Extract
Interest in the etiology, diagnosis, and treatment of hip pain in young
adults has recently heightened. Improved diagnostic techniques with use of
physical examination, magnetic resonance
arthrography1,2,
and three-dimensional computed tomographic imaging better define the diagnoses
of femoroacetabular
impingement3 and
acetabular and/or proximal femoral
dysplasia4-6.
Newer treatment methods, such as surgical dislocation and
débridement7-10
and periacetabular
osteotomy11-30,
show promise as nonarthroplasty alternatives in young
patients6,8,10,11,31.
Interest in the etiology, diagnosis, and treatment of hip pain in young
adults has recently heightened. Improved diagnostic techniques with use of
physical examination, magnetic resonance
arthrography1,2,
and three-dimensional computed tomographic imaging better define the diagnoses
of femoroacetabular
impingement3 and
acetabular and/or proximal femoral
dysplasia4-6.
Newer treatment methods, such as surgical dislocation and
débridement7-10
and periacetabular
osteotomy11-30,
show promise as nonarthroplasty alternatives in young
patients6,8,10,11,31.
In our experience, femoroacetabular impingement and dysplasia are the main
reasons why young adults present with hip pain. Labral pathology may
frequently coexist, but it is usually secondary to morphological abnormalities
of the hip resulting in abnormal loading and impingement. In our opinion,
abnormal morphology of the hip, although sometimes subtle, is the predominant
underlying abnormality leading to the development of hip pain in the young
adult. We believe that, in most patients, optimum treatment should be directed
at normalizing morphology.
The clinical history in these patients is important. Typically, the pain is
described as being located in the anterior part of the groin and sometimes in
the lateral aspect of the hip, but without tenderness over the greater
trochanter, as the main symptom. The type of pain can vary. When it is
described as sharp and catching, worse with sitting or deep flexion, it is
likely related to impingement. If it also includes substantial catching or
popping, labral pathology may be involved. Pain that occurs with walking and
standing, is generalized over the activities of daily living, and possibly
involves subluxation sensations may be more related to dysplasia with lack of
coverage of the femoral head. The duration of pain varies from six months to
many years. The history should also identify what specialized tests,
injections, procedures, or treatments, such as prior surgery, have already
been performed with what effects.
On physical examination, the range of motion of the hip can be different in
dysplasia compared with impingement. Patients with acetabular undercoverage
due to dysplasia usually have full motion with more internal rotation than
external rotation, with limited pain. In contrast, hip motion with
femoroacetabular impingement usually shows profound limitation of internal
rotation with pain. These patients usually have a positive impingement
test3. The test is
performed by placing the patient in the supine position with the hip in
90° of flexion and then adducting and internally rotating the hip
(Fig. 1). The goal of this test
is nearly complete reproduction of the type and location of the pain.
Imaging
The key radiographs to make are an anteroposterior view of the pelvis
(Fig. 2), and a cross-table
lateral (groin lateral) view. Magnetic resonance arthrography is helpful to
evaluate for an abnormal head-neck junction and to identify possible labral
pathology (Fig. 3). More
recently, we have been acquiring a three-dimensional reconstruction of the hip
with use of thin-cut computed tomographic arthrography
(Fig. 4). We have found it to
be very helpful for evaluating acetabular and femoral
retroversion4-6.
In most patients, a diagnostic intra-articular injection in the hip of a local
anesthetic and corticosteroid (3 mL of Marcaine [bupivacaine], 3 mL of
lidocaine, and 2 mL of Depo-Medrol [methylprednisolone]) under fluoroscopy
relieves the pain and at the same time provides diagnostic information
confirming that intra-articular pathology is the source of the pain.
With use of the relevant history, physical examination findings, and
imaging studies, the primary site of the abnormal morphology is usually
identifiable. For patients who have had pain for greater than six months and
substantial changes in the activities of daily living or recreational
activities, the next step in determining the appropriate surgical treatment is
to assess the integrity of the articular surface of the acetabulum and femoral
head. In patients with primary abnormal acetabular morphology with preserved
articular surfaces, our preference has been to perform a reorientation
periacetabular osteotomy. In patients with femoroacetabular impingement due
primarily to abnormal morphology of the femoral head-neck junction, our
preference has been to perform surgical dislocation and débridement of
the hip. In the relatively common situation of morphological abnormalities on
both sides of the joint, with or without articular surface damage, the optimum
treatment method is more difficult to discern and may involve combinations of
both surgical techniques.
From 1996 to 2005, 112 Bernese periacetabular
osteotomies11-30
were performed by one surgeon (C.L.P.) for the treatment of symptomatic hip
dysplasia32. There
were seventy-one female and twenty-six male patients. Fifteen staged bilateral
procedures were performed. The average patient age was twenty-eight years
(range, fifteen to forty-seven years). All 112 hips had dysplasia, and
seventy-eight (70%) had classic dysplasia with lack of lateral coverage, yet
the acetabulum was still anteverted. Thirty-four hips (30%) had acetabular
retroversion, manifested by a more prominent anterior wall, a positive
cross-over sign4,
and a relatively deficient posterior
wall4-6.
Radiographs of the left hip of a patient before and after a periacetabular
osteotomy can be seen in Figures
5 and
6.
The results of the periacetabular osteotomy in our patients have been good,
with survival of 107 of the 112 osteotomies. Four hips were converted to a
total hip arthroplasty after a mean of fifty months (range, twenty-four to 120
months) because of continued pain and progressive arthrosis. One revision
periacetabular osteotomy was performed for impingement and postoperative
neutral wall relationships before we had a complete understanding of
retroversion (prior to 2001). Complications included three transient femoral
nerve palsies, four hematomas, and three infections; all resolved with
appropriate treatment. Nine of the ten major complications occurred in the
first thirty procedures, indicating the learning curve of this difficult
operation. The average Harris hip score improved from 54 points preoperatively
to 87 points at the time of the last follow-up.
Between 2001 and 2005, the senior surgeon (C.L.P.) performed forty-two
surgical dislocation and débridement
procedures7-10
to treat femoroacetabular impingement. There were eighteen female (one had a
staged bilateral procedure) and twenty-three male patients, with an average
age of twenty-nine years (range, thirteen to fifty-one years). All forty-two
hips had femoroacetabular impingement, and twenty hips (48%) also had
acetabular retroversion. Most had either cam impingement or a combination of
cam and pincer-type
impingement3,6,8,9.
(Pincer impingement was generally treated at our institution with a
periacetabular
osteotomy28.) A
false-profile lateral radiograph and the magnetic resonance arthrographic
image for one patient with femoroacetabular impingement are shown in Figures
7 and
8.
The results of surgical dislocation and débridement for
femoroacetabular impingement have been good, with four of forty-two hips
requiring conversion to total hip arthroplasty, after a mean of twenty-eight
months (range, twelve to sixty-one months). The hips that were converted to
total hip arthroplasty had severe delaminations of the acetabular articular
cartilage noted at the time of arthrotomy. There were no instances of
infection, hematoma, osteonecrosis, or hardware failure. The average Harris
hip score had improved from 70 points preoperatively to 87 points at the time
of the last follow-up. Currently, our treatment for hips with substantial
acetabular articular cartilage damage includes labral take-down, acetabular
rim débridement including the area of softened or delaminated cartilage
and underlying bone, and repair of the labrum to the new acetabular rim with
suture anchors. In hips without articular cartilage delamination, labral
pathology is usually seen at the articular margin and can be treated with a
limited débridement with or without labral repair with suture
anchors.
Our experience with open treatment directed at normalizing abnormal hip
morphology has been influenced by a number of patients who have undergone
arthroscopic treatment without resolution of symptoms. Of twenty-four patients
referred to us with persistent symptoms after hip arthroscopy, ten (eleven
hips) were treated with a periacetabular osteotomy or surgical dislocation and
débridement. The unrecognized, or undertreated, diagnosis was
retroversion of the acetabulum in six hips. Classic acetabular dysplasia with
femoroacetabular impingement was found in three hips, and femoroacetabular
impingement alone was present in two hips. Six hips were treated with a
periacetabular osteotomy, and five underwent surgical dislocation and
débridement. Ten of the eleven hips were also treated with an
osteochondroplasty of the femoral head-neck junction.
At the time of arthrotomy, the intraoperative findings included a missing
anterior labrum in four hips, a damaged and torn labrum in two hips, and a
visible lack of femoral head-neck offset at the femoral head-neck junction in
ten of the eleven hips. The acetabular articular cartilage surface was graded
during surgical dislocation and débridement with use of the Outerbridge
classification
system32; however,
without dislocating the hip, it was not possible to assess the articular
cartilage during periacetabular osteotomy. During the five surgical
dislocation and débridement procedures, two hips were found to have
chondral delaminations (Outerbridge grade IV), while the other three hips had
Outerbridge grade-III chondral
damage33. A
three-dimensional computed tomography image of the right hip made after
arthroscopy as well as intraoperative photographs showing the head-neck
osteochondroplasty and the articular damage to the femoral head found after
arthroscopy are shown in Figures
9-A,
9-B, and
9-C.
All eleven hips continued to survive at a mean of seventeen months (range,
twelve to forty-four months) postoperatively. None were converted to total hip
arthroplasty. The mean Harris hip score had improved from 65 points
preoperatively to 87 points at the time of the latest follow-up.
Recently, the etiology of hip pain in young adults has been better defined;
often it is a manifestation of acetabular and/or proximal femoral dysplasia
resulting in abnormal hip morphology. Clinically, the abnormal morphology
results in femoroacetabular impingement or dysplasia with cartilage and/or
labral damage. We believe that treatment of labral pathology alone, whether
open or arthroscopic, rarely is effective because of a failure to treat the
underlying abnormal morphology of the hip.
The results of periacetabular osteotomy in our patients who had a spectrum
of acetabular dysplasia, including classic acetabular dysplasia and acetabular
retroversion, have been good, with 92% survivorship of the 112 osteotomies at
fifty months. Recognition of the true preoperative acetabular version and
reorientation of the acetabulum into an appropriately anteverted position have
become important factors in surgical decision-making. Furthermore, we have
found that surgical dislocation and débridement has been effective in
reducing pain and improving function with a low rate of complications in the
hips without substantial articular cartilage damage. This treatment plan
emphasizes the need for better imaging methods to assess the extent of
acetabular articular cartilage damage and to facilitate timely treatment of
femoroacetabular impingement.
Subject-specific three-dimensional computational modeling and finite
element analysis can better define the relationship between the pathomechanics
of all types of dysplasia and the development of osteoarthritis
(Fig. 10), as well as enhance
our surgical planning and decision-making. In the future, the goal will be to
use these techniques to evaluate the results of our surgical treatments and
further define the pathoanatomy of hip dysplasia. ?
Note: The authors acknowledge Jeff Weiss and Andy Anderson of
the University of Utah Bioengineering Laboratory for their contribution of the
computational three-dimensional modeling and images.
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