Treatment of Anemia in Lower-Risk Myelodysplastic Syndrome.

OPINION STATEMENT: A majority of patients with lower-risk myelodysplastic syndrome (MDS) will present with or develop anemia. Anemia in MDS is associated with decreased quality of life and may correlate with decreased progression-free survival and overall survival. In this state of the art review we summarize current risk stratification approaches to identify lower-risk MDS (LR-MDS), the natural history of the disease, and meaningful clinical endpoints. The treatment landscape of LR-MDS with anemia is also rapidly evolving; we review the role of supportive care, erythropoietin stimulating agents, lenalidomide, luspatercept, hypomethylating agents (HMAs), and immunosuppressive therapy (IST) in the management of LR-MDS with anemia. In patients with deletion 5q (del5q) syndrome lenalidomide has both efficacy and durability of response. For patients without del5q who need treatment, the management approach is impacted by serum erythropoietin (EPO) level, SF3B1 mutation status, and ring sideroblast status. Given the data from the Phase III COMMANDS trial, we utilize luspatercept in those with SF3B1 mutation or ring sideroblasts that have an EPO level < 500 U/L; in patients without an SF3B1 mutation or ring sideroblasts there is equipoise between luspatercept and use of an erythropoietin stimulating agent (ESA). For patients who have an EPO level ≥ 500 U/L or have been previously treated there is not a clear standard of care. For those without previous luspatercept exposure it can be considered particularly if there is an SF3B1 mutation or the presence of ring sideroblasts. Other options include HMAs or IST; the Phase III IMERGE trial supports the efficacy of the telomerase inhibitor imetelstat in this setting and this may become a standard option in the future as well.

Hip Arthroscopy Results in Similar Short-Term Function Compared to Total Hip Arthroplasty in Patients of Similar Demographic Profiles.

Purpose: To review short-term functional outcomes in patients who underwent hip arthroscopy and to compare their outcomes to those of a demographically similar cohort who underwent total hip arthroplasty (THA). Methods: Data were prospectively collected and retrospectively reviewed for patients undergoing hip arthroscopy (SCOPE) between April 2008 and October 2015. SCOPE patients were included if they were ≥35 years, had preoperative and postoperative 2-year follow-up, and had no prior hip condition or ipsilateral hip surgery. SCOPE patients were matched 1:1 to a demographically similar cohort of patients who underwent THA at our institution. Matching criteria included similar age (within 5 years), gender, and body mass index (within 5). SCOPE patients were assessed with modified Harris Hip Score (mHHS), non-arthritic hip score, and visual analogue scale (VAS). THA patients were assessed with mHHS, forgotten joint score, and VAS. Results: Sixty-seven patients were included in each cohort. Patients who underwent hip arthroscopy for management of labral tears achieved nearly equivalent mHHS, Health Survey Short Form (SF-12) Mental, SF-12 Physical, Veterans RAND 12 Item Health Survey (VR-12) Mental, VR-12 Physical scores at latest follow-up compared to demographically similar patients who underwent THA. There was no significant difference in mHHS scores (SCOPE = 82.9 ± 16.4 vs THA = 87.3 ± 15, P = .095) between the 2 group groups. In addition, average patient satisfaction on a 10-point scale was 8.1 for the SCOPE cohort and 8.8 for the THA cohort (P = .052). Conclusions: Our results show that hip arthroscopy, when performed in patients with the appropriate indications, can lead to comparably excellent outcomes as total hip arthroplasty with significant pain relief at short term follow-up. Level of Evidence: Level III, retrospective cohort study.

Effect of marital status on patient-reported outcomes following total hip arthroplasty: a matched analysis with minimum 2-year follow-up.

INTRODUCTION: Mental health and patient expectation have been identified as key predictors of recovery following THA; however, there is limited literature examining the effects of social support and marital status on patient-reported outcomes (PROs). METHODS: Data were prospectively collected and retrospectively reviewed for patients who underwent THA between July 2008 and January 2016. Patients were included if they underwent primary THA during this period and if they had documented preoperative marital status of married, divorced, or never married. Married patients were group matched to non-married patients (divorced or never married) with similar sex, age, body mass index (BMI), gender distribution, and frequency of surgical approach. RESULTS: There were 414 married patients and 98 non-married patients who were eligible and had minimum 2-year follow-up. Mean PROs were significantly worse in the non-married group than the married group for the following measures: modified Harris Hip Score (p = 0.002), Harris Hip Score (p = 0.002), Forgotten Joint Score (p = 0.04), and the physical portions of the Veterans RAND (p = 0.025) and Short Form (p = 0.02) surveys. CONCLUSIONS: Our study demonstrated inferior absolute PRO scores at latest follow-up for patients who were non-married compared to married following THA. These results show that while total hip replacement may still yield clinical benefit in all patients, non-married patients may ultimately achieve an inferior functional status, and expectations should be adjusted accordingly. Physicians should assess levels of psychosocial support in their patients prior to undergoing hip arthroplasty in order to optimise results.

Effect of alcohol consumption on patient-reported outcomes in hip arthroscopy: a matched controlled study with minimum 2-year follow-up.

INTRODUCTION: There is a paucity of literature examining the effects of alcohol consumption on patient-reported outcomes (PROs) after hip arthroscopy. The purpose of this study was to report 2-year outcomes of hip arthroscopy in patients who consume alcohol compared to patients who abstain. METHODS: Registry data were prospectively collected and retrospectively reviewed to identify heavy drinkers at the time of primary hip arthroscopy. Patients were matched 1:1 (heavy drinkers:non-drinkers) based on age, sex, BMI, acetabular Outerbridge grade, and capsular treatment. All patients were assessed with 4 validated PROs: mHHS, NAHS, HOS-SSS, and iHOT-12. Pain was estimated with VAS. RESULTS: 42 patients were pair matched in each group (heavy drinkers:non-drinkers). Both groups demonstrated significant improvement for all PROs and VAS. Heavy drinkers reported lesser improvement in HOS-SSS (p = 0.0169), smaller decrease in VAS (p = 0.0157), and lower final scores on iHOT-12 (p = 0.0302), SF-12 mental (p = 0.0086), and VR-12 mental (p = 0.0151). Significantly fewer patients in the heavy-drinking group reached PASS for mHHS (p = 0.0464). Odds of achieving PASS for mHHS was 2.5 times higher for patients who abstain from alcohol. The rates of revision hip arthroscopy and conversion to total hip arthroplasty were not statistically different between groups. CONCLUSION: While hip arthroscopy may still yield clinical benefit in drinkers, patients who consume heavy amounts of alcohol may ultimately achieve an inferior functional status and should be counselled on drinking cessation to optimise their results.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols.

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).

Does Femoral Retroversion Adversely Affect Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Midterm Analysis.

PURPOSE: To report 5-year outcomes of arthroscopic treatment of femoroacetabular impingement syndrome in patients with femoral retroversion compared with a control group of patients with normal femoral anteversion. METHODS: Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy between August 2008 and April 2013. Patients were included in analysis if they underwent hip arthroscopy during this period and had femoral version ≤0° calculated using magnetic resonance imaging. Exclusion criteria included prior ipsilateral hip conditions/surgeries or Tönnis grade >1. These patients were pair matched with patients having femoral anteversion between 10° and 20° based on gender, body mass index ± 10, and age ± 10 years. Patient-reported outcomes (PROs) were collected at 3 months and 1 year postoperatively and annually thereafter. An a priori power analysis was performed. RESULTS: A total of 59 patients were identified as the experimental group out of 69 eligible for inclusion (86%). All 59 patients were matched, with a mean age of 37.4 years and mean body mass index of 26.9. Twenty patients were female, and 39 were male. These patients demonstrated significant improvement from their preoperative state in all patient-reported outcomes and visual analog score scores (P < .001). Thirty-eight patients met the threshold for minimal clinically important difference, and 35 achieved patient acceptable symptomatic state for the modified Harris Hip Score questionnaire. Seven patients converted to total hip replacement. No differences were noted between retroverted and control patients in any of the outcome measures collected, in pain or satisfaction ratings, in the frequency of or duration to secondary surgeries or in complication rate (P > .05). CONCLUSIONS: Patients with femoral retroversion demonstrated significantly higher outcomes at minimum 5-year follow-up after undergoing arthroscopic hip surgery. These outcomes were not different from those of patients with normal femoral version. While femoral retroversion should not be considered a contraindication to hip arthroscopy, it should be carefully considered as a factor in patient selection and surgical planning. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Perineal Pressure During Hip Arthroscopy Is Reduced by Use of Trendelenburg: A Prospective Study With Randomized Order of Positioning.

BACKGROUND: The use of traction during hip arthroscopy is commonly used to provide safe joint access and to improve visualization. However, traction during hip arthroscopy has been associated with complications ranging from transient neuropraxias to devastating soft-tissue necrosis. Trendelenburg positioning may be helpful, but the degree to which this is true is not well understood. QUESTIONS/PURPOSES: To determine whether there would be a reduction in perineal pressure at 5°, 10°, and 15° of Trendelenburg compared with baseline (0° of Trendelenburg) while in the modified supine position during hip arthroscopy. METHODS: A consecutive cohort of 50 patients treated with hip arthroscopy by a single, high-volume orthopaedic surgeon was analyzed. There were 30 females and 20 males in this study, with a mean age of 36 ± 16 years (range, 14 to 66 years); mean BMI was 26 kg/m. In the operating room, patients were placed in the modified supine position on a traction extension table with a well-padded perineal post. A standard blood pressure cuff was secured to the post to measure pressure exerted on the perineum as traction was applied to distract the hip. For each patient, pressure against the perineum was measured at four different positions using a digital level: 0°, 5°, 10°, and 15° of Trendelenburg. These positions were tested in a random order for each patient. Mean pressure was compared within patients under the four-period crossover design using a repeated-measure (mixed) ANOVA model. Examination of the residual error quantile plot showed that the pressure data followed a normal distribution, making the use of a parametric model appropriate. Tests were made for period and order effects. RESULTS: Compared with baseline (0° or no Trendelenburg) there was a reduction in pressure of 4.4 (15.5%) at 5° of Trendelenburg (p = 0.203), 8 (28%) at 10° of Trendelenburg (p = 0.022) and 13.1 (46%) at 15° (p = 0.006). These results were maintained regardless of the sequence of positions used in each patient (0°, 5°, 10°, 15°). CONCLUSIONS: Trendelenburg positioning of 10° and 15° during hip arthroscopy resulted in decreased perineal pressure compared with the neutral (0°) position. This technique is intended to harness gravity to exert the majority of countertraction while retaining the perineal post as a backup patient stabilizer. Routine introduction of Trendelenburg during hip arthroscopy reduces perineal pressure against the post, which may decrease complications related to traction and perineal pressure. Future studies should assess whether the observed differences in perineal pressure will reduce the frequency of post-related complications after hip arthroscopy. LEVEL OF EVIDENCE: Level II, therapeutic study.

Minimum 5-Year Outcomes of Arthroscopic Hip Labral Reconstruction With Nested Matched-Pair Benchmarking Against a Labral Repair Control Group.

BACKGROUND: Labral reconstruction has demonstrated short-term benefit for the treatment of irreparable labral tears. Nonetheless, there is a scarcity of evidence for midterm outcomes of this treatment. HYPOTHESES: Arthroscopic segmental reconstruction in the setting of irreparable labral tears would show improvement in patient-reported outcomes (PROs) and high patient satisfaction at minimum 5-year follow-up. Second, primary labral reconstruction (PLRECON) would result in similar improvement in PROs at minimum 5-year follow-up when compared with a matched-pair primary labral repair (PLREPAIR) control group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data from February 2008 to April 2013 were retrospectively reviewed. Patients were included if they underwent hip arthroscopy for segmental labral reconstruction in the setting of irreparable labral tear and femoroacetabular impingement, with minimum 5-year follow-up for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, patient satisfaction, and visual analog scale for pain. Exclusion criteria were Tönnis osteoarthritis grade >1, prior hip conditions, or workers' compensation claims. PLRECON cases were matched in a 1:3 ratio to a PLREPAIR control group based on age ±5 years, sex, and body mass index ±5 kg/m2. RESULTS: Twenty-eight patients were eligible for the study, of which 23 (82.14%) had minimum 5-year follow-up. The authors found significant improvement from preoperative to latest follow-up in all outcome measures recorded: 17.8-point increase in modified Harris Hip Score (P = .002), 22-point increase in Nonarthritic Hip Score (P < .001), 25.4-point increase in Hip Outcome Score-Sports Specific Subscale (P = .003), and a 2.9-point decrease in visual analog scale pain ratings (P < .001). Mean patient satisfaction was 7.1 out of 10. In the nested matched-pair analysis, 17 patients who underwent PLRECON were matched to a control group of 51 patients who underwent PLREPAIR. PLRECON demonstrated comparable survivorship and comparable improvements in all PROs with the exception of patient satisfaction (6.7 vs 8.5, P = .04). CONCLUSION: Hip arthroscopy with segmental labral reconstruction resulted in significant improvement in PROs at minimum 5-year follow-up. PLRECON reached comparable functional outcomes when compared with a benchmark PLREPAIR control group but demonstrated lower patient satisfaction at latest follow-up.

Midterm Outcomes of Iliopsoas Fractional Lengthening for Internal Snapping as a Part of Hip Arthroscopy for Femoroacetabular Impingement and Labral Tear: A Matched Control Study.

PURPOSE: To report minimum 5-year outcomes and rate of painful snapping resolution for patients who underwent iliopsoas fractional lengthening (IFL) as a part of hip arthroscopy for femoroacetabular impingement (FAI) and labral tear. In addition, to match this group to a group of patients who underwent hip arthroscopy for FAI and labral tear without internal snapping. METHODS: Patients were eligible for inclusion if they underwent hip arthroscopy for treatment of FAI and labral tear with concomitant IFL for painful snapping and had preoperative baseline scores for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Subscale, and visual analog scale for pain. The exclusion criteria for this study were preoperative Tönnis grade >0, active workers' compensation claims, or previous ipsilateral hip conditions. These patients were matched to a control group of patients who did not have snapping or undergo IFL but who otherwise satisfied the same inclusion and exclusion criteria. RESULTS: There were 57 eligible cases (80.3% follow-up). Mean follow-up time was 69.3 months (from 60.0 to 91.9). All patient-reported outcomes measures demonstrated statistically significant improvements between preoperative and latest follow-up scores for the following measures (P < .001): modified Harris Hip Score (from 64.3 to 84.9), Nonarthritic Hip Score (from 61.7 to 85.2), Hip Outcome Score-Sports Subscale (from 47.0 to 75.0), and visual analog scale (from 6.5 to 2.2). Mean satisfaction was 8.1 out of 10. Painful snapping was resolved in 80.7% of cases. Ten hips (17.5%) required secondary arthroscopy at a mean of 30.5 months. Three hips (5.3%) required total hip arthroplasty at a mean of 57.5 months. One case (1.8%) had minor postoperative complications. There were no statistically significant differences between the groups in outcomes, complications, and secondary surgeries. CONCLUSIONS: IFL as part of hip arthroscopy for treatment of FAI and labral tears demonstrated similar favorable improvement, complication rates, and secondary surgeries, when compared with a control group that did not undergo IFL. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prevalence of Generalized Ligamentous Laxity in Patients Undergoing Hip Arthroscopy: A Prospective Study of Patients' Clinical Presentation, Physical Examination, Intraoperative Findings, and Surgical Procedures.

BACKGROUND: Recent studies identified microinstability in the hip as a pathoetiology of painful hip conditions, and it was proposed that generalized ligamentous laxity conditions may predispose patients to such microinstability. PURPOSE: To study the relationship of generalized ligamentous laxity with patient characteristics, clinical presentation, intraoperative findings, and surgical treatments in a cohort of patients undergoing hip arthroscopy. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Registry data were prospectively collected and retrospectively reviewed between February 2014 and November 2017 for patients who underwent primary hip arthroscopy and had a documented Beighton score to assess generalized ligamentous laxity. Patients with a history of an ipsilateral hip condition or ipsilateral hip surgery, those with Tönnis grade >1, and those who had simultaneous arthroscopic and open procedures were excluded from the study. Two comparisons were made between patients with low and high Beighton scores: Beighton 0 vs ≥1 (B 0 vs B ≥1) and Beighton 0-3 vs ≥4 (B 0-3 vs B ≥4). Patient demographics, symptomatology, physical examination, and intraoperative findings were compared between these low and high Beighton groups. RESULTS: A total of 1381 patients met our inclusion and exclusion criteria. Within this patient population, there were 882 with B 0, 499 with B ≥1, 1120 with B 0-3, and 261 with B ≥4. B 0 was 54.1% female, compared with 84.2% of B ≥1. Similarly, B 0-3 was 58.5% female, while B ≥4 was 92.7% female. The difference in sex makeup was significant between both sets of groups ( P < .0001). The relative risk of having B ≥1 for women versus men was 2.869, and the relative risk of having B ≥4 for women versus men was 6.873. The patients with higher Beighton scores in B ≥1 and B ≥4 had a younger mean age at onset of symptoms ( P < .0001) and lower mean body mass index ( P < .0001) than those in B 0 and B 0-3, respectively. The B ≥1 group had higher preoperative range of motion with internal rotation ( P = .05), external rotation ( P = .017), and flexion ( P < .0001) than B 0 patients, as well as a lower frequency of Trendelenburg gait pattern ( P = .0268). Similarly, the B ≥4 group had higher range of motion than the B 0-3 group with internal rotation ( P = .030), external rotation ( P = .003), flexion ( P < .0001), and abduction ( P = .002). As compared with the lower-score groups, the higher-score groups also had smaller labral size and tear dimension ( P < .0001), and a higher proportion of these patients underwent labral repair, capsular repair, and iliopsoas fractional lengthening. CONCLUSION: Patients undergoing hip arthroscopy who have generalized ligamentous laxity are overall younger, have a lower body mass index, and are more often female, as compared with patients who have lesser laxity. Patients with higher preoperative Beighton scores had greater hip range of motion and smaller intraoperative labral size and tear dimensions. Additionally, these patients were more likely to undergo labral repair, capsular plication, and iliopsoas fractional lengthening.

Patients undergoing hip arthroscopy with active workers' compensation claims do not demonstrate inferior outcomes at mid-term.

INTRODUCTION: Workers' compensation (WC) claims have been associated with poor short-term outcomes after hip arthroscopy. We aim to report mid-term outcomes and return to work (RTW) among patients with WC claims. METHODS: Data were prospectively collected and retrospectively reviewed for patients undergoing hip arthroscopy between September 2008 and July 2011. Inclusion criteria were an active WC claim at time of surgery with preoperatively-documented patient-reported outcomes (PROs). Exclusion criteria were a previous hip condition and preoperative Tönnis grade >1. Patient-reported WC cases were pair-matched to non-WC cases based on body mass index (BMI) ± 5, age ± 5 years, gender, preoperative LCEA, labral treatment, and capsular treatment. RESULTS: 52 patients had minimum 5-year outcomes. Mean age was 40.6 (±10.6) years and a mean BMI of 27.5 (±5.3). 9 (16.7%) hips underwent secondary arthroscopies. 5 hips (9.3%) were converted to THA. There were 5 (9.3%) reports of numbness, all of which resolved spontaneously. Work status details were available for 49 patients and 47 patients (95.9%) returned to work. 42 WC hips were matched to 42 control hips. At ⩾5-year follow-up, patient-reported outcomes, visual analogue scale (VAS) and satisfaction were not different between the groups. All magnitudes in improvement were significantly higher in the WC group (p = < 0.001) except for VAS. No significant differences were found in rates of secondary arthroscopies, conversions to THA, or complications between the groups. CONCLUSIONS: WC patients have equal favourable mid-term outcomes as non-WC patients after hip arthroscopy for the treatment of femoroacetabular impingement and labral pathology.

Concomitant Arthroscopy With Labral Reconstruction and Periacetabular Osteotomy for Hip Dysplasia.

In the setting of true hip dysplasia, the high prevalence of intra-articular pathology may lead to recurrent symptoms and failure after periacetabular osteotomy (PAO). Femoral neck osteochondroplasty, microfracture, removal of loose bodies, and labral repair are examples of procedures that are performed with concomitant arthroscopy. When damage to the labrum is too severe to repair, reconstruction instead of extensive debridement before PAO can be more effective in restoring the labral seal to maintain joint lubrication and chondral protection. This Technical Note describes a method for concomitant hip arthroscopy with circumferential labral reconstruction with allograft and PAO.

In Revision Hip Arthroscopy, Labral Reconstruction Can Address a Deficient Labrum, but Labral Repair Retains Its Role for the Reparable Labrum: A Matched Control Study.

BACKGROUND: Revision hip arthroscopy is increasingly common and often addresses acetabular labrum pathology. There is a lack of consensus on indications or outcomes of revision labral repair versus reconstruction. PURPOSE: To report clinical outcomes of labral reconstruction during revision hip arthroscopy at minimum 2-year follow-up as compared with pair-matched labral repair during revision hip arthroscopy (control group) and to suggest a decision-making algorithm for labral treatment in revision hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent revision hip arthroscopy with labral reconstruction were matched 1:2 with patients who underwent revision arthroscopic labral repair. Patients were matched according to age, sex, and body mass index. Outcome scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, and a visual analog scale for pain, were collected preoperatively and at minimum 2-year follow-up. At latest follow-up, patient satisfaction on a 0-10 scale and the abbreviated International Hip Outcome Tool (iHOT-12) were collected. Complications, subsequent arthroscopies, and conversion to total hip arthroplasty were collected as well. RESULTS: A total of 15 revision labral reconstructions were pair matched to 30 revision labral repairs. The reconstructions had fewer isolated Seldes type I detachments ( P = .008) and lower postoperative lateral center-edge angle, but there were otherwise no significant differences in demographics, radiographics, intraoperative findings, or procedures. Both groups demonstrated significant improvements in all outcomes and visual analog scale at minimum 2-year follow-up. The revision repairs trended toward better preoperative scores: mHHS (mean ± SD: 59.3 ± 16.5 vs 54.2 ± 16.0), Non-Arthritic Hip Score (61.0 ± 16.7 vs 51.2 ± 17.6), Hip Outcome Score-Sport-Specific Subscale (39.6 ± 25.1 vs 30.5 ± 22.1), and visual analog scale (5.8 ± 1.8 vs 6.2 ± 2.2). At follow-up, the revision repair group had significantly higher mHHS (84.1 ± 14.8 vs 72.0 ± 18.3, P = .043) and iHOT-12 (72.2 ± 23.3 vs 49.0 ± 27.6, P = .023) scores than the reconstruction group. The magnitudes of pre- to postoperative improvement between the groups were comparable. The groups also had comparable rates of complications: 1 case of numbness in each group ( P > .999), subsequent arthroscopies (repair: n = 2, 6.5%; revision: n = 3, 20%; P = .150), and conversion to total hip arthroplasty (1 patient in each group, P > .999). CONCLUSION: Labral reconstruction safely and effectively treats irreparable labra in revision hip arthroscopy. However, labral repair is another treatment option for reparable labra, yielding similar magnitude of improvement. A proposed algorithm may assist in surgical decision making to achieve optimal outcomes based on the condition and history of each patient's acetabular labrum.

Hip Arthroscopy in Patients Ages 50 Years or Older: Minimum 5-Year Outcomes, Survivorship, and Risk Factors for Conversion to Total Hip Replacement.

PURPOSE: To report minimum 5-year outcomes and risk factors for conversion to total hip arthroplasty (THA) in patients ≥50 years old undergoing hip arthroscopy to treat labral tears and femoroacetabular impingement (FAI). METHODS: Data were prospectively collected on patients who underwent hip arthroscopy to treat labral tears and FAI between February 2008 and January 2012. The inclusion criteria were ≥50 years old at surgery, arthroscopic treatment for both labral tears and FAI, and preoperative patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and Visual Analog Scale (VAS). The exclusion criteria were Tönnis grade > 1 and previous hip conditions or surgeries. RESULTS: Of 103 eligible cases, 94 hips (91.3%) had minimum 5-year follow-up at a mean of 70.1 months (range, 60.0-95.1 months). All PROs and VASs demonstrated significant improvement at latest follow-up (P = .0001). Mean patient satisfaction was 8.4. All mean scores demonstrated durability from 2 years to latest follow-up, and NAHS (P = .009), HOS-SSS (P = .02), and VAS (P = .04) continued to significantly improve. Fifty-one (54.3%) of cases reached patient acceptable symptomatic state for mHHS, and 49 cases (52.1%) achieved minimal clinically important difference for this outcome measure. Four cases (4.3%) required secondary arthroscopy, and survivorship was 72.3%. Compared with survivors, the subgroup requiring THA demonstrated higher body mass indexes (P = .01), had larger alpha angles (P = .0200) and smaller lateral center-edge angles (P = .0200), and had higher proportions of Tönnis grade 1 (P = .0012), acetabular Outerbridge grade ≥ 2 (P = .0500), and femoral head Outerbridge grade ≥2 (P = .0001). CONCLUSIONS: Hip arthroscopy for the treatment of labral tears and FAI in patients ≥50 years old demonstrates statistically significant PRO improvements at minimum 5-year follow-up. However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. LEVEL OF EVIDENCE: Level IV, case series.

Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial.

BACKGROUND: Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL). METHODS: Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation. RESULTS: There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups. CONLCUSION: Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.

Arthroscopic Iliopsoas Fractional Lengthening.

BACKGROUND: Iliopsoas fractional lengthening (IFL) is performed on patients with symptomatic internal snapping. This condition is defined as painful and sometimes audible snapping of the iliopsoas (IP) tendon over the femoral head or iliopectineal line. Arthroscopic IFL is performed if the snapping is unresponsive to conservative treatment1,2. DESCRIPTION: Hip arthroscopy is performed with the patient in the supine position on a traction table. The portals used to access the joint capsule include standard anterolateral, mid-anterior, and distal anterolateral accessory (DALA) portals3. With a 70° arthroscope, diagnostic arthroscopy is conducted to assess the quality of labral tissue, acetabular and femoral cartilage surfaces, and the ligamentum teres. When indicated, supplementary procedures, such as acetabuloplasty, labral repair, or labral reconstruction4, are performed prior to IFL. With traction still applied, IFL is then performed from the central compartment at the level of the joint line. Exposure of the IP tendon is achieved with the use of a curved blade to extend the capsulotomy medially over the 3 o'clock position (right hip). Once the tendon can be appropriately visualized, a progressive and complete transverse cut is made in the tendinous portion, taking care to avoid the muscular portion. During this process, the anterolateral and mid-anterior portals serve as visualization and working portals, respectively5. ALTERNATIVES: Prior to arthroscopic IFL for painful internal snapping, nonsurgical options6,7 may include (1) physical therapy programs, (2) activity modification, (3) nonsteroidal anti-inflammatory drugs (NSAIDs), or (4) ultrasound-guided cortisone injections.