A Rare Case of Primary Epithelioid Hemangioma of Bone with WWTR1::FOSB Fusion: A Benign Lesion with the Potential to Mimic Malignancy.

Epithelioid hemangioma of bone is a rare benign, locally aggressive vascular tumor that can be particularly challenging to diagnose given its frequent multifocality, non-specific imaging findings, and wide range of morphologic appearances. Additionally, some epithelioid hemangiomas demonstrate atypical histologic features including increased cellularity, necrosis, and moderate cytologic atypia - characteristics that may raise concern for malignancy. Molecular studies can serve as a powerful, objective tool in the differential diagnosis of diagnostically challenging epithelioid vascular tumors. Importantly, FOS and FOSB gene rearrangements have been identified as the genetic hallmarks of osseous epithelioid hemangioma, present in greater than 70% of cases. FOSB-fusion-positive epithelioid hemangioma, in particular, may display atypical histologic features. While ZFP36 is the typical FOSB fusion partner in epithelioid hemangioma, we herein present a case of epithelioid hemangioma of bone with a rare WWTR1::FOSB fusion. This case demonstrates the diagnostic challenges associated with epithelioid hemangioma, especially in the setting of FOSB gene rearrangements, and the importance of genomic studies in the work up of these vascular tumors.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity.

BACKGROUND: Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. PURPOSE: To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. RESULTS: A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively(P = .6288). The average body mass index was significantly higher in the male group (P < .0001). GLL was more common in women (38.6%) than men (13.6%) (P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) (P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° (P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). CONCLUSION: In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up.

PURPOSE: To describe patient-reported outcomes (PROs) and return to play at any level in amateur soccer players undergoing hip arthroscopy for femoroacetabular impingement syndrome at short- to mid-term follow-up. METHODS: Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between March 2009 and June 2014. Patients who participated in amateur soccer within 1 year prior to surgery and intended to return to their sport after hip arthroscopy for femoroacetabular impingement syndrome were considered for inclusion in our study. Patients were excluded if they had a preoperative Tönnis osteoarthritis grade of 2 or greater, previous ipsilateral hip conditions or hip surgical procedures, or Workers' Compensation status. The patients from the initial group who had preoperative and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in our final group. In addition to PROs, data regarding the patients' return to soccer, surgical complications, and secondary surgical procedures were collected. RESULTS: A total of 41 patients were eligible for inclusion in our study, of whom 34 (82.9%) had a mean follow-up period of 47.4 months. Five patients were not eligible because they did not intend to return to soccer. There were 15 male hips (44.1%) and 19 female hips (55.9%). The mean age at surgery was 20.8 ± 7.4 years. All PROs and the visual analog scale score improved significantly from preoperatively to latest follow-up. Of the 34 patients, 27 (79.4%) returned to soccer. Of the patients who returned to soccer, 19 (70.4%) were competing at the same level or a higher level compared with their highest level within 1 year of surgery. Regardless of competitive level, 21 patients (77.8%) reported that their athletic ability was the same as or higher than it was within 1 year of surgery. CONCLUSIONS: Hip arthroscopy was associated with significant improvements in PROs for amateur soccer players. There was a high level of return to soccer and a high proportion of patients whose competitive level was similar or improved. As such, hip arthroscopy is a good option for soccer players, in the absence of underlying osteoarthritis, presenting with hip pathology. LEVEL OF EVIDENCE: Level IV, case series.

The 'upper deck view' improves visualization during acetabuloplasty without chondro-labral detachment.

The 'upper deck' view is an arthroscopic perspective which visualizes the labral-osseous junction without detachment of the chondro-labral junction. The aim of this study was to evaluate the utility of the 'upper deck' view in preventing incomplete acetabuloplasty. Data were prospectively collected from September 2016 to November 2016 for all hip arthroscopies. We recorded the amount and clock-face of residual pincer-lesion acetabular bone resected using the 'upper deck' view. We noted whether this residual pincer-lesion acetabular bone was visible fluoroscopically, as well as the amount and clock-face of the overall acetabuloplasty. During the study period, 87 hip arthroscopies were performed; 50 met the inclusion criteria. Forty-six (92%) patients had residual pincer-lesion acetabular bone after completion of the acetabuloplasty resected from the bird's eye view. In all such cases the residual pincer-lesion acetabular bone was not visible under fluoroscopy and could only be detected using this specific view. The average maximum resection for the acetabuloplasty was 2.1 ± 0.9 and 1.4 ± 0.5 mm (P = 0.16) for resection of residual pincer-lesion acetabular bone. The 'upper deck' view provides the ability to decrease the risk of incomplete acetabuloplasty, due to the high likelihood (92%) of a residual beak of pincer-lesion acetabular bone when this view is not used during rim trimming.

Five-Year Outcomes and Return to Sport of Runners Undergoing Hip Arthroscopy for Labral Tears With or Without Femoroacetabular Impingement.

BACKGROUND: Recent evidence has demonstrated a high rate of return to running after hip arthroscopy for femoroacetabular impingement at short-term follow-up. The midterm outcomes and rates of continued running of these patients are unknown. PURPOSE: To evaluate midterm rates of return to running and outcomes after hip arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data were prospectively collected for patients who underwent hip preservation surgery between July 2008 and November 2011. Patients were excluded for preoperative Tönnis osteoarthritis grade ≥2, previous ipsilateral hip conditions or hip surgery, or workers' compensation status. All patients who participated in mid- to long-distance running before their surgery and intended on returning after their operation were considered for inclusion. Preoperative and minimum 5-year postoperative measures for the following patient-reported outcome scores (PROs) were necessary for inclusion in the final cohort: the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale (VAS) for pain. All patients were counseled about the risks of continued running after hip arthroscopy. RESULTS: Sixty patients (62 hips) were eligible for inclusion, of which 50 (83.3%; 52 hips) had minimum 5-year follow-up. There were 10 male hips and 42 female hips. Mean ± SD age at surgery was 32.4 ± 12.4 years (range, 14.9-62.4), and mean body mass index was 22.9 ± 3.2 (range, 17.7-30.1). Latest follow-up was recorded at a mean 69.3 ± 8.5 months (range, 60.0-92.1 months). Level of competition included 39 recreational, 7 high school, 4 collegiate, and 2 professional athletes. There were significant improvements in all PROs and VAS scores preoperatively to latest follow-up. Mean modified Harris Hip Score improved from 67.5 to 88.2; mean Non-arthritic Hip Score, from 65.9 to 88.3; mean Hip Outcome Score-Sports Specific Subscale, from 49.5 to 81.0; and mean VAS, from 5.2 to 1.5. At latest follow-up, patient satisfaction was 8.4. Thirty-nine patients (78.0%, 41 hips) had returned to running postoperatively. When stratified by level of competition, 79% (31 of 39) of recreational, 100% (7 of 7) of high school, 50% (2 of 4) of collegiate, and 50% (1 of 2) of professional athletes returned to running. CONCLUSION: Hip arthroscopy for all levels of runners is associated with a significant increase in PROs and a low risk of complications. The rate of return to running is moderately high after hip arthroscopy at midterm follow-up. Hip arthroscopy may be considered for runners presenting with symptoms of femoroacetabular impingement that fail nonoperative treatments. Patients should be educated on the rate of return to running over time and the risks of continued running after hip arthroscopy.

Clinical Outcomes After Hip Arthroscopy for Patients With Rheumatoid Arthritis: A Matched-Pair Control Study With Minimum 2-Year Follow-Up.

PURPOSE: This study analyzed minimum 2-year hip arthroscopy outcomes in rheumatoid arthritis (RA) patients and non-RA control patients. It also examined whether disease-modifying antirheumatic drugs (DMARDs) affected RA patient outcomes. We hypothesized that patients with RA undergoing hip arthroscopy would have lower reported outcome scores. METHODS: Data were prospectively collected on all hip arthroscopies performed from 2009-2013. The indications for surgery were patients with hip pain and with physical examination and imaging studies confirming intra-articular pathology in whom conservative management had failed. The exclusion criteria were previous ipsilateral hip conditions and Tönnis grade greater than 1. Patients with at least 2 years of follow-up and preoperative RA diagnoses were matched (1:2 ratio) to controls without RA (based on age ± 5 years, body mass index ± 5, and lateral center-edge angle [18°-25°, 26°-39°, or >39°]). RA cases were further analyzed based on DMARD use. Patient-reported outcome (PRO) scores were collected preoperatively and postoperatively at 3 months, as well as annually thereafter. The outcomes collected included the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, visual analog scale (VAS) score for pain, satisfaction rating, future procedures, and complications. RESULTS: We matched 26 hips in 20 RA patients to a control group of 52 hips in 52 patients. At a minimum of 2 years of follow-up, RA patients reported no significant improvements except in the Non-Arthritic Hip Score, whereas the control group significantly improved in all PRO and VAS scores. Preoperative PRO and VAS scores between the RA and control groups were not significantly different, but postoperatively, all scores were lower in RA patients at a minimum of 2 years, whether they were taking DMARDs or not. Patients taking DMARDs showed slightly more improvement in PRO and VAS scores. There was a greater trend toward more secondary arthroscopy procedures for RA patients (19.2% vs 7.7%, P = .47), but total hip arthroplasty rates were similar. Complication rates were low in both groups. CONCLUSIONS: Patients undergoing hip arthroscopy who have a diagnosis of RA had less improvement in PRO and VAS scores and were less satisfied than a matched control group of patients without RA at a minimum 2-year follow-up. Patients who were taking DMARDs had slightly better improvement in their PRO and VAS scores than nonmedicated patients. With this early follow-up, we could not show a difference in the rate of conversion to total hip arthroplasty, although RA patients required more revision arthroscopies than controls. Patients with a diagnosis of RA who undergo hip arthroscopy should be counseled about the potential for lesser degrees of postoperative improvement and should have their expectations managed accordingly. LEVEL OF EVIDENCE: Level III, comparative trial.

Diagnostic accuracy of a new clinical test (resisted internal rotation) for detection of gluteus medius tears.

The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination for detection of gluteus medius (GM) tears. A case group of 50 patients undergoing arthroscopy with GM repair was compared with a control group of 50 patients undergoing arthroscopy who had no peritrochanteric symptoms. Both groups were examined clinically, had magnetic resonance imaging studies performed and underwent arthroscopic surgery. Recorded clinical examinations included abnormal gait (Trendelenburg), tenderness to palpation of the greater trochanter, resisted abduction and the test being studied, resisted internal rotation. For all clinical tests, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates were calculated and compared with the arthroscopic and MRI data for the case group, and the MRI data for the control group. The resisted internal rotation test had a sensitivity of 92%, specificity of 85% and diagnostic accuracy of 88% in the detection of GM tears, with a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of Trendelenburg gait, showed inferior rates. Trendelenburg gait had a higher specificity, but much lower sensitivity. The resisted internal rotation test aides in the detection of GM pathology. Due to the good results of the resisted internal rotation test in all the diagnostic parameters, we recommend incorporating it on the physical exam of patients with hip pain.

Hip Arthroscopy in Patients Ages 50 Years or Older: Minimum 5-Year Outcomes, Survivorship, and Risk Factors for Conversion to Total Hip Replacement.

PURPOSE: To report minimum 5-year outcomes and risk factors for conversion to total hip arthroplasty (THA) in patients ≥50 years old undergoing hip arthroscopy to treat labral tears and femoroacetabular impingement (FAI). METHODS: Data were prospectively collected on patients who underwent hip arthroscopy to treat labral tears and FAI between February 2008 and January 2012. The inclusion criteria were ≥50 years old at surgery, arthroscopic treatment for both labral tears and FAI, and preoperative patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and Visual Analog Scale (VAS). The exclusion criteria were Tönnis grade > 1 and previous hip conditions or surgeries. RESULTS: Of 103 eligible cases, 94 hips (91.3%) had minimum 5-year follow-up at a mean of 70.1 months (range, 60.0-95.1 months). All PROs and VASs demonstrated significant improvement at latest follow-up (P = .0001). Mean patient satisfaction was 8.4. All mean scores demonstrated durability from 2 years to latest follow-up, and NAHS (P = .009), HOS-SSS (P = .02), and VAS (P = .04) continued to significantly improve. Fifty-one (54.3%) of cases reached patient acceptable symptomatic state for mHHS, and 49 cases (52.1%) achieved minimal clinically important difference for this outcome measure. Four cases (4.3%) required secondary arthroscopy, and survivorship was 72.3%. Compared with survivors, the subgroup requiring THA demonstrated higher body mass indexes (P = .01), had larger alpha angles (P = .0200) and smaller lateral center-edge angles (P = .0200), and had higher proportions of Tönnis grade 1 (P = .0012), acetabular Outerbridge grade ≥ 2 (P = .0500), and femoral head Outerbridge grade ≥2 (P = .0001). CONCLUSIONS: Hip arthroscopy for the treatment of labral tears and FAI in patients ≥50 years old demonstrates statistically significant PRO improvements at minimum 5-year follow-up. However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. LEVEL OF EVIDENCE: Level IV, case series.

Radiographic Risk Factors and Signs of Abductor Tears in the Hip.

PURPOSE: The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears. METHODS: Between April 2008 and October 2015, patients with intraoperative diagnosis of partial- or full-thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5 years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior-posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses. RESULTS: There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group (n = 58) versus the control group (n = 54; P = .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8 cm for abductor tears vs 14.3 cm for control; P < .001), body weight moment arm (11.1 cm vs 10.9 cm; P < .001), and abductor moment arm (7.8 cm vs 7.6 cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P = .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear. CONCLUSIONS: Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Fresh Femoral Head Osteochondral Allograft Transplantation for Treating Osteochondritis Dissecans of the Femoral Head.

Treatment options for the management of osteochondritis dissecans (OCD) lesions of the femoral head are limited. Although arthroscopic surgery of the hip can treat a variety of intra- and extra-articular pathologies, an OCD lesion located at the superior and medial zone of the femoral head is often difficult to access and cannot be adequately treated arthroscopically. The use of fresh-stored osteochondral allograft allows surgeons to both avoid donor-site morbidity and treat lesions of a larger surface area. We present our technique for surgical treatment of a femoral head OCD lesion with open surgical dislocation of the hip through stepped trochanteric osteotomy and osteochondral transplantation of fresh-stored femoral head allograft.

Return to Play Among Golfers Undergoing Hip Arthroscopy: Short- to Mid-term Follow-up.

There are approximately 25 million amateur golfers in the United States, making up almost 10% of the entire US population. The purpose of this study was to evaluate short-term outcomes and rates of return to sport among recreational golfers who underwent hip arthroscopy for the treatment of labral tears. Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy by one surgeon between August 2008 and February 2015. Exclusion criteria were previous ipsilateral hip surgeries or conditions, preoperative Tönnis osteoarthritis grade greater than 1, or workers' compensation status. Patients who played golf at a recreational level within 1 year prior to their surgery, attempted to return to golf postoperatively, and had preoperative and minimum 2-year postoperative measures for the modified Harris hip score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in the final cohort. Data on return to sport, surgical complications, and secondary surgeries were recorded. Of the 49 patients eligible for inclusion, 40 (81.6%) had minimum 2-year follow-up at a mean of 51.0 months. Mean age at surgery was 49.1 years. All patient-reported outcomes and visual analog scale scores were significantly improved at latest follow-up. Thirty-six (90%) of the 40 patients returned to golf after surgery. Hip arthroscopy leads to significant improvement in patient-reported outcomes and a high rate of return to sport for recreational golfers presenting with labral tears. Therefore, it is a good treatment option for this patient population. [Orthopedics. 2018; 41(4):e545-e549.].

Robot-assisted total hip arthroplasty: Clinical outcomes and complication rate.

BACKGROUND: The purpose of this study was to report minimum 2-year outcomes and complications for robotic-arm-assisted total hip arthroplasty (THA). METHODS: Data were prospectively collected and retrospectively reviewed between June 2011 and April 2014. Inclusion criteria were primary robotic-arm-assisted THAs treating idiopathic osteoarthritis with ≥ 2-year follow-up. Demographics, operating time, complications, 2-year outcome scores and satisfaction, and subsequent surgeries were recorded. RESULTS: There were 181 cases eligible for inclusion, of which 162 (89.5%) had minimum 2-year follow-up. At the latest follow-up, the mean visual analogue scale was 0.7, satisfaction was 9.3, Harris hip score was 91.1 and forgotten joint score was 83.1. Six (3.7%) intraoperative complications and six (3.7%) postoperative complications were reported. No leg length discrepancies (LLDs) or dislocations were reported. CONCLUSIONS: Robotic-arm-assisted THA demonstrates favourable short-term outcomes and does not result in a higher complication rate compared to non-robotic THA as reported by the literature.

Patient-Reported Outcomes of Capsular Repair Versus Capsulotomy in Patients Undergoing Hip Arthroscopy: Minimum 5-Year Follow-up-A Matched Comparison Study.

PURPOSE: To elucidate whether capsular closure during hip arthroscopy affected patient outcomes over midterm follow-up. METHODS: Between 2008 and 2011, data were prospectively collected and retrospectively reviewed on patients who underwent hip arthroscopy. Patients were then matched for age, gender, worker's compensation, body mass index, and acetabular coverage. The inclusion criteria were capsular repair or unrepaired capsulotomy, lateral-center edge angle ≥18°, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery or conditions and Tönnis grade >1. Patient-reported outcome scores (PROs) included modified Harris hip score (mHHS), nonarthritic hip score, hip outcome score sport-specific subscale, and visual analog score for pain, which were collected preoperatively, at 3 months, and annually thereafter. Minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for both groups were analyzed. Patient satisfaction was noted as well as any complications, secondary surgery, and conversion to arthroplasty. RESULTS: Minimum 5-year follow-up was available for 82.5% (287 of 348) hips that met the inclusion criteria and were eligible for matching. Ultimately, 65 patients who underwent capsular repair could be matched in a 1:1 ratio to 65 patients with release. Both groups had significant improvements in all mean PROs. The repair group had significant improvement of mean PROs, visual analog score, and patient satisfaction at both 2-year and minimum 5-year follow-up. The unrepaired group had a significant decrease in mHHS (P = .001) and patient satisfaction (P = .01) between 2- and 5-year follow-up. Despite decreasing mHHS in the repair group between 2- and 5-year follow-up, both groups met the MCID and PASS criteria with no significant difference between them. More patients in the release group required conversion to hip arthroplasty (18.5% vs 10.8%). Subgroup analysis considering various perioperative factors confirmed this trend. Rate of revision arthroscopy was the same in both groups (15.4%). Complication rate was low (4.6% vs 6.4%) in both groups. CONCLUSIONS: Patients undergoing hip arthroscopy and who have minimal or no arthritis have significant short-term improvement, whether the capsule is closed or left unrepaired. However, at midterm follow-up, patients who had unrepaired capsules had deterioration in mHHS as well as a higher rate of conversion to arthroplasty, even when controlling for various perioperative variables. Despite this, patients in both groups met the MCID and PASS criteria. This study suggests that routine capsular closure may lead to more consistently durable outcome in patients undergoing hip arthroscopy, but also that individual patient pathology may dictate capsular management. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Endoscopic Repair of Partial-Thickness Undersurface Tears of the Abductor Tendon: Clinical Outcomes With Minimum 2-Year Follow-up.

PURPOSE: To report the minimum 2-year outcomes of transtendinous repair of partial-thickness undersurface tears of the abductor tendon using patient-reported outcomes (PROs), visual analog scale (VAS) scores, and patient satisfaction scores. METHODS: All patients who underwent endoscopic transtendinous gluteus medius repair between October 2009 and May 2013 at 1 institution were prospectively evaluated. The exclusion criteria consisted of less than 2 years' follow-up, previous hip surgery, inflammatory arthritis, open surgery, full-thickness abductor tear, and Workers' Compensation patients. All patients underwent a documented preoperative physical examination with strength testing (scale of 0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively; at 3 months postoperatively; and at 1, 2, 5, and 10 years after surgery. The PRO scores collected were the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VAS score. Preoperative strength and gait were compared with latest follow-up. RESULTS: There were 25 patients who fit our criteria. Significant improvement in PRO scores were shown for the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VAS score from 54.9 to 76.2, from 50.2 to 80.6, from 30.1 to 67.3, from 51.9 to 82.4, and from 7.1 to 2.7, respectively (P < .001). Before surgery, 11 patients had objective weakness; 7 of these patients moved up at least 1 strength grade by final follow-up. Preoperatively, 14 patients had a Trendelenburg gait; 12 of them had a normal gait at latest follow-up (P < .001). The average patient satisfaction rating was 7.5. There were no revision surgical procedures, and no complications were noted. CONCLUSIONS: Partial-thickness undersurface tears of the abductor can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of the superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to nonoperative treatment because patients showed clinical benefit at greater than 2 years' follow-up that exceeded substantial clinical benefit and the minimal clinically important difference. LEVEL OF EVIDENCE: Level IV, case series.

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.

Hip Arthroscopic Surgery With Labral Preservation and Capsular Plication in Patients With Borderline Hip Dysplasia: Minimum 5-Year Patient-Reported Outcomes.

BACKGROUND: The arthroscopic management of hip dysplasia has been controversial and has historically demonstrated mixed results. Studies on patients with borderline dysplasia, emphasizing the importance of the labrum and capsule as secondary stabilizers, have shown improvement in patient-reported outcomes (PROs). Purpose/Hypothesis: The purpose was to assess whether the results of hip arthroscopic surgery with labral preservation and concurrent capsular plication in patients with borderline hip dysplasia have lasting, positive outcomes at a minimum 5-year follow-up. It was hypothesized that with careful patient selection, outcomes would be favorable. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data were prospectively collected and retrospectively reviewed for patients aged <40 years who underwent hip arthroscopic surgery for intra-articular abnormalities. Inclusion criteria included lateral center-edge angle (LCEA) between 18° and 25°, concurrent capsular plication and labral preservation, and minimum 5-year follow-up. Exclusion criteria were severe dysplasia (LCEA ≤18°), Tönnis grade ≥2, pre-existing childhood hip conditions, or prior hip surgery. PRO scores including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) and the visual analog scale (VAS) score for pain were collected preoperatively, at 3 months, and annually thereafter. Complications and revisions were recorded. RESULTS: Twenty-five hips (24 patients) met the inclusion criteria. Twenty-one hips (19 patients, 84%) were available for follow-up. The mean age at surgery was 22.9 years. The mean preoperative LCEA and Tönnis angle were 21.7° (range, 18° to 24°) and 6.9° (range, -1° to 16°), respectively. The mean follow-up was 68.8 months. The mean mHHS increased from 70.3 to 85.9 ( P < .0001), the mean NAHS from 68.3 to 87.3 ( P < .0001), and the mean HOS-SSS from 52.1 to 70.8 ( P = .0002). The mean VAS score improved from 5.6 to 1.8 ( P < .0001). Four hips (19%) required secondary arthroscopic procedures, all of which resulted in improved PRO scores at latest follow-up. No patient required conversion to total hip arthroplasty. CONCLUSION: While periacetabular osteotomy remains the standard for treating true acetabular dysplasia, hip arthroscopy may provide a safe and durable means of managing intra-articular abnormalities in the setting of borderline acetabular dysplasia at midterm follow-up. These procedures should be performed by surgeons with expertise in advanced arthroscopic techniques, using strict patient selection criteria, with emphasis on labral preservation and capsular plication.

Outcomes of Femoral Head Marrow Stimulation Techniques at Minimum 2-Year Follow-up.

This study compared patients who underwent femoral head microfracture with a control group of patients who did not require microfracture. Patients had more than 2 years of follow-up. The patient groups had similar demographic and radiographic features, including sex, age within 5 years, body mass index within 5 points, equal Tönnis grade, lateral center edge angle within 5°, labral treatment, and capsular closure vs release. Inclusion criteria were a minimum of 2 years of follow-up, Outerbridge grade IV cartilage damage, and femoral head marrow stimulation technique performed at the time of arthroscopy. Exclusion criteria were revision surgery, dysplasia, Tönnis grade of greater than 1, protrusio or profunda acetabuli, Perthes disease of the hip, slipped capital femoral epiphysis, abductor tear, and avascular necrosis of the hip. Patient-reported outcomes included modified Harris hip score, nonarthritic hip score, hip outcome score-activity of daily living subscale, hip outcome score-sports subscale, and visual analog scale score for pain. Fifteen patients had femoral head microfracture with more than 2 years of follow-up. Mean improvements in modified Harris hip score, nonarthritic hip score, hip outcome score-sports subscale, and visual analog scale score were 17.1, 19.4, 30.5, and 2.8, respectively, for the microfracture group compared with 11.8, 18.5, 22.2, and 3.0, respectively, for the control group. Both groups showed statistically significant improvement (P<.05) for all patient-reported outcomes, and no significant difference was found between the 2 patient groups at latest follow-up. Two patients in the microfracture group vs 3 patients in the control required hip arthroplasty. Femoral head microfracture is a technically difficult procedure, but when performed correctly, the results are similar to those of patients who do not require microfracture. Further study of femoral head microfracture is necessary to confirm these encouraging short-term outcomes. [Orthopedics. 2018; 41(1):e70-e76.].

Outcomes of Hip Arthroscopy in Adolescents: A Comparison of Acute Versus Chronic Presentation. Two-Year Minimum Follow-up.

BACKGROUND: Hip arthroscopy has been shown to be effective in managing various hip pathologies, including labral tears in adolescent patients. The purpose of this study was to ascertain whether outcomes of hip arthroscopy in patients under the age of 18 treated for labral tears differ depending on whether the presentation was acute or chronic. We also present the outcomes of the largest prospectively collected study on hip arthroscopy performed for labral tears in adolescents. METHODS: Patient reported outcome scores (PROs) for 194 patients undergoing hip arthroscopy for hip pathology, who were 18 or under at the time of surgery were prospectively collected and retrospectively reviewed. Modified Harris hip score (mHHS), Nonarthritic hip score (NAHS), Hip Outcome score-sport specific scale (HOS-SSS) and Visual Analogue Score (VAS) were the PROs collected. The overall cohort was assessed for outcome and a comparison was made between those patients who presented with acute onset of symptoms versus those who presented with insidious onset. RESULTS: There was significant improvement in all the PROs for the overall cohort, with improvement maintained over an average of 38.5 months. There was no significant difference in outcome scores, between the acute and chronic groups except for change in VAS. Preoperative scores in the acute group were significantly lower, while postoperative scores did not differ. A trend toward more improvement was noted for the acute group. Overall need for revision surgery was 12%, with a higher rate of revision in the acute group. CONCLUSIONS: Hip arthroscopy in adolescent patients being treated for intra-articular pathology is a safe procedure with favorable outcomes at minimum 2-year follow-up, with no significant difference in final outcomes between patients with acute onset of symptoms as opposed to those with more a more chronic presentation. Reoperation rate may be higher in patients with an acute onset. LEVEL OF EVIDENCE: Level II.