Arthroscopy Patients Research Articles

Metabolic phenotypes reflect patient sex and injury status: A cross-sectional analysis of human synovial fluid

Osteoarthritis is a heterogeneous disease. The objective was to compare differences in underlying cellular mechanisms and endogenous repair pathways between synovial fluid (SF) from male and female participants with different injuries to improve the current understanding of the pathophysiology of downstream post-traumatic osteoarthritis (PTOA). SF from n=33 knee arthroscopy patients between 18 and 70 years with no prior knee injuries was obtained pre-procedure and injury pathology assigned post-procedure. SF was extracted and analyzed via liquid chromatography-mass spectrometry metabolomic profiling to examine differences in metabolism between injury pathologies (ligament, meniscal, and combined ligament and meniscal) and patient sex. Samples were pooled and underwent secondary fragmentation to identify metabolites. Different knee injuries uniquely altered SF metabolites and downstream pathways including amino acid, lipid, and inflammatory-associated metabolic pathways. Notably, sexual dimorphic metabolic phenotypes were examined between males and females and within injury pathology. Cervonyl carnitine and other identified metabolites differed in concentrations between sexes. These results suggest that different injuries and patient sex are associated with distinct metabolic phenotypes. Considering these phenotypic associations, a greater understanding of metabolic mechanisms associated with specific injuries, sex, and PTOA development may yield data regarding how endogenous repair pathways differ between male and female injury types. Ongoing metabolomic analysis of SF in injured male and female patients can be performed to monitor PTOA development and progression.

Bilateral arthroscopy of the temporomandibular joint: clinical outcomes and the role of a second intervention-a prospective study.

Evaluate the efficacy of bilateral temporomandibular joint (TMJ) arthroscopy in patients with different categories of severity based on Dimitroulis classification (categories 2-4) and the role of a second TMJ intervention in primary failure. A 3-year prospective study was designed, including patients submitted to bilateral TMJ arthroscopy. The primary outcome was TMJ pain (VAS, 0-10) and the secondary outcomes were the maximum mouth opening (MMO) and masticatory myalgia degree (0-3). In cases of symptomatic relapse, a second TMJ intervention was performed (TMJ arthrocentesis or TMJ open surgery). Eighty patients (93.4% women) were enrolled, with a mean age of 32.40 ± 11.41years. With an average follow-up of 523.7 days (34-1606), a statistically significant improvement in TMJ pain, MMO, and myalgia degree was observed (P < 0.0001). The overall successful outcome of one-single bilateral arthroscopy was ~ 69%. Twenty-two patients relapsed: (1) arthralgia (n = 15, 68.18%); (2) arthralgia + myalgia (n = 4, 18.18%); (3) dislocated disc without reduction (DDwoR) (n = 2, 9.09%); (4) DDwoR + osteoarthrosis (OA) (n = 1, 4.55%). Arthralgia was re-managed with TMJ arthrocentesis with local anesthesia (n = 19, 86.36%). New DDwoR with or without OA was re-treated with TMJ open surgery (n = 3, 13.64%). After the second intervention, the success rate increased to 85%. Bilateral TMJ arthroscopy presented overall benefit in all parameters evaluated. This study highlights the importance of TMJ arthroscopy as the first line of treatment for moderate-severe temporomandibular disorders cases contributing to the reduction of TMJ open surgeries. In cases of arthroscopy unsuccess, TMJ arthrocentesis under local anesthesia was an effective and safe intervention for patients with recurrent TMJ arthralgia.

Patients Undergoing Revision Hip Arthroscopy Demonstrate Comparable Survivability and Improvement but Worse Postoperative Outcomes Compared to Patients Undergoing Primary Hip Arthroscopy: A Propensity Matched Study at Five-Year Follow-Up

To compare mid-term clinical outcomes between patients undergoing primary hip arthroscopy (HA) versus revision hip arthroscopy (RHA) for femoroacetabular impingement syndrome (FAIS). A retrospective cohort study was conducted on 1,862 patients who underwent hip arthroscopy for FAIS from January 2012 to April 2017. Patients who underwent RHA were propensity matched in a 1:4 ratio by age, sex, body mass index (BMI), and exercise status to patients who underwent primary HA. Preoperative and postoperative radiographs were assessed. Patient-reported outcomes before and at 5 years after surgery, including the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and Visual Analog Scale (VAS) for Pain and Satisfaction, were compared between groups. Minimally clinically important difference and patient-acceptable symptomatic state (PASS) achievement rates were compared using previously published thresholds. Fifty-one patients who underwent RHA (35 female, 16 male; age 36.2 ± 10.2 years; BMI 26.5 ± 5.9) were followed up for 63.9 ± 9.2 months and then propensity matched in a 1:4 ratio by sex, age, and BMI to 204 control patients who underwent primary HA. At midterm follow-up, patients in the RHA cohort had significantly lower scores for HOS-SS (RHA 64.9 ± 32.5 vs HA 75.3 ± 26.2, P= .044), mHHS (RHA 72.2 ± 22.4 vs HA 80.1 ± 18.1, P= .039), and iHOT-12 (RHA 61.4 ± 29.3 vs HA 71 ± 27.6, P= .043) compared to primary HA patients. Rates of achieving PASS were significantly decreased for HOS-SS (RHA 38.3% vs HA 55.4%, P= .039) and iHOT-12 (RHA 41.9% vs HA 59.9%, P= .035) in the RHA cohort. There were no significant differences in rates of conversion to THA or subsequent reoperation on the index hip between groups. Patients undergoing revision hip arthroscopy demonstrate comparable survivability and magnitude of improvement but may experience worse overall outcome scores and meet thresholds for clinically significant outcomes less often when compared to primary hip arthroscopy patients. Level III; retrospective comparative study.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories. We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model. 285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P= .006) and at 2-year follow-up (P= .008). There were no significant intergroup differences in time to achievement for MCID (P= .92) or SCB (P= .69), but obese patients had longer time to PASS than normal BMI patients (P= .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR= .55; P= .007) but not MCID (HR= 0.91; P= .68) or SCB (HR= 1.06; P= .30). Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. Level III, retrospective comparative study.

Poster 220: Outcomes of Hip Arthroscopy in Patients with Hip-Spine Syndrome: A Matched-Pair Controlled Study with Minimum Two-Year Follow-Up

Objectives: Hip–spine syndrome is a phenomenon commonly seen in the geriatric population presenting with concurrent hip osteoarthritis and lumbar spine degenerative disease. Secondary hip-spine syndrome can develop when compensatory stresses are placed on the lumbosacral spine due to pathologies that limit hip range of motion, such as femoroacetabular impingement (FAI). The literature remains conflicted on the impact of hip arthroscopy in hip-spine syndrome and there is a paucity of studies that report long term outcomes. The purpose of this study was to conduct a matched-pair analysis to assess the effects of lumbar spine pathology on minimum two-year clinical outcomes of patients undergoing hip arthroscopy for FAI. Methods: An institutional review board-approved retrospective review of a prospectively collected, single-surgeon database was performed to identify patients who underwent hip arthroscopy for FAI with evidence of concomitant lumbar spine pathology. Importantly, all patients participated in the same postoperative protocol and underwent capsular management via the previously published puncture capsulotomy technique. Additionally, included patients had failed conservative treatment, a minimum of two-year follow-up, and symptoms of low back pain with objective evidence of lumbar pathology (i.e., herniation, degenerative disc disease, stenosis, spondylosis, etc.) at the time of surgery. Patients were excluded if they had any previous hip surgery, evidence of hip dysplasia (lateral center edge angle ≤25°), or advanced osteoarthritis (Tönnis ≥2). Patients in the hip-spine (HS) cohort were matched 1:1 by age within 5 years, body mass index (BMI) within 5.0 kg/m2, and sex to a matched control (MC) cohort. The MC cohort lacked subjective or objective evidence of lumbar spine pathology. The following patient- reported outcomes (PROs) were recorded in each cohort: Modified Hip Harris Score (mHHS), International Hip Outcome Tool-33 (iHOT-33), Non-Arthritic Hip Score (NAHS), rates of revision arthroscopy, and conversion to total hip arthroplasty (THA). Results: A total of 60 patients with lumbar disease (HS; age = 39.5 ±10.2, BMI = 26.3 ±4.0, 48.3% Female) were matched with 60 control patients (MC; age = 39.4 ±11.6, BMI = 25.7 ±4.1, 48.3% Female). At baseline, all PROs were significantly lower in the HS cohort (all p&lt;0.05). At one-year follow-up, the HS cohort exhibited a greater magnitude of improvement in all PROs, with significant differences in the NAHS (p = 0.006). Additionally, a higher percentage of patients in the HS cohort achieved the minimal clinically important difference (MCID) threshold for all outcome measures at one-year, and a significant difference was identified in the NAHS (p = 0.026; Tables 1&amp;2). At two-year follow-up, all PROs were significantly lower in the HS cohort (all p&lt;0.05), however at three- and five-year follow-up no differences were identified between cohorts in mean PROs, magnitude of improvement, or percentage of patients achieving MCID thresholds (all p&gt;0.05). No significant differences in the rates of revision (0% vs. 0%) or conversion to THA (5.3% vs. 3.4%) were identified between cohorts (all p&gt;0.99). Conclusions: While patients with a history of lumbar spine pathology achieved lower short-term outcomes after hip arthroscopy, these differences were mitigated when follow-up was expanded to 3- and 5- years (Figure 1). While the HS cohort exhibited lower baseline PROs at the time of surgical intervention, these patients had an equal or greater magnitude of improvement across all time points. This study’s findings have implications for the shared decision-making process and managing patient expectations prior to undergoing hip arthroscopy for FAI. Although it may take greater than two years, patients with hip-spine syndrome can attain clinically meaningful improvement in hip function following hip arthroscopy for FAI. [Table: see text][Table: see text]

Opioid-Sparing Strategies in Arthroscopic Surgery

Background: Opioid overprescription is a problem in orthopaedic surgery. Arthroscopic surgery, given its minimally invasive nature, represents an opportunity to minimize opioid prescription and consumption by using effective pain management adjuncts. Thus, the primary question posed in this study was which noninvasive pain management modalities can effectively manage pain and reduce opioid intake after arthroscopic surgery. Methods: The databases PubMed, MEDLINE, EMBASE, Scopus, and Web of Science were searched on August 10, 2022. Randomized controlled trials (RCTs) evaluating noninvasive pain management strategies in arthroscopy patients were evaluated. Eligible studies were selected through a systematic screening process. Meta-analysis was performed for pain scores and opioid consumption at time points which had sufficient data available. Results: Twenty-one RCTs were included, with a total of 2,148 patients undergoing shoulder, knee, and hip arthroscopy. Meta-analysis comparing nonopioid, oral analgesic regimens, with or without patient education components, with the standard of care or placebo demonstrated no difference in pain scores at 24 hours, 4 to 7 days, or 14 days postoperatively. Nonopioid regimens also resulted in significantly lower opioid consumption in the first 24 hours postoperatively (mean difference, −37.02 mg oral morphine equivalents, 95% confidence interval, −74.01 to −0.03). Transcutaneous electrical nerve stimulation (TENS), cryotherapy, and zolpidem were also found to effectively manage pain and reduce opioid use in a limited number of studies. Conclusions: A range of noninvasive pain management strategies exist to manage pain and reduce opioid use after arthroscopic procedures. The strongest evidence base supports the use of multimodal nonopioid oral analgesics, with some studies incorporating patient education components. Some evidence supports the efficacy of TENS, cryotherapy, and nonbenzodiazepine sleeping aids. Direction from governing bodies is an important next step to incorporate these adjuncts into routine clinical practice to manage pain and reduce the amount of opioids prescribed and consumed after arthroscopic surgery. Level of Evidence: Level II, systematic review and meta-analysis of RCTs. See Instructions for Authors for a complete description of the levels of evidence.

Paper 64: Patient Reported Outcomes Associated With “Completely Better” Status After Hip Arthroscopy

Objectives: Contextualizing patient-reported outcomes (PROs) can help to differentiate meaningful outcomes. Measures such as patient acceptable symptom state and minimum clinically important difference have been increasingly investigated in recent years. Assessment of patients’ perception of being “completely better” (CB) after hip arthroscopy has not been studied and may be of particular value for this rapidly growing field. The purpose of this study was to assess the rate of patient-reported CB status 2 years after hip arthroscopy and determine associations with PROs. Methods: An orthopaedic registry at a single institution was retrospectively analyzed. All patients who underwent hip arthroscopy from 2015 to 2020, and had 2 year follow up data were included in this study. Patients were administered Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Score, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) expectations domains and Surgical Satisfaction Questionnaire (SSQ8) preoperatively and at 2 years postoperatively. Patients completed a CB anchor question at 2 years after surgery. Threshold values for PRO scores associated with achieving a CB status were identified with 90% specificity. Variables were selected a posteriori for inclusion into multivariable analysis based off Area Under Curve (AUC) greater than 0.80 on a receiver operating characteristic (ROC) curve. Results: Overall, 29 of the 62 patients (46.8%) reported their condition CB at 2 years postoperatively. There were no differences in demographics of age, sex, BMI, race, prior hip surgery, pre-op opioid use, or smoking status between the CB and non-CB groups (Table 1). The 2-year and change in PROMIS Physical Function, Pain Interference, Social Satisfaction, Fatigue, and Anxiety, and MODEMS Met Expectations, and SSQ8 PROs were significantly better in the CB group than in the non-CB group (Table 2). Numeric Pain Score in the operative hip was significantly better at 2 years in the CB group. There were no differences in preoperative expectations between groups. Thresholds of 2-year PROMIS PF ≥51.3, change in PROMIS PF ≥12, 2-year PROMIS PI ≤46.6, change in PROMIS PI ≤-12.2, 2- year Numeric Pain Score – operative hip ≤1.0, MODEMS Met Expectations ≥ 95.0, and 2-year SSQ8 ≥87.5 were the best predictors of achieving CB status (Table 3). Multivariate analysis of CB status demonstrated that SSQ8 and change in PROMIS Physical Function were independent predictors of CB status when controlling for potential confounding variables (Table 4). Conclusions: Almost half of hip arthroscopy patients reported being completely better 2 years after surgery. Multiple PROs including physical function, pain, and satisfaction were significant associated with CB status. Improvement in PROMIS Physical Function and two-year satisfaction were independent predictors of CB status. This is the first study to assess CB status 2 years after hip arthroscopy and provides contextualization to PROs for orthopaedic surgeons and researchers. [Table: see text][Table: see text][Table: see text][Table: see text]

Poster 232: Clinical Outcomes Among Individuals with Global Acetabular Retroversion who Underwent Hip Arthroscopy for FAI with Minimum 5-Year Follow-Up

Objectives: The purpose of this study was to compare functional outcomes and clinical threshold achievement rates of patients with radiographic signs of global acetabular retroversion who underwent hip arthroscopy for FAI with minimum follow-up of 5 years. Methods: Patients were identified from a single-surgeon prospectively-collected database who underwent primary hip arthroscopy for treatment of FAI. Patients completed patient-reported outcome (PRO) surveys at both baseline and at 5-year follow-up. Demographic data was collected including age, sex, BMI at time of surgery, and patient-reported symptom length. Intraoperative findings were recorded, including the Outerbridge grade, presence of labral tears, chondral delamination, subspine impingement, cam lesions, pincer lesions, and mixed-type FAI. Global acetabular retroversion was assessed on AP view using three radiographic signs: ischial spine, posterior wall, and crossover signs. Other radiographic measures included alpha angle measured on three view (AP, 45° Dunn, 90° Dunn), lateral center edge angle (LCEA), and Tönnis grade. Results: We identified 124 primary hip arthroscopy patients who had minimum 5-year follow-up with adequate imaging and complete 5-year PROs. Preoperative X-rays demonstrated presence of ischial spine sign in 65 patients (52.4%), posterior wall sign in 61 patients (49.2%), and crossover sign in 75 patients (60.5%). Mean alpha angle was highest on AP view (62.2°), followed by 45° Dunn view (55.9°) and 90° Dunn view (50.9°) and mean LCEA was 38.5°. A baseline comparison demonstrated no significant differences between groups in age, sex, BMI, preoperative symptom length, Tönnis grade, Outerbridge grade, and preoperative mHHS or NAHS (p&gt;0.05). At 5-year follow-up, patients reported significant improvement in both mHHS (mean 50.4 to 82.7, p&lt;0.001) and NAHS (49.4 to 85.5, p&lt;0.001). Achievement rates were high for MCID (90.3%), SCB (80.7%), and PASS (79.0%) for the mHHS. Three-way frequency comparison of acetabular retroversion signs found that all three signs tended to be present together (40 patients, 32.3%) or absent together (31 patients, 25.0%). Pairwise comparisons with tetrachoric correlation testing found all three signs to be significantly correlated with one another: ischial spine sign versus posterior wall (rtet=0.65, corrected p&lt;0.001), ischial spine sign versus crossover sign (rtet=0.74, corrected p&lt;0.001), and posterior wall sign versus crossover sign (rtet=0.51, corrected p&lt;0.001). Multivariable analysis did not find any of the three signs to be significant independent predictors of 5-year improvement in mHHS or NAHS (p&gt;0.05). Posterior wall sign was associated with lower odds of achieving the MCID (OR = 0.62, 95% CI [0.06 to 1.09]) but this did not achieve significance (χ2=3.39, p=0.07). Overall, achievement rates for MCID, SCB, and PASS did not significantly differ between the cohorts with respect to each sign (p&gt;0.05). Conclusions: Clinical outcomes and achievement rates at 5-year follow-up demonstrated no significant differences among patients with respect to each sign of acetabular retroversion based on mHHS, NAHS, MCID, SCB and PASS. Surgeons should be reassured that these patients regain function at a rate similar to the greater FAI population.

Poster 227: The Impact of Hip Arthroscopy on Pregnancy-Related Decision-Making and Outcomes among Female Patients: A Single Surgeon’s Experience

Objectives: Women of reproductive age are among the most frequent recipients of hip arthroscopic procedures in the U.S., and anecdotal evidence suggests that some female patients consider pregnancy a factor in their decision to undergo, delay, or avoid such surgeries. In addition, anatomical changes during pregnancy may exacerbate existing hip pathologies such as femoroacetabular impingement (FAI) and labral tears, potentially leading to greater pain and risk of complications during gestation, labor, and delivery. However, the impact of hip pain and arthroscopy on pregnancy-related decision-making and outcomes is poorly understood. The aims of this study were to determine (1) how pregnancy planning affected patients’ decisions to pursue hip arthroscopy, (2) whether undergoing hip arthroscopy affected hip pain before and after pregnancy, and (3) whether hip arthroscopy was associated with any pregnancy-related complications. Methods: We retrospectively studied female patients aged 18-45 years who underwent hip arthroscopy for the treatment of FAI and/or labral tears at our center from 2010-2021. Subjects were identified using a prospectively-collected single-surgeon database. Eligible subjects were administered an electronic survey that assessed obstetrical history, concerns about how their hip pain and/or the process of undergoing hip arthroscopy could affect future pregnancies, location and intensity of hip pain at various time points (before surgery, after surgery, during pregnancy), and complications experienced during pregnancy. Hip pain intensity was reported on a 10-point Visual Analog Scale (VAS). Subjects also completed the modified Harris Hip Score (mHHS). Continuous variables were compared within groups with Wilcoxon signed rank test and between groups with Kruskal-Wallis test. Fisher’s exact test was used to compare categorical variables between groups. P-values &lt; 0.05 were considered significant. Results: A total of 86 patients completed the survey. Mean age at time of surgery was 32.3 ± 6.4 years (range 18 - 45), mean BMI was 24.5 ± 4.7 (range 18.7 – 39.8), and mean follow-up time was 52.0 ± 34.3 months (range 6 – 146). 47 patients (54.7%) had been pregnant at least once. Half of the cohort reported moderate or high concern that their hip pain would worsen during a future pregnancy, while a slight majority felt that hip surgery would not raise their risk of complications during pregnancy (56.0%) or impair hip function after pregnancy (51.2%). 27 patients (31.4%) had become pregnant after hip surgery at an average of 6.3 ± 1.4 months (range 2 – 8) postoperative, of whom 13 (48.2%) cited hip pain as a factor in getting surgery before pregnancy and 9 (33.3%) reported delaying a planned pregnancy to undergo surgery. Patients who became pregnant after surgery experienced a significant increase in VAS hip pain during pregnancy (p = 0.02), most commonly during the third trimester, though pain resolved after pregnancy in most (19 of 27, 70.4%). Five patients (5 of 27, 18.5%) experienced a miscarriage and the most common complication reported was vaginal/perineal tear (13 of 27, 48.1%). Of the 39 nulligravid patients, 28 (71.2%) were considering a future pregnancy and 32 (84.2%) did not consider hip pain to be a factor in their nulligravid status. There was no significant difference in mHHS at latest follow-up between nulligravid patients, patients who had not been pregnant since hip surgery, and patients who got pregnant after hip surgery (mean 79.6 vs 80.0 vs 79.6, p = 0.94). Conclusions: Most female hip arthroscopy patients were not concerned that their surgery would have a negative impact on their pregnancy outcomes or hip function after pregnancy. Within the hip arthroscopy population, although hip pain was exacerbated during pregnancy, most patients experienced a resolution of pain following delivery. Pregnancy-related complications did not occur more frequently in the hip arthroscopy cohort compared to the wider U.S. population. Patient-reported hip outcomes were comparable between nulligravid women and those who had only been pregnant prior to surgery.

Poster 142: Capsular Repair Demonstrates Similar Restoration of Resistance to Axial Distraction in Interportal and Periportal Capsulotomies: An In Vivo Propensity Matched Cohort Study

Objectives: Hip arthroscopy has become increasingly prevalent in the United States for treating young adult hip disorders. The periportal capsulotomy, in comparison to the interportal capsulotomy, has been proposed as a technique for decreasing post-arthroscopy hip instability; however, the effects of this technique are largely theoretical. The objectives of this study were to compare the intraoperative distraction profiles of hip arthroscopy patients undergoing interportal versus periportal capsulotomies. The authors hypothesized the periportal capsulotomy would demonstrate greater resistance to axial distraction at both 1) the capsulotomy and 2) final capsular repair, when compared to the interportal capsulotomy. Methods: Patients undergoing primary hip arthroscopy by a single surgeon underwent intraoperative axial distraction testing at 25-, 50-, 75-, and 100-pounds force with each axial distraction distance measured by standardized, normalized fluoroscopic evaluation. Demographics, hip radiographic characteristics, and distraction distance measurements were collected on patients undergoing periportal capsulotomy and on a historical control group undergoing an interportal capsulotomy (Figure 1). Propensity matching was conducted using native state distraction, lateral center edge angle, and gender as covariate to achieve balance between groups. Between group comparisons were then conducted across the matched interportal and periportal groups. Student’s T-test for continuous variables and the Fisher exact test for categorical variables. Intragroup comparison was conducted across three capsule states: native, capsulotomy, and repair. Sequential testing of capsular states for each patient was conducted with the paired T-test. Results: Seventy-four interportal capsulotomies and 122 periportal capsulotomies were identified. Propensity matching yielded 74 hips in each group with standard mean differences of &lt;0.03. Demographic and radiographic characteristics were similar between matched cohorts (p &gt; 0.05) (Table 1). Distraction distances were similar between the interportal and periportal groups in both the capsulotomy and repair states (p &gt; 0.05), while the periportal capsulotomy repair demonstrated decreased hip distraction distance when compared to the native state by 1.48mm at 75lbf and 1.54mm at 100lbf (p &lt; 0.001) (Figure 2). Conclusions: The present study demonstrates that periportal capsulotomy and interportal capsulotomy have similar effects on in vivo hip distractibility. An unrepaired interportal capsulotomy led to an increase in hip distraction of 2.71 mm at 100 lbf (p &lt; 0.001) compared to the native state, while an unrepaired periportal capsulotomy led to an increase in hip distraction of 2.44 mm at 100 lbf (p &lt; 0.001). The periportal capsulotomy technique has been discussed as having the unique advantage of not fully disrupting the iliofemoral ligament and therefore potentially not require a repair; however, the results of the present study indicate that it is biomechanically similar to the interportal capsulotomy in the unrepaired state. Although this finding does not definitively establish a need for capsular repair in all cases when utilizing a periportal capsulotomy, if the surgeon wishes to re-establish native biomechanics, repair should be considered. The present study establishes the in vivo, intraoperative biomechanics of the periportal capsulotomy, for which there were previously no available data. Further, this study establishes that although periportal capsulotomy is a minimally disruptive technique, it has a substantial effect on in-vivo, intraoperative hip stability as measured by hip distraction distance as a result of axial traction forces. While this paper is able to address the biomechanics at the time of surgery, this paper cannot make any conclusions about the healing potential of the capsule when comparing an interportal and a periportal capsulotomy. In conclusion, an unrepaired periportal capsulotomy and interportal capsulotomy have a similar effect on increasing hip axial distraction distance intra-operatively. Performing a capsular repair restores intra- operative resistance to axial distraction in both the periportal and interportal capsulotomy. [Table: see text]

Paper 66: Short-Term Outcomes in Hip Arthroscopy Patients Participating in Formal Physical Therapy vs a Home Exercise Program: A Prospectively Enrolled Cohort Analysis

Objectives: The treatment of femoroacetabular impingement (FAI) has evolved over the last two decades, transitioning from an open hip dislocation to a more minimally invasive arthroscopic approach as the gold standard for treatment. The non-surgical management of FAI has evolved as well, and a key mainstay of the treatment paradigm for FAI has become physical therapy, both in the preoperative and postoperative periods. Previous research has demonstrated the importance of physical therapy in reducing pain and improving function in patients with FAI. As FAI treatment has changed, the delivery of patient physical therapy and rehabilitation has similarly changed, specifically with the introduction of home exercise programs that are patient-driven methods of postoperative rehabilitation. While other areas of orthopaedic surgery, such as shoulder and knee arthroplasty, have demonstrated similar results when comparing formal physical therapy programs with home-based programs, a comparable study has yet to be conducted specifically in the hip arthroscopy patient population. Given this lack of investigation, the purpose of this study was to compare the short-term outcomes of a formal physical therapy program or a home exercise program (HEP) in FAI patients treated with hip arthroscopy. Our hypothesis was that individuals in both groups would report similar outcomes at short- term follow up and would be significantly improved from their preoperative baselines. Methods: Patients undergoing hip arthroscopy for the treatment of FAI at a single center from October 2020 to October 2021 were prospectively enrolled. Inclusion criteria were 1) completion of a preoperative survey, 2) age greater than 18 years at time of surgery, and 3) lack of previous hip surgery. Patients were allowed to self-select to a formal physical therapy (FPT) program, which consisted of a traditional physical therapy course, or a home exercise program (HEP). Patients were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. Included in the survey was a single assessment numeric evaluation (SANE), visual analogue scale (VAS) pain scores, the International Hip Outcome Tool-12 (iHOT-12), the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and patient satisfaction of physical therapy and their overall care. Demographic characteristics were collected from the electronic medical record. Statistical analysis was conducted using descriptive statistics, unpaired and paired t-tests, and Chi Square and Fisher’s Exact tests for categorical variable comparisons. A p-value of &lt; 0.05 was used to indicate statistical significance. Results: A total of 147 patients were included in this study, with 61 in the FPT group and 86 in the HEP group. There were no significant differences regarding patient sex (p = 0.675) and body mass index (p = 0.188), though the HEP group was slightly older than the FPT group (33.6 ± 9.5 years vs 30.1 ± 11.4 years; p = 0.048). At 12 months postoperative, no significant differences were reported between the FPT and HEP groups regarding hip function rated as a percent of normal (p = 0.576), VAS pain scores at rest (p = 0.262) or during activities of daily living (p = 0.214) or during sport (p = 0.066), PROMIS PF scores (p = 0.426), and iHOT-12 scores (p = 0.421). Furthermore, no differences were reported in patient satisfaction (p &gt; 0.05). Outcome scores at 12 months postoperative were significantly improved from the preoperative baseline across all measures in both groups (p &gt; 0.05). Conclusions: For patients undergoing hip arthroscopy for the treatment of FAI, formal physical therapy and home exercise programs are similarly efficacious in terms of patient-reported outcomes of hip function, with both rehabilitation options resulting in significant patient improvement at short term follow-up from their preoperative baseline. [Table: see text][Table: see text]

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes

To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P= .03) and NAHS (P= .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (β= -1.14, P= .02) and NAHS (β= -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR]= 0.82, P= .02) and NAHS MCID (OR= 0.88, P= .04). Older age was predictive of reduced improvement in NAHS (β= -0.31, P= .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR= 3.98, P= .02). Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. Level III, retrospective comparative prognostic trial.

Total Knee Conversion Rates and Functional Outcome After Calcium Phosphate Injection for Bone Marrow Lesions of the Knee.

Untreated osteoarthritis (OA)-related bone marrow lesions (OA-BML) can hasten the progression of knee OA. Previous studies have shown that fluoroscopically guided intraosseous calcium-phosphate (CaP) injections of OA-BML during knee arthroscopy can lead to pain reduction, improved functionality, and prolonged time until conversion to total knee arthroplasty (TKA). The purpose of this retrospective study is to compare the clinical outcomes of patients who underwent knee arthroscopy and CaP injection for OA-BML versus knee arthroscopy for non-OA-BML pathologies. Two-year follow-up data and patient-reported outcomes including knee injury and operative outcome scores, joint replacement scores (KOOS, JR) were available for 53 patients in the CaP group and 30 patients in the knee arthroscopy group. Results indicate that patients in the CaP group had less frequent conversion to TKA compared with patients in the knee arthroscopy group. Statistical analysis demonstrated a statistical difference between preoperative and postoperative KOOS, JR within the CaP group but not for the knee arthroscopy group. Two-year postoperative KOOS, JR for CaP patients was statistically greater than the 2-year postoperative KOOS, JR of knee arthroscopy patients. Results indicate greater improvement in functional outcomes with knee arthroscopy and CaP injection of OA-BML compared with knee arthroscopy alone for non-OA-BML diagnoses. The results of this retrospective study help to distinguish the benefits of knee arthroscopy accompanied by CaP intraosseous injection from that of knee arthroscopy alone.

Patients aged 50-75years take longer to achieve the patient acceptable symptom state than patients aged 20-34years following primary hip arthroscopy for femoroacetabular impingement syndrome.

Though an increasing number of adults older than 50years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS. A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34years, 35-49years, and 50-75years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model. Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34years, 92 (32.3%) aged 35-49years, and 78 (27.4%) aged 50-75years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03). Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75years who undergo primary hip arthroscopy compared to those aged 20-34years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts. III.

In-office needle arthroscopy is a cost-effective alternative for operating room diversion in medial meniscectomy: a financial analysis

BackgroundIn-office needle arthroscopy (IONA) has been described as a diagnostic alternative to magnetic resonance imaging (MRI) for intra-articular pathology. However, few studies have analyzed its impact on cost and wait times when used as a therapeutic intervention. The purpose of this study was to investigate the impact on cost and wait times associated with offering IONA for partial medial meniscectomy as an alternative to traditional operating room (OR) arthroscopy for patients with irreparable medial meniscus tears on MRI.MethodsTwo models were created comparing the existing care pathway (current state) to a proposed future state utilizing IONA. Data sources were accounting data from an academically affiliated hospital in Canada and supplemented with literature values. A Monte Carlo simulation combined with DuPont analysis running 10,000 simulations was conducted to calculate the revenue, expenses, profits, and effect on surgical waitlists (i.e., throughput) between the states. Sensitivity analyses examined the influence of patient preference and revision rates on profit and throughput. Two-sample Student’s t test was performed (p < .05).ResultsAn average of 198 (standard deviation (SD) 31) patients underwent arthroscopic meniscectomy or repair each year from 2016 to 2020. The IONA revision rate was calculated as 20.3%. Compared to the current state, annual expenses in the IONA pathway were significantly reduced ($266,912.68 versus $281,415.23, p < .0001), while improving throughput by 21.2% (3.54%). Sensitivity analysis revealed 10% of patients need to select IONA over traditional OR arthroscopy with the revision rate remaining below 40% for the proposed state profit to be higher than the current state.ConclusionsIONA is a cost-effective alternative to traditional OR arthroscopy in patients undergoing partial medial meniscectomy. The next steps are to assess patients’ perceptions of IONA as an alternative to traditional OR arthroscopy, and to carry out clinical trials to determine the efficacy, patient-reported outcome metrics, and complications of IONA.

Particulated Costal Hyaline Cartilage Allograft With Subchondral Drilling Improves Joint Space Width and Second-Look Macroscopic Articular Cartilage Scores Compared With Subchondral Drilling Alone in Medial Open-Wedge High Tibial Osteotomy

To compare the articular cartilage regeneration based on second-look arthroscopy in patients who underwent medial open-wedge high tibial osteotomy (MOWHTO) combined with particulated costal hyaline cartilage allograft (PCHCA) implantation with those who underwent MOWHTO and subchondral drilling (SD). Moreover, we compared the clinical and radiographic outcomes between the groups. From January 2014 to November 2020, patients with full-thickness cartilage defect on the medial femoral condyle who underwent MOWHTO combined with PCHCA (group A) or SD (group B) were reviewed. Fifty-one knees were matched after propensity score matching. The status of regenerated cartilage was classified according to the International Cartilage Repair Society-Cartilage Repair Assessment (ICRS-CRA) grading system and Koshino staging system, based on second-look arthroscopic findings. Clinically, the Knee Injury and Osteoarthritis Outcome Score, the Western Ontario and McMaster Universities Osteoarthritis Index, and range of motion were compared. Radiographically, we compared the differences in the minimum joint space width (JSW) and change in JSW. The average age was 55.5 years (range, 42-64 years), and the average follow-up period was 27.1 months (range, 24-48 months). Group A showed a significantly better cartilage status than group B based on the ICRS-CRA grading system and Koshino staging system (P < .001 and <.001, respectively). There were no significant differences in clinical and radiographic outcomes between groups. In group A, the minimum JSW at the last follow-up was significantly increased than that before surgery (P= .013), and a significantly greater increase in JSW was observed in group A (P= .025). When performed with MOWHTO, the combination of SD and PCHCA was associated with superior articular cartilage regeneration on the ICRS-CRA grading and Koshino staging on second-look arthroscopy performed at a minimum of 2 years follow-up than SD alone. However, there was no difference in clinical outcomes. Level III, retrospective comparative study.

Outcomes of Hip Arthroscopy in Patients with Hip-Spine Syndrome: A Matched Control Study with Minimum 2-Year Follow-Up

Outcomes of Hip Arthroscopy in Patients with Hip-Spine Syndrome: A Matched Control Study with Minimum 2-Year Follow-Up

Recovery After Hip Arthroscopy in Patients With Combined Femoroacetabular Impingement and Labral Tears Compared With Isolated Pathology

Background: Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology. Purpose: To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT–12). Study Design: Cohort study; Level of evidence, 3. Methods: A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT–12 scores at 1.5, 3, 6, 12, 18, and &gt;24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS). Results: Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT–12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) ( P &lt; .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively ( P &lt; .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively. Conclusion: The final iHOT–12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau.

Enhanced in vivo and ex vivo thrombin generation after lower-leg trauma, but not after knee arthroscopy

BackgroundThere is room for improvement of prevention of venous thromboembolism (VTE) after lower-leg cast application or knee arthroscopy. Information about the mechanism of clot formation in these patients may be useful to identify new prophylaxis targets. We aimed to study the effect of 1) lower-leg injury and 2) knee arthroscopy on thrombin generation.MethodsA cross-sectional study was conducted using plasma samples of POT-(K)CAST trials to measure ex vivo thrombin generation (Calibrated Automated Thrombography [CAT]) and plasma levels of prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin (TAT), fibrinopeptide A (FPA). Plasma was obtained shortly after lower-leg trauma or before and after (< 4 h) knee arthroscopy. Participants were randomly selected from those who did not develop VTE. For aim 1, samples of 88 patients with lower-leg injury were compared with 89 control samples (i.e., preoperative samples of arthroscopy patients). Linear regression was used to obtain mean differences (or ratios if ln-retransformed because of skewedness) adjusted for age, sex, body mass index, comorbidities. For aim 2, pre- and postoperative samples of 85 arthroscopy patients were compared, for which mean changes were obtained.ResultsIn patients with lower-leg injury (aim 1), endogenous thrombin potential, thrombin peak, velocity index, FPA and TAT were increased as compared with controls. In arthroscopy patients (aim 2), pre- and postoperative levels were similar for all parameters.ConclusionLower-leg trauma increases thrombin generation both ex vivo and in vivo, in contrast to knee arthroscopy. This may imply that the pathogenesis of VTE is different in both situations.

Relationship between the Depth of Acetabuloplasty and Outcomes of Hip Arthroscopy in Patients with Global Pincer Femoroacetabular Impingement: Study with a Minimum Follow‐Up Period of 2 Years

There has been no definite consensus on the ideal depth of acetabuloplasty, especially in cases of global pincer femoroacetabular impingement (FAI). This study aims to determine whether the depth of acetabuloplasty influences postoperative outcomes in cases of global pincer FAI. Data were retrospectively collected from patients with global pincer FAI who underwent hip arthroscopy with a minimum follow-up period of 2 years from May 2014 to December 2018. Patients with global pincer FAI were subdivided into low or high resection depth groups based on whether the intraoperative acetabular rim was resected by more than 3 mm. Radiographic measurements; arthroscopic procedures; preoperative and postoperative PROs were recorded. Achievement of MCID and PASS was compared for the VAS, mHHS, HOS-ADL, and iHOT-12. A paired Student t-test was used to evaluate the significance of preoperative and postoperative PROs and two-tailed unpaired Student t-test was used to compare demographic data and PROs between different groups. MCID and PASS were evaluated using the chi-square test or the Fisher's exact test. A total of 41 hips with global pincer FAI (15 and 26 patients in low or high resection depth groups, respectively) were included in this study. Both groups showed significant postoperative improvements in the scores of all PROs (p < 0.001). Compared to the low resection depth group, the high resection depth group had a lower degree of improvement through hip arthroscopy, which manifested as lower postoperative mHHS scores (94.29 vs. 85.08, p = 0.006), higher VAS scores (0.93 vs. 2.54, p = 0.002), and lower improvements in VAS (-5.00 vs. -3.35, p = 0.028), HOS-ADL (34.99 vs. 23.90, p = 0.017) and iHOT-12 (39.89 vs. 29.27, p = 0.036). Patients in high resection depth group were less likely to achieve the MCID for the VAS score compared to low resection depth group in significant (73.3 vs. 26.9%, p = 0.004). For patients with global pincer, the outcomes in high resection depth group were slightly worse than the the low resection depth group. It is indicated that excessive resection of the acetabular rim during the procedure should be avoided.