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Management of a large acetabular chondrolabral injury in a young patient with femoroacetabular impingement.

ABSTRACT: Patients with mixed-type femoroacetabular impingement syndrome often have concomitant chondrolabral pathology in addition to the characteristic cam and pincer lesions. Unfortunately, these patients are typically young, and the pathology is localized to the weight-bearing dome of the acetabulum. Complete preoperative characterization of labral and cartilage lesions is often not possible even with advanced imaging techniques, and the full extent of the injury may not be appreciated without direct arthroscopic visualization. Thus management decisions regarding intra-articular pathology may not be possible until the time of surgery. Often, the cartilage and labral pathology in these young patients is part of a contiguous complex of tissue that separates from the underlying subchondral bone. We present an arthroscopic management technique for young patients with this pattern of injury. This includes limited debridement of loose labral and chondral tissue, labral repair to restore the suction-seal effect, microfracture to promote reparative tissue formation, and takedown of the underlying pathoanatomic cam and pincer lesions.

SUBMITTER: Sherman TI

PROVIDER: S-EPMC4314555 | biostudies-literature | 2014 Dec

REPOSITORIES: biostudies-literature

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Management of a large acetabular chondrolabral injury in a young patient with femoroacetabular impingement.

Sherman Thomas I TI Marcel John J JJ Postma William W

Arthroscopy techniques 20141208 6

Patients with mixed-type femoroacetabular impingement syndrome often have concomitant chondrolabral pathology in addition to the characteristic cam and pincer lesions. Unfortunately, these patients are typically young, and the pathology is localized to the weight-bearing dome of the acetabulum. Complete preoperative characterization of labral and cartilage lesions is often not possible even with advanced imaging techniques, and the full extent of the injury may not be appreciated without direct ...[more]

PMID: 25685678

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Project description:BackgroundFemoroacetabular impingement is increasingly recognized as a cause of hip pain but its incidence after an innominate osteotomy for the correction of acetabular dysplasia has not been determined. This information would be essential for the orthopaedic surgeon because it has the potential to produce a poor outcome in the long term when trying to balance acetabular instability and overcorrection.Questions/purposesThe purposes of our study were (1) to determine the frequency with which clinically relevant femoroacetabular impingement (FAI) occurs after an innominate osteotomy for the treatment of acetabular dysplasia; (2) to determine risk factors for the development of FAI; and (3) to compare postoperative radiographic and clinical outcomes in patients having undergone an innominate osteotomy for the correction of acetabular dysplasia both with and without FAI.MethodsThis was a retrospective review of 154 hips (132 patients) that had undergone an innominate osteotomy for acetabular dysplasia and were evaluated at a minimum followup of 10 years (mean = 12 years). Mean age at the time of surgery was 3 years, 114 hips had a concomitant open reduction, and 54 hips also had femoral shortening. One hundred eight hips had a Salter osteotomy and 46 had a Pemberton osteotomy. Radiographs were analyzed to determine the lateral center-edge angle (CE angle) and the presence of a crossover sign. The diagnosis of FAI was established when the CE angle was greater than 40°, there was a positive crossover sign, and the patient had groin pain when flexing the hip less than 90°. Comparisons between nonparametric variables were performed with a Mann-Whitney's U test. Categorical variables were compared with a chi-square test. Change in acetabular index (correction) was dichotomized considering 20° of correction as the cutoff point. Association is presented as odds ratio (95% confidence interval), and logistic regression was performed.ResultsAccording to our criteria, 18 of 154 hips had FAI (12%). Of the 18 patients with FAI, 10 had undergone a Pemberton osteotomy (10 of 46 [22%]) and eight a Salter osteotomy (eight of 108 [7%]). A change in the postoperative acetabular index greater than 20° was associated with a greater likelihood of developing FAI. The mean postoperative acetabular index was lower for the group with FAI, for whom it was 20°, compared with the group without FAI, for whom it was 27° (p = 0.04). The mean Iowa Hip Score for the group with FAI was 85, whereas for those without FAI, it was 93 (p = 0.03).ConclusionsFAI is not common after an innominate osteotomy for the treatment of acetabular dysplasia; however, overcorrection is related to a higher incidence. When FAI is present, it can affect the outcome. Overcorrection should be avoided when performing an innominate osteotomy for the treatment of acetabular dysplasia because it can create iatrogenic FAI and have an adverse effect on outcome.Level of evidenceLevel III, therapeutic study.

Project description:Purpose:To use mirror imaging to identify the location and magnitude of difference in acetabular rim morphology between the symptomatic and unaffected acetabula in patients with symptomatic unilateral pincer-type or mixed femoroacetabular impingement syndrome (FAIS) using 1-dimensional models created with computed tomography (CT). Methods:CT scans of bilateral hips in 33 patients diagnosed with unilateral pincer-type or mixed FAIS were obtained. Three-dimensional bilateral hip models were constructed, and the unaffected hemipelvis was superimposed onto the symptomatic side to compare acetabular thickness. Protrusion of the symptomatic side was recorded, and rim morphology was divided into clock face quadrants to analyze the location of greatest magnitude of difference between affected and unaffected acetabula. Analysis of the quadrants was performed using analysis of variance with post hoc Bonferroni correction. Results:The study group consisted of more females (51.6%) than males, with an average age of 35.72 ± 7.8 years and an average body mass index of 24.3 ± 4.1 kg/m2. Of the 33 hips included, 14 were isolated pincer-type FAIS and 19 were mixed. The average preoperative symptomatic side lateral center edge angle was 37.5° ± 7.2° compared with 29° ± 5.1° on the asymptomatic side (P = .001). The symptomatic acetabular rim was on average 0.43 ± 0.18 mm thicker than the corresponding location on the unaffected rim. When the acetabulum was divided into clock face quadrants, the 12 to 3 o'clock position showed the greatest difference between symptomatic and unaffected sides (0.55 ± 0.18 mm) compared with the 3 to 6 o'clock position (0.4 ± 0.28 mm; P = .006), 6 to 9 o'clock (0.34 ± 0.07 mm; P < .001), and 9 to 12 o'clock (0.38 ± 0.03; P = .001). Conclusions:Patients with unilateral, symptomatic pincer-type or mixed FAIS show statistical differences in rim thickness between the affected and unaffected acetabula. Small changes in acetabular rim morphology on the order of ?0.5 mm may be the difference between symptomatic FAIS and the unaffected hip. Level of Evidence:IV, case series.

Project description:Femoroacetabular impingement is a frequent cause of hip pain and may lead to secondary osteoarthritis, yet little is known about the molecular events linking mechanical hip impingement and articular cartilage degeneration. The first goal of this study was to quantify the expression of inflammatory cytokine and chemokine, matrix-degrading, and extracellular matrix genes in articular cartilage harvested from control hips and hips with femoroacetabular impingement and end-stage osteoarthritis. The second goal was to analyze the relative expression of these genes in articular cartilage harvested at various stages of osteoarthritis.Cartilage samples were obtained from thirty-two hips undergoing hip preservation surgery for femoroacetabular impingement or hip arthroplasty. Three control cartilage samples were also analyzed. Specimens were graded intraoperatively with regard to the severity of cartilage damage, the radiographic osteoarthritis grade was recorded, and quantitative RT-PCR (real-time polymerase chain reaction) was performed to determine relative gene expression.Except for interleukin-1? (IL-1?) and CXCL2, the mRNA (messenger RNA) expression of all other chemokine (IL-8, CXCL1, CXCL3, CXCL6, CCL3, and CCL3L1), matrix-degrading (matrix metalloproteinase [MMP]-13 and ADAMTS-4), and structural matrix (COL2A1 [collagen, type II, alpha] and ACAN [aggregan]) genes was higher overall in cartilage from hips with femoroacetabular impingement compared with hips with osteoarthritis and normal controls. The differences reached significance (p ? 0.05) for seven of these ten quantified genes, with CXCL3, CXCL6, and COL2A1 being elevated in the femoroacetabular impingement group compared with only the control group and IL-8, CCL3L1, ADAMTS-4, and ACAN being elevated compared with both the osteoarthritis and control groups. When samples were grouped according to the stage of the degenerative cascade, mRNA expression was relatively higher in one of the two middle stages of femoroacetabular impingement (chondromalacia or cleavage/thinning), with the difference reaching significance for IL-8, CXCL2, CXCL3, CCL3L1, and ACAN. ACAN expression was diminished in hips with osteoarthritis compared with femoroacetabular impingement but elevated compared with the control articular cartilage.Articular cartilage from the impingement zone of hips with femoroacetabular impingement (and particularly those hips in the cleavage/thinning stage) expressed higher levels of certain inflammatory, anabolic, and catabolic genes, representing a heightened metabolic state.The articular cartilage from the impingement zone of hips with femoroacetabular impingement was metabolically hyperactive, supporting the concept that such impingement is a structural precursor to hip osteoarthritis.

Dataset Information

Management of a large acetabular chondrolabral injury in a young patient with femoroacetabular impingement.

Publications

Management of a large acetabular chondrolabral injury in a young patient with femoroacetabular impingement.

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