Arthroscopic Partial Limbectomy in Hip Joints With Acetabular Hypoplasia

doi:10.1016/j.arthro.2005.01.003

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 5, May 2005, Pages 586-591

https://doi.org/10.1016/j.arthro.2005.01.003 Get rights and content

Purpose: The purpose of this study was to clarify whether arthroscopic partial excision of a torn labrum in acetabular hypoplasia leads to rapid progression of osteoarthritis. Type of Study: Clinical case study. Materials and Methods: We performed arthroscopic partial limbectomy in 10 hips with pre- or early osteoarthritis secondary to acetabular hypoplasia. All the patients were females with mechanical symptoms such as giving way, catching, locking, or clicking sound. Their ages at the time of surgery ranged from 14 to 62 years (mean, 33.7 y). The follow-up period ranged from 2 to 14 years (mean, 8 y). None of the hips had subluxation. Arthroscopic surgery was performed in the supine position on a traction table, using a simultaneous 3-directional approach. The preoperative center-edge (CE) angle ranged from 0° to 20° (mean, 12.4°). Results: In all patients, preoperative radiographs and magnetic resonance imaging (MRI) depicted no tear of the acetabular labrum, whereas arthroscopic examinations revealed tears incarcerated in the joint space. Coxalgia improved within 4 or 5 days after surgery in all patients, showing that the torn labrum had caused the pain. The tears were classified as bucket-handle type in 6 hips, degenerative type in 3 hips, and flap type in 1 hip. Mechanical symptoms had subsided or disappeared in all hips postoperatively for a mean follow-up of 8 years. Radiographs revealed no evidence of osteoarthritis progression, although one case with a preoperative CE angle of 0° showed lateralization of the femoral head. Conclusions: Labral tears in acetabular hypoplasia or dysplastic hip are mostly the bucket-handle type, located at the anterosuperior part of the acetabulum. Incarceration of the torn labrum in the joint space causes coxalgia. Rapid progression of osteoarthritis after limbectomy was not observed up to 8 years after surgery in this series. Level of Evidence: Level IV.

Section snippets

Patients and Methods

Arthroscopic examinations were performed on 419 hips in 368 patients from 1984 to 2000. Among them, 34 hips of 30 patients were diagnosed with pre-osteoarthritis or early osteoarthritis secondary to acetabular hypoplasia. Arthroscopic findings in 10 hips (10 patients, 29.4%) revealed incarceration of the torn labrum in the joint space. The articular cartilage was normal and showed no degenerate changes in 4 cases, and was fibrillated in 6 cases. All patients were females; the mean age at

Preoperative Clinical Findings

All the patients complained of pain on the anterior or lateral aspects of the hip joint in flexion and extension during sports or daily life activities. Seven hips had a history of locking of the hip joint and 6 hips had a history of catching, similar to something caught between the back of the teeth. Four hips had episodes of giving way, with severe pain around the hip joint. All the patients had a history of sudden and extremely severe pain during walking, which occurred on and off.

All 10

Case Presentation

The patient (patient 7) was a 38-year-old woman diagnosed with early osteoarthritis. At the first examination, she had an HHS of 45 points and used a crutch while walking. Arthroscopic findings revealed a labral tear incarcerated in the joint space. Partial excision of the torn labrum was performed. At the latest follow-up evaluation (7 years after surgery), she had an HHS of 100 points (Fig 2).

The patient (patient 8) was a 26-year-old woman diagnosed with early osteoarthritis. At the

Discussion

In 1986, Dorrell et al.¹ reported 11 acetabular hypoplasia hips with labral tears. They performed arthrotomy to excise the torn labrum in 2 hips. In both cases, there was incomplete relief of symptoms and a second procedure (Chiari’s pelvic osteotomy) was needed. In 1990, however, Nishina et al.² reported that in 58 cases treated by Chiari’s pelvic osteotomy, about half of hips in which preoperative hip arthrograms revealed labral tears did not achieve a good outcome. They suggested that a

Conclusions

We conclude the following from our study:

1
In acetabular hypoplasia, a torn labrum incarcerated in the joint space may cause mechanical symptoms including pain in the hip joint.
2
The characteristic clinical manifestation of acetabular labral tear is acute exacerbation of sharp pain elicited by rotational movements with the hip joint in flexion.
3
The labral tear is mostly the bucket-handle type located at the anterosuperior part of the acetabular rim.
4
Rapid progression of osteoarthritis after

References (10)

T. Ide et al.
Arthroscopic surgery of hip joint
Arthroscopy
(1991)
L.A. Farjo et al.
Hip arthroscopy for acetabular labral tears
Arthroscopy
(1999)
J.H. Dorrell et al.
The torn acetabular labrum
J Bone Joint Surg Br
(1986)
T. Nishina et al.
Chiari pelvic osteotomy for osteoarthritis
J Bone Joint Surg Br
(1990)
K. Klaue et al.
The acetabular rim syndrome
J Bone Joint Surg Br
(1991)

There are more references available in the full text version of this article.

Cited by (35)

Hip arthroscopy: Indications, outcomes and complications
2018, International Journal of Surgery
Citation Excerpt :
The status of the articular cartilage is a key prognostic indicator in these cases and arthroscopy has a vital role in making decisions for salvage or reconstructive procedures in young adults with hip dysplasia [47,48]. Furthermore, associated labral pathology can be addressed to help alleviate symptoms, buy time and plan for major and/or definitive surgical treatment [49]. Hip arthroscopy is likely to be more challenging in the paediatric population because of altered anatomy as a result of underlying disorder and any previous surgical treatment.
Hip arthroscopy has recently occupied an important place in the armamentarium of General Orthopedic and especially hip surgeons. It is an effective and innovative procedure with rapidly expanding indications. Advancements in surgical tools and refinement in techniques has revolutionalized modern Hip arthroscopy. Surgeons are now able to address pathology in and around the hip joint that was either misdiagnosed or poorly understood. The procedure allows detailed visualization of acetabular labrum, femoral and acetabular chondral surfaces, fovea, ligamentum teres, synovium and the extra-articular peri-trochanteric space. Minimally invasive surgery is now performed for diagnoses as well as treatment of a variety of Hip disorders. The acceptance and rates of hip arthroscopy are increasing across the board and the associated literature is expanding every day. Increasing surgical experience and improving technology is contributing for more advanced procedures to become popularized, however long-term outcome data about hip arthroscopy is still relatively sparse. We aim to review hip arthroscopy in the light of recent literature and will discuss the current indications, outcomes and complications of the procedure.
Open and Arthroscopic Treatment of Adult Hip Dysplasia: A Systematic Review
2016, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Although all studies included in this review assessed PRO scores, the scores used were not consistent. Three scores were assessed by more than one article; the 36-Item Short Form (SF-36)12,18,23 and the Harris Hip Score (HHS)10,21,24 were assessed in 3 studies each, whereas the modified Harris Hip Score (mHHS) was assessed in 2 studies20,22 (Table 2). Of the studies that reported both pre- and postoperative PRO scores, nearly all reported improvement.
To compare patient-reported outcome (PRO) and rates of conversion to total hip arthroplasty (THA) after hip arthroscopy, Bernese periacetabular osteotomy (PAO), and a combined approach for the management of patients with different grades of hip dysplasia.
We searched MEDLINE and PubMed databases for articles published since 2000 using the following terms: ((((“hip dysplasia”) or “dysplastic”) and “arthroscopy”)) or (((“hip dysplasia”) or “dysplastic”) and “osteotomy”). Two authors independently reviewed the literature. Inclusion criteria were English language, relevance to hip dysplasia, surgical outcomes, and sample size of 10 patients or more. We excluded articles that were reviews or techniques; articles that included overlapping populations, patients with a mean age less than 18 years, patients with other hip conditions, patients with genetic or neuromuscular causes of hip dysplasia, and patients with Tonnis grade 2 or greater arthritis; articles on femoral osteotomy, and articles on previous surgical intervention, except hip arthroscopy. Articles were analyzed for PRO scores and rates of conversion to THA.
Ten of 759 articles reviewed met the inclusion and exclusion criteria. Of 834 hips treated for dysplasia with a mean age of 31 years, 114 were treated with arthroscopy alone, 703 were treated with PAO alone, and 17 were treated with both procedures. Mean follow-up was 3.2 years, 6.5 years, and 5.6 years, respectively. Conversion rates to THA were 4.8%, 12.0%, and 17.7%, respectively. In studies reporting pre- and postoperative PRO scores, all but one reported improvement.
The management of hip dysplasia may entail hip arthroscopy, PAO, or a combined approach. Arthroscopy has resulted in improved outcomes in borderline dysplastic cases (lateral center edge angle between 18° and 25°). PAO has primarily been used in true dysplasia with continued success. There were too few combined procedures of arthroscopy with PAO to reach a reliable conclusion in this subgroup.
Systematic review of Level III and Level IV studies.
Clinicoradiological assessment of 27 Chiari osteotomies performed in adolescence
2014, Revue de Chirurgie Orthopedique et Traumatologique
L’ostéotomie de Chiari à l’adolescence est une chirurgie de sauvetage dans les ostéochondrites primitives fémorales évoluées et les excentrations de hanche non résolutives préalablement ou vues tardivement au-delà de 10 ans d’âge osseux. De moins en moins utilisée, elle n’en reste pas moins d’une très grande efficacité. C’est une chirurgie exigeante pour laquelle le trait d’ostéotomie est sûrement perfectible compte tenu de certains mauvais résultats. Nous avons étudié sur la base d’une série rétrospective exhaustive de 27 enfants, la qualité des résultats au meilleur recul parallèlement à la morphologie de la hanche en préopératoire. On note une amélioration du score de Postel-Merle d’Aubigné en postopératoire. Les couvertures céphaliques antéropostérieure et médiolatérale ont été significativement améliorées. Deux hanches ont dû être prothésées ultérieurement, mais il s’agissait d’arthroses avancées en préopératoire (pincement articulaire de plus de 50 %). Nous n’avons pas retrouvé de rapport entre la qualité de l’ostéotomie et la qualité des résultats finaux. Il existe donc sûrement des paramètres non encore étudiés susceptibles de gréver le pronostic. L’ostéotomie doit être basse afin d’obtenir une congruence optimale à la tête fémorale. L’IRM devrait être systématique en préopératoire afin de déceler les anomalies du bourrelet. La modélisation de la hanche sur un scanner permet probablement d’améliorer le trait d’ostéotomie par rapport à la morphologie du cotyle.
4.
Patient-specific analysis of cartilage and labrum mechanics in human hips with acetabular dysplasia
2014, Osteoarthritis and Cartilage
Acetabular dysplasia is a major predisposing factor for development of hip osteoarthritis (OA), and may result from alterations to chondrolabral loading. Subject-specific finite element (FE) modeling can be used to evaluate chondrolabral mechanics in the dysplastic hip, thereby providing insight into mechanics that precede OA.
To evaluate chondrolabral contact mechanics and congruency in dysplastic hips and normal hips using a validated approach to subject-specific FE modeling.
FE models of ten subjects with normal acetabula and ten subjects with dysplasia were constructed using a previously validated protocol. Labrum load support, and labrum and acetabular cartilage contact stress and contact area were compared between groups. Local congruency was determined at the articular surface for two simulated activities.
The labrum in dysplastic hips supported 2.8–4.0 times more of the load transferred across the joint than in normal hips. Dysplastic hips did not have significantly different congruency in the primary load-bearing regions than normal hips, but were less congruent in some unloaded regions. Normal hips had larger cartilage contact stress than dysplastic hips in the few regions that had significant differences.
The labrum in dysplastic hips has a far more significant role in hip mechanics than it does in normal hips. The dysplastic hip is neither less congruent than the normal hip, nor subjected to elevated cartilage contact stresses. This study supports the concept of an outside–in pathogenesis of OA in dysplastic hips and that the labrum in dysplastic hips should be preserved during surgery.
Emerging topics on the hip: Ligamentum teres and hip microinstability
2012, European Journal of Radiology
Citation Excerpt :
If the patient has pain over the greater trochanter or iliotibial band snapping, an iliotibial band lengthening can be included in the procedure [33]. If the patient has significant dysplasia, the role of hip arthroscopy is not well defined but several reports in the literature have shown excellent results in the management of labral pathology in patients with dysplasia [30,40]. In case of severe dysplasia, the role of reorientation osteotomy should be examined [41,42].
Microinstability and ligament teres lesions are emergent topics on the hip pathology. These entities are an increasingly recognized cause of persistent hip pain and should be considered in the differential diagnosis of the patient with hip pain. Conventional (non-arthrographic) CT and MR have a very limited role in the evaluation of these entities. CTa and MRa have emerged as the modalities of choice for pre-operative imaging of ligamentum teres injuries and microinstability. To date, pre-operative imaging detection of these pathologies is not widespread but with appropriate imaging and a high index of suspicion, preoperative detection should improve. This article discusses current concepts regarding anatomy, biomechanics, clinical findings, diagnosis and treatment of ligament teres lesions and microinstability.
Shelf arthroplasties long-term outcome: Influence of labral tears. A prospective study at a minimal 16 years' follows up
2010, Revue de Chirurgie Orthopedique et Traumatologique
Les lésions d’arthrose et la sévérité de la dysplasie (angle de couverture latérale [VCE] négatif) sont reconnues comme des critères défavorables à la survie des butées effectuées pour la correction de la dysplasie de hanche. Les lésions labrales ont été décrites récemment sur des hanches dysplasiques indiquant une arthrose débutante et aggravant le risque d’instabilité.
Les lésions labrales identifiées au moment de la réalisation d’une butée pour la correction d’une dysplasie de hanche ont une valeur prédictive de la survie de l’intervention.
Évaluer cette hypothèse au moyen d’une étude prospective observationnelle à long terme.
Dix-huit patients adultes (18 hanches dysplasiques) ayant été opérés d’une butée ont été inclus consécutivement dans une étude prospective continue. Au moment de la réalisation de la butée, une arthroscopie de hanche était systématiquement réalisée pour rechercher et exciser si nécessaire une lésion labrale. Quinze patients ont été revus avec un recul minimum de 16 ans. Deux patients sont décédés et un patient a été perdu de vue.
Lors de l’exploration arthroscopique, dix hanches présentaient des lésions labrales (55,6 %). Au recul moyen de 16,3 ans (16–18 ans), huit hanches avaient bénéficiées de la mise en place d’une arthroplastie de hanche. Parmi ces hanches, seulement une hanche ne présentait pas de lésion labrale. Les sept autres hanches avaient une lésion du labrum (p < 0,001). Le taux de survie global était de 41,3 % ; il était de 83,3 % pour les hanches sans lésion labrale et de 15,2 % pour les hanches avec lésion du labrum (p = 0,048).
Les lésions labrales ont une valeur péjorative sur le devenir d’une butée effectuée pour dysplasie de hanche. Cette lésion mérite donc d’être recherchée systématiquement par une exploration appropriée (IRM ou arthro-TDM) avant la réalisation d’une butée de hanche. L’existence d’une lésion labrale préopératoire ne semble pas remettre en cause le geste chirurgical de butée. Elle doit cependant être connue afin d’en fixer les objectifs et les attentes : la survie à long terme étant significativement plus faible en présence de lésion du labrum. Il semble préférable de régulariser sous arthroscopie ce type de lésion au moment de la réalisation de la butée afin d’éviter une source potentielle de douleurs résiduelles, et en considérant que sa résection secondaire sera plus difficile après le geste de couverture.
Niveau 3 étude prospective observationnelle pronostique.

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Original articleArthroscopic Partial Limbectomy in Hip Joints With Acetabular Hypoplasia

Section snippets

Patients and Methods

Preoperative Clinical Findings

Case Presentation

Discussion

Conclusions

Arthroscopy

Arthroscopy

The torn acetabular labrum

J Bone Joint Surg Br

Chiari pelvic osteotomy for osteoarthritis

J Bone Joint Surg Br

The acetabular rim syndrome

J Bone Joint Surg Br

Original article
Arthroscopic Partial Limbectomy in Hip Joints With Acetabular Hypoplasia