A history of eponym usage in hip and pelvis radiography part 1: the paediatric hip.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

Ultrasound Evaluation of Pediatric Orthopaedic Patients.

Ultrasonography is a valuable tool that can be used in many capacities to evaluate and treat pediatric orthopaedic patient. It has the capability to depict bone, cartilaginous and soft-tissue structures, and provide dynamic information. This technique can be readily applied to a wide range of pediatric conditions, including developmental dysplasia of the hip, congenital limb deficiencies, fracture management, joint effusions, and many other musculoskeletal pathologies. There are many benefits of implementing ultrasonography as a regular tool. It is readily accessible at most centers, and information can be quickly obtained in a minimally invasive way, which limits the need for radiation exposure. Ultrasonography is a safe and reliable tool that pediatric orthopaedic surgeons can incorporate into the diagnosis and management of a broad spectrum of pathology.

Hip Arthroscopy Successfully Treats Femoroacetabular Impingement in Adolescent Athletes.

BACKGROUND: There is evidence that femoroacetabular impingement (FAI) is increasingly prevalent among adolescent athletes. Abnormal contact forces across the hip and alterations in bony morphology characteristic of FAI may be especially detrimental in this group, given their young age and active lifestyle. PURPOSE: The purpose of this study was to report the findings, outcomes, and return to sport percentage among adolescent athletes with FAI treated with hip arthroscopy. METHODS: A retrospective review of all patients younger than 18 years who underwent hip arthroscopy for FAI at a single institution was performed. All athletes who were attempting to return to sport and underwent hip arthroscopy were included. Patients with previous hip surgery and/or hip conditions were excluded. Arthroscopic procedures and an assessment of intra-articular findings were recorded. Patient-reported outcome measures were recorded at 3 months, 1 year, and 2 years postoperatively, and included the modified Harris hip score, the nonarthritic hip score, hip outcome score-sports subscale, visual analogue scale for pain, and patient satisfaction. Return to sport percentage and ability levels were also noted. RESULTS: There were 96 eligible cases of adolescent athletes treated with hip arthroscopy; 81 (84.4%) hips in 69 patients had 2-year follow-up. Running/track and field was the most common sport (25), followed by soccer (12), dance (10), baseball/softball (9), and basketball (6). There were 61 females and 20 males, whose average age was 15.9±1.2 y (range: 13.1 to 18.0 y). The most common procedures were labral repair (81.5%), iliopsoas fractional lengthening (72.8%), femoroplasty (69.1%), and acetabuloplasty (66.7%). Capsular repair or plication was performed in most patients (81.5%). Cartilage damage was more common on the acetabulum than the femur, with Outerbridge grade 2 or higher occurring in 23.5% and 4.9% of hips, respectively. Statistically significant improvements were seen in all patient-reported outcomes from preoperative to minimum 2-year follow-up. A total of 84.0% of patients had returned to their sport at latest follow-up. There were 6 (7.4%) patients who underwent revision arthroscopy at a mean of 37.3 months postoperatively. CONCLUSION: Symptomatic FAI in adolescent athletes can be successfully treated with hip arthroscopy, with a higher return to sport rate and low complications and reoperation rate at minimum 2-year follow-up.

A novel surgical navigation technology for placement of implants in slipped capital femoral epiphysis.

BACKGROUND: Fixation with a single screw is the recommended treatment for slipped capital femoral epiphysis (SCFE). Achieving optimal implant positioning can be difficult owing to the complex geometry of the proximal femur in SCFE. We assessed a novel navigation technology incorporating an inertial measurement unit to facilitate implant placement in an SCFE model. METHODS: Guidewires were placed into 30 SCFE models, using a navigation system that displayed the surgeon's projected implant trajectory simultaneously in multiple planes. The accuracy and the precision of the system were assessed as was the time to perform the procedure. RESULTS: Implants were placed an average of 5.3 mm from the femoral head center, with a system precision of 0.94 mm. The actual trajectory of the implant deviated from the planned trajectory by an average of 4.9° ± 2.2°. The total average procedure time was 97 seconds. CONCLUSION: The use of computer-based navigation in a SCFE model demonstrated good accuracy and precision in terms of both implant trajectory and placement in the center of the femoral head.

Radiographic and Clinical Outcomes of Adolescents With Acetabular Retroversion Treated Arthroscopically.

BACKGROUND: Retroversion of the acetabulum is a cause of pincer impingement. Symptomatic retroversion has traditionally been treated with anteverting periacetabular osteotomy (PAO). However, arthroscopic rim trimming can also treat pincer impingement associated with acetabular retroversion. The purpose of this study was to report the outcomes and radiographic findings in a series of adolescent patients with symptomatic acetabular retroversion treated arthroscopically. METHODS: Data were prospectively gathered at a single institution using an established hip preservation registry. Patients below 18 years with a retroverted acetabulum that underwent primary hip arthroscopy with 2-year follow-up were included. Acetabular retroversion was defined by 3 radiographic criteria: the presence of crossover, ischial spine sign, and posterior wall sign. Radiographic measurements of the lateral center-edge angle, anterior center-edge angle, alpha angle, and crossover percentage were reported preoperatively and postoperatively. Patient-reported outcome (PROs) measures included the modified Harris Hip Score, the non-Arthritic Hip Score, Hip Outcome Score Sports Subscale, visual analog scale, and patient satisfaction, recorded at 3 months, 1 year, and 2 years, postoperatively. In addition, International Hip Outcome Tool scores were gathered at 2 years. RESULTS: Between April 2008 and July 2014, there were 43 patients (48 hips) treated with hip arthroscopy who met the inclusion criteria. The average age was 16.1 years (range, 13.9 to 17.9 y) and there were 38 females and 10 males. The average follow-up was 50.4 months, with a minimum of 2 years. Statistically significant improvements in all PROs were found at 2 years postoperatively. There were 9 hips with lateral center-edge angle ≤25 degrees; the PROs of this group was not different than patients with normal coverage. Three patients underwent arthroscopic revision. No patient subsequently underwent anteverting PAO during the study period. There were no reported complications. CONCLUSIONS: Femoroacetabular impingement caused by acetabular retroversion treated with hip arthroscopy demonstrates good outcomes at 2 years with a low complication rate. Symptomatic adolescents may be safely and successfully treated arthroscopically, potentially avoiding anteverting PAO. STUDY DESIGN: Level of evidence 4-case series.

Arthroscopic Labral Treatment in Adolescents: Clinical Outcomes With Minimum 5-Year Follow-up.

BACKGROUND: The success of hip arthroscopy has led to increased application in younger populations. However, hip arthroscopy remains a challenging procedure, and its safety and efficacy in the adolescent population have been controversial. Most existing literature on outcomes in such patients contains only short-term follow-up, and a paucity of evidence is available regarding long-term outcomes in adolescents. PURPOSE: To report on clinical outcomes at a minimum 5-year follow-up in patients younger than 18 years who underwent arthroscopic treatment of labral tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data were prospectively collected and retrospectively reviewed on all patients younger than 18 years who underwent hip arthroscopy in a tertiary hip preservation setting at a single institution. Patients were excluded if they had previous ipsilateral hip conditions or surgery. All patients underwent either labral repair or debridement for treatment of a labral tear. Patient-reported outcome measures were recorded at 3 months and at 1, 2, or a minimum of 5 years. These included the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale, and patient satisfaction. Additionally, the abbreviated International Hip Outcome Tool and Short Form Health Survey were collected at latest follow-up. RESULTS: The study included 44 hips in 32 patients that underwent arthroscopic labral repair (86.4%) or labral debridement (13.6%) between April 2008 and April 2011, with latest follow-up at a mean of 69.2 months (range, 60.0-89.9 months) postoperatively. The average age at surgery was 16.3 years (range, 14.2-17.9 years), and 39 hips from female patients. Statistically significant improvements were seen in all patient-reported outcome measures from preoperative to minimum 5-year follow-up. Improvements were noted at 1-year follow-up and maintained at minimum 5-year follow-up. At the latest follow-up, the Patient Acceptable Symptomatic State was achieved in 95.5% of patients for the mHHS and 72.7% for the HOS-SSS. Two patients subsequently underwent secondary arthroscopy on the ipsilateral hip; however, the survivorship of all hips was 100%. CONCLUSION: Hip arthroscopy for the treatment of labral tears in adolescents remains a technically challenging procedure that should be approached with appropriate caution. The results of the present study on a population treated in a specialized hip preservation center demonstrate that hip arthroscopy is a safe procedure with stable improvement in patient-reported outcome measures at 5 years.

Acetabular microfracture in hip arthroscopy: clinical outcomes with minimum 5-year follow-up.

INTRODUCTION: There is a paucity in the literature regarding mid-term results of microfracture in hip arthroscopy. We aim to assess 5-year outcomes of patients who underwent acetabular microfracture for full-thickness chondral lesions as a part of hip arthroscopy. METHODS: Between August 2008 and September 2011, data were prospectively gathered for patients undergoing acetabular microfracture during hip arthroscopy with minimum 5-year follow-up. All patients were assessed pre- and postoperatively, with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score - Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS). International Hip Outcome Tool (iHOT-12) and satisfaction were collected postoperatively. Exclusion criteria included previous hip conditions, or preoperative Tönnis grade ≥2. RESULTS: Fifty three hips were eligible for this study. Of these, 43 (81.1%) hips in 42 patients had follow-up. The study group had a male majority (65.1%) and an average age of 44.4 ± 9.5 years. There was statistically significant improvement in all patient-reported outcomes (PROs) and VAS at follow-up. Patient satisfaction was 7.6 ± 2.6. A comparison of 2-year to minimum 5-year follow-up results identified no statistically significant deterioration in PROs, VAS, and patient satisfaction. Survivorship was 72.1% with 12 patients converted to total hip arthroplasty (THA). 4 patients (10.8%) underwent secondary arthroscopy. CONCLUSIONS: In the mid-term, microfracture as a part of hip arthroscopy demonstrated favourable outcomes and 72% survivorship. Careful patient selection is warranted to limit the risk of conversion to THA.

Midterm Outcomes and Return to Sports Among Athletes Undergoing Hip Arthroscopy.

BACKGROUND: Hip arthroscopy is an established surgical treatment for pathologic hip conditions in athletes. There is a paucity in the literature regarding outcomes and return to sport for athletes in the midterm. PURPOSE: To report minimum 5-year outcomes, return to sport, and level of sport among athletic patients who underwent hip arthroscopy. In addition, we compared 2- and 5-year outcomes to evaluate whether there is a deterioration in functional status. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data were prospectively collected on all patients who underwent hip arthroscopy between February 2009 and November 2011 at 1 institution. Athletes at the high school, collegiate, or professional level who underwent hip arthroscopy and had preoperative patient-reported outcome (PRO) scores were considered for inclusion. Exclusion criteria were preoperative Tönnis grade >1 or prior ipsilateral hip conditions or surgery. Data on sports participation, competition level, and ability were collected. At a minimum of 5 years postoperatively, PROs, visual analog scale (VAS), iHOT-12 (short version of International Hip Outcome Tool), satisfaction, and postoperative complication data were collected. RESULTS: Seventy-seven hips met all criteria, among which 66 (85.7%) had a minimum 5-year follow-up and were included. There were 37 high school, 20 collegiate, and 9 professional athletes. Mean ± SD improvements at a minimum of 5 years were as follows: modified Harris Hip Score, 66.8 ± 16.3 to 87.0 ± 14.8 ( P < .001); nonarthritic hip score, 66.2 ± 19.9 to 87.2 ± 15.2 ( P < .001); Hip Outcome Score-Sports Specific Subscale, 47.0 ± 22.4 to 79.1 ± 23.0 ( P < .001); and VAS, 5.4 ± 2.5 to 1.8 ± 2.1 ( P < .001). At latest follow-up, mean iHOT-12 was 78.8 ± 22.7, and satisfaction was 8.2. A total of 50 athletes (53 hips, 80.3%) reported that they returned to sports; 71.2% reported "same" or "higher" sport ability as compared with a year before surgery. Postoperative complications included 3 cases (4.5%) of numbness and 1 case (1.5%) of pulmonary embolism. Ten hips (15.2%) required secondary arthroscopies, and no hips were converted to total hip arthroplasty. There were no significant differences between 2- and 5-year PROs, VAS, or satisfaction. CONCLUSION: Midterm results of hip arthroscopy in athletes are shown to be safe and favorable. Most athletes return to sports and continue to play after 5 years with the same or higher ability.

Should Acetabular Retroversion Be Treated Arthroscopically? A Systematic Review of Open Versus Arthroscopic Techniques.

PURPOSE: To compare patient-reported outcomes, progression of radiographic arthritis, revision rates, and complications for hips with acetabular retroversion treated by open versus arthroscopic methods. METHODS: The PubMed and EMBASE databases were searched in August 2016 for literature on the open and arthroscopic techniques using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method. All studies published in the English language that focused on the surgical treatment of femoroacetabular impingement caused by retroversion were included. All arthroscopic procedures, such as acetabuloplasty and labral repair, and open procedures, including anteverting periacetabular osteotomy and surgical dislocation with osteoplasty, were included. Articles that did not describe how retroversion was defined were excluded, as were studies with less than 6 months' follow-up and fewer than 5 patients. Two authors screened the results and selected articles for this review based on the inclusion and exclusion criteria. All results were scored using the Methodological Index for Non-randomized Studies (MINORS) criteria. RESULTS: There were 386 results returned and 15 articles that met the inclusion criteria of this study. Among the studies, 11 reviewed arthroscopic techniques and 4 reviewed open surgical procedures. Both techniques yield good results based on patient-reported outcomes with minimal progression of osteoarthritis and low complication rates. CONCLUSIONS: This review showed statistically and clinically significant improvements for the treatment of acetabular retroversion based on patient-reported outcomes, with low progression of radiographic arthritis, revision rates, and complications using both open and arthroscopic methods. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Should the Capsule Be Repaired or Plicated After Hip Arthroscopy for Labral Tears Associated With Femoroacetabular Impingement or Instability? A Systematic Review.

PURPOSE: To critically evaluate the existing literature on hip capsule biomechanics, clinical evidence of instability, and outcomes of capsular management to answer the following question: Should the capsule be repaired or plicated after hip arthroscopy for labral tears associated with femoroacetabular impingement or instability? METHODS: We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines to find articles using PubMed and Embase. Included studies were Level I through V studies and focused on hip capsule biomechanics, postarthroscopic instability, and clinical outcomes. Articles were excluded if they discussed treatment of the hip capsule during arthroplasty, dislocations without a history of arthroscopy, and pre-existing conditions. The Methodological Index for Non-randomized Studies (MINORS) was used for quality assessment of clinical outcome studies. RESULTS: A total of 34 articles were included: 15 biomechanical studies, 9 instability case reports, and 10 outcome studies. There is consensus from biomechanical studies that the capsule is an important stabilizer of the hip and repairing it provides better stability than when unrepaired. Case reports of instability have raised concerns about capsular management during the index procedure to decrease the complications associated with this problem. Furthermore, outcome studies suggest that there may be an advantage of capsular closure versus capsulotomy during hip arthroscopy for nonarthritic patients. CONCLUSIONS: Short-term outcome studies suggest that capsular closure is safe and effective in nonarthritic patients undergoing hip arthroscopic procedures and may yield superior outcomes compared with unrepaired capsulotomy. Moreover, biomechanical evidence strongly supports the role of capsular repair in maintaining stability of the hip. In patients with stiffness or inflammatory hip disorders, a release may be appropriate. In patients who have signs and symptoms of instability, there is existing evidence that capsular plication may be associated with significant improvement in patient-reported outcomes. Although the multiple procedures performed in combination with capsular treatment present confounding variables, current evidence appears to support routine capsular closure in most cases and to support capsular plication in cases of instability or borderline dysplasia. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

An Analysis of Relative Gait Impairment in Commonly Diagnosed Pediatric Conditions.

BACKGROUND: Gait indices were developed to represent the magnitude of impairment extracted from a gait analysis with a single value. The Gillette Gait Index (GGI), and the Gait Deviation Index (GDI) are 2 widely used indices that represent gait impairment differently based on their statistical properties. Our purpose was to (1) report on the results of gait analysis for a broad spectrum of pediatric conditions using the GGI and GDI, and (2) identify the parameters that dominate impairment. METHODS: A total of 1439 children with 13 different diagnoses with a complete, baseline gait analysis were identified. The GGI and its 16 parameters were calculated in all cases, and the GDI was calculated from a smaller subset. T tests, and z-scores were used to compare each of these values to typically developing children for each diagnosis. A separate linear regression controlling for age, sex, and use of an orthosis, or assistive device was performed for the GGI. RESULTS: In our series, there were 71 typically developing children with a GGI of 31. We qualify relative gait impairment as severe, mild, or moderate as based on the GGI, and propose that values <100 represent mild, 100 to 200 represent moderate, and >200 represents severe impairment. On the basis of strong correlation between the GGI and GDI, we suggest that GDI values >80 represent mild, and values <70 represent severe impairment. T tests and z-scores demonstrated that both the number and magnitude of abnormal parameters increase the GGI. These tests also identified the most clinically relevant parameters contributing to functional impairment for each diagnosis. Multivariate linear regression showed that all diagnoses except flatfoot and scoliosis demonstrated statistically significant differences in GGI scores. CONCLUSIONS: This is the first study to apply these gait indices to a large population of diverse pediatric conditions. We propose GGI and GDI values to qualify gait impairment among these conditions as severe, moderate, or mild. Furthermore, impairment in gait reflects both the number and magnitude of abnormal parameters within each condition. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Selective Debridement With Labral Preservation Using Narrow Indications in the Hip: Minimum 5-Year Outcomes With a Matched-Pair Labral Repair Control Group.

BACKGROUND: Arthroscopic labral debridement in the hip can be an effective treatment for labral tears but has demonstrated inferior outcomes compared with labral repair. Thus, the role for labral debridement has become unclear. Hypothesis/Purpose: The purpose was to evaluate the outcomes of a selective debridement with labral preservation (SDLP) group with a minimum 5-year follow-up. It was hypothesized that, with narrow indications, SDLP would produce statistically improved patient-reported outcome (PRO) scores, comparable with those of a matched-pair labral repair control group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were collected on all patients undergoing primary hip arthroscopic surgery between February 2008 and September 2011. Exclusion criteria were acetabular or femoral head Outerbridge grade 4 chondral damage, preoperative Tnnis grade ≥2, workers' compensation claims, previous hip conditions, severe dysplasia (lateral center-edge angle <18°), or previous ipsilateral hip surgery. Patients who underwent arthroscopic labral debridement and had preoperative and minimum 5-year PRO scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score-Sports-Specific Subscale (HOS-SSS) as well as the visual analog scale (VAS) for pain, were included. In a nested matched-pair comparison, the SDLP group was matched 1:1 to an arthroscopic labral repair control group based on age ±5 years, body mass index ±5 kg/m2, sex, and Seldes tear type. RESULTS: One hundred twenty-five hips were eligible for inclusion, of which 101 (80.8%) hips had a minimum 5-year follow-up. All PRO scores were significantly improved ( P < .001) at latest follow-up (mHHS, 63.4 to 82.4; NAHS, 57.4 to 83.6; HOS-SSS, 44.2 to 74.5). The mean VAS score decreased from 5.8 to 2.3 ( P < .001). The mean patient satisfaction score was 8.1. Four (4.0%) patients underwent second-look arthroscopic surgery (mean, 18.5 months), and 14 (13.9%) patients converted to total hip arthroplasty (mean, 46.9 months). In the matched-pair comparison, 69 in the SDLP group were matched 1:1 with those undergoing labral repair. Outcomes at latest follow-up of the SDLP group were comparable with those of the control group, respectively: mHHS, 83.0 vs 86.1 ( P = .084); NAHS, 85.0 vs 85.4 ( P = .415); HOS-SSS, 74.8 vs 76.8 ( P = .219); VAS, 2.3 vs 2.0 ( P = .277); international Hip Outcome Tool-12 (iHOT-12), 73.8 vs 76.4 ( P = .136); Short Form Health Survey-12 (SF-12) mental, 57.4 vs 55.1 ( P = .031); SF-12 physical, 48.7 vs 48.9 ( P = .357); Veterans RAND Health Survey-12 (VR-12) mental, 61.6 vs 59.8 ( P = .160); VR-12 physical, 50.1 vs 50.2 ( P = .340); and patient satisfaction, 8.0 vs 8.3 ( P = .211). CONCLUSION: In select cases of stable labral tears, SDLP may allow the preservation of a functional labrum. At a minimum 5-year follow-up, SDLP using narrow indications produced favorable outcomes comparable with a matched-pair labral repair group.

Normative data on femoral version.

Femoral version is reported to vary in relation to age, gender and other patient-specific factors. Differences in femoral version are suspected to contribute to the development of hip pathology. However, normative data on pathologic hips has never been reported. To evaluate the femoral version in a large population of patients with symptomatic hip pathology treated with arthroscopy and report differences within this group based on age, gender, bony morphology and other hip-related factors. A prospectively gathered database of 1449 hips was reviewed. All patients underwent pre-operative MRI with measure of femoral version. The average femoral version of the entire population was 8.4+ 9.2°, range -23 to 63. There no statistically significant differences encountered based on age, gender, bony morphology or other hip-related factors. Across all groups, there was wide variation in the femoral version present. Among younger patients, there was trend to have a greater proportion of retroversion. Significant variation in femoral version exists in patients with symptomatic hip pathology. Although the geometry of the proximal femur is commonly described as anteverted, relative retroversion is also frequently encountered.

Arthroscopic Labral Base Repair in the Hip: 5-Year Minimum Clinical Outcomes.

BACKGROUND: Arthroscopic labral base repair (LBR) in the hip is a previously described technique designed to restore the native functional anatomy of the labrum by reproducing its seal against the femoral head. LBR has been shown to have good short-term outcomes. Hypothesis/Purpose: The purpose was to evaluate clinical outcomes of an LBR cohort with a minimum 5-year follow-up. It was hypothesized that patients who underwent LBR would continue to have significant improvement from their preoperative scores and maintain scores similar to their 2-year outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data for patients undergoing primary hip arthroscopic surgery with LBR from February 2008 to May 2011 with a minimum 5-year follow-up were prospectively collected and retrospectively reviewed. Patients with preoperative Tonnis osteoarthritis grade ≥2, previous hip conditions (slipped capital femoral epiphysis, avascular necrosis, Legg-Calv-Perthes disease), severe dysplasia (lateral center-edge angle <18°), or previous ipsilateral hip surgery were excluded. Statistical equivalence tests evaluated patient-reported outcomes (PROs) including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and patient satisfaction (0-10 scale; 10 = very satisfied). RESULTS: Of the 70 patients (74 hips) who met inclusion and exclusion criteria, 60 (85.7%) patients (64 hips) were available at a minimum 5-year follow-up. All PRO scores significantly improved from preoperative values with a mean follow-up of 67.8 ± 7.4 months (range, 60.0-89.7 months). The mean mHHS increased from 64.4 ±13.8 to 85.3 ± 17.7 ( P < .001), the mean NAHS from 63.7 ± 17.0 to 87.0 ± 14.7 ( P < .001), and the mean HOS-SSS from 47.1 ± 23.2 to 76.5 ± 25.9 ( P < .001). The mean VAS score decreased from 5.9 ± 2.4 to 2.0 ± 2.1 ( P < .001). The mean patient satisfaction score was 8.1 ± 2.0. The improvement in PRO scores was sustained from 2- to 5-year follow-up. At 2 and 5 years, survivorship rates were 96.9% and 90.6%, respectively, and the respective secondary arthroscopic surgery rates were 10.9% (7/64) and 17.2% (11/64). CONCLUSION: At a minimum 5-year follow-up, arthroscopic LBR continued to be a successful procedure and valid technique based on 3 PROs, the VAS, patient satisfaction, and survivorship. Significantly improved outcome scores were maintained compared with preoperative values and showed no signs of deterioration from the 2-year scores. The long-term survivorship of hip arthroscopic surgery has yet to be determined; however, these midterm results demonstrate the rates of additional procedures (both secondary arthroscopic surgery and conversion to total hip arthroplasty), that may be necessary after 2 years.

Outcomes of Hip Arthroscopic Surgery in Patients With Tönnis Grade 1 Osteoarthritis at a Minimum 5-Year Follow-up: A Matched-Pair Comparison With a Tönnis Grade 0 Control Group.

BACKGROUND: Studies on midterm outcomes of the arthroscopic treatment of femoroacetabular impingement (FAI) and labral tears with mild osteoarthritis (OA) are limited. PURPOSE: To evaluate outcomes of the arthroscopic treatment of FAI and labral tears in patients with mild preoperative OA (Tönnis grade 1) at a minimum 5-year follow-up, and to perform a matched-pair comparison to a control group with Tönnis grade 0. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected on patients who underwent hip arthroscopic surgery between February 2008 and April 2011. Inclusion criteria were arthroscopic treatment for FAI and labral tears and having preoperative patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) scores for pain. Exclusion criteria were workers' compensation claims, preoperative Tönnis grade ≥2, and previous hip conditions (ipsilateral surgery, slipped capital femoral epiphysis, avascular necrosis, and dysplasia). Patients with minimum 5-year outcomes were eligible for matching on a 1:1 ratio (Tönnis grade 0 vs 1) based on age ±5 years, body mass index ±5 kg/m2, sex, labral treatment, and capsular treatment. RESULTS: Of 356 eligible hips, 292 hips had minimum 5-year outcomes (82%). Eighty-five hips with Tönnis grade 1 were evaluated. At 5-year follow-up, patients with Tönnis grade 1 had significant improvements in all PRO and VAS scores ( P < .0001). The overall satisfaction score was 8.2. The survivorship rate with respect to conversion to total hip arthroplasty for the Tönnis grade 1 group was 69.4% at 5 years, while in the Tönnis grade 0 group, it was 88.4% ( P = .0002). Sixty-two hips with Tönnis grade 0 were matched to 62 hips with Tönnis grade 1. Both groups demonstrated improvements in all PRO and VAS scores from preoperatively to postoperatively ( P < .0001). No significant differences existed between preoperative or postoperative scores or survivorship between the groups. CONCLUSION: The arthroscopic treatment of FAI and labral tears in patients with Tönnis grade 1 had good results at 5-year follow-up. After controlling for other variables using a matched-pair comparison, patients with Tönnis grade 1 had similar, durable improvements to those with Tönnis grade 0. While strict surgical indications and appropriate expectations are recommended for patients with mild OA, Tönnis grade 1 alone should not be considered a contraindication to hip arthroscopic surgery.

Perioperative Blood Management in Pediatric Spine Surgery.

Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.

Dynamizations and Exchanges: Success Rates and Indications.

OBJECTIVE: To characterize the timing, indications, and "success rates of secondary interventions, dynamization and exchange nailing, in a large series of tibial nonunions" (dynamization and exchange nailing are types of secondary interventions). SETTING: Retrospective multicenter analysis from level 1 trauma hospitals. PATIENTS: A total of 194 tibia fractures that underwent dynamization or exchange nailing for delayed/nonunion. INTERVENTION: Records and radiographs to characterize demographic data, fracture type, and cortical contact after tibial nailing were gathered. The radiographic union score for tibias (RUST) and the timing of intervention and time to union were calculated. MAIN OUTCOME MEASURES: The primary outcome was success of either intervention, defined as achieving union, with the need for further intervention defining failure. Other outcomes included RUST scores at intervention and union, and timing to intervention and union for both techniques. Two-tailed t tests and Fisher exact with P set at <0.05 for significance were used as indicated. RESULTS: A total of 194 tibia fractures underwent dynamization (97) or exchange nailing (97). No statistical differences were found between groups with demographic characteristics. The presence of a fracture gap (P = 0.01) and comminuted fractures (P = 0.002) was more common in the exchange group. The success rates of the interventions and RUST scores were not different when performed before versus after 6 months; therefore, data were pooled. The RUST scores at the time of intervention were not different for successful or failed dynamizations (7.13 vs. 7.07, P = 0.83) or exchanges (6.8 vs. 7.3, P = 0.37). Likewise, the time to successful versus failed dynamization (165 vs. 158 days, P = 0.91) or exchange nailing (224 vs. 201 days, P = 0.48) was not different. No cortical contact or a gap was a statistically negative factor for both exchange nails (P = 0.09) and dynamizations (P = 0.06). When combined, the success in the face of a gap was 78% versus 92% when no gap was present (P = 0.02). CONCLUSIONS: Previous literature has few reports of the success rates of secondary interventions for tibial nonunions. The indications for dynamization and exchange were similar. Comminuted fractures, and fractures with no cortical contact or "gap" present after intramedullary nailing, favored having an exchange nail performed over dynamization. Fracture gap was also found to be a negative prognostic factor for both procedures. Overall, this study demonstrates high rates of union for both interventions, making them both viable options. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment options in patients with impaired bone quality.

BACKGROUND: Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process. QUESTIONS/PURPOSES: We address the following issues: (1) current methods of clinically assessing bone quality; (2) emerging technologies; (3) how bone quality connects with surgical decision-making and the ultimate surgical outcome; and (4) gaps in knowledge that need to be closed to better characterize bone quality for more relevance to clinical decision-making. METHODS: PubMed was used to identify selected papers relevant to our discussion. Additional sources were found using the references cited by identified papers. RESULTS: Bone mineral density remains the most commonly validated clinical reference; however, it has had limited specificity for surgical decision-making. Other structural and geometric measures have not yet received enough study to provide definitive clinical applicability. A major gap remains between the basic research agenda for understanding bone quality and the transfer of these concepts to evidence-based practice. CONCLUSIONS: Basic bone quality needs better definition through the systematic study of emerging technologies that offer a more precise clinical characterization of bone. Collaboration between basic scientists and clinicians needs to improve to facilitate the development of key questions for sound clinical studies.