Risk factors for prolonged opioid consumption following hip arthroscopy: A secondary analysis of the Femoroacetabular Impingement RandomiSed controlled Trial and embedded cohort study.

PURPOSE: The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study. METHODS: Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage state that may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively. RESULTS: A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001). CONCLUSION: Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco use and more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery. LEVEL OF EVIDENCE: Level III.

Health-related quality of life does not deteriorate while waiting for anterior cruciate reconstruction.

PURPOSE: The aim of this study was to determine how preoperative health-related quality of life (HRQoL) is affected by the duration of the wait time (WT) for anterior cruciate ligament reconstruction (ACLR) once a decision is made to proceed with surgery. METHODS: This was a multi-centre prospective cohort study. One hundred and twenty-two patients 14 years of age and above waiting for ACLR completed the International Knee Documentation Committee (IKDC) demographic, current health assessment and subjective knee evaluation (SKF) forms on the day of decision to operate and the day of surgery. Changes in scores were analyzed for the entire cohort, adjusted for WTs and a subset was compared for patients with isolated anterior cruciate ligament (ACL) tears and ACL tears with concurrent meniscal involvement. Changes in HRQoL scores from the day of the decision to operate to the 9-month postoperative appointments were also assessed. RESULTS: Energy/Fatigue (p < 0.05), Pain (p < 0.05), General Health (p < 0.05) and the IKDC-SKF Score (p < 0.05) significantly increased between the day of the decision to operate and the day of surgery. Only the change in IKDC-SKF score remained significantly higher after adjusting for WT. Baseline HRQoL scores significantly improved by the 9-month postoperative appointment. CONCLUSION: The length of time waiting for ACLR did not adversely influence HRQoL in this study. However, low preoperative HRQoL and the significant improvement in HRQoL of patients followed postoperatively suggest that timely surgery is beneficial for this patient population. LEVEL OF EVIDENCE: Level II.

Adhesions After Hip Arthroscopy Are Associated With Revision But Show Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review.

PURPOSE: To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions that developed after hip arthroscopy (HA). METHODS: A systematic search of the MEDLINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was designed and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Eligible studies included patients with confirmed adhesions after HA that reported one or more of the following: (1) diagnostic procedures and criteria used; (2) indications for and details surrounding surgical management; and (3) clinical outcomes after the operative management of adhesions (e.g., patient-reported outcome measures). RESULTS: Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female sex) were included in this review. The quality of evidence was found to be fair for both comparative studies (mean, 17; range, 13-21) and noncomparative studies (mean, 10; range, 5-12) according to the Methodological Index for Non-randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intraoperatively at the time of revision surgery (10 of 19 studies, 53%), with only 3 studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (9 of 19, 47%), but this was often grossly stated for revision HA rather than being specific to adhesions. Patient-reported outcome measures were the most reported postoperative outcomes (9 of 19, 47%) and generally showed significant improvement from preoperative assessment across the short-term follow-up period (range, 24.5-38.1 months). There was a paucity of objective measures of clinical improvement (3 of 19, 16%) and of mid- and long-term follow-up (i.e., 5-7 years and ≥10 years, respectively). CONCLUSIONS: Despite the growing body of evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, although the operative management of adhesions after HA has shown satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid- to long-term outcomes, as well as minimal use of objective assessment of clinical improvement (e.g., biomechanics). LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Labral repair, reconstruction, and augmentation improve postoperative outcomes in patients with irreparable or hypoplastic labra: A systematic review.

PURPOSE: To review the postoperative outcomes of arthroscopic surgical options in treating irreparable and hypoplastic labrum of the hip. METHODS: Three online databases (PubMed, MEDLINE, and EMBASE) were searched from database inception to June 27, 2023 to identify literature on treatment strategies for hypoplastic/irreparable acetabular labrum. Data pertaining to classification of irreparable tears or labral hypoplasia, indication for surgery, description of treatment, radiographic findings, and clinical outcomes were recorded and described. The methodological quality of included studies was assessed by the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Seven level IV case series, eleven level III retrospective cohort studies, and two level II prospective cohort studies comprising 1937 patients were included for analysis. Studies were divided into an irreparable labral group comprising 1002 patients and a hypoplastic labral group comprising 935 patients. Treatments included repair, augmentation, or reconstruction. In the irreparable group, 12 studies recorded improvement of modified Harris Hip Score (mHHS) with preoperative scores ranging from 50.3 to 67.3 and postoperative scores ranging from 76.2 to 95.0. The rate of conversion to total hip arthroplasty (THA) and rate of revision arthroscopy were 6.6% and 5.9%, respectively across all studies. In the hypoplastic group, two studies that focused on repair noted no statistical difference in mHHS for repair in hypoplastic labrum vs repair in non-hypoplastic labrum. One study showed that there was a difference in post-operative mHHS for labral repair for hypoplastic vs non-hypoplastic labrum, with repair in non-hypoplastic labrum showing superior mHHS (p â€‹< â€‹0.001). CONCLUSION: The findings of this review suggest that treatment of irreparable labra with reconstruction or augmentation results in improved patient-reported outcome measures (PROMs). For the hypoplastic labrum, primary repair also results in improvement in PROMs. Future studies focusing on the hypoplastic labra alone with an appropriate control group, rather than irreparable labral tears, are needed to properly assess patient outcomes and guide surgical indications.

The McMaster osteotomy-a novel surgical treatment to chronic slipped capital femoral epiphysis: description of surgical technique and case study.

Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder that can lead to complex proximal femur deformities and devastating consequences such as avascular necrosis, femoroacetabular impingement syndrome and early-onset osteoarthritis. Existing surgical techniques are often insufficient to fully address the constellation of multiplanar deformities in patients with severe SCFE. Therefore, the McMaster Osteotomy, a novel intertrochanteric proximal femur osteotomy, was developed to improve anatomic correction and hip mechanics in patients with chronic SCFE. The McMaster Osteotomy was implemented in two patients (A: 16-year-old male, B: 17-year-old female) with proximal femur deformities due to chronic SCFE. Surgical planning was facilitated with a 3D-printed pelvic model generated from a CT scan of a patient with the SCFE deformity. Patient B also underwent concurrent arthroscopic osteochondroplasty and labral repair. Pre- and post-operative function and radiographic measurements were recorded. Post-operatively, patient A's neck-shaft angle improved from 125° to 136°, Southwick angle from 52° to 33°, neck length from 66 mm to 80 mm and hip internal rotation from 5° to 25°. Patient B's post-operative neck-shaft angle improved from 122° to 136°, Southwick angle from 25° to 15°, neck length from 76 mm to 84 mm, hip internal rotation from 5° to 20° and alpha angle from 87.6° to 44.3°. Both patients are pain-free and have obtained full union of their osteotomies. The McMaster Osteotomy is a versatile technique that can produce a more anatomic reconstruction of hip anatomy and restoration of abductor mechanics. As an extracapsular technique, the risk of femoral head avascular necrosis is minimized.

Editorial Commentary: Standardized Evaluation of Cartilage Damage and Restoration in Hip Arthroscopy Requires Consideration of Clinical, Imaging, and Patient-Reported Outcomes.

Articular cartilage lesions of the acetabulum may result in significant pain and dysfunction for patients with treatment options consisting of either microfracture or various forms of cartilage restoration procedures. A systematic review of 529 patients demonstrated similar, if not lower, reoperation rates and patient-reported outcomes in patients receiving cartilage restoration procedures compared with microfracture. The primary outcomes examined in this review were reoperation rates and patient-reported outcomes with no clear mention of radiographic outcomes and no clearly defined indications as to who would benefit from a cartilage-based procedure. This raises the question as to whether there should be a consensus-based and standardized criteria established and standardized among the hip preservation expert community to evaluate the success of these cartilage restoration procedures from an imaging standpoint. These criteria can also be incorporated into a composite evaluation that combines clinical, imaging, and patient-reported outcomes to determine optimal patient candidacy for cartilage procedures as well. This would be a very useful steppingstone for much-needed future Level I randomized studies or prospective, registry-based data on this topic.

Editorial Commentary: Borderline Hip Dysplasia Combined With Increased Anteversion and Ligamentum Teres Disruption Is a Recipe for Hip Microinstability.

The ligamentum teres (LT) is known to play a role as a secondary stabilizer of the hip joint. LT tears can be associated with hip instability. In patients with borderline developmental dysplasia of the hip (BDDH), the correlation between LT tears and microinstability is even more pronounced because of the increased mechanical stress placed on the ligament. This relationship may lead certain surgeons to consider new indications for LT reconstructions. However, caution is warranted regarding the potential role of LT reconstruction in these patients, particularly since the primary deficiency in BDDH is bony undercoverage. Addressing this bony undercoverage should be a primary consideration that may be supplemented with other procedures, which may include addressing soft-tissue injuries around the hip such as LT tears. This is especially the case in those patients with persistent symptoms after management of labral tears or LT disruption.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery.

Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design: Position statement. Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis.

PURPOSE: To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis. METHODS: MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics. RESULTS: Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015). CONCLUSION: Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS. LEVEL OF EVIDENCE: I.

Editorial Commentary: Hip Arthroscopy Outcomes in Older Patients Can Equal Outcomes in Younger Patients With Proper Surgical Indications.

Hip arthroscopy patients often present with clinical features that help broadly categorize them as the younger patient with femoroacetabular impingement, the microinstability- or instability-related patient, those patients with predominant peripheral compartment disease, and the older patient with femoroacetabular impingement plus peripheral compartment disease. Outcomes in older patients can equal outcomes in younger patients with proper surgical indications. Specifically, older hip arthroscopy patients do well in the absence of degenerative articular cartilage changes. Although some studies have suggested a potential for greater conversion rate to hip arthroplasty in an older age group, with proper patient selection, hip arthroscopy may lead to durable and significant improvements.

Outcomes After Hip Arthroscopy Show No Differences Between Sexes: A Systematic Review.

PURPOSE: To assess differences in postoperative outcomes between male and female patients following hip arthroscopy. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Cochrane, and PubMed databases were searched. Key words included "hip," "arthroscopy," "outcome," "gender difference," "sex difference," "gender," and "patient-reported outcome." Studies were included that reported sex-specific analysis of outcomes following primary hip arthroscopy with minimum 2-year follow-up. Methodological Index for Non-Randomized Studies criteria were applied to each study. Data collected included patient-reported outcome measures (PROMs), complications, rates of revision arthroscopy (RA), and conversion to total hip arthroplasty (THA). Forest plots were generated for the most frequently reported PROMs, RA, and THA rates. RESULTS: In total, 38 studies met the inclusion criteria, with 40,194 (57% female) hips included. The most common indications for hip arthroscopy were femoroacetabular impingement and labral tears. Eighteen studies reported PROMs, with no clear trend towards sex differences. Eleven studies reported on RA rates, with 4 showing a significantly greater rate of RA in female patients. Seventeen studies reported on conversion to THA, with an overall conversion rate of 9.64%. There were no clear sex differences in conversion to THA. CONCLUSIONS: There was no difference between sexes for postoperative PROM scores. Male patients were less likely to reach the MCID for the HOS-SSS than female patients in the majority of studies, and there were no sex differences for PASS rates. There were no significant differences between sexes in revision arthroscopy rates and conversion to total hip arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III and IV studies.

MRI Does Not Improve Inter- or Intrarater Reliability for Hip Arthritis Grading Systems.

BACKGROUND: Magnetic resonance imaging (MRI) scans and radiographs are often utilized in assessing for preoperative osteoarthritis in patients undergoing hip preservation surgery. PURPOSE: To determine if MRI scans improve inter- or intrarater reliabilities over radiographs for findings of hip arthritis. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Anteroposterior and cross-table lateral radiographs as well as a representative coronal and sagittal T2-weighted MRI scan were reviewed for 50 patients by 7 experienced subspecialty hip preservation surgeons, with a minimum experience of 10 years. Radiographs and MRI scans were assessed for joint space narrowing, subchondral cysts, osteophytes, subchondral sclerosis, Likert osteoarthritis grade (none, mild, moderate, or severe), and Tönnis grade. MRI scans were also evaluated for bony edema, heterogeneous articular cartilage, and chondral defects. Inter- and intrarater reliabilities were calculated utilizing the Fleiss method with a 95% CI. RESULTS: The scans of 50 patients (28 female and 22 male) with a mean age of 42.8 years (SD, 14.2 years; range, 19-70 years) were reviewed. Radiographs revealed fair agreement for joint space narrowing (κ = 0.25 [95% CI, 0.21-0.30]), osteophytes (κ = 0.26 [95% CI, 0.14-0.40]), Likert osteoarthritis grading (κ = 0.33 [95% CI, 0.28-0.37]) and Tönnis grade (κ = 0.30 [95% CI, 0.26-0.34). Radiographs revealed moderate agreement for subchondral cysts (κ = 0.53 [95% CI, 0.35-0.69]). MRI scans demonstrated poor to fair agreement for joint space narrowing (κ = 0.15 [95% CI, 0.09-0.21]), subchondral sclerosis (κ = 0.27 [0.19-0.34]), heterogeneous articular cartilage (κ = 0.07 [95% CI, 0.00-0.14]), Likert osteoarthritis grade (κ = 0.19 [95% CI, 0.15-0.24]), and Tönnis grade (κ = 0.20 [95% CI, 0.15-0.24]). MRI scans demonstrated substantial agreement for subchondral cysts (κ = 0.73 [95% CI, 0.63-0.83]). Intrarater reliabilities were statistically improved compared with interrater reliabilities, but no differences were found between radiographs and MRI scans for joint space narrowing, subchondral cysts, osteophytes, osteoarthritis grade, or Tönnis grade. CONCLUSION: Radiographs and MRI scans had substantial limitations and inconsistency between raters in evaluating common markers of hip osteoarthritis. MRI scans demonstrated strong reliability in evaluating for subchondral cysts but did not improve the interobserver variability of grading hip arthritis.

Editorial Commentary: A Patient-Specific Approach to Preventing Venous Thromboembolism After Hip Arthroscopy Is Essential.

The incidence of hip arthroscopy (HA) has seen a dramatic rise over the past decade, with a bimodal distribution of patient age with peaks at both 18 and 42 years of age. Thus, it is essential to reduce complications, including venous thromboembolism (VTE), given reported incidences as high as 7%. Fortunately, more recent research, perhaps reflecting an evolution resulting in lower HA surgical traction times, has shown a VTE incidence of 0.6%. Perhaps because of such a low rate, recent research has also shown that generally, thromboprophylaxis does not significantly decrease the odds of VTE. The strongest predictors of VTE after HA are oral contraceptive use, prior malignancy, and obesity. Rehabilitation is also an important factor as some patients are ambulatory on postoperative day 1, reducing the VTE risk, whereas others require a few weeks of protected weight bearing, increasing their risk. A patient-specific approach to VTE prevention after HA, rather than a one-size-fits-all approach, is essential.

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation.

BACKGROUND: The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation. PURPOSE/HYPOTHESIS: Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for <0.00, slight for 0.00-0.20, fair for 0.21-0.40, moderate for 0.41-0.60, substantial for 0.61-0.80, and almost perfect for >0.80. RESULTS: A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities. CONCLUSION: Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms.

The Radiographic Femoroepiphyseal Acetabular Roof Index Is a Reliable and Reproducible Diagnostic Tool in Patients Undergoing Hip-Preservation Surgery: A Systematic Review.

PURPOSE: To assess the utility of the femoroepiphyseal acetabular roof (FEAR) index as a diagnostic tool in hip-preservation surgery. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception until May 2022 for literature addressing the utility of the FEAR index in patients undergoing hip-preservation surgery, and the results are presented descriptively. RESULTS: Overall, there were a total of 11 studies comprising 1,458 patients included in this review. The intraobserver agreement for the FEAR index was reported by 3 of 11 studies (intraclass correlation coefficient range = 0.86-0.99), whereas the interobserver agreement was reported by 8 of 11 studies (intraclass correlation coefficient range = 0.776-1). Among the 5 studies that differentiated between hip instability and hip impingement, the mean FEAR index in 319 patients in the instability group ranged from 3.01 to 13.3°, whereas the mean FEAR index in 239 patients in the impingement group ranged from -10 to -0.77° and the mean FEAR index in 105 patients in the control group ranged from -13 to -7.7°. Three studies defined a specific cutoff value for the FEAR index, with 1 study defining a cutoff value of 5°, which correctly predicted treatment decision between periacetabular osteotomy versus osteochondroplasty 79% of the time with an AUC of 0.89, whereas another defined a cutoff of 2°, which correctly predicted treatment 90% of the time and the last study set a threshold of 3°, which provided an AUC of 0.86 for correctly predicting treatment decision. CONCLUSIONS: This review demonstrates that the FEAR index has a high agreement and consistent application, making it a useful diagnostic tool in hip-preservation surgery particularly in patients with borderline dysplastic hips. However, given the variability in FEAR index cutoff values across studies, there is no absolute consensus value that dictates treatment decision. LEVEL OF EVIDENCE: Level IV; Systematic Review of Level II-IV studies.

Hip microinstability diagnosis and management: a systematic review.

PURPOSE: The purpose of this systematic review is to present the most common causes, diagnostic features, treatment options and outcomes of patients with hip micro-instability. METHODS: Three online databases (MEDLINE, Embase, and PubMed) were searched from database inception March 2022, for literature addressing the diagnosis and management of patients with hip micro-instability. Given the lack of consistent reporting of patient outcomes across studies, the results are presented in a descriptive summary fashion. RESULTS: Overall, there were a total of 9 studies including 189 patients (193 hips) included in this review of which 89% were female. All studies were level IV evidence with a mean MINORS score of 12 (range: 10-13). The most commonly used features for diagnosis of micro-instability on history were anterior pain in 146 (78%) patients and a subjective feeling of instability with gait in 143 (81%) patients, while the most common feature on physical examination was the presence of anterior apprehension with combined hip extension and external rotation in 123 (65%) patients. The most common causes of micro-instability were iatrogenic instability secondary to either capsular insufficiency or cam over-resection in 76 (62%) patients and soft tissue laxity in 38 (31%) patients. CONCLUSION: The most common symptom of micro-instability on history was anterior hip pain and on physical exam was pain with hip extension and external rotation. There are many treatment options and when managed appropriately based on the precise cause of micro-instability, patients may demonstrate improved outcomes. LEVEL OF EVIDENCE: IV.

Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review.

PURPOSE: The primary purpose of this study was to systematically review the literature on intraoperative findings during endoscopic treatment for greater trochanteric pain syndrome (GTPS). Secondary outcomes were preoperative imaging findings and postoperative functional outcome measures. METHODS: Medline, PubMED, and Embase databases were searched from inception (1946, 1966, and 1974, respectively), to July 15, 2021, for records reporting intraoperative findings during endoscopic surgery for GTPS. Studies of Level I-IV evidence were eligible. All studies were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) score. RESULTS: Sixteen studies met the inclusion criteria. Most patients underwent endoscopic greater trochanteric bursectomy with repair of the gluteal tendons. Intraoperative conditions reported were gluteal tendon tears usually involving the gluteus medius tendon, labral tears, and chondral lesions. Three studies reported an average of 9% of patients who subsequently underwent conversion to total hip arthroplasty. Pain was assessed using the visual analog scale, and functional outcome measures were measured using the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score Sport-Specific subscale, Hip Outcome Score Activities of Daily Living subscale, and iHOT-12. Pain and functional outcomes demonstrated significant improvement in nearly all the studies where they were reported. CONCLUSIONS: Patients who underwent endoscopic management of GTPS commonly underwent repair of gluteal tendon tears, and in many cases had concomitant labral tears and chondral lesions identified intraoperatively. There were low rates of adverse events, repair failure, and revision surgery. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively. LEVEL OF EVIDENCE: IV, systematic review of level IV or better investigations.

The anterior hip capsule is thinner in dysplastic hips: a study comparing different young adult hip patients.

PURPOSE: To investigate the thickness and intra-substance change of anterior capsule of the hip joint, and compare the difference of the capsular features in patients with different statuses of hip stability. METHODS: A retrospective study was performed to review a hip preservation database. Using the lateral center edge angle(LCEA), patients with borderline dysplasia of the hip (BDH) of 20° ≤ LCEA ≤ 25°, femoracetabular impingement(FAI) with LCEA > 30° and dysplasia of the hip (DH) of LCEA < 20° were enrolled and stratified into different treatment groups. The patients' imaging was reviewed by two experienced musculoskeletal radiologists who were blinded to clinical outcomes. Thickness and intra-substance change of the anterior hip capsule was measured on the sagittal oblique sequences of MRI. A surgeon measured the thickness of the anterior hip capsule during arthroscopy. The capsular thickness and intra-substance change were compared among different groups. RESULTS: Thirty patients (17 women and 13 men) enrolled in each group (FAI, BDH, and DH) matched by sex and ages were evaluated. There were no significant differences in terms of age, sex, BMI, Alpha angle, and Tönnis grade among all three groups. The mean thickness of the anterior capsule in the DH group was 3.2 ± 0.5 mm, which was significantly thinner than that in the BDH and FAI groups (4.5 ± 0.8 mm and 4.7 ± 0.6 mm), and there was no significant difference in capsular thickness between the BDH and FAI groups. The Median of anterior capsule thickness via arthroscopic measuring was 6 mm and 7 mm in the BDH and FAI groups respectively, which has no statistical difference. The intra-substance change of the anterior capsule shows a significant difference among the three groups, and a higher incidence of delamination of the capsule was found in DH groups (p < 0.001). CONCLUSIONS: Patients with hip dysplasia have a significantly reduced capsular thickness on MRI and delaminated anterior joint capsule, which could be a sequence of instability. The clinical relevance of this study is that capsular thickness and intra-substance changes of the anterior capsule vary which could alter capsular management strategies. LEVEL OF EVIDENCE: Level III of evidence, DIAGNOSTIC STUDIES, No consistently applied reference standard.