Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Hip arthroscopy is an effective treatment tool for athletes with femoroacetabular impingement (FAI) syndrome. However, long-term data are scarce. PURPOSE: To assess survivorship, minimum 10-year patient-reported outcome measures (PROMs), and sports participation after primary hip arthroscopy for FAI syndrome in athletes and to perform a propensity-matched comparison between patients undergoing labral debridement and labral repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Athletes who underwent hip arthroscopy for FAI syndrome between February 2008 and December 2010 were eligible. Exclusion criteria were other ipsilateral hip condition, Tönnis grade ≥2, or no baseline PROMs. Survivorship was defined as no conversion to total hip arthroplasty. The Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), maximum outcome improvement (MOI) satisfaction threshold, and sports participation were reported. A propensity-matched comparison between labral debridement and labral repair was performed. Two additional propensity-matched subanalyses were performed for capsular management and cartilage damage. RESULTS: In total, 189 hips (177 patients) were included. The mean ± SD follow-up was 127.2 ± 6.0 months. Survivorship was 85.7%. Significant improvement in all PROMs was reported (P < .001). A total of 46 athletes with labral repair were propensity matched to 46 athletes with labral debridement. This subanalysis demonstrated significant and comparable improvement in all PROMs at minimum 10-year follow-up (P < .001). For the labral repair group, the PASS achievement rates were 88.9% for the modified Harris Hip Score (mHHS) and 80% for the Hip Outcome Score-Sport Specific Subscale (HOS-SSS); the MCID achievement rates were 80.6% for the mHHS and 84% for HOS-SSS; and for the MOI satisfaction threshold, rates were 77.8%, 80.6%, and 55.6% for the mHHS, Nonarthritic Hip Score, and visual analog scale, respectively. For the labral debridement group, the PASS achievement rates were 85.3% for the mHHS and 70.4% for the HOS-SSS; the MCID achievement rates were 81.8% for the mHHS and 74.1% for HOS-SSS; and for the MOI satisfaction threshold, rates were 72.7%, 81.8%, and 66.7% for the mHHS, Nonarthritic Hip Score, and visual analog scale. Total hip arthroplasty conversions occurred significantly sooner with labral debridement than labral repair (P = .048). Age was identified as a significant predictor of achieving the PASS. CONCLUSION: Primary hip arthroscopy for FAI syndrome in athletes results in 85.7% survivorship and sustained PROM improvement at a minimum 10-year follow-up. A significant time delay to total hip arthroplasty conversion at 10-year follow-up was reported with labral repair over debridement, although this should be interpreted with caution, as the total number of conversions was small.

Patients Who Underwent Primary Hip Arthroscopy for Femoroacetabular Impingement with Acetabular Microfracture Show 77% Survivorship at 10-Year Follow-Up.

PURPOSE: To report minimum 10-year follow-up survivorship, defined as non-conversion to total hip arthroplasty (THA), and patient-reported outcome scores (PROS) after primary hip arthroscopy with acetabular microfracture in the setting of femoroacetabular impingement syndrome (FAIS) and acetabular chondral lesions, respectively. METHODS: Data were prospectively collected and retrospectively analyzed on all patients who underwent a primary hip arthroscopy and received an acetabular microfracture between June 2009 and January 2011. Patients with a minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain were included. If available, the minimum 10-year follow-up for the Hip Outcome Score-Sport-Specific Subscale was reported. The demographics, intraoperative findings, surgical procedures, PROS, rate of achieving the minimal clinical important difference (MCID), and secondary surgeries were analyzed and reported. RESULTS: Twenty-two hips (20 patients) were included in the study, and the mean follow-up time was 124.5 ± 2.2 months. There were 17 hips (77.3%) from males and 5 hips (22.7%) from females. The average patient age at the time of surgery was 42.3 years ± 9.6. All patients on average experienced statistically significant improvement (P < .05) between preoperative and minimum 10-year follow-up scores for all PROs. In total, 77.3% of the patients did not require conversion to THA. Additionally, 83.3% of the patients achieved the MCID for the mHHS, NAHS, and VAS for pain. CONCLUSION: At a minimum 10-year follow-up, survivorship of 77.3% was reported for patients who underwent primary hip arthroscopy with acetabular microfracture for the treatment of FAIS and focal/full-thickness acetabular cartilage lesions. Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated. LEVEL OF EVIDENCE: IV, case-series study.

Outcomes Following Primary Total Hip Arthroplasty With Concomitant Gluteus Medius Repair Using the Direct Anterior Approach.

Outcomes following total hip arthroplasty (THA) with concomitant gluteus medius (GM) repair using the direct anterior approach (DAA) are scarce. The primary purpose of this study was to report patient-reported outcome measures (PROMs) with 2-year follow-up of patients with osteoarthritis and GM tear who underwent primary THA and GM repair through the DAA. The secondary purpose was to compare these outcomes with a benchmark propensity-matched control group who underwent a DAA THA without GM tear. Patients were eligible if they received a primary THA and GM repair via the DAA between January 2015 and October 2018 and had baseline PROMs with 2-year follow-up. Patients were excluded if they had workers' compensation or were unwilling to participate. PROM subanalysis was performed between patients and a propensity-matched control group with DAA THA without GM tear. Fourteen patients were included in the study, all of whom were female. Significant improvement for all PROMs and high rate of achieving the minimal clinically important difference (MCID) at 2-year follow-up were reported. All patients were propensity-matched to 28 patients for sex, age, and body mass index. Preoperative PROMs between groups were similar, and both groups reported comparable improvement, satisfaction, and MCID achievement at 2-year follow-up. Primary THA with concomitant GM repair using the DAA yielded good functional outcomes and a high rate of MCID achievement at 2-year follow-up. Based on these results, the DAA can be used safely to address symptomatic GM tears during THA. Furthermore, these outcomes were comparable to a propensity-matched control group without GM tear. [Orthopedics. 2023;46(1):39-46.].

Minimum 5-Year Outcomes After Primary Segmental Labral Reconstruction for Irreparable Labral Tears in the Hip With Hamstring Grafts: With a Subanalysis Comparing Autograft Versus Allograft.

BACKGROUND: Comparable short-term outcomes have been obtained using hamstring allografts versus autografts after primary segmental labral reconstruction (SLR). Midterm results have not yet been determined. PURPOSE: (1) To evaluate minimum 5-year patient-reported outcome (PRO) scores in patients who underwent primary SLR with hamstring grafts in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare the outcomes of hamstring autografts versus allografts in a subanalysis using propensity-matched groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Prospectively collected data were retrospectively reviewed for patients who underwent primary hip arthroscopy between September 2010 and November 2015. Patients were included if they underwent SLR using hamstring autografts or allografts and had preoperative and minimum 5-year PROs. The exclusion criteria were previous ipsilateral hip surgery or conditions, dysplasia, or Tönnis grade >1. Patients with autograft SLR were propensity matched 1 to 1 based on age, sex, and body mass index (BMI) to patients who underwent SLR using hamstring allografts. The minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) were calculated. RESULTS: Overall, 48 patients (N = hips 48) were eligible to be included in this study, and 41 patients (n = 41 hips [85.4%]) had a minimum 5-year follow-up reporting significant improvements in all PROs. Within the entire cohort, 9.8% required a secondary arthroscopy, with a mean time of 19 ± 1.8 months, and survivorship was 82.9%. Of the 41 included patients, 15 underwent an SLR with a hamstring autograft and were matched to 15 patients with labral reconstruction using a hamstring allograft. Groups were similar for sex (P > .999), age (P = .775), and BMI (P = .486). The mean follow-up times were 80.8 ± 25.5 and 66.1 ± 8.3 months (P = .223) for the autograft and allograft groups, respectively. Baseline PROs, preoperative radiographic measurements, surgical findings, and intraoperative procedures were similar. The groups achieved significant and comparable improvements for all PROs (P < .0001), satisfaction (P = .187), and the rate of achieving the MCID and the PASS. However, a tendency for higher postoperative PROs favoring allograft reconstruction was found. CONCLUSION: At a minimum 5-year follow-up, patients who underwent primary arthroscopic SLR in the context of FAIS and irreparable labra, with either autograft or allograft hamstring tendons, reported significant improvements and comparable postoperative scores for all PROs, patient satisfaction, MCID, and PASS.

The Fragility Index of Total Hip Arthroplasty Randomized Control Trials: A Systematic Review.

INTRODUCTION: Although randomized controlled trials (RCTs) are considered the benchmark study design, a change of outcomes for a few patients can lead to a reversal of study conclusions. As such, examination of the fragility index (FI) of RCTs has become an increasingly popular method to provide further information regarding the relative robustness of RCT results. The purpose of this study was to systematically characterize and assess the predictors of the FI RCTs in total hip arthroplasty literature. METHODS: PubMed/MEDLINE, Embase, and Cochrane were systematically searched for all total hip arthroplasty RCTs published between January 2015 and December 2020, which had an equal assignment of participants to a two parallel-arm study design, examined a surgical intervention, and reported on at least one statistically significant dichotomous outcome in the abstract. Potential factors associated with the FI were examined using the Spearman correlation and Mann-Whitney U test. RESULTS: Thirty-four RCTs were selected, with a median number of study participants of 111 (interquartile range [IQR] 72-171] and a median total number of events of 15 (IQR 9.5 to 29). The median FI was 2 (IQR 1 to 6), while six studies had a FI of 0. In 18 cases (52.9%), the number of patients needed to change from no event to event was less than that loss to follow-up. Larger sample size was found to predictive of a higher FI (rs = 0.367, P = 0.033), but the year of publication, journal impact factor, the calculated power analysis size, and loss to follow-up were not associated with FI. CONCLUSION: The FI serves as a useful addition to other more commonly used approaches of quantitative analyses, such as P values, effect sizes, and confidence intervals, and widespread reporting the FI may provide clinicians with further information about RCT results. LEVEL OF EVIDENCE: Level I, systematic review of Level I studies.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity.

BACKGROUND: Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. PURPOSE: To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. RESULTS: A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively(P = .6288). The average body mass index was significantly higher in the male group (P < .0001). GLL was more common in women (38.6%) than men (13.6%) (P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) (P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° (P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). CONCLUSION: In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

Patients With Concomitant Painful External Snapping Hip and Femoroacetabular Impingement Syndromes Reported Complete Snapping Resolution With Release of the Gluteus Maximus and Iliotibial Band, and Comparable Minimum 2-Year Outcomes to a Propensity-Matched Control Group.

PURPOSE: To report minimum 2-year patient-reported outcome measures (PROMs) following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and painful external snapping hip (ESH) treatment and ESH resolution, and to compare these PROMs to a benchmark FAIS propensity-matched control group without ESH. METHODS: Data were prospectively collected and retrospectively reviewed between November 2009 and April 2018. Patients were eligible if they were preoperatively diagnosed with FAIS and painful ESH and received primary hip arthroscopy to address these pathologies. ESH was treated with gluteus maximus and iliotibial band releases. Inclusion criteria were baseline and minimum two-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1 and previous hip conditions. A secondary subanalysis was performed to benchmark these outcomes to a FAIS propensity-matched control group without ESH, according to age, sex, body mass index (BMI), Tönnis grade, and preoperative lateral center-edge and α-angles using a 1:3 ratio. The minimal clinically important difference (MCID) and the maximum outcome improvement (MOI) rates were reported. RESULTS: Twenty-two hips (21 patients) were included. The mean age, BMI, and follow-up were 31.3 years ± 14.0, 26 kg/m2 ± 5.0, and 31.4 months ± 4.4, respectively, with 68.2% being female. ESH was resolved in 100% of patients. Significant improvement for all PROMs at a minimum two-year (P < .001) was reported. The minimum two-year PROMs and the rate of achieving the MCID and MOI threshold were comparable to the control group. CONCLUSION: Following primary hip arthroscopy for FAIS and painful ESH, patients demonstrated significant improvement in all PROMs, and the rate of resolution of ESH was 100% at minimum two-year follow-up: with gluteus maximus and iliotibial band releases. Functional outcomes and rates of MCID and MOI achievement were comparable to a FAIS propensity-matched benchmark control group without ESH. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Total hip arthroplasty after pelvic osteotomy for acetabular dysplasia: A systematic review.

The purposes were (1) to investigate and compare the findings of patients undergoing total hip arthroplasty (THA) following a corrective pelvic osteotomy (PO), to a control group of patients who underwent THA but not PO and (2) to evaluate the outcomes and complications for secondary THA after PO. Three studies recorded reduced cup anteversion in the osteotomy group. Two studies reported higher PROs for the control group. The most common complication after failed PAO was dislocations. PO may entail challenges on a subsequent THA, illustrated by higher intraoperative blood loss, lower consistency in cup positioning and compromised patients reported outcomes.

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.

Borderline Dysplastic Female Patients With Painful Internal Snapping Improve Clinical Outcomes At Minimum 2-Year Follow-Up Following Hip Arthroscopy With Femoroplasty, Labral Repair, Iliopsoas Fractional Lengthening, and Capsular Plication: A Propensity-Matched Controlled Comparison.

PURPOSES: To report minimum 2-year follow-up patient-reported outcome scores (PROs) in borderline dysplastic female patients who underwent primary hip arthroscopy with femoroplasty, labral repair, iliopsoas fractional lengthening, and plication of the capsule (FLIP procedure) for cam-type femoroacetabular impingement syndrome (FAIS), labral tear, and painful internal snapping and to compare these PROs to a propensity-matched borderline dysplastic control group without painful internal snapping. METHODS: Data were retrospectively reviewed for patients who underwent primary hip arthroscopy for cam-type FAIS and labral tear between September 2008 and May 2017. Females with borderline dysplasia (lateral center-edge angle of ≥18° to ≤25°) and painful internal snapping, who underwent the FLIP procedure, with minimum 2-year PROs for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports-Specific Subscale, patient satisfaction, and visual analog scale (VAS) for pain were included. The group was matched 1:1 to a control group without painful internal snapping for age, sex, body-mass index (BMI), and surgical procedures. The minimal clinically important difference (MCID) was calculated. P-value was set at .05. RESULTS: Seventy-four hips were included. The mean was 26.82 ± 10.49 years and 23.62 ± 4.56 kg/m2 for age and BMI, respectively. Improvement was reported for all PROs and VAS (P < .0001). Twenty-nine patients were matched. At minimum 2-year follow-up, the FLIP procedure demonstrated comparable improvement in PROs and rate of achievement of MCID to the control group. CONCLUSION: After primary hip arthroscopy and FLIP procedure, females with borderline dysplasia and painful internal snapping demonstrated significant improvement in PROs at minimum 2 years' follow-up. When compared to a propensity-matched control group without painful internal snapping, the improvement between groups was comparable. LEVEL OF EVIDENCE: III; Case-Control study.

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.

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.

Outcomes of Open and Endoscopic Repairs of Chronic Partial- and Full-Thickness Proximal Hamstring Tendon Tears: A Multicenter Study With Minimum 2-Year Follow-up.

BACKGROUND: The preponderance of literature on the repair of proximal hamstring tendon tears focuses on the acute phase (<4 weeks). As such, there is a paucity of data reporting on the outcomes of chronic proximal hamstring tears. PURPOSE: To report minimum 2-year postoperative patient-reported outcome (PRO) scores, visual analog scale (VAS) for pain, and patient satisfaction from patients who underwent open or endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. STUDY DESIGN: Case series study; Level of evidence, 4. METHODS: Between April 2002 and May 2017, prospectively collected data from 3 tertiary care institutions were retrospectively reviewed for patients who underwent open and endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. Patients were included only if they had a chronic proximal hamstring tear (defined as ≥4 weeks from symptom onset to surgery). Patients were excluded if they had a tear treated <4 weeks after injury, underwent hamstring reconstruction, or claimed workers' compensation. Patients who reported minimum 2-year follow-up for VAS, patient satisfaction, and the following PROs had their outcomes analyzed: the modified Hip Harris Score, Non-arthritic Hip Score, iHOT-12 (International Hip Outcome Tool), and Hip Outcome Score-Sports Specific Subscale. RESULTS: Fifty patients (34 females and 16 males) were included in this study. There were 19 endoscopic repairs and 31 open repairs. Within the cohort, 52.0% had a full-thickness tendon tear on magnetic resonance imaging, and 48.0% had a partial tear. Average follow-up time was 58.07 ± 37.27 months (mean ± SD; range, 24-220 months). The mean age and body mass index of the group were 46.13 ± 13 years and 25.43 ± 5.14. The average time from injury to surgery was 66.73 weeks (range, 5.14-215.14 weeks). Average postoperative PROs were as follows: modified Hip Harris Score, 91.94 ± 9.96; Non-arthritic Hip Score, 91.33 ± 9.99; iHOT-12, 87.17 ± 17.54; Hip Outcome Score-Sports Specific Subscale, 87.15 ± 18.10; and VAS, 1.16 ± 1.92. Patient satisfaction was 8.22 ± 1.20. CONCLUSION: Patients who underwent open and endoscopic repairs for chronic partial- and full-thickness proximal hamstring tendon tears reported high PROs and satisfaction at a minimum 2-year follow-up with low rates of complications.

Combined Transfer of the Gluteus Maximus and Tensor Fasciae Latae for Irreparable Gluteus Medius Tear Using Contemporary Techniques: Short-Term Outcomes.

Combined transfer of the gluteus maximus and tensor fasciae latae (TFL) has been acknowledged as a treatment for irreparable full-thickness gluteus medius tears; yet, there is a paucity of reports on outcomes for this topic in the current literature. The purpose of the present study was to report short-term patient-reported outcome scores in patients who underwent combined transfer of the gluteus maximus and TFL in the setting of an irreparable gluteus medius tear. METHODS: Data for patients who underwent hip preservation and hip arthroplasty between July 2011 and November 2017 were prospectively collected and retrospectively reviewed. Patients were considered for this study if they had undergone combined transfer of the gluteus maximus and TFL for irreparable gluteus medius tears. Inclusion criteria consisted of patients who had a minimum 1-year follow-up for the modified Harris hip score, Non-Arthritic Hip Score, Hip Outcome Score Sports Specific Subscale, visual analog scale score for pain, and patient satisfaction. The exclusion criterion was Workers' Compensation status. RESULTS: The study included 18 hips in 18 patients who underwent combined transfer of the gluteus maximus and TFL, with a mean follow-up of 39.75 months (range, 12.04 to 93.88 months). The average age was 68.48 ± 11.05 years, the average body mass index was 29.54 ± 6.23 kg/m2, and 13 patients were female. Abductor strength improved in 7 of 17 patients, with abduction data unavailable for 1 patient. Significant improvements were observed in modified Harris hip score from 49.73 ± 16.85 to 74.94 ± 17.91 (p < 0.001), Non-Arthritic Hip Score from 55.02 ± 22.53 to 72.78 ± 19.17 (p = 0.032), and visual analog scale for pain from 5.42 ± 3.42 to 1.57 ± 1.68 (p = 0.0004). No secondary surgeries were reported. CONCLUSIONS: Significant improvements in patient-reported outcomes were observed in patients who underwent combined transfer of the gluteus maximus and TFL for the treatment of irreparable full-thickness gluteus medius tears at short-term follow-up. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Optimal Treatment of Cam Morphology May Change the Natural History of Femoroacetabular Impingement.

BACKGROUND: There is debate in the literature whether cam morphology is associated with increased risk for hip osteoarthritis. The capability of femoroplasty to alter the natural history of cam morphology is still in question. PURPOSE: To (1) investigate the correlation between cam morphology and damage to the articular cartilage and (2) assess whether correction of the cam morphology affects survivorship of the joint, progression to arthroplasty, and functional patient-reported outcome scores. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected for patients presenting for hip arthroscopy between February 2008 and April 2017. Cases were divided into 3 groups: control group with an alpha angle <50° pre- and postoperatively, treated group with an alpha angle >55° preoperatively and <50° postoperatively, and a group with an alpha angle >55° pre- and postoperatively. All patients had minimum 2-year postoperative follow-up for the modified Harris Hip Score, the Non-arthritic Hip Score, and visual analog scale for pain. Conversion to total hip arthroplasty was recorded. RESULTS: A 1:1:1 match successfully yielded 98 hips for each group. Follow-up time was 50.77 ± 24.60 months (mean ± SD). The pre- and postoperative mean alpha angles were 45.2°± 3.4° and 40.6°± 4.3° in the control group, respectively; 66.2°± 8.4° and 42.3°± 5.9° in the treated group; and 68.5°± 9.4° and 61.4°± 7.6° in the alpha >55° group. Intraoperatively, the alpha >55° and treated groups had greater acetabular cartilage damage than the control group (P = .0245 and P = .0036, acetabular labrum articular disruption, respectively; P = .0347 and P = .0211, acetabular Outerbridge). The alpha >55° group achieved the patient acceptable symptomatic state for the modified Harris Hip Score (58.2%) significantly less than the treated (75.5%; P = .0100) and control (73.5%; P = .0239) groups. Progression to arthroplasty was significantly higher in the alpha >55° group (n = 17) when compared with the control (n = 8) and treated (n = 10) groups (P = .0034 and P = .0338, respectively). CONCLUSION: Cam deformity was associated with higher-grade damage of the acetabular articular cartilage. An alpha angle >55° after surgery was associated with lower native hip joint survivability and less successful functional outcomes when compared with that of treated cam deformity as well as no deformity. These data suggest that correcting the cam deformity may positively affect the natural history of these patients.

Full-Thickness Gluteus Medius Tears With or Without Concomitant Hip Arthroscopy: Minimum 2-Year Outcomes Using an Open Approach and Contemporary Tendon Repair Techniques.

BACKGROUND: Gluteus medius (GM) tears are a well-established source of pain and disability. An open approach has been recognized with complete full-thickness and large GM tears, yet the current literature provides few reports on outcomes for this specific situation. PURPOSE: To report and analyze minimum 2-year patient-reported outcomes (PROs) from patients who underwent open GM repair in the setting of a full-thickness tear with or without concomitant hip arthroscopy through use of contemporary tendon repair techniques. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Prospectively collected data were retrospectively reviewed for patients who underwent hip preservation surgery and total hip arthroplasty (THA) between April 2008 and May 2017. Patients were included in this study if they underwent open repair of GM full-thickness tears. The exclusion criteria were incomplete follow-up, workers' compensation status, repair regarding size and pattern of the GM, open repair of partial GM tear, open repair with allograft or autograft augmentation, and/or additional gluteus maximus transfer. Pre- and postoperative PROs for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain and satisfaction were recorded. Statistical significance was set at P < .05. RESULTS: A total of 36 patients were included, of whom 12 received concomitant hip arthroscopy for intra-articular procedures. The mean ± SD age, body mass index, and follow-up time were 65.18 ± 12.69 years, 28.97 ± 4.95 kg/m2, and 40.8 ± 26.19 months, respectively. At minimum 2-year follow-up, the following outcome measures improved significantly: mHHS (from 54.72 ± 15.89 to 73.12 ± 19.47; P < .0001), NAHS (from 56.05 ± 12.47 to 75.22 ± 19.15; P < .0001); HOS-SSS (from 20.30 ± 20.21 to 44.23 ± 35.85; P < .0001), and VAS (from 4.95 ± 2.70 to 2.67 ± 2.81; P < .0001). There was 1 (2.8%) conversion to THA at 48 months after the index procedure. CONCLUSION: Patients who underwent open repairs in the setting of full-thickness GM tears via contemporary tendon repair techniques, with or without concomitant hip arthroscopy, achieved favorable results in several PRO scores at minimum 2-year follow-up.

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.

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.

Achieving a Perfectly Spherical Femoroplasty: Pearls, Pitfalls, and Optimal Surgical Technique.

Femoroacetabular impingement describes a pathologic interaction between the bony femoral head/neck junction and acetabulum. Cam-type femoroacetabular impingement results from an aspherical femoral head architecture, which increases early contact along the acetabular surface during hip range of motion. Errant arthroscopic femoroplasty recently has been discussed within the literature to describe a preventable etiology of failed hip arthroscopy, most notably cam over- and under-resection. We present an arthroscopic surgical technique for achieving the perfectly spherical femoroplasty, meant to minimize complications and improve postoperative outcomes.

Consensus-based classification system for intra-operative management of labral tears during hip arthroscopy-aggregate recommendations from high-volume hip preservation surgeons.

The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients >40 years of age and by >84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by >80% of respondents for patients ≤40 years of age and > 80% of respondents if the labral size was >3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was <3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.