Knotless Tensionable Anchors: Versatility, Tips, and Tricks

Arthroscopic surgery, including implants and advanced techniques, continues to advance in the field of orthopaedics. The evolution of suture anchors has undergone design changes, passing from first-generation metal anchors, biodegradable materials, different plastic polymers, to all-suture constructs. Knotless technology also has been found to be a more reproducible method and have comparable outcomes with those found using knotted anchors. This Technical Note describes the advantages and different ways this tensionable anchor can be used in arthroscopic procedures. This implant and its understanding will be useful in the sports medicine area by simplifying procedures and making them more reproducible. The aim of the present Technical Note is to detail the simplicity and versatility of the anchor and discuss different scenarios in which this technology can be used to address common hip pathologies.

Slightly reduced early subsidence with similar outcomes and complications rate in collared stems - A systematic review of randomized clinical trials

Background

There is a growing trend towards using femoral stems with a medial calcar collar during total hip arthroplasty (THA).

Purpose

Systematically review the literature comparing a femoral collared stem and femoral collarless stem on subsidence, patient-reported outcomes (PROs), and revision rate.

Study design

Systematic Review, Level of Evidence 1.

Methods

A literature search of Pubmed and Medline was according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials that evaluated collared and collarless stems, subsidence and PROs for adult patients undergoing total hip arthroplasty (THA) were included. Additional data collection included patient demographics, stem-calcar contact, canal-fill ratio (CFR), stem orientation, surgical approach, Dorr Type, complications, and revisions.

Results

Five studies met inclusion criteria. 674 patients (704 hips) were included. Mean patient ages ranged 58.5-72.4 years old, and mean BMI ranged 26.6-29.8 kg/m2. Mean reported follow-up of the included clinical trials ranged 1-9.6 years. Two studies reported mean early subsidence at two weeks postoperatively, which was 0.36, 0.99 mm for collared stems and 0.52, 3.22 mm for collarless stems, proving to be statistically significant (P = 0.023), (P = 0.05). All studies demonstrated improved PROs at most recent follow-up. Revision rates ranged from 4 to 11.3 %, but these were not statistically significant.

Conclusions

Implantation of collared stems compared to collarless may reduce early post-operative subsidence, while no substantial effect on aseptic loosening, thigh pain, proximal femoral fracture, and revision is seen. When measuring patient-reported outcomes, the collared femoral stem was not superior to the collarless femoral stem as both resulted in similar improvement preoperatively to postoperative state.

Defining the Percent Thresholds for Achieving the Maximum Outcome Improvement of the Modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Sports Subscale, the Visual Analog Scale for Pain, and the International Hip Outcome Tool-12 in Revision Hip Arthroscopy at Minimum 2-Year Follow-Up

PURPOSE

To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following revision hip arthroscopy, and to identify predictors for achieving the MOI.

METHODS

An anchor question was provided to patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included for the final analysis if they answered the anchor question and had minimum 2-year follow-up. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. A P-value of < .05 was considered significant.

RESULTS

In total, 318 patients underwent revision hip arthroscopy. Of those patients, 292 (91.8%) had minimum 2-year follow-up. Of this cohort, 68 answered the anchor question, with 49 (72.1%) female and 19 (27.9%) male patients. The mean age, and body mass index time were 32.9 ± 13 years and 25.4 ± 5.1, respectively. It was determined that 42.1%, 50%, 48.1%, 50%, and 50% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, HOS-SS, VAS for pain, and the iHOT-12, respectively. The presence of unaddressed subspine impingement was a significant predictor for achieving the MOI threshold for the VAS (odds ratio 1.40; 95% confidence interval 1.00-1.95; P = 0.0273).

CONCLUSIONS

Following revision hip arthroscopy, the percent thresholds for achieving the MOI at a minimum 2-year follow-up for the mHHS, NAHS, HOS-SS, VAS for pain, and iHOT-12 were 42.1%, 50%, 48.1%, 50%, and 50.9%, respectively. Addressing residual subspine impingement was identified as significant positive predictor for achieving the MOI.

LEVEL OF EVIDENCE

Level IV, case-series.

Dancers Show Significant Improvement in Outcomes and Favorable Return-to-Dance Rates After Primary Hip Arthroscopy With Femoral Head Cartilage Status Being a Predictor of Secondary Surgical Procedures at Mid-Term Follow-Up

PURPOSE

To report minimum 5-year follow-up patient-reported outcome measurement (PROM) scores and return-to-dance rates in dancers who underwent primary hip arthroscopy and to identify predictors of secondary surgical procedures.

METHODS

Prospectively collected data from patients who underwent hip arthroscopy between May 2010 and June 2016 were retrospectively reviewed. Patients were included if they participated in dance at any level 1 year prior to surgery and had preoperative and minimum 5-year follow-up scores consisting of the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale pain score. The exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade greater than 1, or lateral center-edge angle less than 18°. The minimal clinically important difference (MCID) was reported. Dancers who discontinued dance for reasons other than pain in the operative hip were excluded from the return-to-dance analysis. A logistic regression model was used to identify predictors of secondary surgical procedures.

RESULTS

Fifty-one hips (48 female dancers) were included. The average age and average follow-up period were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROM scores (P < .001) was reported. Achievement rates of the MCID for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale pain score were 83.3%, 85.7%, and 85.7%, respectively. Revision hip arthroscopy was performed in 5 dancers (9.8%). Conversion to total hip arthroplasty was performed in 4 dancers (7.8%). The return-to-dance rate was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was identified as a predictor of secondary surgical procedures (P = .045; odds ratio, 6.752 [95% confidence interval, 1.043-43.688]).

CONCLUSIONS

After primary hip arthroscopy, dancers experienced significant improvement in all PROM scores collected and achieved the MCID at a high rate at minimum 5-year follow-up. The return-to-dance rate in dancers who did not discontinue dance because of lifestyle transitions was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was found to be a predictor of secondary surgical procedures.

LEVEL OF EVIDENCE

Level IV, case series.

No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy With Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity-Matched Multicenter Study With Minimum 5-Year Follow-Up

PURPOSE

To compare minimum 5-year patient-reported outcome measures after hip arthroscopy (HA) and periacetabular osteotomy (PAO) for borderline hip dysplasia.

METHODS

Hips with a lateral center-edge angle (LCEA) between 18° and less than 25° that underwent either PAO or HA were selected from 2 institutions. The exclusion criteria were as follows: LCEA less than 18°, Tönnis osteoarthritis grade greater than 1, prior hip surgical procedures, active inflammatory disease, Workers' Compensation, and concomitant surgery. Patients underwent propensity matching based on age, sex, body mass index, and Tönnis osteoarthritis grade. Patient-reported outcome measures included the modified Harris Hip Score, as well as calculation of the minimal clinically important difference, patient acceptable symptom state, and maximum outcome improvement satisfaction threshold. Preoperative radiographic predictors included comparison of the Femoro-epiphyseal Acetabular Roof index and ligamentum teres lesions.

RESULTS

A total of 28 PAO patients underwent propensity matching to 49 HA patients. The 2 groups were similar in terms of mean age, sex, preoperative body mass index, and LCEA. The PAO group had a longer mean follow-up period (95.8 months vs 81.3 months, P = .001). The mean Femoro-epiphyseal Acetabular Roof index was significantly lower preoperatively in the HA group (P < .001). The 2 groups showed similar and significant improvements in the mean modified Harris Hip Score from preoperatively to latest follow-up (P < .001). The relative risk of subsequent surgery in the PAO group was 3.49 (P = .024), mostly attributed to hardware removal (25%). The revision rate was 3.6% in the PAO group and 8.2% in the HA group (P = .65). One patient in the PAO group required revision HA for intra-articular adhesions. Three of the patients requiring revision in the HA group underwent PAO because of persistent pain, and one underwent revision HA alone. Conversion to total hip arthroplasty was required in 1 patient in the HA group and no patients in the PAO group.

CONCLUSIONS

Both PAO and HA with capsular plication provide borderline hip dysplasia patients with clinically significant improvements and low revision rates at a minimum of 5 years postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic trial.

Editorial Commentary: Primary Treatment of Hip Labral, Osseous, Chondral, Capsular, and Extra-Articular Pathology Is Essential: Outcomes Following Revision Are Less Predictable

Appropriate labral management is one of many procedures during hip arthroscopy that affects postoperative outcomes and revision rates. Both primary labral repair and reconstruction have been shown to have superior clinical and functional outcomes compared with labral debridement when treating unstable labral tears. Arthroscopic labral reconstruction is one of the most powerful techniques in the arsenal of complex hip-preservation surgeons, and although often reserved for the revision setting, when the native labrum is irreparable, a primary reconstruction may be indicated when the only alternatives are selective labral debridement or a suboptimal repair. Labral reconstruction, either in primary or revision procedures, is indicated when the existing labrum is deemed irreparable based on an intraoperative evaluation. Current indications for primary labral reconstruction, either in the primary or revision setting, include a calcified labrum, an irreparable mixed Seldes type 1 and 2 tear, or a hypoplastic labrum with less than 3 mm of viable tissue. Primary hip arthroscopy has been shown to have superior outcomes compared with revision hip arthroscopy, whether with labral repair or reconstruction. Finally, appropriate labral management is necessary but not always sufficient. Hip arthroscopy requires management of osseous deformities, with care taken to avoid under- and over-resection during both femoroplasty and acetabuloplasty; management of chondral injury; and management of the hip capsule with repair or plication. Consideration also must be given to potential extra-articular pain generators, such as abductor insufficiency, ischiofemoral impingement, lumbar spine disease, as well as deformities requiring open surgical correction such as acetabular dysplasia or pathologic femoral version. The primary goal is getting it right the first time.

Editorial Commentary: Concomitant Hip Arthroscopy and Periacetabular Osteotomy Treat Both the Cause and the Effects of Hip Dysplasia: The Best of Both Worlds

In the management of true hip dysplasia, the bony deformity is nearly always accompanied by, and often causal of, intra-articular pathology. It is strongly recommended to conduct a comprehensive preoperative evaluation as well as arthroscopic evaluation and treatment of coexisting hip joint conditions prior to performing an open Bernese periacetabular osteotomy. The osteotomy improves coverage of the femoral head and corrects the abnormal joint mechanics and loading patterns, which result in cartilage damage and subsequent osteoarthritis. Arthroscopy allows treatment of the intra-articular pathology. Combining the hip arthroscopy and periacetabular osteotomy procedures into a single surgical intervention, performed by either a single surgeon or a collaborative surgical team, allows us to address both the cause and the effects of dysplasia. This once-controversial combined technique has become a standard practice in the field with widespread adoption.

Acetabular Labral Reconstruction Does Not Demonstrate Superior Biomechanical Properties Compared to Labral Repair or Intact Native Labrum but Is Superior to Labral Excision: A Systematic Review of Cadaveric Studies

PURPOSE

To systematically review and compare biomechanical properties of labral reconstruction to labral repair, intact native labrum, and labral excision in cadaveric studies.

METHODS

A search of the PubMed and Embase databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Cadaveric studies focused on hip biomechanics related to intact labrum, labral repair, labral reconstruction, labral augmentation, and labral excision were included. Investigated parameters included biomechanical data measures, such as distraction force, distance to suction seal rupture, peak negative pressure, contact area, and fluid efflux. Review articles, duplicates, technique reports, case reports, opinion articles, articles written in a language other than English, clinical studies focusing on patient-reported outcomes, studies performed in animals, and articles with no abstract available were also excluded.

RESULTS

Fourteen cadaveric biomechanical studies were included that compared labral reconstruction to labral repair (4 studies), labral reconstruction to labral excision (4 studies); and evaluation of distractive force of the labrum (3 studies), the distance to suction seal rupture (3 studies), fluid dynamics (2 studies), displacement at peak force (1 study), and stability ratio (1 study). Data pooling was not performed because of methodological heterogenicity of the studies. Labral reconstruction did not outperform labral repair in restoring the hip suction seal or any other biomechanical property. Labral repair significantly prevented greater fluid efflux when compared to labral reconstruction. Labral repair and reconstruction improved the distractive stability of the hip fluid seal from the labral tear and labral excision stage, respectively. Furthermore, labral reconstruction demonstrated to have better biomechanical properties than labral excision.

CONCLUSIONS

In cadaveric studies, labral repair or intact native labrum was biomechanically more superior than labral reconstruction; however, labral reconstruction can restore acetabular labral biomechanical properties and was biomechanically superior to labral excision.

CLINICAL RELEVANCE

In cadaveric models, labral repair outperforms segmental labral reconstruction in preserving the hip suction seal; nonetheless, segmental labral reconstruction biomechanically outperforms labral excision at time 0.

A comprehensive review of hip arthroscopy techniques and outcomes

Transforming the orthopedic landscape, hip arthroscopy pioneers a minimally invasive surgical approach for diagnosing and addressing hip pathologies. With its origins dating back to Burman's 1931 cadaveric study, this groundbreaking technique gained clinical relevance in 1939 through Takagi's report. However, the 1980s marked the actual emergence of hip arthroscopy for treating a wide range of hip disorders. Now, a staple in modern orthopedics, hip arthroscopy empowers patients with previously undiagnosed and untreated hip conditions, enabling them to obtain relief and reclaim their lives. By employing a compact camera and specialized tools, surgeons expertly navigate the hip joint, performing procedures from excising loose bodies and mending labral tears to addressing femoroacetabular impingement and tackling other intricate issues. This innovative approach has dramatically elevated patients' quality of life, allowing them to embrace targeted treatments and resume daily activities without resorting to lifestyle alterations.

Non-metallic cerclage fixation methods for proximal femoral osteotomy and periprosthetic hip fractures offer promising outcomes: A systematic review

Background

Periprosthetic femur fracture (PFF) is an important complication to consider in total hip arthroplasty (THA). The purpose of this systematic review was to compare outcomes of conventional metallic versus modern non-metallic cerclage systems for PFFs and proximal femoral osteotomy.

Methods

The PubMed, MEDLINE, and Google Scholar databases were searched for clinical studies reporting PFFs or extended trochanteric osteotomy (ETO) in THA patients and cerclage fixation techniques.

Results

Eight studies with 1362 patients (1366 hips) were included. The mean age ranged from 48.2 to 81.7 years, and the study population was 79.4 % female. The infection rate at the site of the PFF or ETO was 0.22 % (3 of 1366 hips), all occurring in patients with non-metallic cerclage fixation. Sixteen of 18 (88.9 %) cases of stem subsidence occurred following metallic cerclage fixation. Significant stem subsidence was substantially higher in hips with metallic device fixation compared to those with non-metallic fixation, at rates of 5.1 % and 0.19 %, respectively. Hips with non-metallic fixation had a clinical or radiologic healing rate of 93.9 %. Loss of fixation was only seen in hips with metallic fixation, at a rate of 0.6 %. Postoperative outcome scores were comparable across both groups.

Conclusion

The findings of this systematic review suggest that available non-metallic cerclage fixation methods demonstrate similar clinical success as conventional metallic fixation methods when utilized in hip arthroplasty. The current use of novel materials appears to be safe and reliable for these surgeries and can be considered a dependable option for surgeons.

Level of evidence

Level IV, systematic review of level III and IV studies.

Endoscopic Tendon Compression Bridge Technique for Repair of Partial-Thickness Gluteus Medius Tears With Concomitant Arthroscopy for Labral Tears: Minimum 2-Year Outcomes With Benchmark Control Group

BACKGROUND

The transtendinous technique has been used to treat partial-thickness gluteus medius tears in the setting of concomitant arthroscopy for labral tears. The tendon compression bridge technique for gluteus medius repair has been developed as an alternative method, providing several advantages; however, comparative studies between the 2 techniques are lacking in the literature.

PURPOSE

(1) To evaluate the short-term patient-reported outcomes (PROs) of the tendon compression bridge technique and (2) to compare these findings with short-term PROs of the transtendinous technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected on patients who were followed for a minimum of 2 years after an endoscopic tendon compression bridge procedure for gluteus medius repair in the setting of concomitant hip arthroscopy for labral tears. The following PROs were collected preoperatively and postoperatively: modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, visual analog scale score for pain, and the International Hip Outcome Tool. Clinical outcomes were assessed using the Patient Acceptable Symptom State, minimal clinically important difference, and maximum outcome improvement satisfaction threshold. Patients were propensity matched 1:1 to a cohort that underwent gluteus medius repair using the endoscopic transtendinous technique with concomitant hip arthroscopy.

RESULTS

A total of 48 hips (48 patients) that met inclusion criteria (age, 53.3 ± 9.8 years; 92% female; body mass index, 26.7 ± 4.6), with a mean follow-up of 38.5 ± 15.7 months, were matched to 48 hips (46 patients) that underwent gluteus medius repair using the transtendinous technique. Both groups demonstrated significant improvement from preoperative scores to latest follow-up (P < .05). Mean magnitude of improvement and latest follow-up scores were not significantly different between the tendon compression bridge group and the transtendinous group, and the groups demonstrated similar favorable rates of achieving Minimal Clinically Important Difference (79% vs 79%, respectively), Patient Acceptable Symptom State (73% vs 73%, respectively), and Maximum Outcome Improvement Satisfaction threshold (65% vs 58%, respectively) for modified Harris Hip Score (P > .05). Patient satisfaction between groups was similar (8.1 ± 2.2 vs 7.7 ± 2.7, respectively) (P = .475).

CONCLUSION

At minimum 2-year follow-up, the endoscopic tendon compression bridge technique for partial-thickness gluteus medius tears, when performed with concomitant hip arthroscopy, was associated with significant improvement in functional outcomes. These postoperative results were comparable with those of a matched cohort that underwent the endoscopic transtendinous technique for partial-thickness gluteus medius tears, suggesting that the tendon compression bridge technique for gluteus medius repair is an effective treatment option for partial-thickness gluteus medius tears.

Defining Thresholds and Predictors for Achieving the Patient Acceptable Symptom State for Patient-Reported Outcome Measures After Revision Hip Arthroscopy

BACKGROUND

The Patient Acceptable Symptom State (PASS) after primary hip arthroscopy has been determined; nonetheless, the PASS still needs to be defined for revision hip arthroscopy.

PURPOSE

To define minimum 2-year follow-up PASS thresholds for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and International Hip Outcome Tool-12 (iHOT-12) after revision hip arthroscopy, and to identify predictors of achieving the PASS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included if they had baseline and minimum 2-year follow-up scores for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12. PASS was calculated using the anchor-based method. Receiver operating characteristic curve analysis was used to determine the thresholds for the PASS. A multivariate logistic regression was used to identify predictors for achieving the PASS.

RESULTS

A total of 318 patients who underwent revision hip arthroscopy met the inclusion criteria. Of those patients, 292 (91.8%) had baseline and minimum 2-year follow-up. Of this group, 68 patients (72.1% female and 27.9% male; mean age, 32.9 years) answered the PASS anchor question. Achievement PASS rates were 58.8%, 41.2%, 52.9%, 60.3%, and 52.9% for the mHHS, NAHS, HOS-SSS, VAS, and iHOT-12, respectively. The area under the curve (AUC) values for the PASS for mHHS, NAHS, HOS-SSS, VAS, and iHOT-12 were 0.912, 0.888, 0.857, 0.903, and 0.871, respectively, indicating excellent discrimination. The PASS for the mHHS was 76 (sensitivity, 0.809; specificity, 0.905), for the NAHS was 86.3 (sensitivity, 0.660; specificity, 1), for the HOS-SSS was 64.3 (sensitivity, 0.745; specificity, 0.905), for the VAS was 3 (sensitivity, 0.830; specificity, 0.905), and for the iHOT-12 was 64.3 (sensitivity, 0.745; specificity, 0.905). Body mass index (BMI) was identified as a significant predictor of achieving PASS for the NAHS (OR, 0.967; 95% CI, 0.940-0.996; P = .027), as patients with a BMI ≤25.4 had 1.03 times higher odds ratio of achieving PASS for the NAHS.

CONCLUSION

After revision hip arthroscopy, the minimum 2-year follow-up PASS thresholds for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12 were 76, 86.3, 64.3, 3, and 64.3, respectively. The odds ratio of achieving PASS for the NAHS was 1.03 times higher for patients with a BMI ≤25.4.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review

PURPOSE

To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up.

METHODS

The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM.

RESULTS

Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting.

CONCLUSIONS

Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations.

LEVEL OF EVIDENCE

IV.

TEMPORARY REMOVAL: Favorable and Durable Outcomes at 10-Year Follow Up After Endoscopic Gluteus Medius Repair With Concomitant Hip Arthroscopy

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Utility of 3D Planning Software in Understanding Residual Proximal Femoral Deformity for Planning of Revision Hip Arthroscopy

BACKGROUND

During the early evolution of femoroacetabular impingement (FAI) treatment, undercorrection of femoral deformity was a leading cause of hip arthroscopy failures. As the pendulum has swung, overresection of femoral deformity has increased in prevalence as a cause of persistent hip pain after arthroscopy. Computed tomography (CT) scans are increasingly being used in hip arthroscopy for preoperative planning purposes and may allow for improved 3-dimensional (3D) assessment of complex femoral deformities after previous femoroplasty.

PURPOSE

To assess whether CT scans provide additional utility over standard radiographs in understanding proximal femoral morphology in patients being evaluated for revision hip arthroscopy after previous femoroplasty in the setting of FAI.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Preoperative CT scans and standard radiographs were obtained in 80 patients who underwent revision hip arthroscopy for FAI. The anteroposterior and Dunn radiographic views were used to assess patients for residual proximal femoral deformity and were compared with the CT scan views using a commercially available software program. Determinations of underresection were made using alpha angle, while overresection was determined according to a previously described technique. Chi-square tests were performed to determine statistical significance between radiographic and CT classifications of overresection, underresection, and concomitant over- and underresection. A kappa value was calculated to determine the agreement between measurements on the radiographs and CT scans.

RESULTS

There were 30 patients (37.5%) for whom the CT scans revealed information about femoral morphology that was not detected on the radiographs. The kappa value of agreement was 0.28 between CT and radiographic measurements. Underresected cams were detected in 30 patients (37.5%) on CT scans versus 17 patients (21.3%) on radiographs (P = .024). Overresected cams were detected in 31 patients (38.8%) on CT scans versus 14 patients (17.5%) on radiographs (P = .0049). Concomitant areas of under- and overresection were detected in 12 patients (15.0%) on CT scans versus 3 patients (3.8%) on radiographs (P = .027).

CONCLUSION

CT scans with 3D planning software may be more sensitive than traditional radiographic views at detecting aberrant proximal femoral anatomy in the setting of failed FAI surgery. The use of 3D planning software may be considered as an adjunctive tool to better understand complex deformity in the proximal femur for the planning of revision hip arthroscopy.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review

PURPOSE

To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures.

METHODS

Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.).

RESULTS

Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS.

CONCLUSIONS

The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Periacetabular osteotomy with intraoperative computer-assisted modalities: a systematic review

The role of intraoperative computer-assisted modalities for periacetabular osteotomy (PAO), as well as the perioperative and post-operative outcomes for these techniques, remains poorly defined. The purpose of this systematic review was to evaluate the techniques and outcomes of intraoperative computer-assisted modalities for PAO. Three databases (PubMed, CINAHL/EBSCOHost and Cochrane) were searched for clinical studies reporting on computer-assisted modalities for PAO. Exclusion criteria included small case series (<10 patients), non-English language and studies that did not provide a description of the computer-assisted technique. Data extraction included computer-assisted modalities utilized, surgical techniques, demographics, radiographic findings, perioperative outcomes, patient-reported outcomes (PROs), complications and subsequent surgeries. Nine studies met the inclusion criteria, consisting of 208 patients with average ages ranging from 26 to 38 years. Intraoperative navigation was utilized in seven studies, patient-specific guides in one study and both modalities in one study. Three studies reported significantly less intraoperative radiation exposure (P < 0.01) in computer-assisted versus conventional PAOs. Similar surgical times and estimated blood loss (P > 0.05) were commonly observed between the computer-assisted and conventional groups. The average post-operative lateral center edge angles in patients undergoing computer-assisted PAOs ranged from 27.8° to 37.4°, with six studies reporting similar values (P > 0.05) compared to conventional PAOs. Improved PROs were observed in all six studies that reported preoperative and post-operative values of patients undergoing computer-assisted PAOs. Computer-assisted modalities for PAO include navigated tracking of the free acetabular fragment and surgical instruments, as well as patient-specific cutting guides and rotating templates. Compared to conventional techniques, decreased intraoperative radiation exposure and similar operative lengths were observed with computer-assisted PAOs, although these results should be interpreted with caution due to heterogeneous operative techniques and surgical settings.

Fixation of the Proximal Hamstring Tendon Using an All-Suture Tensionable Knotless Technique

Proximal hamstring injuries are a common sports and recreational injury among the active patient population. Surgical fixation of the tendons of the hamstring muscle complex, as opposed to conservative treatment alone, has shown improved patient outcomes, prompting the evolution of the suture anchors utilized in these repairs. Previous studies investigating the biomechanical properties of hamstring repair anchors have focused on double-row knotless techniques, in which the fixation of the overall construct relies on each individual anchor to maintain fixation. While these constructs have demonstrated biomechanical strength and clinical durability, each suture anchor represents a potential point of failure for the entire construct due to the crossed stitch anchor configuration. To address this limitation, recent tensionable knotless all-suture anchor designs have been implemented with success due to their smaller size and biomechanical strength. The aim of this technical note is, thus, to describe a technique for proximal hamstring repair using a tensionable knotless all-suture anchor construct that has 5 independent mattress sutures and, in doing so, employs the biomechanical strength of knotless fixation but eliminates the potential single point of failure seen with current knotless suture anchor designs.

Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

Hip arthroscopy is an effective treatment tool for athletes with femoroacetabular impingement (FAI) syndrome. However, long-term data are scarce.

PURPOSE

To assess survivorship, minimum 10-year patient-reported outcome measures (PROMs), and sports participation after primary hip arthroscopy for FAI syndrome in athletes and to perform a propensity-matched comparison between patients undergoing labral debridement and labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Athletes who underwent hip arthroscopy for FAI syndrome between February 2008 and December 2010 were eligible. Exclusion criteria were other ipsilateral hip condition, Tönnis grade ≥2, or no baseline PROMs. Survivorship was defined as no conversion to total hip arthroplasty. The Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), maximum outcome improvement (MOI) satisfaction threshold, and sports participation were reported. A propensity-matched comparison between labral debridement and labral repair was performed. Two additional propensity-matched subanalyses were performed for capsular management and cartilage damage.

RESULTS

In total, 189 hips (177 patients) were included. The mean ± SD follow-up was 127.2 ± 6.0 months. Survivorship was 85.7%. Significant improvement in all PROMs was reported (P < .001). A total of 46 athletes with labral repair were propensity matched to 46 athletes with labral debridement. This subanalysis demonstrated significant and comparable improvement in all PROMs at minimum 10-year follow-up (P < .001). For the labral repair group, the PASS achievement rates were 88.9% for the modified Harris Hip Score (mHHS) and 80% for the Hip Outcome Score-Sport Specific Subscale (HOS-SSS); the MCID achievement rates were 80.6% for the mHHS and 84% for HOS-SSS; and for the MOI satisfaction threshold, rates were 77.8%, 80.6%, and 55.6% for the mHHS, Nonarthritic Hip Score, and visual analog scale, respectively. For the labral debridement group, the PASS achievement rates were 85.3% for the mHHS and 70.4% for the HOS-SSS; the MCID achievement rates were 81.8% for the mHHS and 74.1% for HOS-SSS; and for the MOI satisfaction threshold, rates were 72.7%, 81.8%, and 66.7% for the mHHS, Nonarthritic Hip Score, and visual analog scale. Total hip arthroplasty conversions occurred significantly sooner with labral debridement than labral repair (P = .048). Age was identified as a significant predictor of achieving the PASS.

CONCLUSION

Primary hip arthroscopy for FAI syndrome in athletes results in 85.7% survivorship and sustained PROM improvement at a minimum 10-year follow-up. A significant time delay to total hip arthroplasty conversion at 10-year follow-up was reported with labral repair over debridement, although this should be interpreted with caution, as the total number of conversions was small.

Borderline Dysplasia After Primary Hip Arthroscopy with Capsular Plication and Labral Preservation: Ten-Year Survivorship and Patient-Reported Outcomes

BACKGROUND

The arthroscopic management of borderline hip dysplasia (BHD) is controversial, and long-term follow-up data are scarce. The purpose of this study was to report prospectively collected survivorship and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up following primary hip arthroscopy with capsular plication and labral preservation in patients with BHD.

METHODS

Data were prospectively collected on all patients who underwent primary hip arthroscopy between September 2008 and September 2011. Patients with BHD (defined by a lateral center-edge angle [LCEA] between 18° and 25°) were included. Preoperative and minimum 10-year follow-up scores for the modified Harris hip score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were collected. Exclusion criteria were prior ipsilateral hip surgery, Workers' Compensation status, Tönnis grade of >1, previous hip conditions, or LCEA of <18°. Survivorship was defined as no conversion to total hip arthroplasty (THA). The risk factors for THA conversion were analyzed. The achievement rate for the minimal clinically important difference (MCID) was reported. A propensity-matched comparison with a control group without BHD was performed.

RESULTS

Forty-five (80%) of 56 eligible hips were included in this study: 38 hips (84%) of female patients and 7 hips (16%) of male patients. The mean patient age was 31.0 ± 12.9 years, and the mean patient body mass index (BMI) was 24.5 ± 5.4 kg/m2. The 10-year survivorship was 82.2%, and there was significant improvement in all PROMs and VAS pain from baseline to the minimum 10-year follow-up (p < 0.001). The odds of undergoing conversion to THA were 4.4 times higher for patients with a BMI of ≥23 kg/m2 and 7.1 times higher for patients who were ≥42 years of age. The MCID was achieved at high rates for the mHHS (79%), NAHS (79%), HOS-SSS (70%), and VAS pain (76%). The minimum 10-year survivorship, PROMs, and MCID achievement rates for the BHD group were comparable with those for the control group.

CONCLUSIONS

Patients with BHD who underwent primary hip arthroscopy with capsular plication and labral preservation demonstrated an overall survivorship of 82.2% and significant improvement in all PROMs and achieved the MCID at high rates at a minimum 10-year follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survivorship, Outcomes, and Risk Factors for Conversion to Total Hip Arthroplasty After Revision Hip Arthroscopic Surgery in Obese Patients: Results at a Minimum 5-Year Follow-up

Background

There is a paucity of literature reporting outcomes after revision hip arthroscopic surgery in obese patients.

Purpose

To report the minimum 5-year survivorship, patient-reported outcomes (PROs), clinical benefit, and risk factors for conversion to total hip arthroplasty (THA) in obese patients after revision hip arthroscopic surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Data were prospectively collected and retrospectively reviewed for patients who underwent revision hip arthroscopic surgery by a single surgeon between April 2010 and August 2016. Inclusion criteria were a body mass index ≥30 and baseline and minimum 5-year postoperative values for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1 and hip dysplasia. Survivorship was defined as no conversion to THA. Clinical benefit was measured using the minimal clinically important difference (MCID). Survivors and nonsurvivors underwent further bivariate and regression analyses to determine the predictors of conversion to THA.

Results

Included were 24 hips in 24 patients. The mean patient age was 39.3 ± 12.7 years, and the mean follow-up was 83.9 ± 26.5 months. The survivorship rate was 75.0%, and patients demonstrated a significant improvement in all PROs (P < .01). At 5-year follow-up, the MCID for the mHHS, NAHS, HOS-SSS, and VAS was achieved by 70.6%, 94.1%, 92.9%, and 64.7%, respectively, of the patients. Older age, higher grade ligamentum teres tears, and acetabuloplasty were significant on bivariate analysis for conversion to THA, and increased age was identified as a significant variable for conversion to THA on regression analysis (odds ratio, 1.297 [95% CI, 1.045-1.609]; P = .018), with a 29.7% greater risk for every additional year of age at the time of revision.

Conclusion

In this study, 25.0% of obese patients who underwent revision hip arthroscopic surgery required conversion to THA. The study patients who did not need conversion to THA had a significant improvement in all PROs, with >90% achieving MCID for one or more outcome measures. Older age was identified as a significant predictor of conversion to THA.

Editorial Commentary: Treatment of Concomitant Intra-Articular Pathology in Patients With Greater Trochanteric Pain Syndrome Is Indicated by Provocative Impingement or Instability Physical Examination and Ultrasound-Guided Analgesic Injection Testing

Endoscopic surgery can be used to address peritrochanteric pathology in patients with greater trochanteric pain syndrome. During management of these patients, surgeons must decide whether adjunctive hip arthroscopy to treat concomitant intra-articular pathology (such as labral tears or chondral lesions) is required, because the prevalence of intra-articular findings may be greater than the clinical significance. A thorough history and physical examination can help distinguish whether the symptoms are arising from a peritrochanteric issue (e.g., gluteal tendinopathy, trochanteric bursitis, external coxa saltans) versus an intra-articular pain generator. Increased symptoms with provocative impingement or instability testing indicate adjunctive hip arthroscopy to address intra-articular abnormalities. In addition, an ultrasound-guided analgesic injection into the hip joint or peritrochanteric region may aid in diagnosis. A patient with partial symptomatic relief from separate injections into both areas is a classic presentation and consistent with a mixed-picture of peritrochanteric and intra-articular pathology, which may be addressed with a combined endoscopic and arthroscopic approach.

Periacetabular Osteotomy in Athletes With Symptomatic Hip Dysplasia Allows for Participation in Low-, Moderate-, and High-Impact Sports, With Greater Than 70% Return to Sport for Competitive Athletes: A Systematic Review

PURPOSE

To systematically review the literature and report the rate of return to sport (RTS) in athletes following periacetabular osteotomy (PAO) for symptomatic hip dysplasia.

METHODS

A literature search of the PubMed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting on athletes undergoing PAO surgery for symptomatic hip dysplasia. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, radiographic measurements, rate and timing of RTS, baseline and most recent patient-reported outcomes (PROs), and subsequent surgeries.

RESULTS

Six studies met inclusion criteria with 341 patients undergoing PAO. There were 2 level III and 4 level IV studies, with an average MINORS score of 11. Preoperative and postoperative lateral center edge angles ranged from 8° to 18° and 23° to 41.3°, respectively. One study reported solely on dancers with a 63% rate of RTS at 1 year postoperatively. Two other studies reported RTS of 80% and 82% for multiple sports, with slightly lower rates (73% and 78%) in competitive athletes. Three studies demonstrated a comparable distribution of sports participation, from the preoperative to postoperative period, in low-impact (61.4% to 72.1% and 63.7% to 85.7%), moderate-impact (10.3% to 21.0% and 4.3% to 25.4%), and high-impact (8.5% to 17.6% and 5.1% to 10.8%) sports. Three studies reported time to RTS after PAO, ranging from 8.8 to 12.8 months. Of the 3 studies noting reasons for not returning to sport, concerns related to the operative hip ranged from 36.4% to 67%. Of the studies that reported both preoperative and postoperative PROs, improvements in all values were observed, with modified Harris Hip Scores and Hip Disability Osteoarthritis Outcome Scores at most recent follow-up ranging from 81 to 95 and 72 to 93, respectively.

CONCLUSIONS

In athletes with symptomatic hip dysplasia undergoing PAO, postoperative participation in low-, moderate-, and high-impact sports was observed, with greater than 70% RTS for competitive athletes. These findings suggest that PAO, with appropriate indications, is an efficacious treatment option in this active patient population with severe dysplasia.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

Durable Outcomes After Hip Labral Reconstruction at Minimum 5-Year Follow-Up: A Systematic Review

PURPOSE

To systematically review and report the mid- to long-term patient reported outcomes (PROs) following hip labral reconstruction.

METHODS

A literature search of the Pubmed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting mid- to long-term PROs at minimum five year follow-up following arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.

RESULTS

Four studies met inclusion criteria, with 182 hips (age range, 27.9 to 38.7 years) undergoing labral reconstruction in primary and revision hip surgery with minimum five year follow-up. There were three level III studies and one level IV study, with an average MINORS score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum. Three studies performed segmental labral reconstructions, while another study utilized a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, iliotibial band autograft, and tensor fascia lata autograft. All studies demonstrated improved PROs from baseline to most recent follow-up, with four studies reporting modified Harris Hip Score (mHHS) values that increased from baseline (range, 58.9 to 66.8) to most recent follow-up (range, 80.1 to 86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3% and conversion to total hip arthroplasty ranged from 1.6% to 27%.

CONCLUSION

Improved PROs were observed in all studies at minimum 5-year follow-up, suggesting that labral reconstruction can offer durable results beyond short-term follow-up. While surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were utilized across studies, limiting the ability to determine an optimal treatment approach.

High-Level Athletes With Borderline Hip Dysplasia Achieve Favorable Outcomes and Return to Sport Rates Following Primary Hip Arthroscopy: Minimum 5-Year Outcomes Comparison to a Propensity-Matched Control Group

PURPOSE

(1) To report minimum 5-year patient-reported outcomes (PROs) and return to sport (RTS) rates in high-level athletes with borderline hip dysplasia (BHD) following primary hip arthroscopy for labral pathology and femoroacetabular impingement syndrome and (2) to compare results to a propensity-matched control group of athletes with normal acetabular coverage.

METHODS

Data were reviewed for surgeries performed between February 2009 and February 2016. Patients were eligible if they underwent primary hip arthroscopy in the setting of BHD (lateral center-edge angle [LCEA] 18-25°) and competed in professional, collegiate, or high school sports. Inclusion criteria were preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Non-Arthritis Hip Score, Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale for pain. Rates of achieving the minimal clinically importance difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold (MOIST) were recorded in addition to RTS. BHD athletes were matched by age at the time of surgery, sex, body mass index, Tönnis grade, follow-up time, sport type, and competition level to a control group of 58 athletes with normal acetabular coverage (LCEA 25°-40°) for comparison.

RESULTS

A total of 34 BHD athletes were included with a mean follow-up of 73.6 ± 10.7 months. BHD athletes showed significant improvements in all PROs, demonstrated high RTS rates (90.0%), and achieved PASS/MCID/MOIST for mHHS (MCID: 80.0%, PASS: 93.3%, MOIST: 80.0%) and HOS-SSS (MCID: 76.7%, PASS: 73.3%) at high rates. When compared to a propensity-matched group with normal acetabular coverage, BHD athletes demonstrated similar postoperative PROs, rates of achieving psychometric thresholds, and RTS rates (P > .05). Additionally, by the latest follow-up, no athlete in either group required conversion to total hip arthroplasty.

CONCLUSIONS

High-level athletes with BHD undergoing primary hip arthroscopy for labral pathology and femoroacetabular impingement syndrome may expect favorable midterm outcomes and high RTS rates. These results were comparable to a control group of athletes with normal coverage.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Patient-Reported Outcomes Improve at 2-Year Minimum Follow-Up After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Systematic Review

PURPOSE

To provide an updated review of recent literature on postoperative outcomes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS), focusing on larger-population studies with a minimum 2-year follow-up published within the last 5 years.

METHODS

A literature search of the PubMed, Ovid Medline, Web of Science, and Cochrane databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were screened for clinical studies published from 2017 to 2022 with greater than 100 patients and minimum 2-year follow-up. Exclusion criteria included failure to report postoperative patient-reported outcomes (PROs), no preoperative radiographic measurements, and surgery for pathology other than FAIS. Data collection included study characteristics, patient demographics, radiographic findings, intraoperative findings, procedures performed, postoperative PROs, and subsequent surgeries.

RESULTS

Nine studies met inclusion criteria. Mean or median patient ages ranged from 32.3 to 41 years, with 4 studies reporting on greater than 50% female patients. Mean preoperative lateral center edge angles and alpha angles ranged from 30.2° to 37° and from 56.2° to 71°, respectively. Labral repairs (range 69.7%-100%) were performed more commonly than debridements (range 0%-26.3%). All studies demonstrated improved PROs at most recent follow-up. Seven studies reported mean or median modified Harris Hip Scores, with preoperative and postoperative values that ranged from 53.1 to 80 and from 67.4 to 100, respectively. Revision hip arthroscopies and conversions to hip arthroplasty ranged from 0.8% to 11.6% and from 0% to 34%, respectively.

CONCLUSIONS

All included studies found improvements in PROs after hip arthroscopy for FAIS at a minimum of 2-year follow-up. Conversion to total hip arthroplasty is most common in older patients at minimum 10-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Hip Capsular Repair Results in Improved Patient-Reported Outcomes and Survivorship: A Systematic Review of the Literature

PURPOSE

To determine whether routine capsular closure following hip arthroscopy for femoroacetabular impingement (FAI) in patients without dysplasia results in improved patient-reported outcomes (PROs) and increased survivorship rates.

METHODS

A literature search of the PubMed, Embase, and Cochrane Library databases was performed using the Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting PROs following arthroscopic hip labral repair for FAI. A quality assessment was performed using the Methodological Index for Non-randomized Studies grading system. Inclusion criteria consisted of comparative clinical studies investigating routine capsular closure with nonclosure in patients undergoing hip arthroscopy for the treatment of FAI and labral tears. Exclusion criteria included non-English language, minimum follow-up of less than 2 years after surgery, technique articles, case reports, noncomparative case series of fewer than 10 patients, failure to report surgical technique, absence of postoperative PROs, or partial repair. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.

RESULTS

A total of 531 articles were reviewed, of which 3 were included with 249 hips that underwent capsular repair and 157 hips that underwent capsulotomy with no repair. There were 2 Level III studies and 1 Level II study, with an average The Methodological Index for Non-randomized Studies score of 16.7. All studies cited FAI and labral tear as an indication for surgery. All studies demonstrated improved PROs from baseline to most recent follow-up. Postoperatively, the repair group reported modified Harris Hip Score values ranging from 80.8 to 87, whereas the nonrepair group reported scores ranging from 76 to 81.7. In addition, the repair group reported postoperative Hip Outcome Score - Sports-Specific Subscale values ranging from 68.1 to 9, whereas the nonrepair group reported scores ranging from 65.3 to 76.1. The studies also reported minimal clinically important difference for modified Harris Hip Score, with the repair group reporting percentages ranging from 71 to 100 and the nonrepair group reporting percentages ranging from 52 to 95.6. All 3 studies also observed a lower rate of hip survivorship in the nonrepair group, ranging from 94.6 to 100 in the repair group and 90.8 to 100 in the nonrepair group. There were no significant differences in the rate of revision arthroscopy between groups.

CONCLUSIONS

Patients without dysplasia who undergo capsular repair have greater improvements in PROs and greater survivorship rates at early- and mid-term follow-up than patients who do not undergo capsular repair.

LEVEL OF EVIDENCE

III, systematic review of level II and III studies.

Lateral to Medial Joint Space Ratio is Predictive of Survivorship After Primary Hip Arthroscopy

PURPOSE

To assess whether preoperative joint space measures would be predictive of survivorship in patients undergoing hip arthroscopy (HA) for femoroacetabular impingement (FAI).

METHODS

Data on consecutive patients who underwent hip arthroscopy between February 2008 and February 2018 were retrospectively reviewed. To be eligible for final analysis, patients were required to have preoperative radiographs for joint space measurements and data indicating conversion to a total hip arthroplasty (THA), hip resurfacing, or neither; at a minimum of 2 years after primary hip arthroscopy. Survivorship following HA was defined as remaining conversion free and served as the primary outcome. A multivariate logistic regression analysis and receiver operator curve (ROC) were used to evaluate the correlation between joint space measurements and survivorship following HA.

RESULTS

A total of 1,885 primary arthroscopy cases were included in this study. The multivariate regression analysis found preoperative lateral-to-medial joint space ratio (L/M ratio) to be the strongest predictive factor of survivorship after primary hip arthroscopy (OR = 2.084, CI_95% = 1.239-3.503; P = .006). The ROC curve for the model demonstrated acceptable discrimination with an area under the curve (AUC) of 0.792. Patients with an L/M ratio ≥0.75 had a survivorship rate of 91.7% compared to a rate of 75% for patients with an L/M ratio <0.75 (OR: 3.68).

CONCLUSIONS

This study found that, of the factors evaluated in this study, the most significant factor in predicting survivorship at 2 years after undergoing primary hip arthroscopy was a larger lateral-to-medial joint space ratio. This may suggest an initiation of primary arthritis at the edge-loading area of the lateral acetabulum. LEVEL OF EVIDENCE: III, retrospective comparative observation study.

Arthroscopic Peripheral Compartment Iliopsoas Release for Iliopsoas Impingement After Primary Total Hip Arthroplasty

Anterior iliopsoas (IP) impingement after total hip arthroplasty is an underrecognized and continued cause for postoperative pain. There are multiple etiologies for this impingement from cup positioning and sizing to changes in the leg length, and offset must be evaluated to confirm no need for implant revision. Additionally, tension of the IP tendon can be increased in patients with diminished spinal mobility, either from prior fusion or with increasing age. Managing this surgically after failing conservative treatment options is best done arthroscopically to prevent additional large, open procedures that place the arthroplasty at unnecessary risk of infection and potential instability. In this article, we describe an arthroscopic technique using fluoroscopy to guide the release of the iliopsoas tendon from the peripheral compartment.

Telemedicine: An Effective Tool for Patient-Physician Communication

The purpose of this study was to evaluate the effectiveness of telemedicine appointments in a tertiary orthopedic hip clinic during the COVID-19 pandemic, as a substitute for traditional in-person visits. One hundred sixty-three patients had a telemedicine visit from March to September 2020. Patients were divided into two cohorts. The presurgical group included all patients who had not undergone any prior surgical hip procedures. The pre-surgical group was further subdivided into two groups based on the purpose of the visit: conservative treatment and imaging review. Patients who were indicated for surgical treatment from these two groups were identified to assess their compliance with the surgical indication. The effectiveness was measured by assessing whether patients required an in-person visit before the scheduled follow-up after the telemedicine visit for further medical assessment. Fifty (30.7%) men and 113 (69.3%) women had a telemedicine visit during the 6-month period. The mean age was 43.68 (±16.95) years. There were 92 (56.4%) patients in the presurgical group, of whom 41% followed up after indication for conservative treatment and 59% visited to review imaging. From these groups, 27% were indicated for surgical treatment. The postsurgical group contained 71 (43.6%) patients, divided into three groups based on their surgery date: 0 to 3 months (27%), 4 to 12 months (59%), and more than 12 months (14%). All patients were compliant with the scheduled follow-up after their telemedicine visit. This study showed that telemedicine can be an effective tool for patient-physician communication, obviating the need for subsequent follow-up beyond regularly scheduled visits. [Orthopedics. 20XX;XX(X):xx-xx.].

Propensity-Matched Patients Undergoing Revision Hip Arthroscopy Older Than the Age of 40 Years Had Greater Risk of Conversion to Total Hip Arthroplasty Compared With Their Primary Counterparts

PURPOSE

To report patient-reported outcomes (PROs) and survivorship following revision hip arthroscopy in patients aged ≥40 years and to compare these results with a propensity-matched primary hip arthroscopy control group.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between June 2008 and January 2019. Patients were included if they were ≥40 years of age at the time of surgery and had minimum 2-year follow-up for the modified Harris Hip Score, Nonarthritic Hip Score, Visual Analog Scale for pain, and the Hip Outcome Score-Sports Specific Subscale. Patients who had a previous hip condition, or those who lacked minimum 2-year follow-up, were excluded. The revision group was further analyzed by conducting a 1:1 propensity-matched sub-analysis to a primary hip arthroscopy control group based on age, sex, body mass index, and acetabular labrum articular disruption grade. Statistical significance was set at P < .05.

RESULTS

Eighty-nine hips (92.7% follow-up) were included, with 66.3% being females. The mean age, body mass index, and follow-up time were 49.4 ± 8.0 years, 26.6 ± 4.1, and 62.7 ± 38.5 months, respectively. Significant improvement in all PROs (P < .001) was reported, and 71.8%, 58 74.4%, and 65.2% achieved the minimal clinically important difference for the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, respectively. Eighty-seven revision hips were successfully propensity-matched to 87 primary hips. Both groups reported similar improvement for all PROs, but the relative risk of conversion to total hip arthroplasty was 2.63 times greater (95% confidence interval 1.20-5.79) for the revision group.

CONCLUSIONS

Patients aged ≥40 years who underwent revision hip arthroscopy reported significant improvement in all PROs at a mean follow-up of 62.7 months with favorable rates of achieving the minimal clinically important difference. When compared to the propensity-matched control group, both achieved similar rates of improvement, but the revision group was 2.63 times more likely to convert to total hip arthroplasty.

LEVEL OF EVIDENCE

III. case-control study.

Outcomes Following Primary Total Hip Arthroplasty With Concomitant Gluteus Medius Repair Using the Direct Anterior Approach

Outcomes following total hip arthroplasty (THA) with concomitant gluteus medius (GM) repair using the direct anterior approach (DAA) are scarce. The primary purpose of this study was to report patient-reported outcome measures (PROMs) with 2-year follow-up of patients with osteoarthritis and GM tear who underwent primary THA and GM repair through the DAA. The secondary purpose was to compare these outcomes with a benchmark propensity-matched control group who underwent a DAA THA without GM tear. Patients were eligible if they received a primary THA and GM repair via the DAA between January 2015 and October 2018 and had baseline PROMs with 2-year follow-up. Patients were excluded if they had workers' compensation or were unwilling to participate. PROM subanalysis was performed between patients and a propensity-matched control group with DAA THA without GM tear. Fourteen patients were included in the study, all of whom were female. Significant improvement for all PROMs and high rate of achieving the minimal clinically important difference (MCID) at 2-year follow-up were reported. All patients were propensity-matched to 28 patients for sex, age, and body mass index. Preoperative PROMs between groups were similar, and both groups reported comparable improvement, satisfaction, and MCID achievement at 2-year follow-up. Primary THA with concomitant GM repair using the DAA yielded good functional outcomes and a high rate of MCID achievement at 2-year follow-up. Based on these results, the DAA can be used safely to address symptomatic GM tears during THA. Furthermore, these outcomes were comparable to a propensity-matched control group without GM tear. [Orthopedics. 2023;46(1):39-46.].

Inflation-Adjusted Medicare Reimbursement for Hip Arthroscopy Fell by 21.1% on Average Between 2011 and 2022

Purpose

To examine Medicare reimbursement for hip arthroscopy from 2011 to 2022.

Methods

The seven most common procedures performed with hip arthroscopy by a single surgeon were gathered. The Physician Fee Schedule Look-Up Tool was utilized to access financial data of the associated Current Procedural Terminology (CPT) codes. The reimbursement data for each CPT were gathered from the Physician Fee Schedule Look-Up Tool. With the consumer price index database and inflation calculator, reimbursement values were adjusted for inflation to 2022 U.S. dollars.

Results

Following an adjustment for inflation, it was found that reimbursement rate for hip arthroscopy procedures on average was 21.1% lower between 2011 and 2022. The average reimbursement per CPT code for the included codes was $899.21 in 2022 compared to inflation adjusted $1,141.45 in 2011, a difference of $242.24.

Conclusions

From 2011 to 2022, the average inflation-adjusted Medicare reimbursement has steadily declined for the most common hip arthroscopy procedures. As Medicare is one of the largest insurance payers, these results have substantial financial and clinical implications for orthopaedic surgeons, policy makers, and patients.

Level of Evidence

Level IV, economic analysis.

Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes and Clinical Benefit Achievement Rates at Short-Term Follow-Up. A Multicenter Analysis

PURPOSE

To report minimum 2-year follow-up patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery.

METHODS

Prospectively collected data from two high-volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge-angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted.

RESULTS

A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow-up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported (P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS-SSS, and iHOT-12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery (P = .03).

CONCLUSION

The results of this multi-center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

IV, retrospective multicenter study.

Minimum 10-year Survivorship and Clinical Outcomes Following Primary Hip Arthroscopy with Acetabular Microfracture

PURPOSE

To report minimum 10-year follow-up survivorship, defined as non-conversion to total hip arthroplasty (THA), and patient-reported outcome scores (PROS) after primary hip arthroscopy with acetabular microfracture in the setting of femoroacetabular impingement syndrome (FAIS) and acetabular chondral lesions, respectively.

METHODS

Data were prospectively collected and retrospectively analyzed on all patients who underwent a primary hip arthroscopy and received an acetabular microfracture between June 2009 and January 2011. Patients with a minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain were included. If available, the minimum 10-year follow-up for the Hip Outcome Score-Sport-Specific Subscale was reported. The demographics, intraoperative findings, surgical procedures, PROS, rate of achieving the minimal clinical important difference (MCID), and secondary surgeries were analyzed and reported.

RESULTS

Twenty-two hips (20 patients) were included in the study, and the mean follow-up time was 124.5 ± 2.2 months. There were 17 hips (77.3%) from males and 5 hips (22.7%) from females. The average patient age at the time of surgery was 42.3 years ± 9.6. All patients on average experienced statistically significant improvement (P < .05) between preoperative and minimum 10-year follow-up scores for all PROs. In total, 77.3% of the patients did not require conversion to THA. Additionally, 83.3% of the patients achieved the MCID for the mHHS, NAHS, and VAS for pain.

CONCLUSION

At a minimum 10-year follow-up, survivorship of 77.3% was reported for patients who underwent primary hip arthroscopy with acetabular microfracture for the treatment of FAIS and focal/full-thickness acetabular cartilage lesions. Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated.

LEVEL OF EVIDENCE

IV, case-series study.

It's not arthritis! Resolution of the illusion of joint space narrowing with acetabuloplasty and labral reconstruction for the calcified labrum

Labral calcification may be part of the natural history of untreated femoroacetabular impingement syndrome (FAIS) in certain patients, making it a potential target for intervention with the goal of preserving the hip joint. The purpose of this study was to investigate if calcified labra create the appearance of lateral joint space narrowing and report minimum 2-year patient-reported outcome measures (PROMs) after treating patients with arthroscopic acetabuloplasty and labral reconstruction. Prospectively collected data on patients who underwent primary hip arthroscopy for FAIS and labral tearing from February 2015 to April 2021 were reviewed. Patients treated with primary labral reconstruction for an intraoperatively confirmed diagnosis of labral calcification were included. A sub-analysis was performed for patients with a minimum of 2-year follow-up. Preoperative and postoperative PROMs for the modified Harris hip score, nonarthritic hip score, the International Hip Outcome Tool-12 and visual analog scale for pain were recorded. Forty-six hips (46 patients) were included, with 19 hips in the sub-analysis. There was a significant increase in apparent lateral joint space width (JSW) measured on supine anteroposterior (AP) pelvis radiographs with no significant changes in medial and central JSW and significant decreases in the lateral and anterior center-edge angles and alpha angle. Patients experienced significant increases in PROMs and high rates of achieving psychometric thresholds. Patients presenting with FAIS and calcified labra may have apparent lateral joint space narrowing on pre-operative supine AP pelvis radiographs. These patients have low rates of full-thickness femoral head and acetabular cartilage pathology, this apparent narrowing can be corrected and excellent outcomes and survivorship can be achieved, with primary labral reconstruction.

Outcomes Among Athletes Versus Nonathletes After Arthroscopic Management of Femoroacetabular Impingement

This study synthesizes and reports patient-reported outcomes (PROs) among athletes vs nonathletes after hip arthroscopy for femoroacetabular impingement. A systematic review was performed in November 2020 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. We included studies that reported PROs for athletes vs nonathletes. We excluded articles that did not contain full text, that were not in English, and that included level IV evidence. Four studies reporting on a total of 294 athletes and 230 nonathletes were included. Of these studies, 3 found superior outcomes among athletes, and 1 found that athletes recovered faster, but nonathletes had equivalent outcomes at later follow-up. Athletes and nonathletes showed significant improvements in PROs; however, athletes showed a trend toward superior PROs. Thus, pre-operative athletic activity is associated with favorable outcomes after hip arthroscopy. [Orthopedics. 2022;45(6):e288-e294.].

Competitive Athletes Who Underwent Hip Arthroscopy With Capsular Repair Showed Greater Improvement in Patient-Reported Outcome Scores Compared With Those Who Did Not Undergo Repair

PURPOSE

To compare minimum 2-year postoperative patient-reported outcome (PRO) scores and return to sport between competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome with interportal capsulotomy repair and competitive athletes with an unrepaired interportal capsulotomy.

METHODS

Data on all consecutive competitive athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between February 2012 and December 2018 were collected. Athletes were divided into 2 groups: those who underwent repair and those without repair. Athletes were considered eligible if they participated in sports within 1 year prior to surgery. Patients were eligible if the return-to-sport status and the following preoperative and minimum 2-year postoperative PROs were available: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain. Patients were excluded if they underwent prior hip surgery, had Workers' Compensation, were unwilling to consent, had a Tönnis grade greater than 1, or had a previous hip condition. The percentages of patients achieving the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold were recorded. Athletes who underwent interportal capsulotomy repair were propensity score matched in a ratio of 2:1 to athletes without interportal capsulotomy repair according to age, sex, body mass index, sport level, and acetabular labrum articular disruption grade.

RESULTS

Forty-nine athletes (53 hips) without repair with an average follow-up time of 36.5 ± 10.2 months and age of 32.1 ± 13.3 years were matched to 79 athletes (84 hips) with repair with an average follow-up time of 41.3 ± 9.4 months and age of 30.1 ± 12.1 years. Athletes in the repaired group showed significantly greater improvements in the NAHS, HOS-SSS, and VAS score and significantly higher rates of achievement of the MCID for the HOS-SSS compared with athletes in the unrepaired group.

CONCLUSIONS

Competitive athletes who underwent primary hip arthroscopy with interportal capsulotomy repair showed a significantly greater magnitude of improvement in PRO scores (NAHS, HOS-SSS, and VAS score) and rates of achieving the MCID (HOS-SSS) compared with a propensity score-matched control group of competitive athletes with an unrepaired interportal capsulotomy.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Elite Female Athletes Demonstrate a Comparable Improvement in Midterm Patient-Reported Outcome Scores and Rate of Return to Sport Compared With Elite Male Athletes After Hip Arthroscopic Surgery: A Sex-Based Comparison in Professional and Collegiate Athletes

BACKGROUND

Few studies have compared outcomes, return to sport (RTS), and continuation of sport (CTS) after primary hip arthroscopic surgery between matched groups of male and female athletes with a minimum 5-year follow-up.

PURPOSE

(1) To report minimum 5-year patient-reported outcome (PRO) scores as well as RTS and CTS rates for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) and (2) to compare clinical results with those of a matched control group of elite male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for elite (collegiate or professional) female athletes who underwent primary hip arthroscopic surgery for FAIS between March 2009 and March 2016. Inclusion criteria were preoperative and minimum 5-year scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous ipsilateral hip surgery/conditions, and those unwilling to participate. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) were recorded in addition to RTS. CTS was also recorded and defined as athletes reporting continued sport activity at a minimum 5-year follow-up after initially reporting returning to sport. Elite female athletes were propensity matched in a 1:1 ratio to elite male athletes for comparison.

RESULTS

A total of 81 hips in elite female athletes that underwent primary hip arthroscopic surgery met the inclusion criteria, and follow-up was available for 65 hips (80.2%) at a mean of 67.6 ± 6.5 months, with a mean age of 24.3 ± 6.8 years. Female athletes demonstrated significant improvements in all recorded PRO scores; achieved the MCID, PASS, and MOIST at high rates; returned to sport at a rate of 80.4%; and continued sport at a rate of 97.1%. Female athletes demonstrated lower preoperative PRO scores compared with male athletes, but postoperative PRO scores; improvements in scores; rates of achieving the MCID, PASS, MOIST; and RTS and CTS rates were similar between female and male athletes.

CONCLUSION

Elite female athletes undergoing primary hip arthroscopic surgery for FAIS demonstrated favorable PRO scores and high RTS and CTS rates at a minimum 5-year follow-up. These results were comparable with those of a propensity-matched control group of elite male athletes.

The Circumferential Femoroplasty: An All-Arthroscopic Technique for Addressing a Challenging Hip Deformity

Femoroacetabular impingement is recognized as a common cause of hip pain. Cam-type femoroacetabular impingement results from abnormal contact between an aspherical femoral head and the acetabular rim during hip range of motion, leading to labral tearing, cartilage damage, and, eventually, osteoarthritis. Arthroscopic correction of this bony deformity has been well described, particularly in the anterolateral quadrant of the femoral neck. Some deformities extend well beyond this quadrant, involving most or all of the circumference of the femoral neck, making arthroscopic decompression a challenge. We present a post-less, all-arthroscopic technique for performing a circumferential cam decompression using 3-dimensional preoperative planning software and interactive fluoroscopy-integrated computer vision interface.

Anchor Arthropathy Caused by Cartilage Penetration: An Approach to Revision Hip Arthroscopy With Removal of Problematic Anchors

Hip arthroscopy has been proven to effectively treat labral tears in the setting of femoroacetabular impingement. Anchors used for this treatment have constantly evolved and improved to ensure safety and minimal invasion. However, acetabular drilling and anchor placement are technically challenging due to the concavity of the acetabular articular surface, limited angles for anchor insertion, and finite bone availability in the anterior and posterior column. Inadequate technique can result in protruding anchors, which may lead to full-thickness articular cartilage damage, manifesting in pain, mechanical symptoms, and impaired function. This Technical Note demonstrates arthroscopic removal of protruding anchors and management of the iatrogenic grade IV cartilage damage. In this description, the technical pearls and pitfalls of acetabular anchor placement to treat labral pathology are presented along with the aforementioned technique.

Determining Clinically Meaningful Thresholds for the Hip Outcome Score Sport-Specific Subscale in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

The minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), substantial clinical benefit (SCB), and maximum outcome improvement (MOI) satisfaction threshold for the Hip Outcome Score Sport-Specific Subscale (HOS-SSS) have not been established in athletes undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine threshold MCID, PASS, SCB, and MOI satisfaction threshold values for the HOS-SSS in athletes undergoing hip arthroscopy for FAIS at minimum 2-year follow-up.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Anchor questions were administered to recreational, organized amateur, high school, college, and professional athletes who underwent primary hip arthroscopy for FAIS between May 2015 and March 2019. Patients were included if they were younger than 50 years, answered the anchor questions, and had preoperative and minimum 2-year follow-up for the HOS-SSS, modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery or conditions. Receiver operating characteristic (ROC) analysis was used to determine PASS, SCB, and MOI satisfaction for the HOS-SSS. Two distribution methods were used to calculate MCID for HOS-SSS.

RESULTS

A total of 225 athletes who underwent primary hip arthroscopy met the inclusion criteria. Of those athletes, 200 (88.9%) who had minimum 2-year follow-up and information regarding return to sport (RTS) were included. The cohort included 124 (62.0%) women and 76 (38.0%) men with a mean ± standard deviation age of 29.4 ± 10.4 years, body mass index of 25.6 ± 5.4, and follow-up of 29.5 ± 5.1 months. Athletes experienced significant improvements in HOS-SSS, mHHS, NAHS, and VAS from preoperative to latest postoperative follow-up (P < .001), and mean satisfaction was 8.2. The RTS rate was 83.7%. ROC analysis determined that the PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID (baseline/change score methods) for the HOS-SSS were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively, with athletes achieving thresholds at high rates (80.0%, 80.5%, 45.0%, 54.0%, and 79.5%, respectively).

CONCLUSION

This study identified values for the HOS-SSS that can be used to define clinically meaningful outcomes in athletes after primary hip arthroscopy for FAIS. The PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID for the HOS-SSS at minimum 2-year follow-up in athletes after primary hip arthroscopy were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively.

Athletes Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy Demonstrate Greater Than 80% Return-to-Sport Rate at 2-Year Minimum Follow-Up

PURPOSE

To report minimum 2-year follow-up patient-reported outcomes and return-to-sport (RTS) rates in athletes undergoing concomitant hip arthroscopy and periacetabular osteotomy (PAO) to treat acetabular dysplasia and intra-articular pathologies such as cam deformity and labral tears.

METHODS

We reviewed the data of consecutive athletes undergoing concomitant primary hip arthroscopy and PAO for acetabular dysplasia and cam deformity from November 2010 to December 2018. Patients were included in the study if they had the following preoperative and minimum 2-year postoperative scores: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The percentage of patients who achieved the minimal clinically important difference was recorded, in addition to RTS status.

RESULTS

A total of 29 athletes (29 hips) were included, with a mean follow-up time of 34.1 ± 7.9 months, mean age of 26.0 ± 8.7 years, and mean body mass index of 23.7 ± 3.4. These athletes showed significant improvements in the mHHS, NAHS, and HOS-SSS from baseline to latest follow-up (P < .001). The minimal clinically important difference was achieved at high rates for the mHHS (82.8%), NAHS (86.2%), and HOS-SSS (79.3%). Athletes who attempted to RTS successfully returned at a rate of 81.8%.

CONCLUSIONS

Athletes undergoing concomitant hip arthroscopy and PAO showed significant improvements in patient-reported outcomes at minimum 2-year follow-up and had an RTS rate of 81.8%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis

BACKGROUND

The aims of this systematic review were: (1) to investigate the prophylactic effect of radiotherapy (RT) and NSAIDs in high-risk patients following total hip arthroplasty (THA); and (2) to compare the efficacy of non-selective and COX-II selective NSAIDs in preventing post-THA HO, utilising a meta-analysis of randomised control studies.

METHODS

The PubMed, Embase, and Cochrane Databases were searched for articles regarding HO following THA in March 2019. Studies were included if they contained data regarding HO incidence after THA or contained data regarding HO prophylaxis comparison of NSAIDs and/or RT in terms of dosage or duration.

RESULTS

24 studies reported on populations that were not at high-risk for HO. These studies reported between 47.3% and 90.4% of their patient populations had no HO formation; between 2.8% and 52.7% had mild formation; and between 0.0% and 10.4% had severe formation. A total of 13 studies reported on populations at high-risk for HO. Studies analysing RT in high-risk patients reported between 28.6% and 97.4% of patients developed no HO formation; between 1.9% and 66.7% developed mild HO formation; and between 0.0% and 11.9% developed severe HO formation. Studies analysing NSAID treatment among high-risk populations reported between 76.6% and 88.9% had no HO formation; between 11.1% and 23.4% had mild HO formation, and between 0.0% and 1.8% had severe HO formation. 9 studies were identified as randomised control trials and subsequently used for meta-analysis. The relative risk for COX-II in developing any HO after THA was not significantly different compared to non-selective NSAIDs (RR 1.00; CI, 0.801-1.256; p = 0.489).

CONCLUSIONS

NSAIDs prophylaxis for HO may have better efficacy than RT in high-risk patients following THA. Non-selective and COX-II selective NSAIDs have comparable efficacy in preventing HO. Factors such as medical comorbidities and side-effect profile should dictate the prophylaxis recommendation.

Outcomes of Staged Bilateral Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome: A Nested Matched-Pair Control Study Focusing on the Effect of Time Between Procedures

BACKGROUND

Bilateral hip symptoms from femoroacetabular impingement syndrome (FAIS) are a common finding in patients regardless of athletic involvement. Oftentimes, patients and surgeons choose to stage bilateral hip arthroscopic surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was (1) to compare minimum 2-year outcomes between patients who underwent staged bilateral hip arthroscopic surgery for FAIS to a propensity score-matched control group that underwent unilateral hip arthroscopic surgery and (2) to investigate the effect of time between bilateral procedures on patient-reported outcomes (PROs). We hypothesized that, after bilateral hip arthroscopic surgery, the improvement in outcomes would be similar to that after unilateral hip arthroscopic surgery and the time duration between bilateral procedures would not affect the final outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively reviewed on a consecutive series of patients who underwent primary hip arthroscopic surgery at our institution between June 2008 and November 2017. Patients who underwent bilateral hip arthroscopic surgery with minimum 2-year PROs for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), patient satisfaction, and a visual analog scale (VAS) for pain were included. The study group was matched 1:1 based on age, sex, and body mass index to a control group that only required unilateral hip arthroscopic surgery. Additionally, a subanalysis was performed on the study group to determine the effect of time between arthroscopic procedures. Rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the mHHS and HOS-SSS were determined. The P value was set at <.05.

RESULTS

A total of 205 patients (410 hips) were included. The mean age and body mass index of the study group were 32.3 ± 13.2 years and 25.0 ± 5.1, respectively. All 410 hips that met the inclusion criteria were matched. There were no significant differences in patient, radiographic, or procedural data. A significant and comparable improvement was reported for all PRO measures and the VAS (P < .0001) in both groups. Similarly, rates of achieving the MCID and PASS were comparable. After dividing the study group based on whether the contralateral procedure was performed <3 months or >3 months after the first procedure, it was determined that patients had a significant improvement and favorable outcomes regardless of time between bilateral procedures.

CONCLUSION

Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAIS had a significant and comparable improvement in PROs at a minimum 2-year follow-up. A time interval of <3 months or >3 months between bilateral procedures did not affect PROs.

5-Year Arthroscopy-Free Survivorship and Outcomes of Adolescents Undergoing Primary Hip Arthroscopy: A Comparison Between Traumatic and Atraumatic Injuries

BACKGROUND

There is a paucity of literature evaluating the outcomes of adolescent patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with a discrete traumatic event related to an injury.

PURPOSE

(1) To evaluate 5-year outcomes of adolescents undergoing hip arthroscopy for FAIS with traumatic injuries (TIs) and (2) to compare the traumatic group with a propensity-matched control group of patients with atraumatic injuries.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reviewed for all adolescent patients (<18 years) undergoing primary hip arthroscopy for FAIS with a TI between November 2008 and March 2015. Patients were included if they had preoperative and minimum 5-year follow-up outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. The Patient Acceptable Symptom State (PASS), minimum clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOIT) were also calculated for both groups. Adolescents with TI were propensity matched in a 1:2 ratio according to age at surgery, sex, and body mass index (BMI) to a control group of adolescents who reported atraumatic hip symptoms (AHSs). Survivorship was defined as having no secondary surgery on the ipsilateral hip.

RESULTS

A total of 31 patients (32 hips) with TI, out of 39 total patients (40 hips) (80%), were included with a mean follow-up time of 72.2 ± 24.1 months and age of 15.8 ± 1.3 years. The TI group demonstrated significant improvement in all patient-reported outcomes (PROs) (P < .001) and demonstrated high rates of MCID (78.3%) and PASS (91.3%) for the mHHS. When compared with a propensity-matched control group of 64 AHS hips (57 patients), the TI group demonstrated similar rates of improvement in all PROs, as well as rates of achieving the MCID, PASS, and MOIT for all PROs; however, the TI group demonstrated significantly higher revision rates compared with controls (28.1% vs 6.3%; P = .008).

CONCLUSION

Adolescent patients with TIs undergoing hip arthroscopy demonstrated favorable outcomes for all PROs (P < .001) and achieved high rates of MCID (78.3%) and PASS (91.3%) for the mHHS. When compared with a propensity-matched control group of adolescents with atraumatic injuries undergoing hip arthroscopy, they achieved similar levels of improvement, postoperative scores, and clinical benefit thresholds; however, reoperation rates were higher in the TI group compared with controls.

Females and Males Achieved Comparable Outcomes and Clinical Benefits Following Primary Hip Arthroscopy with Labral Repair, but Age Affected Outcomes and Conversion to Total Hip Arthroplasty. A Short and Mid-Term Follow-Up Analysis with Dual Stratification

PURPOSE

To report and compare, according to sex and age, minimum 2-and minimum 5-year patient-reported outcome scores (PROs) and survivorship in a large cohort of patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from February 2008 to September 2018 were reviewed. Patients aged 60 and younger who underwent primary hip arthroscopy with minimum 2-year follow-up were included. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous hip conditions, or any labral treatment different than repair. Minimum 5-year PROs were also collected. All patients included were divided into groups by sex. For further analysis, males and females were stratified according to age: < 21 years old, 21-30 years old, 31-40 years old, 41-50 years old, and 51-60 years old.

RESULTS

In total, 1,326 hips had minimum 2-year follow-up, including 860 (64.9%) females and 466 males (35.1%), with a mean age of 31.6 years (range, 12.8-60.9 years) and a mean follow-up of 58.7 ± 28.9 months. Of those, 772 had minimum 5-year follow-up, 515 females (66.7%), and 257 males (33.3%) with a mean age of 31.7 years (range, 13.1-60.7 years) and a mean follow-up of 78.5 ± 23.0 months. All patients showed significant improvements in PROs at minimum 2-and 5-year follow-up (P < .001). Between sex analysis revealed comparable PROs at latest follow-up between females and males across any age group. Within sexes, and when sexes were combined, patients <21 years old had significantly better outcomes compared to other age groups. There were more females <21 years old that required revision arthroscopy than males <21 years old (P = .015). Conversion to total hip arthroplasty (THA) showed no significant difference between sexes (P > .05). Rates of THA were <21 years (.8%), 21-30 years (2.1%), 31-40 years (4%), 41-50 years (8.9%), and 51-60 years (14.3%).

CONCLUSIONS

Following primary hip arthroscopy for FAIS, all patients reported significant improvements in all PROs at minimum 2-and minimum 5-year follow-up, with females and males achieving similar success. Age affected outcomes, with patients under 21 years old reporting better scores regardless of sex. Although the conversion rate to THA was similar between the sexes, it was lower in the younger ages groups in both sexes.

LEVEL OF EVIDENCE

III, retrospective comparative observation trial.

Hip Arthroscopy Results in Similar Short-Term Function Compared to THA in Patients of Similar Demographic Profiles

Purpose

To review short-term functional outcomes in patients who underwent hip arthroscopy and to compare their outcomes to those of a demographically similar cohort who underwent total hip arthroplasty (THA).

Methods

Data were prospectively collected and retrospectively reviewed for patients undergoing hip arthroscopy (SCOPE) between April 2008 and October 2015. SCOPE patients were included if they were ≥35 years, had preoperative and postoperative 2-year follow-up, and had no prior hip condition or ipsilateral hip surgery. SCOPE patients were matched 1:1 to a demographically similar cohort of patients who underwent THA at our institution. Matching criteria included similar age (within 5 years), gender, and body mass index (within 5). SCOPE patients were assessed with modified Harris Hip Score (mHHS), non-arthritic hip score, and visual analogue scale (VAS). THA patients were assessed with mHHS, forgotten joint score, and VAS.

Results

Sixty-seven patients were included in each cohort. Patients who underwent hip arthroscopy for management of labral tears achieved nearly equivalent mHHS, Health Survey Short Form (SF-12) Mental, SF-12 Physical, Veterans RAND 12 Item Health Survey (VR-12) Mental, VR-12 Physical scores at latest follow-up compared to demographically similar patients who underwent THA. There was no significant difference in mHHS scores (SCOPE = 82.9 ± 16.4 vs THA = 87.3 ± 15, P = .095) between the 2 group groups. In addition, average patient satisfaction on a 10-point scale was 8.1 for the SCOPE cohort and 8.8 for the THA cohort (P = .052).

Conclusions

Our results show that hip arthroscopy, when performed in patients with the appropriate indications, can lead to comparably excellent outcomes as total hip arthroplasty with significant pain relief at short term follow-up.

Level of Evidence

Level III, retrospective cohort study.

After Revision Hip Arthroscopy, Patients Having Either Circumferential or Segmental Labral Reconstructions for the Management of Irreparable Labra Show Clinical Improvement Based on Proper Indications

PURPOSE

To compare a minimum of two-year follow-up patient-reported outcome scores (PROs) in patients who underwent revision hip arthroscopy for acetabular circumferential labral reconstruction (CLR) and segmental labral reconstruction (SLR) using propensity-matched groups, in the setting of irreparable labral tear.

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent revision hip arthroscopy from April 2010 to September 2018. Patients were included if they underwent labral reconstruction and had preoperative and minimum 2-year PROs. Patients unwilling to participate, with Tönnis grade >1, or hip dysplasia were excluded. Patients in the CLR group were propensity-matched on the basis of age, sex, body mass index, and Tönnis grade to patients in the SLR group in a 1:1 ratio. The minimal clinically important difference (MCID) and the patient-acceptable symptomatic state (PASS) rates were calculated.

RESULTS

Twenty-six hips (25 patients) with CLR were propensity-matched to 26 hips (26 patients) with SRL. The mean follow-up time 25.92 and 27.78 months for the CLR and SLR, respectively (P = .845). Groups reported comparable findings for sex (P = .773), age (P = .197), body mass index (P = .124), preoperative Tönnis grade (P = .124), lateral-center edge angle (P = .144), and alpha angle (P = .264), and comparable improvement for all PROs at minimum 2-year follow-up. Patient satisfaction was similar (P = .612). Rates of achievement for the MCID and PASS were comparable.

CONCLUSION

Following revision hip arthroscopy, patients who underwent CLR or SLR for complete and segmental irreparable labral tears, respectively, reported significant and comparable postoperative improvement for all PROs and rate of achievement for the MCID and PASS at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

III, retrospective comparative therapeutic trial.

Intra-articular Damage and Patient Outcome Comparison Between Athletes and Nonathletes After Hip Arthroscopy

BACKGROUND

The body of literature comparing hip arthroscopy between athletes and nonathletes is relatively scarce. Analyzing these groups can help to shed light on the severity of intra-articular damage and end-stage osteoarthritis that may result from participation in strenuous activities.

PURPOSE

(1) To compare the intra-articular damage at the time of hip arthroscopy between athletes and nonathletes, and (2) to compare the pre- and postoperative outcomes between the groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were considered eligible for analysis if they had received a primary hip arthroscopy between August 2008 and June 2018, were participating in competitive athletics, and had preoperative baseline scores and minimum 2-year follow-up for the following patient-reported outcomes: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Propensity score matching was used to match eligible patients in a 1:1 ratio to patients who were not participating in any sports greater than a recreational level before surgery.

RESULTS

A total of 234 patients were included. There were no significant differences in the severity of labral tears, ligamentum teres tears, or cartilage damage (P > .05). The procedures performed between cohorts were similar (P > .05). The athlete population had higher preoperative means scores for the modified Harris Hip Score and NAHS (each P < .001). Likewise, the athlete population had higher postoperative means scores for the NAHS, Hip Outcome Score-Sports Specific Subscale, and visual analog scale (P = .031, P = .030, and P = .032, respectively). Additionally, the athlete cohort reported higher minimum 2-year outcomes than the nonathlete cohort for the 12-Item Short Form Health Survey (mental component; P = .003) and Veterans RAND 12-Item Health Survey (mental component, P = .032; physical component, P = .005).

CONCLUSION

At the time of hip arthroscopy, athletes demonstrate similar intra-articular damage to their nonathlete counterparts. Given their higher preoperative scores, it is possible that athletes better tolerate the damage to the hip joint. Despite their strenuous activities and potentially higher tolerance to pain, athletes should not necessarily be expected to have greater severity of intra-articular pathology.