In-Office Needle Arthroscopy of the Knee With Lateral Parapatellar Retinacular Release.

The lateral patellofemoral joint, composed of multiple soft-tissue structures, balances the knee by aiding patella tracking, stability, and force distribution. Arthroscopic lateral release is a well-described procedure that addresses patellofemoral knee pain and, in cases with patellar instability, may be combined with medial stabilization. In-office needle arthroscopy is an up-trending technique that simultaneously diagnoses and treats patellofemoral pathology in the office, leading to a quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this Technical Note is to describe in-office needle arthroscopy technique to address patellofemoral pain and lateral patellar mal-tracking, with special consideration for achieving adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Needle Arthroscopy with Meniscal Repair for Meniscal Lesions of the Knee.

Meniscal injuries are a common cause of knee pain and are often an indication for knee arthroscopy, the most common orthopedic surgical procedure in the United States. In-office needle arthroscopy (IONA) is a described technique with the ability to diagnose and treat meniscal injuries in the office. IONA allows for diagnosis and treatment at a significantly deceased cost, with both quicker patient recovery, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office needle arthroscopy for meniscal injuries of the knee, including the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

Reproducible and Effective Biceps Tenodesis Method Utilizing In-Office Nano-Arthroscopy.

Biceps tendinopathy is a common cause of chronic anterior shoulder pain characterized by altered joint mechanics with considerable deficits in range of motion secondary to pain. The benefits of in-office nano-arthroscopy (IONA) include the ability to diagnosis and treat biceps tendinopathy, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing IONA for biceps tendinopathy (biceps tenotomy/biceps tenodesis), with special consideration for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Needle Arthroscopy With Cartilage Allograft Extracellular Matrix Application for Cartilage Lesions of the Knee.

Chondral and osteochondral lesions of the knee are a common cause of pain, mechanical symptoms, and swelling for patients. The benefits of in-office needle arthroscopy (IONA) include the ability to diagnose and treat chondral or osteochondral lesions in the office, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical note is to describe the technique for performing in-office needle arthroscopy for chondral or osteochondral contained lesions of the knee, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Nano-Arthroscopy of the Shoulder with Acromioplasty.

Subacromial decompression with acromioplasty is among the most commonly performed shoulder procedures. The advantages of in-office nano-arthroscopy include the capability of diagnosing and treating subacromial impingement, swifter patient recovery, improved cost-effectiveness, and superior patient satisfaction. The purpose of this technical report is to describe our technique for performing in-office nano-arthroscopy for subacromial decompression (subacromial bursectomy and acromioplasty), with a particular focus on appropriate indications, providing sufficient local anesthesia, optimizing visualization, and discussing the advantages of the in-office setting compared to the operating room.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used.

BACKGROUND: Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES: (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS: In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS: After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION: In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Surface Mapping of the Musculotendinous Attachments at the Pubic Symphysis in Cadaveric Specimens: Implications for the Treatment of Core Muscle Injury.

PURPOSE: To characterize the 3-dimensional muscular, musculotendinous, and neurovascular anatomy about the pubic symphysis relevant to core muscle injury (CMI). METHODS: Ten cadaveric hips were dissected to characterize the musculotendinous insertion of the rectus abdominis and inguinal ligament, origins of the adductor longus and adductor brevis, and the pubic cartilage plate. A 3-dimensional coordinate measuring system and data acquisition software were used to calculate structure cross-sectional area, and the landmark anatomical relationships to 1 another and relevant neurovascular structures. RESULTS: All specimens were male with an average age of 62 ± 2 years. The mean footprints of the rectus abdominis, inguinal ligament, adductor longus, and adductor brevis were 8.4 ± 3.1, 1.2 ± 0.5, 3.8 ± 1.6, and 2.9 ± 1.3 cm2, respectively. The mean pectineus and gracilis footprints were 6.3 ± 2.4 and 3.4 ± 0.9 cm2, respectively. The mean cross-sectional area of the cartilage plate was 24.8 ± 5.6 cm2. The adductor longus was an average 1.5 ± 0.25 cm from the adductor brevis and 0.69 ± 0.52 cm from the rectus abdominis. The genital branch of the genitofemoral nerve was an average of 4.3 cm (range, 2.8-6.4) lateral to the insertion of the inguinal ligament. The femoral vein and artery were 3.0 cm (range, 2.5-3.6) and 3.7 cm (range, 2.5-5.9) lateral to the inguinal ligament footprint. The obturator nerve was 2.5 cm (range, 1.6-3.4) lateral to the adductor longus. CONCLUSIONS: Familiarity with the anatomy of the pubic symphysis is essential for surgeons treating patients with CMI. We have shown that this relatively small area is the site of many muscular, musculotendinous, and neurovascular structures with various sized footprints and described the 3-dimensional anatomy of the anterior pubic symphysis. The origin of the adductor longus lies in close proximity to other structures, such as the adductor brevis, the insertion of the rectus abdominis, and the obturator nerve. These findings should be considered when operating in this region and treating patients with chronic groin pain. CLINICAL RELEVANCE: The anatomy of the pelvic region and pubic symphysis has not been well characterized. Intimate knowledge of relevant anatomy is essential to treating CMI, also known as athletic pubalgia or sports hernia.

Preoperative Predictors of Achieving Clinically Significant Athletic Functional Status After Hip Arthroscopy for Femoroacetabular Impingement at Minimum 2-Year Follow-Up.

PURPOSE: To identify predictors of achieving clinically significant sport function in athletic patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data were analyzed for all patients who treated for FAIS between 2012 to 2016 and reported being athletes, including recreational and competitive athletes. All patients had a minimum of 2-year follow-up with patient-reported athletic function in the form of the Hip Outcome Score-Sport Specific (HOS-SS), visual analog score-pain, and patient satisfaction. Achieving clinically significant sports function was defined as either reaching the minimally clinical important difference (MCID) or the patient acceptable symptomatic state (PASS) for HOS-SS at 2-year follow-up. An exploratory factor analysis was used to determine specific domains for the predictor variables and to reduce the redundancy in these variables. A logistic regression analysis was used to identify significant predictors of achieving clinically significant sports function [corrected]. RESULTS: Of 780 qualifying patients, 626 completed the 2-year minimum follow-up (80%), with a mean age and body mass index of 31.6 ± 11.9 years and 24.6 ± 8.6, respectively. A total of 500 patients (86.5%) achieved high functional status, with 77.9% achieving MCID HOS-SS and 68.7% achieving PASS HOS-SS. Logistic regression analysis identified increased the α angle (odds ratio [OR] 0.976; P = .027), preoperative pain duration (OR 0.729; P = .011), and body mass index (BMI) (OR 0.919; P = .018), as well as the presence of femoral chondral defects (OR 0.769; P = .013), as negative predictors for achieving MCID. Negative predictors for achieving PASS HOS-SS included the presence of a preoperative limp (OR 0.384; P = .013), anxiety or depression (OR 0.561; P = .041), and increased BMI (OR 0.945; P = .018) and preoperative pain duration (OR 0.987; P < .001). CONCLUSIONS: Several predictors of achieving clinically significant sport function performance exist, including a history of anxiety or depression, BMI, preoperative α angle, limp, femoral chondral damage, *and preoperative symptom duration. Our results suggest there are both modifiable and nonmodifiable preoperative factors that have the potential to predict achieving high athletic function after hip arthroscopy for FAIS. LEVEL OF EVIDENCE: IV, Case Series.

How Should We Define Clinically Significant Outcome Improvement on the iHOT-12?

BACKGROUND: There is increased emphasis on efficiently administering patient-reported outcome measures (PROMs). The International Hip Outcome Tool-12 (iHOT-12) is a short-form version of the iHOT-33, and relatively little is known about clinically significant outcomes using the iHOT-12. QUESTIONS/PURPOSES: The purpose of this study was to define minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the iHOT-12 and to identify predictors for achieving these psychometric end points in patients undergoing arthroscopic treatment of femoroacetabular impingement (FAI). METHODS: Data was prospectively collected and retrospectively analyzed as part of an institutional hip preservation repository. One hundred and twenty patients were included; mean age and body mass index (BMI) were 38.7 years and 25.9, respectively. A majority of patients were female (67.5%) and white (81.7%) and participated in recreational sports (79.2%). The iHOT-12 was administered pre-operatively and at 1-year follow-up to patients undergoing primary hip arthroscopy for FAI. The following anchor question was also asked at 1-year follow-up: "Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?" MCID was calculated using a distribution-based method. Receiver-operating characteristic analysis with area under the curve was used to confirm the significance of the PASS threshold. RESULTS: Mean iHOT-12 scores improved from 35.6 at pre-operative assessment to 70.7 at 1-year follow-up. Patients indicating satisfaction with their outcome improved from 37.5 pre-operatively to 79.0 at 1-year follow-up. MCID value for the iHOT-12 was 13.0. The PASS threshold was 63.0, indicating an excellent predictive value that patients scoring above this threshold were likely to have met an acceptable symptom state. Worker's compensation patients and those with increased BMI were less likely to achieve PASS; lower pre-operative iHOT-12 score was predictive for achieving MCID, and achieving MCID was predictive for achieving PASS. CONCLUSION: This is the first study to define PASS and MCID for the iHOT-12, which measures clinically significant outcome improvement comparably to that of other commonly used hip PROMs. As its use becomes more widespread, the iHOT-12 data-points presented in this study can be used to determine clinically significant improvement of patient-reported outcomes.

Survivorship and Outcome of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Performed With Modern Surgical Techniques.

BACKGROUND: Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly growing field in sports surgery; however, factors associated with poor outcomes and identification of predictor models of inferior clinical outcomes is unclear. PURPOSE: To analyze predictors of clinical failure and inferior clinical outcomes among patients undergoing hip arthroscopy for treatment of FAIS. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were collected and analyzed from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS from a single fellowship-trained surgeon between January 2012 and November 2015. Baseline data, postoperative patient-reported outcomes, and rates of clinical failure and inferior clinical outcomes were recorded at 2 years postoperatively. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Inferior clinical outcome was defined as not reaching the minimal clinically important difference (MCID) or patient acceptable symptomatic state for Hip Outcome Score-Activities of Daily Living. A multivariate logistic regression analysis was used to identify significant predictors of clinical failure and inferior clinical outcome. RESULTS: Out of 1161 eligible patients, 935 (80.5%) completed 2-year postoperative patient-reported outcomes. The mean ± SD age and body mass index were 33.3 ± 12.3 years and 25.4 ± 8.2 kg/m2, respectively. The overall clinical failure rate was 3.6% (n = 34), including 23 cases (2.5%) of revision hip arthroscopy and 11 cases (1.2%) of conversion to total hip arthroplasty. Predictors of clinical failure were lower preoperative International Hip Outcome Tool score ( P = .016), chronic preoperative pain ( P = .001), and chondromalacia in the affected hip ( P = .04). The inferior clinical outcome group, consisting of those who failed to reach the MCID for Hip Outcome Score-Activities of Daily Living, included 256 patients (27.4%). Predictors of inferior clinical outcomes were Tönnis grade >1 ( P = .01), workers' compensation ( P < .001), and increased body mass index ( P = .02). CONCLUSION: This study demonstrates that 73% of all patients treated for symptomatic FAIS with primary hip arthroscopy and routine capsular closure achieved the MCID. Clinical failure is predicted by a number of modifiable and nonmodifiable factors, including chronic preoperative pain and presence of chondromalacia. The current study updates the midterm failure rates and outcomes achievable with hip arthroscopy for FAIS.

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.

Influence of Acetabular Labral Tear Length on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome With Capsular Plication.

BACKGROUND: The literature on the effects of labral tear on patient-reported outcomes, midterm pain, and overall patient satisfaction is limited. PURPOSE: To determine the effect of labral tear length on postoperative outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Consecutive patients undergoing primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified in a prospectively collected database. All patients completed the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale for pain and satisfaction. Patients were stratified by labral tear length into small (<2.5 cm) or large (≥2.5 cm) based on the receiver operating characteristic curve analysis. Patient characteristics and outcomes were analyzed with multivariate linear regression analyses to identify predictors of labral tear length. Binary logistic regression analysis was performed to determine whether labral tear length predicted the likelihood of achieving the minimal clinically important difference. RESULTS: Of the 747 eligible patients, 600 (80.3%) had 2-year reported outcomes and were included in the final analysis. Mean age, body mass index, and tear length were 33.5 ± 12.3 years, 25.4 ± 9.2 kg/m2, and 2.7 ± 0.7 cm, respectively. Men had higher frequency of large tears when compared with women (77% vs 43.7%, P < .001). Independent t test demonstrated significant differences in 2-year outcomes between patients with tears <2.5 and ≥2.5 cm, respectively: HOS-ADL (87.3 ± 16.3 vs 84.3 ± 18.1, P = .033), HOS-SS (76.6 ± 23.5 vs 70.5 ± 27.7, P = .005), mHHS (82.5 ± 18.0 vs 78.5 ± 18.2, P = .009), and satisfaction (83.5 ± 23.4 vs 77.8 ± 34.9, P = .026). Binary logistic regression analysis demonstrated that labral tear length is an independent predictor of visual analog scale for satisfaction, HOS-ADL, HOS-SS, and mHHS. Binary logistic regression analysis demonstrated that patients with small labral tears had a higher likelihood of achieving the minimal clinically important difference for the HOS-SS (odds ratio, 1.61; 95% CI, 1.39-1.92; P < .02) and the patient acceptable symptomatic state for the mHHS (odds ratio, 1.56; 95% CI, 1.11-2.2; P = .038) than those with larger tears. CONCLUSION: Labral tear length is independently predictive of patient-reported outcomes after hip arthroscopy for FAIS. Furthermore, patients with smaller tears (<2.5 cm) had better outcomes and a higher likelihood of achieving a minimal clinically important difference at 2-year follow-up. However, the mean differences between changes in pre- and postoperative outcomes were relatively small and may not be clinically meaningful.

Do Female Athletes Return to Sports After Hip Preservation Surgery for Femoroacetabular Impingement Syndrome?: A Comparative Analysis.

BACKGROUND: Female patients undergoing surgery for femoroacetabular impingement syndrome (FAIS) often experience inferior clinical outcomes and higher failure rates when compared with male patients. The influence of athletic status on hip arthroscopic outcomes in female patients, however, is unclear. PURPOSE: To compare patient-reported outcomes (PROs) of athletic and nonathletic female patients undergoing hip arthroscopic surgery for FAIS, and to determine the return-to-sports rate in the athlete group. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Two-year PROs were assessed in female patients who had undergone hip arthroscopic surgery for FAIS by a single surgeon. Patients who self-identified as athletes were compared with nonathletes. Preoperative and postoperative PRO scores including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport-Specific (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction were analyzed and compared between athletes and nonathletes. Subanalysis was performed based on patient age and body mass index (BMI). RESULTS: A total of 330 female patients undergoing hip arthroscopic surgery for FAIS were identified. Of these, 221 patients identified as athletes (mean age, 29.1 ± 11.1 years; mean BMI, 23.0 ± 3.5 kg/m2) and 109 as nonathletes (mean age, 39.3 ± 11.4 years; mean BMI, 27.8 ± 5.8 kg/m2). Both groups demonstrated improvements in HOS-ADL, HOS-SS, mHHS, VAS for pain, and VAS for satisfaction scores (P < .001 for all). Athletes had significantly higher postoperative PRO scores compared with nonathletes (P < .001 for all). A 1:1 matched-pair subanalysis of 97 athletes and 97 nonathletes controlling for age and BMI indicated that these relationships held independently of potential demographic confounders (P < .001 for all). The number of patients meeting the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the HOS-ADL, HOS-SS, and mHHS was significantly higher in athletes aged ≤25 years versus those aged >25 years and for athletes versus nonathletes (P < .05 for all). Further, 189 of 194 athletes returned to sports at a mean of 6.0 ± 3.9 months postoperatively, with 93.7% reporting returning to the same or higher level of competition. CONCLUSION: Among female patients undergoing hip arthroscopic surgery for FAIS, patients considered athletes achieved superior clinical outcomes compared with patients considered nonathletes. In addition, younger female athletes had higher rates of achieving the MCID and PASS for all PRO measures.

Patients With Unilateral Femoroacetabular Impingement Syndrome Have Asymmetrical Hip Muscle Cross-Sectional Area and Compensatory Muscle Changes Associated With Preoperative Pain Level.

PURPOSE: To compare the symptomatic hip muscle cross-sectional area (CSA) in patients with unilateral femoroacetabular impingement syndrome (FAIS) with the asymptomatic-side hip muscle CSA and to determine whether correlations exist between the hip muscle CSA and preoperative pain level, preoperative symptom duration, and postoperative function. METHODS: We performed a retrospective review of magnetic resonance imaging data of patients who underwent hip arthroscopy from January 2012 through June 2015 for the treatment of unilateral FAIS and who had a minimum of 2 years' follow-up after hip arthroscopy for FAIS. A picture archiving and communication system workstation with an embedded region-of-interest tool was used to measure the muscle CSA of both the symptomatic and asymptomatic sides in FAIS patients. One-way repeated-measures analyses of variance were used to determine differences between symptomatic and asymptomatic hip muscle CSAs. Spearman rank correlations were used to determine relations between the symptomatic-side hip muscle CSA and preoperative pain level, preoperative symptom duration, and multiple validated patient-reported outcomes to quantify the level of function. RESULTS: A total of 50 patients met the inclusion criteria and were analyzed. The mean age of the patients was 34.22 ± 14.12 years, and 64% were women. Specific muscles of the symptomatic hip displaying significantly decreased CSAs compared with the asymptomatic hip included the gluteus maximus (P = .007), gluteus minimus (P = .022), and rectus femoris (P = .028). The tensor fascia lata (ρ = 0.358; P = .011), pectineus (ρ = 0.369, P = .008), adductor longus (ρ = 0.286, P = .044), and obturator externus (ρ = 0.339, P = .016) showed a moderate positive correlation with preoperative pain level on a visual analog scale in unilateral FAIS patients. No associations were found between the symptomatic-side hip muscle CSA in patients with unilateral FAIS and symptom duration or patient-reported function. CONCLUSIONS: Patients with unilateral FAIS have a significantly decreased muscle CSA in the symptomatic hip compared with the asymptomatic hip. The symptomatic-side hip muscle CSA was correlated with the preoperative pain level on a visual analog scale. The association between the muscle CSA and preoperative pain level may represent a compensatory change in muscle function around the hip joint in patients with unilateral FAIS. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Predictors of Persistent Postoperative Pain at Minimum 2 Years After Arthroscopic Treatment of Femoroacetabular Impingement.

BACKGROUND: Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly expanding field, and preoperative factors predictive of persistent postoperative pain are currently unknown. PURPOSE: To identify predictors for persistent postoperative pain at the site of surgery after hip arthroscopy for FAIS. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients who underwent hip arthroscopy for FAIS and had a minimum 2-year follow-up with patient-reported outcomes (PROs) were included in this study. Patients with previous open hip surgery and diagnoses other than FAIS were excluded. Patients were grouped by visual analog scale scores for pain as limited (<30) and persistent (≥30). Patient factors and outcomes were analyzed with univariate and correlation analyses to build a logistic regression model to identify predictors of persistent postoperative pain. RESULTS: The limited pain (n = 514) and persistent pain (n = 174) groups totaled 688 patients (449 females). There was a statistically significant difference in age between groups, with the persistent pain group being older than the low pain group (35.9 ± 12.2 vs 32.4 ± 12.6, respectively; P = .002). Patients with persistent postoperative pain demonstrated significantly lower preoperative PRO scores in the Hip Outcome Score-Activities of Daily Living (57.6 ± 21.2 vs 67.7 ± 16.8), Hip Outcome Score-Sport Specific (35.9 ± 23.9 vs 44.1 ± 22.7), modified Harris Hip Score (51.6 ± 16.2 vs 59.6 ± 12.9), and International Hip Outcome Tool (32.0 ± 16.8 vs 40.0 ± 17.82) but no significant differences in preoperative visual analog scale scores for pain (7.3 ± 1.8 vs 7.2 ± 1.7). Mean postoperative PRO differences between pain groups were all statistically significant. Bivariate logistic regression analysis demonstrated that history of anxiety or depression (odds ratio, 1.8; 95% CI, 1.02-3.32; P = .042), revision hip arthroscopy (odds ratio, 8.6; 95% CI, 1.79-40.88; P = .007), and a low preoperative modified Harris Hip Score (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .30) were predictors of persistent postoperative pain. CONCLUSION: Independent predictors for persistent postoperative pain include revision hip arthroscopy and mental health history positive for anxiety and depression. Our analysis demonstrated significant improvements in pain and functional PROs in the limited pain and persistent pain groups; however, those with persistent pain demonstrated significantly lower PRO scores.

Assessment of Association Between Spino-Pelvic Parameters and Outcomes Following Gluteus Medius Repair.

PURPOSE: To evaluate postoperative coronal/sagittal spinal plane and spinopelvic parameters in patients undergoing gluteus medius repair and to identify associations between outcomes and the aforementioned spinopelvic variables. METHODS: Patients who underwent gluteus medius/minimus repair by a single surgeon between January 20, 2012, and November 25, 2015, were retrospectively identified from a prospectively collected database. Radiographic measurements included Cobb angle, lumbar lordosis, sagittal vertical axis (SVA), pelvic tilt, sacral slope, and pelvic incidence. Patient-reported outcomes (PROs) were obtained at baseline and a minimum of 22 months after surgery. Bivariate correlation determined effects of spinopelvic measurements on PROs. Scoliosis and nonscoliosis groups were compared using independent samples t-test, and multivariate analysis determined whether the preoperative variables affected outcomes. RESULTS: Thirty-eight (80.9%) of 47 consecutive patients were radiographically evaluated with a scoliosis series. All patients demonstrated significant improvements in all PROs and pain (P < .001 for all), as well as at an average 28.2 ± 7.8 (range, 22-51) months after surgery. There were significant negative relationships between SVA and Hip Outcome Score-Activities of Daily Living (r = -0.405, P = .026) and Hip Outcome Score-Sports Specific (r = -0.492, P = .011) scores. Patients with a positive SVA (>0 cm) had significantly worse patient-reported outcomes than their counterparts with negative (≤0 cm) SVA. Also, patients with positive sagittal plane deformity (SVA >5 cm) had significantly worse HOS-SS than patients without positive sagittal plane deformity (SVA <5 cm) (47.0 ± 35.3, 73.2 ± 24.0; P = .04). Independent sample t-testing for the patients with scoliosis (n = 18) versus no scoliosis (n = 20) demonstrates a significantly worse postoperative International Hip Outcome Tool (short version) score in the patients with scoliosis (77.4 ± 15.1, 53.8 ± 37.1; P = .043). CONCLUSIONS: Patients with scoliosis presented with lower rates of symptom improvement and ability to return to an active lifestyle in patients with hip disorders. In addition, patients with positive sagittal plane deformity experienced lower hip-related sport-specific outcome scores. Although the direct relationship between the spine and the hip in patients after gluteus medius/minimus repair remains unclear, this study shows an association between these postoperative outcomes and spinopelvic parameters. LEVEL OF EVIDENCE: Level IV, case series.

Intra-articular Volume Reduction With Arthroscopic Plication for Capsular Laxity of the Hip: A Cadaveric Comparison of Two Surgical Techniques.

PURPOSE: To compare intracapsular volume reduction between interportal capsular shift and T-capsulotomy plication in a cadaveric model. METHODS: Twelve pair-matched specimens were randomized into T-capsulotomy plication or interportal capsular shift. T-capsulotomy was performed using a 2-cm interportal and 2-cm bisecting, longitudinal limb to the intertrochanteric line. Plication was performed utilizing 5-mm bites on either side of the capsulotomy with arthroscopic knot tying technique standard alternating half hitches. Pair-matched interportal capsular shift specimens underwent 5-cm interportal capsulotomy, and capsular shift was performed utilizing 5 nonabsorbable sutures placed in 45° orientation at 5 mm from the capsulotomy margin. With each specimen in a position of slight flexion and adduction, a spinal needle was used to inject methylene blue-colored saline solution intra-articularly; the volcano method was used to measure capsular volume before and after each respective plication technique. Mean absolute volumes and relative volumetric reduction for each technique were quantified and compared to determine statistical significance. RESULTS: At baseline, there were no statistically significant differences in capsular volume between pair-matched specimens (T-capsulotomy plication, 42.5 ± 5.1 mL; interportal capsular shift, 45.0 ± 88.6 mL; P = .555). After capsulotomy and secondary plication, both the T-capsulotomy (post: mean = 32.5 ± 8.0 mL; P < .001) and interportal capsulotomy groups (post: mean = 29.4 ± 10.0; P < .0001) demonstrated significant decreases in capsular volume, with average reductions of 10.0 ± 3.3 mL and 15.6 ± 3.2 mL, respectively. Although the interportal capsular shift (35.9% ± 11.3%) demonstrated greater volumetric reduction relative to baseline when compared with the T-capsular plication (24.5% ± 10.8%), these results were not significant (P = .104). CONCLUSIONS: Both T-capsular plication and interportal capsular shift produce statistically significant reductions in overall hip capsular volume. Although the interportal capsular shift may generate modestly higher degrees of capsular reduction, the comparative biomechanical repercussions of each technique are not currently known. CLINICAL RELEVANCE: Irrespective of arthroscopic technique, capsular plication with 5-mm bites decreases capsular volume by approximately one-third to one-fourth that of baseline measures.

Preoperative Symptom Duration Is Associated With Outcomes After Hip Arthroscopy.

BACKGROUND: Prolonged disease chronicity has been implicated as a cause of suboptimal clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), possibly due to disease progression, deconditioning, and the development of compensatory pathomechanics. PURPOSE: To evaluate the effect of increasing duration of preoperative symptoms on patient-reported outcomes, reoperation, and clinical failure of hip arthroscopy for FAIS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed to identify all patients undergoing primary hip arthroscopy between January 1, 2012, and July 30, 2014, by a single surgeon, with minimum follow-up of 2 years. Patient demographics, comorbid medical conditions, and preoperative outcome scores were compared between patients with preoperative symptoms lasting less than 2 years and those with symptoms lasting 2 years or longer. Multivariate regressions were used to compare Hip Outcome Score Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport-Specific (HOS-SS), and modified Harris Hip Score (mHHS) between the 2 cohorts at 2 years of follow-up. RESULTS: A total of 624 patients were included, with an average age of 34.0 ± 13.5 years; 235 (37.7%) patients had experienced preoperative symptoms 2 years or longer. Patients with symptoms lasting less than 2 years had statistically significant higher outcome scores than those with symptoms lasting 2 or more years for the HOS-ADL (86.3 ± 16.4 vs 80.3 ± 19.9, respectively), HOS-SS (75.0 ± 25.3 vs 65.1 ± 29.0), and mHHS (79.1 ± 16.6 vs 74.0 ± 18.8), as well as higher satisfaction (82.1 ± 30.7 vs 71.1 ± 31.6) and lower pain scores (2.6 ± 2.3 vs 3.5 ± 2.6). On multivariate analysis, patients with symptoms 2 years or longer had significantly higher visual analog scale-Pain score (ß = 0.6, P = .039) and lower HOS-ADL (ß = -3.4, P = .033), HOS-SS (ß = -6.3, P = .012), and satisfaction (ß = -6.7, P = .028) at 2-year follow-up. Patients with longer duration of symptoms also demonstrated less improvement in HOS-SS (ß = -10.3, P = .001) at 2 years after surgery. Patients with symptoms for 2 years or longer were significantly less likely to achieve a patient acceptable symptomatic state for HOS-ADL (relative risk [RR] = 0.8, P = .024) and HOS-SS (RR = 0.8, P = .032) at 2 years of follow-up. Patients with symptoms 2 years or longer also demonstrated significantly higher rates of revision arthroscopy (RR = 10.1, P = .046). CONCLUSION: Patients with untreated, FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery when compared with those patients with a shorter duration of preoperative symptoms.

The Influence of Pain in Other Major Joints and the Spine on 2-Year Outcomes After Hip Arthroscopy.

PURPOSE: To determine whether patients who have pain in other major joints or the spine have poorer postsurgical outcomes than patients without comorbid orthopaedic pain. METHODS: We performed a review of a prospectively maintained institutional surgical registry of patients who underwent hip arthroscopy between January 1, 2012, and July 16, 2015, by a single surgeon, with a minimum of 2 years of postoperative follow-up. A musculoskeletal morbidity (MSM) score was assigned to each patient preoperatively based on the presence of pain in other joints and the spine (grade 1, hip only; grade 2, hip and other major joints without spine; grade 3, hip with spine; and grade 4, hip and other major joints with spine). Preoperatively and at 2 years postoperatively, functional outcomes were measured using the Hip Outcome Score-Activities of Daily Living (HOS-ADL), and the percentages of patients achieving a minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated. RESULTS: In total, 821 patients were identified, of whom 700 (85.3%) completed 2-year follow-up. Preoperatively, MSM grade 1 patients had a higher HOS-ADL than grade 2 patients (P = .02), but there was no difference between grade 1 and grade 3 patients (P = .63) or between grade 1 and grade 4 patients (P = .14). Likewise, there was no difference in the preoperative HOS-ADL among grades 2, 3, and 4. Patients with MSM grades 1 and 2 were younger than those with grades 3 and 4. At 2 years postoperatively, MSM grade 1 patients had higher HOS-ADL values than grade 3 (P = .01) and grade 4 (P = .02) but not grade 2 (P = .07) patients. Overall, 84% of patients showed an MCID and 72% of patients achieved a PASS with regard to the HOS-ADL. There were no statistically significant differences among MSM grades in terms of the MCID or PASS. CONCLUSIONS: Overall, 84% of patients improved with hip arthroscopy by MCID criteria for the HOS-ADL. Patients with no pain in other joints (MSM grade 1) had better 2-year postoperative HOS-ADL values after hip arthroscopy than patients with spine pain (grades 3 and 4). However, there were no significant differences in the MCID or PASS among patients with regard to MSM grade. A total of 40.5% of patients who underwent hip arthroscopy had pain in another joint. A limitation, however, is that there is potential for a type II error, in that there may not have been a sufficient number of patients studied to detect a significant difference in outcome among patients with different grades of musculoskeletal comorbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.