Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome

Hip Arthroscopy in Patients With Generalized Joint Hypermobility Yields Successful Outcomes: A Systematic Review

PURPOSE

To evaluate the outcomes of hip arthroscopy in patients with generalized joint hypermobility (GJH).

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An electronic record search was performed in PubMed, Web of Science, Cochrane Library, and Embase. A 2-stage title/abstract and full-text screening was performed using the following inclusion criteria: (1) observational studies, cohort studies, and randomized controlled trials; (2) describing more than 5 patients with a mean age over 18 years and GJH; (3) undergoing arthroscopy of the hip; (4) reporting patient-reported outcome measures (PROMs), return to sport, or complications/reoperations; and (5) published in English.

RESULTS

Of the 517 articles identified, 10 studies meeting all selection criteria were included. Included studies report significant improvements in a range of different functional and pain-based PROMs. Most patients (25.0%-97.0%) in each study achieved a clinically important improvement postoperatively in at least 1 PROM. No complications were described in any of the 4 studies reporting this metric. One study each found an association between GJH and an increased risk of postoperative deep gluteal syndrome and iliopsoas tendinitis. The rate of revision arthroscopy ranged from 0% to 11.4%, and only 2 patients in a single study of 11 hips required conversion to total hip arthroplasty. No statistically significant differences were reported between patients with and without GJH with respect to any of the described outcomes.

CONCLUSIONS

Patients with GJH may achieve good outcomes following hip arthroscopy with respect to PROMs, perioperative complications, reoperation, and return to sport. With effective labral repair and capsular closure, outcomes achieved in patients with GJH are comparable to those reported in patients without hypermobility.

LEVEL OF EVIDENCE

Level IV, systematic review of level III to IV studies.

Hypermobile Patients With Femoroacetabular Impingement Syndrome Can Be Effectively Treated Utilizing Hip Arthroscopy With Periportal Capsulotomy Closure: A Matched Cohort Analysis Compared to Patients Without Joint Hypermobility

PURPOSE

To assess the 2-year outcomes of arthroscopic treatment with periportal capsulotomy closure for femoroacetabular impingement syndrome (FAIS) in patients with generalized ligamentous laxity (GLL).

METHODS

A retrospective analysis was performed from a prospectively collected database of FAIS patients undergoing hip arthroscopy. FAIS patients with GLL were identified as having Beighton score ≥4. FAIS patients with GLL were treated with arthroscopic labral repair, osteochondroplasty, via periportal capsulotomy with subsequent capsular closure. These patients were matched by age, sex, and body mass index (BMI) with a cohort of FAIS patients without GLL who underwent the same procedure via periportal capsulotomy without capsular closure. Preoperatively, and 2 years postoperatively, patients completed patient-reported outcomes (PRO) scores, including the Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey (SF-12) and the visual analog scale (VAS).

RESULTS

Forty patients (5 male, 35 female) with FAIS and GLL were included (age: 29.7 ± 9.0; BMI: 23.3 ± 4.1). FAIS patients with GLL demonstrated similar significant PRO score improvements compared to a matched cohort of FAIS patients without GLL at 2 years after surgery (VAS Pain: (-)2.5 ± 3.0, (-)2.7 ± 2.7; SF-12 PCS: 17.7 ± 14.2, 16.7 ± 15.0; HOOS-Symptoms: 26.3 ± 24.0, 20.6 ± 18.1; HOOS-Pain: 29.8 ± 20.4, 24.4 ± 9.0; HOOS-ADL: 24.9 ± 18.4, 22.0 ± 19.9; HOOS-Sports: 43.6 ± 26.1, 33.1 ± 29.8; and HOOS-QOL: 44.2 ± 27.6, 41.7 ± 27.1, respectively). Both cohorts achieved minimal clinically important differences (MCID) for each HOOS subscore at equivalent high rates (70-88%).

CONCLUSIONS

Patients with GLL in the setting of FAIS can be effectively treated with arthroscopy via periportal capsulotomy and capsular closure. These patients demonstrate significant improvements in PRO scores at 2 years, similar to normal laxity FAIS patients undergoing arthroscopic treatment via periportal capsulotomy without capsular closure.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Hip microinstability diagnosis and management: a systematic review

PURPOSE

The purpose of this systematic review is to present the most common causes, diagnostic features, treatment options and outcomes of patients with hip micro-instability.

METHODS

Three online databases (MEDLINE, Embase, and PubMed) were searched from database inception March 2022, for literature addressing the diagnosis and management of patients with hip micro-instability. Given the lack of consistent reporting of patient outcomes across studies, the results are presented in a descriptive summary fashion.

RESULTS

Overall, there were a total of 9 studies including 189 patients (193 hips) included in this review of which 89% were female. All studies were level IV evidence with a mean MINORS score of 12 (range: 10-13). The most commonly used features for diagnosis of micro-instability on history were anterior pain in 146 (78%) patients and a subjective feeling of instability with gait in 143 (81%) patients, while the most common feature on physical examination was the presence of anterior apprehension with combined hip extension and external rotation in 123 (65%) patients. The most common causes of micro-instability were iatrogenic instability secondary to either capsular insufficiency or cam over-resection in 76 (62%) patients and soft tissue laxity in 38 (31%) patients.

CONCLUSION

The most common symptom of micro-instability on history was anterior hip pain and on physical exam was pain with hip extension and external rotation. There are many treatment options and when managed appropriately based on the precise cause of micro-instability, patients may demonstrate improved outcomes.

LEVEL OF EVIDENCE

IV.

What is the utility of hip arthroscopy in patients with joint laxity? A contemporary systematic review of patient-reported and surgical outcomes

INTRODUCTION

The purpose of this study was to systematically review the literature to understand the contemporary outcomes for patients with joint laxity managed with hip arthroscopy.

MATERIALS AND METHODS

A search was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement guidelines. All literature related to joint laxity in hip arthroscopy patients was identified. Inclusion criteria consisted of patient-reported outcomes and Beighton and Horan Joint Mobility Index scoring. Study quality was assessed using the Methodological Index of Non-Randomized Studies criteria.

RESULTS

Seven articles were identified, including 412 patients (416 hips). Patients were predominantly female (range 83-100%). Mean patient age ranged from 13-69 years. Five studies consisting of 370 hips reported a range of 75 to 100% undergoing labral repair, 0 to 13% labral debridement, 0 to 7% labral reconstruction, 43 to 100% capsular closure, 94 to 99% femoroplasty, 3 to 80% rim resection, and 9 to 50% subspine decompression for surgical management. Post-operative follow-up range was 6-99 months. The mean range of improvement in Hip Outcomes Score Activities of Daily Living, Hip Outcomes Score-Sports Subscale, modified Harris Hip Score, Visual Analog Scale, and 12 item Short Form Health Survey were 17.6-31.3, 31.3-35.1, 22.5-53.8, - 2.79-8, and 12.4-16.9 respectively.

CONCLUSION

Generalized ligamentous laxity patients managed with hip arthroscopy were predominantly young women. At short-term follow-up, mean patient-reported outcomes were positive, with improvement postoperatively in activities of daily living, sports, and quality of life.

Improvement in pain and patient-related outcome measures following hip arthroscopy in patients with femoroacetabular impingement syndrome and concomitant generalized ligamentous laxity: a systematic review

PURPOSE

Within orthopaedic sports medicine, concomitant ligamentous laxity is often found to be a negative prognostic factor for post-operative outcomes following various procedures. The effect of ligamentous laxity on outcomes following hip arthroscopy remains infrequently reported. Therefore, the purpose of this study is to report on the outcomes of hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) with concomitant generalized ligamentous laxity (GLL).

METHODS

A systematic search was performed in Medline, EMBASE, CENTRAL, and SPORTDiscus (from inception to April 2021) for studies reporting outcomes following hip arthroscopy for symptomatic FAIS in patients with concomitant GLL.

RESULTS

Six studies representing 213 patients and 231 hips were included. Outcomes of pain and functional scores as measured by VAS, Harris Hip Score, and Hip Disability and Osteoarthritis Outcomes Score were tabulated. A mean improvement of 4.8 on VAS was observed. Improvements of 30.0 on HHS, 33.1 for ssHOS, and 23.9 for ADL-HOS were observed.

CONCLUSION

Hip arthroscopy is an effective method of alleviating pain and improving function with statistically significant improvements in all PROM in patients with concomitant FAIS with GLL.

LEVEL OF EVIDENCE

IV.

PROSPERO REGISTRATION

CRD42021248864.

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.

Hip Range of Motion Is Increased After Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review

Purpose

To investigate the impact of arthroscopic correction of symptomatic femoroacetabular impingement on postoperative hip range of motion (ROM), as an objectively measured postoperative clinically reported outcome.

Methods

A systematic review of the current literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, OVID/MEDLINE, EMBASE, and Cochrane databases were queried in November 2020. Studies not reporting pre- to postoperative ROM measurements were excluded. Methodologic quality was assessed using the MINORS assessment, and certainty of evidence was assessed using the GRADE approach. Effect size using standardized mean differences assessed magnitude of change between pre- and postoperative ROM.

Results

In total, 23 studies were included evaluating 2,332 patients. Mean age ranged from 18 to 44.2 years. Flexion, internal rotation (IR), and external rotation (ER) were the predominantly measured ROMs reported in 91%, 100% and 65% of studies, respectively. Observed change following hip arthroscopy was considered significant in 57.1% (flexion), 74% (IR), and 20% (ER). Effect size of change in significantly improved ROMs were weak (16.7% flexion, 33.3% ER), moderate (58.3% flexion, 29.4% IR), and large (25% flexion, 64.7% IR, 66.7% ER). For goniometric assessment mean observed changes ranged as follows: flexion: 0.1° to 12.2°; IR: 3.6° to 21.9°; ER: –2.6° to 12.8°. For computed tomography–simulated assessment, the mean observed change ranged as follows: flexion: 3.0° to 8.0°; IR 9.3° to 14.0°.

Conclusions

Outcome studies demonstrate overall increased range of flexion and IR post-hip arthroscopy, with a moderate and large effect respectively. Change in ER is less impacted following hip arthroscopy. Certainty of evidence to support this observation is low. Current research evaluating changes in this functional ability is limited by a lack of prospective studies and non-standardized measurement evaluation techniques.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

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.

Borderline Dysplastic Female Patients With Painful Internal Snapping Improve Clinical Outcomes At Minimum 2-Year Follow-Up Following Hip Arthroscopy With Femoroplasty, Labral Repair, Iliopsoas Fractional Lengthening, and Capsular Plication: A Propensity-Matched Controlled Comparison

PURPOSES

To report minimum 2-year follow-up patient-reported outcome scores (PROs) in borderline dysplastic female patients who underwent primary hip arthroscopy with femoroplasty, labral repair, iliopsoas fractional lengthening, and plication of the capsule (FLIP procedure) for cam-type femoroacetabular impingement syndrome (FAIS), labral tear, and painful internal snapping and to compare these PROs to a propensity-matched borderline dysplastic control group without painful internal snapping.

METHODS

Data were retrospectively reviewed for patients who underwent primary hip arthroscopy for cam-type FAIS and labral tear between September 2008 and May 2017. Females with borderline dysplasia (lateral center-edge angle of ≥18° to ≤25°) and painful internal snapping, who underwent the FLIP procedure, with minimum 2-year PROs for modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports-Specific Subscale, patient satisfaction, and visual analog scale (VAS) for pain were included. The group was matched 1:1 to a control group without painful internal snapping for age, sex, body-mass index (BMI), and surgical procedures. The minimal clinically important difference (MCID) was calculated. P-value was set at .05.

RESULTS

Seventy-four hips were included. The mean was 26.82 ± 10.49 years and 23.62 ± 4.56 kg/m² for age and BMI, respectively. Improvement was reported for all PROs and VAS (P < .0001). Twenty-nine patients were matched. At minimum 2-year follow-up, the FLIP procedure demonstrated comparable improvement in PROs and rate of achievement of MCID to the control group.

CONCLUSION

After primary hip arthroscopy and FLIP procedure, females with borderline dysplasia and painful internal snapping demonstrated significant improvement in PROs at minimum 2 years' follow-up. When compared to a propensity-matched control group without painful internal snapping, the improvement between groups was comparable.

LEVEL OF EVIDENCE

III; Case-Control study.

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

PURPOSE

To (1) compare the rates of reaching threshold hip-specific outcome scores for achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients who underwent partial versus complete T-capsulotomy repair and (2) identify the failure rates in each group 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive patients who underwent hip arthroscopy for FAIS performed by a single fellowship-trained surgeon from January 2011 to March 2013 were collected and analyzed. Baseline data, hip-specific outcomes, and clinical failure rates were recorded at a minimum of 5 years postoperatively. Patients with partial T-capsulotomy repair were matched 1:3 by age, body mass index, and sex to patients with complete T-capsulotomy repair. Threshold scores for achieving the MCID and PASS were calculated and compared between the 2 groups. Additionally, rates of revision and conversion to total hip arthroplasty (THA) were compared between the groups.

RESULTS

A total of 379 patients were available for analysis (39 partial and 340 complete repairs), with 100 patients included in the matching process (25 in the partial-repair group and 75 in the complete-repair group). Comparison of radiographic parameters, including the Tönnis grade, alpha angle, and lateral center-edge angle, between the 2 groups showed no statistically significant difference (P > .05 for all). Comparison of postoperative score averages between the partial- and complete-closure groups showed a significant difference in the Hip Outcome Score-Activities of Daily Living Subscale (85.4 ± 17.7 vs 94.6 ± 7.8, P < .001), Hip Outcome Score-Sports Subscale (76.6 ± 26.2 vs 89.3 ± 16.8, P = .034), modified Harris Hip Score (83.2 ± 19.7 vs 90.5 ± 11.2, P = .035), and visual analog scale pain score (24.5 ± 30.8 vs 13.4 ± 15.8, P = .035). A total of 65 complete-repair patients (95.6%) achieved the MCID for at least 1 outcome measure versus 18 patients with partial repair (78.3%) (P = .04). A total of 69 complete-repair patients (92%) achieved the PASS for at least 1 outcome measure versus 18 partial-repair patients (72%) (P = .017). Of the 39 partial-repair patients, 35.9% (n = 14) underwent revision or conversion to THA, as compared with 2.9% (n = 10) in the overall cohort.

CONCLUSIONS

At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. Furthermore, patients with partial capsular repair undergo revision or conversion to THA at high rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison Between Hip Arthroscopic Surgery and Periacetabular Osteotomy for the Treatment of Patients With Borderline Developmental Dysplasia of the Hip: A Systematic Review

Background:

The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH.

Purpose:

To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH.

Results:

A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures.

Conclusion:

There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.

Tratamento da lesão em onda do quadril através da microfratura reversa: Estudo clínico retrospectivo

Objective  The present study aims to evaluate the treatment of hip wave lesion using reverse microfracture, which is a simple and cheap surgical procedure.

Methods  We retrospectively analyzed 19 patients with acetabular wave lesion treated with reverse microfracture. The patients were assessed by magnetic nuclear resonance imaging (MRI) at the time of diagnosis and 6 months after the surgery and functionally evaluated using the Harris Hip Score (HHS) and the visual analogue scale (VAS) for pain in the preoperative period, and 3 and 6 months after the surgery.

Results  The statistical data showed a significant improvement in HHS and VAS 6 months after the surgery. Six months after the surgery, the MRI revealed that the area subjected to reverse microfracture presented cartilage with the same visual characteristics observed in areas with no chondral injury.

Conclusion  We conclude that the reverse microfracture proved to be an effective, reproducible method for the treatment of wave lesion.

Hypermobile Disorders and Their Effects on the Hip Joint

Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.

Generalized Joint Hypermobility Is Associated With Decreased Hip Labrum Width: A Magnetic Resonance Imaging-Based Study

Purpose

To explore the relationship between generalized joint hypermobility and hip labrum width.

Methods

A retrospective review was performed of a single-surgeon database containing patients who underwent hip arthroscopy between 2014 and 2017. Patients were assessed for generalized laxity via Beighton Test Scoring (BTS), which tests for hyperextension of the fifth metacarpophalangeal joint, thumb apposition, elbow hyperextension, knee hyperextension, and trunk flexion on a 9-point scale. Patients were stratified into a "high BTS cohort" with a BTS ≥4, and a control cohort with BTS <4. Magnetic resonance imaging measurements of labral width for each patient were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clockface" locations using a previously validated technique. Statistical analyses used to determine associations between BTS and labral width included Mann-Whitney U and Fisher exact testing as well as linear regression.

Results

Thirty-four patients met inclusion criteria (17 cases, 17 controls). Both groups were composed exclusively of female patients. There was no significant difference between cases or controls in terms of age (33.3 ± 10.4 years vs 35.2 ± 8.3 years, P = .57) or body mass index (26.1 ± 9.3 vs 23.6 ± 3.4, P = .36). The high Beighton score cohort had significantly thinner labrae at the indirect rectus (5.35 ± 1.2 mm vs 7.1 ± 1.1 mm, P < .001) and anterosuperior position (5.53 ± 1.4 mm vs 7.27 ± 1.6 mm, P = .003). There was no statistical difference between the high Beighton score cohort and controls at the psoas U position (6.47 ± 1.6 mm vs 7.43 ± 1.7 mm, P = .112). Linear regression analysis demonstrated Beighton score was significantly negatively associated with labrum width at the indirect rectus position (R² = 0.33, P < .001) and the anterosuperior position (R² = 0.25, P = .004).

Conclusions

Patients with a BTS ≥4 were found to have significantly thinner labra than those with a BTS of <4.

Level of Evidence

III, retrospective comparative trial.

Pragmatic comparative effectiveness study of multimodal fascia iliaca nerve block and continuous lumbar epidural-based protocols for periacetabular osteotomy

Perioperative pain management protocols have a significant impact on early surgical outcomes and recovery. We hypothesized that multimodal protocol including fascia iliaca compartment nerve block (MM-FICNB) would decrease the length of hospital stay (LOS) by facilitating earlier mobilization, without compromising analgesia, compared to a traditional lumbar epidural-based protocol (EP). Demographics/comorbidities, surgical/block characteristics and perioperative pain/mobilization data were collected from a prospectively recruited MM-FICNB group (N = 16) and a retrospective EP cohort (N = 16) who underwent PAO using similar surgical techniques, physical therapy/discharge criteria. Association of MM-FICNB group with LOS (primary outcome), postoperative pain, postoperative opioid requirements in morphine equivalent rates (MER) (mcg/kg/h) and time to complete physical therapy were tested using multivariable and survival regression. Patient and surgical characteristics were similar between groups. Median time for FICNB performance was significantly less than epidural (6 versus 15 min; P < 0.001). LOS was significantly decreased in the MM-FICNB group (2.88 ± 0.72 days) compared to the EP group (4.38 ± 1.02 days); P < 0.001. MM-FICNB group had significantly lower MER on POD1 (P = 0.006) and POD2 (P < 0.001), with similar pain scores on all POD. MM-FICNB group was associated with decreased LOS and earlier mobilization (P < 0.001) by covariate-adjusted multivariate regression. Cox proportional hazard regression model showed MM-FICNB subjects had 63 (95% CI 7–571, P < 0.001) times the chance of completing physical therapy goals, compared to EP. Compared to EP, MM-FICNB protocol allowed earlier mobilization and decreased post-surgical hospitalization by 1.5 days, without compromising analgesia, with important implications for value-based healthcare and cost-effectiveness.

Portal enlargement in hip arthroscopy preserving the iliofemoral ligament: a novel access technique protecting soft tissue restraints

Capsulotomy in different modalities has been used to provide adequate exposure to access both the central and peripheral compartment in hip arthroscopy. Even though the hip joint has inherent bony stability, soft tissue restraints may be important in patients with ligaments hyperlaxity or in some cases with diminished bony stability. Biomechanical studies and clinical outcomes have shown the relevant role of the capsule in hip stability, mainly the role of the iliofemoral ligament. Although is not very common, iatrogenic post-arthroscopy subluxation and dislocation have been reported and many surgeons are concerned about the role aggressive capsulotomy or capsulectomy in this situation, thus capsule repair has become very popular. We present a novel technique to access the hip without cutting the iliofemoral ligament. With this technique we can obtain adequate arthroscopic access to the hip joint in order to treat adequately the central compartment pathologies reducing the risk of iatrogenic post-operative hip instability.

The effects of venting and capsulotomy on traction force and hip distraction in hip arthroscopy

This study evaluated the effects of venting and capsulotomy on the ratio of normalized distraction distance to traction force, correlating this trend with patient demographic factors. A ratio was chosen to capture the total effect of each intervention on the hip joint. During primary hip arthroscopy, continuous traction force was recorded, and fluoroscopic images were acquired to measure joint distraction before and after the application of traction, venting and interportal capsulotomy. Distraction–traction force ratios were compared using a one-sided paired t-test. A linear regression model was used to determine the relationship between age, sex and body mass index and pre- and post-intervention distraction–traction force ratios. Seventy-two adult patients and 73 hips were included. There was an increase in hip distraction with a decrease in traction force post-venting and capsulotomy (both P’s <0.001). Mean normalized distraction distance increased 1.5% of femoral head size after venting and an additional 2.2% of femoral head size after capsulotomy. Mean traction force decreased 2.2% (14.7 N) after venting and 2.3% (15.3 N) after capsulotomy. Female sex significantly correlated with larger differences in both pre- and post-venting capsulotomy ratios. Venting and capsulotomy both independently improve the ratio of normalized distraction distance to traction force when performed in vivo. However, the effect sizes of each intervention are small and of questionable clinical significance. Specifically, when adequate distraction for safe surgical hip access cannot be obtained despite application of significant traction force, venting and capsulotomy after the application of traction may not afford substantial improvement.

Capsular thinning on magnetic resonance arthrography is associated with intra-operative hip joint laxity in women

Hip microinstability is a recognized cause of hip pain in young patients. Intra-operative evaluation is used to confirm the diagnosis, but limited data exist associating magnetic resonance arthrography (MRA) findings with hip microinstability. To determine if a difference exists in the thickness of the anterior joint capsule and/or the width of the anterior joint recess on MRA in hip arthroscopy patients with and without an intra-operative diagnosis of hip laxity. Sixty-two hip arthroscopy patients were included in the study. Two musculoskeletal radiologists blinded to surgical results reviewed the MRAs for two previously described findings: (i) anterior joint capsule thinning; (ii) widening of the anterior joint recess distal to the zona orbicularis. Operative reports were reviewed for the diagnosis of joint laxity. In all patients with and without intra-operative laxity, there were no significant differences with either MRA measurement. However, twenty-six of 27 patients with intra-operative laxity were women compared with 11 of 35 patients without laxity (P < 0.001). In subgroup analysis of women, the intra-operative laxity group had a higher rate of capsular thinning compared with the non-laxity group (85% versus 45%; P = 0.01). A 82% of women with capsular thinning also had intra-operative laxity, compared with 40% without capsular thinning (P = 0.01). There were no differences regarding the width of the anterior joint recess. In this study, there was an association between capsular thinning and intra-operative laxity in female patients. Measuring anterior capsule thickness on a pre-operative MRA may be useful for the diagnosis of hip microinstability.

Achieving Successful Outcomes of Hip Arthroscopy in the Setting of Generalized Ligamentous Laxity With Labral Preservation and Appropriate Capsular Management: A Propensity Matched Controlled Study

BACKGROUND

Association among generalized ligamentous laxity (GLL), hip microinstability, and patient-reported outcomes (PROs) after hip arthroscopy has yet to be completely established.

PURPOSES

(1) To report minimum 2-year PROs in patients with GLL who underwent hip arthroscopy in the setting of symptomatic labral tears and femoroacetabular impingement syndrome and (2) to compare clinical results with a matched-pair control group without GLL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from a prospectively collected database were retrospectively reviewed between August 2014 and December 2016. Patients were considered eligible if they received primary arthroscopic treatment for symptomatic labral tears and femoroacetabular impingement. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the following PROs: modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain (VAS). From the sample population, 2 groups were created: the GLL group (Beighton score ≥4) and the control group (Beighton score <4). Patients were matched in a 1:2 ratio via propensity score matching according to age, sex, body mass index, Tönnis grade, and preoperative lateral center-edge angle. Patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) for mHHS, Hip Outcome Score-Sports Specific Scale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12) were calculated.

RESULTS

A total of 57 patients with GLL were matched to 88 control patients. Age, sex, body mass index, and follow-up times were not different between groups (P > .05). Preoperative radiographic measurements demonstrated no difference between groups. Intraoperative findings and procedures between groups were similar except for capsular treatment, with the GLL group receiving a greater percentage of capsular plications (P = .04). At minimum 2-year follow-up, both groups showed significant improvement in PROs and VAS (P < .001). Furthermore, the postoperative PROs at minimum 2-year follow-up and the magnitude of improvement (delta value) were similar between groups for mHHS, NAHS, HOS-SSS, and VAS (P > .05). Moreover, groups reached comparable rates of MCID and PASS for mHHS, HOS-SSS, and iHOT-12.

CONCLUSION

Patients with GLL after hip arthroscopy for symptomatic femoroacetabular impingement and labral tears may expect favorable outcomes with appropriate labral and capsular management at minimum 2-year follow-up. When compared with a pair-matched control group without GLL, results were comparable for mHHS, NAHS, HOS-SSS, and VAS and reached PASS and/or MCID for mHHS, HOS-SSS, and iHOT-12.

Editorial Commentary: The Competitive Dancer's Hip-An Acquired Flexible Attitude to a High-Performance Hip

Competitive dancers have a high prevalence of hip injuries. The dancer's hip is a unique scenario in which hip impingement is associated with compensatory soft-tissue laxity. Particularly in these athletes, normal osseous hip morphology with symptomatic femoroacetabular impingement may be observed. The repetitive training, including extreme daily hip range of motion, results in compensatory soft-tissue laxity and secondary impingement-induced subluxation. Peculiarly, hip impingement in dancers occurs in the posterosuperior aspect of the hip and extra-articularly between the anterior inferior iliac spine and the distal femoral neck (subspinous impingement). Normal or even dysplastic hips might impinge during extreme range of motion. An atypical osteochondroplasty, including a subtle distal-based femoral resection, anterior inferior iliac spine decompression, and excellent management of the capsule, should be considered in this population for a successful outcome. Hip dysplasia should always be ruled out in these athletes, and if present, a periacetabular osteotomy should be indicated.

Prospective Randomized Comparison of Capsular Management Techniques During Hip Arthroscopy

BACKGROUND

Capsular management during hip arthroscopy remains controversial. Studies evaluating this topic consist mostly of retrospective comparative reviews of prospectively gathered data on a large series of patients.

PURPOSE/HYPOTHESIS

The purpose was to perform a prospective randomized trial to comparatively assess 3 commonly performed capsular management techniques. It was hypothesized that capsular closure during hip arthroscopy would result in superior outcomes when compared with unclosed capsulotomy management techniques.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients (N = 150) who had hip arthroscopy with labral repairs and femoral osteoplasties performed by the senior author were randomly assigned into 3 groups at the time of their surgery: T-capsulotomy without closure (TC), interportal capsulotomy without closure (IC), and interportal capsulotomy with closure (CC). All patients underwent labral repair and femoral osteoplasty. Patient-reported outcomes were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Other outcomes obtained included the need for future hip surgery.

RESULTS

Patient demographics, preoperative patient-reported outcomes, and radiographic measurements were similar among all 3 groups. Revision hip arthroscopy was performed in 5 TC cases, 2 IC cases, and 1 CC case (P = .17). Conversion to hip arthroplasty occurred in 4 patients in the TC group and none in the IC and CC groups (P = .02). The CC group showed higher modified Harris Hip Score (mHHS) and Hip Outcome Score-Activities of Daily Living (HOS-ADL) at the 2-year follow-up when compared with the IC group (P = .003 and P < .001, respectively). When compared with the TC group, the CC group demonstrated superior mHHS (86.2 vs 76), HOS-ADL (85.6 vs 76.8), and HOS-SSS (Hip Outcome Score-Sports-Specific Subscale; 74.4 vs 65.3) at the final 2-year follow-up (P < .001). At the 2-year follow-up, the IC group had a higher mHHS (81.7 vs 76), HOS-ADL (82 vs 76.8), and HOS-SSS (71.4 vs 65.3; P > .001) as compared with the TC group.

CONCLUSION

Patients undergoing complete capsular closure during hip arthroscopy showed improved patient-reported and surgical outcomes when compared with those with unrepaired T-capsulotomy or interportal capsulotomy. These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Contemporary Management of the Hip Capsule During Arthroscopic Hip Preservation Surgery

PURPOSE OF REVIEW

The importance of the hip capsule and its effect on hip biomechanics, functional outcomes, and hip arthroscopy success rates has been demonstrated in recent studies. These results have led to a shift in management of the hip capsule, where an increasing number of surgeons routinely perform complete capsular closure. The purpose of this review is to highlight recent studies evaluating the hip capsule and describe contemporary capsular management and repair.

RECENT FINDINGS

Biomechanical studies using cadaveric models have demonstrated that complete capsular closure restores hip distraction, rotation, and extension forces back to the native, intact state. Additionally, capsular closure by plication results in quantifiable intraarticular volume reduction, which increases hip stability, particularly in cases of patulous capsule and hypermobility. Clinical studies have demonstrated superior patient-reported functional outcomes and decreased failure rates when undergoing hip arthroscopy with comprehensive capsular management for femoroacetabular impingement surgery. Complete capsular management, including appropriate capsulotomy and subsequent closure, is critical for restoring biomechanical properties of the hip, ensuring high survivorship and improving functional outcomes. This review provides an update on the effects of contemporary capsular management as well as a detailed description of efficient T-capsulotomy and comprehensive capsule closure via plication.