Endoscopic Repair of Hip Abductor Tendon Tears: A Case Report.

Introduction: Greater trochanteric pain syndrome is a common incapacitating hip condition characterized by chronic lateral hip pain. This condition includes a range of pathologies ranging from trochanteric bursitis, hip abductor pathology involving the gluteus medius and minimum, external coxa saltans (snapping hip syndrome), or combinations of these. Hip abductor tendon tears have gained recognition as a main contributor to this condition. This pathology is often misdiagnosed and left untreated because of the frequency of partial-thickness undersurface tears. Once this challenging diagnosis is confirmed, non-operative treatments are considered the first therapeutic approach. Despite the availability and effectiveness of multiple non-operative therapies, a considerable percentage of patients will present with chronic disabling pain and refractory symptoms. Many health-care providers are unaware of accessible advanced surgical techniques that benefit patients unresponsive to conservative management. Case Report: We present the case of a 51-year-old female patient with chronic lateral hip pain refractory to conservative treatment for more than two years, treated successfully with endoscopic abductor tendon repair. The patient returned to the desired activities six months following surgery without any reported complications. Patient's pre-operative reported outcomes utilizing the MHOT-14 and Vail hip scores improved from 27 to 79 points (on a scale of 0-100) and from 30 to 56 points (on a scale of 0-100), respectively, at eight months follow-up. Conclusion: This case report is illustrative of endoscopic surgical repair of the hip abductor tendons in the setting of a chronic full-thickness abductor tendon tear in a female patient after failure of conservative management. The multiple advantages of the technique include performance in an ambulatory day surgery center, soft-tissue preservation, and fewer complications compared to other open techniques. Knowledge of this pathology and its state-of-the-art available treatments is relevant for orthopedic surgeons and a wide range of health providers who encounter patients with chronic lateral hip pain.

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.

Corrigendum to: 'Mini-Max' knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes.

[This corrects the article DOI: 10.1093/jhps/hnab061.].

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.

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.

Hamstring Strain Injury in Athletes.

Hamstring strain injury (HSI) may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. This CPG includes sports-related overloading and overstretching injuries to myofascial or musculotendinous structures in any combination of the 3 hamstring muscles (the semitendinosus, semimembranosus, and biceps femoris). J Orthop Sports Phys Ther 2022;52(3):CPG1-CPG44. doi:10.2519/jospt.2022.0301.

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.

Midseason Screening for Groin Pain, Severity, and Disability in 101 Elite American Youth Soccer Players: A Cross-Sectional Study.

OBJECTIVE: To (1) systematically screen for groin pain and type in young elite soccer players and (2) assess whether hip and groin-related severity and disability differed between players with different levels of groin pain and tenderness. DESIGN: Cross-sectional observational. SETTING: Elite American soccer academy at midseason. PARTICIPANTS: One hundred one academy soccer players (mean age 14.3 ± 1.8 years). INTERVENTION: All players underwent clinical examinations to classify groin pain by the Doha agreement taxonomy. MAIN OUTCOME MEASURES: Tests for groin-related severity and disability included the Copenhagen 5-second squeeze test, Copenhagen Hip and Groin Outcome Score (HAGOS), and Hip Outcome Score (HOS). Players were stratified into 3 groups: those with groin pain, those with tenderness, and those with no groin pain or tenderness. RESULTS: Twenty-two players (22%) reported groin pain. Adductor-related groin pain was the most common (n = 14), followed by iliopsoas-related (n = 3), and pubic-related (n = 2). Multiple locations were present in 3 players. Thirty-nine players (39%) did not have groin pain but were tender to palpation in 1 or more structures related to the Doha agreement taxonomy. Copenhagen 5-second squeeze test differentiated between players with and without groin pain (groin pain vs tenderness group: P = 0.011; groin pain vs no groin pain group P < 0.001). Four HAGOS subscales (pain, symptoms, sport/recreation, and quality of life) differentiated between players with and without groin pain ( P < 0.05). CONCLUSIONS: One in five academy soccer players experiences groin pain with adductor-related most common during a midseason screening. Both Copenhagen 5-second squeeze test and HAGOS subscales can differentiate between players with and without groin pain.

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.

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.

Achievement of Meaningful Clinical Outcomes Is Unaffected by Capsulotomy Type During Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: Results From the Multicenter Arthroscopic Study of the Hip (MASH) Study Group.

BACKGROUND: Capsule management has emerged as an important topic in the field of hip arthroscopy. The 2 most popular techniques are interportal capsulotomy and T-type capsulotomy, but few studies have compared outcomes between these 2 techniques. PURPOSE: To compare 2-year (±2 months) patient-reported outcomes (PROs) between patients who underwent interportal versus T-type capsulotomy during arthroscopic labral repair for femoroacetabular impingement syndrome (FAIS). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a large multicenter registry of patients undergoing arthroscopic hip preservation surgery for FAIS was performed. Data from 9 surgeons across 9 sites between January 2014 and February 2018 were included in the study. Baseline demographic data, preoperative PROs, and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score, and International Hip Outcome Tool-12 (iHOT-12) were recorded. Patients were divided into 2 groups based on whether interportal or T-type capsulotomy was performed according to the senior surgeon's preference and training, and all capsulotomies were then routinely repaired. The 2 groups were matched 1:1 by age, sex, and body mass index (BMI). Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) was compared for the HOS-ADL, HOS-SS, and iHOT-12 between the 2 groups. RESULTS: The final analysis included 658 of 1483 eligible patients with a mean ± SD age of 32.6 ± 11.6 years and BMI of 24.0 ± 3.7; of these, 329 patients were treated via interportal capsulotomy, and 329 patients were treated via T-type capsulotomy. Female patients comprised 66.3% of the study population. Capsulotomy type was not a predictor of 2-year postoperative PROs on multivariate linear regression analysis when adjusted for covariates. Chi-square analysis showed no statistical difference in achievement of MCID, PASS, and SCB between the interportal and T-type groups for HOS-ADL (80.3%, 75.8%, 52.7% and 77.1%, 71.7%, 53.6%, respectively; P > .01 for all), HOS-SS (83.6%, 72.5%, 51.5% and 81.7%, 68.4%, 49.2%, respectively; P > .01 for all), and iHOT-12 (87.5%, 72.0%, 50.5% and 80.0%, 64.7%, 45.6%, respectively; P > .01 for all). CONCLUSION: Arthroscopic management of FAIS resulted in significant clinical improvement that was independent of capsulotomy type when the capsulotomy included repair.

'Mini-Max' knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes.

To describe the 'mini-Max' approach to labrum repair using non-absorbable 2.4-mm knotless suture anchors and report objective clinical outcomes with a large single-surgeon cohort. Level 3 retrospective case series. A retrospective review was conducted to report the use and allocation of non-absorbable 2.4-mm knotless suture anchors during 'mini-Max' labral repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and number of anchors used to arthroscopically repair the acetabular labrum was performed. Paired-samples t-tests were performed to evaluate whether preoperative and 1-year follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of variance was performed comparing PROs with categorized number of labral anchors. A total of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean age of 30.1 ± 11.6 years (mean ± SD) at the time of surgery underwent 'mini-Max' labral refixation. Of the 245 labral tears, 88 (35.9%) were graded as mild, 113 (46.1%) as moderate and 44 (18.0%) as severe. Labral repairs required an average of 2.1 ± 0.67 anchors across all patients included. Forty-one repairs (16.7%) required one anchor, 139 (56.7%) required two anchors, 63 (25.7%) required three anchors and 2 (0.8%) required four anchors. Significant improvements were reported for all PROs (P ≤ .001) at a minimum of 1-year follow-up. Arthroscopic 'mini-Max' labral repair using non-absorbable knotless suture anchors is a safe and effective technique for improving the lives of patients suffering from symptomatic acetabular labrum tears.

Arthroscopic Capsular Management of the Hip: A Comparison of Indications for and Clinical Outcomes of Periportal Versus Interportal Capsulotomy.

PURPOSE: To compare the clinical outcomes of periportal capsulotomy versus interportal capsulotomy with closure using a standard clinical algorithm at a minimum of 2 years after hip arthroscopy. METHODS: A retrospective cohort study of patients treated from July 2015 to October 2017 was conducted to determine the effects of 2 capsular management approaches on clinical outcomes. When patient pathology limited adequate exposure via periportal capsulotomy, an interportal capsulotomy was performed. The capsular management approaches were correlated with the following patient-reported outcomes (PROs) at 2 years: Hip Outcome Score (HOS), 12-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Preoperative comparisons between the 2 groups were analyzed using t tests or the Fisher exact test, depending on the category of data. Two-tailed independent t tests were performed to evaluate whether preoperative and follow-up outcome scores were significantly different between patients treated with a periportal capsulotomy and those treated with an interportal capsulotomy. RESULTS: Overall, patients in both groups experienced significant improvements in all PROs on postoperative comparisons at 2-year follow-up (P < .001). The mean changes in the PROs were as follows: HOS-Activities of Daily Living, 24.7 in the periportal group and 23.5 in the interportal group (P = .484); HOS-Sport-Specific Subscale, 30.2 and 31.3, respectively (P = .895); 12-item International Hip Outcome Tool score, 41.9 and 40.2, respectively (P = .564); and visual analog scale pain score, -40.9 mm and -34.5 mm, respectively (P = .791). Additionally, no statistically significant difference in patient satisfaction at 2-year follow-up was found between patients who underwent interportal capsulotomy and those who underwent periportal capsulotomy (P = .604). CONCLUSIONS: At 2-year follow-up, patients who underwent a periportal capsulotomy reported statistically and clinically significant improvements in PROs and satisfaction with the surgical intervention. This study confirms that the use of a simple clinical algorithm for selection of periportal capsulotomy or interportal capsulotomy with closure results in acceptable management decisions as defined by 2-year PROs. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability.

PURPOSE: The purpose of this study was to report several novel classification systems for intra-articular lesions observed during hip arthroscopy, and to quantify the interrater reliability of both these novel systems and existing classifications of intra-articular lesions when tested by a group of high-volume hip arthroscopists. METHODS: Five hip arthroscopists deliberated over shortcomings in current classification systems and developed several novel grading systems with particular effort made to capture factors important to the treatment and outcomes of hip arthroscopy for labral injury. A video learning module describing the classifications was then developed from the video archive of surgeries performed by the senior author and reviewed by study participants. Following review of the module, a pilot study was completed using five randomly selected videos, after which participating surgeons met once more to discuss points of disagreement and to seek clarification. The final video collection for testing reliability was composed of 29 videos selected with the intent of capturing all sublevels of each classification scheme. Study participants recorded their assessments using each classification scheme, and interrater reliability was calculated by a study participant not involved in grading. RESULTS: The average kappa coefficients for the classification schemes ranged from 0.38 to 0.54, with the interrater reliability of all classification schemes except labral degeneration qualifying as moderate. The percent of cases with absolute agreement ranged from 17.2% to 51.7% across the classification systems. CONCLUSIONS: Even among a group of high-volume hip arthroscopists who engaged in several discussions about the proposed classification schemes, grades were found to have at best moderate interrater reliability. Moderate interrater reliability is demonstrated for novel grading systems for describing labral tear complexity, labral bruising, labral size, and extent of synovitis, and fair reliability is demonstrated for labral degeneration. Further development and refinement of multifactorial grading systems for describing labral injury are indicated. Evaluating the multifactorial nature of intra-articular lesions in the hip is an important part of intraoperative decision-making and defining reliable classifications for intra-articular lesions is a critical first step towards developing generalizable criteria for guiding treatment type. LEVEL OF EVIDENCE: Level III.

Pre-operative comparisons for a return to running protocol in recreational athletes following hip arthroscopy.

The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. A prospective, non-randomized cohort study was conducted to evaluate recreational athletes that returned to running following hip arthroscopy. Return to running was the primary outcome measure and defined as the ability to run at least one mile three times weekly while maintaining patient-reported relief of pre-operative symptoms. Patients included were correlated with the following pre-operative patient-reported outcome measures: hip outcome score (HOS), 12-item international outcome tool (iHOT-12), visual analog scale for pain (VAS) and the Short-Form Health Survey (SF-12). Of the 99 included patients, 94 (95%) returned to running successfully with an average return of 4.8 months. There was no statistical difference in pre-operative comparisons between patients that returned to running and did not return to running (P ≥ 0.154). Evaluation of pre-operative clinical outcomes demonstrated no statistical difference between individuals that returned and did not return to running (P ≥ 0.177), but a large difference between the two groups was identified for HOS-ADL (64.8 versus 53.7, returned versus did not return), iHOT-12 (33.8 versus 25.4) and VAS (58.6 versus 69.3). Patients who returned to running demonstrated similar intraoperative procedures as those that did not return to running (P ≥ 0.214). The current study successfully establishes a management plan and progression protocol for patients identifying a return to recreational running following hip arthroscopy. Level of evidence: 3.

Endoscopic-Assisted Anatomic Reconstruction of Chronic Proximal Hamstring Avulsion With Achilles Allograft.

Hamstring injuries commonly occur at the musculotendinous junction; however, they can occur as proximal avulsion injuries. A lack of recognition can lead to proximal hamstring injuries being frequently misdiagnosed, resulting in delayed treatment. Chronic proximal hamstring tears are often retracted and scarred to the surrounding soft tissues. Owing to the poor quality of tissue at the torn ends of the tendon, an augmented reconstruction using an allograft may be required. In cases with poor visualization of the ischial tuberosity and proximal hamstring footprint, an Achilles tendon allograft can be secured directly to the tuberosity with suture anchors. However, visualization of the footprint can be optimized using an arthroscope. This report describes a technique for endoscopic-assisted anatomic reconstruction using an Achilles allograft with both knotless and knotted suture anchors for chronic complete avulsions of the proximal hamstring.

Risk of intra-articular hip injury in adolescent athletes: a five-year multicentre cohort study.

PURPOSE: The purpose of the current study was to establish a risk stratification for hip injury by presenting the classification of sports among adolescent athletes undergoing hip arthroscopy. METHODS: A multicentre registry was queried to examine the incidence of adolescent athletes undergoing hip arthroscopy. Patients were identified and grouped according to their sport-specific risk classification (level I-III). Chi-square analysis was performed to determine the relationship of classification of sport and gender in adolescent athletes to hip arthroscopy. A second chi-square analysis was performed to determine the relationship of classification of sport and number of sports the adolescent athlete was participating in prior to arthroscopic hip surgery. RESULTS: A total of 297 adolescent athletes were included in the study with 129 (43.4%) participating in level I sports compared with 84 (28.3%) in level II and 84(28.3%) in level III sports. Chi-square testing demonstrated a significant effect on gender and sport classification, X2 (2, N = 297) = 31.18, p < 0.01. There was a greater percentage of athletes participating in a single sport (65.3%) compared with multiple sports (34.6%), but was not statistically significant, X2 (1, N = 297) = 1.88, p = 0.17. CONCLUSION: The current study was successful in stratifying a large, multicentre cohort of adolescent athletes requiring hip arthroscopy based on classification levels of sport. There were more male athletes participating in level I sports, while more female athletes participated in level II and level III sports.

A tiered system using substantial clinical benefit and patient acceptable symptomatic state scores to evaluate 2-year outcomes of hip arthroscopy with the Hip Outcome Score.

There is no information to define variations in hip arthroscopy outcomes at 2-year follow-up using the Hip Outcome Score (HOS). To offer a tiered system using HOS absolute substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) scores for 2-year hip arthroscopy outcome assessment. This was a retrospective review of patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and 2 years (±2 months) post-operatively, subjects completed the HOS activity of daily living (ADL) and Sports subscales, categorical self-rating of function and visual analog scale for satisfaction with surgery. Receiver operator characteristic analysis identified absolute SCB and PASS HOS ADL and Sports subscale scores. Subjects consisted of 462 (70%) females and 196 (30%) males with a mean age of 35.3 years [standard deviation (SD) 13] and mean follow-up of 722 days (SD 29). SCB and PASS scores for the HOS ADL and Sports subscales were accurate in identifying those at a 'nearly normal' and 'normal' self- report of function and at least 75% and 100% levels of satisfaction (area under the curve >0.70). This study provides tiered SCB and PASS HOS scores to define variations in 2-year (±2 months) outcome after hip arthroscopy. HOS ADL subscale scores of 84 and 94 and Sports subscale scores of 61 and 87 were associated with a 'nearly normal' and 'normal' self-report of function, respectively. HOS ADL subscale scores of 86 and 94 and Sports subscale score of 74 and 87 were associated with being at least 75% and 100% satisfied with surgery, respectively. Level of evidence: III, retrospective comparative study.