Subacromial Balloon Spacer for Irreparable Rotator Cuff Tear Treatment Shows Improved Pain and Strength at 5-Year Follow-Up.

PURPOSE: To report on minimum 5-year outcomes following subacromial balloon spacer implantation (SBSI), in terms of survivorship, pain reduction, functional outcomes, complications, and reoperations. METHODS: Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing SBSI between April 1, 2012, and June 30, 2016. Patients completed preoperative and postoperative follow-up for minimum 5 years on the following patient-reported outcomes (PROs): Constant-Murley Score (CMS), visual analog scale for pain (VAS), strength, and patient satisfaction. Reoperations and complications were recorded. Minimal detectable change (MDC) was calculated and the proportion of patients achieving MDC for CMS and VAS were calculated. RESULTS: During the study period, SBSI was performed in 36 patients. Three patients were deceased within 5 years. Of the remaining 33 patients, follow-up was available on 29 patients (80.6%). Mean age at the time of operation was 72.7 ± 4.5 years, and 69% of the patients were males. Mean follow-up time was 72.5 months. Significant improvements from preoperative to last follow-up were demonstrated in CMS (36.08 vs. 63.88; P < .001), VAS (6.72 vs. 1.68; P < .001), and strength (3.8 vs 5.87 kg; P < .001). These improvements were demonstrated at 3 weeks, 6 months, 12 months, 24 months, and 60 months. Mean patient satisfaction at last follow-up was 8.72. The MDC for both CMS and VAS was achieved by 75.9% (22/29) of patients. Four patients underwent conversion to a reverse total shoulder arthroplasty (RTSA). Complications included one patient with balloon dislocation and one patient with a secondary infection due to urinary tract infection. CONCLUSIONS: Pain reduction and functional improvements are sustained at minimum 5 years after SBSI in patients with irreparable rotator cuff tears. The 5-year conversion rate to an RTSA was 13.79%. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

Lateral to Medial Joint Space Ratio is Predictive of Survivorship After Primary Hip Arthroscopy.

PURPOSE: To assess whether preoperative joint space measures would be predictive of survivorship in patients undergoing hip arthroscopy (HA) for femoroacetabular impingement (FAI). METHODS: Data on consecutive patients who underwent hip arthroscopy between February 2008 and February 2018 were retrospectively reviewed. To be eligible for final analysis, patients were required to have preoperative radiographs for joint space measurements and data indicating conversion to a total hip arthroplasty (THA), hip resurfacing, or neither; at a minimum of 2 years after primary hip arthroscopy. Survivorship following HA was defined as remaining conversion free and served as the primary outcome. A multivariate logistic regression analysis and receiver operator curve (ROC) were used to evaluate the correlation between joint space measurements and survivorship following HA. RESULTS: A total of 1,885 primary arthroscopy cases were included in this study. The multivariate regression analysis found preoperative lateral-to-medial joint space ratio (L/M ratio) to be the strongest predictive factor of survivorship after primary hip arthroscopy (OR = 2.084, CI95% = 1.239-3.503; P = .006). The ROC curve for the model demonstrated acceptable discrimination with an area under the curve (AUC) of 0.792. Patients with an L/M ratio ≥0.75 had a survivorship rate of 91.7% compared to a rate of 75% for patients with an L/M ratio <0.75 (OR: 3.68). CONCLUSIONS: This study found that, of the factors evaluated in this study, the most significant factor in predicting survivorship at 2 years after undergoing primary hip arthroscopy was a larger lateral-to-medial joint space ratio. This may suggest an initiation of primary arthritis at the edge-loading area of the lateral acetabulum. LEVEL OF EVIDENCE: III, retrospective comparative observation study.

Editorial Commentary: Hip Joint Laxity, Microinstability, or Instability Require Precise Definition: No Matter What You Call It, It's Here to Stay!

Hip instability has gained recognition as an important cause of hip pathology. Causes include incongruency of the articular surfaces due to dysplasia and/or impingement, joint capsule pathology, labral pathology, ligamentum teres tears, ligamentous laxity, muscular imbalance, and tendon tears. Lacking clearly defined symptoms and tests has hindered identification and treatment of this condition. Furthermore, the relevant literature uses different terms such as hyperlaxity and microinstability to describe this patient population, conveying different messages. However, the different terms convey different messages. Joint hyperlaxity or hypermobility has sometimes been used in reference to the hip; however, these usually refer to a genetic ligamentous and capsular condition affecting collagen structure, such as in Ehlers Danlos Syndrome. More common, and often interchangeable, terms are instability and microinstability. As the authors state in the present study, 'instability' has the advantage of conveying the significant impact the condition has on a patient's life. On the other hand, 'microinstability' may more accurately reflect the vague clinical presentation that we often encounter in the average hip patient with instability. Most patients do not complain of symptoms commonly seen in other joints with "instability," such as giving way, subluxation, and recurrent dislocations. In the hip, the symptoms are generally less tangible, and hence, the term "microinstability" may be more appropriate.

Outcomes Among Athletes Versus Nonathletes After Arthroscopic Management of Femoroacetabular Impingement.

This study synthesizes and reports patient-reported outcomes (PROs) among athletes vs nonathletes after hip arthroscopy for femoroacetabular impingement. A systematic review was performed in November 2020 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. We included studies that reported PROs for athletes vs nonathletes. We excluded articles that did not contain full text, that were not in English, and that included level IV evidence. Four studies reporting on a total of 294 athletes and 230 nonathletes were included. Of these studies, 3 found superior outcomes among athletes, and 1 found that athletes recovered faster, but nonathletes had equivalent outcomes at later follow-up. Athletes and nonathletes showed significant improvements in PROs; however, athletes showed a trend toward superior PROs. Thus, pre-operative athletic activity is associated with favorable outcomes after hip arthroscopy. [Orthopedics. 2022;45(6):e288-e294.].

Predictors of Achieving the Maximal Outcome Improvement Threshold for Willingness to Undergo Revision Hip Arthroscopy.

BACKGROUND: The maximal outcome improvement threshold for willingness to undergo revision hip arthroscopy (MOWT) has not been defined yet. PURPOSE: To determine the percentage MOWT in patients who underwent revision hip arthroscopy and to identify predictors of achieving the MOWT. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: An anchor question was provided to patients who underwent revision hip arthroscopy between April 2008 and June 2020 who returned for follow-up between August 2019 and June 2021 at one institution. Patients were included if they underwent revision hip arthroscopy, had answered the anchor question, and had baseline and postoperative minimum 1-year follow-up scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous hip conditions, or unwillingness to participate. Receiver operating characteristic analysis was used to determine the MOWT. Multivariate logistic regression was used to determine intraoperative predictors of achieving the MOWT. RESULTS: In total, 153 patients (163 hips) were included, with 117 female hips (71.8%), a mean patient age of 34.3 ± 12.4 years, and an average follow-up time of 61.6 ± 42.7 months. It was determined that 77.3% of the patients reported that they would choose to undergo the revision hip arthroscopy again. The MOWT for the mHHS, NAHS, and VAS was 43.1%, 53%, and 33.4%, respectively. The probability of choosing to undergo revision surgery if the MOWT was achieved was 77.5%, 77.6%, and 79.2%, for the mHHS, NAHS, and VAS, respectively. Patients with residual cam-type morphology, which was addressed during the revision, were 2.3 times more likely to achieve the MOWT for the VAS (P = .014). CONCLUSION: Patients who improved 43.1%, 53%, and 33.4% of their MOWT for the mHHS, NAHS, and VAS, respectively, were likely to be willing to undergo revision hip arthroscopy again. Moreover, the presence of residual cam-type femoroacetabular impingement morphology before their revision surgery was identified as a predictor to achieve the MOWT for the VAS.

Personalized Medicine Using Predictive Analytics: A Machine Learning-Based Prognostic Model for Patients Undergoing Hip Arthroscopy.

BACKGROUND: Personalized medicine models to predict outcomes of orthopaedic surgery are scarce. Many have required data that are only available postoperatively, mitigating their usefulness in preoperative decision making. PURPOSE: To establish a method for predictive modeling to enable individualized prognostication and shared decision making based on preoperative patient factors using data from a prospective hip preservation registry. STUDY DESIGN: Cohort study (Prognosis); Level of evidence, 2. METHODS: Preoperative data of 2415 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome between February 2008 and November 2017 were retrospectively analyzed. Two machine-learning analyses were evaluated: Tree-structured survival analysis (TSSA) and Cox proportional hazards modeling for predicting time to event and for computing hazard ratios for survivorship after hip arthroscopy. The Fine-Gray model was similarly used for repeat hip arthroscopy. Variables were selected for inclusion using the minimum Akaike Information Criterion (AIC). The stepwise selection was used for the Cox and Fine-Gray models. A web-based calculator was created based on the final models. RESULTS: Prognostic models were successfully created using Cox proportional hazards modeling and Fine-Gray models for survivorship and repeat hip arthroscopy, respectively. The Harrell C-statistics of the Cox model calculators for survivorship after hip arthroscopy and the Fine-Gray model for repeat hip arthroscopy were 0.848 and 0.662, respectively. Using the AIC, 13 preoperative variables were identified as predictors of survivorship, and 6 variables were identified as predictors for repeat hip arthroscopy. In contrast, the TSSA model performed poorly, resulting in a Harrell C-statistic <0.6, rendering it inaccurate and not interpretable. A web-based calculator was created based on these models. CONCLUSION: This study successfully created an institution-specific machine learning-based prognostic model for predictive analytics in patients undergoing hip arthroscopy. Prognostic models to predict survivorship and the need for repeat surgeries were both adapted into web-based tools to assist the physician with shared decision making. This prognostic model may be useful at other institutions after performing external validation. Additionally, this study may serve as proof of concept for a methodology for the development of patient-specific prognostic models. This methodology may be used to create other predictive analytics models in different realms of orthopaedic surgery, contributing to the evolution from evidence-based medicine to personalized medicine.

The Inverse Relationship Between Labral Size and Acetabular Coverage: Does It Protect the Cartilage in the Dysplastic Hip?

PURPOSE: The aims of this study were to confirm the relationship between osseous coverage and labral size and to investigate the severity of intra-articular damage in borderline dysplastic hips in correlation to labral size. METHODS: Patients treated with primary hip arthroscopy for symptomatic labral tears between 2010 and 2018 were considered for this study. Patients were included if they had preoperative radiographic measures and intraoperative assessments of the labra and cartilage. The study group was divided into borderline dysplastic and nondysplastic groups via 3 measurements: lateral center edge angle (LCEA), acetabular index (Ax), and anterior center edge angle (ACEA). Undercoverage was defined as LCEA ≤ 25°, Ax ≥ 10°, and ACEA ≤ 20°. The labrum was measured in four quadrants: anterosuperior (AS), anteroinferior (AI), posterosuperior (PS), and posteroinferior (PI). Additionally, to assess cartilage damage in borderline dysplastic hips, hips with average labral size in the top quartile were compared to hips with average labral size in the bottom quartile. RESULTS: A total of 1765 hips (1589 patients) were included in the study. The mean LCEA, Ax, and ACEA between the borderline dysplastic and nondysplastic groups were significantly different (P < .001). According to the Ax classification, there was significant evidence that borderline dysplastic hips had larger labra (P < .05). Among the dysplastic group, there was significantly more cartilage damage according to the Outerbridge classifications along both the acetabulum and femoral head in hips with labra in the upper quartile (P =.011 and .005, respectively). CONCLUSION: An inverse relationship may exist between acetabular depth and labral size. Additionally, specifically in borderline dysplastic hips, a relatively large labrum correlates with worse intra-articular damage compared to borderline dysplastic hips with a relatively small labrum. Larger labral size may indicate a higher degree of instability in patients with borderline dysplasia. LEVEL OF EVIDENCE: Level III, case-control study.

Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis.

BACKGROUND: The aims of this systematic review were: (1) to investigate the prophylactic effect of radiotherapy (RT) and NSAIDs in high-risk patients following total hip arthroplasty (THA); and (2) to compare the efficacy of non-selective and COX-II selective NSAIDs in preventing post-THA HO, utilising a meta-analysis of randomised control studies. METHODS: The PubMed, Embase, and Cochrane Databases were searched for articles regarding HO following THA in March 2019. Studies were included if they contained data regarding HO incidence after THA or contained data regarding HO prophylaxis comparison of NSAIDs and/or RT in terms of dosage or duration. RESULTS: 24 studies reported on populations that were not at high-risk for HO. These studies reported between 47.3% and 90.4% of their patient populations had no HO formation; between 2.8% and 52.7% had mild formation; and between 0.0% and 10.4% had severe formation. A total of 13 studies reported on populations at high-risk for HO. Studies analysing RT in high-risk patients reported between 28.6% and 97.4% of patients developed no HO formation; between 1.9% and 66.7% developed mild HO formation; and between 0.0% and 11.9% developed severe HO formation. Studies analysing NSAID treatment among high-risk populations reported between 76.6% and 88.9% had no HO formation; between 11.1% and 23.4% had mild HO formation, and between 0.0% and 1.8% had severe HO formation. 9 studies were identified as randomised control trials and subsequently used for meta-analysis. The relative risk for COX-II in developing any HO after THA was not significantly different compared to non-selective NSAIDs (RR 1.00; CI, 0.801-1.256; p = 0.489). CONCLUSIONS: NSAIDs prophylaxis for HO may have better efficacy than RT in high-risk patients following THA. Non-selective and COX-II selective NSAIDs have comparable efficacy in preventing HO. Factors such as medical comorbidities and side-effect profile should dictate the prophylaxis recommendation.

Comparable Minimum 2-Year Patient-Reported Outcome Scores Between Circumferential and Segmental Labral Reconstruction for the Management of Irreparable Labral Tear and Femoroacetabular Impingement Syndrome in the Primary Setting: A Propensity-Matched Study.

PURPOSE: To compare minimum 2-year follow-up patient-reported outcome scores (PROs) in patients who underwent primary acetabular circumferential and segmental labral reconstruction for irreparable labral tears and femoroacetabular impingement syndrome (FAIS). METHODS: Data were reviewed from August 2010 to December 2017. Patients with primary labral reconstruction and minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Circumferential and segmental reconstruction were selected in each case based on the extent of the labral pathology. Exclusion criteria were previous ipsilateral hip surgery/conditions, dysplasia, or Tönnis grade >1. Patients were propensity matched 1:1 based on age, sex, and body mass index. Secondary surgeries were reported. The P value was set at <.05. RESULTS: In total, 144 hips were eligible, and 17 hips were lost to follow-up, leaving 127 hips (88.2%) for analysis. Eighty hips underwent a segmental reconstruction, and 47 hips underwent a circumferential reconstruction. Forty-seven hips with circumferential reconstruction were matched to 47 hips with segmental reconstruction. The average follow-up and age for the segmental and circumferential groups were 29.0 ± 7.8 and 27.9 ± 7.0 months (P = .732) and 43.1 ± 9.4 and 44.7 ± 10.2 years (P = .442) respectively. The segmental and circumferential groups were 48.9% and 51.1% female, respectively. The groups achieved significant and comparable improvement for all PROs and rates of secondary surgeries. No differences were found for achieving the minimal clinically important difference (MCID) and the patient acceptable symptomatic state (PASS). The MCIDs for the segmental and circumferential groups were 76.7% and 77.8% for the mHHS, 64.9% and 77.8% for the HOS-SSS, 71.1% and 68.9% for the VAS, and 68.9% and 73.9% for the NAHS, respectively. The PASSs for the segmental and circumferential groups were 78.3% and 73.3% for the mHHS, 55.3% and 55.0% for the HOS-SSS, and 75.6% and 71.1% for the International Hip Outcome Tool 12, respectively. CONCLUSIONS: At minimum 2-year follow-up, patients who underwent primary hip arthroscopy for either circumferential or segmental labral reconstruction for irreparable labra and FAIS reported significant improvement and similar postoperative scores for all PROs, with no difference in psychometric outcomes and rate of secondary surgeries. A customized approach, using the extent of the irreparable labral tear, seems to be an appropriate strategy. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Dunn View Alpha Angle More Useful Than Femoral Head-Neck Offset to Predict Acetabular Cartilage Damage in Patients With Femoroacetabular Impingement Syndrome Undergoing Hip Arthroscopy.

PURPOSE: To identify radiographic measurements and demographics that are predictive of acetabular cartilage damage in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. More specifically, to compare the predictive value of alpha angle and femoral head-neck offset, as measured on Dunn view radiographs, in determining the preoperative likelihood and severity of acetabular cartilage damage. METHODS: Patients were included if they underwent primary hip arthroscopy for FAIS between February 2008 and June 2020. Exclusion criteria were prior ipsilateral hip conditions, Tönnis grade of osteoarthritis >1, unwilling to participate, missing intraoperative, demographic or radiographic variables of interest, and lateral center-edge angle (LCEA) >40° or ≤25°. Fourteen variables were assessed in a bivariate comparison and analyzed in a multivariate logistic model. The Acetabular Labrum Articular Disruption (ALAD) and Outerbridge (OB) classifications were used to define acetabular cartilage defects. Those without damage or those with mild acetabular cartilage damage belonged to the ALAD/OB ≤2 group and those with severe damage belonged to the ALAD/OB ≥ 3 group. RESULTS: A total of 1485 patients were analyzed, including 1038 patients with ALAD/OB ≤2 and 447 patients with ALAD/OB ≥3. There was a greater proportion of males in the ALAD/OB ≥3 group (64.21% vs 25.82%; P <.001). The multivariate logistic regression selected age, sex, anterior center-edge angle (ACEA), and alpha angle. Every additional degree in the alpha angle was associated with a 6% increase in the odds of severe acetabular cartilage damage (odds ratio [OR], 1.06 [95% confidence interval [CI], 0.12-8.11]). The multivariate analysis did not identify femoral head-neck offset as a predictor. The odds of severe acetabular cartilage damage were 3.73 times higher in males than females (OR, 3.73 [95% CI, 0.01-1705.96]). Higher age was found to increase the likelihood of ALAD/OB ≥3 (OR, 1.04 [95% CI, 0.13-7.75]). CONCLUSIONS: In a multivariate analysis, factors identified as preoperative predictors of acetabular cartilage damage in patients with FAIS were age, sex, ACEA, and alpha angle. Femoral head-neck offset was not predictive, suggesting that Dunn view alpha angle may take precedence as a predictor of acetabular cartilage damage. LEVEL OF EVIDENCE: Level III, cohort study.

Surgeon-Specific Traction Time During Hip Arthroscopy for Primary Labral Repair Can Continue to Decrease After a Substantial Number of Surgeries.

PURPOSE: The purpose of this study was to evaluate the total traction time and traction time as a function of anchors placed (TTAP) for primary labral repair in patients undergoing hip arthroscopy by a single surgeon. METHODS: Patients were included if they received a primary labral repair with or without acetabuloplasty, chondroplasty, or ligamentum teres debridement as part of the treatment for femoroacetabular impingement (FAI). Patients were excluded if they had a previous ipsilateral hip surgery, prior hip conditions, Tönnis grade >1, open procedures, microfracture, ligamentum teres reconstruction, or labral reconstruction. TTAP was calculated by dividing total traction time by the number of anchors placed. RESULTS: 2,350 hips met the inclusion criteria. The mean age and BMI in this cohort were 34.22 years and 25.72 kg/m2, respectively. A total traction time of 60 minutes was first achieved after 268 cases. Mean overall total traction time was 58.16 minutes (95% CI [57.35, 58.97]) and mean TTAP was 16.24 minutes (95% CI [15.93,16.55]) after 2,350 cases. Total traction time plateaued after 374 cases at 55.92 minutes, while TTAP plateaued after 487 cases at 14.93 minutes. CONCLUSION: Surgeons who introduce hip arthroscopy into their practice can expect to see improvements in traction time during the first 500 surgeries performed, as total traction time plateaued after 374 cases and TTAP plateaued after 487 cases. LEVEL OF EVIDENCE: IV: case series.

Short-term Outcomes of Concomitant Femoral Derotation Osteotomy and Hip Arthroscopy.

The goal of this study is to report the short-term outcomes of concomitant hip arthroscopy and femoral derotational osteotomy (FRO) to treat femoral malrotation and intra-articular pathology. Data were retrospectively reviewed for patients undergoing concomitant hip arthroscopy and FRO between March 2013 and January 2017. Patients were included if they had a minimum of 1 year of follow-up for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12) score, 12-item Short Form Health Survey Physical component and Mental component (SF-12 P and SF-12 M, respectively) scores, Veterans RAND 12-item Health Survey Physical and Mental (VR-12 P and VR-12 M, respectively) scores, visual analog scale (VAS) score for pain, and patient satisfaction ratings. Rates for meeting the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) were also recorded. Nine hips were included, and mean follow-up was 36.9 months. Mean preoperative femoral version was 33.0°. Patients underwent 1 or more concomitant procedures, such as labral treatment, capsular plication, acetabuloplasty, or femoroplasty. At latest follow-up, significant improvement was seen for mHHS, NAHS, HOS-SSS, and VAS score. Additionally, rates of meeting the PASS for mHHS, iHOT-12 score, and HOS-SSS were 100%, 88.9%, and 55.6%, respectively. Rates of achieving MCID for mHHS and HOS-SSS were 77.8% and 66.7%, respectively. One hip required revision derotational osteotomy to treat overcorrection, and 3 hips underwent secondary surgery for hardware removal. Concomitant hip arthroscopy and FRO may yield improved outcomes for patients with concurrent intra-articular pathology and excessive femoral anteversion. Considering that no major complications were diagnosed, this procedure is also relatively safe. [Orthopedics. 2021;44(6):e739-e746.].

Circumferential and Segmental Labral Reconstruction: A Systematic Review.

The purposes of this study were to synthesize, report, and compare patient-reported outcomes (PROs) between arthroscopic segmental and circumferential labral reconstruction. A systematic review was performed in February 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Inclusion criteria were levels I to IV evidence, articles in English, arthroscopic labral reconstruction, and PROs data. Exclusion criteria were labral treatment without reconstruction, open surgery, and less than 6-month follow-up. Eleven studies were identified. Nine studies (212 hips) reported outcomes of segmental reconstruction. Two studies (194 hips) reported outcomes of circumferential reconstruction. Significant improvement in PROs at short-term with either segmental or circumferential reconstruction was found. [Orthopedics. 2021;44(6):361-366.].

Arthroscopic Triple Reconstruction in the Hip Joint: Restoration of Soft-Tissue Stabilizers in Revision Surgery for Gross Instability.

Gross hip instability in an active adult with previous normal hip anatomy is usually due to disruption of the static stabilizers of the hip joint. Although such a disruption can result from a high-grade injury, it can be iatrogenic after previous hip arthroscopy. The patient may present with a painful limp and recurrent subluxation sensation in the affected hip joint. Revision hip arthroscopy in this scenario is generally complicated, and it is not uncommon for all the soft-tissue stabilizers to be compromised. The labrum, ligamentum teres (LT), and capsule of the hip joint are often so damaged that reparation is not an option. Reconstruction of the torn LT is an established method to add secondary stability while addressing the labral pathology in the hip joint with microinstability. Concomitant reconstruction of all the static restraints has yet to be described addressing triple instability. This Technical Note presents a stepwise approach, including tips and pearls, for arthroscopic triple reconstruction of the labrum, LT, and capsule. We believe this method is a safe and reproducible way to effectively treat gross hip instability in young patients.

Pertrochanteric Calcifications in Patients With Greater Trochanteric Pain Syndrome: Description, Prevalence, and Correlation With Intraoperatively Diagnosed Hip Abductor Tendon Injuries.

BACKGROUND: Pertrochanteric calcifications can be found in patients with greater trochanteric pain syndrome (GTPS). A systematic description of the types and prevalence of these calcifications has not been undertaken. Furthermore, there is conflicting evidence regarding their association with abductor tendon injuries. PURPOSE: (1) To describe the various types and prevalence of pertrochanteric calcifications in patients presenting for the surgical management of recalcitrant GTPS. (2) To evaluate the association of the various calcifications with intraoperatively diagnosed hip abductor tendon injuries, including tendinosis, partial-thickness tears, and full-thickness tears. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients undergoing surgical management for GTPS, in isolation or as an ancillary procedure during hip arthroscopy for femoroacetabular impingement, between April 2008 and February 2020 were included. Of these, 85 procedures were isolated treatment of GTPS and the remaining 628 were ancillary to hip arthroscopy. Radiographs were scrutinized for the presence of pertrochanteric calcifications. The hip abductor tendon status was intraoperatively classified as intact, partial-thickness tear, or full-thickness tear. The prevalence and correlation of the various radiographic findings in relation to the intraoperatively classified tendon condition were analyzed via the odds ratio (OR). RESULTS: Surgery was performed on 713 hips with recalcitrant GTPS. No tear was found in 340 hips (47.7%), 289 hips (40.5%) had a partial-thickness tear, and 84 hips (11.8%) had a full-thickness tear. Radiographically, 102 hips (14.3%) demonstrated proximally directed enthesophytes, and 34 (4.8%) had distally directed enthesophytes. In addition, 75 hips (10.5%) had amorphous calcifications, 47 (6.6%) had isolated ossicles, and 110 (15.4%) had surface irregularities. The presence of any calcification was associated with partial-thickness tears (OR, 1.67 [95% CI, 1.21-2.21]; P = .002) and full-thickness tears (OR, 6.40 [95% CI, 3.91-10.47]; P < .001). Distally directed enthesophytes (OR, 10.18 [95% CI, 3.08-33.63]; P < .001) and proximally directed enthesophytes (OR, 8.69 [95% CI, 4.66-16.21]; P < .001) were the findings with the highest OR for the presence of any type of tear. Distally directed enthesophytes were the findings with the highest OR for a full-thickness tear (OR, 15.79 [95% CI, 7.55-33.06]; P < .001). Isolated ossicles were the findings with the highest OR for a partial-thickness tear (OR, 1.73 [95% CI, 0.96-3.13]; P = .070). CONCLUSION: Pertrochanteric calcifications were common radiographic findings in patients with GTPS and can help guide management in these patients. Proximally and distally directed enthesophytes were strong predictors for the presence of a hip abductor tendon tear, and specifically a full-thickness tear, and increasing size of the findings was associated with more severe tendon injuries.

Total hip arthroplasty after pelvic osteotomy for acetabular dysplasia: A systematic review.

The purposes were (1) to investigate and compare the findings of patients undergoing total hip arthroplasty (THA) following a corrective pelvic osteotomy (PO), to a control group of patients who underwent THA but not PO and (2) to evaluate the outcomes and complications for secondary THA after PO. Three studies recorded reduced cup anteversion in the osteotomy group. Two studies reported higher PROs for the control group. The most common complication after failed PAO was dislocations. PO may entail challenges on a subsequent THA, illustrated by higher intraoperative blood loss, lower consistency in cup positioning and compromised patients reported outcomes.

Intraoperative Findings and Clinical Outcomes Associated With Arthroscopic Management of Subspine Impingement: A Propensity-Matched, Controlled Study.

PURPOSE: (1) To investigate intra-articular damage in the hip joint associated with subspine impingement (SSI); (2) to evaluate clinical outcomes of arthroscopic treatment of hips with SSI; and (3) to compare the findings and outcomes to a control group without SSI. METHODS: Eligible patients had arthroscopic treatment for femoroacetabular impingement (FAI) concurrent with SSI between January 2015 and December 2017. Inclusion criteria consisted of preoperative and minimum 2-year patient-reported outcomes and preoperative measurements for Tönnis, lateral center edge angle, and alpha angle. Included patients were propensity-matched in a 1:3 ratio to patients who had FAI without SSI. Patient-reported outcomes were compared between groups. Minimal clinically important difference was calculated for modified Harris Hip Score (mHHS) and Hip Outcome Score-Sports Specific Subscale (HOS-SSS). RESULTS: Fifty SSI cases were matched to 150 patients who had FAI without SSI. A greater proportion of the SSI cohort required labral reconstruction (P = .010). The size and locations for labral tears and chondral defects were comparable between groups (P > .05). Both groups demonstrated similar minimum 2-year outcomes for mHHS (P = .103), Nonarthritic Hip Score (P = .200), HOS-SSS (P = .119), visual analog scale (P = .231), international Hip Outcome Tool-12 (P =.300), Short Form-12 Mental (P = .426), Short Form-12 Physical (P = .328), Veterans RAND 12-Item Health Survey, Mental (P = .419), and Veterans RAND 12-Item Health Survey, Physical (P = .316). The percentage of patients achieving minimal clinically important difference for mHHS and HOS-SSS was similar (P > .05). Survivorship was 96.0% and 98.7% for the SSI and control cohorts at 2 years, respectively. CONCLUSIONS: Arthroscopic treatment of hips with SSI with subspine decompression and concomitant treatment of labral tears and FAI yielded significant improvement in patients' outcomes, which compared favorably with the control group. SSI may correlate with more complex labral tears, not amenable to repair, and complete tears of the ligamentum teres. Other findings, such as location and size of intra-articular damage, were similar between the cohorts. LEVEL OF EVIDENCE: III, case-control study.

Minimum 5-Year Outcomes for Revision Hip Arthroscopy With a Prospective Subanalysis Against a Propensity-Matched Control Primary Group.

BACKGROUND: There is a paucity of midterm outcome data on hip revision arthroscopic surgery. PURPOSE: (1) To report minimum 5-year patient-reported outcome measurement scores (PROMSs) in patients who underwent revision hip arthroscopy, (2) to compare minimum 5-year PROMSs with a propensity-matched control group that underwent primary hip arthroscopy, and (3) to compare the rate of achieving the minimal clinically important difference (MCID) at minimum 5-year follow-up between the revision group and the propensity-matched control primary group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected between June 2008 and April 2014. Patients were included who underwent revision hip arthroscopy with preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patients with Tönnis grade >1 or with hip conditions such as avascular necrosis, Legg-Calve-Perthes disease, Ehlers-Danlos syndrome, and pigmented villonodular synovitis were excluded. A subanalysis was performed against a propensity-matched control group that underwent primary surgery. Groups were propensity matched in a 1:2 ratio for sex, age, body mass index, and follow-up time. RESULTS: A total of 127 revision arthroscopies (113 patients) were included, and the mean ± SD follow-up time was 72.8 ± 23.3 months. The revision group was 74.0% female, and the average age and body mass index were 34.9 ± 12.4 years and 24.8 ± 4.2, respectively. The revision group demonstrated improvement for all PROMSs and reached the MCID for the mHHS (66.1%), HOS-SSS (68.4%), NAHS (66.9%), and VAS (80.0%). All revision cases were propensity matched to 254 primary arthroscopy cases. PROMSs in the revision group were lower than those of the control group before and after surgery. Delta values were similar between groups for all PROMSs. There were no differences in rates of achieving the MCID. The relative risk of arthroplasty conversion was 2.6 (95% CI, 1.5-4.6) for the revision group as compared with the primary group. CONCLUSION: Significant improvement in all PROMSs, including the VAS, and high patient satisfaction at minimum 5-year follow-up were reported after revision hip arthroscopy. A high proportion of patients in the revision cohort reached the MCID for the mHHS, HOS-SSS, NAHS, and VAS, with similar rates and magnitudes of improvement relative to the control group. As expected, these data indicate that patients undergoing primary hip arthroscopy have higher PROMSs before and after surgery and lower rates of conversion to arthroplasty.

Determining Clinically Meaningful Thresholds for the Nonarthritic Hip Score in Patients Undergoing Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: The purpose of this study was to improve the interpretability of the Nonarthritic Hip Score (NAHS) by determining the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) after hip arthroscopy for femoroacetabular impingement. The secondary aim was to identify variables associated with achievement of the thresholds. METHODS: Patients who underwent hip arthroscopy for femoroacetabular impingement and completed postoperative questionnaires between August 2019 and March 2020 were included. Patients were excluded if they underwent previous ipsilateral hip surgery, underwent gluteus medius repair, or had a previous hip condition. The MCID, PASS, and SCB thresholds were calculated for the NAHS at minimum 1-, 2-, and 5-year follow-up. Distribution- and anchor-based methods with receiver operating characteristic analysis were used to determine the thresholds. Multivariate logistic regression was performed to determine predictors of achieving the MCID and PASS. RESULTS: The study included 343 hips with an average follow-up period of 48 months. On the basis of the distribution-based approach, the MCID was 8.7 using a method in which the standard deviation of the baseline score was divided by 2. By use of a method in which the standard deviation of the change score was divided by 2, MCID scores of 9.1, 8.3, and 12.6 resulted at a minimum of 1, 2, and 5 years, respectively. The PASS thresholds for these time points were 81.9, 85.6, and 81.9. The absolute SCB thresholds were 91.9, 94.4, and 93.1 and the change score thresholds were 30.6, 24.4, and 29.3 for a minimum of 1, 2, and 5 years, respectively. The preoperative NAHS was positively associated with achievement of the PASS and inversely related to achievement of the MCID. CONCLUSIONS: This study provides important clinical thresholds for the NAHS. These thresholds were determined for minimum 1-, 2-, and 5-year time points. The MCID was determined as 8.7, the PASS ranged between 81.9 and 85.6, and the absolute SCB value ranged from 91.9 to 94.4. The preoperative NAHS was found to be positively associated with achievement of the PASS and inversely related to achievement of the MCID. LEVEL OF EVIDENCE: Level IV, retrospective case series.