Incidence of heterotopic ossification following hip arthroscopy is low: considerations for routine prophylaxis.

PURPOSE: This scoping review aims to map and summarise the available literature on heterotopic ossification (HO) following hip arthroscopy, with particular focus on incidence, distribution as per Brooker classification, efficacy of prophylactic measures and factors that may influence the likelihood of production of HO. METHODS: A computer-based search was performed on PubMed, Embase, Emcare, Cinahl, ISI web of science and Scopus using the terms 'heterotopic ossification' and 'hip arthroscopy'. Articles reporting heterotopic ossification following hip arthroscopy for any condition were included after two-stage title/abstract and full-text screening. RESULTS: Of the 663 articles retrieved, 45 studies were included. The proportion of patients with HO ranged from 0 to 44%. The majority of the cases were either Brooker grade I or II. Of the six studies investigating the effect of NSAID prophylaxis, five reported a significantly lower incidence of heterotopic ossification associated with its use. Weak evidence suggests that an outside-in arthroscopic approach, no capsular closure, male sex and mixed cam and pincer resection may be associated with an increased risk of HO. CONCLUSION: Although there is a large variation in rates of HO following hip arthroscopy in the current literature, the majority of studies report a low incidence. Evidence exists advocating the administration of post-operative NSAIDs to reduce the incidence of HO following hip arthroscopy. This, combined with the low risk of complications, means there is a favourable risk-benefit ratio for prophylactic NSAID used in HA. Future research should work to identify patient clinical and demographic factors which may increase the risk of development of HO, allowing clinicians to risk stratify and select only specific patients who would benefit from receiving NSAID prophylaxis.

Editorial Commentary: Pain After Hip Arthroscopy-Are We Truly Addressing the Problem?

Pain after hip arthroscopy is a significant and challenging issue as is evidenced by the number of publications on this subject. Various analgesic strategies to circumvent this issue have been tried, with variable results. The central problem is that pain experienced by patients after hip arthroscopy is multifactorial in origin. Regarding local injection, an anatomic approach to the nerve supply to the hip with an effective pain relief strategy should take this into consideration and focus on using drugs with a low risk of complications and infiltration techniques that do not cause an unnecessary delay in rehabilitation and discharge of the patient. Furthermore, addressing traction time, surgical technique, and fluid extravasation and applying an individualized approach, keeping the patient's personality and profile in mind, will ensure adequate analgesia after arthroscopic intervention.

A Prospective Randomized Controlled Trial Comparing the Efficacy of Fascia Iliaca Compartment Block Versus Local Anesthetic Infiltration After Hip Arthroscopic Surgery.

PURPOSE: To compare the efficacy of fascia iliaca compartment block (FICB) with local anesthetic infiltration (LAI) of the arthroscopy portals for pain control after hip arthroscopy. METHODS: A prospective single-blinded randomized controlled trial that involved patients who underwent hip arthroscopy was performed. Participants were randomized to receiving either FICB or LAI of the portal tracts with local anesthetic. Supplemental analgesia was also used in both groups on an on-demand basis. The primary outcome measure was the postoperative level of pain as assessed by numeric pain score at 1, 3, 6, and 24 hours after the procedure in both groups. Secondary outcome measures were the frequency and the dose of morphine and other medications consumed at 1 and 24 hours after surgery as well as any other adverse events relating to pain or medications used for pain relief in both the groups. RESULTS: The study had to be terminated early because there was a significant statistical difference in the primary outcome measure after the recruitment of 46 patients: 20 in the LAI group and 26 in the FICB group. Severity of pain in the FICB group was higher especially during the first hour postoperatively (P = .02). This was associated with a higher consumption of opioids and other analgesics, which resulted in more side effects such as nausea and vomiting. CONCLUSIONS: LAI provided a better analgesia after arthroscopic surgery of the hip in comparison with FICB and was also associated with reduced consumption of opioids and a lower rate of side effects. LEVEL OF EVIDENCE: Level I, single-blinded randomized controlled study.

Osteoarthritis: genes, nature-nurture interaction and the role of leptin.

Osteoarthritis (OA) is a common disease affecting patients at different ages regardless of gender or ethnicity. As with many chronic diseases, OA is thought to have a multifactorial aetiology, which is not fully understood. Whereas the pathophysiological process of OA can be analysed at a cellular and molecular level, the interaction between genes and lifestyle remains an important factor in the development of this disease. The expanding awareness of different genes that may play a role in OA, together with many chemical mediators thought to be associated with the progression of the disease, will help in better management of this condition. Some of the chemical mediators recently implicated in this condition are the adipokines (leptin, adiponectin and resistin). Few but consistent studies suggest that leptin in association with obesity could be an important factor in OA aetiology. Hence, this could establish a strong and direct molecular link between patient life style (nurture) and the pathological process of OA (nature). However, neither a clear mechanism nor a direct clinical association linking leptin to OA has yet been established. In this article, we explore some of the genetic and environmental factors in OA aetiology. We discuss leptin in obesity and assess its possible association with OA aetiology. This should emphasise the important role of health professionals in treating obesity in order to control OA symptoms and possibly progression.

An evidence-based update on the management of articular cartilage defects in the hip.

Objective: Articular cartilage defects in the hip joint pose a significant surgical challenge and remain one of the most important determinants of success following arthroscopic intervention of the hip. The aim of this literature review was to report on the best available evidence on the various treatment options utilised for articular cartilage defects in the hip. Material and methods: A comprehensive literature search was performed on PubMed from its inception to October 2021 using the following search strategy: ((hip) and (cartilage or chondral) and (repair or regeneration or restoration or implantation or chondroplasty or chondrogenic)). Two reviewers (KHSK, MG) independently reviewed titles and abstracts to identify articles for the final analysis. Articles were included if they were original research studies (randomised control trials, cohort studies, case-control studies, or comparative studies) on treatment of hip cartilage defects in humans reporting on a minimum of 5 patients. A total of 1172 articles were identified from the initial literature search. Following a thorough selection process, 35 articles were included in the final analysis to synthesise the evidence. Results: Debridement, microfracture, autologous chondocyte implanatation (ACI) and matrix-induced ACI (MACI) are shown to have good short-to medium-term results. Injectable ACI and MACI have been developed to enable these procedures to be performed via arthroscopic surgery to reduce the post-operative morbidity associated with surgery with promising early results. Large cartilage defects which involved the sub-chondral bone may need the use of osteochondral grafts either autograft or allograft. Newer biological solutions have been developed to potentially deliver a single-stage procedure for hip cartilage injuries but longer-term results are still awaited. Conclusion: Accurate identification of the extent of the injury helps stratify the defect and plan appropriate treatment. Several surgical techniques have shown good short to medium-term outcomes with ACI, AMIC, mosaicplasty and microfracture. Recent advances have enabled the use of injectable MACI and bioscaffolds which show promising results but in the shorter term. However, one needs to be mindful of the techniques which can be used in their surgical setting with the available resources. In order to thoroughly evaluate the benefits of the different surgical techniques for hip cartilage defects, large scale prospective multi-centre studies are necessary. Perhaps inclusion of such procedures in registries may also yield meaningful and pragmatic results.