The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review

Purpose: To compare patient-reported outcomes, progression of osteoarthritis, and conversion to total hip replacement in a dysplastic population when hip arthroscopy was used as an isolated treatment or as an adjunct to pelvic reorientation osteotomy. Methods: An exhaustive search of the existing literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Embase) were searched for studies from January 1930 through January 2018 published in the English language concerning the use of hip arthroscopy with diagnostic and therapeutic intentions in individuals with acetabular dysplasia. We excluded studies that presented ambiguous data sets or in which clear identification of the strategy for arthroscopy was absent. Results: The selection criteria were defined, and 33 studies (1,368 hip arthroscopies) were included in the final analysis. Studies that met the inclusion criteria were classified within 5 different categories: (1) hip arthroscopy for screening, chondral mapping, and planning (9 studies, 729 hip arthroscopies); (2) isolated arthroscopic treatment (13 studies, 434 hip arthroscopies); (3) outcomes of hip arthroscopy after previous reorientation pelvic osteotomy for acetabular dysplasia (4 studies, 52 hip arthroscopies); (4) arthroscopy followed by unplanned hip-preservation surgery (3 studies, 48 hip arthroscopies); and (5) combined arthroscopy and periacetabular osteotomy (4 studies, 106 hip arthroscopies). A risk-of-bias analysis showed a moderate to high risk of bias (level 3 or 4) within and across the included studies. Conclusions: Although hip arthroscopy can be used to accurately grade the severity of chondral injuries in the native hip and provide zone-specific geographic mapping that may aid in subsequent surgical planning, there is insufficient evidence to conclude that arthroscopic characterization alone has any bearing on the ultimate clinical outcomes after osseous structural correction. Isolated arthroscopic treatment is not recommended in the setting of moderate to severe dysplasia, given the inferior clinical outcomes and risk of iatrogenic instability reported for this group. However, there is limited evidence to suggest that the isolated use of hip arthroscopy may be considered in cases of borderline acetabular dysplasia when careful attention is paid to labral and capsular preservation. Limited evidence supports the conclusion that after prior reorientation pelvic osteotomy for acetabular dysplasia, hip arthroscopy leads to improved clinical and functional outcomes and should be considered in this setting. Furthermore, there is insufficient evidence to conclude that failed hip arthroscopy compromises or challenges the ultimate clinical outcomes in patients undergoing subsequent reorientation pelvic osteotomy. Last, there is insufficient evidence to conclude that the adjunctive use of hip arthroscopy with reorientation pelvic osteotomy produces superior clinical outcomes compared with pelvic osteotomy alone. In summary, arthroscopic techniques may provide a useful complement to the correction of acetabular dysplasia and should be thoughtfully considered on a case-by-case basis when designing a comprehensive treatment strategy in dysplastic populations.