Hip Distraction Without a Perineal Post: A Prospective Study of 1000 Hip Arthroscopy Cases

Background: Hip arthroscopy has traditionally been performed with a perineal post, resulting in various groin-related complications, including pudendal nerve neurapraxias, vaginal tears, and scrotal necrosis. Purpose: To assess the safety of a technique for hip distraction without the use of a perineal post. Study Design: Case series; Level of evidence, 4. Methods: We prospectively analyzed a consecutive cohort of 1000 hips presenting to a dedicated hip preservation clinic; all patients had hip pain and were subsequently treated with hip arthroscopy. Demographic variables, hip pathology, and lateral center edge angle were recorded for each case. In the operating room, the patient’s feet were placed in traction boots in a specifically designed distraction setup, and the operative table was placed in varying degrees of Trendelenburg. With this technique, enough resistance is created by gravity and friction between the patient’s body and the bed to allow for successful hip distraction without the need for a perineal post. In a subset of 309 hips (n = 281 patients), the degrees of Trendelenburg as well as the distraction force were analyzed. Results: The mean ± SD Trendelenburg angle used among the subset of 309 hips was 11° ± 2°. The mean initial distraction force necessary was 90 ± 28 lb, which decreased to 65 ± 24 lb by 30 minutes after traction initiation ( P < .0001). The most important variables in determining initial force for this cohort of patients were, in order of magnitude, sex ( P < .0001), weight ( P < .0001), and lateral center edge angle ( P < .01). No groin-related complications occurred among the entire cohort of patients, including soft tissue or nerve-related complications. The rate of deep venous thrombosis was 2 in 1000. Conclusion: The use of the Trendelenburg position and a specially designed distraction setup during hip arthroscopy allows for safe hip distraction without a perineal post, thereby eliminating groin-related soft tissue and nerve complications. Certain patient variables can be used to estimate the required distraction force and inclination angle with this method.

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Periacetabular osteotomy with concomitant hip arthroscopy: A case series with 24 months minimum follow-up

Medwave ◽

10.5867/medwave.2020.11.8082 ◽

2020 ◽

Vol 20 (11) ◽

pp. e8082-e8082

Author(s):

Cristian Barrientos ◽

Julián Brañes ◽

Rodrigo Olivares ◽

Rodrigo Wulf ◽

Álvaro Martinez ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Hip Arthroscopy ◽

Periacetabular Osteotomy ◽

Case Series ◽

Resonance Imaging ◽

Edge Angle ◽

Center Edge ◽

Lateral Center Edge Angle ◽

Center Edge Angle

Purpose To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. Methods Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. Results A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. Conclusion To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

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No Correlation Between Depth of Acetabuloplasty or Postoperative Lateral Center-Edge Angle on Midterm Outcomes of Hip Arthroscopy With Acetabuloplasty and Labral Repair: Response

The American Journal of Sports Medicine ◽

10.1177/03635465211030227 ◽

2021 ◽

Vol 49 (11) ◽

pp. NP57-NP58

Author(s):

Marc J. Philippon ◽

Joseph J. Ruzbarsky ◽

Adam W. Johannsen ◽

Rui Soares ◽

Lauren A. Pierpont ◽

...

Keyword(s):

Hip Arthroscopy ◽

Labral Repair ◽

Edge Angle ◽

Center Edge ◽

Lateral Center Edge Angle ◽

Center Edge Angle

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Superior Clinical Outcomes with Capsular Closure versus Non-Closure in Patients Undergoing Arthroscopic Hip Labral Repair

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00009 ◽

2018 ◽

Vol 6 (3_suppl) ◽

pp. 2325967118S0000 ◽

Cited By ~ 7

Author(s):

Ioanna Bolia ◽

Karen K. Briggs ◽

Marc J. Philippon

Keyword(s):

Clinical Outcomes ◽

Hip Arthroscopy ◽

Labral Repair ◽

Secondary Outcome ◽

Edge Angle ◽

Center Edge ◽

Lateral Center Edge Angle ◽

Closure Group ◽

Center Edge Angle

Objectives: Controversy still exists on closing the capsule following hip arthroscopy. It is unclear if capsular closure at the end of hip arthroscopy results in better clinical outcomes compared to non-closure. The purpose of this study was to compare the clinical outcomes in patients who had a closed capsule to those without a closed capsule following hip arthroscopic labral repair by a single surgeon. Methods: Patients who did not have capsular closure were identified by reviewing arthroscopy video (non-closure group). Fifty consecutive patients without capsular closure were matched with fifty patients who had capsular closure. All patients underwent primary hip arthroscopy and labral repair. The primary patient-reported outcome measure was Hip Outcome Score(HOS)-ADL. Secondary outcome measures included the modified Harris hip score(MHHS), HOS-Sport, WOMAC, general health, and patient satisfaction with outcome. Patients with lateral center edge angle less than 25º were excluded. Results: There were 23 females and 27 males with an average age of 36 years (range:14 to 77) in each group. The average lateral center edge angle was 34º (range, 27 to 48) in both groups. The alpha angle was 68º (range, 40 to 134) in the non-closure group and 70º (range, 41 to 98) in the closure group. No patient had microfractures at the time of surgery. The average follow-up time was 5 years (non-closure group range: 3-10; closure group range 3-9). Eight patients (16%) in the non-closure group required total hip arthroplasty(THA), while 4 patients (8%) in the closure group required THA. Six patients in the non-closure group and 3 patients in the closure group required revision hip arthroscopy. Of those patients who did not require revision or THA, there was a significant difference in the HOS ADL score and the secondary outcome measures (see table). Capsular closure resulted in superior clinical outcomes compared to non-closure. Conclusion: There were twice as many conversion to THA and twice as many hip arthroscopy revisions in patients undergoing hip arthroscopic labral repair without capsular closure compared to those with closure. In addition, the closure group showed significantly higher outcomes scores compared to the non-closure at 5-year follow-up time. [Table: see text]

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Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral Anteversion and Borderline Dysplasia? A Match-Controlled Study

The American Journal of Sports Medicine ◽

10.1177/0363546518812859 ◽

2018 ◽

Vol 47 (1) ◽

pp. 123-130 ◽

Cited By ~ 21

Author(s):

Edwin O. Chaharbakhshi ◽

David E. Hartigan ◽

Itay Perets ◽

Benjamin G. Domb

Keyword(s):

Hip Arthroscopy ◽

Femoral Anteversion ◽

Harris Hip Score ◽

Control Group ◽

Edge Angle ◽

Center Edge ◽

Modified Harris Hip Score ◽

Lateral Center Edge Angle ◽

Center Edge Angle

Background: Appropriate patient selection is critical when hip arthroscopy is considered in the setting of borderline dysplasia (BD). It is presumable that excessive femoral anteversion (EFA) and BD may contraindicate arthroscopy. Hypothesis: Patients with combined EFA and BD (EFABD) demonstrate significantly inferior short-term outcomes after arthroscopic labral preservation and capsular closure when compared with a similar control group with normal lateral coverage and femoral anteversion. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected and retrospectively reviewed on patients undergoing hip arthroscopy between April 2010 and November 2014. The EFABD group’s inclusion criteria were BD (lateral center-edge angle, 18°-25°), labral tear, capsular closure, and femoral version ≥20°, as well as preoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, and visual analog scale. Exclusion criteria were workers’ compensation, preoperative Tönnis grade >1, microfracture, abductor pathology, or previous ipsilateral hip surgery or conditions. Patients in the EFABD group were matched 1:2 to a similar control group with normal coverage and femoral anteversion by age at surgery ± 6 years, sex, body mass index ± 5, acetabular Outerbridge grade (0, 1 vs 2, 3, 4), and iliopsoas fractional lengthening. Results: Sixteen EFABD cases were eligible for inclusion, and 100% follow-up was obtained at ≥2 years postoperatively. Twelve EFABD cases were matched to 24 control cases. Mean femoral version was 22.4° in the EFABD group and 10.2° in the control group ( P = .01). Mean lateral center-edge angle was 22.1° in the EFABD group and 31.5° in the control group ( P < .0001). Acetabuloplasty was performed significantly more frequently in the control group ( P = .0006). No other significant differences were found regarding demographics, findings, procedures, or preoperative scores. At latest follow-up, the EFABD group demonstrated significantly lower mean modified Harris Hip Score (76.1 vs 85.9; P = .005), Nonarthritic Hip Score (74.8 vs 88.5; P < .0001), Hip Outcome Score–Sports Specific Subscale (58.3 vs 78.4; P = .02), and patient satisfaction (7.1 vs 8.3; P = .005). There were 4 secondary surgical procedures (33.3%) in the EFABD group and 1 (4.2%) in the control group ( P = .03). One patient in each group required arthroplasty. Conclusion: Patients treated with arthroscopic labral preservation and capsular closure in the setting of EFABD demonstrated significant improvements from presurgery to latest follow-up. However, their results are significantly inferior when compared with a matched-controlled group. Consideration of periacetabular osteotomy or femoral osteotomy may be warranted in the setting of EFABD to achieve optimal benefit.

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Across the Spectrum from Borderline Dysplasia to Global Pincer Femoroacetabular Impingement: Arthroscopic Outcomes from a Large Hip Arthroscopy Study Group

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00349 ◽

2020 ◽

Vol 8 (7_suppl6) ◽

pp. 2325967120S0034

Author(s):

Benjamin Kivlan ◽

Shane Nho ◽

Andrew Wolff ◽

John Salvo ◽

John Christoforetti ◽

...

Keyword(s):

Hip Arthroscopy ◽

Repeated Measures ◽

Statistical Difference ◽

Acetabular Coverage ◽

Repeated Measures Anova ◽

Edge Angle ◽

Center Edge ◽

Lateral Center Edge Angle ◽

Center Edge Angle ◽

Acetabular Overcoverage

Objectives: Outcomes from hip arthroscopy for dysplasia and global pincer FAI have fallen short of those for patients with normal acetabular coverage, but no study has investigated arthroscopic outcomes across the spectrum of acetabular coverage. Our objective is to report comparative hip arthroscopic outcomes of patients with low (borderline dysplasia), normal, and high (global pincer FAI) lateral acetabular coverage. Methods: A retrospective analysis of prospectively-collected data from a large multi-center registry (seven United States centers) was performed. Primary hip arthroscopy patients were assigned to one of three groups based on preoperative lateral center-edge angle (LCEA): borderline dysplasia (≤25°), normal (26-38°), and pincer FAI (≥39°). Repeated measures ANOVA compared pre-operative to 2-year minimum post-operative iHOT-12 scores. Subsequent ANOVA determined the effect of acetabular coverage on magnitude of change in scores. Results: Of 437 patients, the only statistical difference between groups was lower prevalence of acetabuloplasty in the borderline dysplasia group (p=0.001). A significant improvement in the pre-operative to post-operative iHOT-12 scores for patients with normal acetabular coverage, acetabular undercoverage, and acetabular overcoverage was observed; F(1, 339)=311.06; p<0.001, with no statistical differences in pre-operative (p=0.505) and post-operative (p<0.488) iHOT-12 scores when comparing the groups based on acetabular coverage. Mean iHOT-12 scores increased from 37.3 pre-operatively to 68.7 postoperatively, p<0.001, in the borderline dysplasia group, from 34.4 to 72, p<0.001, in the normal coverage group, and from 35.3 to 69.4, p<0.001, in the pincer group. These pre-operative scores increased by 31.4, 37.8, and 34.1, respectively, with no effect for acetabular coverage on the magnitude of change from pre-operative to post-operative iHOT-12 scores, F(2,339) =1.18; p=0.310. 10 subjects (2.3%) underwent conversion arthroplasty and 19 patients (4.4%) underwent revision arthroscopy with no significant effect of acetabular coverage on the incidence of revision or conversion surgery, X2 (6,433)=11.535, P = 0.073. Conclusion: Lateral acetabular coverage did not influence outcomes from primary hip arthroscopy performed in patients with low (borderline dysplasia), normal, and high (global pincer FAI) LCEA. Borderline dysplasia and moderate global pincer FAI with no or minimal osteoarthritis do not compromise successful 2-year minimum outcomes or survivorship following primary hip arthroscopy when performed by experienced surgeons.

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The Femoral Head “Divot” Sign: A Useful Arthroscopic Sign of Hip Microinstability

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120917919 ◽

2020 ◽

Vol 8 (5) ◽

pp. 232596712091791

Author(s):

Philip J. Rosinsky ◽

Ben C. Mayo ◽

Cynthia Kyin ◽

Jacob Shapira ◽

David R. Maldonado ◽

...

Keyword(s):

Femoral Head ◽

Physical Examination ◽

Hip Arthroscopy ◽

Labral Repair ◽

Edge Angle ◽

Ligamentous Laxity ◽

Capsular Plication ◽

Center Edge ◽

The Mean ◽

Center Edge Angle

Background: A femoral head “divot” is a rare finding during hip arthroscopy. A linear chondral indentation can be observed on the femoral head, just lateral and parallel to the acetabular labrum. Purpose/Hypothesis: The purpose of this study was to describe a novel arthroscopic sign and retrospectively review patients with this finding. We hypothesized that this sign would be found in patients with characteristics consistent with hip microinstability. Study Design: Case series; Level of evidence, 4. Methods: Intraoperative images of patients undergoing primary hip arthroscopy between July 2017 and July 2019 were reviewed for evidence of a femoral head divot. Preoperative characteristics, physical examination findings, radiographic measurements, and magnetic resonance imaging (MRI) findings were described. Results: Of 690 available cases, 14 cases (13 patients; 2.0%) had evidence of a femoral head divot. The mean patient age was 29.1 years, and all but 1 patient (92.3%) were female. Ligamentous laxity was present in 81.8% of patients, anterior apprehension test was positive in 78.6%, and painful internal snapping was present in 50.0%. The mean lateral center-edge angle, anterior center-edge angle, and Tönnis angle were 19.2°, 20.3°, and 12.4°, respectively. The divot was identified in 5 of 12 available MRI scans, most commonly on axial proton density sequence. Intraoperatively, all hips had labral tears, iliopsoas bursitis was demonstrated in 78.6%, and the ligamentum teres was damaged in 42.9%. Labral repair was performed in 12 of the 14 hips, with 2 patients undergoing labral reconstruction. Iliopsoas fractional lengthening was performed in 50.0%, capsular plication was performed in 78.6%, and capsular repair was performed in the remainder. Conclusion: The femoral head divot sign is a rare arthroscopic finding during hip arthroscopy. The results of this study demonstrated that patients who have a divot also present with characteristic radiographic or physical examination findings of hip microinstability due to either acetabular dysplasia or ligamentous laxity. Recognition of a femoral head divot may be valuable for the diagnosis of microinstability during hip arthroscopy and may help guide appropriate management, such as capsular plication. Further studies are needed to determine the exact prevalence of the femoral head divot in patients with microinstability and to evaluate the effect of this finding on patient outcomes.

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