Hip Preservation


19 Hip Preservation


Ahmed El‐Bakoury MBBS PhD1, Asif A. H. Parkar MBBS2, and James N. Powell MD3


1 University Hospitals Plymouth NHS Trust, Plymouth, UK


2 Queen’s Hospital, National Health Service, London, UK


3 Division of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada


Introduction


There has been a resurgence of interest in the preservation of the native hip joint. The development of new techniques in pelvic osteotomies1,2 for hip dysplasia and subsequently the introduction of the concept of femoroacetabular impingement (FAI)3–5 have led to an increase in both open and arthroscopic procedures used in the management of hip pathology in young adults. In this chapter, we aim to review the available evidence for certain hip‐preserving procedures in the orthopedic literature. Table 19.1 lists the common causes of hip pain in young adult patients.


Clinical scenario



  • A 22‐year‐old female patient is reporting progressive pain in her right hip over the last six months.
  • She also has occasional catching sensation in her right hip and she feels that her hip clicks as well. She does not have any medical co‐morbidities.

Top three questions



  1. In patients with femoroacetabular impingement, does hip preservation surgery, compared to nonoperative treatment, result in better functional outcomes?
  2. In young adults with acetabular dysplasia, does periacetabular osteotomy, compared to conservative care, result in better functional outcomes?
  3. Among patients with mild or borderline acetabular dysplasia, does hip arthroscopy, compared to conservative care, produce better functional outcomes?

Question 1: In patients with femoroacetabular impingement, does hip preservation surgery, compared to nonoperative treatment, result in better functional outcomes?


Rationale


The concept of FAI was introduced by Ganz and associates in 2003 as a cause for osteoarthritis of the hip.3 The classic types of FAI include cam deformity, and pincer and mixed impingement.3 The treatment of FAI includes nonsurgical (personalized hip therapy) and surgical methods. Personalized hip therapy provides muscle control, strength around the hip, and movement patterns, which can lead to the avoidance of hip impingement.6 The surgical management has been described through both open7–9 and arthroscopic procedures,10–12 which allows resection of the bony impingement, treatment of the labral tears, and management of articular chondral lesions. Hip arthroscopy has equal or better outcomes compared to open surgical techniques and is associated with a lower incidence of major complications.13 In a systematic review comparing the results of open surgical dislocation, mini‐open technique, and hip arthroscopy, the authors found a higher incidence of complications with open surgical dislocation primarily because of trochanteric osteotomy related issues. The mini‐open procedure had a significantly higher incidence of iatrogenic injury of the lateral femoral cutaneous nerve.13


Table 19.1 Common causes of hip pain in young adult patients.

































A. Intra‐articular
Capsulolabral

  1. Labral tears
  2. Capsular laxity
  3. Adhesive capsulitis
Ligamentous
Ligamentum teres tear
Articular cartilage

  1. Arthritis (osteoarthritis, inflammatory arthritis, post‐traumatic, septic arthritis)
  2. Articular cartilage injury
Synovium

  1. Synovial chondromatosis
  2. Pigmented villonodular synovitis (PVNS)
Osseous

  1. Acetabular under‐coverage (dysplasia)
  2. Acetabular over‐coverage (pincer impingement)
  3. Femoroacetabular impingement
  4. Osteonecrosis
  5. Perthes disease
  6. Slipped capital femoral epiphysis
  7. Osteoid osteoma and other neoplastic causes
  8. Stress fracture
  9. Transient osteoporosis
B. Extra‐articular
Muscular

  1. Adductor muscle strain
  2. Abductor tear
  3. Iliopsoas tendinitis
  4. Piriformis syndrome
  5. Proximal hamstrings avulsion/tear
Impingement
Ischiofemoral impingement
Osseous

  1. Avulsion fracture (e.g. anterior superior iliac spine)
  2. Sacroiliac injuries
  3. Neoplastic
Athletic pubalgia
C. Referred pain
Lumbar spine
Genito‐urinary system
Pathology of abdominal organ or abdominal wall (e.g. inguinal hernia)

Clinical comment


Both hip arthroscopy and personalized hip therapy are successful methods in the management of FAI; however, hip arthroscopy can result in greater improvements of patients’ symptoms in the short term.


Available literature and quality of the evidence



  • Level I: 1 study (hip arthroscopy versus physical therapy).
  • Level IV: 1 meta‐analysis of level III and IV evidence.

Findings


Griffin et al. compared the clinical effectiveness of hip arthroscopy versus the best conservative care for patients with FAI in a multicenter trial (UK FASHIoN study) conducted in 23 hospitals in the UK.6 The study was an assessor‐blinded randomized controlled trial (RCT) that included 348 patients with symptomatic FAI with no radiographic evidence of osteoarthritis. Patients were allocated to receive either hip arthroscopy or personalized hip therapy (an individualized, supervised, and progressive physiotherapist‐led program of conservative care). Their primary outcome was the patient‐reported International Hip Outcome Tool (IHOT‐33) 12 months after randomization. Both groups showed an improvement of the average IHOT‐33; however, the mean difference in IHOT‐33 scores was 6.8 (95% confidence interval [CI]: 1.7–12.0) in favor of hip arthroscopy (p = 0.0093). The UK FASHIoN study is the first RCT that shows that hip arthroscopy is effective in the treatment of FAI. This study published in 2018 reported only 12 months clinical outcome after randomization and longer‐term follow‐up is still needed. In a recent meta‐analysis of 1981 hips assessing the outcome of hip arthroscopy for FAI (level IV), the reported risk of reoperation was 5.5%, while the risk of clinical complications was 1.7%. These complications included heterotopic ossification, transient neuropraxia, adhesions, stiffness, wound infection, skin necrosis, and nondisplaced femoral head‐neck fracture.14


Resolution of clinical scenario

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Hip Preservation

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