The importance of the soft tissue stabilizers of the hip: Three cases of rapid onset osteoarthritis following hip arthroscopy

Recent advances in the direct anterior approach to total hip arthroplasty: a surgeon's perspective

INTRODUCTION

The direct anterior approach (DAA) has its origins in the first and oldest approach for hip replacement in the literature, but at the same time it would not be fanciful to suggest its increasing popularity as the latest approach for hip replacement procedures, especially among younger surgeons. However, in a geographical context, the DAA is not considered the major approach in most countries. Moreover, the term DAA encompasses numerous variations in terms of technique.

AREAS COVERED

In this narrative review, we describe our recent experience of advances in the DAA in terms of improved techniques and devices, along with some of its disadvantages. Also, we express our perspective on its future application.

EXPERT OPINIONS

The DAA is established as one of exemplary approaches to THA. The use of fluoroscopy, the traction table, and appropriate soft tissue management has become essential in the DAA for a safe and trouble-free procedure with adequate patient comfort. With the combination of recent technologies such as robotics, three-dimensional preoperative planning, and artificial intelligence (AI)-based surgeon assist systems, we can look forward to the DAA being performed more efficiently in the future.

Acetabular morphological variation in Asian patients with femoral neck fracture: A three-dimensional CT-based study

AIMS

The acetabular morphology varies greatly among individuals, and hypoplasia is more common in Asia than in Europe. Dislocation after bipolar hip arthroplasty (BHA) for femoral neck fracture occurs at a constant rate, and is affected by the acetabular morphology. This study aimed to clarify individual differences in the acetabula of Asian patients with displaced femoral neck fractures.

PATIENTS AND METHODS

Fifty patients with displaced femoral neck fractures were assessed (50 fractured hips, 50 non-fractured hips). On CT corrected by the anterior pelvic plane, the 100 hips were assessed regarding acetabular coverage (six parameters), acetabular depth (two parameters), and acetabular opening angle (four parameters). Additional parameters related to the fracture and sex were examined. The percentile of each parameter was shown for all hips.

RESULTS

There was no patient with hip dysplasia defined as superior acetabular sector angle (SASA) less than 110° Compared with men, women had a significantly smaller anterior acetabular sector angle (AASA) (p = 0.016), and significantly larger acetabular inclination angle (p = 0.006) and acetabular index angle (p = 0.034). In the group with a normal SASA, seven hips (7.3%) had an anterior wall defect (AASA<50°) and five hips (5.2%) had a posterior wall defect (posterior acetabular sector angle<90°).

CONCLUSION

Older adults with femoral neck fractures can have anterior wall and posterior wall defects, even if their SASA is normal. Hidden acetabular dysplasia may be related to post-BHA dislocation. So, our results suggest that is important to accurately evaluate the acetabulum of patients with femoral neck fracture before surgery.

Ligamentum Teres Reconstruction May Lead to Improvement in Outcomes Following a Secondary Hip Arthroscopy for Symptomatic Microinstability: A Systematic Review

PURPOSE

To present the indications, surgical technique, outcomes, and complications for patients undergoing arthroscopic reconstruction of the ligamentum teres (LT).

METHODS

Articles were included if they had postoperative patient-reported outcomes (PROs) for arthroscopic LT reconstruction. Studies were analyzed for patient demographics, clinical assessment and indications, radiographic and magnetic resonance imaging data, concomitant procedures performed, PROs, surgical techniques, intra-articular classifications, complications, and need for follow-up surgeries. For PROs, the standard mean difference was calculated. The proportion of patients achieving patient acceptable symptomatic state for postoperative modified Harris Hip Score (≥74) was recorded. The number of patients achieving minimal clinically important difference for modified Harris Hip Score (Δ ≥8) was calculated.

RESULTS

The majority of the cases were revision arthroscopies. Of the 3 studies reporting on patients undergoing LT reconstruction due to microinstability, 4, 9, and 11 patients demonstrated a mean improvement of 25.7, 35.2, and 27.7 in modified Harris Hip, respectively. In addition, one of the studies reported a mean improvement of 31.1 and 4.2 in Nonarthritic Hip Score and visual analog scale, respectively. Of the 3 studies, the percentile of patients surpassing minimal clinically important difference and patient acceptable symptomatic state ranged between 50% and 100% and 33.3% and 88.8%, respectively. Overall, 5 patients underwent revision hip arthroscopy due to adhesions, iliopsoas impingement, and persistent microinstability, and 3 patients underwent a secondary hip arthroplasty due to refractory pain and radiographic evidence of hip osteoarthritis.

CONCLUSION

Reconstruction of the LT may be considered in surgical management for patients with symptomatic hip instability due to soft-tissue causes. Current evidence supports for LT reconstruction predominantly for patients experiencing refractory instability following previous hip preservation procedures. Patients' expectations as well as the relatively high reoperation rate (i.e., 33%) should be discussed before the procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Microinstability of the hip: a systematic review of the imaging findings

OBJECTIVES

To undertake a systematic review of the morphologic features associated with hip microinstability and determine whether there are suggestive or diagnostic imaging findings.

METHODS

Four electronic databases were searched up to September 2019 to identify original research reporting morphologic features in individuals with either a clinical diagnosis of hip microinstability (instability without overt subluxation/dislocation) or those with symptomatic laxity demonstrated on imaging (increased femoral head translation/distraction or capsular volume). Studies focussing on individuals with pre-existing hip conditions (including definite dysplasia (lateral centre edge angle < 20°), significant trauma, previous dislocation or surgery were excluded. Methodological quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

RESULTS

Twenty-two studies met inclusion criteria (clinical diagnosis of microinstability n = 15 and demonstration of laxity n = 7). Imaging information gathered from the studies includes radiographs (n = 14), MRI (n = 6), MR arthrography (n = 4), CT (n = 1) and intraoperative examination. Most studies exhibited design features associated with an overall high or unclear risk of bias. Some dysplastic features are associated with microinstability or laxity reference measures; however, microinstability is frequently diagnosed in those with a lateral centre edge angle > 25°. Other associated imaging findings reported include impingement morphology, anterior labral tearing, femoral head chondral injury, ligamentum teres tears and capsular attenuation.

CONCLUSIONS

The current literature does not provide strong evidence for imaging features diagnostic of microinstability. In the appropriate clinical context, dysplastic morphology, anterior labral tears and ligamentum teres tears may be suggestive of this condition although further research is needed to confirm this.

PROSPERO REGISTRATION

CRD42019122406.

In total hip arthroplasty via the direct anterior approach, a dual-mobility cup prevents dislocation as effectively in hip fracture as in osteoarthritis

PURPOSE

The main purpose of this study was to compare the outcome of total hip arthroplasty (THA) via the direct anterior approach (DAA) using a dual-mobility cup (DMC) in patients with femoral neck fracture to those in patients undergoing elective THA for osteoarthritis.

PATIENTS AND METHODS

We retrospectively investigated 40 hips with femoral neck fracture (group A), and 81 hips with osteoarthritis (group B). THA via the DAA using the DMC was performed in both groups. A primary/secondary outcome variable were the presence of dislocation/operative time, intra- and/or peri-operative complication, and mortality.

RESULTS

Dislocation did not occur in either group. The complication rate was slightly higher in group A than in group B, but not statistically significant.

CONCLUSION

THA with the DMC using the DAA was as effective for femoral neck facture as it was for elective THA in patients with osteoarthritis.

Arthroscopic reconstruction of the Ligamentum Teres: a case series in four patients with connective tissue disorders and generalized ligamentous laxity

This study presents the results of four Ligamentum Teres (LT) reconstruction procedures for hip instability with an average of 21.4 months follow-up (range 16.4–27.8). The indication for reconstruction was patients who complained of hip instability (hip giving way on gait or activities of daily living) on a background of a connective tissue disorder and generalized ligamentous laxity. The following data were recorded: age, sex, body mass index, hip range of motion, impingement signs, acetabular coverage (lateral center edge angle and acetabular inclination), acetabular retroversion (ischial spine sign and a crossover sign), femoral alpha angles and femoral neck shaft angles. Four patient recorded outcomes (PROs) were collected at 3 months, 12 months and 24 months. Three patients were female. Three out of four procedures had an improvement in PROs. One patient with bilateral procedures had an improvement in PROs on one side at 1 year but a failure of the graft on the contralateral side. There were no complications reported with the technique. LT reconstruction and concomitant capsular plication in this case series is associated with an improvement in outcomes in three out of four of the patients with hip instability associated with a full thickness tear of the LT and who presented with hip instability on a background of generalized ligamentous laxity and a connective tissue disorder. However, the physical examination, radiographic and intra-operative findings which may help predict who would benefit from LT reconstruction require further investigation.