PurposeTo investigate the return to sport (RTS) rate in patients with hip dysplasia after combined periacetabular osteotomy (PAO) and hip arthroscopy.SignificancePrior studies of patients with hip dysplasia have documented approximately 75% RTS with arthroscopy alone, 75 to 92.5% RTS with PAO alone, and approximately 82% with combined PAO and hip arthroscopy. Combined procedures may be the most successful in this population.MethodologyThis was a retrospective single-institution review of all patients who underwent a combined PAO and hip arthroscopy between 2016 and 2023. One pair of surgeons performed all procedures. Inclusion criteria were hip dysplasia and documented participation in a sport or athletic activity undergoing a combined PAO and hip arthroscopy. Patients were excluded for not participating in a sport or activity or follow up less than 6 months. Demographic data was compiled from electronic medical record review to include age, body mass index (BMI), sex, sports or activities, and history of prior hip surgery. Modified Harris hip score (mHHS), RTS, and time to RTS were documented. Preoperative and postoperative radiographs were reviewed with documentation of lateral center edge angle (LCEA), extrusion index (EI), acetabular index (AI), and alpha angle.ResultsA total of 103 athletic hips were included with a mean age and BMI of 20.3 +/- 6.9 years and 23.9 +/- 4.5, respectively. Mean LCEA and AI were 20.8 +/- 5.4 and 11.9 +/- 4.8, respectively. Average postoperative follow up was 514.9 +/- 326.5 days. From this cohort, 89.3% of hips returned to sport at an average of 297.5 days. There was no significant association between RTS rates and any demographics, diagnoses, or preoperative and postoperative measurements. There was no significant association between RTS and mHHS. There was no significant association between degree of dysplasia and RTS. Contact athletes had an 82.5% RTS and non-contact athletes had an 93.7% RTS.ConclusionsCombined PAO and hip arthroscopy may be the most successful procedure for patients with hip dysplasia hoping to return to sport. Our data suggests higher RTS rates than previously documented, even in patients with severe dysplasia and those participating in contact sports.

BackgroundAtraumatic microinstability of the hip remains a poorly defined clinical entity. The 2023 Delphi consensus study done by Khanduja et al. represents the only structured attempt to categorize diagnostic criteria, classifying various clinical, radiographic, and intraoperative factors as Major, Minor, or Not Included. However, further validation by experienced hip preservation surgeons is needed to assess the real-world relevance and applicability of these classifications.MethodsThe study group, Multicenter Arthroscopic Study of the Hip (MASH), of 10 fellowship-trained hip arthroscopists independently rated 44 potential indicators of atraumatic hip microinstability on a 1–10 scale of diagnostic importance. The 36 factors from the Delphi study were supplemented with additional criteria identified through a systematic review of the literature on hip microinstability performed by our study group. Mean scores were calculated, and factors were divided into tertiles: the top third mapped to Major, the middle third to Minor, and the bottom third to Not Included. Concordance was defined as agreement between the two groupings, and discordant factors were further analyzed.ResultsOf the 44 evaluated factors, only 17 (38.6%) were categorized similarly by both the Delphi and MASH groups, while 27 (61.4%) were placed in different categories of diagnostic importance. Several Major criteria of the Delphi study—including Vacuum sign under manual traction, Positive Hyperextension-External Rotation Test, and Hip pain—were placed in the bottom third by the MASH group. Conversely, factors identified through systematic review, such as Ligamentum Teres Tears and Distended Capsule on MRI, were rated with moderate to high importance by MASH surgeons. Additionally, some Delphi Minor criteria—such as Unrepaired Hip Capsulotomy and History of Dislocation/Subluxation—were among the highest-rated by MASH.DiscussionWhile the Delphi study provides a valuable starting point for defining atraumatic hip microinstability, the majority of factors were not categorized consistently between groups. The MASH group tended to prioritize imaging and intraoperative findings, including systematically identified factors not considered by Delphi, while placing less emphasis on physical exam maneuvers and generic symptoms. These discrepancies highlight the need for a revised, evidence-informed classification system that integrates both emerging diagnostic tools and clinical expertise.

PurposeTo perform a systematic review of studies reporting on minimum 10-year outcomes of patients undergoing hip arthroscopy (HA) to determine whether capsular management influences PROs, rates of clinically significant outcome, rates of revision surgery or conversion to total hip arthroplasty (THA), and rates of osteoarthritis progression.MethodsPubMed and Google Scholar were searched around the terms hip arthroscopy, FAIS, 10-year follow-up, and capsule management. Articles available in English, presenting original data, and reporting minimum 10-year follow-up after HA using either PROs, conversion to THA and/or revision surgery, or rates of osteoarthritis progression were included.ResultsFourteen articles were included. Nine studies were identified without capsular repair including a total of 1,189 hips, at an age of 24.4 – 43.0 years and follow-up range of 10.0-20.0 years. Five studies were identified with capsular repair including a total of 594 hip, at an age range of 16.0 – 34.3 years and follow-up range of 10.0-12.0 years. Nine studies included PROs and all reported significant improvement (p<0.05) at the 10-year timepoint, with modified Harris Hip Score (mHHS) being the most frequent (n=8). No differences were noted between groups regarding any of the measured PROs. Average rates of achieving MCID and PASS for mHHS were similar between patients without capsular repair (MCID 74.5%-88%, PASS 62.0%-83.3%, n=3) and with capsular repair (MCID 75.5%-89.0%, PASS 65.4%-84, n=4). Revision rates in unrepaired capsules ranged from 2.5%-24%, while repaired capsular studies ranged from 4.7%-10%. Conversion to THA occurred in 0%-54% and 0%-9% % for patients with an unrepaired and repaired capsule, respectively. One study reported that hip arthroscopy demonstrated 25% chance of improved Tonnis grade compared to the nonoperative hip, with a relative risk reduction of 42% regarding osteoarthritis progression.ConclusionsPatients undergoing hip arthroscopy for FAI had significant improvement in PRO scores at minimum 10-year follow-up, and scores did not differ between patients that underwent capsular repair and those that did not. Similar rates of markers of clinical benefit and revision were achieved by both groups; however, lower rates of conversion to total hip arthroscopy were demonstrated in the capsular repair cohort.

IntroductionLimited literature exists investigating the relationship between the environmental burden patients face and their outcomes after orthopaedic surgery, especially hip arthroscopy.MethodsThis retrospective cohort study included patients who, after failing conservative treatment, underwent primary hip arthroscopy for symptomatic labral tears secondary to femoroacetabular impingement by a single surgeon. Patients were shortlisted for this specific study if they underwent surgery between 2002 and 2013 and completed surveys for modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT), Lower Extremity Functional Scale (LEFS), and pain relief. Excluded patients did not provide consent, were < 18 years of age, had Tönnis grade ≥ 2, hip dysplasia (LCEa < 20°), incomplete follow-up data, and/or history of ipsilateral hip surgery or revision surgery. Using the CDC’s Environmental Justice Index (EJI) Explorer, included patients were stratified into two main cohorts, low environmental burden (0-49th percentile) and high environmental burden (50-100th percentile). Student’s t-tests and multivariate linear regression were used to compare continuous variables, and categorical variables were compared using chi-squared tests. This study was approved by the IRB.ResultsThe present study included 161 patients (50.9% female; mean age±SD: 37.7±11.22). Patients had a mean±SD follow-up of 10.9±2.33 years and body mass index (BMI) of 26.1±4.29 kg/m^2. In the low environmental burden cohort (n=60), there was a greater proportion of females, and in the high environmental burden cohort, there was a greater proportion of males (57.4% vs 42.6% and 40.0% vs 60.0%, p<0.001). Multivariate linear regression analyses adjusting for demographic, radiographic, and intraoperative findings further demonstrated that the high environmental burden cohort had significantly better outcomes for LEFS and iHOT than the low environmental burden cohort (p<0.05). Patients reached PASS (Patient Acceptable Symptom State) for iHOT at a higher frequency in the high environmental burden cohort than those in the low environmental burden cohort (53.4% vs 34.3%, p<0.05).ConclusionAn association between environmental burden and outcomes after hip arthroscopy exists. Cumulative environmental effects have been shown to have significant effects on patient health. Orthopaedic surgeons and the broader research community should remain cognizant of the multifactorial nature of a patient’s health.

Background and ObjectiveMeralgia paresthetica (MP) results from lateral femoral cutaneous nerve compression, leading to thigh pain and numbness. This review aims to compare surgical outcomes and complications of neurectomy versus decompression.Materials and MethodsWe systematically reviewed 23 studies, assessing 818 surgical cases (neurectomy: 213, decompression: 605). Outcomes and complications were compared using patient-reported outcomes and Methodological Index for Non-Randomized Studies.ResultsNeurectomy yielded a higher positive outcome rate (92.0%) compared to decompression (82.8%) and fewer wound complications (0.5% versus 4.0%).ConclusionNeurectomy offers more reliable symptom relief with fewer wound complications than decompression for MP.Level of EvidenceLevel III systematic review

ObjectiveTo introduce a set of hip arthroscopic capsular management for patients with symptomatic Borderline Developmental Dysplasia of the Hip and evaluate its clinical outcomes at a mean 2-year follow-up.MethodsA retrospective study was conducted on symptomatic BDDH patients who underwent hip arthroscopy for labrum tear from January 2020 to January 2024. Inclusion criteria were that hip arthroscopy with outside-in longitudinal capsulotomy and comprehensive capsular closure, which includes proximal capsular augmentation and anatomical repair of the zona orbicularis addition to the side-to-side plication, and had a minimum follow-up of 6 months. The exclusion criteria included inflammatory synovitis of the hip, infections and frank dysplasia. Demographic data, surgical details and patient-reported outcomes were collected and analyzed, including International Hip Outcome Tool 12 (iHOT-12) Score, Visual Analogue Score (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).ResultFifty-three patients were finally enrolled with an average age of 35.4±10.9 years and a mean follow-up of 2.6±1.5 years. Beside common findings such as labral tear, cartilage injure, and ligamentum teres injuries, a relative thinner anterior capsule was confirmed 4.6±1.0 mm. Comprehensive capsular closure was performed in all cases. Significant improvements were observed in iHOT-12 (44.6±8.2 VS 79.9±7.1), VAS (3.7±1.0 VS 1.1±0.8) and WOMAC (19.4±9.7 VS 9.7±4.0) from preoperative to the final follow-up (P < 0.0001). No significant complications were found in all patients.ConclusionHip arthroscopy with outside-in longitudinal capsulotomy and comprehensive capsular closure provide a feasible and safe solution for BDDH, and it achieve good clinical outcomes in short term follow-up.

IntroductionHip injections are commonly used in the diagnostic workup and conservative management of adolescent hip pain. Intra-articular injections help identify joint-based sources of pain while extra-articular injections target pain coming from surrounding structures. Despite their widespread use, the overall efficacy of injections remains unclear. This study aimed to determine rates of pain relief and progression to surgery following injections in adolescents.MethodsA retrospective review of patients aged 12-18 evaluated and treated by a single surgeon was performed from 2014-2024. Demographic data were reviewed to exclude those with prior hip surgery. Injections were classified as intra-articular or extra-articular if directed into the psoas bursa. Injections were diagnostic if they contained only anesthetic agents or therapeutic if they also included corticosteroids.ResultsA total of 200 hips in 186 patients (mean age 15.6 ± 1.5 years; mean BMI 22.3 ± 4.0 kg/m2; 80% female) were included. Intra-articular injections were administered to 91% of hips (182/200). For patients whose intra-articular injection was diagnostic (n=99), maximum pain relief achieved within 2 weeks was 0% in 4%, 25% in 10%, 50% in 9%, 75% in 27%, and 100% in 50% of hips. For those whose intra-articular injection was therapeutic (n=83), pain relief achieved was 0% in 12%, 25% in 12%, 50% in 15%, 75% in 20%, and 100% in 41% of hips. Independent of relief scores, 77% (76/99) of hips receiving diagnostic intra-articular injections ended up proceeding to surgery compared to 53% (44/83) in the therapeutic intra-articular group. Therapeutic psoas injections were performed in 37 hips as the initial injection (n=18) or second injection following an intra-articular injection (n=19). Of these, 43% (16/37) achieved ≥50% pain relief, and 24% (9/37) progressed to surgery. After exhausting conservative management, the overall surgery rate across all hips undergoing injection was 65% (129/200), with procedures including 97 hip arthroscopies, 16 periacetabular osteotomies (PAOs), 15 combined arthroscopy-PAO cases, and one surgical dislocation with trochanteric and femoral derotation osteotomy.ConclusionOverall, 65% of adolescents receiving intra-articular hip or psoas injections progressed to surgery. Injections appear to be useful diagnostic tools and may provide long-term therapeutic benefits in many patients.

IntroductionHip instability is a common driver of pain and dysfunction in those undergoing hip arthroscopy. While an axial traction exam has thought to correlate well with overall joint stability, the relationship between patient reported outcomes (PROs) and intraoperative distractibility have not been quantified. The purpose of this study was to determine if a relationship exists between ease of intraoperative traction and overall hip function with our hypothesis being that those who distract greater distances will have lower overall function.MethodsAll non-dysplastic female patients >18 years of age who underwent a primary hip arthroscopy surgery with completed traction data were placed into tertiles (with T1 being the least and T3 the most) according to their total distraction distance, defined as the difference between the joint space at 0 and 100 pounds of force. Preoperative PROMIS v2.0 Physical Function scores (PROMIS-PF), Modified Hip Harris Scores (MHHS), patient perceived function (SANE), and pain at rest, pain with activities of daily living, and pain with sports on a scale from 0-10 were reviewed. Significant differences were determined by one-way ANOVA and regression analyses.ResultsOne hundred and fourteen patients were included, with thirty-eight in each tertile. Patients in T1 had significantly higher preoperative PROs on MHHS (Mean 63.9 ± 17.7 vs 52.3 ± 16.1; p=0.013) and SANE scores (63.8 ± 15.5 vs 46.1 ± 18.5; p<0.001) compared to T3. Additionally, linear regression controlling for age, BMI, lateral center edge angle, and alpha angle showed a significant inverse relationship between native hip distractibility and MHHS (β = -2.66, 95% CI [-4.37 to -0.940], p=0.003) and SANE scores (β = -3.50, 95% CI [-5.21 to -1.79], p<0.001), and a direct relationship with distraction distance and increased pain with activities of daily living (β = 0.285, 95% CI [0.093 to 0.477], p=0.004).ConclusionsIncreased native hip distractibility on an intraoperative traction exam prior to capsular violation in non-dysplastic female primary hip arthroscopy patients is associated with lower PROs. Future studies are needed to determine if there is an association between increased time zero postoperative distraction distance following hip arthroscopy and long-term PROs.

IntroductionThis study evaluates the recovery curves and short-term outcomes in GLL patients undergoing hip arthroscopy (HA) compared to a propensity matched benchmark control group with no GLL.MethodsRetrospectively analyzed data for all patients who underwent primary HA between 2012 and 2022. Included patients had pre-operative and minimum 2-year follow-up for at least one patient-reported outcome (PRO): modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), International Hip Outcome Tool (iHOT-12). Patients with a Beighton score of four or higher were propensity matched to patients with a Beighton score of less than four. Recovery curve analysis included PRO comparisons at three months, one-, two-, and five- years, clinical thresholds, and secondary surgery rates. A sub-analysis was conducted comparing individuals with high Beighton scores of 8–9 (HB group) to a control group of non-GLL patients.Results345 patients in the GLL group were successfully matched to 345 patients in the control group. When evaluating the recovery curves for both groups, there were no significant differences in reoperation rate, or postoperative outcomes at any postoperative time point, between the GLL and non-GLL groups. Sub-analysis showed a slower recovery with lower outcome scores and significantly higher pain scores at the three-month (VAS 2.8±2.1 vs. 1.5±1.4; p=0.02) and one-year (VAS 3.0±2.0 vs. 1.8±2.5; p=0.03) time points of HB patients compared to the non-GLL control group, but reached similar outcomes at 2- and 5- years. The HB group had lower PASS achievement rates from 3 months to 1 year.ConclusionHA in patients with GLL defined as a Beighton score of four or greater yielded significant improvements at short to mid-term follow-up, with a comparable recovery curve to patients without GLL. Patients with HB scores did experience a slower recovery curve with lower function and higher pain at 3 months and 1 year.

PurposeHip surgeons seek to understand the complexity and interconnectedness of relationships between preoperative patient-reported symptoms, demographics, and radiographic features. Machine learning (ML) approaches might help to elucidate these potentially non-linear relationships. This study used ML regression modeling to identify radiographic and demographic features that most influence preoperative symptom severity in patients with hip-related symptoms.MethodsA retrospective chart review was performed to identify patients with hip-related symptoms of femoroacetabular impingement and hip instability at a single center. Demographics and radiographic measures (e.g., femoral and acetabular measurements) from 3D CT scans were used as ML model inputs. Separate ML predictive model outcomes were preoperative iHOT-12 (n = 618 hips) and PROMIS Pain Interference (PI) scores (n = 566 hips). The random forest ML model framework was selected for its strength in modeling complex, non-linear relationships. To assess generalizability, models were developed using a train-test split (i.e., 70/30), cross-validation, hyperparameter tuning, and repeated random sampling. Model performance was evaluated using R-squared. SHapley Additive exPlanations (SHAP) analysis was used to identify the most influential model inputs (radiographic and demographic variables).ResultsML models consistently overfit the training data and generalized poorly when predicting iHOT-12 and PROMIS PI scores. Although overfitting occurred, SHAP analysis identified consistent demographic and radiographic features across models that were important for symptom severity prediction: acetabular surface area, femoral torsion, alpha angle at 12 o’clock, and weight for iHOT-12 scores and acetabular surface area, femoral neck shaft angle, acetabular version at 3 o’clock, and combined version for PROMIS PI.ConclusionML models had poor predictive ability to generalize but consistently identified radiographic variables (e.g., acetabular surface area) associated with preoperative symptom severity. Poor model generalizability suggests this study’s specific clinical variables may not adequately represent the complexity of patient symptom variability. Ongoing work aims to clarify whether these relationships exist between demographic and radiographic features and patient-reported preoperative symptoms.