What Is The Success Rate Of Arthroscopic Hip Labral Repair With Femoral Osteoplasty

Purpose

To evaluate the clinical and radiological effect, sum of acetabular and femoral cartilage thickness, and rate of failure in the midterm later on arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair, and rim trimming without labral disengagement.

Methods

This retrospective example series included patients with FAI syndrome who had undergone hip arthroscopy from Jan 2009 to December 2010 by a single surgeon, with a minimum follow-up of 55 months. Data from patients who had undergone arthroscopic hip procedures with labral repair, rim trimming, and femoral osteoplasty were analyzed pre- and postoperatively. Clinical outcome (nonarthritic hip score [NAHS], Short Form 36 [SF-36]), range of motion, progression of osteoarthritis (Tönnis grade), radiological parameters (α angle, lateral eye-edge angle [LCEA], Tönnis angle), femoral and acetabular cartilage thickness (using magnetic resonance imaging [MRI]), and intraoperative findings were evaluated.

Results

Of 148 hip arthroscopies performed, 97 included rim trimming, labral refixation, and femoral osteoplasty. Ten cases were lost to follow-up, leaving 87 hips. Arthroscopic revision was performed on iv hips and full hip replacement on four hips, and 1 hip underwent both arthroscopic revision and full hip replacement. Excluding these ix cases of revision, for which follow-up was not possible (retrospective study), the remaining 78 hips were followed up for a minimum of 55 months (77 ± 11.4, mean ± SD; range 55 to 124). Mean NAHS (65 to 88, P < .001), SF-36 physical subscale (65 to 85, P < .001), and the numerical pain rating scale (NRS) (v to 1, P < .001) improved significantly. Effect scores of minimal clinical importance (NAHS) were achieved in 67.half-dozen% of the patients. Mean range of move improved significantly in flexion (109 to 122, P < .001) and internal rotation (10 to 22.7, P < .001). NAHS was positively associated with flexion of the hip postoperatively (r = 0.307, P = .011). In xvi cases, microfracture was performed (15 acetabular and one femoral). Preoperative α angles (anteroposterior and modified Dunn) were significantly higher in this cohort (P < .001, 95% conviction interval viii.9 to 25.two, P = .001). Twenty hips (28 %) progressed to worse Tönnis grades. Initial Tönnis grades were grade 0, 38; course 1, 48; class 2, viii. Pre- or postoperative Tönnis grades did not testify whatever correlation with pre- or postoperative NAHS and NRS. MRI measurements at the latest follow-upwardly (69 patients) of the femoral and acetabular cartilage thickness did not reveal whatsoever significant reduction at the 12 o'clock position.

Conclusion

Arthroscopic cam resection, rim trimming, and labral repair without disengagement of the labrum provides adept or excellent outcome in 77.1% of hips based on NAHS in the midterm. Higher range of motion in flexion is associated with higher NAHS postoperatively. Arthroscopic cam resection, rim trimming and labral repair without detachment of the labrum is a successful method for the treatment of FAI syndrome in the midterm.

Level of Prove

4, retrospective case series.

Recent evidence has shown that surgical hip dislocation and hip arthroscopy are valid methods for the handling of femoroacetabular impingement (FAI) syndrome in the mid- to long term.

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An unstable labrum should be repaired in a instance of chondrolabral tear. When less extensive incomplete tears or pincer or mixed-type impingements occur, the acetabular rim tin can be accessed by disengagement of the labrum or the over-the-top technique.

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Minimal rim trimming is often performed to generate a healing response for labral repair.

Brusque-term follow-up studies on the over-the-acme technique have been reported

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; withal, midterm follow-up investigations take been rare. Furthermore, no comparative studies have been published regarding labral detachment. The chondral layer preserved in junction with the labrum can human activity as an actress cuff of tissue supporting the suction-seal effect.

Reducing cartilage wear is the main goal of joint-preserving surgery. Currently, however, there is no widely accustomed classification system for categorizing intra-articular damage in patients with FAI syndrome.

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Very few studies have been conducted to assess cartilage thickness using magnetic resonance imaging (MRI) scans.

The aims of this study were to evaluate the clinical and radiological outcome, sum of acetabular and femoral cartilage thickness, and rate of failure in the midterm later on arthroscopic treatment of FAI syndrome with femoral osteoplasty, labral repair, and rim trimming without labral detachment.

^,

⁵

• Ilizaliturri Jr., V.Thousand.
• Joachin P.
• Acuna M.

Description and mid-term results of the 'over the top' technique for the treatment of the pincer deformity in femoroacetabular impingement.

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The hypothesis was that the effect would be significantly better at the final follow-up compared with preoperative values, cartilage thickness would non be reduced, and the revision rate would be acceptable. A further hypothesis was that the α bending and acetabular retroversion alphabetize would be reduced and that low femoral antetorsion would be associated with worse event, as reported previously.

Methods

Data of patients who had undergone an arthroscopic hip procedure with labral repair, variable corporeality of rim trimming, and femoral osteoplasty from January 2009 to Dec 2010 with hip arthroscopy were collected in a prospective style and retrospectively analyzed. The study was approved past the Ethics Board of the Northward-West and Central Switzerland (EKNZ) (registration number: 2015-213).

Inclusion Criteria

A consecutive series of symptomatic patients undergoing hip arthroscopy, with labral repair and femoral osteoplasty in all cases and rim trimming as required by patient anatomic characteristics, were included in the study. Further enrollment criteria were failed nonsurgical direction, such every bit physiotherapy, oral analgesia, and occasional intraarticular cortisone injections, for six months; mixed-type or pincer morphology; and minimum clinical and radiological follow-upwards of 55 months.

Exclusion Criteria

Patients were excluded with <55 months' follow-up, advanced level of osteoarthritis (Tönnis grade 3), previous ipsilateral hip surgery, Perthes disease, or not having undergone labral repair.

Indication for Surgery

FAI syndrome was diagnosed past symptoms (motion- or position-related symptoms), clinical examination (positive impingement examination and exclusion of actress-articular causes of pain), and diagnostic imaging. The cam component of mixed type impingement was defined every bit follows: >fifty° on radial reconstruction of MRI scans or ten-ray (modified Dunn view).

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This threshold was called for the α angle in cases of mixed-blazon or pincer impingement, because the α bending may not necessarily exist as high equally in pure cam-type impingement.

Sclerotic subcortical os at the neck–caput transition was also considered suggestive of impingement. Pincer was diagnosed by the presence of the crossover sign (on the ten-ray) and the analysis of the acetabular version in the proximal 50% on the centric section of the pelvis observed on MRI scans, intraoperative impingement test after sufficient cam correction, coxa profunda morphology, or lateral center-edge bending (LCEA) ≥35°.

Operative Technique

The operative technique has been previously described (Fig 1).

The articulation capsule was opened in an extensive manner, by and large in the surface area of the iliofemoral ligament, to ensure proficient admission. The capsule was then left open without closure.

Fig 1 Acetabular rim trimming (A) and labral refixation without detachment of the labrum (B). Right hip, distal anterolateral portal, lxx° arthroscope, without traction. (B) Drilled for 2.9-mm PEEK push lock anchors from 12 to 1:30 o'clock. Note the reflected head of the rectus tendon at 12 o'clock.

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Acetabuloplasty and Labral Repair

Minimal rim trimming without detachment of the labrum was performed for labral refixation without meaning pincer morphology to support healing. The decision to repair the labrum was based on intraoperative findings, such every bit a the lack of a proper suction seal past the labrum when distracting the joint or pregnant chondrolabral dissociation with unstable labrum to probing. In all other cases, correction of pincer morphology was performed (Fig 1).

Femoral Osteoplasty

Femoral osteoplasty was performed in all cases regardless of the initial α angle, to allow for more impingement-free range of motion (ROM). If significantly positive posterior wall sign was nowadays, compensatory femoral osteoplasty was performed instead of anterosuperior rim trimming.

Clinical Findings

Patient-reported outcomes were assessed by the nonarthritic hip score (NAHS, calibration 0 to 100), Short Form 36 (SF-36, concrete and mental subscale, calibration 0 to 100), and numerical hurting rating scale (NRS, calibration 0 to ten). Minimal clinical importance was determined based on the methodology of Thorborg et al.

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• Thorborg K.
• Kraemer O.
• Madsen A.D.
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Patient-reported outcomes within the commencement year afterward hip arthroscopy and rehabilitation for femoroacetabular impingement and/or labral injury: The divergence between getting meliorate and getting back to normal.

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ROM was assessed using a goniometer; internal and external rotation was measured in 90° flexion with the contralateral hip in 0° flexion. Gait was assessed by checking whether limping occurred (Duchenne gait, antalgic gait), and one-leg stance was assessed in terms of Trendelenburg positivity (0, negative; 1, unstable; 2, positive). Pain intensity during anterior impingement testing was evaluated on a subjective scale (0 to three) at the final follow-up (≥55 months postoperatively). The applied scales to appraise gait and hurting intensity during anterior impingement testing are not validated.

Intraoperative Findings

Acetabular cartilage lesions were assessed using the Outerbridge and Acetabular Labral Articular Disruption (ALAD) classification.

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The Seldes

and Outerbridge classifications were used to assess labral and femoral cartilage lesions, respectively. Intraoperative procedures were also recorded (number of anchors, size of the trimmed acetabular rim, and surface area of microfracture).

Radiographic Analysis

Conventional radiographs were analyzed according to Tönnis course and the anteroposterior LCEA, Tönnis angle, anteroposterior (AP) α bending, and α bending on modified Dunn x-rays (AD)

^,

preoperatively, at 6 weeks, and at the final follow-upward postoperatively. α Angle was measured on the radial reconstruction of the MRI scans according to the sagittal view in cases of suboptimal x-rays. The mean medial proximal femoral bending,

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the posterior wall sign (PWS), and the ischial spine sign (ISS) were as well evaluated.

The acetabular retroversion index (ARI) was quantified every bit described previously.

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Where measurements of two independent readers were available, a 2-way mixed-effects model intraclass correlation coefficient (ICC) was calculated to measure interrater reliability. The level of reliability was categorized as poor (ICC <0.5), moderate (ICC 0.5 to 0.75), practiced (ICC 0.75 to 0.ninety), or excellent (ICC >0.90).

MRI

MRI was performed with intraarticular Gadolinium contrast amanuensis. MRI scans were performed with a Siemens Achieva 3-Tesla preoperatively with a standard protocol and with a Siemens Area i.5 Tesla at the final follow-up (≥55 months postoperatively), applying additional radial reconstruction.

To assess cartilage thickness, coronal proton density (PD) images across the greatest bore of the femoral head were analyzed in the weightbearing area at 12 o'clock, in 3 subregions, from lateral to medial (ane, 2, and 3). With radial reconstruction, based on PD sequences, the cartilage thickness was besides measured in the weightbearing zone at 12 o'clock and posteroinferiorly on the facies lunata, using the iii subregions. Femoral antetorsion was measured in relation to the posterior condylar line of the knee according to Lee et al.

Definition of Failure

Failure was defined equally revision hip arthroscopy, conversion to total hip replacement (THR), and <80 points on the NAHS at the latest follow-up.

Statistical Analysis

All statistical analyses were performed with IBM SPSS Statistics, version 25. Descriptive statistics, including means and standard divergence (SD), were calculated for all continuous variables. Frequency counts and percentages were calculated for categorical variables. Paired t test was used to assess differences between pre- and postoperative information. Bivariate linear correlations were analyzed with the Pearson test for continuous variables and the Spearman exam for categorical variables. The correlation effect sizes were classified equally poor (r = 0.1), medium (r = 0.3), or strong (r = 0.v).

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All tests were performed 2-tailed, P values ≤.05 were considered statistically meaning, and 95% conviction intervals (CIs) are reported where advisable.

Results

Arthroscopic femoral osteoplasty was carried out in 148 cases. Boosted rim trimming and labral repair was performed in 97 cases (83 patients, 49 male person). Birthday, x hips were lost to follow-upwardly (10.3%), leaving 87 hips. Arthroscopic revision was performed on 4 hips and THR on another 4 hips, and one hip underwent both arthroscopic revision and THR. Excluding these 9 cases of revision, for which follow-up was not possible owing to the written report being retrospective, the remaining 78 hips were followed upwards for a minimum of 55 months (77 ± 11.4 months [mean ± SD]; range 55 to 124).

In unilateral cases, the right or left sides were operated in xl and 25 cases, respectively. There were sixteen staged bilateral cases. Amidst the bilateral cases, 1 side of 2 patients were lost to follow-up and 1 side of iii patients were excluded owing to short follow-upwards (Fig 2). The interval betwixt bilateral operations was 10.1 ± eleven.three months (range 0 to 34). Age at surgery was 33.1 ± 11.7 years (range 16 to 66), and body mass index (BMI) was 22.7 ± iii.3 kg/m² (range 15.2 to 31.four)

The hips that were lost to follow-up were non unlike from those with follow-up data in terms of sex, age, BMI, preoperative NAHS, NRS, ALAD classification, and Tönnis grade; nonetheless, they had a higher mean α angle on the modified Dunn view (run into Limitations).

Patient-Reported Event Measures (PROMs)

Results regarding NAHS, SF 36, and NRS are shown in Table ane. The minimal clinically of import nonarthritic hip score, based on the methodology of Thorborg et al.,

¹²

• Thorborg K.
• Kraemer O.
• Madsen A.D.
• Holmich P.

Patient-reported outcomes within the starting time yr after hip arthroscopy and rehabilitation for femoroacetabular impingement and/or labral injury: The deviation betwixt getting better and getting dorsum to normal.

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was accomplished by 67.half dozen% of the patients. Pre- and postoperative NAHS showed a positive correlation with SF-36 concrete subscale before (r = 0.671, P < .001) and after (r = 0.771, P < .001) surgery, and 77.1% of cases were rated good or splendid. The alter in NAHS showed a medium to stiff correlation with BMI, preoperative α bending on Dunn and AP views, change of the α angle on the modified Dunn view, and the Beighton score (Table two).

Table i Patient-reported event measures and Beighton score (paired t examination)

Measure	Baseline	Follow-upwardly	Divergence	95% CI	P Value
NAHS	65 (19.3)	88 (11.9)	21 (17.8)	17.0 to 25.4	<0.001
SF 36 Mental	78 (17.3)	82 (12.6)	4 (sixteen.vi)	0.3 to 8.half dozen	.068
SF 36 Concrete	65 (21.viii)	85 (14.4)	xx (19.6)	14.two to 24.seven	<0.001
NRS pain a Wilcoxon test.	5 (2.0)	1 (1.two)	–4 (2.two)		<0.001
Beighton	i (1.3)

NOTE. Boldface indicates statistical significance. Data are mean (standard deviation).

CI, conviction interval; NAHS, nonarthritic hip score; NRS, numerical pain rating scale; SF 36, short class 36.

a Wilcoxon test.

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Table 2 Correlation of change in NAHS (preoperative versus last follow-up)

Measure out	n	Pearson r	P Value	Correlation
BMI	68	−0.260	.033	Medium
Preoperative α angle, AP pelvis	65	−0.412	.001	Strong
Preoperative α bending, modified Dunn view	62	−0.303	.018	Medium
Change in α angle, modified Dunn view	59	0.320	.014	Medium
Beighton score	54	0.419 a Spearman ρ.	.002	Strong

AP, anteroposterior; BMI, body mass index.

a Spearman ρ.

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The Beighton score was positively correlated with the changes in NAHS (Spearman ρ = 0.419, P = .002) and was negatively associated with acetabular chondropathy (Spearman ρ = –0.259, P = .049). The Beighton score was significantly college in females (P < .001). ROM is shown in Table 3. There was a positive correlation between NAHS and flexion at follow-upwards (r = 0.307, P = .011). Internal rotation showed a significant correlation with flexion postoperatively (r = 0.456, P < .001) (Tabular array 3). The results of impingement testing (flexion, adduction, internal rotation ) are shown in Tabular array 4.

Table 3 Range of motility, gait, and ane-leg stand (paired t exam)

Measure	Baseline	Follow-Up	Difference	95% CI	P Value
Extension	ane (3.half dozen)	11 (6.two)	10 (7.1)	eight.4 to 11.7	<.001 ∗ Statistically significant.
Flexion	109 (ten.0)	122 (eleven.four)	12 (13.3)	9.2 to fifteen.v	<.001 ∗ Statistically significant.
Abduction	39 (6.9)	46 (9.viii)	7 (eleven.6)	3.7 to nine.5	<.001 ∗ Statistically significant.
Adduction	25 (4.5)	26 (7.8)	1 (9.0)	–one.iii to three.two	.410
External rotation	36 (12.0)	39 (9.three)	4 (eleven.vii)	1.two to 6.9	.006 ∗ Statistically pregnant.
Internal rotation	10 (12.6)	22.7 (10.7)	12 (14.v)	8.seven to xv.6	<.001 ∗ Statistically significant.
Gait					.001 ∗ Statistically pregnant. a Wilcoxon examination.
0	62 (lxxx)	67 (97)
1	four (5)	2 (iii)
ii	11 (14)
3	one (i)
ane-leg stand					.408 a Wilcoxon test.
0	73 (95)	69 (99)
one	3 (4)	one (i)
ii	1 (one)

Data are mean (standard deviation) or n (%).

a Wilcoxon exam.

∗ Statistically significant.

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Table iv Anterior impingement test preoperatively and at follow-up (Wilcoxon test)

Mensurate	Baseline	Follow-up	P Value
Impingement			<.001
0	2 (three)	45 (64)
1	13 (17)	13 (xix)
2	41 (54)	10 (14)
3	20 (26)	2 (3)

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Intraoperative Findings and Handling

The distribution of the ALAD lesions were grade I, 36%; grade II, 28%; grade Iii, 22%; and form IV, 12%; those of the acetabular Outerbridge lesions were grade I, 53%; grade Ii, thirty%; grade Three, ten%; and grade IV , five%. Labra showed lesions of Seldes 1, 52%; Seldes 2, 28%; or both, 14% in the indicated proportions. No labral pathology was found in half-dozen% of the hips. In these hips, pincer correction was performed. Femoral Outerbridge lesions were grade I, thirteen%; class Ii, iv%; class Three, i%; and grade 4, one% in the indicated distribution. No pathology was seen in 81% of the cases.

Rim trimming was performed from 0.6 to 7 mm (area 161.74 ± l.56 mm²; range 45 to 350). Microfracturing was performed in 16 cases on the acetabular side (expanse 215 ± 145.86 mm^two; range 90 to 600). Femoral microfracturing was done in 1 example (mean surface area 75 mm²).

Preoperative AP and AD were both significantly college for hips with microfracture (66.0° versus 48.ix°, 95% CI eight.9 to 25.2, P < .001; 70.five° versus 58.2°, 95% CI 5.0 to nineteen.v, P = .001, respectively), every bit was the change of AD (–23.3° versus –13.iii°, 95% CI –15.6 to –iv.four, P = .001). There were no significant differences in PROMs between the 2 cohorts.

Radiological Consequence and MRI Assessment

The comparing of radiological parameters preoperatively and at the last follow-up are shown in Table 5. Mean femoral antetorsion was 8.68° ± eight.07°; range –vi° to 29.7°; 95% CI six.39 to 10.98). Correlations of PROMs, postoperative internal rotation, and flexion with femoral antetorsion are presented in Table 6. No correlation could be establish between femoral antetorsion and any of the assessed PROMs (Tabular array 6). Postoperative internal rotation (Pearson r = 0.392, P = .006) and flexion (Pearson r = 0.354, P = .014) showed an association with femoral antetorsion.

Table 5 Comparison of radiologic parameters pre- and postoperatively (paired t test)

Parameter	Baseline			Follow-Up			Departure			P Value
	n	Mean (SD) or n (%)	ICC	n	Mean (SD)	ICC	due north	Mean (SD)	95% CI
Lateral center edge bending	74	27.two (v.6)	0.798	73	26.8 (half-dozen.1)	0.814	73	–0.5 (3.vii)	–ane.4 to 0.four	.277
Tönnis angle	74	2.8 (v.1)		74	iii.4 (5.iii)		74	0.6 (3.4)	–0.2 to 1.4	.131
α angle on AP pelvis	73	51.5 (13.8)	0.987	73	46.seven (9.6)	0.993	73	–4.viii (14.two)	–8.ane to –1.4	.006
α angle on Dunn view/MRI radial reconstruction	78	59.nine (xi.nine)	0.979	74	42.nine (4.ane)	0.823	65	–14.7 (8.5)	–xvi.eight to –12.six	<.001
Acetabular retroversion alphabetize	56	14.9 (13.three)	0.999	56	8.ane (12.five)		56	6.7 (13.7)	10.4 to three	.001
Medial proximal femoral bending	72	86.9 (vii.1)
Ischial spine sign	72	26 (36)
Posterior wall sign	68	28 (41)

AP, anteroposterior; CI, confidence interval; ICC, intraclass correlation coefficient; SD, standard deviation.

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Table 6 Correlation of the femoral antetorsion

Mensurate	n	Pearson r	P Value	Correlation
NAHS preoperative	46	–0.127	.402	No
NAHS postoperative	46	0.015	.920	No
SF-36 Concrete preoperative	36	–0.040	.816	No
SF-36 Concrete postoperative	43	–0.075	.633	No
Internal rotation postoperative	48	0.392	.006	Medium
Flexion postoperative	48	0.354	.014	Medium

NAHS, nonarthritic hip score; SF 36, short grade 36.

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Quantitative comparisons of cartilage thickness preoperatively and at the latest follow-up were performed. The most relevant subregions, regarding cam impingement, were found at the margin of the acetabulum (Cor PD 1 and ii and Rad 1 and 2). No statistically significant differences were constitute in these subregions. However, at the near medial subregions (Cor PD three and Rad 3), at that place was a significant difference compared with preoperative values, showing slightly thicker cartilage. Cartilage thickness in whatever of the examined subregions at whatever time signal failed to show a correlation with NAHS. SF-36 showed no correlation with cartilage thickness either pre- or postoperatively.

Despite preserved cartilage thickness on the MRI, Tönnis classification showed progression. Results are presented in Table 7. Twenty hips (28%) progressed to worse Tönnis grades, and 52 hips (72%) showed no change. Tönnis nomenclature pre- or postoperatively did not show whatsoever correlation with pre- or postoperative NAHS and NRS scores, nor did information technology correlate with the changes of these scores or radiologic indices such as PWS, ISS, or ARI.

Table 7 Tönnis class postoperatively and at latest follow-up (Wilcoxon test)

Tönnis Grade	Baseline	Follow-Upward
0	38 (forty)	26 (36)
1	48 (51)	33 (45)
2	8 (9)	12 (16)
3		2 (3)

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Failure

Failure was defined as THA, revision hip arthroscopy for whatever reason, and postoperative NAHS <80. Five patients (5 hips, 4 female, 2 of them on the correct side) received THR after a mean of 2.4 years postoperatively at the age of 47.2 ± half-dozen.0 years; range 37 to 52. These patients were significantly older (P = .009) and had a significantly college Tönnis grade (Tönnis 2, iii hips; Tönnis 1, 2 hips; P = .003) and more severe acetabular chondropathy (Outerbridge 2, iii hips; Outerbridge 3, 2 hips; P = .007) earlier surgery. Sex, BMI, preoperative NAHS, NRS, ALAD classification, and microfracturing did not show significantly dissimilar results for this accomplice.

Four revision hip arthroscopies were performed after nonsurgical treatment. Fourth dimension to revision was xiv.viii ± 5.76 months. Residuum bony impingement, capsulolabral and capsulofemoral adhesions, or acetabular chondropathy were identified as the causes of failure. All except 1 patient, who received a THR, did better postoperatively. The period subsequently which no pain medication was needed varied from 2 to 12 months. These cases included significantly more than labral impairment (Seldes classification, P = .003) and significantly more frequent microfracturing at the time of the index functioning (3 of 5 versus 13 of 91 cases; P = .017).

There were xiv patients with a postoperative NAHS <lxxx. These patients were slightly merely not significantly older (35.4 versus 32.3 years, P = .393) and had significantly lower hateful preoperative NAHS scores (52 versus 70 points, P = .001). There was no meaning departure in the comeback in NAHS betwixt the 2 groups (13 versus 23 points, P = .74). There was also no pregnant difference in sex distribution (P = .38). Hips with postoperative NAHS <lxxx were significantly unlike in terms of femoral chondropathy (P = .004), NRS (P < .001), preoperative gait (P < .001), and 1-leg stand up postoperatively (P = .038).

The only radiological parameter that was significantly different for hips with NAHS <fourscore was the LCEA. Mean LCEA was significantly higher preoperatively (30.viii versus 26.4, 95% CI 0.8 to vii.8, P = .016) and postoperatively (30.one versus 26.0, 95% CI 0.24 to seven.96, P = .038) for hips with NAHS <eighty. The extent of chondrolabral disruption (ALAD) (P = .764), labral lesion (Seldes) (P = .454), acetabular chondropathy (Outerbridge) (P = .362), and pre- and postoperative Tönnis grade (P = .281 and P = .642, respectively) were not significantly different in these patients (NAHS <fourscore). Overall failure rate was 22.9%.

Word

Afterwards the arthroscopic treatment of FAI syndrome with femoral osteoplasty, labral repair and rim trimming without labral detachment in a consecutive series of patients, the PROMs (NAHS and SF-36 concrete), hip ROM (except adduction), and impingement examination positivity improved significantly past the last follow-upward date (minimum 55 months). The hypothesis that the outcome would be significantly better at the final follow-up compared with preoperative values was confirmed.

The directly measured thickness of the femoral and acetabular cartilage did not decrease significantly, and the revision charge per unit was 9.3%, with a relatively high pct of Tönnis 1 and ii cases at baseline afterward the arthroscopic treatment of FAI syndrome with femoral osteoplasty, labral repair, and rim trimming without labral disengagement. Thus, the hypotheses that the cartilage thickness would not decrease and the revision charge per unit would be acceptable were confirmed.

A farther hypothesis was that the α angle and acetabular retroversion index would exist reduced. The α angle and acetabular retroversion index were reduced significantly. Therefore, this hypothesis was also supported by the study'southward results. Even so, the hypothesis that femoral antetorsion would be associated with worse outcome was rejected, as femoral antetorsion did not correlate with whatever of the PROMs.

PROMs

The investigated PROMs (NAHS and SF-36) improved significantly postoperatively (final follow-upwards at minimum 55 months) and were comparable to those of other studies.

²

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Arthroscopic labral repair with the over-the-top technique yielded practiced and excellent midterm results in 77.1% of the hips, and minimal clinically important difference was achieved in 67.six% of the patients based on NAHS.

The changes in NAHS showed medium to strong correlations with the BMI and the Beighton score. The office of BMI has been considered controversial in previous studies. Two reports could not discover a negative prognostic value of BMI, although the study of Saltzman et al.

²⁵

• Saltzman B.M.
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may take been underpowered.

^,

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All the same, in line with the electric current study, Krych et al.

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identified BMI equally a negative prognostic factor. This consequence appears plausible, since a higher BMI may reduce patients' power to perform postoperative physiotherapy exercises, thus negatively influencing improvement of PROMs.

Preoperative cartilage thickness measured by MRI did not show any correlation with PROMs. This may be due to the small-scale sample size and the difficulty to perform exact measurements on areas with thin cartilage layers.

²⁷

• Neumann J.
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Studies have shown that patients with class 3 and 4 cartilage lesions have worse outcomes.

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Range of Motion

Hip ROM improved significantly in all directions except adduction.

The increase in extension, abduction, and external rotation may be explained by the extensive capsulotomy without repair.

No revisions were performed for instability, subluxations, or dislocations. This may exist due to labrum repair carried out in each case instead of labral debridement or resection and the lack of dysplastic hips. However, the latter does not necessarily preclude subluxations or dislocations without capsular repair.

The postoperative degree of flexion correlated with postoperative NAHS. This finding is indirectly supported past Krauetler et al.,

^thirty

• Kraeutler M.J.
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Femoral version abnormalities significantly outweigh effect of cam impingement on hip internal rotation.

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who found that cam morphology was responsible for the limitation of flexion rather than internal rotation.

Surprisingly, no direct link between ROM and PROMs could be found in the literature of arthroscopic hip preservation until now, although information technology seems plausible. An association between postoperative flexion and internal rotation at final follow-up was found, which may be explained by simultaneous cam and pincer correction, leading to higher flexion and, to a bottom extent, internal rotation based on the data of Kelly et al.

³¹

• Kelly B.T.
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Internal rotation in ninety° flexion did not show any significant correlation with NAHS, SF-36 physical, or NRS, possibly owing to blazon II error.

Radiologic Parameters

Preoperative α angle on AP pelvis and modified Dunn views were shown to negatively correlate with the change of NAHS. The reduction of the α angle on the modified Dunn view was associated with the improvement of NAHS. These findings suggest that severe cam morphology was more difficult to correct, which is in accordance with the results of Lansdown et al.,

³²

• Lansdown D.A.
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who found that femoral-side measurements were the strongest independent predictors of postoperative event.

Hips with a posterior wall sign were associated with less improvement in NAHS. This may be due to a potential instability every bit a event of decreased posterior coverage combined with a reduced inductive coverage due to rim trimming. Lack of sheathing closure may have contributed to this consequence. Tannast et al.

plant, however, that PWS was a normal phenomenon.

In spite of rim trimming, the LCEA was not reduced significantly. This could be considering rim trimming was initiated more than anteriorly than the 12 o'clock position; thus the LCEA and Tönnis bending did not change significantly. Reduction of the ARI showed but a weak association with the change in ROM or NAHS. This may be due to a type 2 error.

Femoral Antetorsion

In dissimilarity to a previous written report,

³³

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femoral antetorsion did not correlate with any PROMs, but was associated with ROM (postoperative internal rotation and flexion). This finding was partially supported past Krauetler et al.,

^xxx

• Kraeutler M.J.
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who showed that femoral antetorsion outweighed cam morphology in terms of internal rotation.

Cartilage Thickness

Cartilage thickness was measured on MRI scans pre- and postoperatively. Slightly thicker cartilage was institute postoperatively in four subregions. No significant differences between cartilage thickness could be detected in two subregions. Despite the limitations of the applied cess, meaning reduction in cartilage thickness could not be establish in the examined subregions.

Impingement Test

Flexion-adduction-internal-rotation exam results showed meaning improvement postoperatively. It must be noted, however, that the sensitivity and specificity of this test has been found to exist low, and thus information technology is recommended every bit a screening tool but, according to previous reports.

³⁴

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The pes progression angle walking test has been described and recommended recently to improve diagnostic accuracy.

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Handling of Cartilage Lesions

The mean surface area of microfracture was 215 mm^two. This was larger than in other studies dealing with microfracture.

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In spite of this, the cases with microfracture did not differ from the rest in terms of PROMs, but had significantly college preoperative AP, Ad, and reduction of AD. The latter serves as an explanation for more advanced chondral lesions on the acetabular side, which reflects the natural history of cam morphology.

These results are similar to other studies, in which no differences were found in patient-reported outcomes between cases with or without microfracture.

³⁷

• Hartigan D.Due east.
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^,

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Moreover, none of these cases were revised to THR, which seems to support the efficacy of this technique of cartilage regeneration.

Tönnis Grade

A big proportion of hips progressed to worse Tönnis grades. The inclusion criteria reflected the routine indication of surgery past the senior writer in 2009 and 2010. Even Tönnis grade 2 hips were operated on in the study period, and the proportion of operated Tönnis 1 hips was likewise high, which would not occur in today's practice. There is a clear discrepancy between the progression of Tönnis course and measured cartilage thickness pre- and postoperatively on MRI. As suggested previously,

this may be due to the fair to moderate inter- and intraobserver reliability of the Tönnis classification, specially in cases of less avant-garde degenerative changes.

Failure

Revision surgery, including THR and arthroscopy, and a final NAHS <80 were considered failure. The overall failure rate was 22.ix%, which may be partly explained by the application of rather strict criteria (NAHS <eighty).

Revision to THR

Revision rate to THR was similar

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or slightly lower compared with other reports; however, Tönnis 2 hips were also included in the current report. Assuming that all hips that were lost to follow-up had received a THR, the revision rate (15.six%) would all the same remain comparable to other midterm studies.

^ane

• Kaldau N.C.
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^,

²

• Domb B.G.
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Historic period, Tönnis grade, and acetabular chondropathy appear to be take chances factors for THR, which has been extensively studied in the literature. Microfracturing was not performed in this accomplice, as opposed to the rest of the cases.

Arthroscopic Revision

The 4 cases with arthroscopic revision had significantly more labral harm and underwent microfracture more frequently at the index operation. Revision was performed for persistent bony deformity and chondrolabral adhesions. Minor chondral harm was also noted near the acetabular rim. Adhesiolysis was performed in near 40% of the revision cases, according to previous data, whereas residuum impingement was cited every bit the no. 1 reason for revision.

^,

Postoperative NAHS <eighty

There were 14 patients with a postoperative NAHS <lxxx. These hips were significantly dissimilar in terms of femoral chondropathy, NRS, preoperative gait, and ane-leg stand. More patients said they would not be willing to undergo surgery again in this group. Patients in this cohort had lower baseline NAHS but showed comparable improvement postoperatively. The sex distribution, age, extent of chondrolabral disruption (ALAD), labral lesion (Seldes), acetabular chondropathy (Outerbridge), and pre- and postoperative Tönnis grades were not significantly different in this cohort. These results do not reverberate the findings of previous studies, which reported worse outcomes for cases with chondral lesions.

²⁸

• Krych A.J.
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• Sousa P.Fifty.
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We likewise found college lateral coverage (LCEA) of the femoral head in these patients, although information technology was still inside the normal range. The effect on outcome is unclear. NRS and the accomplice of hips with NAHS <80 did not testify any association with Beighton score.

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• Saadat A.A.
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Limitations

The study has several limitations. This is a single-surgeon case series written report with a small patient cohort without a control group. The hips that were lost to follow-upwards had significantly college preoperative α angles on the modified Dunn view (77.5° versus 59.9°, P < .001) than those with follow-up information. This may have biased the results. Cartilage thickness measurements were biased, since pre- and postoperative measurements were performed on two different MRI scanners, and no semiquantitative scores such as the hip osteoarthritis MRI scoring organisation (HOAMS)

were practical.

Furthermore, no multivariate linear regression analysis was performed; thus, no independent predictors of failure could exist identified. In analyses where parameters and their relationships were not constitute to be significant and correlation consequence sizes were classified as depression, the results may have been due to blazon two error. Correlation effect sizes were classified as low between the following parameters:

• •

  microfracture and PROMs;

• •

  Tönnis class and NAHS;

• •

  THR and microfracture, ALAD classification, and preoperative NAHS;

• •

  ARI and ROM, impingement test, and NAHS; and

• •

  NAHS <80 and ALAD classification, Seldes classification, Outerbridge class, and Tönnis grade pre- and postoperatively.

Conclusion

Arthroscopic cam resection, rim trimming and labral repair without detachment of the labrum provides proficient or excellent upshot in 77.one% of hips based on NAHS in the midterm. Higher ROM in flexion is associated with higher NAHS postoperatively. Arthroscopic cam resection, rim trimming, and labral repair without detachment of the labrum is a successful method for the treatment of FAI syndrome in the midterm.

Acknowledgments

Nosotros thank Michael Thomas for his valuable language assistance and proofreading.

Supplementary Information

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Article Info

Publication History

Published online: Dec 21, 2020

Accepted: October 11, 2020

Received: August 12, 2019

See commentary on page 552

Footnotes

The authors report that they have no conflicts of involvement in the authorship and publication of this article. Total ICMJE author disclosure forms are bachelor for this article online, as supplementary material.

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DOI: https://doi.org/10.1016/j.arthro.2020.x.012

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© 2021 The Author(s). Published by Elsevier Inc. on behalf of the Arthroscopy Clan of North America.

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