Patient-Reported Outcomes Are Similar in the First 2 Years After Staged Versus Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia.

PURPOSE: To compare early patient-reported outcomes after staged versus combined hip arthroscopy and periacetabular osteotomy for hip dysplasia. METHODS: A prospective database was retrospectively reviewed to identify patients that underwent combined or staged hip arthroscopy and periacetabular osteotomy (PAO) from 2012 to 2020. Patients were excluded if they were >40 years of age, had prior ipsilateral hip surgery, or did not have at least 12-24 months of postoperative patient-reported outcome (PRO) data. PROs included the Hip Outcomes Score (HOS) Activities of Daily Living (ADL) and Sports Subscale (SS), Non-Arthritic Hip Score (NAHS), and the Modified Harris Hip Score (mHHS). Paired t-tests were used to compare preoperative to postoperative scores for both groups. Outcomes were compared using linear regression adjusted for baseline characteristics, including age, obesity, cartilage damage, acetabular index, and procedure timing (early vs late practice). RESULTS: Sixty-two hips were included in this analysis (39 combined, 23 staged). The average length of follow-up was similar between the combined and staged groups (20.8 vs 19.6 months; P = .192). Both groups reported significant improvements in PROs at final follow up compared to preoperative scores (P < .05 for all). There were no significant differences in HOS-ADL, HOS-SS, NAHS, or mHHS scores between groups preoperatively or at 3, 6, or 12 months postoperatively (P > .05 for all). There was no significant difference in PROs between the combined and staged groups at the final postoperative time point: HOS-ADL (84.5 vs 84.3; P = .77), HOS-SS (76.0 vs 79.2; P = .68), NAHS (82.2 vs 84.5; P = .79), and mHHS (71.0 vs 71.0, P = .75), respectively. CONCLUSIONS: Staged hip arthroscopy and PAO for hip dysplasia leads to similar PROs at 12-24 months compared to combined procedures. This suggests that with careful and informed patient selection, staging these procedures is an acceptable option for these patients and does not change early outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review.

PURPOSE: To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology. METHODS: A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded. RESULTS: The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I2 = 63.9% and 72.9%, respectively). CONCLUSIONS: Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Biomechanical Response to Distraction of Hip Capsular Reconstruction With Human Acellular Dermal Patch Graft.

PURPOSE: To quantify the biomechanical properties of the hip capsule with human dermal allograft reconstruction to determine whether a dermal patch restored capsular resistance to distraction. METHODS: Nine cadaveric hip specimens were dissected until capsule and bony structures remained and were then mounted in a testing fixture in neutral flexion and abduction. Four states of the hip capsule were sequentially tested under axial distraction of 5 mm measured with video analysis and with resultant force measurement: (1) intact hip capsule, (2) interportal capsulotomy, (3) capsulectomy to the zona orbicularis, and (4) capsular reconstruction with human dermal allograft using acetabular anchors and capsule-to-patch sutures. RESULTS: Capsulectomy was different from intact (P = .036), capsulotomy differed from capsulectomy (P = .012), and the repair was statistically significantly different from capsulectomy (P = .042); intact and reconstructed cases were not statistically significantly different. The force required for 5 mm of distraction decreased after interportal capsulotomy by an average of 9% compared with the intact state and further decreased after capsulectomy by 30% compared with the intact state. After capsular reconstruction using dermal allograft, force requirements increased by an average of 36% from the capsulectomy state, only 5% below the intact state. CONCLUSIONS: Human dermal allograft tissue graft provides restoration of distractive strength for use during hip capsule reconstruction with acetabular anchor fixation and distal soft-tissue fixation after capsulectomy in a cadaveric model. CLINICAL RELEVANCE: Capsular repair or reconstruction with a dermal patch offers time-zero restoration of function; intact and reconstructed cases showed no difference, and reconstruction restored a capsulectomy to a biomechanical equivalent of the intact case when distraction was applied.

Iliopsoas snapping hip: improving the diagnostic value of magnetic resonance imaging with a novel parameter.

OBJECTIVE: To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome. METHODS: This retrospective cohort study reviewed hip MRI images of all patients seen by a single surgeon between January 2015 and March 2016. The comparison group included all patients with clinical internal hip snapping, versus the control group that did not. MRI images were processed using minimum intensity projection. Measurements obtained of the pelvis and course of the iliopsoas tendon included: pelvic incidence, coronal angle, and sagittal opening angle (SOA). Comparison of measurements between the groups was performed with Mann-Whitney U analysis and receiver operator curve (ROC) plotting, with a significance cutoff of p = 0.05. RESULTS: The control group (n = 85) and comparison group (n = 48) demonstrated no difference in age or gender. Pelvic incidence was similar [51.3 (± 10.7) degrees control versus 52.2 (± 7.7) degrees comparison (p = 0.36)], as was coronal angle [13.9 (± 4.6) degrees control versus 14.8 (±4.8) degrees comparison (p = 0.15)]. There was a significant difference in SOA [137.0 (± 5.9) degrees control versus 141.9 (± 6.5) degrees comparison (p < 0.01)]. ROC analysis revealed SOA threshold of 140 degrees for clinical IP hip snapping (p < 0.01), with odds ratio 5.2 (2.4-11.3) for SOA > 140 degrees. CONCLUSIONS: Iliopsoas hip snapping is often part of a more complex disease process. While challenging to diagnose, advanced imaging parameters, like the sagittal opening angle, relate with clinical pathology. The SOA offers diagnostic value, with a threshold of greater than 140 degrees significantly correlating with clinical presentation.

The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review.

PURPOSE: To compare patient-reported outcomes, progression of osteoarthritis, and conversion to total hip replacement in a dysplastic population when hip arthroscopy was used as an isolated treatment or as an adjunct to pelvic reorientation osteotomy. METHODS: An exhaustive search of the existing literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Embase) were searched for studies from January 1930 through January 2018 published in the English language concerning the use of hip arthroscopy with diagnostic and therapeutic intentions in individuals with acetabular dysplasia. We excluded studies that presented ambiguous data sets or in which clear identification of the strategy for arthroscopy was absent. RESULTS: The selection criteria were defined, and 33 studies (1,368 hip arthroscopies) were included in the final analysis. Studies that met the inclusion criteria were classified within 5 different categories: (1) hip arthroscopy for screening, chondral mapping, and planning (9 studies, 729 hip arthroscopies); (2) isolated arthroscopic treatment (13 studies, 434 hip arthroscopies); (3) outcomes of hip arthroscopy after previous reorientation pelvic osteotomy for acetabular dysplasia (4 studies, 52 hip arthroscopies); (4) arthroscopy followed by unplanned hip-preservation surgery (3 studies, 48 hip arthroscopies); and (5) combined arthroscopy and periacetabular osteotomy (4 studies, 106 hip arthroscopies). A risk-of-bias analysis showed a moderate to high risk of bias (level 3 or 4) within and across the included studies. CONCLUSIONS: Although hip arthroscopy can be used to accurately grade the severity of chondral injuries in the native hip and provide zone-specific geographic mapping that may aid in subsequent surgical planning, there is insufficient evidence to conclude that arthroscopic characterization alone has any bearing on the ultimate clinical outcomes after osseous structural correction. Isolated arthroscopic treatment is not recommended in the setting of moderate to severe dysplasia, given the inferior clinical outcomes and risk of iatrogenic instability reported for this group. However, there is limited evidence to suggest that the isolated use of hip arthroscopy may be considered in cases of borderline acetabular dysplasia when careful attention is paid to labral and capsular preservation. Limited evidence supports the conclusion that after prior reorientation pelvic osteotomy for acetabular dysplasia, hip arthroscopy leads to improved clinical and functional outcomes and should be considered in this setting. Furthermore, there is insufficient evidence to conclude that failed hip arthroscopy compromises or challenges the ultimate clinical outcomes in patients undergoing subsequent reorientation pelvic osteotomy. Last, there is insufficient evidence to conclude that the adjunctive use of hip arthroscopy with reorientation pelvic osteotomy produces superior clinical outcomes compared with pelvic osteotomy alone. In summary, arthroscopic techniques may provide a useful complement to the correction of acetabular dysplasia and should be thoughtfully considered on a case-by-case basis when designing a comprehensive treatment strategy in dysplastic populations. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

The Effect of Intra-articular Cocktail Versus Femoral Nerve Block for Patients Undergoing Hip Arthroscopy.

PURPOSE: To compare clinical efficacy and complication rate as measured by postoperative falls and development of peripheral neuritis between intra-articular blockade and femoral nerve block in patients undergoing arthroscopic hip surgery. METHODS: An institutional review board approved retrospective review was conducted on a consecutive series of patients who underwent elective arthroscopic hip surgery by a single surgeon, between November 2013 and April 2015. Subjects were stratified into 2 groups: patients who received a preoperative femoral nerve block for perioperative pain control, and patients who received an intra-articular "cocktail" injection postoperatively. Demographic data, perioperative pain scores, narcotic consumption, incidence of falls, and iatrogenic peripheral neuritis were collected for analysis. Postoperative data were then collected at routine clinical visits. RESULTS: A total of 193 patients were included in this study (65 males, 125 females). Of them, 105 patients received preoperative femoral nerve blocks and 88 patients received an intraoperative intra-articular "cocktail." There were no significant differences in patient demographics, history of chronic pain (P = .35), worker's compensation (P = .24), preoperative pain scores (P = .69), or intraoperative doses of narcotics (P = .40). Patients who received preoperative femoral nerve blocks reported decreased pain during their time in PACU (P = .0001) and on hospital discharge (P = .28); however, there were no statistically significant differences in patient-reported pain scores at postoperative weeks 1 (P = .34), 3 (P = .64), and 6 (P = .70). Administration of an intra-articular block was associated with a significant reduction in the rate of postoperative falls (P = .009) and iatrogenic peripheral neuritis (P = .0001). CONCLUSIONS: Preoperative femoral nerve blocks are associated with decreased immediate postoperative pain, whereas intraoperative intra-articular anesthetic injections provide effective postoperative pain control in patients undergoing arthroscopic hip surgery and result in a significant reduction in the rate of postoperative falls and iatrogenic peripheral neuritis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Utility of Postoperative Radiographs 2 Years After Primary Total Knee Arthroplasty.

BACKGROUND: Radiographs are routinely used to evaluate patients postoperatively after total knee arthroplasty, but no evidence-based guidelines exist regarding their use. The purpose of this study is to quantify the use of radiographs within 2 years of primary total knee arthroplasty by one surgeon and to determine if routine studies in asymptomatic patients altered patient management. METHODS: Patients undergoing consecutive primary total knee arthroplasties between 2008 and 2010 were identified. Patients undergoing revision or additional simultaneous procedures or those with less than 6 months of radiographic follow-up were excluded. Operative and clinic notes, radiographs, and radiology reports were reviewed. RESULTS: A total of 263 patients were identified; each patient had an average of 13.5 ± 3.8 individual radiographs obtained in 6.5 ± 1.7 series. Twelve radiographic series were noted to have abnormal findings by either the attending surgeon or by radiology report. Three of these patients underwent reoperation directly related to the findings; 2 for deep infections and 1 for extensor mechanism disruption. All 3 patients had reported abnormal symptoms when their films were obtained. The remaining 9 abnormal radiographic findings included focal lucencies or osteolysis, asymmetric spacer wear, a healing stress fracture, an inferior patellar avulsion fracture, and heterotopic ossification. No patient had symptoms attributable to these findings when the radiographs were obtained, and in no case was the management altered based on these finding. CONCLUSION: This study suggests that the observed frequency of routine postoperative radiographs in asymptomatic patients may not be necessary in the first 2 years after primary total knee arthroplasty.

Comparison of Two Injection Techniques for Intra-articular Hip Injections.

OBJECTIVES: Intra-articular hip joint injections have traditionally relied on the use of image guidance to confirm intra-articular needle placement. Musculoskeletal ultrasound (US) has emerged as a popular tool to aid the clinician in performing intra-articular hip injections. Modern automated injection delivery systems are commercially available and may offer the potential to optimize clinical efficiency while limiting procedural morbidity. The purpose of this study was to compare patient-reported outcomes and clinical efficiency between two US-guided intra-articular hip injection techniques. The hypothesis was that the use of an automated delivery system for US-guided intra-articular hip joint injections would show superiority in clinical efficiency over traditional syringe injections. METHODS: This study was a level 1 randomized prospective postmarket clinical evaluation. Forty patients were randomly assigned to undergo a single intra-articular corticosteroid injection of the hip using either an automated delivery system (Navigator Delivery System; Carticept Medical, Inc, Alpharetta, GA) or a traditional syringe injection. Enrolled patients were prospectively followed at 1, 6, and 12 weeks after injection. A battery of patient-reported outcomes were collected at baseline and again at 1, 6, and 12 weeks after injection. Preparation times were documented for all injections. RESULTS: Forty patients met inclusion criteria and were enrolled. Twenty patients were randomly assigned to receive US guided intra-articular hip injections using the automated system (group A), and 20 patients were treated with standard syringe injections (group B). Body mass index, smoking history, symptom duration, baseline patient-reported outcomes, and demographic data were similar between groups. Improvements from baseline scores were noted at all time points for all patient-reported outcomes regardless of the injection technique used. However, no significant differences were noted at any time point for any of the patient-reported outcomes based on which injection delivery system was used. Statistically significant differences were noted at 6 and 12 weeks for the subjective global assessment score, which favored the use of the automated delivery system over the standard injection technique (6 weeks, P = .029; 12 weeks, P = .028). Between the two injection procedures, there was no difference in pain experienced by the patient (mean Visual Analog Scale pain score ± SEM: group A, 34.9 ± 6.49; group B, 34.5 ± 5.99; P = .960). Body mass index did not influence pain associated with an intra-articular hip injection (P = .870); however, younger patient age was found to be an independent predictor of increased pain associated with injection (P = .011). Although there were no differences among male or female patients in hip injection pain based on the delivery method, statistically significant differences were encountered between male and female patients, irrespective of treatment assignment (male/female: group A, 25.1/41.4; group B, 26.7/46.1; P= .049). Among patients with a smoking history, large differences were noted for injection pain when data for both groups were pooled, regardless of the delivery method (no history, 30.0 ± 4.86; smoking history, 40.8 ± 9.94). Clinical efficiency (as measured by injection preparation time) was found to be inferior for the automated system compared to traditional syringe injection (P < .0001). CONCLUSIONS: Use of an automated delivery system for US-guided intra-articular hip injections did not show superior efficiency or patient comfort over traditional syringe injections. Intra-articular corticosteroid injections led to clinically and statistically significant improvements in pain and function for patients with intra-articular hip pain, irrespective of the delivery method. Smoking history and female sex were independent predictors of increased pain associated with intra-articular hip joint injections.

Does Femoroacetabular Impingement Cause Hip Instability? A Systematic Review.

PURPOSE: To determine whether femoroacetabular impingement (FAI) is associated with hip instability. METHODS: A systematic search examining FAI and hip instability was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Clinical and basic science studies were included. Instability had to be documented with either a clinical or imaging examination. Studies were excluded if they did not define diagnostic criteria for FAI, involved prosthetic hips, were not in English, were review articles, or reported Level V evidence (case reports, expert opinion). Rates of FAI morphologic features in patients with documented hip instability were determined. Mechanisms and rates of FAI-induced hip subluxation were examined in basic science studies. RESULTS: The search yielded 1,630 relevant studies. Seven studies (4 clinical and 3 basic science) met inclusion criteria. Four studies investigated an association between FAI and hip instability in 92 patients with an average age of 31 years. Seventy-six patients experienced frank dislocations and 16 experienced posterior subluxation events. The prevalence of FAI was documented in 89 patients with hip instability. The rates of cam and pincer morphologic characteristics were 74% and 64%, respectively. The average lateral center edge angle and prevalence of acetabular retroversion were 30° and 70%, respectively (n = 76 patients). All 3 basic science studies had real-time visualization of FAI-induced hip subluxations. CONCLUSIONS: High rates of FAI morphologic characteristics are present in patients with hip instability. FAI morphologic characteristics may predispose the hip to instability through anatomic conflict caused by pincer or cam lesions (or both) levering the femoral head posteriorly. LEVEL OF EVIDENCE: Level IV, systematic review of Level III, Level IV, and non-clinical studies.

Acetabular Labral Debridement/Segmental Resection Versus Reconstruction in the Comprehensive Treatment of Symptomatic Femoroacetabular Impingement: A Systematic Review.

PURPOSE: To perform a systematic review comparing outcomes of labral debridement/segmental resection with labral reconstruction as part of a comprehensive treatment strategy for femoroacetabular impingement. METHODS: A systematic review was conducted according to established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using defined inclusion and exclusion criteria. The study groups were divided into labral debridement/segmental resection (group 1) and labral reconstruction (group 2). Multiple search engines were queried (PubMed, Medline) for this analysis. RESULTS: After an exhaustive search of the available literature, 20 publications were included. Twelve studies explored outcomes after labral debridement/resection in a total of 400 hips, whereas 7 studies reported on outcomes after labral reconstruction in a total of 275 hips. One additional matched-pair control study compared labral resection (22 hips) with reconstruction (11 hips). The surgical intervention was a revision in 0% to 100% for group 1 versus 5% to 55% for group 2. A direct anterior approach was not performed in group 2, and cam-type impingement appeared to make up a larger percentage of group 1. The Tönnis grade ranged from 0 to 1 for group 1 versus 0.3 to 1.1 for group 2. Joint replacements were performed in 0% to 30% and 0% to 25%, respectively. The modified Harris Hip Score was the most widely used patient-reported outcome measure and suggested that labral reconstruction was not inferior to labral debridement/segmental resection. CONCLUSIONS: Clinical outcomes after labral debridement/segmental resection versus labral reconstruction were found to be comparable. In the setting of unsalvageable labral pathology, labral reconstruction was used more frequently as a revision option whereas debridement may be more commonly used in the index setting. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Effect of Subspine Decompression on Rectus Femoris Integrity and Iliopsoas Excursion: A Cadaveric Study.

PURPOSE: To determine the relative influence of anteroinferior iliac spine (AIIS) or subspine decompression on proximal rectus femoris integrity and iliopsoas excursion throughout a physiological range of motion. METHODS: Nineteen cadaveric hips from 10 specimens were dissected to retain the origin of the rectus femoris direct and indirect heads. The anatomic footprints of the origins were measured with calipers. Serial 5-mm resections of the AIIS were made to determine the extent of proximal tendon disruption that corresponded to each resection. Iliopsoas tendon tracking was also assessed after sequential AIIS decompression by measuring the excursion of the medial border of the iliopsoas tendon as it traveled from its native resting position to the point where it first encountered bony impingement at the AIIS. RESULTS: The mean proximal-distal footprint of the rectus femoris direct head was 17.95 ± 2.99 mm. The mean medial-lateral distance was 11.84 ± 2.34 mm. There was a consistent bare area along the inferior aspect of the AIIS that averaged 4.84 ± 1.42 mm. The average percentage of remaining footprint after each 5-mm resection (5 to 25 mm) was 96%, 65%, 35%, 14%, and 11%, respectively, with statistical significance noted after resections larger than 5 mm (P < .001). The native excursion distance of the iliopsoas tendon was 14.05 mm. With each 5-mm resection, the percentage of excursion before impingement on the AIIS increased by 18%, 45%, 72%, 95%, and 100%, respectively, which was statistically significance after all resections (P < .001). CONCLUSIONS: Our study maps the anatomic footprint of the direct head of the rectus femoris tendon and confirms a previously identified bare area along the inferior aspect of the AIIS. Female cadaveric hips had a significantly smaller rectus footprint than male cadavers in our study (P < .001). Subspine decompression greater than 10 mm significantly compromises the rectus femoris origin and should be avoided when performing arthroscopic AIIS decompression. In addition, subspine decompression significantly improves tracking of the iliopsoas tendon throughout a physiological range of motion and may be considered a surgical adjunct when treating symptomatic iliopsoas snapping. CLINICAL RELEVANCE: Arthroscopic subspine decompression serves as an important treatment modality for AIIS impingement. With a more thorough understanding of AIIS anatomy, subspine decompression can be used to relieve impingement symptoms and possibly improve iliopsoas tracking while safely maintaining rectus femoris footprint integrity.

Influence of capsular repair versus unrepaired capsulotomy on 2-year clinical outcomes after arthroscopic hip preservation surgery.

PURPOSE: The primary objective of this study was to determine whether capsular management technique influences clinical outcomes at a minimum of 2 years after arthroscopic hip preservation surgery. METHODS: A retrospective review of prospectively collected data was conducted to determine the relative influence of 2 capsular management strategies on clinical outcomes: unrepaired capsulotomy (group A) and capsular repair (group B). Four hundred three patients who had undergone arthroscopic hip preservation surgery met the inclusion criteria and had 2-year outcome data available. All patients completed 4 patient-reported outcome (PRO) questionnaires preoperatively and at a minimum of 2 years' follow-up. These included the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) subsets, Non-Arthritic Hip Score (NAHS), and modified Harris Hip Score (mHHS). RESULTS: Group A included 235 patients and group B, 168. The mean age of all patients at final follow-up was 36.9 years. Patients in group A were significantly older (42.3 years v 29.4 years, P < .0001) and had a significantly higher body mass index (26.8 kg/m(2)v 22.9 kg/m(2), P < .0001) compared with group B. In addition, female patients were more likely than male patients to undergo capsular repair (136 female patients v 32 male patients, P < .0001). Patients in group A also showed greater chondral damage by acetabular labrum articular disruption classification (P = .0081) and reduced preoperative PROs (HOS-ADL of 60.5 v 66.0, P = .087; HOS-SSS of 37.0 v 46.4, P = .0002; NAHS of 54.6 v 62.2, P < .0001; mHHS of 58.7 v 64.4, P = .0009; and visual analog scale score of 6.3 v 5.84, P = .028). All PROs showed statistically significant improvements for both groups at a minimum follow-up of 2 years (HOS-ADL, 60.5 to 82.2 in group A and 66 to 86.1 in group B; HOS-SSS, 36.9 to 67.3 and 46.4 to 71.2, respectively; NAHS, 54.6 to 79 and 62.2 to 82.8, respectively; visual analog scale score, 6.3 to 3.1 and 5.8 to 2.9, respectively; and mHHS, 58.7 to 81 and 64.4 to 83.8, respectively; P < .0001 for all differences). Furthermore, group B showed greater overall improvements than group A for the HOS-ADL (P = .03) and NAHS (P = .03) on uncorrected univariate analysis, but significance was lost once we controlled for confounding variables. CONCLUSIONS: Arthroscopic capsular repair, used in conjunction with arthroscopic hip preservation surgery, appears to be safe and did not negatively influence clinical outcomes in this study. When confounding variables were controlled for, the use of capsular repair did not show clinically relevant superiority over the use of unrepaired capsulotomy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Cumulative Radiation Exposure to Patients Undergoing Arthroscopic Hip Preservation Surgery and Occupational Radiation Exposure to the Surgical Team.

PURPOSE: To quantify cumulative radiation exposure in patients undergoing arthroscopic hip preservation surgery and occupational exposure to operating room (OR) personnel during such surgery; a secondary objective of this study was to identify factors affecting radiation exposure in patients undergoing hip arthroscopy. METHODS: Radiation exposure from all preoperative and intraoperative imaging studies was determined for 52 patients undergoing hip arthroscopy. Cumulative and effective radiation doses were calculated and correlated with pathology and body mass index (BMI). Badge dosimeters were worn by OR personnel to measure cumulative occupational exposure. A highly sensitive portable ion chamber was used to evaluate the radiation scatter during surgery performed on a high-BMI patient and a low-BMI patient to reflect a "worst-case scenario" and "best-case scenario," respectively. RESULTS: Forty-three patients underwent procedures for femoroacetabular impingement (FAI) and 9 underwent procedures for soft-tissue pathologies (ST). The median cumulative exposure was 8.6 mGy and 5.0 mGy for FAI patients and ST patients, respectively (P = .01). The cumulative effective radiation dose was 490 mrem and 350 mrem for FAI patients and ST patients, respectively (P = .47). BMI significantly correlated with cumulative exposure (P = .0004) and trended toward significance with cumulative effective dose (P = .073). OR staff cumulative occupational exposure was low (9 mrem for the surgeon). Ion chamber data showed that increasing patient BMI resulted in increased occupational exposure. CONCLUSIONS: The median cumulative effective radiation dose to patients undergoing arthroscopic hip preservation surgery is 490 mrem and results in an excess lifetime risk of death from cancer of 0.025%. Greater BMI correlates with increased cumulative radiation exposure and may increase risk to OR personnel. Occupational exposure to the surgical team from hip arthroscopy ranges from 7 to 9 mrem per 50 hip arthroscopies (+0.0005% excess lifetime risk of death from cancer). LEVEL OF EVIDENCE: Level IV, diagnostic.

Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients.

Background: The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods: Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results: A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion: Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.

Hip anatomic variants that may mimic abnormalities at MRI: labral variants.

OBJECTIVE: Normal anatomic variants of the acetabular labrum are observed on MR images and include labral variants, several sublabral sulci, and perilabral sulcus. Because variants can be misidentified as labral abnormalities such as labral tears, the radiologist needs to avoid the pitfall of mistaking variants as abnormalities. CONCLUSION: The hip has multiple anatomic variants that can mimic abnormalities at hip MRI. The labrum has several anatomic variants that can be confused with true labral tears.

Hip anatomic variants that may mimic pathologic entities on MRI: nonlabral variants.

OBJECTIVE: The hip has several anatomic variants that may be mistaken for pathologic abnormalities. The radiologist needs to be able to distinguish these variants from true abnormalities. In this review, we present nonlabral variants of the hip that can be seen on MRI. CONCLUSION: The hip has multiple anatomic variants that may mimic disease on hip MRI. Like labral variants, nonlabral variants can be confused for true abnormalities.

Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability.

PURPOSE: The purpose of this systematic review was to critically evaluate the available literature exploring the role of the hip joint capsule in the normal state (stable) and pathologic states (instability or stiffness). Furthermore, we examined the various ways that arthroscopic hip surgeons address the capsule intraoperatively: (1) capsulotomy or capsulectomy without closure, (2) capsulotomy with closure, and (3) capsular plication. METHODS: Two independent reviewers (B.D.G. and B.G.D.) performed a systematic review of the literature using PubMed and the reference lists of related articles by means of defined search terms. Relevant studies were included if these criteria were met: (1) written in English, (2) Levels of Evidence I to V, (3) focus on capsule and its role in hip stability, and (4) human studies and reviews. Articles were excluded if they evaluated (1) total hip arthroplasty constructs using bony procedures or prosthetic revision, (2) developmental dysplasia of the hip where reorientation osteotomies were used, (3) syndromic instability, and (4) traumatic instability with associated bony injury. RESULTS: By use of the search method described, 5,085 publications were reviewed, of which 47 met appropriate criteria for inclusion in this review. Within this selection group, there were multiple publications that specifically addressed more than 1 of the inclusion criteria. Relevant literature was organized into the following areas: (1) capsular anatomy, biomechanics, and physiology; (2) the role of the capsule in total hip arthroplasty stability; (3) the role of the capsule in native hip stability; and (4) atraumatic instability and capsulorrhaphy. CONCLUSIONS: As the capsuloligamentous stabilizers of the hip continue to be studied, and their role defined, arthroscopic hip surgeons should become facile with arthroscopic repair or plication techniques to restore proper capsular integrity and tension when indicated. LEVEL OF EVIDENCE: Level IV, systematic review.

Inpatient radiation exposure in patients with spinal trauma.

CONTEXT/OBJECTIVE: Radiation exposure from medical imaging is an important patient safety consideration; however, patient exposure guidelines and information on cumulative inpatient exposure are lacking. DESIGN/SETTING: Trauma patients undergo numerous imaging studies, and spinal imaging confers a high effective dose; therefore, we examined cumulative effective radiation dose in patients hospitalized with spinal trauma. We hypothesized that people with spinal cord injury (SCI) would have higher exposures than those with spine fractures due to injury severity. PARTICIPANTS/INTERVENTIONS: Retrospective data were compiled for all patients with spine injuries admitted to a level I trauma center over a 2-year period. OUTCOME MEASURES: Injury severity score (ISS) and cumulative radiation exposure were then determined for these patients, including 406 patients with spinal fractures and 59 patients with SCI. RESULTS: Cumulative effective dose was 45 millisieverts (mSv) in SCI patients, compared to 38 mSv in spinal fracture patients (P = 0.01). Exposure was higher in patients with an ISS over 16 (P = 0.001). Mean exposure in both groups far exceeded the European annual occupational exposure maximum of 20 mSv. More than one-third of patients with SCI exceeded the US occupational maximum of 50 mSv. CONCLUSION: Patients with SCI had significantly higher radiation exposure and ISS than those with spine fracture, but the effective dose was globally high. Dose did not correlate with injury severity for patients with SCI. While the benefits of imaging are clear, radiation exposure does involve risk and we urge practitioners to consider cumulative exposure when ordering diagnostic tests.

Comparable Injury to the Indirect Head of the Rectus Femoris During Interportal and Periportal Capsulotomy: A Cadaveric Study.

Background: There is concern for maintaining the integrity of the reflected head of the rectus femoris during arthroscopic hip joint access. Because of the proximity to the indirect head of the rectus femoris (IHRF), capsulotomy technique and capsular closure during routine hip arthroscopy may play a role in postoperative tendinitis. Purpose: To quantify the extent of injury sustained to the IHRF during interportal versus periportal capsulotomy for routine arthroscopic hip joint access. Study Design: Controlled laboratory study. Methods: A cadaveric study was conducted using 20 fresh-frozen cadaveric hips, in which hip joint access through a periportal capsulotomy (n = 10) or interportal capsulotomy (n = 10) was performed. Capsular closure followed by a layered dissection to the capsuloligamentous complex of the hip joint was then performed to localize the IHRF. Suture proximity to the tendon, tendon disruption, and the IHRF footprint was documented to the nearest 0.01 mm using digital calipers. Statistical analysis was performed using unpaired Student t tests. Results: The mean capsulotomy length for the interportal specimens was 19.27 ± 3.25 mm, and the mean medial and lateral capsulotomy length for the periportal specimens was 4.47 ± 1.60 and 4.26 ± 0.89 mm, respectively. There was violation of the tendon in 3 of 10 interportal specimens and 4 of 10 periportal specimens. There was no significant difference in the closest suture measured to the IHRF for specimens with versus without tendon violation, for either interportal or periportal capsulotomy. Conclusion: We found comparable outcomes with regard to violation of the IHRF between interportal and periportal capsulotomy, with no significant difference in suture proximity to the IHRF in specimens with or without tendon violation. There remains no consensus on the ideal method by which to avoid iatrogenic damage to the IHRF. Clinical Relevance: Our findings provide insight that may lead to future advances in surgical care, such that protection of the tendon during routine hip arthroscopy may allow for improved postoperative rehabilitation and strength.

Multifid Iliopsoas Tendons Are More Common in Patients With Painful Snapping Iliopsoas Tendons.

Purpose: To retrospectively determine the prevalence of multifid tendons in a population of patients who underwent iliopsoas release for painful snapping iliopsoas tendons. Methods: Patients who underwent iliopsoas release for painful snapping iliopsoas tendons were retrospectively identified from a database of patients who had undergone arthroscopic hip surgery performed by a single surgeon between 2011 and 2020. Patients who had incomplete data or who underwent prior fracture fixation, joint arthroplasty, pelvic surgery, or other interventions for snapping hip were excluded. Magnetic resonance imaging (MRI) and operative reports were reviewed and compared with those of an age-matched control group of patients who had undergone hip or pelvic MRI examinations in the past year for different indications. Results: This study included 91 patients (78 female and 13 male patients; mean age, 23.3 years) who were treated operatively for painful snapping hip and 78 controls (54 female and 24 male patients; mean age, 28.4 years) who received hip or pelvic MRI for other indications. Among the patients who underwent iliopsoas release, there were 5 unifid iliopsoas tendons (5.5%) compared with 86 multifid iliopsoas tendons (94.5%) when classified with MRI whereas operative examination showed 19 unifid tendons (20.9%) compared with 72 multifid tendons (79.1%, P < .001). When the MRI scans of the operative group were compared with the MRI scans of the control group, the patients who underwent surgery for painful snapping hip had a higher rate of multifid tendons (94.5% of operative hips compared with 69.2% of control right hips [P < .001] and 74.4% of control left hips [P < .001]). However, when the operative reports were used to classify the iliopsoas tendon, there was no significance between the operative and control groups (79.1% of operative hips had multifid tendons compared with 69.2% of control right hips [P = .141] and 74.4% of control left hips [P = .464]). Conclusions: For patients with symptomatic snapping hip undergoing iliopsoas lengthening, multifid iliopsoas tendons are more prevalent than in a control population. Level of Evidence: Level IV, prognostic case series.