Adhesions Post Hip Arthroscopy are Associated with Revision but Demonstrate Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review.

PURPOSE: To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions developed following hip arthroscopy (HA). METHODS: A systematic search of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL was designed and conducted in accordance with PRISMA guidelines. Eligible studies included patients with confirmed adhesions following HA, with one or more of the following reported: i) diagnostic procedures and criteria employed, ii) indications for and details surrounding surgical management, and iii) clinical outcomes following the operative management of adhesions (e.g., patient-reported outcome measures (PROMs), etc.). RESULTS: Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female) were included in this review. The quality of evidence was found to be fair for both comparative (mean = 17; range, 13-21) and non-comparative (mean = 10; range, 5-12) studies according to the Methodological Index for Non-Randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intra-operatively at the time of revision surgery (n = 10/19; 53%), with only three studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (n = 9/19; 47%), but this was often grossly stated for revision HA, rather than being specific to adhesions. PROMs were the most reported post-operative outcomes (n = 9/19; 47%), and generally demonstrated significant improvement from pre-operative assessment across the short-term follow-up period (range, 24.5 to 38.1 months). There was a paucity of objective measures of clinical improvement (n = 3/19; 16%), and an absence of mid-to-long term follow-up (i.e., 5-7 years, and ≥10-years, respectively). CONCLUSION: Despite increasing evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, while the operative management of adhesions post HA has demonstrated satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid-to-long term outcomes, and minimal employment of objective assessment (e.g., biomechanics) of clinical improvement.

Functional and radiological outcomes of periacetabular osteotomy for hip dysplasia in patients under fifty years using a minimally invasive approach-a single surgeon series with a minimum follow up of two years.

PURPOSE: We conducted a retrospective analysis of prospectively collected data to evaluate (1) the extent of surgical correction following minimally invasive periacetabular osteotomy, (2) improvements in functional outcomes and any potential predictors for favourable outcome, and (3) complications after minimally invasive periacetabular osteotomy. METHODS: A total of 352 minimally invasive periacetabular osteotomy procedures were performed on 312 hip dysplasia patients between 2013 and 2020. Radiological parameters such as lateral centre edge angle, acetabular index, and Tönnis grade of arthritis were calculated. Patients also completed a range of patient reported outcome measures. Wilcoxon signed-rank tests were performed to assess for differences between patient reported outcome measures and radiological outcomes across the follow-up periods. Univariate linear regression and logistic regression were used to assess for predictors of change in functional outcome. RESULTS: Patients had a significant correction in mean lateral centre edge angle from 17.2° to 35.3° (p < 0.001) and mean acetabular index from 13.2° to - 0.82°. At one year follow-up all patient reported outcome measures were significantly greater than their baseline measurements and this improvement was maintained at two years. Changes in patient reported outcome measures were independent of radiological parameters such as change in the lateral centre edge angle and acetabular index, pre-operative Tönnis grade, and patient factors such as age and sex. A total of 5.11% of patients developed post-operative complications, with four requiring posterior column fixation. Four patients (1.12%) needed a total hip replacement. CONCLUSION: Minimally invasive periacetabular osteotomy is a safe procedure that provides significant functional outcome improvements following surgery at six months which is maintained at two years. More than three-fourths of patients achieved improvement of iHOT-12 score beyond the minimal clinically important difference and more than half of the patients achieved substantial clinical benefit for iHOT-12 score.

Development of Machine-Learning Algorithms to Predict Attainment of Minimal Clinically Important Difference After Hip Arthroscopy for Femoroacetabular Impingement Yield Fair Performance and Limited Clinical Utility.

PURPOSE: To determine whether machine learning (ML) techniques developed using registry data could predict which patients will achieve minimum clinically important difference (MCID) on the International Hip Outcome Tool 12 (iHOT-12) patient-reported outcome measures (PROMs) after arthroscopic management of femoroacetabular impingement syndrome (FAIS). And secondly to determine which preoperative factors contribute to the predictive power of these models. METHODS: A retrospective cohort of patients was selected from the UK's Non-Arthroplasty Hip Registry. Inclusion criteria were a diagnosis of FAIS, management via an arthroscopic procedure, and a minimum follow-up of 6 months after index surgery from August 2012 to June 2021. Exclusion criteria were for non-arthroscopic procedures and patients without FAIS. ML models were developed to predict MCID attainment. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: In total, 1,917 patients were included. The random forest, logistic regression, neural network, support vector machine, and gradient boosting models had AUROC 0.75 (0.68-0.81), 0.69 (0.63-0.76), 0.69 (0.63-0.76), 0.70 (0.64-0.77), and 0.70 (0.64-0.77), respectively. Demographic factors and disease features did not confer a high predictive performance. Baseline PROM scores alone provided comparable predictive performance to the whole dataset models. Both EuroQoL 5-Dimension 5-Level and iHOT-12 baseline scores and iHOT-12 baseline scores alone provided AUROC of 0.74 (0.68-0.80) and 0.72 (0.65-0.78), respectively, with random forest models. CONCLUSIONS: ML models were able to predict with fair accuracy attainment of MCID on the iHOT-12 at 6-month postoperative assessment. The most successful models used all patient variables, all baseline PROMs, and baseline iHOT-12 responses. These models are not sufficiently accurate to warrant routine use in the clinic currently. LEVEL OF EVIDENCE: Level III, retrospective cohort design; prognostic study.

Hip Arthroscopy for Femoroacetabular Impingement Is Associated With Improved Sexual Function And Quality of Life.

PURPOSE: The purpose of this study was to investigate changes in sexual function and activity after arthroscopic hip surgery for femoroacetabular impingement using the United Kingdom Non-Arthroplasty Hip Registry dataset. Subanalyses were performed between males and females, and patients over 40 and under 40 years old. METHODS: Patients who had arthroscopic hip surgery between January 1, 2012, and October 31, 2020, were aged over 16, and completed the relevant patient-reported outcome measures were included. Question 9 of the International Hip Outcome Tool-12 (sexual activity question [SAQ]) refers to problems with sexual activity, and responses to this were compared before surgery and at 6 and 12 months after surgery. Subanalyses were also performed, including SAQ scores by patients' sex or age. SAQ scores were correlated with Euroqol-5 dimension-5 level self-reporting tool (EQ-5D-5L) scores using Spearman's rank coefficient. RESULTS: SAQ was answered by 2,547 patients before and at 6 months after surgery (62.3% female, median age = 36.2, interquartile range [IQR] = 29-44 years) and by 2,314 at 12 months (61.9% female, median age = 36.2, IQR = 29-44 years). Scores for sexual activity increased from 35.0 before surgery to 70.0 at 6 months (P < .001) and were maintained at 12 months (P < .001). Female patients demonstrated a significantly greater improvement in their scores for sexual function from before surgery (median = 30.0, IQR = 14-50) to 6 months (median = 60, IQR = 28-86, P < .001) and 12 months (median = 62.0, IQR = 29-90, P < .001), compared to male patients (preoperative median = 50.0, IQR 25-84; 6-month median = 80, IQR = 45-97; 12-month median = 80, IQR = 41-98). The effect of age on improvements in sexual function did not demonstrate a significant difference. A significant positive correlation was found between improvements in sexual function and quality of life, as measured by the EQ-5D-5L, at 6 and 12 months (P < .001). CONCLUSION: Hip arthroscopy for symptomatic femoroacetabular impingement produces an improvement in sexual function and activity. Scores for sexual function improved regardless of patient age or sex; however, female patients experienced a greater improvement in sexual function than males. LEVEL OF EVIDENCE: Level III (Retrospective cohort study).

Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset.

PURPOSE: Results from recent randomised controlled trials demonstrate the superiority of surgery over physiotherapy in patients with femoroacetabular impingement (FAI) of the hip in early follow-up. However, there is paucity of evidence regarding which factors influence outcomes of FAI surgery, particularly notable is the lack of information on the effect of impingement subtype (cam or pincer or mixed) on patient reported outcomes measures (PROMs). This study aims to evaluate the early outcomes of hip arthroscopy for FAI, and their determinants. METHODS: This is a retrospective analysis of prospectively collected data from the UK Non-Arthroplasty Hip Registry (NAHR) of patients undergoing arthroscopic intervention for FAI between 2012 and 2019. The null hypothesis was that there is no difference in PROMs, based on morphological subtype of FAI treated or patient characteristics, at each follow-up timepoint. The outcome measures used for the study were the iHOT-12 score and the EQ5D Index and VAS 6- and 12-month follow-up. RESULTS: A cohort of 4963 patients who underwent arthroscopic treatment of FAI were identified on the NAHR database. For all FAI pathology groups, there was significant improvement from pre-operative PROMs when compared to those at 6 and 12 months. Overall, two-thirds of patients achieved the minimum clinically important difference (MCID), and almost half achieved substantial clinical benefit (SCB) for iHOT-12 by 12 months. Pre-operatively, and at 12-month follow-up, iHOT-12 scores were significantly poorer in the pincer group compared to the cam and mixed pathology groups (p < 0.01). Multivariable analysis revealed PROMS improvement in the setting of a higher-grade cartilage lesion. CONCLUSION: This registry study demonstrates that hip arthroscopy is an effective surgical treatment for patients with symptomatic FAI and results in a statistically significant improvement in PROMs which are maintained through 12 months follow-up. LEVEL OF EVIDENCE: III.

Proximal femoral derotation osteotomy for management of femoral malversion: a systematic review.

Femoral malversion is an under-recognized contributor to hip pain in younger adults. Under treatment is often a contributor to poor outcomes in hip preservation surgery. We reviewed the literature to analyse the outcomes of proximal femoral derotation osteotomy as a treatment for femoral malversion as well as propose our own management algorithm for treating such patients. A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching four databases (PubMed, CINALH, MEDLINE and EMBASE) for studies investigating the outcomes of derotation osteotomy in treating malversion. Nine studies were found encompassing 229 hips. At a mean follow-up of 39.9 months across the studies, there were only two conversions (1%) to total hip arthroplasty and four revision cases in total. Seven of the nine studies reported improved functional outcomes in their cohorts, with the mean Harris hip score improved from 63.7 to 87.3 where reported. There is a paucity of literature around the outcomes of proximal femoral derotation osteotomy. However, both the evidence available and the authors' experience suggest that consideration of femoral malversion is an essential component of hip preservation surgery, improving functional outcomes in cases of excessive femoral anteversion and femoral retroversion.

Comparison of early outcomes of arthroscopic labral repair or debridement : a study using the UK Non-Arthroplasty Hip Registry dataset.

AIMS: This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum. METHODS: Data on adult patients who underwent arthroscopic labral debridement or repair between 1 January 2012 and 31 July 2019 were extracted from the UK Non-Arthroplasty Hip Registry. Patients who underwent microfracture, osteophyte excision, or a concurrent extra-articular procedure were excluded. The EuroQol five-dimension (EQ-5D) and International Hip Outcome Tool 12 (iHOT-12) questionnaires were collected preoperatively and at six and 12 months post-operatively. Due to concerns over differential questionnaire non-response between the two groups, a combination of random sampling, propensity score matching, and pooled multivariable linear regression models were employed to compare iHOT-12 improvement. RESULTS: A total of 2,025 labral debridements (55%) and 1,659 labral repairs (45%) were identified. Both groups saw significant (p < 0.001) EQ-5D and iHOT-12 gain compared to preoperative scores at 12 months (iHOT-12 improvement: labral repair = +28.7 (95% confidence interval (CI) 26.4 to 30.9), labral debridement = +24.7 (95% CI 22.5 to 27.0)), however there was no significant difference between procedures after multivariable modelling. Overall, 66% of cases achieved the minimum clinically important difference (MCID) and 48% achieved substantial clinical benefit at 12 months. CONCLUSION: Both labral procedures were successful in significantly improving early functional outcome following hip arthroscopy, regardless of age or sex. Labral repair was associated with superior outcomes in univariable analysis, however there was no significant superiority demonstrated in the multivariable model. Level of evidence: III Cite this article: Bone Jt Open 2022;3(4):291-301.

Scaling up Quality Improvement for Surgical Teams (QIST)-avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS.

BACKGROUND: The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement. METHODS: We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative. RESULTS: There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52-2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42-2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively. CONCLUSIONS: Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS. TRIAL REGISTRATION: Prospectively registered on 15 February 2018, ISRCTN11085475.

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man.

BACKGROUND: Prosthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings. METHODS: Adult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data. RESULTS: In total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001) CONCLUSION: This study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.

Effect of COVID-19 pandemic on hip preservation surgery-a prospective surveillance from the UK Non-Arthroplasty Hip Registry.

A multi-centre, registry-based cohort study was conducted to assess the effect of the coronavirus disease 2019 (COVID-19) pandemic on the provision of non-arthroplasty hip surgery (NAHS) in the UK by (i) comparing the number of NAHS performed during the pandemic to pre-pandemic levels, (ii) prospectively auditing compliance to established guidance and (iii) evaluating post-operative outcomes and their predictors. Patients who underwent NAHS during the pandemic/pre-pandemic were selected from the Non-Arthroplasty Hip Registry, which collects demographic, procedural and pre-operative outcome data. Patients during the pandemic period were emailed separate COVID-19 surveillance questionnaires, which evaluated adherence to guidelines and post-operative outcomes. Fisher's exact tests and logistic regression were used to identify predictors for developing COVID-19 and being re-admitted into hospital, post-surgery. There was a 64% reduction of NAHS performed during the pandemic compared to the pre-pandemic period. Ninety-nine percent of participants self-isolated, and 96.8% received screening, pre-operatively. No participant was COVID-19-positive peri-operatively. Post-operatively, participants had an intensive care unit admission rate of 2%, median hospital stay of 1 day, hospital readmission rate of 4.2%, COVID-19 development rate of 2.3% and a thromboembolic complication rate of 0.32%. No COVID-19-positive patient developed adverse post-operative outcomes. Participants who developed COVID-19 post-operatively had greater odds of having undergone osteotomy in comparison to arthroscopic surgery (P = 0.036, odds ratio = 5.36). NAHS was performed with good compliance to established guidance, and adverse operative outcomes remained low. If guidance is followed, the risk of COVID-19 post-op development is low. Although bigger operations have a slightly higher risk, this does not impact their prognosis.

Does hip preservation surgery prevent arthroplasty? Quantifying the rate of conversion to arthroplasty following hip preservation surgery.

Hip arthroscopic surgery for femoroacetabular impingement and periacetabular osteotomy (PAO) for dysplasia is the most commonly used contemporary treatment for these conditions and has been shown to provide pain relief and restore function. What is less understood and perhaps of more interest to health economists, is the role of these procedures in preserving the hip joint and avoiding hip arthroplasty. The aim of this systematic review was to determine whether hip joint preservation surgery, indeed, preserves the hip joint by looking at conversion rates to total hip arthroplasty (THA). Two separate searches were undertaken, using PRISMA guidelines and utilizing PubMed and Open Athens search engines, identifying manuscripts that looked at conversion to THA following either hip arthroscopy (HA) or PAO. When considering HA, we found 64 eligible papers. Out of these studies, there were 59 430 hips with 5627 undergoing conversion to THA (9.47% [95% CI 9.23-9.71%]) with a mean conversion time of 24.42 months. Regarding PAO, there were 46 eligible papers including 4862 patients who underwent PAO with subsequent conversion to THA in 404 patients (8.31% [95% CI 7.54-9.12%]). with a mean conversion time of 70.11 months. Certain features were associated with increased conversion rates, including increasing age, worsening arthritis and joint space <2 mm. This study demonstrates that the mean conversion rates to be <10% for HA and PAO, during the mean follow-up periods of included manuscripts. Joint preserving surgery appears to defer or at least delay the need for THA.

Periacetabular Osteotomy for Developmental Dysplasia of the Hip and Femoroacetabular Impingement: A Study Using the U.K. Non-Arthroplasty Hip Registry (NAHR) Data Set.

BACKGROUND: Periacetabular osteotomy (PAO) is a well-recognized procedure for the treatment of hip dysplasia in young adults and can be used for the surgical management of femoroacetabular impingement (FAI) with acetabular retroversion. The aim of this study was to use a national database to assess the outcomes of PAO for developmental dysplasia of the hip (DDH) and for FAI. METHODS: All patients in whom an isolated PAO had been performed between January 2012 and February 2019 were identified in the Non-Arthroplasty Hip Registry (NAHR). Their outcomes were assessed using the EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool (iHOT)-12 preoperatively and then at 6 months, 12 months, and 2 years postoperatively. RESULTS: Six hundred and thirty (630) PAOs were identified, with 558 (89%) performed for DDH and 72 (11%) performed for FAI. Most patients (90%) were female. The mean age in the DDH group (31.2 years) was significantly higher (p < 0.0001) than that in the FAI group (26.5 years). There were no other significant between-group demographic differences. Preoperatively and at each follow-up time-period, iHOT-12 scores were better in the DDH group than in the FAI group; however, only the preoperative scores differed significantly. There was significant improvement between the preoperative and 6-month iHOT-12 and EQ-5D index scores in both the DDH and the FAI group. This improvement was maintained at 12 months postoperatively, by which time almost 90% of the patients had achieved the minimum clinically important difference (MCID) in their iHOT-12 score. CONCLUSIONS: This study shows that PAO is a successful surgical intervention for DDH and FAI in the short term, with significant improvement in patient-reported outcome scores that is maintained up to 2 years postoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroscopy and Borderline Developmental Dysplasia of the Hip: A Systematic Review.

PURPOSE: To provide an up-to-date evidence-based review of hip arthroscopy for patients with borderline developmental dysplasia of the hip (BDDH). METHODS: Literature describing hip arthroscopy in patients with BDDH was systematically identified from PubMed, EMBASE, and Cochrane Library using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All studies that involved BDDH and not just those reporting their clinical outcomes were included. Methodological Index for Non Randomized Studies criteria and Newcastle-Ottawa Scale were used to assess the quality of studies. The definition of BDDH, operative technique, correlation with labrum and/or cartilage lesions, outcome, and factors associated with poor outcome were collected and analyzed. RESULTS: Assessment of the articles yielded 28 studies involving 1502 hips that were included for final analysis. There were no studies with a high risk of bias. BDDH was defined as lateral center-edge angle of 20° to 25° in most studies. Hip arthroscopy for BDDH showed an improvement in the weighted mean postoperative modified Harris Hip Score, from 60.2 to 81.7, a relatively high rate of acquisition of minimal clinically important difference of 79.5% to 87%, and had 1.0% rate of complications. Eleven studies reported on all the patients undergoing a capsular plication. Four studies reported that BDDH was associated with cartilage damage on the femoral head. Age older than 35 or 42 years and ≥20° of femoral anteversion were reported as risk factors for poor outcomes. CONCLUSIONS: Hip arthroscopy for BDDH with capsular plication provides improvement in patient-reported outcome measures and a relatively high rate of acquisition of minimal clinically important difference with a low rate of complications in the shorter term. BDDH may be associated with cartilage damage on the femoral head. Female sex is a factor related to good outcomes, whereas older age, excessive femoral anteversion, and anterior undercoverage of acetabulum are risk factors related to poorer outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of Level III to IV studies.

Does Platelet-rich Plasma Augmentation Following Hip Arthroscopy Improve Outcomes: A Systematic Review.

Platelet-rich plasma (PRP) has gathered widespread acceptance among orthopaedic surgeons because of its multimodal effects on tissue healing. Varying results have been reported when PRP injections are combined with hip arthroscopic surgery. To evaluate the influence of PRP on clinical outcomes following hip arthroscopy. We hypothesized that patients treated with PRP would have improved postoperative outcome scores. A search of the National Institute for Health and Care Excellence (NICE) healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE, and AMED databases) was conducted from their years of inception to May 2018 with the keywords: "Hip Arthroscopy" and "Platelet-Rich Plasma". A quality assessment was performed based on the Cochrane risk of bias tool. Three studies were included for analysis; two of which had low risk of bias. The studies included 363 hips, of which 141 were randomised for PRP treatment. The mean age of all patients was 35 years and the follow-up ranged from 18.5 to 36 months. Authors used different PRP systems and preparations. Modified Harris hip score was reported in all three studies with two studies favouring the use of PRP. The use of PRP following hip arthroscopy did not lead to significantly improved postoperative pain or functional outcomes when compared to control groups in the studies included in this review.

Mechanics of Psoas Tendon Snapping. A Virtual Population Study.

Internal snapping of the psoas tendon is a frequently reported condition, especially in young adolescents involved in sports. It is defined as an increased tendon excursion over bony or soft tissue prominence causing local irritation and inflammation of the tendon leading to groin pain and often is accompanied by an audible snap. Due to the lack of detailed dynamic visualization means, the exact mechanism of the condition remains poorly understood and different theories have been postulated related to the etiology and its location about the hip. In the present study we simulated psoas tendon behavior in a virtual population of 40,000 anatomies and compared tendon movement during combined abduction, flexion and external rotation and back to neutral extension and adduction. At risk phenotyopes for tendon snapping were defined as the morphologies presenting with excess tendon movement. There were little differences in tendon movement between the male and female models. In both populations, abnormal tendon excursion correlated with changes in mainly the femoral anatomy (male r = 0.72, p < 0.001, female r = 0.66, p < 0.001): increased anteversion and valgus as well as a decreasing femoral offset and ischiofemoral distance. The observed combination of shape components correlating with excess tendon movement in essence presented with a medial positioning of the minor trochanter. This finding suggest that psoas snapping and ischiofemoral impingement are possibly two presentations of a similar underlying rotational dysplasia of the femur.

Complications and outcome after periacetabular osteotomy - influence of surgical approach.

BACKGROUND: Bernese periacetabular osteotomy (PAO) was introduced by Ganz as a novel surgical technique for hip dysplasia with a congruent hip to reorient the acetabulum in skeletally mature patients. The PAO through a modified Smith-Petersen (Iliofemoral) approach, has been subject to many modifications in order to avoid complications and to minimise risks for failure. AIM: The aim of this review was to report on the complication rates, functional and radiological outcomes in relation to surgical approaches. METHODS: A search of NICE healthcare database advanced search, was conducted from the year of inception to May 2018. We included studies that reported complications of PAO. Data extracted from case series was analysed to detect the incidence of complications, relation to surgical approach and temporal trend of complications. RESULTS: 40 studies including 4070 hips with a mean age of 29 years and a mean follow-up of 52.8 month, were analysed. Outcome measures demonstrated good to excellent outcome in 82%. Higher rates of LFCN and sciatic nerve injuries were found to be associated with the ilioinguinal and the 2-incision approach. Minimally invasive (MIS) modified Smith-Petersen (MSP), minimally invasive trans-sartorial and trans-trochanteric approaches were not reported to be associated with any major wound complications. Radiological correction achieved with a mean improvement in acetabular inclination of 17.90 (range 4.5-40), anterior centre-edge correction 25.40 (range 10-51), lateral centre-edge correction 23.30 (range 15-44.6) and medial translation of 6 mm (range 3.2-10). CONCLUSIONS: The complication rates seem to be lower in this current review (7%) as compared to the previous review performed by Clohisy et al. (6-37%). The MIS trans-sartorial/MIS MSP and intertrochanteric approaches are associated with an even reduced complications rates. This review enables favouring the minimally invasive approaches with regard to reducing nerve injury and wound complications.

Editorial Commentary: Readmission Rate After Hip Arthroscopy: Is There a Cause for Concern?

Readmission after hip arthroscopic surgery is an undesired and unusual event. The causes may range from wound-related issues, deep infection, increasing pain, complications of surgery, to medical events. It adds to the economic burden of the procedure and causes unnecessary anguish to the patients and indeed clinicians. It is also one of the less-studied areas of hip arthroscopic surgery because of its rarity. There would be benefit in being able to identify the risk factors of readmission such that pre-emptive measures can be put in place to prevent or indeed counsel the patients before the surgery. In certain cases, readmission may remain an unpreventable event. In our experience, the readmission rate after hip arthroscopy is 0.5%, whereas patients with elevated body mass index are at greater risk.