Telemedicine: An Effective Tool for Patient-Physician Communication.

The purpose of this study was to evaluate the effectiveness of telemedicine appointments in a tertiary orthopedic hip clinic during the COVID-19 pandemic, as a substitute for traditional in-person visits. One hundred sixty-three patients had a telemedicine visit from March to September 2020. Patients were divided into two cohorts. The presurgical group included all patients who had not undergone any prior surgical hip procedures. The pre-surgical group was further subdivided into two groups based on the purpose of the visit: conservative treatment and imaging review. Patients who were indicated for surgical treatment from these two groups were identified to assess their compliance with the surgical indication. The effectiveness was measured by assessing whether patients required an in-person visit before the scheduled follow-up after the telemedicine visit for further medical assessment. Fifty (30.7%) men and 113 (69.3%) women had a telemedicine visit during the 6-month period. The mean age was 43.68 (±16.95) years. There were 92 (56.4%) patients in the presurgical group, of whom 41% followed up after indication for conservative treatment and 59% visited to review imaging. From these groups, 27% were indicated for surgical treatment. The postsurgical group contained 71 (43.6%) patients, divided into three groups based on their surgery date: 0 to 3 months (27%), 4 to 12 months (59%), and more than 12 months (14%). All patients were compliant with the scheduled follow-up after their telemedicine visit. This study showed that telemedicine can be an effective tool for patient-physician communication, obviating the need for subsequent follow-up beyond regularly scheduled visits. [Orthopedics. 2023;46(3):e173-e178.].

Outcomes of Staged Bilateral Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome: A Nested Matched-Pair Control Study Focusing on the Effect of Time Between Procedures.

BACKGROUND: Bilateral hip symptoms from femoroacetabular impingement syndrome (FAIS) are a common finding in patients regardless of athletic involvement. Oftentimes, patients and surgeons choose to stage bilateral hip arthroscopic surgery. PURPOSE/HYPOTHESIS: The purpose of this study was (1) to compare minimum 2-year outcomes between patients who underwent staged bilateral hip arthroscopic surgery for FAIS to a propensity score-matched control group that underwent unilateral hip arthroscopic surgery and (2) to investigate the effect of time between bilateral procedures on patient-reported outcomes (PROs). We hypothesized that, after bilateral hip arthroscopic surgery, the improvement in outcomes would be similar to that after unilateral hip arthroscopic surgery and the time duration between bilateral procedures would not affect the final outcome. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were retrospectively reviewed on a consecutive series of patients who underwent primary hip arthroscopic surgery at our institution between June 2008 and November 2017. Patients who underwent bilateral hip arthroscopic surgery with minimum 2-year PROs for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), patient satisfaction, and a visual analog scale (VAS) for pain were included. The study group was matched 1:1 based on age, sex, and body mass index to a control group that only required unilateral hip arthroscopic surgery. Additionally, a subanalysis was performed on the study group to determine the effect of time between arthroscopic procedures. Rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the mHHS and HOS-SSS were determined. The P value was set at <.05. RESULTS: A total of 205 patients (410 hips) were included. The mean age and body mass index of the study group were 32.3 ± 13.2 years and 25.0 ± 5.1, respectively. All 410 hips that met the inclusion criteria were matched. There were no significant differences in patient, radiographic, or procedural data. A significant and comparable improvement was reported for all PRO measures and the VAS (P < .0001) in both groups. Similarly, rates of achieving the MCID and PASS were comparable. After dividing the study group based on whether the contralateral procedure was performed <3 months or >3 months after the first procedure, it was determined that patients had a significant improvement and favorable outcomes regardless of time between bilateral procedures. CONCLUSION: Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAIS had a significant and comparable improvement in PROs at a minimum 2-year follow-up. A time interval of <3 months or >3 months between bilateral procedures did not affect PROs.

Editorial Commentary: Allogenic Dermal Fibroblasts in Collagen Matrix Scaffold Enhance Rotator Cuff Repair in an Animal Model.

There has been a recent surge of interest on the use of biologic supplements to facilitate rotator cuff repair healing. Experimental evidence appears to support use of allogenic dermal fibroblasts (ADFs), either in the form of local injection or tenocytes embedded in collagen matrix scaffold, to enhance healing of a repaired rotator cuff tendon tear in an animal model. When compared with the ADFs, the platelet-rich plasma (PRP)-induced response seems to be limited in terms of the specific increases in local collagen 1 concentration, thus resulting in a bone-tendon healing response that is inferior in both biology and biomechanical behavior under the same laboratory conditions. While on the one hand, there is pilot data supporting use of dermal fibroblast in the clinical setting, thus reinforcing the animal study findings, on the other hand, we are also aware of the encouraging biologic changes that occurred in the retrieved acellular dermal matrix (ADM) allograft that was used for superior capsular reconstruction as a treatment of irreparable rotator cuff tears. In theory, ADFs locally instilled as an injection should further enhance the healing response compared to the ADM. However, this needs to be further studied to be able to be widely applicable clinically.

Hip Pain Increases With Age and Experience Level in Adult Karate Athletes: A Statewide Survey Study.

Purpose: To investigate the prevalence of hip pain from labral tears and femoroacetabular impingement (FAI) in karate athletes using a statewide online survey. Methods: An anonymous electronic survey was distributed via Qualtrics to all registered members of a statewide karate organization who were a purple belt or higher. Basic demographic information was collected as well as belt level, competitive level, and information regarding hip pain and treatment for hip pain. Microsoft Excel was used to store and analyze data. Results: Of 180 respondents, 123 (68.3%) never had hip pain when practicing karate, and 54 (30.0%) had hip pain at some point in their karate career. Three subjects did not provide an answer and were excluded. Furthermore, of the symptomatic individuals, 52 reported the location of their hip pain, whereas 2 subjects did not. Of the symptomatic individuals (54), 32 had formal diagnoses by a medical professional, 4 (12.5%) were diagnosed with FAI of the hip, 6 (18.8%) diagnosed with a hip labral tear, 3 (9.4%) diagnosed with hip bursitis, 3 (9.4%) diagnosed with hip arthritis, and 16 (50%) had other diagnoses. The remaining 22 participants have not received a formal diagnosis by a medical professional. Conclusions: The prevalence of hip pain in karate athletes in this survey was lower compared to athletes of other martial arts and kicking sports. No differences in the percentage of injuries were found between sex and years practiced; however a higher incidence of hip pain was found between elite status and age group. When evaluating hip pain in the karate population, orthopaedic surgeons should maintain an index of suspicion for FAI and hip labral tears. Level of Evidence: Level IV, retrospective cross-sectional study.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study.

BACKGROUND: The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce. PURPOSE: (1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score-Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI). RESULTS: A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05). CONCLUSION: Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports.

BACKGROUND: Athletes who compete in flexibility sports (FS) place unique demands on their hip joints because of the supraphysiologic range of motion required. PURPOSE: To compare the pathologic features, outcomes, and return-to-sports (RTS) rates of high-level athletes participating in FS who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear against a propensity score-matched cohort of high-level athletes participating in non-flexibility sports (NFS). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed for high-level athletes who underwent primary hip arthroscopy for FAIS from April 2008 to December 2018. Patients who participated in FS such as dancing, gymnastics, martial arts, figure skating, and cheerleading were propensity score matched by body mass index, age at time of surgery, sex, sports competition level, and labral treatment to a cohort of high-level athletes participating in all other sports, such as distance running, soccer, volleyball, and softball. Baseline patient characteristics, intraoperative findings, and surgical procedures were compared. Minimum 2-year patient-reported outcome measures were compared for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain and satisfaction. Rates of secondary surgery and RTS were compared. RESULTS: A total of 47 patients (50 hips) who participated in FS were included and propensity score matched to 130 patients (150 hips) who participated in NFS. Follow-up time was 37.5 ± 10.4 months (mean ± SD). Most patients (96.0%) were female with a mean age of 19.5 ± 7.3 years. FS athletes had significantly higher rates of femoral head cartilage lesions (Outerbridge ≥2; 12.0% vs 2.0%; P = .008) and ligamentum teres tears (48% vs 26%; P = .003). FS and NFS athletes demonstrated significant clinical improvements after surgery for all patient-reported outcome measures. Of the patients who attempted, 34 (75.6%) participating in FS were able to RTS while 11 (24.4%) were not because of ongoing hip issues. This was not significantly different than the NFS group (P = .073). CONCLUSION: High-level athletes who participated in FS and were treated for FAIS with hip arthroscopy exhibited higher rates of femoral head cartilage lesions and ligamentum teres tears requiring debridement when compared with a benchmark group of athletes who participated in other sports. Despite this, both groups demonstrated similar improvements in outcome scores and comparable rates of RTS at minimum 2-year follow-up.

Dunn View Alpha Angle More Useful Than Femoral Head-Neck Offset to Predict Acetabular Cartilage Damage in Patients With Femoroacetabular Impingement Syndrome Undergoing Hip Arthroscopy.

PURPOSE: To identify radiographic measurements and demographics that are predictive of acetabular cartilage damage in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. More specifically, to compare the predictive value of alpha angle and femoral head-neck offset, as measured on Dunn view radiographs, in determining the preoperative likelihood and severity of acetabular cartilage damage. METHODS: Patients were included if they underwent primary hip arthroscopy for FAIS between February 2008 and June 2020. Exclusion criteria were prior ipsilateral hip conditions, Tönnis grade of osteoarthritis >1, unwilling to participate, missing intraoperative, demographic or radiographic variables of interest, and lateral center-edge angle (LCEA) >40° or ≤25°. Fourteen variables were assessed in a bivariate comparison and analyzed in a multivariate logistic model. The Acetabular Labrum Articular Disruption (ALAD) and Outerbridge (OB) classifications were used to define acetabular cartilage defects. Those without damage or those with mild acetabular cartilage damage belonged to the ALAD/OB ≤2 group and those with severe damage belonged to the ALAD/OB ≥ 3 group. RESULTS: A total of 1485 patients were analyzed, including 1038 patients with ALAD/OB ≤2 and 447 patients with ALAD/OB ≥3. There was a greater proportion of males in the ALAD/OB ≥3 group (64.21% vs 25.82%; P <.001). The multivariate logistic regression selected age, sex, anterior center-edge angle (ACEA), and alpha angle. Every additional degree in the alpha angle was associated with a 6% increase in the odds of severe acetabular cartilage damage (odds ratio [OR], 1.06 [95% confidence interval [CI], 0.12-8.11]). The multivariate analysis did not identify femoral head-neck offset as a predictor. The odds of severe acetabular cartilage damage were 3.73 times higher in males than females (OR, 3.73 [95% CI, 0.01-1705.96]). Higher age was found to increase the likelihood of ALAD/OB ≥3 (OR, 1.04 [95% CI, 0.13-7.75]). CONCLUSIONS: In a multivariate analysis, factors identified as preoperative predictors of acetabular cartilage damage in patients with FAIS were age, sex, ACEA, and alpha angle. Femoral head-neck offset was not predictive, suggesting that Dunn view alpha angle may take precedence as a predictor of acetabular cartilage damage. LEVEL OF EVIDENCE: Level III, cohort study.

Surgeon-Specific Traction Time During Hip Arthroscopy for Primary Labral Repair Can Continue to Decrease After a Substantial Number of Surgeries.

PURPOSE: The purpose of this study was to evaluate the total traction time and traction time as a function of anchors placed (TTAP) for primary labral repair in patients undergoing hip arthroscopy by a single surgeon. METHODS: Patients were included if they received a primary labral repair with or without acetabuloplasty, chondroplasty, or ligamentum teres debridement as part of the treatment for femoroacetabular impingement (FAI). Patients were excluded if they had a previous ipsilateral hip surgery, prior hip conditions, Tönnis grade >1, open procedures, microfracture, ligamentum teres reconstruction, or labral reconstruction. TTAP was calculated by dividing total traction time by the number of anchors placed. RESULTS: 2,350 hips met the inclusion criteria. The mean age and BMI in this cohort were 34.22 years and 25.72 kg/m2, respectively. A total traction time of 60 minutes was first achieved after 268 cases. Mean overall total traction time was 58.16 minutes (95% CI [57.35, 58.97]) and mean TTAP was 16.24 minutes (95% CI [15.93,16.55]) after 2,350 cases. Total traction time plateaued after 374 cases at 55.92 minutes, while TTAP plateaued after 487 cases at 14.93 minutes. CONCLUSION: Surgeons who introduce hip arthroscopy into their practice can expect to see improvements in traction time during the first 500 surgeries performed, as total traction time plateaued after 374 cases and TTAP plateaued after 487 cases. LEVEL OF EVIDENCE: IV: case series.

Patients Obtain Meaningful Clinical Benefit After Hip Arthroscopy Despite Preoperative Psychological Distress: A Propensity-Matched Analysis of Mid-Term Outcomes.

PURPOSE: To evaluate the influence of baseline psychological distress on patient-reported outcomes (PROs) after arthroscopic hip surgery for femoroacetabular impingement at a minimum of 5 years. METHODS: Demographic and intraoperative data were prospectively collected from patients who underwent primary arthroscopic hip surgery for femoroacetabular impingement and labral tears after failure of conservative management between June 2012 and December 2014. Included patients had preoperative and minimum 5-year postoperative PROs and visual analog scale scores for pain and satisfaction. The 12-item Short Form Health Survey (SF-12) Mental Component Summary (MCS) score was used to stratify patients into 2 cohorts: Patients with an average or above-average score (SF-12 MCS score ≥ 50) were considered psychologically non-distressed, whereas those who scored below average (SF-12 MCS score < 50) were considered to have psychological distress. Distressed patients were propensity matched by age, sex, and body mass index to an equal number of non-distressed patients. RESULTS: Of the 153 hips that met the inclusion criteria, 117 (76.5%) had minimum 5-year follow-up. Eighty-two hips were included in the final analysis after propensity matching, with 41 in both the distressed and non-distressed cohorts. Preoperatively, patients in the distressed cohort reported inferior scores for all PROs. There was a significant difference in the SF-12 MCS score between groups at 2 years, but similar scores were observed for all other PROs. At minimum 5-year follow-up, there were no differences between groups for any PRO. There were no differences in the rates of achieving the minimal clinically important difference for all PROs or in achieving the patient acceptable symptomatic state for the modified Harris Hip Score. CONCLUSIONS: Patients with baseline psychological distress may have a lower functional status at the time of presentation but still gain meaningful clinical benefit and pain improvement from arthroscopic hip surgery, with mid-term outcomes comparable to those obtained by patients without preoperative psychological distress. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical Outcomes and Reoperation Rates After Hip Arthroscopy in Female Athletes With Low Versus Normal Body Mass Index: A Propensity-Matched Comparison With Minimum 2-Year Follow-up.

BACKGROUND: The effect of low body mass index (BMI) on outcomes in female athletes is unknown. PURPOSE: (1) To report minimum 2-year patient-reported outcomes and return to sports for high-level female athletes with low BMI undergoing hip arthroscopy for femoroacetabular impingement syndrome and (2) to compare results with those of a propensity-matched control group of high-level female athletes with a normal BMI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were collected on all professional, collegiate, and high school female athletes who had a low BMI and underwent primary hip arthroscopy between September 2009 and March 2017 at our institute. Return-to-sports status and minimum 2-year patient-reported outcomes were collected for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale (VAS) for pain. The percentage of patients achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) was also recorded. These patients were propensity matched to high-level female athletes with a normal BMI for comparison. RESULTS: A total of 21 high-level female athletes (25 hips) with a mean ± SD follow-up of 58.9 ± 31.5 months were included. They demonstrated significant improvement from preoperatively to latest follow-up for the mHHS, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and VAS (P < .001). When outcomes were compared with those of the control group, female athletes with low BMI demonstrated lower rates of achieving the MCID for the mHHS (54.5% vs 77.4%; P = .041), PASS for the International Hip Outcome Tool-12 (45.5% vs 72.6%; P = .022), and MOIST for the VAS (31.8% vs 56.5%; P = .047). There were no other significant differences in the rate of achieving the MCID, PASS, or MOIST between the groups (P > .05). Female athletes with low BMI also had higher rates of revision when compared with the control group (27.2% vs 10.6%; P = .049), but there were comparable return-to-sports rates (75.0% vs 74.5%; P > .05). CONCLUSION: High-level female athletes with low BMI undergoing primary hip arthroscopy for femoroacetabular impingement syndrome demonstrated significant improvement in patient-reported outcomes and acceptable rates of return to play. When compared with a control group with normal BMI, they exhibited higher rates of revision and lower rates of achieving the MCID for the mHHS, PASS for the International Hip Outcome Tool-12, and MOIST for the VAS.

Return to Sports and Minimum 2-Year Outcomes of Hip Arthroscopy in Elite Athletes With and Without Coexisting Low Back Pain: A Propensity-Matched Comparison.

BACKGROUND: Patient-reported outcomes (PROs) and return to sports (RTS) after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) have not been established in elite athletes with coexisting low back pain (LBP). PURPOSE: (1) To report minimum 2-year PROs and RTS rates after primary hip arthroscopy for FAIS in elite athletes with coexisting LBP and (2) to compare clinical results with a propensity-matched control group of elite athletes without back pain. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were reviewed for elite athletes (college and professional) who underwent hip arthroscopy for FAIS and had coexisting LBP between October 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip or spine surgery or conditions. Rates of achieving the minimal clinically importance difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. For the subanalysis, the elite athlete study group was propensity matched to an elite athlete control group without back pain. RESULTS: A total of 48 elite athletes with LBP who underwent primary hip arthroscopy met inclusion criteria, and follow-up was available for 42 (87.5%) at 53.2 ± 31.6 months (mean ± SD). Elite athletes with coexisting LBP demonstrated significant improvements in all recorded PROs and achieved the MCID and PASS for the HOS-SSS at rates of 82.5% and 67.5%, respectively. They also returned to sports at a high rate (75.8%), and 79% of them did not report LBP postoperatively. PROs, rates of achieving the MCID and PASS for the HOS-SSS, and RTS rates were similar between the study group and propensity-matched control group. CONCLUSION: Elite athletes with coexisting LBP who undergo primary hip arthroscopy for FAIS may expect favorable PROs, rates of achieving the MCID and PASS for the HOS-SSS, and RTS rates at minimum 2-year follow-up. These results were comparable to those of a propensity-matched control group of elite athletes without back pain. In athletes with hip-spine syndrome, successful treatment of their hip pathology may help resolve their back pain.

Younger Age, Capsular Repair, and Larger Preoperative Alpha Angles Are Associated With Earlier Achievement of Clinically Meaningful Improvement After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: The purpose of the study was to analyze demographic, radiographic, and intraoperative factors that influence the time to achieve the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold (MOIT) after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear. METHODS: Included patients had undergone hip arthroscopy with labral repair or reconstruction for FAIS with labral tear between February 2008 and October 2018. Patients were excluded if they had a prior ipsilateral hip surgery, prior hip conditions, a Tonnis grade > 1, or were unwilling to participate. Multiple demographic, radiographic, and intraoperative variables were collected. The modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were collected before surgery and at 3 months, 1 year, and 2 years after surgery. The MCID and MOIT for the mHHS and NAHS were either calculated or determined through previously published values. A time-to-event analysis was performed to determine variables predictive of early or delayed achievement of MCID or MOIT. Early achievement was defined as achieving MCID or MOIT at the 3-month timepoint. RESULTS: Six hundred thirty-two hips (632 patients) were included. Of those that achieved MCID and MOIT, 428 (73.0%) and 414 (73.0%) patients achieved MCID and 253 (47.9%) and 264 (52.5%) patients achieved MOIT by 3 months after surgery for mHHS and NAHS, respectively. Younger age, capsular repair, and increasing alpha angle were associated with earlier achievement for either MCID or MOIT. Increasing age, worker's compensation claims, and higher baseline patient-reported outcome measure scores were associated with delayed achievement for either MCID or MOIT. CONCLUSIONS: Most of the patients who achieved MCID and MOIT for mHHS and NAHS did so by 3 months after surgery. Younger age, capsular repair, and increasing alpha angle were associated with earlier achievement of MCID and MOIT after hip arthroscopy. LEVEL OF EVIDENCE: Level IV, case series.

High-Level Athletes Who Did Not Return to Sport for Reasons Unrelated to Their Hip Achieve Successful Midterm Outcomes With a Benchmarking Against High-Level Athletes Who Returned to Sport.

PURPOSE: 1) To report minimum 2- and 5-year outcomes of high-level athletes who did not return to sport (RTS) after hip arthroscopy for reasons unrelated to their hip (T athletes) and 2) to benchmark these findings against a propensity-matched control group of high-level athletes who returned to sport (RTS athletes). METHODS: Data were prospectively collected and retrospectively reviewed for professional, collegiate, and high school athletes between April 2008 and October 2015, who underwent primary hip arthroscopy. Athletes were considered eligible if they did not return to sport for reasons unrelated to their hip such as loss of interest, graduation, or a lifestyle transition (T athletes). Inclusion criteria were preoperative and minimum 5-year postoperative patient-reported outcomes (PROs) for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and the visual analog scale (VAS) for pain. Clinical outcomes were assessed using the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold (MOIST). T athletes were then propensity-matched to a control group of high-level athletes who returned to sport after hip arthroscopy (RTS athletes) for comparison. RESULTS: Twenty-seven T hips (25 patients) were included in the analysis with a mean follow-up time of 38.9 ± 16.8 and 72.1 ± 16.8 months for minimum 2- and 5-year outcomes, respectively. They demonstrated significant improvement in all measured PROs. When compared to a propensity-matched control group of RTS athletes, T athletes demonstrated similar improvement in PROs (mHHS, NAHS, and HOS-SSS) and achieved MCID at similar rates for NAHS (T: 77.8% vs RTS: 68.8%; P = .570) and HOS-SSS (T: 70.3% vs RTS: 76.6%, P = .824) compared to RTS athletes; however T athletes demonstrated higher rates of achieving MCID for mHHS (T: 88.9% vs RTS: 72.9% P = .033). CONCLUSION: Athletes who did not return to sport for reasons unrelated to their hip demonstrated favorable outcomes at minimum 2- and 5-year follow-up. They had similar PROs and rates of achieving MCID for HOS-SSS compared to a propensity-matched control group of high-level athletes who returned to sport. Return to sport status may not necessarily be correlated to the patient's perception of their own outcome. LEVEL OF EVIDENCE: III, retrospective cohort study.

In-line Pullout Strength of 2 Acetabular Fixation Methods for Ligamentum Teres Reconstruction of the Hip: A Cadaveric Study.

BACKGROUND: Ligamentum teres (LT) reconstruction is an appropriate alternative in select cases of LT full-thickness tears, resulting in hip micro- or macroinstability. Graft fixation at the acetabular fossa is critical to achieving the best functional results. PURPOSE: The purpose of this study is to compare the pullout strength of 2 graft fixation methods used for LT reconstruction of the hip. STUDY DESIGN: Controlled laboratory study. METHODS: In 7 cadaveric specimens, the acetabular socket was prepared after the native LT was transected and the femoral head was removed. Seven separate tibialis anterior grafts were then prepared by suturing a running-locking No. 2 suture on each tail of the graft. Three specimens had fixation of the graft to the acetabulum using an adjustable cortical suspension suture button; the remaining 4 were fixed to the acetabulum using a knotless suture anchor. Specimens were then mounted onto a custom jig within a mechanical test frame to allow for the in-line pull of the graft fixation construct. After a preload of 5 N, each specimen was loaded to failure at 0.5 mm/s. Stiffness and load to failure were measured for each specimen construct. RESULTS: Suture button fixation had a higher mean load to failure when compared with the knotless anchor fixation method (mean ± SD, 438.1 ± 114.3 vs 195.9 ± 50.0 N; P = .01). There was no significant difference in mean stiffness between the methods of fixation (24.5 ± 1.4 vs 26.5 ± 5.8 N/mm; P = .6). CONCLUSION: In this cadaveric study, the suture button fixation demonstrated greater load to failure than the knotless anchor fixation. CLINICAL RELEVANCE: Results of this study can guide surgical decision making when selecting an acetabular fixation method for LT reconstruction.

Favorable Outcomes of Revision Hip Arthroscopy Irrespective of Whether Index Surgery was Performed by the Same Surgeon or a Different Surgeon.

INTRODUCTION: The purpose of this study was to compare minimum 2-year patient-reported outcomes (PROMs) after revision hip arthroscopy between two different patient cohorts who had undergone primary hip arthroscopy with the same surgeon (SS) and a different surgeon (DS). We hypothesized no difference in clinical outcomes between the groups despite differences in intraoperative findings based on the surgical decision making in a revision setting at a high-volume center. METHODS: Between January 2012 and August 2017, 71 SS patients were matched for age, sex, body mass index, and follow-up to 71 DS patients. Modified Harris hip score (mHHS), nonarthritic hip score, and hip outcome score-sports-specific subscale (HOS-SSS) were collected prospectively. The minimal clinically important difference was calculated for mHHS and HOS-SSS. RESULTS: All the DS patients had labral tears, and 94.4% had femoroacetabular impingement from residual bony deformity (P < 0.001). The SS and DS groups demonstrated significant and comparable improvement in mHHS (Δ = 18.3 ± 21.5 versus 19 ± 20.1; P = 0.837), nonarthritic hip score (Δ = 18.8 ± 18.8 versus 18.2 ± 18.8; P = 0.850), and HOS-SSS (Δ = 22 ± 27.4 versus 17.5 ± 28.1; P = 0.275). The rates of achieving minimal clinically important difference for mHHS and HOS-SSS were similar. Furthermore, the need for revision surgery and conversion to total hip arthroplasty were comparable (P = 0.228 and P = 0.383). CONCLUSIONS: Patients undergoing revision hip arthroscopy reported notable and comparable improvement in multiple patient-reported outcomes at a minimum 2-year follow-up, irrespective of intraoperative findings or primary source of patient pool.

Circumferential and Segmental Arthroscopic Labral Reconstruction of the Hip Utilizing the Knotless Pull-Through Technique with All-Suture Anchors.

Appropriate labral tear management is one of the principal priorities of hip-preservation surgery. The labrum's role in the stability and biomechanics of the hip and preservation of the suction seal has been thoroughly demonstrated. Favorable patient-reported outcomes with labral reconstruction and, more recently, labral augmentation have shown that these are viable reconstructive procedures in the setting of irreparable labra. A wide variety of grafts have been used for these advanced labral restoration techniques. The present Technical Note will describe a detailed arthroscopic circumferential labral reconstruction using the pull-through technique with knotless all-suture anchors. The benefits of such can be applied to both segmental and circumferential labral reconstruction procedures, as well as labral augmentation, based on the intraoperative findings and preference of the surgeon.

Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy in High-Level Athletes With a Propensity-Matched Benchmarking Against a Unilateral Control Group.

BACKGROUND: Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established. PURPOSE: (1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery/conditions. Rates of achieving the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. These athletes were then propensity matched in a 1:3 ratio to high-level athletes who underwent unilateral arthroscopy for comparison. Outcomes were compared among the first hip of the study group, the second hip of the study group, and the control group. RESULTS: A total of 74 high-level athletes who underwent bilateral hip arthroscopy met the inclusion criteria, and follow-up was available for 68 (91.9%) at 58.9 ± 24.5 months (mean ± SD). Athletes undergoing bilateral hip arthroscopy returned to sports at a high rate (81.7%), demonstrated significant improvements in all recorded PROs, and achieved the MCID and PASS for the HOS-SSS at rates of 80.9% and 64.7%, respectively. PROs, RTS rate, and rates of achieving the MCID and PASS for the HOS-SSS were similar when the bilateral study group was compared with the unilateral control group (P > .05). CONCLUSION: High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

Short-term Outcomes of Concomitant Femoral Derotation Osteotomy and Hip Arthroscopy.

The goal of this study is to report the short-term outcomes of concomitant hip arthroscopy and femoral derotational osteotomy (FRO) to treat femoral malrotation and intra-articular pathology. Data were retrospectively reviewed for patients undergoing concomitant hip arthroscopy and FRO between March 2013 and January 2017. Patients were included if they had a minimum of 1 year of follow-up for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12) score, 12-item Short Form Health Survey Physical component and Mental component (SF-12 P and SF-12 M, respectively) scores, Veterans RAND 12-item Health Survey Physical and Mental (VR-12 P and VR-12 M, respectively) scores, visual analog scale (VAS) score for pain, and patient satisfaction ratings. Rates for meeting the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) were also recorded. Nine hips were included, and mean follow-up was 36.9 months. Mean preoperative femoral version was 33.0°. Patients underwent 1 or more concomitant procedures, such as labral treatment, capsular plication, acetabuloplasty, or femoroplasty. At latest follow-up, significant improvement was seen for mHHS, NAHS, HOS-SSS, and VAS score. Additionally, rates of meeting the PASS for mHHS, iHOT-12 score, and HOS-SSS were 100%, 88.9%, and 55.6%, respectively. Rates of achieving MCID for mHHS and HOS-SSS were 77.8% and 66.7%, respectively. One hip required revision derotational osteotomy to treat overcorrection, and 3 hips underwent secondary surgery for hardware removal. Concomitant hip arthroscopy and FRO may yield improved outcomes for patients with concurrent intra-articular pathology and excessive femoral anteversion. Considering that no major complications were diagnosed, this procedure is also relatively safe. [Orthopedics. 2021;44(6):e739-e746.].

One Bony Morphology, Two Pathologic Entities: Sex-Based Differences in Patients With Borderline Hip Dysplasia Undergoing Hip Arthroscopy.

BACKGROUND: Sex-based differences have been largely uncharacterized for patients with borderline hip dysplasia (BHD) undergoing hip arthroscopy. PURPOSE: To evaluate for sex-based differences in clinical and pathologic characteristics as well as surgical outcomes in patients with BHD undergoing hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between January 2011 and December 2018, data were prospectively collected on all patients with BHD undergoing primary hip arthroscopy. Patients were included if they had preoperative and minimum 2-year postoperative scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain. Patients with previous ipsilateral hip conditions or surgery, Tönnis grade >1, lateral center-edge angle <18° or >25°, or workers' compensation status were excluded. Patients were then divided by sex and propensity score matched in a 1:1 ratio for body mass index, age, and Tönnis grade. The rates of patients who achieved the minimal clinically important difference were recorded for the mHHS and NAHS. The rates of achieving the patient acceptable symptomatic state for the mHHS were calculated. RESULTS: A total of 344 hips met the inclusion criteria, and 317 hips (92%) had adequate follow-up. Propensity score matching created cohorts of 109 male and 109 female patients. Male patients had significantly higher preoperative average alpha angles (69.79° vs 58.17°, P < .001), more often requiring a femoroplasty (97.2% vs 83.5%, P < .001), and had higher rates of complex labral tearing (50.5% vs 33.0%, P < .001). Male patients also had higher rates of grade 3 and 4 acetabular labral articular disruption (62.4% vs 19.3%, P < .001) and higher rates of grade 3 and 4 acetabular cartilage injury (59.6% vs 20.2%, P < .001) requiring a microfracture more frequently (32.1% vs 7.3%, P < .001). Female patients more typically had painful internal snapping requiring iliopsoas fractional lengthening (60.6% vs 32.1%, P < .001). Female patients also underwent capsular plication more regularly to address hip instability (79.8% vs 45.9%, P < .001). Male and female patients showed significant improvements in all outcome scores after surgery (P < .001). Female patients achieved the minimal clinically important difference for the NAHS at higher rates (85.3% vs 71.6%, P = .020). CONCLUSION: Female and male patients with BHD who underwent hip arthroscopy achieved favorable outcomes but had notably dissimilar pathology. Hence, although they share similar acetabular bony morphology, male and female patients with BHD may represent 2 very different pathologic entities.

Comparing Midterm Outcomes of High-Level Athletes Versus Nonathletes Undergoing Primary Hip Arthroscopy: A Propensity-Matched Comparison With Minimum 5-Year Follow-up.

BACKGROUND: High-level athletes (HLAs) have been shown to have better short-term outcomes than nonathletes (NAs) after hip arthroscopy. PURPOSE: (1) To report midterm outcomes of HLAs after primary hip arthroscopy and (2) to compare their results with a propensity-matched cohort of NA patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed between February 2008 and November 2015 for HLAs (professional, college, or high school) who underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS). HLAs were included if they had preoperative, minimum 2-year, and minimum 5-year follow-up data for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sports-Specific Subscale (HOS-SSS). Radiographic and intraoperative findings, surgical procedures, patient-reported outcomes (PROs), patient acceptable symptomatic state (PASS), minimal clinically important difference (MCID), and return to sport were reported. The HLA study group was propensity-matched to a control group of NA patients for comparison. RESULTS: A total 65 HLA patients (67 hips) were included in the final analysis with mean follow-up time of 74.6 ± 16.7 months. HLAs showed significant improvement in all PROs recorded, achieved high rates of MCID and PASS for mHHS (74.6% and 79.4%, respectively) and HOS-SSS (67.7% and 66.1%, respectively), and returned to sport at high rates (80.4%). When compared with the propensity-matched NA control group, HLAs reported higher baseline but comparable postoperative scores for the mHHS and NAHS. HLA patients achieved MCID and PASS for mHHS at similar rates as NA patients, but the HLA patients achieved PASS for HOS-SSS at higher rates that trended toward statistical significance (66.1% vs 48.4%; P = .07). NA patients underwent revision arthroscopic surgery at similar rates as HLA patients (14.9% vs 9.0%, respectively; P = .424). CONCLUSION: Primary hip arthroscopy results in favorable midterm outcomes in HLAs. When compared with a propensity-matched NA control group, HLAs demonstrated a tendency toward higher rates of achieving PASS for HOS-SSS but similar arthroscopic revision rates at minimum 5-year follow-up.