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Look past inclinations when treating common hip pathology with arthroscopy
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A recently published review calls for heightened discrimination by physicians when opting for hip preservation surgery, such as arthroscopy or open surgical dislocation, for pre-arthritic patients with conditions such as femoroacetabular impingement and slipped capital femoral epiphysis.
“Decisions to optimize the geometry and mechanics of the joint must be guided by fundamental principles and not just a preferred surgical technique,” Asheesh Bedi, MD, told Orthopaedics Today Europe. Bedi, senior author Ira Zaltz, MD, and colleagues reviewed the limits, benefits and disadvantages of using arthroscopic approaches for pre-arthritic hip conditions in an article recently published in Arthroscopy.
Labral tears, cross-over signs
Bedi also recommends a more individual approach to treatment for patients with slipped capital femoral epiphysis, Legg-Calvé-Perthes (LCP) disease, acetabular dysplasia and instability, and femoroacetabular impingement (FAI). “A history, physical examination, and imaging findings of proximal femoral and/or acetabular deformity that is concordant with the patient’s symptoms are essential. Labral tears and cross-over signs are all too common, and treating all of these cases indiscriminately is a recipe for high failure rates and modest outcomes,” Bedi said.
LCP disease, due to its complex nature, was found to be most often treated with open surgical procedures. The same was determined for treating acetabular dysplasia and instability, though the researchers noted “arthroscopic procedures may be used in conjunction with acetabular reorientation.”
Regarding FAI, the researchers urged surgeons to take a more individualized approach to treatment, though patients with greater than Tönnis grade 1 degenerative changes are thought to be at risk for failure of hip preservation surgery regardless of surgical modality.
Need for thoughtful indications
In their discussion, Bedi and colleagues emphasized a lack of generalization in approach and indication.
“The indications and limits of arthroscopy must be carefully defined and indications must evolve correspondingly to avoid an increase in failure rates and unsatisfactory clinical outcomes. Some diagnoses may be better and more comprehensively addressed with open procedures or combined surgical approaches,” they wrote in their study.
“Open surgery remains a powerful and critical tool for complex intra-articular and extra-articular hip pathology, and recognizing the power and role for these operations is of paramount importance. Hip arthroscopy is a tool and approach, but it is not synonymous with hip preservation. Like any tool, it can be more detrimental than beneficial when used indiscriminately, and thoughtful indications are critical for its future success,” Bedi said. – by Christian Ingram
- Reference:
- Zaltz I. Arthroscopy. 2014;doi:10.1016/j.arthro.2013.10.005.
- For more information:
- Asheesh Bedi, MD, can be reached at Department of Orthopaedic Surgery, University of Michigan, MedSport, 24 Frank Lloyd Wright Dr., Lobby A, Ann Arbor, MI 48106, USA; email: abedi@med.umich.edu.
Disclosure: Zaltz receives support from Pivot Medical. Bedi receives support from Smith & Nephew.
Perspective
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Óliver Marín-Peña, MD
I strongly recommend reading this interesting review article about surgical options to manage hip pathology in the young adult with a painful hip. The authors revise widely the current indications of hip arthroscopy and safe surgical dislocation of the hip. The paper was divided into different paragraphs that individually analyze the surgical options to treat slipped capital femoral epiphysis, acetabular dysplasia, femoroacetabular impingement and instability. I found the last part of the paper where they established the main limitations of hip arthroscopy in a highly objective manner especially interesting. Unless the authors describe perfectly the state of the art in hip preserving surgery, I would like to see more references to the indications of the mini-anterior approach and its current role. There is no question that it is worth it to take a few minutes to read this article.
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