Editorial Commentary: The Severity of Femoral and Acetabular Articular Cartilage Defects Is Inversely Proportional to Mid- and Long-Term Success of Hip Arthroscopy.

The health of the articular cartilage is an important determinant of success with hip arthroscopy. Recent research has shown that articular cartilage damage on both the acetabular and femoral sides of the hip joint places patients at higher risk of failure after primary hip arthroscopy, leading to the need for revision arthroscopy or total hip arthroplasty. This risk appears to increase with the degree of cartilage damage and manifests at the mid- and long-term follow-up points. Future studies may use this conclusion as a justification to characterize chondral defects in greater detail, reporting on defect size and location, in addition to grade.

Secondary Hip Labral Reconstruction Yields Inferior Minimum 2-Year Functional Outcomes to Primary Reconstruction Despite Comparable Intraoperative Labral Characteristics.

PURPOSE: To compare intraoperative labral characteristics and minimum 2-year functional outcomes of allograft labral reconstruction in primary versus revision hip arthroscopy across multiple orthopaedic centers. METHODS: A retrospective multicenter hip arthroscopy registry was queried for patients with completed labral reconstruction surgeries from January 2014 to March 2023 with completed 2-year international Hip Outcome Tool-12 (iHOT-12) reports. Age, sex, and major intraoperative variables also were collected. Patients were placed in cohorts based on whether their arthroscopic allograft labral reconstruction was a primary procedure or secondary procedure (reconstruction following failed hip arthroscopy). One-way analysis of variance was performed on continuous variables. χ2 test was performed on categorical variables. Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and Substantial Clinical Benefit (SCB) also was assessed. RESULTS: In total, 77 patients met the inclusion and exclusion criteria and had complete information. The primary reconstruction group (n = 50) was significantly older than the secondary reconstruction group (n = 27) (47.5 ± 10.5 vs 39.1 ± 8.8 years; P = .001). In both cohorts, most patients had labral bruising, advanced labral degeneration, and/or grade III complexity of labral tearing. There was no difference in any recorded intraoperative findings (P = .160, P = .783, P = .357, respectively). Each cohort experienced significant improvement in iHOT-12 scores (P < .0001). However, patients undergoing secondary labral reconstruction reported inferior iHOT-12 scores (60.1 ± 29.2 vs 74.8 ± 27.0; P = .030). Patients undergoing primary reconstruction were more likely to reach MCID, PASS, and nearly normal SCB (92 vs 66.7%, P = .024; 68.0 vs 40.7%, P = .021; 76.0 vs 48.1%, P = .014, respectively). CONCLUSIONS: Primary and secondary allograft labral reconstruction show clinical improvement, but primary reconstruction demonstrates better outcomes and greater percentage of patients reaching MCID, PASS, and nearly normal SCB than reconstruction in the revision setting. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic case-control study.

Heel Pain - Plantar Fasciitis: Revision 2023.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain. J Orthop Sports Phys Ther 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303.

Diet Composition's Effect on Chronic Musculoskeletal Pain: A Narrative Review.

BACKGROUND: In the medical setting, clinicians frequently attend to patients with chronic musculoskeletal pain. Recent literature demonstrates diet may play a role in inflammation and musculoskeletal pain. OBJECTIVES: The purpose of this narrative review is to present the most current literature on the effect of common diet regimes, additions, and eliminations on chronic musculoskeletal pain. STUDY DESIGN: This is a narrative review of the literature on the effect of 1) Mediterranean diets; 2) vegetarian and vegan diets; 3) oils, seafood, and omega-3 fatty acids; 4) fruits; 5) spices and herbal teas; and 6) elimination diets on patient-reported musculoskeletal pain scores. METHODS: In January 2023, the Google Scholar and PubMed databases were reviewed to identify research on the effect of common diet regimes and additions on self-reported pain outcomes in patients with chronic musculoskeletal pain. RESULTS: A total of 32 original research articles and a systematic review were included and used to develop grades of recommendation. There is fair evidence that diverse, plant-based Mediterranean, vegetarian, and vegan diets may reduce musculoskeletal pain. Other dietary considerations, including adding marine oils, seafood, omega-3 fatty acids, antioxidant-rich fruits, and turmeric may also benefit patients with chronic musculoskeletal pain. There is poor-quality or insufficient evidence to support adding olive oil, ginger, or herbal teas to reduce pain. While eliminating aspartame and monosodium glutamate may reduce inflammation, there is poor-quality evidence that it reduces musculoskeletal pain. LIMITATIONS: This narrative review is not systematic in nature; instead, it aims to provide a current update on the effect of various diet regimes, additions, and eliminations on chronic musculoskeletal pain. The studies in this review are limited in sample size, study period, and robust comparisons to controls. This review is limited to studies on patients with either rheumatoid arthritis, osteoarthritis, or fibromyalgia due to the lack of relevant literature on other musculoskeletal pain conditions. CONCLUSIONS: Clinicians can play a role in the well-being of patients with chronic musculoskeletal pain through holistic interventions such as a dietary emphasis on plant-based regimes. Further research is necessary to elucidate the relationship between diet, inflammatory markers, and disease states, as well as the safety and contraindications of these dietary changes.

Editorial Commentary: Cam Femoroacetabular Impingement Requires Dynamic Assessment of Beta-Angle (Femoroacetabular Excursion Angle) and Consideration of Femoral and Acetabular Version: Cam Impingement in Patients With Acetabular or Femoral Retroversion May Warrant Greater Osteoplasty.

Radiographs, magnetic resonance imaging, and computed tomography scans have been commonly used to evaluate femoroacetabular impingement (FAI) and are well accepted forms of surgical planning. Assessing and addressing both the femoral and acetabular sides result in a combination of "one-sided" treatments that, in sum, net a successful treatment of FAI. However, combining one-sided approaches may not consider the dynamic interaction of the femoral head with the acetabulum. Elevated alpha angles alone can be indicative of a cam-type lesion without necessitating the presence of functional FAI. The presence of a cam-type lesion on lateral radiographs, as suggested by a positive alpha angle, does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle. Assessment of the beta angle, or femoroacetabular excursion angle, has the potential to address dynamic nature of FAI more accurately by directly measuring the degree of clearance between the femoral head and acetabulum. In addition, a comprehensive assessment of physical examination findings, particularly range of motion, as well as a summation of acetabular and femoral version (as measured by the McKibbin Index), are required. Cam-type of FAI poses a larger challenge in the patient with acetabular or femoral retroversion, which may warrant greater and more localized osteoplasty, distally, during hip arthroscopy.

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation.

BACKGROUND: The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation. PURPOSE/HYPOTHESIS: Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for <0.00, slight for 0.00-0.20, fair for 0.21-0.40, moderate for 0.41-0.60, substantial for 0.61-0.80, and almost perfect for >0.80. RESULTS: A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities. CONCLUSION: Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms.

Obesity Treatment in Orthopaedic Surgery.

According to the World Health Organization, obesity is a global health epidemic, which has nearly tripled in prevalence since 1975. Worldwide in 2016, 13% of adults 18 years and older had obesity (body mass index ≥ 30 kg/m2) and 39% were overweight (body mass index 25.0 to 29.9 kg/m2). In the United States, approximately 35% of adults have obesity and 31% are overweight. Obesity increases stress throughout the musculoskeletal system and carries a higher risk for the development of osteoarthritis and various other musculoskeletal conditions. When patients with obesity undergo orthopaedic procedures, weight loss is a critical aspect to appropriate preoperative counseling and treatment. Weight loss can improve obesity-related comorbidities such as metabolic syndrome, diabetes, cardiovascular disease, and obstructive sleep apnea, which in turn may reduce complications, minimize long-term joint stress, and improve outcomes among patients undergoing orthopaedic procedures. The effects of obesity on patients undergoing total joint arthroplasty has been previously described, with reported associations of increased risk of infection, revision, blood loss, venous thromboembolism, and overall costs. The purpose of this article was to provide orthopaedic surgeons with strategies for obesity treatment.

Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy.

BACKGROUND: Previous studies have demonstrated a clinically impactful change in patients between 1 and 2 years after hip arthroscopy. Assessment of differences in patient-specific factors between patients who remain the same and those who change (ie, either improve or decline) could provide valuable outcome information for orthopaedic surgeons treating those patients. PURPOSE: To identify patients who experienced change in functional status between 1 and 2 years after hip arthroscopy for femoroacetabular impingement syndrome and assess differences in patient-specific factors between those who improved, remained the same, or declined in functional status. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Prospectively collected data for patients who underwent hip arthroscopy at 1 of 7 centers were analyzed retrospectively at 1 year and 2 years postoperatively. Patients were categorized as "improved,""remained the same," or "declined" between 1- and 2-year follow-up based on the 12-item International Hip Outcome Tool (iHOT-12) minimal clinically important difference (MCID) value. A 1-way analysis of variance was used to assess differences in iHOT-12 scores, age, body mass index (BMI), alpha angle, and center-edge angle (CEA) between groups. Chi-square analyses were used to assess differences in the proportions of male and female patients in the outcome groups. RESULTS: The study included 753 patients (515 women and 238 men), whose mean ± SD age was 34.7 ± 12 years. Average 1-year (±1 month) and 2-year (±2 months) iHOT-12 scores for all patients were 73.7 and 74.9, respectively. Based on the calculated MCID of ±11.5 points, 162 (21.5%) patients improved, 451 (59.9%) remained the same, and 140 (18.6%) declined in status between 1- and 2-year follow-up. Those who improved between 1 and 2 years had lower 1-year iHOT-12 scores (P < .0005). We found no difference in age, BMI, alpha angle, CEA, or sex between groups (P > .05). CONCLUSION: Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. Those with iHOT-12 scores indicating abnormal function at 1 year improved beyond the MCID at 2 years follow-up. Thus, any decisions about the failure or success of arthroscopic hip procedures should not be made until at least the 2-year follow-up. Failing to thrive at 1-year follow-up may not accurately predict outcomes at year 2 or beyond. This could potentially decrease the perceived need for revision surgery in patients who do not thrive before 2-year follow-up.

Symptom duration predicts inferior mid-term outcomes following hip arthroscopy.

INTRODUCTION: Studies have demonstrated a negative relationship between the length of time with symptoms and patient-reported outcome measures in primary hip arthroscopy. Our aim was to expand the generalizability of this finding with a multi-center cohort. METHODS: A multi-center hip arthroscopy registry was queried for patients undergoing primary hip arthroscopy from 2014 to 2017. Patients were stratified according to whether pre-operative symptom duration exceeded two years or did not exceed two years. A Wilcoxon rank sum test was performed for differences in two year post-operative outcome scores. Logistic regression models analyzed the influence of symptom duration on achieving clinically meaningful thresholds (minimum clinically important difference, patient-acceptable symptom state, substantial clinical benefit) when controlling for baseline scores, age, BMI, and sex. RESULTS: Seven hundred forty-four patients met the inclusion criteria, from which 620 had complete outcomes information. The mean ± SD 2-year iHOT-12 scores of patients with symptom duration greater than two years (69 ± 26) were significantly lower than patients with symptom duration less than two years (77 ± 23) (Dunn test, p < 0.001). Chronic duration of pain was a negative predictor of achieving iHOT-12 MCID (0.47 [0.31-0.72]), PASS (0.53 [0.37-0.76]), and SCB (0.67 [0.47-0.94]). CONCLUSION: When controlling for differences in baseline demographic factors and pre-operative iHOT-12 scores, patients with chronic pain report poorer functional outcomes at mid-term follow-up. These results suggest that chronic pain predicts inferior outcomes from primary hip arthroscopy and that surgical intervention at earlier time points may be beneficial in achieving better outcomes.

Acetabular Cartilage Lesions Predict Inferior Mid-Term Outcomes for Arthroscopic Labral Repair and Treatment of Femoroacetabular Impingement Syndrome.

PURPOSE: To analyze the effect of acetabular chondrosis at a minimum of 2 years following hip arthroscopy in patients undergoing labral repair and treatment of femoroacetabular impingement. METHODS: From 2014 to 2017, patients undergoing arthroscopic labral repair were prospectively enrolled in a multicenter hip arthroscopy registry. The registry was retrospectively queried for primary labral repair patients with complete 2-year outcomes and a Tonnis grade of less than 2. Patients were grouped according to severity of articular cartilage damage noted intraoperatively using the Beck classification system: none, low-grade (Grade 1 or 2), or high-grade (Grade 3 or 4) damage. A Kruskal-Wallis test and post hoc Dunn's test with Holm correction compared 2-year postoperative outcome scores of the iHOT-12 scale between groups. The proportion of patients in each cohort who achieved the clinically significant thresholds of the minimum clinically important difference (MCID), patient-acceptable symptom scale, and substantial clinical benefit (SCB) were analyzed. Multivariate logistic regression models identified predictors of achieving clinical thresholds while controlling for demographic variation. RESULTS: 422 patients met inclusion criteria, from which 347 completed 2-year outcomes. All groups experienced improvement in iHOT-12 scores from baseline to follow-up (P < .001). iHOT-12 scores at follow-up were inferior for Low-Grade Damage and High-Grade Damage Groups relative to the No Damage Group (P = .04; P = .03). When accounting for age, body mass index, gender, and preoperative iHOT-12 scores in logistic regression models, the presence of high-grade lesions was a negative predictor for achieving SCB (OR [95% CI], 0.54 [0.29-0.96]) and low-grade lesions a negative predictor for achieving MCID (0.50 [0.27-0.92]. Among patients with high-grade lesions, there was no significant difference in 2-year iHOT-12 scores between those undergoing chondroplasty (n = 50) and those undergoing microfracture (n = 14) (P = .14). CONCLUSIONS: Acetabular cartilage damage portends inferior patient-reported outcomes 2 years after primary labral repair and treatment of femoroacetabular impingement. The presence of cartilage lesions was a negative predictor of individual achievement of several clinical thresholds. LEVEL OF EVIDENCE: III, Retrospective comparative cohort.

Cannabinoids in the Orthopedic Setting: A Literature Review.

Public interest in the analgesic potential of cannabinoids has grown, but there is no consensus regarding orthopedic applications. Available evidence was identified for cannabinoid use in arthritis, neuropathic pain, fibromyalgia, multiple sclerosis, and postoperative pain. Extracted information included the risks of preoperative use, associations with opioid dependence, and surgical complications. There is limited evidence for therapeutic benefit of cannabinoids in rheumatoid arthritis and fibromyalgia. Cannabinoids are not indicated for postoperative pain. Preoperative unregulated use has been linked with postoperative opioid dependence. Cannabinoids may be considered a second- or third-line treatment for analgesia for some orthopedic pathologies. [Orthopedics. 2022;45(4):e183-e189.].

Labral Degeneration Predicts Inferior Mid-Term Outcomes in Hip Labral Repair: A Multicenter Comparative Analysis.

PURPOSE: To analyze and compare the mid-term outcomes of hip arthroscopy for patients with and without labral degeneration from multiple orthopaedic centers. The purpose of this research is to develop an understanding of the impacts of labral degeneration on patient outcomes following arthroscopic treatment of labral tears. METHODS: A prospective multicenter hip arthroscopy registry was queried for primary surgeries from January 2014 to October 2017 with completed 2-year International Hip Outcome Tool-12 (iHOT-12) reports. Patients were placed into cohorts based on the presence or absence of labral degeneration noted intraoperatively during hip arthroscopy. Degeneration was defined as yellowing, ossification, or calcification present in at least 50% of the labrum. Differences in baseline variation between groups were assessed with a Wilcoxon rank-sum test or χ2 test. Two-year outcomes were assessed with iHOT-12. Multivariate logistic regression models were fitted while controlling for age, body mass index, sex, and preoperative iHOT-12 scores to identify significant predictors of achieving the clinically significant thresholds of minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptom scale. RESULTS: In total, 735 patients met inclusion criteria, of whom 613 had complete outcomes information. Relative to the control group, the labral degeneration group was significantly older (mean age 44 ± 11 years vs 33 ± 12 years; P < .01). Both groups experienced statistically significant improvement in iHOT-12 scores from baseline to final follow-up (P < .001); however, patients with labral degeneration reported inferior 2-year iHOT-12 scores when compared with patients without degeneration (P < .001). In the logistic regression models, labral degeneration was a significant negative predictor of achieving iHOT-12 minimal clinically important difference (odds ratio [OR] 0.47; 95% confidence interval [95% CI] 0.28-0.79), patient acceptable symptom state (OR 0.50; 95 CI 0.32-0.77), and substantial clinical benefit (OR 0.58; 95% CI 0.37-0.89). CONCLUSIONS: The results of our study conclude that patients with nondegenerative labral tissue at the time of repair have superior patient-reported outcomes at mid-term follow-up. The presence of labral degeneration was a negative predictor of achieving clinically significant thresholds after controlling for patient age, body mass index, sex, and baseline iHOT-12 scores. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Multicenter Outcomes After Primary Hip Arthroscopy: A Comparative Analysis of Two-Year Outcomes After Labral Repair, Segmental Labral Reconstruction, or Circumferential Labral Reconstruction.

PURPOSE: (1) To report minimum 2-year follow-up patient-reported outcome measures in patients undergoing labral repair (LR), segmental labral reconstruction (SLR), or circumferential labral reconstruction (CLR) in the primary setting; and (2) to compare minimum 2-year follow-up patient-reported outcome measures among these groups. METHODS: A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. Inclusion criteria were patients undergoing hip arthroscopy for treatment of labral tear and femoroacetabular impingement syndrome between January 2014 and October 2017, and completion of minimum 2-year postoperative outcome scores. Exclusion criteria were patients undergoing revision hip surgery, labral treatment limited to debridement, lateral center-edge angle <20°, osteoarthritis (Tönnis grade > 1), slipped capital femoral epiphysis, workers compensation status, and patients undergoing concomitant gluteus medius and/or minimus repair. Labral reconstruction patients were matched (1:3) with labral repair patients on age, sex, and body mass index. The labral reconstruction group was further stratified into SLR, and CLR groups. Patient demographic characteristics and clinical outcomes including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool, and visual analog scale for pain were analyzed, as well as achievement of the minimal clinical improvement difference (MCID). A P-value less than .05 indicated statistical significance. RESULTS: A total of 416 patients were included (LR, n = 312; SLR, n = 53; CLR, n = 51). The age, body mass index, and sex of the matched cohort were 42.3 ± 11.2 years, 24.7 ± 3.7, and 55.0% female. At a minimum of 2-year after hip arthroscopic surgery, no differences were found in preoperative, postoperative, or the delta visual analog scale for pain, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, or international Hip Outcome Tool. Subsequently, the proportion of patients achieving the MCID and the PASS at latest follow-up were analyzed. This analysis revealed that no significant differences in the rate of MCID or PASS achievement for any outcome measure existed based on labral treatment. CONCLUSIONS: In this multicenter study on labral treatment in the primary setting, patients undergoing LR, SLR, and CLR demonstrated no difference in preoperative or postoperative scores, nor the proportion of patients achieving clinically significant outcome improvement. LEVEL OF EVIDENCE: III; therapeutic outcome study with controls.

Addressing Smoking in Musculoskeletal Specialty Care.

➤: Physicians who advise patients to quit smoking substantially improve cessation rates, but cessation counseling is currently underperformed. ➤: Counseling, pharmacotherapy, and additional interventions can improve the chance of successful smoking cessation. Most patients require multiple attempts at quitting to be successful. ➤: A list of referral contacts and resources should be developed and routinely offered to these patients. The national Quitline (1-800-QUIT-NOW) provides free access to trained counselors and "quit coaches" for each state program in the United States. ➤: Government and private insurance plans in the United States are required (in most cases) to cover the cost of 2 quitting attempts per year including counseling referrals and medications. ➤: Several biopsychosocial factors that affect orthopaedic outcomes (weight, anxiety, depression, etc.) are also relevant to smoking cessation; management of these factors is thus potentially aggregately advantageous.

Multicenter Outcomes After Revision Hip Arthroscopy: Comparative Analysis of 2-Year Outcomes After Labral Repair Versus Labral Reconstruction.

BACKGROUND: There is a paucity of literature evaluating patient outcomes in patients undergoing revision labral repair and labral reconstruction. PURPOSE: To compare outcomes in patients undergoing revision hip arthroscopy for treatment of labral tears by labral repair or labral reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. An a priori power analysis determined that a total of 62 patients were required. Patients undergoing revision hip arthroscopy for labral tears with completed 2-year outcome scores were included. Patients undergoing primary hip arthroscopy, labral debridement, concomitant gluteal repair, and patients with hip dysplasia (lateral center-edge angle <20°) were excluded. Patients were grouped into revision labral repair and labral reconstruction groups. Patient demographics and patient-reported outcomes (PROs) including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool-12, visual analog scale for pain and satisfaction, and achievement of minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were analyzed. RESULTS: A total of 40 patients underwent revision labral repair and 55 patients underwent labral reconstruction. Patients undergoing revision labral repair were younger (mean age, 30.0 ± 10.7 years vs 34.4 ± 9.7 years; P = .048), had lower rates of labral degeneration (25.0% vs 62.7%; P = .004), and had lower rates of severe complexity of tears (21.1% vs 66.0%; P = .003). However, the labral repair group had higher rates of articular cartilage damage (62.5% vs 33.3%; P = .009). There were no differences in any preoperative or 2-year postoperative PROs. Furthermore, no differences were seen in achievement of MCID or PASS in any PRO. CONCLUSION: In this multicenter study on revision hip arthroscopy, patients undergoing revision labral repair were younger and had better labral characteristics but greater cartilage damage compared with patients undergoing labral reconstructions. Despite these differences, patients who underwent labral repair reported similar outcomes to those undergoing labral reconstruction.

Arthroscopic Treatment and Outcomes of Borderline Dysplasia With Acetabular Retroversion: A Matched-Control Study From the MASH Study Group.

BACKGROUND: Although acetabular retroversion (AR) occurs in dysplasia, management of the crossover sign (COS) or outcomes in borderline dysplasia (BD) with AR have not been reported. PURPOSE: To report any differences in the management of the COS in BD and nondysplastic hips and to report comparative outcomes of BD with AR with matched controls with BD or AR (ie, focal pincer femoroacetabular impingement [FAI]). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter matched-pair study was performed with data from a large prospectively collected database. Inclusion criteria were patients who had undergone primary unilateral hip arthroscopy including labral repair for FAI and/or chondral pathology without significant osteoarthritis (ie, Tönnis grade 0 or 1). The study group (BD+AR) was defined radiographically by lateral center-edge angle (LCEA) on standing anteroposterior pelvis of 18° to 25° and positive COS. A 1:1:1 matching on age, sex, and body mass index was performed with a control group with BD and another control group with AR (LCEA, >25°+COS). Acetabuloplasty rates were determined for each group. Mean 2-year outcomes including the 12-Item International Hip Outcome Tool (iHOT-12), minimally clinical important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) scores were compared. Subanalysis of the study group both with and without acetabuloplasty was performed. RESULTS: There were 69 patients, with 23 in the study group and 23 in each control group. The effect of dysplasia with or without the presence of the COS resulted in changes in acetabuloplasty rates, with 0% performed in the BD group, 35% in the BD+AR study group, and 91% in the AR group (P = .001). Arthroscopic outcomes demonstrated similar and significant mean 2-year improvement of iHOT-12 patient-reported outcomes, MCID, SCB, and PASS scores in the study and both control groups. There was a trend within the study group toward greater postoperative iHOT-12 scores in patients who received anterior-based acetabuloplasty than those who did not receive acetabuloplasty (81.7 and 70.4, respectively; P = .11). CONCLUSION: Acetabular coverage influences the management of the COS, with significantly lower acetabuloplasty rates in BD with AR compared with AR without BD (focal pincer impingement). Symptomatic patients with combined BD and AR had similar significant successful outcomes to those of patients with BD and those with AR (focal pincer impingement), whether treated without acetabuloplasty or, less frequently, with limited anterior-based acetabuloplasty.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021.

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Allocation of Anchors During Labral Repair: A Multicenter Cohort Analysis of Labral Treatment in Hip Arthroscopy.

BACKGROUND: While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue. PURPOSE/HYPOTHESIS: To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o'clock denoted the anterior extent of the tear and 9 o'clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of "hours" spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers. RESULTS: A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o'clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size (P < .001 for all), using 1 to 1.6 anchors for 1-hour tears, 1.7 to 2.4 anchors for 2-hour tears, 2.1 to 3.2 anchors for 3-hour tears, and 2.2 to 4.1 for 4-hour tears. CONCLUSION: Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc >2 hours, at least 2 anchor points were fixated.

Tenotomy for Iliopsoas Pathology is Infrequently Performed and Associated with Poorer Outcomes in Hips Undergoing Arthroscopy for Femoroacetabular Impingement.

PURPOSE: The purpose of this article was to report prevalence of iliopsoas pathology in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI), incidence of rendered tenotomy, and outcomes of hips with iliopsoas involvement compared with those with primary FAI. METHODS: A cohort study from a hip arthroscopy study group using a prospectively-collected multicenter database was performed. Patients who underwent isolated hip arthroscopy for FAI from January 2016 to March 2017 were assigned to the Iliopsoas group (defined as preoperative diagnosis of coxa saltans internus, intraoperative anteroinferior labral bruising or tear, and preoperative positive psoas injection) or control group. The prevalence of iliopsoas pathology, radiographic and intraoperative findings, and rendered procedures between groups were compared. Mean 2-year (minimum 1.8 year) outcomes of iliopsoas groups with and without rendered tenotomy and a control group were compared. RESULTS: There were 1393 subjects, of which 92 (7%) comprised the iliopsoas study group with 1301 subjects control subjects. Sixteen subjects in the iliopsoas group received tenotomy (17% of iliopsoas group, 1% of all subjects), whereas 76 subjects (83% of iliopsoas group) with iliopsoas involvement did not. There was significant effect on postoperative International Hip Outcome Tool-12 (iHOT-12) scores based on iliopsoas involvement and treatment, F(2,1390) = 3.74, P = .02. Compared with the control group (M = 73, standard deviation [SD] = 24), the non-tenotomized iliopsoas group (M = 69, SD = 32) had similar postoperative scores (P = .46), whereas the tenotomized iliopsoas group (M = 57, SD = 28) averaged lower postoperative scores (P = .03). In the tenotomy group, 25% achieved the iHOT-12 substantial clinical benefit and patient acceptable symptomatic state value for normal function and 100% satisfaction, compared to 49% and 41% for the without tenotomy and control groups. CONCLUSIONS: Tenotomy in patients with iliopsoas pathology undergoing arthroscopic surgery for FAI is infrequently performed and is associated with poorer outcomes. Co-afflicted patients treated without tenotomy have similar successful outcomes to patients with primary FAI. Indiscriminate tenotomy for iliopsoas pathology in this setting should be cautiously considered. LEVEL OF EVIDENCE: Level III, cohort study.