Arthroscopic Hip Preservation Surgery Research Articles

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

Background: The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion. Purpose: To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA). Results: A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up. Conclusion: After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Hip Capsular Closure in Distraction: A Technique to Allow Easier Closure of T and Interportal Capsulotomies

Capsule closure during hip arthroscopy is increasingly being shown to optimize outcomes and minimize complications. Although various techniques and suture configurations have been described, closure of the hip capsule remains a technically challenging step for many hip arthroscopists. The purpose of this Technical Note is to summarize capsular management in arthroscopic hip-preservation surgery and to outline a technique of passing capsule sutures under hip traction. This technique is useful, as it facilitates adequate visualization of the vertical limb of the T capsulotomy and interportal capsulotomy, which is difficult when attempted with the hip out of traction and flexed. Our technique also helps to reduce the risk of iatrogenic cartilage injury during suture passage by increasing the distance between the femoral head and capsule leaflets, or the functional working area for capsule closure.

Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort.

Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature. We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes. This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables. The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p=0.007). Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.

External Validation of a Machine Learning Algorithm for Predicting Clinically Meaningful Functional Improvement After Arthroscopic Hip Preservation Surgery

Background: Individualized risk prediction has become possible with machine learning (ML), which may have important implications in enhancing clinical decision making. We previously developed an ML algorithm to predict propensity for clinically meaningful outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome. External validity of prognostic models is critical to determine generalizability, although it is rarely performed. Purpose: To assess the external validity of an ML algorithm for predicting clinically meaningful improvement after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: An independent hip preservation registry at a tertiary academic medical center was queried for consecutive patients/athletes who underwent hip arthroscopy for femoroacetabular impingement syndrome between 2015 and 2017. By assuming a minimal clinically important difference (MCID) outcome/event proportion of 75% based on the original study, a minimum sample of 132 patients was required. In total, 154 patients were included. Age, body mass index, alpha angle on anteroposterior pelvic radiographs, Tönnis grade and angle, and preoperative Hip Outcome Score–Sports Subscale were used as model inputs to predict the MCID for the Hip Outcome Score–Sports Subscale 2 years postoperatively. Performance was assessed using identical metrics to the internal validation study and included discrimination, calibration, Brier score, and decision curve analysis. Results: The concordance statistic in the validation cohort was 0.80 (95% CI, 0.71 to 0.87), suggesting good to excellent discrimination. The calibration slope was 1.16 (95% CI, 0.74 to 1.61) and the calibration intercept 0.13 (95% CI, –0.26 to 0.53). The Brier score was 0.15 (95% CI, 0.12 to 0.18). The null model Brier score was 0.20. Decision curve analysis revealed favorable net treatment benefit for patients with use of the algorithm as compared with interventional changes made for all and no patients. Conclusion: The performance of this algorithm in an independent patient population in the northeast region of the United States demonstrated superior discrimination and comparable calibration to that of the derivation cohort. The external validation of this algorithm suggests that it is a reliable method to predict propensity for clinically meaningful improvement after hip arthroscopy and is an essential step forward toward introducing initial use in clinical practice. Potential uses include integration into electronic medical records for automated prediction, enhanced shared decision making, and more informed allocation of resources to optimize patient outcomes.

Use of a larger surface area tip on bipolar radiofrequency wands in hip arthroscopy is associated with significantly lower traction and total surgery times.

ABSTRACTClinical outcomes in arthroscopic hip preservation surgery have improved over the past two decades due to many factors, including advancements in technique and instrumentation. Complications following hip arthroscopy are associated with increased traction and overall surgical times. The purpose of this study was to compare traction and surgical times during hip arthroscopy using two different radiofrequency ablation wands produced by the same manufacturer. The authors hypothesized that the wand with a larger surface area would result in significantly less traction and surgical times. This study was a retrospective comparative investigation on patients who underwent arthroscopic surgery of the central, peripheral, peritrochanteric and/or deep gluteal space compartments of the hip. Both wands are 50-degree-angled probes, but the tip and shaft diameters are 3 and 3.75 mm for Wand A (Ambient Super MultiVac 50; tip surface area 7.1 mm2) compared to 4.7 and 4.7 mm for Wand B (Ambient HipVac 50; tip surface area 17.3 mm2), respectively. There was no difference (P = 0.16) in mean age of Wand A patients (30 females, 20 males; 35.2 years) versus Wand B patients (31 females, 19 males; 32.7 years). Traction time was significantly less in the Wand B group (41 ± 6 versus 51 ± 18 min; P < 0.001), as was surgical time (102 ± 13 versus 118 ± 17 min; P < 0.001). There were no significant differences in the number of labral anchors used or Current Procedural Terminology codes performed between groups. In conclusion, it was observed that the use of a larger surface area wand was associated with significantly less traction and surgical times during hip arthroscopy.

Incidence of Heterotopic Ossification with NSAID Prophylaxis Is Low After Open and Arthroscopic Hip Preservation Surgery

PurposeWe evaluate the incidence of heterotopic ossification (HO) development with nonsteroidal anti-inflammatory drug (NSAID) prophylaxis in patients after open and arthroscopic hip preservation surgery.MethodsA retrospective review identified patients who underwent hip preservation surgery at a single institution within the past 3 years. Patients who underwent hip arthroscopy with or without periacetabular osteotomy (PAO) or femoral osteotomy (FO) were included. Those who did not receive 3-month postoperative radiographs were excluded. The incidence and Brooker classification (BC) of HO in patients taking Naproxen or another NSAID (meloxicam, celecoxib, indomethacin, or aspirin alone) was assessed using AP radiographs available from 3-, 6-, and 12-month follow-up appointments. Univariate analysis was conducted to compare numerical means and categorical data (significance level P = .05).ResultsA total of 328 hips (284 patients) were included. All patients received hip arthroscopy, while 71 patients (21.6%) received concurrent periacetabular osteotomy (PAO; n = 65) or femoral osteotomy (FO; n = 6). Overall, 276 hips (84.4%) received Naproxen for HO prophylaxis. In total, 5 of 328 hips (1.5%) developed HO (4, BC I; 1, BC III). The rate of HO development was significantly higher in males versus females (4 of 121 (3.31%) vs 1 of 207 (.48%), P = .0441). All 5 patients received arthroscopic cam resection and labral repair, and 1 patient also received PAO. Three patients in the Naproxen group (.91%) developed HO, which was not statistically different from those taking a different NSAID (.61%, P = .1797).ConclusionThe incidence of HO development was low with NSAID prophylaxis after hip preservation surgery.

Achievement of Meaningful Clinical Outcomes Is Unaffected by Capsulotomy Type During Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: Results From the Multicenter Arthroscopic Study of the Hip (MASH) Study Group

Background: Capsule management has emerged as an important topic in the field of hip arthroscopy. The 2 most popular techniques are interportal capsulotomy and T-type capsulotomy, but few studies have compared outcomes between these 2 techniques. Purpose: To compare 2-year (±2 months) patient-reported outcomes (PROs) between patients who underwent interportal versus T-type capsulotomy during arthroscopic labral repair for femoroacetabular impingement syndrome (FAIS). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a large multicenter registry of patients undergoing arthroscopic hip preservation surgery for FAIS was performed. Data from 9 surgeons across 9 sites between January 2014 and February 2018 were included in the study. Baseline demographic data, preoperative PROs, and minimum 2-year postoperative PROs including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score, and International Hip Outcome Tool–12 (iHOT-12) were recorded. Patients were divided into 2 groups based on whether interportal or T-type capsulotomy was performed according to the senior surgeon’s preference and training, and all capsulotomies were then routinely repaired. The 2 groups were matched 1:1 by age, sex, and body mass index (BMI). Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) was compared for the HOS-ADL, HOS-SS, and iHOT-12 between the 2 groups. Results: The final analysis included 658 of 1483 eligible patients with a mean ± SD age of 32.6 ± 11.6 years and BMI of 24.0 ± 3.7; of these, 329 patients were treated via interportal capsulotomy, and 329 patients were treated via T-type capsulotomy. Female patients comprised 66.3% of the study population. Capsulotomy type was not a predictor of 2-year postoperative PROs on multivariate linear regression analysis when adjusted for covariates. Chi-square analysis showed no statistical difference in achievement of MCID, PASS, and SCB between the interportal and T-type groups for HOS-ADL (80.3%, 75.8%, 52.7% and 77.1%, 71.7%, 53.6%, respectively; P > .01 for all), HOS-SS (83.6%, 72.5%, 51.5% and 81.7%, 68.4%, 49.2%, respectively; P > .01 for all), and iHOT-12 (87.5%, 72.0%, 50.5% and 80.0%, 64.7%, 45.6%, respectively; P > .01 for all). Conclusion: Arthroscopic management of FAIS resulted in significant clinical improvement that was independent of capsulotomy type when the capsulotomy included repair.

Multi-center Analysis of Sports-Related Outcomes of Adolescents following Hip Arthroscopy

Symptoms of hip pathology are becoming more commonly recognized in pediatric and adolescent athletes. Arthroscopic surgical approaches to correct morphological and structural abnormalities in adults have been introduced to younger patients to improve dysfunction and reduce the progression of hip pathology. However, a paucity in the literature exists regarding how the pediatric and adolescent athletes respond to hip preservation surgery and the impact hip arthroscopy may have on athletic activity. The purpose of this study was to describe the changes of functional and sports related outcomes of adolescents at 2 years following arthroscopic hip preservation surgery. De-identified patient data from a multi-centered hip arthroscopy registry from January 1, 2016 – January 1, 2017 was analyzed. The data was collected from 7 individual surgeon practices that each perform greater than 100 hip arthroscopy cases per year for a minimum of 8 years. A statistical software program (SPSS, IBM Inc.) computed paired t-tests with an a priori alpha set at 0.05 to determine significance of the change in scores from pre-operative to 2-years post hip arthroscopic surgery. Outcome measures included visual analog pain scales, Hip Outcome Score Sports subscale (HOS Sports), and International Hip Outcome Tool-12 scores. The magnitude to change in these outcome measures and the frequency of patients that surpassed Patient Acceptable Symptomatic State (PASS) scores was determined for the cohort. A chi square analysis was then conducted to determine changes in sports-related skills and activities from pre to post hip preservation surgery. There were 50 adolescent athletes (14 male; 36 female) included in the analysis. The most common sports were running (28%), lacrosse (6%), baseball (10%), swimming (10%), dance (8%), and cheerleading (8%). Sports related outcomes measured by the HOS Sports Subscale improved (p<0.001) from an average score of 43.7 (SD=21.3) to 90.0 (SD=10.0), with 54% meeting the PASS score. Running was the most commonly reported sport specific skill/activity that was categorized as extremely difficult or unable to do by 46% of athletes prior to surgery. This percentage dropped to 8% of athletes at 2 years post-surgery. The greatest improvements of sports specific activities were noted in jumping, landing, stop/start movements, and cutting/lateral movements in which 88% - 90% of the athletes reported either slight or no difficulty at all with these activities. Self-reported functional outcomes showed that the iHOT-12 improved (p<0.001) from an average score of 37.4 (SD 17.4) to 85.4 (SD=15.0), with 72% of patients meeting the PASS score. Pain visual analog scores also improved (p<0.001) from 39.7 (SD=21.7) to 12.4 (SD=15.8). The results of this study show that sport specific function of adolescent athletes greatly improves and is sustained 2 years following hip preservation surgery. Running was shown to be the most difficult sport specific skill to perform due to hip pathology prior to surgery, but improved after surgery. Other skills that showed large improvements after surgery included jumping, landing, stopping/starting, and cutting/lateral movements. Despite large improvements, some athletes may report sports related dysfunction at 2 years following hip preservation surgery.

Midterm Outcomes and Satisfaction After Hip Arthroscopy Are Associated With Postoperative Rehabilitation Factors.

Background:Arthroscopic hip-preservation surgery is commonly performed to address nonarthritic sources of hip pain in young, active individuals. However, there is little evidence to support postoperative rehabilitation protocols, including the most appropriate frequency and length of individual formal physical therapy sessions. There is also a lack of information to look at patients’ perceived value of their home program/self-practice in relation to outcomes.Purpose:To investigate postoperative rehabilitation factors after hip arthroscopy related to formal physical therapy and home program/self-practice and their correlation with patient outcomes and satisfaction.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 125 patients who underwent hip arthroscopy for femoroacetabular impingement syndrome and a labral tear (75 men) were included. The mean age was 34.6 ± 14.4 years, and the mean follow-up time was 4.9 ± 1.6 years. Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL) scores, overall satisfaction scores, and factors related to supervised physical therapy and home program/self-practice were collected. Correlations between continuous variables and differences in the length of individual formal physical therapy and patients’ rating of the importance of their home program/self-practice between those who would and those who would not undergo surgery again were assessed.Results:The frequency and length of individual formal physical therapy sessions were significantly correlated with postoperative HOS-ADL scores (r = 0.22, P = .014; and r = 0.24, P = .007, respectively) and level of satisfaction (r = 0.24, P = .007; and r = 0.21, P = .02, respectively). The length of individual formal physical therapy sessions was significantly greater in those who noted they would undergo surgery again (35.3 vs 26.3; P = .033). A significant correlation was identified between the rating of the importance of their home program/self-practice and postoperative HOS-ADL scores (r = 0.29; P = .001) and their level of satisfaction (r = 0.23; P = .009). There was a significant difference in the rating of the importance of their home program/self-practice between those who would undergo surgery again and those who would not (8.9 vs 7.8; P = .007).Conclusion:Surgeons and physical therapists should emphasize the value of home program/self-practice when it comes to outcomes and may want to encourage their patients to participate in more frequent, longer, formal physical therapy sessions.

Defining the MCID, PASS and SCB for Arthroscopic Hip Preservation Surgery at Minimum Five-Year Follow-up

Objectives:Minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically significant outcome, however, it is unknown what represents meaningful patient reported outcome improvement in the medium to long-term. The purpose of the present study was to define MCID, PASS and SCB at a minimum five years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Secondarily, we sought to evaluate the time dependent nature of MCID, PASS and SCB.Methods:Patients undergoing hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score at 1-, 2-, and 5- years. MCID was calculated using a distribution-based method while PASS and SCB were calculated using an anchor method.Results:Two hundred and eighty-three patients were included with an average age of 34.2+11.9 years. The one year, two year and five-year MCID scores were as follows respectively: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4) and iHOT-12 (15.1, 13.9, 15.1). PASS scores were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6) and iHOT-12 (69.1, 72.2, 74.3). SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4) and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB and PASS at two-year follow-up than at one-year follow-up. However, 79.3% of the patients achieved MCID by 5 years.Conclusion:The greatest proportion of patients achieve clinically significant outcome improvement at two-year follow-up after arthroscopic treatment of FAIS. Improvements are maintained out to five-year follow-up although there is a slight decrease in the proportion of patients achieving clinical significance.Table 1.Frequency of patients achieving any MCID, PASS, or SCB threshold at 1,2, and 5-years 1-year 2-year 5-year p-value Any MCID233 (82.6%)247 (87.3%)224 (79.3%)0.035Any PASS191 (67.6%)211 (74.9%)191 (67.5%)0.114Any SCB176 (62.3%)190 (67.2%)160 (56.6%)0.034

Intra- and interobserver reliability for predicting hip preservation versus hip arthroplasty utilizing plain radiographs with comparison of surgeon specialization.

Surgeon subspecialty training and practice landscape are formative in diagnostic evaluation and treatment recommendations. Varying recommendations can have substantial impact on patients’ care pathways and outcomes. We investigated intra- and interobserver reliability of treatment predictions for total hip arthroplasty (THA) between surgeons performing arthroplasty and/or arthroscopic hip preservation surgery. Anterior–posterior (AP) hip radiographs cropped to include the lateral sourcil, medial sourcil and foveal region of 53 patients with Tönnis Grade 0–3 were evaluated by five surgeons (two performing arthroplasty, two performing arthroscopic hip preservation and one performing both interventions). Surgeons predicted THA versus no THA as the treatment for each image. Predictions were repeated three times with image order randomized, and intra- and interobserver reliability were calculated. Surgeons were blinded to patient characteristics and clinical information. Interobserver reliability was 0.452 whereas intraobserver reliability ranged from 0.270 to 0.690. Arthroscopic hip preservation surgeons were more likely to predict THA (36.9%) than arthroplasty surgeons (32.7%), P = 0.041. Intra- and interobserver reliabilities of surgeons predicting THA versus no THA based on an AP hip radiograph were average at best. Arthroscopic hip preservation surgeons were more likely to predict THA than arthroplasty surgeons. Subjective surgeon interpretation can lead to variability in recommendations to patients; potentially complicating care pathways.

Contemporary Management of the Hip Capsule During Arthroscopic Hip Preservation Surgery.

The importance of the hip capsule and its effect on hip biomechanics, functional outcomes, and hip arthroscopy success rates has been demonstrated in recent studies. These results have led to a shift in management of the hip capsule, where an increasing number of surgeons routinely perform complete capsular closure. The purpose of this review is to highlight recent studies evaluating the hip capsule and describe contemporary capsular management and repair. Biomechanical studies using cadaveric models have demonstrated that complete capsular closure restores hip distraction, rotation, and extension forces back to the native, intact state. Additionally, capsular closure by plication results in quantifiable intraarticular volume reduction, which increases hip stability, particularly in cases of patulous capsule and hypermobility. Clinical studies have demonstrated superior patient-reported functional outcomes and decreased failure rates when undergoing hip arthroscopy with comprehensive capsular management for femoroacetabular impingement surgery. Complete capsular management, including appropriate capsulotomy and subsequent closure, is critical for restoring biomechanical properties of the hip, ensuring high survivorship and improving functional outcomes. This review provides an update on the effects of contemporary capsular management as well as a detailed description of efficient T-capsulotomy and comprehensive capsule closure via plication.

Hip Arthroscopy for Femoroacetabular Impingement Improves Sleep Quality Postoperatively

To describe the prevalence of abnormal sleep quality in patients with femoroacetabular impingement syndrome and to determine whether arthroscopic hip preservation surgery with cam/pincer correction, labral preservation, and capsular plication can improve sleep quality postoperatively. All patients undergoing primary hip arthroscopy for cam/pincer correction who failed nonoperative management between March 1, 2017, and July 1, 2017, were administered a validated sleep quality questionnaire-the Pittsburgh Sleep Quality Index (PSQI)-preoperatively and at 3, 6, 12, and 24weeks postoperatively. Exclusion criteria included patients undergoing revision arthroscopy, gluteus medius repair, or a contralateral procedure during the follow-up period and those with known sleep disorders. A global (total) PSQI score >5 indicates poor sleep quality. The Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 were used to assess functional outcomes. A repeated measures analysis of variance with post hoc Greenhouse-Geisser and Bonferroni corrections was conducted to determine statistically significant changes in sleep patterns. A total of 52 patients (94.6%) were included in the final analysis. The mean (± standard error) patient age was 37.8 ± 1.9years, and body mass index was 27.6 ± 0.7. Preoperatively, 49 (94.2%) of patients experienced poor sleep quality, defined as a global PSQI score >5, with a mean PSQI score of 9.8 ± 0.6. At 24weeks postoperatively, 10 (21.7%) of patients experienced poor sleep quality with a mean PSQI score of 2.2 ± 0.2. All patients had significant improvements in all hip outcome instruments at 24weeks postoperatively (P < .001). Preoperatively, patients with femoroacetabular impingement syndrome have a high prevalence of sleep disturbance. These patients experience subsequent improvement in sleep disturbance after arthroscopic hip surgery early in the postoperative period. Level IV, case series.

The Application of the Patient Reported Outcomes Information System (PROMIS) on Hip Arthroscopy Patients

Objectives:Legacy measures, such as the modified Harris Hip Score, have traditionally been utilized in the assessment of hip arthroscopy patients, but have been criticized for their application in this active patient population. Recently, the NIH funded the establishment of the Patient Reported Outcomes Information System (PROMIS). This computer adaptive testing (CAT) scale has multiple components and has been validated using various other orthopedic patient populations. To date, no published studies have utilized PROMIS as an assessment tool among patients who have undergone hip arthroscopy for the treatment of FAI, labralchondral pathology, and/or other associated conditions. The purpose of this study was to determine whether there is an association between a patient’s pre-operative outcome score and their likelihood of experiencing a clinically meaningful change at specified postoperative intervals following arthroscopic hip preservation surgery.Methods:A piecewise longitudinal regression models was used to examine changes over time in the primary outcomes of function, pain, and mood evaluated by PROMIS. This was accomplished by determining the regression of these outcomes from pre-op measurement to the first follow-up visit and then from the first follow-up visit through the 5-7 week, 3-4 month, 5-7 month and 10-14 month visits. Patient enrollment at each of the intervals were 405, 396, 336, 192, 93 and 42 respectively. Assessed variables included demographic characteristics, labral repair vs debridement, iliopsoas lengthening, number of allergies, body mass index (BMI), institutional team based physical therapy vs. non-specialized therapy, and insurance type.Results:As anticipated, function was found to be poorer and pain scores greater at the first postoperative follow-up visit (βFunction= -12.66, p<0.0001 βPain= 4.23, p<0.0001) compared with pre-op values. Subsequent visits demonstrated statistically significant improvements in function and reduction in pain (βFunction = 19.70, p<0.0001; and βPain= -13.54, p=<0.0001). Associated p-values indicated that the slopes were significantly different than 0, indicating that a trend was present, and showing a change in performance as anticipated. The mood scale presented a slightly different picture with the first segment (βMood= -1.28, p=0.20) suggesting that there was no change in depression from pre-op to first follow-up but there was a marked decrease from first follow-up to the 10-14 month visit (βMood = -3.27, p=0.0012).As anticipated, function was found to be poorer and pain scores greater at the first postoperative follow-up visit (βFunction= -12.66, p<0.0001 βPain= 4.23, p<0.0001) compared with pre-op values. Subsequent visits demonstrated statistically significant improvements in function and reduction in pain (βFunction = 19.70, p<0.0001; and βPain= -13.54, p=<0.0001). Associated p-values indicated that the slopes were significantly different than 0, indicating that a trend was present, and showing a change in performance as anticipated. The mood scale presented a slightly different picture with the first segment (βMood= -1.28, p=0.20) suggesting that there was no change in depression from pre-op to first follow-up but there was a marked decrease from first follow-up to the 10-14 month visit (βMood = -3.27, p=0.0012).Conclusion:Results from this study suggest that use of the PROMIS CAT tool was applicable to patient centered outcomes and informed decision making following arthroscopic hip surgery and may be used to facilitate discussions with patients regarding expected benefits for patient specific attributes. Prior to surgery, it is equally important that surgeons convey accurate prognostic information to patients, and that surgeons are able to identify patients who are unlikely to improve by a clinically important margin if surgery is undertaken. This study suggests that PROMIS offers potential to achieve these valuable objectives in a population of hip arthroscopy patients, and should be considered as a highly efficient and generalizable tool to collect pre- and postoperative data during clinical patient encounters.

Arthroscopic hip preservation surgery practice patterns: an international survey.

To design and conduct a survey analyzing pre-, intra- and post- hip arthroscopy practice patterns among hip arthroscopists worldwide. A 21-question, IRB-exempt, HIPAA-compliant, cross-sectional survey was conducted via email using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. Seventy-five respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing AP pelvis, false profile and Dunn 45 were the most common radiographs utilized. CT scans were utilized by 54% of surgeons at least some of the time. Only 56% of participants recommended an arthrogram with MRI. Nearly all surgeons either never (40%) or infrequently (58%) performed arthroscopy in Tönnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51% never; 44% infrequently). Only 25% of participants perform a routine ‘T’ capsulotomy and 41% close the capsule if the patient is at risk for post-operative instability. Post-operatively, 52% never use a brace, 39% never use a continuous passive motion, 11% never recommended heterotopic ossification prophylaxis and 30% never recommended formal thromboembolic disease prophylaxis. Among a large number of high-volume experienced hip arthroscopists worldwide, pre-, intra- and post- hip arthroscopy practice patterns have been established and reported. Within this cohort of respondents, several areas of patient evaluation and management remain discordant and controversial without universal agreement. Future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Cumulative Radiation Exposure to Patients Undergoing Arthroscopic Hip Preservation Surgery and Occupational Radiation Exposure to the Surgical Team

To quantify cumulative radiation exposure in patients undergoing arthroscopic hip preservation surgery and occupational exposure to operating room (OR) personnel during such surgery; a secondary objective of this study was to identify factors affecting radiation exposure in patients undergoing hip arthroscopy. Radiation exposure from all preoperative and intraoperative imaging studies was determined for 52 patients undergoing hip arthroscopy. Cumulative and effective radiation doses were calculated and correlated with pathology and body mass index (BMI). Badge dosimeters were worn by OR personnel to measure cumulative occupational exposure. A highly sensitive portable ion chamber was used to evaluate the radiation scatter during surgery performed on a high-BMI patient and a low-BMI patient to reflect a "worst-case scenario" and "best-case scenario," respectively. Forty-three patients underwent procedures for femoroacetabular impingement (FAI) and 9 underwent procedures for soft-tissue pathologies (ST). The median cumulative exposure was 8.6 mGy and 5.0 mGy for FAI patients and ST patients, respectively (P= .01). The cumulative effective radiation dose was 490 mrem and 350 mrem for FAI patients and ST patients, respectively (P= .47). BMI significantly correlated with cumulative exposure (P= .0004) and trended toward significance with cumulative effective dose (P= .073). OR staff cumulative occupational exposure was low (9 mrem for the surgeon). Ion chamber data showed that increasing patient BMI resulted in increased occupational exposure. The median cumulative effective radiation dose to patients undergoing arthroscopic hip preservation surgery is 490 mrem and results in an excess lifetime risk of death from cancer of 0.025%. Greater BMI correlates with increased cumulative radiation exposure and may increase risk to OR personnel. Occupational exposure to the surgical team from hip arthroscopy ranges from 7 to 9 mrem per 50 hip arthroscopies (+0.0005% excess lifetime risk of death from cancer). Level IV, diagnostic.

International trends in arthroscopic hip preservation surgery-are we treating the same patient?

The goal of this study was to perform a systematic review and meta-analysis of the entire arthroscopic hip preservation literature to answer the question, ‘Across the world, are we treating the same patient?’ There are significant differences in arthroscopic hip preservation publications, subjects and techniques based on both continent and country published. A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available databases. Therapeutic clinical outcome investigations reporting arthroscopic hip preservation were eligible for inclusion. All study, subject and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student's t-tests, one-way analysis of variance, chi-squared and two-proportion Z-tests. There were 134 studies included in the analysis (10 752 subjects; 11 007 hips; 51% female; mean 37.6 years of age; mean 27.2 months length of follow-up), which had a low Modified Coleman Methodology Score (mean 32.4; poor). North America published the largest number of studies (58%) and the most subjects (55%) and hips (56%). Australia (22%) and Europe (18%) operated on subjects with some amount of osteoarthritis most commonly. North America (2.7%) and Europe (2.0%) operated on subjects with dysplasia or borderline dysplasia most commonly. The Modified Harris Hip Score was the most frequently utilized outcome score (24% of studies). The quantity and quality of arthroscopic hip preservation literature is significantly increasing with time. Several significant differences in study, subject and surgical technique demographics between continents and countries were identified. Deficiencies in use of clinical outcome scores and definitions of treated pathologies preclude complete subject comparisons and serve as an impetus for future study quality improvements.

Subtrochanteric osteotomy for femoral mal-torsion through a surgical dislocation approach.

Missed torsional femur deformities may contribute to reasons for failure after open and more likely arthroscopic hip preservation surgery. A number of surgical approaches have been described for addressing torsion abnormalities. This report describes a subtrochanteric osteotomy technique in a consecutive series of patients with complex hip pathologies, for which intertrochanteric osteotomy is not suitable and precise derotation is required. Subtrochanteric derotation was performed, always in combination with a surgical hip dislocation, in accordance with the authors’ preferred technique. Before osteotomy, a localized decortication was executed. Application of a 4.5-mm broad or narrow plate was undertaken with dynamic compression of the osteotomy. Twenty-eight consecutive subtrochanteric derotational osteotomies were performed in 26 patients. Twenty-one females and five males were treated at an average age of 21.4 years (range, 12–43). Underlying diagnoses included dysplasia, arthrogryposis, cerebral palsy, Down’s syndrome, instability and impingement. The decision to perform derotation was for antetorsion over 20° or less than 0° (retrotorsion). Patients were followed clinically and radiographically till final follow-up. All patients went on to successful osteotomy union. There were two initial failures: one delayed union prompting revision fixation in a chronic smoker and one plate failure due to self-accelerated weight-bearing in a patient status post successful contralateral derotational osteotomy. Rotational deformity of the femur must be considered in the patient undergoing hip preservation surgery. This technique of subtrochanteric derotational osteotomy, with adjunctive surgical hip dislocation, is applicable and reproducible in the setting of complex hip pathologies. Level of evidence: IV, case series.

Influence of Capsular Repair Versus Unrepaired Capsulotomy on 2-Year Clinical Outcomes After Arthroscopic Hip Preservation Surgery

The primary objective of this study was to determine whether capsular management technique influences clinical outcomes at a minimum of 2 years after arthroscopic hip preservation surgery. A retrospective review of prospectively collected data was conducted to determine the relative influence of 2 capsular management strategies onclinical outcomes: unrepaired capsulotomy (group A) and capsular repair (group B). Four hundred three patients whohad undergone arthroscopic hip preservation surgery met the inclusion criteria and had 2-year outcome data available. All patients completed 4 patient-reported outcome (PRO) questionnaires preoperatively and at a minimum of 2years' follow-up. These included the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) subsets, Non-Arthritic Hip Score (NAHS), and modified Harris Hip Score (mHHS). Group A included 235 patients and group B, 168. The mean age of all patients at final follow-up was 36.9 years. Patients in group A were significantly older (42.3 years v 29.4 years, P < .0001) and had a significantly higher body mass index (26.8 kg/m(2)v 22.9 kg/m(2), P < .0001) compared with group B. In addition, female patients were more likely than male patients to undergo capsular repair (136 female patients v 32 male patients, P<.0001). Patients in group A also showed greater chondral damage by acetabular labrum articular disruption classification (P= .0081) and reduced preoperative PROs (HOS-ADL of 60.5 v 66.0, P=.087; HOS-SSS of 37.0 v 46.4, P= .0002; NAHS of 54.6 v 62.2, P < .0001; mHHS of 58.7 v 64.4, P= .0009; and visual analog scale score of 6.3 v 5.84, P= .028). All PROs showed statistically significant improvements for both groups at a minimum follow-up of 2 years (HOS-ADL, 60.5 to 82.2 in group A and 66 to 86.1 in group B; HOS-SSS, 36.9 to 67.3 and 46.4 to 71.2, respectively; NAHS, 54.6 to 79 and 62.2 to 82.8, respectively; visual analog scale score, 6.3 to 3.1 and 5.8 to 2.9, respectively; and mHHS, 58.7 to 81 and 64.4 to 83.8, respectively; P<.0001 for all differences). Furthermore, group B showed greater overall improvements than group A for the HOS-ADL (P= .03) and NAHS (P= .03) on uncorrected univariate analysis, but significance was lost once we controlled for confounding variables. Arthroscopic capsular repair, used in conjunction with arthroscopic hip preservation surgery, appears to be safe and did not negatively influence clinical outcomes in this study. When confounding variables were controlled for, the use of capsular repair did not show clinically relevant superiority over the use of unrepaired capsulotomy. Level IV, therapeutic case series.

Validation of A Computer-Assisted Dynamic Simulation For Treatment of Femoroacetabular Impingement (FAI)

An incomplete resection with residual deformity is a common cause for failure after arthroscopic hip preservation surgery for femoroacetabular impingement (FAI). The purpose of this study was (i) to compare the morphology of a virtual osteoplasty as templated by CT-based, 3D dynamic simulation modeling to the morphology after actual operative treatment of symptomatic FAI by a high volume surgeon, and (ii) to compare the morphology of a virtual osteoplasty to the actual operative treatment executed by less experienced surgeons in patients presenting for revision FAI surgery.