Hip arthroscopy in patients with recurrent pain following Bernese periacetabular osteotomy for acetabular dysplasia: operative findings and clinical outcomes

摘要

With institutional review board approval, a comprehensive hip procedural database at an academic referral center was used to retrospectively identify a series of patients who underwent hip arthroscopy for recurrent ipsilateral hip pain following previous PAO performed for acetabular dysplasia. PAO procedures were performed by a single surgeon between 2000 and 2009, with a previously described technique [7, 24]. Hip arthroscopy was performed by multiple surgeons; three surgeons at our institution performed a total of 13 of the post-PAO hip arthroscopies, and three surgeons from outside institutions performed a post-PAO hip arthroscopy, from which operative reports were obtained in all cases. The indications for hip arthroscopy after PAO included recurrent hip symptoms, such as pain, subjective complaints of instability without frank subluxation or dislocation, and/or snapping, in the post-PAO period that was refractory to conservative management. All patients reported improvement immediately following diagnostic intra-articular injections, but the improvement was transient in all cases, despite corticosteroid in the injection material. No such cases were performed for patients advanced osteoarthritic changes. We excluded patients for whom operative records for both PAO and hip arthroscopy were not available. Data analysed included basic demographic information (gender, date of birth, age at time of PAO, age at time of post-PAO hip arthroscopy and laterality), preceding surgeries (number, type and documented surgical indications), radiographic findings, arthroscopic findings (cam lesion, pincer lesion, labral tear, chondral injury to the acetabulum or femoral head, synovitis, tear of ligamentum teres and psoas tendonitis), pre- and post-operative functional outcome measures, including University of California Los Angeles (UCLA) activity score [25], Modified Harris Hip Score (MHHS) [26] and Hip Disability and Orthoarthritis Outcome Score (HOOS) [27], which includes the Western Ontario (WOMAC) domains for pain, stiffness and function, and re-operations following arthroscopy. Magnetic resonance imaging (MRI) was obtained following PAO and prior to hip arthroscopy using 1.5 Tesla delayed gadolinium-enhanced magnetic resonance imaging (dGEMRIC) [28, 29]. Answers to an original questionnaire with questions specifically related to patients' perceptions of their outcomes following the hip arthroscopy after PAO were also analysed. These included: (i) do you feel that your hip arthroscopy improved the hip pain that you were experiencing after the PAO?; (ii) do you feel that your hip arthroscopy improved the hip stiffness that you were experiencing after the PAO?; (iii) do you feel that your hip arthroscopy improved your hip function after the PAO? and (iv) are you satisfied today with the results of the surgeries that were performed on your hip? Demographic information for patients was summarized with means, standard deviations and ranges. Comparisons between outcome scores were via two-sample Student t-test with significance level P?=?0.05 using SPSS Statistical Software (Chicago, IL). Of 556 patients undergoing PAO by a single surgeon at an academic referral center over a 10-year period with minimum 2-year follow-up following PAO, 16 patients (3.1%) and 17 hips underwent post-PAO arthroscopy. One patient with incomplete arthroscopy records from an outside hospital was excluded from the data analysis (Fig. 1). For the remaining 16 hips in 15 patients (13 females, 2 males; 9 right hip, 7 left hip, 1 bilateral), the mean age at time of PAO was 23.8 years (range 12.6–44.3 years), and the mean age at time of hip arthroscopy was 27.0 years (range 15.2–49.5 years), with a mean interval of 3.3 years (range 0.6–7.7 years) between PAO and hip arthroscopy. Two hips in two patients (12.5%) had undergone multiple surgeries for additional proximal femoral deformities prior to the PAO (Table I). Of the 16 hips studied, nine hips (56.25%) underwent arthrotomy at the time of the PAO, which revealed labral tears in four hips, significant labral hypertrophy without labral tear in four hips and chondromalacia of the femoral head in four hips. Among these nine patients, four had multiple findings, four had only one significant finding and one had no findings. Six hips (37.5%) underwent additional procedures concurrent with the PAO: three hips underwent debridement of labral tears, one hip underwent greater trochanteric distal and lateral transfer for trochanteric overgrowth and three hips underwent intertrochanteric osteotomy (two for coxa valga and one for coxa vara) (Table II). All 15 patients (16 hips) who underwent hip arthroscopy after PAO had experienced recurrent hip symptoms, such as pain, subjective complaints of instability without frank subluxation or dislocation, and/or snapping, in the post-PAO period that was refractory to conservative management, including intra-articular steroid injections in all cases. Of note, all pati