Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis

Background

Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery.

Purpose

To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement.

Study Design

Case-control study; Level of evidence, 3.

Methods

We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression.

Results

A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (β = -1.468 [95% CI, -2.049 to -0.887]; P < .001).

Conclusion

Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.

Hip Arthroscopic Surgery With Chondrolabral Refixation, Osteochondroplasty, and Routine Capsular Closure for Femoroacetabular Impingement Syndrome: Clinical Outcomes at a Minimum 10-Year Follow-up

BACKGROUND

Hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) has proven to be an effective surgical intervention, with high rates of return to sport and work as well as favorable outcomes at short- and midterm follow-up. However, limited data exist on outcomes at long-term follow-up.

PURPOSE

To evaluate patient-reported outcomes (PROs) at a minimum 10-year follow-up after primary hip arthroscopic surgery including labral repair, femoral osteochondroplasty, acetabular osteochondroplasty, and capsular closure for FAIS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent primary hip arthroscopic surgery for FAIS between June 2012 and January 2013 were identified. PROs were collected preoperatively and at a minimum of 10 years postoperatively, including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. Unique minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds were calculated, and their rates of achievement were analyzed. An alpha level of <.05 was used to determine statistical significance.

RESULTS

A total of 94 patients (55 female; mean age, 34.3 ± 12.4 years) were analyzed with a mean follow-up of 10.1 ± 0.3 years (range, 10.0-10.7 years). Patients demonstrated significant 10-year improvement across all PRO measures (P < .001). MCID and PASS thresholds were calculated as follows: HOS-ADL (10.4 and 85.3, respectively), HOS-SS (14.6 and 60.2, respectively), mHHS (8.8 and 76.0, respectively), VAS pain (14.6 and 27.5, respectively), and iHOT-12 (PASS: 71.4). The majority of patients achieved the MCID and PASS for each PRO measure: HOS-ADL (73.4% and 70.9%, respectively), HOS-SS (78.5% and 77.2%, respectively), mHHS (81.0% and 70.9%, respectively), VAS pain (88.6% and 70.9%, respectively), and iHOT-12 (PASS: 73.4%). Overall, 9 patients (9.6%) underwent subsequent revision hip arthroscopic surgery at a mean 4.9 ± 3.7 years (range, 1.1-10.1 years) postoperatively, and 6 patients (6.4%) underwent conversion to total hip arthroplasty at a mean 4.1 ± 3.1 years (range, 0.9-9.3 years) postoperatively.

CONCLUSION

Patients who underwent primary hip arthroscopic surgery for FAIS utilizing contemporary methods of labral repair, acetabular and/or femoral osteochondroplasty, and capsular closure commonly experienced sustained clinical improvement and reported high levels of satisfaction at a minimum 10-year follow-up with low rates of reoperation.

Hip joint contact pressure and force: a scoping review of in vivo and cadaver studies

Aims

Research on hip biomechanics has analyzed femoroacetabular contact pressures and forces in distinct hip conditions, with different procedures, and used diverse loading and testing conditions. The aim of this scoping review was to identify and summarize the available evidence in the literature for hip contact pressures and force in cadaver and in vivo studies, and how joint loading, labral status, and femoral and acetabular morphology can affect these biomechanical parameters.

Methods

We used the PRISMA extension for scoping reviews for this literature search in three databases. After screening, 16 studies were included for the final analysis.

Results

The studies assessed different hip conditions like labrum status, the biomechanical effect of the cam, femoral version, acetabular coverage, and the effect of rim trimming. The testing and loading conditions were also quite diverse, and this disparity limits direct comparisons between the different researches. With normal anatomy the mean contact pressures ranged from 1.54 to 4.4 MPa, and the average peak contact pressures ranged from 2 to 9.3 MPa. Labral tear or resection showed an increase in contact pressures that diminished after repair or reconstruction of the labrum. Complete cam resection also decreased the contact pressure, and acetabular rim resection of 6 mm increased the contact pressure at the acetabular base.

Conclusion

To date there is no standardized methodology to access hip contact biomechanics in hip arthroscopy, or with the preservation of the periarticular soft-tissues. A tendency towards improved biomechanics (lower contact pressures) was seen with labral repair and reconstruction techniques as well as with cam correction.

Microbial Colonization of Capsular Traction Sutures in Hip Arthroscopic Surgery

Background

A common practice in hip arthroscopic surgery is the utilization of capsular traction sutures that can be incorporated into the capsular repair site at the end of the procedure, potentially seeding the hip joint with colonized suture material.

Purpose

To investigate the rate of the microbial colonization of capsular traction sutures used during hip arthroscopic surgery and to identify patient-associated risk factors for this microbial colonization.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 50 consecutive patients who underwent hip arthroscopic surgery with a single surgeon were enrolled. There were 4 braided nonabsorbable sutures utilized for capsular traction during each hip arthroscopic procedure. These 4 traction sutures and 1 control suture were submitted for aerobic and nonaerobic cultures. Cultures were held for 21 days. Demographic information was collected, such as age, sex, and body mass index. All variables underwent bivariate analysis, and variables with a P value <.1 underwent further analysis in a multivariate logistic regression model.

Results

One of 200 experimental traction sutures and 1 of 50 control sutures had a positive culture. Proteus mirabilis and Citrobacter koseri were isolated in both these positive experimental and control cultures from the same patient. Age and traction time were not significantly associated with positive cultures. The rate of microbial colonization was 0.5%.

Conclusion

The rate of the microbial colonization of capsular traction sutures used in hip arthroscopic surgery was low, and no patient-associated risk factors were identified for microbial colonization. Capsular traction sutures used in hip arthroscopic surgery were not a significant potential source of microbial contamination. Based on these results, capsular traction sutures can be incorporated in capsular closure with a low risk of seeding the hip joint with microbial contaminants.

The Relationship Between the Joint Space and Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: Reevaluating the 2-mm Rule

BACKGROUND

A limited joint space (<2 mm) is associated with poorer outcomes and conversion to total hip arthroplasty (THA) after hip arthroscopic surgery. As indications for hip arthroscopic surgery expand, it is important to reevaluate established risk factors among large patient populations.

PURPOSE

To reevaluate the relationship between the radiographic joint space and outcomes after hip arthroscopic surgery and to assess the validity of a joint space of 2 mm as the accepted cutoff for successful hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients aged 18 to 50 years who underwent hip arthroscopic surgery for femoroacetabular impingement between January 2008 and December 2016 and had a minimum 2-year follow-up were included. Patients with previous ipsilateral hip surgery, a history of hip fractures, dysplasia (lateral center-edge angle <20°), or osteoarthritis (Tonnis grade >2) were excluded. The joint space was categorized as diminished (≤2 mm), borderline (>2 to ≤3 mm), or preserved (>3 mm). Minimum 2-year patient-reported outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sports-Specific Subscale [HOS-SSS]), revision rates, and rates of conversion to THA were compared between groups.

RESULTS

A total of 699 patients (782 hips) with a mean age of 33.8 ± 10.1 years met 2-year inclusion criteria. The mean follow-up time was 4.2 ± 2.1 years. Overall, 51 hips (6.5%) had a diminished joint space, 297 (38.0%) had a borderline joint space, and 434 (55.5%) had a preserved joint space. Patients with a diminished joint space had larger femoral and acetabular defects compared with those with larger joint spaces. All groups had improved patient-reported outcome scores compared with baseline (P < .001 for all), and there were no differences between the groups in the percentage of patients who reached the minimal clinically important difference or patient acceptable symptom state. There were also no differences between the groups in revision rates (P = .95). A greater number of hips with a diminished joint space converted to THA (n = 8 [15.7%]) compared with those with a borderline (n = 9 [3.0%]) or preserved (n = 9 [2.1%]) joint space (P < .001). Considering joint space as a continuous variable, adjusted logistic regression showed that for every millimeter decrease in the joint space, the odds of conversion to THA increased by a factor of 2.5 (odds ratio, 2.5 [95% CI, 1.6-3.8]).

CONCLUSION

This study demonstrated that patients with a diminished joint space were at a higher risk of conversion to THA. Although 2 mm should not serve as a strict cutoff, patients should be counseled based on their preoperative radiographic findings accordingly.

Long-term Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement for Patients With Borderline Dysplasia

BACKGROUND

Outcomes after isolated hip arthroscopic surgery for patients with dysplasia have been unfavorable. Results have included iatrogenic instability and conversion to total hip arthroplasty at a young age. However, patients with borderline dysplasia (BD) have shown more favorable results at short- and medium-term follow-up.

PURPOSE

To assess long-term outcomes after hip arthroscopic surgery for femoroacetabular impingement in patients with BD (lateral center-edge angle [LCEA] = 18°-25°) compared with a control group of patients without dysplasia (LCEA = 26°-40°).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We identified a group of 33 patients (38 hips) with BD who were treated for FAI between March 2009 and July 2012. An age- and sex-matched control group of 83 patients (96 hips) was also identified. Patient-reported outcome scores were collected preoperatively and subsequently at a mean of 9.6 years postoperatively.

RESULTS

The mean LCEA and Tönnis angle were 22.42°± 2.02° and 6.27°± 3.23° in the BD group, respectively, and 31.71°± 3.52° and 2.42°± 3.02° in the control group, respectively (P < .001). At a mean follow-up of 9.6 years (range, 8.2-11.6 years), there was a significant improvement in all patient-reported outcome scores in both groups (P < .001). There were no significant differences between preoperative and postoperative scores or rates of achieving the minimal clinically important difference between the BD and control groups. Bilateral surgery was noted to be a risk factor for any revision during the follow-up period (P < .001). There were 2 hips (5.3%) that underwent revision surgery in the BD group and 10 hips (10.4%) in the control group; of these, 1 patient in the BD group underwent total hip arthroplasty, and 1 patient who had undergone bilateral surgery in the control group underwent bilateral hip resurfacing.

CONCLUSION

Durable outcomes (>9 years) with low revision rates can be expected after hip arthroscopic surgery with an approach that involves labral preservation where possible and careful attention to capsular closure in patients with BD. The observed outcomes were similar to those of a femoroacetabular impingement group with normal coverage. These results highlight the importance of classifying patients into impingement or instability categories and tailoring treatment appropriately with arthroscopic surgery or periacetabular osteotomy, respectively.

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.

Outcomes for Treatment of Capsulolabral Adhesions With a Capsular Spacer During Revision Hip Arthroscopy

BACKGROUND

The presence of adhesions is a common source of pain and dysfunction after hip arthroscopic surgery and an indication for revision surgery. The placement of a capsular spacer in the capsulolabral recess after lysis of adhesions has been developed to treat and prevent the recurrence of adhesions.

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at a minimum of 2 years after revision hip arthroscopic surgery with capsular spacer placement for capsular adhesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2013 and June 2018, a total of 95 patients (99 hips) aged ≥18 years underwent revision hip arthroscopic surgery for the treatment of capsular adhesions with the placement of a capsular spacer. Overall, 53 patients (56 hips) met the inclusion criteria and had a minimum 2-year follow-up, forming the cohort of this study. Exclusion criteria included confounding metabolic bone diseases (eg, Legg-Calve-Perthes disease, Marfan syndrome), labral deficiency, or advanced osteoarthritis (Tönnis grade 2 or 3). Preoperative and postoperative outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sport-Specific Subscale [HOS-SSS], 12-Item Short Form Health Survey [SF-12], and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were collected and compared in addition to the revision rate, conversion to total hip arthroplasty, and patient satisfaction.

RESULTS

The mean age of the cohort was 32 ± 11 years, with 32 female hips (57%) and a median number of previous hip arthroscopic procedures of 1 (range, 1-5). The arthroplasty- and revision-free survivorship rate at 2 years was 91%. Overall, 5 patients (6 hips; 11%) underwent revision surgery at a mean of 2.4 ± 1.4 years after capsular spacer placement, with symptomatic capsular defects being the most common finding. There were 4 patients (7%) who converted to total hip arthroplasty. For hips not requiring subsequent surgery (n = 46), there was a significant improvement in outcome scores except for the SF-12 Mental Component Summary, with rates of achieving the minimal clinically important difference of 70%, 70%, and 65% for the mHHS, HOS-ADL, and HOS-SSS, respectively.

CONCLUSION

Capsular spacers, as part of a systematic approach including lysis of adhesions with early and consistent postoperative physical therapy including circumduction exercises, resulted in improved PROs as well as high arthroplasty- and revision-free survivorship (91%) at a minimum 2-year follow-up. Capsular spacers should be considered in revision hip arthroscopic procedures when an adequate labral volume remains but adhesions continue to be a concern.

Combined 3-Dimensional CT and Multidirectional CT Arthrography for Femoroacetabular Impingement and Hip Lesions: A Cross-sectional Study Comparing Imaging and Hip Arthroscopic Surgery Findings

Background

There is limited research investigating the diagnostic strength of 3-dimensional computed tomography (3D-CT) and multidirectional CT arthrography (CTA) for femoroacetabular impingement (FAI) and related hip lesions.

Purpose

To evaluate the diagnostic strength of combined 3D-CT and CTA in patients with FAI and related hip lesions by comparing it with hip arthroscopic surgery findings.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

This study included patients who were suspected of having FAI and related hip lesions and who underwent a combination of 3D-CT and CTA and subsequent hip arthroscopic surgery between December 2013 and December 2017. The CT and intraoperative arthroscopic findings were recorded and compared. The sensitivity, specificity, and accuracy of 3D-CT for FAI and those of CTA for related hip lesions were calculated.

Results

A total of 114 patients with 114 hips were included in our study. There were 101 patients with positive findings and 13 patients with negative findings for FAI (including cam, pincer, and combined morphology) according to 3D-CT. The sensitivity, specificity, and accuracy of 3D-CT for FAI were 91.58%, 57.14%, and 89.47%, respectively. The sensitivity, specificity, and accuracy of CTA for labral tears were 94.64%, 100.00%, and 94.73%, respectively. For acetabular cartilage defects, the sensitivity, specificity, and accuracy of CTA were 60.71%, 91.37%, and 76.31%, respectively. For femoral cartilage defects, the sensitivity, specificity, and accuracy of CTA were 82.22%, 76.81%, and 78.94%, respectively.

Conclusion

The study results indicated that 3D-CT was able to provide excellent accuracy for FAI compared with hip arthroscopic surgery findings. In addition, multidirectional CTA demonstrated promising diagnostic strength for hip lesions such as labral tears and chondral defects.

Sex-Based Differences in Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review

BACKGROUND

While sex-based differences in outcomes after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) are often recorded, no studies have been dedicated to analyzing the literature as a whole.

PURPOSE

To investigate whether sex is a predictor of outcomes in studies evaluating hip arthroscopic surgery for FAIS.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Embase, Cochrane, Ovid, and PubMed Central databases for English-language studies that evaluated sex-specific outcomes in human populations. The search terms used were as follows: ("Hip Arthroscopy") AND ("Femoroacetabular Impingement" OR "FAI") AND ("Sex" OR "Gender" OR "Male" OR "Female"). Studies with evidence levels 2 through 4 were included. The studies were then screened, followed by data extraction. Modified Harris Hip Score (mHHS) outcomes and return-to-sport (RTS) rates were recorded. These were analyzed using random-effects meta-analysis. Heterogeneity was calculated using the I ² statistic.

RESULTS

Of 256 full-text articles screened, 48 articles were included in this analysis; of these, 14 studies (29%) concluded that female sex was a negative predictor of postoperative outcomes, while 6 studies (13%) found female sex to be positive predictor. The remaining 28 studies (58%) found no sex-based differences in postoperative outcomes. Of 7 studies (416 male and 519 female) included in the mHHS analysis, 2 studies concluded that male patients had significantly higher postoperative mHHS scores. Of 6 studies (502 male and 396 female) included in the RTS analysis, 1 study concluded that male patients had a significantly higher RTS rate.

CONCLUSION

Almost one-third of the included studies determined that female sex was a negative predictor of postoperative outcomes, 13% found female sex to be a positive predictor, and 58% found no sex-based differences. Our study illustrates an insufficiency of high-level evidence supporting sex-specific differences in outcomes after hip arthroscopic surgery, but findings indicated that the postoperative mHHS score and RTS rate may be influenced by sex.

Use of Anatomic Radiographic Horizons for the Lateral Center-Edge Angle in the Classification of Hip Dysplasia

BACKGROUND

The lateral center-edge angle of Wiberg (LCEA) and Tönnis angle (TA) rely on a "horizon" that functions as a reference point for measurements of hip dysplasia on weightbearing anteroposterior pelvis radiographs. There are 3 different horizons that are currently utilized depending on surgeon preference: (1) a line parallel to the radiographic floor (F), (2) a line that connects the inferior portions of the acetabular teardrops (ATs), or (3) a line that connects the ischial tuberosities (ITs). It is imperative to accurately assess the degree of hip dysplasia on initial workup to select the appropriate surgical intervention.

PURPOSE

To assess how the choice of a radiographic horizon affects the measurements of the LCEA and TA. The secondary purpose was to assess how the horizon affected the classification of hips as either normal, borderline dysplastic, or dysplastic.

STUDY DESIGN

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

METHODS

The LCEA and TA were measured on all preoperative weightbearing anteroposterior pelvis radiographs for 186 consecutive patients who underwent hip preservation surgery between February 2016 and November 2020 (140 hip arthroscopic procedures, 46 combined hip arthroscopic procedures with periacetabular osteotomy), 3 times per hip, each time using an F, AT, and IT horizon. The Student t test was used to analyze the differences in the measurements of the LCEA and TA, and discordance rates in the dysplasia classification between horizons were quantified.

RESULTS

For the entire study population, the mean LCEA_F (23.4°± 7.4°) was significantly greater than the mean LCEA_IT (23.1°± 7.2°) (95% CI, -0.634 to -0.003; P = .047) and mean LCEA_AT (23.0°± 7.1°) (95% CI, -0.723 to -0.139; P = .004). There was no difference between the LCEA_IT and LCEA_AT (95% CI, -0.305 to 0.080; P = .251). When stratified by hip arthroscopic surgery, the mean LCEA_F (26.3°± 5.6°) was significantly greater than the mean LCEA_AT (25.8°± 5.3°) (95% CI, -0.845 to -0.162; P = .004). Overall, there was a 17.7% and 18.3% discordance rate in the dysplasia classification using the LCEA_IT and LCEA_AT compared with the LCEA_F, respectively. There were no statistically significant differences between the mean TA_IT, TA_AT, and TA_F for the entire study population, the arthroscopic surgery group, and the combined arthroscopic surgery and periacetabular osteotomy group.

CONCLUSION

There was no statistical difference between the AT and IT horizons for LCEA measurements. The dysplasia classification was in better agreement between the 2 anatomic horizons compared with the F horizon. The TA was not affected by changes in the horizon.

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.

Effect of Anchor Density on Functional Outcomes After Arthroscopic Hip Labral Repair

BACKGROUND

While labral repair has been widely adopted as the first line treatment for labral injury during hip arthroscopy, there is no widespread consensus on the procedural technique, including the number of anchors that should be used to avoid recurrent instability and revision surgery.

PURPOSE

To determine if anchor density can predict patient-reported outcomes after arthroscopic labral repair in the hip.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients aged 18 to 50 years who underwent primary hip arthroscopic surgery with labral repair between January 2011 and December 2016 were identified from a prospectively collected database. Exclusion criteria consisted of previous ipsilateral surgery, osteoarthritis (Tönnis grade >1), and severe cartilage defects (Outerbridge grade III/IV) or concomitant labral reconstruction, capsular reconstruction, or microfracture. Minimum 2-year patient-reported outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score [HOS]-Activities of Daily Living [ADL], HOS-Sport Specific Subscale [SSS], 12-Item Short Form Health Survey [SF-12]), rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) for each score, revision surgery rate, and rate of conversion to total hip arthroplasty (THA) were compared based on anchor density (number of anchors per millimeter of labral tear).

RESULTS

A total of 634 hips (575 patients) with a mean age of 30.4 ± 9.5 years (range, 18.0-49.9 years) met inclusion criteria. The mean labral tear size was 31 ± 11 mm (range, 2-70 mm) with a median number of anchors used for labral repair of 3 (range, 1-7) and mean anchor density of 0.11 ± 0.08 anchors (range, 0.03-1.33) per millimeter of labral tear. Hips with a minimum 2-year follow-up (451/634 [71.1%]) had significant improvements on the mHHS, HOS-ADL, HOS-SSS, and SF-12 Physical Component Summary (P < .001 for all). There was no significant correlation detected between anchor density or number of anchors used and postoperative scores (correlation coefficient range, -0.05 to 0.17; P > .05 for all). The rate of revision surgery was 6.4% (28 patients), with 8 hips found to have labral tears and/or deficiency on revision. Additionally, 6 hips (1.3%) had to undergo THA at a mean of 3.6 ± 2.1 years (range, 2.0-5.5 years).

CONCLUSION

Anchor density did not have a correlation with postoperative outcomes, achieving the MCID or PASS, revision hip arthroscopic surgery, complications, or conversion to THA.

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.

Hip Dislocation and Subluxation in Athletes: A Systematic Review

BACKGROUND

Hip dislocation is a rare occurrence during sports but carries serious implications for athletes.

PURPOSE

To systematically review treatment strategies and outcomes for hip dislocation in athletes, with the ultimate goal of providing sports medicine physicians with the information necessary to appropriately treat and counsel patients sustaining this injury.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PubMed, MEDLINE, and Embase were searched for studies relating to hip instability and athletics from January 1, 1989 to October 1, 2019. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Inclusion criteria were the following: (1) data from ≥1 patients, (2) native hip dislocation or subluxation occurring during sports, (3) patients aged at least 10 years, and (4) written in English. Exclusion criteria were (1) patients younger than 10 years; (2) nonnative or postoperative hip dislocation or subluxation; (3) a native hip injury without dislocation or subluxation; (4) patients with dislocation or subluxation secondary to neuromuscular, developmental, or syndromic causes; (5) dislocation or subluxation not occurring during sports; (6) patients with physeal fractures; or (7) review articles or meta-analyses. Data were recorded on patient demographics, injury mechanism, treatment strategies, and clinical and radiographic outcomes. Where possible, pooled analysis was performed. Studies were grouped based on reported outcomes. Meta-analysis was then performed on these pooled subsets.

RESULTS

A total of 602 articles were initially identified, and after screening by 2 reviewers, 27 articles reporting on 145 patients were included in the final review. There were 2 studies that identified morphological differences between patients with posterior dislocation and controls, including decreased acetabular anteversion (P = .015 and .068, respectively), increased prevalence of a cam deformity (P < .0035), higher alpha angles (P≤ .0213), and decreased posterior acetabular coverage (P < .001). No differences were identified for the lateral center edge angle or Tonnis angle. Protected postreduction weightbearing was most commonly prescribed for 2 to 6 weeks, with 65% of reporting authors recommending touchdown, toe-touch, or crutch-assisted weightbearing. Recurrence was reported in 3% of cases. Overall, 4 studies reported on findings at hip arthroscopic surgery, including a 100% incidence of labral tears (n = 27; 4 studies), 92% incidence of chondral injuries, 20% incidence of capsular tears, and 84% incidence of ligamentum teres tears (n = 25; 2 studies). At final follow-up, 86% of patients reported no pain (n = 14; 12 studies), 87% reported a successful return to play (n = 39; 10 studies), and 11% had radiographic evidence of osteonecrosis (n = 38; 10 studies).

CONCLUSION

Various treatment strategies have been described in the literature, and multiple methods have yielded promising clinical and radiographic outcomes in patients with native hip dislocation sustained during sporting activity. Data support nonoperative treatment with protected weightbearing for hips with concentric reduction and without significant fractures and an operative intervention to obtain concentric reduction if unachievable by closed means alone. Imaging for osteonecrosis is recommended, with evidence suggesting 4- to 6-week magnetic resonance imaging and follow-up at 3 months for those with suspicious findings in the femoral head.

Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial.

PURPOSE/HYPOTHESIS

We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes.

RESULTS

Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033).

CONCLUSION

This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study

BACKGROUND

The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce.

PURPOSE

(1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score-Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI).

RESULTS

A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05).

CONCLUSION

Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Comparison of Acetabular Labral Reconstruction With 7-mm Tibialis Anterior Allograft and 5-mm Iliotibial Band Autograft at Minimum 2-Year Follow-up

BACKGROUND

Labral reconstruction has been described as a treatment option for irreparable labral tear. Labral graft size ranges from 5 to 7 mm² for reconstruction. A thicker labral graft could support mechanical stability and protect cartilage better. No study has compared the effect of graft thickness on clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare patient-reported outcomes between hips reconstructed with an autologous iliotibial band (AUITB; 5 mm²) graft and with an allogenic tibialis anterior (ALTA; 7 mm²) tendon graft. Our hypothesis was that hips reconstructed with a thicker allograft (7 mm²) would have better clinical outcomes than those with a smaller autograft (5 mm²).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 42 patients (aged 21 to 54 years) underwent arthroscopic hip segmental labral reconstruction during the study period of January 2016 to November 2018. Twenty patients had reconstruction with AUITB grafts (5 mm²) and 22 with ALTA grafts (7 mm²). Both groups had minimum 2 year follow-up. Patients were evaluated with patient-related outcome scores: modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific. Pain evaluation was performed using a visual analog scale.

RESULTS

There were significant differences in all studied variables when comparing pre- and postoperative scores. Yet, there were no differences in terms of patient-related outcome scores between the groups postoperatively. Postoperative visual analog scale scores averaged 2.1 for the AUITB group vs 1.9 for the ALTA group (P = .89); modified Harris Hip Score, 82.7 vs 83.3 (P = .77); Nonarthritic Hip Score, 81.1 vs 82.2 (P = .81); and Hip Outcome Score-Sports Specific, 81.6 vs 82.5 (P = .67).

CONCLUSION

No differences were found in terms of clinical outcomes between the 7-mm² ALTA graft and the 5-mm² AUITB graft. Both graft types and thicknesses might be considered comparable choices for primary reconstruction. Although a thicker-graft labral reconstruction seemed to have more ability to cover joint surface, clinical results did not show any superiority of a thicker graft whether it is autologous or allogenic.

Patient-Reported Outcome Scores and Rate of Return to Sport After Hip Arthroscopic Surgery: A Sex-Based Comparison in Professional and Collegiate Athletes

BACKGROUND

No studies have compared outcomes and return to sport (RTS) after hip arthroscopic surgery between matched groups of male and female athletes with a minimum 2-year follow-up.

PURPOSE

(1) To report minimum 2-year postoperative patient-reported outcome (PRO) scores and the RTS rate for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI) and (2) to compare clinical results with a matched control group of elite male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data on all consecutive female athletes who underwent primary hip arthroscopic surgery performed at our institution between March 2009 and July 2018 were collected. Patients were eligible if they underwent hip arthroscopic surgery for labral tears or FAI and participated in collegiate or professional athletics within 1 year of surgery. Minimum 2-year postoperative PRO scores were collected 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 as well as RTS status. The percentages of patients achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state were recorded. These patients were matched to elite male athletes for comparison.

RESULTS

A total of 73 female hips were included, with a mean follow-up of 65.1 ± 27.9 months. They demonstrated a significant improvement from preoperatively to latest follow-up on the mHHS, NAHS, HOS-SSS, and VAS (P < .05). When outcomes were compared with a control group of male athletes, female athletes demonstrated lower preoperative scores, similar postoperative scores, and a significantly greater magnitude of improvement (delta value) on the mHHS, NAHS, and VAS. Female athletes also achieved the MCID at higher rates than did male athletes for the HOS-SSS (85.1% vs 70.0%, respectively; P = .035) and NAHS (79.1% vs 62.9%, respectively; P = .037). RTS rates among patients who attempted were similar between the 2 groups (female: 75.4%; male: 83.1%; P = .409).

CONCLUSION

Elite female athletes undergoing primary hip arthroscopic surgery for FAI demonstrated a significant improvement in PRO scores and a high RTS rate. Female athletes exhibited a greater improvement in PRO scores (mHHS, NAHS, VAS) and achieved the MCID (HOS-SSS, NAHS) at higher rates compared with a control group of male athletes.

Arthroscopic Circumferential Acetabular Labral Reconstruction for Irreparable Labra in the Revision Setting: Patient-Reported Outcome Scores and Rate of Achieving the Minimal Clinically Important Difference at a Minimum 2-Year Follow-up

BACKGROUND

There is a paucity in the literature reporting patient-reported outcome (PRO) scores and the minimal clinically important difference (MCID) after revision hip arthroscopic surgery with circumferential labral reconstruction.

PURPOSE

To report minimum 2-year PRO scores and the rate of achieving the MCID in patients who underwent revision hip arthroscopic surgery with circumferential labral reconstruction in the setting of irreparable labral tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were retrospectively reviewed for all patients who underwent revision hip arthroscopic surgery between February 2016 and November 2017. Patients were included if they had undergone circumferential labral reconstruction and had preoperative and postoperative scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), 12-Item Short Form Health Survey physical and mental components (SF-12 P and SF-12 M, respectively), Veterans RAND 12-Item Health Survey physical and mental components (VR-12 P and VR-12 M, respectively), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, fractures, hip dysplasia, or revision labral treatment different from circumferential labral reconstruction. The MCID was calculated. Secondary surgical procedures were documented.

RESULTS

A total of 26 hips (26 patients; 61.5% female) were included. The mean age and body mass index were 33.2 ± 10.4 years and 25.5 ± 4.9, respectively. Significant improvements were reported for the mHHS (17.0 ± 19.5; P = .0002), NAHS (17.9 ± 16.7; P < .0001), HOS-SSS (21.7 ± 23.1; P = .0005), VAS (-2.2 ± 3.0; P = .006), iHOT-12 (25.8 ± 32.5; P = .0007), SF-12 P (8.5 ± 11.2; P = .001), and VR-12 P (8.9 ± 11.6; P = .001). Rates of meeting the MCID for the mHHS, NAHS, HOS-SSS, iHOT-12, and VAS were 76.9%, 80.0%, 65.0%, 62.5%, and 69.2%, respectively. No case of re-revision arthroscopic surgery was documented, but 1 case of conversion to total hip arthroplasty was documented at 38.6 months.

CONCLUSION

In the setting of revision hip arthroscopic surgery and irreparable labral tears, circumferential labral reconstruction resulted in significant improvements in all PRO and VAS scores at a minimum 2-year follow-up with a high rate of achieving the MCID.

Influence of Femoral Version on the Outcomes of Hip Arthroscopic Surgery for Femoroacetabular Impingement or Labral Tears: A Systematic Review and Meta-analysis

BACKGROUND

It remains controversial whether abnormal femoral version (FV) affects the outcomes of hip arthroscopic surgery for femoroacetabular impingement (FAI) or labral tears.

PURPOSE

To review the outcomes of hip arthroscopic surgery for FAI or labral tears in patients with normal versus abnormal FV.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Embase, PubMed, and the Cochrane Library were searched in July 2020 for studies reporting the outcomes after primary hip arthroscopic surgery for FAI or labral tears in patients with femoral retroversion (<5°), femoral anteversion (>20°), or normal FV (5°-20°). The primary outcome was the modified Harris Hip Score (mHHS), and secondary outcomes were the visual analog scale (VAS) for pain, Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), Non-Arthritic Hip Score (NAHS), failure rate, and patient satisfaction. The difference in preoperative and postoperative scores (Δ) was also calculated when applicable.

RESULTS

Included in this review were 5 studies with 822 patients who underwent hip arthroscopic surgery for FAI or labral tears; there were 166 patients with retroversion, 512 patients with normal version, and 144 patients with anteversion. Patients with retroversion and normal version had similar postoperative mHHS scores (mean difference [MD], 2.42 [95% confidence interval (CI), -3.42 to 8.26]; P = .42) and ΔmHHS scores (MD, -0.70 [96% CI, -8.56 to 7.15]; P = .86). Likewise, the patients with anteversion and normal version had similar postoperative mHHS scores (MD, -3.09 [95% CI, -7.66 to 1.48]; P = .18) and ΔmHHS scores (MD, -1.92 [95% CI, -6.18 to 2.34]; P = .38). Regarding secondary outcomes, patients with retroversion and anteversion had similar ΔNAHS scores, ΔHOS-SSS scores, ΔVAS scores, patient satisfaction, and failure rates to those with normal version, although a significant difference was found between the patients with retroversion and normal version regarding postoperative NAHS scores (MD, 5.96 [95% CI, 1.66-10.26]; P = .007) and postoperative HOS-SSS scores (MD, 7.32 [95% CI, 0.19-14.44]; P = .04).

CONCLUSION

The results of this review indicated that abnormal FV did not significantly influence outcomes after hip arthroscopic surgery for FAI or labral tears.

Comparison Between Hip Arthroscopic Surgery and Periacetabular Osteotomy for the Treatment of Patients With Borderline Developmental Dysplasia of the Hip: A Systematic Review

Background:

The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH.

Purpose:

To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH.

Results:

A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures.

Conclusion:

There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.

Iliopsoas Tenotomy During Hip Arthroscopy: A Systematic Review of Postoperative Outcomes

BACKGROUND

Arthroscopic iliopsoas tendon release is a surgical treatment option for painful snapping hips, although it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy.

PURPOSE

To systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopic surgery as an intervention for painful snapping hips.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A total of 3 online databases (Embase, PubMed, and MEDLINE) were searched from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopic surgery. Studies were screened by 2 reviewers independently and in duplicate, and studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all included studies.

RESULTS

Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824), with a mean age of 28.1 years (range, 12-62 years) and mean follow-up of 32.1 months (range, 3-73 months). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) or the lesser trochanter in 64 hips (7.3%). The overall reported success rate of the procedure in resolving snapping hips was 93.0% (266/286), and all studies reported an improvement in functional outcome scores. Only 6 studies (93 hips) discussed postoperative hip flexion strength, with complete recovery of strength reported in 4 studies (47 hips) and mild decreases reported in the other 2 studies (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies; 66 hips) and was found postoperatively in 92.4% (61/66) of hips. No major complications were reported.

CONCLUSION

Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. Although patients demonstrated some early postoperative weakness and iliopsoas atrophy on radiological imaging, the results from studies to date showed satisfactory clinical function and return to sports/activities. High-quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release to determine the optimal technique and location of tendon release.

The Learning Curve for Hip Arthroscopic Surgery: A Prospective Evaluation With 2-Year Outcomes in Patients With Femoroacetabular Impingement

Background

The use of hip arthroscopic surgery in the treatment of femoroacetabular impingement (FAI) is increasing, but it is universally known as a technically demanding procedure with a "steep" learning curve. There are limited data investigating the correlation between surgeon experience and patient-reported outcomes (PROs) as well as procedure and traction times.

Purpose

To prospectively evaluate the relationship between surgeon experience and PROs after hip arthroscopic surgery for the treatment of FAI.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 190 patients undergoing primary hip arthroscopic surgery for FAI were prospectively enrolled during a sports medicine fellowship-trained surgeon's first 36 months of practice. A radiographic evaluation as well as PRO surveys including the 12-Item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS) were administered preoperatively and at 2 years postoperatively. Logistic regression as well as analysis of variance was performed to evaluate for correlations between surgical experience and PROs, procedure time, and traction time.

Results

Of the 190 patients, 168 (88%; mean age, 35.3 ± 9.6 years; mean body mass index, 25.07 ± 3.98) completed a 2-year follow-up and were included for analysis. The mean procedure time was 91.5 ± 23.9 minutes, and the mean traction time was 54.0 ± 17.7 minutes. Patients demonstrated significant improvements at 2 years after surgery for all PRO scores (mHHS, HOOS, and SF-12 physical component summary; P < .001), except the SF-12 mental component summary, which had no change (P = .43). The procedure time significantly decreased after 70 cases, while the traction time continued to decrease until 110 cases (R ² = 0.99; P < .0001). There was no correlation between increasing case volume and 2-year PRO scores (P > .2 for mHHS, HOOS, and SF-12). There was also no difference with increasing case volume and amount of improvement from preoperative to 2-year postoperative PRO scores for the SF-12 and HOOS. Case volume did not affect the complication rate, as this cohort experienced 4 minor cases of neurapraxia.

Conclusion

Surgical efficiency in hip arthroscopic surgery for the treatment of FAI was maximized after 110 cases in this cohort. However, significant PRO improvements can be achieved early in a surgeon's practice prior to maximizing surgical efficiency.

Postoperative Deep Gluteal Syndrome After Hip Arthroscopic Surgery

Background

Deep gluteal syndrome (DGS) is an uncommon source of buttock and groin pain, resulting from entrapment of the sciatic nerve in the deep gluteal space. The incidence and risk factors of postoperative DGS after primary hip arthroscopic surgery are currently unknown.

Purpose

To investigate the incidence and risk factors of postoperative DGS after primary hip arthroscopic surgery.

Study Design

Case-control study; Level of evidence, 3.

Methods

This study reviewed 1167 patients who underwent arthroscopic surgery between 2010 and 2018 by a single surgeon at a single center in Japan. DGS was defined using the seated piriformis stretch test, active hamstring test, and evidence of a hypertrophic sciatic nerve on magnetic resonance imaging. Overall, 11 of 1167 patients were diagnosed with DGS postoperatively. The DGS group (n = 11) was compared with the non-DGS group (n = 1156). Patient age, sex, body mass index (BMI), generalized joint laxity (GJL; Beighton score >6), number of hip arthroscopic procedures, and radiographic parameters including lateral center-edge angle, Sharp angle, vertical center anterior angle, Tönnis angle, alpha angle, ischiofemoral distance, ischiofemoral space, and quadratus femoris space were compared. The prevalence of developmental dysplasia of the hip (DDH) and borderline DDH (BDDH) was also compared. Logistic regression analysis was conducted to identify potential predictors for a postoperative DGS diagnosis.

Results

The incidence of postoperative DGS in our study was 0.9%. Female sex (male:female ratio: 0:11 in DGS group vs 568:588 in non-DGS group; P < .01), mean number of hip surgical procedures (1.8 ± 0.9 in DGS group vs 1.1 ± 0.4 in non-DGS group; P < .01), and GJL (P < .01) were significantly higher in the DGS group, while the mean BMI was significantly lower in the DGS group (19.8 ± 1.8 vs 22.7 ± 3.6 kg/m², respectively; P < .01). Radiographic parameters were not significantly different between groups. Logistic regression analysis revealed that female sex (odds ratio [OR], 22.0 [95% CI, 1.29-374.56]), multiple surgical procedures (OR, 7.8 [95% CI, 2.36-25.95]), GJL (OR, 40.9 [95% CI, 8.74-191.70]), lower BMI (OR, 0.77 [95% CI, 0.644-0.914]), and DDH/BDDH (OR, 18.1 [95% CI, 2.30-142.10]) were potential predictors of postoperative DGS.

Conclusion

The incidence of postoperative DGS in our study was 0.9%. The predictors for postoperative DGS after hip arthroscopic surgery were female sex, GJL, multiple hip surgical procedures, and DDH/BDDH. Although hip arthroscopic surgery can provide favorable clinical outcomes, surgeons should be aware of the risk factors for DGS as a complication of hip arthroscopic surgery.

Radiographic Indices Are Not Predictive of Clinical Outcomes Among 1735 Patients Indicated for Hip Arthroscopic Surgery: A Machine Learning Analysis

BACKGROUND

The relationship between the preoperative radiographic indices for femoroacetabular impingement syndrome (FAIS) and postoperative patient-reported outcome measure (PROM) scores continues to be under investigation, with inconsistent findings reported.

PURPOSE

To apply a machine learning model to determine which preoperative radiographic indices, if any, among patients indicated for the arthroscopic correction of FAIS predict whether a patient will achieve the minimal clinically important difference (MCID) for 1- and 2-year PROM scores.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 1735 consecutive patients undergoing primary hip arthroscopic surgery for FAIS were included from an institutional hip preservation registry. Patients underwent preoperative computed tomography of the hip, from which the following radiographic indices were calculated by a musculoskeletal radiologist: alpha angle, beta angle, sagittal center-edge angle, coronal center-edge angle, neck shaft angle, acetabular version angle, and femoral version angle. PROM scores were collected preoperatively, at 1 year postoperatively, and at 2 years postoperatively for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)-Activities of Daily Living (HOS-ADL) and -Sport Specific (HOS-SS), and the International Hip Outcome Tool (iHOT-33). Random forest models were created for each PROM at 1 and 2 years' follow-up, with each PROM's MCID used to establish clinical meaningfulness. Data inputted into the models included ethnicity, laterality, sex, age, body mass index, and radiographic indices. Comprehensive and separate models were built specifically to assess the association of the alpha angle, femoral version angle, coronal center-edge angle, McKibbin index, and hip impingement index with respect to each PROM.

RESULTS

As evidenced by poor area under the curves and P values >.05 for each model created, no combination of radiographic indices or isolated index (alpha angle, coronal center-edge angle, femoral version angle, McKibbin index, hip impingement index) was a significant predictor of a clinically meaningful improvement in scores on the mHHS, HOS-ADL, HOS-SS, or iHOT-33. The mean difference between 1- and 2-year PROM scores compared with preoperative values exceeded the respective MCIDs for the cohort.

CONCLUSION

In patients appropriately indicated for FAIS corrective surgery, clinical improvements can be achieved, regardless of preoperative radiographic indices, such as the femoral version angle, coronal center-edge angle, and alpha angle. No specific radiographic parameter or combination of indices was found to be predictive of reaching the MCID for any of the 4 studied hip-specific PROMs at either 1 or 2 years' follow-up.

Intra-abdominal Fluid Extravasation: Is Endoscopic Deep Gluteal Space Exploration a Risk Factor?

Background

The extravasation of fluid into the intra-abdominal space is recognized as a possible complication of hip arthroscopic surgery/endoscopy. The exposure of anatomic areas to elevated pump pressures and high volumes of irrigation fluid increases the risk of fluid leakage into anatomic spaces around the hip joint, especially to the abdomen and pelvis.

Purpose

To estimate the incidence and risk factors related to intra-abdominal fluid extravasation (IAFE) after hip endoscopy or arthroscopic surgery.

Study Design

Cohort study; Level of evidence, 2.

Methods

A prospective study was carried out between June 2017 and June 2018. A total of 106 hip procedures (endoscopy or arthroscopic surgery) performed for extra- or intra-articular abnormalities were included. Before and after surgery, in the operating room, ultrasound was performed by a trained anesthesiologist to detect IAFE. The hepatorenal (Morison pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. Patients were monitored for 3 hours after surgery to assess for abdominal pain. The data collected included maximum pump pressure, duration and volume of irrigation fluid (Ringer lactate), total surgical time, and traction time.

Results

The incidence of IAFE was 31.1% (33/106; 95% CI, 23.1%-40.5%). The frequency of IAFE was 52.9% (9/17) in cases with isolated extra-articular abnormalities and 15.9% (7/44) in cases with isolated femoroacetabular impingement; in cases with both extra- and intra-articular abnormalities, the frequency was 37.8% (17/45). An intervention in the subgluteal space was identified as a risk factor for IAFE (odds ratio, 3.62 [95% CI, 1.47-8.85]). There was no statistically significant difference between groups (with vs without IAFE) regarding total surgical time, maximum pump pressure, or fluid volume. Postoperative abdominal pain was found in 36.4% (n = 12) of cases with IAFE compared with 2.7% (n = 2) of cases without extravasation (P < .001). No patient with IAFE developed abdominal compartment syndrome.

Conclusion

IAFE was a frequent finding after hip arthroscopic surgery/endoscopy in patients with extra-articular abnormalities. Exploration of the subgluteal space may increase the risk of IAFE. Pain and abdominal distension during the immediate postoperative period were early warning signs for IAFE. These results reinforce the need for careful intraoperative and postoperative monitoring by the surgeon and anesthesiologist to identify and avoid complications related to IAFE.

The Danish Hip Arthroscopy Registry: Registration Completeness and Patient Characteristics Between Responders and Non-Responders

Purpose

To report completeness of registered surgeries in the Danish hip arthroscopy registry (DHAR) and proportion of patients completing patient-reported outcome measures (PROMs) prior to surgery and at 1-year follow-up.

Patients and Methods

Completeness was determined as the number of surgeries registered in DHAR in comparison with the number of surgeries registered in the Danish National Patient Registry database (DNPR). The number of patients self-reporting pre-surgical PROMs was compared to the total number of surgeries registered in DHAR. Further, we evaluated potential differences in baseline characteristics between the groups of responders and non-responders at 1-year follow-up. Patient characteristics included age, sex, activity levels measured by the hip sports activity scale (HSAS), and PROMs (Copenhagen Hip and Groin Outcome Score, EQ-5D-3L and general hip status). Age was stratified in three groups (<25, 25–39, ≥40).

Results

From February 2012 to September 2018, 5565 arthroscopic hip surgeries were registered in DNPR, and 4937 were registered in DHAR (89%). The yearly rate of registrations in DHAR compared to DNPR increased from 77% in 2012 to 85% in 2018 and peaking in 2015 at 94%. A total of 3294 DHAR-registered patients (67%) had self-reported their pre-surgical outcome scores, and of those, 2886 (58%) completed PROMs at 1-year follow-up. More males (45 vs 41%, p = 0.002) and individuals younger than 25 years of age (24% vs 18%, p<0.001) had not completed follow-up questionnaire. The PROM baseline scores of the responders at follow-up did not differ from the non-responders.

Conclusion

The proportion of arthroscopic hip surgeries registered in the Danish Hip Arthroscopy Registry and the proportion of self-reporting PROM scores have increased to acceptable levels, whereas the proportion of patients with follow-up data is comparably low. For further quality improvement, more attention should be given to patients completing PROMs, focusing on younger males and follow-up PROMs.

Prospective Analysis of Arthroscopic Hip Anatomic Labral Repair Utilizing Knotless Suture Anchor Technology: The Controlled-Tension Anatomic Technique at Minimum 2-Year Follow-up

BACKGROUND

Labral tears are the most common abnormalities in patients undergoing hip arthroscopic surgery. Appropriate management is crucial, as it has been shown that better overall outcomes can be achieved with labral restoration.

PURPOSE

To report the patient-reported outcomes (PROs) at minimum 2-year follow-up of patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique in the setting of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery for FAIS for labral tear repair using the knotless controlled-tension anatomic technique. Patients were excluded if they had prior hip conditions, prior ipsilateral surgery, Tönnis grade >1, a lateral center-edge angle (LCEA) <25°, or workers' compensation claims. Preoperative and postoperative scores at minimum 2-year follow-up were recorded for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The proportion of patients who achieved the minimal clinically important difference (MCID) or patient acceptable symptomatic state (PASS) for the mHHS, HOS-SSS, and iHOT-12 were also reported.

RESULTS

A total of 309 hips were included. The mean patient age was 36.2 years (range, 12.8-75.9 years). The mean preoperative LCEA and alpha angle were 31.9° and 57.1°, respectively. A significant improvement on the mHHS (62.6 ± 15.7 preoperatively vs 86.9 ± 16.2 at 2-year follow-up), NAHS (63.1 ± 16.7 vs 86.1 ± 16.7), and HOS-SSS (39.8 ± 22.0 vs 74.2 ± 27.3) was found (P < .001 for all). A significant decrease was shown for VAS scores (P < .001). Also, 78.6% and 82.2% of patients achieved the MCID and PASS for the mHHS, respectively; 60.8% and 69.9% of patients met the MCID and PASS for the HOS-SSS, respectively; and the MCID for the iHOT-12 was met by 77.3% of patients.

CONCLUSION

In the setting of FAIS and labral tears, patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique demonstrated significant improvement in several validated PRO measures, the VAS pain score, and patient satisfaction at a minimum 2 years of follow-up. Based on this evidence, labral tear repair using the knotless controlled-tension anatomic technique seems to be a safe option.

The Femoral Head "Divot" Sign: A Useful Arthroscopic Sign of Hip Microinstability

Background:

A femoral head “divot” is a rare finding during hip arthroscopy. A linear chondral indentation can be observed on the femoral head, just lateral and parallel to the acetabular labrum.

Purpose/Hypothesis:

The purpose of this study was to describe a novel arthroscopic sign and retrospectively review patients with this finding. We hypothesized that this sign would be found in patients with characteristics consistent with hip microinstability.

Study Design:

Case series; Level of evidence, 4.

Methods:

Intraoperative images of patients undergoing primary hip arthroscopy between July 2017 and July 2019 were reviewed for evidence of a femoral head divot. Preoperative characteristics, physical examination findings, radiographic measurements, and magnetic resonance imaging (MRI) findings were described.

Results:

Of 690 available cases, 14 cases (13 patients; 2.0%) had evidence of a femoral head divot. The mean patient age was 29.1 years, and all but 1 patient (92.3%) were female. Ligamentous laxity was present in 81.8% of patients, anterior apprehension test was positive in 78.6%, and painful internal snapping was present in 50.0%. The mean lateral center-edge angle, anterior center-edge angle, and Tönnis angle were 19.2°, 20.3°, and 12.4°, respectively. The divot was identified in 5 of 12 available MRI scans, most commonly on axial proton density sequence. Intraoperatively, all hips had labral tears, iliopsoas bursitis was demonstrated in 78.6%, and the ligamentum teres was damaged in 42.9%. Labral repair was performed in 12 of the 14 hips, with 2 patients undergoing labral reconstruction. Iliopsoas fractional lengthening was performed in 50.0%, capsular plication was performed in 78.6%, and capsular repair was performed in the remainder.

Conclusion:

The femoral head divot sign is a rare arthroscopic finding during hip arthroscopy. The results of this study demonstrated that patients who have a divot also present with characteristic radiographic or physical examination findings of hip microinstability due to either acetabular dysplasia or ligamentous laxity. Recognition of a femoral head divot may be valuable for the diagnosis of microinstability during hip arthroscopy and may help guide appropriate management, such as capsular plication. Further studies are needed to determine the exact prevalence of the femoral head divot in patients with microinstability and to evaluate the effect of this finding on patient outcomes.

Outcomes of Hip Arthroscopic Surgery in Adolescents With a Subanalysis on Return to Sport: A Systematic Review

BACKGROUND

There is a plethora of literature on outcomes after hip arthroscopic surgery in the adult population; however, outcomes in the adolescent population have not been as widely reported. Additionally, as adolescents represent a very active population, it is imperative to understand their athletic activity and return to sport after hip arthroscopic surgery.

PURPOSE

To analyze patient-reported outcomes (PROs) after hip arthroscopic surgery in adolescents (aged 10-19 years) and present a return-to-sport analysis in the athletic adolescent subgroup.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles that reported PROs after hip arthroscopic surgery in adolescents. The standardized mean difference was calculated to compare the effect size of hip arthroscopic surgery on various PROs. For the athletic subgroup, a return-to-sport summary was also provided.

RESULTS

Ten studies, with 618 adolescent hips and a collective study period of December 2004 to February 2015, were included in this systematic review. Across all studies, the mean age was 15.8 years (range, 11.0-19.9 years), and female patients composed approximately 56.7% of the entire cohort. The mean follow-up was 34.5 months (range, 12-120 months). The modified Harris Hip Score (mHHS) was reported in 9 studies, and at latest follow-up, scores were excellent in 4 studies (range, 90-95) and good in the remaining 5 studies (range, 82.1-89.6). All adolescents also showed significant improvement on the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Activities of Daily Living (HOS-ADL), the HOS-Sport-Specific Subscale (HOS-SSS), the physical component of the 12-Item Short Form Health Survey (SF-12P), a visual analog scale for pain (VAS), and both versions of the International Hip Outcome Tool (iHOT-12 and iHOT-33) at latest follow-up (P < .05). Further, mean improvements reported in all studies surpassed reported values of the minimal clinically important difference and patient acceptable symptomatic state for the mHHS, HOS-ADL, HOS-SSS, and iHOT-33. Finally, the collective return-to-sport rate among athletic adolescents was 84.9%.

CONCLUSION

In the setting of labral tears and femoroacetabular impingement, hip arthroscopic surgery can safely be performed in adolescents and leads to significant functional improvement. Furthermore, athletic adolescents return to sport at high levels after hip arthroscopic surgery.

Arthroscopic labral debridement versus labral repair for patients with femoroacetabular impingement: A meta-analysis

OBJECTIVE

Femoroacetabular impingement (FAI) is a common cause of hip pain and even tearing of the acetabular labrum in young adults and athletes. Either arthroscopic labral debridement (LD) or labral repair (LR) technique for FAI patients is needed to choose. We conducted this systematic review and meta-analysis to compare the clinical outcomes of arthroscopic LD versus LR intervention.

METHODS

The five studies were acquired from PubMed, Medline, Embase, and Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed by RevMan5.3. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias.

RESULTS

Four observational studies and one prospective randomized study were assessed. The methodological quality of the trials indicated a low to moderate risk of bias. The pooled results of Non-Arthritic Hip Score (NAHS), failure rate of surgeries and complications showed that the differences were not statistically significant between the two interventions. The difference of modified Harris Hip Score (mHHS), the Visual Analogue Scale (VAS) score and satisfaction rate was statistically significant between LD and LR intervention, and LR treatment was more effective. Sensitivity analysis proved the stability of the pooled results and there were too less included articles to verify the publication bias.

CONCLUSIONS

Hip arthroscopy with either LR or LD is an effective treatment for symptomatic FAI. The difference of mHHS, VAS score, and satisfaction rate was statistically significant between LD and LR intervention, and arthroscopic LR could re-create suction-seal effect, potentially reduce microinstability, which demonstrated a trend toward better clinical efficacy and comparable safety compared with LD. The arthroscopic LR technique is recommended as the optical choice for acetabular labrum tear with FAI.

Outcomes of Revision Hip Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes (PROs) generally improve after revision procedures, the extent of their improvement is not well defined.

PURPOSE

To determine the outcomes and efficacy of revision hip arthroscopic surgery in patients who remain symptomatic after their index procedure.

STUDY DESIGN

Meta-analysis and systematic review.

METHODS

The terms "hip arthroscopy,""revisions,""outcomes," and "femoroacetabular impingement" were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar. After screening, 15 studies were included for review. In addition to hip-specific metrics, functional outcome measures were included. Pooled estimates and 95% CIs were calculated using inverse variance methods.

RESULTS

A total of 4765 hips in 4316 patients were identified. The most common indication for revision surgery was inadequate bony resection during the index procedure. Meta-analysis showed that all PROs improved significantly from baseline to final follow-up after revision hip arthroscopic surgery. Notably, the modified Harris Hip Score (mHHS) increased a mean of 17.20 points after revision hip arthroscopic surgery, the Hip Outcome Score-Activities of Daily Living (HOS-ADL) improved by 13.98, and the visual analog scale (VAS) for pain decreased by 3.16. However, when compared with primary hip arthroscopic surgery, the mean PRO scores after revision hip arthroscopic surgery were lower. After revision hip arthroscopic surgery, the rates of conversion to total hip arthroplasty ranged from 0% to 14.3%, and the rates of further arthroscopic revision ranged from 2% to 14%.

CONCLUSION

Inadequate bony resection represents the most common indication for revision hip arthroscopic surgery. PROs improve significantly after revision hip arthroscopic surgery but remain lower than those of patients undergoing primary hip arthroscopic surgery.

An Intact Ligamentum Teres Predicts a Superior Prognosis in Patients With Borderline Dysplasia: A Matched-Pair Controlled Study With Minimum 5-Year Outcomes After Hip Arthroscopic Surgery

BACKGROUND

Hip arthroscopic surgery in patients with borderline dysplasia continues to be controversial. In addition, it has been suggested that ligamentum teres (LT) tears may lead to inferior short-term patient-reported outcomes (PROs) when compared with a match-controlled group.

PURPOSES

(1) To report minimum 5-year PROs in patients with borderline dysplasia and LT tears who underwent hip arthroscopic surgery and (2) to compare these PROs to those of a matched-pair control group of patients with borderline dysplastic hips without LT tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery between September 2008 and August 2013. Patients were included if they had a preoperative diagnosis of borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and had preoperative and minimum 5-year postoperative modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain scores. Exclusion criteria were osteoarthritis of Tönnis grade >1, previous hip conditions, any previous ipsilateral hip surgery, or workers' compensation status. There were 2 borderline dysplastic groups created. An LT tear group was matched 1:1 to a control group (no LT tear) with similar age, sex, body mass index (BMI), and laterality via propensity score matching. Significance was set at P < .05.

RESULTS

A total of 24 patients with an LT tear (24 hips) were matched to 24 patients without an LT tear (24 hips). There was no significant difference in age, sex, BMI, or laterality between groups. The mean age was 36.2 ± 17.2 and 34.9 ± 15.9 years for the control and LT tear groups, respectively (P = .783). There were 17 (70.8%) and 16 (66.7%) female patients in the control and LT tear groups, respectively, and the mean preoperative LCEA was 23.3° and 22.2° in the control and LT tear groups, respectively. No differences were observed between groups in baseline PROs, intraoperative findings, or surgical procedures. LT debridement was performed in 17 (70.8%) patients in the LT tear group compared with 0 (0.0%) in the control group. Also, 5-year postoperative PROs were comparable in both groups, with the control group exhibiting superior Veterans RAND 12-Item Health Survey (VR-12) mental (P = .041) and Short Form-12 (SF-12) mental (P = .042) scores. Finally, hips with an intact LT were significantly more likely (P = .022) to achieve the patient acceptable symptomatic state (PASS) for the mHHS (100.0% and 75.0%, respectively). No significant differences were present between the groups for the minimal clinically important difference (MCID) of the mHHS (P = .140), MCID of the Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) (P = .550), or PASS of the HOS-SSS (P = .390).

CONCLUSION

After hip arthroscopic surgery, patients with borderline dysplasia and LT tears demonstrated favorable PROs at a minimum 5-year follow-up. Outcomes were similar to a matched-pair control group without LT tears, with the group with intact LTs showing higher VR-12 mental and SF-12 mental scores. Furthermore, patients with borderline dysplasia and intact LTs were significantly more likely to achieve the PASS for the mHHS.

Radiofrequency Microdebridement as an Adjunct to Arthroscopic Surgical Treatment for Recalcitrant Gluteal Tendinopathy: A Double-Blind, Randomized Controlled Trial

Background:

Recalcitrant greater trochanteric pain is increasingly recognized as an indication for surgical intervention. The arthroscopic approach has become rapidly more common than the open alternative.

Hypothesis:

Patients undergoing radiofrequency microdebridement (RFMD) as an adjunct to arthroscopic gluteal bursectomy (AGB) and iliotibial band release (ITBR) will experience better functional improvement than AGB and ITBR alone at 1 year.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 33 patients with failed nonoperative treatment of gluteal tendinopathy were randomly allocated to undergo AGB/ITBR or AGB/ITBR + RFMD. Full-thickness tears were excluded. The primary outcome measure was the modified Harris Hip Score (mHHS) at 52 weeks. Secondary outcome measures included the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and 12-item Short Form Health Survey (SF-12), which were evaluated at 0, 6, 12, 24, and 52 weeks. Statistical significance was defined as P < .05.

Results:

A total of 33 participants (33 hips; 30 female and 3 male; mean age, 58 years) were randomized; 16 patients underwent AGB/ITBR + RFMD, and 17 underwent AGB/ITBR. Participants’ functionality improved in both groups at all time intervals. The mean mHHS score improved from 57.49 ± 10.61 to 77.76 ± 18.40 (P = .004) and from 58.98 ± 12.33 to 79.96 ± 18.86 (P = .001) at 52 weeks in the AGB/ITBR and AGB/ITBR + RFMD groups, respectively, although there was no statistically significant difference between groups. There were no device-related adverse events.

Conclusion:

AGB/ITBR led to significant improvements in patients with recalcitrant gluteal tendinopathy. In this small RCT, the addition of RFMD showed no additional benefit to AGB/ITBR but provided a safe adjunct for the surgical management of recalcitrant gluteal tendinopathy.

Registration:

NCT01562366 (ClinicalTrials.gov identifier).

Defining the Minimal Clinically Important Difference in Athletes Undergoing Arthroscopic Correction of Sports-Related Femoroacetabular Impingement: The Percentage of Possible Improvement

BACKGROUND

Measures of clinically meaningful improvement in patient-reported outcomes within orthopaedics are becoming a minimum requirement to establish the success of an intervention.

PURPOSE

To (1) define the minimal clinically important difference (MCID) at 2 years postoperatively in competitive athletes undergoing hip arthroscopic surgery for symptomatic, sports-related femoroacetabular impingement utilizing existing anchor- and distribution-based methods and (2) derive a measure of the MCID using the percentage of possible improvement (POPI) method and compare against existing techniques.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

There were 2 objective outcome measures-the modified Harris Hip Score (mHHS) and 36-Item Short Form Health Survey (SF-36)-administered at baseline and 2 years postoperatively. External anchor questions were used to determine the MCID through mean change, mean difference, and receiver operating characteristic (ROC) techniques. Distribution-based calculations consisted of 0.5 SD, effect size, and standard error of measurement techniques. The POPI was calculated alongside each technique as an achieved percentage change of maximum available improvement for each athlete relative to the individual baseline score. The impact of the preoperative baseline score on the MCID was assessed by assigning athletes to groups determined by baseline percentiles. Statistical analysis was performed, with P < .05 considered significant.

RESULTS

There were 576 athletes (96% male; mean age, 25.9 ± 5.7 years). The MCID score change (and POPI) for the mHHS and SF-36 ranged from 2.4 to 16.7 (21.6%-63.6%) and from 3.3 to 24.9 (22.1%-57.4%), respectively. The preoperative threshold value for achieving the ROC-determined MCID was 80.5 and 86.5 for the mHHS and 70.1 and 72.4 for the SF-36 for the patient-reported outcome measure (PROM) score- and POPI-calculated MCID, respectively. Through the commonly used mean change method, 40.0% (mHHS) and 42.4% (SF-36) of athletes were unable to achieve the MCID because of high baseline scores and PROM ceiling effects compared with 0% when the POPI technique was used. A highly significant difference for the overall MCID was observed between preoperative baseline percentile groups for the mHHS (P = .014) and SF-36 (P = .004) (improvement in points), while there was no significant difference between groups for either the mHHS (P = .487) or SF-36 (P = .417) using the POPI technique.

CONCLUSION

The MCID defined by an absolute value of improvement was unable to account for postoperative progress in a large proportion of higher functioning athletes. The POPI technique negated associated ceiling effects, was unrestricted by the baseline score, and may be more appropriate in quantifying clinically important improvement.

Radiographic and Demographic Factors Can Predict the Need for Primary Labral Reconstruction in Hip Arthroscopic Surgery: A Predictive Model Using 1398 Hips

BACKGROUND

Labral tears are the most common findings in patients with symptomatic femoroacetabular impingement (FAI). The restoration of labral function is critical, and labral reconstruction has been proposed as an alternative for irreparable tears.

PURPOSE

To compare preoperative radiographic measurements and demographics of patients who underwent primary arthroscopic labral reconstruction versus primary labral repair and to identify factors that are predictive of the need for reconstruction.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent their index hip arthroscopic procedure between October 2010 and November 2018 and underwent either labral reconstruction or repair were included in the study. A total of 18 variables (14 radiographic and 4 demographic) were assessed in a bivariate comparison and analyzed in a multivariate logistic model.

RESULTS

A total of 251 primary reconstruction and 1147 primary repair procedures were included. The logistic model selected age, body mass index (BMI), Tönnis grade, lateral center-edge angle (LCEA), and alpha angle. The odds of reconstruction were 2.52 times higher in patients with Tönnis grade 1 than 0 (odds ratio [OR], 2.52 [95% CI, 1.82-3.49]). Each additional degree in the LCEA was associated with a 6% increase in the odds of reconstruction (OR, 1.06 [95% CI, 1.04-1.09]) and 4% for each additional degree in the alpha angle (OR, 1.04 [95% CI, 1.03-1.05]). Higher age (per log 10 unit) and BMI also increased the likelihood of reconstruction (OR, 11.29 [95% CI, 4.23-30.10] and OR, 1.03 [95% CI, 1.00-1.06], respectively).

CONCLUSION

In a multivariate analysis, factors identified as preoperative predictors for primary arthroscopic labral reconstruction in the setting of FAI and labral tears were Tönnis grade, LCEA, age, and BMI. These predictive factors may be useful for the clinician in determining the preoperative likelihood of primary labral reconstruction.

Can the FEAR Index Be Used to Predict Microinstability in Patients Undergoing Hip Arthroscopic Surgery?

BACKGROUND

Atraumatic hip instability, or microinstability, is a challenging diagnosis for clinicians to make. Several radiographic parameters have been proposed to help identify patients with instability as a means to direct treatment. The Femoro-epiphyseal Acetabular Roof (FEAR) index was recently offered as a parameter to predict instability in a borderline dysplastic population.

PURPOSE

To evaluate the FEAR index in a series of predominantly nondysplastic patients undergoing hip arthroscopic surgery to determine if it can accurately predict patients with diagnosed microinstability at the time of surgery.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

A consecutive series of 200 patients undergoing hip arthroscopic surgery were evaluated for microinstability intraoperatively. Microinstability was diagnosed based on previously published criteria. Retrospectively, radiographic parameters were measured including the lateral center edge angle of Wiberg (LCEA), Tönnis angle, physeal scar angle, and FEAR index. Patients were excluded if they previously had any type of bony procedures performed, underwent prior open hip surgery or total hip arthroplasty of the ipsilateral hip, had osteoarthritis (Tönnis grade >1), or had any radiographic features of moderate-to-severe acetabular dysplasia including an LCEA <18°.

RESULTS

After applying exclusion criteria, 167 hips in 150 patients were analyzed. Based on an intraoperative assessment, 96 hips (57.5%) were considered stable, and 71 hips (42.5%) had signs of microinstability (unstable group). Patients in the unstable group had fewer radiographic findings of femoroacetabular impingement and higher rates of borderline dysplasia. All 4 measured angles were found to have excellent interobserver agreement. The FEAR index was significantly more positive in the unstable group compared with the stable group (-7.8° vs -11.3°, respectively; P = .004). A more positive FEAR index was also found in patients meeting intraoperative criteria for instability, with the exception of chondral wear pattern. Unstable nondysplastic patients (LCEA ≥25°, Tönnis angle ≤10°) also were found to have higher FEAR index values (-9.0° vs -12.0°, respectively; P = .012). A FEAR index cut-off of -5.0° was associated with a specificity of 92.4% and accuracy of 69.4% for predicting instability in a nondysplastic population.

CONCLUSION

The FEAR index was validated to improve the recognition of unstable patients preoperatively across a population with both borderline dysplastic and nondysplastic features.

Patient-Specific 3-D Magnetic Resonance Imaging-Based Dynamic Simulation of Hip Impingement and Range of Motion Can Replace 3-D Computed Tomography-Based Simulation for Patients With Femoroacetabular Impingement: Implications for Planning Open Hip Preservation Surgery and Hip Arthroscopy

BACKGROUND

Femoroacetabular impingement (FAI) is a complex 3-dimensional (3D) hip abnormality that can cause hip pain and osteoarthritis in young and active patients of childbearing age. Imaging is static and based on 2-dimensional radiographs or computed tomography (CT) scans. Recently, CT-based 3D impingement simulation was introduced for patient-specific assessments of hip deformities, whereas magnetic resonance imaging (MRI) offers a radiation-free alternative for surgical planning before hip arthroscopic surgery.

PURPOSE

To (1) investigate the difference between 3D models of the hip, (2) correlate the location of hip impingement and range of motion (ROM), and (3) correlate diagnostic parameters while comparing CT- and MRI-based osseous 3D models of the hip in symptomatic patients with FAI.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

The authors performed an institutional review board-approved comparative and retrospective study of 31 hips in 26 symptomatic patients with FAI. We compared CT- and MRI-based osseous 3D models of the hip in the same patients. 3D CT scans (slice thickness, 1 mm) of the entire pelvis and the distal femoral condyles were obtained. Preoperative MRI of the hip was performed including an axial-oblique T1 VIBE sequence (slice thickness, 1 mm) and 2 axial anisotropic (1.2 × 1.2 × 1 mm) T1 VIBE Dixon sequences of the entire pelvis and the distal femoral condyles. Threshold-based semiautomatic reconstruction of 3D models was performed using commercial software. CT- and MRI-based 3D models were compared with specifically developed software.

RESULTS

(1) The difference between MRI- and CT-based 3D models was less than 1 mm for the proximal femur and the acetabulum (median surface distance, 0.4 ± 0.1 mm and 0.4 ± 0.2 mm, respectively). (2) The correlation for ROM values was excellent (r = 0.99, P < .001) between CT and MRI. The mean absolute difference for flexion and extension was 1.9°± 1.5° and 2.6°± 1.9°, respectively. The location of impingement did not differ between CT- and MRI-based 3D ROM analysis in all 12 of 12 acetabular and 11 of 12 femoral clock-face positions. (3) The correlation for 6 diagnostic parameters was excellent (r = 0.98, P < .001) between CT and MRI. The mean absolute difference for inclination and anteversion was 2.0°± 1.8° and 1.0°± 0.8°, respectively.

CONCLUSION

Patient-specific and radiation-free MRI-based dynamic 3D simulation of hip impingement and ROM can replace CT-based 3D simulation for patients with FAI of childbearing age. On the basis of these excellent results, we intend to change our clinical practice, and we will use MRI-based 3D models for future clinical practice instead of CT-based 3D models. This allows radiation-free and patient-specific preoperative 3D impingement simulation for surgical planning and simulation of open hip preservation surgery and hip arthroscopic surgery.

Hip Arthroscopic Surgery in Borderline Developmental Dysplastic Hips: A Systematic Review

BACKGROUND

It remains controversial whether hip arthroscopic surgery should be applied to patients with a borderline developmental dysplastic hip (BDDH).

PURPOSE

To review the outcomes of hip arthroscopic surgery for a BDDH and which factors influence these outcomes.

STUDY DESIGN

Systematic review.

METHODS

PubMed, Embase, and the Cochrane Library were searched through March 2018 for studies reporting the outcomes of primary hip arthroscopic surgery in patients with a BDDH. Inclusion in the review was based on the definition of a BDDH, patient-reported outcomes, and duration of follow-up. The primary outcome was the modified Harris Hip Score (mHHS). The failure rate, visual analog scale, satisfaction score, and patient-reported outcomes such as the Hip disability and Osteoarthritis Outcome Score were defined as secondary outcomes.

RESULTS

Nine studies with 425 patients who underwent hip arthroscopic surgery were included in this review. The mean follow-up times ranged from 25.4 to 28.8 months across the studies. A significant improvement was obtained in the mHHS, with a mean score of 61.8 preoperatively to 82.8 postoperatively; all other patient-reported outcomes also improved significantly, except the 12-Item Short Form Health Survey mental component summary. The overall failure rate was 14.1%, and the mean reoperation rate was 8.5%. The rate of conversion to total hip arthroplasty ranged from 4.4% to 26.0%, and the rate of conversion to periacetabular osteotomy was 4.0%. Combined defects such as cartilage damage, hip osteoarthritis, ligamentum teres tears, and femoroacetabular impingement could influence the outcomes after arthroscopic surgery in BDDHs.

CONCLUSION

Hip arthroscopic surgery was demonstrated to be a promising approach for BDDHs, but the outcomes could be influenced by multiple risk factors. A higher level of evidence is still needed to support current findings.

Preoperative Performance of the PROMIS in Patients Undergoing Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) is being increasingly evaluated for use in orthopaedic surgery. The performance of the PROMIS in patients undergoing hip preservation surgery is unknown.

Purpose:

To investigate the psychometric performance of the PROMIS compared with legacy patient-reported outcome measures (PROMs) in patients indicated for hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Data from consecutive patients who underwent primary hip arthroscopic surgery between January and October 2018 for the treatment of FAIS were collected and analyzed. Baseline data, including preoperative PROM scores and demographics, were recorded. PROMs included the PROMIS Physical Function (PF), the Hip Outcome Score (HOS), the modified Harris Hip Score (mHHS), the International Hip Outcome Tool–12 (iHOT-12), and the Veterans RAND 12-item health survey (VR-12). Pearson and Spearman coefficient analyses were used to identify correlations between continuous and noncontinuous variables, respectively. Correlation was defined as excellent (>0.80), very good (0.71-0.80), good (0.61-0.70), fair (0.41-0.60), or poor (0.21-0.40). A multivariate linear regression analysis was used to identify preoperative predictors of having higher preoperative PROMIS scores.

Results:

A total of 197 patients with a mean age and body mass index (BMI) of 32.8 ± 12.6 years and 25.7 ± 5.6 kg/m², respectively, were included in the final analysis. There were no ceiling or floor effects for the PROMIS PF score observed in the study group. With regard to hip-specific measures, PROMIS PF scores demonstrated excellent correlation with HOS–Activities of Daily Living (r = 0.801; P < .001) scores, very good correlation with mHHS (r = 0.721; P < .001) and iHOT-12 (r = 0.722; P < .001) scores, and good correlation with HOS–Sports Specific (r = 0.675; P < .001) scores. With regard to general health–related quality of life (HRQoL) measures, PROMIS PF scores demonstrated very good correlation with VR-12 mental (r = 0.721; P < .001) scores, good correlation with VR-12 physical (r = 0.618; P < .001) scores, and poor correlation with visual analog scale for pain (r = –0.365; P < .001) scores. Patients who reported being physically active were more likely to have a higher preoperative PROMIS score (β = 3.216; P = .004). Lower PROMIS scores were found in patients with a higher BMI (β = –0.236; P = .005) and in female patients (β = –2.608; P = .014).

Conclusion:

In patients with FAIS, the preoperative PROMIS PF scores demonstrated excellent to good correlation with legacy hip-specific instruments as well as with HRQoL measures. No ceiling or floor effects were identified. Notably, of the hip-specific PROMs administered, the PROMIS PF demonstrated the weakest correlation with the HOS–Sports Specific subscale. Physical activity, BMI, and sex were predictors of preoperative PROMIS scores in our patient population.

Biomarkers for Femoroacetabular Impingement and Hip Osteoarthritis: A Systematic Review and Meta-analysis

BACKGROUND

The early recognition and management of patients with hip lesions, such as femoroacetabular impingement (FAI) and early hip osteoarthritis (OA), may preempt significant hip morbidity. The identification of reliable biomarkers may help guide decision making in an efficient and cost-effective manner.

PURPOSE

To determine the biomarkers that have been associated with FAI as well as identify serum, synovial, and urinary analytes that have shown clinical utility in the prediction or identification of hip OA.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The terms "hip arthroscopy," "femoroacetabular impingement," "labral tear," "osteoarthritis," and "biomarker" were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, yielding 276 articles. After screening, 7 articles were included. Pooled estimates were calculated utilizing a fixed-effects inverse-variance model weighted for individual study size.

RESULTS

A total of 1747 patients with a mean age of 37.5 ± 4.5 years (76.4% female) were identified. Forty-three unique biomarkers were assessed. Although general proinflammatory cytokines IL-1 and TNF-α exhibited inconsistent trends in arthritic hips, IL-6 demonstrated a consistent increase (+84.8% [95% CI, 81.9%-87.6%]; P < .05). A significant difference was found in levels of the fibronectin-aggrecan complex (FAC) in patients with OA compared with controls (0.08 ± 0.40 vs 1.15 ± 0.35 μg/mL, respectively; P < .001). It was the only specific analyte to show a significant difference between those with and without OA. In the setting of FAI, cartilage oligomeric matrix protein (COMP) was significantly increased in athletes after adjusting for concurrent knee and hip OA. A statistically significant difference was present in FAI-positive hips (9.0 ± 0.1 [95% CI, 8.8-9.3]) compared with controls (8.4 ± 0.1 [95% CI, 8.2-8.4]) (P < .05). Other biomarkers, such as CXCL3, which exhibited statistically significant differences compared with controls, did not control for underlying factors such as age and concomitant lesions.

CONCLUSION

COMP and FAC are specific biomarkers with potential utility in the diagnosis and management of FAI and hip OA, given their ability to differentiate between controls and patients with hip lesions. Further research is necessary to identify their ability in determining disease severity, predicting the response to treatment, and establishing an association with the risk of long-term OA.

Hip Function 6 to 10 Months After Arthroscopic Surgery: A Cross-sectional Comparison of Subjective and Objective Hip Function, Including Performance-Based Measures, in Patients Versus Controls

Background:

Little is known about hip-related function, mobility, and performance in patients after hip arthroscopic surgery (HA) during the time that return to sports can be expected.

Purpose:

To evaluate measures of subjective and objective hip function 6 to 10 months after HA in patients compared with healthy controls and to compare objective function in the HA group between the operated and nonoperated hips.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 33 patients who had undergone HA (mean, 8.1 ± 2.6 months postoperatively) and 33 healthy participants matched on sex, age, and activity level were compared regarding subjective hip function (Copenhagen Hip and Groin Outcome Score [HAGOS]) and objective function including hip range of motion (ROM; flexion, internal rotation, and external rotation), isometric hip muscle strength (adduction, abduction, flexion, internal rotation, and external rotation), and performance-based measures: the Y Balance Test (YBT), medial and lateral triple-hop test, and Illinois agility test. Group differences were analyzed using independent-samples t tests. Paired-samples t tests were used for a comparison of the operated and nonoperated hips. Standard effect sizes (Cohen d) were provided for all outcomes.

Results:

The HA group reported worse subjective hip function than the control group (HAGOS subscores: d = –0.7 to –2.1; P ≤ .004). Objective measures of hip ROM (d = –0.5 to –1.1; P ≤ .048), hip flexion strength (d = –0.5; P = .043), and posteromedial reach of the YBT (d = –0.5; P = .043) were also reduced in the HA group, although there were no significant differences between groups regarding the remaining objective measures (d = –0.1 to –0.4; P ≥ .102 to .534). The only significant difference between the operated and nonoperated hips in the HA group was reduced passive hip flexion (d = –0.4; P = .045).

Conclusion:

Patients who had undergone HA demonstrated reduced subjective hip function compared with controls 6 to 10 months after surgery, when return to sports can be expected. While most objective strength and performance test results were comparable between the HA and control groups at 6 to 10 months after surgery, the HA group presented with impairments related to hip mobility and hip flexion strength. No consistent pattern of impairments was found in operated hips compared with nonoperated hips.

Understanding Preoperative Demographics and Risk Factors for Early Revision Surgery in Patients Undergoing Hip Arthroscopic Surgery: A Large Database Study

BACKGROUND

Hip arthroscopic surgery has become an increasingly common surgical technique to diagnose and treat various hip abnormalities. While increased efficacy has been reported, debate remains regarding appropriate surgical indications. Multiple factors including patient demographics, surgical procedure, and underlying disease have been associated with poor surgical outcomes. Preoperative diagnostic and treatment interventions including physical therapy and injections may affect surgical indications and outcomes.

PURPOSE

To identify patient characteristics and preoperative factors associated with an increased risk of early revision surgery and/or extended postoperative medical care after index hip arthroscopic surgery.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Utah's All Payer Claims Database, a state-mandated registry containing data from all payers, including private insurance, Medicare Advantage, and Medicaid, was queried to identify patients who underwent hip arthroscopic surgery during a 3-year period (January 1, 2013, to December 31, 2015). Demographics, comorbidities, nonoperative care modalities, pain medications, and revision procedures were collected using claims data at 6 months preoperatively and 12 months postoperatively.

RESULTS

A total of 1283 patients who underwent primary hip arthroscopic surgery were analyzed, of whom 57.6% (n = 739) were female. Within 1 year of index surgery, 7.8% and 2.1% of patients underwent revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA), respectively. Patients older than 60 years and male patients were more likely to undergo revision arthroscopic surgery (odds ratio [OR], 0.89; P < .001 and OR, 1.59; P = .04, respectively) and convert to THA (OR, 1.03; P = .01 and OR, 2.25; P = .05, respectively). Preoperative opioid use was significantly associated with increased odds of revision surgery (OR, 1.64; P = .05) and THA (OR, 2.70; P = .03). No significant relationship existed between preoperative physical therapy or intra-articular hip injections and revision hip arthroscopic surgery (OR, 1.20; P = .45 and OR, 1.18; P = .52, respectively) or conversion to THA (OR, 0.89; P = .79 and OR, 0.71; P = .46, respectively).

CONCLUSION

This study showed that predictable patient factors can effectively guide preoperative decision making and may improve prognosis. Certain patient pools require optimization preoperatively, and a subset of patients appears to require additional surgical indications.

Influence of Cigarette Smoking at the Time of Surgery on Postoperative Outcomes in Patients With Femoroacetabular Impingement: A Matched-Pair Cohort Analysis

BACKGROUND

There is literature on the association between smoking in patients undergoing orthopaedic procedures and poor short-term outcomes. However, there are few data on smoking as an independent predictor of midterm outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI).

PURPOSE

To evaluate 2-year postoperative outcomes in patients undergoing hip arthroscopic surgery for FAI in current smokers compared with an age- and body mass index (BMI)-matched group with no smoking history.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients undergoing primary hip arthroscopic surgery for FAI between June 2012 and January 2016 were screened for smoking habits. Exclusion criteria included revision or bilateral surgery, dysplasia, and less than 2-year follow-up. Forty current smokers at the time of surgery were matched 1:2 by age and BMI to patients with no smoking history. Outcome measures included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports-Specific Subscale (SSS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction. Minimal clinically important difference (MCID) and patient acceptable symptom state rates were calculated for all patients.

RESULTS

All patients demonstrated significant improvements in all outcome measures ( P < .001). Current smokers experienced inferior postoperative HOS-ADL (80.4 vs 89.1, respectively; P = .013) and HOS-SSS (65.8 vs 75.6, respectively; P = .046) scores and greater VAS pain scores (3.2 vs 1.8, respectively; P = .011) than nonsmokers. Current smoking was correlated with inferior HOS-ADL ( r = -0.27, P = .003) and HOS-SSS ( r = -0.18, P = .046) scores and greater VAS pain scores ( r = 0.26, P = .005). Controlling for age, sex, and BMI, smoking was a significant independent predictor of postoperative HOS-ADL (β = -8.7 [95% CI, -14.3 to -3.0]; P = .003), HOS-SSS (β = -9.8 [95% CI, -19.5 to -0.2]; P = .046), and VAS pain (β = 14.6 [95% CI, 4.4 to 23.7]; P = .005) scores. Current smokers had lower odds of achieving the MCID for the HOS-ADL (odds ratio, 0.31 [95% CI, 0.12-0.83]; P = .019) and mHHS (odds ratio, 0.31 [95% CI, 0.10-0.88]; P = .028).

CONCLUSION

Current smokers had inferior postoperative HOS-ADL and HOS-SSS scores, increased pain, and lower odds of achieving the MCID for the HOS-ADL and mHHS at 2 years postoperatively than patients without any smoking history.

Use of Air Arthrograms to Aid in Joint Distraction During Hip Arthroscopic Surgery Decreases Postoperative Pain and Opioid Requirements

BACKGROUND

Positive-pressure air arthrography and venting of the hip capsule are techniques used to decrease the traction forces needed for joint distraction during hip arthroscopic surgery. Little is known about the effects that these techniques have on postoperative pain.

HYPOTHESIS

Positive-pressure air arthrography and venting during hip arthroscopic surgery will decrease patient-reported pain and narcotic requirements in the acute postoperative setting.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort analysis was conducted to analyze 35 patients who underwent positive-pressure air arthrography and venting to aid joint distraction during hip arthroscopic surgery versus a group with similar demographics, pathologies, and treatments who did not undergo air arthrography. Numeric pain rating scale (NPRS) scores and medication administration including narcotic and nonnarcotic analgesia in the postanesthesia care unit (PACU) were tracked and compared.

RESULTS

The maximum (7.17 vs 4.97, respectively), minimum (2.43 vs 1.09, respectively), and mean (5.15 vs 3.11, respectively) NPRS scores were all higher in the control group compared with the air arthrogram group (P < .001, P = .007, and P < .001, respectively). The administration of oral morphine equivalents (OMEs) during the PACU stay was significantly lower in the air arthrogram group, with a mean of 36.75 ± 11.37 OMEs, compared with 44.53 ± 16.06 OMEs in the control group (P = .023). There was no difference in postoperative nonopioid medications, such as ketorolac or acetaminophen, given between groups.

CONCLUSION

Patients undergoing hip arthroscopic surgery with air arthrography and venting used to aid distraction had significantly less postoperative pain and required a lower total dosage of opioids during their PACU stay when compared with patients who underwent hip arthroscopic surgery without air arthrography.

Primary Hip Arthroscopic Surgery With Labral Reconstruction: Is There a Difference Between an Autograft and Allograft?

Background:

Labral reconstruction has been described as a solution for the irreparable labrum. Initial techniques employed autografts, while more recent procedures have utilized allografts. No study, to our knowledge, has compared graft types.

Purpose:

To compare outcomes between patients who underwent primary labral reconstruction with a hamstring allograft versus hamstring autograft.

Hypothesis:

No significant differences in outcomes will be found between patients who underwent primary labral reconstruction with an allograft versus autograft.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data from September 2010 to March 2015 were reviewed. Inclusion criteria were primary hip arthroscopic surgery with labral reconstruction using either a hamstring allograft (ALLO group) or autograft (AUTO group), with minimum 2-year follow-up scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Exclusion criteria were previous ipsilateral hip surgery, previous hip conditions, preoperative Tönnis osteoarthritis grade >1, and workers’ compensation claims. Significance was set at P = .05.

Results:

Twenty-nine patients (29 hips) were included (85.3% follow-up). There were 17 patients (17 hips) in the ALLO group and 12 patients (12 hips) in the AUTO group. All patient-reported outcome scores demonstrated significant improvements at latest follow-up except for the mHHS for the AUTO group (P = .064). Comparisons between the ALLO and AUTO groups at the preoperative and latest follow-up time points showed no significant differences (preoperative mean [range]: mHHS, 67.5 [33.0-100.0] and 65.8 [29.0-96.0], respectively [P = .826]; NAHS, 65.6 [26.3-92.5] and 58.5 [35.0-79.0], respectively [P = .322]; HOS-SSS, 43.7 [12.5-100.0] and 40.1 [19.0-78.0], respectively [P = .707]) (latest follow-up mean [range]: mHHS, 86.4 [56.0-100.0] and 81.4 [57.0-100.0], respectively [P = .46]; NAHS, 87.7 [60.0-100.0] and 82.4 [56.3-100.0], respectively [P = .396]; HOS-SSS, 81.7 [0.0-100.0] and 70.9 [27.8-100.0], respectively [P = .423]).

Conclusion:

Primary arthroscopic hip labral reconstruction yielded improvements in patient-reported outcome scores and high patient satisfaction. In this small series, no differences were found in clinical outcomes between hamstring allografts and autografts. Based on these results, hamstring allografts and autografts may be considered comparable graft choices for primary reconstruction. Because of the avoidance of donor site morbidity and the possible increase in patient satisfaction, allografts may be the preferred choice in a surgical setting when they are accessible.

Do Female Athletes Return to Sports After Hip Preservation Surgery for Femoroacetabular Impingement Syndrome?: A Comparative Analysis

Background

Female patients undergoing surgery for femoroacetabular impingement syndrome (FAIS) often experience inferior clinical outcomes and higher failure rates when compared with male patients. The influence of athletic status on hip arthroscopic outcomes in female patients, however, is unclear.

Purpose

To compare patient-reported outcomes (PROs) of athletic and nonathletic female patients undergoing hip arthroscopic surgery for FAIS, and to determine the return-to-sports rate in the athlete group.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two-year PROs were assessed in female patients who had undergone hip arthroscopic surgery for FAIS by a single surgeon. Patients who self-identified as athletes were compared with nonathletes. Preoperative and postoperative PRO scores including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport-Specific (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction were analyzed and compared between athletes and nonathletes. Subanalysis was performed based on patient age and body mass index (BMI).

Results

A total of 330 female patients undergoing hip arthroscopic surgery for FAIS were identified. Of these, 221 patients identified as athletes (mean age, 29.1 ± 11.1 years; mean BMI, 23.0 ± 3.5 kg/m²) and 109 as nonathletes (mean age, 39.3 ± 11.4 years; mean BMI, 27.8 ± 5.8 kg/m²). Both groups demonstrated improvements in HOS-ADL, HOS-SS, mHHS, VAS for pain, and VAS for satisfaction scores (P < .001 for all). Athletes had significantly higher postoperative PRO scores compared with nonathletes (P < .001 for all). A 1:1 matched-pair subanalysis of 97 athletes and 97 nonathletes controlling for age and BMI indicated that these relationships held independently of potential demographic confounders (P < .001 for all). The number of patients meeting the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the HOS-ADL, HOS-SS, and mHHS was significantly higher in athletes aged ≤25 years versus those aged >25 years and for athletes versus nonathletes (P < .05 for all). Further, 189 of 194 athletes returned to sports at a mean of 6.0 ± 3.9 months postoperatively, with 93.7% reporting returning to the same or higher level of competition.

Conclusion

Among female patients undergoing hip arthroscopic surgery for FAIS, patients considered athletes achieved superior clinical outcomes compared with patients considered nonathletes. In addition, younger female athletes had higher rates of achieving the MCID and PASS for all PRO measures.

Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18° and 25° Appropriately?

BACKGROUND

Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population.

HYPOTHESIS

Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tönnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO.

RESULTS

Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P < .001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients.

CONCLUSION

A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.