Editorial Commentary: "The Earth is Not Flat": Progressing From Plain Radiographs to Three-Dimensional Imaging When Evaluating Hip Disorders

Dysplastic hip morphologies have received increasing attention in the hip preservation community. Defining and characterizing "transitional acetabular coverage" or "borderline" dysplasia has been extraordinarily challenging, and these hips have been lumped together based on focal radiographic measurements such as the lateral center edge and Tonnis angles. Some of these hips are treated with arthroscopy and some with corrective osteotomies without definitive patient-related outcome measure winners in our literature. Three-dimensional imaging evaluation of these hips with regard to acetabular and femoral-sided anatomy will be required to more clearly define any consistent anatomic variants and their respective optimal surgical approaches.

Ischemic Therapy in Musculoskeletal Medicine

BACKGROUND

The competitive environment of athletics has promoted the exploration of any technology application that may offer an edge with performance and recovery from injury. Ischemic therapy is one such technology that has rapidly been incorporated into training rooms and physical therapy clinics worldwide. This therapy modality is reported to increase an athlete's ability to improve muscle mass, strength, and endurance.

PURPOSE

To provide the sports medicine physician with an understanding of the current state of ischemic therapy technology, including treatment specifications, known physiological effects, hypothesized mechanisms, biochemical effects, athletic applications, medical applications, animal models, and future research recommendations.

STUDY DESIGN

Literature review.

METHODS

A computer-based search of the PubMed database was used to perform a comprehensive literature review on musculoskeletal ischemic therapy.

RESULTS

The current research on ischemic therapy is largely composed of case series with varying equipment, methods, and therapy specifications. The publication of case series has value in identifying this technology for future research, but the results of these studies should not be justification for application to athletes without validation of safety and effectiveness.

CONCLUSION

To date, ischemic therapy remains unvalidated, and the mechanism by which it improves muscle performance is not clear.

Lateral Center-Edge Angle Is Not Predictive of Acetabular Articular Cartilage Surface Area: Anatomic Variation of the Lunate Fossa

BACKGROUND

Surgical treatment of symptomatic femoroacetabular impingement (FAI) and dysplasia requires careful characterization of acetabular morphology. The lateral center-edge angle (LCEA) is often used to assess lateral acetabular anatomy. Previous work has questioned the LCEA as a surrogate for acetabular contact/articular cartilage surface area because of the variable morphology of the lunate fossa.

HYPOTHESIS

We hypothesized that weightbearing articular cartilage of the acetabulum would poorly correlate with LCEA secondary to significant variation in the size of the lunate fossa.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Patients with 3D CT imaging undergoing either hip arthroscopy or periacetabular osteotomy for FAI or symptomatic hip instability were retrospectively identified. The LCEA and femoral head diameter were measured on an anteroposterior pelvis radiograph. Patients were grouped according to their lateral acetabular coverage as undercoverage (LCEA, <25°), normal coverage (LCEA, 25°-40°), or overcoverage (LCEA, >40°). Patients were randomly identified until each group contained 20 patients. The articular surface area was measured from preoperative 3D CT data. Linear regression analysis was performed to examine the relationship between articular surface area and LCEA. Continuous and categorical data were analyzed utilizing analysis of variance and chi-square analysis. Statistical significance was set at P < .05.

RESULTS

No difference in age (P = .52), body mass index (BMI) (P = .75), or femoral head diameter (P = .66) was noted between groups. A significant difference in articular surface area was observed between patients with undercoverage and those with overcoverage (20.4 cm² vs 24.5 cm²; P = .01). No significant difference was identified between the undercoverage and normal groups (20.4 cm² vs 23.3 cm²; P = .09) or the normal and overcoverage groups (23.3 cm² vs 24.5 cm²; P = .63). A moderate positive correlation was observed between LCEA and articular surface area across all patients (r = 0.38; P = .002) but not when patients with undercoverage were excluded (r = 0.02; P = .88). Significant variation in surface area was observed within each group such that no patient in any group was outside of 2 SDs of the means of the other groups. When patients were categorized into quartiles established by the articular surface area for the entire population, 40% of patients with overcoverage were observed in the first or second quartile (lower area).

CONCLUSION

Lateral acetabular undercoverage based on the LCEA (<25°) correlates with decreased acetabular surface area. Normal or increased acetabular coverage (LCEA, >25°), however, is not predictive of increased, normal, or decreased acetabular surface area.

Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis in Skeletally Immature Patients: Surgical Technique

Pediatric anterior cruciate ligament (ACL) reconstructions have a relatively high risk for re-rupture, and a low proportion of these patients report a successful return to sport. With an increasing emphasis on youth participation in pivoting sports, the incidence of these injuries has increased in recent years. A reappreciation of lateral extra-articular stabilizing procedures in high-risk adult populations who undergo ACL reconstruction has demonstrated potential improved outcomes for vulnerable ACL reconstructions. However, the open status of the pediatric physes makes the use of these procedures more challenging. Therefore, the purpose of this Technical Note is to describe the current authors' surgical technique for a combined ACL reconstruction with a lateral extra-articular tenodesis for these high-risk patients with open physes.

Editorial Commentary: Comparing Medial and Lateral Meniscal Root Tears Is Like Comparing Apples and Oranges

The importance of treating meniscal root tears has been increasingly recognized, and surgeons have to make conscious decisions routinely regarding repair for select patients. The clinical and patient demographic differences between medial and lateral meniscal root tears are important and ultimately leave us wondering whether outcome differences are due to unique anatomic factors or the patient population sustaining these injuries.

The Dancer's Hip: The Hyperflexible Athlete: Anatomy and Mean 3-Year Arthroscopic Clinical Outcomes

PURPOSE

To report preoperative anatomy, patient-related outcomes measures, and return to dance rates in a cohort of competitive dancers undergoing an arthroscopic hip procedure.

METHODS

Competitive dancers who underwent an arthroscopic hip procedure between 2008 and 2016 were included. Specific types of dance performed, morphology, and radiographic parameters were documented. Outcomes were evaluated with Modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey, visual analog scale, and Hip Disability and Osteoarthritis Outcome Scores (HOOS).

RESULTS

There were 63 competitive dancers (77 hips) with a mean age 21.2 years in the current study. Specific types of dance performed included 57 studio dance and 41 high-kick dance, and 28 dancers (44%) were professional-level. Morphology included cam-type femoroacetabular impingement (95%), pincer-type femoroacetabular impingement (40%), anterior inferior iliac spine impingement (subspine) (83%), and mild (borderline) dysplasia (11%). Procedures performed included 95% labral repairs, 5% labral debridements, 99% femoral resections, 49% rim resections, 88% subspine decompressions, and 66% capsular plications. At mean 36 months' follow-up post-arthroscopy, the mean outcome improvements were 25.6 points (mHHS), 18.9 points (HOOS-activities of daily living), 29.9 points (HOOS-Sports), 8.7 points (12-Item Short Form Health Survey), and 3.7 points (visual analog scale) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for mHHS (60.0 vs 85.6 points), HOOS-activities of daily living (72.5 vs 91.5 points), and HOOS-Sports (49.7 vs 79.6) (P < .01). Sixty-three percent of dancers returned to their previous level of competitive dance, 21% returned to limited or modified dance, and 16% were unable to return to dance, including 1 retirement.

CONCLUSIONS

A careful arthroscopic approach to address cam-type pathomorphology, highly prevalent subspine impingement, and capsular laxity in competitive dancers can achieve a modest rate of return to sport and good-to-excellent patient-reported outcomes at short- to mid-term (3-year) follow-up. Eighty-four percent of dancers ultimately returned to competitive dance, although only 63% returned to their preinjury competitive level.

LEVEL OF EVIDENCE

IV, case series.

Editorial Commentary: Total Hip Arthroplasty After Hip Arthroscopy-Solution for the Failed Arthroscopy or a Matter of Pushing the Envelope and Questionable Indications

With the inevitable explosion of arthroscopic hip procedures being performed, the less frequent indications and failures are becoming prevalent enough to analyze. As with any procedure, failures occur and solutions are sought after. "Total hip arthroplasty after prior hip arthroscopy" is a statement that brings to mind several questions and comments. Yes, it is important to evaluate the impact of a prior arthroscopy on eventual total hip arthroplasty outcomes and complication rates. The bigger question when the arthroplasty is performed less than 2 years after hip arthroscopy, however, is "How did we get here?" The pivotal issue at hand might be one of pushing surgical indications a bit too forcefully on multiple fronts. It might be time to return to "Indications 101" to minimize an exponential increase regarding this particular topic with this particular failure timeline.

Arthroscopic Surgery for Femoroacetabular Impingement in Skeletally Immature Athletes: Radiographic and Clinical Analysis

PURPOSE

To evaluate radiographic and clinical outcomes after arthroscopic femoroacetabular impingement (FAI) correction in symptomatic adolescent athletes with open physes.

METHODS

We retrospectively reviewed radiographic and clinical outcomes in patients treated with a non-physeal-sparing arthroscopic approach for symptomatic FAI with open physes and a minimum 1-year follow-up. Specific plain radiographic and computed tomography parameters were determined, and preoperative and postoperative outcomes were prospectively evaluated with modified Harris Hip Score (mHHS), 12-Item Veterans-Rand, and pain on a visual analog scale.

RESULTS

Thirty-seven hips (28 patients; 75% male) with a mean age of 15.9 years (range, 12.8-18.3 years) had imaging studies consistent with open femoral neck and iliac crest physes. The ischial tuberosity and greater trochanteric physes were open in 95% and 54% of the hips, respectively. All patients participated in organized athletics, and 50% were in multiple sports year-round. Mean follow-up was 39.8 months post-arthroscopic FAI correction. There was a mean 27.7-point improvement in the mHHS (P < .001), a 4.8-point decrease in the visual analog scale for pain (P < .001), and a 15.2-point improvement in the 12-Item Veterans-Rand physical component (P < .001). Ninety-three percent of patients returned to their preinjury level of sports participation without limitations. Thirty (81.1%) patients demonstrated improvements in mHHS greater than the minimally clinically important difference (of mHHS 8 points). Two patients could not reach minimally clinically important difference because of a preoperative mHHS of > 92. There were no postoperative physeal growth arrests, growth disturbances, physeal instability, or avascular necrosis.

CONCLUSIONS

A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability in patients with a minimum of 1 year (mean, 39.8 months) of follow-up after surgery. Young, highly athletic adolescent patients with larger FAI deformities demonstrated greater outcomes improvement after arthroscopy.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Editorial Commentary: Subspine Hip Abnormalities: Exploring the Difference Between "Morphology" and "Impingement"

Subspine impingement has been increasingly recognized as a source of hip pain over the past 5 to 10 years. Some surgeons routinely perform subspine/anterior inferior iliac spine (AIIS) decompressions, whereas others rarely perform these procedures as part of an arthroscopic hip procedure. Subspine impingement has been implicated with high range-of-motion activities, various AIIS morphologies and deformities, and in the setting of persistent anterior hip pain after intra-articular anesthetic injections. Dynamic computed tomographic imaging has recently shown subspine impingement even with relatively normal AIIS morphology and in the setting of decreased femoral anteversion. These findings further emphasize the importance of understanding and defining relationships between morphology and impingement. Ultimately, subspine decompressions might be critical to achieve the best possible outcome after arthroscopic hip procedures in a subset of patients, but making the diagnosis remains challenging for clinicians.

Characterization and Correction of Symptomatic Hip Impingement in American Football Linemen

BACKGROUND

Femoroacetabular impingement (FAI) morphology can lead to range-of-motion deficits in football players. It is therefore important for physicians treating these players to be aware of the location and implications of FAI morphology.

PURPOSE/QUESTIONS

We sought to characterize the radiographic deformity and dynamic impingement observed in a consecutive series of American football linemen with symptomatic, mechanical hip pain who underwent surgical treatment for FAI and to use software analysis to identify the location of impingement and terminal range of motion and the effects of simulated correction.

METHODS

A retrospective analysis was conducted of 17 hips in 13 football linemen who underwent arthroscopic correction for symptomatic FAI. Computed tomography (CT) scans were used to generate preoperative three-dimensional models of the hips. Femoral and acetabular measurements, maximum hip flexion, abduction, internal rotation at 90° flexion (IR90), and flexion/adduction/internal rotation (FADIR) were determined, and areas of bony collision were defined. Simulated femoral correction was performed and motion analysis was repeated.

RESULTS

Mean femoral version was 13.1° (range, 0 to 26°), while mean femoral neck-shaft angle was 132.1° (range, 123 to 145°). Mean maximum alpha angle on the radial reformatted CT was 69.2° (range, 48 to 95°) and was located at the 12:45 clock-face position (range, 11:30 to 2:15). Mean acetabular version values at 1:30 and 3:00 were 1.1° (range, - 11 to 11°) and 12.7° (range, 2 to 20°), respectively. Fifty-three percent of hips showed a "crossover" sign. Mean lateral center-edge angle was 31.7° (range, 25 to 44°). CT-derived motion analysis demonstrated a mean preoperative flexion of 108.2° (range, 73 to 127°), IR90 of 20.5° (range, 0 to 52°), and FADIR of 12.3° (range, 0 to 39°). Simulated correction resulted in significant improvements in flexion (6.6°), IR90 (11.3°), and FADIR (10.6°).

CONCLUSIONS

While cephalad retroversion was observed in approximately half of the hips, a significant cam deformity was seen maximally at 12:45, a more posterior cam location than that of the general population. Managing this pathology required obtaining preoperative and intraoperative images to characterize lesions and allow for their complete correction. With complete correction of the deformity, simulated range of motion demonstrated significant improvement in flexion, IR90, and FADIR maneuvers.

Effects of Arthroscopy for Femoroacetabular Impingement Syndrome on Quality of Life and Economic Outcomes

BACKGROUND

The diagnosis and treatment of femoroacetabular impingement (FAI) have increased steadily within the past decade, and research indicates clinically significant improvements after treatment of FAI with hip arthroscopy.

PURPOSE

This study examined the societal and economic impact of hip arthroscopy by high-volume surgeons for patients with FAI syndrome aged <50 years with noncontroversial diagnosis and indications for surgery.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 2.

METHODS

The cost-effectiveness of hip arthroscopy versus nonoperative treatment was evaluated by calculating direct and indirect treatment costs. Direct cost was calculated with Current Procedural Terminology medical codes associated with FAI treatment. Indirect cost was measured with the patient-reported data of 102 patients who underwent arthroscopy and from the reimbursement records of 32,143 individuals between the ages of 16 and 79 years who had information in a private insurance claims data set contained within the PearlDiver Patient Records Database. The indirect economic benefits of hip arthroscopy were inferred through regression analysis to estimate the statistical relationship between functional status and productivity. A simulation-based approach was then used to estimate the change in productivity associated with the change in functional status observed in the treatment cohort between baseline and follow-up. To analyze cost-effectiveness, 1-, 2-, and 3-way sensitivity analyses were performed on all variables in the model, and Monte Carlo analysis evaluated the impact of uncertainty in the model assumptions.

RESULTS

Analysis of indirect costs identified a statistically significant increase of mean aggregate productivity of $8968 after surgery. Cost-effectiveness analysis showed a mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy versus nonoperative treatment. Hip arthroscopy also conferred a gain of 2.03 quality-adjusted life years over this period. The mean cost for hip arthroscopy was estimated at $23,120 ± $10,279, and the mean cost of nonoperative treatment was estimated at $91,602 ± $14,675. In 99% of trials, hip arthroscopy was recognized as the preferred cost-effective strategy.

CONCLUSION

FAI syndrome produces a substantial economic burden on society that may be reduced through the indirect cost savings and economic benefits from hip arthroscopy.

Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction: Prospective, Case-Control Study With Mean 6 Years Follow-up

PURPOSE

To determine whether generalized hypermobility and contralateral knee hyperextension affect failure rates and patient-related outcomes after anterior cruciate ligament reconstruction (ACLR).

METHODS

A total of 226 consecutive patients presenting with acute ACL tears were prospectively evaluated for generalized hypermobility by a modified Beighton criteria. Minimum 2-year follow-up was achieved for 183 knees (81%). Patients underwent ACLR with either bone-patellar-tendon (BPTB) autograft (n = 46), quadrupled hamstring (HT) autograft (n = 85), or allograft tissue (n = 52). KT-1000 measurements, International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scores were obtained.

RESULTS

Forty-one of 183 consecutive patients were categorized as hypermobile. At mean 6 years' follow-up (range 2-12.5 years), IKDC (P = .003), Cincinnati (P = .001), and Lysholm scores (P < .001) were significantly better in the Non-Hypermobile group for patients with an intact graft. The failure rate was higher in the Hypermobile group (10 knees, 24.4% failure rate) compared with the Nonhypermobile group (11 knees, 7.7% failure rate) (P = .006). The overall ACL injury rate (ACL graft injury, excessive graft laxity, plus contralateral ACL tear) was higher in the Hypermobile group (34.1%) compared with the Nonhypermobile group (12.0%) (P = .002). Heel height >5 cm (P = .009) and fifth metacarpophalangeal (MCP) extension >90° (P = .006) were independently predictive of failure for the entire study population.

CONCLUSIONS

Graft failure rates were higher and inferior subjective outcomes were observed after ACLR in patients with generalized hypermobility. Heel height and fifth MCP hyperextension were most predictive of ACL injury/reinjury and poorer outcome scores. Nearly one-third of hypermobile patients sustained a contralateral ACL tear, ipsilateral graft failure, or had excessive graft laxity.

LEVEL OF EVIDENCE

Level III, case control study.

Editorial Commentary: Patient-Related Outcome Measures, Minimal Clinically Important Differences, and Substantial Clinical Benefits for Adolescent Hip Arthroscopy: Making Progress With Outcome Measures or Unquestionably Spinning out of Control?

With the myriad of potential patient-related outcome measures, it is nearly inevitable that we become a bit delirious with regard to evaluating our patients. A potential improvement in outcome assessment, from the standpoint of clinical relevance, is a focus on the minimal clinically important difference and substantial clinical benefit. Large improvements in outcome scores are required in order for adolescent hip patients to perceive substantial clinical benefit. Meaningful data and outcomes are clearly critical issues; however, a variety of patient-related outcome measures used in current and previous studies introduce the risk of "reporting bias." In the end, we might need to find some common ground with regard to patient evaluation if we are to compare current and future studies with each other or historic published controls. If we fail to develop some uniformity, I fear we will be left to reinvent the wheel for years to come.

Indications for Hip Arthroscopy

CONTEXT

Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies.

EVIDENCE ACQUISITION

Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders.

CONCLUSION

Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.

Radiographic Hip Anatomy Correlates With Range of Motion and Symptoms in National Hockey League Players

BACKGROUND

Hip disorders in athletes have been increasingly recognized.

PURPOSE

To characterize radiographic hip anatomy for National Hockey League (NHL) players and correlate it with hip range of motion and hip symptoms and/or surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Fifty-nine professional hockey players (118 hips) with 1 NHL organization (mean age, 24.2 years; range, 18-36) prospectively underwent history and physician examination by 2 independent orthopaedic surgeons. Current or previous groin and/or hip pain or surgery was noted. Anteroposterior (AP) pelvis and bilateral Dunn lateral radiographs were obtained for all players with assessment of hip morphology by 2 blinded independent orthopaedic surgeons.

RESULTS

Good to very good reliability of radiographic assessments was noted (intraclass correlation coefficients = 0.749-0.958). Sixty-four percent of athletes had a positive crossover sign, while 86% and 60% had a positive posterior wall sign and a prominent ischial spine sign, respectively. Twenty-one percent of hips demonstrated dysplastic acetabular features (lateral center edge angle <25°). Eighty-five percent and 89% of hips demonstrated cam-type morphology based on alpha angle (>50° Dunn lateral) and head-neck offset, respectively. Good to very good reliability was noted for ROM assessments (intraclass correlation coefficient >0.69). Mean hip flexion was 107.4º ± 6.7º, and mean hip internal rotation was 26.1º ± 6.6º. Thirty-one percent of hips had a history of hip-related pain and/or surgery. Higher AP, Dunn lateral, and maximal alpha angles correlated with decreased hip internal rotation ( P = .004). Greater AP alpha angle correlated with decreased hip extension/abduction ( P = .025), and greater Dunn lateral and maximal alpha angle correlated with decreased hip flexion/abduction ( P = .001). A positive posterior wall sign correlated with increased straight hip abduction, while other radiographic acetabular parameters were not predictive of range of motion. Only decreased hip external rotation and total arc of motion correlated with an increased risk for current or prior hip symptoms or surgery ( P < .001).

CONCLUSION

Hip anatomy in NHL players is characterized by highly prevalent cam-type morphology (>85%) and acetabular retroversion (>60%). In addition, acetabular dysplasia (21%) was relatively common. Greater cam-type morphology correlated with decreased hip range of motion, and a positive crossover sign correlated with increased hip abduction. Decreased hip external rotation and total arc of motion were predictive of hip-related pain and/or surgery.

Ischiofemoral impingement and hamstring dysfunction as a potential pain generator after ischial tuberosity apophyseal fracture non-union/malunion

PURPOSE

The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement.

METHODS

All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS).

RESULTS

Ten patients with a mean age of 18 years (range 14-28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7-3.5), the median post-operative mHHS was 89.7 (65.7-96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal.

CONCLUSION

Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.

LEVEL OF EVIDENCE

IV.

Hip Arthroscopy for Removal of an Acetabular Rim-Based Osteoid Osteoma and Concomitant Femoroacetabular Impingement Correction

Minimally invasive percutaneous radiofrequency ablation (RFA) techniques are the standard of care for treating simple osteoid osteomas (OOs). Historically, OOs were treated with open en bloc resection or curettage of the nidus. RFA procedures have been linked to soft-tissue complications of varying severity. In addition, RFA may be a poor choice for periarticular OOs because of the potential for procedure-related articular cartilage damage. Hip arthroscopy is a widely accepted approach for the treatment of femoroacetabular impingement. We describe arthroscopic resection of an acetabular rim-based OO as part of a rim resection and labral repair. Early clinical follow-up suggests that arthroscopic resection of an OO in this unusual location is precise and predictable, allows for an additional evaluation of associated symptomatic pathology (i.e., femoroacetabular impingement), and results in prompt symptom resolution.

Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A Prospective Multicenter Trial Utilizing a Validated Grading Scheme

BACKGROUND

There is limited literature looking at comprehensive complication rates after arthroscopic hip procedures.

PURPOSE

To prospectively report complication rates for a consecutive series of hips undergoing arthroscopic procedures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 29-month period, 1615 consecutive hips in patients with a mean age of 30.5 years underwent arthroscopic hip procedures at 4 institutions. The diagnosis, demographic information, and procedures were recorded, and a validated grading classification for complications of hip joint surgery was utilized prospectively. The cohort with complications was observed postoperatively for a mean of 36.7 months (range, 24-54 months).

RESULTS

There were 1487 primary hip arthroscopic procedures and 128 revision hip arthroscopic procedures. Arthroscopic femoroacetabular impingement correction was performed in 1505 hips (93.2%), and 1273 hips (78.8%) underwent a labral repair procedure. The most common event was postoperative lateral femoral cutaneous (LFC) nerve disturbance (16.5%), which persisted beyond 6 months in only 1.6%. The incidence of iatrogenic chondral injuries was 1.2%, iatrogenic labral punctures was 0.9%, superficial portal infections was 1.1%, sensory deficits about the foot was 0.8%, deep venous thrombosis was 0.1%, pulmonary embolism was 0.1%, perineal numbness (pudendal nerve) was 1.4%, heterotopic ossification was 0.8%, and femoral neck stress fractures was 0.1%. There was no iatrogenic instability, avascular necrosis, or extra-abdominal fluid extravasation identified in this cohort. The overall complication rate, not including temporary LFC periportal and thigh numbness (sequela), was 8.3% (134 hips). Overall, a grade 1 complication was seen in 7.2% (117 hips), grade 2 in 0.6% (10 hips), grade 3 in 0.4% (6 hips), and grade 4 in 0.1% (1 hip). There was a significantly higher rate of complications for longer surgical time and traction time (P < .01) and for female patients as compared with male patients (P = .017). Most notably, traction time longer than 60 minutes was associated with a significantly increased complication rate (P < .001). Hips with pudendal nerve neurapraxia had longer traction times than those without (61.5 vs 43.8 minutes, respectively; P < .001). No differences were found between primary versus revision cases (P = .123) or between labral repair versus debridement (P = .209), and body mass index had no effect on the complication rate (P = .103).

CONCLUSION

The overall complication rate after hip arthroscopic surgery at tertiary hip centers was 8.3%, with higher rates reported for longer traction times (>60 minutes) and for female patients. Compared with surgical hip dislocation using the same classification system, the overall rate of complications was similar, but the rate of higher grade complications was lower for arthroscopic hip procedures.

The Hip in Ice Hockey: A Current Concepts Review

Ice hockey is a fast, physical sport with unique associated biomechanical demands often placing the hip in forced and repetitive supraphysiological ranges of motion. Ice hockey players commonly endure and are sidelined by nebulous groin injury or hip pain. Underlying causes can be chronic or acute and extra-articular, intra-articular, or "hip-mimicking." This article serves to review common hip-related injuries in ice hockey. For each, we define the particular condition; comment on risk factors and preventive strategies; discuss key historical, physical examination, and imaging findings; and finally, suggest nonoperative and/or operative treatment plans.

Allograft and Autograft Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Outcomes and Complications

PURPOSE

The purpose of the study was to evaluate outcomes, graft failure rates, and complications after transphyseal soft-tissue allograft and autograft anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with open growth plates.

METHODS

Twenty-nine skeletally immature athletes (30 knees) with a mean age of 13.9 years (range, 9 to 16 years) underwent transphyseal ACLR (22 with quadrupled hamstring autograft and 8 with tibialis anterior allograft). Of the patients, 5 were Tanner stage I, 17 were Tanner stage II, and 7 were Tanner stage III. Outcomes included KT-1000 (MEDmetric, San Diego, CA) measurements and International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scoring. Radiographs were evaluated for asymmetrical physeal closure, growth arrest lines, and knee alignment.

RESULTS

The mean outcomes scores, excluding the 5 graft failures, were 91.8 points for the IKDC score, 93.0 points for the Cincinnati score, and 91.5 points for the Lysholm score at a mean of 4 years' follow-up (range, 24 to 84 months). The 95% confidence intervals for the differences were -27.7 to -18.0 for the IKDC score, -26.4 to -12.1 for the Cincinnati score, and -20.1 to -6.4 for the Lysholm score. One hundred percent of patients ultimately returned to their prior level of sports, but only 76% maintained that level at most recent follow-up. The mean KT-1000 side-to-side difference at most recent follow-up was 0.4 mm (SD, 1.3 mm; range, -2 to 3 mm) (n = 25). Evaluation at a minimum of 2 years postoperatively showed 4 patients with Harris growth arrest lines and 1 genu valgum deformity that spontaneously corrected at latest follow-up. For the remaining 29 knees, there was a mean side-to-side difference of 1.3° (range, 0° to 4°) in the radiographic tibiofemoral angle and 0.2 cm (range, 0 to 1 cm) for clinical leg-length measurements. Sports-related graft failure occurred at a mean of 24 months after ACLR in 16.7% of patients (37.5% with allografts [3 of 8] v 9% with autografts [2 of 22], P = .10). In 5 patients (16.7%), a contralateral ACL injury was sustained.

CONCLUSIONS

Transphyseal ACLR in patients with open growth plates resulted in a high rate of return to sports with a low rate of growth arrest and deformity at a mean of 4 years' follow-up. Harris growth arrest lines and a case of genu valgum deformity that spontaneously corrected, however, were observed. Graft failure rates and contralateral ACL tears were not insignificant in this young patient population.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Hip Arthroscopy in Trauma: A Systematic Review of Indications, Efficacy, and Complications

PURPOSE

This systematic review explored the indications, efficacy, and complications of hip arthroscopy in the setting of trauma.

METHODS

Databases (PubMed, Medline, Embase, and Web of Science) were searched from database inception to March 2015 for studies using hip arthroscopy in trauma treatment. Systematic screening of eligible studies was undertaken in duplicate. The inclusion criteria included studies pertaining to arthroscopic intervention of all traumatic hip injuries. Abstracted data were organized in table format with descriptive statistics presented.

RESULTS

From an initial search yield of 2,809 studies, 32 studies (25 case reports and 7 case series) satisfied the criteria for inclusion. A total of 144 patients (age range, 10 to 53 years) underwent hip arthroscopy for 6 indications associated with trauma: 8 patients for bullet extraction, 6 for femoral head fixation, 82 for loose body removal, 6 for acetabular fracture fixation, 20 for labral intervention, and 23 for ligamentum teres debridement. Patients were followed up postoperatively for a mean of 2.9 years (range, 8 days to 16 years). Successful surgery was achieved in 96% of patients. The rate of major complications (i.e., pulmonary embolism and abdominal compartment syndrome) was 1.4% (2 of 144); avascular necrosis, 1.4% (2 of 144); and nerve palsy, 0.7% (1 of 144).

CONCLUSIONS

Hip arthroscopy appears effective and safe in the setting of trauma. These data should be interpreted with caution because of the low-quality evidence of the included studies. Surgeons should be aware of the potential complications such as abdominal compartment syndrome and thromboembolic events when performing hip arthroscopy in the setting of trauma.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Arthroscopic Management of Dysplastic Hip Deformities: Predictors of Success and Failures With Comparison to an Arthroscopic FAI Cohort

BACKGROUND

Reports regarding arthroscopy for mild hip dysplasia have conflicting results.

HYPOTHESIS

Arthroscopy for borderline/mild hip dysplasia would lead to improved outcomes but be inferior to arthroscopy for femoroacetabular impingement (FAI).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 88 hips (77 patients, 71% female; mean age, 33.9 years) with dysplastic radiographic findings were retrospectively reviewed at a mean follow-up of 26.0 months after hip arthroscopy. Specific procedures included labral repair (76%), labral debridement (23%), capsular repair/plication (82%), and femoral osteochondroplasty (72%). Radiographic parameters included lateral center-edge angle, neck-shaft angle, Tönnis angle, extrusion index, femoral head lateralization, and break in the Shenton line. Pre- and postoperative function were evaluated prospectively with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey, and visual analog scale for pain. The results of the dysplastic cohort were compared with an age-matched cohort of 231 hips without radiographic dysplasia that underwent arthroscopic FAI correction during the study period (mean follow-up, 22.7 months).

RESULTS

The mean lateral center-edge angle was 20.8° (range, 8.7°-24.5°), and the mean Tönnis angle was 11.0° (range, 0°-22.2°). At the time of final follow-up, the dysplastic cohort demonstrated a mean mHHS of 81.3 with a mean 15.6-point improvement in mHHS, compared with 88.4 and 24.4 points, respectively, in the FAI cohort (P = .00044). The dysplastic cohort had 60.9% good/excellent results and 32.2% failures, compared with 81.2% good/excellent results and 10.5% failures for the FAI cohort (P < .01). Failure was defined as an mHHS ≤70 or eventual pelvic/femoral osteotomy or total hip arthroplasty. Dysplastic hips that underwent capsular plication and labral repair had greater good/excellent results (73%) and mean latest mHHS (85), as well as lower failure rates (18%) compared with the remainder of the dysplastic cohort (P < .05). Grade 4 chondral defects were predictive of lower scores (P = .02). There were no other statistically significant differences for outcomes regarding sex, age, or radiographic parameters (P > .05). There were no iatrogenic subluxations/dislocations.

CONCLUSION

Arthroscopic management of mild to moderate acetabular dysplasia had inferior good/excellent results and higher failure rates when compared with an FAI cohort; therefore, isolated arthroscopic procedures in this population should be cautiously considered. These results were independent of patient sex. Labral repair and capsular plication resulted in better clinical outcomes in this mildly dysplastic cohort.