Combined Borderline Acetabular Dysplasia and Increased Femoral Anteversion Is Associated With Worse Outcomes in Female Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To determine the relationship of increased femoral anteversion and borderline acetabular dysplasia on the outcomes of hip arthroscopy for femoroacetabular impingement in a female cohort of patients. METHODS: This is a retrospective study of female patients undergoing hip arthroscopy for femoroacetabular impingement. All patients had preoperative radiographs and computed tomography scans from which lateral center edge angle (LCEA) and femoral anteversion were measured. Patient outcome was quantified by preoperative and postoperative International Hip Outcome Tool 12-item instrument (iHOT-12). All patients had follow-up at 2 to 4 years postoperatively. Published values for minimum clinically important difference, substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and a normal or abnormal hip were used to determine outcome as well as the final score and delta of the iHOT-12. RESULTS: There were 243 female patients included in the cohort (83% follow-up) who had iHOT-12 scores at 2- to 4-year follow-up (mean 36.9 months). Female patients with combined LCEA ≤25° and femoral anteversion >20° had lower final IHOT-12 scores (P = .001) and delta iHOT-12 (P = .010) and were less likely to achieve a normal hip (P = .013), minimum clinically important difference (P = .018), SCB (P < .001), or PASS (P < .001) and more likely to have an abnormal hip (P = .002). In addition, patients with an LCEA ≤25° and normal femoral version were less likely to achieve a normal hip (P = .013), SCB (P < .001), and PASS (P < .001) compared with those with normal acetabular coverage (all P < .05). There was no difference in these outcome measures between the groups with an LCEA >25° with or without increased femoral version. CONCLUSIONS: Female patients with femoral anteversion >20° and borderline acetabular dysplasia did poorly after hip arthroscopy. However, those with increased femoral anteversion and normal acetabular coverage had outcomes similar to control hips. LEVEL OF EVIDENCE: Level IV, case series.

Effect of Physical Therapy Visits on Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction With and Without Concurrent Meniscal Repair.

BACKGROUND: Health care payment reform has increased employers and health insurance companies' incentive to take measures to control the rising costs of medical care in the United States. To date, limited research has investigated the influence outpatient physical therapy (PT) visits have on clinical outcomes following anterior cruciate ligament reconstruction (ACLR) with and without a concurrent meniscal repair. OBJECTIVE: To examine the relationship between the number of PT visits and patient-reported outcome scores following ACLR outpatient rehabilitation. STUDY DESIGN: Retrospective cohort. LEVEL OF EVIDENCE: 2b. METHODS: Patients following ACLR with (n = 62) and without (n = 328) meniscal repair were identified through an electronic medical record database. RESULTS: Patients with more PT visits had higher knee outcome survey-activities of daily living (KOS-ADL) change scores (P = .01) following ACLR without meniscal repair. Younger patients yielded significantly higher KOS-ADL change scores (P = .05) in the same cohort. Patients in the semisupervised PT visit strata recorded an 11.1 higher KOS-ADL change score compared with patients within the unsupervised PT visit stratum (P = .02). Younger patients also yielded significantly larger reductions in numeric pain (P = .01) following ACLR without meniscal repair. No significant differences were found between PT visits and either patient-reported outcome following ACLR with meniscal repair. CONCLUSIONS: Our findings suggest that younger patients and those in a semisupervised PT visit model have superior patient-reported outcomes following ACLR without meniscal repair. Preliminary findings indicate no relationship with PT visits and patient-reported outcomes in patients after ACLR with meniscal repair surgery. CLINICAL RELEVANCE: These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.

Editorial Commentary: To Pump or Not to Pump? Gravity Versus Fluid Pumps for Shoulder and Knee Arthroscopy.

Recent studies and our clinical experience have supported the safety and efficacy of various arthroscopic pumps for use in practice. Different pump designs are to be used in different ways. Although gravity flow can lead to constant low pressure in a cadaveric knee or shoulder, it may not provide optimal visualization or performance to best complete your surgical procedure. To take the best care of our patients, understanding basic fluid pump design and understanding what pump design resides in your operating room is important for all practicing arthroscopists.

Do Arthroscopic Fluid Pumps Display True Surgical Site Pressure During Hip Arthroscopy?

PURPOSE: To report on the accuracy of 5 commercially available arthroscopic fluid pumps to measure fluid pressure at the surgical site during hip arthroscopy. METHODS: Patients undergoing hip arthroscopy for femoroacetabular impingement were block randomized to the use of 1 of 5 arthroscopic fluid pumps. A spinal needle inserted into the operative field was used to measure surgical site pressure. Displayed pump pressures and surgical site pressures were recorded at 30-second intervals for the duration of the case. Mean differences between displayed pump pressures and surgical site pressures were obtained for each pump group. RESULTS: Of the 5 pumps studied, 3 (Crossflow, 24K, and Continuous Wave III) reflected the operative field fluid pressure within 11 mm Hg of the pressure readout. In contrast, 2 of the 5 pumps (Double Pump RF and FMS/DUO+) showed a difference of greater than 59 mm Hg between the operative field fluid pressure and the pressure readout. CONCLUSIONS: Joint-calibrated pumps more closely reflect true surgical site pressure than gravity-equivalent pumps. With a basic understanding of pump design, either type of pump can be used safely and efficiently. The risk of unfamiliarity with these differences is, on one end, the possibility of pump underperformance and, on the other, potentially dangerously high operating pressures. LEVEL OF EVIDENCE: Level II, prospective block-randomized study.

The effects of early aggressive rehabilitation on outcomes after anterior cruciate ligament reconstruction using autologous hamstring tendon: a randomized clinical trial.

STUDY DESIGN: Prospective randomized clinical trial. METHODS AND MEASURES: Thirty-six patients who had a primary anterior cruciate ligament reconstruction (ACL-R) with a semitendinosus-gracilis (STG) autograft from a single orthopedic surgeon were prospectively randomized into 2 groups. Nineteen patients were randomized to the aggressive group (53% male, mean age 30.1 + 10.5 y) and 17 to the nonaggressive group (88% male, mean age 33.1 + 10.9 y). Impairment measures of anteroposterior (A-P) knee laxity, range of motion (ROM), and peak isometric force (PIF) values were obtained 12 wk postoperatively. Subjective response to the International Knee Documentation Committee knee form (IKDC) was collected 1, 12, and 24 wk postoperatively. One-way ANOVA was used to analyze differences between groups at 12 wk for A-P knee laxity, ROM, and PIF. Differences between the groups for the IKDC scores were determined using 1-way ANOVA with repeated measures 1, 12, and 24 wk postoperatively. Bonferroni adjustment was used for multiple comparisons. RESULTS: There were no differences between the groups for the baseline characteristics (P > .05). There was no difference found between the groups in respect to A-P knee laxity, ROM, or PIF at 12 wk (P > .05). Further analysis also showed no significant differences in the IKDC scores between groups at 12 or 24 wk (P > .05). CONCLUSIONS: No differences were found between early aggressive and nonaggressive rehabilitation after an isolated ACL-R using STG autografts for the primary outcomes of A-P knee laxity and subjective IKDC score. In addition, no differences were observed for secondary outcomes between groups for differences in ROM and PIF values.

Association of Radiographic Markers of Hip Instability and Worse Outcomes 2 to 4 Years After Hip Arthroscopy for Femoroacetabular Impingement in Female Patients.

BACKGROUND: Reported outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) with underlying borderline acetabular dysplasia are mixed. This may in part be the result of mixed-sex reporting. PURPOSE: To determine the effect of radiographic measures of acetabular dysplasia and hip instability on outcomes of female patients undergoing hip arthroscopy for FAI. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a retrospective study of female patients undergoing arthroscopic surgery for FAI. All patients had preoperative radiographs including a standing anteroposterior pelvic view on which lateral center-edge angle (LCEA), anterior wall index (AWI), posterior wall index (PWI), and femoroepiphyseal acetabular roof (FEAR) index were measured. Patient outcomes were quantified by preoperative and postoperative 12-Item International Hip Outcome Tool (iHOT-12) scores. All patients had follow-up at 2 to 4 years postoperatively. Published values for minimal clinically important difference (MCID), substantial clinical benefit (SCB), Patient Acceptable Symptom State (PASS), and a normal (iHOT-12 > 86 points) or abnormal (iHOT-12 < 56 points) hip were used to determine outcome, as well as the final iHOT-12 score and iHOT-12 preoperative to postoperative difference. RESULTS: The cohort consisted of 249 female patients (83% follow-up) with iHOT-12 scores at 2 to 4 years after surgery (mean, 34.6 months). Female patients with combined LCEA ≤25° and AWI <0.35 had lower final iHOT-12 score and iHOT-12 difference and were less likely to meet MCID, SCB, and PASS and have a normal hip and were more likely to have an abnormal hip as determined by iHOT-12 cutoffs when compared with those patients who had an LCEA >25° and an AWI ≥0.35 (all P < .05). There was no effect of PWI on outcomes. Similarly, female patients with combined LCEA ≤25° and a laterally oriented (positive) FEAR index were less likely to meet MCID, SCB, and PASS and have a normal hip and were more likely to have an abnormal hip compared with those patients who had an LCEA >25° and a negative (medial) FEAR index (all P < .05). In multivariate regression, an LCEA between 18° and 25° was an independent predictor of worse outcomes. CONCLUSION: An LCEA of 18° to 25°, in combination with an AWI of <0.35 or a laterally opening FEAR index, was predictive of worse outcomes in female patients undergoing hip arthroscopy for FAI.

Transition to Telehealth Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement: A Pilot Study With Retrospective Matched-Cohort Analysis.

BACKGROUND: Telehealth use has increased significantly of late. However, outside of total hip and knee arthroplasty, there is minimal evidence regarding its efficacy in orthopaedics and postoperative rehabilitation. PURPOSE: To determine the efficacy and cost-effectiveness of a transition to postoperative telehealth physical therapy in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 51 patients undergoing postoperative physical therapy after hip arthroscopy for FAI. The intervention group consisted of patients undergoing initial in-person visits followed by a transition to telehealth physical therapy for 3 months postoperatively (group 1; n = 17). Comparison groups included patients undergoing in-person physical therapy with the same physical therapy team as the telehealth group (group 2; n = 17) and patients undergoing in-person therapy with a different therapy team at the same facility (group 3; n = 17). All groups were matched 1-to-1 by patient age and sex. All patients completed the short version of the International Hip Outcome Tool (iHOT-12) both preoperatively and at 3 months postoperatively. At 3 months postoperatively, it was determined whether patients met the minimally clinically important difference (MCID; ≥13 points) or substantial clinical benefit (SCB; ≥28 points) or whether they reached a Patient Acceptable Symptomatic State (PASS; ≥64 points). Billed charges were recorded as a measure of cost. RESULTS: The overall mean age of the study patients ranged from 33 to 34 years. Among the 3 groups, there was no significant difference in the preoperative, postoperative, or pre- to postoperative change in iHOT-12 scores or in the percentage of patients meeting MCID, SCB, or PASS at 3 months. Group 1 had significantly lower mean costs ($1015.67) compared with group 2 ($1555.62; P = .011) or group 3 ($1896.38; P < .001). CONCLUSION: In this pilot study, telehealth physical therapy after hip arthroscopy was found to lead to similar short-term outcomes and was cost-effective compared with in-person physical therapy.

Trajectory of clinical outcomes following hip arthroscopy in female subgroup populations.

To describe the recovery trajectory in a group of relatively older borderline dysplastic female femoroacetabular impingement syndrome (FAIS) patients following arthroscopic surgery, to determine if outcomes in this group differs from females with different age and bony morphology characteristics. Four subgroups were created to define (i) older females (>35 years), borderline dysplastic (lateral center edge angle [LCEA] ≤ 25 degrees) and anterior wall index (AWI) deficient (AWI ≤ 0.40) (older, borderline dysplastic, anterior wall deficient [ODD, reference]); (ii) younger (≤35 years), borderline dysplastic (LCEA ≤ 25 degrees) and deficient anterior wall (AWI ≤ 0.40) (younger, borderline dysplastic, anterior wall deficient [YDD]); (iii) older (>35 years), non-dysplastic (LCEA > 25 degrees) and non-deficient anterior wall (AWI > 0.40) (older, non-dysplastic, non-deficient anterior wall [ONN]); and (iv) younger (≤35 years), non-dysplastic (LCEA > 25 degrees) and non-deficient anterior wall (AWI > 0.40) (younger, non-dysplastic, non-deficient anterior wall [YNN]). One hundred and seventy-three female patients were included. Comparing mean scores, the ODD group reported significantly lower International Hip Outcome Tool (iHOT-12) change scores compared with the ONN group [23.58 ± 9.73; P = 0.03] at 12 months. ODD group also demonstrated significantly lower iHOT-12 change scores compared with the ONN (27.62 ± 8.22; P < 0.01) and YNN (25.39 ± 7.68; P < 0.01) groups at 24 months. Relatively older females with borderline dysplasia and anterior acetabular wall deficiencies had poorer iHOT-12 outcomes at both 12 and 24 months post-operatively compared with other female subgroups. In the absence of hip dysplasia and anterior wall deficiencies, superior iHOT-12 outcomes were observed in both older and younger females post-operatively.

Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation.

BACKGROUND: Septic arthritis after arthroscopic anterior cruciate ligament reconstruction is rare, and the most appropriate treatment is unclear. Current recommendations are that, if the graft is removed, reimplantation should be delayed for 6 to 9 months. HYPOTHESIS: Early removal of the graft with appropriate infection management followed by early reimplantation can lead to good results. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Records of all patients who developed postoperative infection after anterior cruciate ligament reconstruction were reviewed. Four patients had early graft removal and appropriate infection management including 6 weeks of intravenous antibiotics followed by anterior cruciate ligament graft reimplantation within 6 weeks of completion of antibiotic therapy. RESULTS: Follow-up at an average of 21 months (range, 14 to 31) showed that the patients treated with early reimplantation had full symmetric knee range of motion and no effusion. The average modified Lysholm score was 92.5. Radiographs demonstrated no joint-space narrowing or osteophyte formation. The 30-pound KT-1000 arthrometer side-to-side difference averaged 3 mm. CONCLUSION: Graft removal after confirmed anterior cruciate ligament graft infection and intravenous antibiotic administration followed by early graft reimplantation can give excellent results.