Hip Disorders in Bull Riders: Clinical Observations and Outcomes of Arthroscopy.

Bull riders represent a microcosm of athletes in whom severe consequences of femoroacetabular impingement may challenge the limits of arthroscopic intervention. Observations of this cohort may provide meaningful insight into the treatment of other populations. All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris Hip Score. Sixteen consecutive bull riders (21 hips) with minimum 2-year follow-up are reported. The average age was 26 years, duration of symptoms was 33 months, and follow-up was 57 months. Arc of rotational hip motion averaged 31°. All had femoroacetabular impingement (17 combined and 4 cam impingements). Among the cam impingements, 1 also had dysplasia and 1 also had borderline dysplasia. Radiographic Tönnis grades were as follows: 2 Tönnis 1; 18 Tönnis 2; and 1 Tönnis 3. All had acetabular articular damage (14 Outerbridge grade 4; 6 Outerbridge grade 3; and 1 Outerbridge grade 1). Nine underwent microfracture. Four had accompanying femoral chondral lesions (3 grade 3; 1 grade 4). There were 20 labral tears (14 repaired and 6 debrided). All but 1 (95%) improved after surgery. One bilateral case underwent conversion to resurfacing arthroplasty on one side and revision arthroscopy on the other. The average improvement was 21.3 points. Thirteen (81.25%) returned to bull riding at an average of 7 months. Among the 3 who did not return, each had undergone bilateral procedures. There were no complications. Femoroacetabular impingement can be a significant problem among bull riders. Limited range of motion, grade 4 articular damage, and Tönnis 2 radiographic changes may not preclude successful arthroscopic treatment, but advanced bilateral disease may be too much even for these hardened athletes. [Orthopedics. 2024;47(2):79-82.].

Endoscopic Hip Abductor Tendon Repair Results in Successful Outcomes With 5- to 10-Year Follow-up.

PURPOSE: To report the outcomes of endoscopic repair in a consecutive series of patients with follow-up ranging from 5 to 10 years. METHODS: Sixty-five consecutive hips in 63 patients (2 bilateral) undergoing endoscopic abductor tendon repair with minimum 5-year follow-up were assessed with the modified Harris Hip Score. The minimal clinically important difference (MCID) was determined as one-half the standard deviation of the amount of improvement. RESULTS: The mean age was 56.6 years (standard deviation [SD], 11.3 years), with 58 female and 5 male patients. Follow-up was obtained on 64 hips (98.5%) at a mean of 85 months (SD, 15.7 months). There were 33 full-thickness and 32 partial-thickness tears, with 40 gluteus medius tears, 23 medius and minimus tears, and 2 isolated minimus tears. Concomitant arthroscopy of the hip joint was performed in 50 patients (52 hips), including 15 with correction of femoroacetabular impingement. The mean modified Harris Hip Score was 48.4 (SD, 15.7) preoperatively and 83.4 (SD, 15.9) postoperatively, reflecting a mean improvement of 34.9 (95% confidence interval, 34.9 ± 4.3), with 92.2% of patients achieving the MCID of 8.7. There were no complications. Three patients underwent further surgery: One underwent total hip replacement at 11 months after abductor repair, one underwent repeated arthroscopy for joint debridement at 12 months after repair, and one underwent revision abductor repair at 6 years postoperatively. CONCLUSIONS: Collectively, with 5- to 10-year follow-up, patients undergoing endoscopic abductor tendon repair can respond exceptionally well, with 92.2% achieving the MCID, even among a heterogeneous group of partial- and full-thickness tears with single- and 2-tendon involvement undergoing single- and double-row repair. LEVEL OF EVIDENCE: Level IV, case series.

MRI Does Not Improve Inter- or Intrarater Reliability for Hip Arthritis Grading Systems.

BACKGROUND: Magnetic resonance imaging (MRI) scans and radiographs are often utilized in assessing for preoperative osteoarthritis in patients undergoing hip preservation surgery. PURPOSE: To determine if MRI scans improve inter- or intrarater reliabilities over radiographs for findings of hip arthritis. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Anteroposterior and cross-table lateral radiographs as well as a representative coronal and sagittal T2-weighted MRI scan were reviewed for 50 patients by 7 experienced subspecialty hip preservation surgeons, with a minimum experience of 10 years. Radiographs and MRI scans were assessed for joint space narrowing, subchondral cysts, osteophytes, subchondral sclerosis, Likert osteoarthritis grade (none, mild, moderate, or severe), and Tönnis grade. MRI scans were also evaluated for bony edema, heterogeneous articular cartilage, and chondral defects. Inter- and intrarater reliabilities were calculated utilizing the Fleiss method with a 95% CI. RESULTS: The scans of 50 patients (28 female and 22 male) with a mean age of 42.8 years (SD, 14.2 years; range, 19-70 years) were reviewed. Radiographs revealed fair agreement for joint space narrowing (κ = 0.25 [95% CI, 0.21-0.30]), osteophytes (κ = 0.26 [95% CI, 0.14-0.40]), Likert osteoarthritis grading (κ = 0.33 [95% CI, 0.28-0.37]) and Tönnis grade (κ = 0.30 [95% CI, 0.26-0.34). Radiographs revealed moderate agreement for subchondral cysts (κ = 0.53 [95% CI, 0.35-0.69]). MRI scans demonstrated poor to fair agreement for joint space narrowing (κ = 0.15 [95% CI, 0.09-0.21]), subchondral sclerosis (κ = 0.27 [0.19-0.34]), heterogeneous articular cartilage (κ = 0.07 [95% CI, 0.00-0.14]), Likert osteoarthritis grade (κ = 0.19 [95% CI, 0.15-0.24]), and Tönnis grade (κ = 0.20 [95% CI, 0.15-0.24]). MRI scans demonstrated substantial agreement for subchondral cysts (κ = 0.73 [95% CI, 0.63-0.83]). Intrarater reliabilities were statistically improved compared with interrater reliabilities, but no differences were found between radiographs and MRI scans for joint space narrowing, subchondral cysts, osteophytes, osteoarthritis grade, or Tönnis grade. CONCLUSION: Radiographs and MRI scans had substantial limitations and inconsistency between raters in evaluating common markers of hip osteoarthritis. MRI scans demonstrated strong reliability in evaluating for subchondral cysts but did not improve the interobserver variability of grading hip arthritis.

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation.

BACKGROUND: The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation. PURPOSE/HYPOTHESIS: Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for <0.00, slight for 0.00-0.20, fair for 0.21-0.40, moderate for 0.41-0.60, substantial for 0.61-0.80, and almost perfect for >0.80. RESULTS: A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities. CONCLUSION: Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms.

Hip Capsular Reconstruction Made Easy: The Timing and the Technique.

An iatrogenic capsular defect can be a major contributing factor to macroinstability of the hip. For this circumstance, capsular reconstruction may be appropriately indicated when the capsule cannot be primarily reconstituted. Severe dysfunction may accompany previous failed arthroscopy. This dysfunction should be assessed and addressed with a properly structured rehabilitation program prior to revision surgery. We describe a simplified technique for capsular reconstruction using a dermal allograft.

Make the Right Diagnosis: My Pearls for Working Up Hip-related Pain.

The origin of pain around the hip is commonly more elusive than other joints; often obscured by compensatory disorders. Hip problems tend to be multifactorial and require a multidisciplinary approach in the evaluation. The best strategy is to team with a capable physical therapist to unveil the layers of problems. Ultrasonography and imaging/ultrasound-guided injections can be the most valuable adjunct to the history and physical examination. Plain radiographs are an essential element in the workup. Magnetic resonance imaging can underestimate damage in the joint, but positive findings can sometimes be the normal consequence of age and activity. Magnetic resonance imaging is often as important for what it rules out as much as what it rules in. Computed tomography scans with 3-dimensional reconstructions can be especially helpful in surgical planning but are not used in routine screening, being thoughtful of radiation exposure even with low-dose protocols. Arthroscopic access to the hip is more challenging than other joints, and similarly, unlocking its clinical secrets can be more imposing as well.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success.

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Editorial Commentary: Hip Arthroscopy-A Microcosm in the Evolution of Arthroscopy in Sports Medicine.

Hip arthroscopy represents a microcosm in the evolution of arthroscopy within sports medicine. It has evolved right before our eyes over a condensed time frame with current-day techniques in arthroscopy and concepts in sports medicine. Early on, arthroscopy identified labral tears and other painful problems that had previously gone unrecognized and untreated because open procedures were rarely performed for these poorly defined conditions. The evolution of hip arthroscopy changed when femoroacetabular impingement was described and open surgical procedures were used for treatment. Open procedures for the hip, like the knee and shoulder before it, then evolved to less invasive arthroscopic methods. Techniques, technology, and understanding of hip disorders have all evolved simultaneously, resulting in a quickly changing landscape in the role of arthroscopy. And an improved focus has been gained on disorders other than femoroacetabular impingement that can lead to hip problems. This evolution is not novel because we have seen it in other joints, as well as among other general surgical procedures; most important, this evolution is not complete. Miles to go before we sleep.

Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process.

BACKGROUND: Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols. METHODS: The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting. RESULTS: Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants. CONCLUSION: We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

Arthroscopic Acetabular Labral Repair Using the Q-FIX Suture Anchor.

The goal of acetabular labral repair is to preserve/restore labral function. Maintaining labral function necessitates recreating the labrum's anatomy, especially avoiding a nonanatomic repair of the labrum to the acetabular rim. The purpose of this report is to detail the technique of acetabular labral repair using this Q-FIX all-suture anchor.

The Safety of Hip Arthroscopy within 3 Months of an Intra-Articular Injection.

BACKGROUND: Ultrasound-guided intra-articular hip injections have become a mainstay in the diagnosis and treatment of various hip disorders. Concern arises with regard to the chronological proximity of an injection to subsequent arthroscopy. Thus, the purpose of this study was to report the risk of postoperative infections among patients who have undergone an intra-articular corticosteroid injection within 3 months of hip arthroscopy. METHODS: In-office, ultrasound-guided, intra-articular hip injections were first performed at this center in 2011. Corticosteroid is used for therapeutic purposes in the presence of painful hip conditions to reduce joint symptoms, either to allow for more effective supervised physical therapy or simply as a last line of nonoperative management. A retrospective review of patient records was performed, identifying all patients who had undergone arthroscopy and had received an intra-articular injection of corticosteroid at this institution within 3 months of the surgical procedure. RESULTS: Five hundred patients underwent an ultrasound-guided intra-articular injection of corticosteroid within 3 months of a hip arthroscopy. The mean age was 37.6 years (range, 14 to 74 years), with 112 male patients and 388 female patients. The mean time between the injection and the arthroscopy was 59 days (range, 15 to 92 days). There were no postoperative infections. CONCLUSIONS: When both the injection and the procedure are performed in a tertiary referral center, an ultrasound-guided intra-articular injection of corticosteroid within 3 months prior to arthroscopy, at a mean time of 59 days, resulted in no postoperative infections among 500 cases and can represent an acceptably low rate of complication. To our knowledge, this is the largest reported series on this subject. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Labral Ossification and Sacroiliac Joint Disease: Could There Be a Link to an Autoimmune Etiology?

PURPOSE: To determine the prevalence of ipsilateral sacroiliac (SI) joint disease among patients with symptomatic femoroacetabular impingement (FAI) associated with labral ossification (LO) who underwent hip arthroscopy compared with a matched control group of patients with symptomatic FAI and no LO. METHODS: Computed tomography (CT) scans of all patients undergoing arthroscopic correction of FAI were obtained. The inclusion criterion for the study group was a diagnosis of FAI with a secondary diagnosis of LO made by plain radiography, CT, or magnetic resonance imaging or made intraoperatively. The exclusion criterion was the absence of evidence of LO. We reviewed 52 patients (56 hips) with LO to assess the SI joint and compared them with a control group matched by age, sex, and FAI type. The SI joints were graded according to the modified New York criteria. RESULTS: CT scans were available for evaluation of the ipsilateral SI joint in 28 patients (29 hips) with LO: 17 women and 11 men with an average age of 44.6 years (range, 26-56 years). Of the hips, 23 had combined FAI and 6 had pincer-type FAI. The control group consisted of 29 hips, exactly matched for sex and FAI type, with an average age of 44.8 years (range, 21-58 years). Grade 3 SI joint abnormalities were significantly more prevalent in the LO group (28%) than in the control group (7%, P = .037), and grade 0 or 1 changes (relatively normal SI joints) were significantly less common in patients with LO (38%) than in controls (72%, P = .008). Subanalysis showed that 35% of the LO group aged 45 years or younger had ipsilateral grade 3 SI joint abnormalities compared with none of the control patients aged 45 years or younger (P = .041). Grade 3 changes were found in 42% of male patients with LO compared with 8% of male controls (P = .155). Grade 3 changes were noted in 18% of women in the LO group compared with 6% of female controls (P = .601). CONCLUSIONS: Patients with symptomatic FAI and LO are more likely to show associated SI joint pathology than patients with FAI not involving LO. These differences are greatest among men and among patients aged 45 years or younger. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Editorial Commentary: Great Expectations or "We'll See," Said the Zen Master-Hip Arthroscopy Patient Selection.

Successful hip arthroscopy is most dependent on patient selection. Chief among the selection criteria are patient expectations. There are few objective contraindications to hip arthroscopy. Subjective contraindications may take precedence and can be less well defined. Paramount among these subjective considerations are unreasonable expectations. Efforts to quantitate patient expectations can be helpful to surgeons to avoid patient selection traps and unsuccessful outcomes.

Ultrasound-Guided Intra-Articular Injection of the Hip: The Nashville Sound.

Ultrasound-guided intra-articular injection has become a mainstay in the diagnosis and treatment of a variety of hip disorders. It is the single greatest adjunct to history and examination in the clinical assessment of hip problems and has substantial therapeutic value in the conservative management of symptomatic disorders, especially when used in conjunction with supervised physical therapy.

Arthroscopic Acetabular Labral Repair in Patients Over the Age of 60 Years: A Matched Case-Control Study.

PURPOSE: To report the results of labral repair in a population of patients older than 60 years and compare these with a matched population of younger adults. METHODS: We compared 21 consecutive patients older than 60 years undergoing labral repair with minimum 1-year follow-up with a contemporaneous group of 21 patients aged 18 to 55 years matched for sex, degree of chondral damage, and associated femoroacetabular impingement or dysplasia. RESULTS: Follow-up averaged 18.9 months (range, 12-24 months). The average age in the study group was 63.2 years (range, 61-71 years), and 20 patients had femoroacetabular impingement whereas 1 had dysplasia. Of these patients, 19 had acetabular articular damage (grade IV in 2, grade III in 11, grade II in 5, and grade I in 1) and 6 had femoral changes (grade IV in 1 and grade III in 5). The average age in the control group was 35.8 years (range, 20-54 years). We found average improvements of 28.1 points for the modified Harris Hip Score and 37.5 points for the International Hip Outcome Tool score within the study group and 21.2 points for the modified Harris Hip Score and 37.1 points for the International Hip Outcome Tool score within the control group. No statistically significant difference between the 2 groups was noted in the amount of improvement, with statistically and clinically significant improvements noted in both. Two study group patients underwent total hip arthroplasty (THA) at an average of 10 months, with 1 control group THA at 11 months. All 3 patients with conversion to THA had combined grade IV acetabular and grade III femoral damage. No repeated arthroscopies were performed and no complications occurred in either group. CONCLUSIONS: Patients older than 60 years can benefit from arthroscopic labral repair with improved outcomes, a modest rate of conversion to THA, and a small risk of complications. The results are comparable to those of younger adults. Combined bipolar grade IV and grade III articular damage may be a harbinger of conversion to THA regardless of age. LEVEL OF EVIDENCE: Level III, comparative therapeutic trial.

Piriformis Injection: An Ultrasound-Guided Technique.

Piriformis syndrome is an elusive condition that likely is overlooked and overdiagnosed in equal proportions. Image-guided injection of the muscle is an essential element in the assessment and management of this disorder. Ultrasonography allows visualization of the anatomy of the piriformis and its relation with the sciatic nerve. Ultrasound-guided injection of the muscle can be performed in an effective, reproducible fashion and, with careful attention to the details of the procedure, can be performed with minimal morbidity to the patient. This method has the advantage of being exceptionally well tolerated by the patient and can be performed in the office with minimal patient inconvenience and the opportunity for a real-time assessment of the patient's response to the injection. Our ultrasound-guided technique of piriformis muscle injection is detailed in this article.

Editorial Commentary: The Warrior Athlete: An Illustrative Microcosm in the War Against Hip Femoroacetabular Impingement.

From an orthopaedic perspective, our military personnel truly are warrior athletes. Distilling the information available in these subjects provides an enlightening microcosm of the management of femoroacetabular impingement (FAI). Symptoms associated with damage caused by FAI represent the culmination of a process present since childhood. Thus, while arthroscopic correction can result in significant improvement, it does not invariably result in full restoration of function. Numerous factors influence an individual's response to injury and recovery from surgery, including subjective parameters such as resiliency. Thus, function is not always based simply on objective parameters. In view of compelling literature to support the efficacy of arthroscopic correction and treatment of FAI, servicemen and women have historically been discriminated against by unilateral lack of coverage. This trend has only partly been reversed as it is now deemed acceptable for active-duty personnel but arbitrarily not for their dependent family members. The war on FAI goes on in terms of better understanding of the FAI enemy, better techniques and technology to use during the war, and better solicitation of the homeland resources for continuing this important battle.

Influence of Tönnis grade on outcomes of arthroscopy for FAI in athletes: a comparative analysis.

Based on a previously reported study, it is hypothesized that Tönnis 2 changes may not be a harbinger of poor results. The purpose is to report outcomes comparing Tönnis 2 changes to those with Tönnis 0&1 changes. Previously published outcomes (modified Harris Hip Score and return to sport) among 200 consecutive athletes undergoing arthroscopic correction of femoroacetabular impingement with minimum 1-year follow-up were correlated with the Tönnis grade. Independent variables of gender and age were also evaluated. Average age was 28.6 years (range 11-60), with 148 males and 52 females. The average improvement was Tönnis 0 23.1 points (n = 37), Tönnis 1 20.6 points (n = 113) and Tönnis 2 16.4 points (n = 48). A trend (P = 0.055) towards lower scores with increasing Tönnis grade was not statistically significant. There was both statistically (P < 0.01) and clinically (>8 patients) significant improvement across all Tönnis grades, and there was no statistically significant difference between Tönnis 0 and 1 compared with Tönnis 2 (P = 0.078). The percent that returned to sport was as follows: Tönnis 0 95%, Tönnis 1 92% and Tönnis 2 85%. A trend (P = 0.098) towards lower rates of return to sport with increasing Tönnis grade was not statistically significant, and there was no statistically significant difference between Tönnis 0 and 1 compared with Tönnis 2. Within each grade, there was no correlation with age, such that increasing age did not reflect lower scores. There was also no correlation with gender. Statistically and clinically successful outcomes can be encountered among athletes with Tönnis 2 radiographic features.