Faculty Bibliography

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient co- hort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients under- going hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgi- cal proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

OBJECTIVE: This study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized dGEMRIC at 3T and evaluate intra- and inter-observer repeatability. DESIGN: We retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3T along radial imaging planes of the hip and standardized to remove the effects of patient's age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic MRI. RESULTS: Using z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement. CONCLUSIONS: Standardized dGEMRIC at 3T is accurate in detecting cartilage damage and could improve preoperative assessment in FAI. As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage.

BACKGROUND:This is a systematic review to determine if prophylactic surgical intervention for asymptomatic patients with radiographic evidence of femoroacetabular impingement (FAI) is warranted to prevent early degenerative joint disease of the hip. METHODS:A systematic search was performed from 1965 to 2013 in PubMed and EMBASE. Inclusion criteria were prospective or retrospective studies comparing skeletally mature asymptomatic patients with radiographic evidence of FAI treated with prophylactic hip arthroscopic surgery versus nonoperative management. A total of 840 references were identified from the searches. After detailed eligibility screening, none of the references met the eligibility criteria. RESULTS:No trials were identified that met the criteria for inclusion in the review. CONCLUSION:There is a lack of available evidence to support surgical intervention for the treatment of FAI in asymptomatic patients. This article attempts to address this dilemma by reviewing the available literature to answer several questions that would indirectly address the topic. First, what is the prevalence of FAI in the asymptomatic population? Second, what is the natural history of FAI if left untreated? Upon reviewing these issues, the authors' conclusion parallels that of the systematic review: Current evidence does not support prophylactic surgery for asymptomatic FAI in the vast majority of cases. However, limited evidence suggests that asymptomatic patients who have previously undergone total hip arthroplasty for FAI-induced osteoarthritis of the contralateral hip are at a significantly increased risk for early degenerative joint disease. Further research is needed to better clarify surgical indications.

Avascular necrosis (AVN) of the femoral head is a progressive disease affecting young adults that results in collapse of the femoral head and subsequent degenerative joint disease. Although precollapse stages of AVN can be successfully treated with core decompression, making the diagnosis is often difficult given alternative sources of hip pain in this age group. We propose that arthroscopic-assisted core decompression of the femoral head offers an effective method of addressing AVN of the femoral head as well as coexistent hip disorders in the same operation. This article describes in detail the technique used to perform an arthroscopic-assisted core decompression of the femoral head, and a companion video demonstrating the procedure is included. Our experience suggests that arthroscopic-assisted core decompression can be used as an alternative to open core decompression, while simultaneously addressing other sources of hip pain, with successful outcomes.

Chondral injury in the knee is a unique challenge to the orthopaedic surgeon. Given the high probability of progression to knee arthrosis, the treatment of symptomatic cartilage defects of the knee has become an important surgical intervention in young, active patients. The demand for an alternative to prosthetic resurfacing has driven the trend towards biologic resurfacing and joint preservation. Osteochondral allografts are composed of hyaline cartilage attached to subchondral bone and are suited for large osteochondral lesions. This allograft tissue must be harvested, processed, and stored appropriately to reduce the risks of graft failure and potential complications. With appropriate indications and surgical techniques, osteochondral allografts have been shown to have good long-term graft survival and patient outcomes.

BACKGROUND: The incidence of heterotopic ossification (HO) after hip arthroscopy reportedly ranges from less than 1.0% to 6.3%. Although open debridement has been described and a few series mention arthroscopic debridement, the techniques for arthroscopic excision of HO have not been described in detail. We describe the arthroscopic treatment of this complication. DESCRIPTION OF TECHNIQUE: Revision arthroscopy was completed in the central and peripheral compartments using prior portals and fluoroscopy was used to identify the HO. Spinal needle localization was used to triangulate onto the HO. Cannulas were inserted over the spinal needle. Once the HO was clearly identified with the arthroscope, it was excised using a burr and confirmed on fluoroscopy. METHODS: We retrospectively reviewed 66 patients who underwent arthroscopic treatment of femoroacetabular impingement between July 2008 and June 2010. There were 36 females and 30 males with an average age of 38 years (range, 15-68 years). Eight of the 66 (12%) patients had HO develop. Using the grading of Brooker et al., six patients had Grade 1, one had Grade 2, and one had Grade 3 HO. Three patients with HO were symptomatic and underwent arthroscopic resection. We obtained modified Harris hip scores (HHS) and radiographs at followup. The minimum followup for the three patients with revision surgery was 2 years (mean, 2 years 2 months; range, 2 years-2 years 8 months). RESULTS: The three patients who underwent arthroscopic resection had HHS ranging from 85 to 96 at last followup. No patient had recurrence of HO. CONCLUSIONS: Our data suggest HO is not uncommon after hip arthroscopy for the treatment of femoroacetabular impingement but most patients have minor degrees and no symptoms. In symptomatic patients, arthroscopic excision appears to relieve pain and restore function.

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg-Calve-Perthes' disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions.

Indications for arthroscopic surgery of the hip have increased over the past several years, along with the number of procedures performed annually. In addition, the number of unsuccessful procedures and subsequent revision surgeries have also increased. Recent literature has defined several common causes for failed hip arthroscopy. Severe osteoarthritis and osteonecrosis are associated with poor outcomes. Findings during revision hip arthroscopy consistently demonstrate untreated femoroacetabular impingement, chondral defects, labral tears, and postoperative adhesions. The treating surgeon must be diligent in his or her indications for surgery, as well as in addressing all pathology at the initial surgery.

PURPOSE: To evaluate the utility of femoral nerve blocks in postoperative pain control after hip arthroscopy. METHODS: Forty consecutive patients scheduled for hip arthroscopy were randomized into 2 groups for postoperative pain control. Half were to receive routine intravenous narcotics for pain scores of 7 or above in the postanesthesia care unit (PACU), and the other half were to receive a femoral nerve block in the PACU for the same pain scores. Data were compared with respect to patient sex, patient age, traction times, type of procedure, nausea, overall patient satisfaction with analgesia, and duration of time in the PACU. RESULTS: Thirty-six patients had initial pain scores of 7 of 10 or greater on a visual analog scale. Of these patients, 16 were randomized to receive postoperative morphine and 20 to receive a femoral nerve block. There were no significant differences between the 2 groups with respect to sex, age, traction times, or type of procedure performed. Patients who received morphine had a significantly longer time to discharge from the PACU (216 minutes) than the femoral nerve block group (177 minutes). The morphine group was also significantly more likely to report postoperative nausea (75%) than the femoral nerve block group (10%). Patients receiving femoral nerve blocks were significantly more likely to be satisfied with their postoperative pain control (90%) than those who had received morphine (25%). All of the patients receiving a femoral nerve block stated that they would undergo the block again if they needed another hip arthroscopy. CONCLUSIONS: On the basis of all criteria studied (quality of pain relief, length of stay in the PACU, side effects, and patient satisfaction), a femoral nerve block is an excellent alternative to routine narcotic pain medication in patients undergoing hip arthroscopy. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

SUMMARY By all criteria studied (quality of pain relief, length of stay in the PACU, side effects and patient satisfaction), a femoral nerve block is an excellent alternative to routine narcotic pain medication in patients undergoing hip arthroscopy. DATA Purpose: To evaluate the utility of femoral nerve blocks in post-operative pain control after hip arthroscopy. Methods: Forty consecutive patients scheduled for hip arthroscopy were randomized into two groups for postoperative pain control. Half were to receive routine intravenous narcotics for pain scores of seven or above in the PACU, the other half were to receive a femoral nerve block in the PACU for the same pain scores. Data was compared with respect to patient sex, age, nausea, overall satisfaction with analgesia, and duration of time in the PACU. Results: Thirty-six patients had initial pain scores of seven or greater. Sixteen were randomized to receive post-operative morphine, and twenty to receive a femoral nerve block. There were no significant differences between the two groups with respect to sex or age of the patients. Patients who received morphine had a significantly longer time to discharge from the PACU (216 mins) than the femoral nerve block group (177 mins). The morphine group was also significantly more likely to report post-operative nausea (75%) than the femoral nerve block group (10%). Patients receiving femoral nerve blocks were significantly more likely to be satisfied with their post-operative pain control (90%) than those who had received morphine (25%). All of the patients receiving femoral nerve block stated that they would have the block again if they needed another hip arthroscopy