Richard N. Villar

The acetabular labral tear: An arthroscopic classification

Acetabular labral tears are well recognized in the pathology of hip disease. The patterns of such tears found in 37 patients undergoing hip arthroscopy have been analyzed. Distinct categories of labral tear were found, and may be classified in terms of etiology (traumatic, 18.9% of cases; degenerative, 48.6%; idiopathic, 27.1%; congenital, 5.4%) and morphology (radial flap, 56.8%; radial fibrillated, 21.6%; longitudinal peripheral, 16.2%; unstable, 5.4%).

Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty

Metal-on-metal (MOM) bearings for hip arthroplasty are increasing in popularity. Concern remains, however, regarding the potential toxicological effects of the metal ions which these bearings release. The serum levels of cobalt and chromium in 22 patients who had undergone MOM resurfacing arthroplasty were compared with a matched group of 22 patients who had undergone 28 mm MOM total hip arthroplasty (THA). At a median of 16 months (7 to 56) after resurfacing arthroplasty, we found the median serum levels of cobalt and chromium to be 38 nmol/l (14 to 44) and 53 nmol/l (23 to 165) respectively. These were significantly greater than the levels after 28 mm MOM THA which were 22 nmol/l (15 to 87, p = 0.021) and 19 nmol/l (2 to 58, p < 0.001) respectively. Since the upper limit for normal patients without implants is typically 5 nmol/l, both groups had significantly raised levels of metal ions. MOM bearings of large diameter, however, result in a greater systemic exposure of cobalt and chromium ions than bearings of small diameter. This may be of relevance for potential long-term side-effects. It is not known to what extent this difference is due to corrosion of the surfaces of the component or of the wear particles produced.

Acetabular Labral Tears: Result of Arthroscopic Partial Limbectomy

SUMMARY Acetabular labral tears are a rare but well recognized cause of hip symptoms in young adults. Both clinical and radiographic diagnoses are difficult. The treatment of choice in the past has been either conservative or open arthrotomy. Hip arthroscopy has proved to be an effective tool for both diagnostic and therapeutic purposes in patients with chronic hip pain refractory to conservative treatment. We reviewed a series of 76 arthroscopic limbectomies. All patients had experienced hip symptoms for more than 6 months. None responded to nonsurgical treatment. Results were evaluated with the Harris Hip Score and with a questionnaire. Fifty-eight cases had a mean 3.5 years follow-up (range, 24 to 61 months). Thirty-nine patients (67.3%) were pleased with the result of their operation. The remaining 19 (32.7%) were not satisfied. Arthroscopy is an effective noninvasive procedure for the assessment and treatment of labral lesions. Short-term follow-up shows encouraging results.

The ligamentum teres of the hip: An arthroscopic classification of its pathology

Pathology of the ligamentum teres is rarely diagnosed. We describe the classification of the lesions seen at hip arthroscopy based on a group of 20 patients. Three groups are noted: complete rupture, partial rupture, and the degenerate ligamentum. The complete ligamentum teres rupture group had a history of either major trauma or surgery and had a high incidence of other hip pathology such as labral tears and articular damage. The partial ligamentum rupture group presented with a long history of ill-defined hip pain. Minor associated hip abnormalities were seen at arthroscopy. Degenerate ligamentum teres rupture presented with symptoms of the underlying osteoarthritis. Debridement or washout was performed but, at 2 years, patients had severe persistent symptoms or had had a joint replacement.

Arthroscopic anatomy of the hip: An in vivo study*

Hip arthroscopy is an exciting, new, and expanding field of orthopaedic surgery. The anatomy seen arthroscopically is considerably enlarged and more extensive than described in the classical anatomy texts. Orthopaedic surgeons must be familiar with the normal arthroscopic anatomy before embarking on hip arthroscopy.

Hip arthroscopy: current concepts and review of literature

Diagnosis and treatment of intra-articular hip problems in young patients present a challenge to hip surgeons. Previous studies have shown that non-invasive investigations such as radiography, computed tomography and magnetic resonance imaging provide limited help. Non-operative treatment is likely to result in persistent symptoms, and surgical options for intra-articular hip problems involve open arthrotomy of the hip joint, which carries potential risks associated with joint dislocation. Arthroscopy of the hip joint, therefore, seems to be an attractive option. It was once thought that introduction of a straight arthroscope into the ball-and-socket hip joint was almost impossible. Hip arthroscopy has seen several advances since then, and the speed at which it developed in recent years directly corresponded to the rate at which the conditions affecting the hip joint were identified. Athletes and other young individuals with hip injuries are increasingly being diagnosed with an ever evolving series of conditions. Many of these conditions were previously unrecognised and thus left untreated, resulting in premature ends to the patients’ competitive careers. Hip arthroscopy, as with any procedure, is not without risks. The procedure is not widely available as it requires specialist equipment and takes a long time to learn. Complications are few, occurring in <5% of patients.

Arthroscopic repair of delaminated acetabular articular cartilage using fibrin adhesive. Results at one to three years

We describe one- to three-year results of a novel use of fibrin glue in the treatment of cartilage damage by arthroscopy in the hip. This technique uses the microfracture technique and fibrin adhesive to bond delaminated articular cartilage to the underlying subchondral bone. This is generally performed in conjunction with treatment of underlying pathology such as femoroacetabular impingement. Patients were assessed using the modified Harris Hip Score (MHHS) pre- and post-operatively, and statistical significance determined by Students t-test. We report the mid-term results of 43 patients with femoroacetabular impingement who have undergone this technique for re-attachment of delaminated chondral flaps. There was a statistically significant improvement in MHHS at a mean of 28 months (16 to 42 months) after surgery (p<0.0001). The MHHS for pain improved significantly from 21.8 (95% CI 19.0 to 24.7) pre-operatively to 35.8 (95% CI 32.6 to 38.9) post-operatively (p<0.0001). The MHHS for function also showed significant, although more modest, improvements from 40.0 (95% CI 37.7 to 42.3) pre-operatively to 43.6 (95% CI 41.4 to 45.8) post-operatively (p=0.0006). There were three patients who had early (within 12 months of the index procedure) revision arthroscopy for iliopsoas pathology. Arthroscopic repair of delaminated acetabular articular cartilage using fibrin adhesive is a useful technique in the treatment of early cartilage damage. We have seen encouraging mid-term results, although further studies are warranted.

The arthroscopic management of femoroacetabular impingement

Femoroacetabular impingement (FAI) has recently been implicated in causing a spectrum of injury ranging from anterior hip pain, labral tears, chondral damage, and eventually perhaps to idiopathic arthritis of the hip. Three distinct types have been described: cam, pincer and mixed, with the mixed one being the commonest. Surgical treatment of femoroacetabular impingement is focused towards providing an adequate clearance to alleviate femoral abutment against the acetabular rim. This is achieved by restoring a normal femoral head–neck offset and recessing the acetabular rim if necessary. The treatment of FAI has been achieved with reasonable success by open surgical dislocation as described by the Swiss group. However, the protracted post-operative recovery coupled with the trauma sustained during the open procedure, have led to the development of an arthroscopic approach to manage this problem. The purpose of this article is to provide the reader with an up-to-date knowledge of the clinical and diagnostic aspects of FAI, to describe our arthroscopic technique in detail with its pitfalls and possible complications and to discuss the results and future of FAI.

Arthroscopic reconstruction of the ligamentum teres.

We describe a case of arthroscopic reconstruction of the ligamentum teres using a novel technique. This technique is both simple and reproducible. We believe it to be a useful addition to the procedures available to the arthroscopic hip surgeon.

Impact of arthroscopy of the hip for femoroacetabular impingement on quality of life at a mean follow-up of 3.2 years

The benefit of arthroscopy of the hip in the treatment of femoroacetabular impingement (FAI) in terms of quality of life (QoL) has not been reported. We prospectively collected data on 612 patients (257 women (42%) and 355 men (58%)) with a mean age at the time of surgery of 36.7 years (14 to 75) who underwent arthroscopy of the hip for FAI under the care of a single surgeon. The minimum follow-up was one year (mean 3.2 years (1 to 7)). The responses to the modified Harris hip score were translated using the Rosser Index Matrix in order to provide a QoL score. The mean QoL score increased from 0.946 (-1.486 to 0.995) to 0.974 (0.7 to 1) at one year after surgery (p < 0.001). The mean QoL score in men was significantly higher than in women, both before and one year after surgery (both p < 0.001). However, the mean change in the QoL score was not statistically different between men and women (0.02 (-0.21 to 0.27) and 0.04 (-0.16 to 0.87), respectively; p = 0.12). Linear regression analysis revealed that the significant predictors of a change in QoL score were pre-operative QoL score (p < 0.001) and gender (p = 0.04). The lower the pre-operative score, the higher the gain in QoL post-operatively (ρ = -0.66; p < 0.001). One year after surgery the QoL scores in the 612 patients had improved in 469 (76.6%), remained unchanged in 88 (14.4%) and had deteriorated in 55 (9.0%).