Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Case Report
Clinical research study
Current Issue
Editorial Board
Literature Review
Narrative review
Original Article
Research Article
Review Article
Short Report
Surgical techniques
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Case Report
Clinical research study
Current Issue
Editorial Board
Literature Review
Narrative review
Original Article
Research Article
Review Article
Short Report
Surgical techniques
View/Download PDF

Translate this page into:

70 (); 133-137
doi:
10.1016/j.jor.2025.03.012

One stage total hip arthroplasty and contralateral hip arthroscopy for bilateral femoroacetabular impingement and osteoarthritis: A clinical trial

, , , , , ,
a Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
b Department of Life Sciences, Health, and Health Professions, Link Campus University, Via del Casale di San Pio V, 00165, Rome, Italy
c Department of Orthopaedic, Istituto Clinico Humanitas, Rozzano, Milan, Italy
d Residency Program of the University Federico II of Naples, Naples, Italy
e Department of Trauma and Reconstructive Surgery, University Hospital of Halle (Saale), Germany

⁎Corresponding author: Filippo Migliorini. migliorini.md@gmail.com

Received: , Accepted: ,
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The management of cam morphology of FAI associated with osteoarthritis (OA) is debated. However, current surgical indications are becoming obsolete, and hip arthroscopy spreads in different settings. The present clinical trial evaluated the outcome of one-stage unilateral hip arthroscopy and contralateral total hip arthroplasty (THA) in patients with bilateral cam deformity associated with labral tears and early and advanced OA stages, respectively. The outcomes of interest were patient-reported outcome measures (PROMs) and the rate of complications.

All patients who underwent one-stage THA and contralateral hip arthroscopic for symptomatic cam deformity were prospectively invited to participate in the present study. Arthroscopies were performed first with patients in a supine position on a traction bed under fluoroscopic control. Three standard portals were used. The intraarticular joint space was inspected, and the peripheral acetabular labral lesions were selectively debrided. Cam bunectomy was performed, and labral tears were debrided and repaired using bio-resorbable anchors. After arthroscopy, patients were positioned in a lateral position, and THA was performed using a minimally invasive posterolateral approach. All patients received uncemented short stems with ceramic heads and vitamin-E augmented polyethylene (GTS, Zimmer Biomet, United States or 3C, Link, Germany).

All 16 patients were men, with a mean age of 41 years ±7.9. The mean length of the follow-up was 4.2 ± 1.3 years (range, 2 to 6). All patients returned to their normal daily activities within one month. PROMs were statistically significantly increased from baseline to the last follow-up in all patients. No patient experienced minor or major complications. One patient required THA five years after arthroscopy for symptomatic and radiographic progression of osteoarthritis. No other patients progressed to THA. No patient underwent revision surgery for failed arthroscopy.

One-stage arthroscopy and contralateral arthroplasty are effective in managing FAI combined with early and mild to severe OA, respectively.

Keywords

Femoroacetabular impingement
FAI
Arthroplasty
Arthroscopy
1

1 Introduction

Femoroacetabular impingement (FAI) is common.1;2 FAI causes pain and chondrolabral damage via mechanical overload during hip motion. FAI is common in the asymptomatic population, especially in the young and active population.3;4 Traditionally, FAI was managed with open dislocation; however, open procedures are becoming less common and arthroscopic surgery is gaining popularity.5;6 The head retroversion and loss of sphericity of cam morphology induce a mechanical conflict between the superior acetabular rim, which might cause labral damage on the superior side and chondral damage on the inferomedial side of the acetabulum.7 The latter may evolve into inferomedial osteoarthritis (OA) if left untreated. In patients with cam deformity without OA, arthroscopic management showed promising results, with high patient satisfaction and a high rate of return to sport within a few months.8;9 Labral tears can be arthroscopically debrided, repaired, or reconstructed according to the lesion morphology. In patients with cam deformity and end-stage OA, total hip arthroplasty (THA) may represent a feasible option. The management of FAI associated with OA is debated. However, current surgical indications are becoming obsolete, and hip arthroscopy spreads in different settings.

Cam deformity is often bilateral.10;11 The association between radiographic evidence of cam deformity and the onset of hip pain is not linear.8;12 Indeed, most patients report symptoms only on one side, or symptoms start at different times.13;14 In the author's experience, the cam deformity is evident in varying stages in patients with bilateral FAI. The present clinical trial evaluated the outcome of one-stage unilateral hip arthroscopy and contralateral THA in patients with bilateral cam deformity associated with early and advanced OA stages, respectively. The outcomes of interest were patient-reported outcome measures (PROMs) and the rate of complications.

2

2 Methods

2.1

2.1 Study protocol

The present study was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).15 Ethical approval was obtained by the Ethical Committee of the Humanitas Research Hospital (ID 618/17). All procedures in this study followed the ethical standards of the institutional and the national research committee and the 1964 Helsinki Declaration and its later amendments. All patients were informed of the nature of the study and signed informed consent to participate in the present clinical trial.

All patients who underwent one-stage THA and contralateral hip arthroscopic for symptomatic cam deformity were prospectively invited to participate in the present study. This clinical trial was conducted at the Department of Orthopaedics of the Humanitas Research Hospital, Milan, from October 2017 to February 2021.

2.2

2.2 Eligibility criteria

All patients underwent radiography and magnetic resonance imaging preoperatively. Plain hip radiography in anteroposterior, axial, and 45° Dunn views confirmed bilateral cam and OA stages I on one side and II to III on the contralateral side according to the Tönnis classification.16 All patients should present bilateral labrum injury at MRI. The inclusion criteria were: (1) radiographic evidence of cam deformity with symptoms and pain characteristic of FAI; (2) bilateral OA at different stages: Tönnis I at the arthroscopy side and stages II to III at the THA side (Fig. 1); (3) alpha angle >55°; (4) pain not responsive to conservative management for at least six months; (5) Lateral Centred Edge Angle (LCEA) > 25° and <39°. The exclusion criteria were: (1) previous hip surgery; (2) any hip deformity or malformation acquired or congenital; (3) uncontrolled chronic disease; (4) chondral defect other pathology than FAI which might influence the outcome at the arthroscopy side; (5) patients unable to understand the nature of the treatment and the finalities of the study. Only patients who completed the last follow-up were included for analysis (Fig. 2.

Radiographic evidence of OA Tönnis I (right) and III (left).
Fig. 1 Radiographic evidence of OA Tönnis I (right) and III (left).
Left: labral detachment at the acetabular rim. Right: Intraoperative radiographic control of bunionectomy.
Fig. 2 Left: labral detachment at the acetabular rim. Right: Intraoperative radiographic control of bunionectomy.
2.3

2.3 Surgical protocol

Clinical examinations and surgical treatments were performed by an experienced hip surgeon in a highly standardised fashion. Arthroscopies were performed first with patients in a supine position on a traction bed under fluoroscopic control. Arthroscopies were performed as described in a previously published fashion.17 Briefly, three portals were used: anterolateral, distal anterolateral, and mid-anterior. The intraarticular joint space was inspected, and the labral lesions were identified (Fig. 1, right).

Cam bunectomy was performed using a standard arthroscopic bony reamer until the cam deformity was removed (Fig. 1, left). Labral tears were selectively debrided and repaired using three to four bio-resorbable anchors (Microraptor, Smith & Nephew, United Kingdom). No additional procedures were performed, such as synovectomy, chondroplasty, or microfracture. After arthroscopy, patients were positioned in a lateral position, and THA was conducted in a previously published fashion.18 All THAs were performed using a minimally invasive posterolateral approach. All patients received uncemented short stems with ceramic heads and vitamin-E augmented polyethylene (GTS, Zimmer Biomet, United States or 3C, Link, Germany).

Weight-bearing was limited to 50 % for the first four weeks. After that, patients were gradually allowed to return to weight-bearing. All patients started physical therapy on the first postoperative day to improve the range of motion in both hips. Furthermore for the arthroscopic side , isometric toning exercises were granted in association with continuous passive motion (CPM) with ROM 0–90°. All patients underwent prophylaxis of heterotopic ossification using naproxene 500 mg daily for four weeks. All patients underwent prophylaxis of thromboembolism using rivaroxaban 10 mg daily until full weight-bearing was reached. Sports participation was allowed starting from the 6th month postoperatively.

2.4

2.4 Clinical assessment

At a minimum of 24 months postoperatively, patients were invited to participate in the follow-up. The following PROMs were administered on admission and at the last follow-up: the short version of the International Hip Outcome Tool (iHOT-12),19;20 the University of California Los Angeles activity score (UCLA),21 the modified version of the modified version of the Harris Hip Score (mHHS),22;23 the Hip Disability and Osteoarthritis Outcome Score (HOOS),24 and visual analogue scale (VAS).25 The minimally clinically important difference (MCID), patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimally important change (MIC) of each PROM are reported in Table 1.

Table 1 Results of PROMs (FU: follow-up; MD: mean difference).
Endpoint At baseline At last FU MD P
mHHS 78.9 ± 22.4 97.3 ± 4.8 18.4 <0.0001
HOOS 82.1 ± 24.3 97.8 ± 6.8 15.7 0.001
iHOT-12 89.1 ± 30.7 117.5 ± 7.1 28.4 <0.0001
VAS 7.2 ± 1.1 1.5 ± 1.4 −5.7 <0.0001
UCLA 4.1 ± 2.4 7.3 ± 1.2 3.2 0.0003
Table 2 Evaluation of PROMs (PROMs: patient-reported outcome measures; MCID: minimal clinically important difference; PASS: patient acceptable symptom state; SCB: substantial clinical benefit; MIC: minimally important change; mHHS: modified Harris Hip Score; iHOT: International Hip Outcome Tool; UCLA: University of California, Los Angeles; VAS: visual analogue scale).
PROMs MCID PASS SCB MIC
iHOT-12 13.0 74.3 57.8
mHHS 14.6 70.7 94.0 8.0
UCLA 0.8
VAS 14.8 21.6 15.4

Data on the rate of revision surgery, progression to THA, minor (swelling, superficial wound infection) and major complications (neurovascular damage, deep infection, persistent pain) were collected.

2.5

2.5 Statistical analyses

The main author (FM) conducted the statistical analyses using the IBM SPSS version 25 software. For continuous data, the arithmetic mean and standard deviation were used. The mean difference effect measure and paired t-test were used to evaluate the improvement in PROMs, with values of P < 0.05 considered statistically significant.

3

3 Results

3.1

3.1 Patient enrolment

A total of 34 patients underwent one-stage hip arthroscopy and contralateral arthroplasty for FAI. A total of 13 patients were excluded for the following reasons: LCEA <25° or >39° (N = 2), symptomatic chondral defects at the arthroscopy site (N = 3), alpha angle <55° (N = 1), previous hip surgery (N = 4), hip deformity/malformation (N = 2), uncontrolled chronic disease (N = 1). This left 21 eligible patients. A further five patients were lost to the follow-up: declined to participate (N = 4) and were not reachable by phone (N = 1). Finally, 16 patients were included in the present study (Fig. 3).

Flowchart of the patient enrolment.
Fig. 3 Flowchart of the patient enrolment.
3.2

3.2 Patient demographics

All 16 patients were men, with a mean age of 41 years ±7.9 (Table 2). The mean length of the follow-up was 4.2 ± 1.3 years (range, 2 to 6).

3.3

3.3 Results syntheses

All patients returned to their normal daily activities within one month. PROMs were statistically significantly increased from baseline to the last follow-up in all patients (Table 1). No patient experienced minor or major complications. One patient (6 %) required THA five years after arthroscopy for symptomatic and radiographic progression of osteoarthritis. No other patients progressed to THA. No patient underwent revision surgery for failed arthroscopy. Fig. 4 reports a radiographic control at 36 months of follow-up.

Radiographic control at 36 months of follow-up.
Fig. 4 Radiographic control at 36 months of follow-up.
4

4 Discussion

The present clinical trial evaluated the outcome of one-stage unilateral hip arthroscopy and contralateral THA in patients with bilateral cam deformity associated with early and advanced OA stages, respectively. According to the main findings of the present study, this one-stage bilateral surgical approach is effective in restoring PROMs at approximately four years of follow-up. All PROMs of interest statistically significantly improved at the last follow-up compared to the baseline; this improvement overcame their MCID, PASS, SCB, and MIC, indicating that such a procedure was clinically effective. One patient (6 %) progressed to Tönnis III at the arthroscopically treated side. Although this frequency suggests a high rate of progression to THA, the relatively low number of patients included in the present study might overestimate the actual rate of this complication. To correctly estimate the rate of progression to THA, additional studies should evaluate the outcomes of this procedure on a larger scale. The reported procedure in the present clinical trial carries the advantages of single-stage procedures. Performing arthroplasty and, subsequently, arthroscopy on the contralateral side might expose patients to double surgical interventions and possible discomfort and stress. However, bilateral procedures include prolonged limb traction, anaesthesia, and surgical time.

While strict surgical indications are recommended for patients with mild to severe OA,26;27 current evidence on arthroscopic management of FAI with combined Tönnis grade I are debated.28;29 In a previous matched-pair comparison on 292 hips of Tönnis grade I versus 0, both groups demonstrated similar outcomes and durable improvements.28 Despite all PROMs being statistically significantly improved, no between-group difference was found at baseline and at the last follow-up.28 Another study compared the survivorship (conversion to THA) of the arthroscopic management of early (Tönnis 0 and I) versus mild and advanced (II and III) OA.29 At approximately ten years of follow-up, the early OA group evidenced a statistically significantly longer survivorship rate (86.3 %) than the mild and advanced OA group (46.4 %).29 Mild to moderate Tönnis grade were the main risk factors for joint survivorship, increasing the risk of conversion by 133 %.29 Approximately half of all patients with Tönnis II and III converted to THA within 11 years.29 Within the Tönnis II and III group, young men mainly represented the non-converters, considered independent positive prognostic factors.29 These results suggest that hip OA stage Tönnis I might not be considered a contraindication for FAI arthroscopy. Although arthroscopy for FAI in patients with Tönnis I OA is controversial, the benefit of its association with a simultaneous THA at the contralateral side still remains unclear. The authors hypothesised that the improvement in pain and function promoted by the THA at the contralateral side might promote a benefit on the arthroscopic side greater than arthroscopy alone. Few studies evaluated the correlation in the outcome between the operated and non-operated side in bilateral hip degenerations. The clinical outcomes of unilateral THA are affected by opposite hip status.30 In this context, it is crucial to evaluate bilateral procedures, especially in patients with bilateral symptoms. In patients with bilateral hip symptoms, the chance of subsequent contralateral THA after unilateral THA is anywhere from 16 % to 85 %.31–33 A previous study found that 41 % of patients with hip symptomatic OA will also develop symptomatic OA in the contralateral hip after ten years.34 Another study 24 found that 37 % of contralateral hips diagnosed as ‘‘normal’’ will develop OA within ten years, and 8 % will undergo THA. Vossinakis et al.35 found that patients with unilateral idiopathic OA are more prone to develop OA in the contralateral hip than patients with hip dysplasia. Features of FAI are more frequently encountered in the asymptomatic contralateral hip of patients who have undergone hip arthroplasty secondary to idiopathic OA than in control subjects.36

Additional investigations are required to increase evidence and knowledge on the improvement or worsening performances of a hip and its effect on the contralateral hip in terms of symptoms and function. The present study has the limitation of including a relatively small number of patients and relatively short-term follow-up. Such limitations might jeopardise the efficacy of the present investigation in estimating survivorship and complication rates. Additional investigations are necessary to understand the feasibility of patient-tailored bilateral procedures and validate the results of the present clinical trial on a larger scale.

5

5 Conclusion

One-stage arthroscopy and contralateral arthroplasty are effective in managing FAI combined with early and mild to severe OA, respectively.

CRediT authorship contribution statement

Filippo Migliorini: Methodology, Formal analysis, writing (original and revision). Francesco Coppola: writing (original). Marco Rosolani: writing (revision). Alessio D'Addona: writing (revision). Vincenzo Di Francia: writing (revision). Guido Grappiolo: writing (revision). Federico Della Rocca: Conceptualization, writing (original), All authors have agreed to the final version to be published and agree to be accountable for all aspects of the work.

Ethical approval

Ethical approval was obtained by the Ethical Committee of the Humanitas Research Hospital (ID 618/17).

Availability of data and materials

The datasets generated during and/or analysed during the current study are available throughout the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

  1. , , , et al . Hip arthroscopy with initial access to the peripheral compartment for femoroacetabular impingement: midterm results from a large-scale patient cohort. J Orthop Traumatol. 2024;25(1):29.
    [Google Scholar]
  2. , , , . Femoroacetabular impingement in young adults: assessment and management. Br J Hosp Med (Lond). 2019;80(10):584-588.
    [Google Scholar]
  3. , , , , , , . Return to sport after arthroscopic surgery for femoroacetabular impingement. Surgeon. 2023;21(1):21-30.
    [Google Scholar]
  4. , , , . Best practices: hip femoroacetabular impingement. AJR Am J Roentgenol. 2021;216(3):585-598.
    [Google Scholar]
  5. , , , , , , . Arthroscopic labral repair for femoroacetabular impingement: a systematic review. Surgeon. 2022;20(5):e225-e230.
    [Google Scholar]
  6. , , , , , , . Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: a systematic review. Surgeon. 2022;20(3):194-208.
    [Google Scholar]
  7. , , , , , , . Midterm results after arthroscopic femoral neck osteoplasty combined with labral debridement for cam type femoroacetabular impingement in active adults. J Orthop Surg Res. 2023;18(1):67.
    [Google Scholar]
  8. , , , et al . Medium-term results of arthroscopic treatment for femoroacetabular impingement. Br Med Bull. 2021;138(1):68-84.
    [Google Scholar]
  9. , , . Arthroscopic management of femoroacetabular impingement in adolescents: a systematic review. Am J Sports Med. 2021;49(13):3708-3715.
    [Google Scholar]
  10. , , , , , . Prevalence and preoperative demographic and radiographic predictors of bilateral femoroacetabular impingement. Am J Sports Med. 2013;41(4):762-768.
    [Google Scholar]
  11. , , , et al . Bilateral hip arthroscopy for treating femoroacetabular impingement: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2022;30(3):1095-1108.
    [Google Scholar]
  12. , , , et al . Osteoarthritis risks and sports: an evidence-based systematic review. Sports Med Arthrosc Rev. 2022;30(3):118-140.
    [Google Scholar]
  13. , , , , . Prevalence of associated deformities and hip pain in patients with cam-type femoroacetabular impingement. J Bone Joint Surg Br. 2009;91(5):589-594.
    [Google Scholar]
  14. , , , , . An examination of the association between different morphotypes of femoroacetabular impingement in asymptomatic subjects and the development of osteoarthritis of the hip. J Bone Joint Surg Br. 2011;93(5):580-586.
    [Google Scholar]
  15. , , , et al . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349.
    [Google Scholar]
  16. , , , . Influence of Tönnis grade on outcomes of arthroscopy for FAI in athletes: a comparative analysis. J Hip Preserv Surg. 2018;5(2):162-165.
    [Google Scholar]
  17. , , , , , , . Arthroscopic repair of hip labrum with suture anchors. Arthrosc Tech. 2017;6(6):e2143-e2149.
    [Google Scholar]
  18. , , , . Minimally invasive total hip replacement: the posterolateral approach. Am J Orthop (Belle Mead NJ). 2006;35(5):218-224.
    [Google Scholar]
  19. , , , et al . The Development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33) Arthroscopy. 2012;28(5):595-605.
    [Google Scholar]
  20. , , , et al . Validation of a German version of the international hip outcome tool 12 (iHOT12) according to the COSMIN checklist. Health Qual Life Outcome. 2016;14:3.
    [Google Scholar]
  21. , , , , . Assessing activity in joint replacement patients. J Arthroplast. 1998;13(8):890-895.
    [Google Scholar]
  22. , , , , , . Reliability of modified Harris hip score as a tool for outcome evaluation of total hip replacements in Indian population. J Clin Orthop Trauma. 2019;10(1):128-130.
    [Google Scholar]
  23. , , , , , . Are range of motion measurements needed when calculating the Harris hip score? J Arthroplast. 2016;31(4):815-819.
    [Google Scholar]
  24. , , , et al . Performance of the HOOS-12 and KOOS-12 instruments for evaluating outcomes from joint replacement surgery. Osteoarthr Cartil. 2021;29(6):815-823.
    [Google Scholar]
  25. , , , . A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain. 2000;16(1):22-28.
    [Google Scholar]
  26. , , , et al . Is arthroscopic hip labral repair/reconstruction surgery effective for treating femoroacetabular impingement in the presence of osteoarthritis? Clin J Sport Med. 2021;31(4):367-373.
    [Google Scholar]
  27. , , , et al . Function and osteoarthritis progression after arthroscopic treatment of femoro-acetabular impingement: a prospective study after a mean follow-up of 4.6 (4.2-5.5) years. Orthop Traumatol Surg Res. 2014;100(6):651-656.
    [Google Scholar]
  28. , , , , , , . Outcomes of hip arthroscopic surgery in patients with Tönnis grade 1 osteoarthritis at a minimum 5-year follow-up: a matched-pair comparison with a Tönnis grade 0 control group. Am J Sports Med. 2017;45(10):2294-2302.
    [Google Scholar]
  29. , , , et al . Osteoarthrosis, advanced age, and female sex are risk factors for inferior outcomes after hip arthroscopy and labral debridement for femoroacetabular impingement syndrome: case series with minimum 10-year follow-up. Arthroscopy. 2021;37(6):1822-1828.
    [Google Scholar]
  30. , , , , , , . Does unilateral total hip arthroplasty improve pain and function in the non-operative hip joint? Eur J Orthop Surg Traumatol. 2020;30(8):1411-1416.
    [Google Scholar]
  31. , , , , , . Joint arthroplasty within 10 years after primary charnley total hip arthroplasty. Am J Orthop (Belle Mead NJ). 2009;38(8):E141-E143.
    [Google Scholar]
  32. , , , et al . Outcome of the contralateral hip following total hip arthroplasty for osteoarthritis. J Arthroplast. 1996;11(3):242-246.
    [Google Scholar]
  33. , , , , . Incidence of contralateral THA after index THA for osteoarthritis. Clin Orthop Relat Res. 2012;470(2):535-540.
    [Google Scholar]
  34. , , . The natural history of osteoarthritis: what happens to the other hip? Clin Orthop Relat Res. 2016;474(8):1802-1809.
    [Google Scholar]
  35. , , , , . Unilateral hip osteoarthritis: can we predict the outcome of the other hip? Skelet Radiol. 2008;37(10):911-916.
    [Google Scholar]
  36. , , , , , , . Prevalence of femoroacetabular impingement in asymptomatic contralateral hips in patients with unilateral idiopathic osteoarthritis. J Int Med Res. 2011;39(3):790-797.
    [Google Scholar]

Fulltext Views
253

PDF downloads
8
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections

Suggested read for related articles: