The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 10

The Orthopaedic Forum | October 01, 2008

AOA Symposium: Hip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment^*

John C. Clohisy, MD¹; Paul E. Beaulé, MD, FRCSC²; Aran O'Malley, MD³; Marc R. Safran, MD³; Perry Schoenecker, MD⁴

¹ Washington University School of Medicine, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110. E-mail address: clohisyj@wudosis.wustl.edu
² University of Ottawa, 501 Smyth Road, Suite 5004, Ottawa, ON K1H 8LC, Canada
³ Stanford University, 300 Pasteur Avenue, R-105, Edwards Building, Stanford, CA 94305-2200
⁴ Shriners Hospital for Children-St. Louis Children's Hospital, One Children's Place, St. Louis, MO 63110-1081

View Disclosures and Other Information

This report is based on a symposium presented at the Annual Meeting of the American Orthopaedic Association on June 13-16, 2007, in Asheville, North Carolina.

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Zimmer, Inc and the Washington University Institute of Clinical and Translational Sciences. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Oct 01;90(10):2267-2281. doi: 10.2106/JBJS.G.01267

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

The understanding, diagnosis, and treatment of arthritic hip disease in young patients are rapidly evolving. A variety of new and refined surgical techniques are now being utilized worldwide, and continued progress in this realm of orthopaedics is inevitable. Nevertheless, there are major challenges to optimize the introduction and utilization of these procedures on a more widespread basis. In this American Orthopaedic Association (AOA) symposium, the attendees were asked whether "the overall quality of diagnostic evaluation and surgical treatment of prearthritic and early arthritic hip disease in the United States is optimal, acceptable or deficient"¹. Fifty-seven percent of the respondents answered that diagnostic and surgical care is deficient, indicating a need for improved medical management of these patients.

Figures in this Article

Introduction

Progress in this subspecialty area is dependent on the development of improved methods of patient evaluation and selection for surgery, effective dissemination of new knowledge, and the clinical investigation of refined and new surgical interventions. Young adult patients pose a unique challenge in that they present to the orthopaedic surgeon with hip symptoms that originate from a wide range of disease processes, and the patient age range spans from adolescence through middle age. Perhaps most notable is that these patients present to a variety of orthopaedic surgeons with different treatment perspectives. These include general orthopaedists as well as pediatric, sports medicine, adult reconstruction, and trauma subspecialists.

The purposes of this report are to describe the spectrum of hip disease encountered in young adult patients and to review the contemporary concepts of the etiology and surgical treatment of such disorders. Importantly, there is a relative lack of high-level clinical evidence for alternative hip procedures. The majority of reports regarding these interventions are Level IV, and many of the technical aspects of treatment continue to evolve without the support of strong clinical outcomes research. This fact underscores the need for surgeons to carefully consider the utilization of new procedures in these patients and to perform higher-level clinical studies to assess the true value of these interventions.

I. Etiology of Hip Disease

Mechanical hip dysfunction is a major cause of early hip degeneration and osteoarthritis^2-8. A variety of structural hip disorders have been proposed as etiologies of joint pathomechanics. These include developmental dysplasia of the hip, Perthes disease, slipped capital femoral epiphysis, and impingement disorders^3,4,9. Mechanical disorders of the hip can be divided into two major categories: structural instability (dysplasia) and femoroacetabular impingement, or combinations of the two (Fig. 1). Osteoarthritis most commonly occurs secondary to repetitive and/or chronic shear stress at the acetabular rim^10,11. Acetabular dysplasia and femoroacetabular impingement are the two most common causes of excessive shear stress and acetabular rim syndrome¹⁰.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: A diagram depicting the most common etiologies of hip disease. It is important to note that many patients have a combination of factors that play a role in the pathophysiology of hip disease. DDH = developmental dysplasia of the hip. (Reproduced, with modification, from: Beaulé PE. Young adult with hip pain monograph. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007. p 2. Reprinted with permission.)

In developmental dysplasia of the hip, inadequate osseous coverage of the femoral head results in mechanical overload of the anterolateral acetabular rim and labrum. As a result, patients with developmental dysplasia of the hip commonly have the development of anterolateral labral tears, anterolateral acetabular chondromalacia, acetabular rim fractures, and synovial cysts. This acetabular rim overload syndrome progresses to arthrosis with time unless the hip joint pathomechanics are corrected¹².

Femoroacetabular impingement is characterized by decreased clearance and abnormal contact between the femoral head-neck junction and the acetabular rim^3,9 (Fig. 2). These disorders are due to proximal femoral and/or acetabular rim deformity and are now recognized as common causes of prearthritic hip pain and secondary osteoarthritis^3,9. Abnormal femoroacetabular abutment, particularly in positions of hip flexion and internal rotation, predispose affected patients to labral tears, articular cartilage damage, and premature osteoarthritis. Impingement abnormalities can be divided into two major categories, namely, cam-type and pincer-type impingement disorders (Fig. 2)⁹.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2: Femoroacetabular disease patterns. The reduced clearance during joint motion leads to repetitive abutment between the proximal part of the femur and the anterior acetabular rim. A: The normal clearance of the hip. B: Reduced femoral head and neck offset (cam impingement). C: Excessive overcoverage of the femoral head by the acetabulum (pincer impingement). D: A combination of reduced head and neck offset and excessive anterior overcoverage (combined impingement). (Reproduced, with modification, from: Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement. Part I. Techniques of joint preserving surgery. Clin Orthop Relat Res. 2004;418:61-6. Reprinted with permission.)

Cam femoroacetabular impingement results from deformities of the proximal part of the femur. Most commonly, the anterolateral head-neck junction has an insufficient head-to-neck offset, creating a relative prominence at the anterolateral head-neck junction. This results in repetitive trauma of the anterolateral head-neck junction with the anterosuperior acetabular rim and results in shear stresses at the chondrolabral junction that can eventually produce chondrolabral separation, labral detachment, and articular cartilage damage¹³ (Figs. 3-A through 3-D).

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3-A Fig. 3-B: Figs. 3-A through 3-D A thirty-one-year-old woman with cam impingement that was managed arthroscopically. At arthroscopy, the anterolateral acetabular rim cartilage was delaminated (arrow) (Fig. 3-A), and the acetabular labrum was torn along the articular margin (Fig. 3-B). FH = femoral head, A = acetabulum, and L = labrum.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3-C Fig. 3-D: The impingement lesion of the femoral head-neck junction (arrows) can be noted (Fig. 3-C), and the prominence of the anterolateral head-neck junction was removed with an arthroscopic burr (Fig. 3-D) to relieve anterior femoroacetabular impingement.

Pincer impingement disease results from acetabular overcoverage of the femoral head, resulting in repetitive abutment of the femoral neck against the labrum and prominent acetabular rim. The acetabular labrum is compressed between the neck and rim, causing both labral and articular cartilage damage. Retroversion of the acetabulum, coxa profunda, and protrusio^14,15 are the major pathomechanic etiologies of pincer impingement. These abnormalities can also be combined with cam femoral deformities, creating a combined impingement disorder¹³.

In addition to structural disorders of the hip, osteonecrosis of the femoral head with the potential for collapse and joint deterioration is a common cause of hip dysfunction in young patients. Additional patient-specific factors can also contribute to early hip disease and subsequent degeneration (Fig. 1). These include sports activities, patient age, soft-tissue laxity, previous injury or trauma, and so-called biologic susceptibility¹⁶ of the joint. All of these factors alone or in combination can contribute to the onset and progression of hip disease.

II. Clinical Evaluation

A detailed patient evaluation is focused on identifying the specific etiology of the patient's symptoms, carefully defining the structural anatomy of the hip joint, and assessing the extent of joint degeneration². Patient-specific factors, such as age, activity level, comorbidities, and physical condition, are also important determinants in the final treatment plan.

Patient Interview

The medical history should include the age and overall health of the patient, a detailed description of the pain characteristics, the activity level, associated comorbidities, and any previous hip disease or related treatments. Care should be taken to carefully determine the specific pattern of symptoms. It should be clarified whether the symptoms are primarily associated with weight-bearing activities or hip flexion positions such as sitting. Hip pain exacerbated by sitting is commonly associated with femoroacetabular impingement. A history of true locking or catching can be indicative of an intra-articular mechanical problem such as an acetabular labral tear or chondral flap.

Physical Examination

On examination, the overall physical condition of the patient is observed. The sitting posture and gait pattern should be noted. Abductor strength, limb lengths, and neurovascular status are determined. An assessment of hip range of motion is extremely important in delineating an accurate diagnosis and for selecting the most appropriate surgical intervention. Specifically, the range of hip flexion must be measured accurately. Internal rotation should be assessed at 90° of flexion as a screening maneuver for anterior femoroacetabular impingement. Patients with so-called classic developmental dysplasia of the hip tend to have good hip flexion and internal rotation in flexion. Patients with femoroacetabular impingement have restricted hip flexion and reduced internal rotation in flexion. An additional examination maneuver that is noteworthy is the anterior impingement test, which is performed by passively placing the hip in flexion, adduction, and internal rotation. A positive test reproduces the patient's groin pain. It is a sensitive screening test for patients with acetabular labral disease and impingement. It can also be utilized as a nonspecific screening tool for intra-articular disease and hip joint irritability. In the setting of an uncertain diagnosis, the physical examination can be expanded to include a fluoroscopically guided, diagnostic hip injection and an examination after the injection.

Imaging

The goals of imaging are to assess the structural anatomy of the hip, the congruency of the articulation, and the integrity of the cartilage space. A supine or standing anteroposterior pelvic radiograph can provide the majority of information regarding structural anatomy. The anteroposterior pelvic radiograph depicts the acetabular coverage of the femoral head, head sphericity, acetabular inclination, horizontal position of the joint center, loss of joint space, and the version of the acetabulum. The degree of inclination (the Tönnis angle) of the sourcil (the weight-bearing dome of the acetabulum) is measured, with normal values being between 0° and 10° from the horizontal¹⁷. The lateral center-edge angle assesses lateral acetabular coverage of the femoral head, and normal values are between 25° and 35°^11,17. Specific lateral radiographs can be considered to better define the osseous anatomy of the proximal part of the femur, the anterior and posterior joint spaces, and acetabular rims, not all of which may be well visualized with the anteroposterior pelvic radiograph. Lateral radiographs include the false-profile¹⁸, true cross-table lateral, frog-leg lateral¹⁹, or Dunn radiographs²⁰. The false-profile radiograph demonstrates the anterior coverage of the femoral head, joint space integrity of the anterosuperior and posteroinferior aspects of the joint, and anterior acetabular rim osteophytosis (Fig. 4). The other lateral radiographs are most valuable for defining the structural anatomy of the anterolateral head-neck junction. Ideally, an initial radiographic screening by a general orthopaedist includes an anteroposterior pelvic radiograph and a lateral radiograph of choice. If additional evaluation and imaging is required, this may be best orchestrated by the treating surgeon.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4: Schematic drawing demonstrating the false-profile radiographic technique. The right hip is being imaged. (By permission of the Mayo Foundation.)

Magnetic resonance imaging, magnetic resonance arthrography, and computed tomography scanning are effective in excluding other sources of hip symptoms and in defining the detailed intra-articular and extra-articular abnormalities about the hip. A standard magnetic resonance imaging scan is most useful as a screening mechanism to diagnose osteonecrosis of the femoral head, stress fractures, neoplasm, and infection. Magnetic resonance arthrography with a small field of view centered on the hip has been popularized for more detailed evaluation of intra-articular structures. Para-axial magnetic resonance arthrography imaging has been endorsed as an optional imaging strategy for visualization of the anatomy of the femoral head-neck junction and evaluation of impingement abnormalities^21,22. The dGEMRIC (delayed gadolinium-enhanced magnetic resonance imaging of cartilage) imaging technique holds promise in assessing the integrity of articular cartilage and quantitating early arthritic disease. This imaging modality assesses the glycosaminoglycan content of the articular cartilage and has been shown to be of prognostic value in predicting the response of dysplastic hips to joint-preserving osteotomies²³. Computed tomography scanning has assumed a larger role for detailed evaluation of osseous hip anatomy²⁴, and it can be utilized to better characterize osseous impingement lesions, assess acetabular version, and delineate structural anatomy in severely deformed hips. Three-dimensional reconstructions are particularly informative in characterizing and localizing osseous impingement lesions and in planning the details of impingement lesion resection.

III. Open Treatment of Femoroacetabular Impingement

Surgical treatment for symptomatic femoroacetabular impingement (Table I) should primarily address relief of the mechanical impingement and consider treatment of any secondary intra-articular disease. The specific type of treatment depends on the pattern and extent of impingement disease. Less invasive surgical techniques are most commonly considered for focal cam impingement, while more invasive open procedures are most suitable to treat nonfocal or combined cam-pincer disease patterns. Open interventions include anteversion periacetabular osteotomy, surgical dislocation of the hip, and anterior arthrotomy techniques. Less invasive options include a limited anterior approach to the hip alone or in combination with hip arthroscopy. Isolated hip arthroscopy techniques to address intra-articular disease components and associated impingement lesions have also evolved.

View Larger

TABLE I Common Findings in the Evaluation of Femoroacetabular Impingement

Patient history

Predominant anterior inguinal (groin) pain

Pain exacerbation with activity and hip flexion (sitting)

Mechanical symptoms

Physical examination

Limited passive hip flexion (=105°)

Limited internal rotation at 90° of hip flexion (=15°)

Positive anterior impingement test

Radiographic evaluation

Anteroposterior pelvic radiograph

Cam impingement: aspherical femoral head and insufficient head-neck offset

Pincer impingement: excessive head coverage (acetabular retroversion, protrusio, or profunda)

Lateral radiographs (cross-table, Dunn, or frog-leg lateral)

Aspherical femoral head and insufficient head-neck offset

Imaging

Magnetic resonance arthrography

Acetabular labral tears, acetabular rim chondromalacia, and insufficient head-neck offset

Computed tomography

Cam impingement: aspherical femoral head and insufficient head-neck offset

Pincer impingement: acetabular retroversion, overcoverage, and rim fractures

Add to My JBJS

TABLE I Common Findings in the Evaluation of Femoroacetabular Impingement

Patient history

Predominant anterior inguinal (groin) pain

Pain exacerbation with activity and hip flexion (sitting)

Mechanical symptoms

Physical examination

Limited passive hip flexion (=105°)

Limited internal rotation at 90° of hip flexion (=15°)

Positive anterior impingement test

Radiographic evaluation

Anteroposterior pelvic radiograph

Cam impingement: aspherical femoral head and insufficient head-neck offset

Pincer impingement: excessive head coverage (acetabular retroversion, protrusio, or profunda)

Lateral radiographs (cross-table, Dunn, or frog-leg lateral)

Aspherical femoral head and insufficient head-neck offset

Imaging

Magnetic resonance arthrography

Acetabular labral tears, acetabular rim chondromalacia, and insufficient head-neck offset

Computed tomography

Cam impingement: aspherical femoral head and insufficient head-neck offset

Pincer impingement: acetabular retroversion, overcoverage, and rim fractures

Anteversion periacetabular osteotomy is an uncommonly performed procedure that is indicated in the setting of major acetabular retroversion and posterior wall insufficiency¹⁵. This technique can provide anteversion correction of the acetabulum and improved mechanics between the femoral head-neck junction and the acetabular rim. This procedure is indicated in a small subgroup of patients with pincer impingement.

A trochanteric slide osteotomy with surgical dislocation of the hip is the most well-documented surgical strategy for the treatment of impingement disease^25-29. This surgical approach preserves the blood supply to the femoral head, yet it allows complete dislocation of the hip with circumferential exposure of the acetabulum and the femoral head-neck junction. Care is taken to preserve the deep branch of the medial femoral circumflex artery²⁸. This procedure allows direct visualization and correction of impingement disease that can encompass osteochondroplasty of the femoral head-neck junction, osteochondroplasty of the acetabular rim, repair of the acetabular labrum, relative femoral neck lengthening, trochanteric advancement, and articular cartilage procedures of the femoral head and acetabulum.

Less invasive surgical procedures are now being developed and refined to address impingement disease. The goals of these procedures are to treat intra-articular disease precisely with arthroscopic techniques and to correct the cam and/or pincer structural abnormalities either arthroscopically or through direct visualization by less invasive open procedures. Access to the anterolateral femoral head-neck junction, acetabular labrum, and acetabular rim can be obtained through the Smith-Petersen interval or the Heuter anterior approach. The anterolateral head-neck junction is contoured to create a more normal head-neck offset. The acetabular labrum can be inspected and repaired, and acetabular rim trimming can be performed if needed. Hip arthroscopy can be used as an adjunct to the anterior approach to address acetabular labral tears, articular cartilage disease, and synovitis.

Hip arthroscopy techniques are now evolving to the point at which a variety of impingement disease patterns can be treated arthroscopically^30-33. Nevertheless, extensive arthroscopic experience and understanding of hip pathomechanics are needed to apply these surgical techniques effectively. Disease components in the central compartment are treated, and then the peripheral compartment of the joint is visualized and femur-based cam impingement abnormalities are corrected (Figs. 3-A through 3-D). Additionally, techniques have been developed for acetabular labral takedown, repair, and trimming of the acetabular rim³². Presently, published clinical follow-up on arthroscopic impingement procedures is very limited, and there is a need for studies to define the efficacy of these procedures.

IV. Open Treatment of Developmental Dysplasia of the Hip

Hip-preserving acetabular reorientation osteotomies allow a major correction of dysplasia and great improvement in clinical function^28,34-42. For example, the periacetabular and rotational acetabular osteotomy can provide major, multidimensional acetabular correction for the mechanically jeopardized dysplastic hip. Additionally, acetabular reorientation can be augmented by a variety of other surgical techniques to optimize the procedure^{11,34,35,37,40}. Acetabular labral repair or partial resection, femoral head recontouring, femoral head-neck junction osteochondroplasty, relative femoral neck lengthening, trochanteric advancement, and proximal femoral osteotomy are now part of the surgeon's armamentarium and can be utilized to refine the hip reconstruction. With use of these surgical techniques and strategies, the symptomatic dysplastic hip can be preserved, and relief of pain and improved function is predictable^{3437,40,41,43,44}. Optimal candidates have no or minimal secondary osteoarthritis and a highly congruent hip joint while maintaining hip range of motion. Although there are several osteotomy techniques to reorient the acetabulum, including rotational acetabular osteotomies and triple innominate osteotomies, the Bernese periacetabular osteotomy³⁷ has been widely adopted. Surgical correction is directed at the restoration of joint stability while minimizing secondary impingement¹¹.

Surgical Technique Concepts for Periacetabular Osteotomy

The periacetabular osteotomy is usually performed through a modified Smith-Petersen abductor-sparing approach^11,35,45. The fundamental goal is correction of the acetabular insufficiency by repositioning the weight-bearing surface laterally and anteriorly to enhance femoral head coverage. The abnormal lateral position of the hip joint center can also be corrected by medial translation of the acetabulum⁴⁶. In addressing dysplasia, the end goal is to achieve stability and medialization without retroverting the acetabulum and potentiating impingement. The standard reduction maneuver is a combination of internal rotation, forward tilt (extension), and medial translation. Intraoperatively, the surgical correction obtained must be carefully scrutinized with plain radiographs or fluoroscopy (Table II). Following acetabular redirection, there should be a minimum of 90° of flexion and 30° of abduction.

View Larger

TABLE II Periacetabular Osteotomy Assessment*

1	Acetabular sourcil (weight-bearing surface) is repositioned in a more horizontal orientation with a superolateral inclination of 0° to 10°
2	Lateral femoral head coverage is improved with a goal of achieving 25° to 35°
3	The hip joint center is translated medially (if needed) to place the medial aspect of the femoral head to within 5 to 10 mm of the ilioischial line
4	Version is correct; look for undesirable retroversion as detected by crossover of the anterior and posterior rims
5	Anterior femoral head coverage is improved to 20° to 25° on the false-profile radiograph (and is not excessive)
6	The correction maintains or produces a congruent joint space, and subluxation is corrected
7	Adequate head-neck offset is present or has been restored with osteochondroplasty
8	Adequate internal fixation with acceptable screw position
9	Hip flexion of =90° and hip abduction of =30°

These are optimal parameters, and the correction obtained will vary depending upon the severity and characteristics of the deformity.

Add to My JBJS

TABLE II Periacetabular Osteotomy Assessment*

1	Acetabular sourcil (weight-bearing surface) is repositioned in a more horizontal orientation with a superolateral inclination of 0° to 10°
2	Lateral femoral head coverage is improved with a goal of achieving 25° to 35°
3	The hip joint center is translated medially (if needed) to place the medial aspect of the femoral head to within 5 to 10 mm of the ilioischial line
4	Version is correct; look for undesirable retroversion as detected by crossover of the anterior and posterior rims
5	Anterior femoral head coverage is improved to 20° to 25° on the false-profile radiograph (and is not excessive)
6	The correction maintains or produces a congruent joint space, and subluxation is corrected
7	Adequate head-neck offset is present or has been restored with osteochondroplasty
8	Adequate internal fixation with acceptable screw position
9	Hip flexion of =90° and hip abduction of =30°

These are optimal parameters, and the correction obtained will vary depending upon the severity and characteristics of the deformity.

On completion of the periacetabular osteotomy, we routinely perform an anterior arthrotomy to assess both the labrum and the anterolateral head-neck offset. Degenerative labral tears, unstable flaps, or entire detachments may be débrided and/or repaired. Alternatively, if labral disease is suspected from the history, physical examination, and magnetic resonance arthrography, it may be advantageous to combine hip arthroscopy with the acetabular osteotomy. Commonly, there is insufficient anterolateral femoral head-neck offset⁴⁷, and an osteochondroplasty may be performed as an adjunct to acetabular reorientation. This minimizes secondary hip-joint impingement. If relative coxa valga precludes the restoration of satisfactory lateral coverage and residual instability remains, a proximal femoral varus osteotomy is performed. When a Perthes-like deformity (instability with impingement) is addressed, it is typically necessary to combine the periacetabular osteotomy with a valgus flexion-producing proximal femoral osteotomy and/or extensive recontouring of the head-neck junction and trochanteric advancement. This enhances the range of motion in abduction and flexion and prevents secondary femoroacetabular impingement³⁶.

The Bernese periacetabular osteotomy (and other acetabular reorientation techniques) predictably relieves pain and increases the function of the involved hip (Fig. 5). The reported outcomes of surgical treatment for symptomatic hip dysplasia have been very satisfactory as recently reported by Millis and Murphy¹¹, Matheney et al.⁴⁰, and Siebenrock et al.⁴¹. The utilization of this procedure is now expanding to encompass severely dysplastic hips, acetabular dysplasia with associated Perthes-like femoral deformities, and hips that have had a previous osteotomy^34,36,48.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 5: Anteroposterior radiographs of a seventeen-year-old girl with symptomatic bilateral acetabular dysplasia and acetabular rim fractures (a). She was treated with staged periacetabular osteotomies and had an excellent clinical result with both hips (b).

V. Hip Arthroscopy

The number of hip arthroscopy procedures is increasing on an annual basis. With appropriate indications, sound patient selection criteria for surgery, and realistic patient expectations, hip arthroscopy can be a reliable intervention for the diagnosis and treatment of intra-articular and periarticular disease. Nevertheless, it is important to realize that the majority of clinical evidence is Level IV and Level V, with relatively short-term follow-up in most studies. Clearly, there is a major need for higher-level clinical evidence to determine the true efficacy of hip arthroscopy procedures.

Indications and Contraindications

The most common indications include acetabular labral disease, focal articular cartilage lesions, femoroacetabular impingement, loose bodies, and synovial disorders^49-53. Absolute contraindications to hip arthroscopy include any clinical situation that prevents safe distraction of the hip joint. Relative contraindications include altered anatomy precluding safe portal placement (previous surgery), open wounds, severe obesity, and infection (other than to wash out a hip that has an active joint infection). Additionally, arthroscopic treatment alone is rarely appropriate in the setting of major, uncorrected structural deformities and is unlikely to benefit patients with advanced osteoarthritis or osteonecrosis with femoral head collapse.

Nonstructural Intra-Articular Disorders

In its most basic form, hip arthroscopy serves as a diagnostic tool. Given that both magnetic resonance imaging and magnetic resonance arthrography have limited sensitivity for detecting certain intra-articular disorders⁵⁴, hip arthroscopy occasionally plays a diagnostic role in evaluating hip pain of unknown etiology. Nevertheless, in the large majority of patients, the diagnosis and underlying pathomechanics of the joint are elucidated prior to surgery. Current concepts suggest that labral tears in young to middle-aged patients are often the result of other intrinsic disorders, such as developmental dysplasia of the hip, femoroacetabular impingement, and hip instability^6,7,55. Thus, an effort should be made to identify and correct the underlying etiology of the labral tear in addition to treating the tear itself.

Hip arthroscopy is increasingly used to treat acetabular labral tears and associated abnormalities, yet the diagnosis of these lesions and the selection of appropriate surgical candidates are still evolving. Studies have found the most common locations for labral disease are the anterior or anterior-superolateral regions^51,56-58. Partial arthroscopic resection of symptomatic acetabular labral tears has a reported success rate of between 68% and 84%^{50,51,55,59,60}, with less predictable results in the setting of more extensive articular cartilage disease^51,61. Arthroscopic acetabular labral repair is technically feasible, although the indications and clinical outcomes need to be defined. Interest in labral repair is increasing as there is clinical and basic-science evidence that supports the importance of the labrum for normal hip function by acting as a gasket, maintaining joint fluid pressure, and providing structural stability^27,62. Short-term preliminary reports with this type of tear pattern have suggested that outcomes are equivalent to those of partial labrectomy^63,64.

Arthroscopic treatment for focal chondral damage has been reported, with mixed results^52,65. As discussed previously, chondral damage is highly associated with labral tears, and the preoperative diagnosis of chondral damage remains a considerable challenge^54,66. Although microfracture and abrasion chondroplasty of the hip are also possible, the indications and outcomes need to be defined⁶⁵. Symptomatic soft-tissue instability of the hip is an uncommon entity that has recently been proposed as a cause of hip symptoms. The diagnosis is challenging, and there is an incomplete understanding of this diagnosis and the role of surgical treatment. It may present as chronic hip pain in athletes (including gymnasts and ballet dancers), after a traumatic episode, or more commonly in active individuals with underlying hyperlaxity states. These patients may respond to capsulolabral repair⁶⁷. Recent reviews of the topic have suggested that arthroscopic examination is indicated when hip instability is suspected and the patient gets relief from an intra-articular anesthetic injection but fails to respond to six months of conservative treatment^68,69. There is an obvious need to more clearly define the diagnosis, indications, and results of treating soft-tissue laxity about the hip, as current evidence for intervention is primarily Level V.

Arthroscopic treatment is possible for other uncommon conditions of the hip such as rupture of the ligamentum teres⁷⁰ and synovial disorders^53,71,72. Arthroscopic management of adhesive capsulitis and of infection have also been reported^73-76.

Mild Structural Disorders

The optimal treatment strategies for intra-articular hip disease associated with mild structural abnormalities remains controversial. Specifically, the necessity for and degree of deformity correction need to be determined. Advances in hip arthroscopy have led to the development of specific techniques for the treatment of hip impingement disorders^30-33, yet further evaluation of the clinical results of these techniques is necessary to accurately establish the advantages and disadvantages of these procedures.

The role of hip arthroscopy in the dysplastic hip remains quite controversial, as an arthroscopic procedure cannot correct the underlying pathomechanics of the joint and may even accelerate the degenerative process⁵¹. Therefore, comprehensive correction of the underlying structural abnormality of the hip should be strongly considered. Nevertheless, arthroscopy has been used successfully in the treatment of some intra-articular disease patterns (labral tears, chondral flaps, and ligamentum teres tears) in patients with mild developmental dysplasia of the hip and mechanical symptoms⁷⁷. Arthroscopy should be considered only for patients with mild dysplasia or as a relatively short-term solution for symptom relief in patients who are not appropriate candidates for an osteotomy. For example, débridement of an irreparable labral tear for temporary symptom relief may be appropriate in certain patients. In contrast, we would not recommend labral repair without concurrent structural deformity correction.

The role of hip arthroscopy in the treatment of femoral head osteonecrosis or established osteoarthritis is very limited. Uncommonly, it may offer the potential for relief of mechanical symptoms by débridement of chondral or labral flaps^61,78-80. The results clearly deteriorate with increasing levels of chondral damage and joint involvement.

Surgical Technique—General Principles

Hip arthroscopy is performed with the patient in either the supine or lateral position, depending on surgeon preference^81,82. The key requirement for both positions is adequate joint distraction (8 to 10 mm) to allow safe access to the central compartment (the area between the acetabulum and the femoral head). The peripheral compartment (the intracapsular space outside the acetabulum) can be accessed without traction. Almost all surgeons utilize the anterior and anterolateral portals, while some surgeons also advocate the routine use of a posterolateral portal. An anterior capsulotomy or partial capsular resection facilitates visualization in the peripheral compartment. If it is needed, an accessory anterolateral portal can be established approximately 4 to 5 cm distal to the anterolateral portal⁸³.

For the correction of a cam impingement deformity, the arthroscope is placed in the peripheral compartment and an arthroscopic burr is used to resect the prominent, nonspherical area on the anterolateral femoral head-neck junction. Care is taken to avoid damage to the blood supply to the femoral head by protecting the posterolateral retinacular vessels that originate from the medial circumflex femoral artery⁸⁴. For correction of a pincer impingement deformity, the arthroscope is placed in the central compartment and the anterolateral and anterior portals are used to perform an acetabular "rim trimming." The damaged labrum in the area of excess acetabular rim can be detached while the joint is distracted. It is important to emphasize that the takedown of an intact chondrolabral junction is controversial and of uncertain benefit. After release of the damaged labrum, a burr is then used to resect the area of overhanging acetabulum. After resection, the labrum is repaired with suture anchor fixation or, alternatively, is resected. Recent evidence²⁷ has indicated that, with open treatment of impingement disease, labral repair is associated with improved clinical outcomes compared with a full-thickness resection.

VI. Treatment Options for End-Stage Hip Disease

Despite the innovation and positive clinical results with various surgical techniques for joint preservation, many young patients present for treatment with end-stage degeneration of the hip and are not candidates for joint-preserving surgery. In this clinical setting, joint replacement procedures are considered with the goals of relieving pain, maintaining activity levels, restoring hip function, and enhancing quality of life. The introduction of alternative prosthetic bearing surfaces and improved hip-resurfacing implants suggests that there is potential for improved function and survivorship of prosthetic hip reconstructions. The major challenges going forward are to identify the optimal prosthetic bearing surfaces, determine the clinical efficacy of contemporary hip replacement and hip resurfacing implants, and delineate the mid-term to long-term survivorship of these two procedures. In choosing between hip replacement and hip resurfacing, the surgeon should consider a variety of factors including patient age, sex, activity level, body-mass index, and comorbidities⁸⁵. Proximal femoral bone quality and a history of surgery should also be assessed as these variables may impact the success of the surgical procedure.

Total Hip Replacement

The excellent clinical results of total hip replacement in all age groups are well known, and, with the use of improved wear-resistant bearing couples, these results will most likely continue to improve over time. Total hip replacement has several advantages. These include broader criteria for patient selection, less invasive surgical techniques, implant modularity, documented long-term efficacy, protection from proximal femoral fracture, and technical ease. Total hip replacement is appropriate in the vast majority of young patients, even in the setting of poor proximal femoral bone stock (cystic degeneration, osteonecrosis, and osteoporosis), femoral head-neck deformity, compromised acetabular bone stock, inflammatory arthritis, limb-length discrepancy, and obesity. Additionally, less invasive surgical techniques⁸⁶ and multimodality pain management protocols have quickened patient recovery and reduced perioperative pain associated with the procedure. The implant-related versatility of hip replacement is also advantageous with respect to bearing surface materials (ceramics, highly cross-linked polyethylene, and metals), femoral head-neck diameter sizes and lengths, and acetabular liner options (elevated lips, offset, and constrained). Implant fixation characteristics with contemporary devices are excellent and durable. With aging, the femoral neck and intertrochanteric region of the proximal part of the femur are "protected" from fracture by the femoral implant. Technically, primary total hip arthroplasty is a straightforward procedure performed with a variety of surgical approaches and techniques. Arguable disadvantages of total hip replacement relative to total hip resurfacing include dislocation (with standard femoral head sizes), compromise of proximal femoral bone stock with component insertion, the potential for excessive lengthening⁸⁷, proximal femoral stress-shielding over long periods of time⁸⁸, and perceived activity limitation. It should be noted that prosthesis survivorship as a means of measuring outcome has limitations in terms of assessing health-related quality of life⁸⁹, especially in active, high-demand patients. Consequently, integrating patient activity level in the assessment of total hip arthroplasty function provides relevant qualitative information that is not contained in current hip-scoring systems^90,91. Using the University of California at Los Angeles (UCLA) activity score⁹², one recent study compared the outcome of total hip replacement and hip resurfacing. That prospective randomized trial showed that patients with hip resurfacing had a higher mean activity score than their total hip counterparts at twelve months of follow-up. This potential disadvantage of total hip replacement must be confirmed with longer-term follow-up studies and must be interpreted in the context of a lower risk of revision surgery after total hip replacement^93-95. Nevertheless, these data are consistent with the concept that patients with a high activity level may be the most appropriate candidates for a hip-resurfacing procedure. These data also underscore the need for improved, validated activity scores for high-demand patients. Such scores will facilitate surgical decision-making and will be the basis for comparison studies of total hip replacement and resurfacing.

Hip Resurfacing

Resurfacing arthroplasty of the hip has experienced a resurgence in popularity over the last decade⁹⁶. With improvement in design technology and metallurgy, many of the problems that plagued early designs, such as massive bone loss with cemented acetabular components⁹⁷ and high polyethylene wear rates associated with larger femoral head sizes, have been overcome^98-101. Current hip-resurfacing systems utilize a hybrid design, with a press-fit acetabular component and a cemented femoral component^96,102. Early and mid-term results have been reported and are favorable compared with early designs of hip-resurfacing implants^103-106. As in other alternative hip procedures, careful patient selection helps to minimize complications and the need for early reoperation⁸⁵. Conversely, because of the improved survivorship of total hip replacement¹⁰⁷ and the excellent short-term performance of new bearing couples^108,109, one may rightly question the role of hip resurfacing in today's armamentarium of replacement procedures.

Several potential advantages are emphasized by the proponents of hip resurfacing. These include preservation of proximal femoral bone stock, more physiologic stress transfer in the proximal part of the femur¹¹⁰, more normal hip kinematics⁹⁶, a low dislocation rate, and easy femoral revision procedures¹¹¹. Perhaps the most emphasized potential benefit is the tolerance of high activity levels that may enhance quality of life or patient-perceived quality of life. Thus, there is a major need for investigation of activity levels and quality of life after hip resurfacing. An additional theme in hip-resurfacing reports is that careful patient selection is important to optimize clinical results and avoid complications. The surface arthroplasty risk index⁸⁵ (Table III) is useful in guiding the treatment decision-making process when contemplating hip resurfacing compared with total hip replacement¹⁰³.

View Larger

TABLE III Surface Arthroplasty Risk Index⁹²

	Points
Femoral head cyst of >1 cm in size	2
Patient weight of <82 kg	2
Previous hip surgery	1
UCLA activity level of >6	1
Maximum score	6

Add to My JBJS

TABLE III Surface Arthroplasty Risk Index⁹²

	Points
Femoral head cyst of >1 cm in size	2
Patient weight of <82 kg	2
Previous hip surgery	1
UCLA activity level of >6	1
Maximum score	6

The disadvantages of hip resurfacing include a larger surgical exposure and a technically more demanding procedure, limitations in the setting of compromised femoral bone quality, a lack of modularity, limitations with regard to lengthening the extremity, early femoral neck fracture, and metal ion-associated problems. Over long-term follow-up periods, the potential complications of recurrent femoroacetabular impingement and proximal femoral fracture also need to be investigated. In a practical sense, hip resurfacing has not been within the training curriculum of orthopaedic surgeons for the last two decades and a learning curve will likely occur as the procedure is utilized more commonly. For example, the failure mechanisms of femoral loosening^103,112-115 secondary to malalignment and femoral neck fractures are commonly related to surgical technique. The prevalence of femoral neck fracture has been reported to range from 0.8% to 1.45%^105,112, and these fractures tend to occur within the first six months after surgery, with osteonecrosis and femoral neck notching being implicated as potential causes^113,116,117. On the other hand, the prevalence of failures secondary to femoral component loosening has been reported to range from 6% to 10%^103,114,115.

An additional controversial aspect of hip resurfacing is the importance of metal ion release from the bearing surface. The major concern is for patients with compromised renal function since metal ions generated from a metal-on-metal bearing are excreted through the urine, and the lack of clearance of these ions may lead to excessive levels in the blood^118,119. Currently, the only clear complication from exposure to metal ions is a hypersensitivity reaction, which occurs in approximately 0.3% of patients^120,121. The clinical findings associated with this phenomenon are persistent pain and periprosthetic osteolysis with or without component loosening^120,121. More importantly, a recent paper examining metal ions in umbilical cord blood showed that cobalt and chromium ions cross the placental barrier¹²² and may be a source of concern for women of childbearing age who are contemplating a resurfacing procedure. Clearly, a major disadvantage of hip resurfacing remains the associated release of metal ions, which leaves the patient exposed to elevated ion levels for decades.

The key aspects to the surgical technique for hip resurfacing can be divided into three steps: the choice of the surgical approach, selection of implant size, and positioning of the implant^103,123. In terms of surgical approach, the vascularity of the proximal aspect of the femur should be considered because the femoral component rests on the reamed femoral head. Disruption of the blood flow to the femoral head via the posterior approach could cause an osteonecrotic event that disrupts the bone-cement interface and leads to premature loosening or, in extreme cases, neck fracture¹¹⁶. Nevertheless, several centers have reported excellent short-term to medium-term results using the posterior approach. With respect to implant sizing, it is recommended that referencing should be off the femur in order to avoid neck notching. Once the femoral component size is selected, then one verifies that the matching acetabular component is appropriate for the patient's anatomy. If the anatomy necessitates an in-between size, it is better to go up one size with the acetabular implant than to notch the femoral neck when preparing it for a smaller femoral component. Finally, implant positioning in hip resurfacing is more demanding since the margin for acceptable implant positioning is narrower. On the acetabular side, it is critical to avoid excessively vertical placement because of the risk of runaway wear. One should aim for an abduction angle of 40° to 45°. Alternatively, an excessively horizontal position of the acetabular component can be a source of anterior femoroacetabular impingement and should also be avoided. On the femoral side, slight valgus orientation relative to the femoral neck is favorable to implant survivorship by minimizing tensile stresses on the femoral neck¹²⁴.

Metal-on-metal hip-resurfacing arthroplasty will continue to play a role in the treatment of end-stage hip arthritis in young patients. Currently, the ideal candidate is an active male patient who is less than sixty years of age with a diagnosis of osteoarthritis. Since we now have hip resurfacing implants with good-to-excellent clinical results at short-term to mid-term follow-up, it is imperative that future studies better define optimal patient selection criteria for surgery, investigate the true quality-of-life benefit, and determine longer-term complications and survivorship. Future clinical studies should focus on comparing the results of resurfacing procedures and total hip replacement in similar patient cohorts.

Hip Arthrodesis

Arthrodesis, although uncommonly carried out, is indicated for young patients with end-stage unilateral hip arthritis who have contraindications for both joint preserving and joint replacement procedures. Hip arthrodesis preserves bone stock and can provide pain relief indefinitely¹²⁵. The ultimate goal for these patients is a return to an active lifestyle with minimal restrictions. The ideal candidate is an adolescent or young adult (less than thirty years of age) with a history of multiple hip surgeries, posttraumatic arthritis, and/or postinfectious hip disease. Activity demands are high, and the patient should not have preexisting disease of the lumbar spine, ipsilateral knee, or contralateral hip¹²⁶. The surgical approach chosen for the fusion should attempt to minimize trauma to the abductor muscle mass¹²⁷ in case total hip arthroplasty is subsequently performed. With proper patient selection and with the hip fused in an optimal position, the onset of notable pain in adjacent joints can be delayed for up to twenty-five years^126,128.

VII. Overview

The care of hip disease in adolescent and young adult patients has engendered recent interest associated with a number of factors, which include an improved understanding of the mechanical etiology of disease in many patients and of the effectiveness of mechanically based treatment in many situations. This realm of orthopaedics is now experiencing rapid growth and high levels of interest because of the improved understanding of hip disease and innovation in surgical techniques. It is imperative that the orthopaedic community educate other health-care providers regarding the diagnosis and treatment of early hip disease. Specifically, we should target pediatricians, primary care physicians, radiologists, and physical therapists with the message that early diagnosis and referral for specialized care may optimize clinical outcomes and alter the natural history of these disorders. Surgical strategies for joint preservation should be viewed as desirable alternatives compared with persistent hip dysfunction and progressive joint degeneration. As we move forward, it is critical that these interventions be evaluated with sound clinical research. Specifically, hip arthroscopy and surgical techniques in joint preservation need to be analyzed with respect to symptom relief, activity tolerance, quality of life, and survivorship. Low-wear implant bearings and resurfacing implants need to be followed for longer terms in order to distinguish their clinical benefit and wear characteristics.

There is great need for improved validated activity and quality-of-life scores for these high-demand patients. In addition, determining the role of genetic factors in hip disease and developing effective screening protocols for various hip disorders may lead to an earlier diagnosis and preventive care. Collectively, progress in these areas will lead to continued improvements in the orthopaedic care of this traditionally underserved patient group.

References

Clohisy JC, Safran MR, Schoenecker PL, Beaule PE. The young adult with hip arthrosis: there are finally options. Read at the Annual Meeting of the American Orthopaedic Association; 2007 Jun 13-16; Asheville, NC. 2007

Clohisy JC, Keeney JA, Schoenecker PL. Preliminary assessment and treatment guidelines for hip disorders in young adults. Clin Orthop Relat Res.2005;441:168-79.441168 2005 [PubMed][CrossRef]

Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res.2003;417:112-20.417112 2003

Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res.1986;213:20-33.21320 1986

Millis MB, Kim YJ. Rationale of osteotomy and related procedures for hip preservation: a review. Clin Orthop Relat Res.2002;405:108-21.405108 2002 [CrossRef]

Peelle MW, Della Rocca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clin Orthop Relat Res.2005;441:327-33.441327 2005 [CrossRef]

Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res.2004;426:145-50.426145 2004 [CrossRef]

Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res.2008;466:264-72.466264 2008 [CrossRef]

Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res.2004;418:61-6.41861 2004 [CrossRef]

Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome. A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br.1991;73:423-9.73423 1991

Millis MB, Murphy SB. Periacetabular osteotomy. In: Callaghan JJ, Rosenberg AG, Rubash HE, editors. The adult hip. 2nd ed, vol 1. Philadelphia: Lippincott, Williams and Wilkins; 2007. p 795-815. 2007

Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am.1995;77:985-9.77985 1995

Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br.2005;87:1012-8.871012 2005 [CrossRef]

Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br.1999;81:281-8.81281 1999 [CrossRef]

Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res.2003;407:241-8.407241 2003 [CrossRef]

Felson DT. Risk factors for osteoarthritis: understanding joint vulnerability. Clin Orthop Relat Res.2004;427 Suppl:S16-21.427S16 2004 [CrossRef]

Dietrich T. Telger TC, translator. Congenital dysplasia and dislocation of the hip in children and adults. Berlin: Springer; 1987. General radiography of the hip joint; p 100-42. 1987

Lequesne M, de Seze S. [False profile of the pelvis. A new radiographic incidence for the study of the hip. Its use in dysplasias and different coxopathies]. Rev Rhum Mal Osteoartic.1961;28:643-52. French.28643 1961

Clohisy JC, Nunley RM, Otto RJ, Schoenecker PL. The frog-leg lateral radiograph accurately visualized hip cam impingement abnormalities. Clin Orthop Relat Res.2007;462:115-21.462115 2007 [CrossRef]

Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res.2006;445:181-5.445181 2006

Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br.2001;83:171-6.83171 2001 [CrossRef]

Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br.2002;84:556-60.84556 2002 [CrossRef]

Cunningham T, Jessel R, Zurakowski D, Millis MB, Kim YJ. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage to predict early failure of Bernese periacetabular osteotomy for hip dysplasia. J Bone Joint Surg Am.2006;88:1540-8.881540 2006 [CrossRef]

Klaue K, Wallin A, Ganz R. CT evaluation of coverage and congruency of the hip prior to osteotomy. Clin Orthop Relat Res.1988;232:15-25.23215 1988

Beaulé PE, Le Duff MJ, Zaragoza E. Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. J Bone Joint Surg Am.2007;89:773-9.89773 2007 [CrossRef]

Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res.2004;418:67-73.41867 2004 [CrossRef]

Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. J Bone Joint Surg Am.2006;88:925-35.88925 2006 [CrossRef]

Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br.2001;83:1119-24.831119 2001 [CrossRef]

Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. J Bone Joint Surg Am.2006;88:1735-41.881735 2006 [CrossRef]

Bare AA, Guanche CA. Hip impingement: the role of arthroscopy. Orthopedics.2005;28:266-73.28266 2005

Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy.2006;22:95-106.2295 2006 [CrossRef]

Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med.2006;25:299-308, ix.25299 2006 [CrossRef]

Sampson TG. Arthroscopic treatment of femoroacetabular impingement: a proposed technique with clinical experience. Instr Course Lect.2006;55:337-46.55337 2006

Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am.2005;87:254-9.87254 2005 [CrossRef]

Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique. J Bone Joint Surg Am.2006;88 Suppl 1 (Pt 1):65-83.8865 2006 [CrossRef]

Clohisy JC, Nunley RM, Curry MC, Schoenecker PL. Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities. J Bone Joint Surg Am.2007;89:1417-23.891417 2007 [CrossRef]

Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res.1988;232:26-36.23226 1988

Mardones RM, Gonzalez C, Chen Q, Zobitz M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. J Bone Joint Surg Am.2005;87:273-9.87273 2005 [CrossRef]

Mardones RM, Gonzalez C, Chen Q, Zobitz M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. Surgical technique. J Bone Joint Surg Am.2006;88 Suppl 1 (Pt 1):84-91.8884 2006

Matheney T, Kim YJ, Zurakowski D, Matero C, Millis MB. Long-term results following Bernese periacetabular osteotomy and predictors of clinical outcome. Unpublished data.

Siebenrock KA, Leunig M, Ganz R. Periacetabular osteotomy: the Bernese experience. Instr Course Lect.2001;50:239-45.50239 2001

Ninomiya S, Tagawa H. Rotational acetabular osteotomy for the dysplastic hip. J Bone Joint Surg Am.1984;66:430-6.66430 1984

Siebenrock KA, Scholl E, Lottenbach M, Ganz R. Bernese periacetabular osteotomy. Clin Orthop Relat Res.1999;363:9-20.3639 1999

Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am.1995;77:73-85.7773 1995

Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy and background work. Instr Course Lect.2001;50:229-38.50229 2001

Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Medial translation of the hip joint center associated with the Bernese periacetabular osteotomy. Iowa Orthop J.2004;24:43-8.2443 2004

Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res.1999;363:93-9.36393 1999

Mayo KA, Trumble SJ, Mast JW. Results of periacetabular osteotomy in patients with previous surgery for hip dysplasia. Clin Orthop Relat Res.1999;363:73-80.36373 1999

Byrd JW. Hip arthroscopy: patient assessment and indications. Instr Course Lect.2003;52:711-9.52711 2003

Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy.2000;16:578-87.16578 2000 [CrossRef]

Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy.1999;15:132-7.15132 1999 [CrossRef]

Kelly BT, Williams RJ 3rd, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med.2003;31:1020-37.311020 2003

Krebs VE. The role of hip arthroscopy in the treatment of synovial disorders and loose bodies. Clin Orthop Relat Res.2003;406:48-59.40648 2003 [CrossRef]

Keeney JA, Peelle MW, Jackson J, Rubin D, Maloney WJ, Clohisy JC. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res.2004;429:163-9.429163 2004 [CrossRef]

Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am.2006;88:1448-57.881448 2006 [CrossRef]

Fitzgerald RH Jr. Acetabular labrum tears. Diagnosis and treatment. Clin Orthop Relat Res.1995;311:60-8.31160 1995

McCarthy J, Noble P, Aluisio FV, Schuck M, Wright J, Lee JA. Anatomy, pathologic features, and treatment of acetabular labral tears. Clin Orthop Relat Res.2003;406:38-47.40638 2003 [CrossRef]

McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The role of labral lesions to development of early degenerative hip disease. Clin Orthop Relat Res.2001;393:25-37.39325 2001 [CrossRef]

Potter BK, Freedman BA, Andersen RC, Bojescul JA, Kuklo TR, Murphy KP. Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement. Am J Sports Med.2005;33:864-70.33864 2005 [CrossRef]

Santori N, Villar RN. Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy.2000;16:11-5.1611 2000 [CrossRef]

Chen R, Clohisy JC. Arthroscopic acetabular labral debridement in patients older than forty years. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2007 Feb 14-18; San Diego, CA. 2007

Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech.2003;36:171-8.36171 2003 [CrossRef]

Hines SL, Philippon MJ, Kuppersmith D, Maxwell RB. Early results of labral repair (SS-17). Arthroscopy.2007;23(Suppl):e9-10.23e9 2007

Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy.2005;21:1496-504.211496 2005 [CrossRef]

Byrd JWT, Jones KS. Microfracture for grade IV chondral lesions of the hip (SS-89). Arthroscopy.2004;20(Suppl):e41.20e41 2004

Mintz DN, Hooper T, Connell D, Buly R, Padgett DE, Potter HG. Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy.2005;21:385-93.21385 2005 [CrossRef]

Lieberman JR, Altchek DW, Salvati EA. Recurrent dislocation of a hip with a labral lesion: treatment with a modified Bankart-type repair. Case report. J Bone Joint Surg Am.1993;75:1524-7.751524 1993

Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med.2001;10:817-29.10817 2001

Shindle MK, Ranawat AS, Kelly BT. Diagnosis and management of traumatic and atraumatic hip instability in the athletic patient. Clin Sports Med.2006;25:309-26, ix-x.25309 2006 [CrossRef]

Byrd JW, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy.2004;20:385-91.20385 2004 [CrossRef]

Holgersson S, Brattstrom H, Mogensen B, Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop.1981;1:273-8.1273 1981 [CrossRef]

Okada Y, Awaya G, Ikeda T, Tada H, Kamisato S, Futami T. Arthroscopic surgery for synovial chondromatosis of the hip. J Bone Joint Surg Br.1989;71:198-9.71198 1989

Byrd JW, Jones KS. Adhesive capsulitis of the hip. Arthroscopy.2006;22:89-94.2289 2006 [CrossRef]

DeAngelis NA, Busconi BD. Hip arthroscopy in the pediatric population. Clin Orthop Relat Res.2003;406:60-3.40660 2003 [CrossRef]

Kim SJ, Choi NH, Ko SH, Linton JA, Park HW. Arthroscopic treatment of septic arthritis of the hip. Clin Orthop Relat Res.2003;407:211-4.407211 2003 [CrossRef]

Hyman JL, Salvati EA, Laurencin CT, Rogers DE, Maynard M, Brause DB. The arthroscopic drainage, irrigation, and debridement of late, acute total hip arthroplasty infections: average 6-year follow-up. J Arthroplasty.1999;14:903-10.14903 1999 [CrossRef]

Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy.2003;19:1055-60.191055 2003 [CrossRef]

Clohisy JC, Wright RW. Hip arthroscopy in the treatment of osteoarthritis. Oper Tech Sports Med.2002;10:219-23.10219 2002 [CrossRef]

O'Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy.2001;17:181-8.17181 2001 [CrossRef]

Villar RN. Arthroscopic debridement of the hip. J Bone Joint Surg Br.1991;73(Suppl 2):170-1.73170 1991

Byrd JW. Hip arthroscopy utilizing the supine position. Arthroscopy.1994;10:275-80.10275 1994 [CrossRef]

Glick JM. Hip arthroscopy using the lateral approach. Instr Course Lect.1988;37:223-31.37223 1988

Dienst M, Godde S, Seil R, Hammer D, Kohn D. Hip arthroscopy without traction: in vivo anatomy of the peripheral hip joint cavity. Arthroscopy.2001;17:924-31.17924 2001 [CrossRef]

Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br.2000;82:679-83.82679 2000 [CrossRef]

Beaulé PE, Dorey FJ, LeDuff M, Gruen T, Amstutz HC. Risk factors affecting outcome of metal-on-metal surface arthroplasty of the hip. Clin Orthop Relat Res.2004;418:87-93.41887 2004 [CrossRef]

Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE. Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study. J Bone Joint Surg Am.2007;89:1153-60.891153 2007 [CrossRef]

Girard J, Lavigne M, Vendittoli PA, Roy AG. Biomechanical reconstruction of the hip: a randomised study comparing total hip resurfacing and total hip arthroplasty. J Bone Joint Surg Br.2006;88:721-6.88721 2006 [CrossRef]

Rubash HE, Sinha RK, Shanbhag AS, Kim SY. Pathogenesis of bone loss after total hip arthroplasty. Orthop Clin North Am.1998;29:173-86.29173 1998 [CrossRef]

Gartland JJ. Orthopaedic clinical research. Deficiencies in experimental design and determinations of outcome. J Bone Joint Surg Am.1988;70:1357-64.701357 1988

Beaulé PE, Dorey FJ, Hoke R, Leduff M, Amstutz HC. The value of patient activity level in the outcome of total hip arthroplasty. J Arthroplasty.2006;21:547-52.21547 2006 [CrossRef]

Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip replacement. J Bone Joint Surg Br.1994;76:229-34.76229 1994

Vendittoli PA, Lavigne M, Roy AG, Lusigan D. A prospective randomized clinical trial comparing metal-on-metal total hip arthroplasty and metal-on-metal total hip resurfacing in patients less than 65 years old. Hip Int.2006;16(Suppl 4):S73-81.16S73 2006

Chandler HP, Reineck FT, Wixson RL, McCarthy JC. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am.1981;63:1426-34.631426 1981

Feller JA, Kay PR, Hodgkinson JP, Wroblewski BM. Activity and socket wear in the Charnley low-friction arthroplasty. J Arthroplasty.1994;9:341-5.9341 1994 [CrossRef]

Kilgus DJ, Dorey FJ, Finerman GA, Amstutz HC. Patient activity, sports participation, and impact loading on the durability of cemented total hip replacements. Clin Orthop Relat Res.1991;269:25-31.26925 1991

Mont MA, Ragland PS, Etienne G, Seyler TM, Schmalzried TP. Hip resurfacing arthroplasty. J Am Acad Orthop Surg.2006;14:454-63.14454 2006

Treuting RJ, Waldman D, Hooten J, Schmalzried TP, Barrack RL. Prohibitive failure rate of the total articular replacement arthroplasty at five to ten years. Am J Orthop.1997;26:114-8.26114 1997

Amstutz HC, Grigoris P, Dorey FJ. Evolution and future of surface replacement of the hip. J Orthop Sci.1998;3:169-86.3169 1998 [CrossRef]

Buechel FF, Drucker D, Jasty M, Jiranek W, Harris WH. Osteolysis around uncemented acetabular components of cobalt-chrome surface replacement hip arthroplasty. Clin Orthop Relat Res.1994;298:202-11.298202 1994

100

Howie DW, Cornish BL, Vernon-Roberts B. Resurfacing hip arthroplasty. Classification of loosening and the role of prosthesis wear particles. Clin Orthop Relat Res.1990;255:144-59.255144 1990

101

Kabo JM, Gebhard JS, Loren G, Amstutz HC. In vivo wear of polyethylene acetabular components. J Bone Joint Surg Br.1993;75:254-8.75254 1993

102

Beaulé PE. Surface arthroplasty of the hip: a review and current indications. Semin Arthroplasty.2005;16:70-6.1670 2005 [CrossRef]

103

Amstutz HC, Beaulé PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen TA. Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study. J Bone Joint Surg Am.2004;86:28-39.8628 2004

104

Back DL, Dalziel R, Young D, Shimmin A. Early results of primary Birmingham hip resurfacings. An independent prospective study of the first 230 hips. J Bone Joint Surg Br.2005;87:324-9.87324 2005 [CrossRef]

105

Daniel J, Pynsent PB, McMinn DJ. Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br.2004;86:177-84.86177 2004 [CrossRef]

106

Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br.2005;87:167-70.87167 2005 [CrossRef]

107

McLaughlin JR, Lee KR. Total hip arthroplasty in young patients. 8- to 13-year results using an uncemented stem. Clin Orthop Relat Res.2000;373:153-63.373153 2000 [CrossRef]

108

McKellop H, Shen FW, Lu B, Campbell P, Salovey R. Development of an extremely wear-resistant ultra high molecular weight polyethylene for total hip replacements. J Orthop Res.1999;17:157-67.17157 1999 [CrossRef]

109

Sieber HP, Rieker CB, Kottig P. Analysis of 118 second-generation metal-on-metal retrieved hip implants. J Bone Joint Surg Br.1999;81:46-50.8146 1999 [CrossRef]

110

Kishida Y, Sugano N, Nishii T, Miki H, Yamaguchi K, Yoshikawa H. Preservation of the bone mineral density of the femur after surface replacement of the hip. J Bone Joint Surg Br.2004;86:185-9.86185 2004 [CrossRef]

111

Ball ST, Le Duff MJ, Amstutz HC. Early results of conversion of a failed femoral component in hip resurfacing arthroplasty. J Bone Joint Surg Am.2007;89:735-41.89735 2007 [CrossRef]

112

Amstutz HC, Campbell PA, Le Duff MJ. Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am.2004;86:1874-7.861874 2004

113

Campbell P, Beaulé PE, Ebramzadeh E, LeDuff M, De Smet K, Lu Z, Amstutz HC. A study of implant failure in metal-on-metal surface arthroplasties. Clin Orthop Relat Res.2006;453:35-46.45335 2006 [CrossRef]

114

Pollard TC, Baker RP, Eastaugh-Waring SJ, Bannister GC. Treatment of the young active patient with osteoarthritis of the hip. A five- to seven-year comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing. J Bone Joint Surg Br.2006;88:592-600.88592 2006 [CrossRef]

115

Revell MP, McBryde CW, Bhatnagar S, Pynsent PB, Treacy RB. Metal-on-metal hip resurfacing in osteonecrosis of the femoral head. J Bone Joint Surg Am.2006;88 Suppl 3:98-103.8898 2006 [CrossRef]

116

Beaulé PE, Campbell P, Lu Z, Leunig-Ganz K, Beck M, Leunig M, Ganz R. Vascularity of the arthritic femoral head and hip resurfacing. J Bone Joint Surg Am.2006;88 Suppl 4:85-96.8885 2006 [CrossRef]

117

Little CP, Ruiz AL, Harding IJ, McLardy-Smith P, Gundle R, Murray DW, Athanasou NA. Osteonecrosis in retrieved femoral heads after failed resurfacing arthroplasty of the hip. J Bone Joint Surg Br.2005;87:320-3.87320 2005 [CrossRef]

118

Brodner W, Grohs JG, Bancher-Todesca D, Dorotka R, Meisinger V, Gottsauner-Wolf F, Kotz R. Does the placenta inhibit the passage of chromium and cobalt after metal-on-metal total hip arthroplasty? J Arthroplasty.2004;19(8 Suppl 3):102-6.19102 2004

119

Jacobs JJ, Skipor AK, Doorn PF, Campbell P, Schmalzried TP, Black J, Amstutz HC. Cobalt and chromium concentrations in patients with metal on metal total hip replacements. Clin Orthop Relat Res.1996;329 Suppl:S256-63.329S256 1996 [CrossRef]

120

Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and retrieval analysis of Sikomet metal-on-metal total hip replacements at a mean of seven years. J Bone Joint Surg Am.2006;88:1173-82.881173 2006 [CrossRef]

121

Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Köster G, Lohmann CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am.2005;87:28-36.8728 2005

122

Ziaee H, Daniel J, Datta AK, Blunt S, McMinn DJ. Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: a controlled study. J Bone Joint Surg Br.2007;89:301-5.89301 2007 [CrossRef]

123

Beaulé PE, Poitras P. Femoral component sizing and positioning in hip resurfacing arthroplasty. Instr Course Lect.2007;56:163-9.56163 2007

124

Beaulé PE, Lee JL, Le Duff MJ, Amstutz HC, Ebramzadeh E. Orientation of the femoral component in surface arthroplasty of the hip. A biomechanical and clinical analysis. J Bone Joint Surg Am.2004;86:2015-21.862015 2004

125

Liechti R. Hip arthrodesis and associated problems. Berlin: Springer; 1978. 1978

126

Beaulé PE, Matta JM, Mast JW. Hip arthrodesis: current indications and techniques. J Am Acad Orthop Surg.2002;10:249-58.10249 2002

127

Stover MD, Beaulé PE, Matta JM, Mast JW. Hip arthrodesis: a procedure for the new millennium? Clin Orthop Relat Res.2004;418:126-33.418126 2004 [CrossRef]

128

Callaghan JJ, Brand RA, Pedersen DR. Hip arthrodesis. A long-term follow-up. J Bone Joint Surg Am.1985;67:1328-35.671328 1985

Topics

neck ; femur ; head of femur ; hip region ; hip dislocation, congenital ; hip joint ; hip replacement arthroplasty ; hip arthroscopy ; femoral acetabular impingement ; acetabular rim

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'AOA Symposium: Hip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment*'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'AOA Symposium: Hip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment*'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

John C. Clohisy, Paul E. Beaulé, Aran O'Malley, Marc R. Safran, Perry Schoenecker; AOA SymposiumHip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment*. The Journal of Bone & Joint Surgery. 2008 Oct;90(10):2267-2281.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment