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Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

ABSTRACT: Femoral retroversion is an uncommon cause of cam femoroacetabular impingement that may require surgical treatment beyond arthroscopic or open femoroplasty. We present the case of a young adult with bilateral severe femoral retroversion in whom such treatment failed. We discuss the rationale, surgical technique, and outcome of this patient, who underwent bilateral closed intramedullary derotational proximal femoral osteotomies and interlocked nailing with adjunctive pre- and post-osteotomy hip arthroscopies. Clinical improvement with normal foot progression angles, radiographic union, and resolution of bilateral cam femoroacetabular impingement from femoral retroversion was achieved. This surgery permits rapid institution of weight-bearing ambulation and an early rehabilitative program. Femoral retroversion may be an underappreciated and insufficiently treated cause of cam femoroacetabular impingement that may be readily detected and successfully remedied with this less invasive procedure.

SUBMITTER: Matsuda DK

PROVIDER: S-EPMC3986483 | biostudies-literature | 2014 Feb

REPOSITORIES: biostudies-literature

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Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

Matsuda Dean K DK Gupta Nikhil N Martin Hal D HD

Arthroscopy techniques 20140110 1

Femoral retroversion is an uncommon cause of cam femoroacetabular impingement that may require surgical treatment beyond arthroscopic or open femoroplasty. We present the case of a young adult with bilateral severe femoral retroversion in whom such treatment failed. We discuss the rationale, surgical technique, and outcome of this patient, who underwent bilateral closed intramedullary derotational proximal femoral osteotomies and interlocked nailing with adjunctive pre- and post-osteotomy hip ar ...[more]

PMID: 24749047

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Project description:Hip arthroscopy is one of the most rapidly growing fields in orthopaedic surgery. One of the most frequent pathologies treated with hip arthroscopy remains femoroacetabular impingement, which is addressed by labral repair and femoral osteoplasty. The most commonly cited reason for failure of arthroscopic treatment of femoroacetabular impingement is under-resection of the cam lesion. Surgeons frequently use evaluations of preoperative images, intraoperative fluoroscopy, and dynamic range of motion to ensure adequate resection. In this article, we describe a reproducible and standardized technique to assist in appropriate resection. This is achieved by a 2-tiered resection technique: Tier 1 aims to set the depth of resection and restore the head-neck offset. Tier 2 then matches the depth of the resection set by tier 1 and allows for retention of appropriate transition of the proximal convexity to the distal concavity seen in more ideally shaped femoral heads. With this technique, we offer a tool to avoid under-resection in the area of maximal conflict while simultaneously minimizing the risk of proximal over-resection and thus compromising the fluid seal dynamics of the joint in deeper flexion angles. Technique Video Video 1 Visualization of femoral osteoplasty from distal anterolateral portal. The resection begins with visual inspection and localization of important anatomy including the lateral retinacular vessels. The osteoplasty ensues in a 2-tiered manner. The tier 1 resection is begun 1.5 burr widths distal to the articular surface margin with the goal to create the depth of resection required to re-create the native head-neck offset. This is also confirmed with fluoroscopic imaging from the Dunn lateral view to identify the physeal scar as the proximal extent of the osteoplasty. During the tier 1 resection, the proximal head-neck junction is contoured to achieve sphericity. The tier 2 resection is then begun distal to tier 1 with the goal of matching the depth and resecting the remainder of the cam. Finally, attention is turned back to the head-neck junction with the goal of creating a smooth, spherical head via gentle contouring. During the resection, multiple views through the distal anterolateral portal are used to gather a greater perspective of the resection. At the completion of the procedure, evaluation of dynamic hip range of motion under direct visualization, along with fluoroscopic imaging, is used to ensure adequate resection of the cam lesion.

Project description:PurposeTo evaluate clinical depression scores and functional outcomes following arthroscopic treatment of femoroacetabular impingement syndrome in patients with elevated preoperative depressive symptoms as defined by Patient-Reported Outcomes Measurement Information System for Depression (PROMIS-D).MethodsPatients with femoroacetabular impingement syndrome completed the PROMIS-D Computer Adaptive Test and additional patient-reported outcome (PRO) measures preoperatively and at the time of postoperative visits. Patients were categorized into preoperative clinically depressed (CD) and nonclinically depressed (NCD) groups based on preoperative PROMIS-D scores. Scores ≥55 correlate to mild clinical depression, and this cutoff was used to determine preoperative depression status. PROMIS-D scores and functional outcome scores were assessed at 6 months and a minimum of 1-year postoperatively.ResultsIn total, 100 patients were included with complete PROs at a minimum of 1-year follow-up. Of those included, 21 (21%) were categorized with preoperative CD. There were no differences in demographic or radiographic variables between the preoperative CD and NCD groups. At 6 months and 12 months postoperatively, the percentage of patients in the preoperative CD group with continued depression was 33.3% and 23.8%, respectively. Overall, 1-year change in PROMIS-D score for the CD group was -9.1 versus -0.8 in the NCD group (P = .001). There was no significant difference in rates of patients achieving patient acceptable symptom state between the preoperative CD and NCD groups.ConclusionsPatients with symptoms of preoperative CD, as defined by the PROMIS-D score, demonstrated significant improvement in depressive symptoms following hip arthroscopy. In addition, patients with CD preoperatively did not show decreased rates of achieving minimum clinically important difference or patient acceptable symptom state on postoperative PROs compared with patients with NCD.Level of evidenceLevel IV, therapeutic case series.

Dataset Information

Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

Publications

Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.

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