Arthroscopic Capsular Plication in Patients With Labral Tears and Borderline Dysplasia of the Hip: Analysis of Risk Factors for Failure

Revision Hip Arthroscopy in Patients with Borderline Dysplasia Has a Role: Indications Are Narrow Versus Periacetabular Osteotomy

Hip arthroscopy (HA) is preferred for surgical management of femoroacetabular impingement syndrome, while periacetabular osteotomy (PAO) is the gold standard for frank developmental hip dysplasia in young adults. Borderline hip dysplasia (BHD) is a conundrum, with data supporting the use of either or both, not to mention that BHD is defined by varying lateral center-edge angle thresholds between 18°-25° or 20°-25° and features generalized ligamentous laxity and variations in acetabular and femoral version. That said, HA for BDH has been shown to have 10-year survivorship of 82%. In a revision situation after HA in patients with BHD, PAO seems a logical next step, but HA may be indicated under very narrow indications. From a technical standpoint, capsular preservation, labral function restoration, and avoiding acetabular rim over-resection are key points when performing HA in BHD. Most important, particularly in the revision setting, is to determine the root cause of failure. Primarily, instability-driven symptoms are an indication for PAO.

Noninterportal capsulotomy of hip arthroscopy showed improved outcomes in borderline hip dysplasia: A retrospective study with minimum 2-year follow-up

PURPOSE

The present study aimed to evaluate the functional outcomes of hip arthroscopy using a noninterportal capsulotomy technique to address labral tears in patients with borderline hip dysplasia (BHD). Additionally, we also compared these outcomes with those of patients with BHD who underwent the standard repaired interportal capsulotomy (RIPC) arthroscopy.

METHODS

Data from patients with BHD were retrieved from a database of patients who underwent arthroscopic hip surgery with noninterportal capsulotomy or RIPC to treat labral tears between January 2014 and December 2020. Data collected included both pre- and postoperative patient-reported outcomes (PROs).

RESULTS

A total of 58 patients (noninterportal capsulotomy, n = 37; RIPC, n = 21) with a mean age of 30.9 ± 5.6 and 28.6 ± 5.5 years, respectively, met the inclusion criteria. All of the patients underwent a minimal 2-year follow-up. The mean lateral centre-edge angle was 23.3 ± 1.2° in the noninterportal capsulotomy group and 23.7 ± 1.0° in the RIPC group, with no significant difference. The PROs improved from the preoperative to the latest follow-up, with a p < 0.001. There were no differences between the groups.

CONCLUSION

Using strict patient selection criteria, hip arthroscopy with noninterportal capsulotomy demonstrated significant pre- to postoperative improvements in patients with BHD and achieved results comparable to those from hip arthroscopy with RIPC.

LEVEL OF EVIDENCE

Level III.

No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy With Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity-Matched Multicenter Study With Minimum 5-Year Follow-Up

PURPOSE

To compare minimum 5-year patient-reported outcome measures after hip arthroscopy (HA) and periacetabular osteotomy (PAO) for borderline hip dysplasia.

METHODS

Hips with a lateral center-edge angle (LCEA) between 18° and less than 25° that underwent either PAO or HA were selected from 2 institutions. The exclusion criteria were as follows: LCEA less than 18°, Tönnis osteoarthritis grade greater than 1, prior hip surgical procedures, active inflammatory disease, Workers' Compensation, and concomitant surgery. Patients underwent propensity matching based on age, sex, body mass index, and Tönnis osteoarthritis grade. Patient-reported outcome measures included the modified Harris Hip Score, as well as calculation of the minimal clinically important difference, patient acceptable symptom state, and maximum outcome improvement satisfaction threshold. Preoperative radiographic predictors included comparison of the Femoro-epiphyseal Acetabular Roof index and ligamentum teres lesions.

RESULTS

A total of 28 PAO patients underwent propensity matching to 49 HA patients. The 2 groups were similar in terms of mean age, sex, preoperative body mass index, and LCEA. The PAO group had a longer mean follow-up period (95.8 months vs 81.3 months, P = .001). The mean Femoro-epiphyseal Acetabular Roof index was significantly lower preoperatively in the HA group (P < .001). The 2 groups showed similar and significant improvements in the mean modified Harris Hip Score from preoperatively to latest follow-up (P < .001). The relative risk of subsequent surgery in the PAO group was 3.49 (P = .024), mostly attributed to hardware removal (25%). The revision rate was 3.6% in the PAO group and 8.2% in the HA group (P = .65). One patient in the PAO group required revision HA for intra-articular adhesions. Three of the patients requiring revision in the HA group underwent PAO because of persistent pain, and one underwent revision HA alone. Conversion to total hip arthroplasty was required in 1 patient in the HA group and no patients in the PAO group.

CONCLUSIONS

Both PAO and HA with capsular plication provide borderline hip dysplasia patients with clinically significant improvements and low revision rates at a minimum of 5 years postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic trial.

Endoscopic Tendon Compression Bridge Technique for Repair of Partial-Thickness Gluteus Medius Tears With Concomitant Arthroscopy for Labral Tears: Minimum 2-Year Outcomes With Benchmark Control Group

BACKGROUND

The transtendinous technique has been used to treat partial-thickness gluteus medius tears in the setting of concomitant arthroscopy for labral tears. The tendon compression bridge technique for gluteus medius repair has been developed as an alternative method, providing several advantages; however, comparative studies between the 2 techniques are lacking in the literature.

PURPOSE

(1) To evaluate the short-term patient-reported outcomes (PROs) of the tendon compression bridge technique and (2) to compare these findings with short-term PROs of the transtendinous technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected on patients who were followed for a minimum of 2 years after an endoscopic tendon compression bridge procedure for gluteus medius repair in the setting of concomitant hip arthroscopy for labral tears. The following PROs were collected preoperatively and postoperatively: modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, visual analog scale score for pain, and the International Hip Outcome Tool. Clinical outcomes were assessed using the Patient Acceptable Symptom State, minimal clinically important difference, and maximum outcome improvement satisfaction threshold. Patients were propensity matched 1:1 to a cohort that underwent gluteus medius repair using the endoscopic transtendinous technique with concomitant hip arthroscopy.

RESULTS

A total of 48 hips (48 patients) that met inclusion criteria (age, 53.3 ± 9.8 years; 92% female; body mass index, 26.7 ± 4.6), with a mean follow-up of 38.5 ± 15.7 months, were matched to 48 hips (46 patients) that underwent gluteus medius repair using the transtendinous technique. Both groups demonstrated significant improvement from preoperative scores to latest follow-up (P < .05). Mean magnitude of improvement and latest follow-up scores were not significantly different between the tendon compression bridge group and the transtendinous group, and the groups demonstrated similar favorable rates of achieving Minimal Clinically Important Difference (79% vs 79%, respectively), Patient Acceptable Symptom State (73% vs 73%, respectively), and Maximum Outcome Improvement Satisfaction threshold (65% vs 58%, respectively) for modified Harris Hip Score (P > .05). Patient satisfaction between groups was similar (8.1 ± 2.2 vs 7.7 ± 2.7, respectively) (P = .475).

CONCLUSION

At minimum 2-year follow-up, the endoscopic tendon compression bridge technique for partial-thickness gluteus medius tears, when performed with concomitant hip arthroscopy, was associated with significant improvement in functional outcomes. These postoperative results were comparable with those of a matched cohort that underwent the endoscopic transtendinous technique for partial-thickness gluteus medius tears, suggesting that the tendon compression bridge technique for gluteus medius repair is an effective treatment option for partial-thickness gluteus medius tears.

Acetabular deficiency in borderline hip dysplasia is underestimated by lateral center edge angle alone

INTRODUCTION

In hip preservation surgery, the term "borderline hip dysplasia" was used when the lateral center edge angle (LCEA), historically described by Wiberg, measured 18-25°. In recent years, several radiographic parameters have been described to assess the antero posterior coverage of the femoral head, for example, the anterior and posterior wall index (AWI and PWI). This allowed an increasingly comprehensive understanding of acetabular morphology and a questioning of the borderline definition.

MATERIAL AND METHODS

A retrospective review of 397 consecutive hips was performed, all treated with triple pelvic osteotomy (TPO) due to symptomatic hip dysplasia. On all preoperative pelvic radiographs with a LCEA of 18-25°, acetabular index (AI), AWI and PWI were measured. With these values, the hips were categorized into laterally, antero-laterally and postero-laterally dysplastic and stratified by gender. Intra- and interobserver correlation of the parameters was analyzed by intraclass correlation coefficient (ICC).

RESULTS

According to LCEA, 192 hips were identified as "borderline dysplastic". Based on AWI and PWI, the categorization resulted in 116 laterally dysplastic (60.4%), 33 antero-laterally (17.2%) and 43 postero-laterally dysplastic hips (22.4%). Gender stratification revealed that male acetabula seemed to be slightly more postero-laterally deficient than female (mean PWI 0.80 vs 0.89; p = 0.017). ICC confirmed highly accurate and reproducible readings of all parameters.

CONCLUSION

The rather high proportion of symptomatic hips labelled borderline dysplastic suggested, that there might be substantial acetabular deficiency not recognizable by LCEA. Comprehensive deformity analysis using LCEA, AI, AWI and PWI showed, that 40% of these hips were deficient either antero-laterally or postero-laterally. Male acetabula were more deficient postero-laterally than female.

Borderline Dysplasia After Primary Hip Arthroscopy with Capsular Plication and Labral Preservation: Ten-Year Survivorship and Patient-Reported Outcomes

BACKGROUND

The arthroscopic management of borderline hip dysplasia (BHD) is controversial, and long-term follow-up data are scarce. The purpose of this study was to report prospectively collected survivorship and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up following primary hip arthroscopy with capsular plication and labral preservation in patients with BHD.

METHODS

Data were prospectively collected on all patients who underwent primary hip arthroscopy between September 2008 and September 2011. Patients with BHD (defined by a lateral center-edge angle [LCEA] between 18° and 25°) were included. Preoperative and minimum 10-year follow-up scores for the modified Harris hip score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were collected. Exclusion criteria were prior ipsilateral hip surgery, Workers' Compensation status, Tönnis grade of >1, previous hip conditions, or LCEA of <18°. Survivorship was defined as no conversion to total hip arthroplasty (THA). The risk factors for THA conversion were analyzed. The achievement rate for the minimal clinically important difference (MCID) was reported. A propensity-matched comparison with a control group without BHD was performed.

RESULTS

Forty-five (80%) of 56 eligible hips were included in this study: 38 hips (84%) of female patients and 7 hips (16%) of male patients. The mean patient age was 31.0 ± 12.9 years, and the mean patient body mass index (BMI) was 24.5 ± 5.4 kg/m2. The 10-year survivorship was 82.2%, and there was significant improvement in all PROMs and VAS pain from baseline to the minimum 10-year follow-up (p < 0.001). The odds of undergoing conversion to THA were 4.4 times higher for patients with a BMI of ≥23 kg/m2 and 7.1 times higher for patients who were ≥42 years of age. The MCID was achieved at high rates for the mHHS (79%), NAHS (79%), HOS-SSS (70%), and VAS pain (76%). The minimum 10-year survivorship, PROMs, and MCID achievement rates for the BHD group were comparable with those for the control group.

CONCLUSIONS

Patients with BHD who underwent primary hip arthroscopy with capsular plication and labral preservation demonstrated an overall survivorship of 82.2% and significant improvement in all PROMs and achieved the MCID at high rates at a minimum 10-year follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Periacetabular Osteotomy in Athletes With Symptomatic Hip Dysplasia Allows for Participation in Low-, Moderate-, and High-Impact Sports, With Greater Than 70% Return to Sport for Competitive Athletes: A Systematic Review

PURPOSE

To systematically review the literature and report the rate of return to sport (RTS) in athletes following periacetabular osteotomy (PAO) for symptomatic hip dysplasia.

METHODS

A literature search of the PubMed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting on athletes undergoing PAO surgery for symptomatic hip dysplasia. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, radiographic measurements, rate and timing of RTS, baseline and most recent patient-reported outcomes (PROs), and subsequent surgeries.

RESULTS

Six studies met inclusion criteria with 341 patients undergoing PAO. There were 2 level III and 4 level IV studies, with an average MINORS score of 11. Preoperative and postoperative lateral center edge angles ranged from 8° to 18° and 23° to 41.3°, respectively. One study reported solely on dancers with a 63% rate of RTS at 1 year postoperatively. Two other studies reported RTS of 80% and 82% for multiple sports, with slightly lower rates (73% and 78%) in competitive athletes. Three studies demonstrated a comparable distribution of sports participation, from the preoperative to postoperative period, in low-impact (61.4% to 72.1% and 63.7% to 85.7%), moderate-impact (10.3% to 21.0% and 4.3% to 25.4%), and high-impact (8.5% to 17.6% and 5.1% to 10.8%) sports. Three studies reported time to RTS after PAO, ranging from 8.8 to 12.8 months. Of the 3 studies noting reasons for not returning to sport, concerns related to the operative hip ranged from 36.4% to 67%. Of the studies that reported both preoperative and postoperative PROs, improvements in all values were observed, with modified Harris Hip Scores and Hip Disability Osteoarthritis Outcome Scores at most recent follow-up ranging from 81 to 95 and 72 to 93, respectively.

CONCLUSIONS

In athletes with symptomatic hip dysplasia undergoing PAO, postoperative participation in low-, moderate-, and high-impact sports was observed, with greater than 70% RTS for competitive athletes. These findings suggest that PAO, with appropriate indications, is an efficacious treatment option in this active patient population with severe dysplasia.

LEVEL OF EVIDENCE

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

Hip Arthroscopy in the Presence of Advanced Osteoarthritis Results in 57% Survivorship, With 78% Survivor Satisfaction, at 10 Years. A Matched-Control Study

PURPOSE

To (1) determine the 10-year survivorship (avoidance of total hip arthroplasty, THA) for patients with advanced osteoarthritis (OA) undergoing hip arthroscopy for femoroacetabular impingement, and (2) compare survivorship and patient-reported outcomes (PROs) with a matched-control group without OA.

METHODS

Advanced OA hips (Tönnis ≥2) were matched in a 1:1 ratio (age ± 5 years, sex) to hips with preoperative Tönnis grade ≤1. Exclusion criteria was dysplasia, age <18 years, previous hip conditions/surgeries, and bilaterally operated patients with OA on one side only. Survival was estimated by Kaplan-Meier analysis for levels of sex, age groups and Tönnis. Cox proportional hazards model estimated hazard ratios (HR) of undergoing THA conversion. Where THA was avoided, outcomes and proportion of cases achieving patient acceptable symptomatic state was determined RESULTS: 53 OA hips were matched with 53 control hips. Survival distributions were significantly different for: (1) Group: OA 57.1%, control 87.0% (P = .001); (2) Tönnis grade: Tönnis 0, 89.2%; Tönnis 1, 77.8%; Tönnis 2, 67.6%; Tönnis 3, 25.0% (P < .001); and (3) age: (OA: 75.0% vs 44.8%, control: 100%, vs 75.0%, for <35 and >35 years respectively) (P = .002). Conversion to THA was greater for increasing Tönnis: HR 1.9 (P = .450), 3.5 (P = .032), and 11.0 (P < .001) for Tönnis 1, 2, and 3 respectively, relative to no OA (Tönnis 0) and >35 years: HR 4.3 (95% confidence interval 1.6-11.3, P = .003). Patient acceptable symptomatic state achievement was similar for both groups (78% OA vs 91% control, P = .167). modified Harris Hip Score and Short Form-36 significantly improved within both groups from baseline to 10 years CONCLUSIONS: Arthroscopic correction of femoroacetabular impingement, in the presence of advanced OA results in 57% survivorship at 10 years (68% Tönnis 2, 25% Tönnis 3). Where THA was avoided, 78% considered their 10-year post-HA state to be satisfactory, with patient-reported outcomes similar to a matched non-OA cohort. Tönnis 2 in particular should be considered for arthroscopic hip preservation to avoid the need to prematurely replace the hip joint.

LEVEL OF EVIDENCE

IV, case series.

Midterm results after arthroscopic femoral neck osteoplasty combined with labral debridement for cam type femoroacetabular impingement in active adults

INTRODUCTION

Arthroscopic labral procedures are frequently undertaken in patients with femoroacetabular impingement (FAI). The role of arthroscopic femoral neck osteoplasty is well established, but less is known about labral procedures. This study evaluates the midterm efficacy and feasibility of arthroscopic osteoplasty with concomitant labral debridement for cam impingement in active adults.

METHODS

The present study was conducted according to the STROBE Statement. All 108 patients who underwent primary hip arthroscopy for cam type FAI combined with labral debridement were considered. Axial and anteroposterior plain radiographs of the pelvis were obtained preoperatively to identify the cam deformity and assess the presence of osteoarthritis, the lateral centre-edge angle, and the alpha angle. The ROM (flexion, extension, abduction, adduction, and intra/extra rotation) was evaluated. The following PROMs were administered: visual analogic scale (VAS), Tegner Activity Scale, non-arthritic hip score (NAHS), the international Hip Outcome Tool (iHOT-33) overall score, and related subscales: symptoms and functional limitations, sports and recreational activities, job-related concerns, and social, emotional, and lifestyle concerns.

RESULTS

At a mean of 2.0 ± 1.1 months, all 108 patients returned to their daily activities with no limitation. At a mean of 2.6 ± 1.4 months, all 108 patients were able to return to sport with no limitation. At 11.9 ± 2.1-month follow-up, no differences were reported in the range of motion compared to baseline: flexion (P = 0.3), extension (P = 0.09), abduction (P = 0.1), adduction (P = 0.3), internal rotation (P = 0.4), and external rotation (P = 0.6). At 72.8 ± 21.7-month follow-up, the mean VAS score was 1.7 ± 3.0, Tegner Activity Scale 3.5 ± 1.4, NAHS 92.1 ± 21.5, iHOT33 83.3 ± 27.2. At a mean of 21.7 ± 15.5 months following the index procedure, 14 of 108 patients had undergone total hip arthroplasty. No further revisions or complications were reported.

CONCLUSION

Arthroscopic femoral neck osteoplasty with concomitant labral debridement for cam type of FAI in active adults yields the reliable results, with a rate of progression to total hip arthroplasty of 13% (14 of 108) at 3-year follow-up. All patients returned to their daily activities with no limitation 2 months postoperatively. Within 3 months, all patients returned to sport with no limitations. No complication related to the index procedure was reported, and no further arthroscopic procedures were necessary.

Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes and Clinical Benefit Achievement Rates at Short-Term Follow-Up. A Multicenter Analysis

PURPOSE

To report minimum 2-year follow-up patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery.

METHODS

Prospectively collected data from two high-volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge-angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted.

RESULTS

A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow-up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported (P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS-SSS, and iHOT-12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery (P = .03).

CONCLUSION

The results of this multi-center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

IV, retrospective multicenter study.

The Circumferential Femoroplasty: An All-Arthroscopic Technique for Addressing a Challenging Hip Deformity

Femoroacetabular impingement is recognized as a common cause of hip pain. Cam-type femoroacetabular impingement results from abnormal contact between an aspherical femoral head and the acetabular rim during hip range of motion, leading to labral tearing, cartilage damage, and, eventually, osteoarthritis. Arthroscopic correction of this bony deformity has been well described, particularly in the anterolateral quadrant of the femoral neck. Some deformities extend well beyond this quadrant, involving most or all of the circumference of the femoral neck, making arthroscopic decompression a challenge. We present a post-less, all-arthroscopic technique for performing a circumferential cam decompression using 3-dimensional preoperative planning software and interactive fluoroscopy-integrated computer vision interface.

Borderline Developmental Dysplasia of the Hip: A Risk Factor Predicting the Development and Poor Prognosis after Core Decompression for Idiopathic Osteonecrosis of the Femoral Head

OBJECTIVE

It is unclear whether idiopathic osteonecrosis of the femoral head (ONFH) is associated with borderline developmental dysplasia of the hip (BDDH). This study aimed to compare the incidence of BDDH between patients with idiopathic ONFH and matched control subjects and determine the influence of BDDH on poor prognosis after core decompression (CD).

METHODS

We retrospectively examined 78 consecutive patients (111 hips) with idiopathic ONFH undergoing CD and 1:2 matched with 156 control subjects (222 hips). The anteroposterior pelvic radiographs were used to measure the acetabular anatomical parameters and divide included subjects into BDDH or non-BDDH group. The incidence of BDDH and acetabular anatomical parameters were compared between patients with idiopathic ONFH and matched controls. Clinical outcomes, such as Harris Hip Score (HHS), progression of collapse, and conversion to total hip arthroplasty (THA), were compared between patients with BDDH and without BDDH in the idiopathic ONFH group, with a mean follow-up of 72.1 ± 36.6 months.

RESULTS

Patients with idiopathic ONFH had a significantly higher incidence of BDDH than matched controls (29.7% vs 12.2%, p < 0.001). Less acetabular coverage was also found in patients with idiopathic ONFH than in matched controls as demonstrated by lower CEA (28.5° ± 4.7° vs 33.1° ± 5.7°, p < 0.001), AHI (82.4 ± 5.0 vs 86.3 ± 5.4, p < 0.001), ADR (299.6 ± 28.4 vs 318.8 ± 31.3, p < 0.001), and a higher sharp angle (40.0° ± 3.4° vs 37.4° ± 3.7°, p < 0.001). In patients with idiopathic ONFH, the BDDH group had a significantly lower mean HHS at the last follow-up (83.5 ± 17.4 vs 91.6 ± 9.7, p = 0.015) with a different score distribution (p = 0.004), and a lower 5-year survival rate with both clinical failure (66.7%, 95% CI 52.4%-84.9% vs 83.7%, 95% CI 75.2%-93.1%; p = 0.028) and conversion to THA (74.6%, 95% CI 60.7%-91.6% vs 92.1%, 95% CI 85.6%-99.0%; p = 0.008) as the endpoints than the non-BDDH group.

CONCLUSION

The incidence of BDDH was significantly higher in patients with idiopathic ONFH than matched controls, and idiopathic ONFH patients who underwent CD with BDDH had lower mean HHS as well as 5-year survival rate than those without BDDH. Therefore, BDDH should be considered a risk factor predicting the development of idiopathic ONFH as well as poor prognosis after CD.

Predictors of Achieving the Maximal Outcome Improvement Threshold for Willingness to Undergo Revision Hip Arthroscopy

BACKGROUND

The maximal outcome improvement threshold for willingness to undergo revision hip arthroscopy (MOWT) has not been defined yet.

PURPOSE

To determine the percentage MOWT in patients who underwent revision hip arthroscopy and to identify predictors of achieving the MOWT.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

An anchor question was provided to patients who underwent revision hip arthroscopy between April 2008 and June 2020 who returned for follow-up between August 2019 and June 2021 at one institution. Patients were included if they underwent revision hip arthroscopy, had answered the anchor question, and had baseline and postoperative minimum 1-year follow-up scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous hip conditions, or unwillingness to participate. Receiver operating characteristic analysis was used to determine the MOWT. Multivariate logistic regression was used to determine intraoperative predictors of achieving the MOWT.

RESULTS

In total, 153 patients (163 hips) were included, with 117 female hips (71.8%), a mean patient age of 34.3 ± 12.4 years, and an average follow-up time of 61.6 ± 42.7 months. It was determined that 77.3% of the patients reported that they would choose to undergo the revision hip arthroscopy again. The MOWT for the mHHS, NAHS, and VAS was 43.1%, 53%, and 33.4%, respectively. The probability of choosing to undergo revision surgery if the MOWT was achieved was 77.5%, 77.6%, and 79.2%, for the mHHS, NAHS, and VAS, respectively. Patients with residual cam-type morphology, which was addressed during the revision, were 2.3 times more likely to achieve the MOWT for the VAS (P = .014).

CONCLUSION

Patients who improved 43.1%, 53%, and 33.4% of their MOWT for the mHHS, NAHS, and VAS, respectively, were likely to be willing to undergo revision hip arthroscopy again. Moreover, the presence of residual cam-type femoroacetabular impingement morphology before their revision surgery was identified as a predictor to achieve the MOWT for the VAS.

Capsular Mechanics After Periacetabular Osteotomy for Hip Dysplasia

BACKGROUND

Hip dysplasia is characterized by insufficient acetabular coverage around the femoral head, which leads to instability, pain, and injury. Periacetabular osteotomy (PAO) aims to restore acetabular coverage and function, but its effects on capsular mechanics and joint stability are still unclear. The purpose of this study was to examine the effects of PAO on capsular mechanics and joint range of motion in dysplastic hips.

METHODS

Twelve cadaveric dysplastic hips (denuded to bone and capsule) were mounted onto a robotic tester and tested in multiple positions: (1) full extension, (2) neutral 0°, (3) flexion of 30°, (4) flexion of 60°, and (5) flexion of 90°. In each position, the hips underwent internal and external rotation, abduction, and adduction using 5 Nm of torque. Each hip then underwent PAO to reorient the acetabular fragment, preserving the capsular ligaments, and was retested.

RESULTS

The PAO reduced internal rotation in flexion of 90° (∆IR = -5°; p = 0.003), and increased external rotation in flexion of 60° (∆ER = +7°; p = 0.001) and flexion of 90° (∆ER = +11°; p = 0.001). The PAO also reduced abduction in extension (∆ABD = -10°; p = 0.002), neutral 0° (∆ABD = -7°; p = 0.001), and flexion of 30° (∆ABD = -8°; p = 0.001), but increased adduction in neutral 0° (∆ADD = +9°; p = 0.001), flexion of 30° (∆ADD = +11°; p = 0.002), and flexion of 60° (∆ADD = +11°; p = 0.003).

CONCLUSIONS

PAO caused reductions in hip abduction and internal rotation but greater increases in hip adduction and external rotation. The osseous acetabular structure and capsule both play a role in the balance between joint mobility and stability after PAO.

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.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study

BACKGROUND

The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce.

PURPOSE

(1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score-Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI).

RESULTS

A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05).

CONCLUSION

Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Editorial Commentary: Hip Dysplasia-Arthroscopic Femoroacetabular Impingement Versus Periacetabular Osteotomy: Do Not FEAR the Size of the Next Step

Hip dysplasia is characterized by inadequate acetabular coverage of the femoral head. There is a consensus that hip dysplasia with a lateral center edge angle (LCEA) less than18° should be treated with realignment of acetabular coverage by acetabular osteotomy, but there is controversy whether milder, borderline dysplasia with an LCEA between 18° and 25° should be treated with arthroscopy or acetabular reorientation. Identifying whether the problem is related to dysplasia or femoroacetabular impingement syndrome is essential, and a crucial factor is whether the hip is unstable. A femoroepiphyseal acetabular roof (FEAR) index with a cutoff value of 2 predicts hip stability with 90% probability, even with a normative LCEA. In addition, according to the anterior-wall index (AWI), the anterior acetabular border should cross onto the middle third of the medial femoral head radius on a line that runs parallel to the femoral neck axis through the center of the femoral head. A reduced AWI suggests a deficient anterior rim. Next, lateral labrum length correlates with the FEAR index and anterior labrum length with AWI, i.e., anterior dysplasia. Consequently, the lateral labrum increases in size with progressive instability, and the anterior labrum increases in size with decreased anterior coverage. Threshold values for labrum size should be defined to guide clinical decision making. Ultimately, we require an algorithm to guide arthroscopy versus bony correction.

Comparable Minimum 2-Year Patient-Reported Outcome Scores Between Circumferential and Segmental Labral Reconstruction for the Management of Irreparable Labral Tear and Femoroacetabular Impingement Syndrome in the Primary Setting: A Propensity-Matched Study

PURPOSE

To compare minimum 2-year follow-up patient-reported outcome scores (PROs) in patients who underwent primary acetabular circumferential and segmental labral reconstruction for irreparable labral tears and femoroacetabular impingement syndrome (FAIS).

METHODS

Data were reviewed from August 2010 to December 2017. Patients with primary labral reconstruction and minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Circumferential and segmental reconstruction were selected in each case based on the extent of the labral pathology. Exclusion criteria were previous ipsilateral hip surgery/conditions, dysplasia, or Tönnis grade >1. Patients were propensity matched 1:1 based on age, sex, and body mass index. Secondary surgeries were reported. The P value was set at <.05.

RESULTS

In total, 144 hips were eligible, and 17 hips were lost to follow-up, leaving 127 hips (88.2%) for analysis. Eighty hips underwent a segmental reconstruction, and 47 hips underwent a circumferential reconstruction. Forty-seven hips with circumferential reconstruction were matched to 47 hips with segmental reconstruction. The average follow-up and age for the segmental and circumferential groups were 29.0 ± 7.8 and 27.9 ± 7.0 months (P = .732) and 43.1 ± 9.4 and 44.7 ± 10.2 years (P = .442) respectively. The segmental and circumferential groups were 48.9% and 51.1% female, respectively. The groups achieved significant and comparable improvement for all PROs and rates of secondary surgeries. No differences were found for achieving the minimal clinically important difference (MCID) and the patient acceptable symptomatic state (PASS). The MCIDs for the segmental and circumferential groups were 76.7% and 77.8% for the mHHS, 64.9% and 77.8% for the HOS-SSS, 71.1% and 68.9% for the VAS, and 68.9% and 73.9% for the NAHS, respectively. The PASSs for the segmental and circumferential groups were 78.3% and 73.3% for the mHHS, 55.3% and 55.0% for the HOS-SSS, and 75.6% and 71.1% for the International Hip Outcome Tool 12, respectively.

CONCLUSIONS

At minimum 2-year follow-up, patients who underwent primary hip arthroscopy for either circumferential or segmental labral reconstruction for irreparable labra and FAIS reported significant improvement and similar postoperative scores for all PROs, with no difference in psychometric outcomes and rate of secondary surgeries. A customized approach, using the extent of the irreparable labral tear, seems to be an appropriate strategy.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

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.

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.

Return to Sport in Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

Data on outcomes in patients with borderline hip dysplasia (BHD) who undergo hip arthroscopy remain limited, particularly in regard to return to sport (RTS).

PURPOSE

To evaluate outcomes in patients with BHD and their ability to RTS after hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients with self-reported athletic activity and radiographic evidence of BHD, characterized by a lateral femoral center-edge angle (LCEA) between 18° and 25° and a Tönnis angle >10°, who underwent hip arthroscopy for FAIS between November 2014 and March 2017 were identified. Patient characteristics and clinical outcomes including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were analyzed at minimum 2-year follow-up. In addition, all patients completed an RTS survey.

RESULTS

A total of 41 patients with a mean age and body mass index (BMI) of 29.6 ± 13.4 years and 25.3 ± 5.6, respectively, were included. Mean LCEA and Tönnis angle for the study population were 22.7°± 1.8° and 13.3°± 2.9°, respectively. A total of 31 (75.6%) patients were able to RTS after hip arthroscopy at a mean of 8.3 ± 3.2 months. A total of 14 patients (45.2%) were able to RTS at the same level of activity, 16 patients (51.6%) returned to a lower level of activity, and only 1 (3.2%) patient returned to a higher level of activity. Of the 11 high school and collegiate athletes, 10 (90.9%) were able to RTS. All patients demonstrated significant improvements in all patient-reported outcome measures (PROMs) as well as in pain scores at a mean of 26.1 ± 5.4 months after surgery. Patients who were able to RTS had a lower preoperative BMI than patients who did not RTS. Analysis of minimum 2-year PROMs demonstrated better HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcomes for pain in patients able to RTS versus those who did not RTS (P < .05).

CONCLUSION

Of the patients with BHD studied here, 75.6% of patients successfully returned to sport at a mean of 8.3 ± 3.2 months after hip arthroscopy for FAIS. Of the patients who successfully returned to sport, 45.2% returned at the same level, and 3.2% returned at a higher activity level.

Labral Tear Management in Patients Aged 40 Years and Older Undergoing Primary Hip Arthroscopy: A Propensity-Matched Case-Control Study With Minimum 2-Year Follow-up

BACKGROUND

Previous literature has suggested that primary acetabular labral reconstruction leads to lower secondary surgery rates than does labral repair for patients aged ≥40 years.

PURPOSE

To report minimum 2-year patient-reported outcome (PRO) scores, survivorship, and secondary surgeries in patients aged ≥40 years who underwent primary hip arthroscopy with labral reconstruction compared with a propensity-matched primary labral repair group.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent a primary hip arthroscopy for femoroacetabular impingement syndrome between January 2014 and June 2018. Patients aged ≥40 years who underwent a labral reconstruction or a labral repair and had preoperative and minimum 2-year PROs for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS) for pain were included. Patients with previous ipsilateral hip conditions and surgery, Tönnis grade >1, hip dysplasia, or workers' compensation status were excluded. Patients in the reconstruction group were propensity matched 1:2 to patients in the repair group based on age, sex, and body mass index. Secondary surgeries and achievement of the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and maximum outcome improvement (MOI) were recorded.

RESULTS

A total of 53 and 106 hips were included in the labral reconstruction and repair groups, respectively. The average follow-up time was 37.6 months. The average ages for the reconstruction and repair groups were 48.01 ± 5.4 years and 48.61 ± 6.0 years, respectively. Both groups achieved significant improvements in all PROs at a minimum of 2 years, with similar achievements of MCID, PASS, and MOI, and comparable secondary surgery rates.

CONCLUSION

Patients aged ≥40 years who received primary labral repair and primary labral reconstruction achieved similar significant improvements in all PROs, VAS pain, and patient satisfaction at the minimum 2-year follow-up, with comparable rates of secondary surgeries and achieving MCID, PASS, and MOI. Based on these findings, labral repair remains the gold standard treatment for viable labrum in this population group, while reconstruction is a useful alternative for irreparable labrum.

Endoscopic Shelf Procedure and Ischiofemoral Decompression with Arthroscopic Acetabular Labral Reconstruction: A Case Report

CASE

A 43-year-old female patient complained of pain in the right hip. The diagnoses of hip dysplasia, ischiofemoral impingement (IFI), femoroacetabular (FAI) cam-type morphology, and labral tear were made. The patient underwent hip arthroscopy with labral reconstruction for an irreparable labral tear and cam-morphology correction, and hip endoscopy for shelf procedure and ischiofemoral decompression. Favorable outcomes were reported at 1-year follow-up.

CONCLUSION

Hip arthroscopy for FAI cam-type morphology with labral reconstruction and concomitant hip endoscopy for shelf and ischiofemoral decompression seem to be safe for the treatment of active young adult patients with FAI cam-type morphology, irreparable labral tear, dysplasia, and IFI diagnoses. Nevertheless, the results presented should not be extrapolated as this is a case report.

In search of labral restoration function with hip arthroscopy: outcomes of hip labral reconstruction versus labral repair: a systematic review

PURPOSE

To perform a systematic review comparing patient-reported outcomes (PROs) in patients who underwent hip arthroscopy with labral repair versus labral reconstruction in the setting of femoroacetabular impingement syndrome (FAIS) and labral tears.

METHODS

A systematic review of the PubMed, Embase, and Cochrane databases was performed in May 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Articles were included in the analysis if they compared PROs between a labral repair and labral reconstruction cohort. For all PROs, the standardised mean difference (SMD) was calculated to compare the effect size of labral repair and labral reconstruction.

RESULTS

10 comparative studies, with 582 reconstruction cases and 631 repair cases, were included in this analysis. The mean age for the reconstruction and the repair groups ranged from 27.0 years to 52.6 years and 27.5 years to 47.0 years, respectively. The mean follow-up for the reconstruction and the repair groups ranged from 24.0 months to 66.0 months and 24.0 months to 71.0 months, respectively. The modified Harris Hip Scores (mHHS) was favourable in 8 reconstruction studies (range 80.4-95.0) and 9 repair studies (range 84.1-93.0). Average NAHS scores for the repair and reconstruction cohorts ranged from 77.9-88.6 and 73.9-92.4, respectively. Additionally, the effect sizes regarding NAHS and mHHS scores were large (SMD > 0.8) in both the reconstruction and repair groups for the majority of studies. Finally, reconstruction patients underwent a subsequent total hip arthroplasty (THA) at a slightly higher rate.

CONCLUSIONS

In the setting of FAIS and labral tears, patients who underwent hip arthroscopy may expect significant improvement in PROs at short-term follow-up with either labral repair or labral reconstruction. Although, not statistically significant, the repair group trended towards higher scores and exhibited a lower risk of conversion to THA.

[Arthroscopic labrum reconstruction for femoroacetabular impingement syndrome: 12 cases report]

To investigate the surgical effect of hip arthroscopic labrum reconstruction. A retrospective study was performed on the clinical data of 12 patients who underwent hip arthroscopic labrum reconstruction in our department from September 2017 to February 2021 and were followed up for 5-46 months, with an average of 21.5 months. All the patients had a hip joint space of more than 2 mm, and Tonnis grade less than level Ⅱ. These 12 patients underwent arthroscopic debridement of hyperplastic synovium, femoral head and neck and/or acetabular osteoplasty, and labrum reconstruction using autograft iliotibial band or gracilis tendon. After the surgery, we conducted follow-up and data collection, recorded the satisfaction of the patients and occurrence of complications, as well as the cartilage lesion of hip joint observed under the arthroscopy. We compared the alpha angle of Dunn X-ray film, center-edge angle (CE angle) of AP X-ray film, modified Harris hip score (mHHS score), hip outcome score (HOS), international hip outcome tool 12 score (iHOT12 Score), and visual analogue scale (VAS scale) before and after the arthroscopic operation, to assess clinical symptom relief and joint function recovery. The 12 patients were followed up for 5-46 (21.5±12.8) months. The VAS scale were (5.3±2.5) and (2.5±1.4) before and after the surgery, showing significant decrease (P=0.018). The mHHS score were (60.6±22.2) and (83.1±5.8) before and after the surgery, showing significant increase (P=0.003). The patient satisfaction was high (7.8±2.0) (range: 0-10). None of the 12 patients had serious complications, revision surgery, or total hip replacement at the end of the last follow-up. Autologous tendon transplantation for reconstruction of acetabular labrum under arthroscopy can improve the clinical symptoms and joint function of patients with femoroacetabular impingement (FAI), which is a safe and effective treatment.

Intraoperative Findings and Clinical Outcomes Associated With Arthroscopic Management of Subspine Impingement: A Propensity-Matched, Controlled Study

PURPOSE

(1) To investigate intra-articular damage in the hip joint associated with subspine impingement (SSI); (2) to evaluate clinical outcomes of arthroscopic treatment of hips with SSI; and (3) to compare the findings and outcomes to a control group without SSI.

METHODS

Eligible patients had arthroscopic treatment for femoroacetabular impingement (FAI) concurrent with SSI between January 2015 and December 2017. Inclusion criteria consisted of preoperative and minimum 2-year patient-reported outcomes and preoperative measurements for Tönnis, lateral center edge angle, and alpha angle. Included patients were propensity-matched in a 1:3 ratio to patients who had FAI without SSI. Patient-reported outcomes were compared between groups. Minimal clinically important difference was calculated for modified Harris Hip Score (mHHS) and Hip Outcome Score-Sports Specific Subscale (HOS-SSS).

RESULTS

Fifty SSI cases were matched to 150 patients who had FAI without SSI. A greater proportion of the SSI cohort required labral reconstruction (P = .010). The size and locations for labral tears and chondral defects were comparable between groups (P > .05). Both groups demonstrated similar minimum 2-year outcomes for mHHS (P = .103), Nonarthritic Hip Score (P = .200), HOS-SSS (P = .119), visual analog scale (P = .231), international Hip Outcome Tool-12 (P =.300), Short Form-12 Mental (P = .426), Short Form-12 Physical (P = .328), Veterans RAND 12-Item Health Survey, Mental (P = .419), and Veterans RAND 12-Item Health Survey, Physical (P = .316). The percentage of patients achieving minimal clinically important difference for mHHS and HOS-SSS was similar (P > .05). Survivorship was 96.0% and 98.7% for the SSI and control cohorts at 2 years, respectively.

CONCLUSIONS

Arthroscopic treatment of hips with SSI with subspine decompression and concomitant treatment of labral tears and FAI yielded significant improvement in patients' outcomes, which compared favorably with the control group. SSI may correlate with more complex labral tears, not amenable to repair, and complete tears of the ligamentum teres. Other findings, such as location and size of intra-articular damage, were similar between the cohorts.

LEVEL OF EVIDENCE

III, case-control study.

Short-term patient-reported outcomes following concomitant hip arthroscopy and the endoscopic modified shelf procedure for the treatment of acetabular dysplasia and intra-articular pathology

The shelf procedure is a treatment of acetabular dysplasia, with the aim of increasing weight-bearing acetabular coverage. Although several shelf techniques have been described, the endoscopic procedure with concomitant hip arthroscopy is a new, less invasive alternative. Outcomes following this procedure are scarce. The purpose of this study was to report short-term patient-reported outcomes (PROs) following concomitant hip arthroscopy and endoscopic modified shelf procedure in the setting of acetabular dysplasia and labral tears. Patients that met extraordinarily selective surgical indications and underwent the abovementioned surgery between February 2016 and October 2019 and had minimum 1-year follow-up were included. There were five females with a mean age of 40.18 ± 5.05 years and follow-up of 21.55 ± 8.68 months. The lateral center-edge angle increased from 15.80° to 23.20° (P = 0.003), and vertical center-edge angle increased from 16.60° to 23.60° (P < 0.001). The Tönnis angle decreased from 15.40° to 3.74° (P < 0.001). The alpha angle decreased from 58.46° to 40.70° (P < 0.001). PROs demonstrated significant improvement at latest follow-up (modified Harris Hip Score, P = 0.042; Non-Arthritic Hip Score, P < 0.001; Hip Outcome Score–Sports Specific Subscale, P = 0.035; Visual Analog Scale, P < 0.001; International Hip Outcome Tool-12, P = 0.043), and satisfaction was 8.60 ± 0.89. No secondary surgeries were reported. Concomitant hip arthroscopy and endoscopic modified shelf procedure appears to be a safe and effective procedure for patients with acetabular dysplasia and labral tears yielding favorable outcomes and satisfaction at short-term follow-up.

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.

Minimum 5-Year Outcomes for Revision Hip Arthroscopy With a Prospective Subanalysis Against a Propensity-Matched Control Primary Group

BACKGROUND

There is a paucity of midterm outcome data on hip revision arthroscopic surgery.

PURPOSE

(1) To report minimum 5-year patient-reported outcome measurement scores (PROMSs) in patients who underwent revision hip arthroscopy, (2) to compare minimum 5-year PROMSs with a propensity-matched control group that underwent primary hip arthroscopy, and (3) to compare the rate of achieving the minimal clinically important difference (MCID) at minimum 5-year follow-up between the revision group and the propensity-matched control primary group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected between June 2008 and April 2014. Patients were included who underwent revision hip arthroscopy with preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patients with Tönnis grade >1 or with hip conditions such as avascular necrosis, Legg-Calve-Perthes disease, Ehlers-Danlos syndrome, and pigmented villonodular synovitis were excluded. A subanalysis was performed against a propensity-matched control group that underwent primary surgery. Groups were propensity matched in a 1:2 ratio for sex, age, body mass index, and follow-up time.

RESULTS

A total of 127 revision arthroscopies (113 patients) were included, and the mean ± SD follow-up time was 72.8 ± 23.3 months. The revision group was 74.0% female, and the average age and body mass index were 34.9 ± 12.4 years and 24.8 ± 4.2, respectively. The revision group demonstrated improvement for all PROMSs and reached the MCID for the mHHS (66.1%), HOS-SSS (68.4%), NAHS (66.9%), and VAS (80.0%). All revision cases were propensity matched to 254 primary arthroscopy cases. PROMSs in the revision group were lower than those of the control group before and after surgery. Delta values were similar between groups for all PROMSs. There were no differences in rates of achieving the MCID. The relative risk of arthroplasty conversion was 2.6 (95% CI, 1.5-4.6) for the revision group as compared with the primary group.

CONCLUSION

Significant improvement in all PROMSs, including the VAS, and high patient satisfaction at minimum 5-year follow-up were reported after revision hip arthroscopy. A high proportion of patients in the revision cohort reached the MCID for the mHHS, HOS-SSS, NAHS, and VAS, with similar rates and magnitudes of improvement relative to the control group. As expected, these data indicate that patients undergoing primary hip arthroscopy have higher PROMSs before and after surgery and lower rates of conversion to arthroplasty.

Arthroscopic Circumferential Acetabular Labral Reconstruction for Irreparable Labra in the Revision Setting: Patient-Reported Outcome Scores and Rate of Achieving the Minimal Clinically Important Difference at a Minimum 2-Year Follow-up

BACKGROUND

There is a paucity in the literature reporting patient-reported outcome (PRO) scores and the minimal clinically important difference (MCID) after revision hip arthroscopic surgery with circumferential labral reconstruction.

PURPOSE

To report minimum 2-year PRO scores and the rate of achieving the MCID in patients who underwent revision hip arthroscopic surgery with circumferential labral reconstruction in the setting of irreparable labral tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were retrospectively reviewed for all patients who underwent revision hip arthroscopic surgery between February 2016 and November 2017. Patients were included if they had undergone circumferential labral reconstruction and had preoperative and postoperative scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), 12-Item Short Form Health Survey physical and mental components (SF-12 P and SF-12 M, respectively), Veterans RAND 12-Item Health Survey physical and mental components (VR-12 P and VR-12 M, respectively), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, fractures, hip dysplasia, or revision labral treatment different from circumferential labral reconstruction. The MCID was calculated. Secondary surgical procedures were documented.

RESULTS

A total of 26 hips (26 patients; 61.5% female) were included. The mean age and body mass index were 33.2 ± 10.4 years and 25.5 ± 4.9, respectively. Significant improvements were reported for the mHHS (17.0 ± 19.5; P = .0002), NAHS (17.9 ± 16.7; P < .0001), HOS-SSS (21.7 ± 23.1; P = .0005), VAS (-2.2 ± 3.0; P = .006), iHOT-12 (25.8 ± 32.5; P = .0007), SF-12 P (8.5 ± 11.2; P = .001), and VR-12 P (8.9 ± 11.6; P = .001). Rates of meeting the MCID for the mHHS, NAHS, HOS-SSS, iHOT-12, and VAS were 76.9%, 80.0%, 65.0%, 62.5%, and 69.2%, respectively. No case of re-revision arthroscopic surgery was documented, but 1 case of conversion to total hip arthroplasty was documented at 38.6 months.

CONCLUSION

In the setting of revision hip arthroscopic surgery and irreparable labral tears, circumferential labral reconstruction resulted in significant improvements in all PRO and VAS scores at a minimum 2-year follow-up with a high rate of achieving the MCID.

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.

Successful return to sport in patients with symptomatic borderline dysplasia following hip arthroscopy and T-shaped capsular plication

PURPOSE

This study aims to evaluate the return to sport and correlations of patients with symptomatic borderline hip dysplasia (BHD) after hip arthroscopy and T-shaped capsular plication at a minimum follow-up of 24 months.

METHODS

Twenty-five patients who underwent hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All the patients were evaluated clinically prior to surgery (T₀) and at two consecutive follow-ups (T₁:15 ± 1.2 months and T₂: 53.9 ± 23.2 months) using the visual analogue scale (VAS) pain score, whereas sports activity was assessed by the Hip Outcome Score Sport Specific Subscale (HOS-SSS), the University of California, Los Angeles (UCLA) activity scale, the Tegner score and the physical component (PCS) of the Short Form-12 (SF-12). Furthermore, the presence of correlations and the possible differences between subgroups were evaluated and analysed.

RESULTS

A significant difference was found for HOS-SSS, VAS, Tegner, UCLA and PCS with the Friedman test for repeated measures through time points (p < 0.0001). Moreover, all the scores reported significant improvement compared to the previous time point (p < 0.0001) except the HOS-SSS between T₁ and T₂ (n.s.). Body Mass Index (BMI) was negatively correlated with HOS-SSS at T₀ (rho = - 0.526 p = 0.006) and T₁ (rho = - 0.425; p = 0.034), with Tegner at each follow-up (T₀: rho = - 0470 p = 0.017; T₁: rho = - 0.450; p = 0.024; T₂: rho = - 0.448; p = 0.024), with UCLA at T₁ (rho = - 0.396 p = 0.049), with pre-operative PCS (rho = - 0.413 p = 0.0401), and positively correlated with pre-operative VAS (rho = 0.436 p = 0.0291).

CONCLUSIONS

Hip arthroscopy and T-shaped capsular plication in young patients with symptomatic BHD demonstrates a significant increase in return to sport and physical activity and low risk of complications. T-shaped capsular plication procedure may be considered in young and active patients for whom non-operative treatment failed and who have a significant limitation in sports activity; in these patterns of patients, the ideal treatment should reliably allow fast recovery in combination with very low invasiveness which will prevent osteoarthritis. The results of this study provide more accurate information regarding return to sport in patients with BHD after hip arthroscopy and T-shaped capsular plication.

LEVEL OF EVIDENCE

Level IV.

Large Heterogeneity Among Minimal Clinically Important Differences for Hip Arthroscopy Outcomes: A Systematic Review of Reporting Trends and Quantification Methods

PURPOSE

To perform a systematic review of reporting trends and quantification methods for the minimal clinically important difference (MCID) within the hip arthroscopy literature.

METHODS

Cochrane, PubMed, and OVID/MEDLINE databases were queried for hip arthroscopy articles that reported the MCID. Studies were classified as (1) calculating new MCID values for their specific study-population or (2) referencing previously established MCID values. Data pertaining to patient demographics, study characteristics, outcome measures, method of MCID quantification, MCID value, anchor questions, measurement error, and study from which referenced MCID values were obtained were extracted.

RESULTS

A total of 59 articles with 18,830 patients (19,867 hips) was included. A total of 19 unique outcome measures was reported. A total of 33 (n = 55.9%) studies (follow-up range 6-60 months) used previously established MCID values to assess their study population (MCID values established at a follow-up range 6-31 months). The remaining 26 studies (44.1%) performed new MCID calculations. The MCID values were inconsistent and varied widely (Hip Outcome Score-Activities of Daily Living: 5.0-15.4; Hip Outcome Score-Sports Subscale: 6-25; modified Harris hip score: 2.4-20.9). Among the 33 studies that used previously established MCID values, 10 different studies were cited as the reference. Among the remaining 26 studies that calculated a new MCID value, the most common method was 0.5 standard deviation method (n = 21, 80.8%). Only 3 of 26 (11.5%) studies reported a measurement of error in conjunction with their MCID values.

CONCLUSIONS

Inconsistencies in MCID reporting and quantification methods led to a wide range of MCID values for commonly administered outcome measures within the hip arthroscopy literature-even for the same outcome measures. The majority of studies referenced previously established MCID values with variable ranges of follow-up and applied those values to assess their specific study population at varying follow-ups.

LEVEL OF EVIDENCE

IV, systematic review.

Mid-Term Outcomes of Combined Hip Arthroscopy and Limited Open Capsular Plication in the Non-Dysplastic Hip

BACKGROUND

Hip microinstability remains poorly-defined but increasingly diagnosed in the setting of borderline dysplasia (LCEA 20-25°), soft tissue laxity, or following unrepaired arthroscopic capsulotomy. While hip microinstability is com-monly treated with arthroscopic capsular plication with short-term outcomes reported, this procedure has been performed open for some time. The purpose of current study was to assess the durability of outcomes of combined arthroscopy and open capsular plication in treating symptomatic hip microinstability at mid-term follow-up.

METHODS

We retrospectively identified hips that underwent combined hip arthroscopy and open capsular plication for symptomatic microinstability between 2008 and 2013. Hips with excessive femoral anteversion (femoral version >35°) or classic acetabular dysplasia (LCEA <20°) were treated with bony reorientation and were not included in the current study. Patient reported outcomes scores were collected preoperatively and at a minimum five year follow-up. Hips that required reoperation or did not meet criteria for minimally clinically important difference (MCID, ≥8 increase in mHHS) or patient acceptable symptom scores (PASS, mHHS) were considered failures.

RESULTS

A total of 27 hips met criteria for inclusion and follow-up was obtained for 22 hips (81.5%) at a mean of 7.1 years. All patients were female with a mean age of 25.9 years and 7 (32%) hips had previous surgery. Patients undergoing the combined procedure improved from a mean baseline mHHS of 55.3±13 to a mean follow-up mHHS of 74.5±20.9 (p<0.001). At midterm follow-up, 54.5% of hips met criteria for PASS and 68.2% of hips met criteria for MCID, with 72.7% of hips meeting criteria for either MCID or PASS. Overall, 10 hips (45%) were considered failures with 6 hips (27%) requiring reoperation and an additional 4 hips (18%) with clinical failure. Hips without previous surgery had a failure rate of 33.3% (5/15) while 71.4% (5/7) of those with previous surgery failed (P=.09).

CONCLUSION

Our study demonstrates a high (45%) rate of reoperations and persistent symptoms in hips with microinstability treated with combined arthroscopy and open capsular plication. Further mid- and long-term studies evaluating soft tissue plication are needed, as well as comparisons with bony procedures in the setting of microinstability are needed.Level of Evidence: III.

Revision Hip Arthroscopy in the Borderline Dysplastic Population: Reporting Outcomes With Minimum 2-Year Follow-up, With a Subanalysis Against a Propensity-Matched Nondysplastic Control Group

BACKGROUND

Hip arthroscopy in patients with borderline dysplasia continues to be surrounded by controversy. Even more controversial is the management of the failed hip arthroscopy in this population. There is a paucity of studies in contemporary literature regarding outcomes after arthroscopic revision surgery.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores in patients with borderline dysplasia who underwent revision hip arthroscopy and (2) to compare these PRO scores with those of a propensity-matched control group without dysplasia who underwent revision hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected between August 2009 and November 2017. Inclusion criteria were revision arthroscopic surgery, capsular plication, and baseline and minimum 2-year follow-up for the following PROs: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patients with Tönnis grade >1 or previous hip conditions were excluded. Two groups were created: a study group with borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and a control group without dysplasia (LCEA, 25°-40°). Groups were propensity-matched in a 1:3 ratio for sex, age, body mass index, and follow-up time.

RESULTS

A total of 22 revision borderline dysplastic hips (21 patients) had a minimum 2-year follow-up during the study period. Patients in this group reported significant improvements for all PROs from baseline and achieved the minimal clinically important difference (MCID) for the mHHS at a rate of 70%. Moreover, 21 borderline dysplastic hips (21 patients) were matched to 63 control hips (63 patients). Mean LCEA for the study and control groups was 22.6 ± 1.7 and 32.0 ± 5.0, respectively. Both groups reported similar improvement in all PROs. The rate for achieving the MCID for the mHHS and VAS was similar between groups; however, the control group had higher rates of meeting the MCID for the HOS-SSS and NAHS (P = .042 and P = .025, respectively). The rates of conversion to hip arthroplasty were 7.9% (n = 5) in the control group and 23.8% (n = 5) in the borderline dysplasia propensity-matched group (P = .052). The rate of re-revision arthroscopy was 11.1% (n = 7) in the control group and 19.0% (n = 4) on the borderline dysplasia group (P = .350).

CONCLUSION

After revision hip arthroscopy, significant improvement was obtained for all PROs in patients with borderline dysplasia at a minimum 2-year follow-up. Moreover, outcomes, patient satisfaction, the rate for achieving the MCID for the mHHS and VAS, and the rate for secondary surgery were similar to those of a propensity-matched control group without dysplasia. Nevertheless, there was a nonsignificant trend toward higher secondary procedures in the study group; therefore, arthroscopic revision surgery in the borderline patients should be approached with measured prognosis.

Arthroscopic acetabular labral reconstruction: a review

The function and importance of the acetabular labrum in hip biomechanics have been determined. A labral tear is one of the most common findings in the hip preservation field, commonly associated with femoroacetabular impingement (FAI) syndrome. It has been established that the restoration of labral anatomy and function are key factors to improve patient-reported outcome measurements (PROMs) and psychometric tools following arthroscopic hip arthroscopy in the context of FAI syndrome. Labral repair or refixation is currently the gold-standard surgical option when facing labral tears, with clinical mid to long-term data supporting its use. Labral selective debridement has proven to be a valid alternative in selective patients. Acetabular labral reconstruction has risen as an alternative to labral excision or resection when repair is not an option due to labral tissue deficiency. Restoring the labral sealing mechanism is the goal behind the acetabular labral reconstruction. It has been proven that labral reconstruction leads to superior PROMs when compared with resection. This review presents an analysis of the indications, techniques, and outcomes for arthroscopic acetabular labral reconstruction.

Circumferential Labral Reconstruction for Irreparable Labral Tears in the Primary Setting: Minimum 2-Year Outcomes With a Nested Matched-Pair Labral Repair Control Group

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores of primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare these PROs with a matched-pair primary labral repair group.

METHODS

Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary circumferential labral reconstruction with anterior tibialis tendon allograft during February 2016 to April 2017 for irreparable labral tears and FAIS and had preoperative and minimum 2-year follow-up for modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale, Non-arthritic Hip Score, International Hip Outcome Tool 12 (iHOT-12), 12-Item Short Form Health Survey physical component and mental component, Veterans RAND 12-Item Health Survey physical component and mental component, and visual analog scale for pain. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, Tönnis grade 2 or higher, or dysplasia (lateral center-edge angle ≤ 18°). Labral tears were considered irreparable if the labrum appeared (1) to be mostly or completely calcified and (2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was matched 1:3 based on age, sex, and body mass index to a benchmark control group of hips undergoing labral repair from the same period. The minimal clinically important difference and patient acceptable symptomatic state for the mHHS and iHOT-12 score were calculated.

RESULTS

A total of 37 hips (37 patients) underwent circumferential labral reconstruction. There were 19 female patients (51.4%) and 18 male patients (48.6%). The mean age was 45.6 ± 11.6 years, and the average body mass index was 27.1 ± 5. At minimum 2-year follow-up, the circumferential labral reconstruction group showed statistically significant improvements in the mHHS, Non-arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, iHOT-12 score, and visual analog scale score. All hips in the reconstruction group were successfully matched to 111 labral repair hips. At latest follow-up, improvements in all PROs between the 2 groups were comparable. The revision rates were 0% and 3.6% in the reconstruction and repair groups, respectively.

CONCLUSIONS

After primary hip arthroscopy, primary circumferential labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS and irreparable labral tears resulted in significant improvements in several PROs at minimum 2-year follow-up and high patient satisfaction. Primary circumferential labral reconstruction reached comparable functional outcomes to those of a benchmark matched-pair primary labral repair control group.

LEVEL OF EVIDENCE

Level III, case-control study.

Computer assistance in hip preservation surgery-current status and introduction of our system

INTRODUCTION

Preservation surgery of the hip with open or arthroscopic approach has always been challenging as complex 3-D anatomy and limited surgical access make intraoperative evaluation difficult. Recent advances in computer technology offer a wide range of innovative solutions with a goal to improve accuracy and safety of corrective procedures on human joints.

METHOD

The author critically reviews currently available literature in the field of computer assistance in hip preservation surgery. Basic features of unique planning software and navigation surgical system used in treatment of femoroacetabular impingement and hip dysplasia are introduced.

RESULTS

Currently available software provides preoperative identification of hip deformity on CT-based 3-D model and planning of the surgical correction using kinematic protocols. Real-time intraoperative 3-D orientation is possible, and execution of surgical correction can be performed either with navigation of surgical tools or with printed templates. Computer assistance in hip preservation surgery is in the developing phase. First clinical experiences of its use in treatment of femoroacetabular impingement, hip dysplasia, hip tumors, and avascular necrosis of the femoral head are promising.

CONCLUSION

Computer assistance has been applied for treatment of several hip disorders. Technical advances are suggested and quality basic studies and clinical trials are encouraged for the novel technology to become more user friendly and widely accepted.

Editorial Commentary: Arthroscopy for Borderline Developmental Dysplasia of the Hip: Selection Determines the Outcomes

Although the literature has presented results that favored arthroscopic procedures in treating borderline developmental dysplasia of the hip (BDDH), it remains controversial whether arthroscopic surgery would be better than periacetabular osteotomy for BDDH. Instead of a debate on the application of arthroscopy, the issue worthy of discussion should be distinguishing suitable BDDH candidates for hip arthroscopy. First, identification of patients with real BDDH is critical for making management choices. Second, it should be distinguished whether the major symptoms result from mechanical lesions or functional hip instability. Third, once hip arthroscopy is suggested for BDDH patients, relative contraindications such as advanced age and osteoarthritis should be taken into consideration, in addition to labral repair and capsular closure or plication intraoperatively. In conclusion, more long-term and high-grade evidence is still demanded to end the debate, but we believe that an individualized management strategy based on an accurate diagnosis and comprehensive assessment will bring optimal outcomes for BDDH patients.

Hip Arthroscopy and Borderline Developmental Dysplasia of the Hip: A Systematic Review

PURPOSE

To provide an up-to-date evidence-based review of hip arthroscopy for patients with borderline developmental dysplasia of the hip (BDDH).

METHODS

Literature describing hip arthroscopy in patients with BDDH was systematically identified from PubMed, EMBASE, and Cochrane Library using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All studies that involved BDDH and not just those reporting their clinical outcomes were included. Methodological Index for Non Randomized Studies criteria and Newcastle-Ottawa Scale were used to assess the quality of studies. The definition of BDDH, operative technique, correlation with labrum and/or cartilage lesions, outcome, and factors associated with poor outcome were collected and analyzed.

RESULTS

Assessment of the articles yielded 28 studies involving 1502 hips that were included for final analysis. There were no studies with a high risk of bias. BDDH was defined as lateral center-edge angle of 20° to 25° in most studies. Hip arthroscopy for BDDH showed an improvement in the weighted mean postoperative modified Harris Hip Score, from 60.2 to 81.7, a relatively high rate of acquisition of minimal clinically important difference of 79.5% to 87%, and had 1.0% rate of complications. Eleven studies reported on all the patients undergoing a capsular plication. Four studies reported that BDDH was associated with cartilage damage on the femoral head. Age older than 35 or 42 years and ≥20° of femoral anteversion were reported as risk factors for poor outcomes.

CONCLUSIONS

Hip arthroscopy for BDDH with capsular plication provides improvement in patient-reported outcome measures and a relatively high rate of acquisition of minimal clinically important difference with a low rate of complications in the shorter term. BDDH may be associated with cartilage damage on the femoral head. Female sex is a factor related to good outcomes, whereas older age, excessive femoral anteversion, and anterior undercoverage of acetabulum are risk factors related to poorer outcomes.

LEVEL OF EVIDENCE

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

Patient-related risk factors associated with less favourable outcomes following hip arthroscopy

AIMS

This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy.

METHODS

Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review.

RESULTS

Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers' compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy.

CONCLUSION

Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822-831.

A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia

BACKGROUND

Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO.

PURPOSE

To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD.

STUDY DESIGN

Narrative review.

METHODS

A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia.

RESULTS

The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented.

CONCLUSION

Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

Prospective Analysis of Arthroscopic Hip Anatomic Labral Repair Utilizing Knotless Suture Anchor Technology: The Controlled-Tension Anatomic Technique at Minimum 2-Year Follow-up

BACKGROUND

Labral tears are the most common abnormalities in patients undergoing hip arthroscopic surgery. Appropriate management is crucial, as it has been shown that better overall outcomes can be achieved with labral restoration.

PURPOSE

To report the patient-reported outcomes (PROs) at minimum 2-year follow-up of patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique in the setting of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery for FAIS for labral tear repair using the knotless controlled-tension anatomic technique. Patients were excluded if they had prior hip conditions, prior ipsilateral surgery, Tönnis grade >1, a lateral center-edge angle (LCEA) <25°, or workers' compensation claims. Preoperative and postoperative scores at minimum 2-year follow-up were recorded for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The proportion of patients who achieved the minimal clinically important difference (MCID) or patient acceptable symptomatic state (PASS) for the mHHS, HOS-SSS, and iHOT-12 were also reported.

RESULTS

A total of 309 hips were included. The mean patient age was 36.2 years (range, 12.8-75.9 years). The mean preoperative LCEA and alpha angle were 31.9° and 57.1°, respectively. A significant improvement on the mHHS (62.6 ± 15.7 preoperatively vs 86.9 ± 16.2 at 2-year follow-up), NAHS (63.1 ± 16.7 vs 86.1 ± 16.7), and HOS-SSS (39.8 ± 22.0 vs 74.2 ± 27.3) was found (P < .001 for all). A significant decrease was shown for VAS scores (P < .001). Also, 78.6% and 82.2% of patients achieved the MCID and PASS for the mHHS, respectively; 60.8% and 69.9% of patients met the MCID and PASS for the HOS-SSS, respectively; and the MCID for the iHOT-12 was met by 77.3% of patients.

CONCLUSION

In the setting of FAIS and labral tears, patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique demonstrated significant improvement in several validated PRO measures, the VAS pain score, and patient satisfaction at a minimum 2 years of follow-up. Based on this evidence, labral tear repair using the knotless controlled-tension anatomic technique seems to be a safe option.

Arthroscopic Hip Capsular Plication With Augmentation Using a Bioinductive Collagen Implant

With advancements in arthroscopic techniques and instrumentation, hip arthroscopy has become an increasingly used technique to treat soft-tissue and osseous pathologies about the hip. Patient predisposition to labral and capsular injuries can present as femoroacetabular impingement or hip dysplasia, sometimes in combination. Capsular management continues to be a topic of debate, with capsular repair becoming the standard of care in most cases. Furthermore, in cases of borderline dysplasia and microinstability, considerations for not only capsular repair but with plication has shown significant clinical success. Although plication in this setting has shown promise, given a 20% failure rate, we suggest capsular augmentation to bolster the repair. We present a technique of capsular augmentation using a bioinductive collagen implant (Smith & Nephew) to improve the capsular integrity following repair and plication. The benefits of this implant are easy delivery through standard arthroscopic portals and secure fixation to the capsular tissue. These implants have a proven track record in the shoulder and serve as a scaffold for improved tissue quality, and their application in hip arthroscopy has potential by increasing the integrity of the capsular repair. Future studies are needed to address the clinical outcomes of this technique.

Return to play after hip arthroscopy among tennis players: outcomes with minimum five-year follow-up

BACKGROUND

Playing tennis is associated with various movements that can lead to labral injuries and may require arthroscopic surgery. While hip arthroscopies have demonstrated good outcomes in athletes, there is limited literature reporting patient reported outcomes (PROs) and return to sport (RTS) in competitive or recreational tennis players after arthroscopic hip surgery. Therefore, the purpose of the present study was to (1) report minimum five-year PROs and RTS in tennis players who underwent arthroscopic hip surgery and (2) compare outcomes between recreational and competitive tennis players.

METHODS

Data for patients who underwent hip arthroscopy surgery in the setting of femoroacetabular impingement and labral tears between March 2009 and January 2014 and who played tennis within one-year of surgery were retrospectively reviewed. Patients with preoperative and minimum five-year postoperative scores for the following PROs were included: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patient Acceptable Symptomatic State (PASS) and Minimal Clinically Important Difference (MCID) for mHHS and HOS-SSS were calculated.

RESULTS

Of 28 patients, 31 hips met all inclusion and exclusion criteria of which 28 (90.3%) had minimum 5-year follow-up (mean: 72.8 ± 13.9 months). There were 3 professional, 3 collegiate, 2 high school, 2 organized amateur, and 18 recreational level tennis players. All PROs significantly improved at latest follow-up: mHHS from 67.0 to 86.7 (P <  0.001), NAHS from 65.9 to 87.2 (P <  0.001), HOS-SSS from 50.0 to 77.9 (P = 0.009), and VAS from 5.4 to 1.8 (P <  0.001). There was a 75.0% RTS rate. Additionally, 66.7% of patients achieved MCID and 83.3% achieved PASS for mHHS, and 63.6% achieved MCID and 58.3% achieved PASS for HOS-SSS.

CONCLUSION

Regardless of the level of participation, tennis players who underwent arthroscopic hip surgery reported statistically significant PRO improvements. A favorable rate of RTS was also achieved by players with a continued interest in playing. The data here may be useful in counseling tennis players of various levels who are considering arthroscopic treatment of a hip injury.

LEVEL OF EVIDENCE

IV.

A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the Tönnis Angle

BACKGROUND

Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes.

PURPOSE

To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05.

RESULTS

A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group (P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle >10°, 84% required secondary operation.

CONCLUSION

Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle >10°, 84% required a secondary operation.

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.

Is Hip Arthroscopy an Adequate Therapy for the Borderline Dysplastic Hip? Correlation Between Radiologic Findings and Clinical Outcomes

Background

Recent studies have shown that assessment of the lateral center-edge angle (LCEA) between 18° and 25° is not sufficient to adequately classify mildly dysplastic hips and that further radiological features should be considered. However, no correlation between different morphologic features and clinical outcomes has been investigated so far.

Purpose

To analyze the clinical outcomes of patients with different subtypes of borderline dysplastic hips who underwent arthroscopic surgery.

Study Design

Cohort study; Level of evidence, 3.

Methods

We examined patients with an LCEA between 18° and 25° who underwent arthroscopic treatment for femoroacetabular impingement syndrome between January 2015 and December 2016. A hierarchical cluster analysis was performed to identify hip morphologic subtypes according to radiographic parameters, including the LCEA, femoro-epiphyseal acetabular roof (FEAR) index, anterior and posterior wall indices (AWI and PWI), Tönnis angle, alpha angle, and femoral neck-shaft angle. In addition, the International Hip Outcome Tool 12 (iHOT-12) and a visual analog scale (VAS) for pain were applied preoperatively and at follow-up, and the results were compared among the different clusters. Previously reported minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values were used to determine clinically significant improvements.

Results

A total of 40 patients were identified. Of these, 36 patients were available for evaluation at a mean follow-up of 43.8 months. In total, 4 sex-independent clusters with different morphologic patterns of the hip were identified: cluster 1, unstable anterolateral deficiency (FEAR index >2°, AWI <0.35); cluster 2, stable anterolateral deficiency (FEAR index <2°, AWI <0.35); cluster 3, stable lateral deficiency (FEAR index >2°, normal AWI and PWI); and cluster 4, stable posterolateral deficiency (FEAR index <2°, PWI <0.85). At follow-up, clusters 1, 2, and 3 showed significantly improved iHOT-12 (P < .0001) and VAS pain (P < .0001) scores, and cluster 4 showed no significant improvements. The MCID of 15.2 points was achieved by all patients in clusters 2 and 3, by 63% of patients in cluster 1, and by 23% of patients in cluster 4. Clusters 2 and 3 differed significantly from clusters 1 and 4 (P = .02). A postoperative PASS score of 60 was achieved by all patients in cluster 3, by 86% of patients in cluster 2, by 63% of patients in cluster 1, and by 20% of patients in cluster 4. The differences between the groups were statistically significant (P = .01).

Conclusion

Arthroscopic surgery yielded good results in the treatment of stable borderline hip dysplasia with anterolateral and lateral deficiency. In contrast, borderline hip dysplasia with acetabular retroversion showed no improvements after arthroscopic therapy. This study underlines the need for an accurate analysis of all possible radiological signs to adequately classify borderline dysplastic hips.

An Intact Ligamentum Teres Predicts a Superior Prognosis in Patients With Borderline Dysplasia: A Matched-Pair Controlled Study With Minimum 5-Year Outcomes After Hip Arthroscopic Surgery

BACKGROUND

Hip arthroscopic surgery in patients with borderline dysplasia continues to be controversial. In addition, it has been suggested that ligamentum teres (LT) tears may lead to inferior short-term patient-reported outcomes (PROs) when compared with a match-controlled group.

PURPOSES

(1) To report minimum 5-year PROs in patients with borderline dysplasia and LT tears who underwent hip arthroscopic surgery and (2) to compare these PROs to those of a matched-pair control group of patients with borderline dysplastic hips without LT tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery between September 2008 and August 2013. Patients were included if they had a preoperative diagnosis of borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and had preoperative and minimum 5-year postoperative modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain scores. Exclusion criteria were osteoarthritis of Tönnis grade >1, previous hip conditions, any previous ipsilateral hip surgery, or workers' compensation status. There were 2 borderline dysplastic groups created. An LT tear group was matched 1:1 to a control group (no LT tear) with similar age, sex, body mass index (BMI), and laterality via propensity score matching. Significance was set at P < .05.

RESULTS

A total of 24 patients with an LT tear (24 hips) were matched to 24 patients without an LT tear (24 hips). There was no significant difference in age, sex, BMI, or laterality between groups. The mean age was 36.2 ± 17.2 and 34.9 ± 15.9 years for the control and LT tear groups, respectively (P = .783). There were 17 (70.8%) and 16 (66.7%) female patients in the control and LT tear groups, respectively, and the mean preoperative LCEA was 23.3° and 22.2° in the control and LT tear groups, respectively. No differences were observed between groups in baseline PROs, intraoperative findings, or surgical procedures. LT debridement was performed in 17 (70.8%) patients in the LT tear group compared with 0 (0.0%) in the control group. Also, 5-year postoperative PROs were comparable in both groups, with the control group exhibiting superior Veterans RAND 12-Item Health Survey (VR-12) mental (P = .041) and Short Form-12 (SF-12) mental (P = .042) scores. Finally, hips with an intact LT were significantly more likely (P = .022) to achieve the patient acceptable symptomatic state (PASS) for the mHHS (100.0% and 75.0%, respectively). No significant differences were present between the groups for the minimal clinically important difference (MCID) of the mHHS (P = .140), MCID of the Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) (P = .550), or PASS of the HOS-SSS (P = .390).

CONCLUSION

After hip arthroscopic surgery, patients with borderline dysplasia and LT tears demonstrated favorable PROs at a minimum 5-year follow-up. Outcomes were similar to a matched-pair control group without LT tears, with the group with intact LTs showing higher VR-12 mental and SF-12 mental scores. Furthermore, patients with borderline dysplasia and intact LTs were significantly more likely to achieve the PASS for the mHHS.

Achieving a Perfectly Spherical Femoroplasty: Pearls, Pitfalls, and Optimal Surgical Technique

Femoroacetabular impingement describes a pathologic interaction between the bony femoral head/neck junction and acetabulum. Cam-type femoroacetabular impingement results from an aspherical femoral head architecture, which increases early contact along the acetabular surface during hip range of motion. Errant arthroscopic femoroplasty recently has been discussed within the literature to describe a preventable etiology of failed hip arthroscopy, most notably cam over- and under-resection. We present an arthroscopic surgical technique for achieving the perfectly spherical femoroplasty, meant to minimize complications and improve postoperative outcomes.