Hip Capsulolabral Complex: Anatomy, Disease, MRI Features, and Postoperative Appearance.

The hip is a uniquely constrained joint with critical static stability provided by the labrum, capsule and capsular ligaments, and ligamentum teres. The labrum is a fibrocartilaginous structure along the acetabular rim that encircles most of the femoral head. Labral tears are localized based on the clock-face method, which determines the extent of the tear while providing consistent terminology for reporting. Normal labral variants can mimic labral disease and can be differentiated by assessment of thickness or width, shape, borders, location, and associated abnormalities. The Lage and Czerny classification systems are currently the most well-known arthroscopic and imaging systems, respectively. Femoroacetabular impingement is a risk factor for development of labral tears and is classified according to bone dysmorphisms of the femur ("cam") or acetabulum ("pincer") or combinations of both (mixed). The capsule consists of longitudinal fibers reinforced by ligaments (iliofemoral, pubofemoral, ischiofemoral) and circular fibers. Capsular injuries occur secondary to hip dislocation or iatrogenically after capsulotomy. Capsular repair improves hip stability at the expense of capsular overtightening and inadvertent chondral injury. The ligamentum teres is situated between the acetabular notch and the fovea of the femoral head. Initially considered to be inconsequential, recent studies have recognized its role in hip rotational stability. Existing classification systems of ligamentum teres tears account for injury mechanism, arthroscopic findings, and treatment options. Injuries to the labrum, capsule, and ligamentum teres are implicated in symptoms of hip instability. The authors discuss the labrum, capsule, and ligamentum teres, highlighting their anatomy, pathologic conditions, MRI features, and postoperative appearance. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Editorial Commentary: Indications for Acetabular Labral Debridement Versus Repair and Reconstruction: There is Still a Role for Selective Labral Debridement.

Not all acetabular labral tears, tissue quality, and size are the same. There is still a role for selective debridement of the acetabular labrum when stable, functional labral tissue remains. An unstable labrum that appears very different than the rest of the labrum is an easy target for repair. Tears requiring resection require graft augmentation or reconstruction.

Tissue Regrowth and Its Vascularization Through Bone Marrow Stimulation: Microfracture at the Acetabular Rim for Irreparable Labral Tear in a Porcine Model.

BACKGROUND: The treatment of irreparable acetabular labral tear remains a great challenge. Whether fibrocartilage-like tissue can regrow with sufficient volume to fill the labral defect area through bone marrow stimulation remains unknown. PURPOSE: To characterize the healing process and vascularization course of the regrown tissue after microfracture at the acetabular rim for irreparable labral tears in a porcine model. STUDY DESIGN: Descriptive laboratory study. METHODS: Twelve pigs randomly underwent unilateral microfracture at the acetabular rim after the resection of a 10 mm-long section of labrum from 10 to 1 o'clock. Pigs were randomly sacrificed at 6 and 12 weeks postoperatively. The regrown tissues were harvested for macroscopic evaluation and histologic assessment. The regrown tissue was zoned into 2 halves to observe the vascular distribution: the capsular half (zone I) and the articular half (zone II). Each zone was divided into 2 parts: the peripheral part (IA and IIA) and the part attached to the acetabulum (IB and IIB). RESULTS: At 6 weeks, all regrown tissue was hypotrophic with <50% filling of the labral defect. Fibrochondrocytes were concentrated at the interface between the acetabulum and the regrown tissue. The vascularization was equal among each part within the regrown tissue. As compared with regrown tissue at 12 weeks, proteoglycan and collagen type 1 and 2 were more evident within the regrown tissue at 6 weeks. At 12 weeks, tissue disintegration occurred in all regrown tissue with <25% filling of the labral defect area. The vascular structure could barely be observed, with few fibrochondrocytes found at the area adjacent to the acetabulum. CONCLUSION: Fibrocartilage-like tissue did regrow with well-distributed vascular ingrowth of each part of the regrown tissue through bone marrow stimulation at the early stage. However, insufficient volume of the regrown tissue led to loss of the hip suction seal and subsequent tissue disintegration. CLINICAL RELEVANCE: Microfracture at the rim of the acetabulum alone could not restore the morphology and function of the acetabular labrum. Nonetheless, microfracture at the acetabular rim might be a viable adjunct to labral reconstruction, as the well-distributed vascularization through bone marrow stimulation might overcome the obstacle of poor vascular ingrowth of the articular half of the autograft.

Hip Magnetic Resonance Arthrography Using Normal Saline Is Less Accurate Than Using a Gadolinium-Based Contrast Agent.

PURPOSE: To evaluate the diagnostic performance of hip magnetic resonance (MR) arthrography with a gadolinium-based contrast agent (GBCA) or normal saline (NS) for intra-articular pathologies. METHODS: This retrospective study was approved by the institutional review board of our hospital, and the requirement for informed consent was waived. The study included 37 consecutive patients (38 hips; 21 right hips; 24 males; mean age, 33 years) who underwent GBCA-hip MR arthrography from July 2011 to January 2020 and 30 consecutive patients (30 hips; 20 right hips; 21 males; mean age, 40 years) who underwent NS-hip MR arthrography from January 2018 to June 2020. All images were evaluated twice independently by two radiologists blinded to the arthroscopic findings for the presence of labral tears, cartilage abnormalities, or ligamentum teres tears. Intrareader and interreader reliabilities were determined by kappa values (k) using the chi-squared test, and diagnostic performance was evaluated based on the arthroscopic findings. A P value less than .05 was considered to indicate statistical significance. RESULTS: Intra-reader reliability in the detection of intra-articular pathologies ranged from moderate to almost perfect (k = 0.510-0.840) and inter-reader reliability ranged from moderate to substantial (k = 0.441-0.695) for GBCA- and NS-hip MR arthrography. The diagnostic accuracy of GBCA- and NS-hip MR arthrography was as follows: 81.6-92.1% and 66.7-73.3% for labral tears, respectively; 68.4-86.8% and 63.3-70.0% for cartilage abnormality, respectively; and 68.4-76.3% and 50.0-56.7% for ligamentum teres tears, respectively. CONCLUSION: NS-hip MR arthrography may be less accurate than GBCA-hip MR arthrography. LEVEL OF EVIDENCE: Level II of development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding).

Clinical Outcomes for Open Hip Abductor Repair Using Tenodesis and Bone Trough Repair Techniques.

BACKGROUND: Hip abductor complex tears remain an injury without a clear consensus on management. Surgical treatment has been recommended after unsuccessful nonoperative management. This study evaluates both tenodesis and bone trough techniques, with treatment choices guided by previously described tear classification. METHODS: This is a retrospective cohort study of 45 hips in 44 patients who underwent surgical treatment for symptomatic, chronic hip abductor tear unresponsive to nonoperative treatment. Demographics and preoperative and postoperative values (including visual analog scale pain scores, gait assessment, and muscle strength) were evaluated. Type I tears were treated using tendon tenodesis. Type II tears were treated through a bone trough repair. RESULTS: Forty-five hips (44 patients) were operated on with a minimum of 6-month follow-up. There were 27 type I and 18 type II tears. Eighty-seven percent of patients were female. Twenty-eight percent of type II patients (5/18) had a preexisting arthroplasty in place. Significant improvements in pain (P < .001), gait (P < .001), and muscle strength (P < .001) were achieved in both the tear types. Type I repairs showed superior results to type II repairs. However, both showed significant improvements. Postoperative magnetic resonance imaging at 6 months showed healed tenodesis in 81% (17/21) of type I tears and 50% (5/10) of type II tears. CONCLUSION: Our study shows improvement in pain and function after surgical repair of hip abductor tendon injuries in both simple and complex tears. This improvement is seen even during ongoing surgical site healing. Magnetic resonance imaging findings may remain abnormal for more than 1 year after surgery and do not clearly denote repair failure.

Can a Hip Brace Improve Short-Term Hip-Related Quality of Life for People With Femoroacetabular Impingement and Acetabular Labral Tears: An Exploratory Randomized Trial.

OBJECTIVES: To examine whether a hip brace can improve hip health quality-of-life (QoL) and is well-tolerated in people with femoroacetabular impingement syndrome (FAIS) or symptomatic labral tears after 6 weeks of wear. DESIGN: Parallel, two-arm, exploratory randomized trial. SETTING: Hospital and private clinics of orthopaedic surgeons. PARTICIPANTS: Individuals >18 years with FAIS or labral tears. INTERVENTIONS: Usual conservative care versus usual conservative care plus a hip brace. MAIN OUTCOMES: Patient-reported outcomes were assessed with the International Hip Outcome Tool (iHOT-33), and Copenhagen Hip and Groin Outcome Scores (HAGOS). Brace acceptability was measured using the Quebec User Evaluation of Satisfaction with Assistive Technology survey. Independent t-tests assessed between-group differences. RESULTS: Thirty-eight participants were recruited, 19 each group, 60% women, mean age 39.3 ± 11.8 years, body mass index 25.3 ± 4.4 kg/m2, iHOT-33 36.6 ± 24.8. Three participants dropped out (one usual care, 2 braced). The mean between-group difference for iHOT-33 was 19.4 (95% confidence interval [CI] 1.68-37.06, P = 0.03) favoring the brace. There were improvements in most HAGOS subscale scores favoring the brace. Issues with brace tolerability for some participants were perceived comfort and effectiveness. Three brace-related adverse events were reported. CONCLUSION: Between-group differences favored the braced group for hip health QoL, pain, symptoms, and function. Although these were promising results, the CIs for the estimates were wide, the small sample size likely a contributing factor. Our results suggest that further investigation of the brace is warranted, we calculated sample sizes and made recommendations for the design of a future trial.

Portal Setup: the Key Point in the Learning Curve for Hip Arthroscopy Technique.

OBJECTIVE: To analyze the learning curve experience of hip arthroscopy based on patient demographics, surgical time, portal setup time, and postoperative complications and to find the key point in the learning curve. METHODS: From May 2016 to February 2019, a prospective study on the learning curve experience of hip arthroscopy was performed in our hospital. We evaluated the first 50 consecutive hip arthroscopy procedures performed by a single surgeon. There were nine females and 41 males with a mean age of 30.8 years. We divide the patients into early group and late group according to the date of their operation, with each group including 25 patients. Data on patient demographics, types of procedure, surgical time, portal setup time, and postoperative complications were collected. Functional scores were assessed with the modified Harris Hip Score (mHHS). RESULTS: Patients were followed up for 16.4 months on average (range, 13-27 months). The early group of patients had a mean age of 35.2 years and the late group a mean age of 26.5 years. The most common procedures performed for the early group were debridement (17 patients, 68%), and in the late group, most patients underwent labral repair (18 patients, 72%). Mean total surgical time was 168 min for the early group and 143 min for the late group, and there was no statistically significant difference between two groups. The portal setup time in the early group and late group was 40.2 ± 12.4 min and 18.5 ± 6.2 min, respectively (P < 0.001), and the portal setup time was significantly longer in the early group. Further analysis of the learning curve of portal setup showed that the average portal setup time was not statistically significant changed after 30 cases. There were six complications including iatrogenic cartilage injury and iatrogenic labrum injury in the early group and five complications including perineal crush injury and nerve stretch injury in the late group. The functional score of patients in the late group was significantly higher than that in the early group during follow-up. CONCLUSION: The steep learning curve of hip arthroscopy is mainly caused by the challenge of portal setup and portalrelated complications were more common in the early group than in the late group. Surgical time is not an effective indicator for evaluating progress on the learning curve of hip arthroscopy.

Microfracture of Acetabular Rim After Segmental Labral Resection to Restore the Morphology and Function of Labrum: A Retrospective Study of More than 2 Years Follow-up.

OBJECTIVE: To report on the clinical outcome of patients undergoing combined arthroscopic treatment of labral resection and microfracture at the rim of acetabulum at a minimum 2-year follow-up. METHODS: The retrospective study included 38 patients undergoing hip arthroscopy for irreparable labral injury from 24 February 2014 to 26 February 2018. Thirteen patients were excluded owing to patient refusal of participation and concomitant diseases like synovial chondromatosis and dysplasia hip. The study group consisted of patients undergoing combined arthroscopic labral resection and microfracture at the rim of acetabulum (MICRO Group: 20 patients), arthroscopic labral resection alone (RESEC Group: five patients). Postoperative three-dimensional (3D) double-echo steady-state (DESS) sequence with radial imaging at 3 Tesla were obtained and fluoroscopic image of the involved hip under distraction were used to observe the restoration of vacuum effect. Patient-reported outcome scores (PROs) including the Harris Hip Score (HHS), Visual Analogue Score (VAS), Hip Outcome Score Activities of Daily Living Subscale (HOS-ADL), Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were collected and compared between two groups. RESULTS: All patients were followed up for at least 6 months. The follow-up time of RESEC group is longer than MICRO group (46.6 months vs 23.9 months, P < 0.05). The 3D DESS imaging demonstrated intermediate signal intensity at the relative area where the labrum resected followed by microfracture at the acetabular rim in MICRO group. Meanwhile, regrowth of labrum-like tissue was not observed in MRI imaging of the RESEC group. Furthermore, vacuum effect was more apparent in MICRO group compared with RESEC group. All PROs in both groups showed a statistically significant improvement at follow-up compared with preoperative levels. RESEC group: HHS (73.0 vs 93.8, P < 0.05); HOS-ADL (51.5 vs 89.1, P < 0.05); HOS-SSS (47.8 vs 88.3, P < 0.05); VAS (6.4 vs 2.0, P < 0.05). MICRO group: HHS (70.5 vs 91.5, P < 0.05); HOS-ADL (52.4 vs 87.0, P < 0.05); HOS-SSS (48.1 vs 86.5, P < 0.05); VAS (6.3 vs 1.6, P < 0.05). One patient of MICRO group had transient neurapraxias of the pudendal nerve that resolved completely by 3 months. There showed no statistically significant difference between groups regarding the preoperative and postoperative PROs. CONCLUSION: Compared to labral resection, combined arthroscopic labral resection and microfracture at the rim of acetabulum is able to fulfill the labral defect area with the potential to restore the seal effect of labrum as an effective and safe option for irreparable segmental labral tears.

Capsular Healing in Interportal and Periportal Capsulotomy Methods of Hip Arthroscopy.

OBJECTIVE: To evaluate the midterm outcomes and the capsular healing in patients who had interportal capsulotomy versus periportal capsulotomy of hip arthroscopy. METHODS: Retrospectively reviewed 33 patients with labral tear received hip arthroscopy, with an average age of 41 (27-67) years, including 13 cases of Cam deformity and three cases of Pincer deformity. All patients had positive sign of flexion adduction internal rotation or flexion abduction external rotation. With MRI and radiographic (CT, X plain) imageological examination. MRI showed that all patients had labral tear. Radiographic finding (CT, X plain) showed the pathological changes of acetabular and femoral neck osteophyte. One group with 23 patients were treated with periportal capsulotomy. Another group with 10 patients were treated with interportal capsulotomy. All patients did not close the capsule. Clinical outcomes were measured with the Hip Outcome Score Activities of Daily Living (HOS-ADL) and the modified Harris Hip Score (mHHS), patient satisfaction measured with visual analogue scale (VAS). The healing of the capsule was evaluated by MRI. MRI showed continuous capsular indicated healing, discontinuous capsular indicated unhealing. Postoperatively 6 months, mHHS and HOS-ADL were obtained. Randomized controlled trials were used in this study for analysis. RESULTS: All patients were followed up with average time of 9.3 months(3-29 months). The postoperative symptoms were obviously relieved, the VAS decreased from (4.9 ± 0.6) to (1.2 ± 0.2) after 3 months postoperative. Follow up 6 months post-operation, patients in the interportal group, the mHHS and HOS-ADL scores improvement were respectively 69.4 ± 9.3 & 70 ± 8.8 pre-operation, and 92.5 ± 5.0 & 86.6 ± 5.4 post-operation (P < 0.05); Patients in the periportal group, the mHHS and HOS-ADL scores improvement were respectively 69.9 ± 15.8, 68.1 ± 15.0 pre-operation, and 90.1 ± 9.3 & 86.7 ± 7.9 post-operation (P < 0.05).The differences were statistically significant. Six months after operation, MRI showed that 23 patients with periportal capsulotomy, the capsule have healed, without other complications. Three of the ten patients with interportal capsulotomy were healed and seven were not. CONCLUSION: Interportal and periportal capsulotomy had good outcomes. The technique of periportal capsulotomy had little damage to the joint capsule. Although the capsule did not close, the capsule healed well in postoperative follow-up. The nonunion rate of the joint capsule was high in the interportal capsulotomy without close the capsule.

The Application of Arthroscopic Techniques in the Diagnosis and Treatment of Hip-Related Conditions in China.

The hip joint is the largest weight-bearing joint in the body and is surrounded by dense capsules and thick muscles. Hip arthroscopic techniques are suitable for the treatment of hip-related conditions. These minimally invasive techniques have rapidly developed in China since 2007. Moreover, they have been used in the treatment of gluteal muscle contracture, snapping hip syndrome, femoral acetabular impingement, acetabular labral injury, hip labral calcification, synovial chondroma, osteoid osteoma, synovitis, osteonecrosis of the femoral head, and developmental dysplasia of the hip. This technique has showed its advantage in the total debridement of lesions, precision treatment, and less trauma. However, we lack understanding of the overall development of arthroscopic techniques in China. This review illustrates the recent development of hip arthroscopic techniques in China and related research progress.

Defining the Maximum Outcome Improvement of the Modified Harris Hip Score, the Nonarthritic Hip Score, the Visual Analog Scale For Pain, and the International Hip Outcome Tool-12 in the Arthroscopic Management for Femoroacetabular Impingement Syndrome and Labral Tear.

PURPOSE: To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following hip arthroscopy for femoroacetabular impingement syndrome and labral tear, and to identify preoperative predictors of reaching the mHHS, NAHS, VAS, and the iHOT-12 thresholds for achieving the MOI. METHODS: An anchor question was provided to patients who underwent hip arthroscopy between April 2008 and April 2019. Patients were included if they answered the anchor question and had minimum 1-year follow-up. Patients were excluded if they had a previous ipsilateral hip surgery, a Tönnis grade >1, hip dysplasia, or a previous hip condition. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. Multivariate logistic regression was used to determine predictors of achieving the MOI threshold. RESULTS: In total, 407 hips (375 patients) were included, with 279 female patients (68.6%). The average age, body mass index, and follow-up time were 38.8 ± 13.7 years, 26.6 ± 5.8, and 51.8 ± 33.2 months, respectively. Satisfaction with the current state of their hip was reported in 77.9% (317) of the cases. It was determined that 54.8%, 52.5%, 55.5%, and 55.8% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, VAS, and iHOT-12, respectively. Predictors of achieving MOI were not identified. CONCLUSIONS: Following hip arthroscopy in the context of femoroacetabular impingement syndrome and labral tear, the thresholds for achieving the MOI for the mHHS, NAHS, VAS for pain, and iHOT-12 were 54.8%, 52.5%, 55.5%, and 55.8% respectively. No preoperative predictors of achieving the MOI were identified. LEVEL OF EVIDENCE: IV, case-series.

Capsular Management Techniques and Hip Arthroscopy.

There has been an increased emphasis on capsular management during hip arthroscopy in the literature in recent years. The capsule plays a significant role in the hip joint stability and studies have demonstrated that capsular closure can restore the biomechanics of the hip back to the native state. Capsular management also affects functional outcomes with capsular repair resulting in better clinical outcomes in some studies. Management of the capsule has evolved in recent years with more surgeons performing routine capsular closure. Management techniques and degree of capsular closure, however, can be quite variable between surgeons. This review will discuss hip capsular anatomy, the importance of the capsule in hip biomechanics, management of the capsule during arthroscopy, and functional outcomes as it relates to the various capsular closure techniques versus leaving the capsulotomy unrepaired.

Determining Reliability of Arthroscopic Classifications for Hip Labral Tears.

OBJECTIVE: Evaluate interobserver and intraobserver reliability of hip arthroscopic classifications for labral tears. DESIGN: Retrospective diagnostic study of nonconsecutive patients. SETTING: Institutional study. PATIENTS: From a database of 278 hip arthroscopy videos for treatment of femoroacetabular impingement, 70 videos were chosen by simple random sampling. Exclusion criteria included presence of radiological arthrosis (Tonnis > 2), previous hip surgery, inadequate lesion palpation, poor image quality, and refusal to participate in the study. The final sample included 60 videos. INTERVENTIONS: Four hip surgeons evaluated the videos twice at 1-month intervals and classified the lesions according to Lage, Seldes, and Beck classifications for hip labral tears. MAIN OUTCOME MEASURES: Interobserver and intraobserver reliability with the percent of agreement and weighted Cohen kappa values. RESULTS: Patients had a mean age of 33 years (SD, 7; range, 18-47 years), and 32 (53%) were men. Femoroacetabular impingement types included combined (CAM and pincer) in 31 (52%), CAM in 27 (45%), and pincer in 2 (3%). For interobserver reliability, the average weighted kappa values were 0.68, 0.65, and 0.78 for the Lage, Seldes, and Beck classifications, respectively. For intraobserver reliability, the mean weighted kappa values were 0.87, 0.64, and 0.93 for the Lage, Seldes, and Beck classifications, respectively. CONCLUSIONS: Beck classification had the highest average values for interobserver and intraobserver agreements. Lage, Seldes, and Beck scores for acetabular labrum tears showed substantial interobserver agreement. In the intraobserver evaluation, the Seldes system presented substantial agreement, whereas Lage and Beck classifications were considered excellent agreement.

Differences in Clinical Presentations and Surgical Outcomes of Gluteus Medius Tears Between Men and Women.

BACKGROUND: Gluteus medius (GM) tears often occur in women aged >50 years. There is a paucity of literature comparing sex-based differences in those undergoing GM repair. PURPOSE: To report differences between women and men in clinical presentations and patient-reported outcome (PRO) scores at a minimum 2-year follow-up after undergoing GM repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed. All included patients had postoperative scores for the following PROs: modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12. Men were propensity score matched 1:3 to women according to concomitant arthroscopic procedures and follow-up time. Clinical effectiveness was determined through a uniquely calculated minimal clinically important difference (MCID) for the mHHS and NAHS specific to this study population. RESULTS: Thirteen men were successfully propensity score matched to 39 women. Women and men were 55.87 ± 11.0 and 62.38 ± 11.63 years old (mean ± SD), respectively (P = .02). Men were at increased risk for associated lumbar pathology as compared with women (relative risk, 3.32; P = .02). Women showed significant improvement from preoperative to minimum 2-year follow-up for the mHHS (59.32 ± 15.36 to 83.81 ± 16.82; P < .01), NAHS (56.23 ± 15.61 to 83.78 ± 17.66; P < .01), HOS-SSS (33.35 ± 20.28 to 67.88 ± 32.35; P < .01), and visual analog scale (5.48 ± 2.00 to 1.93 ± 2.29; P < .01). Similarly, men showed significant improvement for the mHHS (63.50 ± 16.41 to 84.77 ± 13.91; P < .01), NAHS (61.52 ± 9.87 to 84.42 ± 14.87; P < .01), HOS-SSS (33.97 ± 21.20 to 63.62 ± 26.20; P < .01), and visual analog scale (4.93 ± 2.69 to 1.86 ± 2.10; P < .01). The MCIDs for the mHHS and NAHS were calculated to be 7.89 and 7.24. Of the women, 28 (72%) and 34 (87%) met the MCID for the mHHS and NAHS. Eleven (85%) men met the MCID for the mHHS and NAHS. CONCLUSION: These results suggest that women and men can both benefit after GM repair. Men were older and had increased risk for associated lumbar pathology than women at the time of surgery. Men and women both experienced significant improvements in PROs and compared favorably in terms of clinical effectiveness at a minimum 2-year follow-up.

Hip Arthroscopy in Patients Aged 40 Years and Older: Greater Success With Labral Reconstruction Compared With Labral Repair.

PURPOSE: To assess the outcomes of complete, primary, arthroscopic hip labral reconstruction among patients aged 40 years and older compared with those who underwent primary labral repair and compared with patients aged 30 to 39 years who underwent complete, primary labral reconstruction. METHODS: We recruited all patients who underwent arthroscopic labral reconstruction between March 2010 and June 2015 and were aged 30 to 65 years or who underwent arthroscopic labral repair between June 2009 and June 2015 and were aged 40 to 65 years. The modified Harris Hip Score (mHHS), Lower Extremity Function Score, and visual analog scale score for average pain were collected preoperatively and at minimum 2-year follow-up. Failure was defined as the need for revision ipsilateral hip surgery. The rate of conversion to total hip arthroplasty (a subset of failure) was assessed separately. RESULTS: A total of 363 hips in 343 patients met the inclusion criteria. Follow-up was available for 312 hips (86.0%), and the average time to follow-up was 4.2 years (range, 2.0-8.5 years). After adjustment for differences in follow-up time between groups, failure was 3.29 times more likely for hips in the repair group aged 40 years and older than for hips in the reconstruction group aged 40 years and older (relative rate, 3.29; 95% confidence interval, 1.25-8.69; P = .02), and there was no difference in the failure rate for hips in the reconstruction group aged 40 years and older compared with hips in the reconstruction group aged 30 to 39 years (relative rate, 0.58; 95% confidence interval, 0.18-1.89; P = .37). The rate of conversion to total hip arthroplasty was not meaningfully different between the 3 groups. Among hips for which treatment did not fail, average improvement in the mHHS measured 35 points and both labral reconstruction groups saw a greater mHHS improvement than the labral repair group of patients aged 40 years and older (P = .01 and P < .01). CONCLUSIONS: Labral reconstruction led to a lower failure rate, greater average improvement in the mHHS, and equivalent postoperative patient-reported outcome scores compared with labral repair among patients aged 40 years and older in this study population, and the outcomes of labral reconstruction were similar between patients aged 40 years and older and those aged 30 to 39 years. Complete labral reconstruction may be particularly advantageous in patients aged 40 years and older. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Opioid Use After Common Sports Medicine Procedures: A Systematic Review.

CONTEXT: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION: Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS: A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION: Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Outcomes After Arthroscopic Repair in Patients With Tears of Hypertrophic Versus Morphologically Normal Acetabular Labra.

BACKGROUND: Recently, a hypertrophic labrum has been reported in the absence of hip dysplasia, which can possibly contribute to an acetabular labral tear. PURPOSE: To compare the clinical outcomes and complications, including the incidence of iatrogenic acetabular labrum and cartilage injury, in patients with tears of hypertrophic versus morphologically normal acetabular labra over a minimum follow-up period of 2 years and to assess the morphologic changes at follow-up computed tomography arthrography in the 2 groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between January 2010 and December 2016, 20 patients (22 hips) with a hypertrophic labrum underwent arthroscopic hip surgery. A total of 22 patients (22 hips) without a hypertrophic labrum were assigned to the control group based on matching criteria, including age, sex, body mass index, labral tear, and labral repair. Clinical outcomes were assessed with the visual analog scale score, UCLA activity scale score (University of California, Los Angeles), and modified Harris Hip Score. Radiologic outcomes were assessed through serial radiography. Patients were followed for at least 2 years. RESULTS: The mean age at surgery was 42 years. The most common cause of arthroscopic surgery in the study group was an isolated acetabular labral tear without any bony structural abnormalities (68.2%, 15 of 22 hips). All improvements in both groups were statistically significant at the last postoperative follow-up (P < .001). Although the radiologic and clinical outcomes were not significantly different between the groups, the complication rates, including iatrogenic labral perforations and cartilage injury, were significantly higher in patients with hypertrophic acetabular labral tears (9 vs 3, P = .042). The patient-reported satisfaction scores at the last postoperative follow-up were 8.4 and 7.9 in the study and control groups, respectively (P = .351). CONCLUSION: The high rates of patient-reported satisfaction and the clinical outcomes after arthroscopic repair in both groups are encouraging. Arthroscopic treatment in patients with hypertrophic acetabular labral tears should be carefully performed to prevent iatrogenic injury during the surgery, and isolated hypertrophic labral tears can have good results after repair.

Hip Fusion Takedown with Subsequent Hip and Knee Arthroplasty. Case Study.

There is no uniform standard of treatment for patients with hip fusion and accompanying symptomatic osteoarthritis of the ipsilateral knee. Fusion takedown is associated with an increased risk of complications, and often the results are not satisfactory for patients. Therefore, each case should be considered individually. We present a case report regarding a 70-year-old patient with hip fusion as a result of tuberculosis at a young age who underwent hip fusion takedown with total hip arthroplasty followed by total knee arthroplasty as a second step. The 70-year-old patient with end-stage renal failure and hip fusion as a complication of tuberculosis in adolescence complained of increasing pain in the left knee. After taking into account his comorbidities and discussing with the patient possible treatment options and their limitations, he was qualified for 2-step surgery involving hip replacement and total knee replacement spaced 5 months apart. At the last follow-up visit the patient did not report any pain, with a hip joint mobility of 110° flexion and -10° extension and internal and external rotation of 35° each. The range of knee flexion was 110°. On a VAS scale, the patient's quality of life was rated 85/100 vs. 30/100 preoperatively. In patients with hip fusion, satisfactory results can be achieved with 2-stage hip and knee replacement, even despite significant co-morbidities. However, this requires careful intraoperative planning and management of patient expectations.

Traumatic brain injury enhances the formation of heterotopic ossification around the hip: an animal model study.

INTRODUCTION: The incidence of heterotopic ossification (HO) is at its highest when trauma of the hip or pelvis concurs with traumatic brain injury (TBI). The pathogenic mechanisms underlying the neurogenic enhancement of the formation of HO remain, however, poorly understood. Hence, the goal of the present study was to develop a novel small animal model that combines hip and brain trauma that can prove the enhancement of HO around the hip after TBI. MATERIALS AND METHODS: Forty male Wistar rats were divided into four groups, to undergo hip surgery alone (group 1), hip surgery + moderate TBI (group 2), hip surgery + severe TBI (group 3) and only severe TBI (group 4). The femoral canal was reamed up to 2 mm and a muscle lesion was made to simulate hip surgery. An established controlled cortical impact model was used to create a TBI. Twelve weeks after surgery, the hip with the proximal half of the femur and the pelvic bone was removed and subjected to micro-computed tomography (µCT) analysis. A quantitative analysis using a modified Brooker score as well as a quantitative analysis using a bone-to-tissue ratio was used. RESULTS: No HO could be found in all the ten animals that did not undergo hip surgery (group 4). In the animals that did undergo surgery to the hip, no HO was found in only one animal (group 1). All the other animals developed HO. In this study, significantly more HO was found in animals that underwent an additional severe TBI. CONCLUSION: The newly developed rat model, with a combined hip and brain trauma, showed an enhancement of the HO formation around the hip after severe TBI.

Performance and Return to Sport After Hip Arthroscopy in the National Basketball Association.

PURPOSE: To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players. METHODS: NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ2 was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008. RESULTS: Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570). CONCLUSIONS: The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls. LEVEL OF EVIDENCE: Level III case-control study.