Endoscopic or arthroscopic iliopsoas tenotomy for iliopsoas impingement following total hip replacement. A prospective multicenter 64-case series.

INTRODUCTION: Impingement between the acetabular component and the iliopsoas tendon is a cause of anterior pain after total hip replacement (THR). Treatment can be non-operative, endoscopic or arthroscopic, or by open revision of the acetabular component. Few studies have assessed these options. The present study hypothesis was that endo/arthroscopic treatment provides rapid pain relief with a low rate of complications. METHODS: A prospective multicenter study included 64 endoscopic or arthroscopic tenotomies for impingement between the acetabular component and the iliopsoas tendon, performed in 8 centers. Mean follow-up was 8months, with a minimum of 6months and no loss to follow-up. Oxford score, patient satisfaction, anterior pain and iliopsoas strength were assessed at last follow-up. Complications and revision procedures were collated. Forty-four percent of patients underwent rehabilitation. RESULTS: At last follow-up, 92% of patients reported pain alleviation. Oxford score, muscle strength and pain in hip flexion showed significant improvement. The complications rate was 3.2%, with complete resolution. Mean hospital stay was 0.8 nights. In 2 cases, arthroscopy revealed metallosis, indicating revision of the acetabular component. The only predictive factor was acetabular projection on oblique view. Rehabilitation significantly improved muscle strength. CONCLUSION: Endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. The low complications rate makes this the treatment of choice in case of failure of non-operative management. Arthroscopy also reorients diagnosis in case of associated joint pathology. Projection of the acetabular component on preoperative oblique view is the most predictive criterion, guiding treatment.

Function and osteoarthritis progression after arthroscopic treatment of femoro-acetabular impingement: a prospective study after a mean follow-up of 4.6 (4.2-5.5) years.

BACKGROUND: Outcomes after arthroscopic femoro-acetabular impingement (FAI) surgery are promising in the short-term but have rarely been evaluated in the mid-term (e.g., about 5 years). Here, our objectives were to obtain mid-term data on functional and radiographic outcomes, to identify prognostic factors, and to determine the mid-term rate of arthroplasty revision with the associated risk factors. HYPOTHESIS: We hypothesized that the results of arthroscopic FAI surgery were sustained over time. MATERIALS AND METHODS: We conducted a prospective multi-surgeon study of 53 Tönnis grade 0 or 1 hips treated arthroscopically for symptomatic FAI (23 cam, 10 pincer, and 20 mixed deformities). We obtained short-term (10 months) and mid-term (4.6 years) data on the functional outcome (WOMAC and satisfaction scores), proportion of patients without revision arthroplasty, and development of osteoarthritis (graded using the Tönnis classification). RESULTS: In the patients without revision arthroplasty, the WOMAC score improved significantly (P<0.01) from baseline (61.4 ± 15.6) to 10 months (84.2 ± 15.6) and last follow-up (85.2 ± 15.5) but remained unchanged between the two postoperative time points, confirming the stability of the results. The proportion of satisfied patients was 79% after 10 months and 68% (36/53) at last follow-up (NS). Osteoarthritis developed in 13/35 (37%) hips for which radiographs were obtained at last follow-up. At last follow-up, 46/53 hips (87%; 95%CI, 78-96) did not required revision surgery; arthroplasty was required in the 7 remaining hips. The main prognostic factor was the preoperative osteoarthritis Tönnis grade: at last follow-up, compared to Tönnis grade 0 hips, Tönnis grade 1 hips had lower WOMAC scores (77 vs. 88), lower satisfaction rates (50% versus 77%), a higher rate of osteoarthritis progression (57% versus 24%), and a higher rate of arthroplasty (33.3% versus 2.9%). DISCUSSION: Our results are consistent with published data. The outcomes of arthroscopic FAI surgery are sustained over time and the preoperative osteoarthritis status is the main predictor of mid-term outcomes. LEVEL OF EVIDENCE: IV, prospective cohort study.

Arthroscopic treatment of femoroacetabular impingement: Technical review.

The objectives of surgical treatment of femoroacetabular impingement are to improve the symptoms and to prevent or slow the progression of osteoarthritis by improving joint clearance between the acetabular rim and the femoral neck. Arthroscopic correction of bone abnormalities and treatment of articular lesions requires the use of techniques that provide good access to the peripheral and central compartments of the hip joint. Various patient positions and portal placements have been suggested. The sequence used to access the two compartments may differ according to the option chosen. Entering the central compartment first is the most popular technique for arthroscopic hip joint access and requires joint distraction under fluoroscopic monitoring. Accessing the peripheral compartment first can be achieved without distraction and does not always require fluoroscopic guidance. Regardless of the sequence, capsulotomy greatly facilitates the therapeutic procedures that are common to all approaches. Osteoplasties are conducted after careful pre-operative planning based on various visual or fluoroscopic landmarks. Several options are available for treating articular cartilage and labral lesions.

Technique and results of endoscopic tenotomy in iliopsoas muscle tendinopathy secondary to total hip replacement: a series of 10 cases.

INTRODUCTION: There have been numerous recommendations for management of iliopsoas tendinopathy secondary to hip replacement: medical treatment, cup replacement, and open or arthroscopic tenotomy. MATERIAL AND METHOD: We report on a series of 10 endoscopic iliopsoas tenotomies. Arthroplasty comprised five primary conventional total prostheses, two large head diameter metal-metal models, one resurfacing and one revision arthroplasty. All patients underwent clinical (PMA, WOMAC), imaging (X-ray, CT, scintigraphy) and biological assessment. Seven cases showed mechanical impingement (six involving the anterior edge of the cup, and one a cement fragment); the other three involved large femoral components (two large head diameter models, one resurfacing). Infiltration test was positive in eight cases out of nine. Endoscopic iliopsoas tenotomy for recurrence was performed in dorsal decubitus on an ordinary table, under fluoroscopy, using two approaches (inferior for the endoscope, superior for the instruments) converging on the lesser trochanter. DISCUSSION: There were no complications. At a mean 20 months' follow-up (range, 12-60 months), mean pain grade was 5.5 (4-6). Eight patients showed complete relief, and two partial relief (two atypical cases). Mean PMA score was 16.9 (15-18) and mean WOMAC score 84 (60-95). Muscle force was recovered at a mean 3.25 months (0.5-6). Eight patients were very satisfied, one satisfied and one moderately satisfied. CONCLUSION: This technique is much less heavy than implant replacement; postoperative course is shorter than for open tenotomy and the technique is simpler than arthroscopic tenotomy, with lower risk. Subsequent cup change, where necessary, is not compromised. LEVEL OF EVIDENCE: IV, retrospective, case series.

Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study.

INTRODUCTION: Surgical treatment of femoroacetabular impingement can be performed under arthroscopic control, to limit associated morbidity. Encouraged by recent good reports, arthroscopy is replacing alternative techniques for this indication. HYPOTHESIS: Arthroscopy enables femoroacetabular impingement to be corrected with a low rate of associated morbidity. AIM OF STUDY: To assess the indications for and quality of the technique and its impact on preliminary results and complications. To investigate preoperative prognostic factors. PATIENT AND METHODS: One hundred and eleven hips in 110 patients (78 male, 32 female; mean age, 31 years) were operated on under arthroscopic control for femoroacetabular impingement, by six senior surgeons. Sixty-five patients showed no radiographic sign of osteoarthritis, and 36 showed grade-1 early osteoarthritis on the Tönnis scale. RESULTS: Mean WOMAC score rose from 60.3 preoperatively to 83 (p<0.001) at a mean 10 months' FU (range, 6-18 mo). Seventy-seven percent of patients were satisfied or very satisfied with their result. Patients with early osteoarthritis had significantly lower WOMAC and satisfaction scores than those free of osteoarthritis. Operative crossover to open surgery occurred in only one case. Five patients (4%) had revision: total hip replacement or resurfacing. There were seven complications (6%): three cases of heterotopic ossification, one of crural palsy, one of pudendal palsy, one of labium majus necrosis, and one non-displacement stress fracture of the femoral head/neck junction (managed by non-weight-bearing). There was no palsy of the territory of the lateral cutaneous nerve of the thigh. DISCUSSION: Results confirmed the efficacy and low associated morbidity of arthroscopy in the management of femoroacetabular impingement. Short-term functional results matched those of the literature. Planning and assessment seem not yet to be fully standardized. Preoperative osteoarthritis on X-ray was associated with poorer functional results. This attitude does not seem to be indicated for hips showing evolved osteoarthritis (>grade 1).

Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.

Two hundred and ninety-two patients, aged between 16 and 50 years and presenting with mechanical hip pathology, were included in a prospective multicenter study. The descriptive study concerned the clinical examination and analysis of three X-ray views (AP pelvic, Lequesne false profile and lateral axial view). The series comprised 62% males, mean age 35 years, with 53% right side and 22% bilateral involvement. Initial trauma was reported in 19% of cases, and direct familial history of hip pathology in 20%. Seventy percent of the patients played sports, 30% were high-level athletes, and 17% played combat sports. The physical impingement sign was present in 18% to 65% of cases depending on the variant studied. On imaging (n=241), 62% of hips showed osteoarthritis, with 25% at the evolved stage. In the series, as a whole, there was a 35% rate of dysplasia, 63% of impingement and 5% of normal X-ray results. The radiologic impingement aspects were 58% cam-type, 19% pincer-type and 23% mixed. Twenty-two percent of dysplasia cases showed signs of associated impingement. Pain experienced exclusively in flexion/internal rotation/adduction on examination showed little sensitivity (20%) but considerable specificity (86%) for the main diagnosis of impingement. The links between impingement and dysplasia are discussed, and an integrative schema of all risk factors is put forward.

Imaging data in a prospective series of adult hip pain in under-50 year-olds.

Two hundred and ninety-two patients under the age of 50 years, presenting with mechanical hip pain, were included in a prospective multicenter study. In 241 cases, imaging assessment included AP standing pelvic X-ray and Lequesne's false profile (LFP) and/or lateral neck (Ducroquet, Dunn or variant) hip X-ray. Cross-sectional arthroscan and/or arthro-MRI images were available in 81 cases. Exploration looked for acetabular and femoral head/neck dysplasia liable to induce cam or pincer anterior femoroacetabular impingement (AFAI), respectively. Labral and chondral lesions arise secondarily to hip osteoarthritis (HOA) and/or AFAI. Two-thirds of patients showed HOA. Only 6% showed a strictly normal aspect on imaging. More than half (52%) of cases had cam AFAI, half of these involving an osteophytic neck, associated in more than 90% of cases with large multifocal bone spurs of the head, neck and acetabula. These cases were considered ambiguous, due to the uncertainty as to the congenital nature of the cervico-cephalic dysmorphy; if they are excluded, only 23% of the series involved cam AFAI. Crossover sign on AP standing pelvic X-ray is the best assessment criterion for acetabular retroversion, the most frequent form of acetabular dysplasia underlying pincer AFAI, and should be explored for. Secondary neck lesions were visible only on lateral neck view in 42% of cases: this view should be included in standard radiologic work-up in under-50 year-olds. The alpha angle can be measured on this type of lateral view and on axial arthroscan and arthro-MR images; more than half of the cases in which it was pathological involved an osteophytic neck and thus a pseudo-cam effect.

Update to femoroacetabular impingement arthroscopic management.

INTRODUCTION: Arthroscopic treatment of femoroacetabular impingement (FAI) is recommended since it is a minimally invasive procedure allowing full access to the hip joint. HYPOTHESIS: Arthroscopic treatment can alleviate FAI without use of a perineal support. GOALS OF THE STUDY: To describe an early experience of hip arthroscopy in the treatment of FAI using two types of hip distraction without perineal support; to assess morbidity of FAI release under arthroscopic control and its early clinical and radiological outcome. PATIENTS AND METHODS: In the first 32 cases, the procedure used an invasive distractor and started with the central compartment. In the last six cases, it started with the peripheral compartment using a dedicated traction table with a contralateral buttock support. Inclusion criteria were: positive impingement test and radiological evidence of FAI. Thirty-eight consecutive patients with mean age 36 years (range 24-64) underwent arthroscopic treatment for FAI. Clinical outcome used WOMAC and Postel Merle d'Aubigné (PMA) scores. Radiological development of osteoarthritis (OA) was graded according to Tönnis score. RESULTS: At mean final follow-up of 1.3 years (range 0.5-3), there were no complications of either type of traction technique used. Mean WOMAC score increased from 55 to 75 points and PMA from 14.6 to 16.7 points. The subjective overall satisfaction rate was 79%. Radiological OA changes appeared in two hips, were unchanged in 33, and deteriorated in three. DISCUSSION: Invasive distraction device has been effective but appeared complex and costly. The procedure is now performed without it and begins at the peripheral compartment by the capsulotomy, which allows secondary distraction using a contralateral buttock. Preoperative OA seems to be a negative prognostic factor for clinical outcome. CONCLUSIONS: Arthroscopic treatment of FAI is a safe technique which can be achieved without perineal complications. Limited anterior-superior capsulectomy and cephalic bone resection represent the first operative step, allowing acetabular trimming, labral reattachment and FAI relief. It is effective in terms of early clinical results. LEVEL OF EVIDENCE: Level IV: retrospective study.

[Hip dysplasia and misalignment in patients aged 20-50 years]. / Dysplasie et conflits de hanche de 20 à 50 ans.

Anterior hip pain in young adult (20 to 50) has two main causes: secondary osteo-arthritis on development dysplasia of the hip, and femoro-acetabular impigement (FAI). This symposium had two parts: the first one analyses long-term results of non-prosthetic surgery (283 osteotomies and shelfs at 15 years FU). The second part concerned the different syndromes with acute anterior hip pain, especially due to FAI and to labral tears.In hip dysplasia, 56 shelf operations, 100 proximal femoral varus osteotomies associated or not with a shelf arthroplasty,and 127 Chiari osteotomies were examined with 10 years minimum follow-up. Only 15% of patients were lost at follow-up before 10 years and average follow-up was 15 years. Results were considered as satisfactory when the Merle d'Aubigne rating was 15/18 or more. The 3 main factors of good prognosis were: a complete correction of both femoral and acetabular dysplasia; age at operation under 40; a moderate arthritis (grade I or II according to De Mourgues and Patte). In single acetabular dysplasia with 3 favorable prognosis factors(no coxa valga, age under 40, arthritis 1 or 2), 85% good results were achieved at 15 years. When patients were over 40 at operation, or in arthritis grade over 2, only 55% of good results were observed. Varus osteotomies, associated or not with shelf arthroplasties, achieved also 85% goods results at 15 years when the 3 favorable prognosis factors were present. Similar good results were also obtained by Chiari osteotomy, but this operation was associated with 12% complications, and more that 25% of lasting limping. Therefore, with 85% good results at 15 years (and often over 20 years), non prosthetic surgery performed at 30-35 years, achieved better functional results than total hip arthroplasty, longer lasting, and not jeopardizing any further possibility of prosthetic surgery.As concerns acute anterior pain of the hip, the clinical and imaging patterns of the different syndromes have been precised: femoro-acetabular impigement by cam (or by pincer), labral tears in hip dysplasia. There were distinguished from the other secondary impigements, for example by acetabular malposition due to pelvis anteflexion or by other hip diseases: overuse arthritis, coxa retrorsa, etc. Several examples of typical syndromes were presented to support the recommended imaging techniques. The results of the speakers with different surgical treatments were reported as well as concerns open surgery than arthroscopic treatment (60 cases).

[Deltoid muscle flap for massive rotator cuff tears: 41 cases with a mean 7-year (minimum 5 year) follow-up]. / Le lambeau deltoïdien dans les ruptures massives de la coiffe des rotateurs: quarante et un cas avec un recul moyen de 7 ans (minimun 5 ans).

PURPOSE OF THE STUDY: The aim of this study was to assess outcome after deltoid muscle flap repair of massive rotator cuff tears. We examined functional and radiological results at least five years after surgery. MATERIAL AND METHODS: We reviewed 41 shoulders operated by three senior surgeons (MC, DK, HT). None of the patients were lost to follow-up. The global Constant score was used for pre- and postoperative functional assessment. Three groups were distinguished by preoperative active flexion (group I<90 degrees, group II 90 degrees -120 degrees, group III > 120 degrees ). AP, double oblique (3 rotation views to measure the subacromial space), and Lamy lateral radiographs were obtained in all patients. Shoulder anatomy was evaluated at last follow-up in eight patients: magnetic resonance imaging (MRI) because of persistent pain in one patient and ultrasonography performed by one radiologist (NC) in seven patients. RESULTS: The study population included 26 men and 15 women, mean age at surgery 59 years (42-78, 8). Mean follow-up was 7 years (5-8.5, 0.9). In the coronal plane, there were no distal tears, the stump was in an intermediate position in 7 cases (17%) and retracted to the glenoid in 34 (83%). In the sagittal plane, the supraspinatus exhibited a full thickness tear in all cases. The tear extended anteriorly or posteriorly in all cases. Thirty-eight patients (92%) were satisfied at last follow-up; their global Constant score had improved from 37 to 62 points. Mean anterior flexion improved from 113 degrees to 148 degrees and flexion force from 1.3 kg to 2.9 kg. When preoperative flexion was less than 90 degrees (11 cases), mean gain was + 89 degrees. Inversely, 7 of the 18 patients with flexion > 120 degrees lost a mean 40 degrees at last follow-up. Twenty-seven patient were reviewed at 12 and 89 months: pain relief and force were maintained. The subacromial space, measured in 88% of the cases, was 7.3 mm preoperatively and 5.5 mm at last follow-up. The subacromial space narrowed in 20 patients (56%); none of the patients exhibited an improvement. The flap was explored by ultrasonography in seven patients and by MRI in one: the flap was continuous in 50% and measured more than 4 mm in thickness. Reviews at 12 then 89 months demonstrated good maintenance of pain relief and progression of active flexion and force. DISCUSSION AND CONCLUSION: This long-term study confirms the usefulness of the deltoid flap for the treatment of full thickness massive tears of the rotator cuff. The flap provides persistent pain relief and good function and force. This technique should be discussed for young patients in good physical condition when preoperative imaging demonstrates and irreparable alteration of the tendinomuscular structures (supraspinatus retraction, fatty degeneration, severe amyotrophy). The technique is particularly useful when preoperative flexion is less than 90 degrees. Although the population size is too small for statistical analysis, indications for deltoid flap repair should probably be limited to tears involving at most two tendons and sparing the subscapularis.

[Stiff painful spine in an 11-year-old girl with SAPHO syndrome]. / Rachis raide et douloureux chez une enfant de 11 ans et syndrome SAPHO.

Compression of the cervical spinal cord developed six months after the first signs of a stiff and painful spine in an 11-year-old girl. The clinical course, the association with other skeletal localization, particularly the sacroiliac joint and the roof of the acetabulum and the pathology findings of nonspecific inflammation led to the diagnosis of chronic recurrent multifocal osteomyelitis that can be included in a SAPHO syndrome (synovitis-acne-pustulosis- hyperostosis-osteitis). We report the specific findings in our case and review the literature to define the nosology framework of this rather uncommon condition. To our knowledge, this is the first report of spinal cord injury in a child related to SAPHO syndrome.