No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy With Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity-Matched Multicenter Study With Minimum 5-Year Follow-Up.

PURPOSE: To compare minimum 5-year patient-reported outcome measures after hip arthroscopy (HA) and periacetabular osteotomy (PAO) for borderline hip dysplasia. METHODS: Hips with a lateral center-edge angle (LCEA) between 18° and less than 25° that underwent either PAO or HA were selected from 2 institutions. The exclusion criteria were as follows: LCEA less than 18°, Tönnis osteoarthritis grade greater than 1, prior hip surgical procedures, active inflammatory disease, Workers' Compensation, and concomitant surgery. Patients underwent propensity matching based on age, sex, body mass index, and Tönnis osteoarthritis grade. Patient-reported outcome measures included the modified Harris Hip Score, as well as calculation of the minimal clinically important difference, patient acceptable symptom state, and maximum outcome improvement satisfaction threshold. Preoperative radiographic predictors included comparison of the Femoro-epiphyseal Acetabular Roof index and ligamentum teres lesions. RESULTS: A total of 28 PAO patients underwent propensity matching to 49 HA patients. The 2 groups were similar in terms of mean age, sex, preoperative body mass index, and LCEA. The PAO group had a longer mean follow-up period (95.8 months vs 81.3 months, P = .001). The mean Femoro-epiphyseal Acetabular Roof index was significantly lower preoperatively in the HA group (P < .001). The 2 groups showed similar and significant improvements in the mean modified Harris Hip Score from preoperatively to latest follow-up (P < .001). The relative risk of subsequent surgery in the PAO group was 3.49 (P = .024), mostly attributed to hardware removal (25%). The revision rate was 3.6% in the PAO group and 8.2% in the HA group (P = .65). One patient in the PAO group required revision HA for intra-articular adhesions. Three of the patients requiring revision in the HA group underwent PAO because of persistent pain, and one underwent revision HA alone. Conversion to total hip arthroplasty was required in 1 patient in the HA group and no patients in the PAO group. CONCLUSIONS: Both PAO and HA with capsular plication provide borderline hip dysplasia patients with clinically significant improvements and low revision rates at a minimum of 5 years postoperatively. LEVEL OF EVIDENCE: Level III, retrospective, comparative therapeutic trial.

Maintenance of Surgical Optimization in Total Joint Arthroplasty Patients.

BACKGROUND: There are increased efforts to maximize medical optimization to improve the outcomes of total joint arthroplasty (TJA). However, there is a paucity of literature demonstrating that optimized parameters are maintained throughout the perioperative period. METHODS: A retrospective review of 877 elective TJA patients from 2015 to 2019 was conducted. Patients who underwent medical optimization for body mass index (BMI), hemoglobin A1c (HbA1c), hemoglobin, albumin, and smoking status were reviewed at the initial visit, preoperatively, time of surgery, and one year postoperatively. For each of these variables at each time point, patients were stratified into 3 optimization groups. Analyses were performed to identify mean time to optimization, loss of optimization, and maintenance of optimization. RESULTS: Patients considered not optimized due to specific parameters at the initial visit were as follows: BMI (19%), HbA1c (13.5%), hemoglobin (16%), albumin (19%), and smoking status (9.5%). The mean time to optimization was 187.7 days [longest being BMI (220.1 days), and the shortest being HbA1c (60.9 days) (P = .0003)]. Patients who had intermediate optimization of BMI at the preoperative visit were at higher risk [odds ratio: 2.1 (0.97 to 4.6)] of worsening BMI by time of surgery (P < .0001). Between the preoperative and surgery time points, over 93.5% of patients maintained or improved optimization. CONCLUSIONS: Surgeon led medical optimization efforts alongside a TJA program provide maintenance of, or improvement in optimization in more than half of TJA patients up to one year postoperatively. Patients who had a BMI between 40 and 45 at the preoperative visit are at significant risk of increasing their BMI by the day of surgery.

Do Larger Acetabular Chondral Defects Portend Inferior Outcomes in Patients Undergoing Arthroscopic Acetabular Microfracture? A Matched-Controlled Study.

PURPOSE: To elucidate the effect, if any, of acetabular chondral defect size on surgical outcomes after arthroscopic microfracture was performed with concomitant treatment for labral tears and femoroacetabular impingement (FAI) syndrome. METHODS: The study period was between February 2008 and November 2014. Data were collected on patients who underwent hip arthroscopy. The inclusion criteria were acetabular microfracture; concomitant treatment for labral tears and FAI syndrome; and preoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Exclusion criteria were Workers' Compensation, preoperative Tönnis grade >1, or previous ipsilateral hip surgeries or conditions. Patients were grouped based on smaller chondral defects (SCDs) or larger chondral defects (LCDs), then matched 1:1 by age at surgery ±10 years, sex, body mass index ±5, labral treatment, capsular treatment, acetabuloplasty, and femoroplasty. Outcomes, secondary arthroscopies, and conversions to total hip arthroplasty (THA) were documented. RESULTS: Of 131 eligible cases, 107 (81.7%) had minimum 2-year follow-up. Before matching, the conversion rate to THA was higher for LCDs (24.6%) than for SCDs (12.0%). Thirty-five patients were matched for each group. Mean follow-up time was 47.9 months (range, 24.0, 84.1) for the matched LCD group and 46.1 months (range, 24.0, 88.1) for the matched SCD group. Ligamentum teres debridement (P = .03) was performed more frequently in the LCD group. No other differences were found regarding demographics, intraoperative findings, procedures, traction time, preoperative scores, or follow-up scores. Both groups demonstrated significant improvements in all scores. Rates of revision or conversion to THA were similar between groups. The relative risk for conversion to THA was 2.33 for patients with defects ≥300 mm2 compared with patients with defects ≤250 mm2 (P = .13). Deep vein thrombosis occurred in 3 (5.3%) patients with LCDs. CONCLUSIONS: Matched patients with either SCDs or LCDs undergoing arthroscopic acetabular microfracture with concomitant treatment for labral tears and FAI syndrome demonstrated similar improvements at minimum 2-year follow-up. Patients with chondral defects approaching 300 mm2 or greater may have a higher propensity toward conversion to THA. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Do Femoral Head Osteochondral Lesions Predict a Poor Outcome in Hip Arthroscopy Patients? A Matched Control Study With Minimum 5-Year Follow-Up.

PURPOSE: To determine whether the presence of femoral head (FH) lesions affects patient-reported outcomes (PROs) of patients undergoing hip arthroscopy for labral tears. METHODS: Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy for labral tears at our institution from April 2008 to March 2011. Patients with FH lesions were matched to those without (control) for age, body mass index, sex, and lateral center-edge angle. The inclusion criteria were FH lesions, labral tears, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery, prior hip conditions, inflammatory arthritis, Workers' Compensation claims, and Tönnis grade greater than 1. PRO scores, including the modified Harris Hip Score, Non-Arthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, were collected preoperatively and postoperatively. Visual analog scale (VAS) scores for pain and patient satisfaction were recorded. RESULTS: We matched 96 hips with FH lesions to 96 control hips. The FH group had slightly longer follow-up (71.4 months vs 67 months, P = .004). Patients with FH lesions tended to have higher-grade acetabular lesions (grade 4 acetabular labrum articular disruption and Outerbridge grade 4 acetabular lesions). All PRO scores, VAS scores, and patient satisfaction ratings were statistically improved at latest follow-up in both groups. No statistical difference in improvement (ΔPRO and ΔVAS scores) was noted between groups. However, patients with FH lesions had a higher rate of conversion to arthroplasty (32% vs 16%, P = .0027). Patients in the control group underwent more secondary arthroscopies (14% vs 5%, P = .05). CONCLUSIONS: Finding an FH chondral lesion at arthroscopy does not necessarily portend a worse clinical outcome or conversion to total hip arthroplasty, when controlling for other variables. Patients with FH lesions were, however, found to have worse intra-articular hip pathology. When combined with these factors, patients with FH lesions had lower outcome scores and double the rate of conversion to arthroplasty than patients without them. LEVEL OF EVIDENCE: Level III, case-control study.

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.

Arthroscopic Reconstruction of the Irreparable Acetabular Labrum: A Match-controlled Study.

PURPOSE: To report clinical outcomes of arthroscopic labral reconstruction in the hip at minimum 2-year follow-up in comparison to a pair-matched labral repair group. METHODS: Patients were included in this study if they underwent labral reconstruction during hip arthroscopy and had minimum 2-year follow-up data available. Exclusion criteria were active workers' compensation claims or previous ipsilateral hip surgery or conditions. Reconstruction patients were matched 1:2 to patients that underwent arthroscopic labral repair but otherwise met all inclusion and exclusion criteria. Matching criteria were age within 5 years, sex, body mass index within 5, same capsular treatment, and whether there was chondral damage of Outerbridge grade II or greater. Three patient-reported outcome (PRO) measures and visual analog scale (VAS) for pain were recorded preoperatively and at a minimum of 2 years postoperatively. International Hip Outcome Tool and patient satisfaction were also collected at latest follow-up. RESULTS: Thirty-four reconstruction patients were matched to 68 repair patients. There were no significant differences in age (P = .941), sex (P > .999), body mass index (P = .935), or any other demographics between groups. A statistically significant increase was seen in PROs for both the reconstruction group (Modified Harris Hip Score, P = .002; Hip Outcome Score - Sports Subscale, P<.001; Non-arthritic Hip Score, P<.001) and the repair group (Modified Harris Hip Score, P<.001; Hip Outcome Score - Sports Subscale, P < .001; Non-arthritic Hip Score, P<.001) at minimum 2-year follow-up. Significant decrease was shown for VAS for both groups (reconstruction VAS, P<.001; repair, P<.001) at minimum 2-year follow-up. There were no significant differences in rates of postoperative complications (P>.999), secondary arthroscopy (P>.999), or conversion to total hip arthroplasty (P = .728) between groups. CONCLUSIONS: Arthroscopic labral reconstruction is associated with significant improvement in PROs and a low incidence of secondary surgery within 2-year follow-up. Improvements in PROs, VAS, patient satisfaction, and incidence of secondary procedures were comparable to a match control treated with labral repair. Although there were no differences shown in the 2 groups with respect to complication rate, secondary arthroscopy, or conversion to total hip arthroplasty, the study was not powered to compare these outcome parameters. Based on this evidence, either labral repair or reconstruction may be selected depending upon the clinical scenario. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Midterm Outcomes of Iliopsoas Fractional Lengthening for Internal Snapping as a Part of Hip Arthroscopy for Femoroacetabular Impingement and Labral Tear: A Matched Control Study.

PURPOSE: To report minimum 5-year outcomes and rate of painful snapping resolution for patients who underwent iliopsoas fractional lengthening (IFL) as a part of hip arthroscopy for femoroacetabular impingement (FAI) and labral tear. In addition, to match this group to a group of patients who underwent hip arthroscopy for FAI and labral tear without internal snapping. METHODS: Patients were eligible for inclusion if they underwent hip arthroscopy for treatment of FAI and labral tear with concomitant IFL for painful snapping and had preoperative baseline scores for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Subscale, and visual analog scale for pain. The exclusion criteria for this study were preoperative Tönnis grade >0, active workers' compensation claims, or previous ipsilateral hip conditions. These patients were matched to a control group of patients who did not have snapping or undergo IFL but who otherwise satisfied the same inclusion and exclusion criteria. RESULTS: There were 57 eligible cases (80.3% follow-up). Mean follow-up time was 69.3 months (from 60.0 to 91.9). All patient-reported outcomes measures demonstrated statistically significant improvements between preoperative and latest follow-up scores for the following measures (P < .001): modified Harris Hip Score (from 64.3 to 84.9), Nonarthritic Hip Score (from 61.7 to 85.2), Hip Outcome Score-Sports Subscale (from 47.0 to 75.0), and visual analog scale (from 6.5 to 2.2). Mean satisfaction was 8.1 out of 10. Painful snapping was resolved in 80.7% of cases. Ten hips (17.5%) required secondary arthroscopy at a mean of 30.5 months. Three hips (5.3%) required total hip arthroplasty at a mean of 57.5 months. One case (1.8%) had minor postoperative complications. There were no statistically significant differences between the groups in outcomes, complications, and secondary surgeries. CONCLUSIONS: IFL as part of hip arthroscopy for treatment of FAI and labral tears demonstrated similar favorable improvement, complication rates, and secondary surgeries, when compared with a control group that did not undergo IFL. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

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.

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.

The Correlation Between Arthroscopically Defined Acetabular Cartilage Defects and a Proposed Preoperative Delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage Index in Hips of Patients With Femoroacetabular Impingement Syndrome.

PURPOSE: To evaluate a delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) index designed to predict focal acetabular articular cartilage damage in patients with femoroacetabular impingement (FAI). METHODS: The inclusion criteria were patients who underwent dGEMRIC and hip arthroscopy between April 2010 and August 2015 for FAI syndrome. The exclusion criteria were previous hip conditions, a Tönnis grade greater than 1, and a delay between magnetic resonance imaging and surgery greater than 180 days. The cutoff value for full-thickness chondral damage was set to 350 milliseconds. The coronal anterolateral (CAL) index was designed to evaluate focal articular anterolateral chondral defects. We calculated the binary classification test of the CAL index for full-thickness chondral damage, with arthroscopy as the gold standard. We calculated the correlation between the CAL index and the arthroscopically defined acetabular labrum articular disruption (ALAD) and Outerbridge grades and tested for differences between no or mild focal chondral damage and moderate or severe focal chondral damage. We repeated this analysis on the sagittal superior index, a combination of the sagittal anterior and posterior indices. RESULTS: A total of 195 hips (183 patients) were reviewed. The CAL index showed a sensitivity of 55% (95% confidence interval [CI], 32%-76%), specificity of 81% (95% CI, 74%-86%), positive predictive value of 27% (95% CI, 18%-37%), and negative predictive value of 93% (95% CI, 90%-96%). The CAL index showed a significant difference between no or mild focal chondral damage and moderate or severe focal chondral damage per both ALAD and Outerbridge groups (P < .0001). The CAL index was moderately inversely correlated with ALAD and Outerbridge grades (ρ = -0.403, P < .0001). The sagittal superior index was not significantly different between the groups and showed a weak correlation with focal defects. CONCLUSIONS: The CAL index may play a role in ruling out full-thickness articular cartilage defects in patients with FAI syndrome. In addition, it may help in differentiating between no or mild focal chondral damage and moderate or severe focal chondral damage. LEVEL OF EVIDENCE: Level III, case-control study.

Clinical Outcomes and Return to Sport in Competitive Athletes Undergoing Arthroscopic Iliopsoas Fractional Lengthening Compared With a Matched Control Group Without Iliopsoas Fractional Lengthening.

PURPOSE: To compare the minimum 2-year outcomes and return to sports in competitive athletes after arthroscopic iliopsoas fractional lengthening (IFL) and treatment for femoroacetabular impingement (FAI) to competitive athletes treated for FAI who did not undergo IFL. METHODS: Data were prospectively collected and retrospectively reviewed between November 2009 and April 2014. Included patients were high school, collegiate, or professional athletes who underwent arthroscopic IFL, treatment for FAI, and preoperative modified Harris Hip Score, Non-Arthritic Athletic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Exclusion criteria were patients younger than 16 years, Tönnis grade >1, microfracture, abductor pathology, and previous hip conditions. A subgroup of athletes were matched to athletes who did not undergo IFL by age ± 5 years, sex, and body mass index ± 5. RESULTS: There were 75 athletes eligible for inclusion, 60 (80.0%) of whom had minimum 2-year follow-up. All patient-reported outcome (PRO) scores demonstrated significant improvements at latest follow-up (P < .001). Mean satisfaction was 7.9. No patients converted to arthroplasty. Painful snapping was resolved in 55 athletes (91.7%). Nine athletes (15.0%) had nonpainful snapping at follow-up. Thirty-nine (65%) returned to their sport. Forty (66.7%) maintained or improved their competitive abilities. There was one case (1.6%) of temporary postoperative numbness. There were no complaints of weakness in hip flexion. Forty-one IFL athletes were matched to 41 controls. No differences were detected in demographics, follow-up time, intraoperative findings, procedures, mean magnitudes of improvement, or return to sports. CONCLUSIONS: In competitive athletes, IFL during hip arthroscopy is safe and demonstrates favorable improvements in PROs and VAS, high satisfaction, and high rate of symptom resolution at a minimum of 2 years postoperatively. Most patients were able to return to sports and maintain or improve their competitive levels. These results were similar to a control group of athletes not requiring IFL. LEVEL OF EVIDENCE: Level III, case-control study.

Arthroscopic Treatment of Iliopsoas Snapping in Patients With Radiographic Acetabular Dysplasia Using Iliopsoas Fractional Lengthening and Capsular Plication.

PURPOSE: The purpose of this study was to evaluate the greater than 2-year patient-reported outcomes (PROs) and patient satisfaction of patients who were treated with hip arthroscopy for snapping iliopsoas tendons that were painful with concomitant acetabular dysplasia and who underwent iliopsoas lengthening for symptomatic iliopsoas tendon snapping with concomitant capsular plication and treatment of hip impingement. Secondary measures included observation of the change in the Tönnis grade at greater than 2 years' follow-up. METHODS: Between July 2009 and December 2011, data on patients with a lateral center-edge angle (LCEA) of less than 25° (range, 19°-24°) who underwent hip arthroscopy with central-compartment iliopsoas fractional lengthening and capsular plication were prospectively collected and retrospectively reviewed. Interportal capsular repair was performed using between 2 and 5 simple sutures. Patients also underwent procedures to treat hip impingement pathology. All patients had preoperative and minimum 2-year postoperative PRO measures: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score. The visual analog scale score and patient satisfaction with surgery (from 0 to 10) were also collected. Radiographs were analyzed preoperatively and at latest follow-up to assess progression of the Tönnis grade. RESULTS: We analyzed 32 patients who met the inclusion criteria (30 female and 2 male patients; mean age, 25 years). The mean LCEA and anterior center-edge angle were 21.6° and 25.5°, respectively. Four patients required revision arthroscopy for labral retears. Among the 28 patients who did not undergo revision surgery, the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and Non-arthritic Hip Score improved from 68.7 to 83.5, from 64.9 to 86.6, from 71.6 to 86.7, and from 52.6 to 75.8, respectively (P < .001). The visual analog scale score improved from 5.6 preoperatively to 1.9 at latest follow-up (P < .001). The mean patient satisfaction rating was 8.0. There was no radiographic progression of the Tönnis grade at final follow-up. CONCLUSIONS: This study showed that patients with an LCEA of less than 25° and associated painful iliopsoas snapping can be treated by addressing concomitant pathology and performing central-compartment fractional lengthening of the iliopsoas tendon with concomitant capsular plication and have high satisfaction, improvement in PROs, and improved pain scores, without significant progression of osteoarthritis. LEVEL OF EVIDENCE: Level IV, case series.

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.

Does Bony Regrowth Occur After Arthroscopic Femoroplasty in a Group of Young Adolescents?

PURPOSE: To evaluate femoral head-neck bone regrowth and PROs in skeletally immature patients that underwent arthroscopic femoroplasties over a minimum 2-year period. METHODS: Eleven skeletally immature hips (10 patients) with open femoral head physes underwent femoroplasty between October 2008 and November 2013. Inclusion criteria were minimum 2-year follow-up with patient-reported outcomes (PROs) and radiographs preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. Exclusion criteria were >16 years of age, preoperative Tönnis grade >1 and previous hip conditions. Preoperative radiographs were used to assess skeletal immaturity, which was indicated by a Risser score ≤4 and femoral head physis >1 mm. Alpha angles were measured preoperatively, at 2 weeks, and at a minimum of 2 years postoperatively. PROs, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) score, were measured preoperatively and at the latest follow-up. RESULTS: Mean age at surgery was 14.7 years (range: 13.2-15.9). Mean follow-up was 35.7 months (range: 23.3-61.4). All hips tested positive for anterior impingement preoperatively. The mean preoperative alpha angle was 61.8°, which decreased to 41.5° postoperatively (P < .0001) and was 40.7° at a minimum of 2 years postoperatively. No bony regrowth was documented at the latest follow-up. Mean improvements in scores were as follows: mHHS = 58.5 to 79.8 (P < .0001), NAHS = 56.8 to 87.1 (P = .008), HOS-SSS = 34.3 to 78.3 (P = .004), and VAS score = 7.5 to 1.3 (P < .0001). Mean patient satisfaction was 8.7 ± 1.7. One hip (9.0%) required revision arthroscopy at 31.1 months. No postoperative complications were reported. CONCLUSIONS: Bony regrowth of the femoral head-neck region did not occur in this study of skeletally immature females who underwent arthroscopic femoroplasty. In this group of patients, hip arthroscopic treatment of FAI and labral tears is a safe and favorable intervention because of its high patient satisfaction and outcome scores and absence of postoperative complications. LEVEL OF EVIDENCE: Level IV, prognostic study.

Endoscopic Gluteus Medius Repair With Concomitant Arthroscopy for Labral Tears: A Case Series With Minimum 5-Year Outcomes.

PURPOSE: To report the minimum 5-year outcomes of endoscopic gluteus medius repair for partial- and full-thickness tears with concomitant hip arthroscopy. METHODS: Data for all patients who underwent hip arthroscopy between February 2009 and September 2011 were prospectively collected. We included patients who underwent endoscopic gluteus medius repair with concomitant arthroscopic labral treatment and for whom the following measures were obtained preoperatively and at a minimum of 5 years' follow-up: modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score for pain. For included patients, the International Hip Outcome Tool-12 (iHOT-12) score and satisfaction rating were also available at latest follow-up. Patients with at least 1 of the following criteria were excluded: preoperative Tönnis osteoarthritis grade of 2 or greater, previous hip conditions, severe dysplasia, and Workers' Compensation claims. RESULTS: There were 16 patients eligible for inclusion, 14 (87.5%) of whom had minimum 5-year follow-up, with a mean of 68.8 months (range, 60.1-79.6 months). The study group consisted of 13 women (92.9%) and 1 man (7.1%) with a mean age at surgery of 57.4 years (range, 46.3-74.8 years). Outcome scores improved as follows: modified Harris Hip Score, from 52.4 to 81.2 (P = .004); Non-Arthritic Hip Score, from 48.0 to 82.5 (P = .002); Hip Outcome Score-Sports Specific Subscale, from 30.1 to 66.4 (P < .001); and visual analog scale score, from 6.2 to 2.6 (P = .001). At minimum 5-year follow-up, the mean iHOT-12 score was 73.8 and the mean patient satisfaction rating was 8.4. Survivorship was 92.9%, with 1 patient who underwent conversion to total hip arthroplasty. There was no deterioration in patient outcomes and satisfaction between 2 and 5 years postoperatively. There were no clinical failures of gluteus medius repair and no complications. CONCLUSIONS: Endoscopic gluteus medius repair with concomitant hip arthroscopy for labral tears is safe and shows favorable outcomes at minimum 5-year follow-up. Patient outcomes were as favorable at 5 years as they were at 2 years postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Outcomes of Hip Arthroscopy in Competitive Athletes.

PURPOSE: To evaluate the minimum 2-year postoperative clinical outcomes and the rate of return to sports in athletes who underwent capsular plication for the treatment of ligamentous laxity and/or borderline dysplasia during hip arthroscopy for the treatment of femoroacetabular impingement and labral pathology. METHODS: Since 2008, data were prospectively collected on patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement and/or labral tears. Inclusion criteria were as follows: athlete at the high school, collegiate, or professional levels preoperatively, underwent capsular plication, and preoperatively recorded patient-reported outcome scores including modified Harris hip score (mHHS), nonarthritic athletic hip score (NAHS), hip outcome score-sports-specific subscale (HOS-SSS), and visual analog scale (VAS). Exclusion criteria were as follows: <16 years old, preoperative Tönnis grade >1, and previous hip conditions. Sports activity and competitive levels were collected at a minimum of 2 years postoperatively. RESULTS: Fifty-one hips (49 patients) met the inclusion criteria, and 41 hips (39 patients) had minimum 2-year follow-up (80.4% follow-up). Mean mHHS increased from 67.1 preoperatively to 83.5 (P < .0001). Mean NAHS increased from 66.8 to 88.8 (P < .0001). Mean HOS-SSS improved from 46.8 to 80.1 (P < .0001). Mean VAS decreased from 5.1 to 1.7 (P < .0001). Thirty-five (85.4%) hip arthroscopies allowed the patients to return to sports at follow-up. Thirty-four (82.9%) hip arthroscopies allowed the patients to maintain their competitive physical abilities at follow-up. CONCLUSIONS: Patient-reported outcomes and VAS in athletes significantly improved at a minimum of 2 years after capsular plication as a part of hip arthroscopy addressing varying pathologies. In addition, most patients returned to sports at similar or higher competitive levels. These results suggest that capsular plication is a favorable treatment option in athletes with ligamentous laxity and/or borderline dysplasia. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Treatment of Hip Pain in Adolescent Patients With Borderline Dysplasia of the Hip: Minimum 2-Year Follow-Up.

PURPOSE: To examine arthroscopic treatment of hip pain in patients with borderline hip dysplasia (lateral center edge angle [LCEA] between 20° and 25°). METHODS: From 2008 to 2013, patients below 18 years of age who underwent arthroscopic hip surgery with an LCEA between 20° and 25° were retrospectively matched 1:1 to a control group without dysplasia (LCEA ≥25°) based on age, gender, femoroplasty, labral treatment, and capsular plication. Indications for surgery included failure to improve with nonoperative treatments and anti-inflammatory medications after 3 months. Patient-reported outcome data were collected using modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale. RESULTS: From 2008 to 2013, 168 patients below the age of 18 underwent arthroscopic hip surgery. Twenty-one patients met inclusion criteria and were matched 1:1 to a control group. Follow-up was achieved for 17 patients in both groups (81%). Mean follow-up time, age, and LCEA were 2.19 years, 15.5 years, and 22.3° for the dysplastic group and 2.16 years, 16.0 years, and 31.2° for the control group, respectively. Preoperative patient-reported outcomes between groups were not statistically different. At the latest follow-up, both groups showed statistically significant improvement over baseline in modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale (P < .001). Latest follow-up scores were not statistically different between groups. CONCLUSIONS: This study shows favorable 2-year outcomes in adolescent patients with borderline dysplasia undergoing labral treatment and capsular plication. Outcomes in the borderline dysplastic patients were as good as those of a control group. Although adolescents with borderline dysplasia have traditionally been a challenging group of patients to treat, these results suggest that an arthroscopic approach that addresses both labral pathology and instability may be beneficial. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Treatment of Labral Tears of the Hip in Adolescents: Patterns of Clinical Presentation, Intra-articular Derangements, Radiological Associations and Minimum 2-Year Outcomes.

PURPOSE: To report on patterns of clinical presentation, intra-articular derangements, radiological associations, and minimum 2-year outcomes after hip arthroscopy (HA) in patients 18 years or younger. METHODS: This study was a retrospective case series on patients 18 years or younger who had undergone HA for labral tears that had failed nonoperative management from April 2008 to April 2013 with a minimum 2-year follow-up. Exclusion criteria were previous hip conditions or surgery. The following were recorded: demographic, examination, radiological and intraoperative findings, intraoperative procedures performed, patient-reported outcomes (PROs), and patient satisfaction. The PROs reported included the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, Hip Outcome Score-Activities of Daily Living, and Visual Analogue Score for pain. RESULTS: One hundred and two patients satisfied the inclusion criteria, of whom 90 (88.2%, 77 females and 13 males) had minimum 2-year follow-up. Females had increased external rotation in flexion (58.9° vs 50.0°, P = .041). Sixty-eight females had a Beighton's score of >4 compared to 6 males (P < .001). There was no distinct pattern within the group or between genders for radiological markers of acetabular coverage, depth, or version and femoral cam size. Mean femoral anteversion for females was 15.7° and for males 11.3°. Females had significantly smaller labral tears (1.73 hours vs 2.34 hours on the acetabular clock face, P = .028). Females were more likely to require a capsular plication and iliopsoas fractional lengthening (88.3% vs 46.2%, and 77.9% vs 38.5%, respectively). There was a significant improvement in all PRO measures in both males and females (P < .01), but females had lower preoperative and postoperative scores. Mean preoperative and postoperative PROs for males and females were as follows: modified Harris Hip Score 71.0/94.3 and 63.4/88.8, Hip Outcome Score-Activities of Daily Living 78.1/93.4 and 64.0/91.8, Hip Outcome Score-Sport-Specific Subscale 51.7/91.0 and 45.7/78.6, Non-Arthritic Hip Score 78.1/94.5 and 63.1/89.2, and visual analog score 4.77/1.85 and 6.29/2.21. The mean patient satisfaction score was 8.29 out of 10. Five patients (5.56%) required a revision procedure. CONCLUSIONS: HA is associated with improved outcomes and pain and high satisfaction scores at minimum 2-year follow-up in adolescent population. The pattern of labral injury is different in males and females and dictates the arthroscopic approach. Females are likely to require a capsular plication and iliopsoas release to address soft-tissue laxity and impingement. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Broad-complex, tramtrack, and bric-à-brac (BTB) proteins: Critical regulators of development.

Broad-complex, Tramtrack, and Bric-à-brac/poxvirus and zinc finger (BTB/POZ) family proteins are a diverse family of proteins that are characterized by the presence of a common protein-protein interaction domain, known as the BTB domain. BTB proteins have been identified in poxviruses and many eukaryotes, and have diverse functions, ranging from transcriptional regulation and chromatin remodeling to protein degradation and cytoskeletal regulation. Specificity of function is determined in part by additional domains present in BTB family proteins, as well as by interaction partners. Studies of BTB proteins in Drosophila and mammalian systems have revealed the importance of these genes in multiple developmental contexts, as well as in cancer and neurological and musculoskeletal diseases. In this review, we discuss the functions of BTB/POZ proteins during development with an emphasis on BTB-zinc finger (BTB-ZF) proteins, which play critical roles in transcriptional regulation and chromatin remodeling.