Primary and Revision Hip Arthroscopy in Borderline Hip Dysplasia Shows Comparable Outcomes at a Minimum 5-Year Follow-Up.

PURPOSE: To compare patient-reported outcomes (PROs), achievement of clinically significant outcomes, and reoperation-free survivorship between primary and revision hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in propensity-matched borderline hip dysplasia (BHD) patients at a minimum 5-year follow-up. METHODS: Patients with BHD, characterized by a lateral center-edge angle 18° to 25°, who underwent HA for FAIS with capsular repair by a single surgeon between January 2012 and June 2018 with a minimum 5-year follow-up were identified. Cases of revision HA were propensity-matched 1:2 to cases of primary HA, controlling for age, sex, and body mass index. A 1:2 ratio was chosen to maximize the number of included patients. Collected PROs included Hip Outcome Score-Activities of Daily Living and Sport Subscales, International Hip Outcome Score 12, modified Harris Hip Score, and Visual Analog Scale for Pain. Achievement of minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit for any measured PRO was compared between groups along with reoperation-free survivorship using Kaplan-Meier analysis. RESULTS: Thirty-six revision HA hips (34 patients) were propensity-matched to 72 primary HA hips (70 patients). The groups were similar in age (31.5 ± 10.3 years vs 30.5 ± 11.2, P = .669), sex (69.4% female vs 70.8%, P = .656), and body mass index (25.7 ± 4.0 vs 25.5 ± 3.7, P = .849). The revision group showed a greater prevalence of prolonged preoperative pain (50.0% vs 27.8%, P = .032) compared with the primary group. A significant improvement in all PROs was observed for both groups with comparable PROs preoperatively and at the 5-year follow-up between groups (P ≥ .086). The revision and primary groups showed comparable minimal clinically important difference (95.0% vs 95.7%, P ≥ .999), patient acceptable symptom state (80.0% vs 83.6%, P = .757), and substantial clinical benefit (62.5% vs 70.7%, P = .603) achievement for any PRO. Comparable reoperation-free survivorship was observed (P = .151). CONCLUSIONS: Propensity-matched patients with BHD undergoing primary and revision hip arthroscopy for FAIS achieved similar minimum 5-year PROs, clinically significant outcomes, and reoperation-free survivorship. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Computer-Assisted Arthroscopic Cam Resection.

Determining the appropriate femoral cam resection during hip arthroscopy for femoroacetabular impingement syndrome is both critical for the patient and challenging for the surgeon. Incomplete bone resection is a leading cause of failed hip arthroscopy, whereas over-resection may increase the risk of femoral neck fracture. The alpha angle is a validated 2-dimensional radiographic measurement used to both diagnose femoroacetabular impingement syndrome preoperatively and to determine resection adequacy postoperatively. Computer-assisted intraoperative guidance systems enhance the accuracy of femoral cam resection, although a preoperative 3-dimensional computed tomography scan may be required. Other systems, such as the HipCheck software (Stryker, Kalamazoo, MI), have been developed to provide intraoperative guidance with live feedback using simultaneous alpha angle measurements overlayed on fluoroscopic images without the requirement for routine preoperative computed tomography. Via intraoperative touchscreen navigation, the surgeon identifies the midpoint of the femoral neck and femoral head. A commercial software program provides real-time alpha angle measurements, as well as enhanced visualization of the femoral cam deformity with an adjustable resection curve. Before the surgeon performs the cam resection, the software provides a template for appropriate resection depth in 6 positions of the hip. Upon completion of the femoral cam resection, the hip is again assessed in the same 6 positions and the alpha angle is assessed to ensure a complete resection.

Increased Alpha Angles and Younger Age Increase the Risk of Contralateral Femoral Acetabular Impingement Syndrome Symptom Development and Surgical Intervention: A Systematic Review.

PURPOSE: To identify the preoperative risk factors associated with contralateral symptom development and surgical intervention for patients presenting with unilateral femoral acetabular impingement (FAI) syndrome. METHODS: A literature search was performed using PubMed and Scopus computerized databases according to the 2020 Preferred Reporting Items for Systematic Meta-Analyses guidelines. Studies evaluating preoperative risk factors associated with the contralateral progression of FAI were included. Quality assessment was completed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: A total of 5 studies (n = 1,011 patients; mean age, 29.9 years) published from 2013 to 2022 met the inclusion/exclusion criteria. Mean follow-up ranged from 12 to 132 months. The overall rate of contralateral progression of symptomatic FAI ranged from 32.4% to 81%. Increased alpha angle was frequently reported factor associated with contralateral symptom progression, followed by decreased total arc of rotation, decreased internal rotation, reduced neck-shaft angle, and head-neck offset. The incidence rate of progression to contralateral surgery ranged from 15.7% to 24% of patients. Younger age was frequently reported factor associated with contralateral surgical intervention, followed by male sex, increased level of activity, and increased alpha angle. CONCLUSIONS: Increased alpha angle and younger age were commonly reported risk factors associated with an increased risk of symptom development and surgical progression of contralateral FAI, respectively. The overall rate of contralateral progression of symptomatic FAI and the rate of progression to surgical intervention ranged up to 81% and 24%, respectively. This information may help both patients and surgeons to establish expectations regarding development of contralateral hip symptoms and possible need for surgery. LEVEL OF EVIDENCE: Level III; systematic review of Level II-III studies.

Gluteus Repair Yields Satisfactory Clinically Significant Outcome Achievement by 1 Year in Mostly Partial-Thickness Tears With Preoperative Hip Abduction Weakness Associated With Delayed Achievement.

PURPOSE: To define the time to achievement of clinically significant outcomes (CSOs) after primary gluteus medius and/or minimus (GM) repair and to identify factors associated with delayed CSO achievement. METHODS: Patients who underwent primary GM repair between January 2012 and June 2021 with complete preoperative, 6-month, 1-year, and 2-year Hip Outcome Score-Activities of Daily Living (HOS-ADL) were retrospectively identified. Cohort-specific minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated. The time to achievement of MCID and PASS was analyzed using Kaplan-Meier survival analysis. Median time to MCID and PASS achievement was recorded. Multivariate stepwise Cox regressions were used to identify factors associated with delayed CSO achievement. RESULTS: Fifty GM repairs were identified (age 59.4 ± 9.7 years, body mass index 27.9 ± 6.2, 94% female). Tears were grade 1 in 39 cases, grade 2 in 7 cases, and grade 3 in 4 cases. Endoscopic repair was performed in 35 cases, and open repair was performed in 15 cases. Labral debridement and repair were each performed in 15 cases. Median time to CSO achievement was 5.7 months for MCID and 11.0 months for PASS. The 2-year cumulative probability of MCID and PASS achievement was 92.7% and 66.7%, respectively. Preoperative hip abduction weakness on physical examination was associated with delayed achievement of MCID (hazard ratio 2.27, confidence interval 1.067-7.41, P = .039) and PASS (hazard ratio 3.89, confidence interval 1.341-11.283, P = .012). CONCLUSIONS: This study demonstrated that in patients undergoing repair of primarily grade 1 GM tears, most achieved MCID by 6 months, and more than one half achieved PASS by 12 months. Preoperative hip abduction weakness on physical examination was associated with delayed CSO achievement. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Hip Arthroscopy Patients With Lower Back Pain Show Delayed Clinical Improvement and Inferior Time-Dependent Survivorship: A Propensity Matched Study at Mid-Term Follow-Up.

PURPOSE: To evaluate patient-reported outcomes (PROs) and survivorship at mid-term follow-up after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in patients with and without preoperative lower back pain (LBP). METHODS: Patients with self-endorsed preoperative LBP who underwent HA for FAIS with mid-term follow-up were identified and propensity matched 1:1 to patients without back pain by age, sex, and body mass index (BMI). PROs collected preoperatively and at postoperative years 1, 2, and 5 included Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Subscale (HOS-SS), 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and Visual Analog Scale (VAS) for Pain. Achievement of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were compared. Survivorship was compared with Kaplan-Meier analysis. RESULTS: In total, 119 patients with LBP were matched to 119 patients without LBP. Group demographic factors were as follows: age (37.4 ± 11.9 vs 37.6 ± 12.6 years, P = .880), sex (64.4% vs 67.7% female, P = .796), and BMI (25.3 ± 5.1 vs 25.3 ± 5.4, P = .930). Average follow-up duration was 6.0 ± 1.9 years. LBP patients showed similar preoperative PROs, yet lower 1-year scores for all PROs (P ≤ .044). At final follow-up, similar PROs were shown between groups (P ≥ .196). LBP and non-LBP patients had similar MCID achievement for HOS-ADL (59.3% vs 63.1%, P = .640), HOS-SS (73.9% vs 70.8%, P = .710), mHHS (66.7% vs 73.4%, P = .544), iHOT-12 (85.1% vs 79.4%, P = .500), and VAS Pain (75.6% vs 69.9%, P = .490). Groups also had similar PASS achievement for HOS-ADL (63.5% vs 61.3%, P = .777), HOS-SS (57.0% vs 62.5%, P = .461), mHHS (81.9% vs 79.1%, P = .692), iHOT-12 (54.6% vs 61.2%, P = .570), and VAS Pain (51.0% vs 55.4%, P = .570). Additionally, achievement of MCID ≥ 1 PRO (P ≥ .490) and PASS ≥ 1 PRO (P ≥ .370) was similar across groups. Conversion to total hip arthroplasty occurred in 3.4% of hips with LBP and 0.8% of hips without LBP (P = .370). Back pain patients demonstrated inferior time-dependent survivorship compared with patients without back pain on Kaplan-Meier survival analysis (P = .023). CONCLUSIONS: Patients undergoing primary hip arthroscopy for FAIS with LBP achieve comparable PROs and clinically significant outcomes to patients without back pain at mid-term, despite lower 1-year PRO scores. LBP patients show inferior reoperation-free time-dependent survivorship compared with those without LBP. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Patients With Lateral and Anterolateral Cam Morphology Have Greater Deformities Versus Typical Anterolateral Deformity Alone but No Differences in Postoperative Outcomes: A Propensity-Matched Analysis at Minimum 5-Year Follow-Up.

PURPOSE: To compare pre- and postoperative findings between patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with lateral impingement versus those without lateral impingement METHODS: Patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between 2012 and 2017 with minimum 5-year follow-up were included. Alpha angle (AA) was measured on preoperative anteroposterior (AP) and 90° Dunn radiographs. Patients with AA >60° on Dunn view but not AP view (no lateral impingement) were propensity matched by sex, age, and body mass index in a 1:3 ratio to patients with AA >60° on both views (lateral impingement). Demographic characteristics, radiographic and intraoperative findings, reoperation rates, and patient-reported outcomes (PROs) were compared between groups. Categorical variables were compared using the Fisher exact testing and continuous variable using 2-tailed Student t tests. RESULTS: Sixty patients with lateral impingement (65.0% female, age: 35.3 ± 13.0 years) were matched to 180 patients without lateral impingement (65.0% female, age: 34.7 ± 12.5 years, P ≥ .279). Patients with lateral impingement had larger preoperative AAs on both Dunn (71.0° ± 8.8° vs 67.6° ± 6.1°, P = .001) and AP radiographs (79.0° ± 12.1° vs 48.2° ± 6.5°, P < .001). However, there were no differences in postoperative AAs on either view (Dunn: 39.0° ± 6.1° vs 40.5° ± 5.3°, AP: 45.8° ± 9.0° vs 44.9° ± 7.0°, P ≥ .074). Labral tears began more superiorly in patients with lateral impingement (12:00 ± 0:49 vs 12:17 ± 0:41, P = .030), and they demonstrated greater rates of acetabular and femoral cartilage damage (P = .030 for both); however, there were no differences in PROs or reoperation rates between the groups at 5-year follow-up. CONCLUSIONS: Although cam deformities located laterally and anterolaterally are larger than those located anterolaterally alone, both can be resected adequately, resulting in similar postoperative radiographic measurements, PROs, and survivorship. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Patient-Reported Outcomes Measurement Information System Is Not as Responsive as Legacy Scores in Detecting Patient Outcomes in Hip Preservation: A Systematic Review.

PURPOSE: To evaluate publication trends of Patient-Reported Outcomes Measurement Information System (PROMIS) in hip preservation literature, assess the usage of PROMIS as an outcome measure, and evaluate correlations of all available published PROMIS domains with legacy patient-reported outcomes (PROs). METHODS: The PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Google Scholar databases were queried for articles evaluating PROMIS scores among hip preservation populations. Inclusion criteria consisted of studies with Level IV evidence or above (per the Sackett et al. levels of evidence), such as case series and cohort studies, reporting on perioperative use of hip PROMIS scores. Exclusion criteria consisted of arthroplasty and trauma studies. Patient demographics, PROMIS usage, and PROMIS Pearson or Spearman correlation coefficients to historic PROs were recorded for each study. RESULTS: Fifteen articles published between 2017 and 2021 were included in the analysis, with the majority (75%) published between 2020 and 2021. Studies assessing postoperative outcomes had follow-up periods ranging from 6 months to 5 years. The most common PROMIS domain reported was Physical Function (PF), and there was varying usage of other domains including Pain Intensity, Anxiety, and Depression. PROMIS validity was most often assessed in comparison to the modified Harris Hip Score (mHHS) by calculating the Pearson coefficient, which assumes normal data distribution, or Spearman coefficient, which is rank-based and does not require normal data distribution. Studies comparing PROMIS-PF with mHHS reported Pearson coefficients ranging from 0.49 to 0.72 and Spearman coefficients ranging from 0.67 to 0.71. CONCLUSIONS: There has been a chronologic increase in PROMIS usage in hip preservation literature. PROMIS demonstrates moderate-to-strong correlations with legacy PROs, but there is substantial heterogeneity in follow-up periods, PROMIS domains used, and statistical methodology. The current data show that PROMIS is not as responsive as historically used, validated PROs in quantitatively assessing function and pain in hip preservation patients. CLINICAL RELEVANCE: Surgeons using PROMIS solely should be aware that the score may not be as responsive as legacy PROs in closely assessing improvements or deterioration in patient performance after hip preservation surgery. Rather than being used alone, PROMIS may be useful as a replacement for a group of legacy PROs. Thus, when used alongside select legacy PROs, overall questionnaire burden can be reduced while maintaining a high level of accuracy in assessing health status.

Patients Maintain Clinically Significant Outcomes at 5-Year Follow-Up After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Systematic Review.

PURPOSE: To assess 5-year outcomes and survival rate of hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and to determine achievement rates of clinically significant outcomes. METHODS: Three databases were searched around the following terms: hip arthroscopy, FAIS, and 5-year follow-up. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after primary HA using either patient-reported outcomes (PROs) or conversion to total hip arthroplasty (THA) and/or revision surgery were included. Quality assessment was completed using MINORS assessment, and relative agreement was calculated using Cohen's kappa. RESULTS: Fifteen articles were included. MINORS assessment ranged from 11 to 22, with excellent (k = 0.842) inter-rater reliability between reviewers. 2,080 patients were included at a follow-up range of 60.0-84 months. Labral repair was the most commonly performed procedure (range: 8.0%-100%). All studies included PROs, and all reported statistically significant improvement (P < .05) at the 5-year timepoint. The most frequent PRO was modified Harris Hip Score (mHHS) (n = 8). Nine studies reported on clinically significant outcome achievement, with mHHS being the most common (n = 8). The rate of achieving minimal clinically important difference (MCID) ranged from 64 to 100%, patient-acceptable symptomatic state (PASS) ranged from 45 to 87.4%, and substantial clinical benefit (SCB) ranged from 35.3 to 66%. Conversion to THA and revision surgery varied across studies, with ranges of 0.0%-17.9% (duration: 28.8-87.1 months) and 1.3%-26.7% (duration: 14.8-83.7 months), respectively. The most common definition of failure was conversion to THA or revision (n = 7). Increased age (n = 5) and greater joint degeneration (n = 4) were the most common predictors of clinical failure. CONCLUSIONS: Patients undergoing primary hip arthroscopy for FAIS demonstrated significant improvement at 5-year follow-up, with maintained rates of achievement of MCID, PASS, and SCB. Survival rate of HA at 5 years is overall high, with ranges of 0.0-17.9% and 1.3-26.7% conversion to THA or revision surgery, respectively. Across studies, increased age and greater joint degeneration were the most commonly cited predictors of clinical failure. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Capsular Repair Is Associated With Lower Revision Rates Yet Similar Clinical Outcomes and Arthroplasty Conversion 5 Years After Hip Arthroscopy: A Systematic Review.

PURPOSE: To perform a systematic review of studies reporting on minimum 5-year outcomes of patients undergoing primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) to determine whether capsular management influences patient-reported outcomes (PROs), rates of clinically significant outcome, and rates of revision surgery or conversion to total hip arthroplasty (THA). METHODS: PubMed, Scopus, and Google Scholar were searched around the terms hip arthroscopy, FAIS, five-year follow-up, and capsule management. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after HA using either PROs or conversion to THA or revision surgery were included. Quality assessment was completed using MINORS assessment. Articles were stratified into unrepaired and repaired capsule cohorts (excluding periportal capsulotomy techniques). RESULTS: Eight articles were included. MINORS assessment ranged from 11-22, with excellent (k = 0.842) inter-rater reliability. Populations without capsular repair were identified in 4 studies including a total of 387 patients, at an age of 33.1 to 38.0 years and follow-up range of 60.0 to 77 months. Populations with capsular repair were identified in 5 studies including a total of 835 patients, at an age range of 33.6 to 43.1 years and follow-up range of 60.0 to 78.0 months. All studies included PROs and all reported significant improvement (P < .05) at the 5-year timepoint, with modified Harris Hip Score (mHHS) being the most frequent (n = 6). No differences were noted between groups regarding any of the measured PROs. Average rates of achieving MCID and PASS for mHHS were similar between patients without capsular repair (MCID 71.1%, PASS 73.7%, n = 1) and with capsular repair (MCID 66.0%-90.6%, PASS 55.3%-87.4%, n = 4). Conversion to THA occurred in 12.8% to 18.5% and 0.0% to 29.0% for patients with an unrepaired and repaired capsule, respectively. Revision HA occurred in 15.4% to 25.5% and 3.1% to 15.4% in unrepaired and repaired capsular patients, respectively. CONCLUSIONS: Patients undergoing hip arthroscopy for FAI had significant improvement in PRO scores at minimum 5-year follow-up, and scores did not differ between patients who underwent capsular repair and those who did not. Similar rates of markers of clinical benefit and THA conversion were achieved by both groups; however, lower rates of revision hip arthroscopy were demonstrated in the capsular repair cohort. LEVEL OF EVIDENCE: Level IV; systematic review of Level II-IV studies.

Return to Sport Following Distal Triceps Repair.

PURPOSE: The purpose of this investigation was to examine the timeline of return-to-sport following distal triceps repair; evaluate the degree of participation and function upon returning to sport; and identify risk factors for failure to return to sport. METHODS: Patients who underwent distal triceps repair with a minimum of 1 year of follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire and were scored on a visual analog scale for pain; the Mayo Elbow Performance Index; the Quick Disabilities of the Arm, Shoulder, and Hand; and the Single Assessment Numerical Evaluation. RESULTS: Out of 113 eligible patients who had a distal triceps repair, 81 patients (71.7%) were contacted. Sixty-eight patients (84.0%) who participated in sports prior to surgery were included at 6.0 ± 4.0 years after surgery, and the average age was 46.6 ± 11.5 years. Sixty-one patients (89.7%) resumed playing at least 1 sport by 5.9 ± 4.4 months following distal triceps repair. However, 18 patients (29.5%) returned to a lower level of activity intensity. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand; Mayo Elbow Performance; visual analog scale for pain; and Single Assessment Numerical Evaluation scores were 8.2 ± 14.0, 89.5 ± 13.4, 2.0 ± 1.7, and 82.2 ± 24.3, respectively. No patients underwent revision surgery at the time of final follow-up. CONCLUSIONS: Distal triceps repair enables 89.7% of patients to return to sport by 5.9 ± 4.4 months following surgery. However, 29.5% of patients were unable to return to their preinjury level of activity. It is imperative that patients are appropriately educated to manage postoperative expectations regarding sport participation following distal triceps repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Knockout of the gene encoding the extracellular matrix protein SNED1 results in early neonatal lethality and craniofacial malformations.

BACKGROUND: The extracellular matrix (ECM) is a fundamental component of multicellular organisms that orchestrates developmental processes and controls cell and tissue organization. We previously identified the novel ECM protein SNED1 as a promoter of breast cancer metastasis and showed that its level of expression negatively correlated with breast cancer patient survival. Here, we sought to identify the roles of SNED1 during murine development. RESULTS: We generated two novel Sned1 knockout mouse strains and showed that Sned1 is essential since homozygous ablation of the gene led to early neonatal lethality. Phenotypic analysis of the surviving knockout mice revealed a role for SNED1 in the development of craniofacial and skeletal structures since Sned1 knockout resulted in growth defects, nasal cavity occlusion, and craniofacial malformations. Sned1 is widely expressed in embryos, notably by cell populations undergoing epithelial-to-mesenchymal transition, such as the neural crest cells. We further show that mice with a neural-crest-cell-specific deletion of Sned1 survive, but display facial anomalies partly phenocopying the global knockout mice. CONCLUSIONS: Our results demonstrate requisite roles for SNED1 during development and neonatal survival. Importantly, the deletion of 2q37.3 in humans, a region that includes the SNED1 locus, has been associated with facial dysmorphism and short stature.

Risk Factors for Wound Complication following Primary Total Hip Arthroplasty.

This study assessed the National Surgical Quality Improvement Program (NSQIP), which provides data on 30-day post-operative complications from 500+ institutions, to identify risk factors for wound complications in patients undergoing primary total hip arthroplasty (THA). Patients undergoing primary THA between 2010-2017 were retrospectively reviewed. Patients experiencing post-operative wound complications were stratified based on pre-operative characteristics. Multivariate regression model was used to assess these characteristics as independent risk factors for post-operative complications. Of 119,096 patients undergoing primary THA, 1,264 (1.06%), 280 (0.2%), 622 (0.52%) and 139 (0.12%) experienced wound complications, deep surgical site infection, superficial surgical site infection, and wound dehiscence, respectively. Pre-operative transfusion (p < 0.0001), steroid use (p = 0.01), and obesity (p < 0.0001) were risk factors for wound dehiscence. Pre-operative transfusion (p < 0.0001), cardiac comorbidities (p = 0.02), and steroid use (p = 0.01) were risk factors for superficial surgical site infection. Assessment of the NSQIP identified modifiable risk factors for wound complications following primary THA, including pre-operative transfusion, steroid use, and obesity. (Journal of Surgical Orthopaedic Advances 31(4):242-247, 2022).

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Provides Clinically Significant Outcome Benefit at Minimum 5-Year Follow-Up.

PURPOSE: To report the rates of achieving clinically significant outcomes as defined by the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) in adolescent patients and the rates of clinical failure 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from consecutive adolescent patients (defined by the American Academy of Pediatrics as age 11 to 21 years) who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2015 by a single, fellowship-trained surgeon was collected. Baseline data, clinical outcomes including Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris hip score, international Hip Outcome Tool, and clinical failure rates were recorded at 5 years after operative. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Clinically significant outcomes was defined as achieving MCID, PASS, or SCB on at least 1 hip-specific outcome measure. RESULTS: Of the 139 eligible patients, a total of 85 (60.4%) patients (85 hips) were included in the final analysis, with an age and body mass index average of 17.6 ± 2.5 years (range 13-21) and 22.3 ± 3.1 kg/m2, respectively. The majority of the patients were female (80.6%) and participated in sports (76.2%). There was statistically significant difference between preoperative and postoperative score averages across every reported outcome (P < .001). At 5 years, 88.4%, 67.6%, and 64.9% reached at least 1 threshold for achieving MCID, PASS, and SCB, respectively, whereas 89.2% achieved at least one of the meaningful outcome thresholds. Last, 2 patients (2.4%) failed clinically, with both undergoing revision (2.4%) because of continued pain. There were no conversions to total hip arthroplasty. CONCLUSION: This study demonstrated that a large majority (89.2%) of adolescent patients undergoing primary arthroscopic treatment for symptomatic FAIS achieved meaningful clinically significant outcomes. Furthermore, only 2.4% of patients failed clinically, requiring revision hip arthroscopy because of continued pain. LEVEL OF EVIDENCE: IV, Retrospective Case Series.

Complete Capsular Closure Provides Higher Rates of Clinically Significant Outcome Improvement and Higher Survivorship Versus Partial Closure After Hip Arthroscopy at Minimum 5-Year Follow-Up.

PURPOSE: To (1) compare the rates of reaching threshold hip-specific outcome scores for achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients who underwent partial versus complete T-capsulotomy repair and (2) identify the failure rates in each group 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from consecutive patients who underwent hip arthroscopy for FAIS performed by a single fellowship-trained surgeon from January 2011 to March 2013 were collected and analyzed. Baseline data, hip-specific outcomes, and clinical failure rates were recorded at a minimum of 5 years postoperatively. Patients with partial T-capsulotomy repair were matched 1:3 by age, body mass index, and sex to patients with complete T-capsulotomy repair. Threshold scores for achieving the MCID and PASS were calculated and compared between the 2 groups. Additionally, rates of revision and conversion to total hip arthroplasty (THA) were compared between the groups. RESULTS: A total of 379 patients were available for analysis (39 partial and 340 complete repairs), with 100 patients included in the matching process (25 in the partial-repair group and 75 in the complete-repair group). Comparison of radiographic parameters, including the Tönnis grade, alpha angle, and lateral center-edge angle, between the 2 groups showed no statistically significant difference (P > .05 for all). Comparison of postoperative score averages between the partial- and complete-closure groups showed a significant difference in the Hip Outcome Score-Activities of Daily Living Subscale (85.4 ± 17.7 vs 94.6 ± 7.8, P < .001), Hip Outcome Score-Sports Subscale (76.6 ± 26.2 vs 89.3 ± 16.8, P = .034), modified Harris Hip Score (83.2 ± 19.7 vs 90.5 ± 11.2, P = .035), and visual analog scale pain score (24.5 ± 30.8 vs 13.4 ± 15.8, P = .035). A total of 65 complete-repair patients (95.6%) achieved the MCID for at least 1 outcome measure versus 18 patients with partial repair (78.3%) (P = .04). A total of 69 complete-repair patients (92%) achieved the PASS for at least 1 outcome measure versus 18 partial-repair patients (72%) (P = .017). Of the 39 partial-repair patients, 35.9% (n = 14) underwent revision or conversion to THA, as compared with 2.9% (n = 10) in the overall cohort. CONCLUSIONS: At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. Furthermore, patients with partial capsular repair undergo revision or conversion to THA at high rates. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Gender and Age-Specific Differences Observed in Rates of Achieving Meaningful Clinical Outcomes 5-Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To compare the impact of age and gender on achieving meaningful outcomes among minimum patients 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Consecutive patients undergoing hip arthroscopy for FAIS by a single fellowship-trained surgeon between January 2012 and October 2014 were analyzed. Study inclusion criteria included any patient undergoing primary hip arthroscopy for FAIS, with 5 years follow-up. Preoperative and 5-year postoperative functional scores were collected, including the Hip Outcome Score Activities of Daily Living Subscale (HOS-ADL), HOS-Sport Subscale (HOS-SS), modified Harris hip score (mHHS), and Visual Analog Scale for satisfaction. Patients were matched 1:1 by gender and age to compare outcomes between these 2 demographics. Minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) were calculated for each functional measure and compared by gender and age. RESULTS: Of the 340 patients (70.5%) with 5 years' follow up, 150 were matched by gender and age into one of the following groups: female patients <30 years, female patients 30 to 45 years, female patients >45 years, male patients <30 years, male patients 30 to 45 years, and male patients >45 years of age. At minimum 5-year follow-up, all 6 groups demonstrated statistically significant improvement in the functional outcome score averages and pain (P < .001 for all). Both within gender and within age category analysis of postoperative functional scores did not demonstrate any statistical differences (P > .05). Analysis of achieving MCID and PASS demonstrated that females had higher rates of reaching the HOS-SS and mHHS threshold for achieving MCID as compared to their male counterparts (P < .05). Furthermore, patients <30 years old had higher rates of reaching the HOS-ADL and mHHS for achieving PASS when compared to patients >45 years old (P < .05). CONCLUSION: The majority of patients achieve clinically significant outcome improvement at 5-year follow-up after arthroscopic FAIS surgery. Females reach the mHHS threshold for achieving MCID at significantly higher rates than males. Patients <30 years of age achieved PASS on the HOS-ADL and mHHS threshold scores at higher rates than those >45 years old. LEVEL OF EVIDENCE: Level III, case-control study.

Return to work following distal triceps repair.

PURPOSE: The purpose of this study was to evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR). METHODS: Consecutive patients undergoing DTR from 2009 to 2017 at our institution were retrospectively reviewed at a minimum of 1 year postoperatively. Patients completed a standardized and validated work questionnaire; a visual analog scale for pain; the Mayo Elbow Performance Score; the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and a satisfaction survey. RESULTS: Of 113 eligible patients who underwent DTR, 81 (71.7%) were contacted. Of these patients, 74 (91.4%) were employed within 3 years prior to surgery (mean age, 46.0 ± 10.7 years; mean follow-up, 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. Sixty-six patients (89.2%) were able to return to the same level of occupational intensity. Patients who held sedentary-, light-, medium-, and high-intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9%, respectively, by 0.3 ± 0.5 months, 1.8 ± 1.5 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months, respectively, postoperatively. Of the workers' compensation patients, 15 (75%) returned to work by 6.5 ± 4.3 months postoperatively, whereas 100% of non-workers' compensation patients returned to work by 1.1 ± 1.6 months (P < .001). Seventy-one patients (95.9%) were at least somewhat satisfied, with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would undergo the operation again if presented the opportunity. A single patient (1.4%) required revision DTR. CONCLUSIONS: Approximately 93% of patients who underwent DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher-intensity occupations had an equivalent rate of return to work but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups. RESULTS: A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1 ± 25.9, P = .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P = .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P = .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all). CONCLUSIONS: Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Defining Meaningful Functional Improvement on the Visual Analog Scale for Satisfaction at 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To (1) define Substantial Clinical Benefit (SCB), Patient Acceptable Symptomatic State (PASS), and Minimal Clinically Important Difference (MCID) for the visual analog scale (VAS) Satisfaction in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS), and (2) identify preoperative predictors of achieving each outcome end-point. METHODS: Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and January 2017 were prospectively collected and retrospectively analyzed. Inclusion criteria consisted of patients with clinical and radiographic diagnosis of FAIS, who failed nonoperative treatment, underwent primary hip arthroscopy to address the FAIS, and had at minimum 2-year follow-up. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement on the VAS)Satisfaction, we calculated MCID, PASS, and SCB for this outcome measure. A multivariate logistic regression analysis was used to identify preoperative predictors of achieving SCB, PASS, and MCID satisfaction. RESULTS: A total of 335 patients were included in the final analysis, with an average age and body mass index (BMI) of 32.8 (standard deviation ± 12.4) years and 25.2 (standard deviation ± 5.3), respectively, and the majority being female (69.3%). The values on the VAS satisfaction were identified to represent MCID, PASS, and SCB, respectively: 52.8, 80.9, and 89.7. The rates of achieving clinically significant improvement on the VAS Satisfaction was 85.6%, 68.1%, and 56.9% for MCID, PASS, and SCB, respectively. A larger preoperative alpha angle was predictive for achieving SCB (odds ratio [OR], 1.076; P = .046), whereas lower BMI (OR, 0.955; P = .047) and larger preoperative alpha angle (OR, 1.12; P = .025) were predictors for achieving PASS. CONCLUSIONS: This study identified threshold VAS satisfaction scores of 52.8, 80.9, and 89.7 for achieving MCID, SCB, and PASS, respectively, at 2-year follow-up following hip arthroscopy for FAIS. Furthermore, preoperative variables including larger preoperative alpha angles and lower BMI are predictors of achieving superior clinical satisfaction. LEVEL OF EVIDENCE: Level IV, Case Series.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up.

BACKGROUND: Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD. PURPOSE: To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups. RESULTS: In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835). CONCLUSION: Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction.

Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.