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Editorial Commentary: Hip Arthroscopy in Dysplastic Hip Population? A Must, a Maybe, or a No Go?
Editorial Commentary: Hip Arthroscopy in Dysplastic Hip Population? A Must, a Maybe, or a No Go? Robert Stapf, M.D.
Abstract: Treating symptomatic patients with dysplasia involves a controversy in therapy. The question is whether to obtain osseous correction with the help of pelvic reorientation osteotomy or to address intra-articular pathology with an arthroscopic approach. Neither isolated therapy nor the other method seems to be sufficient, but conducting both treatment options simultaneously has also not proved to be superior and carries the risk of additional complications. Different treatment options have been presented on this topic over the years and should be considered on a case-by-case basis. Pelvic reorientation osteotomy in patients with moderate to severe acetabular dysplasia remains uncontested, but it lacks the ability to obtain visualization of the central hip compartment. The isolated arthroscopic approach seems to be favorable for treatment of intra-articular pathologies in patients with mild to borderline dysplasia, whereas collateral arthroscopy in pelvic reorientation osteotomy may achieve better clinical outcomes in patients with more complex cases.
See related article on page 237
I
n their systematic review of patient outcome reports in a dysplastic population, titled “The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review,” Adler and Giordano1 investigated data on the use of hip arthroscopy as an isolated treatment and as an adjunct to pelvic reorientation osteotomy. Three databases were selected, and 33 studies (1368 hip arthroscopies) were found and analyzed. For greater clarity, 5 categories were defined and respectively presented. Hip arthroscopy for screening, chondral mapping, and planning (category 1) did not show sufficient evidence of improved clinical outcomes after reorientation osteotomy of the pelvis. Limited evidence was shown for isolated arthroscopic treatment (category 2) when restricted to cases of mild to borderline dysplasia, whereas no recommendation was given in the setting of moderate to severe dysplasia because of the risk of iatrogenic instability and subsequent inferior patient outcomes. Giving attention to preservation of the
Potsdam, Germany The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181199/$36.00 https://doi.org/10.1016/j.arthro.2018.10.015
labrum and capsule seems to be necessary to provide encouraging clinical patient outcomes. Neither hip arthroscopy after reorientation pelvic osteotomy (category 3) nor hip-preservation surgery after hip arthroscopy (category 4) led to improved clinical and functional outcomes (limited evidence), thus implying insufficient evidence. Finally, hip arthroscopy as an adjunctive treatment option to reorientation pelvic osteotomy (category 5) did not show superior clinical outcomes (insufficient evidence), but 3 of 4 studies presented a high rate of concomitant intra-articular pathology. All subgroups showed a moderate to high risk of bias (Level III or IV). In summary, the authors recommended the careful use of hip arthroscopy on a case-by-case basis as a useful supplement in corrective treatment of acetabular dysplasia. In my occupational routine, a recurrent dilemma is the younger patient complaining of hip pain showing radiologic dysplastic hip confirmation. Pelvic reorientation osteotomy has become the gold standard in surgical treatment of symptomatic dysplastic hip diseases, with satisfactory outcomes in the long term.2,3 The high incidence of intra-articular pathology in the dysplastic hip population has been reported repeatedly4-6 and may encourage the surgeon to conduct collateral arthroscopic procedures. Domb et al.7 recently showed a significant change in patient
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 1 (January), 2019: pp 249-250
249
250
EDITORIAL COMMENTARY
outcomes, with excellent outcomes obtained in 82% of patients. In all patients (N ¼ 17), chondrolabral damage was identified and treated. In contrast, Thanacharoenpanich et al.8 did not find significant differences in clinical, radiologic, or functional outcomes between patients who underwent periacetabular osteotomy in isolation and those in whom this procedure was combined with hip arthroscopy or arthrotomy. Although chondrolabral pathology is common in the dysplastic population, the clinical relevance of those intra-articular pathologies remains unclear. Thus, conflicting results have been published in the past,2,9-14 and further study is needed to identify whether chondrolabral treatment in patients undergoing pelvic reorientation is necessary to improve patients’ outcomes. Referring to this, Faucett15 recently complained about inconsistent definitions of hip dysplasia in our current literature and the need for reliable treatment options based on short-term, midterm, and long-term studies. Despite a few limitations (e.g., diverse and heterogeneous study populations and retrospective collection of data), Adler and Giordano1 give us a supporting tool in dealing with a controversial topic and a complex and frequent dilemma. Careful treatment concepts are recommended to determine successful therapy of patients with hip dysplasia. Isolated arthroscopic procedures seem to be suitable when preservation of the labrum and capsule is considered and strong patient selection is observed. Reorientation pelvic osteotomy and concomitant hip arthroscopy appear to be appropriate in more complex situations by addressing all pathologies due to symptomatic hip dysplasia. Thus, comprehensive and combined treatment concepts may facilitate better clinical outcomes in the future.
References 1. Adler KL, Giordano BD. The utility of hip arthroscopy in the setting of acetabular dysplasia: A systematic review. Arthroscopy 2018;35:237-248. 2. Matheney T, Kim YJ, Zurakowski D, et al. Intermediate to long-term results following the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone Joint Surg Am 2009;91:2113-2123.
3. Steppacher SD, Tannast M, Ganz R, et al. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 2008;466:1633-1644. 4. Fujii M, Nakashima Y, Jingushi S, et al. Intraarticular findings in symptomatic developmental dysplasia of the hip. J Pediatr Orthop 2009;29:9-13. 5. Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med 2011;39:72S-78S. 6. Domb BG, Lareau JM, Baydoun H, et al. Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy? Clin Orthop Relat Res 2014;472:674-680. 7. Domb BG, LaReau JM, Hammarstedt JE, Gupta A, Stake CE, Redmond JM. Concomitant hip arthroscopy and periacetabular osteotomy. Arthroscopy 2015;31:2199-2206. 8. Thanacharoenpanich S, Boyle MJ, Murphy RF, et al. Periacetabular osteotomy for developmental hip dysplasia with labral tears: Is arthrotomy or arthroscopy required? J Hip Preserv Surg 2018;5:23-33. 9. Matta JM, Stover MD, Siebenrock K. Periacetabular osteotomy through the Smith-Petersen approach. Clin Orthop Relat Res 1999:21-32. 10. Troelsen A, Elmengaard B, Soballe K. A new minimally invasive transsartorial approach for periacetabular osteotomy. J Bone Joint Surg Am 2008;90:493-498. 11. Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: The learning curve at an academic medical center. J Bone Joint Surg Am 2006;88: 1920-1926. 12. Kim KI, Cho YJ, Ramteke AA, et al. Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia. J Bone Joint Surg Br 2011;93:732-737. 13. Cventanovich GL, Heyworth BE, Murray K, et al. Hip arthroscopy in patients with recurrent pain following Bernese periacetabular osteotomy for acetabular dysplasia: Operative findings and clinical outcomes. J Hip Preserv Surg 2015;2:295-302. 14. Nassif NA, Schoenecker PL, Thorsness R, et al. Periacetabular osteotomy and combined femoral head-neck junction osteochondroplasty: A minimum two-year follow-up cohort study. J Bone Joint Surg Am 2012;94: 1959-1966. 15. Faucett SC. Editorial commentary: Hip arthroscopy in hip dysplasia: Just because you are doing it, should you? Arthroscopy 2018;34:454-455.
Abstract: Treating symptomatic patients with dysplasia involves a controversy in therapy. The question is whether to obtain osseous correction with the help of pelvic reorientation osteotomy or to address intra-articular pathology with an arthroscopic approach. Neither isolated therapy nor the other method seems to be sufficient, but conducting both treatment options simultaneously has also not proved to be superior and carries the risk of additional complications. Different treatment options have been presented on this topic over the years and should be considered on a case-by-case basis. Pelvic reorientation osteotomy in patients with moderate to severe acetabular dysplasia remains uncontested, but it lacks the ability to obtain visualization of the central hip compartment. The isolated arthroscopic approach seems to be favorable for treatment of intra-articular pathologies in patients with mild to borderline dysplasia, whereas collateral arthroscopy in pelvic reorientation osteotomy may achieve better clinical outcomes in patients with more complex cases.
See related article on page 237
I
n their systematic review of patient outcome reports in a dysplastic population, titled “The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review,” Adler and Giordano1 investigated data on the use of hip arthroscopy as an isolated treatment and as an adjunct to pelvic reorientation osteotomy. Three databases were selected, and 33 studies (1368 hip arthroscopies) were found and analyzed. For greater clarity, 5 categories were defined and respectively presented. Hip arthroscopy for screening, chondral mapping, and planning (category 1) did not show sufficient evidence of improved clinical outcomes after reorientation osteotomy of the pelvis. Limited evidence was shown for isolated arthroscopic treatment (category 2) when restricted to cases of mild to borderline dysplasia, whereas no recommendation was given in the setting of moderate to severe dysplasia because of the risk of iatrogenic instability and subsequent inferior patient outcomes. Giving attention to preservation of the
Potsdam, Germany The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181199/$36.00 https://doi.org/10.1016/j.arthro.2018.10.015
labrum and capsule seems to be necessary to provide encouraging clinical patient outcomes. Neither hip arthroscopy after reorientation pelvic osteotomy (category 3) nor hip-preservation surgery after hip arthroscopy (category 4) led to improved clinical and functional outcomes (limited evidence), thus implying insufficient evidence. Finally, hip arthroscopy as an adjunctive treatment option to reorientation pelvic osteotomy (category 5) did not show superior clinical outcomes (insufficient evidence), but 3 of 4 studies presented a high rate of concomitant intra-articular pathology. All subgroups showed a moderate to high risk of bias (Level III or IV). In summary, the authors recommended the careful use of hip arthroscopy on a case-by-case basis as a useful supplement in corrective treatment of acetabular dysplasia. In my occupational routine, a recurrent dilemma is the younger patient complaining of hip pain showing radiologic dysplastic hip confirmation. Pelvic reorientation osteotomy has become the gold standard in surgical treatment of symptomatic dysplastic hip diseases, with satisfactory outcomes in the long term.2,3 The high incidence of intra-articular pathology in the dysplastic hip population has been reported repeatedly4-6 and may encourage the surgeon to conduct collateral arthroscopic procedures. Domb et al.7 recently showed a significant change in patient
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 1 (January), 2019: pp 249-250
249
250
EDITORIAL COMMENTARY
outcomes, with excellent outcomes obtained in 82% of patients. In all patients (N ¼ 17), chondrolabral damage was identified and treated. In contrast, Thanacharoenpanich et al.8 did not find significant differences in clinical, radiologic, or functional outcomes between patients who underwent periacetabular osteotomy in isolation and those in whom this procedure was combined with hip arthroscopy or arthrotomy. Although chondrolabral pathology is common in the dysplastic population, the clinical relevance of those intra-articular pathologies remains unclear. Thus, conflicting results have been published in the past,2,9-14 and further study is needed to identify whether chondrolabral treatment in patients undergoing pelvic reorientation is necessary to improve patients’ outcomes. Referring to this, Faucett15 recently complained about inconsistent definitions of hip dysplasia in our current literature and the need for reliable treatment options based on short-term, midterm, and long-term studies. Despite a few limitations (e.g., diverse and heterogeneous study populations and retrospective collection of data), Adler and Giordano1 give us a supporting tool in dealing with a controversial topic and a complex and frequent dilemma. Careful treatment concepts are recommended to determine successful therapy of patients with hip dysplasia. Isolated arthroscopic procedures seem to be suitable when preservation of the labrum and capsule is considered and strong patient selection is observed. Reorientation pelvic osteotomy and concomitant hip arthroscopy appear to be appropriate in more complex situations by addressing all pathologies due to symptomatic hip dysplasia. Thus, comprehensive and combined treatment concepts may facilitate better clinical outcomes in the future.
References 1. Adler KL, Giordano BD. The utility of hip arthroscopy in the setting of acetabular dysplasia: A systematic review. Arthroscopy 2018;35:237-248. 2. Matheney T, Kim YJ, Zurakowski D, et al. Intermediate to long-term results following the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone Joint Surg Am 2009;91:2113-2123.
3. Steppacher SD, Tannast M, Ganz R, et al. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 2008;466:1633-1644. 4. Fujii M, Nakashima Y, Jingushi S, et al. Intraarticular findings in symptomatic developmental dysplasia of the hip. J Pediatr Orthop 2009;29:9-13. 5. Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med 2011;39:72S-78S. 6. Domb BG, Lareau JM, Baydoun H, et al. Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy? Clin Orthop Relat Res 2014;472:674-680. 7. Domb BG, LaReau JM, Hammarstedt JE, Gupta A, Stake CE, Redmond JM. Concomitant hip arthroscopy and periacetabular osteotomy. Arthroscopy 2015;31:2199-2206. 8. Thanacharoenpanich S, Boyle MJ, Murphy RF, et al. Periacetabular osteotomy for developmental hip dysplasia with labral tears: Is arthrotomy or arthroscopy required? J Hip Preserv Surg 2018;5:23-33. 9. Matta JM, Stover MD, Siebenrock K. Periacetabular osteotomy through the Smith-Petersen approach. Clin Orthop Relat Res 1999:21-32. 10. Troelsen A, Elmengaard B, Soballe K. A new minimally invasive transsartorial approach for periacetabular osteotomy. J Bone Joint Surg Am 2008;90:493-498. 11. Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: The learning curve at an academic medical center. J Bone Joint Surg Am 2006;88: 1920-1926. 12. Kim KI, Cho YJ, Ramteke AA, et al. Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia. J Bone Joint Surg Br 2011;93:732-737. 13. Cventanovich GL, Heyworth BE, Murray K, et al. Hip arthroscopy in patients with recurrent pain following Bernese periacetabular osteotomy for acetabular dysplasia: Operative findings and clinical outcomes. J Hip Preserv Surg 2015;2:295-302. 14. Nassif NA, Schoenecker PL, Thorsness R, et al. Periacetabular osteotomy and combined femoral head-neck junction osteochondroplasty: A minimum two-year follow-up cohort study. J Bone Joint Surg Am 2012;94: 1959-1966. 15. Faucett SC. Editorial commentary: Hip arthroscopy in hip dysplasia: Just because you are doing it, should you? Arthroscopy 2018;34:454-455.