Marc J. Philippon

Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: MINIMUM TWO-YEAR FOLLOW-UP

Over an eight-month period we prospectively enrolled 122 patients who underwent arthroscopic surgery of the hip for femoroacetabular impingement and met the inclusion criteria for this study. Patients with bilateral hip arthroscopy, avascular necrosis and previous hip surgery were excluded. Ten patients refused to participate leaving 112 in the study. There were 62 women and 50 men. The mean age of the patients was 40.6 yrs (95% confidence interval (CI) 37.7 to 43.5). At arthroscopy, 23 patients underwent osteoplasty only for cam impingement, three underwent rim trimming only for pincer impingement, and 86 underwent both procedures for mixed-type impingement. The mean follow-up was 2.3 years (2.0 to 2.9). The mean modified Harris hip score (HHS) improved from 58 to 84 (mean difference = 24 (95% CI 19 to 28)) and the median patient satisfaction was 9 (1 to 10). Ten patients underwent total hip replacement at a mean of 16 months (8 to 26) after arthroscopy. The predictors of a better outcome were the pre-operative modified HHS (p = 0.018), joint space narrowing >or= 2 mm (p = 0.005), and repair of labral pathology instead of debridement (p = 0.032). Hip arthroscopy for femoroacetabular impingement, accompanied by suitable rehabilitation, gives a good short-term outcome and high patient satisfaction.

Arthroscopic Management of Femoroacetabular Impingement Osteoplasty Technique and Literature Review

Morphological and spatial abnormalities of the proximal femur and acetabulum have been recently recognized as causes of femoroacetabular impingement. During joint motion in hips with femoroacetabular impingement, abnormal bony contact occurs, and soft tissue structures (chondral and labral) often fail. Femoroacetabular impingement has been reported to be a contributor to early-onset joint degeneration. Ganz et al have described good midterm success with an open surgical dislocation approach to reconstruct normal joint clearance. The purpose of this report is to discuss relevant literature and describe an arthroscopic approach to treat femoroacetabular impingement. This approach has particular relevance in high-demand patients, particularly in athletes seeking to return to high-level sport.

Revision Hip Arthroscopy

Background Hip arthroscopy has become increasingly popular; however, little is known about revision hip arthroscopy. Hypothesis Revision hip arthroscopy is associated with unaddressed femoroacetabular impingement. The purpose of this study was to describe reasons for revision hip arthroscopy. Study Design Case series; Level of evidence, 4. Methods Between March 2005 and March 2006, 37 revision hip arthroscopies were performed by the senior author. Data were collected through retrospective review of clinical and operative notes. Results All patients required revision surgery because of persistent hip pain. There were 25 women and 12 men with an average age of 33 years (range, 16-53 years). The average time from prior surgery to revision was 20.5 months (range, 2.9-84 months). Common findings among patients needing revision were hip pain, decreased range of motion, and functional disability. The average modified Harris Hip Score was 53 (range, 22-99). Thirty-six patients had radiographic evidence of femoroacetabular impingement at the time of revision. Revision procedures included 34 (95%) for femoroacetabular impingement, 32 (87%) for labral lesions, 26 (70%) for a chondral defect, 23 (62%) for lysis of adhesions, and 13 (35%) for previously unaddressed instability. Two patients had total hip arthroplasty after revision, and 3 patients required further revision. Of the remaining 32 patients, early follow-up was obtained on 27 (84%) at an average of 12.7 months postoperatively (range, 6-19 months). Outcomes showed patients regained some of their lost function within the first year. Conclusion Patients commonly required revision hip arthroscopy because of persistent impingement.

Hip Arthroscopy: Current Indications, Treatment Options, and Management Issues

The management of hip injuries in athletes has evolved significantly in the past few years with the advancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in both recreational and elite athletes. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular abnormalities that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and, thus, left untreated. Current indications for hip arthroscopy include the presence of symptomatic acetabular labral tears, hip capsule laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies (for example, synovial chondromatosis). Less common indications include management of osteonecrosis of the femoral head, bony impingment, synovial abnormalities, crystalline hip arthropathy (gout and pseudogout), infection, and posttraumatic intraarticular debris. In rare cases, hip arthroscopy can be used to temporize the symptoms of mild-to-moderate hip osteoarthritis with associated mechanical symptoms. This article discusses the current clinical and radiographic methods to detect early hip joint disease and the current indications and surgical techniques of hip arthroscopy.

Clinical presentation of femoroacetabular impingement.

The purpose of this study was to identify subjective complaints and objective findings in patients treated for femoroacetabular impingement (FAI). Three hundred and one arthroscopic hip surgeries were performed to treat FAI. The most frequent presenting complaint was pain, with 85% of patients reporting moderate or marked pain. The most common location of pain was the groin (81%). The average modified Harris Hip score was 58.5(range 14–100). The average sports hip outcome score was 44.0 (range 0–100). The anterior impingement test was positive in 99% of the patients. Range of motion was reduced in the injured hip. Patients who had degenerative changes in the hip had a greater reduction in range of motion. The most common symptom reported in patients with FAI was groin pain. Patient showed decreased ability to perform activities of daily living and sports. Significant decreases in hip motion were observed in operative hips compared to non-operative hips.

Arthroscopic Labral Repair and Treatment of Femoroacetabular Impingement in Professional Hockey Players

Background Hip injuries are common among professional hockey players in the National Hockey League (NHL). Hypothesis Professional hockey players will return to a high level of function and ice hockey after arthroscopic labral repair and treatment of femoroacetabular impingement. Study Design Case series; Level of evidence, 4. Methods Twenty-eight professional hockey players (NHL) were unable to perform at the professional level due to unremitting and debilitating hip pain. Players underwent arthroscopic labral repair and were treated for femoroacetabular impingement from March 2005 to December 2007. Players who had bilateral hip symptoms were excluded. Athletes completed the Modified Harris Hip Score preoperatively and postoperatively and also completed a patient satisfaction questionnaire postoperatively. Return to sport was defined as the player resuming skating for training or participation in the sport of ice hockey. Results The average age at the time of surgery was 27 years (range, 18-37). There were 11 left hips and 17 right hips. Player positions included 9 defensemen, 12 offensive players, and 7 goaltenders. All players had labral lesions that required repair. In addition, all patients had evidence of femoroacetabular impingement at the time of surgery. The average time to return to skating/hockey drills was 3.4 months. The average time to follow-up was 24 months (range, 12-42). The Modified Harris Hip Score improved from 70 (range, 57-100) preoperatively to an average of 95 (range, 74-100) at follow-up. The median patient satisfaction was 10 (range, 5-10). Two players had reinjury and required additional hip arthroscopy. Conclusion Treatment of femoroacetabular impingement and labral lesions in professional hockey players resulted in successful outcomes, with high patient satisfaction and prompt return to sport.

Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement.

PURPOSE The purpose of this study was to examine the relationship between the size of cam lesions and the presence of cartilage damage, labral damage, or changes in range of motion in the hips with signs and symptoms of femoroacetabular impingement (FAI). METHODS Cross-table lateral radiographs were available for 102 consecutive patients presenting with signs and symptoms of FAI. Radiographs with excessive external rotation, dysplasia, severe arthritis, avascular necrosis, or Legg-Calvé-Perthes syndrome were excluded, leaving 82 patients available for analysis (47 men, 35 women; average age, 25 yr [range, 12 to 55 yr]). Offset angle alpha was measured from the films with a digital goniometer. Patients subsequently underwent hip arthroscopy and the surgical findings and hip range of motion were prospectively recorded. RESULTS Higher offset angle alpha was associated with the presence of acetabular rim chondral defects (P = .044) and full-thickness delamination of the acetabular cartilage (P = .034). Patients with detachment of the base of the labrum had a higher offset angle alpha (P = .016). Higher offset angle alpha was related to male sex (P = .001) and decreased range of motion (P < .05), but not to age. CONCLUSIONS Cam-type FAI, as measured by an increased offset angle alpha, was correlated with increased chondral damage, labral injury, and decreased range of motion.

Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement

PURPOSE To analyze the current approaches to the surgical management of symptomatic femoroacetabular impingement (FAI). METHODS Thirteen relevant queries were used in four search engines (PubMed, EMBASE, Ovid, and the Cochrane Review) with a resultant 5,856 articles. Eighteen peer-reviewed treatment outcome studies met the inclusion criteria with minimum 1-year follow-up of the surgical treatment of skeletal pathoanatomy and associated chondrolabral pathology in skeletally mature patients with FAI. RESULTS There were 6 open surgical dislocation, 4 mini-open, and 8 arthroscopic studies, all with Levels of Evidence III or IV. The only prospective studies were in the arthroscopic category. Outcome data were extracted and analyzed with respect to surgical efficacy, failure rates, and complications. CONCLUSIONS The open dislocation, mini-open, and arthroscopic methods for treating symptomatic FAI are effective in improving pain and function in short-term to midterm studies and are relatively safe procedures. The historical gold standard of open dislocation surgery had a comparatively high major complication rate primarily because of trochanteric osteotomy-related issues. The mini-open method showed comparable efficacy but a significant incidence of iatrogenic injury to the lateral femoral cutaneous nerve in some studies. The arthroscopic method had surgical outcomes equal to or better than the other methods with a lower rate of major complications when performed by experienced surgeons.

Can Microfracture Produce Repair Tissue in Acetabular Chondral Defects

PURPOSE The purpose of this study was to investigate percent fill and repair grade of microfractured lesions of the acetabulum. METHODS Nine patients underwent revision hip arthroscopy for a variety of procedures after undergoing microfracture for treatment of a full-thickness chondral defect of the acetabulum at primary arthroscopy. The size of the chondral defect was measured during primary arthroscopy, and the percent fill of the defect and repair grade were noted at revision hip arthroscopy. RESULTS Mean time from primary arthroscopy to revision was 20 months (range, 10 to 36 months). The average percent fill of the acetabular chondral lesions at second-look was 91% (range, 25% to 100%). Eight of the patients had grade 1 or 2 repair product at second-look. The 1 patient with 25% fill and grade 4 repair product had diffuse osteoarthritis on the femur and acetabulum at primary microfracture. One patient required total hip arthroplasty 66 months after the index microfracture. CONCLUSIONS In this study, 8 of 9 patients had 95% to 100% coverage of an isolated acetabular chondral lesion or acetabular lesion associated with a femoral head lesion, with grade 1 or 2 appearance of the repair product at an average of 20 months follow-up. One patient who had diffuse osteoarthritis failed, with only 25% coverage with a grade IV appearance of the repair product 10 months after index arthroscopy. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Role of the Acetabular Labrum and the Iliofemoral Ligament in Hip Stability An In Vitro Biplane Fluoroscopy Study

Background Recent biomechanical reports have described the function of the acetabular labrum and iliofemoral ligament in providing hip stability, but the relative stability provided by each structure has not been well described. Hypothesis Both the iliofemoral ligament and acetabular labrum are important for hip stability by limiting external rotation and anterior translation, with increased stability provided by the iliofemoral ligament compared with the acetabular labrum. Study Design Controlled laboratory study. Methods Fifteen fresh-frozen male cadaveric hips were utilized for this study. Each specimen was selectively skeletonized down to the hip capsule. Four tantalum beads were embedded into each femur and pelvis to accurately measure hip translations and rotations using biplane fluoroscopy while either a standardized 5 N·m external or internal rotation torque was applied. The hips were tested in 4 hip flexion angles (10° of extension, neutral, and 10° and 40° of flexion) in the intact state and then by sectioning and later repairing the acetabular labrum and iliofemoral ligament in a randomized order. Results External rotation significantly increased from the intact condition (41.5° ± 7.4°) to the sectioned iliofemoral ligament condition (54.4° ± 6.6°) and both-sectioned condition (61.5° ± 5.7°; P < .01), but there was no significant increase in external rotation when the labrum alone was sectioned (45.6° ± 5.9°). The intact and fully repaired conditions were not significantly different. External rotation and internal rotation significantly decreased when the hip flexion angle decreased from 40° of flexion to 10° of extension (P < .01) regardless of sectioned condition. Anterior translation varied significantly across sectioned conditions but not across flexion angles (P < .001). The ligament-sectioned (1.4 ± 0.5 mm), both-sectioned (2.2 ± 0.2 mm), and labrum-repaired (1.1 ± 0.2 mm) conditions all resulted in significantly greater anterior translation than the intact condition (−0.4 ± 0.1 mm) (P < .001). Conclusion The iliofemoral ligament had a significant role in limiting external rotation and anterior translation of the femur, while the acetabular labrum provided a secondary stabilizing role for these motions. Clinical Relevance These results suggest that, if injured, both the acetabular labrum and iliofemoral ligament should be surgically repaired to restore native hip rotation and translation. In addition, a careful repair of an arthroscopic capsulotomy should be performed to avoid increased external hip rotation and anterior translation after arthroscopy.