RCT.
- What the papers say
Authors: Malviya A.
Abstract: The Journal of Hip Preservation Surgery (JHPS) is not the only place where work in the field of hip preservation may be published. Although our aim is to offer the best of the best, we continue to be fascinated by work that finds its way into journals other than our own. There is much to learn from it so JHPS has selected six recent and topical articles for those who seek a brief summary of what is taking place in our ever-fascinating world of hip preservation. What you see here are the mildly edited abstracts of the original articles, to give them what JHPS hopes is a more readable feel. If you are pushed for time, what follows should take you no more than 10 min to read. So here goes …
- Imaging of femoroacetabular impingement-current concepts
Authors: Albers CE; Wambeek N, Hanke MS, et al.
Abstract: Following the recognition of femoroacetabular impingement (FAI) as a clinical entity, diagnostic tools have continuously evolved. While the diagnosis of FAI is primarily made based on the patients’ history and clinical examination, imaging of FAI is indispensable. Routine diagnostic work-up consists of a set of plain radiographs, magnetic resonance imaging (MRI) and MR-arthrography. Recent advances in MRI technology include biochemically sensitive sequences bearing the potential to detect degenerative changes of the hip joint at an early stage prior to their appearance on conventional imaging modalities. Computed tomography may serve as an adjunct. Advantages of CT include superior bone to soft tissue contrast, making CT applicable for image-guiding software tools that allow evaluation of the underlying dynamic mechanisms causing FAI. This article provides a summary of current concepts of imaging in FAI and a review of the literature on recent advances, and their application to clinical practice.
- The simplest method to classify CAM lesions
Authors: Plastow R; Hakim Z, Fehily M, et al.
Abstract: CAM lesions are now seen as a significant pathology that could cause osteoarthritis of the hip joint. Currently there is no gold standard for classifying these lesions. We aim to show a simple method for classifying these lesions based on shape and position. Using CT 3D reconstruction, 91 preoperative CT scans from patients who had undergone hip arthroscopy for femoroacetabular impingement, were reconstructed to produce 3D images. Two senior hip surgeons have devised a simple four type classification system from previous experience. The system highlights the position and shape of different CAM lesions present in patients. The two senior surgeons and one junior surgeon reviewed the scans individually to assess whether the system could be used at all levels of surgical experience. The two senior surgeons agreed on which type of CAM lesion was present in all 91 cases. Intra observer reliability scores for the senior surgeons were 0.90 and 0.91. The junior surgeon reviewed the scans and disagreed on eight cases. This gave a Kappa co-efficient score of 0.87, which confirms a reliable system. We believe this classification system is simple and reproducible. It will aid surgeons in pre and intra-operative management of CAM lesions. Surgeons will be able to select the optimal portal placement and resect less capsule depending on the exact CAM lesion identified. This will potentially reduce complications and improve outcomes in junior hip arthroscopy surgeons.
- The incidence of proximal deep vein thrombosis after elective hip
arthroscopy: a prospective cohort study in low risk patients
Authors: Mohtadi NG; Johnston K, Gaudelli C, et al.
Abstract: Prospectively assess the incidence of deep venous thrombosis (DVT) using Doppler Ultrasound, in patients receiving elective hip arthroscopy without pharmacologic/mechanical prophylaxis. One hundred and fifteen consecutive patients (mean 35.4 years, SD = 10.3) underwent elective hip arthroscopy. Patients with previous major risk factors for DVT were excluded. Signs/symptoms of DVT/pulmonary embolism were assessed at 2-week post-operatively. A bilateral whole leg Duplex color (Doppler) Ultrasonography was scheduled between 10- and 22-day post-op. The primary outcome was frequency of DVT. Secondary outcomes assessed surgical risk factors. One hundred and ten patients (mean = 34.3 years, SD = 10.1) did not get a DVT. Five patients (mean = 43.8 years, SD = 12.1) were diagnosed with a DVT, 2- to 22-day post-operatively. All DVT patients received arthroscopy in the supine position (n = 76), versus no patients in the lateral position (n = 39). Average traction time was 38 (SD = 4) and 61 (SD = 4) minutes for patients with and without a DVT, respectively. All other a priori defined risk factors were similar. Four out of five patients presented with symptoms of a DVT, confirmed by ultrasound. One patient was without symptoms/clinical findings. Four patients had a DVT restricted to the calf veins; one patient had involvement of the popliteal vein. No patients had proximal extension into the thigh or pelvis. No pulmonary emboli were suspected or occurred. The incidence of deep venous thromboembolism is 4.3%. The majority of patients had symptomatic and distal venous thromboembolic events. This study provides supportive evidence that routine prophylaxis and/or screening may not be necessary in low risk patients undergoing elective hip arthroscopy.
- Does the femoral head/neck contour in the skeletally mature change over
Authors: Gala L; Khanna V, Rakhra KS, et al.
Abstract: The purpose of this study was to determine whether anterior/anterolateral femoral head/neck contour of the hip is static or dynamic over time within the context of the cam deformity. From a previously published cohort of 200 asymptomatic patients who had a magnetic resonance imaging (MRI) of their hips, 23 patients were randomly selected: 10 with a cam lesion and 13 with no evidence of a cam lesion in either hip. There were 7 females and 16 males with a mean age of 37.5 years (range 30–56 years). A repeat MRI or computed tomography scan was performed. Femoral head/neck contour was assessed with alpha angle measurements at the 3 and 1:30 positions. At mean time of 5.3 years (range 2.5–7.2 years) between the two time points, the mean alpha angle for the entire cohort was not significantly different with alpha angle of 43.4°/53.7° (3:00/1:30 positions) at first visit and 46.1°/54.2° (3:00/1:30 positions) at second visit, respectively. Subdividing the cohort into cam negative and cam positive groups, there are no clinically relevant differences (i.e.
- Multicenter outcomes of arthroscopic surgery for femoroacetabular
impingement in the community hospital setting
Authors: Matsuda DK; Khatod M, Antounian F, et al.
Abstract: The purpose of this study is to determine multi-center outcomes from arthroscopic surgery for femoroacetabular impingement in the community hospital setting. A prospective design with 2-year minimum follow-up using the nonarthritic hip score (NAHS), a 100-point scale of perceived post-operative change for pain, activities of daily living, sports activities, and patient satisfaction was implemented at three community hospitals. Of 150 enrolled patients (159 hips) with mean age of 40 years (range, 12–73), there was 81% participation. Mean NAHS at preoperative was 54.9, 3 months: 66.6, 12 months: 74.9 and 24 months: 75.4. This represents a 20.5-point improvement in NAHS (P < 0.001). On the 100-point scale, pain was rated +73.5, ADL’s: +76.2 and sports: +68.6. 64% of patients were satisfied with their surgical outcome. Conversion arthroplasty rate was 8.8% and complication rate was 2.5%. In conclusion, arthroscopic surgery for symptomatic femoroacetabular impingement in the community setting provides safe and successful outcomes.
- Hip arthroscopy for intra-capsular benign tumors: a case series
Authors: Sharfman ZT; Atzmon R, Gortzak Y, et al.
Abstract: The purpose of this study is to demonstrate the assessment of intra-capsular femoral head and neck tumors, and to describe the arthroscopic surgical technique used to resect and fill the bone defects. Three cases of benign femoral head and neck lesions are presented. Two benign enchondromas and one benign osteochondroma were resected arthroscopically. Traction was used in one case. Modified Harris Hip Score improved in all three cases to scores of 95 or greater with an average improvement of 16 points with a minimum follow up of 15 months. Arthroscopic surgical resection of intra-capsular femoral hip lesions offers an effective alternative to open resection. This technique offered good outcomes in the limited cohort. We suggest that arthroscopic resection of intra-capsular femoral hip lesions be considered in relevant cases as an alternative to open resection.
- The morphologic characteristics and range of motion in the hips of
athletes and non-athletes
Authors: Jónasson P; Thoreson O, Sansone M, et al.
Abstract: The cam deformity may cause impingement and probably leads to osteoarthritis of the hip. The aetiology of the cam deformity is incompletely understood. Vigorous training during skeletal growth can lead to the development of cam and symptoms of femoro-acetabular impingement and subsequent osteoarthritis of the hip. The purpose of this study was to compare the radiographic characteristics and range of motion between a group of athletes and a non-athletic control group. Thirty-two male athletes (17 soccer players and 15 ice-hockey players) and thirty non-athletes, used as a control group, were examined clinically and radiographically. Hip range of motion was measured and the FADIR and FABER tests were performed. Standard radiographs of both hips were taken. The centre-edge angle, alpha angle, caput-collum-diaphysis angle, head-neck offset and Tönnis grade were registered. The athletes had a higher Tönnis grade (right P = 0.009, left P = 0.004), more pain on the FADIR test (right P = 0.006, left P = 0.001) and lower ROM in internal (right P = 0.003, left P = 0.025) and external rotation (P
- Pre-operative lumbar plexus block provides superior post-operative
analgesia when compared with fascia iliaca block or general anesthesia
alone in hip arthroscopy
Authors: Wolff AB; Hogan GW, Capon JM, et al.
Abstract: The objective of this study is to retrospectively examine the effects of pre-operative fascia iliaca (FI) and lumbar plexus (LPB) nerve blocks on post-operative pain and secondary post-operative variables following arthroscopic surgery of the hip. Subjects undergoing arthroscopic surgery of the hip received one of three pre-operative anesthetic techniques; general anesthesia only, general anesthesia with FI or general anesthesia with LPB. Patient reported pain scores (0–10) were recorded at 0, 30, 60, 90 and 120 min after admission to the post-anesthesia care unit (PACU). Secondary variables examined include time spent in the PACU, morphine equivalent administered, presence of nausea, persistent numbness, parasthesia, weakness, increased narcotic usage for rebound pain, ED visits and hospital admissions. The mean pain scores over all time points were significantly lower in the LPB group (2.38) than the FI group (4.08, P
- The ‘Hip Vacuum Sign’—a new radiographic phenomenon in
Authors: Schröder JH; Marschalek N, Hufeland M, et al.
Abstract: Femoro-acetabular impingement (FAI) is a frequent cause for groin pain in young and active patients. We discovered a so far undescribed radiographic phenomenon only visible in frog-leg lateral radiographs. The aim of this study was to describe this new radiological sign, to determine its prevalence in a symptomatic population and to investigate the correlation to a potential underlying pathology. We retrospectively reviewed all patients, who had been sent to our clinic between 2010 and 2012 for hip complaints. We excluded patients older than 50 years and patients with advanced osteoarthritis. Two independent investigators blinded to clinical data independently examined all images for the presence, location and dimension of a vacuum phenomenon and a potential underlying hip pathology. We included 242 patients. 137 of them showed clinical and radiological signs of FAI. A hip vacuum phenomenon was identified in 20 of 242 patients (8%). Interestingly, all these patients showed distinct signs of femoro-acetabular impingement. In reference to this, the prevalence of the “Hip Vacuum Sign” was 15% (20/137) in symptomatic patients with FAI. There was no correlation with age or gender. We identified a new radiological sign, the “Hip Vacuum Sign”, in 15% of symptomatic patients with FAI. It was only visible in frog-leg lateral radiographs. We suggest that it represents a subluxation of the femoral head due to a lever mechanism between the femoral neck and the acetabular rim and is, therefore, a hint for a relevant femoro-acetabular impingement mechanism.
- Arthroscopic reconstruction of the Ligamentum Teres: a case series in four
patients with connective tissue disorders and generalized ligamentous
Authors: Chandrasekaran S; Martin TJ, Close MR, et al.
Abstract: This study presents the results of four Ligamentum Teres (LT) reconstruction procedures for hip instability with an average of 21.4 months follow-up (range 16.4–27.8). The indication for reconstruction was patients who complained of hip instability (hip giving way on gait or activities of daily living) on a background of a connective tissue disorder and generalized ligamentous laxity. The following data were recorded: age, sex, body mass index, hip range of motion, impingement signs, acetabular coverage (lateral center edge angle and acetabular inclination), acetabular retroversion (ischial spine sign and a crossover sign), femoral alpha angles and femoral neck shaft angles. Four patient recorded outcomes (PROs) were collected at 3 months, 12 months and 24 months. Three patients were female. Three out of four procedures had an improvement in PROs. One patient with bilateral procedures had an improvement in PROs on one side at 1 year but a failure of the graft on the contralateral side. There were no complications reported with the technique. LT reconstruction and concomitant capsular plication in this case series is associated with an improvement in outcomes in three out of four of the patients with hip instability associated with a full thickness tear of the LT and who presented with hip instability on a background of generalized ligamentous laxity and a connective tissue disorder. However, the physical examination, radiographic and intra-operative findings which may help predict who would benefit from LT reconstruction require further investigation.
- Defining the greater trochanter-ischial space: a potential source of
extra-articular impingement in the posterior hip region
Authors: Kivlan BR; Martin RL, Martin HD.
Abstract: The purpose of this study was to describe greater trochanteric-ischial impingement and the relative position of the hip joint where impingement occurs. Twenty-three hips from 13 embalmed cadavers (seven males and six females) with a lifespan ranging between 46 and 91 years were used for this study. The pelvic region of each cadaver was skeletonized leaving only the hip capsule and the sciatic nerve. From 90° of flexion, the hip was extended while maintaining a position of 30° abduction and 60° external rotation. The position of hip flexion was recorded when there was contact between the greater trochanter and the ischium. The procedure was repeated in 0° abduction. A Flexion-Abduction-External Rotation (FABER) test was then performed on all specimens with a positive finding defined as contact between the greater trochanter and the ischium. In 30° abduction, contact of the ischium and the greater trochanter occurred in 87% (20/23) of the hips at an average of 47° of flexion (SD 10; range 20–60°). In 0° abduction, a positive finding was noted in 39% (9/23) of hips at an average of 59° flexion (SD 6; range 52–70°). A positive finding in the FABER test position was noted in 96% (22/23) of hips. The greater trochanter can impinge on the ischium when the hip is extended from 90° flexion in a 60° externally rotated position. This impingement occurred more commonly when the hip was in 30° abduction compared with neutral abduction. The FABER test position consistently created greater trochanteric–ischial impingement.