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Journal Club

May 2010

Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular chondral damage

• Authors: B. Haviv, P. J. Singh, A. Takla, J. O’Donnell
  
• Institution: St Vincents and Mercy Private Hospital, Melbourne, Victoria, Australia
  
• Journal: J Bone Joint Surg [Br] 2010;92-B:629-33. VOL. 92-B, No. 5, MAY 2010

Introduction

• Purpose:
  • To evaluate the outcome of femoral osteochondroplasty for cam lesions in relation to the stage of acetabular chondral damage in the absence of other intra-articular pathology
• Hypothesis:
  • Improving mechanical properties by femoral osteochondroplasty is beneficial in the presence of acetabular chondral damage

Methodology

• Retrospective case series 170 hips (166 pt)
  • Single surgeon
    
  • Standardised operative and rehab protocol
    
  • Greater than 12 months follow up
    
  • Outcomes: Modified Harris Hip Score, Non Arthritic Hip Score
• Patient selection:
  • “Cam lesions and acetabular chondral damage”
    
  • Hip pain and mechanical symptoms
    
  • Painful ROM and impingement on examination
    
  • Confirmed on xray and CT in position of functional impingement
    
  • Unresponsive to 12 weeks nonoperative management (unspecified)
    
  • Advanced arthritis, other pathology at surgery excluded

Operative technique

Classification of Anterolateral Acetabular Defects

Grade	Description
I	small, partial thickness
II	full thickness, <30% width from acetabular edge to fovea
III	full thickness, >30%

 

Arthroscopic Treatment of Anterolateral Acetabular Defects

Grade	Treatment
I	radiofrequency ablation
II & III	debridement of unstable flaps
II & III <300mm²	microfracture

 

• Femoral osteochondroplasty
  
  • Followed by reassessment under II to ensure adequate resection
• Post op management:
  
  • Weight bearing as tolerated
    
  • Physiotherapy
    
  • Activity modification
    
  • Jogging & running after 8/52 (microfracture 14-16/52)
• Statistical Analysis
  
  • Student’s t test for paired measures
    
  • One way ANOVA to assess effect of degree of chondral damage on outcome
    
  • Pearson’s correlation coefficient: chondral damage and scores

Results

• 135 of 170 hips were either grade II or III
  
  • Ages ranged from 14 to 78.
    
  • Better preoperative scores correlated with less damage and better outcome
    
  • All groups improved significantly
    
  • Most improvement was seen in younger patients with less damage at operation
• MHHS & NAHS over time
  
  • Grade I damage showed improvement continuing over twelve months of follow up
    
  • Grade II and III showed early improvement however plateaued early.
• Microfracture
  
  • Subgroup of patients since 2007 with grade II and III lesions under 300mm²
    
  • Again, improved noted in grade II and III with or without microfracture
    
  • Most notable improvement in NAHS was with microfracture group

Discussion

• The all-arthroscopic technique of femoral osteochondroplasty enables better function and patient satisfaction
  • authors observed a continued improvement in the hip scores throughout the first year.
• cam impingement
  • bony prominence at the femoral neck produces mainly mechanical limitation
  • chondral damage and reactive synovitis are responsible for a significant proportion of the
    pain
  • synovitis is localised and most commonly found in the anterosuperior part of the acetabulum,
    which coincides with the area of chondral damage.

Pros of Study

• Interesting local paper
  
• Significant contribution to literature
  
• Confirmed functional impingement intraoperatively
  
• Clear grading and surgical method
  
• Prescriptive, multidisciplinary approach to treatment and rehab
  
• Avoided distracting debate

Cons of Study

• Lack of control group
  
  • 4 key components:
    
    • Non operative
      
    • Osteochondroplasty vs debridement vs microfracture
      
• Mixed, poorly described patient group
  
• Poor generalisability
  
• No clear recommendations: however appropriate to level of study
  
• Insufficient recognition of contentious issues