Aims. The number of patients undergoing arthroscopic surgery of the hip has increased significantly during the past decade. It has now become an established technique for the treatment of many intra- and extra-articular conditions affecting the hip. However, it has a steep learning curve and is not without the risk of complications. The purpose of this systematic review was to determine the prevalence of complications during and following this procedure. Materials and Methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in designing this study. Two reviewers systematically searched the literature for complications related to arthroscopy of the hip. The research question and eligibility criteria were established a priori. Pertinent data were abstracted and analysed. Results. We found 276 relevant studies with a total of 36 761 arthroscopies that met the inclusion criteria. The mean age of the patients was 36.7 years (1.7 to 70) and the mean body mass index was 25.7 kg/m. 2. (20.2 to 29.2). Femoroacetabular impingement and labral tears were the most common indications for the procedure. The total number of complications was 1222 (3.3%). Nerve injury (0.9%), mainly involving the pudendal and lateral femoral cutaneous nerves, and iatrogenic chondral and labral injury (0.7%), were the two most common complications. There were 58 major complications (0.2%), the most common being intra-abdominal extravasation of fluid, which was found in 13 cases (0.04%). There were three deaths (0.008%). Conclusion. Arthroscopic surgery of the hip is a procedure with a relatively low rate of complications, although some may be significant in this young cohort of patients. This study relied on the reported complications only and the results should be interpreted with caution. Cite this article: Bone Joint J 2017;99-B:1577–83

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients. This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip. Cite this article: Bone Joint J 2013;95-B:10–19

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. . Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. . In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. . The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). . The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration. Take home message: Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes. Cite this article: Bone Joint J 2016;98-B:21–7

Although good to excellent short-term results of arthroscopic partial limbectomy of the hip have been reported, there is little information on the long-term outcome of the procedure. We report a case with a 16-year follow-up. A 34-year old woman presented with a three-month history of severe pain and limitation of movement of the hip. Plain radiographs and arthrography showed no abnormality. MRI showed an effusion and a deformity of the anterosuperior part of the labrum. This was confirmed as an inverted labral tear that was debrided arthroscopically. At 16 years post-operatively, she remained symptom-free. Plain radiographs showed no abnormality and MRI suggested that the sealing effect of the scar tissue prevented articular damage and degeneration

Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection

Femoroacetabular impingement causes groin pain and decreased athletic performance in active adults. This bony conflict may result in femoroacetabular subluxation if of sufficient magnitude. The ligamentum teres has recently been reported to be capable of withstanding tensile loads similar to that of the anterior cruciate ligament, and patents with early subluxation of the hip may become dependent on the secondary restraint that is potentially provided by the ligamentum teres. Rupture of the ligamentum may thus cause symptomatic hip instability during athletic activities. An arthroscopic reconstruction of the ligamentum teres using iliotibial band autograft was performed in an attempt to restore this static stabiliser in a series of four such patients. Early clinical results have been promising. The indications, technique and early outcomes of this procedure are discussed

Aims. What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI. Patients and Methods. Between October 2005 and June 2016, 88 patients (97 hips) underwent arthroscopic cam resection and concomitant labral debridement and/or refixation. There were 57 male and 31 female patients with a mean age of 31.0 years (17.0 to 48.5) and a mean body mass index (BMI) of 25.4 kg/m. 2. (18.9 to 34.9). We used the Hip2Norm, an object-oriented-platform program, to perform 3D analysis of hip joint morphology using 2D anteroposterior pelvic radiographs. The lateral centre-edge angle, anterior coverage, posterior coverage, total femoral coverage, and alpha angle were measured for each hip. The presence or absence of crossover sign, posterior wall sign, and the value of acetabular retroversion index were identified automatically by Hip2Norm. Patient-reported outcome scores were collected preoperatively and at final follow-up with the Hip Disability and Osteoarthritis Outcome Score (HOOS). Results. At a mean follow-up of 2.7 years (1 to 8, . sd. 1.6), all functional outcome scores significantly improved overall. Radiographically, only preoperative anterior coverage had a negative correlation with the improvement of the HOOS symptom subscale (r = -0.28, p = 0.005). No significant difference in relative change in HOOS subscale scores was found according to the presence or absence of radiographic signs of retroversion. Discussion. Our study demonstrated the anterior coverage as an important modifier influencing the functional outcome of arthroscopically treated cam-type FAI. Cite this article: Bone Joint J 2018;100-B:831–8

This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage

We reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54). The mean modified Harris hip score improved by 19.2 points (95% confidence interval 13.6 to 24.9; p < 0.001) while the mean non-arthritic hip score improved by 15.0 points (95% confidence interval 10.9 to 19.1, p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The overall level of satisfaction was high with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred. Arthroscopic femoral osteochondroplasty performed in selected patients over 60 years of age, who have hip pain and mechanical symptoms resulting from cam femoroacetabular impingement, is beneficial with a minimal risk of complications at a mean follow-up of 30 months

Open reduction of the prominence at the femoral head-neck junction in femoroacetabular impingement has become an established treatment for this condition. We report our experience of arthroscopically-assisted treatment of femoroacetabular impingement secondary to paediatric hip disease in 14 hips in 13 consecutive patients (seven women, six men) with a mean age of 30.6 years (24 to 39) at the time of surgery. The mean follow-up was 2.5 years (2 to 4). Radiologically, 13 hips had successful restoration of the normal geometry and only one had a residual deformity. The mean increase in the Western Ontario McMasters Osteoarthritis Index for the series at the last follow-up was 9.6 points (4 to 14). No patient developed avascular necrosis or sustained a fracture of the femoral neck or any other complication. These findings suggest that femoroacetabular impingement associated with paediatric hip disease can be treated safely by arthroscopic techniques

We undertook a prospective pilot study to determine whether arthroscopic surgery through the central compartment of the hip was effective in the management of a snapping iliopsoas tendon. Seven patients were assessed pre-operatively and at three, six, 12 and 24 months after operation. This included the assessment of pain on a visual analogue scale (VAS) and function using the modified Harris hip score. All the patients had resolution of snapping post-operatively and this persisted at follow-up at two years. The mean VAS score for pain fell from 7.7 (6 to 10) pre-operatively to 4.3 (0 to 10) by three months (p = 0.051), and to 3.6 (1 to 8) (p = 0.015), 2.4 (0 to 8) (p = 0.011) and 2.4 (0 to 8) (p = 0.011) by six, 12 and 24 months, respectively. The mean modified Harris hip score increased from 56.1 (13.2 to 84.7) pre-operatively to 88.4 (57.2 to 100) at one year (p = 0.018) and to 87.9 (49.5 to 100) at two years (p = 0.02). There were no complications and no weakness occurred in the musculature around the hip. Our findings suggest that this treatment is effective and would support the undertaking of a larger study comparing this procedure with other methods of treatment

Femoroacetabular impingement is recognised as being a cause of labral tears and chondral damage. We report a series of five patients who presented with persistent pain in the hip after arthroscopy for isolated labral debridement. All five had a bony abnormality consistent with cam-type femoroacetabular impingement. They had a further operation to correct the abnormality by chondro-osteoplasty of the femoral head-neck junction. At a mean follow-up of 16.3 months (12 to 24) all had symptomatic improvement.

Aims. Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system. Methods. A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected. Results. A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015). Conclusion. There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable. Cite this article: Bone Joint J 2023;105-B(7):751–759

Aims. This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. Methods. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology. Results. The mean follow-up was 96 months (67 to 139). The SHV, mHHS, WOMAC, and Tegner scores significantly improved (p < 0.001) at last follow-up. According to SHV and mHHS, there were three hips (7%) with poor results (SHV < 70), three (7%) with a fair score (70 to 79), eight (19%) with good results (80 to 89), and 28 (67%) who scored excellent (> 90) at the last follow-up. There were 11 subsequent operations: nine implant removals due to local irritation, one resection of postoperative heterotopic ossification, and one hip arthroscopy for intra-articular adhesions. No hips were converted to total hip arthroplasty at last follow-up. The presence of preoperative labral lesions or LT lesions did not influence any PROMs at last follow-up. From the three hips that had poor PROMs, two have developed severe osteoarthritis (> Tönnis II), presumably due to surgical overcorrection (postoperative AI < -10°). Conclusion. PAO is reliable in treating BHD with favourable mid-term outcomes. Concomitant LT and labral lesions did not negatively influence outcomes in our cohort. Technical accuracy with avoidance of overcorrection is essential in achieving successful outcomes. Cite this article: Bone Joint J 2023;105-B(7):735–742

Aims. A borderline dysplastic hip can behave as either stable or unstable and this makes surgical decision making challenging. While an unstable hip may be best treated by acetabular reorientation, stable hips can be treated arthroscopically. Several imaging parameters can help to identify the appropriate treatment, including the Femoro-Epiphyseal Acetabular Roof (FEAR) index, measured on plain radiographs. The aim of this study was to assess the reliability and the sensitivity of FEAR index on MRI compared with its radiological measurement. Patients and Methods. The technique of measuring the FEAR index on MRI was defined and its reliability validated. A retrospective study assessed three groups of 20 patients: an unstable group of ‘borderline dysplastic hips’ with lateral centre edge angle (LCEA) less than 25° treated successfully by periacetabular osteotomy; a stable group of ‘borderline dysplastic hips’ with LCEA less than 25° treated successfully by impingement surgery; and an asymptomatic control group with LCEA between 25° and 35°. The following measurements were performed on both standardized radiographs and on MRI: LCEA, acetabular index, femoral anteversion, and FEAR index. Results. The FEAR index showed excellent intraobserver and interobserver reliability on both MRI and radiographs. The FEAR index was more reliable on radiographs than on MRI. The FEAR index on MRI was lower in the stable borderline group (mean -4.2° (. sd. 9.1°)) compared with the unstable borderline group (mean 7.9° (. sd. 6.8°)). With a FEAR index cut-off value of 2°, 90% of patients were correctly identified as stable or unstable using the radiological FEAR index, compared with 82.5% using the FEAR index on MRI. The FEAR index was a better predictor of instability on plain radiographs than on MRI. Conclusion. The FEAR index measured on MRI is less reliable and less sensitive than the FEAR index measured on radiographs. The cut-off value of 2° for radiological FEAR index predicted hip stability with 90% probability. Cite this article: Bone Joint J 2019;101-B:1578–1584

Aims

Hip arthroscopy has gained prominence as a primary surgical intervention for symptomatic femoroacetabular impingement (FAI). This study aimed to identify radiological features, and their combinations, that predict the outcome of hip arthroscopy for FAI.

Arthroscopy of the native hip is an established diagnostic and therapeutic procedure. Its application in the symptomatic replaced hip is still being explored. We describe the use of arthroscopy of the hip in 24 symptomatic patients following total hip replacement, resurfacing arthroplasty of the hip and partial resurfacing (study group), and compared it with arthroscopy of the native hip in 24 patients (control group). A diagnosis was made or confirmed at arthroscopy in 23 of the study group and a therapeutic arthroscopic intervention resulted in relief of symptoms in ten of these. In a further seven patients it led to revision hip replacement. In contrast, arthroscopy in the control group was diagnostic in all 24 patients and the resulting arthroscopic therapeutic intervention provided symptomatic relief in 21. The mean operative time in the study group (59.7 minutes (35 to 93)) was less than in the control group (71 minutes (40 to 100), p = 0.04) but the arthroscopic approach was more difficult in the arthroplasty group. We suggest that arthroscopy has a role in the management of patients with a symptomatic arthroplasty when other investigations have failed to provide a diagnosis

There is a known association between femoroacetabular impingement and osteoarthritis of the hip. What is not known is whether arthroscopic excision of an impingement lesion can significantly improve a patient’s symptoms. This study compares the results of hip arthroscopy for cam-type femoracetabular impingement in two groups of patients at one year. The study group comprised 24 patients (24 hips) with cam-type femoroacetabular impingement who underwent arthroscopic debridement with excision of their impingement lesion (osteoplasty). The control group comprised 47 patients (47 hips) who had arthroscopic debridement without excision of the impingement lesion. In both groups, the presence of femoroacetabular impingement was confirmed on pre-operative plain radiographs. The modified Harris hip score was used for evaluation pre-operatively and at one-year. Non-parametric tests were used for statistical analysis. A tendency towards a higher median post-operative modified Harris hip score was observed in the study group compared with the control group (83 vs 77, p = 0.11). There was a significantly higher proportion of patients in the osteoplasty group with excellent/good results compared with the controls (83% vs 60%, p = 0.043). Additional symptomatic improvement may be obtained after hip arthroscopy for femoroacetabular impingement by the inclusion of femoral osteoplasty

Aims

The aim of this study is to evaluate whether acetabular retroversion (AR) represents a structural anatomical abnormality of the pelvis or is a functional phenomenon of pelvic positioning in the sagittal plane, and to what extent the changes that result from patient-specific functional position affect the extent of AR.

Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis