Editorial Commentary: Patients With Lumbar Pathology or Ipsilateral Knee Pathology Improve After Hip Arthroscopy, but Outcomes Are Not as Good as in Patients With Femoroacetabular Impingement Syndrome Without Concomitant Pathology.

From the lumbar spine to foot, the joints of the lower extremity are all intimately connected. Their movements are synchronized in a complex biomechanical dance. Pain in one joint tends to affect the joint above and joint below. Understanding the influence of adjacent-joint disease on the hip can help us better counsel patients undergoing hip surgery. Low-back pathology has been shown to negatively influence outcomes after hip arthroscopy. Ipsilateral knee pain appears to do the same. Patients with femoroacetabular impingement syndrome with ipsilateral knee pain should be counseled that their outcomes may not be quite as good as those without knee pain, but they should be able to expect meaningful improvement of their symptoms, both at the hip and at the knee after hip arthroscopy.

After Revision Hip Arthroscopy, Patients Having Either Circumferential or Segmental Labral Reconstructions for the Management of Irreparable Labra Show Clinical Improvement Based on Proper Indications.

PURPOSE: To compare a minimum of two-year follow-up patient-reported outcome scores (PROs) in patients who underwent revision hip arthroscopy for acetabular circumferential labral reconstruction (CLR) and segmental labral reconstruction (SLR) using propensity-matched groups, in the setting of irreparable labral tear. METHODS: Prospectively collected data were retrospectively reviewed for patients who underwent revision hip arthroscopy from April 2010 to September 2018. Patients were included if they underwent labral reconstruction and had preoperative and minimum 2-year PROs. Patients unwilling to participate, with Tönnis grade >1, or hip dysplasia were excluded. Patients in the CLR group were propensity-matched on the basis of age, sex, body mass index, and Tönnis grade to patients in the SLR group in a 1:1 ratio. The minimal clinically important difference (MCID) and the patient-acceptable symptomatic state (PASS) rates were calculated. RESULTS: Twenty-six hips (25 patients) with CLR were propensity-matched to 26 hips (26 patients) with SRL. The mean follow-up time 25.92 and 27.78 months for the CLR and SLR, respectively (P = .845). Groups reported comparable findings for sex (P = .773), age (P = .197), body mass index (P = .124), preoperative Tönnis grade (P = .124), lateral-center edge angle (P = .144), and alpha angle (P = .264), and comparable improvement for all PROs at minimum 2-year follow-up. Patient satisfaction was similar (P = .612). Rates of achievement for the MCID and PASS were comparable. CONCLUSION: Following revision hip arthroscopy, patients who underwent CLR or SLR for complete and segmental irreparable labral tears, respectively, reported significant and comparable postoperative improvement for all PROs and rate of achievement for the MCID and PASS at a minimum 2-year follow-up. LEVEL OF EVIDENCE: III, retrospective comparative therapeutic trial.

Postoperative Alpha Angle Is Predictive of Return to Sport in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To identify clinical and radiographic factors that predict return to sport in athletes undergoing hip arthroscopy and to determine thresholds for significant predictors. METHODS: Data were reviewed on all patients who underwent primary hip arthroscopy between November 2008 and August 2018. Patients were included if they played professional, college, or high school sports within 1 year before surgery and had preoperative, 3-month, 1-year, and 2-year postoperative patient-reported outcome scores for modified Harris Hip Score, Hip Outcome Score-Sport Specific-Subscale, and Nonarthritic Hip Score. Rates of achieving the minimal clinically important difference also were evaluated. Patients were divided into groups based on whether they returned to sport at the same or greater level. Multivariate logistic regression and receiver operator characteristic analysis were used to evaluate the correlation between significant variables and return to sport. RESULTS: A total of 136 patients with a mean age of 20.8 ± 7.07 years were included. Among athletes who attempted to return, professional and collegiate athletes returned to sport at any level at a rate of 85.0% (51/60), and high-school athletes returned at a rate of 88.1% (52/59). Competition level, postoperative alpha angle, change in alpha angle, and postoperative patient-reported outcomes were significantly different between groups. Athletes who returned to sport achieved the minimal clinically important difference for Hip Outcome Score-Sport Specific-Subscale at significantly higher rates than athletes who did not return to sport (91.6% vs 71.7%, P = .002, S = 8.97). The multivariate logistic regression model identified postoperative alpha angle as a statistically significant predictor of return to sport (P < .001, S > 9.97 [odds ratio 0.85, 95% confidence interval 0.79-0.91]). The receiver operator characteristic curve for postoperative alpha angle demonstrated acceptable discrimination between patients returning to sport and patients not returning to sport with an area under the curve of 0.71 and a threshold value of 46°. Athletes with a postoperative alpha angle ≤46° returned to sport at significantly higher rates than those with a postoperative alpha angle >46° [(P < .001, S > 9.97 [odds ratio 6.3, 95% confidence interval 2.6-15.2]). CONCLUSIONS: Postoperative alpha angle was identified as a predictor of return to sport in athletes. The odds of returning to sport were 6.3 times greater in athletes with postoperative alpha angles ≤46° compared with athletes with angles >46°. LEVEL OF EVIDENCE: III, retrospective cohort study.

Females and Males Achieved Comparable Outcomes and Clinical Benefits Following Primary Hip Arthroscopy with Labral Repair, but Age Affected Outcomes and Conversion to Total Hip Arthroplasty. A Short and Mid-Term Follow-Up Analysis with Dual Stratification.

PURPOSE: To report and compare, according to sex and age, minimum 2-and minimum 5-year patient-reported outcome scores (PROs) and survivorship in a large cohort of patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Data from February 2008 to September 2018 were reviewed. Patients aged 60 and younger who underwent primary hip arthroscopy with minimum 2-year follow-up were included. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous hip conditions, or any labral treatment different than repair. Minimum 5-year PROs were also collected. All patients included were divided into groups by sex. For further analysis, males and females were stratified according to age: < 21 years old, 21-30 years old, 31-40 years old, 41-50 years old, and 51-60 years old. RESULTS: In total, 1,326 hips had minimum 2-year follow-up, including 860 (64.9%) females and 466 males (35.1%), with a mean age of 31.6 years (range, 12.8-60.9 years) and a mean follow-up of 58.7 ± 28.9 months. Of those, 772 had minimum 5-year follow-up, 515 females (66.7%), and 257 males (33.3%) with a mean age of 31.7 years (range, 13.1-60.7 years) and a mean follow-up of 78.5 ± 23.0 months. All patients showed significant improvements in PROs at minimum 2-and 5-year follow-up (P < .001). Between sex analysis revealed comparable PROs at latest follow-up between females and males across any age group. Within sexes, and when sexes were combined, patients <21 years old had significantly better outcomes compared to other age groups. There were more females <21 years old that required revision arthroscopy than males <21 years old (P = .015). Conversion to total hip arthroplasty (THA) showed no significant difference between sexes (P > .05). Rates of THA were <21 years (.8%), 21-30 years (2.1%), 31-40 years (4%), 41-50 years (8.9%), and 51-60 years (14.3%). CONCLUSIONS: Following primary hip arthroscopy for FAIS, all patients reported significant improvements in all PROs at minimum 2-and minimum 5-year follow-up, with females and males achieving similar success. Age affected outcomes, with patients under 21 years old reporting better scores regardless of sex. Although the conversion rate to THA was similar between the sexes, it was lower in the younger ages groups in both sexes. LEVEL OF EVIDENCE: III, retrospective comparative observation trial.

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

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

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

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

Patients With Concomitant Painful External Snapping Hip and Femoroacetabular Impingement Syndromes Reported Complete Snapping Resolution With Release of the Gluteus Maximus and Iliotibial Band, and Comparable Minimum 2-Year Outcomes to a Propensity-Matched Control Group.

PURPOSE: To report minimum 2-year patient-reported outcome measures (PROMs) following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and painful external snapping hip (ESH) treatment and ESH resolution, and to compare these PROMs to a benchmark FAIS propensity-matched control group without ESH. METHODS: Data were prospectively collected and retrospectively reviewed between November 2009 and April 2018. Patients were eligible if they were preoperatively diagnosed with FAIS and painful ESH and received primary hip arthroscopy to address these pathologies. ESH was treated with gluteus maximus and iliotibial band releases. Inclusion criteria were baseline and minimum two-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1 and previous hip conditions. A secondary subanalysis was performed to benchmark these outcomes to a FAIS propensity-matched control group without ESH, according to age, sex, body mass index (BMI), Tönnis grade, and preoperative lateral center-edge and α-angles using a 1:3 ratio. The minimal clinically important difference (MCID) and the maximum outcome improvement (MOI) rates were reported. RESULTS: Twenty-two hips (21 patients) were included. The mean age, BMI, and follow-up were 31.3 years ± 14.0, 26 kg/m2 ± 5.0, and 31.4 months ± 4.4, respectively, with 68.2% being female. ESH was resolved in 100% of patients. Significant improvement for all PROMs at a minimum two-year (P < .001) was reported. The minimum two-year PROMs and the rate of achieving the MCID and MOI threshold were comparable to the control group. CONCLUSION: Following primary hip arthroscopy for FAIS and painful ESH, patients demonstrated significant improvement in all PROMs, and the rate of resolution of ESH was 100% at minimum two-year follow-up: with gluteus maximus and iliotibial band releases. Functional outcomes and rates of MCID and MOI achievement were comparable to a FAIS propensity-matched benchmark control group without ESH. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

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

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

Arthroscopic Subspine Decompression Is Commonly Reported in a Heterogenous Patient Population With Concomitant Procedures: A Systematic Review.

PURPOSE: To systematically review the evaluation, management, and surgical outcomes of arthroscopic subspine decompression in conjunction with other intra-articular hip preservation procedures. METHODS: Two databases (PubMed and Embase) were searched from 2010 to 2021, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for articles investigating arthroscopic subspine decompression using the key words: "subspine impingement", "AIIS impingement", and "extra-articular impingement." Exclusion criteria included diagnostic studies, failure to report postoperative outcomes, and case series of less than 10 hips. Studies were assessed for patient demographics, diagnostic criteria, clinical findings, concomitant procedures, outcomes, and postoperative complications. The quality of the studies was analyzed by 2 independent reviewers (A.J.C. and A.E.J.) using the Methodological Index for Non-randomized Studies (MINORS). RESULTS: Ten studies consisting of 438 patients (460 hips, 48.6% female) met the inclusion criteria, with average ages and follow-up ranging from 24.9 to 34.7 years and 6.0 to 44.4 months, respectively. There was 1 Level II study, 3 Level III studies, and 6 Level IV studies. The MINORS criteria yielded an average quality assessment of 13.0 (range: 7-22), with 3 methodological domains demonstrating mean scores of less than 1: unbiased assessment of the study endpoint (.25), loss of follow up less than 5% (.25), and prospective calculation of the study size (.7). The most common exam maneuver used was the subspine impingement test (9 studies). Most subspine decompressions were performed in addition to traditional femoroacetabular impingement syndrome (FAIS) procedures, with only one study (33 hips) reporting solely on isolated subspine osteoplasty. Average preoperative and postoperative modified Harris Hip Score (mHHS) values ranged from 44.93 to 75.7 and 79.5 to 98.0, respectively. Three studies noted improved hip flexion in the postoperative period. Five surgical complications were reported. CONCLUSIONS: Arthroscopic subspine decompression is commonly reported in a heterogenous patient population with intra-articular hip pathology. A combination of the subspine impingement test and anterior inferior iliac spine (AIIS) morphology on imaging is frequently used for diagnosis. While improved patient-reported outcomes (PROs) are consistently observed following arthroscopic decompression, conclusions are limited by study methodology and concurrent procedures performed at the time of surgery. LEVEL OF EVIDENCE: IV, systematic review of Level II through Level IV studies.

Minimum 2-Year Outcomes Following Arthroscopic Hip Labral Reconstruction in Adolescents and Young Adults.

BACKGROUND: Labral repair is generally preferred when facing labral tears. When an irreparable labral tear in the context of femoroacetabular impingement syndrome is present, arthroscopic labral reconstruction has been proven to be a valid option for labral restoration. However, data on this procedure for the adolescent population is scarce. The purpose of the present study was to report minimum 2-year follow-up patient-reported outcome measures (PROMs) on adolescents and young adults following arthroscopic acetabular labral reconstruction. METHODS: Data were prospectively collected and retrospectively reviewed on adolescents and young adults who underwent hip arthroscopy between March 2009 and June 2018. Inclusion criteria were labral reconstruction, baseline and minimum 2-year follow-up PROMs. Patients were excluded if they were unwilling to participate in the study, had Tönnis grade >1, or dysplasia. RESULTS: Twenty-three hips (22 patients) that underwent labral reconstruction were included. Ten hips (10 patients) underwent primary labral reconstruction, and 13 hips (12 patients) underwent revision reconstruction. The mean age was 19.3 years and 56.5% of patients were males. All patients improved significantly at minimum 2 years for all PROMs (P<0.001) with high satisfaction. Patients in both groups demonstrated improvement for all PROMs, patient satisfaction, and a rate of achieving the minimal clinically important difference. CONCLUSION: Arthroscopic labral reconstruction in adolescents and young adults demonstrated significant improvement and high patient satisfaction at minimum 2-year follow-up in the setting of irreparable labral tear. Favorable outcomes, high patient satisfaction, and high achievement rate for the minimal clinically important difference were obtained following labral reconstruction in this population the primary and revision scenarios. LEVEL OF EVIDENCE: Level IV, case-series.

Predictors of Achieving the Patient Acceptable Symptomatic State at Minimum 5-Year Follow-up Following Primary Hip Arthroscopy in the Adolescent Athlete.

BACKGROUND: Predictors of outcomes in adolescent athletes undergoing hip arthroscopy have not been established. The purpose of this study was to identify factors correlated with achieving the Patient Acceptable Symptomatic State (PASS) for the Hip Outcome Score-Sports Specific Subscale (HOS-SSS) at a minimum 5-year follow-up in adolescent athletes undergoing primary hip arthroscopy. METHODS: Data were reviewed on adolescent (below 18 y old) athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between March 2008 and October 2015. Patients were included if they participated in sport within 1 year before surgery and had preoperative, 2-year, and minimum 5-year postoperative patient-reported outcome (PRO) scores for the modified Harris Hip Score, HOS-SSS, Visual Analog Scale for pain (VAS), and Non-Arthritic Hip Score (NAHS). Patients were divided into 2 groups based on whether they achieved PASS for HOS-SSS. Demographics, intraoperative findings, radiographic variables, surgical treatments, and PRO were compared. Multivariate logistic regression with corresponding odds ratios (ORs) quantified the correlation between variables and achievement of the PASS. RESULTS: A total of 123 athletes with a mean age of 16.2±1.1 years were included. These athletes demonstrated significant imrpovement from preoperative to minimum 5-year follow-up for all recorded PROs (P<0.001). The multivariate logistic regression model identified preoperative NAHS (P=0.019, OR: 1.033), 2-year postoperative HOS-SSS (P=0.014, OR: 1.037), and 2-year postoperative VAS (P=0.003, OR: 0.590) as statistically significantly correlated with achieving the PASS. Athletes with a 2-year postoperative VAS pain score ≤2 achieved PASS at a rate of 81.9%, while those with a score >2 achieved PASS at a rate of 24.1% (P<0.001, OR: 14.2, 95% confidence interval: 5.23-38.7). CONCLUSIONS: Favorable outcome were achieved at mid-term follow-up in adolescent athletes undergoing primary hip arthroscopy. Preoperative NAHS, 2-year postoperative HOS-SSS, and 2-year postoperative VAS pain scores were correlated with achieving the PASS for HOS-SSS at a minimum 5-year follow-up. Patients with 2-year postoperative VAS ≤2 were significantly more likely to achieve the PASS at 5-year follow-up than those with scores >2. LEVEL OF EVIDENCE: Level III-case-control study.

Capsular Repair May Improve Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review of Comparative Outcome Studies.

PURPOSE: To review the existing literature in order to determine the effect of hip capsule repair on outcomes after hip arthroscopy for femoroacetabular impingement syndrome. METHODS: This study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find articles by using PubMed and Embase. Included studies were Level I through III studies that focused on patient outcomes as a function of hip capsular treatments: capsulotomy repair, partial repair, plication, and unrepaired capsulotomies. The Methodological Index for Non-randomized Studies was used for quality assessment of clinical outcome studies. After applying inclusion and exclusion criteria, a total of 16 comparative outcome studies evaluating 2,996 hips were included; they evaluated the following capsular management techniques: complete repair (n = 1,112, 37.1%), partial repair (n = 32, 1.1%), plication (n = 223, 7.4%), and unrepaired capsulotomy (n = 1629, 54.4%). RESULTS: Of the 16 studies, 13 included patient-reported outcome scores (PROs), 3 included imaging outcomes data, and 2 reported on reoperation. Of the studies, 10 directly compared patient-reported outcomes between a capsular repair group and an unrepaired group. Of the 10 studies that directly compared PROs between a group with unrepaired capsulotomy and a group with capsular repair, 8 studies demonstrated statistically significantly better PROs in the repaired group compared to the unrepaired group, and 2 studies found no difference between the groups. Reoperation rates demonstrated mixed results between groups, and no difference was found in regard to imaging outcomes. CONCLUSIONS: Midterm outcome studies suggest that capsular repair is safe and effective in patients without arthritis who are undergoing hip arthroscopy, and it may result in superior PROs compared with those found after unrepaired capsulotomy. Studies consistently demonstrate similar or superior outcomes in cohorts after capsular repair compared to unrepaired capsulotomy, and no studies reported superior results in unrepaired capsulotomy patients. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through Level III studies.

Hip Capsular Management in Patients With Femoroacetabular Impingement or Microinstability: A Systematic Review of Biomechanical Studies.

PURPOSE: To investigate the correlation between hip capsular management (repair or reconstruction) and biomechanical results in the setting of femoroacetabular impingement and microinstability. METHODS: A search of the PubMed and Embase databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies focused on hip biomechanics related to capsular release, repair of I- and T-capsulotomy, or capsular reconstruction. Studies were assessed for external/internal rotation of the femur, femoral head translation, rotational torque, and distraction force. Articles were excluded if they discussed treatment of the hip capsule related to surgical dislocation, mini-open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. RESULTS: Twenty-four biomechanical studies were included that evaluated rotation/translation (11 studies), distraction (3 studies), the capsular role in microinstability (simulated with anterior capsule pie crusting [2 studies] and cyclical loading [2 studies]), allograft reconstruction (3 studies), and anatomic properties (3 studies). Repair and reconstruction demonstrated improvements in maximum distractive force, total ROM, and torsional stability when compared to capsular release. Significant differences were observed between capsular repair and release in total ROM in the coronal plane with improved stability in the repair groups (standardized mean difference [SMD]: -1.3°, 95% confidence interval [CI] -1.68 , -0.854; P < .001). There was significantly increased total motion in the coronal plane in the capsular laxity state compared to the native state (SMD: 1.4° (95% CI 0.32, 2.49; P = .012). CONCLUSIONS: Biomechanical evidence supports closure of the capsule after hip arthroscopy to reverse the significant effects of capsulotomy. Simulated capsule laxity models created altered joint motion and translation. Capsule reconstruction appears to restore the hip to its native capsule state. CLINICAL RELEVANCE: Investigating the biomechanical outcomes of capsular repair and reconstruction will help surgeons better understand the rationale and implications of these capsular management strategies.

Outcomes Following Primary Total Hip Arthroplasty With Concomitant Gluteus Medius Repair Using the Direct Anterior Approach.

Outcomes following total hip arthroplasty (THA) with concomitant gluteus medius (GM) repair using the direct anterior approach (DAA) are scarce. The primary purpose of this study was to report patient-reported outcome measures (PROMs) with 2-year follow-up of patients with osteoarthritis and GM tear who underwent primary THA and GM repair through the DAA. The secondary purpose was to compare these outcomes with a benchmark propensity-matched control group who underwent a DAA THA without GM tear. Patients were eligible if they received a primary THA and GM repair via the DAA between January 2015 and October 2018 and had baseline PROMs with 2-year follow-up. Patients were excluded if they had workers' compensation or were unwilling to participate. PROM subanalysis was performed between patients and a propensity-matched control group with DAA THA without GM tear. Fourteen patients were included in the study, all of whom were female. Significant improvement for all PROMs and high rate of achieving the minimal clinically important difference (MCID) at 2-year follow-up were reported. All patients were propensity-matched to 28 patients for sex, age, and body mass index. Preoperative PROMs between groups were similar, and both groups reported comparable improvement, satisfaction, and MCID achievement at 2-year follow-up. Primary THA with concomitant GM repair using the DAA yielded good functional outcomes and a high rate of MCID achievement at 2-year follow-up. Based on these results, the DAA can be used safely to address symptomatic GM tears during THA. Furthermore, these outcomes were comparable to a propensity-matched control group without GM tear. [Orthopedics. 2023;46(1):39-46.].

Telemedicine: An Effective Tool for Patient-Physician Communication.

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

Effect of Cigarette Smoking on Midterm Outcomes After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome: A Propensity-Matched Controlled Study With Minimum 5-Year Follow-up.

Background: There is limited literature evaluating patient-reported outcomes (PROs) in cigarette smokers undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at midterm follow-up. Purpose: (1) To report minimum 5-year PROs for cigarette-smoking patients who underwent primary hip arthroscopy for FAIS and (2) to compare these results with a propensity-matched control group of never-smoking patients. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected for all patients who underwent primary hip arthroscopy for FAIS between June 2009 and March 2016. Patients were eligible if they indicated that they smoked cigarettes within 1 month of surgery and had minimum 5-year postoperative outcomes for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12). The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and maximum outcome improvement satisfaction threshold were recorded. The study group was then propensity matched in a 1:2 ratio to patients who had never smoked for comparison. Results: Included were 35 patients (35 hips) with a mean age of 39.4 ± 13.0 years and mean follow-up of 64.6 ± 4.1 months. These patients demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for all recorded PROs (P < .05). When compared with 70 control patients (70 hips), smoking patients demonstrated significantly worse preoperative scores for all PROs (P < .05). Study patients also demonstrated worse minimum 5-year scores for all recorded PROs compared with control patients, which did not reach statistical significance but trended toward significance for HOS-SSS (70.4 vs 81.9; P = .076) and iHOT-12 (74.7 vs 82.2; P = .122). Smoking patients also trended toward lower rates of achieving PASS for the iHOT-12 compared with never-smoking patients (50.0% vs 68.2%; P = .120). Conclusion: Patients who smoked cigarettes and underwent primary hip arthroscopy for FAIS demonstrated significant improvement in PROs at a minimum 5-year follow-up. When compared with a propensity-matched control group of never-smokers, they trended toward lower postoperative HOS-SSS and iHOT-12 scores and lower rates of achieving PASS on the iHOT-12.

Minimum 5-Year Outcomes After Primary Segmental Labral Reconstruction for Irreparable Labral Tears in the Hip With Hamstring Grafts: With a Subanalysis Comparing Autograft Versus Allograft.

BACKGROUND: Comparable short-term outcomes have been obtained using hamstring allografts versus autografts after primary segmental labral reconstruction (SLR). Midterm results have not yet been determined. PURPOSE: (1) To evaluate minimum 5-year patient-reported outcome (PRO) scores in patients who underwent primary SLR with hamstring grafts in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare the outcomes of hamstring autografts versus allografts in a subanalysis using propensity-matched groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Prospectively collected data were retrospectively reviewed for patients who underwent primary hip arthroscopy between September 2010 and November 2015. Patients were included if they underwent SLR using hamstring autografts or allografts and had preoperative and minimum 5-year PROs. The exclusion criteria were previous ipsilateral hip surgery or conditions, dysplasia, or Tönnis grade >1. Patients with autograft SLR were propensity matched 1 to 1 based on age, sex, and body mass index (BMI) to patients who underwent SLR using hamstring allografts. The minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) were calculated. RESULTS: Overall, 48 patients (N = hips 48) were eligible to be included in this study, and 41 patients (n = 41 hips [85.4%]) had a minimum 5-year follow-up reporting significant improvements in all PROs. Within the entire cohort, 9.8% required a secondary arthroscopy, with a mean time of 19 ± 1.8 months, and survivorship was 82.9%. Of the 41 included patients, 15 underwent an SLR with a hamstring autograft and were matched to 15 patients with labral reconstruction using a hamstring allograft. Groups were similar for sex (P > .999), age (P = .775), and BMI (P = .486). The mean follow-up times were 80.8 ± 25.5 and 66.1 ± 8.3 months (P = .223) for the autograft and allograft groups, respectively. Baseline PROs, preoperative radiographic measurements, surgical findings, and intraoperative procedures were similar. The groups achieved significant and comparable improvements for all PROs (P < .0001), satisfaction (P = .187), and the rate of achieving the MCID and the PASS. However, a tendency for higher postoperative PROs favoring allograft reconstruction was found. CONCLUSION: At a minimum 5-year follow-up, patients who underwent primary arthroscopic SLR in the context of FAIS and irreparable labra, with either autograft or allograft hamstring tendons, reported significant improvements and comparable postoperative scores for all PROs, patient satisfaction, MCID, and PASS.

Maximal Outcome Improvement Willingness Thresholds Are Predictive of a Patient's Willingness to Undergo the Same Surgery, in Retrospect, Given the Known Outcome of Their Primary Hip Arthroscopy.

Purpose: To determine the percent maximal outcome improvement willingness thresholds (MOWTs) for the Nonarthritic Hip Score (NAHS) and the visual analog scale (VAS) for pain that were associated with a patient's willingness to undergo surgery, in retrospect, given the known outcome of their primary hip arthroscopy with concomitant endoscopy for gluteus medius (GM) tear repair. Methods: An anchor question was provided to patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome with concomitant endoscopic GM tear repair between April 2008 to April 2020. Patients were included if they answered the anchor question and had baseline and postoperative minimum 1-year follow-up scores for the NAHS and VAS. Patients were excluded if they had a previous ipsilateral hip surgery, Tönnis grade >1, hip dysplasia, previous hip conditions, or a preoperative score that was already at the maximum value for the NAHS and VAS scores. Receiver operating characteristic (ROC) analysis was used to determine the MOWT. Significance was indicated by a P value <.05. Results: A total of 107 patients (107 hips) were included, with 101 (94.4%) females and 6 (5.6%) males. The average age and body mass index was 56.20 ± 9.88 years and 28.80 ± 4.92 kg/m2, respectively. The average follow-up time was 54.89 ± 29.52 months. The ROC analysis determined that the MOWT for the mHHS and VAS were 54.7%, and 62.6%, respectively. The probability of a patient being willing to undergo surgery again if they met the MOWT was 85.8% and 85.6% for the NAHS and VAS, respectively. Conclusion: The MOWTs that were predictive of willingness to undergo surgery again following primary hip arthroscopy with concomitant endoscopy for GM tear repair were 54.7% and 62.6% for the NAHS, and VAS, respectively. Clinical Relevance: Outcome assessment has been a point of increasing emphasis in hip preservation surgery. Having a tool to measure whether patients would go through the process of surgery again knowing their current outcome status is important to understanding outcomes after surgery.

It's not arthritis! Resolution of the illusion of joint space narrowing with acetabuloplasty and labral reconstruction for the calcified labrum.

Labral calcification may be part of the natural history of untreated femoroacetabular impingement syndrome (FAIS) in certain patients, making it a potential target for intervention with the goal of preserving the hip joint. The purpose of this study was to investigate if calcified labra create the appearance of lateral joint space narrowing and report minimum 2-year patient-reported outcome measures (PROMs) after treating patients with arthroscopic acetabuloplasty and labral reconstruction. Prospectively collected data on patients who underwent primary hip arthroscopy for FAIS and labral tearing from February 2015 to April 2021 were reviewed. Patients treated with primary labral reconstruction for an intraoperatively confirmed diagnosis of labral calcification were included. A sub-analysis was performed for patients with a minimum of 2-year follow-up. Preoperative and postoperative PROMs for the modified Harris hip score, nonarthritic hip score, the International Hip Outcome Tool-12 and visual analog scale for pain were recorded. Forty-six hips (46 patients) were included, with 19 hips in the sub-analysis. There was a significant increase in apparent lateral joint space width (JSW) measured on supine anteroposterior (AP) pelvis radiographs with no significant changes in medial and central JSW and significant decreases in the lateral and anterior center-edge angles and alpha angle. Patients experienced significant increases in PROMs and high rates of achieving psychometric thresholds. Patients presenting with FAIS and calcified labra may have apparent lateral joint space narrowing on pre-operative supine AP pelvis radiographs. These patients have low rates of full-thickness femoral head and acetabular cartilage pathology, this apparent narrowing can be corrected and excellent outcomes and survivorship can be achieved, with primary labral reconstruction.

Effect of Cigarette Smoking on Outcomes in Patients Undergoing Primary Hip Arthroscopy and Labral Reconstruction: A Propensity-Matched Controlled Study With Minimum 2-Year Follow-up.

BACKGROUND: There is a paucity of literature evaluating the effect of cigarette smoking on outcomes in patients undergoing hip arthroscopy and labral reconstruction. PURPOSE: (1) To report minimum 2-year patient-reported outcome (PRO) scores for patients who smoke cigarettes and underwent primary hip arthroscopic labral reconstruction and (2) to compare these results with those of a propensity-matched control group of patients who have never smoked. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were collected for all patients who underwent primary hip arthroscopy for labral reconstruction between January 2011 and January 2019. Patients were eligible for the study if they indicated that they smoked cigarettes within 1 month of surgery and had minimum 2-year postoperative outcome scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain. The percentage of patients achieving the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) was recorded. Rates of revision surgery were also documented. These patients were then propensity matched in a 1:3 ratio to patients who had never smoked (controls) for comparison. RESULTS: A total of 20 patients (20 hips) were included with a mean follow-up of 39.9 ± 13.0 months and mean age of 41.4 ± 10.4 years. These patients demonstrated significant improvement from preoperatively to the minimum 2-year follow-up for mHHS, NAHS, and VAS (P < .05). They also achieved MCID for mHHS and VAS at acceptable rates, 70% for both. When outcomes were compared with those of 60 control patients (60 hips), patients who smoke demonstrated lower preoperative PRO scores but similar minimum 2-year postoperative PRO scores for mHHS and NAHS. Patients who smoke demonstrated lower rates of achieving PASS for mHHS (55% vs 75%) and NAHS (40% vs 61.7%) compared with controls; however, these findings were not statistically significant. Rates of secondary surgery were statistically significantly higher in the smoking group compared with controls (25% vs 5%; P = .031). Survivorship for the smoking patients was 80% and 98.3% for the control group. At the two-year mark survivorship was 90% for the smoking group and 100% for the control group (P = .06). CONCLUSION: While smokers can still derive significant improvement from hip arthroscopy, their ultimate functional outcome and rate of secondary surgeries are inferior to those of nonsmokers. As smoking is a significant and modifiable risk factor, we should continue to counsel smokers on smoking cessation prior to and after surgery.