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Lian Jiangen,Lian Junfeng,Zhong Mingjin 대한정형외과학회 2020 Clinics in Orthopedic Surgery Vol.12 No.2
To the Editor: With the rapid growth of the use of hip arthroscopy and strong evidence on its clinical efficacy and safety in the treatment of femoroacetabular impingement (FAI), we read with great interest the recent article entitled “Arthroscopic treatment for femoroacetabular impingement with extraspinal diffuse idiopathic skeletal hyperostosis” by Hwang et al.1) To the best of our knowledge, it is the first paper that studied the clinical outcomes of hip arthroscopy in patients with extraspinal diffuse idiopathic skeletal hyperostosis (DISH) that involves the hip joint. This retrospective study suggests that extraspinal DISH involving the hip joint could lead to FAI and arthroscopic treatment could provide good outcomes. The study also emphasizes that FAI patients who have painful hip and limitation of range of motion should also be evaluated to determine whether they have extraspinal DISH involving the hip.1) We really appreciate the excellent work of the authors. However, there are some issues worth to be explored. Ossification with bony overgrowth in extraspinal DISH mostly involves the acetabular rim of the hip joint, which leads to pincer-type FAI. Pincer FAI occurs in two forms: focal and global.2) Focal acetabular overcoverage can exist in the anterosuperior acetabulum (as shown in Fig. 2)1) with a center-edge angle (CEA; Wiberg angle) of 25°–39°. Global FAI has more generalized and typically more extreme acetabular overcoverage, resulting in a CEA of 40° or greater with protrusio acetabuli or coxa profunda2) (as shown in Fig. 1).1) The reduction in CEA is a more important determinant of hip function than is the magnitude of the preoperative or postoperative CEA.3) Therefore, we think the preoperative and postoperative CEAs should have been carefully evaluated in the study. The authors described that the central compartment (CC) of the hip joint was addressed first during the hip arthroscopic surgery. However, because of severe acetabular overcoverage, joint space narrowing, and early stage osteoarthritis (Fig. 1),1) traction is usually very difficult to achieve, and the entry needle access into the CC is often blocked from the anterolateral or anterior portal.4) In this condition, the peripheral compartment (PC) of the hip joint would be explored first as Dienst et al.5) described: the patient is placed on a standard traction table without joint traction and with the hip and knee semiflexed. The entry needle is used for confirmation of entry to the joint by lateral and caudal displacement of the femoral head under fluoroscopy. The PC is easily explored by portal exchange and internal and external rotation of the hip. Then, acetabuloplasty and femoroplasty from PC are performed until sufficient to permit CC access. After PC manipulation, the hip and knee are extended, the CC is addressed with traction. We are convinced that hip arthroscopy for the treatment of patients with extraspinal DISH involving the hip joint will show good clinical results without any intra- or postoperative complications related to the surgical procedure. However, extraspinal DISH is a progressive disease characterized by abnormal calcification and ossification around joints, which may be one of the causes of secondary osteoarthritis. In patients with FAI, older age (>45 years), elevated BMI (>24.5 kg/m2), osteoarthritic changes, and increased CEA are predictors of negative outcomes after hip arthroscopy.6) Obviously, the 17 hips (12 patients) met one or more of those conditions. Therefore, the degree of hip arthritis and rates of revision surgery and conversion to total hip arthroplasty should be assessed in the long term. We look forward to seeing the long-term follow-up outcomes of the study in terms of patients' function, painful symptoms, and complications. We respect the great contribution of the authors and are much interested in the authors' thoughts on these issues.
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