Technology and Health Care 21 (2013) 599–606 DOI 10.3233/THC-130761 IOS Press
599
The role of arthroscopy in patients with persistent hip pain after total hip arthroplasty Matthias Lahnera,∗ , Christoph von Schulze Pellengahra , Thomas K. Lichtingera, Gregor Vettera , Stephan Herbert Pesendorfera , Marco Hagenb , Kiriakos Daniilidisc, Lars Victor von Engelhardtd and Wolfram Teskea a Department
of Orthopaedic Surgery, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany Laboratory Department of Sport and Movement Sciences, University of Duisburg-Essen, Essen, Germany c Department of Orthopaedic Surgery, Annastift Hannover (Medical School Hannover, MHH), Hannover, Germany d Faculty of Health Sciences, University of Witten/Herdecke, Witten, Germany b Biomechanics
Received 27 August 2013 Accepted 30 September 2013 Abstract. BACKGROUND: Total hip arthroplasty (THA) is a safe and successful procedure for the treatment of osteoarthritis. One of the most common postoperative problems remains persistent hip pain. The arthroscopic evaluation of persistent hip pain following THA can be a valuable diagnostic tool in a select number of patients when carried out by experts in this technique. OBJECTIVE: Indication for arthroscopy was persistent pain after THA. Inclusion criteria were an absence of radiological loosening and a sterile aspiration 6 weeks before arthroscopy. Hip joint function and pain were evaluated pre- and postoperatively using the visual analogue scale (VAS) and the Hip Outcome Score (HOS), which scored the activities of daily living (ADL), and a sports subscale. METHODS: 5 patients (3 female, 2 male) with an average age of 60.2 ± 4.27 years (range 51–72 years) were included in the study. Arthroscopy with biopsy, adhesiolysis and psoas tendon release was performed 21.0 ± 21.97 months (range 6– 57 months) after primary hip replacement. RESULTS: Pathological findings were prosthetic joint infection (two cases), impingement between acetabular component and psoas tendon (two cases), adhesions of the periprosthetic tissue (one case). The patients achieved a significant improvement of the Hip Outcome Score (HOS), from an average of 45.6 ± 22.5 (range 14.0–63.1) to 76.5 ± 3.8 (range 41.0–89.4, P = 0.016). Evaluation of the VAS showed a significant improvement from a preoperative value of 8.8 ± 0.5 to a postoperative value of 3.4 ± 1.0 (P = 0.001). CONCLUSION: Hip arthroscopy provides a minimal-invasive tool for diagnosis and therapy. In cases of persistent pain after THA, standard diagnostic procedures should be utilised. Arthroscopy of a hip post-THA would be highly specialised. As a next step, arthroscopy helps the diagnosis and therapy of persistent pain after THA. Keywords: Hip arthroscopy, total hip arthroplasty, persistent hip pain, periprosthetic hip infection
∗ Corresponding author: Matthias Lahner, Gudrunstr. 56, Bochum 44791, Germany. Tel.: +49 234 5092707; Fax: +49 234 5092508; E-mail: [email protected].
c 2013 – IOS Press and the authors. All rights reserved 0928-7329/13/$27.50
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M. Lahner et al. / Arthroscopy after hip arthroplasty
1. Background The implantation of total hip arthroplasty (THA) is a safe and successful procedure in the treatment of osteoarthritis. Nevertheless, numerous complications may be present after elective THA. Infections, periprosthetic fractures, loosening, recurrent dislocation, vascular and nerve injuries are described as complications [1–4]. Normally, these cases can be diagnosed through a clinical and radiological examination, blood test, bone scintigraphy and hip aspiration. In cases of unclear diagnosis, a revision of the THA is often performed because loosening is suspected. The incidence of post-THA hip pain may increase in the future. This is due to a longer life expectancy and the secondary knock-on effect of osteoarthritis development requiring THA. Therefore, the number of revisions may increase substantially in the coming decades [5]. In such cases, arthroscopy may take on an increasingly important role. Several authors report on arthroscopy as a useful tool for the diagnosis and treatment of painful knee and shoulder arthroplasties [6–8]. The value of arthroscopic tissue biopsy for the detection or evaluation of an infection of total knee replacements before revision arthroplasty is proven, especially in cases of a sterile aspiration [9]. However, only few publications exist on the arthroscopic procedure in patients with persistent pain after hip arthroplasty [10–13]. The role of the hip arthroscopy is not clearly with the respect to the diagnostic use for septic arthritis when the aspiration was sterile before. The aim of the study was to evaluate the diagnostic and therapeutic value of arthroscopy in patients with continuous hip pain after THA.
2. Materials and methods 2.1. Patients R AcetabIn the present study, patients with persistent hip pain after non-cemented THA (Plasmacup R ular cup, Exia Stem, Braun, Tuttlingen, Germany) were included in the study. Inclusion and exclusion criteria are presented in Table 1. THA was performed between 2006 and 2012. Indication for arthroscopy was persistent pain with an absence of radiological loosening and a sterile aspiration. The radiographs were analysed with regards to osteolysis, osteointegration and cup migration. Preoperatively, the laboratory test including C-reactive protein (CRP) was within the normal range in the study population. All patients had an anteriorposterior (AP) and an axial view of the pelvis. Two patients underwent a computed tomography (CT) scan preoperatively to evaluate the coronal inclination and to exclude a pathological protrusion of the acetabular cup. A superior overhang of the acetabular cup of more than 12 mm was defined as a critical value. The X-ray assessment was performed by an experienced radiologist. Hip aspiration under fluoroscopy was performed preoperatively in all patients under sterile conditions 6 weeks before arthroscopy. The aspiration fluid showed a serous viscosity in all cases. The patients were tested pre- and postoperatively with the assistance of a standardized data entry form for the Hip Outcome Score (HOS) and the visual analogue scale (VAS) [14,15]. The HOS contained 19-item activities of daily living (ADL) and a scored 9-item sports subscale [14]. The patients were requested to complete the survey 6 weeks before arthroscopy and in the last follow-up examination, a mean of 10.4 months after arthroscopy. In this retrospective study, back or knee pain was excluded with clinical examination. All participants were informed that the arthroscopy may not lead to a final diagnosis and that postoperative residual problems may remain. All patients gave informed consent before inclusion into the study.
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Table 1 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria Presence of a total hip prosthesis Loosening of the prosthesis Primary arthroplasty Signs of infection with redness and swelling of the scar Continous pain after total hip prosthesis Previous impaired wound healing Normal A-P and lateral radiograph Revision arthroplasty Normal CRP (5 mg/L) Sterile hip aspiration Septic hip aspiration
Fig. 1. Placement of the ventral portal under arthroscopic and fluoroscopic using a 14-gauge needle.
Fig. 2. Visualisation of the prosthesis head (PH) and femoral neck (FN). A biopsy from the inflamed synovial tissue (S) is taken with the tissue grasper (TG).
2.2. Surgical technique Each patient had surgery with a standardized arthroscopic technique under general anaesthesia. The surgery was performed by two orthopaedic surgeons experienced in hip arthroscopy (M.L. and T.K.L.). The patient was placed in supine position on the fracture table without distraction (Orthostar II, Maquet, Rastatt, Germany). The fluoroscope was placed diagonally across the table (Ziehm Vision, Ziehm Imaging, Nürnberg, Gemany). The aspiration was performed on the neck of the prosthesis under fluoroscopy control with a 14-gauge spinal needle through the future site of the ventrolateral portal [16]. After the instillation of saline solution, the fluid was harvested for bacterial culture as a second joint aspirate. Thereafter, an intravenous antibiotic was administered. The hip capsule was widened atraumatically through a 1.5 mm guide wire with sequential telescoping 4 mm and 6 mm portal dilators (Arthrex, Naples, FL, USA). After advancing a 5.5 mm fenestrated metal cannula into the joint, an arthroscopic evaluation was performed with a 30◦ and a 70◦ 4 mm scope (Arthrex, Naples, FL, USA). The ventral instrumentation portal was placed 4 cm below a line from the anterior superior iliac spine along a line connecting the anterior superior iliac spine to the upper pole of the patella. The instrument portal was established with a 14-gauge needle under arthroscopic and fluoroscopic view (Fig. 1). The ventral hip capsule was extended with a 4 mm dilator and an 8 mm × 4 cm pass port button cannula was positioned to create a stable portal and avoid fluid loss into the soft tissue (Arthrex, Naples, FL, USA). Synovial
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Fig. 3. Debridement of the psoas tendon (PT) and the periprosthetic soft tissues (PS) to visualize the acetabular component (AC).
Fig. 4. CT axial scan at the middle of the femoral head. The acetabular cup shows an overhang of 7.6 mm (black arrow) and an anteversion angle (α) of 25.2◦ .
biopsies were collected for culture and microscopy (Fig. 2). After debridement of the periprosthetic soft tissues, the components of the prosthesis and the iliopsoas tendon were inspected (Fig. 3). Then arthroscopic lavage of the joint was performed with 15 L saline. A suction drain was inserted, which was removed on the first postoperative day. The patients spent 4 days in hospital postoperatively to get intensive physiotherapy two times a day. After hip arthroscopy, all patients followed the same rehabilitation protocol. Physical therapy began the day after surgery. To avoid postoperative fibrosis of the capsule, we applied a continuous passive motion (CPM) device which started between 0◦ and 45◦ of hip flexion and increased by 10◦ , and we used nonsteroidal anti-inflammatory drugs for 12 days. We allowed half weight-bearing for 2 weeks on crutches. The patients were seen for postoperative controls at 6 weeks, 3 months, and 1 year after arthroscopy. 2.3. Statistics All pre- and postoperative examination results were recorded on a case report form. The selected patient cohort was grouped in an Excel file (version 2003, Microsoft Corporation, Seattle, USA). The arithmetic mean value, SD and 95% confidence intervals were calculated for the age of patients, time of surgery, HOS and VAS and measured with Microsoft Excel. Univariate comparisons were performed using the independent-samples t-test. Statistical significance was accepted in the level of P < 0.05. 3. Results 5 patients (3 women and 2 men) with an average age of 60.2 ± 4.27 (range 51–72 years) were included in the study. Before arthroscopic surgery, physical examination showed tenderness to palpation in the ventral groin area. 5 patients had non-cemented prostheses. 4 prostheses were implanted in our department between 2009 and 2011. 1 patient was operated elsewhere in 2006. In 4 patients, the THA
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Table 2 Patients data Patient Age Sex Time since Indication for Definite HOS sports HOS sports HOS ADL HOS ADL VAS VAS No (yrs) THA (m) arthroscopy diagnosis Preop Postop Preop Postop Preop Postop 1 58 F 57 Impingement Adhesions 11.1 16.6 53.9 80.2 10 4 of scar tissue impingement 2
51
F
13
Psoas tendinitis
Tendinitis impingement
52.7
55.5
63.1
89.4
8
4
3
60
M
9
Psoas tendinitis
Adhesions tendinitis corrosion at head-neckjunction
41.6
41.6
52.6
85.5
8
2
4
60
M
20
Impingement Low-grade of scar tissue Infection
27.7
27.7
44.7
86.8
9
4
5
72
F
6
Impingement Low-grade of scar tissue infection
8.0
24.0
14.0
41.0
9
3
had been performed because of osteoarthritis of the hip and in 1 patient due to avascular necrosis of the femoral head. The hip aspiration was sterile in all cases after an incubation period of 2 to 4 weeks. In the CT scan, no pathological cup overhanging of the acetabular cup has been detected. In 2 cases, the overhang had totalled 7.6 and 0 mm with normal anteversion (20◦ , 25.2◦, Fig. 4). The arthroscopy took place on average 21.0 ± 21.97 months (range 6–57 months) after primary hip replacement. Total surgical time was 73.6 ± 4.2 minutes (range 59–95 minutes). Pathological findings included prosthetic joint infection (two cases), corrosion at the femoral head–neck junction (one case), impingement between acetabular component and psoas tendon (two cases), as well as synovitis and adhesions of the periprosthetic tissue (two cases). In two patients with suspected psoas tendinitis, a R psoas tendon release was performed with an ablation probe (CoolCut Radio Frequency Ablation, Arthrex, Naples, FL, USA). There were no perioperative complications in this series. The joint access was performed arthroscopically despite the adhesion of the hip capsule. Arthroscopy was successfully carried out in all 5 cases, no mini-open or open arthrotomy was necessary. In 2 cases, we performed an arthroscopic psoas release. In 3 cases, there was a chronic fibrosis in the biopsy without low-grade infection. In 2 cases, a low-grade infection was detected in the microbiological biopsy after long-term incubation. In one case, this was followed by a revision of the THA due to the persistent pain after arthroscopy. The second patient with low-grade infection was treated with antibiotics about 6 weeks after arthroscopy. During the follow-up period of a mean of 10.4 ± 10.3 months (range 3–27 months), all patients completed the study. Heterotopic ossifications were not detected in the follow-up examination on the postoperative radiographs. Overall, all patients had successful outcomes by HOS ADL and VAS. The patients showed a significant improvement of the HOS ADL, from an average of 45.6 ± 22.5 (range 14.0–63.1) to 76.5 ± 3.8 (range 41.0–89.4, P = 0.0016, Table 2). The preoperative average VAS of 8.8 ± 0.5 could be reduced significantly to a postoperative average of 3.4 ± 1.0 (P = 0.001). Regarding the HOS sports, a postoperative improvement could not be identified (Table 2). 4. Discussion and conclusions This study relates specifically to persistent hip pain of unknown origin after THA. Despite extensive diagnostic procedures, the causes of the continuous pain cannot be identified in some cases. When all
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investigations failed to show pathological findings, hip arthroscopy was a diagnostic and therapeutic option. The role of hip arthroscopy has significantly increased in recent years. Arthroscopic instrumentation systems have been developed to minimize the time and effort necessary to access the hip joint and enable orthopaedic surgeons to treat pathological findings safely and effectively [17]. Consequently, the number of arthroscopists who perform hip arthroscopy has risen. Pathologies of the labrum, cartilage lesions, loose bodies, synovial pathologies, mild osteoarthritis and septic joint infection can be treated sufficient with hip arthroscopy [18]. Persistent pain frequency after THA is often observed in clinical routine. Several authors reported an incidence of 18% to 27% after total hip replacement [19–21]. This problem represents a major challenge for orthopaedic surgeons. In the presence of a hip prosthesis, there are still no clear guidelines for the role of arthroscopy. Thus far, there are only few studies and case reports in the literature which examine the indication and the outcome for hip arthroscopy after THA [10,11,22,23]. In one case, Fontana et al. [22] reported the use of arthroscopy to diagnose polyethylene wear after THA. The loosening of the acetabular cup was seen during the diagnostic hip arthroscopy. A revision arthroplasty was done in a second surgery. Nordt et al. [23] reported a successful arthroscopic recovery of incarcerated debris following dislocation of THA. Hyman et al. [10] performed an arthroscopic intervention and irrigation in 8 patients with periprosthetic hip infection after positive bacterial aspiration. The authors could show that the regime of intravenous antibiotics is sufficient for a period to 6 weeks to treat the infection. In our department, we treated acute periprosthetic hip infections with an arthrotomy and change of the mobile components. However, hip arthroscopy has an important role in the diagnosis of periprosthetic infections. In our study, we detected a periprosthetic infection by means of arthroscopy which was not detected in hip aspiration before. McCarthy et al. [11] evaluated the outcome of 16 hips which underwent hip arthroscopy after THA. In 9 cases, anterior scar tissue impingement was found. 3 hips had migrated wires or loosening screws. There was corrosion at the head-neck junction (one case) and a loosening of a peripheral acetabular screw (one case) which was seen on the preoperative radiograph. 2 patients had septic arthritis, which was treated arthroscopically. 12 of the 16 hips were treated successfully with the arthroscopic procedure. In our study, we improved 3 of 5 patients with hip arthroscopy, regarding the HOS ADL and VAS. In one case, where the symptoms persisted and a corrosion of the head-neck junction was found, a revision arthroplasty could be necessary in the future. Pattyn et al. [12] examined arthroscopically 15 patients with continuous pain after hip resurfacing arthroplasty (HRA). The authors detected a pronounced metal wear in 3 hips which is defined through an excessive birefringent material found in the synovial biopsy. In 3 patients, a metal hypersensitivity by histological analysis was found, so a revision arthroplasty with a ceramic bearing followed. The authors suggested that the metal-on metal (MoM) bearings leaded to an immunological reaction from hypersensitivity to metal debris. In 3 cases, a femoral neck impingement was treated by an arthroscopic femoral osteoplasty which was seen as a reduced femoral offset on the preoperative radiograph. Two cases remained inconclusive and one low-grade infection was detected. In 3 cases, an iliopsoas tendinitis was treated by a psoas tendon release, in which one patient had a recurrence of symptoms. In our study, one of our patients who underwent an arthroscopic tendon release had a complete clearance of symptoms, while the other patient did not benefit from the psoas tenotomy. However, in the latter case, the psoas tenotomy was performed only partially. Additionally, metal wear of the prosthesis and the
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associated synovitis were objectified as other pain causes. In the conservative treatment failure of psoas tendinitis, the arthroscopic tenotomy represents a safe and reproducible procedure. Wettstein et al. [24] reviewed nine patients after arthroscopic psoas tenotomy. The patients had full hip flexion strength in the follow-up examination. In the presence of a THA, the postoperative outcome was much worse. Van Riet et al. [13] stated that the operative arthroscopic technique did not cause postoperative complications, but the patients showed no significant improvement in the HOS. However, the HOS sports remained at a low level, because the sports ability is already limited by the presence of an arthroplasty itself. In addition, the sports activity in our patients was low even before arthroplasty. Common causes of iliopsoas irritation are an oversized or malaligned of the acetabular component. CT is considered the gold standard in imaging of the impingement of the psoas tendon after THA [25, 26]. A protrusion of the acetabular cup or pinching of cement shares can also be detected in CT scans. Cyteval et al. [27] showed that the ilioposoas impingement (IPI) occurs in a protrusion of the acetabular component with more of than 12 mm. Arthroscopy is also a very sensitive tool for the diagnosis of IPI. With arthroscopy, we detected an IPI in a case of a protrusion with 7.6 mm, which a preoperative CT scan had failed to detect. The results of the study must be interpreted carefully. The design of the study may be criticized because there is no control group. Another limitation of our study was the very small number of patients. Due to the small study population, static tests could not apply. The follow-up examination after a mean of 10.4 months is a rather short period. Despite the small study population, our study shows that hip arthroscopy represents a valuable and safe tool in unclear diagnoses after THA. In our study, a low-grade infection and impingement of the psoas tendon was detected only with the use of arthroscopy. In some cases, an unnecessary revision arthroplasty can be prevented. Arthroscopy should be considered instead of a revision arthroplasty, which is a very distressing procedure, especially in elderly patients. Hip arthroscopy is considered by many orthopaedic surgeons to be a specialised procedure carried out by those with expertise and training in this area. Furthermore, arthroscopy of a hip post-THA would be highly specialised. The risks associated with instrumentation of a prosthetic joint are not addressed. Ultimately, it is necessary to examine the role of hip arthroscopy in further studies with a larger number of patients.
Funding sources None.
References [1] [2] [3] [4] [5]
Dale H, Skråmm I, Løwer HL, Eriksen HM, Espehaug B, Furnes O, Skjeldestad FE, Havelin LI, Engesaeter LB. Infection after primary hip arthroplasty: a comparison of 3 Norwegian health registers. Acta Orthop. 2011; 82: 646-654. Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME. Minimum ten-year follow-up of a straight-stemmed, plasmasprayed, titanium-alloy, uncemented femoral component in primary total hip arthroplasty. J Bone Joint Surg Am. 2004; 86-A: 92-97. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Sur Br. 2011; 93: 96-101. Pulido L, Parvizi J, Macgibeny M, Sharkey PF, Purtill JJ, Rothman RH, Hozack WJ. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008; 23(Suppl 1): 139-145. Ong KL, Mowat FS, Chan N, Lau E, Halpern MT, Kurtz SM. Economic burden of revision hip and knee arthroplasty in Medicare enrollees. Clin Orthop Relat Res. 2006; 446: 22-28.
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Bocell JR, Thorpe CD, Tullos HS. Arthroscopic treatment of symptomatic knee arthroplasty. Clin Orthop Relat Res. 1991; 271: 125-134. [7] Hersch JC, Dines DM. Arthroscopy for failed shoulder arthroplasty. Arthroscopy. 2000; 16: 606-612. [8] Johnson DR, Friedmann RJ, McGinty JB, Mason JL, St. Mary EW. The role of arthroscopy in the problem total knee replacement. Arthroscopy. 1990; 6: 30-32. [9] Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late periprosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008; 90: 874-878. [10] Hyman JL, Salvati EA, Laurencin CT, Rogers DE, Maynard M, Brause DB. The arthroscopic drainage, irrigation, and debridement of late, acute total hip arthroplasty infections: average 6-year follow-up. J Arthroplasty. 1999; 14: 903-910. [11] McCarthy JC, Jibodh SR, Lee JA. The role of arthroscopy in evaluation of painful hip arthroplasty. Clin Orthop Relat Res. 2009; 467: 174-180. [12] Pattyn C, Verdonk R, Audenaert E. Hip arthroscopy in patients with painful hip following resurfacing arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1514-1520. [13] Van Riet A, De Schepper J, Delport HP. Arthroscopic psoas release for iliopsoas impingement after total hip replacement. Acta Orthop Belg. 2011; 77: 41-46. [14] Martin RL, Philippon MJ. Evidence of reliability and responsiveness for the hip outcome score. Arthroscopy. 2008; 24: 676-682. [15] Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH, Reading AE. Pain measurement: an overview. Pain. 1985; 22: 1-31. [16] Byrd JWT. Surgical technique. Supine position. Oper Techn Orthop. 2005; 15: 203-217. [17] Ilizaliturri VM Jr, Acosta-Rodriguez E, Camacho-Galindo J. A minimalist approach to hip arthroscopy: the slotted cannula. Arthroscopy. 2007; 23: 560.e1-e3. [18] Rühmann O, Börner C, Bohnsack M, Wirth CJ. Arthroscopy of the hip. Orthopade. 2003; 32:754-768. [19] Henderson RA, Lachiewicz PF. Groin pain after replacement of the hip: aetiology, evaluation and treatment. J Bone Joint Surg. 2012; 94: 145-151. [20] Hohberg M, Holzapfel BM, Rudert M. Painful hip arthroplasty: a diagnostic algorithm. Orthopade. 2011; 40: 474-480. [21] Wlyde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011; 152: 566-572. [22] Fontana A, Zecca M, Sala C. Arthroscopic assessment of total hip replacement and polyethylene wear: a case report. Knee Surg Sports Traumatol Arthrosc. 2000; 8: 244-245. [23] Nordt W, Giangarra CE, Levy IM, Habermann ET. Arthroscopic removal of entrapped debris following dislocation of a total hip arthroplasty. Arthroscopy. 1987; 3: 196-198. [24] Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy. 2006; 22: 907 e1-e4. [25] Della Valle CJ, Rafii M, Jaffe WL. Iliopsoas tendinitis after total hip arthroplasty. J Arthroplasty. 2001; 16: 923-926. [26] Jasani V, Richards P, Wynn-Jones C. Pain related to the psoas muscle after total hip replacement. J Bone Joint Surg Br. 2002; 84: 991-993. [27] Cyteval C, Sarrabère MP, Cottin A, Assi C, Morcos L, Maury P, Taourel P. Iliopsoas impingement on the acetabular component: radiologic and computed tomography findings of a rare hip prothesis complication in eight cases. J Comput Assist Tomogr. 2003; 27: 183-188.
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599
The role of arthroscopy in patients with persistent hip pain after total hip arthroplasty Matthias Lahnera,∗ , Christoph von Schulze Pellengahra , Thomas K. Lichtingera, Gregor Vettera , Stephan Herbert Pesendorfera , Marco Hagenb , Kiriakos Daniilidisc, Lars Victor von Engelhardtd and Wolfram Teskea a Department
of Orthopaedic Surgery, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany Laboratory Department of Sport and Movement Sciences, University of Duisburg-Essen, Essen, Germany c Department of Orthopaedic Surgery, Annastift Hannover (Medical School Hannover, MHH), Hannover, Germany d Faculty of Health Sciences, University of Witten/Herdecke, Witten, Germany b Biomechanics
Received 27 August 2013 Accepted 30 September 2013 Abstract. BACKGROUND: Total hip arthroplasty (THA) is a safe and successful procedure for the treatment of osteoarthritis. One of the most common postoperative problems remains persistent hip pain. The arthroscopic evaluation of persistent hip pain following THA can be a valuable diagnostic tool in a select number of patients when carried out by experts in this technique. OBJECTIVE: Indication for arthroscopy was persistent pain after THA. Inclusion criteria were an absence of radiological loosening and a sterile aspiration 6 weeks before arthroscopy. Hip joint function and pain were evaluated pre- and postoperatively using the visual analogue scale (VAS) and the Hip Outcome Score (HOS), which scored the activities of daily living (ADL), and a sports subscale. METHODS: 5 patients (3 female, 2 male) with an average age of 60.2 ± 4.27 years (range 51–72 years) were included in the study. Arthroscopy with biopsy, adhesiolysis and psoas tendon release was performed 21.0 ± 21.97 months (range 6– 57 months) after primary hip replacement. RESULTS: Pathological findings were prosthetic joint infection (two cases), impingement between acetabular component and psoas tendon (two cases), adhesions of the periprosthetic tissue (one case). The patients achieved a significant improvement of the Hip Outcome Score (HOS), from an average of 45.6 ± 22.5 (range 14.0–63.1) to 76.5 ± 3.8 (range 41.0–89.4, P = 0.016). Evaluation of the VAS showed a significant improvement from a preoperative value of 8.8 ± 0.5 to a postoperative value of 3.4 ± 1.0 (P = 0.001). CONCLUSION: Hip arthroscopy provides a minimal-invasive tool for diagnosis and therapy. In cases of persistent pain after THA, standard diagnostic procedures should be utilised. Arthroscopy of a hip post-THA would be highly specialised. As a next step, arthroscopy helps the diagnosis and therapy of persistent pain after THA. Keywords: Hip arthroscopy, total hip arthroplasty, persistent hip pain, periprosthetic hip infection
∗ Corresponding author: Matthias Lahner, Gudrunstr. 56, Bochum 44791, Germany. Tel.: +49 234 5092707; Fax: +49 234 5092508; E-mail: [email protected].
c 2013 – IOS Press and the authors. All rights reserved 0928-7329/13/$27.50
600
M. Lahner et al. / Arthroscopy after hip arthroplasty
1. Background The implantation of total hip arthroplasty (THA) is a safe and successful procedure in the treatment of osteoarthritis. Nevertheless, numerous complications may be present after elective THA. Infections, periprosthetic fractures, loosening, recurrent dislocation, vascular and nerve injuries are described as complications [1–4]. Normally, these cases can be diagnosed through a clinical and radiological examination, blood test, bone scintigraphy and hip aspiration. In cases of unclear diagnosis, a revision of the THA is often performed because loosening is suspected. The incidence of post-THA hip pain may increase in the future. This is due to a longer life expectancy and the secondary knock-on effect of osteoarthritis development requiring THA. Therefore, the number of revisions may increase substantially in the coming decades [5]. In such cases, arthroscopy may take on an increasingly important role. Several authors report on arthroscopy as a useful tool for the diagnosis and treatment of painful knee and shoulder arthroplasties [6–8]. The value of arthroscopic tissue biopsy for the detection or evaluation of an infection of total knee replacements before revision arthroplasty is proven, especially in cases of a sterile aspiration [9]. However, only few publications exist on the arthroscopic procedure in patients with persistent pain after hip arthroplasty [10–13]. The role of the hip arthroscopy is not clearly with the respect to the diagnostic use for septic arthritis when the aspiration was sterile before. The aim of the study was to evaluate the diagnostic and therapeutic value of arthroscopy in patients with continuous hip pain after THA.
2. Materials and methods 2.1. Patients R AcetabIn the present study, patients with persistent hip pain after non-cemented THA (Plasmacup R ular cup, Exia Stem, Braun, Tuttlingen, Germany) were included in the study. Inclusion and exclusion criteria are presented in Table 1. THA was performed between 2006 and 2012. Indication for arthroscopy was persistent pain with an absence of radiological loosening and a sterile aspiration. The radiographs were analysed with regards to osteolysis, osteointegration and cup migration. Preoperatively, the laboratory test including C-reactive protein (CRP) was within the normal range in the study population. All patients had an anteriorposterior (AP) and an axial view of the pelvis. Two patients underwent a computed tomography (CT) scan preoperatively to evaluate the coronal inclination and to exclude a pathological protrusion of the acetabular cup. A superior overhang of the acetabular cup of more than 12 mm was defined as a critical value. The X-ray assessment was performed by an experienced radiologist. Hip aspiration under fluoroscopy was performed preoperatively in all patients under sterile conditions 6 weeks before arthroscopy. The aspiration fluid showed a serous viscosity in all cases. The patients were tested pre- and postoperatively with the assistance of a standardized data entry form for the Hip Outcome Score (HOS) and the visual analogue scale (VAS) [14,15]. The HOS contained 19-item activities of daily living (ADL) and a scored 9-item sports subscale [14]. The patients were requested to complete the survey 6 weeks before arthroscopy and in the last follow-up examination, a mean of 10.4 months after arthroscopy. In this retrospective study, back or knee pain was excluded with clinical examination. All participants were informed that the arthroscopy may not lead to a final diagnosis and that postoperative residual problems may remain. All patients gave informed consent before inclusion into the study.
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601
Table 1 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria Presence of a total hip prosthesis Loosening of the prosthesis Primary arthroplasty Signs of infection with redness and swelling of the scar Continous pain after total hip prosthesis Previous impaired wound healing Normal A-P and lateral radiograph Revision arthroplasty Normal CRP (5 mg/L) Sterile hip aspiration Septic hip aspiration
Fig. 1. Placement of the ventral portal under arthroscopic and fluoroscopic using a 14-gauge needle.
Fig. 2. Visualisation of the prosthesis head (PH) and femoral neck (FN). A biopsy from the inflamed synovial tissue (S) is taken with the tissue grasper (TG).
2.2. Surgical technique Each patient had surgery with a standardized arthroscopic technique under general anaesthesia. The surgery was performed by two orthopaedic surgeons experienced in hip arthroscopy (M.L. and T.K.L.). The patient was placed in supine position on the fracture table without distraction (Orthostar II, Maquet, Rastatt, Germany). The fluoroscope was placed diagonally across the table (Ziehm Vision, Ziehm Imaging, Nürnberg, Gemany). The aspiration was performed on the neck of the prosthesis under fluoroscopy control with a 14-gauge spinal needle through the future site of the ventrolateral portal [16]. After the instillation of saline solution, the fluid was harvested for bacterial culture as a second joint aspirate. Thereafter, an intravenous antibiotic was administered. The hip capsule was widened atraumatically through a 1.5 mm guide wire with sequential telescoping 4 mm and 6 mm portal dilators (Arthrex, Naples, FL, USA). After advancing a 5.5 mm fenestrated metal cannula into the joint, an arthroscopic evaluation was performed with a 30◦ and a 70◦ 4 mm scope (Arthrex, Naples, FL, USA). The ventral instrumentation portal was placed 4 cm below a line from the anterior superior iliac spine along a line connecting the anterior superior iliac spine to the upper pole of the patella. The instrument portal was established with a 14-gauge needle under arthroscopic and fluoroscopic view (Fig. 1). The ventral hip capsule was extended with a 4 mm dilator and an 8 mm × 4 cm pass port button cannula was positioned to create a stable portal and avoid fluid loss into the soft tissue (Arthrex, Naples, FL, USA). Synovial
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Fig. 3. Debridement of the psoas tendon (PT) and the periprosthetic soft tissues (PS) to visualize the acetabular component (AC).
Fig. 4. CT axial scan at the middle of the femoral head. The acetabular cup shows an overhang of 7.6 mm (black arrow) and an anteversion angle (α) of 25.2◦ .
biopsies were collected for culture and microscopy (Fig. 2). After debridement of the periprosthetic soft tissues, the components of the prosthesis and the iliopsoas tendon were inspected (Fig. 3). Then arthroscopic lavage of the joint was performed with 15 L saline. A suction drain was inserted, which was removed on the first postoperative day. The patients spent 4 days in hospital postoperatively to get intensive physiotherapy two times a day. After hip arthroscopy, all patients followed the same rehabilitation protocol. Physical therapy began the day after surgery. To avoid postoperative fibrosis of the capsule, we applied a continuous passive motion (CPM) device which started between 0◦ and 45◦ of hip flexion and increased by 10◦ , and we used nonsteroidal anti-inflammatory drugs for 12 days. We allowed half weight-bearing for 2 weeks on crutches. The patients were seen for postoperative controls at 6 weeks, 3 months, and 1 year after arthroscopy. 2.3. Statistics All pre- and postoperative examination results were recorded on a case report form. The selected patient cohort was grouped in an Excel file (version 2003, Microsoft Corporation, Seattle, USA). The arithmetic mean value, SD and 95% confidence intervals were calculated for the age of patients, time of surgery, HOS and VAS and measured with Microsoft Excel. Univariate comparisons were performed using the independent-samples t-test. Statistical significance was accepted in the level of P < 0.05. 3. Results 5 patients (3 women and 2 men) with an average age of 60.2 ± 4.27 (range 51–72 years) were included in the study. Before arthroscopic surgery, physical examination showed tenderness to palpation in the ventral groin area. 5 patients had non-cemented prostheses. 4 prostheses were implanted in our department between 2009 and 2011. 1 patient was operated elsewhere in 2006. In 4 patients, the THA
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Table 2 Patients data Patient Age Sex Time since Indication for Definite HOS sports HOS sports HOS ADL HOS ADL VAS VAS No (yrs) THA (m) arthroscopy diagnosis Preop Postop Preop Postop Preop Postop 1 58 F 57 Impingement Adhesions 11.1 16.6 53.9 80.2 10 4 of scar tissue impingement 2
51
F
13
Psoas tendinitis
Tendinitis impingement
52.7
55.5
63.1
89.4
8
4
3
60
M
9
Psoas tendinitis
Adhesions tendinitis corrosion at head-neckjunction
41.6
41.6
52.6
85.5
8
2
4
60
M
20
Impingement Low-grade of scar tissue Infection
27.7
27.7
44.7
86.8
9
4
5
72
F
6
Impingement Low-grade of scar tissue infection
8.0
24.0
14.0
41.0
9
3
had been performed because of osteoarthritis of the hip and in 1 patient due to avascular necrosis of the femoral head. The hip aspiration was sterile in all cases after an incubation period of 2 to 4 weeks. In the CT scan, no pathological cup overhanging of the acetabular cup has been detected. In 2 cases, the overhang had totalled 7.6 and 0 mm with normal anteversion (20◦ , 25.2◦, Fig. 4). The arthroscopy took place on average 21.0 ± 21.97 months (range 6–57 months) after primary hip replacement. Total surgical time was 73.6 ± 4.2 minutes (range 59–95 minutes). Pathological findings included prosthetic joint infection (two cases), corrosion at the femoral head–neck junction (one case), impingement between acetabular component and psoas tendon (two cases), as well as synovitis and adhesions of the periprosthetic tissue (two cases). In two patients with suspected psoas tendinitis, a R psoas tendon release was performed with an ablation probe (CoolCut Radio Frequency Ablation, Arthrex, Naples, FL, USA). There were no perioperative complications in this series. The joint access was performed arthroscopically despite the adhesion of the hip capsule. Arthroscopy was successfully carried out in all 5 cases, no mini-open or open arthrotomy was necessary. In 2 cases, we performed an arthroscopic psoas release. In 3 cases, there was a chronic fibrosis in the biopsy without low-grade infection. In 2 cases, a low-grade infection was detected in the microbiological biopsy after long-term incubation. In one case, this was followed by a revision of the THA due to the persistent pain after arthroscopy. The second patient with low-grade infection was treated with antibiotics about 6 weeks after arthroscopy. During the follow-up period of a mean of 10.4 ± 10.3 months (range 3–27 months), all patients completed the study. Heterotopic ossifications were not detected in the follow-up examination on the postoperative radiographs. Overall, all patients had successful outcomes by HOS ADL and VAS. The patients showed a significant improvement of the HOS ADL, from an average of 45.6 ± 22.5 (range 14.0–63.1) to 76.5 ± 3.8 (range 41.0–89.4, P = 0.0016, Table 2). The preoperative average VAS of 8.8 ± 0.5 could be reduced significantly to a postoperative average of 3.4 ± 1.0 (P = 0.001). Regarding the HOS sports, a postoperative improvement could not be identified (Table 2). 4. Discussion and conclusions This study relates specifically to persistent hip pain of unknown origin after THA. Despite extensive diagnostic procedures, the causes of the continuous pain cannot be identified in some cases. When all
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investigations failed to show pathological findings, hip arthroscopy was a diagnostic and therapeutic option. The role of hip arthroscopy has significantly increased in recent years. Arthroscopic instrumentation systems have been developed to minimize the time and effort necessary to access the hip joint and enable orthopaedic surgeons to treat pathological findings safely and effectively [17]. Consequently, the number of arthroscopists who perform hip arthroscopy has risen. Pathologies of the labrum, cartilage lesions, loose bodies, synovial pathologies, mild osteoarthritis and septic joint infection can be treated sufficient with hip arthroscopy [18]. Persistent pain frequency after THA is often observed in clinical routine. Several authors reported an incidence of 18% to 27% after total hip replacement [19–21]. This problem represents a major challenge for orthopaedic surgeons. In the presence of a hip prosthesis, there are still no clear guidelines for the role of arthroscopy. Thus far, there are only few studies and case reports in the literature which examine the indication and the outcome for hip arthroscopy after THA [10,11,22,23]. In one case, Fontana et al. [22] reported the use of arthroscopy to diagnose polyethylene wear after THA. The loosening of the acetabular cup was seen during the diagnostic hip arthroscopy. A revision arthroplasty was done in a second surgery. Nordt et al. [23] reported a successful arthroscopic recovery of incarcerated debris following dislocation of THA. Hyman et al. [10] performed an arthroscopic intervention and irrigation in 8 patients with periprosthetic hip infection after positive bacterial aspiration. The authors could show that the regime of intravenous antibiotics is sufficient for a period to 6 weeks to treat the infection. In our department, we treated acute periprosthetic hip infections with an arthrotomy and change of the mobile components. However, hip arthroscopy has an important role in the diagnosis of periprosthetic infections. In our study, we detected a periprosthetic infection by means of arthroscopy which was not detected in hip aspiration before. McCarthy et al. [11] evaluated the outcome of 16 hips which underwent hip arthroscopy after THA. In 9 cases, anterior scar tissue impingement was found. 3 hips had migrated wires or loosening screws. There was corrosion at the head-neck junction (one case) and a loosening of a peripheral acetabular screw (one case) which was seen on the preoperative radiograph. 2 patients had septic arthritis, which was treated arthroscopically. 12 of the 16 hips were treated successfully with the arthroscopic procedure. In our study, we improved 3 of 5 patients with hip arthroscopy, regarding the HOS ADL and VAS. In one case, where the symptoms persisted and a corrosion of the head-neck junction was found, a revision arthroplasty could be necessary in the future. Pattyn et al. [12] examined arthroscopically 15 patients with continuous pain after hip resurfacing arthroplasty (HRA). The authors detected a pronounced metal wear in 3 hips which is defined through an excessive birefringent material found in the synovial biopsy. In 3 patients, a metal hypersensitivity by histological analysis was found, so a revision arthroplasty with a ceramic bearing followed. The authors suggested that the metal-on metal (MoM) bearings leaded to an immunological reaction from hypersensitivity to metal debris. In 3 cases, a femoral neck impingement was treated by an arthroscopic femoral osteoplasty which was seen as a reduced femoral offset on the preoperative radiograph. Two cases remained inconclusive and one low-grade infection was detected. In 3 cases, an iliopsoas tendinitis was treated by a psoas tendon release, in which one patient had a recurrence of symptoms. In our study, one of our patients who underwent an arthroscopic tendon release had a complete clearance of symptoms, while the other patient did not benefit from the psoas tenotomy. However, in the latter case, the psoas tenotomy was performed only partially. Additionally, metal wear of the prosthesis and the
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associated synovitis were objectified as other pain causes. In the conservative treatment failure of psoas tendinitis, the arthroscopic tenotomy represents a safe and reproducible procedure. Wettstein et al. [24] reviewed nine patients after arthroscopic psoas tenotomy. The patients had full hip flexion strength in the follow-up examination. In the presence of a THA, the postoperative outcome was much worse. Van Riet et al. [13] stated that the operative arthroscopic technique did not cause postoperative complications, but the patients showed no significant improvement in the HOS. However, the HOS sports remained at a low level, because the sports ability is already limited by the presence of an arthroplasty itself. In addition, the sports activity in our patients was low even before arthroplasty. Common causes of iliopsoas irritation are an oversized or malaligned of the acetabular component. CT is considered the gold standard in imaging of the impingement of the psoas tendon after THA [25, 26]. A protrusion of the acetabular cup or pinching of cement shares can also be detected in CT scans. Cyteval et al. [27] showed that the ilioposoas impingement (IPI) occurs in a protrusion of the acetabular component with more of than 12 mm. Arthroscopy is also a very sensitive tool for the diagnosis of IPI. With arthroscopy, we detected an IPI in a case of a protrusion with 7.6 mm, which a preoperative CT scan had failed to detect. The results of the study must be interpreted carefully. The design of the study may be criticized because there is no control group. Another limitation of our study was the very small number of patients. Due to the small study population, static tests could not apply. The follow-up examination after a mean of 10.4 months is a rather short period. Despite the small study population, our study shows that hip arthroscopy represents a valuable and safe tool in unclear diagnoses after THA. In our study, a low-grade infection and impingement of the psoas tendon was detected only with the use of arthroscopy. In some cases, an unnecessary revision arthroplasty can be prevented. Arthroscopy should be considered instead of a revision arthroplasty, which is a very distressing procedure, especially in elderly patients. Hip arthroscopy is considered by many orthopaedic surgeons to be a specialised procedure carried out by those with expertise and training in this area. Furthermore, arthroscopy of a hip post-THA would be highly specialised. The risks associated with instrumentation of a prosthetic joint are not addressed. Ultimately, it is necessary to examine the role of hip arthroscopy in further studies with a larger number of patients.
Funding sources None.
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