News & Press https://www.esska.org/news/default.asp Sun, 19 Jul 2026 04:53:25 GMT Tue, 21 Oct 2025 13:46:00 GMT Copyright © 2025 European Society of Sports Traumatology, Knee Surgery and Arthroscopy From the ESSKA Hip Section - Report from The Danish Hip Arthroscopy Registry 2025 https://www.esska.org/news/news.asp?id=716765 https://www.esska.org/news/news.asp?id=716765

Report from The Danish Hip Arthroscopy Registry 2025

Steering committee:
Bjarne Mygind-Klavsen, Aarhus University Hospital, chairman.
Otto Kraemer, Amager-Hvidovre University Hospital.
Per Hölmich, Amager-Hvidovre University Hospital.
Bent Lund, Horsens Regional Hospital.
Christian Dippmann, Bispebjerg-Frederiksberg University Hospital.
Jens Kristinsson, Hjørring Hospital.

The Danish Hip Arthroscopy Registry (DHAR) is the world’s oldest registry dedicated to recording hip arthroscopy procedures. It was established in response to a new health legislation in 2010, which restricted hip arthroscopies to a limited number of hospitals in Denmark that met specific expertise requirements. These regulations required hospitals and clinics to document the procedures they performed, prompting the creation of a national hip arthroscopy registry. DHAR was officially launched in 2012, with development funded by a grant from the Danish Association of Arthroscopy and Sports Orthopedics (SAKS).

The registry enables the extraction of data on individual patients, as well as groups of patients, various treatment modalities, and different types of injuries. While all surgeons have access to their own data, full access is restricted to the steering committee. The database is secure and not publicly accessible. Data can only be released upon written request, accompanied by a research protocol outlining the nature of the request, and must receive approval from the Danish Data Protection Agency. The structure of DHAR has been published [1].

In Denmark, hip arthroscopies are regulated by the Danish Health Authorities, and only 11 public hospitals are authorized to perform these procedures on patients from the public healthcare system. From DHAR was established, surgeons have completed the questionnaire forms online.

Patients are asked to complete various Patient-Reported Outcome Measures (PROMs) before surgery, including HAGOS, iHOT12, VAS-hip function, NRS-rest (pain), NRS-walk (pain), EQ-5D, and the HSAS score. Both surgeon-related and patient-related registrations are conducted online. Due to the absence of a Danish version, iHOT12 was included starting in 2019 [1].

By the end of 2024, the DHAR has recorded 10,070 hip arthroscopies [2]. This includes 5,807 pre-operative PROMs, 4,526 PROMs at the 1-year mark, and 3,280 PROMs at the 2-year mark. To date, there are 1,997 PROMs with a 5-year follow-up in the registry and 461 patients that have completed 10-year follow-up.

Most patients in DHAR are females (60%) and the average age was 37.2 years. The average Lateral Center Edge Angle and Alpha Angle was 31 and 66 degrees respectively. Ninety-six percent of the patients had a joint space width above 3 mm, measured at the lateral sourcil.

Except in cases where re-modelling of cam- and pincer-morphologies were performed, 90% of the cases had a torn labrum detected, of which 79% was repaired.

An overall improvement between preoperative and follow-up data was demonstrated in all PROMs. HAGOS subdomains physical activity and quality of life significantly improved between one and two years follow-up and two and five years follow-up.

Five years after surgery, nearly 70% of the patients were satisfied with their procedure and the willingness to repeat the surgery if necessary was nearly 70%. After 8 years, 13–14% have had a revision arthroscopy and the number of revisions per year seems to be increasing.

A major challenge in registries is the completeness of data. From preoperative data collection until ten years follow-up the completeness declines from 58% to 23%.


Fig.2Failure rates, defined as re-arthroscopies.

References:
1. Mygind-Klavsen B, Nielsen TG, Maagaard N et al. Danish Hip Arthroscopy Registry: an epidemiologic and perioperative description of the first 2000 procedures. J Hip Preserv Surg 2016 Feb 25; 3(2):138-45. https://doi.org/10.1093/jhps/hnw004
2. DHAR annual report 2024: https://saks.ortopaedi.dk/wp-content/uploads/2025/09/DHAR-Annual-Report-2024.pdf

]]> Tue, 21 Oct 2025 14:46:00 GMT Expanding Hip Arthroscopy Limits: https://www.esska.org/news/news.asp?id=710666 https://www.esska.org/news/news.asp?id=710666

Expanding Hip Arthroscopy Limits

Endoscopic Management of an Aneurysmal Bone Cyst of the Femoral Head

Marc Tey-Pons
Vice President AEA (Spanish Association of Arthroscopy)
Foundational member and Board of EHPA (European Hip Preservation Associates of ESSKA)
Foundational member of GIPCA (Iberian group of preserving hip surgery)
Associate Professor, Universitat Autònoma de Barcelona

Introduction

Hip arthroscopy has evolved dramatically over the last two decades, primarily driven by the recognition and treatment of femoroacetabular impingement (FAI). What started as a technique to address labral tears and bony deformities has grown into a sophisticated surgical discipline, supported by a dedicated armamentarium and refined skills. This evolution has not only transformed the management of intra-articular pathology but has also created the conditions to expand the scope of hip arthroscopy beyond its original boundaries, developing the endoscopic techniques around the hip joint.

One such example is the case presented here: the endoscopic treatment of an aneurysmal bone cyst (ABC) of the femoral head. To our knowledge, this is the first reported case of an intraosseous endoscopic management of such a lesion in the hip, combining arthroscopic and osseoscopic approaches to achieve tumor excision, bone grafting, and labral repair in a minimally invasive manner.

Case Presentation

An 18-year-old male, a recreational athlete engaged in tennis and gym training, presented with six months of progressive groin pain. There was no history of trauma. Pain was limiting his daily activities and exacerbated by hip flexion and internal rotation.

Clinical examination revealed positive FADIR and FABER tests, with restricted range of motion (flexion 100°, internal rotation 20°). He was already using crutches due to persistent pain.

Imaging studies were performed: plain radiographs, CT, and MRI demonstrated an intraosseous lesion of the femoral head consistent with an aneurysmal bone cyst. Associated findings included a cam morphology and an anterior labral tear.

The diagnosis posed a double challenge: a benign tumor located in a critical weight-bearing region, and symptomatic intra-articular pathology requiring attention.

Innovation in Surgical Technique

The surgical plan aimed to address both the intra-articular pathology and the bone cyst in a single minimally invasive procedure.

Hip arthroscopy was performed through standard anterolateral (AL) and mid-anterior distal (MAD) portals. Arthroscopic inspection confirmed cartilage integrity and an anterior labral tear, which was addressed later in the procedure.

For the intraosseous component, a lateral femoral approach was used to create two 10-mm bone tunnels, through the femoral neck, directed towards the cyst under fluoroscopic guidance. An endoscopic system was then introduced into the lesion cavity, allowing direct visualization.

The steps included:

  • Biopsy and excision: a mass consistent with aneurysmal bone cyst tissue was grasped and excised under endoscopic vision. Radiofrequency was used to control bleeding during the procedure.
  • Bone debridement: the cyst walls were debrided using an expandable burr, ensuring thorough removal of pathological tissue.
  • Bone grafting: autologous cancellous bone from the iliac crest was introduced through a cannula, and gently impacted until a slight deformation of the chondral surface was observed under arthroscopic control. In addition, 10-mm cylinders of allograft were used to complete the filling of the bone tunnels.
  • Labral reattachment: the associated labral tear was repaired arthroscopically.

This combined arthroscopic–intraosseous endoscopic technique is unprecedented in the literature for femoral head ABCs. It provides direct visual control both intra-articularly and intraosseously, offering safety, precision, and preservation of joint integrity.

Postoperative Results

Postoperative CT confirmed satisfactory filling of the cyst cavity with the bone graft. The patient’s recovery was uneventful. He used crutches with proprioceptive weight bearing during the first month, followed by partial weight bearing during the second month. After this period, he started a standard rehabilitation protocol for labral repair. At follow-up, pain had resolved, and there were no radiographic signs of recurrence. Functional recovery allowed resumption of recreational activities.

Discussion

Traditional management of aneurysmal bone cysts of the femoral head typically involves open curettage with bone grafting, either by a trapdoor technique with obvious violation of the cartilage, or by a retrograde technique through the femoral neck under fluoroscopic guidance but without direct articular control of the femoral head surface. While effective, these procedures carry significant morbidity, risk of fracture, and prolonged rehabilitation. Other options, such as selective arterial embolization, may reduce vascularity but do not address the mechanical defect directly

By contrast, the endoscopic approach offers several advantages:

  • Minimally invasive access to a deep-seated lesion.
  • Direct visualization of both intra-articular and intraosseous pathology.
  • Concurrent treatment of associated lesions, such as labral tears or impingement morphology.
  • Preservation of biomechanics by minimizing collateral damage to the joint.

However, this technique also presents challenges. It requires advanced skills in hip arthroscopy, familiarity with intraosseous endoscopy, and access to specialized instruments. The long-term outcomes remain to be validated, and recurrence must be monitored carefully.

Most importantly, this case illustrates how the progression of hip arthroscopy from FAI surgery has equipped surgeons with the tools and expertise to attempt such innovative approaches. The meticulous techniques developed for managing complex intra-articular pathology now enable safe exploration of intraosseous disease.

Future Perspectives

Expanding the limits of hip arthroscopy opens exciting possibilities. Intraosseous endoscopy may be applied to other benign bone lesions in difficult-to-access locations, offering patients less invasive options with faster recovery. As technology advances—with improved optics, expandable burrs, and navigational systems—the potential applications will only increase.

Equally important is the role of data and registries. Long-term outcomes must be recorded to establish the true effectiveness and safety of these novel techniques. ESSKA and its affiliated sections are ideally placed to foster multicenter collaborations, ensuring that innovative procedures are not only described but validated.

Finally, this case underscores the educational impact. For young surgeons, exposure to such techniques expands horizons and stimulates critical thinking. The story of hip arthroscopy—born in FAI and now pushing into intraosseous territory—is a reminder of how innovation emerges from persistence, creativity, and the willingness to challenge established limits.

Conclusion

The endoscopic management of an aneurysmal bone cyst of the femoral head represents an innovative extension of hip arthroscopy beyond its conventional indications. Built on the foundation of FAI surgery, this approach combines arthroscopic and intraosseous visualization to achieve effective tumor excision, bone grafting, and labral repair with minimal morbidity.

This case exemplifies how innovation and technical evolution can redefine the boundaries of our field. As hip surgeons, we are now not only preserving joints but also expanding the horizons of what hip arthroscopy can achieve.

Figures (1–5)

Figure 1. Preoperative MRI showing the aneurysmal bone cyst right femoral head Coronal view (1a) and sagittal view, (1b), with blood level clearly identified (Sequence: sPDFS_PDW_TSE)

Figure 1a
Figure 1b

Figure 1. Intraoperative image of intraosseous endoscopy (2a) and radioscopic control (2b). Note that hip is under traction and cannula is in the joint to continuous control of hip joint

Figure 2a
Figure 2b

Figure 3. Excision of bone tumor (3a) & Arthroscopic view of the labral repair(3b)

Figure 3a
Figure 3b

Figure 4. Bone grafting (4a) under arthroscopic control of femoral head (4b).

Figure 4a
Figure 4b

Figure 5. Postoperative CT showing graft filling. Autograft from iliac crest at cyst cavity (solid arrow) and 10mm cylindrical allograft at bone tunnels (dotted arrow).

Figure 5
]]> Tue, 23 Sep 2025 12:09:00 GMT EHPA Focus Meeting in Cambridge https://www.esska.org/news/news.asp?id=702855 https://www.esska.org/news/news.asp?id=702855

Dear EHPA members and friends,

The recent FOCUS meeting of the European Hip Preservation Associates (EHPA) was a resounding success. It was held on 24 & 25 April in the city of Cambridge, a university town renowned for its scientific excellence, inspiration, natural and architectural beauty, and networking opportunities. The two-day meeting took place in the grounds of Clare College, one of Cambridge’s most historic colleges.

Attended by 73 hip-preservation-focused surgeons from across Europe, the meeting embodied a spirit of knowledge-sharing, idea exchange, and evidence-based best-practice guidelines.

The first half-day, dedicated exclusively to our EHPA members (34 participants), featured high-quality papers on novel surgical techniques and patient management, as well as the EHPA-ESMA consensus on adult hip and groin pain.

Main Session Topics

  • Pediatric and adolescent hip pathology
  • Femoroacetabular impingement (FAI)
  • Dysplasia
  • Microinstability
  • Extra-articular hip and groin problems
  • Lateral hip pathology
  • Posterior hip pathology
  • Registries
  • Articular cartilage & capsular management
  • Orthobiologics and the young arthritic hip
  • Outcomes, complications & THR in the young
  • The future of hip preservation: AI to robotics

We also organised the first combined EHPA–EHS webinar on hip preservation, broadcast live from Cambridge.

A highlight was the plenary lecture by Mr R.N. Villar, one of the pioneers of modern hip preservation surgery, who shared his remarkable three-decade journey from experimental beginnings to today’s established practice.

The black-tie dinner in the Clare College grounds provided informal networking and lasting friendships. Many attendees promised to reconvene in two years’ time in Greece.

Throughout the meeting, the sense of community among EHPA members was unmistakable. Respectful and constructive dialogue encouraged everyone to contribute, reinforcing our shared commitment to tackling the challenges of hip preservation surgery.

In conclusion, the meeting’s academic excellence and high-level surgeon turnout have solidified ESSKA-EHPA’s position as Europe’s leading hip preservation scientific society.

With kind regards,

Athanasios Papavasiliou
EHPA Section Chair

Vikas Khanduja
Scientific Chair, EHPA Focus Meeting 2025

]]> Thu, 22 May 2025 13:48:00 GMT From our EHPA Section - What's coming up! https://www.esska.org/news/news.asp?id=696886 https://www.esska.org/news/news.asp?id=696886

News: EHPA

Dear EHPA members and Hip preservation enthusiasts,

The aim of this communication is to inform and update you on several important activities of the EHPA section in the next few months.

Firstly, we have the first EHPA Focus meeting to be held in Cambridge, Claire College, UK on 24 & 25 April 2025. A Focus meeting is a new concept that bridges the traditional Closed meeting (section members only) and Specialty Days (open to all). A Focus meeting aims to bring together EHPA members or ESSKA members that have declared an interest in hip preservation.

We chose Cambridge, UK for this inaugural EHPA meeting because it is renowned through the ages for its scientific excellence, inspiration, natural and architectural beauty, and networking opportunities. Cambridge was also the place where three decades ago the few and brave hip arthroscopists of the time gathered from all around the world to exchange their pioneering ideas. Now that we are established and many, it only seems appropriate to restart from the same city.

We named it “The DNA of Hip Preservation” in honour of our hosting city but also because the programme aims to cover hip preservation surgery from its core principles to the most advanced. We managed to gather, and we will be honoured by the presence of many of the leading surgeons in hip preservation from around Europe and we hope that with your help and attendance, we will manage to establish ESSKA-EHPA as the leading hip preservation scientific society in Europe.

Secondly, we are also planning the first “all about” ESSKA - EHPA hip arthroscopy course that is to be held in Istanbul on 15-16 May 2025. It is a collaboration between ESSKA-EHPA and the Turkish Society of Preventive Hip Surgery to be hosted in the facilities of Acibadem University, with an international faculty that will deliver an exceptional cadaver course.

Course Highlights
The comprehensive programme will cover a wide range of topics, including fundamental principles of hip arthroscopy indications, basic set-up to capsular management, and microinstability.

Distinguished Faculty

  • Dr. Asim Kayaalp
  • Prof. Baris Kocagolu (course chair)
  • Prof. Safa Gursoy (course chair)
  • Prof. Gokhan Polat
  • Dr. Oliver Marin-Peña
  • Prof. Ramazan Akmese
  • Prof. Reha Tandogan
  • Prof. Tahsin Beyzadeoglu
  • Athanasios (Thanos) Papavasiliou

We are looking forward to seeing ALL of you in Cambridge and many of you in Istanbul.

Best wishes,

Athanasios (Thanos) Papavasiliou
Interbalkan Medical Center – Greece
EHPA Chair

Prof. Safa Gursoy
Acibadem University
Istanbul, Türkiye

]]> Tue, 25 Mar 2025 14:27:00 GMT Report from The Danish Hip Arthroscopy Registry 2024. https://www.esska.org/news/news.asp?id=687855 https://www.esska.org/news/news.asp?id=687855

Steering committee:

  • Bent Lund, Horsens Regional Hospital, chairman.
  • Otto Kraemer, Amager-Hvidovre University Hospital.
  • Per Hölmich, Amager-Hvidovre University Hospital.
  • Bjarne Mygind-Klavsen, Aarhus University Hospital.
  • Christian Dippmann, Bispebjerg-Frederiksberg University Hospital.
  • Jens Kristinsson, Hjørring Hospital.

The Danish Hip Arthroscopy Registry (DHAR) is the world’s oldest registry dedicated to recording hip arthroscopy procedures. It was established in response to a new health legislation in 2010, which restricted hip arthroscopies to a limited number of hospitals in Denmark that met specific expertise requirements. These regulations required hospitals and clinics to document the procedures they performed, prompting the creation of a national hip arthroscopy registry. DHAR was officially launched in 2012, with development funded by a grant from the Danish Association of Arthroscopy and Sports Orthopedics (SAKS). It is one of only two national non-arthroplasty hip registries currently in existence. The registry enables the extraction of data on individual patients, as well as groups of patients, various treatment modalities, and different types of injuries. While all surgeons have access to their own data, full access is restricted to the steering committee. The database is secure and not publicly accessible. Data can only be released upon written request, accompanied by a research protocol outlining the nature of the request, and must receive approval from the Danish Data Protection Agency. The structure of DHAR has been published [1].

In Denmark, hip arthroscopies are regulated by the Danish Health Authorities, and only 11 public hospitals are authorized to perform these procedures on patients from the public healthcare system. From DHAR was established, surgeons have completed the questionaire forms online.

Patients are asked to complete various Patient-Reported Outcome Measures (PROMs) before surgery, including HAGOS, iHOT12, VAS-hip function, NRS-rest (pain), NRS-walk (pain), EQ-5D, and the HSAS score. Both surgeon-related and patient-related registrations are conducted online. Due to the absence of a Danish version, iHOT12 was included starting in 2019 [1].

By the end of 2023, the DHAR has recorded 9,283 hip arthroscopies [2]. This includes 5,297 pre-operative PROMs, 4,354 PROMs at the 1-year mark, and 3,172 PROMs at the 2-year mark. To date, there are 1,630 PROMs with a 5-year follow-up in the registry.

Most patients in DHAR are females (60%) and the average age was 37.2 years. Almost 20% of the patients had previous surgery such as periacetabular osteotomy, total hip replacement and osteosyntesis of Sub Capital Femoral Epifysiolysis (SCFE). The average Lateral Center Edge Angle and Alpha Angle was 31 and 66 degrees respectively. Ninety-five percent of the patients had a joint space width above 3 mm, measured at the lateral sourcil.

Except in cases were re-modelling of cam- and pincer-morphologies were performed, 90% of the cases had a torn labrum detected, of which 79% was repaired. Thirteen percent received a revision hip arthroscopy within five years.

An overall improvement between preoperative and follow-up data was demonstrated in all PROMs. HAGOS subdomains physical activity and quality of life significantly improved between one and two years follow-up and two and five years follow-up, figure 1. Five years after surgery, nearly 70% of the patients were satisfied with their procedure and the willingness to repeat the surgery if necessary was nearly 70%.

A major challenge in registries is the completeness of data. From preoperative data collection until five years follow-up the completeness declines from 57% to 31%.

Fig. 1.Fig. 1. HAGOS outcomes at 1, 2 and 5 years for all surgeries compared to the pre-scores.

References:

1. Mygind-Klavsen B, Nielsen TG, Maagaard N et al. Danish Hip Arthroscopy Registry: an epidemiologic and perioperative description of the first 2000 procedures. J Hip Preserv Surg 2016 Feb 25;3(2):138-45. 2. DHAR annual report 2023: https://saks.ortopaedi.dk/wp-content/uploads/2024/08/DHAR-Annual-Report-2023.pdf

]]> Mon, 25 Nov 2024 12:03:00 GMT Arthroscopic excision of an intra-articular osteoid osteoma on the femoral neck https://www.esska.org/news/news.asp?id=670547 https://www.esska.org/news/news.asp?id=670547

 

Angelo V. Vasiliadis1
Margarita Natsika 1,2
Athanasios Papavasiliou 3

1 MD, PhD, Orhtopaedic Surgeon, St. Luke’s Hospital, Thessaloniki, Greece
2 MD, MSK Radiologist, Kosmoitariki, Athens
3 MD, PhD, Orhtopaedic Surgeon, ESSKA-EHPA Vice-Chair, Interbalkan Medical Center Thessaloniki and Hygeia Hospital Athens, Greece

Arthroscopic excision of an intra-articular osteoid osteoma on the femoral neck mimicking features of bone marrow edema

Introduction

Osteoid osteoma (OO) is the third most common benign bone-forming tumor, which accounts for 10 to 14% of all benign bone tumors [1]. The most common anatomical location is the diaphysis or metaphysis of the long bones, with lower extremities being more frequently affected [1,2]. Intra-articular location is less common leading to a longest diagnostic delay and frequent misdiagnoses with the initial clinical image that can masquerade inflammatory arthritis [2]. This poor diagnostic accuracy inevitably leads to negative consequences and limits the provided treatment management [2].

We report a case of arthroscopic excision of osteoid osteoma of the femoral neck, which initially managed as bone marrow edema due to diagnostic delay.


Case presentation

A 19-year-old male, university student, was referred to our department with persistent and non-specific groin pain in his right hip that he had for almost a year. The patient reports the insidious onset of initially mild pain but gradually increased in severity. No comorbidities, no trauma or any other relevant history was noted. On clinical examination he walked with an antalgic gait and range of motion was reduced to 90 flexion and no internal or external rotation with intense pain at the FADDIR or FABER test.

The initial radiographic examination, anteroposterior and lateral hip radiographs (Figure 1) did not reveal any relevant abnormality. Blood test were unremarkable. Three consecutive MRI’s within 12-month interval, revealed marked bone marrow edema on the anatomical portion of the femoral neck (Figure 2) and significant joint effusion. The provisional diagnosis was one of transient osteoporosis. The fact that it was in a very usual location and within 12 months no improvement was recorded increased our suspicion for the presence of OO. A computed tomography (CT) was ordered, which revealed the typical nidus and surrounding rim of peripheral reactive sclerotic bone (Figure 3), along the medial cortex of the femoral neck, suggesting the presence of intra-articular OO of the hip.

Arthroscopic excision of the lesion was considered because of the anatomic location of the OO (superficial and medial head-neck junction). Hip arthroscopy was performed under general anesthesia with the patient in supine position. After the initial central compartment assessment, the traction was released and the peripheral compartment was accessed using the PMAP (proximal mid-anterior portal) for the 70 scope and MAP (mid-anterior portal) as a working portal. Significant synovitis was revealed and a prominent mass with high vascularity was seen (Figure 4). The location checked by the Image Intensifier was the area which the CT revealed the lesion. It was removed using a curette and reactive sclerotic rim was removed using motorized burr and then cauterized with radiofrequency (RF). Histological examination of the resection specimen confirmed the presence of OO.

At 2-months follow-up the patient was pain free, had full range of motion, and regained normal gait. A follow-up MRI confirmed the complete regression of the bone edema and much reduced synovitis (Figure 5).


Discussion

Osteoid osteoma is an uncommon but important cause of hip pain [1]. Patients present with constant and progressive pain, which worsen at night and relieved by non-steroidal anti-inflammatory drugs [3]. Clinical examination may reveal limitation of joint motion, limp during gait and muscle weakness or extensive muscle atrophy of the surrounding muscles [4]. Thus, osteoid osteoma may be mistaken for more common causes of synovitis, such as inflammatory arthritis, idiopathic transient osteoporosis, stress fracture of the femoral neck, aseptic osteonecrosis of the femoral head and/or pigmented villonodular synovitis [3,4].

CT is usually the modality of choice not only for proper diagnosis but also for specifying the exact anatomical location of the lesion [1]. Hosalkal et al. [5] found that CT afforded more confident and accurate detection of the nidus of the osteoid osteoma than MRI in children.

According to Wenger et al [6], the detection rate of osteoid osteoma of the hip joint by CT is close to 100%. In their retrospective study, OO was initially misdiagnosed for up to 70% of cases, as a femoral neck stress fracture, femoral acetabular impingement, Legg-Calve-Perthes disease, inflammatory arthritis, or other joint pathology. They Concluded that the utilization of CT is critical for making a timely and accurate diagnosis.

Recently, with the introduction of MRI-perfusion the literature suggests that it is equally successful in identifying OO with the added benefit of minimizing radiation exposure. (7)

Surgical treatment is frequently used with a high efficacy rate, using various methods, such as open surgical resection, drilled resection, or CT-guided percutaneous ablation [4,8-10]. However, in these techniques, care must be taken to avoid damaging the cartilage during the procedure which could have detrimental effects to the joint in the long term [9,11].

Arthroscopic excision in selected cases is a safe and efficient method of the treatment of OO with fast rehabilitation time [11]. Several studies reported a success rate of more than 90%, if the lesion is accessible [8,9,12].


Conclusion

Intra-articular OO has clinical features that can masquerade as any mono-articular inflammatory arthropathy. The clinical presentation may confuse the physician and the lesion may be not recognized in plain radiographs or MRI. If the bone oedema on the MRI is persistent it should raise the suspicion of an OO and a CT or an MRI-perfusion should be ordered. If the location of the OO is intra-articular arthroscopic-assisted resection is an effective technique to direct visualize, biopsy and treat the pathology.


Figure 1: Anteroposterior (A) and lateral (B) radiographs of the right hip.


Figure 2: MRI imaging bone marrow edema of the right femoral neck in three different examinations within 12 months.


Figure 3: Computed tomography imaging in coronal (A) and axial (B) views shows a central osteolytic lesion (nidus) and perinidal sclerosis in the medial area of the femoral neck of the right hip.


Figure 4: Arthroscopic view of the OO lesion (A), intra-operative fluoroscopic image of the lesion, curettage under II (B) and the final result after the arthroscopic excision (C).


Figure 5: 2-month post-operative magnetic resonance imaging shows complete regression of the bone edema.

References
1. Tepelenis K, Skandalakis GP, Papathanakos G, et al. Osteoid osteoma: An updated review of epidemiology, pathogenesis, clinical presentation, radiological features and treatment option. In Vivo 2021;35(4):1929-1938.
2. Civino A, Diomeda F, Giordano L, et al. Intra- and juxta-articular osteoid osteoma mimicking arthritis: Case series and literature review. Children 2023;10(5):829.
3. Papagelopoulos PJ, Mavrogenis AF, Kyriakopoulos CK, et al. Radiofrequency ablation of intra-articular osteoid osteoma of the hip. J Inter Med Res 2006;34:537-544.
4. Ramaswamy AG, Kumaraswamy V, Patil N, Pattanshetti V. Arthroscopic excision of osteoid osteoma of the femoral neck. Indian J Orthop 2018;52:568-571.
5. Hosalkar HS, Garg S, Moroz L, Pollock A, Dormans JP. The diagnostic accuracy of MRI versus CT imaging for osteoid osteoma in children. Clin Orthop Relat Res 2005;433:171-177.
6. Wenger DE, Tibbo ME, Hadley ML, Sierra RJ, Welch TJ. Osteoid osteomas of the hip: a well-recognized entity with a proclivity for misdiagnosis. Eur Radiol 2023;33(1):8343-8352.
7. Kostrzewa M, Henzler T, Schoenberg SO, Diehl SJ, Rathmann N. Clinical and Quantitative MRI Perfusion Analysis of Osteoid Osteomas Before and After Microwave Ablation. Anticancer Res. 2019 Jun;39(6):3053-3057.
8. Yoon BH, Kim JG, Ha YC. Arthroscopic excision of an osteoid osteoma of the lesser trochanter of the femoral neck. Arthrosc Tech 2017;6(4):1361-1365.
9. Spiker AM, Rotter B-Z, Chang B, Mintz DN, Kelly BT. Clinical presentation of intr-articular osteoid osteoma of the hip and preliminary outcomes after arthroscopic resection: a case series. J Hip Preserv Surg 2018;5(1):88-99.
10. Bianchi G, Zugaro L, Palumbo P, Candelari R, Paci E, Floridi C, Giovagnoni A. Interventional radiology’s osteoid osteoma management: Percutaneous thermal ablation. J Clin Med 2022;11(3):723.
11. Karmani RS, Moradi A, Vaziri AS, Nabian MH, Ghane B. Arthroscopic ablation of an osteoid osteoma of the elbow: a case series with a minimum of 18 months’ follow-up. J Shoulder Elbow Surg 2017;26(5):e122-e127.
12. Dai L, Zhang X, Mei Y, Gao G, Huang H, Wang C, Ju X, Xu Y, Wang J. Arthroscopic excision of intrarticular osteoid osteoma of the hip: A case series. Arthroscopy 2021;39(10):3104-3112.

]]> Mon, 22 Apr 2024 09:43:00 GMT The role of isolated or augmented core decompression in osteonecrosis of the femoral head https://www.esska.org/news/news.asp?id=655551 https://www.esska.org/news/news.asp?id=655551
João Dinis1
André Sarmento1,2

1 Department of Orthopaedic Surgery, Centro Hospitalar De Vila nova de Gaia/Espinho, Porto, Portugal
2 Department of Orthopaedic Surgery, Clínica Espregueira – Fifa center of excellence, Porto, Portugal


Introduction

Non-traumatic osteonecrosis of the femoral head (ONFH)1 is characterized by the death of the bone following a disruption of the femoral head blood flow. Initially, osteonecrosis was described as a late complication of traumatic hip injuries. Later, during the 20th century, it was associated with several risk factors, such as diving, hemoglobinopathies, corticosteroid use, radiation, and alcohol abuse. We will only explore the non-traumatic osteonecrosis of the femoral head (ONFH).

ONFH is responsible for 10% of total hip arthroplasties (THA) in the United States of America2. It affects mainly young adults with an average age at treatment of 33 to 38 years old3. Its incidence increased in the early 2000s4 due to two factors: the availability of Magnetic Resonance Imaging (MRI), which detects early stages, and an increase in patients treated with corticosteroids.

ONFH diagnosis and stratification are mandatory. Overall, femoral head collapse may be expected in up to 80% of the hips if no treatment is provided5. However, inside this big group of ONFH there are the small lesions that seldom progress and larger lesions, which have a poor prognosis, even if surgically treated.

After stratification, appropriate treatment should be provided. In this work, we will consider only the precollapse stage treatment, especially core decompression and its augmented variants.

Pathophysiology

Alcohol abuse and use of corticosteroids are responsible for up to 80% of non-traumatic ONFH6, however, its pathophysiology is not completely understood.

They are believed to cause an intra-osseous compartment syndrome: the hyperplasia of the bone marrow fat cell creates intra-osseous hypertension which results in an impartment of the blood flow. There is bone marrow necrosis and osteocytic death. Until this point the lesion is reversible. After the necrotic phase, the reparative process starts with the deposition of fibrovascular tissue around the dead bone and saponification of the necrotic marrow. At this point, there is a definitive ONFH 1,7. At this stage the cancellous bone loses its mechanical properties and stress fractures arise, eventually leading to collapse.

The steroids are not only responsible for deregulation of the lipid metabolism, but they also decrease osteogenesis potential and blood supply and induce apoptosis8. In a similar fashion, alcohol abuse is also credited with deregulation of mesenchymal differentiation towards osteoblastic cells, however, current literature does not explain why only some patients develop ONFH9. A genetic predisposition may be an answer and a mutation to type II collagen gene has already been described10.

The progression between early necrosis and irreversible scared osteonecrosis is a critical step and is determined by the inability to produce adequate fibrinolysis and angiogenesis capable of restoring the normal blood flow11. Is at this critical stage that core decompression may help change the course of the disease.

Classification

The diagnosis is easily made today with MRI and radiographs. MRI is the most sensible exam, with up to 100% of sensitivity. Radiographs are only positive when there is already some bone remodeling in place: sclerosis, osteoporosis, or osteolysis are early signs. Subcondral fractures are the continuation of the pathogenic spectrum and may be better diagnosed by Computer Tomography. Depression and overly collapse are clear in the radiographs12 as a crescent sign13. If MRI is not available or is contraindicated SPECT/CT has proven to be a suitable alternative14.

As mentinoned, ONFH must be classified according to the stage of the disease and, the dimensions and location of the lesion.

Ficat, Steinberg, and Japanese Orthopaedic Association systems have historically been used. The Association Research Circulation Osseus (ARCO) classification system was created by merging the previous systems and tried to create a universal system that facilitates scientific discussion7. Stage I and II are preccolapse stages. At stage I only MRI is positive while at Stage II there are already subtle radiographic signs. On post-collapse stages, ARCO system focused on the head depression cut-off of 2mm because of its proven implications on survival after joint salvage surgery (bone graft, osteotomy): Stage IIIA lesions present a subchondral fracture < 2mm and have a better prognosis than IIIB lesions which have a head depression greater than 2 mm7,15. Stage IV lesions are characterized by manifest osteoarthritis.

Steinberg and Kerboul classifications were classically used to classify the size of the lesion in the radiograph. Japanese Investigation Committee (JIC) system characterized the lesion by its size in midcoronal MRI image. Ha et al. modified the Kerboul measurement by adapting it to MR images: therefore, the size of the lesion is measured in midsagittal and midcoronal images. If the combined angle is less than 140º it is a small lesion. Large lesions are classified by a necrotic angle superior to 240º16. It also has prognostic value as small lesions did not progress in the initial study. Recently, Ruckli et all. showed that volumetric and surface measurements on MRI are better correlated with ARCO classification and prognosis: the amount of necrosis is actually bigger in later stages of the disease, pointing out that a significant articular change has occurred17.

Core decompression

If we consider the intra-osseous compartment syndrome theory, it is sound reasoning to decompress the bone marrow as in any other compartment syndrome. This has been the principle behind core decompression for 50 years, during which it has shown superior results compared to conservative treatment18,19, with survival rates from 54,5 to 100%12. A systematic revision has concluded it should be performed at precollapse stages, ARCO I and II on smaller lesions. It may also be considered for short-term symptomatic relief in Stage III20.

Most patients present at stage II and at this point there is already definitive scar tissue around the necrotic area and decompression alone does not remove or clear all the debris. In an attempt to change local biology, different strategies have been pursued: augmentation of the decompression with bone grafts21; small-diameter drilling with supplementation with bone Marrow Aspirated Concentrate (BMAC)22,23 or platelet-rich plasma (PRPs)24,25; reverse reaming with grafting and BMAC26. In fact, recent studies have proved the superiority of augmentation with BMAC versus CD alone 27,28.

However, even with augmentation of CD, large-diameter lesions continue to have a poor prognosis and the size of the lesion continues to be the major predictor of collapse29: Boontanapibul et all22 showed that a modified Kerboul angle >250º is associated with progression and collapse even if CD augmented with BMAC is performed.

Another factor that must be considered is the etiology behind ONFH. In the case of steroid induced-ONFH, it must be assessed If the patient continues the therapy. Corticosteroids alter the activity of mesenchymal cells and therefore there might not be a benefit of augmenting CD with autologous BMAC28.

Our center experience is similar to published results. Between 2015 and 2021 we performed CD alone or augmented with PRPs in 41 hips – Figure 1-4. The mean age was 45 years. 6 hips presented at ARCO stage 1, 31 at stage 2, and 4 at stage IIIA. At a minimum follow-up of 2 years, we found progression to THA in 38% of the hips in the precollapse stage. All the hips initially at stage IIIA progressed to THA – Figure 5-7. We did not find a difference between CD alone or augmentation with PRPs. A higher combined necrotic angle was also associated with higher progression to collapse: from the 17 hips with a modified Kerboul angle >250º, 12 progressed to collapse.

Figure 1: A 46-year-old male presents with left hip pain. MRI presents bilateral ONFH. The left hip had a small lesion with a modified Kerboul angle of 154º.

Figure 2: We performed core decompression augmented with PRPs.

Figure 3: 1 year pos-operatively MRI shows absence of progression of the lesion.

Figure 4: Two years pos-op radiograph shows absence of collapse.

Figure 5: A 40-year-old male patient presents with right hip pain. The radiograph shows subtle sclerotic changes – ARCO Stage II.

Figure 6: MRI control at 6 months post-operatively. There is no regression in the size of the lesion and joint effusion is present.

Figure 7: The patient kept pain in his right hip. Loss of sphericity is already present and a total hip arthroplasty was performed.

Further research

When reviewing the literature, two questions arise: do we really need to decompress the small lesions? Do they progress? There is no definitive answer as no large study can be conducted at the expense of those patients who might have benefited from CD and ended up with a hip prosthesis30.

Regarding large lesions, what is the best treatment? Should we be more aggressive and openly debride those hips and grafts?

Further research must clearly stratify the patients in order for proper metanalysis to be performed: what are the patient-specific risk factors? Is the patient still on steroids? What is the ARCO grade of the lesion and what is its size according to the modified Kerboul angle16 or to the volumetric and surface area17?

The advance of tissue engineering will also add another factor to the equation as new biomaterials and techniques are discovered. Maybe the solution for the treatment of large lesions rests in the perfect mechanical and biological scaffold31.

Biography
1. Hines, Jeremy T., et al. "Osteonecrosis of the femoral head: an updated review of ARCO on pathogenesis, staging and treatment." Journal of Korean medical science 36.24 (2021).
2. Mont, Michael A., et al. "Nontraumatic Osteonecrosis of the femoral head: where do we stand today?: a ten-year update." JBJS 97.19 (2015): 1604-1627.
3. Petek, Daniel, Didier Hannouche, and Domizio Suva. "Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment." EFORT open reviews 4.3 (2019): 85-97.
4. Lieberman, Jay R., et al. "Osteonecrosis of the hip: management in the 21st century." Instructional course lectures 52 (2003): 337-355.
5. Min, Byung-Woo, et al. "Untreated asymptomatic hips in patients with osteonecrosis of the femoral head." Clinical orthopaedics and related research 466 (2008): 1087-1092.
6. Mont, Michael A., and David S. Hungerford. "Non-traumatic avascular necrosis of the femoral head." JBJS 77.3 (1995): 459-474.
7. Yoon, Byung-Ho, et al. "The 2019 revised version of association research circulation osseous staging system of osteonecrosis of the femoral head." The Journal of arthroplasty 35.4 (2020): 933-940.
8. Wang, Ao, Ming Ren, and Jincheng Wang. "The pathogenesis of steroid-induced osteonecrosis of the femoral head: a systematic review of the literature." Gene 671 (2018): 103-109.
9. Hirota, Yoshio, et al. "Association of alcohol intake, cigarette smoking, and occupational status with the risk of idiopathic osteonecrosis of the femoral head." American journal of epidemiology 137.5 (1993): 530-538.
10. Liu, Yu-Fen, et al. "Type II collagen gene variants and inherited osteonecrosis of the femoral head." New England Journal of Medicine 352.22 (2005): 2294-2301.
11. Seamon, Jesse, et al. "The pathogenesis of nontraumatic osteonecrosis." Arthritis 2012 (2012).
12. Mont, Michael A., et al. "Nontraumatic osteonecrosis of the femoral head: where do we stand today?: a 5-year update." The Journal of Bone and Joint Surgery. American Volume 102.12 (2020): 1084.
13. Petek, Daniel, Didier Hannouche, and Domizio Suva. "Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment." EFORT open reviews 4.3 (2019): 85-97.
14. Iqbal, Basit, and Geoff Currie. "Value of SPECT/CT in the diagnosis of avascular necrosis of the head of femur: a meta-analysis." Radiography 28.2 (2022): 560-564.
15. Zuo, Wei, et al. "Investigating clinical failure of bone grafting through a window at the femoral head neck junction surgery for the treatment of osteonecrosis of the femoral head." PLoS One 11.6 (2016): e0156903.
16. Ha, Yong-Chan, et al. "Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images." JBJS 88.suppl_3 (2006): 35-40.
17. Ruckli, Adrian C., et al. "A Deep Learning Method for Quantification of Femoral Head Necrosis Based on Routine Hip MRI for Improved Surgical Decision Making." Journal of personalized medicine 13.1 (2023): 153.
18. Mont, Michael A., John J. Carbone, and Adrian C. Fairbank. "Core decompression versus nonoperative management for osteonecrosis of the hip." Clinical Orthopaedics and Related Research (1976-2007) 324 (1996): 169-178.
19. Stulberg, Bernard N., et al. "Osteonecrosis of the femoral head. A prospective randomized treatment protocol." Clinical orthopaedics and related research 268 (1991): 140-151.
20. Roth, A., et al. "S3-Guideline non-traumatic adult femoral head necrosis." Archives of orthopaedic and trauma surgery 136 (2016): 165-174.
21. Sallam, Asser A., et al. "Inverted femoral head graft versus standard core decompression in nontraumatic hip osteonecrosis at minimum 3 years follow-up." Hip International 27.1 (2017): 74-81.
22. Boontanapibul, Krit, et al. "Modified Kerboul angle predicts outcome of core decompression with or without additional cell therapy." The Journal of Arthroplasty 36.6 (2021): 1879-1886.
23. Kang, Joon Soon, et al. "Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression." Stem cell research & therapy 9 (2018): 1-9.
24. Rocchi, Martina, et al. "Core decompression with bone chips allograft in combination with fibrin platelet-rich plasma and concentrated autologous mesenchymal stromal cells, isolated from bone marrow: results for the treatment of avascular necrosis of the femoral head after 2 years minimum follow-up." Hip International 30.2_suppl (2020): 3-12.
25. Lyu, Jinyang, et al. "Core decompression with β-tri-calcium phosphate grafts in combination with platelet-rich plasma for the treatment of avascular necrosis of femoral head." BMC Musculoskeletal Disorders 24.1 (2023): 40.
26. Li, Qingtian, et al. "Combining autologous bone marrow buffy coat and angioconductive bioceramic rod grafting with advanced core decompression improves short-term outcomes in early avascular necrosis of the femoral head: a prospective, randomized, comparative study." Stem Cell Research & Therapy 12.1 (2021): 1-10.
27. Wang, Zhan, et al. "Core decompression combined with autologous bone marrow stem cells versus core decompression alone for patients with osteonecrosis of the femoral head: a meta-analysis." International Journal of Surgery 69 (2019): 23-31.
28. Li, Mengyuan, et al. "Stem cell therapy combined with core decompression versus core decompression alone in the treatment of avascular necrosis of the femoral head: a systematic review and meta-analysis." Journal of Orthopaedic Surgery and Research 18.1 (2023): 560.
29. Martinot, Pierre, et al. "Does augmented core decompression decrease the rate of collapse and improve survival of femoral head avascular necrosis? Case-control study comparing 184 augmented core decompressions to 79 standard core decompressions with a minimum 2 years’ follow-up." Orthopaedics & Traumatology: Surgery & Research 106.8 (2020): 1561-1568.
30. Yoon, Byung-Ho, et al. "No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis." International Orthopaedics 42 (2018): 2737-2743.
31. Murab, Sumit, et al. "Tissue engineering strategies for treating avascular necrosis of the femoral head." Bioengineering 8.12 (2021): 200.

]]> Thu, 26 Oct 2023 06:00:00 GMT Trochanteric Advancement in the treatment of Legg-Calvé-Perthes sequelae https://www.esska.org/news/news.asp?id=652584 https://www.esska.org/news/news.asp?id=652584
José Ricardo Oliveira1
André Sarmento1,2

1 Department of Orthopaedic Surgery, Centro Hospitalar De Vila nova de Gaia/Espinho, Porto, Portugal
2 Department of Orthopaedic Surgery, Clínica Espregueira Fifa center of excellence, Porto, Portugal


Trochanteric overgrowth is a common sequela in Legg-Calvé-Perthes disease, and it is caused by a premature closure of the capital femoral physis while sparing the greater trochanteric physis[1]. This deformity can be explained by the 3 physeal zones of the proximal femur[2]. The functional consequences of the relative overgrowth of the greater trochanter include a decrease tension and mechanical efficiency of the abductor muscles; the greater trochanter moves closer to the center of rotation of the hip, decreasing the resting length and lever arm of the hip abductor muscles, and impairing muscular stabilization of the hip; the muscle force vector becomes more vertical increasing the pressure force over a diminished area of hip joint surface; and an extra-articular impingement of the trochanter on the acetabular rim during abduction decreasing the range of motion[3]–[6]. Clinically, the patients present with a trendelenburg gait and a positive trendlenburg sign, gluteus medius lurch, and fatigue pain on walking[7]. The examination may reveal limited and painful active or passive hip abduction and extension[8]. Macnicol and Makris described a “gear-stick” sign which is based on the observation that hip abduction is limited by impingement of the greater trochanter on the ilium when the hip is extended but full abduction is possible when the hip is fully flexed[9].

Several surgical interventions for a high-standing greater trochanter have been suggested and they all have the same target: improve the hip biomechanics. Trochanteric epiphysiodesis is effective only in younger patients as a prophylactic measure in the active stage of the disease[3], [4], [10]. Distal and lateral advancement of the trochanter was first described by Jani (1969) and has been advocated for the late treatment of Legg-Calvé-Perthes disease improving gluteal efficiency and increasing the range of abduction[5], [6], [11]–[15].

We retrospectively reviewed all patients who underwent trochanteric osteotomy for a high-standing greater trochanter between April 2013 and February 2019 in our institution. There were 7 patients, 5 males and 2 females; 4 of the hips were left and 3 were right. The mean age of patients was 32 years (range: 21-42). The patients had no previous surgery. All patients were available for complete follow-up evaluation. The minimum follow-up period was 12 months (median, 17 months; range 12–36 months) for the entire group. The same surgeon performed a stepped osteotomy as described by Johannes et al. in all patients[16]. The patient was positioned in the lateral decubitus position and a straight direct lateral 18- to 23-cm incision centered on the greater trochanter was made with one-third of the incision extended proximal to the tip of the greater trochanter. The iliotibial band was split longitudinally, proximally following the anterior border of the gluteus maximus muscle and then the interval between the gluteus maximus and the gluteus medius was developed. The posterior origin of the vastus lateralis fascia was released and the muscle lifted from the bone epiperiosteally, leaving the tendinous origin from the tubercle intact. A stepped osteotomy of the trochanter was performed, starting at the posteriosuperior tip of the greater trochanter and ending distally 15 mm distal to the lateralis tubercule (Fig. 1). The fragment was subsequently advanced and fixed with two 3.5-mm cortical screws (Fig. 2). This technique allows us to maintain the majority of the gluteus medius tendon on the fragment and provides more stability. The patients remain with progressive partial weightbearing for the first 6 weeks after the surgery. Active abduction and passive adduction were prohibited until any signs of consolidation, usually at 6-8 weeks.

Figure 1: Intraoperative view shows completion of the osteotomy. The osteotomy is fully visualized with the gluteus medius and minimus muscles and vastus lateralis muscle attached to the trochanteric fragment.

Figure 2: Schematic view show the reduction of the trochanteric fragment after a stepped trochanteric osteotomy.

All the osteotomies healed with no signs of malunion, like proximal migration of the fragment. We have one case of delayed union (70 days). The hardware was removed in 6 patients after a median of 7 months. No patients had perioperative complication and no revision surgery was necessary. Four patients were completely pain-free, furthermore all patients decreased pain intensity (median of 5 points decrease in Likert scale). Limp was eliminated or gait was considerably improved in 5 of 7 patients. The Hip Disability and Osteoarthritis Outcome Score improved in all patients (median 46 points, range 31-55 points). Biomechanical measurements with good-quality x-rays found a significant improvement in the joint reactive force ranging from -14 to 17%.

Figure 3: A pre and postoperative radiographic anteroposterior view show the anatomic reduction and fixation of the trochanteric fragment after a stepped trochanteric osteotomy.

Our results compared favourably with those found in the literature [17]–[23]. Distal transfer of the greater trochanter provides good outcomes, improving the clinical, functional and radiologic scores. A variety of surgical techniques for greater trochanteric transfer have been described in the literature. The stepped osteotomy used by the surgeon and described by Johannes et al. is more demanding than a flat cut, however, does have technical advantages: reduction of the fragment is easier; the proximal limb can be more shallow, permitting one to stay out of the trochanteric fossa in cases in which the tip of the trochanter is unusually hooked or small; the step provides more stability, the fragment does not rotate or migrates proximally when held for screw placement.

This technique does not allow the treatment of intra-articular lesions, so the selection criteria must be precise and sometimes a surgical hip dislocation need to be combined.

More studies with a greater number of patients are necessary to prove the value of the trochanteric osteotomy in the treatment of the Legg-Calve-Perthes sequelae.

Biography
1. J. Robichon, J. P. Desjardins, M. Koch, e C. E. Hooper, «The femoral neck in Legg-Perthes’ disease. Its relationship to epiphysial change and its importance in early prognosis», J Bone Joint Surg Br, vol. 56, n.o 1, pp. 62–68, fev. 1974.
2. R. S. Siffert, «Patterns of deformity of the developing hip», Clin Orthop Relat Res, n.o 160, pp. 14–29, out. 1981.
3. D. Schneidmueller, C. Carstens, e M. Thomsen, «Surgical treatment of overgrowth of the greater trochanter in children and adolescents», J Pediatr Orthop, vol. 26, n.o 4, pp. 486–490, 2006, doi: 10.1097/01.bpo.0000226281.01202.94.
4. P. M. Stevens e S. S. Coleman, «Coxa breva: its pathogenesis and a rationale for its management», J Pediatr Orthop, vol. 5, n.o 5, pp. 515–521, 1985.
5. A. S. Kelikian, M. O. Tachdjian, M. J. Askew, e M. Jasty, «Greater trochanteric advancement of the proximal femur: a clinical and biomechanical study», Hip, pp. 77–105, 1983.
6. H. Wagner, «Femoral Osteotomies For Congenital Hip Dislocation», em Acetabular Dysplasia, U. H. Weil, Ed., em Progress in Orthopaedic Surgery. Berlin, Heidelberg: Springer, 1978, pp. 85–105. doi: 10.1007/978-3-642-66737-4_4.
7. S. Y. Joo, K. S. Lee, I. H. Koh, H. W. Park, e H. W. Kim, «Trochanteric Advancement in Patients with Legg-Calvé-Perthes Disease Does Not Improve Pain or Limp», Clin Orthop Relat Res, vol. 466, n.o 4, pp. 927–934, abr. 2008, doi: 10.1007/s11999-008-0128-4.
8. S. W. Cheatham, «Extra-articular hip impingement: a narrative review of the literature», J Can Chiropr Assoc, vol. 60, n.o 1, pp. 47–56, mar. 2016.
9. M. F. Macnicol e D. Makris, «Distal transfer of the greater trochanter», J Bone Joint Surg Br, vol. 73, n.o 5, pp. 838–841, set. 1991, doi: 10.1302/0301-620X.73B5.1894678.
10. A. Van Tongel e G. Fabry, «Epiphysiodesis of the greater trochanter in Legg-Calvé-Perthes disease: The importance of timing», Acta Orthop Belg, vol. 72, n.o 3, pp. 309–313, jun. 2006.
11. L. Jani, «Die Entwicklung des Schenkelhalses nach der Trochanterversetzung», Arch orthop Unfall-Chir, vol. 66, n.o 2, pp. 127–132, 1969, doi: 10.1007/BF00417245.
12. J. Cohen, «Congenital dislocation of the hip. Case report of an unusual complication and unusual treatment», J Bone Joint Surg Am, vol. 53, n.o 5, pp. 1007–1011, jul. 1971.
13. G. W. Westin, F. W. Ilfeld, e J. Provost, «Total avascular necrosis of the capital femoral epiphysis in congenital dislocated hips», Clin Orthop Relat Res, n.o 119, pp. 93–98, set. 1976.
14. C. Tauber, A. Ganel, H. Horoszowski, e I. Farine, «Distal transfer of the greater trochanter in cox vara», Acta Orthop Scand, vol. 51, n.o 4, pp. 661–666, ago. 1980, doi: 10.3109/17453678008990858.
15. G. C. Lloyd-Roberts, M. H. Wetherill, e M. Fraser, «Trochanteric advancement for premature arrest of the femoral capital growth plate», J Bone Joint Surg Br, vol. 67, n.o 1, pp. 21–24, jan. 1985, doi: 10.1302/0301-620X.67B1.3968136.
16. J. D. Bastian, A. T. Wolf, T. F. Wyss, e H. P. Nötzli, «Stepped osteotomy of the trochanter for stable, anatomic refixation», Clin Orthop Relat Res, vol. 467, n.o 3, pp. 732–738, mar. 2009, doi: 10.1007/s11999-008-0649-x.
17. R. E. Eilert, K. Hill, e J. Bach, «Greater trochanteric transfer for the treatment of coxa brevis», Clin Orthop Relat Res, n.o 434, pp. 92–101, mai. 2005, doi: 10.1097/01.blo.0000163474.74168.6f.
18. N. Shohat, R. Gilat, R. Shitrit, Y. Smorgick, Y. Beer, e G. Agar, «A long-term follow-up study of the clinical and radiographic outcome of distal trochanteric transfer in Legg-Calvé-Perthes’ disease following varus derotational osteotomy», Bone Joint J, vol. 99-B, n.o 7, pp. 987–992, jul. 2017, doi: 10.1302/0301-620X.99B7.BJJ-2016-1346.R2.
19. M. Lengsfeld, P. Schuler, e P. Griss, «The long-term (8-12 years) results of valgus and lengthening osteotomy of the femoral neck», Arch Orthop Trauma Surg, vol. 121, n.o 4, pp. 201–204, 2001, doi: 10.1007/s004020000214.
20. P. Lascombes, J. Prevot, A. Allouche, J. N. Ligier, e J. P. Metaizeau, «[Lengthening osteotomy of the femoral neck with transposition of the greater trochanter in acquired coxa vara]», Rev Chir Orthop Reparatrice Appar Mot, vol. 71, n.o 8, pp. 599–601, 1985.
21. R. Libri e L. Marchesini Reggiani, «A modified technique for reconstruction of the femoral neck in paediatric patients», Hip Int, vol. 20, n.o 4, pp. 529–534, 2010, doi: 10.1177/112070001002000418.
22. M. Leunig e R. Ganz, «Relative neck lengthening and intracapital osteotomy for severe Perthes and Perthes-like deformities», Bull NYU Hosp Jt Dis, vol. 69 Suppl 1, pp. S62-67, 2011.
23. L. A. Anderson, J. A. Erickson, E. P. Severson, e C. L. Peters, «Sequelae of Perthes disease: treatment with surgical hip dislocation and relative femoral neck lengthening», J Pediatr Orthop, vol. 30, n.o 8, pp. 758–766, dez. 2010, doi: 10.1097/BPO.0b013e3181fcbaaf.

]]> Thu, 28 Sep 2023 08:01:00 GMT Does Sporting Activity Influence the Development of Cam Morphology? https://www.esska.org/news/news.asp?id=635272 https://www.esska.org/news/news.asp?id=635272
Karadi Hari Sunil Kumar1
 MBBS, MCh (Orth), MFSEM, FEBOT, FRCSEd (Tr&Orth)
Vikas Khanduja2
MB BS, MA (Cantab), MSc, FRCS (Orth), PhD

1Consultant Orthopaedic Surgeon – Cambridge Young Adult Hip Service
Addenbrookes – Cambridge University Hospital NHS Foundation trust, United Kingdom
2Consultant Orthopaedic Surgeon – Cambridge Young Adult Hip Service
Affiliate Associate Professor – University of Cambridge
Addenbrookes – Cambridge University Hospital NHS Foundation trust, United Kingdom
Chair – ESSKA European Hip Preservation Associates
Past President – British Hip Society

Femoroacetabular impingement (FAI) has gained considerable focus in the last two decades since Ganz et al published the possible association of FAI with the development of osteoarthritis [2]. There has been a significant progress in the treatment of FAI from the initial open surgical dislocation described by Ganz to the recent advances in arthroscopic hip surgery [3]. FAI can be classified into (1) cam deformity – an abnormality of the femoral head-neck junction with a reduced head-neck offset, (2) pincer deformity – an acetabular over coverage with a lateral centre-edge angle of > 40° and (3) mixed type with features of both cam and pincer deformities. Cam deformity (figure 1) has gained considerable interest because this is the most common type of FAI and is defined as an alpha angle of > 55° (figure 2). Advanced hip arthroscopic techniques are aimed at correcting this morphological abnormality and concurrently treat the resultant pathology of the acetabular labrum and articular cartilage. However, we still do not understand as to who and how does one develop a cam deformity.

There are concerns that the development of cam may be linked to an increased level of sporting activity whilst the physis is still open predisposing to morphological abnormalities. Repetitive impact due to high level sporting activities increases the stress at the physis potentially leading to the development of cam deformity. Our group has tried to evaluate the current available literature on development of the cam deformity in athletes and whether there is an association between development of the cam deformity and different sporting activities [1, 5], A systematic review (SR) was undertaken to answer each question.

Figure 1: CT scan with 3D reconstruction showing cam deformity of both hips

Figure 2: Alpha angle measurement on lateral view of the hip joint.

Our first SR aimed to determine the aetiology of the cam morphology in athletes looking at three main issues (1) timing of development of cam deformity in relation to physeal closure, (2) whether cam deformity was associated with other proximal femoral deformities and (3) effect of sporting activities and the duration of training on cam development [5]. This SR identified 16 articles reporting on the development of cam lesion, out of which 12 were used for quantitative synthesis of results with a meta-analysis. We noted a greater incidence of a higher alpha angle in the anterosuperior femoral neck in male athletes after physeal closure [5]. However, there was no conclusive association between physeal closure and the prevalence of cam deformity per hip. Interestingly, age of the individual was found to be a significant predictor for cam deformity not only for the prevalence per hip but also prevalence per individual. A two-phase meta-regression model showed that age was associated with cam deformity for both per hip and per individual. This supports that fact that cam deformity potentially develops at the time of growth spurt and just before physeal closure. In addition, the SR found a strong positive correlation between epiphyseal extension and alpha angle. This may perhaps be a result of the cartilaginous physis undergoing temporal displacement from 11 o’clock to 2 o’clock eventually leading to the development of the cam deformity in this region. Furthermore, a positive correlation between those individuals who trained more than 4 times a week and the development of cam deformity was identified. Therefore, the younger the child the more likelihood they developed cam deformity with a higher alpha angle, if they trained more than 4 times or played sport. Similarly, there was a positive association between the length of the sporting career and alpha angle in adults. Therefore, our first SR revealed that those individuals who regularly played sport or trained more than 4 times a week from an early age were at risk of developing cam deformity [5].

Our second SR aimed to assess (1) prevalence of cam-type FAI across various sports, (2) whether kinematic variation among sports influenced morphology of the hip and (3) whether performance level, duration and frequency of training in this population influenced hip morphology [1]. This SR identified 49 articles which described a higher prevalence of cam-type FAI in athletes compared to asymptomatic general population. Athletes were 1.83 times more likely to be diagnosed with FAI when compared to non-athletes. Sports which involve recurrent movement of the hip beyond normal range of motion (flexion, adduction and internal rotation) leading to impingement were associated with the highest prevalence of cam FAI. In addition, contact sports and those involving cutting movements reported high prevalence of cam deformity. This SR found that the athletes had a significantly higher mean alpha angle than controls. Ice hockey players were noted to have the highest prevalence of cam-type FAI. They also noted that elite ice hockey players were 3 times more likely to develop cam deformity compared to the general population [1]. This is potentially because the hip is put through increased stress from an early age for a longer period of time, which has been shown to have an association with cam development in our first SR [5].

Moreover, Ice hockey players were also 4 times more likely than skiers to have an alpha angle more than 550. There was a higher incidence of FAI with cam impingement in ice hockey players when compared to skiers (79% vs 40% respectively). This higher incidence of FAI in ice hockey players may be a result of the repetitive stress placed on the hip because of the unique impinging skating motion. Similarly, ice hockey butterfly goalkeepers were at risk of cam-type FAI as their hips are in a flexed, adducted and internal rotated position. Furthermore, mogul and Alpine skiers were also reported to have a significantly higher prevalence of cam versus controls. This type of skiing involves high ground reaction forces, and acrobatic jumps resulting in high-impact landings. These results reinforce the idea that when the hips are put under an extreme biomechanical stress, there is a potential to develop cam deformity suggesting that the type of sport influences morphology of the hip. In addition, those who participated in martial arts had a higher incidence of cam deformity compared with those whose primary sport was not a martial art [1].

Interestingly, the location of the maximum alpha angle varied in different ice hockey players. The positional players had maximum alpha angle at 1:45 o’clock position compared to 1 o’clock seen in goalkeepers [1]. This again supports the fact that the position of the hips during sport and training predisposes to the site of cam development. A higher proportion of cam deformity with a larger alpha angle was associated with increasing age. However, the prevalence of cam deformity was lower is East Asian athletes when compared to Caucasian players who played soccer. Interestingly, there was no difference in the hip morphology amongst different ethnicities in the Japanese baseball league. This is something which needs exploring further as baseball is not an impingement sport and perhaps the stress on the hip joint during physeal growth is not as much as during impingement type of sporting activities. Therefore, this further supports the fact that not only there is a genetic component to the development of cam deformity but also a mechanical component during growth which contributes to the development of the cam deformity.

Our two systematic reviews have shown that biomechanical factors play an important role in the development of cam deformity. Playing sport or training more than four times a week from an early age increased the risk of developing cam deformity. In addition, sports which increased the stress in the hip joint for long periods of time, such as in flexion, adduction and internal rotation, showed an increased prevalence of cam deformity. Further longitudinal research is urgently needed to confirm these findings with long term monitoring of children engaged in sporting academies to assess whether there they do go on to develop cam deformity and if yes then to inform on the appropriate time and regime of training.

References
1. Doran C, Pettit M, Singh Y, Sunil Kumar KH, Khanduja V (2022) Does the Type of Sport Influence Morphology of the Hip? A Systematic Review. Am J Sports Med 50:1727–1741
2. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA (2003) Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 112–120
3. Khanduja V, Villar RN (2006) Arthroscopic surgery of the hip: current concepts and recent advances. J Bone Joint Surg Br 88:1557–1566
4. Mirtz TA, Chandler JP, Eyers CM (2011) The effects of physical activity on the epiphyseal growth plates: a review of the literature on normal physiology and clinical implications. J Clin Med Res 3:1–7
5. Pettit M, Doran C, Singh Y, Saito M, Sunil Kumar KH, Khanduja V (2021) How does the cam morphology develop in athletes? A systematic review and meta-analysis. Osteoarthritis Cartilage 29:1117–1129

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