Hip Arthroscopy for Acetabular Dysplasia: A Pipe Dream?

Purpose : Hip arthroscopy is a well established therapeutic intervention for an increasing number of painful hip conditions. Developmental dysplasia of the hip (DDH) is commonly associated with intra-articular hip pathology. However, some surgeons perceive patients with hip dysplasia as poor candidates for hip arthroscopy. Our aim was to describe early outcomes of arthroscopic treatment for patients with DDH, who also had femoroacetabular impingement (FAI) treated when necessary, and to compare these outcomes against a control group of patients without DDH. Methods : Prospective case-control study of 68 consecutive hip arthroscopy patients assessed with a modified Harris Hip Score (mHHS) preoperatively and at six weeks, six months, and one year after surgery. Presence of DDH was determined using a standard anteroposterior (AP) pelvic radiograph to measure the centre-edge angle (CEA) of Wiberg, with a CEA < 20º used as threshold for diagnosis of DDH. Results : 12 patients (eight female and four male) with acetabular dysplasia and mean CEA of 15.4º (9º to 19º). The control, nondysplastic group comprised 54 patients (23 females and 31 males) with a mean CEA of 33.1º (22º to 45º). All patients in the dysplastic group had a labral tear and 11 (91.7%) had associated femoral cam impingement lesion addressed at arthroscopy. Our study demonstrates a significant (p=0.02) improvement in outcome in the dysplastic group at one year using the mHHS. Conclusion : Hip arthroscopy in the presence of DDH is effective in relieving pain for at least one year after surgery although does not address underlying acetabular abnormality.

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The Addition of Hip Arthroscopy to Periacetabular Osteotomy Does Not Increase Complication Rates: A Prospective Case Series

The American Journal of Sports Medicine ◽

10.1177/0363546518820528 ◽

2019 ◽

Vol 47 (3) ◽

pp. 543-551 ◽

Cited By ~ 7

Author(s):

Casey M. Sabbag ◽

Jeffrey J. Nepple ◽

Cecilia Pascual-Garrido ◽

Gopal R. Lalchandani ◽

John C. Clohisy ◽

...

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Case Series ◽

Hazard Ratio ◽

Acetabular Retroversion ◽

Complication Rates ◽

Reoperation Rates ◽

Grade Iii

Background: Previous studies on periacetabular osteotomy (PAO) reported complication and reoperation rates of 5.9% and 10%, respectively. Hip arthroscopy is increasingly utilized as an adjunct procedure to PAO to precisely treat associated intra-articular pathology. The addition of this procedure has the potential of further increasing complication rates. Purpose: To determine the rates of complication and reoperation of combined hip arthroscopy and PAO for the treatment of acetabular deformities and associated intra-articular lesions. Study Design: Case series; Level of evidence, 4. Methods: Using a prospective database, the authors retrospectively reviewed 248 hips (240 patients) that underwent combined hip arthroscopy and PAO between 2007 and 2016. Data were collected at scheduled follow-up visits at approximately 1 month, 3 to 4 months, and 1 and 2 years after surgery. Mean follow-up from surgery was 3 years (range, 1-8 years). A total of 220 PAOs were done for symptomatic acetabular dysplasia, 18 for symptomatic acetabular retroversion, and 10 for combined acetabular dysplasia and acetabular retroversion. Central compartment arthroscopy was performed for treatment of intra-articular chondrolabral pathology in all cases. Select cases underwent femoral head-neck junction osteochondroplasty either arthroscopically before the PAO or through an open approach after it. Complications were graded according to the modified Dindo-Clavien complication scheme, which was validated for hip preservation procedures. Reoperations (excluding hardware removal) were recorded. Results: Grade III complications occurred among 7 patients (3%) while there were no grade IV complications. Grade III complications included deep infection (n = 3), wound dehiscence (n = 1), hematoma requiring exploration (n = 1), symptomatic heterotopic ossification requiring excision (n = 1), and deep venous thrombosis (n = 1). There were 13 reoperations (5%), and 3 were repeat hip arthroscopy. Univariate Cox hazard models were used to estimate the relative risk factors for complication and reoperation. Increased age (per decade) showed over twice the increased likelihood for complications (hazard ratio, 2.5; 95% CI, 1.67-3.74). Also, preoperative diagnosis of acetabular retroversion, not acetabular dysplasia, showed >3 times the increased risk of reoperation (hazard ratio, 3.05; 95% CI, 1.41-6.61). Conclusion: The rate of complications reported is comparable (3%) with previously published complication rates of PAO without hip arthroscopy. In this cohort, increasing age and diagnosis of acetabular retroversion were associated with higher complication and reoperation rates.

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Outcomes of periacetabular osteotomy for borderline hip dysplasia in adolescent patients

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnaa012 ◽

2020 ◽

Vol 7 (2) ◽

pp. 249-255

Author(s):

Ishaan Swarup ◽

Ira Zaltz ◽

Stacy Robustelli ◽

Ernest Sink

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Hip Pain ◽

Center Edge ◽

Outcome Scores ◽

Adolescent Patients ◽

History Of ◽

Outcome Tool

Abstract Treatment of borderline acetabular dysplasia (lateral center edge angle ≥18°) remains controversial, and there is a paucity of literature focusing on outcomes in adolescent patients. The purpose of this study was to evaluate the outcomes of a periacetabular osteotomy (PAO) as surgical management of borderline acetabular dysplasia in adolescent patients. We performed a retrospective review of prospectively collected data and included patients ≤ 21 years of age that underwent PAO for borderline acetabular dysplasia. All patients had a minimum of 1-year follow-up. Outcomes were assessed using modified Harris Hip Scores (mHHS), Hip Outcome Scores (HOS) and international Hip Outcome Tool (iHOT-33). Descriptive and univariate statistical analyses were performed. This study included 33 adolescent patients (35 hips) with symptomatic, borderline acetabular dysplasia. The majority of patients was female (32 patients, 97%); half of all patients reported a history of hip pain for over 1 year; and seven patients had previous hip arthroscopy. In addition to PAO, seven hips (20%) underwent a concurrent hip arthroscopy at the time of surgery. There were significant improvements in mean mHHS, HOS-activities of daily living (ADL), HOS-Sport and iHOT-33 scores after surgery (P < 0.01). Minimal clinically important difference in outcome scores was achieved for over 90% of patients at a minimum of 1-year follow-up. Borderline acetabular dysplasia is a major cause of hip pain in adolescent patients. Patients with symptomatic borderline acetabular dysplasia report a significant benefit after a PAO to correct structural hip instability.

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OUTCOME OF SURGICAL TREATMENT IN PATIENTS WITH BORDERLINE ACETABULAR DYSPLASIA: A COMPARATIVE ANALYSIS OF HIP ARTHROSCOPY AND PERIACETABULAR OSTEOTOMY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00209 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0020

Author(s):

Jeffrey J Nepple ◽

Maria Schwabe ◽

Elizabeth Graesser ◽

Cecilia Pascual-Garrido ◽

John C Clohisy

Keyword(s):

Surgical Outcomes ◽

Hip Arthroscopy ◽

Hip Dysplasia ◽

Acetabular Dysplasia ◽

Periacetabular Osteotomy ◽

Treatment Decision ◽

Patient Characteristics ◽

Diagnosis And Treatment ◽

Radiographic Measurements ◽

Significant Difference

Background: Optimal treatments of patients with borderline hip dysplasia, defined as LCEA 20°-25°, is controversial. These patients can have symptomatic impingement and/or instability. The optimal treatment of either hip arthroscopy (HA) alone or periacetabular osteotomy (PAO) (with/without hip arthroscopy) has not been established. Purpose: The purpose of this study was to evaluate surgical outcomes of patients with borderline hip dysplasia at a minimum of 2-year follow-up. Methods: A longitudinal cohort was utilized to identify patients with borderline acetabular dysplasia defined via prospective radiographic measurements. Demographics and radiographic measurements were recorded. Patient evaluation, diagnosis and treatment decisions (PAO v HA) were made by one treating surgeon. Outcome were assessed at baseline and a minimum 2 years postoperative. Descriptive and comparative statistics were performed. Failure was defined as reoperation, or failure to reach mHHS MCID (8 points) or PASS (mHHS <74). Results: Total of 113 hips were included at 4.7 years postoperatively (range 2.0-11.2 years). Overall, 76% were female and 42% of hips had PAO (65% combined with hip arthroscopy), while 58% had isolated hip arthroscopy (HA). For PAO group, mHHS improved from 57.9 to 82.8 postoperatively, compared to 62.6 to 84.0 for the HA group. Similarly, HOOS pain (PAO 48.2 to 79.1, HA 61.2 to 82.0) and HOOS Sports (PAO 36.5 to 73.0, HA 47.8 to 74.4) demonstrated similar improvements. Comparing the PAO and HA groups, the change in PRO was significantly greater for the PAO group for HOOS Pain (10.5 ±23.2, p=0.02) and HOOS ADL (9.4 ±20.5, p=0.04) which was primarily due to a lower baseline score (similar final score). No significant difference was detected for other PROs. Reoperations in the PAO group were 2% (1 hip arthroscopy) and 6% for hip arthroscopy group (3 hip arthroscopies, 1 PAO). The failure rate was 17% for PAO and 15% for HA (p=0.86). Discussion: Surgical outcomes at minimum of 2 years in patients with borderline hip dysplasia in selected patients undergoing PAO or hip arthroscopy were good. Significant differences in patient characteristics and radiographic parameters were present between hips indicated for PAO vs. HA emphasizing the need for careful diagnosis and treatment decision-making.

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Multi-Centered Comparison of Outcomes After Hip Arthroscopy Versus Combined Hip Arthroscopy Alone and Peri-acetabular Osteotomy in Patients with Acetabular Dysplasia

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2018.10.050 ◽

2018 ◽

Vol 34 (12) ◽

pp. e14-e15

Author(s):

Raymond Kenney ◽

Benjamin G. Domb ◽

Justin Lareau ◽

P. Christopher Cook ◽

Brian D. Giordano

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia

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Trends of hip arthroscopy in the setting of acetabular dysplasia

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hny026 ◽

2018 ◽

Vol 5 (3) ◽

pp. 267-273 ◽

Cited By ~ 9

Author(s):

Jacob A Haynes ◽

Cecilia Pascual-Garrido ◽

Tonya W An ◽

Jeffrey J Nepple ◽

Paul Beaulé ◽

...

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia

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Imaging Markers of Hip Instability are Associated with Worse Outcomes at Two to Four-year Follow-up in Female Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00427 ◽

2020 ◽

Vol 8 (7_suppl6) ◽

pp. 2325967120S0042

Author(s):

Brandy Horton ◽

Hugh West ◽

Jenny Marland ◽

James Wylie

Keyword(s):

Hip Arthroscopy ◽

Acetabular Dysplasia ◽

Posterior Wall ◽

Anterior Wall ◽

Femoral Anteversion ◽

Hip Instability ◽

Female Patients ◽

Imaging Markers ◽

Fear Index

Objectives: To investigate the effect of radiographic markers of hip instability on outcomes of female patients undergoing hip arthroscopy for femoroacetabular impingement. Methods: This was a retrospective reviewof a prospectively collected cohort of females undergoing hip arthroscopy with a diagnosis of FAI treated with femoral osteoplasty with or without labral repair. iHOT-12 was collected preoperatively and at 2 to 4-year follow-up. Radiographs were reviewed and anterior wall index (AWI), posterior wall index (PWI), femoro-epiphyseal acetabular roof (FEAR) index, and lateral center edge angle (LCEA) were recorded in all patients. Computed tomography was used to quantify femoral anteversion in all patients. A laterally oriented FEAR index is considered positive (unstable), while a medially oriented fear index is considered negative (impingement/stable). An AWI of <0.30 and a PWI<0.80 were considered anterior wall deficient (AWD) and posterior wall deficient (PWD), respectively. Patients with borderline acetabular dysplasia (LCEA≤25) were groups as medially or laterally oriented FEAR index. Similarly, patients with borderline acetabular dysplasia(LCEA≤25) were groups as elevated femoral anteversion (>15 degrees) or not. Differences in means were tested using a students t-test or an analysis of variance with a post-hoc tukey’s test. Results: There were 175 Female patients with a mean age of 33 years. Mean follow up was 34.6 months. Mean preoperative iHOT12 was 30.4. Mean postoperative iHOT12 was 74.8. Mean FA was 11.7 (Range 1 to 34) degrees. There were 64 patients with an LCEA≤25, 138 patients had no AWD or PWD, 18 patients with an AWI <0.30 and 18 patients with a PWI <0.80. One patient was excluded from the analysis for having both an AWI<0.30 and a PWI<0.8. Patients with AWD had lower mean iHOT at follow up (54.5 compared with those with no wall deficiency 77.7, p=0.001.) Patents with PWD did not (72.4 compared with those with no wall deficiency 77.7, p=0.669.) Similarly, patients with AWD had lower mean iHOT improvement at follow up (24.2 compared with those with no wall deficiency 47.0, p=0.001). Patents with PWD did not (43.1 compared with those with no wall deficiency 47.0, p=0.808). Mean FEAR index was -7.1(Range -30 to 15) degrees. The FEAR index correlated with both the iHOT12 at follow up (-0.171, p=0.024) and the improvement in the iHOT12(-0.192, p=0.011). There were 31 patients with a laterally oriented FEAR index. These patients had worse iHOT12 at follow-up (64.9 points versus 77.0 points, p=0.037) and less improvement in iHOT12 (34.3 points versus 46.6 points, p=0.015). There were 110 patients with LCEA>25, 42 patients with LCEA≤25 with a medially oriented FEAR index and 23 patients with an LCEA≤25 with a laterally oriented FEAR index. Patients with LCEA≤25 and a laterally oriented FEAR index had worse iHOT12 at follow-up (60.7 points versus 78.9 points, p=0.005) and less improvement in iHOT12 from surgery (30.0 points versus 49.5 points, p=0.002) compared to those with an LCEA>25. There were 110 patients with LCEA>25, 46 patients with LCEA≤25 and FA <15 degrees and 17 patients with LCEA≤25 and FA≥15 degrees. Patients with LCEA≤25 had worse iHOT12 at follow-up (68.0 points versus 78.9 points, p=0.010) and less improvement in iHOT12 from surgery (36.0 points versus 49.5 points, p=0.001) compared to those with an LCEA>25. Patients with LCEA≤25 and FA≥15 degrees had worse iHOT12 at follow-up (59.5 points versus 78.9 points, p=0.008) and less improvement in iHOT12 from surgery (28.2 points versus 49.5 points, p=0.003) compared to those with an LCEA>25. In addition, patients with LCEA≤25 and FA<15 degrees had less improvement iHOT12 from surgery (38.0 points versus 49.4 points, p=0.026) compared to those with an LCEA>25. Conclusion: Imaging markers of hip instability, including borderline acetabular dysplasia, increased femoral anteversion, a laterally oriented FEAR index, and anterior wall deficiency are predictive of worse outcomes of hip arthroscopy for FAI in female patients. A more thoughtful imaging analysis of female patients preoperatively may identify patients at risk of worse outcomes after hip arthroscopy and may guide treatment with other joint preserving procedures, including periacetabular or femoral osteotomy.

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