Editorial Commentary: Indications for Acetabular Labral Debridement Versus Repair and Reconstruction: There is Still a Role for Selective Labral Debridement.

Not all acetabular labral tears, tissue quality, and size are the same. There is still a role for selective debridement of the acetabular labrum when stable, functional labral tissue remains. An unstable labrum that appears very different than the rest of the labrum is an easy target for repair. Tears requiring resection require graft augmentation or reconstruction.

Editorial Commentary: Endoscopic Repair of Abductor Tendon Tears Results in Variable Patient Reported Outcomes and Generally Good to Excellent Results.

Abductor tendon pathology is fairly common, with up to a 25% incidence in patients having total hip arthroplasty and 30% having hip arthroscopy. A systematic review of endoscopic abductor tendon repair demonstrated that as few as 41% of patients with endoscopic repair of abductor tendon tears achieve a patient acceptable satisfactory state, but a major limitation of systematic reviews is extreme heterogeneity between included studies. Surgical techniques and skills differ, as do tear severity and confounding pathology such as labral tears. Another limitation is a focus on patient-reported outcome measures (PROMs). PROMs are important (we prefer happy patients with poor healing to unhappy patients with healed repairs), but PROMs are also "subjective," and different cohorts of patients in different studies from different locations may have different perceptions or goals with regard to pain and function. As surgeons, we are able to observe gait, strength, and, with advanced imaging when indicated or for research purposes, healing. These, combined with PROMs, influence overall assessment of outcome. Experience and review of the literature show that endoscopic surgical repair of abductor tendon tears generally shows good or excellent results. If a patient has significant pain improvement and objectively improved gait, a calculation of an outcome threshold based on a subjective survey may not tell the full story.

Editorial Commentary: The Optimal Nerve Block for Hip Arthroscopy Is Undetermined.

The optimal nerve block to help reduce pain after hip arthroscopy is undetermined. The fascia iliaca block was en vogue but may result in weakness, neuropathy, and equivocal pain outcomes. Other options include blocks to the femoral nerve, the lumbar plexus, the quadratus lumborum, and, more recently, the pericapsular nerve group block (PENG), in which ultrasound guidance allows injection under the iliopsoas muscle to affect the accessory obturator nerve and the articular branches of the femoral nerve. PENG block should not result in weakness, but weakness has been reported after PENG block for total hip arthroplasty, and falls could be a risk and a concern. The arthroplasty literature also suggests the PENG block adds little benefit to intra-articular injection beyond the recovery room and is comparable with a fascia iliac block. Perhaps the PENG block could show benefit in select cases such as for severe postoperative pain or in patients with anticipated pain control challenges. Until an ideal block for hip arthroscopy is determined, a patient tailored approach is indicated.

Editorial Commentary: Revision Hip Arthroscopy in Patients Older Than 40 Has a Higher Rate of Conversion to Total Hip Arthroplasty-Get It Right the First Time, and the Second.

Getting hip arthroscopy right the first time is critical to the overall patient outcome. This involves proper patient selection, with avoidance of arthritis, understanding the pathology of each hip, and properly executing the surgery. Care must be taken to restore labral function and preserve capsule function while accurately resecting pincer or cam impingement. While good results can be achieved in patients older than 40 years of age, an opportunity exists for improved optimization of clinical outcomes. Moreover, revision hip arthroscopy in patients older than 40 years of age has a higher rate of conversion to total hip arthroplasty. Again, get it right the first time, and carefully consider indications for revision hip arthroscopy in patients older than 40 years of age if there is a second time.

Editorial Commentary: The Everted Acetabular Labrum. It Is Not Just a Small Labrum.

Everted, hypoplastic acetabular labra represent a variant of acetabular rim development. It is important to be able to recognize this pathology on magnetic resonance imaging and at the time of hip arthroscopy. Proper intraoperative identification of this variant that does not make contact with the femoral head is critical to being able to successfully restore this contact, often through labral advancement, acetabuloplasty of the abnormal rim development, and occasionally labral augmentation. A broad awareness among hip arthroscopy surgeons of this topic will lead to improved clinical outcomes after hip arthroscopy for a challenging cohort.

Editorial Commentary: Microinstability After Cam Osteochondroplasty Results From Over-Resection-Everything in Moderation.

Cam impingement is one of the most common pathologies treated with hip arthroscopy. While it is a common treatment, it can be difficult to achieve the perfect osteochondroplasty, one that neither over- nor under-resects the head-neck junction. Clinical studies and now biomechanical analysis show over-resection of cam lesions can result in inferior clinical outcomes from microinstability.

Editorial Commentary: Labral Calcification in the Setting of Femoroacetabular Impingement Syndrome: The Gratification of Eradication and Treatment of the Problem.

Acetabular labral calcifications are occasionally encountered during hip arthroscopy for labral tears and femoroacetabular impingement. Clinical outcomes after removal of this calcification and repair of labral tearing have been shown to be good. Since these are found in asymptomatic patients, the labral repair and treatment of femoroacetabular impingement seem to be more important than removal of the calcification. However, amorphous calcium deposits need to be distinguished from the more serious conditions of labral ossification or rim fractures, which require significant preoperative planning and patient counseling. Labral reconstruction or rim fixation will alter the surgical procedure and potentially the postoperative rehabilitation.

Editorial Commentary: Large Heterogeneity of Minimal Clinically Important Difference Utilization in Hip Arthroscopy Studies: Where Do We Go From Here?

The minimal clinically important difference is a relatively new method to evaluate outcomes after surgery, defined as the lowest value of change in the outcome score that results in a perceived clinical improvement. There is no clear delineation of use for this metric, resulting in a heterogeneous application in hip arthroscopy research, making comparisons with other studies difficult. Cohort-specific values calculated using an anchor-based method are best.

Editorial Commentary: The Hip Capsule: To Close or Not to Close? Is That Still the Question?

The question of capsule closure or no closure after hip arthroscopy remains controversial as we try to decipher best practice and which patients should and should not have a repair. Closure seems of particular importance in younger patients and with larger capsulotomies. In my practice, I routinely repair the capsule after hip arthroscopy, except in patients with significant stiffness. Capsule repair may not be vital in some patients, as a smaller capsulotomy could sometimes heal on its own, but my patients and I certainly do not want to learn the hard way.

Editorial Commentary: Hip Joint Space as a Predictor of Cartilage Pathology: A Basic Tool for a Complex Task.

Predicting articular cartilage pathology in the hip with radiographic joint space has been unreliable for patients having joint spaces >2 mm in width. Joint space width is a tool that can be used, but with some limitation. Other methods of investigation such as magnetic resonance imaging should be used in conjunction with radiographic joint space.

Editorial Commentary: Hip Arthroscopy With Concomitant Periacetabular Osteotomy: Teamwork Makes This Dream Work.

Arthroscopy provides a powerful tool to successfully treat intra-articular hip pathology secondary to dysplasia while improving the bony coverage/alignment with periacetabular osteotomy; a concept no different than high tibial osteotomy. Through a specialized team approach, all relevant pathology can be addressed and successful outcomes achieved.

Editorial Commentary: Fluid Extravasation in Hip Arthroscopy-A Tough Case Just Got Much Worse.

Hip arthroscopy has its complications like any other surgery, but abdominal compartment syndrome is unique to the hip and is a complication with devastating consequences. Avoidance is the rule.

Supine and Standing AP Pelvis Radiographs in the Evaluation of Pincer Femoroacetabular Impingement.

BACKGROUND: Pelvic tilt can affect the presence of the ischial spine sign and crossover sign. Numerous studies of pelvic tilt on radiographic measurements of pincer impingement have shown that increasing anterior tilt is associated with more radiographic signs of pincer impingement. However, to our knowledge, no study has directly compared supine and standing plain radiographs in patients with respect to lateral center-edge (LCE) angle, acetabular inclination, crossover sign, and ischial spine sign. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the differences in supine and standing AP pelvis radiographs as they relate to the radiographic parameters of pincer impingement in an adult population evaluated for femoroacetabular impingement, specifically intrapelvic distances (sacrococcygeal to symphysis [SC-S] and coccyx tip to symphysis [T-S]), crossover sign (presence and percentage), LCE angle, inclination, and ischial spine sign. METHODS: Between August 2013 and June 2014, we obtained supine and standing radiographs for all new patients younger than 60 years who were evaluated for hip pain, when the diagnosis of fracture was not being considered; these formed the basis of this retrospective study. Patients were excluded if they had arthritis (Tönnis grade ≥ 2), lumbar fusion, previous hip surgery, or malrotated films. Forty-six hips, symptomatic side, met the inclusion criteria (age of patients, 33 ± 14 years; 13 males, 33 females). Radiographic data that were collected included SC-S distance, T-S distance, LCE angle, acetabular inclination, presence and percentage of crossover sign, and presence of ischial spine sign. A paired t-test was used to compare continuous variables and chi-square test was used for categorical variables. Two independent readers performed measurements. RESULTS: From supine to standing films, the T-S distance decreased from 19 ± 18 mm to 6 ± 19 mm (p < 0.001), and SC-S distance decreased from 47 ± 19 mm to 32 ± 20 mm (p < 0.001), indicating less pelvic tilt in the standing position. The number of hips that had crossover signs decreased from supine (n = 18, 39%) to standing (n = 9, 20%) (p = 0.039). The amount of crossover decreased from 23% ± 10% to 11% ±13% (p < 0.001). LCE angle did not change (27° ± 7° to 27° ± 8°) (p = 0.64) and inclination angle increased by a small amount (4.2° ± 5° to 5.3° ± 5°) (p = 0.002). The ischial spine sign decreased from supine (n = 20, 43%) to standing (n = 7, 15%) position (p = 0.003). CONCLUSIONS: There is a decrease in the amount of pelvic tilt on standing AP pelvis radiographs resulting in a decrease in the incidence and amount of crossover sign and ischial spine sign, and a small increase in inclination. Standing radiographs should be the standard in evaluation of nonarthritic hip pain, specifically pincer femoroacetabular impingement. Surgeons should use caution in interpreting supine AP radiographs in the evaluation of pincer impingement, specifically the crossover sign. LEVEL OF EVIDENCE: Level III, diagnostic study.

Biomechanical differences of the anterior and posterior bands of the ulnar collateral ligament of the elbow.

PURPOSE: The main purpose of this study was to examine the functional characteristics of the anterior and posterior bands of the anterior bundle of the ulnar collateral ligament (UCL). METHODS: Six cadaveric elbows were tested using a digital tracking system to measure the strain in the anterior band and posterior band of the anterior bundle of the UCL throughout a flexion/extension arc. The specimens were then placed in an Instron materials testing machine and loaded to failure to determine yield load and ultimate load of the UCL. RESULTS: The posterior band showed a linear increase in strain with increasing degrees of elbow flexion while the anterior band showed minimal change in strain throughout. The bands showed similar strain at yield load and ultimate load, demonstrating similar intrinsic properties. CONCLUSION: The anterior band of the anterior bundle of the UCL shows an isometric strain pattern through elbow range of motion, while the posterior band shows an increasing strain pattern in higher degrees of elbow flexion. Both bands show similar strain in a load to failure model, indicating insertion point, not intrinsic differences, of the bands determine the function of the anterior bundle of the UCL. This demonstrates a biomechanical rationale for UCL reconstructions using single point anatomical insertion points.

Acetabular Labral Base Repair Versus Circumferential Suture Repair: A Matched-Paired Comparison of Clinical Outcomes.

PURPOSE: To determine whether an acetabular labral repair technique would be superior to another repair technique based on clinical outcomes measured by patient-reported outcome (PRO) scores. METHODS: We identified 465 patients who underwent labral base repair or circumferential suture repair from February 2008 to February 2012. The type of repair performed was based on labral size and tear type. The 2 groups were pair matched for age within 5 years, sex, crossover sign within 15%, coxa profunda, Workers' Compensation status, and microfracture (femur, acetabulum, or none). Data were prospectively collected and retrospectively reviewed. PROs included a visual analog scale score and the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living, and Hip Outcome Score-Sports-Specific Subscale. RESULTS: One hundred ten patients met the inclusion criteria for labral base repair and were pair matched on a 1:1 basis with 110 patients who underwent circumferential suture repair. The mean follow-up period was 30 months for both groups, with a range of 19.2 to 60 months for the labral base repair group and 19.2 to 67 months for the circumferential suture repair group. Radiographic data were similar between groups with respect to the lateral center-edge angle (P = .906), acetabular inclination (P = .329), anterior center-edge angle (P = .208), alpha angle (P = .387), and joint space width (P = .388). All preoperative PRO scores were statistically similar. Both groups showed significant improvements in all PROs. There were no statistical differences in postoperative PRO scores at latest follow-up (modified Harris Hip Score, P = .215; Hip Outcome Score-Activities of Daily Living, P = .839; Hip Outcome Score-Sports-Specific Subscale, P = .561; Non-Arthritic Hip Score, P = .333; visual analog scale score, P = .373; and satisfaction, P = .483). There were similar rates of revision (n = 10 for both groups) and conversion to arthroplasty (n = 2 for both groups). CONCLUSIONS: On the basis of PRO scores at 2 years' follow-up, there is no difference in outcomes based on the type of labral repair performed. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of femoral anteversion on clinical outcomes after hip arthroscopy.

PURPOSE: To compare the clinical outcomes after hip arthroscopy of patients with femoral retroversion, normal femoral version, and excessive femoral anteversion. METHODS: Patients who underwent primary hip arthroscopy from August 2008 to April 2011 and underwent femoral anteversion measurement by magnetic resonance imaging/magnetic resonance arthrogram were included. The patients were divided into 3 groups: retroversion, normal version, and excessive anteversion. The normal-version group was considered to have a value within 1 SD of the mean femoral version value. Four patient-reported outcome scores and the visual analog pain score were prospectively collected with analysis performed retrospectively. RESULTS: Two hundred seventy-eight patients met the inclusion criteria. Among these patients, mean anteversion was 8.2° ± 9.3°, creating a retroversion group defined as -2° or less and an anteversion group defined as 18° or greater. There were 25 patients in the retroversion group, 219 in the normal-version group, and 34 in the excessive-anteversion group. Most labral tears were noted in the 12- to 2-o'clock range, with the main difference at the anterior 3-o'clock position, where the excessive-anteversion group showed a lower incidence of tearing (30%) than the retroversion group (73%) and normal-anteversion group (78%). Postoperatively, there was a statistically significant improvement from preoperative scores in all 3 groups and for all scores (P < .001). When the postoperative scores were compared for the 3 groups, although all scores were higher in the retroversion group than in the other 2 groups, this was not statistically significant and there were no significant differences in scores among the 3 groups (modified Harris Hip Score, P = .104; Non-Arthritic Hip Score, P = .177; Hip Outcome Score-Activities of Daily Living, P = .152; Hip Outcome Score-Sport-Specific Subscale, P = .276; visual analog scale score, P = .508). CONCLUSIONS: On the basis of patient-reported outcome scores without accounting for diagnoses and treatments, the amount of femoral anteversion does not appear to affect the clinical outcomes after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Joint-preserving surgical options for management of chondral injuries of the hip.

Management of injuries to the articular cartilage is complex and challenging; it becomes especially problematic in weight-bearing joints such as the hip. Several causes of articular cartilage damage have been described, including trauma, labral tears, and femoroacetabular impingement, among others. Because articular cartilage has little capacity for healing, nonsurgical management options are limited. Surgical options include total hip arthroplasty, microfracture, articular cartilage repair, autologous chondrocyte implantation, mosaicplasty, and osteochondral allograft transplantation. Advances in hip arthroscopy have broadened the spectrum of tools available for diagnosis and management of chondral damage. However, the literature is still not sufficiently robust to draw firm conclusions regarding best practices for chondral defects. Additional research is needed to expand our knowledge of and develop guidelines for management of chondral injuries of the hip.

Revision hip preservation surgery with hip arthroscopy: clinical outcomes.

PURPOSE: To analyze and report the clinical outcomes of a cohort of patients who underwent revision hip preservation with arthroscopy and determine predictors of positive and negative outcomes. METHODS: During the study period from April 2008 to December 2010, all patients who underwent revision hip preservation with arthroscopy were included. This included patients who had previous open surgery and underwent revision with arthroscopy. Patient-reported outcome (PRO) scores were obtained preoperatively and at 3-month, 1-year, 2-year, and 3-year follow-up time points. Any revision surgeries and conversions to total hip arthroplasty were noted. A multiple regression analysis was performed to look for positive and negative predictive factors for improvement in PROs after revision hip arthroscopy. RESULTS: Forty-seven hips in 43 patients had completed 2 years' follow-up or needed total hip arthroplasty. The mean length of follow-up was 29 months (range, 24 to 47 months). Of the hips, 31 (66%) had either unaddressed or incompletely treated femoroacetabular impingement. There was a significant improvement in all PRO scores at a mean of 29 months after revision (P < .0001). The visual analog scale score improved from 7.3 ± 1.5 to 3.9 ± 2.5 (P < .0001). Improvements in the Non-Arthritic Hip Score of at least 10 points and 20 points were found in 28 hips (65%) and 19 hips (44%), respectively. Four hips in 3 patients required conversion to total hip arthroplasty. Positive predictive factors for PRO improvement were previous open surgery, pincer impingement, cam impingement, symptomatic heterotopic ossification, and segmental labral defects treated with labral reconstruction. CONCLUSIONS: On the basis of multiple PROs, revision hip preservation with hip arthroscopy can achieve moderately successful outcomes and remains a viable treatment strategy after failed primary hip preservation surgery. Preoperative predictors of success after revision hip arthroscopy include segmental labral defects, unaddressed or incompletely addressed femoroacetabular impingement, heterotopic ossification, and previous open surgery. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic labral base repair in the hip: clinical results of a described technique.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of a cohort of patients who underwent labral repair by use of a previously published labral base repair suture technique for the treatment of acetabular labral tears and pincer-type femoroacetabular impingement (FAI). METHODS: Patients who received hip arthroscopy for symptomatic intra-articular hip disorders and underwent the previously described labral base repair technique were included in the study group. Patients who had Tönnis arthritis grade 2 or greater, had Legg-Calves-Perthes disease, or underwent simple looped stitch repair were excluded. The patient-reported outcome scores included the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Activities of Daily Living, and the Hip Outcome Score-Sport-Specific Subscale obtained preoperatively and at 2 years' and 3 years' follow-up. Any complications, revision surgeries, and conversions to total hip arthroplasty were noted. RESULTS: Of the patients, 54 (82%) were available for follow-up. The mean length of follow-up for this cohort was 2.4 years (range, 1.7 to 4.1 years). At final follow-up, there was significant improvement in all 4 patient-reported outcome scores (modified Harris Hip Score, 63.7 to 89.9; Non-Arthritic Hip Score, 60.9 to 87.9; Hip Outcome Score-Activities of Daily Living, 66.9 to 91.0; and Hip Outcome Score-Sport-Specific Subscale, 46.5 to 79.2) (P < .0001). A good or excellent result was achieved in 46 patients (85.2%). There was significant improvement in pain as measured by the change in visual analog scale score from 6.5 to 2.3 (P < .0001), and the patient satisfaction rating was 8.56 ± 2.01. There were no perioperative complications. Revision surgery was required in 3 patients (5.6%), and 2 patients (3.7%) required conversion to total hip arthroplasty. CONCLUSIONS: The clinical results of this labral base repair technique showed favorable clinical improvements based on 4 patient-reported outcome questionnaires, visual analog scale, and patient satisfaction. More clinical, biomechanical, and histologic studies are needed to determine the optimal repair technique. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Radiographic, histologic, and arthroscopic findings in amorphous calcifications of the hip labrum.

PURPOSE: The purpose of this study was to evaluate the clinical, radiographic, histologic, and intraoperative findings of an amorphous calcification involving the acetabular labrum. METHODS: From October 2008 to April 2013, all patients who underwent arthroscopic hip surgery for symptomatic intra-articular hip disorders and were found to have the characteristic calcific deposit involving the acetabular labrum were included. These patients were reviewed retrospectively on prospectively collected data. Radiographs were retrospectively evaluated for morphologic features of impingement and characteristics of labral calcification. RESULTS: Sixteen patients were identified as having amorphous calcification at the time of arthroscopy. There were 15 women and 1 man. Mean age was 37.3 years (range, 30 to 50 years). Symptoms were present for a mean of 9.3 months (range, 3 to 48 months). All patients reported anterior groin pain. Fifteen (94%) patients had positive anterior impingement and 9 (56%) had positive results for lateral impingement. Calcifications measured on average 3.2 mm (range, 1.9 mm to 5.6 mm), and 14 had a clear separation from the rim with increased opacity compared with neighboring trabecular bone. Intraoperatively, the characteristic amorphous calcium deposit was located in the anterosuperior labrum, with the deposit found to be accessible from the capsule-labral recess in all cases. All patients had labral tears and all patients had at least one component of femoroacetabular impingement (FAI). CONCLUSIONS: Calcification in the anterosuperior acetabular labrum presents with a consistent patient demographic and distinct radiographic and arthroscopic presentation that is different from os acetabuli. As with os acetabuli, one should have a high suspicion for FAI when this lesion is encountered. LEVEL OF EVIDENCE: Level IV, therapeutic case series.