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

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

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

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

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

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

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

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

Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome.

PURPOSE: To use a prospectively collected database to internally validate a previously published intraoperative classification system by determining its utility in improving patient-reported outcome scores (PROS). METHODS: Open or endoscopic procedures performed at a single center between February 2008 and March 2018 with minimum 2-year follow-up were reviewed. Patients were prospectively classified intraoperatively as one of five greater trochanteric pain syndrome (GTPS) types according to the Lall GTPS classification system and underwent one of the six following surgical procedures: trochanteric bursectomy (TB, type I); TB with trochanteric micropuncture (type II); endoscopic suture staple repair (type IIIA); endoscopic single row transtendinous repair (type IIIB); open or endoscopic double row repair (type IV); and gluteus maximus/tensor fasciae latae transfers (type V). The following PROS were analyzed to assess the efficacy of treatment and validity of the classification scheme: modified Harris Hip Score (mHHS), Nonarthritic Hip Score, The International Hip Outcome Tool, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale for pain. RESULTS: In total, 324 patients (287 female, 37 male) underwent surgical management per GTPS classification type: 109 type I; 26 type II; 20 type IIIA; 118 type IIIB; 44 type IV; and 7 type V. The mean age and follow-up time were 51.9 ± 12.5 years and 44.5 ± 20.5 months, respectively. All patients PROS improved from baseline to minimum 2-year follow-up (P < .05). High rates of the minimal clinically important difference for mHHS (70.0-100.0) and Nonarthritic Hip Score (73.1-92.7) and patient acceptable symptomatic state for mHHS (70.0-94.5) and International Hip Outcome Tool (58.1-86.7) were achieved per GTPS type. Patient satisfaction was 7.9/10. CONCLUSIONS: This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. These findings provide surgeons with a validated classification system and treatment algorithm to manage peritrochantric pathology diagnosed intraoperatively. LEVEL OF EVIDENCE: III, prognostic study.

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

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

Ligamentum Teres Reconstruction May Lead to Improvement in Outcomes Following a Secondary Hip Arthroscopy for Symptomatic Microinstability: A Systematic Review.

PURPOSE: To present the indications, surgical technique, outcomes, and complications for patients undergoing arthroscopic reconstruction of the ligamentum teres (LT). METHODS: Articles were included if they had postoperative patient-reported outcomes (PROs) for arthroscopic LT reconstruction. Studies were analyzed for patient demographics, clinical assessment and indications, radiographic and magnetic resonance imaging data, concomitant procedures performed, PROs, surgical techniques, intra-articular classifications, complications, and need for follow-up surgeries. For PROs, the standard mean difference was calculated. The proportion of patients achieving patient acceptable symptomatic state for postoperative modified Harris Hip Score (≥74) was recorded. The number of patients achieving minimal clinically important difference for modified Harris Hip Score (Δ ≥8) was calculated. RESULTS: The majority of the cases were revision arthroscopies. Of the 3 studies reporting on patients undergoing LT reconstruction due to microinstability, 4, 9, and 11 patients demonstrated a mean improvement of 25.7, 35.2, and 27.7 in modified Harris Hip, respectively. In addition, one of the studies reported a mean improvement of 31.1 and 4.2 in Nonarthritic Hip Score and visual analog scale, respectively. Of the 3 studies, the percentile of patients surpassing minimal clinically important difference and patient acceptable symptomatic state ranged between 50% and 100% and 33.3% and 88.8%, respectively. Overall, 5 patients underwent revision hip arthroscopy due to adhesions, iliopsoas impingement, and persistent microinstability, and 3 patients underwent a secondary hip arthroplasty due to refractory pain and radiographic evidence of hip osteoarthritis. CONCLUSION: Reconstruction of the LT may be considered in surgical management for patients with symptomatic hip instability due to soft-tissue causes. Current evidence supports for LT reconstruction predominantly for patients experiencing refractory instability following previous hip preservation procedures. Patients' expectations as well as the relatively high reoperation rate (i.e., 33%) should be discussed before the procedure. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

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

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

Patient-Reported Outcomes in Athletes Following Hip Arthroscopy for Femoroacetabular Impingement With Subanalysis on Return to Sport and Performance Level: A Systematic Review.

PURPOSE: To identify present trends in demographics, surgical indications, preoperative findings, and surgical treatment of athletes undergoing hip arthroscopy for femoroacetabular impingement and (2) to investigate the outcomes in this patient population, including patient-reported outcome scores (PROS), return-to-sport, complications, and reoperation data at minimum 2-year follow-up in the athletic population. METHODS: Cochrane, Embase, and PubMed databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to distinguish articles that reported PROS after hip arthroscopy in athletes. Athletes were defined as anyone who played a sport for minimum 2 years at any level. The standardized mean difference was calculated to compare the effect size of hip arthroscopy on various PROS. RESULTS: Eighteen studies, with 904 athlete hips and a collective study period of January 1993 to April 2017, were included in this systematic review. Across all studies, the mean age and body mass index ranged from 15.7-36.7 years and 20.3-26.3, respectively. The follow-up range was 24-240 months. Mean preoperative alpha angle ranged from 57.7° to 80.0°. Athletes most commonly underwent femoroplasty and labral management. At latest follow-up, the modified Harris Hip Score were excellent in 6 studies (range, 92.1-98), good in 10 studies (range, 84.2-88.5), and fair in 1 study (77.1). Each studies' individual athletic cohort showed significant improvement on the modified Harris Hip Score, Nonarthritic Hip Score, the Hip Outcome Score-Activities of Daily Living, the Hip Outcome Score-Sport-Specific Subscale, visual analog scale for pain, and International Hip Outcome Tool at latest follow-up (P < .05). The return-to-sport rate ranged from 72.7% to 100%, with 74.2-100% of these athletes returning to preinjury or greater level. CONCLUSIONS: Athletes undergoing arthroscopic hip surgery in the setting of femoroacetabular impingement, not only exhibit significant functional improvement, but also have a high rate of return to sport at the same or greater competition level compared with preinjury level. LEVEL OF EVIDENCE: IV, systematic review of Level III and IV studies.

Asymptomatic Gluteal Tendinopathies Negatively Impact Outcomes of Total Hip Arthroplasty: A Propensity Score-Matched Study.

BACKGROUND: The purpose of this study is to compare outcomes after total hip arthroplasty (THA) in patients with preoperative asymptomatic gluteus medius and minimus (GMM) pathology to a control group with no GMM pathology. METHODS: Patients undergoing THA for osteoarthritis between August 2012 and March 2018 were retrospectively reviewed. Asymptomatic GMM pathology was considered as the presence of gluteal tendinopathy diagnosed by magnetic resonance imaging (MRI) without the following clinical symptoms: Trendelenburg gait or test, abductor weakness, and lateral thigh tenderness. Patients with asymptomatic GMM pathology were matched (1:1) to patients without GMM pathology on MRI. Two-year data were collected on patient-reported outcomes including Harris Hip Score, Forgotten Joint Score, pain, and satisfaction. Postoperative clinical examination, radiographic measures, complications, and revisions for both groups were reviewed. RESULTS: Fifty cases of asymptomatic GMM pathology were successfully matched to 50 hips without GMM pathology on MRI. Patients with asymptomatic GMM pathology demonstrated significantly worse outcomes regarding 2-year Harris Hip Score (86.24 vs 92.39, P = .04), VAS for pain (1.82 vs 0.98, P = .05), and patient satisfaction (7.69 vs 9.16, P = .002). The study group exhibited significantly higher rates of lateral hip pain postoperatively. Two cases (4%) in the control group underwent a revision THA and 4 cases (8%) in the study group underwent revision THA. CONCLUSION: In patients undergoing THA for osteoarthritis, those with asymptomatic GMM pathology experience inferior 2-year postoperative patient-reported outcomes compared to a matched group. This finding should raise awareness surrounding this important pathology's negative impact on surgical outcomes, thus warranting increased vigilance, and possibly justifying concomitant treatment, even in cases of asymptomatic GMM tears. LEVEL OF EVIDENCE: Level III - Retrospective comparative prognostic study.

Minimum Five-Year Outcomes of Hip Resurfacing: Propensity-Score Matched Against Total Hip Arthroplasty Control Groups.

BACKGROUND: The aim of this study is to evaluate clinical outcomes of patients undergoing Birmingham hip resurfacing (BHR) with a minimum 5-year follow-up and compare these outcomes to 2 matched control groups of patients undergoing either direct anterior approach (DAA) or posterior approach (PA) total hip arthroplasty (THA). METHODS: Data between September 2008 and April 2015 were retrospectively reviewed. Male patients were included if they underwent a THA or BHR with minimum 5-year patient-reported outcomes. BHR patients were propensity-score matched in a 1:1 ratio to 2 control groups of patients: one group who underwent DAA THA and one group who underwent PA THA. RESULTS: Fifty BHR patients were propensity-score matched to 2 control groups: 50 cases of PA THA and 50 cases of DAA THA. Both control groups were well matched with respect to demographics. The BHR 5-year patient-reported outcomes were comparable to both control groups. The BHR cohort compared favorably to the PA THA group with no significant differences in their average Forgotten Joint Score (77.9, 79.4, P = .84 respectively) and the number of patients reporting a score greater than or equal to 50 were also comparable, 41 (82%), 42 (84%), P = .79 respectively. CONCLUSION: BHR yielded good functional status and outcomes, which compared favorably with control groups of DAA THA and PA THA. Decision-making should be based upon other factors such as potential risk factors, the surgeon's and patient's preferences, and the patient's physical demand.

Return to play after hip arthroscopy among tennis players: outcomes with minimum five-year follow-up.

BACKGROUND: Playing tennis is associated with various movements that can lead to labral injuries and may require arthroscopic surgery. While hip arthroscopies have demonstrated good outcomes in athletes, there is limited literature reporting patient reported outcomes (PROs) and return to sport (RTS) in competitive or recreational tennis players after arthroscopic hip surgery. Therefore, the purpose of the present study was to (1) report minimum five-year PROs and RTS in tennis players who underwent arthroscopic hip surgery and (2) compare outcomes between recreational and competitive tennis players. METHODS: Data for patients who underwent hip arthroscopy surgery in the setting of femoroacetabular impingement and labral tears between March 2009 and January 2014 and who played tennis within one-year of surgery were retrospectively reviewed. Patients with preoperative and minimum five-year postoperative scores for the following PROs were included: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patient Acceptable Symptomatic State (PASS) and Minimal Clinically Important Difference (MCID) for mHHS and HOS-SSS were calculated. RESULTS: Of 28 patients, 31 hips met all inclusion and exclusion criteria of which 28 (90.3%) had minimum 5-year follow-up (mean: 72.8 ± 13.9 months). There were 3 professional, 3 collegiate, 2 high school, 2 organized amateur, and 18 recreational level tennis players. All PROs significantly improved at latest follow-up: mHHS from 67.0 to 86.7 (P <  0.001), NAHS from 65.9 to 87.2 (P <  0.001), HOS-SSS from 50.0 to 77.9 (P = 0.009), and VAS from 5.4 to 1.8 (P <  0.001). There was a 75.0% RTS rate. Additionally, 66.7% of patients achieved MCID and 83.3% achieved PASS for mHHS, and 63.6% achieved MCID and 58.3% achieved PASS for HOS-SSS. CONCLUSION: Regardless of the level of participation, tennis players who underwent arthroscopic hip surgery reported statistically significant PRO improvements. A favorable rate of RTS was also achieved by players with a continued interest in playing. The data here may be useful in counseling tennis players of various levels who are considering arthroscopic treatment of a hip injury. LEVEL OF EVIDENCE: IV.

Editorial Commentary: Finally, a Salvage Procedure for Hip Capsular Insufficiency!

Capsular management during hip arthroscopy can influence the outcome of the operation for better or for worse. Capsulectomy and unrepaired capsulotomy can lead to residual hip instability. Capsular repair has been associated with improved outcomes after surgery compared with unrepaired capsulotomies. Repair or plication of the capsule can be facilitated by effective capsular elevation during central- and peripheral-compartment work. If capsular deficiency is present in a symptomatic patient with continued instability, capsular reconstruction is a viable option.

Arthroscopic Ligamentum Teres Reconstruction: Minimum 2-Year Patient-Reported Outcomes With Subanalysis of Patients With Ehlers-Danlos Syndrome.

PURPOSE: To report on minimum 2-year outcomes of patients undergoing arthroscopic ligamentum teres reconstruction (LTR). METHODS: Our institutional registry was retrospectively reviewed for all patients undergoing LTR between December 2012 and February 2016. LTR was indicated for a fully torn or dysfunctional ligamentum teres with symptomatic multidirectional instability not treatable by osteotomy or capsular plication alone. Demographic data, preoperative clinical and radiographic measures, and intraoperative data were recorded. Patient-reported outcome measures including the modified Harris Hip Score, the Non-Arthritic Hip Score, a visual analog scale score for pain, and patient satisfaction were recorded preoperatively and annually postoperatively. Revision arthroscopies and conversions to total hip arthroplasty were recorded. RESULTS: Twelve reconstruction procedures were performed in 10 patients during the study period. Minimum 2-year follow-up was available for 9 patients (11 hips). The mean follow-up time was 44.27 months (range, 24-72 months). There were 7 female and 2 male patients, and the mean age was 30.34 years (range, 17.23-43.68 years). Two hips underwent conversion to total hip arthroplasty at a mean of 21.12 months. For the remaining patients, significant improvements were observed in the modified Harris Hip Score (from 44.1 to 71.8), Non-Arthritic Hip Score (from 47.5 to 78.6), and visual analog scale score (from 7.8 to 3.6) (P < .05). The average patient satisfaction rating was 7.88 (range, 4-10). Subanalysis of 5 patients (7 hips) with a diagnosis of Ehlers-Danlos syndrome showed a higher failure rate in this group. CONCLUSIONS: Although LTRs are indicated and performed only in a select group of patients, the procedure can provide meaningful improvement in patient-reported outcomes, pain reduction, and patient satisfaction. However, most patients undergoing LTR at present have underlying factors that significantly mitigate their prognosis, such as Ehlers-Danlos syndrome or failed previous surgery. Because these patients represent a subset of patients with complex hip pathologies in whom treatment is difficult, the expectations of surgery should be set accordingly. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series.

Mid-Term Outcomes of Endoscopic Gluteus Medius Repair With Concomitant Arthroscopic Labral Treatment: A Propensity-Matched Controlled Study.

PURPOSE: To report mid-term outcomes of patients who underwent endoscopic gluteus medius (GM) repair with arthroscopic labral treatment and to compare them with a control cohort of patients who underwent arthroscopic labral treatment without an endoscopic GM repair. METHODS: Data were prospectively collected and retrospectively reviewed for all patients who underwent primary hip arthroscopy between February 2008 and August 2013. Patients were included if they underwent arthroscopic labral treatment, endoscopic GM repair, and had preoperative with minimum 5-year follow-up for the following patient-reported outcomes: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sports Specific Subscale (HOS-SSS). Propensity score matching was used to create a control cohort of patients who underwent primary arthroscopic labral treatment without GM repair. RESULTS: There were a total of 46 patients with GM repair eligible for the current study, of whom 43 (93.5%) had 5-year follow-up. The average follow-up time was 73.4 months. At minimum 5-year follow-up, all PROs significantly improved (P < .001). Among the entire GM repair cohort, rates for achieving the patient acceptable symptomatic state (PASS) for mHHS, HOS-SSS, and international Hip Outcome Tool (iHOT-12) were 74.4%, 51.9%, and 71.8%, respectively. Rates for reaching a minimal clinically important difference for mHHS, NAHS, and HOS-SSS were 79.5%, 89.7%, and 73.1%, respectively. When the GM repair cohort was matched, there were 37 cases in the GM repair cohort and 78 in the control cohort. The GM repair cohort outcomes compared satisfactorily to the control cohort for mHHS (82.3 vs 82.6), NAHS (81.9 vs 82.3), and HOS-SSS (66.3 vs 67.5). Rates of achieving minimal clinically important difference and PASS for mHHS, NAHS, HOS-SSS, and iHOT-12 were also favorable. CONCLUSIONS: Endoscopic GM repair with arthroscopic labral treatment results in safe, durable, and significant improvement in PROs at a minimum 5-year follow-up. The outcomes compared favorably with a control cohort without GM tears. LEVEL OF EVIDENCE: III, retrospective comparative study.

Circumferential Labral Reconstruction for Irreparable Labral Tears in the Primary Setting: Minimum 2-Year Outcomes With a Nested Matched-Pair Labral Repair Control Group.

PURPOSE: (1) To report minimum 2-year patient-reported outcome (PRO) scores of primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare these PROs with a matched-pair primary labral repair group. METHODS: Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary circumferential labral reconstruction with anterior tibialis tendon allograft during February 2016 to April 2017 for irreparable labral tears and FAIS and had preoperative and minimum 2-year follow-up for modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale, Non-arthritic Hip Score, International Hip Outcome Tool 12 (iHOT-12), 12-Item Short Form Health Survey physical component and mental component, Veterans RAND 12-Item Health Survey physical component and mental component, and visual analog scale for pain. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, Tönnis grade 2 or higher, or dysplasia (lateral center-edge angle ≤ 18°). Labral tears were considered irreparable if the labrum appeared (1) to be mostly or completely calcified and (2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was matched 1:3 based on age, sex, and body mass index to a benchmark control group of hips undergoing labral repair from the same period. The minimal clinically important difference and patient acceptable symptomatic state for the mHHS and iHOT-12 score were calculated. RESULTS: A total of 37 hips (37 patients) underwent circumferential labral reconstruction. There were 19 female patients (51.4%) and 18 male patients (48.6%). The mean age was 45.6 ± 11.6 years, and the average body mass index was 27.1 ± 5. At minimum 2-year follow-up, the circumferential labral reconstruction group showed statistically significant improvements in the mHHS, Non-arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, iHOT-12 score, and visual analog scale score. All hips in the reconstruction group were successfully matched to 111 labral repair hips. At latest follow-up, improvements in all PROs between the 2 groups were comparable. The revision rates were 0% and 3.6% in the reconstruction and repair groups, respectively. CONCLUSIONS: After primary hip arthroscopy, primary circumferential labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS and irreparable labral tears resulted in significant improvements in several PROs at minimum 2-year follow-up and high patient satisfaction. Primary circumferential labral reconstruction reached comparable functional outcomes to those of a benchmark matched-pair primary labral repair control group. LEVEL OF EVIDENCE: Level III, case-control study.

Do Demographic or Anthropometric Factors Affect Lateralization of the Tibial Tubercle in a Diverse Population? A Magnetic Resonance Imaging Analysis.

INTRODUCTION: The tibial tubercle-trochlear groove (TT-TG) distance is commonly used to evaluate and guide treatment for patellar instability. There is limited data available regarding TT-TG variability based on patient demographics and anthropometric factors. MATERIALS AND METHODS: TT-TG was measured on magnetic resonance imaging (MRI) for 384 consecutive adult patients. Demographic information for the corresponding was then gathered from the medical record and analyzed. Demographic variables analyzed included age, sex, race, height, weight, and body mass index (BMI). RESULTS: Mean TT-TG among the 384 patients was 12.68mm (standard deviation [SD]: 4.13mm, 95% confidence interval [CI] 12.26-13.10mm, range, 3.2-27.0mm), and there was a significant correlation with height (p=0.009), weight (p=0.017), and race (p<0.001). However, there was no significant correlation seen with sex (p=0.854), BMI (p=0.253), or age (p=0.096). Height and African American race were identified as independent predictors of increased TT-TG (p=0.007 and p<0.001, respectively); and females were found to have an increased TT-TG relative to height (p=0.015). CONCLUSION: Tibial tubercle-trochlear groove distance was significantly correlated with race and height in the 384 patients examined. These findings may help explain clinical differences in these patients and help establish "norms" for patients of various ethnic and anthropometric variability.

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

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

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

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

Return to Activity After Gluteus Medius Repair in Active Patients Older Than 50 Years.

BACKGROUND: Gluteus medius (GM) tears are a known cause of dysfunction and disability predominantly in older women. PURPOSE: To report on return to activity, patient-reported outcomes (PROs), and a uniquely calculated minimal clinically important difference (MCID) at a minimum 2-year follow-up for active patients who had undergone either an endoscopic or an open GM repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients were considered eligible if they (1) underwent a GM repair with or without concomitant central and peripheral compartment procedures; (2) had baseline preoperative and minimum 2-year scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain; and (3) participated in a physical activity or sport within 1 year before their surgery. Return to activity was defined as the patient being able to participate in his or her activity at a minimum of 2 years postoperatively. RESULTS: Of 87 eligible patients, 84 (96.6%) met all inclusion criteria. The mean follow-up was at 44.5 months. Six patients (7.1%) underwent an open GM repair, while the remaining 78 (92.9%) underwent an endoscopic GM repair. Concomitant central and peripheral compartment arthroscopic procedures were performed in 69 patients (82.1%). All PROs significantly (P < .001) improved as follows: mHHS, from 59.0 to 85.8; NAHS, from 57.9 to 84.0; HOS-SSS, from 32.6 to 63.7; and VAS pain, from 5.4 to 1.9. A total of 57 patients (67.9%) returned to their preoperative activity at the 2-year follow-up. The MCID was calculated for the mHHS, NAHS, and HOS-SSS to be 7.5, 7.4, and 10.9, respectively, with 79.3%, 86.4%, and 70.2% of patients achieving the MCID for each respective PROs. CONCLUSION: Active patients over the age of 50 years may benefit from endoscopic or open repair of GM tears, as the majority of patients in our cohort were able to return to their activity of choice. All measured PROs had significantly improved at a minimum 2-year follow-up, with high survivorship, satisfaction, and clinical effectiveness. Patients with partial-thickness tears compared with full-thickness tears and those who underwent isolated GM repair compared with GM repair with concomitant procedures had similar return to activity rates and PROs at the latest follow-up.