Original Research

Poorer Arthroscopic Outcomes of Mild Dysplasia With Cam Femoroacetabular Impingement Versus Mixed Femoroacetabular Impingement in Absence of Capsular Repair

Am J Orthop. 2017 January;46(1):E47-E53

Dean K. Matsuda, MD

Nikhil Gupta, MD

Monti Khatod, MD

Nicole A. Matsuda

Faith Anthony, MS

Joshua Sampson, MD

Raoul Burchette, MS, MA

Purpose: To compare outcomes of mild dysplasia with cam femoroacetabular impingement (FAI) vs mixed FAI with hip arthroscopy without capsular repair. Methods: A retrospective review of a 2009 to 2010 multicenter prospective outcome study was performed comparing a cohort with mild dysplasia and cam femoroacetabular impingement (cohort D) to a cohort with mixed FAI (cohort M). Outcome measures included Nonarthritic Hip Score (NAHS) and satisfaction with minimum 2-year follow-up. Results: Of 150 patients/159 hips enrolled in the initial prospective outcome study, 10 patients/10 hips had acetabular dysplasia and 8 patients met the inclusion criteria. Cohort D had 8 patients (5 female) of mean age 49.6 years with mean lateral center-edge angle (LCEA) of 19° (range, 16°-24°) demonstrating a mean change in NAHS of +20.00 at 3 months (P = .25), +14.33 at 12 months (P = .03), and -0.75 at 24 months (P = .74). Mean satisfaction was 2.88 out of 5. Cohort M had 69 patients (32 female) of mean age 38.6 years with a mean LCEA of 33° (range, 25°-38°) demonstrating a mean change in NAHS of +12.09 at 3 months (P < .0001), + 20.39 at 12 months (P < .0001), and +21.99 at 24 months (P < .0001). Mean satisfaction was 3.58 out of 5. Cohort D demonstrated significantly less improvement in NAHS (P = .002) and a difference of -31.06 points compared to cohort M at minimum 2-year follow-up. Dysplasia was the only statistically significant predictor of poorer outcomes. Conclusion: The common combination of mild dysplasia and cam FAI has poorer outcomes than mixed FAI following arthroscopic surgery without capsular repair.

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References

1. Paliobeis CP, Villar RN. The prevalence of dysplasia in femoroacetabular impingement. Hip Int. 2011;21(2):141-145.

2. Clohisy JC, Nunley RM, Carlisle JC, Schoenecker PL. Incidence and characteristics of femoral deformities in the dysplastic hip. Clin Orthop Relat Res. 2009;467(1):128-134.

3. Parvizi J, Bican O, Bender B, et al. Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note. J Arthroplasty. 2009;24(6 suppl):110-113.

4. Matsuda DK, Khatod M. Rapidly progressive osteoarthritis after arthroscopic labral repair in patients with hip dysplasia. Arthroscopy. 2012;28(11):1738-1743.

5. Jackson TJ, Watson J, LaReau JM, Domb BG. Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):911-914.

6. Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy. 2003;19(10):1055-1060.

7. Domb BG, Stake CE, Lindner D, El-Bitar Y, Jackson TJ. Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem. Am J Sports Med. 2013;41(11):2591-2598.

8. Jayasekera N, Aprato A, Villar RN. Hip arthroscopy in the presence of acetabular dysplasia. Open Orthop J. 2015;9:185-187.

9. Fukui K, Briggs KK, Trindade CA, Philippon MJ. Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia. Arthroscopy. 2015;31(12):2371-2379.

10. Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Instr Course Lect. 2001;50:239-245.

11. Garras DN, Crowder TT, Olson SA. Medium-term results of the Bernese periacetabular osteotomy in the treatment of symptomatic developmental dysplasia of the hip. J Bone Joint Surg Br. 2007;89(6):721-724.

12. Biedermann R, Donnan L, Gabriel A, Wachter R, Krismer M, Behensky H. Complications and patient satisfaction after periacetabular pelvic osteotomy. Int Orthop. 2008;32(5):611-617.

13. Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011;39(suppl):72S-78S.

14. Domb BG, LaReau JM, Baydoun H, Botser I, Millis MB, Yen YM. Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy? Clin Orthop Relat Res. 2014;472(2):674-680.

15. Kain MS, Novais EN, Vallim C, Millis MB, Kim YJ. Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia. J Bone Joint Surg Am. 2011;93(suppl 2):57-61.

16. Matsuda DK, Villamor A. The modified mid-anterior portal for hip arthroscopy. Arthrosc Tech. 2014;3(4):e469-e474.

17. Javed A, O’Donnell JM. Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age. J Bone Joint Surg Br. 2011;93(3):326-331.

18. Redmond JM, Gupta A, Cregar WM, Hammarstedt JE, Gui C, Domb BG. Arthroscopic treatment of labral tears in patients aged 60 years or older. Arthroscopy. 2015;31(10):1921-1927.

19. Mei-Dan O, McConkey MO, Brick M. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy. 2012;28(3):440-445.

20. Benali Y, Katthagen BD. Hip subluxation as a complication of arthroscopic debridement. Arthroscopy. 2009;25(4):405-407.

21. Jayasekera N, Aprato A, Villar RN. Are crutches required after hip arthroscopy? A case–control study. Hip Int. 2013;23(3):269-273.

22. Domb BG, Stake CE, Finley ZJ, Chen T, Giordano BD. Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery. Arthroscopy. 2015;31(4):643-650.

23. Pereira F, Giles A, Wood G, Board TN. Recognition of minor adult hip dysplasia: which anatomical indices are important? Hip Int. 2014;24(2):175-179.

24. Murphy SB, Ganz R, Müller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am. 1995;77(7):985-989.

25. Matsuda DK, Gupta N, Burchette R, Sehgal B. Arthroscopic surgery for global versus focal pincer femoroacetabular impingement: are the outcomes different? J Hip Preserv Surg. 2015;2(1):42-50.

Take-Home Points

Cam deformity often occurs with dysplasia.
Borderline or mild dysplasia has been treated with isolated hip arthroscopy.
Avoid rim trimming that can make mild dysplasia more severe.
Labral preservation, cam decompression, and capsular repair or plication are currently suggested.
Poorer outcomes occurred in borderline or mild dysplasia with cam impingement relative to controls following hip arthroscopy without capsular repair.
Initial clinical improvement may be followed by clinical deterioration suggesting close long-term follow-up with prompt addition of reorientation acetabular osteotomy if indicated.
It is unknown whether small capsulotomies may yield comparable outcomes with larger capsulotomies plus repair.

It is unknown whether small capsulotomies may yield comparable outcomes with larger capsulotomies plus repair. There is growing interest in hip preservation surgery in general and arthroscopic hip preservation in particular. Chondrolabral pathology leading to symptoms and degenerative progression typically is caused by structural abnormalities, mainly femoroacetabular impingement (FAI) and developmental dysplasia of the hip. Unlike the bony overcoverage of pincer FAI, developmental dysplasia of the hip typically exhibits insufficient anterolateral coverage of the femoral head.

The role of hip arthroscopy in the treatment of dysplasia remains undefined. Emerging evidence shows a high incidence of dysplasia with associated cam deformity,^1,2 but there is a paucity of evidence-based information for this specific patient population. Clinical outcomes of hip arthroscopy in the setting of dysplasia are conflicting: some poor^3-5 and others successful.^1,6-9 Although reorientation periacetabular osteotomy (PAO) is considered a mainstay in the treatment of dysplasia—providing improvement in symptoms, deficient anterolateral acetabular coverage, and hip biomechanics—midterm failure rates approaching 24% have been reported.^10-12 Many young patients with symptomatic dysplasia want a surgical option that is less invasive than open PAO.⁴ Intra-articular central compartment pathology and cam FAI commonly occur with dysplasia and are amenable to arthroscopic treatment.^1,13,14 Moreover, staged PAO may be successful in cases in which arthroscopic intervention fails to provide clinical improvement.^5,15

Emerging evidence suggests beneficial effects of arthroscopic capsular repair or plication in the setting of borderline or mild dysplasia.^7,9However, the literature provides little information on arthroscopic outcomes without capsular repair. One study found poor outcomes of arthroscopic surgery for dysplasia, but its patients underwent labral débridement, not repair.³ Two patients in a case report demonstrated rapidly progressive osteoarthritis after arthroscopic labral repairs and concurrent femoroplasties for cam FAI, but each had marked dysplasia with a lateral center-edge angle (LCEA) of <15°.⁴

Arthroscopy with capsular repair has been assumed to provide better outcomes than arthroscopy without repair, but to our knowledge there are no studies that have compared outcomes of mild dysplasia with cam FAI and outcomes of mixed FAI treated without capsular repair. Clinical equipoise makes it ethically challenging to perform a prospective study comparing dysplasia treated with and without capsular repair. We conducted a study to compare outcomes of mild dysplasia with cam FAI and outcomes of mixed FAI treated with arthroscopic surgery and to fill the knowledge gap regarding outcomes of mild dysplasia treated without capsular repair.

Methods

In this study, which received Institutional Review Board approval, we retrospectively reviewed radiographs and data from a prospective 3-center study of arthroscopic outcomes of FAI in 150 patients (159 hips) who underwent arthroscopic surgery by 1 of 3 surgeons between March 2009 and June 2010. In all cases, digital images of anteroposterior pelvic radiographs were used for radiographic measurements. On these images, the LCEA is formed by the intersection of the vertical line (corrected for obliquity using a horizontal reference line connecting the inferior extents of both radiographic teardrops) through the center of the femoral head (determined with a digital centering tool) with the line extending to the lateral edge of the sourcil (radiographic eyebrow of the weight-bearing region or roof of the acetabulum). Measurements were made in blinded fashion (by a nonsurgeon coauthor, Dr. Nikhil Gupta, who completed training modules) and were confirmed without alteration by the principal investigator Dr. Dean K. Matsuda. Inclusion criteria were mild acetabular dysplasia (LCEA, 15°-24°) and mixed FAI including focal pincer component (LCEA, 25°-39°), radiographic crossover sign, and successful completion of patient-reported outcome (PRO) measures at minimum 2-year follow-up. Exclusion criteria were severe dysplasia (LCEA, <15°), hip subluxation, broken Shenton line, global pincer FAI (LCEA, ≥40°), Tönnis grade 3 osteoarthritis, Legg-Calvé-Perthes disease, osteonecrosis, prior hip surgery, and unsuccessful completion of PRO measures. Outcome measures included investigator-blinded preoperative and postoperative Nonarthritic Hip Score (NAHS) and 5-point Likert satisfaction score. Complications, revision surgeries, and conversion arthroplasties were recorded.

References

1. Paliobeis CP, Villar RN. The prevalence of dysplasia in femoroacetabular impingement. Hip Int. 2011;21(2):141-145.

2. Clohisy JC, Nunley RM, Carlisle JC, Schoenecker PL. Incidence and characteristics of femoral deformities in the dysplastic hip. Clin Orthop Relat Res. 2009;467(1):128-134.

3. Parvizi J, Bican O, Bender B, et al. Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note. J Arthroplasty. 2009;24(6 suppl):110-113.

4. Matsuda DK, Khatod M. Rapidly progressive osteoarthritis after arthroscopic labral repair in patients with hip dysplasia. Arthroscopy. 2012;28(11):1738-1743.

5. Jackson TJ, Watson J, LaReau JM, Domb BG. Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):911-914.

6. Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy. 2003;19(10):1055-1060.

7. Domb BG, Stake CE, Lindner D, El-Bitar Y, Jackson TJ. Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem. Am J Sports Med. 2013;41(11):2591-2598.

8. Jayasekera N, Aprato A, Villar RN. Hip arthroscopy in the presence of acetabular dysplasia. Open Orthop J. 2015;9:185-187.

9. Fukui K, Briggs KK, Trindade CA, Philippon MJ. Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia. Arthroscopy. 2015;31(12):2371-2379.

10. Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Instr Course Lect. 2001;50:239-245.

11. Garras DN, Crowder TT, Olson SA. Medium-term results of the Bernese periacetabular osteotomy in the treatment of symptomatic developmental dysplasia of the hip. J Bone Joint Surg Br. 2007;89(6):721-724.

12. Biedermann R, Donnan L, Gabriel A, Wachter R, Krismer M, Behensky H. Complications and patient satisfaction after periacetabular pelvic osteotomy. Int Orthop. 2008;32(5):611-617.

13. Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011;39(suppl):72S-78S.

14. Domb BG, LaReau JM, Baydoun H, Botser I, Millis MB, Yen YM. Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy? Clin Orthop Relat Res. 2014;472(2):674-680.

15. Kain MS, Novais EN, Vallim C, Millis MB, Kim YJ. Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia. J Bone Joint Surg Am. 2011;93(suppl 2):57-61.

16. Matsuda DK, Villamor A. The modified mid-anterior portal for hip arthroscopy. Arthrosc Tech. 2014;3(4):e469-e474.

17. Javed A, O’Donnell JM. Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age. J Bone Joint Surg Br. 2011;93(3):326-331.

18. Redmond JM, Gupta A, Cregar WM, Hammarstedt JE, Gui C, Domb BG. Arthroscopic treatment of labral tears in patients aged 60 years or older. Arthroscopy. 2015;31(10):1921-1927.

19. Mei-Dan O, McConkey MO, Brick M. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy. 2012;28(3):440-445.

20. Benali Y, Katthagen BD. Hip subluxation as a complication of arthroscopic debridement. Arthroscopy. 2009;25(4):405-407.

21. Jayasekera N, Aprato A, Villar RN. Are crutches required after hip arthroscopy? A case–control study. Hip Int. 2013;23(3):269-273.

22. Domb BG, Stake CE, Finley ZJ, Chen T, Giordano BD. Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery. Arthroscopy. 2015;31(4):643-650.

23. Pereira F, Giles A, Wood G, Board TN. Recognition of minor adult hip dysplasia: which anatomical indices are important? Hip Int. 2014;24(2):175-179.

24. Murphy SB, Ganz R, Müller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am. 1995;77(7):985-989.

25. Matsuda DK, Gupta N, Burchette R, Sehgal B. Arthroscopic surgery for global versus focal pincer femoroacetabular impingement: are the outcomes different? J Hip Preserv Surg. 2015;2(1):42-50.

Poorer Arthroscopic Outcomes of Mild Dysplasia With Cam Femoroacetabular Impingement Versus Mixed Femoroacetabular Impingement in Absence of Capsular Repair

References

Take-Home Points

Methods

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