Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients.

Background: The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods: Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results: A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion: Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.

Comparable Injury to the Indirect Head of the Rectus Femoris During Interportal and Periportal Capsulotomy: A Cadaveric Study.

Background: There is concern for maintaining the integrity of the reflected head of the rectus femoris during arthroscopic hip joint access. Because of the proximity to the indirect head of the rectus femoris (IHRF), capsulotomy technique and capsular closure during routine hip arthroscopy may play a role in postoperative tendinitis. Purpose: To quantify the extent of injury sustained to the IHRF during interportal versus periportal capsulotomy for routine arthroscopic hip joint access. Study Design: Controlled laboratory study. Methods: A cadaveric study was conducted using 20 fresh-frozen cadaveric hips, in which hip joint access through a periportal capsulotomy (n = 10) or interportal capsulotomy (n = 10) was performed. Capsular closure followed by a layered dissection to the capsuloligamentous complex of the hip joint was then performed to localize the IHRF. Suture proximity to the tendon, tendon disruption, and the IHRF footprint was documented to the nearest 0.01 mm using digital calipers. Statistical analysis was performed using unpaired Student t tests. Results: The mean capsulotomy length for the interportal specimens was 19.27 ± 3.25 mm, and the mean medial and lateral capsulotomy length for the periportal specimens was 4.47 ± 1.60 and 4.26 ± 0.89 mm, respectively. There was violation of the tendon in 3 of 10 interportal specimens and 4 of 10 periportal specimens. There was no significant difference in the closest suture measured to the IHRF for specimens with versus without tendon violation, for either interportal or periportal capsulotomy. Conclusion: We found comparable outcomes with regard to violation of the IHRF between interportal and periportal capsulotomy, with no significant difference in suture proximity to the IHRF in specimens with or without tendon violation. There remains no consensus on the ideal method by which to avoid iatrogenic damage to the IHRF. Clinical Relevance: Our findings provide insight that may lead to future advances in surgical care, such that protection of the tendon during routine hip arthroscopy may allow for improved postoperative rehabilitation and strength.

Use of Area Deprivation Index to Predict Minimal Clinically Important Difference for Patient Reported Outcomes Measurement Information System After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Socioeconomic disparities correlate with worse outcomes after arthroscopic rotator cuff repair. However, use of a surrogate to describe socioeconomic disadvantage has been a challenge. The Area Deprivation Index (ADI) is a tool that encompasses 17 socioeconomic variables into a single metric based on census location. HYPOTHESIS: Higher ADI would result in a worse minimal clinically important difference (MCID) for the Patient Reported Outcomes Measurement Information System (PROMIS) and have less improvement in range of motion (ROM) following arthroscopic rotator cuff repair (ARCR). STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: A retrospective review was performed for patients who underwent arthroscopic rotator cuff repair. Patients in the most socioeconomically disadvantaged quartile (ADIHigh) were compared with the least disadvantaged quartile (ADILow) in the ability to reach MCID. Demographic and surgical features were assessed for attainment of MCID. RESULTS: In total 1382 patients were identified who underwent ARCR, of which a total of 306 patients met final inclusion criteria. A higher percentage of patients within the ADIHigh cohort identified as "Black" or "other" race and had government-issued insurance compared with the ADILow cohort (P < .05). The ADIHigh cohort had significantly worse postoperative forward flexion compared with the ADILow cohort (145.0°± 32.5° vs 156.3°± 23.4°; P = .001) despite starting with comparable preoperative ROM (P = .17). Logistic regression showed that ADI was the only variable significant for predicting achievement of MCID for all 3 PROMIS domains, with the ADIHigh cohort having significantly worse odds of achieving MCID Physical Function (odds ratio [OR], 0.31; P = .001), Pain Interference (OR, 0.21; P = .001), and Depression (OR, 0.28; P = .001). Meanwhile, age, sex, body mass index, and smoking history were nonsignificant. Moreover, "other" for race and Medicare insurance were significant for achievement of MCID Depression but not Physical Function or Pain Interference. Finally, ADI was the main feature for predictive logistic regression modeling. CONCLUSION: ADI served as the only significant predictor for achieving MCID for all 3 PROMIS domains after arthroscopic rotator cuff repair. Patients who face high levels of socioeconomic disadvantage have lower rates of achieving MCID. In addition, patients with greater neighborhood disadvantage demonstrated significantly worse improvement in active forward flexion. Further investigation is required to understand the role of ADI on physical therapy compliance and to identify the barriers that prevent equitable postoperative care.

Multifid Iliopsoas Tendons Are More Common in Patients With Painful Snapping Iliopsoas Tendons.

Purpose: To retrospectively determine the prevalence of multifid tendons in a population of patients who underwent iliopsoas release for painful snapping iliopsoas tendons. Methods: Patients who underwent iliopsoas release for painful snapping iliopsoas tendons were retrospectively identified from a database of patients who had undergone arthroscopic hip surgery performed by a single surgeon between 2011 and 2020. Patients who had incomplete data or who underwent prior fracture fixation, joint arthroplasty, pelvic surgery, or other interventions for snapping hip were excluded. Magnetic resonance imaging (MRI) and operative reports were reviewed and compared with those of an age-matched control group of patients who had undergone hip or pelvic MRI examinations in the past year for different indications. Results: This study included 91 patients (78 female and 13 male patients; mean age, 23.3 years) who were treated operatively for painful snapping hip and 78 controls (54 female and 24 male patients; mean age, 28.4 years) who received hip or pelvic MRI for other indications. Among the patients who underwent iliopsoas release, there were 5 unifid iliopsoas tendons (5.5%) compared with 86 multifid iliopsoas tendons (94.5%) when classified with MRI whereas operative examination showed 19 unifid tendons (20.9%) compared with 72 multifid tendons (79.1%, P < .001). When the MRI scans of the operative group were compared with the MRI scans of the control group, the patients who underwent surgery for painful snapping hip had a higher rate of multifid tendons (94.5% of operative hips compared with 69.2% of control right hips [P < .001] and 74.4% of control left hips [P < .001]). However, when the operative reports were used to classify the iliopsoas tendon, there was no significance between the operative and control groups (79.1% of operative hips had multifid tendons compared with 69.2% of control right hips [P = .141] and 74.4% of control left hips [P = .464]). Conclusions: For patients with symptomatic snapping hip undergoing iliopsoas lengthening, multifid iliopsoas tendons are more prevalent than in a control population. Level of Evidence: Level IV, prognostic case series.

Effect of Insurance Reimbursement Status on Pre- and Postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Scores After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Previous studies reported inferior patient-reported outcomes (PROs) after arthroscopic rotator cuff repair for patients receiving workers' compensation (WC) relative to patients with commercial insurance. The extent to which alternative insurance reimbursement, including Medicaid and Medicare, influences outcomes after arthroscopic rotator cuff repair remains understudied. HYPOTHESIS: Compared with patients with commercial insurance reimbursement, patients with WC or government-issued reimbursement would report lower pre- and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores, report higher pre- and postoperative PROMIS Depression (D) and Pain Interference (PI) scores, and experience smaller levels of improvement in all PROMIS domains with surgical intervention. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic and surgical data were extracted from the medical record, and PROMIS domains were prospectively collected. Patients were divided into cohorts based on insurance reimbursement status. Differences between insurance-based cohorts for baseline variables, pre- and postoperative PROMIS scores, and change from baseline to final follow-up (delta) for PROMIS scores were evaluated using Kruskal-Wallis or chi-square tests. Mixed-effects linear regression models were performed to assess the influence of insurance while controlling for other variables. Survival analysis was performed to determine time to achieve minimal clinically important difference (MCID) for each PROMIS domain per cohort. RESULTS: 1252 patients underwent arthroscopic rotator cuff repair, met inclusion criteria, and completed PROMIS questionnaires. Statistically significant differences were noted in demographic variables including age (P < .001), sex (P < .001), ethnicity (P < .001), and body mass index (P < .001) between insurance-based cohorts. Unadjusted analysis revealed significantly higher PF scores and lower PI and D scores for the group with commercial insurance relative to those with Medicare, Medicaid, and WC at 6- and 12-month follow-up (P < .01 all comparisons), except for the Medicare versus commercial subcohort analysis for PI at 6 months (P = .28). These differences persisted for the Medicare, Medicaid, and WC groups (P < .03 all comparisons) after adjustment for confounding variables in linear regression. CONCLUSIONS: The baseline characteristics of patients undergoing arthroscopic rotator cuff repair differed based on insurance reimbursement. Patients with commercial insurance reported improved physical function, decreased pain interference, and improved mood (less depression) relative to patients with government-issued and WC insurance, with maximum improvement 6 to 12 months postoperatively. There were few significant differences between insurance groups in change of PROMIS scores from preoperative to postoperative intervals, indicating that differences in the baseline demographic and surgical characteristics of these groups accounted for differences in response to surgery.

Quantifying Surgeon Intuition Using a Judgment Analysis Model: Surgeon Accuracy of Predicting Patient-Reported Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement Is Moderate at Best.

Purpose: To quantify surgeon intuition, determine whether a surgeon's prediction of outcomes after hip arthroscopy correlates with actual patient-reported outcomes (PRO), and identify differences in clinical judgment between expert and novice examiners. Methods: This prospective, longitudinal study was conducted at an academic medical center on adults undergoing primary hip arthroscopy for treatment of femoroacetabular impingement. A Surgeon Intuition and Prediction (SIP) score was completed preoperatively by an attending surgeon (expert) and physician assistant (novice). Baseline and postoperative outcome measures included legacy hip scores (e.g., Modified Harris Hip score) and Patient-Reported Outcomes Information System tools. Mean differences were assessed using t-tests. Generalized estimating equations assessed longitudinal changes. Pearson correlation coefficients (r) evaluated associations between SIP score and PRO scores. Results: Data from 98 patients (mean age 36 years, 67% female) with complete data sets at 12-month follow-up were analyzed. Weak-to-moderate strength correlations were seen between SIP score and PRO scores (r = 0.36 to r = 0.53) for pain, activity and physical function. Significant improvements were seen in all primary outcome measures at 6 and 12 months postoperatively when compared to baseline scores (P < .05), with about 50% to 80% of patients achieving the minimum clinically important difference and patient acceptable symptomatic state thresholds postoperatively. Conclusions: An experienced, high-volume hip arthroscopist had only weak-to-moderate ability to intuitively predict PRO. Surgical intuition and judgment were not superior in an expert examiner compared to a novice. Level of Evidence: Level III, retrospective comparative prognostic trial.

Patient-Reported Outcomes Are Similar in the First 2 Years After Staged Versus Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia.

PURPOSE: To compare early patient-reported outcomes after staged versus combined hip arthroscopy and periacetabular osteotomy for hip dysplasia. METHODS: A prospective database was retrospectively reviewed to identify patients that underwent combined or staged hip arthroscopy and periacetabular osteotomy (PAO) from 2012 to 2020. Patients were excluded if they were >40 years of age, had prior ipsilateral hip surgery, or did not have at least 12-24 months of postoperative patient-reported outcome (PRO) data. PROs included the Hip Outcomes Score (HOS) Activities of Daily Living (ADL) and Sports Subscale (SS), Non-Arthritic Hip Score (NAHS), and the Modified Harris Hip Score (mHHS). Paired t-tests were used to compare preoperative to postoperative scores for both groups. Outcomes were compared using linear regression adjusted for baseline characteristics, including age, obesity, cartilage damage, acetabular index, and procedure timing (early vs late practice). RESULTS: Sixty-two hips were included in this analysis (39 combined, 23 staged). The average length of follow-up was similar between the combined and staged groups (20.8 vs 19.6 months; P = .192). Both groups reported significant improvements in PROs at final follow up compared to preoperative scores (P < .05 for all). There were no significant differences in HOS-ADL, HOS-SS, NAHS, or mHHS scores between groups preoperatively or at 3, 6, or 12 months postoperatively (P > .05 for all). There was no significant difference in PROs between the combined and staged groups at the final postoperative time point: HOS-ADL (84.5 vs 84.3; P = .77), HOS-SS (76.0 vs 79.2; P = .68), NAHS (82.2 vs 84.5; P = .79), and mHHS (71.0 vs 71.0, P = .75), respectively. CONCLUSIONS: Staged hip arthroscopy and PAO for hip dysplasia leads to similar PROs at 12-24 months compared to combined procedures. This suggests that with careful and informed patient selection, staging these procedures is an acceptable option for these patients and does not change early outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Whole-genome RNA sequencing identifies distinct transcriptomic profiles in impingement cartilage between patients with femoroacetabular impingement and hip osteoarthritis.

Femoroacetabular impingement (FAI) has a strong clinical association with the development of hip osteoarthritis (OA); however, the pathobiological mechanisms underlying the transition from focal impingement to global joint degeneration remain poorly understood. The purpose of this study is to use whole-genome RNA sequencing to identify and subsequently validate differentially expressed genes (DEGs) in femoral head articular cartilage samples from patients with FAI and hip OA secondary to FAI. Thirty-seven patients were included in the study with whole-genome RNA sequencing performed on 10 gender-matched patients in the FAI and OA cohorts and the remaining specimens were used for validation analyses. We identified a total of 3531 DEGs between the FAI and OA cohorts with multiple targets for genes implicated in canonical OA pathways. Quantitative reverse transcription-polymerase chain reaction validation confirmed increased expression of FGF18 and WNT16 in the FAI samples, while there was increased expression of MMP13 and ADAMTS4 in the OA samples. Expression levels of FGF18 and WNT16 were also higher in FAI samples with mild cartilage damage compared to FAI samples with severe cartilage damage or OA cartilage. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. We independently validated the results of the sequencing analysis and found increased expression of anabolic markers in patients with FAI and minimal histologic cartilage damage, suggesting that anabolic signaling may be increased in early FAI with a transition to catabolic and inflammatory gene expression as FAI progresses towards more severe hip OA. Clinical significance:Cam-type FAI has a strong clinical association with hip OA; however, the cellular pathophysiology of disease progression remains poorly understood. Several previous studies have demonstrated increased expression of inflammatory markers in FAI cartilage samples, suggesting the involvement of these inflammatory pathways in the disease progression. Our study further expands the knowledge regarding distinct genetic reprogramming in the cartilage between FAI and hip OA patients. In addition to differences in inflammatory gene expression, we also identified differential expression in multiple pathways involved in hip OA progression.

The surgical destabilization of the abductor muscle leads to development of instability-associated hip osteoarthritis in mice.

Osteoarthritis (OA) of the hip is a common and debilitating painful joint disease. However, there is paucity of surgically induced hip OA models in small animals that allow scientists to study the onset and progression of the disease. A growing body of evidence indicates a positive association between periarticular myotendinous pathology and the development of hip OA. Thus, in the current study, we aimed to establish a novel mouse instability-associated hip OA model via selective injury of the abductor complex around the hip joint. C57BL6/J mice were randomized to sham surgery or abductor injury, in which the myotendinous insertion at the third trochanter and greater trochanter were surgically detached. Mice were allowed free active movement until they were sacrificed at either 3 weeks or 20 weeks post-injury. Histologic analyses and immunohistochemical staining of the femoral head articular cartilage were performed, along with microCT (µCT) analysis to assess subchondral bone remodeling. We observed that mice receiving abductor injury exhibited significantly increased instability-associated OA severity with loss of proteoglycan and type II collagen staining compared to sham control mice at 20 weeks post-surgery, while comparable matrix metalloproteinase 13 expression was observed between injury and sham groups. No significant differences in subchondral bone remodeling were found after 3 or 20 weeks following injury. Our study further supports the link between abductor dysfunction and the development of instability-associated hip OA. Importantly, this novel surgically induced hip OA mouse model may provide a valuable tool for future investigations into the pathogenesis and treatment of hip OA.

Diagnostic intra-articular injection with provocative functional testing predicts patient-reported outcomes following hip arthroscopy: a prospective investigation.

The purpose of this study is to evaluate the predictive value of preoperative diagnostic intra-articular injections with formal provocative post-injection functional testing on patient-reported outcomes (PROs) following hip arthroscopy. Patients aged 14-40 with suspected labral pathology and/or femoroacetabular impingement were prospectively enrolled. Patients received a diagnostic intra-articular anesthetic injection then completed a battery of provocative physical function (PF) tests and were asked to rate the percentage of pain improvement. Patients completed PRO surveys preoperatively and up to 2 years postoperatively. PROs were compared between positive and negative injection response groups. Ninety-six patients received a diagnostic injection with provocative functional testing and subsequently underwent hip arthroscopy, 74 reported a positive injection response (≥75% improvement) and 22 reported a negative injection response (<75% improvement). The average postoperative follow-up was 12 months. Both groups experienced significant improvement in PROs postoperatively. A positive injection response was associated with greater improvements in hip outcome score, Non-Arthritic Hip Score, Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and PROMIS PF at final follow-up compared to a negative injection response. Similar improvements in modified Harris Hip Score, Visual Analog Scale hip pain and PROMIS depression were experienced between groups. These results indicate that diagnostic intra-articular hip anesthetic injection with provocative functional testing may be a valuable predictor of pain and PF following hip arthroscopy. However, patients with negative injection responses still experienced significant clinical improvement in their postoperative outcomes. As such, a negative injection response should not preclude patients from being surgical candidates, but their outcomes may be less predictable.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review.

PURPOSE: To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology. METHODS: A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded. RESULTS: The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I2 = 63.9% and 72.9%, respectively). CONCLUSIONS: Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Arthroscopic Bone and Cartilage Grafting of Acetabular Cysts With Autologous Tissue.

Repair of acetabular cysts and cartilage defects presents a challenge for the hip-preservation surgeon. Currently, most techniques involve allograft sources or open surgery. We present an arthroscopic technique using autologous graft sources for both bone and cartilage to repair subchondral acetabular cysts and the overlying cartilage defect. This technique uses new technology in combination with familiar arthroscopic instruments to decrease morbidity, hasten rehabilitation, and possibly improve the prognosis of these difficult to treat lesions.

Threshold Values for Success After Hip Arthroscopy Using the Patient-Reported Outcomes Measurement Information System Assessment: Determining the Minimum Clinically Important Difference and Patient Acceptable Symptomatic State.

BACKGROUND: Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement. PURPOSE: To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID. RESULTS: There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m2), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients (P = .01) and athletic patients (P = .003) were more likely to attain the PASS. CONCLUSION: The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

Biomechanical Response to Distraction of Hip Capsular Reconstruction With Human Acellular Dermal Patch Graft.

PURPOSE: To quantify the biomechanical properties of the hip capsule with human dermal allograft reconstruction to determine whether a dermal patch restored capsular resistance to distraction. METHODS: Nine cadaveric hip specimens were dissected until capsule and bony structures remained and were then mounted in a testing fixture in neutral flexion and abduction. Four states of the hip capsule were sequentially tested under axial distraction of 5 mm measured with video analysis and with resultant force measurement: (1) intact hip capsule, (2) interportal capsulotomy, (3) capsulectomy to the zona orbicularis, and (4) capsular reconstruction with human dermal allograft using acetabular anchors and capsule-to-patch sutures. RESULTS: Capsulectomy was different from intact (P = .036), capsulotomy differed from capsulectomy (P = .012), and the repair was statistically significantly different from capsulectomy (P = .042); intact and reconstructed cases were not statistically significantly different. The force required for 5 mm of distraction decreased after interportal capsulotomy by an average of 9% compared with the intact state and further decreased after capsulectomy by 30% compared with the intact state. After capsular reconstruction using dermal allograft, force requirements increased by an average of 36% from the capsulectomy state, only 5% below the intact state. CONCLUSIONS: Human dermal allograft tissue graft provides restoration of distractive strength for use during hip capsule reconstruction with acetabular anchor fixation and distal soft-tissue fixation after capsulectomy in a cadaveric model. CLINICAL RELEVANCE: Capsular repair or reconstruction with a dermal patch offers time-zero restoration of function; intact and reconstructed cases showed no difference, and reconstruction restored a capsulectomy to a biomechanical equivalent of the intact case when distraction was applied.

Acetabular Morphologic Characteristics Predict Early Conversion to Arthroplasty After Isolated Hip Arthroscopy for Femoroacetabular Impingement.

BACKGROUND: Hip arthroscopy in the setting of dysplasia and borderline dysplasia is controversial. Dysplasia severity is most often defined by the lateral center edge angle (LCEA) but can also be evaluated radiographically by the acetabular inclination (AI). PURPOSE/HYPOTHESIS: The purpose was to determine the effect of AI on outcomes after isolated hip arthroscopy for femoroacetabular impingement (FAI). We hypothesized that patients with dysplasia would have higher rates of arthroplasty as well as inferior clinical and functional outcomes compared with patients who did not have dysplasia. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A hip arthroscopy registry was reviewed for participants undergoing arthroscopic correction of FAI from February 28, 2008, to June 10, 2013. Participants required a clinical diagnosis and isolated arthroscopic correction of FAI with preoperative imaging and intraoperative cartilage status recorded. AI dysplasia was defined as an AI greater than 10°, LCEA dysplasia as LCEA less than 18°, and borderline LCEA dysplasia as LCEA 18° to 25°. Patients without an acetabular deformity (LCEA 25°-40°; AI <10°) served as a control population. Postoperative variables included patient-reported outcome surveys with conversion to arthroplasty as the primary endpoint. Minimum 5-year outcome scores were obtained for 337 of 419 patients (80.4%) with an average follow-up of 75.2 ± 12.7 months. RESULTS: This study included 419 patients: 9 (2%) with LCEA dysplasia, 42 (10%) with AI dysplasia, and 51 (12%) with borderline dysplasia. The AI but not LCEA was significantly correlated with lower outcome scores on the modified Harris Hip Score (r = 0.13; P = .01), Non-Arthritic Hip Score (r = 0.10; P = .04), and Hip Outcome Score-Sports Subscale (r = 0.11; P = .04). A total of 58 patients (14%) underwent arthroplasty at 31 ± 20 months postoperatively. Patients with LCEA dysplasia had an arthroplasty rate of 56% (odds ratio, 8.4), whereas patients with AI dysplasia had an arthroplasty rate of 31% (odds ratio, 3.3), which was significantly greater than the rate for the nondysplastic cohort (13.5%; P < .0001). Patients with borderline LCEA dysplasia did not have increased rates of arthroplasty. A multivariate analysis found increasing age, increasing AI, Tönnis grade higher than 1, and femoral Outerbridge grade higher than 2 to be most predictive of conversion to arthroplasty. CONCLUSION: We found that an elevated AI, along with increasing age, Tönnis grade, and femoral Outerbridge grade significantly predict early conversion to arthroplasty after isolated hip arthroscopy. We recommend using the AI, in addition to the LCEA, in evaluating hip dysplasia before hip arthroscopy.

Is there a correlation between outcomes after hip arthroscopy for femoroacetabular impingement syndrome and patient cortical bone thickness?

In order to determine the associations between age, sex, cortical bone thickness (CBT), and outcomes following hip arthroscopy for FAIS, a retrospective study of patients undergoing hip arthroscopy for FAIS from a single institution from 2012 to 2014 was performed. Based on preoperative radiographs, femoral cortical index (FCI) and femoral canal-to-calcar ratio (FCC) were used as measures of CBT and used to classify patients using the Dorr classification. Linear and logistic regression was used to determine whether CBT was predictive of 2-year patient reported outoutcomes. Patients were stratified by sex and age (<45 or =45 years old) to determine whether variables were potential effect modifiers on the association between outcomes and CBT. A total of 108 patients were included in the study, with 27 patients in each of the following groups: females <45, females =45, males <45, and males =45 years. The results showed that at 2-year follow-up, all groups demonstrated significant improvements in reported outcomes (HOS-ADL, HOS-SS, and mHHS) (p<0.001). Females =45 scored significantly worse than other groups on all scores (p<0.05 for all). Chi-square test for trend showed a linear by linear association between Dorr classification type and gender/age group (p=0.018). Analysis of the whole study population showed a linear association between FCC and HOS-ADL and mHHS scores. However, CBT measures were not predictive of achieving MCID. In conclusion, patients undergoing hip arthroscopy for FAIS, older female patients had the worst patient-reported outcomes and lowest CBT measures. Furthermore, FCC is independently associated with the HOS-ADL and mHHS. LEVEL OF EVIDENCE: Retrospective comparative study, Level III. WHAT IS KNOWN ABOUT THE SUBJECT: Among patients undergoing hip arthroscopy for FAIS, female patients over the age of 45 have been reported to be at risk for inferior post-operative outcomes. Meanwhile, this patient population is also the most at risk for deteriorating CBT. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE: This study demonstrates that female patients with FAIS over the age of 45 have inferior CBT indices than their male and younger-aged counterparts. Furthermore, this study presents an association between the FCC and 2-year patient-reported outcome measures, suggesting that CBT characterization may withhold prognostic value.

Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy?

BACKGROUND: The Patient Reported Outcomes Information System (PROMIS) is an efficient metric able to detect changes in global health. PURPOSE: To assess the responsiveness, convergent validity, and clinically important difference (CID) of PROMIS compared with disease-specific scales after knee arthroscopy. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: A prospective institutional review board-approved study collected PROMIS Physical Function (PF), PROMIS Pain Interference (PI), International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) results in patients undergoing knee arthroscopy. The change from preoperative to longest follow-up was used in analyses performed to determine responsiveness, convergent validity, and minimal and moderate CID using the IKDC scale as the anchor. RESULTS: Of the 100 patients enrolled, 76 were included. Values of the effect size index (ESI) ranged from near 0 to 1.69 across time points and were comparable across scales. Correlations of the change in KOOS and PROMIS with IKDC ranged from r values of 0.61 to 0.79. The minimal CID for KOOS varied from 12.5 to 17.5. PROMIS PF and PI minimal CID were 3.3 and -3.2. KOOS moderate CID varied from 14.3 to 18.8. PROMIS PF and PI moderate CID were 5.0 and -5.8. CONCLUSION: The PROMIS PF and PI showed similar responsiveness and CID compared with disease-specific scales in patients after knee arthroscopy. PROMIS PI, PROMIS PF, and KOOS correlations with IKDC demonstrate that these scales are measuring a similar construct. The ESIs of PROMIS PF and PI were similar to those of KOOS and IKDC, suggesting similar responsiveness at 6 months or longer (ESI >1.0). Minimum and moderate CID values calculated for PROMIS PF and PI using IKDC as an anchor were sufficiently low to suggest clinical usefulness. CLINICAL RELEVANCE: PROMIS PF and PI can be accurately used to determine improvement or lack thereof with clinically important changes after knee arthroscopy.

The Utility of Hip Arthroscopy in the Setting of Acetabular Dysplasia: A Systematic Review.

PURPOSE: To compare patient-reported outcomes, progression of osteoarthritis, and conversion to total hip replacement in a dysplastic population when hip arthroscopy was used as an isolated treatment or as an adjunct to pelvic reorientation osteotomy. METHODS: An exhaustive search of the existing literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Embase) were searched for studies from January 1930 through January 2018 published in the English language concerning the use of hip arthroscopy with diagnostic and therapeutic intentions in individuals with acetabular dysplasia. We excluded studies that presented ambiguous data sets or in which clear identification of the strategy for arthroscopy was absent. RESULTS: The selection criteria were defined, and 33 studies (1,368 hip arthroscopies) were included in the final analysis. Studies that met the inclusion criteria were classified within 5 different categories: (1) hip arthroscopy for screening, chondral mapping, and planning (9 studies, 729 hip arthroscopies); (2) isolated arthroscopic treatment (13 studies, 434 hip arthroscopies); (3) outcomes of hip arthroscopy after previous reorientation pelvic osteotomy for acetabular dysplasia (4 studies, 52 hip arthroscopies); (4) arthroscopy followed by unplanned hip-preservation surgery (3 studies, 48 hip arthroscopies); and (5) combined arthroscopy and periacetabular osteotomy (4 studies, 106 hip arthroscopies). A risk-of-bias analysis showed a moderate to high risk of bias (level 3 or 4) within and across the included studies. CONCLUSIONS: Although hip arthroscopy can be used to accurately grade the severity of chondral injuries in the native hip and provide zone-specific geographic mapping that may aid in subsequent surgical planning, there is insufficient evidence to conclude that arthroscopic characterization alone has any bearing on the ultimate clinical outcomes after osseous structural correction. Isolated arthroscopic treatment is not recommended in the setting of moderate to severe dysplasia, given the inferior clinical outcomes and risk of iatrogenic instability reported for this group. However, there is limited evidence to suggest that the isolated use of hip arthroscopy may be considered in cases of borderline acetabular dysplasia when careful attention is paid to labral and capsular preservation. Limited evidence supports the conclusion that after prior reorientation pelvic osteotomy for acetabular dysplasia, hip arthroscopy leads to improved clinical and functional outcomes and should be considered in this setting. Furthermore, there is insufficient evidence to conclude that failed hip arthroscopy compromises or challenges the ultimate clinical outcomes in patients undergoing subsequent reorientation pelvic osteotomy. Last, there is insufficient evidence to conclude that the adjunctive use of hip arthroscopy with reorientation pelvic osteotomy produces superior clinical outcomes compared with pelvic osteotomy alone. In summary, arthroscopic techniques may provide a useful complement to the correction of acetabular dysplasia and should be thoughtfully considered on a case-by-case basis when designing a comprehensive treatment strategy in dysplastic populations. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Iliopsoas snapping hip: improving the diagnostic value of magnetic resonance imaging with a novel parameter.

OBJECTIVE: To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome. METHODS: This retrospective cohort study reviewed hip MRI images of all patients seen by a single surgeon between January 2015 and March 2016. The comparison group included all patients with clinical internal hip snapping, versus the control group that did not. MRI images were processed using minimum intensity projection. Measurements obtained of the pelvis and course of the iliopsoas tendon included: pelvic incidence, coronal angle, and sagittal opening angle (SOA). Comparison of measurements between the groups was performed with Mann-Whitney U analysis and receiver operator curve (ROC) plotting, with a significance cutoff of p = 0.05. RESULTS: The control group (n = 85) and comparison group (n = 48) demonstrated no difference in age or gender. Pelvic incidence was similar [51.3 (± 10.7) degrees control versus 52.2 (± 7.7) degrees comparison (p = 0.36)], as was coronal angle [13.9 (± 4.6) degrees control versus 14.8 (±4.8) degrees comparison (p = 0.15)]. There was a significant difference in SOA [137.0 (± 5.9) degrees control versus 141.9 (± 6.5) degrees comparison (p < 0.01)]. ROC analysis revealed SOA threshold of 140 degrees for clinical IP hip snapping (p < 0.01), with odds ratio 5.2 (2.4-11.3) for SOA > 140 degrees. CONCLUSIONS: Iliopsoas hip snapping is often part of a more complex disease process. While challenging to diagnose, advanced imaging parameters, like the sagittal opening angle, relate with clinical pathology. The SOA offers diagnostic value, with a threshold of greater than 140 degrees significantly correlating with clinical presentation.

Patient-Specific 3-Dimensional Modeling and Its Use for Preoperative Counseling of Patients Undergoing Hip Arthroscopy.

BACKGROUND: Femoroacetabular impingement (FAI) represents complex alterations in the bony morphology of the proximal femur and acetabulum. Imaging studies have become crucial in diagnosis and treatment planning for symptomatic FAI but also have limited patient understanding and satisfaction. Exploration of alternative patient counseling modalities holds promise for improved patient understanding, satisfaction, and ultimately for outcomes. PURPOSE: To compare perceived understanding of functional anatomy and FAI pathomorphology among patients counseled with routine computed tomography (CT), generic hip models, and a 3-dimensional (3D) model printed in accordance with a patient's specific anatomy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective randomized analysis of patients presenting with radiographically confirmed FAI was conducted between November 2015 and April 2017. Patients were randomized into groups that received preoperative counseling with CT imaging alone, a generic human hip model, or a haptic 3D model of their hip. All groups were subjected to a novel questionnaire examining patient satisfaction and understanding on a variety of topics related to FAI. Data were compared with bivariate and multivariate analyses. Statistical significance was determined as P < .05. RESULTS: Thirty-one patients were included in this study (25 men, 6 women). Ten patients were randomized to the CT-only group, 11 to the generic hip model group, and 10 to receive custom 3D-printed models of their hips. Patients preoperatively counseled with isolated CT imaging or a generic hip model reported greater understanding of their pathophysiology and the role of surgical intervention when compared with those counseled with haptic 3D models (P = .03). At final follow-up, patients counseled with the use of isolated CT imaging or haptic 3D models reported greater increases and retention of understanding as compared with those counseled with generic hip models alone (P = .03). CONCLUSION: Preoperative counseling with haptic 3D hip models does not appear to favorably affect patient-reported understanding or satisfaction with regard to FAI when compared with the use of CT imaging alone. Continued research into alternative counseling means may serve to further improve patient understanding and satisfaction on this complex anatomic phenomenon.