The Functional Integrity of the Anterior Cruciate Ligament Can Be Objectively Assessed With the Use of Stress Radiographs: A Systematic Review

Background

Stress radiography is a viable imaging modality that can also be used to assess the integrity of the anterior cruciate ligament (ACL) after primary or secondary injury. Because conventional radiography is relatively easy, affordable, and available worldwide, the diagnostic efficacy of ACL standing, lateral decubitus, and supine stress radiography should be evaluated.

Purpose

To examine the existing literature regarding the application of stress radiography in evaluating the integrity of the ACL.

Study Design

Systematic review; Level of evidence, 3.

Methods

Using the PubMed and MEDLINE databases for relevant articles published between 1980 and the present, a systematic review was conducted to identify evidence related to the radiographic diagnosis or assessment of ACL tears. The literature search was conducted in September 2022.

Results

Of 495 studies, 16 (1823 patients) were included. Four studies examined standing stress radiography, and 12 investigated lateral decubitus or supine stress radiography. Significant heterogeneity in imaging technique and recorded anterior tibial translation was identified. Anterior tibial translation for ACL-injured knees ranged from 1.2 to 10.6 mm for standing stress radiographs and 2.7 to 11.2 mm for supine stress radiographs, with high sensitivities and specificities for both.

Conclusion

Stress radiography was a dependable diagnostic method for identifying ACL rupture. Further research is necessary to determine the ideal anatomic landmarks, optimal patient positioning, and appropriate applied stresses to establish a standardized protocol for both assessing ACL tears and evaluating the postoperative integrity of ACL reconstruction using stress radiography.

Editorial Commentary: Trends in Hip Arthroscopy Require Rapid Dissemination From Higher-Volume and Academic Surgeons to the Greater Orthopaedic Community

Trends in hip arthroscopy show that labral repair and preservation, capsular repair and preservation, and treatment of femoroacetabular impingement during hip arthroscopy are associated with superior short-term and mid- to longer-term outcomes. Hip arthroscopy, and in particular arthroscopic femoroacetabular impingement correction, is in its infancy compared with many other orthopaedic procedures. As we assimilate knowledge, data, and evidence-based research, it is critical to evaluate surgical trends and how they affect our management of these patients and pathologies. However, it is important to recognize that there is great variability with regards to surgical volume and awareness of impending evidence-based research for relatively newer procedures such as hip arthroscopy. This can lead to delays for incorporating newer evidence-based techniques. The gap is closing, but the time required to close this disparity in management trends between higher-volume/academic surgeons and the orthopaedic community as a whole could be shorter. Whether this delay for adapting evidence-based trends is consistent across the spectrum of orthopaedic surgery or specific to smaller subspecialty areas such as hip arthroscopy is unclear. Regardless, it is essential that those who are performing the larger volume of cases and research must raise our voices, turn up our loudspeakers, and publish, present, and use social media platforms to spread the word of the latest evidence-based trends quickly! It is equally critical for the greater orthopaedic community to listen for the benefit of patients. If all parties collaborate, we can get up to speed in a timelier manner and achieve the best-possible outcomes together.

Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Acetabular Rim Ossification Variants Are Found in Almost 20% of Patients Presenting With Hip Pain

Purpose

To determine the prevalence of 4 different types of acetabular rim ossifications, including partial labral ossification or punctate calcification, true os acetabuli, acetabular rim stress fracture, and complete labral ossification, and to determine whether different types of periacetabular ossifications are linked to demographic or radiological factors.

Methods

We retrospectively reviewed the medial records of patients presenting for hip-related complaints at 2 sports medicine practices from September 2007 to December 2009. An anteroposterior radiograph of both hips and a lateral radiograph of each hip was obtained for all patients and reviewed for findings of cam and pincer femoroacetabular impingement, degenerative changes (Tönnis grade), and periacetabular calcifications for both hips. These parameters were also evaluated with respect to symptoms, sex, and age.

Results

Four hundred ninety-one consecutive patients (982 hips) presented to 2 orthopaedic surgeons at 2 centers for "hip"-related complaints. There were 223 males and 268 females (age 39 ± 14 years). The overall prevalence of periacetabular calcifications in hips was 17.6%, with 56.6% of calcifications in the symptomatic hip and 43.4% in the contralateral hip. Four basic patterns of calcification were identified: punctuate calcifications within the labrum (8.0% hips), large rounded calcifications (os acetabuli) (4.2% hip), large fragments with a vertical line of the superior-lateral acetabular rim, consistent with healed or non-healed stress fracture (2.0% hips), and complete ossification of the labrum (3.4% hips). Overall, male sex (P = .002), increased lateral center-edge angle (P = .046), and higher Tönnis grade (P < .001) statistically predicted the presence of periacetabular ossification. Punctate calcifications were more prevalent in males (P = .002). Higher Tönnis grade (P = .029) and increased alpha angle (P = .046) were more prevalent with os acetabuli. Younger age (P = .001), male sex (P = .048), increased alpha angle (P = .012), and increased lateral center-edge angle (P < .001) were more prevalent in acetabular rim fractures. No factors were statistically significant at predicting the presence of an ossified labrum.

Conclusions

Periacetabular calcifications are not uncommon. Four particular patterns of calcification are identified: punctate labral calcifications (8%), larger rounded calcifications (i.e., os acetabuli) (4.2%), acetabular rim stress fractures (2%), and complete ossification of the labrum (3.4%) for a combined prevalence of 17.6% in patients presenting to an orthopaedic surgeon with "hip"-related complaints. Nearly half were in the asymptomatic hip. Male sex had a higher prevalence of periacetabular calcifications. An increased lateral center edge angle and higher Tönnis grade also had a higher prevalence of periacetabular calcifications. Younger male patients are more likely to have acetabular rim stress fractures. Patients with an increased alpha angle have a higher prevalence of os acetabuli and rim stress fractures.

Clinical Relevance

This study aims to identify, quantify, and categorize periacetabular calcifications about the hip. Their clinical relationships and relevance have been discussed, but no study has distinctly categorized the various types and their prevalence. This study provides a framework for identification and categorization.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery

BACKGROUND

Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI).

PURPOSE

To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed.

RESULTS

Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up.

CONCLUSION

Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

Clinic and Home-Based Exercise with Blood Flow Restriction Resolves Thigh Muscle Atrophy after Anterior Cruciate Ligament Reconstruction with the Bone-Patellar Tendon-Bone Autograft: A Case Report

Anterior cruciate ligament reconstruction (ACLR) results in thigh muscle atrophy. Of the various interventions proposed to mitigate thigh muscle atrophy, exercise with blood flow restriction (BFR) appears safe and effective. Some literature suggests daily exposure to exercise with BFR may be indicated during the early phase of ACLR rehabilitation; this case report outlines the methodology utilized to prescribe clinic- and home-based BFR within an outpatient rehabilitation program. A 15-year-old male soccer player suffered a left knee injury involving the anterior cruciate ligament and both menisci. He underwent ACLR and completed exercise with BFR as part of his clinic- and home-based rehabilitation program, which included practical blood flow restriction during home-based rehabilitation. After 16 weeks of rehabilitation, surgical limb thigh girth values were objectively larger than the non-surgical limb (surgical, 52.25 cm; non-surgical 50 cm), as well as the multi-frequency bioelectrical impedance analysis of his lower-extremity lean body mass (surgical limb, 10.37 kg; non-surgical limb, 10.02 kg). The findings of this case report suggest that the inclusion of clinic- and home-based BFR within an outpatient rehabilitation program may be indicated to resolve thigh muscle atrophy early after ACLR.

Editorial Commentary: Minimizing Traction Force and Time as Well as Application of Specific Technical Pearls Might Trump the Importance of Choosing Between Post or Postless Hip Arthroscopy With Regards to Complications

Recently, there has been a trend toward performing hip arthroscopy without a post (postless) in an effort to decrease perineal post-related complications. Previous studies have revealed a variable risk of pudendal nerve neuralgia and perineal soft-tissue injury when using a post. There is emerging evidence that arthroscopic hip procedures can be done without the use of a post, with less traction force on the perineal region, and with adequate exposure to safely accomplish a well-done femoroacetabular impingement corrective procedure. Prospective comparative studies with conclusive evidence of the superiority of either technique, however, are lacking. Complications with a post are likely associated with high traction forces, prolonged traction times, and potentially suboptimal technique and patient positioning. In addition, postless traction is in its infancy and new adverse events/outcomes are likely to emerge. There are likely specific situations and patient populations in which one technique might be superior to the other. We are the carpenters of medicine and rather than blaming our tools and throwing out a technique that has served us well for decades, we should better understand some important pearls and pitfalls that might allow either method to be safely performed.

Outcomes of Arthroscopic Decompression of the Anterior Inferior Iliac Spine: A Systematic Review and Meta-analysis

BACKGROUND

Anterior inferior iliac spine (AIIS) impingement has been increasingly recognized as a source of extra-articular impingement and hip pain. However, no aggregate data analysis of patient outcomes after AIIS decompression has been performed.

PURPOSE

To evaluate outcomes after arthroscopic AIIS decompression.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were queried for all English-language studies reporting outcomes of arthroscopic AIIS decompression performed in isolation or in conjunction with hip impingement correction surgery. After screening, 10 articles were included. The indications for AIIS decompression were recorded, and weighted mean improvements in patient-reported outcome (PRO) scores, complication rates, and revision rates were calculated.

RESULTS

A total of 547 patients (311 women; 57%) were identified, with a total of 620 operative hips. The mean age was 28.42 ± 5.6 years, and the mean follow-up was 25.22 ± 11.1 months. A total of 529 hips (85%) underwent AIIS decompression, 530 hips (85%) underwent femoral osteochondroplasty, and 458 hips (74%) underwent labral repair. Of the patients, 13% underwent bilateral AIIS decompression. The mean modified Harris Hip Score improved from 61.3 ± 6.9 to 88.7 ± 4.7 postoperatively (change, 27.4 ± 5.7 points; P < .001), the Hip Outcome Score-Activities of Daily Living improved from 67.2 ± 10.6 to 91.1 ± 3.2 postoperatively (change, 24.0 ± 8.0 points; P = .001), and the Hip Outcome Score-Sports Specific Subscale improved from 36.8 ± 19.2 to 82.8 ± 3.8 postoperatively (change, 46.0 ± 18.2 points; P = .002). The pooled risk of postoperative complications was 1.1% (95% CI, 0.1%-2.1%), and the pooled risk of needing revision surgery was 1.0% (95% CI, 0.1%-2.0%). No complication was directly attributed to the AIIS decompression portion of the procedure.

CONCLUSION

PROs improved significantly after hip arthroscopy with AIIS decompression, with a low risk of postoperative complications and subsequent revision surgeries. Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the AIIS, could lead to poorer outcomes and future revision surgery.

Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers

Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.

Quadriceps Strength following Anterior Cruciate Ligament Reconstruction: Normative Values based on Sex, Graft Type and Meniscal Status at 3, 6 & 9 Months

Background

Higher postoperative quadriceps function has been positively associated with surgical outcomes after anterior cruciate ligament reconstruction (ACLR). However, the impact of autograft harvest and/or a concomitant meniscal procedure on the recovery of quadriceps strength is not well defined.

Purpose

To describe postoperative recovery of quadriceps strength following ACLR related to autograft selection, meniscal status, and sex.

Study Design

Retrospective Cohort.

Methods

One hundred and twenty-five participants who underwent ACLR with either a hamstring tendon (HT), bone-patellar tendon-bone (BPTB) or quadriceps tendon (QT) autograft were included. At postoperative months 3, 6 and 9, each participant completed an isometric quadriceps strength testing protocol at 90-degrees of knee flexion. Participants' quadriceps average peak torque (Q-AvgPKT), average peak torque relative to body weight (Q-RPKT), and calculated limb symmetry index (Q-LSI) were collected and used for data analysis. Patients were placed in groups based on sex, graft type, and whether they had a concomitant meniscal procedure at the time of ACLR. At each time point, One-way ANOVAs, independent samples t-test and chi-square analyses were used to test for any between-group differences in strength outcomes.

Results

At three months after ACLR, Q-RPKT was significantly higher in those with the HT compared to the QT. At all time points, males had significantly greater Q-RPKT than females and HT Q-LSI was significantly higher than BPTB and QT. A concomitant meniscal procedure at the time of ACLR did not significantly affect Q-LSI or Q-RPKT at any testing point.

Conclusion

This study provides outcomes that are procedure specific as well as highlights the objective progression of quadriceps strength after ACLR. This information may help better-define the normal recovery of function, as well as guide rehabilitation strategies after ACLR.

Level of Evidence

3.

Arthroscopic Debridement Versus Refixation of the Acetabular Labrum Associated With Femoroacetabular Impingement: Updated Mean 7-Year Follow-up

BACKGROUND

Short- and midterm follow-up studies suggest that arthroscopic labral refixation/preservation leads to superior outcomes compared with labral excision/debridement.

PURPOSE

To update the previous early (16 months) and midterm (mean, 42 months) follow-up of this cohort, which reported better patient-reported outcome measures and lower failure rates in the repair/refixation group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors identified patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. A consecutive group of patients within the labral debridement group thought to be repairable with the authors' current arthroscopic techniques were compared with a group of consecutive patients who underwent labral repair/refixation. In 46 hips, the labrum was focally excised/debrided consistent with pincer- or combined pincer- and cam-type impingement; in 54 hips, the labrum was repaired/refixed. Subjective outcomes were measured with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) for pain preoperatively and postoperatively.

RESULTS

The mean age was 34.0 years in the debridement group and 28.3 years in the repair/refixation group, with a mean follow-up of 7.3 years (range, 2-13.6 years). At the mean follow-up of 7.3 years, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The mHHS (P = .008), SF-12 score (P = .012), and VAS pain score (P = .002) were all significantly better for the repair/refixation group compared with the debridement group. Although most recent outcomes for both groups fell slightly at the mean follow-up of 7.3 years in comparison with the 16-month and 3.5-year follow-ups, these differences were not significant. However, the failure rate in the debridement group did get significantly worse (P = .014). Good to excellent results were 47.7% in the debridement group and 86.3% in the refixation group (P < .001), and failure rates were 30.4% (debridement) and 13% (refixation) (P = .033). There were 4 revisions in the debridement group and 3 revisions in the refixation group.

CONCLUSION

Longer term, >7-year follow-up comparing focal labral excision/debridement with repair/refixation revealed better patient-reported outcomes and lower failure rates in the labral repair/refixation cohort. Additionally, despite an absolute decrease in patient-related outcome scoring and number of good/excellent results in both groups compared with the 3.5-year report, there was a significantly greater increase in failure rates over time for the excision/debridement group with better maintenance of good to excellent results in the repair/refixation group.

Editorial Commentary: Psoas Tenotomy in the Setting of a Borderline Dysplastic Hip Risks Iatrogenic Instability: Be Extremely Cautious and Particularly in Athletes

Successful outcomes after psoas tenotomies have been reported and proposed in the setting of recalcitrant internal snapping and psoas impingement. However, case reports citing hip flexion weakness and iatrogenic instability created concern regarding the role for psoas tenotomies. Despite these concerns, some recent studies reporting improved outcomes after endoscopic psoas tenotomies breathe further life into this controversial topic. Psoas tenotomy in the setting of a borderline dysplastic hip likely carries an even greater risk for iatrogenic instability. It might be critical to evaluate for clinical signs and symptoms of instability in addition to radiographic parameters to avoid this potentially devastating complication. In addition, the traditional definition of borderline dysplasia is based on lateral acetabular coverage that might be less important than anterior acetabular coverage and femoral version when contemplating psoas tenotomies on the basis of the dynamic anterior stabilizing effect of the iliopsoas myotendinous unit. Surgeons should also be extremely cautious when considering psoas tenotomy in an athletic population with the potential for persistent weakness and limited data hinting at inferior sports specific outcomes. In the end, it is not clear whether the psoas tenotomy "drives" the improvements seen in some studies, or whether many of these patients ultimately battle their way into a minimally clinically important difference "despite" the psoas tenotomy.

High incidence of acute self-reported sleep disturbances in patients following arthroscopic-assisted knee surgery

OBJECTIVES

To evaluate the self-reported incidence of sleep disturbances, defined as ≤7 hours of sleep per 24-hour period, in patients undergoing arthroscopic-assisted knee surgery.

METHODS

Patients who underwent arthroscopic knee surgery over the course of a 4-month period were prospectively included. Patients were excluded if a history of insomnia or other sleep altering medical history was reported. Self-reported sleep metrics included average number of hours of sleep per night, average number of awakenings during sleep per night, perceived quality of sleep, average pain level during sleep and number of hours of physical activity/therapy per week. Data were collected at weeks 1, 3, and 6 postoperatively. Joint circumference was measured on postoperative day 1 and served as an indicator of a knee effusion. Paired t-tests were used to compare preoperative to postoperative hours of sleep. Simple and multiple linear regression were used to evaluate relationships between surgical variables and postoperative sleep metrics.

RESULTS

There were 123 patients who underwent arthroscopic knee surgery during the prospective enrolment period; 83 patients were included in the final analysis. The overall incidence of preoperative sleep disturbances was 20% (n=17). The overall incidence of self-reported postoperative sleep disturbances was 99%, 96% and 90% at weeks 1, 3 and 6, respectively. The average number of hours slept was significantly reduced at 1, 3 and 6 weeks postoperatively compared with the preinjury state (p<0.001). Knee joint circumference had a significantly negative correlation with average number of hours of sleep in the first 6 weeks postoperatively (R=-0.704; p=0.001). Surgical variables including severity of surgery, weekly postoperative pain level and weekly hours of postoperative physical therapy were not significant independent predictors of acute postoperative sleep disturbances (p>0.05).

CONCLUSION

Sleep disturbances were commonly reported in patients following arthroscopic knee surgery without correction of sleep metrics by 6 weeks postoperatively. The majority of sleep disturbances in this cohort correlated with an increased knee effusion. A multidisciplinary team approach is recommended to counsel patients regarding the potential for and problems with acute sleep disturbances following arthroscopic knee surgery.Level of evidence: 3.

Low-Energy Multiligament Knee Injuries Are Associated With Higher Postoperative Activity Scores Compared With High-Energy Multiligament Knee Injuries: A Systematic Review and Meta-analysis of the Literature

BACKGROUND

Multiligament knee injuries (MLKIs) can result from high-energy injury mechanisms such as motor vehicle accidents or low-energy injury mechanisms such as activities of daily living or sports.

PURPOSE/HYPOTHESIS

The purpose was to conduct a systematic review on postoperative patient-reported outcomes after MLKIs and to conduct a meta-analysis of comparable outcome variables based upon high- versus low-energy injury mechanisms. It was hypothesized that MLKIs with low-energy injury mechanisms would demonstrate significantly improved subjective clinical outcome scores compared with high-energy injuries.

STUDY DESIGN

Meta-analysis and systematic review.

METHODS

A systematic review was performed with the inclusion criteria of postoperative MLKI outcomes based upon high-versus low-energy mechanisms of injury with a minimum 2-year follow-up. Outcome scores included were the Lysholm knee scoring scale, Tegner activity scale, and the International Knee Documentation Committee (IKDC) score. High-energy mechanisms included motor vehicle accidents or falls from a height >5 feet; low-energy mechanisms included sports-related injuries, activities of daily living, or falls from <5 feet. A meta-analysis was performed comparing the outcome scores of high- versus low-energy mechanisms of MLKIs.

RESULTS

Overall, 1214 studies were identified, 15 of which were included in the systematic review and meta-analysis. Thirteen studies included surgical reconstructions of all injured ligaments. A total of 641 patients with 275 high-energy and 366 low-energy injuries were grouped for comparison in the meta-analysis. No significant differences in Lysholm scale (78.6 vs 78.0) or IKDC scores (69.0 vs 68.4) were found between high- and low-energy groups at a minimum of 2 years (range, 2-10 years) postoperatively (P > .05). The low-energy injury group demonstrated significantly higher Tegner activity scale scores (5.0 vs 3.9; P = .03). There was no significant difference in failure rates between groups (3.5% vs 2.0%; P = .23).

CONCLUSION

We found in this systematic review and meta-analysis that patients with low-energy mechanisms of MLKI surgery had improved postoperative Tegner activity scores compared with those patients with high-energy mechanisms after MLKI surgery. However, there were no differences in Lysholm score, IKDC score, or failure rates between high- and low-energy MLKI patients at an average of 5.3 years postoperatively.

Is Arthroscopic Hip Labral Repair/Reconstruction Surgery Effective for Treating Femoroacetabular Impingement in the Presence of Osteoarthritis?

OBJECTIVE

To investigate clinical outcomes after arthroscopic labral preservation surgery for femoroacetabular impingement (FAI) in the presence of osteoarthritis (OA) compared with FAI without significant OA.

DESIGN

Retrospective case-control study.

SETTING

Department of Orthopaedic Surgery and Sports Medicine, Hospital of Academic Institute.

PATIENTS

Femoroacetabular impingement patients (n = 97; ≥35 years) undergoing arthroscopic FAI correction with labral preservation surgery from March 2009 to April 2014 were enrolled in this study.

INTERVENTIONS

Patients were divided into 2 groups: FAI group (79 patients), with Tonnis grade 0 or 1, and FAI + OA group (18 patients), with Tonnis grade 2 or 3.

MAIN OUTCOME MEASURES

We examined the clinical outcomes using the Modified Harris Hip Score (MHHS), Nonarthritic Hip Score (NAHS), and the conversion rate to total hip arthroplasty (THA).

RESULTS

No significant differences existed between the 2 groups with respect to age, sex, follow-up period, or preoperative MHHS or NAHS. The mean MHHS and NAHS at the final follow-up were significantly lower in the FAI + OA group than in the FAI group. There was a significant difference in the rate of conversion to THA and failure between the 2 groups (THA 5% vs 50%) (failure 15% vs 67%).

CONCLUSION

Patients with FAI in the presence of OA did not improve after arthroscopic labral preservation surgery and had a high conversion rate to THA.

LEVEL OF EVIDENCE

Level III.

Posterior Tibial Slope: Understand Bony Morphology to Protect Knee Cruciate Ligament Grafts

Improved understanding of the biomechanical significance and clinical repercussions of tibial slope on cruciate ligament function has sparked a newfound clinical interest in this morphological feature. Using either magnetic resonance imaging or lateral tibia radiographs, the anterior-posterior angulation of the tibial plateau relative to the tibial shaft can be measured. Clinical and biomechanical studies have reported that increased posterior tibial slope (PTS) places significantly increased tension on the native and reconstructed anterior cruciate ligament (ACL), leading to an increased risk of failure. It has also been suggested that increased PTS of the lateral tibial plateau has a greater impact on ACL forces and anterior tibial translation than PTS of the medial tibial plateau. Conversely, a decreased PTS has been shown to be a risk factor for recurvatum deformity, posterior cruciate ligament (PCL) injury, and posterior tibial translation and has been linked to single bundle PCL reconstruction failure. In the setting of ACL insufficiency with a PTS greater than 12°, anterior closing wedge osteotomy has been shown to be protective for ACL reconstructions. Alternatively, some surgeons have advocated for the addition of lateral extraarticular stabilization procedures in the setting of increased PTS. Further, in the setting of PCL insufficiency with an anteriorly directed, or flat, PTS, anterior opening wedge osteotomy has shown encouraging results. In addition, double bundle PCL reconstructions should be strongly considered in the setting of anteriorly directed, or flat, tibial slope.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption

PURPOSE

To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.

RESULTS

Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.

CONCLUSIONS

A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.

LEVEL OF EVIDENCE

Level V, systematic review of Level I to V studies.

Capsule-Preserving Approach to Arthroscopic Decompression of the Anterior Inferior Iliac Spine

Hip arthroscopy techniques have evolved to treat a wide range of extra-articular pathologies. Subspine impingement commonly occurs in femoroacetabular impingement, particularly in athletes with a high range of motion, patients with low degrees of femoral version, and those with large subspine deformities. A reliable technique that preserves the hip capsule would be helpful for hip arthroscopy surgeons. This note details our technique using pericapsular windows proximal to the interportal capsulotomy to access and decompress a subspine deformity in the setting of hip femoroacetabular impingement.

Editorial Commentary: Ultrasound-Guided Injection With Dynamic Assessment Could Improve Outcomes in Atypical and Revision Hip Arthroscopy Patients: But Today, Few Are Trained to Hear at Such High Frequencies

Imaging modalities for hip disorders all have their strengths and weaknesses. Magnetic resonance imaging is superior for evaluating soft tissue pathology, computerized tomography best characterizes osseous morphology, and plain radiographs can accurately depict 2-dimensional anatomy and are familiar to most clinicians. Ultrasound-guided injections have become commonplace in the musculoskeletal arena. Ultrasound evaluation of musculoskeletal anatomy has received increased attention, has the ability to image soft tissue and osseous structures, and more importantly, has the ability to dynamically evaluate these structures in real time. A noninvasive dynamic assessment of the hip region could be an absolute game changer for the hip preservation/sports medicine community in the diagnosis of atypical hip pain, femoroacetabular impingement, and labral tears. Widespread ability and expertise to perform these dynamic ultrasound assessments, however, is not in place at this time. We need more training and studies to best harness the potential benefits of these sound waves.

Posterior Tibial Slope Measurements Using the Anatomic Axis Are Significantly Increased Compared With Those That Use the Mechanical Axis

PURPOSE

To compare posterior tibial slope (PTS) measurements from standard lateral knee radiographs with measurements from full-length lateral tibia radiographs.

METHODS

We performed a multicenter, prospective study. Lateral knee and full-length lateral tibia radiographs were obtained for each patient, and PTS was measured. Slope measurements were obtained by measuring the angle between an average of the medial and lateral tibial plateaus and a representative tibial diaphysis line. The proximal anatomic axis was measured on lateral knee radiographs, and both the mechanical axis and anatomic axis were measured on full-length lateral tibia radiographs. The mechanical axis was defined as the center of the plateau to the center of the plafond, and the anatomic axis was defined as the center of the tibial diaphysis. The minimal clinically significant difference was defined a priori as 2° of PTS or greater.

RESULTS

A total of 140 patients met the inclusion criteria. The average PTS using the proximal anatomic axis was 11.6° ± 3.2° on lateral knee radiographs; the PTS measured on full-length lateral tibia radiographs was 9.5° ± 3.4° using the mechanical axis and 11.8° ± 3.1° using the anatomic axis. There was a significant difference between the measurements with the mechanical axis and both anatomic axis measurements (P < .01) but no significant difference between the 2 anatomic axis measurement techniques (P = .574). In total, 55% of patients (n = 77) had a 2° or greater difference between the proximal anatomic axis and mechanical axis PTS measurement techniques.

CONCLUSIONS

There was no significant difference between PTS measurements that used the proximal anatomic axis from lateral knee radiographs and those that used the anatomic axis from full-length lateral tibia radiographs. Thus, lateral knee radiographs are adequate to accurately obtain tibial slope measurements. However, there was a significant difference between PTS measurements that used the anatomic axis and those that used the mechanical axis of the tibia.

CLINICAL RELEVANCE

It is recommended that future studies report tibial slope based upon measurements that utilize the anatomic axis in order to ensure that subsequent conclusions are comparable, independent of the radiographic view.

Surgical Treatment of Femoroacetabular Impingement: Hip Arthroscopy Versus Surgical Hip Dislocation: A Propensity-Matched Analysis

BACKGROUND

Surgical treatment of femoroacetabular impingement (FAI) continues to evolve and is most commonly approached with either hip arthroscopy (HA) or surgical dislocation (SD) of the hip. The purpose of this study was to compare the outcomes of similar patients undergoing surgical treatment of FAI with either HA or SD.

METHODS

A prospective multicenter cohort study of patients undergoing primary surgical treatment of FAI was performed. Follow-up at a minimum of 1 year (mean, 4.3 years) was available for 621 hips (81.7%), including 399 procedures with HA and 222 procedures with SD. Propensity scores were calculated and reflect the likelihood of surgical treatment with HA versus SD for a given set of covariates. Propensity scores allowed 1:1 matching to identify similar patients at baseline. After propensity matching, 128 matched pairs of patients who underwent HA and 128 matched pairs of those who underwent SD were included in the study. The primary outcome was the postoperative modified Harris hip score (mHHS); secondary outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS), the University of California Los Angeles (UCLA) activity score, and the Short Form-12 (SF-12) physical and mental subscores, as well as the rate of persistent symptoms, revision surgery, and total hip arthroplasty (THA).

RESULTS

After propensity matching, the 2 groups exhibited similar distributions of all of the covariates that were included in the model. Both groups demonstrated significant improvements in all patient-reported outcomes (PROs). The final mHHS was not significantly different between the 2 matched groups (81.3 for the HA group versus 80.2 for the SD group, p = 0.67). Likewise, the HOOS pain subscale was similar at the time of final follow-up (77.6 versus 80.5, respectively, p = 0.32). No difference between the HA group and the SD group was identified in the rate of THA (0% and 3.1%, respectively, p = 0.41) and revision surgery (7.8% and 10.9%, respectively, p = 0.35); overall rates of persistent symptoms were 21.9% for the HA group and 24.4% for the SD group (p = 0.55).

CONCLUSIONS

In a propensity-matched analysis of patients who were treated with either approach, patients undergoing HA or SD demonstrated similar outcomes at a mean of 4 years postoperatively.

LEVEL OF EVIDENCE

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

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

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

Ischemic Therapy in Musculoskeletal Medicine

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Literature review.

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, case series.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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

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

Characterization and Correction of Symptomatic Hip Impingement in American Football Linemen

BACKGROUND

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

PURPOSE/QUESTIONS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Economic and decision analysis; Level of evidence, 2.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case control study.

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

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

Indications for Hip Arthroscopy

CONTEXT

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

EVIDENCE ACQUISITION

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

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

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

CONCLUSION

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

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

BACKGROUND

Hip disorders in athletes have been increasingly recognized.

PURPOSE

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

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

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

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

The Hip in Ice Hockey: A Current Concepts Review

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

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

BACKGROUND

Reports regarding arthroscopy for mild hip dysplasia have conflicting results.

HYPOTHESIS

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Ehlers-Danlos Syndrome: Arthroscopic Management for Extreme Soft-Tissue Hip Instability

PURPOSE

To present outcomes in a series of patients with Ehlers-Danlos syndrome (EDS)-hypermobility type who underwent hip arthroscopy for associated hip pain and extreme capsular laxity.

METHODS

A retrospective chart review identified 16 hips with confirmed EDS--hypermobility type that underwent hip arthroscopy for continued pain and capsular laxity. All patients had complaints of "giving way" and pain, an easily distractible hip with manual traction under fluoroscopy, and a patulous capsule at the time of surgery. No patient had osseous evidence of acetabular hip dysplasia or prior confirmed hip dislocation. Outcomes were evaluated preoperatively and postoperatively with the modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey (SF-12), and a visual analog scale (VAS) for pain.

RESULTS

Evidence of symptomatic femoroacetabular impingement (FAI) was found in 15 hips (93.8%). The 16th hip had subjective giving way with a positive anterior impingement test and was easily distractible, had a labral tear, and had a patulous capsule at the time of surgery. The mean follow-up period was 44.61 months (range, 12 to 99 months). The mean preoperative lateral center-edge angle was 31.8° (range, 25° to 44°), and the mean Tönnis angle was 3.6° (range, -2° to 8°). Mean femoral version measured on computed tomography (CT) scans was 19.2° (range, -4.0° to 31.0°). Of the hips, 13 underwent primary arthroscopy and 3 underwent revision. All hips underwent hip arthroscopy with an interportal capsular cut only and arthroscopic capsular plication. There were 13 labral repairs, 2 labral debridements, 8 rim resections, 15 femoral resections, 2 psoas tenotomies, and 1 microfracture. Improved stability with an inability to distract the hip with manual traction under fluoroscopy was noted in all hips after plication. The mean alpha angle preoperatively was 58.7° on anteroposterior radiographs and 63.6° on lateral radiographs compared with 47.4° and 46.1°, respectively, postoperatively. There were significant improvements for all outcomes (mHHS, P = .002; SF-12 score, P = .027; and VAS score, P = .0004). The mean mHHS, SF-12 score, and VAS score were 45.6 points, 62.4 points, and 6.5 points, respectively, preoperatively compared with 88.5 points, 79.3 points, and 1.6 points, respectively, at a mean follow-up of 45 months. No EDS patients were lost to follow-up or excluded from analysis. The mean improvement in mHHS from preoperatively to postoperatively was 42.9 points, and there were no iatrogenic dislocations. One patient underwent further revision arthroscopy for recurrent pain, subjective giving way, and capsular laxity.

CONCLUSIONS

FAI and extreme capsular laxity can be seen in the setting of EDS. Although increased femoral version was common, acetabular dysplasia was not common in our study. Meticulous capsular plication, arthroscopic correction of FAI when present, and labral preservation led to dramatic improvements in outcomes and subjective stability without any iatrogenic dislocations in this potentially challenging patient population.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.