Editorial Commentary: Primary Treatment of Hip Labral, Osseous, Chondral, Capsular, and Extra-Articular Pathology Is Essential: Outcomes Following Revision Are Less Predictable.

Appropriate labral management is one of many procedures during hip arthroscopy that affects postoperative outcomes and revision rates. Both primary labral repair and reconstruction have been shown to have superior clinical and functional outcomes compared with labral debridement when treating unstable labral tears. Arthroscopic labral reconstruction is one of the most powerful techniques in the arsenal of complex hip-preservation surgeons, and although often reserved for the revision setting, when the native labrum is irreparable, a primary reconstruction may be indicated when the only alternatives are selective labral debridement or a suboptimal repair. Labral reconstruction, either in primary or revision procedures, is indicated when the existing labrum is deemed irreparable based on an intraoperative evaluation. Current indications for primary labral reconstruction, either in the primary or revision setting, include a calcified labrum, an irreparable mixed Seldes type 1 and 2 tear, or a hypoplastic labrum with less than 3 mm of viable tissue. Primary hip arthroscopy has been shown to have superior outcomes compared with revision hip arthroscopy, whether with labral repair or reconstruction. Finally, appropriate labral management is necessary but not always sufficient. Hip arthroscopy requires management of osseous deformities, with care taken to avoid under- and over-resection during both femoroplasty and acetabuloplasty; management of chondral injury; and management of the hip capsule with repair or plication. Consideration also must be given to potential extra-articular pain generators, such as abductor insufficiency, ischiofemoral impingement, lumbar spine disease, as well as deformities requiring open surgical correction such as acetabular dysplasia or pathologic femoral version. The primary goal is getting it right the first time.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review.

PURPOSE: To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures. METHODS: Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.). RESULTS: Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS. CONCLUSIONS: The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review.

PURPOSE: To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up. METHODS: The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM. RESULTS: Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting. CONCLUSIONS: Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations. LEVEL OF EVIDENCE: IV.

Editorial Commentary: Bilateral Femoroacetabular Impingement Syndrome: What We Know Now and Where Do We Go From Here?

Patients with bilateral femoroacetabular impingement syndrome treated with either staged or simultaneous hip arthroscopy have similar postoperative outcomes compared with patients undergoing unilateral procedures. A longer duration between surgeries is associated with inferior outcomes; however, the reasons underlying this trend are unclear. Identifying prognostic variables that are associated with contralateral symptom onset and disease progression are important goals for future investigation.

Diversity among academic orthopedic shoulder and elbow surgery faculty in the United States.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis of diversity among academic shoulder and elbow surgeons in the United States. METHODS: US shoulder and elbow surgeons who participated in shoulder and elbow fellowship and/or orthopedic surgery resident education as of November 2018 were included. Demographic data (age, gender, race), practice setting, years in practice, academic rank, and leadership roles were collected through publicly available databases and professional profiles. Descriptive statistics were performed and findings were compared between different racial and gender groups. Statistical significance was set at P <.05. RESULTS: A total of 186 orthopedic shoulder and elbow surgeons were identified as participating in shoulder and elbow fellowship and/or orthopedic surgery residency education. Overall, 83.9% were white, 14.5% were Asian, 1.1% were Hispanic, 0.5% were an other race, and 0% were African American. In addition, 94.6% of surgeons were male, whereas 5.4% were female. Further, 64.5% of all surgeons had been in practice for >10 years, and 39.2% worked in an urban setting. Less than half (40.3%) of the surgeons practicing primarily at academic institutions held a professor rank. White surgeons had a significantly greater time in practice vs. nonwhite surgeons (mean 18.8 vs. 12.6 years, P < .01) and were more likely to hold a professor rank (44.0% vs. 21.7%, P = .04). CONCLUSION: Racial and gender diversity among US shoulder and elbow surgeons who participate in fellowship and residency education is lacking. Hispanic, African American, and female surgeons are underrepresented. Efforts should be made to identify the reasons for these deficiencies and address them to further advance the field of orthopedic shoulder and elbow surgery.

Clinically Meaningful Improvements After Hip Arthroscopy for Femoroacetabular Impingement in Adolescent and Young Adult Patients Regardless of Gender.

BACKGROUND: The objective of this study was to determine if adolescent and young adult patients undergoing hip arthroscopy for symptomatic femoroacetabular impingement (FAI) experience clinically meaningful improvements in functional outcome scores. METHODS: A consecutive series of patients under age 18 who underwent primary hip arthroscopy for symptomatic FAI was identified using our institution's hip registry. Demographics, preoperative radiographic measurements, and preoperative and postoperative patient-reported outcome scores [Hip Outcome Score (HOS), Activity of Daily Living (ADL), and Sports-Specific Subscale (SS), and modified Harris Hip Score (MHHS)] were collected. Percentage of patients achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) were determined using published cutoffs for HOS and MHHS in FAI patients. RESULTS: Forty-three patients met study inclusion criteria, and 37 patients (86%) were available at a minimum follow-up of 2 years. Mean age was 17.0±1.4 years, 70% were female, and 8.1% had an open proximal femoral physis. All competitive high school and college athletes were able to return to sport. Patients experienced significant improvements following hip arthroscopy in HOS-ADL, HOS-SS, and MHHS scores (all P<0.0001). MCID was achieved in 81% of patients (27/34) for HOS-ADL, 97% (33/34) for HOS-SS, and 84% (27/32) for MHHS. PASS was achieved for 76% of patients (26/34) for HOS-ADL, 79% (27/34) for HOS-SS, and 81% (26/32) for MHHS. Lower body mass index but not age or sex was correlated with a greater improvement in MHHS scores (r=0.39; P=0.03). There were 2 minor complications and no revision surgery. CONCLUSIONS: Adolescent and young adult patients experienced statistically significant improved functional outcomes 2 years after hip arthroscopy for FAI. In addition, these outcomes can be achieved with a low complication rate and a high return to preoperative activity. Approximately 80% of patients achieved clinically significant outcomes based on MCID and PASS criteria. Patient improvements in MHHS were equal regardless of age or sex; however, lower preoperative body mass index led to greater postoperative MHHS improvements. LEVEL OF EVIDENCE: Level IV-therapeutic case series.

Amateur and Recreational Athletes Return to Sport at a High Rate Following Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To compare the return-to-play rates, patient-reported outcome (PRO) scores, and satisfaction between high-level amateur athletes and recreational athletes and to evaluate for differences in ability to return to sport in these groups based on patient-related and sport-related characteristics. METHODS: Clinical data were retrieved for 66 (26 male/40 female) consecutive athletes undergoing hip arthroscopy for femoroacetabular impingement. Athletes were classified as high-level amateur or recreational. Athletes were also divided into 6 distinct sporting categories based on the physical demands on the hip. Preoperative and 2-year PROs including a sport-specific questionnaire, modified Harris Hip Score (MHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales were collected. RESULTS: Of the 66 patients, 49 were recreational and 17 were high-level amateur athletes (10 high school and 7 collegiate). High-level athletes were significantly younger than recreational athletes (18.4 ± 2.3 years vs 29.7 ± 6.8 years; P < .001). After 2 years, all PROs had improved significantly, with no differences between the 2 athletic groups. There was a high overall rate of return for both recreational and high-level amateur athletes (94% vs 88%; P = .60). Increasing preoperative withdrawal time from sport prior to surgery was associated with decreased HOS-SS (r = 0.33; P = .04) and MHHS scores (r = 0.02; P = .02). Overall, athletes who had withdrawn from sport for greater than 8 months before surgery returned to sport significantly more slowly (P = .01). Increasing body mass index (BMI) was associated with lower improvements in HOS (r = 0.26; P = .04) and MHHS scores (r = 0.38; P < .01). CONCLUSIONS: Recreational athletes, despite being significantly older than their high-level counterparts, return to play at a similar high rate and with comparable PROs. Increasing preoperative cessation time from sport significantly prolongs return to sport. Additionally, increasing preoperative cessation from sport and higher preoperative BMI were associated with decreased improvements in PROs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Effect of Capsulotomy and Capsular Repair on Hip Distraction: A Cadaveric Investigation.

PURPOSE: To quantify how increasing interportal capsulotomy size affects the force required to distract the hip and to biomechanically compare simple side-to-side suture repair to acetabular-based suture anchors as capsular repair techniques. METHODS: Twelve fresh-frozen cadaveric hip specimens were dissected to the capsuloligamentous complex of the hip joint and fixed in a material testing system, such that a pure axial distraction of the iliofemoral ligament could be achieved. After each hip in was tested an intact state, sequential distraction was tested with 2, 4, 6, and 8 cm capsulotomies. Specimens were assigned randomly to be repaired with either 4 side-to-side suture repair (n = 6) or 2 double-loaded all-suture anchors (n = 6). The distraction force as well as the relative distraction force percentage normalized to the intact capsule were compared between suture repair and suture anchor repair groups. RESULTS: Increasing the size of the capsulotomy resulted in less force required to distract the hip to 6 mm. The force decreased as the capsulotomy was extended with statistical significance in distraction force seen between the intact state and the 4 cm (P = .003), 6 cm (P < .001), and 8 cm (P ≤ .001) capsulotomy but not for the intact state compared to the 2 cm capsulotomy (P = .28). Statistical significance in relative distraction force was seen for each of the capsulotomy conditions (P < .001 for all conditions compared with the intact state). The side-to-side suture repair construct (104.3% of intact force) required greater force to distraction to 6 mm compared with the suture anchor repair (87.1% of intact force) (P = .008). CONCLUSIONS: An interportal capsulotomy significantly affected the force required to distract the hip in a cadaveric model, with the larger the size of capsulotomy resulting in less force required to distract the hip. When we performed an interportal capsulotomy, the iliofemoral ligament strength was altered significantly but capsular repair with either side-to-side sutures or suture anchor-based repair was able to restore the capsular strength to a native intact hip. We found, however, that the side-to-side suture repair was better able to restore the distraction force compared with suture anchor repair. CLINICAL RELEVANCE: Capsular management during hip arthroscopy remains a debated topic, with multiple techniques involving both capsulotomy and capsular closure published in the literature. This study provides insight into capsular stability against axial stress under capsulotomy and capsular repair conditions.

Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients.

PURPOSE: The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy. METHODS: All patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) with routine capsular closure between January 1, 2012, and December 31, 2015, were eligible. Only patients with unilateral surgery and a postoperative magnetic resonance imaging (MRI; ordered for persistent symptoms) were included. Four independent reviewers evaluated each hip capsule for thickness and the absence or presence of defects. RESULTS: During the study, 1,463 patients had hip arthroscopy for FAI with routine capsular closure, and 53 (3.6%) underwent a postoperative MRI. Fourteen of the 53 were excluded owing to revision status or additional procedures. The final study population included 39 patients (23 female patients and 16 male patients), with an average patient age of 31.7 ± 11.4 years and an average body mass index of 23.3 ± 2.9. There were 3 (7.5%) capsular defects, and the intraclass correlation coefficient (ICC) was 0.82. The operative hip capsule was significantly thicker in the zone of capsulotomy, and subsequent repair as compared with the unaffected, contralateral hip capsule (5.0 ± 1.2 mm vs 4.6 ± 1.4 mm; P = .02), ICC 0.83. Additionally, males had thicker hip capsules as compared with their female counterparts, on the operative side (5.4 ± 1.1 mm vs 4.5 ± 1.2 mm; P = .02) and the nonoperative side (4.8 ± 1.6 mm vs 4.1 ± 0.9 mm; P = .08). CONCLUSIONS: In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1 year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Hip Arthroscopy Outcomes With Respect to Patient Acceptable Symptomatic State and Minimal Clinically Important Difference.

PURPOSE: To determine whether the hip arthroscopy literature to date has shown outcomes consistent with published patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) estimates. METHODS: All clinical investigations of hip arthroscopy using modified Harris Hip Score (mHHS) and/or Hip Outcome Score (HOS) outcomes with at least 1 year of follow-up were reviewed. Ninety-one studies (9,746 hips) were included for review. Eighty-one studies (9,317 hips) contained only primary hip arthroscopies and were the primary focus of this review. The remaining studies (429 hips) did not exclude patients with prior surgical history and were thus considered separately. Mean mHHS, HOS-ADL (Activities of Daily Living) and HOS-SS (Sports-Specific) scores were compared with previously published PASS and MCID values. RESULTS: After 31 ± 20 months, 5.8% of study populations required revision arthroscopy and 5.5% total hip arthroplasty. A total of 88%, 25%, and 30% of study populations met PASS for mHHS, HOS-ADL, and HOS-SS, respectively, and 97%, 90%, and 93% met MCID. On bivariate analysis, increasing age was associated with significantly worse postoperative mHHS (P < .01, R(2) = 0.14), HOS-SS (P = .05, R(2) = 0.12), and rates of reoperation (P = .02, R(2) = 0.08). Increasing body mass index was associated with significantly worse HOS-ADL (P = .02, R(2) = 0.35) and HOS-SS (P = .03, R(2) = 0.30). CONCLUSIONS: In this meta-analysis of 81 studies of primary hip arthroscopy, we have found that more than 90% of study populations meet MCID standards for the most commonly used patient-reported outcomes measures in hip arthroscopy literature, mHHS and HOS. Eighty-eight percent meet PASS standards for the mHHS, but PASS standards are far more difficult to achieve for HOS-ADL (25%) and HOS-SS (30%) subscales. Differences in psychometric properties of the mHHS and HOS likely account for the discrepancies in PASS. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Parachute Technique for Dermal Allograft Augmentation in Open Gluteal Abductor Repair.

Retracted full-thickness tears of the gluteus medius tendon are a well-recognized cause of disabling weakness and pain that significantly impact patients' quality of life. We present an efficient knotless parachute technique for dermal allograft augmentation in open gluteal abductor tendon repairs. Our technique reinforces the suture-tendon interface by incorporating a robust biological scaffold into a knotless double-row fixation. This approach capitalizes on the increased pressure and contact area achieved between the greater trochanter and the dermal allograft/gluteus medius tendon construct without the prominence of knotted sutures.

Evaluating the Morphology of Unique Superficial Fissured Cartilage Lesions at the Femoral Head-Neck Junction in Patients with Femoroacetabular Impingement Syndrome.

Background: While an association between femoroacetabular impingement (FAI) and osteoarthritis (OA) has been reported, the mechanistic differences and transition between the 2 conditions is not fully understood. In FAI, cartilage lesions at the femoral head-neck junction can sometimes be visualized during hip arthroscopy. Purpose/Hypothesis: The purpose of this study was to describe a unique dimpled pattern of superficial fissured cartilage lesions on the femoral head-neck junction at impingement site in patients with FAI syndrome (FAIS) and to evaluate the clinical, histological, and genetic phenotype of this cartilage. We hypothesized that the cartilage lesions may indicate risk for, or predict occurrence of, OA. Study Design: Controlled laboratory study. Methods: Six hips (6 patients; mean age, 34.2 ± 12.9 years; range, 19-54 years) with dimpled or fissured cartilage were included among patients who underwent hip arthroscopy for treatment of FAIS from October 2020 through December 2021. This affected cartilage (dimple-pattern group) and normal cartilage (control group) on the femoral head-neck junction were collected from the same patients and evaluated for histological quantification by Mankin scores and expression of proteins related to cartilage degeneration (eg, matrix metalloproteinase [MMP]-1, MMP-2, MMP-3, MMP-10, and MMP-12, tissue inhibitor of metalloproteinase [TIMP]-1 and TMP-2, aggrecan neopepitope CS846, and hyaluronic acid [HA]) with the use of Milliplex Multiplex Assays. Results: All 6 hips were of the mixed FAI subtype. Preoperatively, 4 of 6 hips had Tönnis grade 1 radiographic changes, which was associated with greater femoral head chondral damage visualized intraoperatively. Mankin scores for the normal cartilage group and the dimple-pattern group were 0.67 ± 0.82 and 3.3 ± 0.82, respectively. Dimple pattern fissured cartilage showed a significant increase in Mankin score (P = .031) and a significant increase in protein expression of CS846 (P = .031) compared with normal cartilage. There were no significant differences in MMPs, TIMPs, or HA levels between the 2 groups. Conclusion: The dimple pattern fissured cartilage, compared to normal cartilage, showed histologically significant cartilage degeneration and a significant increase in protein expression of CS846, a biomarker for early OA. Clinical Relevance: This lesion serves as helpful visual indicator of early degeneration of the cartilage of femoral head-neck junction caused by FAIS.

Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction.

Background: Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement. Purpose/Hypothesis: The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement. Study Design: Case series; Level of evidence, 4. Methods: Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS. Results: In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF. Conclusion: Preoperative athletic participation significantly affected the ability to achieve PASS.

Whole-genome RNA sequencing identifies distinct transcriptomic profiles in impingement cartilage between patients with femoroacetabular impingement and hip osteoarthritis.

Femoroacetabular impingement (FAI) has a strong clinical association with the development of hip osteoarthritis (OA); however, the pathobiological mechanisms underlying the transition from focal impingement to global joint degeneration remain poorly understood. The purpose of this study is to use whole-genome RNA sequencing to identify and subsequently validate differentially expressed genes (DEGs) in femoral head articular cartilage samples from patients with FAI and hip OA secondary to FAI. Thirty-seven patients were included in the study with whole-genome RNA sequencing performed on 10 gender-matched patients in the FAI and OA cohorts and the remaining specimens were used for validation analyses. We identified a total of 3531 DEGs between the FAI and OA cohorts with multiple targets for genes implicated in canonical OA pathways. Quantitative reverse transcription-polymerase chain reaction validation confirmed increased expression of FGF18 and WNT16 in the FAI samples, while there was increased expression of MMP13 and ADAMTS4 in the OA samples. Expression levels of FGF18 and WNT16 were also higher in FAI samples with mild cartilage damage compared to FAI samples with severe cartilage damage or OA cartilage. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. We independently validated the results of the sequencing analysis and found increased expression of anabolic markers in patients with FAI and minimal histologic cartilage damage, suggesting that anabolic signaling may be increased in early FAI with a transition to catabolic and inflammatory gene expression as FAI progresses towards more severe hip OA. Clinical significance:Cam-type FAI has a strong clinical association with hip OA; however, the cellular pathophysiology of disease progression remains poorly understood. Several previous studies have demonstrated increased expression of inflammatory markers in FAI cartilage samples, suggesting the involvement of these inflammatory pathways in the disease progression. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. In addition to differences in inflammatory gene expression, we also identified differential expression in multiple pathways involved in hip OA progression.

Acetabular Morphologic Characteristics Predict Early Conversion to Arthroplasty After Isolated Hip Arthroscopy for Femoroacetabular Impingement.

BACKGROUND: Hip arthroscopy in the setting of dysplasia and borderline dysplasia is controversial. Dysplasia severity is most often defined by the lateral center edge angle (LCEA) but can also be evaluated radiographically by the acetabular inclination (AI). PURPOSE/HYPOTHESIS: The purpose was to determine the effect of AI on outcomes after isolated hip arthroscopy for femoroacetabular impingement (FAI). We hypothesized that patients with dysplasia would have higher rates of arthroplasty as well as inferior clinical and functional outcomes compared with patients who did not have dysplasia. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A hip arthroscopy registry was reviewed for participants undergoing arthroscopic correction of FAI from February 28, 2008, to June 10, 2013. Participants required a clinical diagnosis and isolated arthroscopic correction of FAI with preoperative imaging and intraoperative cartilage status recorded. AI dysplasia was defined as an AI greater than 10°, LCEA dysplasia as LCEA less than 18°, and borderline LCEA dysplasia as LCEA 18° to 25°. Patients without an acetabular deformity (LCEA 25°-40°; AI <10°) served as a control population. Postoperative variables included patient-reported outcome surveys with conversion to arthroplasty as the primary endpoint. Minimum 5-year outcome scores were obtained for 337 of 419 patients (80.4%) with an average follow-up of 75.2 ± 12.7 months. RESULTS: This study included 419 patients: 9 (2%) with LCEA dysplasia, 42 (10%) with AI dysplasia, and 51 (12%) with borderline dysplasia. The AI but not LCEA was significantly correlated with lower outcome scores on the modified Harris Hip Score (r = 0.13; P = .01), Non-Arthritic Hip Score (r = 0.10; P = .04), and Hip Outcome Score-Sports Subscale (r = 0.11; P = .04). A total of 58 patients (14%) underwent arthroplasty at 31 ± 20 months postoperatively. Patients with LCEA dysplasia had an arthroplasty rate of 56% (odds ratio, 8.4), whereas patients with AI dysplasia had an arthroplasty rate of 31% (odds ratio, 3.3), which was significantly greater than the rate for the nondysplastic cohort (13.5%; P < .0001). Patients with borderline LCEA dysplasia did not have increased rates of arthroplasty. A multivariate analysis found increasing age, increasing AI, Tönnis grade higher than 1, and femoral Outerbridge grade higher than 2 to be most predictive of conversion to arthroplasty. CONCLUSION: We found that an elevated AI, along with increasing age, Tönnis grade, and femoral Outerbridge grade significantly predict early conversion to arthroplasty after isolated hip arthroscopy. We recommend using the AI, in addition to the LCEA, in evaluating hip dysplasia before hip arthroscopy.

Threshold Values for Success After Hip Arthroscopy Using the Patient-Reported Outcomes Measurement Information System Assessment: Determining the Minimum Clinically Important Difference and Patient Acceptable Symptomatic State.

BACKGROUND: Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement. PURPOSE: To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID. RESULTS: There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m2), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients (P = .01) and athletic patients (P = .003) were more likely to attain the PASS. CONCLUSION: The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

Lack of Additional Advanced Graduate Training by Orthopaedic Surgeons in Academic Practice: Current Employment and Recruitment Trends.

BACKGROUND: Orthopaedic surgery is ever changing and depends on diverse technical and intellectual skill sets. The purpose of the current study was to evaluate the percentage of academic orthopaedic surgeons with additional graduate degrees in the United States. METHODS: Data including advanced degree(s) (eg, PhD, MS, MBA, MPH, JD, and DVM), academic rank, leadership position, subspecialty, years since training completion, and sex were collected from websites for all academic orthopaedic surgery departments in the United States. Univariate analyses were performed to evaluate for differences in demographic data based on the advanced degree status. Data from the National Resident Matching Program (NRMP) were used to characterize graduate degree-holding US senior medical students who ranked orthopaedic surgery first relative to peers without additional advanced degrees and to applicants who ranked other specialties first. RESULTS: Of 4,519 faculty at 175 academic orthopaedic surgery departments in the United States, 7.1% held a graduate degree in addition to a medical doctorate. There was no difference in the percentage of faculty who held departmental leadership positions (P = 0.62) or who were full professors (P = 0.66) based on holding an additional graduate degree. Of 678 US senior applicants who ranked orthopaedic surgery first and successfully matched into the specialty in 2018, 12.5% held an additional graduate degree and 1.3% were MD-PhDs. Orthopaedic surgery had the second lowest percentage of matched medical students with additional advanced degrees, which was significantly lower than the top 10 specialties (range 16.1% to 21.6%; P < 0.05). Orthopaedic surgery recruited 1.6% of all MD-PhD applicants in 2018. DISCUSSION: Few academic orthopaedic surgery faculty and admitted orthopaedic residency candidates have additional graduate school training. The low percentage of orthopaedic faculty and trainees with additional advanced degrees relative to other specialties may represent a missed opportunity to recruit individuals with diverse skills to advance the field of orthopaedic surgery.

A T-capsulotomy provides increased hip joint visualization compared with an extended interportal capsulotomy.

The purpose of this study was to compare the cross-sectional area (CSA) of joint visualization between extended interportal and T-capsulotomies. Twenty fresh-frozen cadaveric hips were dissected to their capsuloligamentous complexes and fixed in a custom apparatus in neutral hip position. Ten hips underwent sequential interportal capsulotomies at lengths of 2, 4, 6, and 8 cm. Ten hips underwent sequential T-capsulotomies starting from a 4 cm interportal capsulotomy, creating a 2 cm T-capsulotomy (Half-T), and finally a 4 cm T-capsulotomy (Full-T). Following each sequential capsule change in both groups, a high-resolution digital photograph was taken to measure the visualized intra-articular cross-sectional area (CSA). Independent t-test was used to compare CSA interportal and T-capsulotomy groups. Analysis demonstrated a statistically significant increase in CSA visualization with each sequential increase in interportal capsulotomy length up to 6 cm (2cm: 0.6 ± 0.2 cm2; 4cm: 2.1 ± 0.5 cm2 (p<0.001); 6cm: 3.6 ± 1.0 cm2 (p=0.001)), and no difference at 8cm (4.2 ± 1.2 cm2 (p=0.20)). For the T-capsulotomy group the average CSA visualization significantly increased from 3.2 ± 0.9 cm2 for the Half-T to 7.1 ± 1.0 cm2 for the Full-T (p<0.001). The Half-T CSA visualization was not statistically different from the 6 cm capsulotomy (p=0.4) and the 8cm capsulotomy (p=0.05). The Full-T had significantly superior CSA visualization area as compared to the 6 cm and 8 cm interportal capsulotomies (p<0.001 for both). In conclusion, T-capsulotomy resulted in improved cross-sectional area of joint visualization compared to an extended (8cm) interportal capsulotomy in a cadaveric model. Surgeons must weigh the benefits of greater visualization from T-capsulotomy that may help to avoid residual FAI while ensuring to completely repair the capsulotomy to avoid iatrogenic instability.

Vertical Extension of the T-Capsulotomy Incision in Hip Arthroscopic Surgery Does Not Affect the Force Required for Hip Distraction: Effect of Capsulotomy Size, Type, and Subsequent Repair.

BACKGROUND: Interportal and T-capsulotomies are popular techniques for exposing femoroacetabular impingement deformities. The difference between techniques with regard to the force required to distract the hip is currently unknown. PURPOSE: To quantify how increasing interportal capsulotomy size, conversion to T-capsulotomy, and subsequent repair affect the force required to distract the hip. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric hip specimens were dissected and fixed in a materials testing system, such that pure axial distraction of the iliofemoral ligament could be achieved. The primary outcome measure was the load required to distract the hip to a distance of 6 mm at a rate of 0.5 mm/s. Each hip was tested in the intact state and then sequentially under varying capsulotomy conditions: 2-cm interportal, 4-cm interportal, half-T (4-cm interportal and 2-cm T-capsulotomy), and full-T (4-cm interportal and 4-cm T-capsulotomy). After serial testing, isolated T-limb repair and then subsequent complete repair were performed. Repaired specimens underwent distraction testing as previously stated to assess the ability to restore hip stability to the native profile. Distraction force as well as the relative distraction force (percentage normalized to the intact capsule) were compared between all capsulotomy and repair conditions. RESULTS: Increasing interportal capsulotomy size from 2 to 4 cm resulted in significantly less force required to distract the hip ( P < .001). The largest relative decrease in force was seen between the intact state (274.6 ± 71.2 N; 100%) and 2-cm interportal (209.7 ± 73.2 N; 76.4% ± 15.6%; P = .0008). There was no significant mean difference in distraction force when 4-cm interportal (160.4 ± 79.8 N) was converted to half-T (140.7 ± 73.5 N; P = .270) and then full-T (112.0 ± 70.2 N; P = .204). When compared with the intact state, isolated T-limb repair partially restored stability (177.3 ± 86.3 N; 63.5% ± 19.8%; P < .0001), while complete repair exceeded native values (331.7 ± 103.7 N; 122.7% ± 15.1%; P = .0008). CONCLUSION: The conversion of interportal capsulotomy to T-capsulotomy did not significantly affect the force required to distract the hip in a cadaveric model. However, larger interportal capsulotomies resulted in significant stepwise decreases in distraction force. When performing interportal or T-capsulotomy, the iliofemoral ligament strength is significantly decreased, but complete capsular repair demonstrated the ability to restore joint stability to the native, intact hip. CLINICAL RELEVANCE: Increasing interportal capsulotomy size decreases the force required to distract the hip. In an effort to maximize visualization and minimize the magnitude of iliofemoral ligament fibers cut, many surgeons have moved from extended interportal capsulotomy to T-capsulotomy. Interportal and T-capsulotomies result in equivalent hip distraction, partial capsular repair marginally improves hip stability, and only complete repair has the ability to restore the hip to its native biomechanical profile.

Hip Arthroscopic Surgery for Femoroacetabular Impingement With Capsular Management: Factors Associated With Achieving Clinically Significant Outcomes.

BACKGROUND: There has been increasing interest in defining clinically meaningful outcomes in patient reported outcomes following orthopaedic surgery. Little is known about the factors associated with clinically meaningful outcomes after hip arthroscopy for femoroacetabular impingement. STUDY DESIGN: Case-control study; Level of evidence, 3. PURPOSE: To report on a large, prospectively collected consecutive series of patients who underwent comprehensive arthroscopic treatment of femoroacetabular impingement (FAI) and capsular management with greater than 2-year follow-up. The objectives were to determine (1) what percentage of patients achieve clinically significant outcomes after hip arthroscopic surgery for FAI as determined by the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) and (2) what factors are associated with achieving the MCID and PASS. METHODS: Data from an institutional repository of consecutive patients undergoing primary hip arthroscopic surgery with routine capsular closure for FAI that had failed nonsurgical management between January 2012 and January 2014 were prospectively collected and analyzed. Of 474 patients during the enrollment period, 386 (81.4%) patients were available for a minimum 2-year follow-up. Demographics, radiographic measurements, intraoperative characteristics, and patient-reported outcome scores were collected. The primary outcome measure was achieving published thresholds for the MCID and PASS for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) in patients with FAI. The HOS-Sport-Specific Subscale (SSS), complications, and reoperations were secondary outcome measures. Multivariate regression analyses were conducted to identify factors associated with achieving the MCID and PASS. RESULTS: At a minimum of 2-year follow-up, the patients had statistically significant improvements in all patient-reported outcomes (HOS-ADL, HOS-SSS, and modified Harris Hip Score [mHHS]; P < .001 for all), with a 1.2% rate of revision hip arthroscopic surgery and 1.7% rate of conversion to total hip arthroplasty. The MCID was achieved by 78.8% of patients for the HOS-ADL, and the PASS was achieved by 62.5% for the HOS-ADL. Younger age ( P = .008), Tönnis grade 0 ( P = .022), and lower preoperative HOS-ADL score ( P < .001) were associated with successfully achieving the MCID for the HOS-ADL. Younger age ( P < .001), larger medial joint space width ( P = .028), and higher preoperative HOS-ADL score ( P < .001) were associated with achieving the PASS for the HOS-ADL. Younger age ( P < .001), lower body mass index ( P = .006), non-workers' compensation status ( P = .020), and lower preoperative HOS-SSS score ( P < .001) were associated with achieving the MCID for the HOS-SSS. Younger age ( P = .001), Tönnis grade 0 ( P = .014), running ( P = .008), and higher preoperative HOS-SSS score ( P < .001) were associated with achieving the PASS for the HOS-SSS. Overall, 49.4% of patients achieved all 4 clinically significant outcomes: both the MCID and PASS for the HOS-ADL and HOS-SSS. CONCLUSION: The majority of patients undergoing hip arthroscopic surgery with routine capsular closure for FAI experienced clinically significant outcomes that met the MCID or PASS criteria, with low rates of revision and conversion to total hip arthroplasty. Factors associated with these successful outcomes on multivariate analyses included younger age with a normal joint space. Patients with lower preoperative HOS scores were more likely to achieve the MCID, whereas patients with higher preoperative HOS scores were more likely to achieve the PASS.