Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up.

PURPOSE: To describe patient-reported outcomes (PROs) and return to play at any level in amateur soccer players undergoing hip arthroscopy for femoroacetabular impingement syndrome at short- to mid-term follow-up. METHODS: Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between March 2009 and June 2014. Patients who participated in amateur soccer within 1 year prior to surgery and intended to return to their sport after hip arthroscopy for femoroacetabular impingement syndrome were considered for inclusion in our study. Patients were excluded if they had a preoperative Tönnis osteoarthritis grade of 2 or greater, previous ipsilateral hip conditions or hip surgical procedures, or Workers' Compensation status. The patients from the initial group who had preoperative and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in our final group. In addition to PROs, data regarding the patients' return to soccer, surgical complications, and secondary surgical procedures were collected. RESULTS: A total of 41 patients were eligible for inclusion in our study, of whom 34 (82.9%) had a mean follow-up period of 47.4 months. Five patients were not eligible because they did not intend to return to soccer. There were 15 male hips (44.1%) and 19 female hips (55.9%). The mean age at surgery was 20.8 ± 7.4 years. All PROs and the visual analog scale score improved significantly from preoperatively to latest follow-up. Of the 34 patients, 27 (79.4%) returned to soccer. Of the patients who returned to soccer, 19 (70.4%) were competing at the same level or a higher level compared with their highest level within 1 year of surgery. Regardless of competitive level, 21 patients (77.8%) reported that their athletic ability was the same as or higher than it was within 1 year of surgery. CONCLUSIONS: Hip arthroscopy was associated with significant improvements in PROs for amateur soccer players. There was a high level of return to soccer and a high proportion of patients whose competitive level was similar or improved. As such, hip arthroscopy is a good option for soccer players, in the absence of underlying osteoarthritis, presenting with hip pathology. LEVEL OF EVIDENCE: Level IV, case series.

Clinical Outcomes After Hip Arthroscopy for Patients With Rheumatoid Arthritis: A Matched-Pair Control Study With Minimum 2-Year Follow-Up.

PURPOSE: This study analyzed minimum 2-year hip arthroscopy outcomes in rheumatoid arthritis (RA) patients and non-RA control patients. It also examined whether disease-modifying antirheumatic drugs (DMARDs) affected RA patient outcomes. We hypothesized that patients with RA undergoing hip arthroscopy would have lower reported outcome scores. METHODS: Data were prospectively collected on all hip arthroscopies performed from 2009-2013. The indications for surgery were patients with hip pain and with physical examination and imaging studies confirming intra-articular pathology in whom conservative management had failed. The exclusion criteria were previous ipsilateral hip conditions and Tönnis grade greater than 1. Patients with at least 2 years of follow-up and preoperative RA diagnoses were matched (1:2 ratio) to controls without RA (based on age ± 5 years, body mass index ± 5, and lateral center-edge angle [18°-25°, 26°-39°, or >39°]). RA cases were further analyzed based on DMARD use. Patient-reported outcome (PRO) scores were collected preoperatively and postoperatively at 3 months, as well as annually thereafter. The outcomes collected included the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, visual analog scale (VAS) score for pain, satisfaction rating, future procedures, and complications. RESULTS: We matched 26 hips in 20 RA patients to a control group of 52 hips in 52 patients. At a minimum of 2 years of follow-up, RA patients reported no significant improvements except in the Non-Arthritic Hip Score, whereas the control group significantly improved in all PRO and VAS scores. Preoperative PRO and VAS scores between the RA and control groups were not significantly different, but postoperatively, all scores were lower in RA patients at a minimum of 2 years, whether they were taking DMARDs or not. Patients taking DMARDs showed slightly more improvement in PRO and VAS scores. There was a greater trend toward more secondary arthroscopy procedures for RA patients (19.2% vs 7.7%, P = .47), but total hip arthroplasty rates were similar. Complication rates were low in both groups. CONCLUSIONS: Patients undergoing hip arthroscopy who have a diagnosis of RA had less improvement in PRO and VAS scores and were less satisfied than a matched control group of patients without RA at a minimum 2-year follow-up. Patients who were taking DMARDs had slightly better improvement in their PRO and VAS scores than nonmedicated patients. With this early follow-up, we could not show a difference in the rate of conversion to total hip arthroplasty, although RA patients required more revision arthroscopies than controls. Patients with a diagnosis of RA who undergo hip arthroscopy should be counseled about the potential for lesser degrees of postoperative improvement and should have their expectations managed accordingly. LEVEL OF EVIDENCE: Level III, comparative trial.

Radiographic Risk Factors and Signs of Abductor Tears in the Hip.

PURPOSE: The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears. METHODS: Between April 2008 and October 2015, patients with intraoperative diagnosis of partial- or full-thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5 years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior-posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses. RESULTS: There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group (n = 58) versus the control group (n = 54; P = .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8 cm for abductor tears vs 14.3 cm for control; P < .001), body weight moment arm (11.1 cm vs 10.9 cm; P < .001), and abductor moment arm (7.8 cm vs 7.6 cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P = .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear. CONCLUSIONS: Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Should the Capsule Be Repaired or Plicated After Hip Arthroscopy for Labral Tears Associated With Femoroacetabular Impingement or Instability? A Systematic Review.

PURPOSE: To critically evaluate the existing literature on hip capsule biomechanics, clinical evidence of instability, and outcomes of capsular management to answer the following question: Should the capsule be repaired or plicated after hip arthroscopy for labral tears associated with femoroacetabular impingement or instability? METHODS: We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines to find articles using PubMed and Embase. Included studies were Level I through V studies and focused on hip capsule biomechanics, postarthroscopic instability, and clinical outcomes. Articles were excluded if they discussed treatment of the hip capsule during arthroplasty, dislocations without a history of arthroscopy, and pre-existing conditions. The Methodological Index for Non-randomized Studies (MINORS) was used for quality assessment of clinical outcome studies. RESULTS: A total of 34 articles were included: 15 biomechanical studies, 9 instability case reports, and 10 outcome studies. There is consensus from biomechanical studies that the capsule is an important stabilizer of the hip and repairing it provides better stability than when unrepaired. Case reports of instability have raised concerns about capsular management during the index procedure to decrease the complications associated with this problem. Furthermore, outcome studies suggest that there may be an advantage of capsular closure versus capsulotomy during hip arthroscopy for nonarthritic patients. CONCLUSIONS: Short-term outcome studies suggest that capsular closure is safe and effective in nonarthritic patients undergoing hip arthroscopic procedures and may yield superior outcomes compared with unrepaired capsulotomy. Moreover, biomechanical evidence strongly supports the role of capsular repair in maintaining stability of the hip. In patients with stiffness or inflammatory hip disorders, a release may be appropriate. In patients who have signs and symptoms of instability, there is existing evidence that capsular plication may be associated with significant improvement in patient-reported outcomes. Although the multiple procedures performed in combination with capsular treatment present confounding variables, current evidence appears to support routine capsular closure in most cases and to support capsular plication in cases of instability or borderline dysplasia. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Patient-Reported Outcomes of Capsular Repair Versus Capsulotomy in Patients Undergoing Hip Arthroscopy: Minimum 5-Year Follow-up-A Matched Comparison Study.

PURPOSE: To elucidate whether capsular closure during hip arthroscopy affected patient outcomes over midterm follow-up. METHODS: Between 2008 and 2011, data were prospectively collected and retrospectively reviewed on patients who underwent hip arthroscopy. Patients were then matched for age, gender, worker's compensation, body mass index, and acetabular coverage. The inclusion criteria were capsular repair or unrepaired capsulotomy, lateral-center edge angle ≥18°, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery or conditions and Tönnis grade >1. Patient-reported outcome scores (PROs) included modified Harris hip score (mHHS), nonarthritic hip score, hip outcome score sport-specific subscale, and visual analog score for pain, which were collected preoperatively, at 3 months, and annually thereafter. Minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for both groups were analyzed. Patient satisfaction was noted as well as any complications, secondary surgery, and conversion to arthroplasty. RESULTS: Minimum 5-year follow-up was available for 82.5% (287 of 348) hips that met the inclusion criteria and were eligible for matching. Ultimately, 65 patients who underwent capsular repair could be matched in a 1:1 ratio to 65 patients with release. Both groups had significant improvements in all mean PROs. The repair group had significant improvement of mean PROs, visual analog score, and patient satisfaction at both 2-year and minimum 5-year follow-up. The unrepaired group had a significant decrease in mHHS (P = .001) and patient satisfaction (P = .01) between 2- and 5-year follow-up. Despite decreasing mHHS in the repair group between 2- and 5-year follow-up, both groups met the MCID and PASS criteria with no significant difference between them. More patients in the release group required conversion to hip arthroplasty (18.5% vs 10.8%). Subgroup analysis considering various perioperative factors confirmed this trend. Rate of revision arthroscopy was the same in both groups (15.4%). Complication rate was low (4.6% vs 6.4%) in both groups. CONCLUSIONS: Patients undergoing hip arthroscopy and who have minimal or no arthritis have significant short-term improvement, whether the capsule is closed or left unrepaired. However, at midterm follow-up, patients who had unrepaired capsules had deterioration in mHHS as well as a higher rate of conversion to arthroplasty, even when controlling for various perioperative variables. Despite this, patients in both groups met the MCID and PASS criteria. This study suggests that routine capsular closure may lead to more consistently durable outcome in patients undergoing hip arthroscopy, but also that individual patient pathology may dictate capsular management. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Endoscopic Repair of Partial-Thickness Undersurface Tears of the Abductor Tendon: Clinical Outcomes With Minimum 2-Year Follow-up.

PURPOSE: To report the minimum 2-year outcomes of transtendinous repair of partial-thickness undersurface tears of the abductor tendon using patient-reported outcomes (PROs), visual analog scale (VAS) scores, and patient satisfaction scores. METHODS: All patients who underwent endoscopic transtendinous gluteus medius repair between October 2009 and May 2013 at 1 institution were prospectively evaluated. The exclusion criteria consisted of less than 2 years' follow-up, previous hip surgery, inflammatory arthritis, open surgery, full-thickness abductor tear, and Workers' Compensation patients. All patients underwent a documented preoperative physical examination with strength testing (scale of 0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively; at 3 months postoperatively; and at 1, 2, 5, and 10 years after surgery. The PRO scores collected were the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VAS score. Preoperative strength and gait were compared with latest follow-up. RESULTS: There were 25 patients who fit our criteria. Significant improvement in PRO scores were shown for the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living Subscale, Hip Outcome Score-Sports-Specific Subscale, Non-arthritis Hip Score, and VAS score from 54.9 to 76.2, from 50.2 to 80.6, from 30.1 to 67.3, from 51.9 to 82.4, and from 7.1 to 2.7, respectively (P < .001). Before surgery, 11 patients had objective weakness; 7 of these patients moved up at least 1 strength grade by final follow-up. Preoperatively, 14 patients had a Trendelenburg gait; 12 of them had a normal gait at latest follow-up (P < .001). The average patient satisfaction rating was 7.5. There were no revision surgical procedures, and no complications were noted. CONCLUSIONS: Partial-thickness undersurface tears of the abductor can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of the superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to nonoperative treatment because patients showed clinical benefit at greater than 2 years' follow-up that exceeded substantial clinical benefit and the minimal clinically important difference. LEVEL OF EVIDENCE: Level IV, case series.

Hip Arthroscopy in Patients Ages 50 Years or Older: Minimum 5-Year Outcomes, Survivorship, and Risk Factors for Conversion to Total Hip Replacement.

PURPOSE: To report minimum 5-year outcomes and risk factors for conversion to total hip arthroplasty (THA) in patients ≥50 years old undergoing hip arthroscopy to treat labral tears and femoroacetabular impingement (FAI). METHODS: Data were prospectively collected on patients who underwent hip arthroscopy to treat labral tears and FAI between February 2008 and January 2012. The inclusion criteria were ≥50 years old at surgery, arthroscopic treatment for both labral tears and FAI, and preoperative patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and Visual Analog Scale (VAS). The exclusion criteria were Tönnis grade > 1 and previous hip conditions or surgeries. RESULTS: Of 103 eligible cases, 94 hips (91.3%) had minimum 5-year follow-up at a mean of 70.1 months (range, 60.0-95.1 months). All PROs and VASs demonstrated significant improvement at latest follow-up (P = .0001). Mean patient satisfaction was 8.4. All mean scores demonstrated durability from 2 years to latest follow-up, and NAHS (P = .009), HOS-SSS (P = .02), and VAS (P = .04) continued to significantly improve. Fifty-one (54.3%) of cases reached patient acceptable symptomatic state for mHHS, and 49 cases (52.1%) achieved minimal clinically important difference for this outcome measure. Four cases (4.3%) required secondary arthroscopy, and survivorship was 72.3%. Compared with survivors, the subgroup requiring THA demonstrated higher body mass indexes (P = .01), had larger alpha angles (P = .0200) and smaller lateral center-edge angles (P = .0200), and had higher proportions of Tönnis grade 1 (P = .0012), acetabular Outerbridge grade ≥ 2 (P = .0500), and femoral head Outerbridge grade ≥2 (P = .0001). CONCLUSIONS: Hip arthroscopy for the treatment of labral tears and FAI in patients ≥50 years old demonstrates statistically significant PRO improvements at minimum 5-year follow-up. However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. LEVEL OF EVIDENCE: Level IV, case series.

Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial.

BACKGROUND: Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL). METHODS: Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation. RESULTS: There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups. CONLCUSION: Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.

Outcomes of Hip Arthroscopy in Adolescents: A Comparison of Acute Versus Chronic Presentation. Two-Year Minimum Follow-up.

BACKGROUND: Hip arthroscopy has been shown to be effective in managing various hip pathologies, including labral tears in adolescent patients. The purpose of this study was to ascertain whether outcomes of hip arthroscopy in patients under the age of 18 treated for labral tears differ depending on whether the presentation was acute or chronic. We also present the outcomes of the largest prospectively collected study on hip arthroscopy performed for labral tears in adolescents. METHODS: Patient reported outcome scores (PROs) for 194 patients undergoing hip arthroscopy for hip pathology, who were 18 or under at the time of surgery were prospectively collected and retrospectively reviewed. Modified Harris hip score (mHHS), Nonarthritic hip score (NAHS), Hip Outcome score-sport specific scale (HOS-SSS) and Visual Analogue Score (VAS) were the PROs collected. The overall cohort was assessed for outcome and a comparison was made between those patients who presented with acute onset of symptoms versus those who presented with insidious onset. RESULTS: There was significant improvement in all the PROs for the overall cohort, with improvement maintained over an average of 38.5 months. There was no significant difference in outcome scores, between the acute and chronic groups except for change in VAS. Preoperative scores in the acute group were significantly lower, while postoperative scores did not differ. A trend toward more improvement was noted for the acute group. Overall need for revision surgery was 12%, with a higher rate of revision in the acute group. CONCLUSIONS: Hip arthroscopy in adolescent patients being treated for intra-articular pathology is a safe procedure with favorable outcomes at minimum 2-year follow-up, with no significant difference in final outcomes between patients with acute onset of symptoms as opposed to those with more a more chronic presentation. Reoperation rate may be higher in patients with an acute onset. LEVEL OF EVIDENCE: Level II.

What Factors Predict Conversion to THA After Arthroscopy?

BACKGROUND: Failure of hip preservation to alleviate symptoms potentially subjects the patient to reoperation or conversion surgery to THA, adding recovery time, risk, and cost. A risk calculator using an algorithm that can predict the likelihood that a patient who undergoes arthroscopic hip surgery will undergo THA within 2 years would be helpful, but to our knowledge, no such tool exists. QUESTIONS: (1) Are there preoperative and intraoperative variables at the time of hip arthroscopy associated with subsequent conversion to THA? (2) Can these variables be used to develop a predictive tool for conversion to THA? MATERIALS AND METHODS: All patients undergoing arthroscopy from January 2009 through December 2011 were registered in our longitudinal database. Inclusion criteria for the study group were patients undergoing hip arthroscopy for a labral tear, who eventually had conversion surgery to THA. Patients were compared with a control group of patients who underwent hip arthroscopy for a labral tear but who did not undergo conversion surgery to THA during the same study period. Of the 893 who underwent surgery during that time, 792 (88.7%) were available for followup at a minimum of 2 years (mean, 31.1 ± 8.1 years) and so were considered in this analysis. Multivariate regression analyses of 41 preoperative and intraoperative variables were performed. Using the results of the multivariate regression, we developed a simplified calculator that may be helpful in counseling a patient regarding the risk of conversion to THA after hip arthroscopy. RESULTS: Variables simultaneously associated with conversion to THA in this model were older age (rate ratio, 1.06; 95% CI, 1.03-1.08; p < 0.0001), lower preoperative modified Harris hip score (rate ratio [RR], 0.98; 95% CI, 0.96-0.99; p = 0.0003), decreased femoral anteversion (RR, 0.97; 95% CI, 0.94-0.99; p = 0.0111), revision surgery (RR, 2.4; 95% CI, 1.15-5.01; p = 0.0193), femoral Outerbridge Grades II to IV (Grade II: RR, 2.23 [95% CI, 1.11-4.46], p = 0.023; Grade III: RR, 2.17, [95% CI, 1.11-4.23], p = 0.024; Grade IV: RR, 2.96 [95% CI, 1.34-6.52], p = 0.007), performance of acetabuloplasty (RR, 1.83; 95% CI, 1.03-3.24; p = 0.038), and lack of performance of femoral osteoplasty (RR, 0.62; 95% CI, 0.36-1.06; p = 0.081). Using the results of the multivariate regression, we developed a simplified calculator that may be helpful in counseling a patient regarding the risk of conversion surgery to THA after hip arthroscopy. CONCLUSION: Multiple risk factors have been identified as possible risk factors for conversion to THA after hip arthroscopy. A weighted calculator based on our data is presented here and may be useful for predicting failure after hip arthroscopy for labral treatment. Determining the best candidates for hip preservation remains challenging; careful attention to long-term followup and identifying characteristics associated with successful outcomes should be the focus of further study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Endoscopic Gluteus Medius Repair With Concomitant Arthroscopy for Labral Tears: A Case Series With Minimum 5-Year Outcomes.

PURPOSE: To report the minimum 5-year outcomes of endoscopic gluteus medius repair for partial- and full-thickness tears with concomitant hip arthroscopy. METHODS: Data for all patients who underwent hip arthroscopy between February 2009 and September 2011 were prospectively collected. We included patients who underwent endoscopic gluteus medius repair with concomitant arthroscopic labral treatment and for whom the following measures were obtained preoperatively and at a minimum of 5 years' follow-up: modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score for pain. For included patients, the International Hip Outcome Tool-12 (iHOT-12) score and satisfaction rating were also available at latest follow-up. Patients with at least 1 of the following criteria were excluded: preoperative Tönnis osteoarthritis grade of 2 or greater, previous hip conditions, severe dysplasia, and Workers' Compensation claims. RESULTS: There were 16 patients eligible for inclusion, 14 (87.5%) of whom had minimum 5-year follow-up, with a mean of 68.8 months (range, 60.1-79.6 months). The study group consisted of 13 women (92.9%) and 1 man (7.1%) with a mean age at surgery of 57.4 years (range, 46.3-74.8 years). Outcome scores improved as follows: modified Harris Hip Score, from 52.4 to 81.2 (P = .004); Non-Arthritic Hip Score, from 48.0 to 82.5 (P = .002); Hip Outcome Score-Sports Specific Subscale, from 30.1 to 66.4 (P < .001); and visual analog scale score, from 6.2 to 2.6 (P = .001). At minimum 5-year follow-up, the mean iHOT-12 score was 73.8 and the mean patient satisfaction rating was 8.4. Survivorship was 92.9%, with 1 patient who underwent conversion to total hip arthroplasty. There was no deterioration in patient outcomes and satisfaction between 2 and 5 years postoperatively. There were no clinical failures of gluteus medius repair and no complications. CONCLUSIONS: Endoscopic gluteus medius repair with concomitant hip arthroscopy for labral tears is safe and shows favorable outcomes at minimum 5-year follow-up. Patient outcomes were as favorable at 5 years as they were at 2 years postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Birmingham Hip Resurfacing vs Total Hip Arthroplasty: A Matched-Pair Comparison of Clinical Outcomes.

BACKGROUND: Birmingham hip resurfacing (BHR) has proven to be a good alternative for younger patients with osteoarthritis. Some have asserted that BHR may yield outcomes which are superior to total hip arthroplasty (THA), and that some studies which failed to show a difference were plagued by ceiling effects and lack of sensitivity of outcome measures. The purpose of this study is to compare outcomes of BHR and THA using the "Forgotten Joint" Score-12 (FJS), a more sensitive score with lesser vulnerability to the ceiling effect. METHODS: Patients who underwent BHR were matched to patients who underwent posterior THA by computing a propensity score using 5 covariates: age, body mass index, gender, worker's compensation claims, and previous hip surgery. Surgical outcomes were assessed using 6 patient-reported outcome measures, including the FJS, the visual analog scale for pain, and patient satisfaction. RESULTS: There were 42 patients in the BHR group and 18 patients in the THA group. The FJS was 78.0 for the BHR group and 76.0 for the THA group. The Veterans RAND 12-Item Health Survey Mental Component Summary and Short Form 12 Mental Component Summary were significantly higher in the BHR group. No differences were seen between all other patient-reported outcomes. CONCLUSION: BHR offers excellent results in young patients that are comparable to THA. As no clinical difference could be shown between BHR and THA, even with the use of the FJS, the choice between BHR and THA should not be based solely on any expectation that either yields superior clinical outcomes compared to the other at short-term follow-up.

Can Stem Version Consistently Correct Native Femoral Version Using Robotic Guidance in Total Hip Arthroplasty?

The purpose of this study is to investigate whether robotic guidance in total hip arthroplasty (THA) can consistently correct native femoral version. One hundred seventy-five consecutive patients who underwent MAKO® (Stryker, Kalamazoo, Michigan) robotic-guidance THA were included in the study. The study population had a mean age of 57.9 years and a mean body mass index (BMI) of 30.41. Forty-eight percent of the population was male and 74% of the procedures were performed through an anterior approach. Robotic guidance in THA was effective in correcting native femoral version toward a target of 15°. This can be achieved using both the anterior and posterior approach; it is not affected by BMI.

The Troubling Rise of Scurvy: A Review and National Analysis of Incidence, Associated Risk Factors, and Clinical Manifestations.

INTRODUCTION: In the era of modern medicine, scurvy has been thought of as a rare disease of ancient times because of improved emphasis on diet and nutrition; however, isolated case reports are plentiful. This investigation presents a comprehensive review of scurvy, including an analysis on its rising incidence, with specific focus on its orthopaedic manifestations and commonly associated diagnoses. METHODS: This comprehensive review includes a retrospective analysis of 19,413,465 pediatric patients in the National Inpatient Sample database from 2016 through 2020. Patients with scurvy were identified by the ICD-10 code, and an estimated incidence of scurvy in the inpatient pediatric population was calculated. Concurrent diagnoses, musculoskeletal reports, and demographic variables were collected from patient records. Comparisons were made using analysis of variance or chi-square with Kendall tau, where appropriate. RESULTS: The incidence of scurvy increased over the study period, from 8.2 per 100,000 in 2016 to 26.7 per 100,000 in 2020. Patients with scurvy were more likely to be younger (P < 0.001), male (P = 0.010), in the lowest income quartile (P = 0.013), and obese (P < 0.001). A majority (64.2%) had a concomitant diagnosis of autism spectrum disorder. Common presenting musculoskeletal reports included difficulty walking, knee pain, and lower limb deformity. Burden of disease of scurvy was markedly greater than that of the average inpatient population, with these patients experiencing greater total charges and longer hospital stays. CONCLUSION: Clinicians should be aware of the increasing incidence of scurvy in modern medicine. In cases of vague musculoskeletal reports without clear etiology, a diagnosis of scurvy should be considered, particularly if risk factors are present. TRIAL REGISTRATION NUMBER: NA.

A Rare Case of Primary Epithelioid Hemangioma of Bone with WWTR1::FOSB Fusion: A Benign Lesion with the Potential to Mimic Malignancy.

Epithelioid hemangioma of bone is a rare benign, locally aggressive vascular tumor that can be particularly challenging to diagnose given its frequent multifocality, non-specific imaging findings, and wide range of morphologic appearances. Additionally, some epithelioid hemangiomas demonstrate atypical histologic features including increased cellularity, necrosis, and moderate cytologic atypia - characteristics that may raise concern for malignancy. Molecular studies can serve as a powerful, objective tool in the differential diagnosis of diagnostically challenging epithelioid vascular tumors. Importantly, FOS and FOSB gene rearrangements have been identified as the genetic hallmarks of osseous epithelioid hemangioma, present in greater than 70% of cases. FOSB-fusion-positive epithelioid hemangioma, in particular, may display atypical histologic features. While ZFP36 is the typical FOSB fusion partner in epithelioid hemangioma, we herein present a case of epithelioid hemangioma of bone with a rare WWTR1::FOSB fusion. This case demonstrates the diagnostic challenges associated with epithelioid hemangioma, especially in the setting of FOSB gene rearrangements, and the importance of genomic studies in the work up of these vascular tumors.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity.

BACKGROUND: Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients. PURPOSE: To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses. RESULTS: A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively(P = .6288). The average body mass index was significantly higher in the male group (P < .0001). GLL was more common in women (38.6%) than men (13.6%) (P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) (P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° (P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001). CONCLUSION: In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

Diagnostic accuracy of a new clinical test (resisted internal rotation) for detection of gluteus medius tears.

The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination for detection of gluteus medius (GM) tears. A case group of 50 patients undergoing arthroscopy with GM repair was compared with a control group of 50 patients undergoing arthroscopy who had no peritrochanteric symptoms. Both groups were examined clinically, had magnetic resonance imaging studies performed and underwent arthroscopic surgery. Recorded clinical examinations included abnormal gait (Trendelenburg), tenderness to palpation of the greater trochanter, resisted abduction and the test being studied, resisted internal rotation. For all clinical tests, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates were calculated and compared with the arthroscopic and MRI data for the case group, and the MRI data for the control group. The resisted internal rotation test had a sensitivity of 92%, specificity of 85% and diagnostic accuracy of 88% in the detection of GM tears, with a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of Trendelenburg gait, showed inferior rates. Trendelenburg gait had a higher specificity, but much lower sensitivity. The resisted internal rotation test aides in the detection of GM pathology. Due to the good results of the resisted internal rotation test in all the diagnostic parameters, we recommend incorporating it on the physical exam of patients with hip pain.

Five-Year Outcomes and Return to Sport of Runners Undergoing Hip Arthroscopy for Labral Tears With or Without Femoroacetabular Impingement.

BACKGROUND: Recent evidence has demonstrated a high rate of return to running after hip arthroscopy for femoroacetabular impingement at short-term follow-up. The midterm outcomes and rates of continued running of these patients are unknown. PURPOSE: To evaluate midterm rates of return to running and outcomes after hip arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data were prospectively collected for patients who underwent hip preservation surgery between July 2008 and November 2011. Patients were excluded for preoperative Tönnis osteoarthritis grade ≥2, previous ipsilateral hip conditions or hip surgery, or workers' compensation status. All patients who participated in mid- to long-distance running before their surgery and intended on returning after their operation were considered for inclusion. Preoperative and minimum 5-year postoperative measures for the following patient-reported outcome scores (PROs) were necessary for inclusion in the final cohort: the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale (VAS) for pain. All patients were counseled about the risks of continued running after hip arthroscopy. RESULTS: Sixty patients (62 hips) were eligible for inclusion, of which 50 (83.3%; 52 hips) had minimum 5-year follow-up. There were 10 male hips and 42 female hips. Mean ± SD age at surgery was 32.4 ± 12.4 years (range, 14.9-62.4), and mean body mass index was 22.9 ± 3.2 (range, 17.7-30.1). Latest follow-up was recorded at a mean 69.3 ± 8.5 months (range, 60.0-92.1 months). Level of competition included 39 recreational, 7 high school, 4 collegiate, and 2 professional athletes. There were significant improvements in all PROs and VAS scores preoperatively to latest follow-up. Mean modified Harris Hip Score improved from 67.5 to 88.2; mean Non-arthritic Hip Score, from 65.9 to 88.3; mean Hip Outcome Score-Sports Specific Subscale, from 49.5 to 81.0; and mean VAS, from 5.2 to 1.5. At latest follow-up, patient satisfaction was 8.4. Thirty-nine patients (78.0%, 41 hips) had returned to running postoperatively. When stratified by level of competition, 79% (31 of 39) of recreational, 100% (7 of 7) of high school, 50% (2 of 4) of collegiate, and 50% (1 of 2) of professional athletes returned to running. CONCLUSION: Hip arthroscopy for all levels of runners is associated with a significant increase in PROs and a low risk of complications. The rate of return to running is moderately high after hip arthroscopy at midterm follow-up. Hip arthroscopy may be considered for runners presenting with symptoms of femoroacetabular impingement that fail nonoperative treatments. Patients should be educated on the rate of return to running over time and the risks of continued running after hip arthroscopy.

The 'upper deck view' improves visualization during acetabuloplasty without chondro-labral detachment.

The 'upper deck' view is an arthroscopic perspective which visualizes the labral-osseous junction without detachment of the chondro-labral junction. The aim of this study was to evaluate the utility of the 'upper deck' view in preventing incomplete acetabuloplasty. Data were prospectively collected from September 2016 to November 2016 for all hip arthroscopies. We recorded the amount and clock-face of residual pincer-lesion acetabular bone resected using the 'upper deck' view. We noted whether this residual pincer-lesion acetabular bone was visible fluoroscopically, as well as the amount and clock-face of the overall acetabuloplasty. During the study period, 87 hip arthroscopies were performed; 50 met the inclusion criteria. Forty-six (92%) patients had residual pincer-lesion acetabular bone after completion of the acetabuloplasty resected from the bird's eye view. In all such cases the residual pincer-lesion acetabular bone was not visible under fluoroscopy and could only be detected using this specific view. The average maximum resection for the acetabuloplasty was 2.1 ± 0.9 and 1.4 ± 0.5 mm (P = 0.16) for resection of residual pincer-lesion acetabular bone. The 'upper deck' view provides the ability to decrease the risk of incomplete acetabuloplasty, due to the high likelihood (92%) of a residual beak of pincer-lesion acetabular bone when this view is not used during rim trimming.

The "Bird's Eye" and "Upper Deck" Views in Hip Arthroscopy: Powerful Arthroscopic Perspectives for Acetabuloplasty.

Arthroscopic acetabuloplasty involves trimming of bone from the acetabular rim. Although early techniques often involved detachment of the labrum prior to bone resection, recent studies have reported on acetabuloplasty without labral detachment. This method has the benefit of preserving the labro-osseous junction, but visualization of the acetabular rim may be more difficult. Compromised visualization can lead to incomplete resection and residual impingement. We describe an arthroscopic perspective called the "bird's eye" and "upper deck" views that facilitates optimal visualization of the acetabuloplasty without labral detachment.