|Year : 2021 | Volume
| Issue : 2 | Page : 129-133
The safety and efficacy of hip arthroscopy performed using a novel knotless suture anchor
Justin Turcotte, McKayla Kelly, Benjamin M Petre
Anne Arundel Medical Center Orthopedics, Annapolis, MD 21401, USA
|Date of Submission||08-Mar-2021|
|Date of Acceptance||16-Aug-2021|
|Date of Web Publication||27-Dec-2021|
Dr. Justin Turcotte
Anne Arundel Medical Center Orthopedics, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401
Source of Support: None, Conflict of Interest: None
Introduction: Hip arthroscopy is commonly performed for patients with from femoroacetabular impingement (FAI); however, this procedure is technically difficult due to the anatomy of the hip joint and surrounding tissue. The purpose of this study was to evaluate the complication rates of hip arthroscopy procedures for FAI performed using the MICRORAPTOR Knotless Suture Anchor system. Materials and Methods: Retrospective review of consecutive patients undergoing hip arthroscopy for FAI was conducted. All patients underwent labral repair or reconstruction using the MICRORAPTOR Knotless suture anchor. The primary endpoint was any intraoperative or postoperative complication. Descriptive and inferential statistics were performed to assess the patient characteristics and outcomes. Results: Forty-three hip arthroscopies in 42 patients were reviewed at an average of 9 months (standard deviation 4 months) postoperatively; 36 (85.7%) were reviewed at over 6 months postoperatively. At presentation, 90.7% of patients demonstrated a positive anterior impingement sign, 86.0% demonstrated a positive posterior impingement sign, and the median pain numeric rating scale (NRS) was 7.0 ± 4.0 on a scale of 0–10. Four surgeries (9.3%) were revision hip arthroscopies, whereas the remaining 39 (90.7%) were primary labral repairs or reconstructions. Overall, the complications occurred in two (4.6%) cases. The median postoperative pain NRS was reduced from 7.0 ± 4.0 preoperatively to 2.0 ± 6.0 postoperatively (P = 0.003). Conclusion: The MICRORAPTOR Knotless suture anchor appears to be safe for use in patients undergoing hip arthroscopy for FAI.
Keywords: Femoroacetabular impingement, hip arthroscopy, knotless suture anchor
|How to cite this article:|
Turcotte J, Kelly M, Petre BM. The safety and efficacy of hip arthroscopy performed using a novel knotless suture anchor. J Orthop Traumatol Rehabil 2021;13:129-33
|How to cite this URL:|
Turcotte J, Kelly M, Petre BM. The safety and efficacy of hip arthroscopy performed using a novel knotless suture anchor. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 26];13:129-33. Available from: https://www.jotr.in/text.asp?2021/13/2/129/333554
| Introduction|| |
In recent years, hip arthroscopy has emerged as a standard of care diagnostic and therapeutic tool for painful hip conditions. From 2006 to 2010 alone, the overall incidence of hip arthroscopy procedures in the US increased by 600%. Hip arthroscopy is recommended for patients with mechanical limitation of the joint and persistent pain remaining after undergoing conservative treatment such as physical therapy. The common indications for arthroscopy include treatment of femoroacetabular impingement (FAI), symptomatic labral tears, debridement of labral lesions, removal of loose bodies, and cartilage defects. The less common indications include avascular necrosis, synovial chondromatosis, osteochondral defects, and synovitis.,,
Despite the increasing incidence of this procedure, arthroscopy of the hip joint is considered a technically difficult procedure to perform. The local thick envelope of soft-tissue anatomy has significant neurovascular structures that surround the hip, including the femoral nerve and artery anteriorly, the lateral femoral cutaneous nerve anterolaterally, and the sciatic nerve and gluteal vessels posteriorly., In addition, the highly constrained nature of the hip partially due to the contour of surfaces of the femoral head and acetabulum requires mechanical traction to expose the intra-articular surface. Even with distraction, the space available for positioning and manipulation of surgical instruments is restricted. The difficult nature of hip arthroscopy facilitates the need for special equipment innovated for the purpose of improving efficiency of this procedure while improving patient postoperative outcomes. Although the difficult nature of hip arthroscopy is widely understood, complications are largely transient and incidences between 0.5% and 6.4% have been reported.
One of the most recent developments in surgical instruments used for this procedure includes a knotless suture anchor. The MICRORAPTOR™ Knotless Suture Anchor (MRK, Smith and Nephew) addresses the current lack of off-axis insertion capabilities for knotless repairs. Proposed benefits of the system include improved off-axis insertion performance, when compared to other commercially available biocomposite knotless anchors, as well as its full-length inserter and rigid implant design, yielding increased access during hip arthroscopy. In addition, the implant has been reported to have less volume, shorter overall construct length, and superior fixation strength in comparison to other commercially available knotless anchors. Finally, the implant's use of REGENESORB™ biocomposite material, which contains calcium sulfate, beta tricalcium sulfate (β-TCP), and poly (lactic-co-glycolic), is designed to keep it mechanically stable for a minimum of 6 months before being absorbed and replaced by bone within 24 months. The purpose of this study was to evaluate the complication rates of hip arthroscopy procedures for FAI performed using the MICRORAPTOR Knotless Suture Anchor system.
| Materials and Methods|| |
This study was Deemed Institutional Review Board exempt by the Health System Clinical Research Committee. A retrospective observational study of a consecutive series of patients undergoing hip arthroscopy for treatment of FAI was conducted. All patients underwent labral repair or reconstruction using the MRK suture anchor. The ACCU-PASS Direct Crescent XL Suture Passer (Smith and Nephew) was used for the labral repair and capsule closure. Medical records were abstracted and patient demographics, clinical presentation, surgical details, intraoperative and postoperative complications, and functional or patient reported outcomes were recorded. Descriptive statistics were performed. Unless otherwise noted, all scale level measures are presented as median ± interquartile range due to small sample size and lack of normal distribution. The MannWhitney U-test was performed to evaluate the differences in the distribution of results between patients completing functional or patient reported outcome assessments during the preoperative and postoperative periods. Statistical significance was assessed at α =0.05.
| Results|| |
Forty-three hip arthroscopies in 42 patients were retrospectively reviewed at an average of 9 months (standard deviation [SD] 4 months) postoperatively; 36 (85.7%) were reviewed at over 6 months postoperatively. Patients had an average confirmed follow-up of 4 months (SD 3 months). All patients had a confirmed diagnosis of FAI. The median age was 45.0 ± 15.0, body mass index (BMI) was 27.0 ± 6.2, and 65.1% of patients were female. At presentation, 90.7% of patients demonstrated a positive anterior impingement sign, 86.0% demonstrated a positive posterior impingement sign, and the median pain numeric rating scale (NRS) was 7.0 ± 4.0 on a scale of 0–10 [Table 1].
Four surgeries (9.3%) were revision hip arthroscopies, whereas the remaining 39 (90.7%) were primary labral repairs (93.0%) or reconstructions (7.0%). Intraoperatively, 11.6% of patients were found to have a calcified labrum, 74.4% had acetabular cartilage defects, and 27.9% of patients had a femoral cartilage defect. All patients had a cam lesion, while 88.4% had a pincer lesion. Cam resection was performed in all cases, while pincer resection was performed in 41.9% of cases. The most common labral tear position was 10–2 o'clock (41.9%), followed by 10–3 o'clock (20.9%). All repairs or reconstructions were performed using MRK anchors, while additional Q-Fix anchors (Smith and Nephew) were used in 30.2% of cases. The median total number of anchors used was 4.0 ± 2.0. The median number of MRK anchors used was 3.0 ± 2.0 while the median number of Q-Fix anchors used in the 13 cases for which they were utilized was 2.0 ± 1.0 [Table 2].
Overall, complications occurred in 2 (4.6%) cases. One intraoperative complication (2.3%) and one postoperative complication (2.3%) occurred. Intraoperatively, one attempted repair was unable to be completed due to a severely degenerative labrum that was torn from the 9–3 o'clock position with a cleavage split through the middle. After multiple repair types were attempted, the labrum was resected. Postoperatively, one patient experienced decreased range of motion and adhesions requiring manipulation under anesthesia 6 months postoperatively; no surgical scar tissue release was required. A detailed description of the complications and surgeries in which they occurred is presented in [Table 3]. No complications were deemed related to the MICRORAPTOR Knotless suture anchor or ACCU-PASS Direct Crescent XL suture passer used in this series of patients. Both the suture anchor and suture passer device performed as intended per their respective instructions for use.
Differences in the distribution of patient reported and functional outcomes from the preoperative to postoperative period are presented in [Table 4] for the subset of patients completing these assessments. No significant differences in the distribution of pre- and post-operative Patient-Reported Outcomes Measurement Information System Global Health scores, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores, or Lower Extremity Functional Scale were observed. The median postoperative pain NRS was reduced from 7.0 ± 4.0 preoperatively to 2.0 ± 6.0 postoperatively (P = 0.003).
|Table 4: Pre and postoperative difference in patient reported and functional outcomes|
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| Discussion|| |
In our study, 42 hip arthroscopies for FAI were performed using the MRK suture anchor. At a median of 9 months postoperatively, a complication rate of 4.6% was observed. The population presented in this study is similar to cohorts presented in previous works. The average age of our patients was 45 and 65% were female. Similarly, Röling et al. analyzed the incidence of symptomatic FAI in a general population and found an average patient age of 40.5, and that female patients were more likely to have symptomatic FAI than males. Other studies have found similar demographic characteristics for this patient population. Chahla et al. analyzed 634 patients undergoing hip arthroscopy for FAI syndrome and found an average BMI of 25.2. Similarly, our study cohort had an average BMI of 27.0. According to the Centers for Disease Control and Prevention, BMI measures between 25 and 30 kg/m2 are classified as overweight; therefore, our patient population falls into the same BMI category stated in previous works. Despite the small sample size presented in our study, the demographic characteristics are similar to those presented previous studies, enhancing the probability that our cohort is representative of the larger patient population.
The complication rate following arthroscopic surgery for FAI varies widely in recent studies. Riff et al. conducted a systematic review to of 7241 hip arthroscopy patients and found an overall complication rate was 1.9%, with neurologic and heterotopic ossification being the most common postoperative complications. In contrast, Larson et al. prospectively analyzed 1615 patients who underwent arthroscopic hip procedures and found an overall complication rate of 8.3%. The complications were more likely in female patients and patients who had a traction time longer than 60 min. The most common complication was postoperative lateral femoral cutaneous nerve disturbance. The overall complication rate in our study was with the range of these previous reported rates at 4.6%, however, there were no neurologic, heterotopic ossification, or infection complications reported during the course of the follow-up period. Mechanical traction is used during hip arthroscopy as a means of providing space for surgical instruments by separating the femoral head from the acetabulum. This process can lead to several surgical complications such as soft tissue injuries from the traction or the countertraction provided by the perineal post. These distraction type injuries are the most common complications resulting from excessive traction force and prolonged procedure. Although distraction-related injuries are a common complication, there were no recorded mechanical traction-related complications in this study population.
The only postoperative complication reported in our patient population was decreased range of motion and adhesions requiring manipulation. After hip arthroscopy, adhesions may occur between the capsule and the labrum or the capsule and the femoral neck. Capsulolabral adhesions can lead to micro instability, decreased range of motion, and pain. Although some level of adhesions likely occur in all patients following surgical dislocation of the hip, approximately 6% of the patients symptomatic., In a study of 37 patients undergoing revision hip arthroscopy, the majority of patients reported decreased range of motion in some form. Decreased flexion was recorded in 73% of patients, 57% had decreased abduction, 54% had decreased internal rotation, and 57% struggled with decreased external rotation. Adhesions were present in 62% of the patients. Overall, the 2.3% rate of symptomatic postoperative adhesions requiring manipulation under anesthesia observed in this study is within the range of normal rates, and it is unlikely that this complication was related to implant selection. Notably, none of the potential device-related failures that have been associated with knotless suture anchors, including suture breakage and suture pullout from the anchor,, were observed in our population.
This study does have multiple limitations. First, its retrospective, single surgeon design increases the probability of selection bias and the potential that our findings are not applicable to other settings. In addition, our study was designed primarily to evaluate device safety over the early postoperative period. Further study is required to evaluate whether FAI surgery performed using MRK suture anchor system produces improvements in function and quality of life that are similar or superior to other implant systems.
| Conclusion|| |
In this retrospective case series of 42 hip arthroscopies, an overall complication rate of 4.6% was observed over the 9-month postoperative period. No device-related complications occurred. The MICRORAPTOR Knotless suture anchor appears to be safe for use in patients undergoing hip arthroscopy for FAI.
This study received grant funding from Smith and Nephew (Grant: MAP-757).
Financial support and sponsorship
This study received grant funding from Smith and Nephew (Grant: MAP-757).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Beaulé PE, Clohisy JC, Schoenecker P, Kim YJ, Millis M, Trousdale RT. Hip arthroscopy: An emerging gold standard. Arthroscopy 2007;23:682.
Bozic KJ, Chan V, Valone FH 3rd
, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28 8 Suppl: 140-3.
Diulus CA, Krebs VE, Hanna G, Barsoum WK. Hip arthroscopy technique and indications. J Arthroplasty 2006;21:68-73.
Griffin DR, Villar RN. Complications of arthroscopy of the hip. J Bone Joint Surg Br 1999;81:604-6.
McCarthy JC. Hip Arthroscopy: Applications and technique. J Am Acad Orthop Surg 1995;3:115-22.
Papavasiliou AV, Bardakos NV. Complications of arthroscopic surgery of the hip. Bone Joint Res 2012;1:131-44.
Röling MA, Mathijssen NM, Bloem RM. Incidence of symptomatic femoroacetabular impingement in the general population: A prospective registration study. J Hip Preserv Surg 2016;3:203-7.
Montgomery SR, Ngo SS, Hobson T, Nguyen S, Alluri R, Wang JC, et al.
Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-5.
Chahla J, Beck EC, Okoroha K, Cancienne JM, Kunze KN, Nho SJ. Prevalence and clinical implications of chondral injuries after hip arthroscopic surgery for femoroacetabular impingement syndrome. Am J Sports Med 2019;47:2626-35.
Riff AJ, Kunze KN, Movassaghi K, Hijji F, Beck EC, Harris JD, et al.
Systematic review of hip arthroscopy for femoroacetabular impingement: The importance of labral repair and capsular closure. Arthroscopy 2019;35:646-56.e3.
Larson CM, Clohisy JC, Beaulé PE, Kelly BT, Giveans MR, Stone RM, et al.
Intraoperative and early postoperative complications after hip arthroscopic surgery: A prospective multicenter trial utilizing a validated grading scheme. Am J Sports Med 2016;44:2292-8.
Philippon MJ, Ferro FP, Nepple JJ. Hip capsulolabral spacer placement for the treatment of severe capsulolabral adhesions after hip arthroscopy. Arthrosc Tech 2014;3:e289-92.
Beck M. Groin pain after open FAI surgery: The role of intraarticular adhesions. Clin Orthop Relat Res 2009;467:769-74.
Krueger A, Leunig M, Siebenrock KA, Beck M. Hip arthroscopy after previous surgical hip dislocation for femoroacetabular impingement. Arthroscopy 2007;23:1285-9.e1.
Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Revision hip arthroscopy. Am J Sports Med 2007;35:1918-21.
Barber FA, Lee Evanson JR. Editorial commentary: Acetabular labral repair-is a knotless anchor better? Arthroscopy 2019;35:77-9.
Safran MR, Behn AW, Botser IB, Mardones R. Knotless anchors in acetabular labral repair: A biomechanical comparison. Arthroscopy 2019;35:70-6.e71.
[Table 1], [Table 2], [Table 3], [Table 4]