Short-term Outcomes After Hip Arthroscopic Surgery in Patients Participating in Formal Physical Therapy Versus a Home Exercise Program: A Prospectively Enrolled Cohort Analysis.

BACKGROUND: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population. PURPOSE/HYPOTHESIS: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores. RESULTS: The patients' mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score (P = .795), visual analog scale for pain score (P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score (P = .699), 12-item International Hip Outcome Tool score (P = .582), and patient satisfaction (P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups (P < .001). CONCLUSION: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

The Role of the Hip Capsule in Restoring Stability in the Initial Phase of Hip Distraction: An In Vivo Analysis.

Background: The labral suction seal has been shown to provide the majority of resistance in the initial phase of hip distraction. However, the effect of an unrepaired interportal capsulotomy and capsular repair on the initial phase of hip distractive stability in vivo is not well understood. Purpose: To investigate the effect of capsular repair on the initial phase of distractive stability of hip joints in patients with femoroacetabular impingement (FAI) syndrome. Study Design: Controlled laboratory study. Methods: Patients undergoing primary hip arthroscopy for FAI between March and August 2020 were prospectively enrolled. Total joint space was measured on fluoroscopic images at the medial and lateral edges of the sourcil at 12.5-lb (5.7-kg) axial traction intervals (up to 100 lb [45.4 kg]) in 3 capsular states: (1) native capsule, (2) interportal capsulotomy, and (3) capsular repair. Distraction on anteroposterior radiographs was calculated as the difference between total joint space at each traction interval and baseline joint space at 0 lb, normalized to millimeters. The native, capsulotomy, and capsular repair states were compared using Wilcoxon signed-rank and McNemar tests. Results: Included were 36 hips in 35 patients. The median force required to distract ≥3 mm was 75 lb (34.0 kg; 95% CI, 70-80 lb [31.8-36.3 kg]) in both the native and capsular repair states (P = .629), which was significantly greater than the median force required to distract ≥3 mm in the capsulotomy state (50 lb [22.7 kg]; 95% CI, 45-55 lb [20.4-24.9 kg]) (P < .001). The most rapid rates of change in joint space were observed at the traction interval at which hips first achieved ≥3 mm of distraction (n = 33 hips; 92%). Conclusion: The traction force at which hips distracted ≥3 mm was 75 lb (34.0 kg) in both the native capsular and capsular repair states. Significantly less traction force (50 lb [22.7 kg]) distracted hips ≥3 mm in the capsulotomy state. Complete capsular closure after interportal capsulotomy resulted in restoration of initial distractive stability relative to the unrepaired capsulotomy state at time zero after primary hip arthroscopy. Clinical Relevance: This study provides surgeons with an improved understanding of the additional stability to the hip joint from capsular repair after hip arthroscopy for FAI syndrome.

Physeal Location on the Distal Femoral Cortical Surface Is Consistently Proximal to Apparent Location on the Perfect Lateral Radiograph: A 3-Dimensional Digitally Reconstructed Radiograph Study.

INTRODUCTION: The perfect knee lateral radiograph visualizes anatomic landmarks on the distal femur for clinical and scientific purposes. However, radiographic imaging is a two-dimensional (2D) representation of a three-dimensional (3D) physis. The aim of this study was to characterize the perceived radiographic projection of the femoral physis using perfect lateral digitally reconstructed radiographs (DRRs) and to evaluate discrepancies from this projection to the physis at the lateral and medial cortices. METHODS: Pediatric patients from a cohort of CT scans were analyzed. Inclusion criteria were an open physis; exclusion criteria were any implant or pathology affecting the physis. CT scans were imported into 3D imaging software and transformed into lateral DRRs and 3D renderings of the femur. The physis was divided into four equal segments, with fiducial markers placed at the "anterior," "midpoint," and "posterior" points. Lines extended from these points in the lateral and medial direction. The vertical distance from these lines, representing the radiographic projection of the physis, was measured relative to the physis at the lateral and medial cortex of the femur on coronal CT slices. RESULTS: Thirty-one patients were included. On the perfect lateral radiograph DRR, the physis on the medial cortex was located proximal to the visualized physis by 6.64 ± 1.74 mm, 11.95 ± 1.67 mm, and 14.30 ± 1.75 mm at the anterior (25%), midpoint (50%), and posterior (75%) locations, respectively. On the lateral side, the physis on the lateral cortex was proximal to the visualized physis by 2.19 ± 1.13 mm, 3.71 ± 1.19 mm, and 6.74 ± 1.25 mm at the anterior, midpoint, and posterior locations, respectively. DISCUSSION: In this cohort of pediatric patients, the location of the cortical physis was, in all areas measured, proximal to the projection of the visualized physis as seen on the perfect knee lateral DRR. The distance from radiographic physis to cortical physis was greater at the medial cortex compared with the lateral cortex. STUDY DESIGN: Descriptive laboratory study. LEVEL OF EVIDENCE: III, observational radiographic anatomic study.

Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis.

Background: Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery. Purpose: To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression. Results: A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (ß = -1.468 [95% CI, -2.049 to -0.887]; P < .001). Conclusion: Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.

Magnetic Resonance Imaging and Magnetic Resonance Arthrography Are Both Reliable and Similar When Measuring Hip Capsule Thickness in Patients With Femoroacetabular Impingement Syndrome.

Purpose: To propose an accurate method of measuring hip capsular thickness in patients with femoroacetabular impingement syndrome and to compare the reliability of these measurements between magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Methods: A previously established database of patients with femoroacetabular impingement syndrome (FAIS) was used to identify candidates with preoperative MRI or MRA from November 2018 to June 2021. Two reviewers independently examined preoperative imaging for 85 patients. Capsular thickness was measured in 12 standardized locations. Intraclass correlation coefficients (ICCs) were calculated using an absolute-agreement, 2-way random-effects model. Using the same method, 30 patients were randomly selected for repeat measurements by 1 reviewer following a washout period. Ten additional patients with preoperative MRI and MRA of the same hip were identified to compare measurements between modalities using paired samples t test. Results: ICCs for measurements on MRIs and MRAs using these proposed measurements to compare inter-rater reliability were 0.981 and 0.985. ICCs calculated using measurements by a single reviewer following a washout period for intrarater reliability were 0.998 and 0.991. When comparing MRI and MRA measurements in the same patient, t test for all pooled measurements found no difference between modality (P = .283), and breakdown of measurements by quadrant found no difference in measurements (P > .05), with the exception of the inferior aspect of the capsule on coronal sequences (P = .023). Conclusions: In patients with FAIS, both MRI and MRA have excellent reliability for quantifying hip capsular thickness. A difference in capsular thickness was found only when comparing MRI and MRA on inferior coronal aspects of the hip capsule, indicating interchangeability of these imaging modalities when measuring the clinically important aspects of the hip capsule. Level of Evidence: Level IV, diagnostic case series.

Correlation of Tibial Tubercle Overgrowth With Increased Posterior Tibial Slope: A Novel Radiographic Assessment.

Background: An elevated posterior tibial slope (PTS) is associated with an increased risk for anterior cruciate ligament and meniscal injury. Recent evidence suggests that the PTS is elevated in patients with Osgood-Schlatter disease. Purpose: To determine whether there is an association between objective measures of anterior tibial tubercle growth and PTS. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 radiographs were randomly selected from a sample of patients who had received a lateral knee radiograph that captured at least 15 cm of the tibia distal to the knee joint line at a single institution between December 2020 and March 2022. The PTS was measured, and tibial tubercle growth was quantified with 2 novel measurements. For these measurements, a line was drawn on the radiograph from the most anterosuperior point on the tibia to the point on the anterior cortex of the tibia 10 cm distal from the starting point. The tibial tubercle height (TTH) was measured as the perpendicular distance from this line to the most prominent portion of the anterior tibia. The anterior tibial tubercle angle (TTA) was measured as the angle between the endpoints of the line made previously and the most prominent portion of the tibial tubercle, with a more acute angle indicating a more prominent tibial tubercle. The relationship between TTA, TTH, and PTS was evaluated using a univariate linear regression model. Results: The mean patient age was 33.1 ± 14.1 years. The mean TTA was 158.6°± 4.7°, the mean TTH was 8.8 ± 2.0 mm, and the mean PTS was 9.7°± 2.6°. A significant correlation was found between PTS and TTA (r = -0.46; ß = -0.46; P < .001) as well as TTH (r = 0.43; ß = 0.43; P < .001). Conclusion: Objective measures of anterior tibial tubercle overgrowth correlated with an elevated PTS. Every 2.2° of anterior TTA deviation from the mean and every 2.3 mm in TTH deviation from the mean correlated with a 1° difference in the PTS. This suggests a link between the development of the tibial tubercle and PTS, and it potentially helps to explain why the PTS is elevated in certain patients.

Association of Relative Skeletal Immaturity of the Triradiate Cartilage with Increased Proximal Femoral Deformity in Prophylactic Fixation for Slipped Capital Femoral Epiphysis: A Radiographic Study.

INTRODUCTION: The purpose of this study was to describe proximal femoral deformity after contralateral hip prophylactic fixation of slipped capital femoral epiphysis (SCFE) in patients and the association of relative skeletal immaturity with this deformity. METHODS: A retrospective review of patients presenting with a SCFE was conducted from 2009 to 2015. Inclusion criteria were (1) radiographic evidence of a unilateral SCFE treated with in situ fixation, (2) contralateral prophylactic fixation of an unslipped hip, and (3) at least 3 years of follow-up. Measurements were made on radiographs and included greater trochanter height relative to the center of the femoral head, femoral head-neck offset, and femoral neck length. Skeletal maturity was evaluated by assessing the status of the proximal femoral physis and triradiate cartilage (TRC) of the hip, in addition to the length of time to closure of these physes. Values were compared from initial presentation to final follow-up. Statistical analysis included descriptive statistics and linear regression. RESULTS: Twenty-seven patients were included. Bivariable linear regression demonstrated that an increased relative trochanteric overgrowth was associated with TRC width (ß = 3.048, R = 0.585, P = 0.001) and an open TRC (ß = -11.400, R = 0.227, P = 0.012). Time to proximal femoral physis closure (ß = 1.963, R = 0.444, P = 0.020) and TRC closure (ß = 1.983, R = 0.486, P = 0.010) were predictive of increased deformity. In addition, multivariable elimination linear regression demonstrated that TRC width (ß = 3.048, R = 0.585, P = 0.001) was predictive of an increased relative trochanteric overgrowth. DISCUSSION: Patients with an open TRC and increased TRC width are associated with increased relative trochanteric overgrowth when undergoing prophylactic fixation for a unilateral SCFE. Increased caution should be exercised when considering contralateral hip prophylactic fixation in skeletally immature patients presenting with a unilateral SCFE. LEVEL OF EVIDENCE: Level IV, case series.

Mid-term outcomes of temporary medial distal femoral hemiepiphysiodesis with and without medial patellofemoral ligament repair for recurrent patellar instability in skeletally immature patients with genu valgum.

Genu valgum contributes to patellar instability, though outcomes following temporary hemiepiphysiodesis via eight plating are less understood. The purpose of this study was to evaluate the outcomes and need for additional procedures following temporary hemiepiphysiodesis for the treatment of pediatric genu valgum and patellar instability, as well as evaluating the utility of a concurrent medial patellofemoral ligament (MPFL) repair. Patients who underwent medial distal femoral epiphysiodesis for the treatment of genu valgum and recurrent patellar instability were identified. Inclusion criteria were minimum 1-year follow-up and lack of concurrent ligamentous reconstruction. Patients were contacted to complete a questionnaire which included the International Knee Documentation Committee (IKDC) form and questions pertaining to knee function and patient satisfaction. Thirty-one patients aged 12.0 ± 1.9 years underwent 47 guided growth procedures and were included in final analysis. Seventeen knees (36%) required subsequent surgery for patellar instability. All patients requiring subsequent surgery were female, compared with 70% of patients not requiring subsequent surgery ( P  = 0.017). The MPFL repair group underwent fewer subsequent procedures to address instability, though this difference was NS (17 vs. 46%, P  = 0.318). Mean IKDC score at 5.3 years follow-up among 18 survey respondents was 78.6. Medial distal femoral hemiepiphysiodesis may partially address recurrent patellar instability in skeletally immature patients with genu valgum. Concurrent MPFL repair may minimize the need for subsequent procedures to address recurrent instability. While correcting alignment may be helpful, patients should be aware of the potential need for further patellar instability surgery. Level of evidence: IV, case series.

Establishing the Patient Acceptable Symptom State Thresholds for Patient-Reported Outcomes after Operatively Treated Tibial Plateau Fractures.

OBJECTIVES: Define patient-acceptable symptom state (PASS) thresholds and factors affecting PASS thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS) following operatively treated tibial plateau fractures. DESIGN: Retrospective cohort. SETTING: Single Level I academic trauma center. PATIENT SELECTION CRITERIA: All patients (n = 159) who underwent fixation of a tibial plateau fracture from 2016 to 2021 and completed patient-reported outcome measures (PROMs) at minimum 1-year follow-up were enrolled for the study. OUTCOME MEASURES AND COMPARISONS: PASS thresholds for global outcome (PASS-Global), pain (PASS-Pain), and function (PASS-Function) were determined using anchor-based questions such as "How satisfied are you today with your injured lower extremity?" with answer choices of very satisfied, satisfied, neutral, unsatisfied, and very unsatisfied. PASS thresholds for each PROM were calculated using 3 methods: (1) 80% specificity, (2) 75th percentile, and (3) Youden Index. RESULTS: Sixty percent of patients were satisfied with their global outcome and 53% with function. Using 80% specificity, 75th percentile, and Youden Index, PASS-Global thresholds were 48.5, 44.5, and 47.9 for PROMIS-PF and 56.3, 56.2, and 56.3 for KOOS-QOL, respectively. PASS-Pain threshold for KOOS-Pain was 84.4, 80.6, and 80.6, respectively. PASS-Function thresholds were 48.9, 46.8, and 48 for PROMIS-PF and 94.1, 90.2, and 86.8 for KOOS-ADL, respectively. Younger patients and those with bicondylar fractures or infections were associated with significantly lower PASS-Pain thresholds. Schatzker II fractures, lateral column involvement, or isolated lateral approach resulted in significantly higher PASS-Global and PASS-Function thresholds. CONCLUSIONS: This study defines global, functional, and pain PASS thresholds for tibial plateau fractures. Patients with bicondylar fractures, infections, and medial column involvement were more often unsatisfied. These thresholds are valuable references to identify patients who have attained satisfactory outcomes and to counsel patients with risk factors for unsatisfactory outcomes following tibial plateau fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Schöttle Point Is Consistently Located Distal to the Medial Femoral Physis in Pediatric Patients: A Digitally Reconstructed Radiographic Study.

BACKGROUND: Significant controversy surrounds ideal tunnel position for medial patellofemoral ligament (MPFL) reconstruction (MPFLR) in the pediatric setting. The start point for femoral tunnel positioning (the Schöttle point) relative to the distal medial femoral physis is not well defined. Previous studies provide conflicting data regarding position of the MPFL origin and the Schöttle point relative to the distal femoral physis. HYPOTHESIS: The Schöttle point would be consistently distal to the distal medial femoral physis. STUDY DESIGN: Descriptive laboratory study. METHODS: The institutional picture archiving and communication system was queried for computed tomography (CT) imaging studies of pediatric knees. Data were imported to an open-source image computing platform. True lateral digitally reconstructed radiographs and 3-dimensional (3D) renderings were generated, and the Schöttle point was registered in 3D space. Then, 3D distance measurements were obtained from the Schöttle point to the distal medial femoral physis. RESULTS: A total of 49 pediatric knee CT scans were included. Mean age was 13.0 ± 2.3 years. Mean minimum distance from the medial physis to the Schöttle point was 9.9 ± 3.0 mm (range, 3.4-16.1 mm). In 49 of 49 cases (100%), the Schöttle point was distal to the physis. Using a 6-mm reaming diameter would result in 3 of 49 (6%) femurs having violation of the distal medial femoral physis. Moving the start point 3 mm distally would result in 0 of 49 (0%) sustaining physeal injury. CONCLUSION/CLINICAL RELEVANCE: The Schöttle point is consistently distal to the distal medial femoral physis. The mean minimum distance from the Schöttle point to the physis on the medial cortex is 9.9 mm. The Schöttle point provides a safe and reliable radiographic landmark for pediatric MPFLR, although reaming diameter should be considered.

Hardware Impingement Is Associated With Shorter Screw Length in Patients Treated With In Situ Screw Fixation for Slipped Capital Femoral Epiphysis: An In Vivo Arthroscopic Evaluation.

Purpose: To determine the incidence of screw impingement on dynamic exam during hip arthroscopy in patients undergoing treatment for femoroacetabular impingement after previous slipped capital femoral epiphysis fixation and to evaluate screw characteristics with hardware impingement. Methods: A retrospective review from 2008 to 2020 was performed of slipped capital femoral epiphysis (SCFE) patients that underwent arthroscopy for symptoms of hip impingement. Patients underwent a dynamic exam under direct arthroscopic visualization to assess for sources of impingement, including bony anatomy and fixation hardware. Slip angle was calculated on lateral radiographs prior to arthroscopy, and screw length was noted in the initial operative reports at treatment of SCFE and reported in millimeters. Normality of data was assessed using Shapiro-Wilk tests, with statistical analysis performed using independent sample t-tests, Mann-Whitney U-nonparametric tests, and multivariable logistic regression. An alpha level of <0.05 was used to indicate statistical significance. Results: Thirty-nine hips were included, with 13 (33.3%) having screw impingement on dynamic exam. Slip angle was found to be increased in the screw impingement group (42.4° vs 35.5°; P = .11). Screw length was noted to be significantly shorter in the screw impingement group (53.1 vs 61.6 mm; P = .021). The presence of screw impingement was found to be associated with shorter screw length (ß = -0.172, R 2 = 0.329; P = .036). Conclusions: Shorter screws (55 mm or less) are at greater risk of causing hardware hip impingement after in situ SCFE fixation. When considering hip arthroscopy for the treatment of femoroacetabular impingement in patients with a previous SCFE, hardware impingement and subsequent hardware removal should be considered in hips with shorter screws and in hips that show objective hardware impingement on dynamic exam. Level of Evidence: Level IV, therapeutic case series.

Female Patients and Decreased Hip Capsular Thickness on Magnetic Resonance Imaging Associated With Increased Axial Distraction Distance on Examination Under Anesthesia: An In Vivo Study.

PURPOSE: To investigate the relation of hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and intraoperative hip joint axial distraction distance on an examination under anesthesia. METHODS: A retrospective review of primary arthroscopic hip procedures performed between November 2018 and June 2021 was conducted. The inclusion criteria included a diagnosis of femoroacetabular impingement syndrome and preoperative radiographic imaging and MRI. Fluoroscopic images were obtained at 0 lb and 100 lb of axial traction force. Total distraction distance was calculated by comparing the initial joint space with the total joint space at 100 lb. Hip capsular thickness was measured on MRI. Analysis was conducted using multiple linear regression, independent-samples t tests, and Mann-Whitney U tests. RESULTS: Eighty patients were included. Bivariable regression showed an association between an increased distraction distance and female sex (ß = 4.303, R = 0.561, P < .001), as well as decreased anterior axial (ß = -1.291, R = 0.365, P < .001) and superior coronal (ß = -1.433, R = 0.501, P < .001) capsular thickness. Multivariable regression (R = 0.645) showed an association between an increased distraction distance and female sex (ß = 3.175, P < .001), as well as decreased superior coronal capsular thickness (ß = -0.764, P = .022). Independent-samples t tests showed that female patients had significantly decreased superior coronal capsular thickness (2.92 ± 1.14 mm vs 3.99 ± 1.15 mm, P < .001). CONCLUSIONS: Female sex and decreased hip capsular thickness in the superior aspect of the coronal plane on magnetic resonance scans were found to be predictors of increased hip joint axial distraction distance on examination under anesthesia prior to hip arthroscopy, with anterior axial capsular thickness being a moderate predictor. Poor predictors of distraction distance were posterior axial and inferior coronal capsular thickness, age, body mass index, and lateral center-edge angle. Female patients were also found to have thinner hip capsules in the superior region, which may explain the association between female patients and increased distraction. These findings further characterize the relation between capsular thickness and hip laxity. LEVEL OF EVIDENCE: Level IV, case series.

Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention.

INTRODUCTION: Opioid overprescribing is a problem in orthopaedic surgery, with many patients having leftover opioid medications after surgery. The purpose of our study was to capture utilization patterns of opioids in pediatric patients undergoing orthopaedic sports medicine surgery, in addition to evaluating patient practices surrounding unutilized opioid medication. Our hypothesis was that there would be low utilization of opioids in this patient population and would in turn contribute to notable overprescribing of opioids and opioid retention in this population. METHODS: Pediatric patients undergoing orthopaedic surgery for knee and hip pathology were prospectively enrolled. A survey was administered 14 days postoperatively, with questions centered on the patient-reported number of opioids prescribed, number of opioids used, number of days opioids were used, and incidences of leftover opioid medication and disposal of leftover medication. The magnitude of opioid overprescribing was calculated using the reported prescribed and reported used number of opioid pills. Linear regression was used to examine associations between opioids and NSAIDs prescribed. RESULTS: One hundred fourteen patients reported a mean prescription of 12.0 ± 5.0 pills, with utilization of 4.4 ± 6.1 pills over 2.7 ± 5.1 days. Patients were prescribed 2.73 times the number of opioid pills required on average. One hundred patients (87.7%) reported having unused opioid medication after their surgery, with 71 (71.0%) reporting opioid retention. Regression results showed an association with opioids used and prescribed opioid amount (ß = 0.582, R = 0.471, P < 0.001). DISCUSSION: Overall, our study results help characterize the utilization patterns of opioid medications in the postsurgical pediatric sports orthopaedic population and suggest that orthopaedic surgeons may be able to provide smaller quantities of opioid pills for analgesia than is typically prescribed, which in turn may help reduce the amount of prescription opioid medications present in the community. LEVEL OF EVIDENCE: Level IV.

Hip Capsular Deficiency-A Cause of Post-Surgical Instability in the Revision Setting Following Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE OF REVIEW: To characterize current concepts in capsular repair and hip instability, and examine findings from biomechanical and clinical studies on hip capsular management strategies as they pertain to hip stability, patient outcomes, and hip arthroscopy failure. Further, we discuss the clinical evaluation and treatment of capsular deficiency. RECENT FINDINGS: There remains debate regarding the optimal capsular management strategies in hip arthroscopy, particularly concerning the necessity of routine capsular repair. A variety of capsulotomy techniques exist and may be used to access the hip joint. Additionally, a wide variety of techniques are employed to repair the hip capsule. Biomechanical evidence supports capsular closure restores hip joint stability to that of the intact, native state. Several clinical studies in both primary and revision hip arthroscopy settings have demonstrated improved pain and functional outcomes in patients who underwent capsular repair or capsular reconstruction. Studies have shown capsular repair may be especially important in patients with ligamentous laxity and hip dysplasia, and in competitive athletes. Post-surgical hip instability secondary to capsular insufficiency is increasingly recognized as a cause of hip arthroscopy failure. Capsular closure restores native biomechanical stability to the hip joint, and several clinical studies report improved pain and functional outcomes following capsular repair or capsular reconstruction in both the primary and revision hip arthroscopy settings. There remains much to learn regarding capsular hip instability as it relates to optimal capsular management surgical technique, intra-operative capsular management decision-making, clinical diagnosis, and related advanced imaging findings.