Both Labral Debridement and Labral Repair Result in >90% Total Hip Arthroplasty-free Survival at 5-Year Follow-Up: An Analysis of the German Cartilage Registry (KnorpelRegister DGOU).

PURPOSE: To compare clinical outcome parameters between labral debridement and repair by analyzing the dataset of a multinational registry. METHODS: The data are based on the hip module of the German Cartilage Registry (KnorpelRegister DGOU). The register included patients designated for cartilage or femoroacetabular impingement surgery (up to July 1, 2021; n = 2725). The assessment consisted of the patient's characteristics, the type of labral treatment, the length of labral therapy, the pathology, the grade of cartilage damage, and the type of performed approach. The clinical outcomes were documented by the international hip outcome tool via an online platform. Separated Kaplan-Meier analyses were used for total hip arthroplasty (THA)-free survival rates. RESULTS: The debridement group (n = 673) showed a mean score increase of 21.9 ± 25.3 points. The repair group (n = 963) had a mean improvement of 21.3 ± 24.6 (P > .05). The 60-month THA-free survival rate was 90% to 93% for both groups (P > .05). A multivariance analysis showed that the grade of cartilage damage was the only independent statistically significant factor (P = .002-.001) influencing patients' outcomes and THA-free survival. CONCLUSIONS: Labral debridement and repair led to good and reliable results. However, these results should not be interpreted with the conclusion that the cheaper and technically easier labral debridement is the recommended treatment due to comparable results in the present study. The clinical outcome and the THA-free survival seemed to be more influenced by the grade of cartilage damage. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Two-Year Results of Injectable Matrix-Associated Autologous Chondrocyte Transplantation in the Hip Joint: Significant Improvement in Clinical and Radiological Assessment.

PURPOSE: Articular cartilage defects are a prevalent consequence of femoroacetabular impingement (FAI) in young active patients. In accordance with current guidelines, large chondral lesions of the hip joint over 2 cm2 are recommended to be treated with matrix-associated, autologous chondrocyte transplantation (MACT); however, the conditions in the hip joint are challenging for membrane-based MACT options. Injectable MACT products can solve this problem. The purpose of the trial was to assess clinical and radiological outcomes 24 months after injectable MACT of focal chondral lesions caused by FAI. METHODS: We present data of 21 patients with focal cartilage defects of the hip [3.0 ± 1.4 cm2 (mean ± SD)], ICRS Grade III and IV caused by CAM-type impingement, who underwent arthroscopic MACT (NOVOCART® Inject) and FAI correction. The outcome was evaluated with the patient-reported outcome instruments iHOT33 and EQ-5D-5L (index value and VAS), whilst graft morphology was assessed based on the MOCART score over a follow-up period of 24 months. RESULTS: The iHOT33 score increased significantly from 52.9 ± 21.1 (mean ± SD) preoperatively to 85.8 ± 14.8 (mean ± SD; p < 0.0001) 24 months postoperatively. The EQ-5D-5L index value (p = 0.0004) and EQ-5D VAS (p = 0.0006) showed a statistically significant improvement as well. MRI evaluation after 24 months showed successful integration of the implant in all patients with a complete defect filling in 11 of 14 patients. CONCLUSIONS: Injectable MACT for the treatment of full-thickness chondral lesions of the hip joint due to FAI in combination with FAI correction improved symptoms, function, and quality of life in the treated cohort. Alongside the treatment of the underlying pathology by the FAI correction, the developed cartilage defect can be successfully repaired by MACT, which is of considerable clinical relevance.

Distraction Gap Needed for Safe Central Compartment Access in Hip Arthroscopy.

BACKGROUND: Sufficient distraction of the hip is the key to a safe central compartment (CC) approach in hip arthroscopy. However, an adequate distraction gap has not been scientifically identified. PURPOSE: To determine the sufficient amount of distraction that could predict a successful CC access as well as to identify the risk factors for a failed or difficult CC access. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients who underwent hip arthroscopy by a single surgeon between January 2018 and April 2019 were prospectively enrolled. We analyzed gaps of the hip on 4 C-arm fluoroscopic images: nondistraction, preoperative manual traction, preoperative maximal traction (without distension), and intraoperative maximal traction (at the end of CC procedures in a successful CC approach or after peripheral compartment procedures in a failed or difficult CC approach). A failed CC approach was defined as failure in introducing the anterolateral portal to the CC under arthroscopic control; a difficult CC approach was defined as the presence of an incomplete diagnostic round in the CC because of a small distraction. The amount of distraction was evaluated by the ratio of the distracted gap to the undistracted gap. Patients were classified into the successful CC access group (group 1) and the failed/difficult CC access group (group 2). The amount of distraction, demographic characteristics, and preoperative radiographic parameters were compared between the groups. RESULTS: A total of 240 patients were included in this study. Group 1 consisted of 205 patients (113 males and 92 females; mean ± SD age, 34.5 ± 11.4 years), and group 2 consisted of 35 patients (27 males and 8 females; age, 32.5 ± 11.2 years). The preoperative joint space width was not significantly different between group 1 (mean ± SD, 3.89 ± 0.83 mm) and group 2 (3.68 ± 0.68 mm). The ratio of the amount of distraction at lateral gaps under all traction conditions was significantly greater in group 1 compared with group 2 (1.50 ± 0.54 vs 1.26 ± 0.35, respectively, under preoperative manual traction; 2.84 ± 0.76 vs 2.03 ± 0.63 under preoperative maximal traction; 3.36 ± 0.96 vs 2.50 ± 0.79 under intraoperative maximal traction). An increase of the lateral gap by >2.2 times (P < .001) under preoperative maximal traction and by >2.7 times (P < .001) under intraoperative maximal traction could predict successful CC access. Male sex (odds ratio [OR], 2.94; P = .017) and increased lateral center-edge angle (OR, 1.08 for every 1° increase; P = .004) were significant risk factors for failed/difficult CC access. CONCLUSION: An increase of the lateral gap by >2.2 times during an unsterile traction test without joint distension could predict successful CC access. Male sex and increased lateral center-edge angle were risk factors for a failed or difficult CC access.

[Labral lesions in femoroacetabular impingement syndrome: evidence-based treatment]. / Labrumläsionen bei femoroazetabulärem Impingement-Syndrom: evidenzbasierte Therapie.

BACKGROUND: The acetabular labrum and the adjacent rim cartilage are the primary targets of primary or secondary degeneration processes in the hip joint. Currently, femoroacetabular impingement syndrome (FAIS) is considered the main mechanical pathology leading to chondrolabral damage. The treatment options for labrum tears range from a debridement/resection, repair to augmentation or transplantation. AIM: Description of surgical treatment options for pathologic changes of the acetabulare labrum and their results with a focus on FAIS. MATERIALS AND METHODS: A literature search was performed on https://pubmed.ncbi.nlm.nih.gov using the following key words: hip, labrum, therapy, resection, repair, augmentation, reconstruction. RESULTS: The different surgical procedures as labrum therapy reduce pain and increase the joint function. Labral repair, augmentation, and reconstruction tend to have better results compared to resection but are associated with a higher rate of postoperative intraarticular adhesions. DISCUSSION: In addition to reducing pain and improving function, the goal of surgical treatment of labrum lesions should be to maintain the functions of the labrum. The labrum should be preserved, in cases of adequate tissue quality and width. In the setting of resective procedures, the resection should be limited to the unstable parts of the labrum. The results of labral augmentation and reconstruction are promising, allowing these procedures to be considered for patients with ongoing symptoms in the revision situation with labral defects or an insufficient residual labrum.

Preoperative Alpha Angles Can Predict Severity of Acetabular Rim Chondral Damage in Symptomatic Cam-Type Femoroacetabular Impingement: A Prospective Observatory Study.

PURPOSE: To identify the relationship between the alpha angle and the severity of chondrolabral separation as well as acetabular rim chondral damage in symptomatic cam-type femoroacetabular impingement (FAI) with or without focal pincer-type FAI. METHODS: Patients who received hip arthroscopy under the diagnosis of symptomatic cam-type FAI between January 2018 and August 2018 were identified in a prospectively collected database. Patients were excluded if preoperative lateral center-edge angle <25°, lateral center-edge angle ≥40°, Tönnis grade >1, with previous surgery on the affected hip, or with concomitant synovial disease. The chondrolabral junction was classified into intact chondrolabral junction, stable chondrolabral separation and unstable chondrolabral separation. The classification of acetabular rim chondral damage was modified from the MAHORN (Multicenter Arthroscopy of the Hip Outcomes Research Network) classification: normal/softening, bubble, pocket, flap, and exposed bone. The relationship between the hip morphology and severity of chondrolabral junction and acetabular rim chondral damage was assessed. RESULTS: A total of 71 patients with the mean age of 33.2 ± 11.0 years were included. Preoperative alpha angles on anteroposterior (AP) or Lauenstein view positively correlated with the severity of acetabular rim chondral damage (P = .028 and P = .016, respectively). A significant increment of the alpha angle between 2 consecutive grades of acetabular rim chondral damage was 7.1° (P = .001) on AP view and 5.2° on Lauenstein view (P = .001). The cut-off values for predicting advanced acetabular rim chondral damage (pocket, flap or bony exposure) were an AP alpha angle of 70° (P = .025) and a Lauenstein alpha angle of 57° (P = .003). There was no significant association between the alpha angle and the severity of chondrolabral separation. CONCLUSIONS: In patients with symptomatic cam-type FAI with or without focal pincer-type FAI, greater preoperative alpha angles on AP and Lauenstein views can predict more severe acetabular chondral damage. LEVEL OF EVIDENCE: Level III.

Outcomes of arthroscopic management for pigmented villonodular synovitis of the hip.

INTRODUCTION: Early synovectomy is considered as the main treatment of pigmented villonodular synovitis (PVNS) of the hip in young patients with preserved cartilage. The purpose of the study is to evaluate outcomes of arthroscopic management for PVNS of the hip. METHODS: Patients who underwent primary hip arthroscopy for the treatment of histology-confirmed PVNS by the senior author between January 2012 and December 2016 were retrospectively reviewed. We excluded patients who had less than 1-year follow-up or had undergone primary surgeries with other surgeons and then received revision hip arthroscopic procedures by the senior author. The recurrence of PVNS and postoperative condition of affected hip were assessed by follow-up magnetic resonance imaging (MRI). Patient-reported outcomes of modified Harris hip score (mHHS) and 12-item International Hip Outcome Tool (iHOT-12) were collected at latest follow-up. RESULTS: Nine patients (2 males, 7 females) with a mean age of 24.3 ± 11.2 years (range 14-44 years) were included in this study. Localized PVNS was observed in four patients, and diffuse PVNS was observed in five patients. No patient presented with advanced osteochondral destruction. Five patients received single adjuvant radiosynoviorthesis. No patient had evidence of recurrence based on follow-up MRI. Patient-reported outcomes were obtained in eight patients at mean 55.8 ± 26.1 months (range 24-84 months) after the index surgery. The mean mHHS was 94.6 ± 4.9 (range 84.7-100) and the mean iHOT-12 was 93.3 ± 20.2 (range 50-120). No patient needed secondary surgery during the follow-up period. CONCLUSION: Arthroscopic subtotal synovectomy can offer favorable short to mid-term outcomes in the treatment of hip PVNS in case of no advanced osteochondral damage at presentation.

The Lisbon Agreement on femoroacetabular impingement imaging-part 2: general issues, parameters, and reporting.

OBJECTIVES: Imaging assessment for the clinical management of femoroacetabular impingement (FAI) is controversial because of a paucity of evidence-based guidance and notable variability among practitioners. Hence, expert consensus is needed because standardised imaging assessment is critical for clinical practice and research. We aimed to establish expert-based statements on FAI imaging by using formal methods of consensus building. METHODS: The Delphi method was used to formally derive consensus among 30 panel members from 13 countries. Forty-four questions were agreed upon, and relevant seminal literature was circulated and classified in major topics to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement (0-10). This is the second part of a three-part consensus series and focuses on 'General issues' and 'Parameters and reporting'. RESULTS: Forty-seven statements were generated and group consensus was reached for 45. Twenty-five statements pertaining to 'General issues' (9 addressing diagnosis, differential diagnosis, and postoperative imaging) and 'Parameters and reporting' (16 addressing femoral/acetabular parameters) were produced. CONCLUSIONS: The available evidence was reviewed critically, recommended criteria for diagnostic imaging highlighted, and the roles/values of different imaging parameters assessed. Radiographic evaluation (AP pelvis and a Dunn 45° view) is the cornerstone of hip-imaging assessment and the minimum imaging study that should be performed when evaluating adult patients for FAI. In most cases, cross-sectional imaging is warranted because MRI is the 'gold standard' imaging modality for the comprehensive evaluation, differential diagnosis assessment, and FAI surgical planning. KEY POINTS: • Diagnostic imaging for FAI is not standardised due to scarce evidence-based guidance on which imaging modalities and diagnostic criteria/parameters should be used. • Radiographic evaluation is the cornerstone of hip assessment and the minimum study that should be performed when assessing suspected FAI. Cross-sectional imaging is justified in most cases because MRI is the 'gold standard' modality for comprehensive FAI evaluation. • For acetabular morphology, coverage (Wiberg's angle and acetabular index) and version (crossover, posterior wall, and ischial spine signs) should be assessed routinely. On the femoral side, the head-neck junction morphology (α° and offset), neck morphology (NSA), and torsion should be assessed.

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 3: imaging techniques.

OBJECTIVES: Imaging diagnosis of femoroacetabular impingement (FAI) remains controversial due to a lack of high-level evidence, leading to significant variability in patient management. Optimizing protocols and technical details is essential in FAI imaging, although challenging in clinical practice. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal consensus techniques driven by relevant literature review. Recommendations on the selection and use of imaging techniques for FAI assessment, as well as guidance on relevant radiographic and MRI classifications, are provided. METHODS: The Delphi method was used to assess agreement and derive consensus among 30 panel members (musculoskeletal radiologists and orthopedic surgeons). Forty-four questions were agreed on and classified into five major topics and recent relevant literature was circulated, in order to produce answering statements. The level of evidence was assessed for all statements and panel members scored their level of agreement with each statement during 4 Delphi rounds. Either "group consensus," "group agreement," or "no agreement" was achieved. RESULTS: Forty-seven statements were generated and group consensus was reached for 45. Twenty-two statements pertaining to "Imaging techniques" were generated. Eight statements on "Radiographic assessment" and 12 statements on "MRI evaluation" gained consensus. No agreement was reached for the 2 "Ultrasound" related statements. CONCLUSION: The first international consensus on FAI imaging was developed. Researchers and clinicians working with FAI and hip-related pain may use these recommendations to guide, develop, and implement comprehensive, evidence-based imaging protocols and classifications. KEY POINTS: • Radiographic evaluation is recommended for the initial assessment of FAI, while MRI with a dedicated protocol is the gold standard imaging technique for the comprehensive evaluation of this condition. • The MRI protocol for FAI evaluation should include unilateral small FOV with radial imaging, femoral torsion assessment, and a fluid sensitive sequence covering the whole pelvis. • The definite role of other imaging methods in FAI, such as ultrasound or CT, is still not well defined.

Correction to: The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 1: overview.

The original version of this article, published on 14 May 2020, unfortunately contained a mistake.

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 1: overview.

OBJECTIVES: Imaging assessment for the clinical management of femoroacetabular impingement (FAI) syndrome remains controversial because of a paucity of evidence-based guidance and notable variability in clinical practice, ultimately requiring expert consensus. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal techniques of consensus building. METHODS: A validated Delphi method and peer-reviewed literature were used to formally derive consensus among 30 panel members (21 musculoskeletal radiologists and 9 orthopaedic surgeons) from 13 countries. Forty-four questions were agreed on, and recent relevant seminal literature was circulated and classified in five major topics ('General issues', 'Parameters and reporting', 'Radiographic assessment', 'MRI' and 'Ultrasound') in order to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement with each statement (0 to 10) during iterative rounds. Either 'consensus', 'agreement' or 'no agreement' was achieved. RESULTS: Forty-seven statements were generated, and group consensus was reached for 45 (95.7%). Seventeen of these statements were selected as most important for dissemination in advance. There was no agreement for the two statements pertaining to 'Ultrasound'. CONCLUSION: Radiographic evaluation is the cornerstone of hip evaluation. An anteroposterior pelvis radiograph and a Dunn 45° view are recommended for the initial assessment of FAI although MRI with a dedicated protocol is the gold standard imaging technique in this setting. The resulting consensus can serve as a tool to reduce variability in clinical practices and guide further research for the clinical management of FAI. KEY POINTS: • FAI imaging literature is extensive although often of low level of evidence. • Radiographic evaluation with a reproducible technique is the cornerstone of hip imaging assessment. • MRI with a dedicated protocol is the gold standard imaging technique for FAI assessment.

Hip arthroscopy via a peripheral compartment first capsular-preserving technique: a step-by-step description.

Hip arthroscopy is a well-recognized procedure for the treatment of several hip pathologies. Different methods of arthroscopic access to the hip have been published. The most popular approach is the central compartment first technique, where the first portal to the central compartment is placed under traction and fluoroscopic control. This technique, however, carries the risk of iatrogenic damage to the cartilage and labrum, especially when adequate distraction cannot be obtained. In addition, secondary exposure of the peripheral compartment frequently requires larger capsulotomies. The current article is to describe an alternative arthroscopic approach to the hip with the peripheral compartment being first accessed. The peripheral compartment first technique offers the advantages of a limited capsular release for peripheral compartment exposure and a reduced risk of iatrogenic cartilage and labrum damage during subsequent central compartment portal placement.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.

Erratum to: The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

[This corrects the article DOI: 10.1093/jhps/hnaa043.].

Arthroscopic matrix-associated, injectable autologous chondrocyte transplantation of the hip: significant improvement in patient-related outcome and good transplant quality in MRI assessment.

PURPOSE: Acetabular chondral lesions are common in patients with FAI. For large full-thickness cartilage defects, arthroscopic matrix-associated autologous chondrocyte transplantation (MACT) using an injectable in situ crosslinking product is an option. Aim of the study was to evaluate clinical and MRI results 12 months after MACT of acetabular cartilage defects in FAI patients. METHODS: We report data on 21 patients with a focal cartilage defect of the hip [2.97 ± 1.44 cm2 (mean ± SD)] caused by FAI treated with an arthroscopically conducted MACT combined with FAI surgery. The results were assessed with patient-reported outcome measures (iHOT33, EQ-5D) pre- as well as post-operatively and by MRI using MOCART scoring system 6 and 12 months post-operatively. RESULTS: The iHOT33 score improved from 52.9 ± 21.14 (mean ± SD) pre-operative to 81.08 ± 22.04 (mean ± SD; p = 0.0012) 12 months post-operatively. The lower the pre-operative iHOT33 score and the larger the defect size, the greater the observed improvement compared to pre-operative scores at 12 months. Patients showed a significant improvement in EQ-5D-5L index value (p = 0.0015) and EQ-5D VAS (p = 0.0006). MRI analysis after 12 months revealed a complete integration of the transplant in 16 of 20 patients. CONCLUSIONS: Injectable MACT is a promising minimally invasive treatment option for full-thickness cartilage defects of the hip caused by FAI. A significant improvement in symptoms and function associated with an increase in quality of life was detected in patients treated with injectable MACT combined with FAI surgery. This is of considerable clinical relevance, since, in addition to the elimination of the mechanical cause, MACT allows the successful therapy of consequential cartilage damage. LEVEL OF EVIDENCE: Level 4, case series.

Surgical Outcomes in the Treatment of Concomitant Mild Acetabular Dysplasia and Femoroacetabular Impingement: A Systematic Review.

PURPOSE: To analyze the current approaches and clinical outcomes in the surgical management of concomitant mild acetabular dysplasia and femoroacetabular impingement (FAI). METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method, the PubMed and Medline databases were searched in March 2019 for studies that reported on surgical outcomes in hips with concomitant mid acetabular dysplasia and FAI. Studies published in English that focused on the surgical outcomes after hip arthroscopy, open surgery, or periacetabular osteotomy of concomitant acetabular dysplasia and FAI, in which the lateral center-edge angle of all subjects was between 15° and 25°, were included. Articles that included subjects with lateral center-edge angle <15°, with a minimum follow-up duration <1 year, had <5 subjects, or were not original articles were excluded. RESULTS: The initial search yielded 748 studies, and 5 studies met the inclusion criteria. All these 5 studies focused on hip arthroscopic treatment for patients with concomitant mild acetabular dysplasia and FAI. Three studies had level III evidence, whereas 2 studies had level IV evidence. The mean patient age range across the studies was 29.8 to 49.6 years, and the female-to-male ratio was 1.14. Improved patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport, modified Harris Hip Score, Short Form-12 Physical Component Summary, Western Ontario and McMaster Universities Osteoarthritis Index) at a minimum 2-year follow-up were obtained in 4 of the 5 studies. Two of these 4 studies had a comparative cohort of patients with FAI with normal acetabular coverage, and there was no significant difference in the postoperative outcomes and secondary procedure rate between patients with mild acetabular dysplasia and those with normal acetabular coverage. CONCLUSIONS: This systematic review indicates that improved patient-reported outcomes can be obtained with hip arthroscopy in the treatment of concomitant mild acetabular dysplasia and FAI at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

[Femoroacetabular impingement - Update 2019]. / Femoroazetabuläres Impingement ­ Update 2019.

BACKGROUND: Since the first description of the femoroacetabular impingement (FAI) concept diagnostic imaging of FAI has continuously been developed. OBJECTIVE: The biomechanical concept is explained and an update on diagnostic imaging of FAI is presented. MATERIAL AND METHODS: Based on a literature search this review article presents the current state of knowledge about FAI mechanisms and gives an overview on state of the art radiological diagnostics. A perspective on new imaging methods is also given. RESULTS: The FAI is a dynamic phenomenon with a mechanical conflict between the femoral head and/or neck and the acetabulum. It is usually suspected clinically; however, imaging plays an essential role in establishing the diagnosis by detecting and defining the underlying deformities of the proximal femur (cam deformity) and the acetabulum (pincer deformity) and by evaluating associated lesions of the articular cartilage and labrum. Basic imaging diagnostics consist of anteroposterior and lateral radiographs. Magnetic resonance imaging (MRI) and MR arthrography are the preferred imaging modalities for detailed analysis of deformities, for the detection and graduation of lesions of articular cartilage (sensitivity 58-91%) and labral lesions (sensitivity 50-92%). Simultaneously, these methods can exclude other hip diseases. Current standards and new developments in FAI imaging are presented. CONCLUSION: For the diagnosis of FAI typical clinical and imaging findings are required. Radiological diagnostics are an indispensable component in establishing the diagnosis of FAI, in the differentiation of the underlying deformities and in the assessment of treatment-relevant joint damage.

[Biologic Reconstruction of Full Sized Cartilage Defects of the Hip: A Guideline from the DGOU Group "Clinical Tissue Regeneration" and the Hip Committee of the AGA]. / Biologische Rekonstruktion lokalisiert vollschichtiger Knorpelschäden des Hüftgelenks: Empfehlungen der Arbeitsgemeinschaft "Klinische Geweberegeneration" der DGOU und des Hüftkomitees der AGA.

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm2. Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary.

Compression and Flip Test for Diagnosis of Unstable Acetabular Labral Tears Using a Peripheral Compartment Approach.

Assessment of integrity of the acetabular labrum is generally done via the central compartment under distraction of the femoral head from the acetabulum. With the technique of raising the extra-articular and peripheral compartment first, there is a need for testing the stability and function of the labrum from the peripheral side in a nondistracted position of the joint. The authors report on the compression and flip test (i.e., the flip test) for the detection of unstable, intrasubstance tears of the labrum or unstable chondrolabral separations. The test can be performed by compressing the labrum with blunt instruments. We grade the labral conditions as follows: grade 0 for firm resistance and elasticity to palpation, grade 1+ as easily compressed by the probe, grade 2+ for eversion of the body of the labrum under compression), and grade 1 for ossified, hard resistance without any elasticity and compressibility. This test can be performed directly after accessing the peripheral compartment through a 2-portal technique without extensive capsular work.

Vascular obstruction at the level of the ankle joint as a complication of hip arthroscopy.

We report a case of foot vascular obstruction as a complication of hip arthroscopy. A 23-year-old female patient underwent hip arthroscopy for femoroacetabular impingement. The duration of the procedure was 80 minutes, including 20 minutes with traction for arthroscopy of the central compartment and 60 minutes without traction for cam treatment in the peripheral compartment. Three days postoperatively, the patient complained of a cold foot and pain and paresthesia during leg and foot elevation with continuous passive motion therapy. With persisting symptoms, she was seen by the referring physician 4 days postoperatively. Pulselessness at the level of the ankle and reduced capillary perfusion were observed. Doppler sonography and magnetic resonance angiography showed an occlusion of the peroneal, posterior tibial, and anterior tibial arteries at the level of the right ankle. The patient was readmitted to the hospital and underwent intravenous prostaglandin E1 therapy for 9 days, followed by oral clopidogrel treatment for 6 weeks. After 8 weeks, follow-up Doppler sonographic findings were normal. Subjective paresthesia and sensation of coldness resolved completely after 6 months. Possible theories for this complication and strategies on how to avoid it are discussed.

[Arthroscopic resection of the cam deformity of femoroacetabular impingement]. / Arthroskopische Behandlung des femoroazetabulären Cam-Impingements der Hüfte.

OBJECTIVE: Resection of the cam deformity of the femoral head-neck junction in order to avoid femoroacetabular impingement and the development of secondary damage to the anterolateral acetabular rim. INDICATIONS: Femoroacetabular cam impingement. Initial femoroacetabular pincer impingement. Advanced femoroacetabular pincer impingement with degenerative tear of the labrum. CONTRAINDICATIONS: Femoroacetabular pincer impingement with significant retroversion and intact acetabular labrum, coxa profunda or circumferential ossification of the labrum. Advanced osteoarthritis. SURGICAL TECHNIQUE: Arthroscopy of the peripheral compartment via three portals with and without traction. The proximal anterolateral portal is used for the arthroscope, instrumentation is done via the anterior and classic anterolateral portal. After resection of the zona orbicularis and the inner parts of the iliofemoral ligament, the anterolateral cam deformity is resected without traction via the anterior portal. After distraction of the head from the acetabulum, the lateral and posterolateral cam deformity is trimmed via the classic anterolateral portal. POSTOPERATIVE MANAGEMENT: Pain-controlled progression to full weight bearing over 1-4 weeks, continuous passive motion therapy and stationary bike for 6 weeks in order to avoid intraarticular adhesions. RESULTS: From 2004 through early 2007, 72 hip arthroscopies were performed for femoroacetabular impingement. So far, 48 patients (25 men, 23 women, mean age 37 years [17-65 years]) were followed up. After a mean follow-up of 18 months, the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was significantly improved from 65 +/- 21 to 82 +/- 18 and the NAHS (Non Arthritic Hip Score) from 57 +/- 19 to 78 +/- 19. COMPLICATIONS: two persistent branch lesions of the lateral femoral cutaneous nerve. One patient was surgically dislocated after 8 months for the treatment of a significant retroversion of the acetabulum; one patient underwent total hip arthroplasty after 1 year.