Orthopedics

Feature Article 

Hip Arthroscopy for Diffuse Idiopathic Skeletal Hyperostosis Using a Capsulotomy-First Approach

Yohei Yukizawa, MD, PhD; Dean K. Matsuda, MD; Akinori Sakai, MD, PhD; Soshi Uchida, MD, PhD

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is a systematic disease of unknown etiology characterized by ossification at the site of spine and major joints entheses, including the hip. Ossified connective tissue may cause pain and joint stiffness, which may require surgical intervention. The purpose of this study was to investigate the clinical, radiographic, and arthroscopic presentation and surgical outcomes of patients with DISH involving the hips. Fourteen hips in 9 patients (mean±SD age, 63±14 years; range, 35–76 years) with overcoverage of the femoral head by DISH were retrospectively reviewed. For all joints, a transverse, capsulotomy-first approach was performed due to an inability to access the central compartment by traction of the lower extremity. After arthroscopic resection of the ossified lesion, labral reconstruction was performed with an iliotibial band autograft. For clinical evaluation, patient-reported outcome scores (modified Harris Hip Score [mHHS], Nonarthritic Hip Score [NAHS], International Hip Outcome Tool-12 [iHot-12], visual analog scale [VAS] pain score, and VAS satisfaction score) were obtained. Arthroscopically, circumferential labral damage with no or mild articular cartilage damage was observed. Mean NAHS, iHot-12 score, and VAS satisfaction score improved significantly (47 to 56, 43 to 71, and 21 to 72, respectively; P<.05). Mean mHHS and VAS pain score did not reach significance but did improve (65 to 92 and 45 to 78, respectively). Using a transverse, capsulotomy-first approach for arthroscopic hip surgery for patients with DISH yields successful outcomes in patient-reported outcome measures and satisfaction, despite minor gains in hip range of motion. [Orthopedics. 2020;43(5):e369–e377.]

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is a systematic disease of unknown etiology characterized by ossification at the site of spine and major joints entheses, including the hip. Ossified connective tissue may cause pain and joint stiffness, which may require surgical intervention. The purpose of this study was to investigate the clinical, radiographic, and arthroscopic presentation and surgical outcomes of patients with DISH involving the hips. Fourteen hips in 9 patients (mean±SD age, 63±14 years; range, 35–76 years) with overcoverage of the femoral head by DISH were retrospectively reviewed. For all joints, a transverse, capsulotomy-first approach was performed due to an inability to access the central compartment by traction of the lower extremity. After arthroscopic resection of the ossified lesion, labral reconstruction was performed with an iliotibial band autograft. For clinical evaluation, patient-reported outcome scores (modified Harris Hip Score [mHHS], Nonarthritic Hip Score [NAHS], International Hip Outcome Tool-12 [iHot-12], visual analog scale [VAS] pain score, and VAS satisfaction score) were obtained. Arthroscopically, circumferential labral damage with no or mild articular cartilage damage was observed. Mean NAHS, iHot-12 score, and VAS satisfaction score improved significantly (47 to 56, 43 to 71, and 21 to 72, respectively; P<.05). Mean mHHS and VAS pain score did not reach significance but did improve (65 to 92 and 45 to 78, respectively). Using a transverse, capsulotomy-first approach for arthroscopic hip surgery for patients with DISH yields successful outcomes in patient-reported outcome measures and satisfaction, despite minor gains in hip range of motion. [Orthopedics. 2020;43(5):e369–e377.]

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease characterized by significant ossification of ligaments and tendon–bone attachment sites of the spine and appendicular skeleton that causes back pain, movement limitation, and a reduced range of joint motion. Forestier and Rotes-Querol1 described ankylosing spinal hyperostosis associated with ossification of the anterior longitudinal ligament of the spine in 1950. In 1976, Resnick and Niwayama2 proposed the concept of a systemic condition that affects not only the spine, but also the appendicular skeleton and named it DISH. Investigators have shown that the radiographic and pathologic incidence of DISH was 12% in 215 cadavers.2

When hip joints are afflicted with DISH, abnormal ossified lesions are formed surrounding both the acetabulum and femoral head. Although DISH often progresses asymptomatically, such abnormal ossification can cause pincer femoroacetabular impingement (FAI), predisposing patients to osteoarthritis. Patients with recalcitrant pain and/or significantly reduced range of motion failing nonsurgical measures may be candidates for surgical treatment.3 Open surgical dislocation with a trochanteric osteotomy may be used for eradication of abnormal ossified lesions, allowing for direct visualization. However, these open surgical procedures are highly invasive, and concerns exist about postoperative complications and hip abductor dysfunction.4–8

Hip arthroscopy is a promising tool for treating FAI,9 but DISH of the hip (circumferential acetabular overcoverage of the femoral head) may prevent central compartment access and instrument navigation.10 To address this, the authors used a transverse, capsulotomy-first approach for hip arthroscopy8 in their practice. It was hypothesized that hip arthroscopy using this approach in patients with DISH is a minimally invasive procedure that provides clinical benefit. The purpose of the current study was to investigate the clinical, radiographic, and arthroscopic presentation and arthroscopic surgical outcomes of patients with DISH.

Materials and Methods

Participants

The local institutional review board approved this study, and all study participants provided informed consent. The authors prospectively followed patients who were diagnosed with DISH according to the Resnick and Niwayam2 criteria and underwent hip arthroscopy by a single surgeon (senior author [S.U.]) at their institution between 2009 and 2016. Surgery was indicated for patients with severe pain and a reduced range of motion due to ossified lesions. A total of 14 joints in 9 patients (1 woman and 8 men) were included in this study. Mean age at the time of surgery was 63±14 years (range, 35–76 years; Table 1).

Patient Demographics

Table 1:

Patient Demographics

Radiographic Evaluation

Radiographs of all patients were assessed both pre- and postoperatively. All radiographic measurements were manually performed using a picture archiving and communication system. The lateral center-edge (LCE) angle,11 vertical center anterior (VCA) angle,12 Tönnis angle,13 and alpha angle14 were obtained on anteroposterior pelvic view, cross-table lateral view, or modified Dunn view.

The shape and location of ossified lesions were evaluated using computed tomography (CT). Magnetic resonance imaging (MRI) was also performed in all patients to detect any lesions of the labrum, cartilage, and sacroiliac joint.

Inter- and intraobserver reproducibility of these radiographic parameters were investigated. For intraobserver reliability, 1 hip surgeon (Y.Y.) measured each radiograph 3 times, with an interval of at least 1 week between measurements. For interobserver reliability, 2 surgeons blinded to the clinical data and details of the radiology reports independently measured each radiograph. Interclass correlation coefficients (ICCs) and corresponding 95% confidence intervals (CIs) were calculated to quantify inter- and intraobserver reliability for continuous variables.

Clinical Outcomes

Patients completed detailed patient-reported outcome scores, including the modified Harris Hip Score (mHHS; of possible 100 points),15 Nonarthritic Hip Score (NAHS; of possible 80 points),4 visual analog scale (VAS) pain score (of possible 100 points), VAS satisfaction score (of possible 100 points), and International Hip Outcome Tool-12 (iHot-12) score.16 Furthermore, the patients were asked whether they had any back pain or stiffness. Patient-reported outcomes from a preoperative evaluation and at last follow-up were obtained and analyzed. In addition, range of hip flexion and abduction were evaluated.

Surgical Technique

Hip arthroscopy was performed with the patient under general anesthesia and supine on a traction table. Because it was difficult to apply sufficient traction due to the excessive ossification at the acetabular rim in all patients, a transverse, capsulotomy-first approach was used (Figure 1). The anterolateral, mid-anterior, and proximal mid-anterior portals were established. Creation of the space between the anterior capsule and gluteus minimus was performed prior to capsulotomy.

Anterolateral arthroscopic images showing the peripheral capsulotomy-first approach. A blunt rod is inserted into the space between the capsule and the gluteus minimus muscle (G. Min.) (a). The inserted blunt rod or ablator expands the space between the capsule and the gluteus minimus muscle (b). A transverse incision is made to the capsule (c). The incision is extending to approach joint (d). Extensive spurs of the anterior and lateral part are observed (e). Excessive spurs were resected by using an osteotomy to create a working space and allow the insertion of instruments into the joint (f). A cam deformity was first resected before insertion of devices into the joint space, if necessary (g). Excessive spur and a cam deformity were resected (h).

Figure 1:

Anterolateral arthroscopic images showing the peripheral capsulotomy-first approach. A blunt rod is inserted into the space between the capsule and the gluteus minimus muscle (G. Min.) (a). The inserted blunt rod or ablator expands the space between the capsule and the gluteus minimus muscle (b). A transverse incision is made to the capsule (c). The incision is extending to approach joint (d). Extensive spurs of the anterior and lateral part are observed (e). Excessive spurs were resected by using an osteotomy to create a working space and allow the insertion of instruments into the joint (f). A cam deformity was first resected before insertion of devices into the joint space, if necessary (g). Excessive spur and a cam deformity were resected (h).

A blunt switching stick was first inserted via the anterolateral portal, and the gluteus minimus muscle was partly separated from the capsule while palpating the underlying femoral neck. A shaver and radiofrequency probe were then used to further develop the space between the capsule and the gluteus minimus muscle, followed by a transverse anterior capsular incision along the anterior rim, which were performed under fluoroscopic and arthroscopic guidance to ensure that the instruments do not damage the underlying femoral head cartilage and labrum.

Extensive spurs along the anterior and lateral rim appeared during transverse capsulotomy. Spur resection and rim trimming were performed under arthroscopic guidance with a motorized round burr and osteotome. After appropriate rim resection, traction was applied to access and evaluate the central compartment pathologies, including chondrolabral status.

Severe labral damage was seen in all patients. When irreparable, a labral reconstruction using an iliotibial band autograft was performed.17 After releasing traction, dynamic arthroscopic examination confirmed cam impingement, which was resolved by cam osteoplasty for all patients. Capsular closure was then performed.18,19

Postoperatively, patients were restricted to partial weight bearing for 1 to 2 weeks; they started range-of-motion exercises and strength training on the first postoperative day.

Arthroscopic Evaluation

Intra-articular pathologies, including labral tearing and cartilage delamination at the acetabular rim, were evaluated according to the proposed Multicenter Arthroscopy of the Hip Outcomes Research Network classification of acetabular rim lesions20; cartilage damage at the femoral head was evaluated according to the International Cartilage Repair Society (ICRS) classification.21

Statistical Analysis

Wilcoxon t test and Mann–Whitney U test were used to compare parameters and clinical scores between pre- and postoperative data. The authors presented these values as mean and ranges. Statistical analyses were performed using the SPSS software package (version 13; SPSS Inc, Chicago, Illinois). P<.05 was considered statistically significant.

Results

Preoperative plain radiographs showed bilateral ossification extending from the acetabular rim and surrounding the femoral head in all patients. The preoperative radiographic measurements of each patient are shown in Table 2.

Preoperative Radiographic Data

Table 2:

Preoperative Radiographic Data

Mean preoperative LCE, Sharp, VCA, and alpha angles were 62° (range, 41° to 65°), 31° (range, 24° to 38°), 42° (range, 33° to 56°), and 73° (range, 64° to 80°), respectively (Table 2). Inter- and intraobserver ICCs of the LCE angles were 0.81 (95% CI, 0.35–0.96) and 0.83 (95% CI, 0.40–0.96), respectively. The ICCs of the Sharp, alpha, and VCA angles were 0.89 (95% CI, 0.56–0.98), 0.54 (95% CI, 0.20–0.92), and 0.69 (95% CI, 0.44–0.92), respectively.

The joint space was preserved in all patients, with 5 patients each exhibiting Tönnis grade 1 or 2 osteoarthritis.22 Ossified lesions were also observed near the lesser trochanter along the iliopsoas muscle in 6 hips and around the greater trochanter in 4 hips. Consistent with the plain radiograph findings, the CT examination revealed significant ossification extending circumferentially around the joint such that the border between the ossified lesions and the original acetabular rim could not be distinguished. The weight-bearing surface had no bone cysts associated with osteoarthritis, and there were no bone spurs in the lunate fossa (except 3 hips of 2 patients showing Tönnis grade 2).

Magnetic resonance imaging showed ossified or degenerative labrum in all patients, and 5 patients with osteoarthritic changes were suspected to have cartilage damage (articular cartilage thinning). No abnormalities of the sacroiliac joint were found on CT or MRI for all patients. Outside the hip joint, 6 (67%) patients had ossified lesions in the shoulder and knee, respectively. Back pain and stiffness were reported by 4 (44%) patients. Preoperative blood chemistry tests showed no elevation of C-reactive protein, erythrocyte sedimentation rate, HLA B27, or other obvious abnormalities.

Arthroscopic findings are detailed in Table 3. Arthroscopically, the articular cartilage at the acetabular weight-bearing region appeared normal in 7 joints of 9 patients; an ICRS score of 1 and 2 was observed in 3 hips each. All patients had an ossified or degenerative labrum with circumferential involvement. According to cartilage delamination at rim lesion, a Multicenter Arthroscopy of the Hip Outcomes Research Network grade 0 was observed in 9 hips, grade 2 in 1 hip, grade 3 in 1 hip, and grade 4 in 2 hips.

Operative Findings

Table 3:

Operative Findings

Labral damage was treated with selective debridement in 4 joints and with reconstruction using the iliotibial band in 9 joints. The weight-bearing cartilage of the femoral head was normal in 8 joints and an ICRS score of 1 was observed in 3 joints and an ICRS score of 2 was observed in 2 joints. For all joints, cam lesion was present and resected arthroscopically. Mean±SD surgical time was 163±35 minutes.

Plain radiographs showed improved mean LCE from 62° preoperatively to 33° postoperatively (postoperative range, 25° to 40°) and improved mean Sharp angle from 31° preoperatively to 39° postoperatively (postoperative range, 31° to 44°; P<.001; Table 4, Figure 2). Similarly, postoperative mean VCA, alpha, and Tönnis angles were also significantly improved.

Change in Radiographic Measurements

Table 4:

Change in Radiographic Measurements

Pre- (A) and postoperative (B) radiographs and pre- (C) and postoperative (D) 3-dimensional computed tomography scans of diffuse idiopathic skeletal hyperostosis. Preoperatively, periarticular hyperostosis abnormally surrounded the femoral heads. Ossification was also seen at the attachment site of the iliopsoas muscle and the rectus femoris muscle. Arthroscopically, the anterosuperior excessive rim was totally trimmed and the obvious cam lesion was resected to relieve impingement.

Figure 2:

Pre- (A) and postoperative (B) radiographs and pre- (C) and postoperative (D) 3-dimensional computed tomography scans of diffuse idiopathic skeletal hyperostosis. Preoperatively, periarticular hyperostosis abnormally surrounded the femoral heads. Ossification was also seen at the attachment site of the iliopsoas muscle and the rectus femoris muscle. Arthroscopically, the anterosuperior excessive rim was totally trimmed and the obvious cam lesion was resected to relieve impingement.

The results of clinical scores were shown in Table 5. Mean scores increased significantly for the NAHS (47 [range, 14 to 76] to 56 [range, 34 to 80]), VAS satisfaction score (21 [range, 0 to 87] to 72 [range, 37 to 98]), and iHot-12 score (43 [range, 1 to 93] to 71 [range, 34 to 98]; all P<.05). A slight, statistically insignificant improvement was observed in mean mHHS (65 [range, 20 to 95] to 92 [range, 53 to 92]) and mean VAS pain score (45 [range, 30 to 84] to 78 [range, 42 to 95]). Mean range of hip flexion changed from 90° (SD, 10.0°) to 100.8° (SD, 4.9°). For mean hip abduction, a slight improvement was observed, from 26.4° (SD, 9.4°) to 30.0° (SD, 8.9°). However, no significant differences were observed for range of motion in flexion and abduction. During the follow-up period, no patients experienced progression of hip osteoarthritis or underwent reoperation or conversion to total hip arthroplasty.

Change in Clinical Scores

Table 5:

Change in Clinical Scores

Discussion

The arthroscopic surgical technique of using a transverse, capsulotomy-first approach for treating a global pincer impingement, such as DISH, is based on an anterior Hueter approach used under endoscopic control.8,23 Matsuda et al10 first described the technique of a capsulotomy- and acetabuloplasty-first approach, which enabled the arthroscopic treatment of extreme global pincer impingement even in protrusio acetabuli.24 When using an inside-out anterior capsulotomy with a 2-portal circumferential acetabuloplasty under arthroscopic and fluoroscopic guidance, controlled central compartment access was achieved, enabling chondrolabral procedures with outcomes similar to patients with less severe focal pincer FAI.25

Another recent study reported successful arthroscopic outcomes approaching, but not reaching, those done for patients without global pincer FAI.26 The technique described in this study for DISH used an outside-in anterior capsulotomy that obviates the need for initial hip distraction followed by acetabuloplasty and spur re-section enabling subsequent central compartment access under distraction. This approach also enabled the necessary treatment, even in the presence of overcoverage resulting from excessive ossification, which would increase both the force and duration of traction, as well as increase the risk of labral or chondral damage.8

Compared with an open surgery, such as a transtrochanteric approach with surgical dislocation, hip arthroscopy is a less invasive procedure that enables the circumferential treatment of intra-articular lesions, including resection of pincer lesions, using an image intensifier as needed. A fluoroscopic templating technique has been described that may aid controlled rim trimming of the anterior, superior, and posterior acetabular rims.27 Although a deep socket of global pincer impingement has inherent bony stability, patients with DISH may actually be at risk of postoperative joint instability following resection of spurs, ossified labrum, and circumferential acetabular rim; arthroscopic labral reconstruction and capsule reefing can minimize this risk while potentially enhancing joint preservation.

Total hip arthroplasty may be a solution for pain relief in patients with DISH. However, these patients may be at a greater risk for heterotopic ossification postoperatively.28–30 In the current study, arthroscopic findings revealed that joint cartilage appears to be normally preserved in 10 of 14 joints. Moreover, the age of patients with DISH was relatively younger than the typical osteoarthritis population. Thus, the current authors believed that patients with DISH would benefit from hip arthroscopic preservation surgery rather than total hip arthroplasty.

Diffuse idiopathic skeletal hyperostosis is mainly characterized by ossification at the spine, which causes back pain and severely reduces spinal mobility.31 The manifestation of DISH is thought to be enthesis or inflammation at the sites where muscles, tendons, or ligaments attach to the bone.32–34

Systemic periarticular ligament ossification can lead to progressive restriction of joint range of motion. Indeed, 44% of patients enrolled in this study had back pain, and 67% of patients had restricted range of motion of joints other than the hips. The systematic pathologic entity of DISH, such as sacroiliac joint stiffness and lumbar spinal arthrosis, may explain the lack of significantly increased hip range of motion following hip arthroscopy in the current study. The presence of these conditions might impact functional and pain scoring. Nevertheless, statistical improvement of satisfaction levels and other clinical scores were seen, so it is plausible that hip arthroscopy is an effective surgical procedure for symptomatic improvement in the hips with DISH.

Circumferential pathology was present in all hips with DISH, and most of the labrum were totally calcified and unsalvageable. Therefore, they had to be resected as part of the comprehensive treatment of pincer FAI to address global overcoverage. Because the acetabular labrum plays an important role in proprioception, nociception, synovial fluid seal effect, static and dynamic joint stability, and as a shock absorber, labral reconstruction was performed.

A recent study demonstrated that reconstruction of the labrum showed as good outcomes in patient-reported outcome scores as labral re-fixation, even though the mean age in the reconstruction group was significantly older than that in the re-fixation group.35 Based on these aforementioned studies, the current authors recommend labral reconstruction for hips with DISH afflicted with irreparable labral damage and/or marked calcification/ossification.

No large-scale epidemiological studies of DISH have been performed, and its reported prevalence ranges from 5.5% to 27.1%.36,37 It occurs most often in men older than 40 years, and the prevalence increases with age.33,38 Because DISH gradually progresses over time and there is no effective medical treatment to modify progression, the disease is expected to severely affect patients' daily lives and social activities. Although surgery only provides local management with resection, an increase in the incidence of hip arthroscopy for DISH is anticipated as the condition becomes more widely recognized. However, there have been few case reports of surgical management, and the long-term outcomes postoperatively, including the risk of recurrence, remain unknown.

Although the current study is the largest case series on hip arthroscopic outcomes in DISH, the small number of patients in the study is a limitation. Moreover, this was a case series study without a control group, so it is necessary to perform a comparative cohort study between patients undergoing arthroscopy and other procedures. The short-term follow-up limits conclusions about the durability of the observed outcomes.

Conclusion

Hips afflicted with DISH had circumferential labral damage, often with labral calcification but preserved articular cartilage, and global pincer and cam femoroacetabular impingement. Hip arthroscopic surgery via an outside-in capsulotomy- and acetabuloplasty-first approach is a safe, minimally invasive technique, enabling circumferential treatment of the acetabular rim and intraarticular pathology and treatment of coexistent cam femoroacetabular impingement.

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Patient Demographics

Patient No.Operative SideAge, ySexBMI, kg/m2Symptoms of Hip JointTime to Surgery, yFollow-up, yAITOther Affected JointsBack Pain
1Bilateral67M16Severe pain, stiffness56+Knee, shoulder+
2Bilateral56M21Moderate pain, stiffness24+NA+
3Bilateral35M22Moderate pain, stiffness1.53+NA+
4Bilateral76M24Moderate pain, stiffness13+NA-
5Right69M25Mild pain, stiffness22-Knee+
6Left60M25Moderate pain, stiffness0.56+Shoulder-
7Left68M25Moderate pain, stiffness12+Shoulder-
8Left73F25Moderate pain, stiffness23+Knee-
9Right65M26Moderate pain, stiffness101+Knee-

Preoperative Radiographic Data

Patient No.Operative SideLCE AngleSharp AngleTönnis AngleVCA AngleAlpha AngleTönnis Classification
1Right65°24°−12°45°78°0
Left60°24°−7°39°70°0
2Right51°26°−2°36°72°2
Left45°30°−8°37°70°2
3Right55°35°−5°38°70°1
Left50°30°−7°44°80°1
4Right48°38°−11°41°72°0
Left60°30°−4°47°77°0
5Right41°32°−8°56°71°0
6Left47°34°−1°39°73°0
7Left54°33°−7°45°75°1
8Left40°38°33°76°2
9Right58°27°−6°48°64°1
Mean±SD62°±14°31°±5°−6°±4°42°±6°73°±4°0.8°±0.8°

Operative Findings

Patient No.SideLabrum/Rim LesionCartilage Damage of Acetabulum (ICRS)Cartilage Damage of Femoral HeadSurgical Time, min


PathologyDelamination on Acetabulum (MAHORN)Surgical ProcedureWeight Bearing (ICRS)Peripheral Site (ICRS)Surgical Procedure
1RightOssified0Reconstruction Rim trimming004Cam resection230
LeftHypoplastic0Reconstruction Rim trimming003Cam resection180
2RightOssified2Resection Rim trimming224Cam resection202
LeftOssified3Resection Rim trimming224Cam resection124
3RightOssified0Reconstruction Rim trimming003Cam resection139
LeftOssified4Reconstruction Rim trimming204Cam resection213
4RightOssified0Resection Rim trimming004Cam resection120
LeftOssified0Resection Rim trimming004Cam resection130
5RightOssified0Reconstruction Rim trimming004Cam resection150
6LeftOssified4Reconstruction Rim trimming004Cam resection160
7LeftOssified0Reconstruction Rim trimming113Cam resection164
8LeftOssified0Reconstruction Rim trimming114Cam resection136
9RightOssified0Reconstruction Rim trimming114Cam resection180

Change in Radiographic Measurements

MeasurementMean (Range)P

PreoperativePostoperative
LCE angle62° (41° to 65°)33° (25° to 40°)<.01
Sharp angle31° (24° to 38°)39° (31° to 44°)<.01
VCA angle42° (33° to 56°)31° (21° to 40°)<.01
Alpha angle73° (64° to 80°)57° (48° to 65°)<.01
Tönnis angle−6° (−12° to −1°)1 (−4° to 4°)<.01

Change in Clinical Scores

Outcome MeasureMean (Range) Score, pointsP

PreoperativePostoperative
mHHS65 (20 to 95)92 (53 to 92).09
NAHS47 (14 to 76)56 (34 to 80).03
VAS, pain45 (30 to 84)78 (42 to 95).07
VAS, satisfaction21 (0 to 87)72 (37 to 98).02
iHot-1243 (1 to 93)71 (34 to 98).03
Authors

The authors are from the Department of Orthopaedic Surgery and Sports Medicine (YY, SU), Wakamatsu Hospital of University of Occupational and Environmental Health, Wakamatsuku, Kitakyushu, Japan; DISC Sports and Spine (DKM), Marina del Rey, California; and the Department of Orthopaedic Surgery (AS), University of Occupational and Environmental Health, Yahatanishiku, Kitakyushu, Japan.

Drs Yukizawa and Sakai have no relevant financial relationships to disclose. Dr Matsuda is a paid consultant for Zimmer Biomet. Dr Uchida is a paid consultant for Smith & Nephew, Zimmer Biomet, and ConMed.

Correspondence should be addressed to: Soshi Uchida, MD, PhD, Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1, Hamamachi, Wakamatsuku, Kitakyushu 8070024, Japan ( soushi@med.uoeh-u.ac.jp).

Received: February 04, 2019
Accepted: June 27, 2019
Posted Online: July 07, 2020

10.3928/01477447-20200619-03

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