October 1999, Supplement 1 Volume 15 Number 7

Transcription

1 October 1999, Supplement 1 Volume 15 Number 7 << Back to topic list Abstracts Previous article in Issue Next article in Issue Drug links from Mosby's DrugConsult Genetic information from OMIM These are the abstracts of the papers presented at the Second Biennial Meeting of The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, Washington, DC, May 29- June 3, Arthroscopic Debridement of Acetabular Labrum Tears. Jason L. Koh, M.D. Michael Maynard, M.D. Douglas Padgett, M.D. Robert Buly, M.D. Abstract: Acetabular labrum tears can cause pain and mechanical symptoms within the hip, and are suspected of causing osteoarthritis. Open debridement of these tears carries significant morbidity and a risk of catastrophic avascular necrosis of the femoral head. Materials and Methods: 27 patients who underwent arthroscopic treatment of labral tears were reviewed. Average age of patients was 36.6 (range 22-58). 12 were male and 15 were female. Primary complaints included pain in 27, "clicking" in 21 (78%), and catching or locking in 12.9 patients had rest pain. 9 had an antalgic gait. Average VAS score was 8.5/10. Three patients had limitation of range of motion in flexion. All patients had limitation of activities, with seven having difficulties with activities of http~2~us~e~sevierhea~th~c~m~inst~ser~e?a~ar~15~7babs&searchdbf~r=art&gr~up=hip+pr~b~ems (1 of 5) [ :58:42 AM]

2 Arthroscopy: The Journal oi: Arthroscopic & Related Surgery Online daily living. Provocative tests (Thomas test, flexion/internal rotation) were positive in 21 patients. The mechanism of injury was sports activities in 11, lifting in 2, MVA in 3, hip dysplasia in 2, degenerative disease in 3, and unknown in 6. Clinical diagnosis was confirmed by MRI in all cases. 6 patients demonstrated ganglion cysts on MRI. 3 had mild degenerative changes on X ray. Average time to diagnosis was 25.0 months (2-84 mo). Arthroscopy was conducted with the use of traction and a well padded perineal post in the lateral or supine position. The joint was entered with a spinal needle under fluoroscopic guidance. Anterolateral and posterolateral portals + anterior portal were used. Torn labrum was debrided using a 4.5 mm shaver to a stable edge. Results: Arthroscopy confirmed the clinical and MRI diagnosis in all cases. Anterosuperior labral tears were found in 26 patients, and a posterior tear in one. Additional pathology was found in 17 patients; femoral head chondromalacia in 8; degenerative disease with cartilage loss in 5, and mild synovitis in 6. One patient also had a loose body. Average length of stay was 1.2 days. Complications were noted in 6 patients, primarily transient perineal numbness (4), lateral femoral cutaneous nerve injury (1), superficial portal site stitch abscess (1), and greater trochanteric bursitis (1). Followup was available an average of 16 months postoperatively (range, 9-27 mo). Most patients experienced significant pain relief and relief of mechanical symptoms. Five patients described rare or occasional pain. One patient had significant improvement but continued mild pain. One patient obtained mild initial relief, but had progressive degenerative disease in the presence of hip dysplasia and underwent femoral osteotomy. Mechanical symptoms were eliminated in 20 patients and significantly reduced in seven. Activity level improved in 26 patients, who reported a return to normal athletic and daily activities. All patients were satisfied with treatment. Discussion: Tears of the acetabular labrum can cause debilitating hip pain and mechanical symptoms. In our series, suspected labral tears were confirmed by MRI and arthroscopy. These tears were successfully debrided with excellent relief of pain and mechanical symptoms in most patients. Complete relief of symptoms was less likely to be achieved in the presence of other hip pathology; the patients with improvement but continued mild pain all had degenerative lesions at arthroscopy. Almost all patients were able to resume usual daily and sporting activities. Arthroscopic debridement of tears of the acetabular labrum is safe and effective Hip Arthroscopy in an Athletic Population. J.W. Thomas Byrd, M.D. Kay S. Jones, M. S.N., R.N. Objective: To report the one year follow up results of a prospective study of hip arthroscopy in an athletic population. Methods: Among 126 consecutive arthroscopy cases, 21 cases (19 patients) were identified as participating in athletic activity and had achieved one year follow up. All patients were assessed with a modified Harris hip score (pain and function) preoperatively and postoperatively at 1, 3, 6, and 12 months or until a subsequent procedure was performed. Variables studied included Age, Sex, Diagnosis, Procedure Performed, Duration of Symptoms, Onset of Symptoms, CE Angle, Type of Sport, and Level of Participation. Results: Follow-up was obtained on all patients. There were 13 males and 6 females with an average art&group Hip+Problems (2 of 5) [12/13/ :58:42 AM]

3 Arthroscopy: The Journal oi: Arthroscopic & Related Surgery Online age of 30 years (range 14-70). Eleven different sports-related activities were identified and the level of participation included: Recreational (9), High School (6), Collegiate (3), and Professional (1). The median score improved from 58 to 85. This included one patient who underwent two subsequent procedures and ultimately improved from an index score of 56 to 96. Median improvement for the following diagnoses was: Osteophyte (60); Labral Lesion (42); Synovitis (41); Arthritis (38); Ruptured Ligamentum Teres (35); Chondral Damage (28); and AVN (0). Median improvement based on Onset of Symptoms demonstrated that those with Traumatic (37) and Acute (46) onset fared better than those with Insidious (16) onset. One transient neuropraxiaof the lateral femoral cutaneous nerve occurred which resolved spontaneously. Conclusions and Significance: In an athletic population, hip arthroscopy can be performed for a variety of conditions (except AVN) with reasonable expectations of success and an acceptable complication rate. This is the first report to quantitate the results of arthroscopy for this population Correlation Between Acetabular Dysplasia, Labral Tears, and Hip Arthritis. Stephen Wardell, M.D. Presenter: J. Bohannon Mason, M.D. A torn labrum has been associated with traumatic hip dislocations and childhood hip disease, but Harris, Nelson & Suzuki have suggested it may predispose to osteoarthritis secondary to destabilization of the acetabular labral complex. We report the findings and results of 62 hip arthroscopies in 58 patients who demonstrated acetabular labral injuries at arthroscopy with a minimum 2 year follow-up. Duration of symptoms prior to surgery averaged 30 months. A traumatic etiology of hip pain was noted in 63%, and an idiopathic etiology in 37%. Clinical results were directly correlated with the degree of labral injury. A Stage 0 lesion (1 hip) constitutes a contusion of the labrum with adjacent synovitis had 100% excellent results. A Stage 1 lesion (10 hips) is a free margin tear with intact femoral and acetabular cartilage had 90% excellent results. The addition of local articular damage to the subjacent femoral head but with intact acetabular cartilage is a Stage 2 lesion (11 hips) which had 82% good to excellent results. A Stage 3 has adjacent acetabular articular cartilage injury with or without femoral head chondromalacia had 58% good to excellent results. A Stage 4 lesion (9 hips) constitutes a complex labral tear with associated diffuse articular damage resulted in 78% poor outcome. A labral injury subjected to repetitive motion and torque by the femoral head may progress and cause reciprocal changes on the adjacent articular surface of the femoral head and/or acetabulum. Disruption of the acetabular labral complex may destabilize the hip joint's ability to distribute load and lead to cartilage breakdown and premature arthritis. Early diagnosis and treatment of patients with symptoms suggestive of an acetabular tear may improve the prognosis and abate the onset of degenerative arthritis Improving Diagnostic Accuracy of Cartilage Hip Joint Injuries: Correlation of Gadolinium MRI With Surgery. art&group Hip+Problems (3 of 5) [12/13/ :58:42 AM]

4 Michael Marchetti, M.D. Arthur Newberg, M.D. William Palmer, M.D. Presenter: J. Bohannon Mason, M.D. This study reviews 45 patients who underwent gadolinium enhanced arthro M.R.I. scanning of the hip joint. Verification of the imaging findings was demonstrated at hip arthroscopy. The patients' age ranged 16 to 64 years, and there were 17 men and 28 women. All had refractory hip pain unresponsive to conservative treatment. Plain radiographs, bone scan, and in 10, conventional MRI failed to reveal the source of their pain. Gadolinium enhanced MRI was performed to attempt increased resolution of the chondral surfaces of the joint. Arthroscopy findings were degenerative changes or chondral flaps in 36% & 56% of femoral heads and acetabuli respectively. The femoral head had Grade I or II changes in 13% and chondral flap lesions in 10%. Acetabular labral tears were found anteriorly in 60%, laterally in 20% and posteriorly in 11%. The acetabulum had Grade I or II changes in 16%. Forty-four percent of all patients had synovitis. The sensitivity of all analyzed aspects of gadolinium enhanced MRI was 55%, though for acetabular labral tears it was 74%. Ten of the 19 labral tears were degenerative in nature. In this study when all labral tears were considered MRI sensitivity, specificity and accuracy were 54%, 94% and 81% respectively. Similarly when all articular cartilage lesions of the femoral head and acetabulum were analyzed together, MRI sensitivity, specificity and accuracy results were 49%, 96% and 74%. Twenty of 22 cartilage lesions detected by MRI were identified arthroscopically. A high index of suspicion, positive physical findings and judicious use of arthroscopy remain the gold standard for diagnosis and treatment of these difficult conditions Intractable Hip Pain After Occult Trauma: Arthroscopic Findings and Treatment. Frank Alusio, M.D. John Meehan, M.D. Victor Krebbs, M.D. Hip pain after occult trauma is an uncommon but potentially disabling problem. Intraarticular disorders can be difficult to diagnose clinically and radiographically. Hip arthroscopy provides an opportunity to both diagnose and treat intraarticular disorders. The purpose of this study is to present the arthroscopic findings and associated treatment of young adults with intractable hip pain after occult trauma. Forty-three patients (45 hips) with a mean age of 34.7 years (18-45) presented with intractable hip pain and mechanical symptoms of painful click, buckling or subjective instability. All developed symptoms related to a previous traumatic event (MVA, fall, etc.) with having no radiographic evidence of intraarticular abnormality and 3 45 having sustained a posterior dislocation. The patients had seen an average of 3 physicians prior to referral to the senior author. Extraarticular and lumbar pathology were art&group Hip+Problems (4 of 5) [12/13/ :58:42 AM]

5 ruled out prior to proceeding with hip arthroscopy. Preoperative symptoms occurred for an average of 3.5 years (6 mos-15 yrs). The symptoms persisted despite extensive non-operative treatment. All patients underwent hip arthroscopy revealing anterior labral pathology (tear, fraying) in 98% of cases. Anterior acetabular chondral flaps were also identified in 58% of cases with associated chondromalacia in 8 (18%). Femoral head degenerative changes were noted in 31%. All patients with femoral head changes also had acetabular changes. There appears to a correlation between length of preoperative symptoms and degree of changes found on arthroscopic examination. Only 5/24 with symptoms less than 2 years had any degree of chondromalacia with 4 24 (16%) having diffuse changes. Thirty percent of those with symptoms from 2-5 years and 91% (10/11 ) with symptoms greater than 5 years had diffuse degenerative changes. Two eventually required arthroplasty for Grade IV changes. Treatment involved debridement of the labral tears and chondral defects/frayed cartilage back to stable edges. For acetabular defects requiring debridement to a bony base, drilling was performed to enhance fibrocartilage formation. Eighty-eight percent reported significant improvement in preoperative symptoms. Six patients were on disability prior to surgery and all returned to work. The labral tear/acetabular chondral defect complex defined in this study may help account for the mechanical symptoms and pain described in this population. The temporal relationship between length of symptoms and extent of disease is an important finding and encourages improved clinical and radiographic methods for establishing a diagnosis, followed by operative intervention. art&group Hip+Problems (5 of 5) [12/13/ :58:42 AM]