Risk factors for prolonged opioid consumption following hip arthroscopy: A secondary analysis of the Femoroacetabular Impingement RandomiSed controlled Trial and embedded cohort study.

PURPOSE: The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study. METHODS: Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage state that may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively. RESULTS: A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001). CONCLUSION: Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco use and more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery. LEVEL OF EVIDENCE: Level III.

Adhesions Post Hip Arthroscopy are Associated with Revision but Demonstrate Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review.

PURPOSE: To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions developed following hip arthroscopy (HA). METHODS: A systematic search of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL was designed and conducted in accordance with PRISMA guidelines. Eligible studies included patients with confirmed adhesions following HA, with one or more of the following reported: i) diagnostic procedures and criteria employed, ii) indications for and details surrounding surgical management, and iii) clinical outcomes following the operative management of adhesions (e.g., patient-reported outcome measures (PROMs), etc.). RESULTS: Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female) were included in this review. The quality of evidence was found to be fair for both comparative (mean = 17; range, 13-21) and non-comparative (mean = 10; range, 5-12) studies according to the Methodological Index for Non-Randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intra-operatively at the time of revision surgery (n = 10/19; 53%), with only three studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (n = 9/19; 47%), but this was often grossly stated for revision HA, rather than being specific to adhesions. PROMs were the most reported post-operative outcomes (n = 9/19; 47%), and generally demonstrated significant improvement from pre-operative assessment across the short-term follow-up period (range, 24.5 to 38.1 months). There was a paucity of objective measures of clinical improvement (n = 3/19; 16%), and an absence of mid-to-long term follow-up (i.e., 5-7 years, and ≥10-years, respectively). CONCLUSION: Despite increasing evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, while the operative management of adhesions post HA has demonstrated satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid-to-long term outcomes, and minimal employment of objective assessment (e.g., biomechanics) of clinical improvement.

The McMaster osteotomy-a novel surgical treatment to chronic slipped capital femoral epiphysis: description of surgical technique and case study.

Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder that can lead to complex proximal femur deformities and devastating consequences such as avascular necrosis, femoroacetabular impingement syndrome and early-onset osteoarthritis. Existing surgical techniques are often insufficient to fully address the constellation of multiplanar deformities in patients with severe SCFE. Therefore, the McMaster Osteotomy, a novel intertrochanteric proximal femur osteotomy, was developed to improve anatomic correction and hip mechanics in patients with chronic SCFE. The McMaster Osteotomy was implemented in two patients (A: 16-year-old male, B: 17-year-old female) with proximal femur deformities due to chronic SCFE. Surgical planning was facilitated with a 3D-printed pelvic model generated from a CT scan of a patient with the SCFE deformity. Patient B also underwent concurrent arthroscopic osteochondroplasty and labral repair. Pre- and post-operative function and radiographic measurements were recorded. Post-operatively, patient A's neck-shaft angle improved from 125° to 136°, Southwick angle from 52° to 33°, neck length from 66 mm to 80 mm and hip internal rotation from 5° to 25°. Patient B's post-operative neck-shaft angle improved from 122° to 136°, Southwick angle from 25° to 15°, neck length from 76 mm to 84 mm, hip internal rotation from 5° to 20° and alpha angle from 87.6° to 44.3°. Both patients are pain-free and have obtained full union of their osteotomies. The McMaster Osteotomy is a versatile technique that can produce a more anatomic reconstruction of hip anatomy and restoration of abductor mechanics. As an extracapsular technique, the risk of femoral head avascular necrosis is minimized.

Labral Repair, Reconstruction, and Augmentation Improve Postoperative Outcomes in Patients with Irreparable or Hypoplastic Labra: A Systematic Review.

PURPOSE: To review the postoperative outcomes of arthroscopic surgical options in treating irreparable and hypoplastic labrum of the hip. METHODS: Three online databases (PubMed, MEDLINE, EMBASE) were searched from database inception to June 27, 2023 to identify literature on treatment strategies for hypoplastic/irreparable acetabular labrum. Data pertaining to classification of irreparable tears or labral hypoplasia, indication for surgery, description of treatment, radiographic findings, and clinical outcomes were recorded and described. The methodological quality of included studies was assessed by the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Seven level IV case series, eleven level III retrospective cohort studies, and two level II prospective cohort studies comprising 1,937 patients were included for analysis. Studies were divided into an irreparable labral group comprising 1,002 patients and a hypoplastic labral group comprising 935 patients. Treatments included repair, augmentation, or reconstruction. In the irreparable group, 12 studies recorded improvement of modified Harris Hip Score (mHHS) with preoperative scores ranging from 50.3-67.3 and postoperative scores ranging from 76.2-95.0. The rate of conversion to total hip arthroplasty (THA) and rate of revision arthroscopy were 6.6% and 5.9%, respectively across all studies. In the hypoplastic group, two studies that focused on repair noted no statistical difference in mHHS for repair in hypoplastic labrum vs repair in non-hypoplastic labrum. One study showed that there was a difference in post-operative mHHS for labral repair for hypoplastic vs non-hypoplastic labrum, with repair in non-hypoplastic labrum showing superior mHHS (p <0.001). CONCLUSION: The findings of this review suggest that treatment of irreparable labra with reconstruction or augmentation results in improved patient reported outcome measures (PROMs). For the hypoplastic labrum, primary repair also results in improvement in PROMs. Future studies focusing on the hypoplastic labra alone with an appropriate control group, rather than irreparable labral tears are needed to properly assess patient outcomes and guide surgical indications.

Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: A systematic review and economic analysis.

IMPORTANCE: Anterolateral augmentation during primary anterior cruciate ligament (ACL) reconstruction (ACLR) may lower rates of ACL graft failure. However, differences in costs between two techniques, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are unclear. OBJECTIVE: To perform a systematic review and subsequent cost-effectiveness analysis comparing LET versus ALLR in the setting of primary ACLR. The hypothesis was that LET is more cost-effective than ALLR. EVIDENCE REVIEW: A systematic review was conducted on studies in which patients underwent primary ACLR with a concomitant LET or ALLR with minimum 24 months follow-up published between January 2013 and July 2023. Primary outcomes included ACL graft failure rates and Knee Injury and Osteoarthritis Outcome Survey-Quality of Life (KOOS-QoL) subscale scores, which were used to determine health utilities measured by quality-adjusted life years (QALYs) gained. A decision tree model with one-way and two-way sensitivity analyses compared the cost of primary ACLR with a concomitant LET, independent autograft ALLR, or independent allograft ALLR. Costs were estimated using a combination of QALYs, institution prices, literature references, and a survey sent to 49 internationally recognized high-volume knee surgeons. FINDINGS: A total of 2505 knees undergoing primary ACLR with concomitant LET (n=1162) or ALLR (n=1343) were identified from 22 studies. There were 77 total ACL graft failures with comparable failure rates between patients receiving LET versus ALLR (2.9% vs. 3.2%, P=0.690). The average QALYs gained was slightly higher for those who received LET (0.77) compared to ALLR (0.75). Survey results revealed a 5 minute longer median self-reported operative time for ALLR (20 â€‹min) than LET (15 â€‹min). The estimated costs for LET, autograft ALLR, and allograft ALLR were $1,015, $1,295, and $3,068, respectively. CONCLUSIONS AND RELEVANCE: Anterolateral augmentation during primary ACLR with LET is more cost-effective than independent autograft and allograft ALLR given the lower costs and comparable clinical outcomes. Surgeons may utilize this information when determining the optimal approach to anterolateral augmentation during primary ACLR, although differences in preferred technique and health care systems may influence operative efficiency and material costs. LEVEL OF EVIDENCE: Systematic review; Level of evidence, IV.

Editorial Commentary: Borderline Hip Dysplasia Combined With Increased Anteversion and Ligamentum Teres Disruption Is a Recipe for Hip Microinstability.

The ligamentum teres (LT) is known to play a role as a secondary stabilizer of the hip joint. LT tears can be associated with hip instability. In patients with borderline developmental dysplasia of the hip (BDDH), the correlation between LT tears and microinstability is even more pronounced because of the increased mechanical stress placed on the ligament. This relationship may lead certain surgeons to consider new indications for LT reconstructions. However, caution is warranted regarding the potential role of LT reconstruction in these patients, particularly since the primary deficiency in BDDH is bony undercoverage. Addressing this bony undercoverage should be a primary consideration that may be supplemented with other procedures, which may include addressing soft-tissue injuries around the hip such as LT tears. This is especially the case in those patients with persistent symptoms after management of labral tears or LT disruption.

Editorial Commentary: Standardized Evaluation of Cartilage Damage and Restoration in Hip Arthroscopy Requires Consideration of Clinical, Imaging, and Patient-Reported Outcomes.

Articular cartilage lesions of the acetabulum may result in significant pain and dysfunction for patients with treatment options consisting of either microfracture or various forms of cartilage restoration procedures. A systematic review of 529 patients demonstrated similar, if not lower, reoperation rates and patient-reported outcomes in patients receiving cartilage restoration procedures compared with microfracture. The primary outcomes examined in this review were reoperation rates and patient-reported outcomes with no clear mention of radiographic outcomes and no clearly defined indications as to who would benefit from a cartilage-based procedure. This raises the question as to whether there should be a consensus-based and standardized criteria established and standardized among the hip preservation expert community to evaluate the success of these cartilage restoration procedures from an imaging standpoint. These criteria can also be incorporated into a composite evaluation that combines clinical, imaging, and patient-reported outcomes to determine optimal patient candidacy for cartilage procedures as well. This would be a very useful steppingstone for much-needed future Level I randomized studies or prospective, registry-based data on this topic.

The Continuous Fragility Index of Statistically Significant Findings in Randomized Controlled Trials That Compare Interventions for Anterior Shoulder Instability.

BACKGROUND: Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes. PURPOSE: To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors. RESULTS: There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes (r = 0.23 [95% CI, 0.13-0.33]; P < .001). CONCLUSION: More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

Defining hip cartilage repair: a modified delphi study to establish the Magnetic Resonance Evaluation of the Repair of Cartilage in the Hip (MERCH) score.

PURPOSE: To develop a standardized scoring system to evaluate pre- to post-operative repair or reconstruction of hip cartilage using magnetic resonance imaging (MRI). METHODS: A two-phase modified Delphi study was conducted. Phase 1 involved a survey with suggested criteria and diagrams to define various stages of articular cartilage repair and phase 2 involved an expert consensus meeting that discussed the survey responses and voted on final scoring criteria. The survey was emailed to members of the Canadian Hip Preservation Research Collaborative (CHIPR) and respondents included both board certified orthopedic surgeons as well as musculoskeletal radiologists. RESULTS: Overall, there were 17 survey respondents from Canada and most (47%, 8/17) participants agreed that the minimum MRI protocol needed to evaluate cartilage repair was a 3.0 T MRI and 94% (17/18) agreed that the minimum time post-operatively that they felt they would be able to accurately evaluate cartilage repair on an MRI was 12 months. Following phases 1 and 2, the final Magnetic Resonance Evaluation of the Repair of Cartilage in the Hip (MERCH) score was developed with 7 domains, 3 criteria per domain: 1) volume fill of cartilage defect, 2) integration into adjacent cartilage, 3) surface of the repair tissue, 4) structure of the repair tissue, 5) bony overgrowth, 6) subchondral changes, and 7) delamination. The score ranges from 60 (optimal) to -20 points (worst/none). CONCLUSIONS: This consensus project established a new MRI scoring system to evaluate post-operative cartilage restoration of the hip. The implementation of the MERCH score is essential in our ability to guide patient management and expectations in a rapidly evolving field and will help with standardizing our evaluation of cartilage repair in future research trials. LEVEL OF EVIDENCE: Level II Diagnostic.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery.

Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design: Position statement. Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

Return-to-Sport Rates After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Flexibility Sports Athletes: A Systematic Review.

CONTEXT: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain in young adults. Flexibility athletes represent an interesting subset due to the extreme range of motion requirements of their sport. OBJECTIVE: The objective of this review was to provide a summary of the outcomes of hip arthroscopy for FAIS in patients who participate in flexibility sports. DATA SOURCES: Three online databases (Medline, Embase, and PubMed) were searched from database inception (1946, 1974, and 1966, respectively) to January 10, 2023. STUDY SELECTION: Studies were screened for literature addressing surgical outcomes for flexibility athletes undergoing hip arthroscopy for FAIS. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Various patient-reported outcomes that evaluated the efficacy of hip arthroscopy in this patient population were abstracted and presented in descriptive and analytical format. Abstraction was performed by 2 reviewers. RESULTS: Overall, a total of 8 Level 3 or 4 studies and 295 patients (312 hips) were included in this review. The pooled standardized mean differences for the Visual Analog Scale for pain score, Modified Harris Hip Score, Hip Outcome Score - Activity of Daily Living scale, and Hip Outcome Score - Sport-Specific Subscale all demonstrated significant improvement after undergoing arthroscopy for FAIS between 12 and 116 months (N = 175, -1.97, 95% CI -2.5 to -1.4, P < 0.01, I2 = 76%; N = 211, 1.82, 95% CI 1.49 to 2.16, P < 0.01, I2 = 52%; N = 164, 1.75, 95% CI 1.42 to 2.05, P < 0.01, I2 = 28%; N = 211, 1.71, 95% CI 1.38 to 2.04, P < 0.01, I2 = 52%, respectively). Across 289 patients, 75.6% to 98% returned to sport at a similar or higher level than presurgery. CONCLUSION: This review demonstrates a trend of improvement in patient-reported pain, function, quality of life, and return to sport at a minimum of 12 months among flexibility athletes after hip arthroscopy to treat FAIS.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis.

PURPOSE: To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis. METHODS: MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics. RESULTS: Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015). CONCLUSION: Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS. LEVEL OF EVIDENCE: I.

Editorial Commentary: Hip Arthroscopy Outcomes in Older Patients Can Equal Outcomes in Younger Patients With Proper Surgical Indications.

Hip arthroscopy patients often present with clinical features that help broadly categorize them as the younger patient with femoroacetabular impingement, the microinstability- or instability-related patient, those patients with predominant peripheral compartment disease, and the older patient with femoroacetabular impingement plus peripheral compartment disease. Outcomes in older patients can equal outcomes in younger patients with proper surgical indications. Specifically, older hip arthroscopy patients do well in the absence of degenerative articular cartilage changes. Although some studies have suggested a potential for greater conversion rate to hip arthroplasty in an older age group, with proper patient selection, hip arthroscopy may lead to durable and significant improvements.

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.

Outcomes After Hip Arthroscopy Show No Differences Between Sexes: A Systematic Review.

PURPOSE: To assess differences in postoperative outcomes between male and female patients following hip arthroscopy. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Cochrane, and PubMed databases were searched. Key words included "hip," "arthroscopy," "outcome," "gender difference," "sex difference," "gender," and "patient-reported outcome." Studies were included that reported sex-specific analysis of outcomes following primary hip arthroscopy with minimum 2-year follow-up. Methodological Index for Non-Randomized Studies criteria were applied to each study. Data collected included patient-reported outcome measures (PROMs), complications, rates of revision arthroscopy (RA), and conversion to total hip arthroplasty (THA). Forest plots were generated for the most frequently reported PROMs, RA, and THA rates. RESULTS: In total, 38 studies met the inclusion criteria, with 40,194 (57% female) hips included. The most common indications for hip arthroscopy were femoroacetabular impingement and labral tears. Eighteen studies reported PROMs, with no clear trend towards sex differences. Eleven studies reported on RA rates, with 4 showing a significantly greater rate of RA in female patients. Seventeen studies reported on conversion to THA, with an overall conversion rate of 9.64%. There were no clear sex differences in conversion to THA. CONCLUSIONS: There was no difference between sexes for postoperative PROM scores. Male patients were less likely to reach the MCID for the HOS-SSS than female patients in the majority of studies, and there were no sex differences for PASS rates. There were no significant differences between sexes in revision arthroscopy rates and conversion to total hip arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III and IV studies.