Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
John C. Clohisy, MD*,
Washington University School of Medicine, St. Louis, Missouri
Posted August 3, 2006
This study by Peters and Erickson is an important
contribution regarding the surgical treatment of hip impingement and associated
intraarticular disease. Specifically, the authors document early clinical and
radiographic results of surgical hip dislocation in treating femoro-acetabular
impingement. Thirty hips were included in the study and followed for a minimum of
two years. The authors document an overall improvement in hip function with use
of the Harris hip score. At surgery, eighteen of the hips were found to have
severe acetabular cartilage damage that was not appreciated preoperatively. At
follow-up, eight of these hips had radiographic progression of osteoarthritis
and four required or were expected to require conversion to total hip
replacement.
Perhaps the most important aspect of this study is the
documentation of the safety and efficacy of the surgical dislocation approach
for the treatment of hip disease. Independent of the original surgeon innovators1,
the authors have demonstrated reproducibility and utility of this technique.
They report no complications of osteonecrosis, trochanteric nonunion, nerve
palsy, or heterotopic bone. These findings indicate that this surgical approach
can and will be safely employed by many surgeons at many institutions.
Secondly, the authors have appropriately emphasized the
severity of acetabular articular cartilage damage found at the time of surgery,
despite minimal evidence of articular cartilage disease on preoperative
radiographs and magnetic resonance arthrography. These findings raise several
important issues relative to the treatment of hip impingement. Most
importantly, a heightened awareness of this disease process is critical to
facilitate early diagnosis and intervention at a more optimal, early stage of
disease. As discussed by the authors, the findings of advanced articular
disease also underscore the importance of developing imaging techniques that
accurately assess the integrity of acetabular cartilage preoperatively2.
Importantly, advanced articular cartilage disease was associated with a
suboptimal clinical result in many of the cases reported. The importance of
this observation cannot be overstated, and hips with mild to moderate
osteoarthritis as seen on radiographs must be considered to be at an increased
risk of failure despite surgical intervention3.
One weakness of this study was the variability in the
treatment of acetabular labral disease, acetabular chondral disease, and pincer-impingement
lesions. Clearly, there exists a major need for future investigation to define
the optimal techniques and indications for labral resection and/or repair,
articular cartilage restoration, and acetabular rim osteoplasty. Less invasive
surgical strategies (arthroscopy and/or limited open techniques) will also
evolve to include the management of impingement disease of the hip. As
alternative treatment options unfold, it is extremely important that surgeons
identify and address all disease components (osseous impingement, labral
disease, and articular cartilage deterioration) as these authors have in the
current study. Specifically, the location and the extent of the osseous
impingement lesion must be considered during preoperative planning. For severe
or extensive disease as encountered in coxa profunda or residual Perthes-like
femoral head deformities, surgical dislocation with wide exposure of the
femoral head and acetabulum will likely remain the optimal technique for
surgical reconstruction of the hip.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119-24.
2. Kim YJ, Jaramillo D, Millis MB, Gray ML, Burstein D. Assessment of early osteoarthritis in hip dysplasia with delayed gadolinium-enhanced magnetic resonance imaging of cartilage. J Bone Joint Surg Am. 2003;85:1987-92.
3. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418,67-73.
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