- Email: [email protected]
Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy
Journal Pre-proof Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy Rahul Mohan, P.N. Unnikrishnan, Ravindra Gudena PII:
S0972-978X(19)30571-9
DOI:
https://doi.org/10.1016/j.jor.2019.11.003
Reference:
JOR 860
To appear in:
Journal of Orthopaedics
Received Date: 27 October 2019 Accepted Date: 2 November 2019
Please cite this article as: Mohan R, Unnikrishnan P, Gudena R, Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy, Journal of Orthopaedics, https://doi.org/10.1016/j.jor.2019.11.003. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
Title Page Title Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy
Running title A retrospective study of the validity of direct magnetic resonance arthrogram [dMRA] in diagnosing labral tear and cartilage delamination in femoroacetabular impingement [FAI] patients and short-term functional outcome of these patients with arthroscopic management.
Authors First Author: Mr Rahul Mohan, Registrar, Trauma and Orthopaedics1 Second Author: Mr PN Unnikrishnan, Consultant Lower limb and young adult hip surgeon2 Third Author Mr Ravindra Gudena, Consultant Lower limb and young adult hip surgeon1 1 2
St Helens and Knowsley NHS Trust The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust.
Study Centre:
St Helens and Knowsley NHS Trust, Whiston Hospital, Warrington Road, L35 5DR United Kingdom
Corresponding author: Mr Rahul Mohan Registrar, Department of Trauma and Orthopaedics St Helens and Knowsley NHS Trust Whiston Hospital, Warrington Road, L35 5DR United Kingdom Mobile Number: 07721816021 Email: [email protected]
1
Author contributions First name, Family name Rahul Mohan PN Unnikrishnan Ravindra Gudena
Concept Academic Literature Statistics Writing search Yes Yes Yes Yes Yes Yes Yes
Editing Yes Yes Yes
Acknowledgement: I would like to thank the department of Orthopaedics St Helens and Knowsley NHS trust.
Conflict of interest: No conflicts of interest.
2
Title Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy
Running title A retrospective study of the validity of direct magnetic resonance arthrogram [dMRA] in diagnosing labral tear and cartilage delamination in femoroacetabular impingement [FAI] patients and short-term functional outcome of these patients with arthroscopic management. Conflict of interest No conflicts of interest. ABSTRACT
Femoroacetabular Impingement is an established cause of labral tears and chondral delamination. The aim was to test the validity of direct magnetic resonance arthrogram [dMRA] in the diagnosis of the same. We also looked at the short term functional outcome in these patients post hip arthroscopy. The dMRA is valuable in diagnosing labral tears nevertheless poor in detecting cartilage delamination. Hip arthroscopic intervention provided a good short-term functional outcome; however, should be offered with caution in patients over 40 years. To our knowledge, this is the single largest series published with similar methodology.
Key Words Young adults, Femoroacetabular impingement, Direct MR Arthrogram, Hip arthroscopy, Functional outcome
1
1
INTRODUCTION
1.1
The femoroacetabular impingement [FAI] is a major cause for the labral
tear and cartilage delamination1. Among the athlete and nonathlete population 22% and 66% respectively present with groin pain and mechanical symptoms proven to have a labral tear2,3. According to Beck et al., labral tear is an important cause for the early age osteoarthritis4. Early diagnosis and management of FAI influence in preventing premature osteoarthrosis and subsequent total hip arthroplasty5,6. Given the increasing number of young age hip arthroplasty surgeries, the approach is shifting towards preventive arthroscopic procedures in patients with femoroacetabular impingement7,8.
1.2
Arthroscopy of the hip is the gold standard in diagnosing labral tears and
chondral delamination. Unlike knee arthroscopy, only a few studies reported the outcome of hip arthroscopy9. Hip arthroscopy in all patients with femoroacetabular impingement may not be ideal, especially in the absence of reliable evidence of its validity. If a successful, less invasive diagnostic tool is identified, hip arthroscopy can be reserved as a definitive therapeutic option10.
1.3
Direct Magnetic Resonance Arthrogram [dMRA] with intraarticular
injection of gadolinium is proved to have high sensitivity and specificity in diagnosing labral tears. However, the detection of chondral delamination is poor in MRA11,12. Direct MRA occasionally reports false-positive labral tear for normal sub labral sulcus13. Hence it is vital to know the validity of the direct MR arthrogram in diagnosing intraarticular pathologies.
2
1.4
The primary aim of this study was to assess the validity of dMRA in
diagnosing labral tears and cartilage delamination. The secondary objective was to study the effects of the arthroscopic intervention on the functional outcome.
2
2.1
METHODS
It is a retrospective, single surgeon case series study between 2013 to
2016 in one of the NHS hospitals at the North West of England. We follow our in-house protocol for the young patients presenting to the outpatient clinic with hip pain and mechanical symptoms. These patients are first evaluated clinically and radiologically to rule out arthritis and non-mechanical aetiologies of hip pain. The patients were then scored using the non-arthritic hip score in the clinic and were referred for direct magnetic resonance arthrogram of the involved hip.
2.2
Hip arthroscopy was performed in patients whome the direct MR arthrogram
and their clinical examination was consistent with FAI. In patients in whome there was non correlation between clinical examination and dMRA proceeded with diagnostic intraarticular hip injection. 8mls 0.5% levobupivacaine and 2ml of 80mg depomedrone was used for hip injection in theatre under fluroscopy control. In patients who responded positively to diagnostic injection were listed for hip arthroscopy. Non-responders were evaluated for other causes of hip pain. Hip arthroscopy was performed not only to confirm the MR arthrogram findings but also for the management of intra and extra-articular hip pathologies.
2.3
The second part of the study was to assess the short-term effects of hip
arthroscopic treatment and the functional outcome. As a part of the postoperative protocol, all
3
patients who underwent hip arthroscopy were given a clinic appointment at six weeks, six months and one year. Patients scored the non arthritic hip score on their final visit. All patients who came to the clinic via the protocol were included and patients who had pre operative arthritic changes on the Xrays and BMI > 35kg/m2 were excluded.
2.4
The researcher was not involved in the treatment of any of these patients. A
data collection proforma was used for systematic data collection. We divided the acetabulum into four quadrants to explain the labral tear and chondral delamination as anterior, anterosuperior, posterior and posterosuperior. Descriptive statistics were used to describe patient demography. Patient characteristics were reported using mean, percentage and range. The sensitivity, specificity, positive predictive value and negative predictive value tests were used to assess the validity of dMRA in comparison with hip arthroscopy. SPSS software was utilised for the statistical analyses. The agreement between dMRA and hip arthroscopy was calculated using Kendall’s tau-b test.
2.5
The paired t-test was used to compare and analyse the pre and post
operative non-arthritic hip scores. The relation between gender, age and cartilage status and postoperative scores were calculated using the inferential statistics and the level of significance was set at a P-value of < 0.05.
2.6
Ethical clearance was obtained from the trust ethical committee and
governance approval obtained from the “Health Research Authority”. All patients signed a consent form before undergoing hip arthroscopy and MR arthrogram, which was checked and confirmed as per NHS trust guidelines. The confidentiality of patients’ details was strictly maintained throughout, according to the "Data protection act".
4
3.
RESULTS
3.1
One hundred thirty-one patients were identified with an average duration of
symptoms of 23.8 months. There were 88 females and 43 males. Of the 131 patients, 51 were involved in contact sports. Majority of the operated patients (76%) had no history of trauma. Arthroscopic findings were taken as the standard to assess the validity of dMRA.
3.2
Table 1 illustrates the cross-tabulation between dMRA and Hip
arthroscopy findings of labral tear. Of the total 23 anterior labral tears identified in the hip arthroscopy, only 9 were reported as anterior in dMRA, the remaining 8 reported as anterosuperior and the rest 6 as the normal labrum. Similarly, of the total 101 patients diagnosed with an anterosuperior labral tear on hip arthroscopy, 74 correlated with the findings on dMRA . dMRA suggested normal labrum in 15 and anterior labral tears in the remaining. Of the seven normal labrum confirmed on hip arthroscopy, dMRA suggested on 5 and on the remaining falsly reported as an anterosuperior labral tear.
Direct MR Arthrogram and Hip arthroscopy cross tabulation for labral tear Labral tear in Hip arthroscope Anterior
Anterosuperior
Normal
Total
Labral tear in
Anterior
9
12
0
21
Direct
Anterosuperior
8
74
2
84
Normal
6
15
5
26
Total
23
101
7
131
MRA
5
Table 1: Cross tabulation of dMRA and hip arthroscope findings for labral tears.
3.3
Consequently, 43 out of the 131 patients have a discrepancy in findings
between the hip arthroscopy and dMRA. The misclassification rate between the two for the labral tear was 32%. The agreement between the dMRA and hip arthroscopy in the diagnosis of labral tear was assessed using Kendall’s tau-b test. This test showed a value of 0.218 with a significance of 0.009 suggesting a direct MR Arthrogram is useful in diagnosing labral tears. Another way to assess the validity of dMRA in diagnosing labral tears can be estimated by calculating the sensitivity and specificity of the dMRA compared with the hip arthroscopy.
3.4
The anterior or anterosuperior labral tear does not make any difference
in the treatment patient was going to receive. Thus both these are considered together as labral tear for the calculation of sensitivity and specificity. The sensitivity and specificity of dMRA in diagnosing labral tear were 83.06 % and 71.43 % respectively, while the Positive predictive value [PPV] and the negative predictive value calculated was 98.1 % and 19.23 % respectively.
3.5
Table 2 illustrates the cross-tabulation results between dMRA and hip
arthroscopy in diagnosing chondral delamination. A total of 9 patients were confirmed with anterior chondral delamination on the hip arthroscopy. dMRA identified this rightly only in 1 patient. Similarly of the 84 patients with anterosuperior chondral delamination, 67 were reported as normal which is a significant number of wrong reports. 16 patients reported correctly as anterosuperior and 1 as anterior.
6
Direct MR Arthrogram and Hip arthroscopy cross tabulation for chondral delamination Chondral delamination in Hip arthroscope Anterior
Antero-
Grade 3/4
superior
changes in
Normal
Total
the hip Chondral delaminati on Direct MRA
in
Anterior
1
1
0
0
2
Antero-
1
16
4
4
25
0
0
1
0
1
Normal
7
67
4
25
103
Total
9
84
9
29
131
superior Grade
3/4
changes in the hip
Table 2: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
3.6
In cases confirmed as advanced arthritis, 8 out of the 9 [88.89%] patients
were reported as normal cartilage on dMRA. However in diagnosing normal cartilage, 25 out of the 29 were diagnosed correctly by dMRA while 4 reported as anterosuperior delamination (Table 2).
3.7
The Kendall's tau-b test was used to detect the agreement between
dMRA and hip arthroscopy in detecting cartilage delamination. This test result was 0.015, 7
with a weak significance of 0.860 questioning the validity of dMRA in identifying cartilage delamination. For the purpose of calculating the validity of dMRA in detecting cartilage changes, the anterior, anterosuperior and global changes were grouped as a single entity. The sensitivity, specificity, positive predictive value and negative predictive value are 23.53%, 86.21 %, 85.71 % and 24.27 % respectively.
3.8
Non-arthritic hip scores were used to assess the outcome of the
arthroscopic intervention in hip impingement patients. The average preoperative nonarthritic hip score was 36.53, and the average postoperative score was 70.49. The hip arthroscopic intervention improved the mean difference of 33.653, which is statistically significant. Majority of the patients [105 out of 131] showed good improvement in the score. However, 26 patients [19.85%] had a poor postoperative outcome score. The average score of this group was 48.23, which might have caused a high standard deviation [13.295] of the postoperative scores.
3.9
It is noted that as the age increases the outcome scores becomes poor14.
Hence, the 131 subjects were sub-grouped according to age and sex [Table 3]. Those less than 20 years had the best average postoperative score of 73.24 with female patients having a better score (76.31) compared to males (63.25). However, the average score decreased to 68 in those aged more than 40. In this group, male patients scored better (71.51) compared to females (69.99).
8
Post-operative score at Discharge Age
Sex
Mean
Number
Standard
Minimum
Maximum
deviation Less than
F
76.31
13
8.548
60
88
M
63.25
4
14.930
49
81
Total
73.24
17
11.366
49
88
F
70.46
46
13.505
32
87
M
73.64
22
11.875
40
85
Total
71.49
68
12.998
32
87
F
66.41
29
14.613
35
87
M
70.71
17
13.541
49
86
Total
68.00
46
14.228
35
87
F
69.99
88
13.546
32
88
M
71.51
43
12.861
40
86
Total
70.49
131
13.295
32
88
20 yrs
20
to
40 yrs
More than 40 yrs
Total
Table 3: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
3.10
Twenty-six patients among the 131 (19.84%) continued to have the
symptoms after the operation scoring a poor average postoperative score of 48.23. Among the 26, 16 patients (61.5%) were over age 40 years out of which females had a poor average postoperative score (46) compared to males. Of the 131, 9 patients (7%) ended up with a total hip replacement due to the grade 3/4 osteoarthritic changes found in the hip arthroscopy. 8 of them were more than 40 years of age and 5 were females. Four 9
out of these eight patients (44.44%) were reported having normal cartilage in the dMRA and another three reported as anterosuperior focal involvement before the operation. The hip arthroscopy in all these seven patients could have been avoided if direct MR Arthrogram diagnosed the advanced cartilage degenerative changes.
4.
4.1
DISCUSSION
Femoroacetabular impingement [FAI] is a important atraumatic cause for
the labral tear and chondral delamination. Early diagnosis and management of FAI are crucial in preventing early age total hip arthroplasty. Imaging in hip impingement patients aims to identify the abnormal bone morphology, labral tears as well as chondral delamination15. Anteroposterior and lateral X-ray views are the common radiological investigation for any symptomatic hip, but it is difficult to quantify the findings on the X-ray.
4.2
Beaulé, Zaragoza et al. conducted a study on 36 patients about the use of
three-dimensional computed tomography (CT) scan to assess the FAI16. They compared patients with radiographs, MRI with gadolinium contrast enhancement and three-dimensional CT scan. They recommend CT scan for head-neck junction abnormalities of the femoral head, though not much useful to diagnose the labral and cartilage pathologies.
4.3
Zlatkin, Pevsner et al. assessed the validity of MRI and indirect MRA to
diagnose labral tears1. Of the 14 patients with proven labral lesions, only 85% were detected by the conventional MRI scan, while the indirect MR arthrogram diagnosed 100% of the labral tears. However, the detection rate for chondral delamination was the same (82%) for MRI scan and MR arthrogram. Saied, Redant et al. conducted a meta-analysis on the validity of conventional MRI [cMRI], direct MR arthrogram [dMRA] and indirect MR arthrogram
10
[iMRA] in detecting the labral and cartilage delamination associated with FAI17. They reported dMRA as the best investigation for diagnosing labral tears and cartilage lesions with an overall 91% sensitivity compared to cMRI (76%) and iMRA (72%).
4.4
A similar meta-analysis by Smith, Hilton et al. reported 87% sensitivity and
64% specificity for dMRA in diagnosing labral tears compared to cMRI values of 66 and 79, respectively18. In a study by Sutter, Zubler et al., one radiologist found dMRA better than cMRI for diagnosing labral tear while another radiologist reported both are same, which suggests that MRI interpretation might be operator dependent19.
4.5
The delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) is a
method of indirect MR arthrogram with delayed T1 relaxation time is a promising new MR investigation, which is shown to improve the sensitivity for detecting cartilage delamination. Bittersohl et al. studied 16 patients with a mean age of 31, which showed a sensitivity of 75 and specificity of 3320. Similarly, another study by Lattanzi, R.Petchprapa, C.Glaser, C. et al. with ten patients with an average age of 19.9 reported a sensitivity of 71 and specificity of 3621. A multicentre study is required to confirm the benefits of the dGEMRIC scan. Of the different MRI sequences, direct MR Arthrogram is the choice investigation because of the high sensitivity and specificity reported in many studies.
4.6
It is proven knowledge that the early arthroscopic management of
femoroacetabular impingement [FAI] could possibly prevent subsequent osteoarthritis. Our study showed that the prompt diagnosis of hip impingement is a challenge as most of the patients presented with insidious onset of hip pain. This finding agrees with Clohisy et al., that the onset of symptoms in this group was insidious in the majority (65%) of the
11
patients22.
4.7
Table 4 below is a comparison of all the recent studies performed with a
similar methodology as ours17. These studies, in general, prove that direct MR Arthrogram has good sensitivity in diagnosing labral tears and good specificity in detecting chondral delamination, which is consistent with our results. In our study, the sensitivity and specificity of direct MR Arthrogram in diagnosing labral tear was 83.06 and 71.43, respectively. dMRA have a positive predictive value of 98.1 in diagnosing true labral tear and negative predictive value of 19.23 in reporting a true normal labrum. To the best of our knowledge, this study has the largest number of patients ever published addressing the aims of this paper.
Study
No
Mean
Pathology
[Year]
of
age
studied
Labral tear
Chondral delamination
case
Sensi
Spe
Sensi
Spe
s
tivity
cific
tivity
cific
ity Crespo R
51
et al23
43+/-
Combined
9
chondral
[2014]
95
100
ity 92
54
89
40
100
90
91
25
50
90
and
labral tear
Sahin et
14
35
Acetabular
al24
chondral lesion
[2014]
Femoral chondral lesion
Sutter et
28
31.8
Acetabular
al19
chondral lesion
[2014]
Femoral chondral lesion
Tian
et
90
35.1
Labral lesion
89
50
Labral lesion
95
84
al25 [2014]
12
Aprato
41
24
al26
et
Acetabular
69
88
46
81
86
50
85
44
chondral lesion
[2013]
Femoral chondral lesion Labral lesion
McGuire
61
32
et al27
91
86
Acetabular chondral lesion Femoral
[2012]
Reurink et
chondral lesion
95
41.3
Labral lesion
96
33
Labral lesion
86
75
Combined
81
51
17
100
100
50
63
33
79
84
22
100
74
90
79
77
23.5
86.2
al28
[2012] Banks et
69
al29
chondral
[2012]
labral lesions
Perdikaki
14
43
and
Combined
s et al30
chondral
[2011]
labral lesions
Zaragoza et
48
38.8
al31
and
Acetabular chondral lesions
[2009] Anderson
27
Acetabular
et al32
chondral lesions
[2009] Pfirrman
44
30.7
n et al33
Acetabular chondral lesions
[2008] Studler et
57
35
Labral lesion
42
37
Combined
97
53
al34 [2008] Schmid al35
et
chondral lesion
[2003] OUR
131
33.2
Combined
83.06
STUDY
chondral
[2018]
labral lesion
71.4
and
Table 4: Comparison of the results of all the recent studies performed with a similar methodology with our study. 13
4.8
Many dMRA studies reported poor sensitivity for diagnosing chondral
delamination. Our study agrees with a low sensitivity of 23.5%. Pfirrmann, Duc, Zanetti et al. specifically investigated this and explained that the hip joint cartilage is quite thin, and the delamination of the cartilage is very difficult to identify due to the narrow hip joint33. Moreover, the femoral head pushes the delaminated portion into the subchondral bone obliterating the cleft, which is difficult to detect by MR Arthrogram. Anderson et al. reiterated this saying that the limited distensibility of the hip joint makes the cartilage delamination difficult to identify32. These might be the reasons for the poor sensitivity of dMRA in detecting chondral delamination. This is significant because out of the eight patients who ended up with a total hip replacement, it was reported as either normal or insignificant cartilage delamination in dMRA.
4.9
A relevant study by Sansone, Ahldén et al. assessed the outcome of hip
arthroscopic treatment on hip impingement36. It was a prospective study of 394 patients. The average age of the study cohort was 37 years, and the mean follow-up period was 25.4 months. They have used valid outcome scores like web-based patient-reported outcomes (PROMs), the Copenhagen Hip and Groin Outcome Score (HAGOS), the International Hip Outcome Tool (iHOT-12), the Hip Sports Activity Scale (HSAS), a standardised instrument (EQ-5D) and a Visual Analogue Score for assessing the overall hip function. The preoperative scores compared statistically with the two years follow up scores and concluded that overall, 82% of the patients [286 patients] were satisfied with the arthroscopic procedure.
14
4.10
Very few outcome measures developed to use in hip arthroscopic
patients37. Christensen, Althausen, Mittleman et al. conducted a study to assess the validity, consistency, reliability and reproducibility of Non-Arthritic Hip Score [NAHS] in comparison with Harris Hip Score and Short Form -1238. They concluded that NAHS is valid, reliable, consistent and reproducible. Similarly, Domb, Martin, Gui et al. also suggested using Non-Arthritic Hip Score in assessing young patients with hip pathologies39. We have used Non-Arthritic Hip Score to determine the functional outcome of hip arthroscopic treatment.
4.11
In our study, the hip arthroscopic intervention made a significant
improvement in nonarthritic hip score. Domb, Martin, Gui et al. reported a similar clinically significant improvement in the NAHS following hip arthroscopy39. They also stated that as the age advances the postoperative score becomes poor. They demonstrated a decrease in the score of 0.208 per year. McCormick et al. shown poor score for patients more than 40 years having hip arthroscopy with an odds ratio of 3.6 for conversion to THR40.
4.12
Our study reported poor NAHS score in patients more than 40 years
with an average score of 68 compared to the score in those less than 20 years (73.24) and 20 to 40 years (71.49). Like the finding of Domb, Martin, Gui et al., the postoperative NAHS score of our patients deteriorated with advanced age39. Another interesting result of their study was the better postoperative score for females compared to males irrespective of age. However, our study demonstrated a better score for females only in less than 20 year age group and males performed better in all other age group. Consistent with our findings, Lindner et al. demonstrated poor outcome scores for females41. There was a high incidence of total hip arthroplasty among females more than 40 years of age in our study. Our study is not free from limitations. It is a case series study. Only articles in
15
English language were used towards referencing. The risk of selection bias cannot be excluded.
5
CONCLUSIONS
5.1
In summary, the dMRA is a valuable investigation to detect labral
tears however poor in diagnosing chondral delamination. The hip arthroscopic intervention in patinets under 40 years provided good short-term functional outcome with a mean difference in the postoperative nonarthritic hip score by 33.65. Female patients generaly had a poor outcome, particularly over 40 years of age. Caution should be maintained if planning hip arthroscopy in FAI patients above 40 years with a normal or focal cartilage damage on dMRA.
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Beaulé PE, Zaragoza E, Motamedi K, Copelan N, Dorey FJ. Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement. J Orthop Res. 2005;23(6):1286-1292. doi:10.1016/j.orthres.2005.03.011
17.
Saied AM, Redant C, El-Batouty M, et al. Accuracy of magnetic resonance studies in the detection of chondral and labral lesions in femoroacetabular impingement: systematic review and meta-analysis. BMC Musculoskelet Disord. 2017;18(1):1-16. doi:10.1186/s12891-017-1443-2
18.
Smith TO, Hilton G, Toms AP, Donell ST, Hing CB. The diagnostic accuracy of acetabular labral tears using magnetic resonance imaging and magnetic resonance arthrography: A meta-analysis. Eur Radiol. 2011;21(4):863-874. doi:10.1007/s00330010-1956-7
19.
Sutter R, Zubler V, Hoffmann A, et al. Hip MRI: How useful is intraarticular contrast material for evaluating surgically proven lesions of the labrum and articular cartilage? Am J Roentgenol. 2014;202(1):160-169. doi:10.2214/AJR.12.10266
20.
Bittersohl B, Hosalkar HS, Apprich S, Werlen SA, Siebenrock KA, Mamisch TC. Comparison of pre-operative dGEMRIC imaging with intra-operative findings in femoroacetabular impingement: preliminary findings. Skeletal Radiol. 2011;40(5):553561. doi:10.1007/s00256-010-1038-6
21.
Lattanzi R, Petchprapa C, Glaser C, et al. A new method to analyze dGEMRIC measurements in femoroacetabular impingement: preliminary validation against arthroscopic
findings.
Osteoarthr
Cartil.
2012;20(10):1127-1133.
doi:10.1016/j.joca.2012.06.012 22.
Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644. doi:10.1007/s11999-008-0680-y
23.
Crespo Rodríguez AM, de Lucas Villarrubia JC, Pastrana Ledesma MA, Millán Santos I, Padrón M. Diagnosis of lesions of the acetabular labrum, of the labral–chondral transition zone, and of the cartilage in femoroacetabular impingement: Correlation between direct magnetic resonance arthrography and hip arthroscopy. Radiol (English Ed. 2015;57(2):131-141. doi:10.1016/j.rxeng.2013.11.001
24.
Sahin M, Calisir C, Omeroglu H, Inan U, Mutlu F, Kaya T. Evaluation of labral pathology and hip articular cartilage in patients with femoroacetabular impingement 18
(FAI): Comparison of multidetector CT arthrography and MR arthrography. Polish J Radiol. 2014;79(1):374-380. doi:10.12659/PJR.890910 25.
Tian CY, Wang JQ, Zheng ZZ, Ren AH. 3.0 T conventional hip MR and hip MR arthrography for the acetabular labral tears confirmed by arthroscopy. Eur J Radiol. 2014;83(10):1822-1827. doi:10.1016/j.ejrad.2014.05.034
26.
Aprato A, Massè A, Faletti C, et al. Magnetic resonance arthrography for femoroacetabular impingement surgery: Is it reliable? J Orthop Traumatol. 2013;14(3):201-206. doi:10.1007/s10195-013-0227-1
27.
McGuire CM, MacMahon P, Byrne DP, Kavanagh E, Mulhall KJ. Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography of the hip is dependent on specialist training of the radiologist. Skeletal Radiol. 2012;41(6):659665. doi:10.1007/s00256-011-1266-4
28.
Reurink G, Jansen SPL, Bisselink JM, Vincken PWJ, Weir A, Moen MH. Reliability and validity of diagnosing acetabular labral lesions with magnetic resonance arthrography.
J
Bone
Jt
Surg
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Ser
A.
2012;94(18):1643-1648.
doi:10.2106/JBJS.K.01342 29.
Banks DBA, Boden RA, Mehan R, Fehily MJ. Magnetic resonance arthrography for labral tears and chondral wear in femoroacetabular impingement. HIP Int. 2012;22(4):387-390. doi:10.5301/HIP.2012.9315
30.
Perdikakis E, Karachalios T, Katonis P, Karantanas A. Comparison of MRarthrography and MDCT-arthrography for detection of labral and articular cartilage hip pathology. Skeletal Radiol. 2011;40(11):1441-1447. doi:10.1007/s00256-011-1111-9
31.
Zaragoza E, Lattanzio P-J, Beaule PE. Magnetic Resonance Imaging with Gadolinium Arthrography to Assess Acetabular Cartilage Delamination. HIP Int. 2009;19(1):1823. doi:10.1177/112070000901900104
32.
Anderson LA, Peters CL, Park BB, Stoddard GJ, Erickson JA, Crim JR. Acetabular cartilage delamination in femoroacetabular impingement. Risk factors and magnetic resonance imaging diagnosis. J Bone Jt Surg - Ser A. 2009;91(2):305-313. doi:10.2106/JBJS.G.01198
33.
Pfirrmann CWA, Duc SR, Zanetti M, Dora C, Hodler J. MR arthrography of acetabular cartilage delamination in femoroacetabular cam impingement. Radiology. 2008;249(1):236-241. doi:10.1148/radiol.2491080093
34.
Studler U, Kalberer F, Leunig M, et al. MR arthrography of the hip: Differentiation between an anterior sublabral recess as a normal variant and a labral tear. Radiology. 19
2008;249(3):947-954. doi:10.1148/radiol.2492080137 35.
Schmid MR, Nötzli HP, Zanetti M, Wyss TF, Hodler J. Cartilage lesions in the hip: Diagnostic effectiveness of MR arthrography. Radiology. 2003;226(2):382-386. doi:10.1148/radiol.2262020019
36.
Sansone M, Ahldén M, Jónasson P, et al. Outcome after hip arthroscopy for femoroacetabular impingement in 289 patients with minimum 2-year follow-up. Scand J Med Sci Sport. 2017;27(2):230-235. doi:10.1111/sms.12641
37.
Baldwin KD, Harrison RA, Namdari S, Nelson CL, Hosalkar HS. Outcomes of hip arthroscopy for treatment of femoroacetabular impingement: A systematic review. Curr Orthop Pract. 2009;20(6):669-673. doi:10.1097/BCO.0b013e3181a9d771
38.
Christensen CP, Althausen PL, Mittleman MA, Lee J, McCarthy JC. The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res. 2003;(406):75-83. doi:10.1097/01.blo.0000043047.84315.4b
39.
Domb BG, Martin TJ, Gui C, Chandrasekaran S, Suarez-Ahedo C, Lodhia P. Predictors of Clinical Outcomes After Hip Arthroscopy: A Prospective Analysis of 1038 Patients With 2-Year Follow-up. Am J Sports Med. 2018;46(6):1324-1330. doi:10.1177/0363546518763362
40.
McCormick F, Nwachukwu BU, Alpaugh K, Martin SD. Predictors of hip arthroscopy outcomes for labral tears at minimum 2-year follow-up: The influence of age and arthritis.
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doi:10.1016/j.arthro.2012.04.059 41.
Lindner D, El Bitar YF, Jackson TJ, Sadik AY, Stake CE, Domb BG. Sex-based differences in the clinical presentation of patients with symptomatic hip labral tears. Am J Sports Med. 2014;42(6):1365-1369. doi:10.1177/0363546514532226
20
TABLES
Direct MR Arthrogram and Hip arthroscopy cross tabulation for labral tear Labral tear in Hip arthroscope Anterior
Anterosuperior
Normal
Total
Labral tear in
Anterior
9
12
0
21
Direct
Anterosuperior
8
74
2
84
Normal
6
15
5
26
Total
23
101
7
131
MRA
Table 1: Cross tabulation of dMRA and hip arthroscope findings for labral tears.
Direct MR Arthrogram and Hip arthroscopy cross tabulation for chondral delamination Chondral delamination in Hip arthroscope Anterior
Antero-
Grade 3/4
superior
changes
Normal
Total
in the hip Chondral delaminat ion
in
Anterior
1
1
0
0
2
Antero-
1
16
4
4
25
0
0
1
0
1
superior
Direct MRA
Grade changes the hip
3/4 in
Normal
7
67
4
25
103
Total
9
84
9
29
131
Table 2: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
Post-operative score at Discharge Age
Sex
Mean
Number
Standard
Minimum
Maximum
deviation Less than
F
76.31
13
8.548
60
88
M
63.25
4
14.930
49
81
Total
73.24
17
11.366
49
88
F
70.46
46
13.505
32
87
M
73.64
22
11.875
40
85
Total
71.49
68
12.998
32
87
F
66.41
29
14.613
35
87
M
70.71
17
13.541
49
86
Total
68.00
46
14.228
35
87
F
69.99
88
13.546
32
88
M
71.51
43
12.861
40
86
Total
70.49
131
13.295
32
88
20 yrs
20
to
40 yrs
More than 40 yrs
Total
Table 3: Table illustrating the age and sex wise distribution of post-operative nonarthritic hip scores
Study
No
Mean
Pathology
[Year]
of
age
studied
Labral tear
Chondral delamination
case s
Sensi
Spe
Sensi
Spe
tivity
cific
tivity
cific
ity Crespo R
51
et al23
43+/-
Combined
9
chondral
95
100
ity 92
54
89
40
100
90
91
25
50
90
69
88
46
81
86
50
85
44
and
labral tear
[2014] Sahin et
14
35
Acetabular
al24
chondral lesion
[2014]
Femoral chondral lesion
Sutter et
28
31.8
Acetabular
al19
chondral lesion
[2014]
Femoral chondral lesion
Tian
et
Labral lesion
89
50
95
84
90
35.1
Labral lesion
41
24
Acetabular
al25 [2014] Aprato et
al26
chondral lesion
[2013]
Femoral chondral lesion Labral lesion
McGuire
61
32
et al27
91
86
Acetabular chondral lesion Femoral chondral lesion
[2012]
Reurink
95
41.3
Labral lesion
96
33
Labral lesion
86
75
et al28 [2012] Banks et
69
Combined
al29
chondral
[2012]
labral lesions
Perdikaki
14
43
s et al30
et
51
17
100
100
50
63
33
79
84
22
100
74
90
79
77
23.5
86.2
and
Combined chondral
and
labral lesions
[2011] Zaragoza
81
48
38.8
al31
Acetabular chondral lesions
[2009] Anderson
27
Acetabular
et al32
chondral lesions
[2009] Pfirrman
44
30.7
n et al33
Acetabular chondral lesions
[2008] Studler et
57
35
Labral lesion
42
37
Combined
97
53
al34 [2008] Schmid al35
et
chondral lesion
[2003] OUR
131
33.2
Combined
83.06
STUDY
chondral
[2018]
labral lesion
71.4
and
Table 4: Comparison of the results of all the recent studies performed with a similar methodology with our study.
S0972-978X(19)30571-9
DOI:
https://doi.org/10.1016/j.jor.2019.11.003
Reference:
JOR 860
To appear in:
Journal of Orthopaedics
Received Date: 27 October 2019 Accepted Date: 2 November 2019
Please cite this article as: Mohan R, Unnikrishnan P, Gudena R, Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy, Journal of Orthopaedics, https://doi.org/10.1016/j.jor.2019.11.003. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
Title Page Title Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy
Running title A retrospective study of the validity of direct magnetic resonance arthrogram [dMRA] in diagnosing labral tear and cartilage delamination in femoroacetabular impingement [FAI] patients and short-term functional outcome of these patients with arthroscopic management.
Authors First Author: Mr Rahul Mohan, Registrar, Trauma and Orthopaedics1 Second Author: Mr PN Unnikrishnan, Consultant Lower limb and young adult hip surgeon2 Third Author Mr Ravindra Gudena, Consultant Lower limb and young adult hip surgeon1 1 2
St Helens and Knowsley NHS Trust The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust.
Study Centre:
St Helens and Knowsley NHS Trust, Whiston Hospital, Warrington Road, L35 5DR United Kingdom
Corresponding author: Mr Rahul Mohan Registrar, Department of Trauma and Orthopaedics St Helens and Knowsley NHS Trust Whiston Hospital, Warrington Road, L35 5DR United Kingdom Mobile Number: 07721816021 Email: [email protected]
1
Author contributions First name, Family name Rahul Mohan PN Unnikrishnan Ravindra Gudena
Concept Academic Literature Statistics Writing search Yes Yes Yes Yes Yes Yes Yes
Editing Yes Yes Yes
Acknowledgement: I would like to thank the department of Orthopaedics St Helens and Knowsley NHS trust.
Conflict of interest: No conflicts of interest.
2
Title Validity of direct magnetic resonance arthrogram in patients with femoroacetabular impingement and their outcome post hip arthroscopy
Running title A retrospective study of the validity of direct magnetic resonance arthrogram [dMRA] in diagnosing labral tear and cartilage delamination in femoroacetabular impingement [FAI] patients and short-term functional outcome of these patients with arthroscopic management. Conflict of interest No conflicts of interest. ABSTRACT
Femoroacetabular Impingement is an established cause of labral tears and chondral delamination. The aim was to test the validity of direct magnetic resonance arthrogram [dMRA] in the diagnosis of the same. We also looked at the short term functional outcome in these patients post hip arthroscopy. The dMRA is valuable in diagnosing labral tears nevertheless poor in detecting cartilage delamination. Hip arthroscopic intervention provided a good short-term functional outcome; however, should be offered with caution in patients over 40 years. To our knowledge, this is the single largest series published with similar methodology.
Key Words Young adults, Femoroacetabular impingement, Direct MR Arthrogram, Hip arthroscopy, Functional outcome
1
1
INTRODUCTION
1.1
The femoroacetabular impingement [FAI] is a major cause for the labral
tear and cartilage delamination1. Among the athlete and nonathlete population 22% and 66% respectively present with groin pain and mechanical symptoms proven to have a labral tear2,3. According to Beck et al., labral tear is an important cause for the early age osteoarthritis4. Early diagnosis and management of FAI influence in preventing premature osteoarthrosis and subsequent total hip arthroplasty5,6. Given the increasing number of young age hip arthroplasty surgeries, the approach is shifting towards preventive arthroscopic procedures in patients with femoroacetabular impingement7,8.
1.2
Arthroscopy of the hip is the gold standard in diagnosing labral tears and
chondral delamination. Unlike knee arthroscopy, only a few studies reported the outcome of hip arthroscopy9. Hip arthroscopy in all patients with femoroacetabular impingement may not be ideal, especially in the absence of reliable evidence of its validity. If a successful, less invasive diagnostic tool is identified, hip arthroscopy can be reserved as a definitive therapeutic option10.
1.3
Direct Magnetic Resonance Arthrogram [dMRA] with intraarticular
injection of gadolinium is proved to have high sensitivity and specificity in diagnosing labral tears. However, the detection of chondral delamination is poor in MRA11,12. Direct MRA occasionally reports false-positive labral tear for normal sub labral sulcus13. Hence it is vital to know the validity of the direct MR arthrogram in diagnosing intraarticular pathologies.
2
1.4
The primary aim of this study was to assess the validity of dMRA in
diagnosing labral tears and cartilage delamination. The secondary objective was to study the effects of the arthroscopic intervention on the functional outcome.
2
2.1
METHODS
It is a retrospective, single surgeon case series study between 2013 to
2016 in one of the NHS hospitals at the North West of England. We follow our in-house protocol for the young patients presenting to the outpatient clinic with hip pain and mechanical symptoms. These patients are first evaluated clinically and radiologically to rule out arthritis and non-mechanical aetiologies of hip pain. The patients were then scored using the non-arthritic hip score in the clinic and were referred for direct magnetic resonance arthrogram of the involved hip.
2.2
Hip arthroscopy was performed in patients whome the direct MR arthrogram
and their clinical examination was consistent with FAI. In patients in whome there was non correlation between clinical examination and dMRA proceeded with diagnostic intraarticular hip injection. 8mls 0.5% levobupivacaine and 2ml of 80mg depomedrone was used for hip injection in theatre under fluroscopy control. In patients who responded positively to diagnostic injection were listed for hip arthroscopy. Non-responders were evaluated for other causes of hip pain. Hip arthroscopy was performed not only to confirm the MR arthrogram findings but also for the management of intra and extra-articular hip pathologies.
2.3
The second part of the study was to assess the short-term effects of hip
arthroscopic treatment and the functional outcome. As a part of the postoperative protocol, all
3
patients who underwent hip arthroscopy were given a clinic appointment at six weeks, six months and one year. Patients scored the non arthritic hip score on their final visit. All patients who came to the clinic via the protocol were included and patients who had pre operative arthritic changes on the Xrays and BMI > 35kg/m2 were excluded.
2.4
The researcher was not involved in the treatment of any of these patients. A
data collection proforma was used for systematic data collection. We divided the acetabulum into four quadrants to explain the labral tear and chondral delamination as anterior, anterosuperior, posterior and posterosuperior. Descriptive statistics were used to describe patient demography. Patient characteristics were reported using mean, percentage and range. The sensitivity, specificity, positive predictive value and negative predictive value tests were used to assess the validity of dMRA in comparison with hip arthroscopy. SPSS software was utilised for the statistical analyses. The agreement between dMRA and hip arthroscopy was calculated using Kendall’s tau-b test.
2.5
The paired t-test was used to compare and analyse the pre and post
operative non-arthritic hip scores. The relation between gender, age and cartilage status and postoperative scores were calculated using the inferential statistics and the level of significance was set at a P-value of < 0.05.
2.6
Ethical clearance was obtained from the trust ethical committee and
governance approval obtained from the “Health Research Authority”. All patients signed a consent form before undergoing hip arthroscopy and MR arthrogram, which was checked and confirmed as per NHS trust guidelines. The confidentiality of patients’ details was strictly maintained throughout, according to the "Data protection act".
4
3.
RESULTS
3.1
One hundred thirty-one patients were identified with an average duration of
symptoms of 23.8 months. There were 88 females and 43 males. Of the 131 patients, 51 were involved in contact sports. Majority of the operated patients (76%) had no history of trauma. Arthroscopic findings were taken as the standard to assess the validity of dMRA.
3.2
Table 1 illustrates the cross-tabulation between dMRA and Hip
arthroscopy findings of labral tear. Of the total 23 anterior labral tears identified in the hip arthroscopy, only 9 were reported as anterior in dMRA, the remaining 8 reported as anterosuperior and the rest 6 as the normal labrum. Similarly, of the total 101 patients diagnosed with an anterosuperior labral tear on hip arthroscopy, 74 correlated with the findings on dMRA . dMRA suggested normal labrum in 15 and anterior labral tears in the remaining. Of the seven normal labrum confirmed on hip arthroscopy, dMRA suggested on 5 and on the remaining falsly reported as an anterosuperior labral tear.
Direct MR Arthrogram and Hip arthroscopy cross tabulation for labral tear Labral tear in Hip arthroscope Anterior
Anterosuperior
Normal
Total
Labral tear in
Anterior
9
12
0
21
Direct
Anterosuperior
8
74
2
84
Normal
6
15
5
26
Total
23
101
7
131
MRA
5
Table 1: Cross tabulation of dMRA and hip arthroscope findings for labral tears.
3.3
Consequently, 43 out of the 131 patients have a discrepancy in findings
between the hip arthroscopy and dMRA. The misclassification rate between the two for the labral tear was 32%. The agreement between the dMRA and hip arthroscopy in the diagnosis of labral tear was assessed using Kendall’s tau-b test. This test showed a value of 0.218 with a significance of 0.009 suggesting a direct MR Arthrogram is useful in diagnosing labral tears. Another way to assess the validity of dMRA in diagnosing labral tears can be estimated by calculating the sensitivity and specificity of the dMRA compared with the hip arthroscopy.
3.4
The anterior or anterosuperior labral tear does not make any difference
in the treatment patient was going to receive. Thus both these are considered together as labral tear for the calculation of sensitivity and specificity. The sensitivity and specificity of dMRA in diagnosing labral tear were 83.06 % and 71.43 % respectively, while the Positive predictive value [PPV] and the negative predictive value calculated was 98.1 % and 19.23 % respectively.
3.5
Table 2 illustrates the cross-tabulation results between dMRA and hip
arthroscopy in diagnosing chondral delamination. A total of 9 patients were confirmed with anterior chondral delamination on the hip arthroscopy. dMRA identified this rightly only in 1 patient. Similarly of the 84 patients with anterosuperior chondral delamination, 67 were reported as normal which is a significant number of wrong reports. 16 patients reported correctly as anterosuperior and 1 as anterior.
6
Direct MR Arthrogram and Hip arthroscopy cross tabulation for chondral delamination Chondral delamination in Hip arthroscope Anterior
Antero-
Grade 3/4
superior
changes in
Normal
Total
the hip Chondral delaminati on Direct MRA
in
Anterior
1
1
0
0
2
Antero-
1
16
4
4
25
0
0
1
0
1
Normal
7
67
4
25
103
Total
9
84
9
29
131
superior Grade
3/4
changes in the hip
Table 2: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
3.6
In cases confirmed as advanced arthritis, 8 out of the 9 [88.89%] patients
were reported as normal cartilage on dMRA. However in diagnosing normal cartilage, 25 out of the 29 were diagnosed correctly by dMRA while 4 reported as anterosuperior delamination (Table 2).
3.7
The Kendall's tau-b test was used to detect the agreement between
dMRA and hip arthroscopy in detecting cartilage delamination. This test result was 0.015, 7
with a weak significance of 0.860 questioning the validity of dMRA in identifying cartilage delamination. For the purpose of calculating the validity of dMRA in detecting cartilage changes, the anterior, anterosuperior and global changes were grouped as a single entity. The sensitivity, specificity, positive predictive value and negative predictive value are 23.53%, 86.21 %, 85.71 % and 24.27 % respectively.
3.8
Non-arthritic hip scores were used to assess the outcome of the
arthroscopic intervention in hip impingement patients. The average preoperative nonarthritic hip score was 36.53, and the average postoperative score was 70.49. The hip arthroscopic intervention improved the mean difference of 33.653, which is statistically significant. Majority of the patients [105 out of 131] showed good improvement in the score. However, 26 patients [19.85%] had a poor postoperative outcome score. The average score of this group was 48.23, which might have caused a high standard deviation [13.295] of the postoperative scores.
3.9
It is noted that as the age increases the outcome scores becomes poor14.
Hence, the 131 subjects were sub-grouped according to age and sex [Table 3]. Those less than 20 years had the best average postoperative score of 73.24 with female patients having a better score (76.31) compared to males (63.25). However, the average score decreased to 68 in those aged more than 40. In this group, male patients scored better (71.51) compared to females (69.99).
8
Post-operative score at Discharge Age
Sex
Mean
Number
Standard
Minimum
Maximum
deviation Less than
F
76.31
13
8.548
60
88
M
63.25
4
14.930
49
81
Total
73.24
17
11.366
49
88
F
70.46
46
13.505
32
87
M
73.64
22
11.875
40
85
Total
71.49
68
12.998
32
87
F
66.41
29
14.613
35
87
M
70.71
17
13.541
49
86
Total
68.00
46
14.228
35
87
F
69.99
88
13.546
32
88
M
71.51
43
12.861
40
86
Total
70.49
131
13.295
32
88
20 yrs
20
to
40 yrs
More than 40 yrs
Total
Table 3: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
3.10
Twenty-six patients among the 131 (19.84%) continued to have the
symptoms after the operation scoring a poor average postoperative score of 48.23. Among the 26, 16 patients (61.5%) were over age 40 years out of which females had a poor average postoperative score (46) compared to males. Of the 131, 9 patients (7%) ended up with a total hip replacement due to the grade 3/4 osteoarthritic changes found in the hip arthroscopy. 8 of them were more than 40 years of age and 5 were females. Four 9
out of these eight patients (44.44%) were reported having normal cartilage in the dMRA and another three reported as anterosuperior focal involvement before the operation. The hip arthroscopy in all these seven patients could have been avoided if direct MR Arthrogram diagnosed the advanced cartilage degenerative changes.
4.
4.1
DISCUSSION
Femoroacetabular impingement [FAI] is a important atraumatic cause for
the labral tear and chondral delamination. Early diagnosis and management of FAI are crucial in preventing early age total hip arthroplasty. Imaging in hip impingement patients aims to identify the abnormal bone morphology, labral tears as well as chondral delamination15. Anteroposterior and lateral X-ray views are the common radiological investigation for any symptomatic hip, but it is difficult to quantify the findings on the X-ray.
4.2
Beaulé, Zaragoza et al. conducted a study on 36 patients about the use of
three-dimensional computed tomography (CT) scan to assess the FAI16. They compared patients with radiographs, MRI with gadolinium contrast enhancement and three-dimensional CT scan. They recommend CT scan for head-neck junction abnormalities of the femoral head, though not much useful to diagnose the labral and cartilage pathologies.
4.3
Zlatkin, Pevsner et al. assessed the validity of MRI and indirect MRA to
diagnose labral tears1. Of the 14 patients with proven labral lesions, only 85% were detected by the conventional MRI scan, while the indirect MR arthrogram diagnosed 100% of the labral tears. However, the detection rate for chondral delamination was the same (82%) for MRI scan and MR arthrogram. Saied, Redant et al. conducted a meta-analysis on the validity of conventional MRI [cMRI], direct MR arthrogram [dMRA] and indirect MR arthrogram
10
[iMRA] in detecting the labral and cartilage delamination associated with FAI17. They reported dMRA as the best investigation for diagnosing labral tears and cartilage lesions with an overall 91% sensitivity compared to cMRI (76%) and iMRA (72%).
4.4
A similar meta-analysis by Smith, Hilton et al. reported 87% sensitivity and
64% specificity for dMRA in diagnosing labral tears compared to cMRI values of 66 and 79, respectively18. In a study by Sutter, Zubler et al., one radiologist found dMRA better than cMRI for diagnosing labral tear while another radiologist reported both are same, which suggests that MRI interpretation might be operator dependent19.
4.5
The delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) is a
method of indirect MR arthrogram with delayed T1 relaxation time is a promising new MR investigation, which is shown to improve the sensitivity for detecting cartilage delamination. Bittersohl et al. studied 16 patients with a mean age of 31, which showed a sensitivity of 75 and specificity of 3320. Similarly, another study by Lattanzi, R.Petchprapa, C.Glaser, C. et al. with ten patients with an average age of 19.9 reported a sensitivity of 71 and specificity of 3621. A multicentre study is required to confirm the benefits of the dGEMRIC scan. Of the different MRI sequences, direct MR Arthrogram is the choice investigation because of the high sensitivity and specificity reported in many studies.
4.6
It is proven knowledge that the early arthroscopic management of
femoroacetabular impingement [FAI] could possibly prevent subsequent osteoarthritis. Our study showed that the prompt diagnosis of hip impingement is a challenge as most of the patients presented with insidious onset of hip pain. This finding agrees with Clohisy et al., that the onset of symptoms in this group was insidious in the majority (65%) of the
11
patients22.
4.7
Table 4 below is a comparison of all the recent studies performed with a
similar methodology as ours17. These studies, in general, prove that direct MR Arthrogram has good sensitivity in diagnosing labral tears and good specificity in detecting chondral delamination, which is consistent with our results. In our study, the sensitivity and specificity of direct MR Arthrogram in diagnosing labral tear was 83.06 and 71.43, respectively. dMRA have a positive predictive value of 98.1 in diagnosing true labral tear and negative predictive value of 19.23 in reporting a true normal labrum. To the best of our knowledge, this study has the largest number of patients ever published addressing the aims of this paper.
Study
No
Mean
Pathology
[Year]
of
age
studied
Labral tear
Chondral delamination
case
Sensi
Spe
Sensi
Spe
s
tivity
cific
tivity
cific
ity Crespo R
51
et al23
43+/-
Combined
9
chondral
[2014]
95
100
ity 92
54
89
40
100
90
91
25
50
90
and
labral tear
Sahin et
14
35
Acetabular
al24
chondral lesion
[2014]
Femoral chondral lesion
Sutter et
28
31.8
Acetabular
al19
chondral lesion
[2014]
Femoral chondral lesion
Tian
et
90
35.1
Labral lesion
89
50
Labral lesion
95
84
al25 [2014]
12
Aprato
41
24
al26
et
Acetabular
69
88
46
81
86
50
85
44
chondral lesion
[2013]
Femoral chondral lesion Labral lesion
McGuire
61
32
et al27
91
86
Acetabular chondral lesion Femoral
[2012]
Reurink et
chondral lesion
95
41.3
Labral lesion
96
33
Labral lesion
86
75
Combined
81
51
17
100
100
50
63
33
79
84
22
100
74
90
79
77
23.5
86.2
al28
[2012] Banks et
69
al29
chondral
[2012]
labral lesions
Perdikaki
14
43
and
Combined
s et al30
chondral
[2011]
labral lesions
Zaragoza et
48
38.8
al31
and
Acetabular chondral lesions
[2009] Anderson
27
Acetabular
et al32
chondral lesions
[2009] Pfirrman
44
30.7
n et al33
Acetabular chondral lesions
[2008] Studler et
57
35
Labral lesion
42
37
Combined
97
53
al34 [2008] Schmid al35
et
chondral lesion
[2003] OUR
131
33.2
Combined
83.06
STUDY
chondral
[2018]
labral lesion
71.4
and
Table 4: Comparison of the results of all the recent studies performed with a similar methodology with our study. 13
4.8
Many dMRA studies reported poor sensitivity for diagnosing chondral
delamination. Our study agrees with a low sensitivity of 23.5%. Pfirrmann, Duc, Zanetti et al. specifically investigated this and explained that the hip joint cartilage is quite thin, and the delamination of the cartilage is very difficult to identify due to the narrow hip joint33. Moreover, the femoral head pushes the delaminated portion into the subchondral bone obliterating the cleft, which is difficult to detect by MR Arthrogram. Anderson et al. reiterated this saying that the limited distensibility of the hip joint makes the cartilage delamination difficult to identify32. These might be the reasons for the poor sensitivity of dMRA in detecting chondral delamination. This is significant because out of the eight patients who ended up with a total hip replacement, it was reported as either normal or insignificant cartilage delamination in dMRA.
4.9
A relevant study by Sansone, Ahldén et al. assessed the outcome of hip
arthroscopic treatment on hip impingement36. It was a prospective study of 394 patients. The average age of the study cohort was 37 years, and the mean follow-up period was 25.4 months. They have used valid outcome scores like web-based patient-reported outcomes (PROMs), the Copenhagen Hip and Groin Outcome Score (HAGOS), the International Hip Outcome Tool (iHOT-12), the Hip Sports Activity Scale (HSAS), a standardised instrument (EQ-5D) and a Visual Analogue Score for assessing the overall hip function. The preoperative scores compared statistically with the two years follow up scores and concluded that overall, 82% of the patients [286 patients] were satisfied with the arthroscopic procedure.
14
4.10
Very few outcome measures developed to use in hip arthroscopic
patients37. Christensen, Althausen, Mittleman et al. conducted a study to assess the validity, consistency, reliability and reproducibility of Non-Arthritic Hip Score [NAHS] in comparison with Harris Hip Score and Short Form -1238. They concluded that NAHS is valid, reliable, consistent and reproducible. Similarly, Domb, Martin, Gui et al. also suggested using Non-Arthritic Hip Score in assessing young patients with hip pathologies39. We have used Non-Arthritic Hip Score to determine the functional outcome of hip arthroscopic treatment.
4.11
In our study, the hip arthroscopic intervention made a significant
improvement in nonarthritic hip score. Domb, Martin, Gui et al. reported a similar clinically significant improvement in the NAHS following hip arthroscopy39. They also stated that as the age advances the postoperative score becomes poor. They demonstrated a decrease in the score of 0.208 per year. McCormick et al. shown poor score for patients more than 40 years having hip arthroscopy with an odds ratio of 3.6 for conversion to THR40.
4.12
Our study reported poor NAHS score in patients more than 40 years
with an average score of 68 compared to the score in those less than 20 years (73.24) and 20 to 40 years (71.49). Like the finding of Domb, Martin, Gui et al., the postoperative NAHS score of our patients deteriorated with advanced age39. Another interesting result of their study was the better postoperative score for females compared to males irrespective of age. However, our study demonstrated a better score for females only in less than 20 year age group and males performed better in all other age group. Consistent with our findings, Lindner et al. demonstrated poor outcome scores for females41. There was a high incidence of total hip arthroplasty among females more than 40 years of age in our study. Our study is not free from limitations. It is a case series study. Only articles in
15
English language were used towards referencing. The risk of selection bias cannot be excluded.
5
CONCLUSIONS
5.1
In summary, the dMRA is a valuable investigation to detect labral
tears however poor in diagnosing chondral delamination. The hip arthroscopic intervention in patinets under 40 years provided good short-term functional outcome with a mean difference in the postoperative nonarthritic hip score by 33.65. Female patients generaly had a poor outcome, particularly over 40 years of age. Caution should be maintained if planning hip arthroscopy in FAI patients above 40 years with a normal or focal cartilage damage on dMRA.
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20
TABLES
Direct MR Arthrogram and Hip arthroscopy cross tabulation for labral tear Labral tear in Hip arthroscope Anterior
Anterosuperior
Normal
Total
Labral tear in
Anterior
9
12
0
21
Direct
Anterosuperior
8
74
2
84
Normal
6
15
5
26
Total
23
101
7
131
MRA
Table 1: Cross tabulation of dMRA and hip arthroscope findings for labral tears.
Direct MR Arthrogram and Hip arthroscopy cross tabulation for chondral delamination Chondral delamination in Hip arthroscope Anterior
Antero-
Grade 3/4
superior
changes
Normal
Total
in the hip Chondral delaminat ion
in
Anterior
1
1
0
0
2
Antero-
1
16
4
4
25
0
0
1
0
1
superior
Direct MRA
Grade changes the hip
3/4 in
Normal
7
67
4
25
103
Total
9
84
9
29
131
Table 2: Cross tabulation between the findings in dMRA and hip arthroscope in patients regarding chondral delamination.
Post-operative score at Discharge Age
Sex
Mean
Number
Standard
Minimum
Maximum
deviation Less than
F
76.31
13
8.548
60
88
M
63.25
4
14.930
49
81
Total
73.24
17
11.366
49
88
F
70.46
46
13.505
32
87
M
73.64
22
11.875
40
85
Total
71.49
68
12.998
32
87
F
66.41
29
14.613
35
87
M
70.71
17
13.541
49
86
Total
68.00
46
14.228
35
87
F
69.99
88
13.546
32
88
M
71.51
43
12.861
40
86
Total
70.49
131
13.295
32
88
20 yrs
20
to
40 yrs
More than 40 yrs
Total
Table 3: Table illustrating the age and sex wise distribution of post-operative nonarthritic hip scores
Study
No
Mean
Pathology
[Year]
of
age
studied
Labral tear
Chondral delamination
case s
Sensi
Spe
Sensi
Spe
tivity
cific
tivity
cific
ity Crespo R
51
et al23
43+/-
Combined
9
chondral
95
100
ity 92
54
89
40
100
90
91
25
50
90
69
88
46
81
86
50
85
44
and
labral tear
[2014] Sahin et
14
35
Acetabular
al24
chondral lesion
[2014]
Femoral chondral lesion
Sutter et
28
31.8
Acetabular
al19
chondral lesion
[2014]
Femoral chondral lesion
Tian
et
Labral lesion
89
50
95
84
90
35.1
Labral lesion
41
24
Acetabular
al25 [2014] Aprato et
al26
chondral lesion
[2013]
Femoral chondral lesion Labral lesion
McGuire
61
32
et al27
91
86
Acetabular chondral lesion Femoral chondral lesion
[2012]
Reurink
95
41.3
Labral lesion
96
33
Labral lesion
86
75
et al28 [2012] Banks et
69
Combined
al29
chondral
[2012]
labral lesions
Perdikaki
14
43
s et al30
et
51
17
100
100
50
63
33
79
84
22
100
74
90
79
77
23.5
86.2
and
Combined chondral
and
labral lesions
[2011] Zaragoza
81
48
38.8
al31
Acetabular chondral lesions
[2009] Anderson
27
Acetabular
et al32
chondral lesions
[2009] Pfirrman
44
30.7
n et al33
Acetabular chondral lesions
[2008] Studler et
57
35
Labral lesion
42
37
Combined
97
53
al34 [2008] Schmid al35
et
chondral lesion
[2003] OUR
131
33.2
Combined
83.06
STUDY
chondral
[2018]
labral lesion
71.4
and
Table 4: Comparison of the results of all the recent studies performed with a similar methodology with our study.