Borderline Dysplasia Research Articles

Association of 5-Year Hip Arthroscopy Outcomes with Hip Morphology and Cartilage Status at Time of Surgery: A National Registry Study With HAGOS Outcomes in 281 Patients With Femoroacetabular Impingement Syndrome.

The effects of specific bony hip morphologies, cam and dysplasia, and cartilage damage on mid- and long-term (≥5 years) patient-reported outcomes (PROs) are understudied. To investigate if changes in PROs from preoperatively to 5 years after hip arthroscopy are associated with preoperative bony hip morphology and cartilage status in patients with femoroacetabular impingement syndrome. Cohort study; Level of evidence, 3. Patients were identified in the Danish Hip Arthroscopy Registry. Hip and groin function was assessed from preoperatively to 5 years postoperatively with the Copenhagen Hip and Groin Outcome Score (HAGOS) Activities of Daily Living (ADL) and Sports and Recreation (Sport) subscales. Morphology was defined using the anterior alpha angle (AA) and lateral center-edge angle (LCEA) as follows: mild to moderate cam (55°≤ AA < 78°), severe cam (AA ≥ 78°), pincer (LCEA > 39°), and borderline dysplasia (20°≤ LCEA < 25°). Joint space width (JSW) was defined as slightly reduced (3.1 mm ≤ JSW ≤ 4 mm) or severely reduced (2.1 mm ≤ JSW ≤ 3 mm). Acetabular cartilage status was defined by modified Beck grades 0 to 4 and femoral head cartilage status by International Cartilage Regeneration & Joint Preservation Society grades 0 to 4. Acetabular and femoral cartilage injury areas were categorized as <1, 1 to 2, or >2 cm2. Multiple regression analyses assessed adjusted associations between hip morphology and cartilage injuries with improvement in HAGOS-ADL and HAGOS-Sport. The study included 281 patients (age, 35 ± 10 years; 52.3% female). No cam and mild-to-moderate cam were associated with greater improvement in HAGOS-ADL (16 points [P = .002] and 7 points [P = .038], respectively) compared with severe cam. Normal JSW was associated with greater improvement in HAGOS-ADL (21 points; P = .026) compared with severely reduced JSW. Femoral head cartilage injury area <1 cm2 was associated with greater improvements in HAGOS-ADL (17 points; P = .03) and HAGOS-Sport (21 points; P = .035) compared with femoral cartilage injury area >2 cm2. Patients having no-to-moderate cam morphology, normal JSW, or femoral head cartilage injury area <1 cm2 had greater improvement in PROs 5 years after hip arthroscopy compared with patients having severe cam morphology, severely reduced JSW, or femoral cartilage injury area >2 cm2.

Primary Hip Arthroscopy in Patients With Acetabular Dysplasia: A Systematic Review of Published Clinical Outcomes at Minimum 5-Year Follow-up

Background: Hip arthroscopy in patients with borderline hip dysplasia has satisfactory outcomes at short-term follow-up; however, the data on midterm outcomes are inconsistent, and failure rates are high in some studies, limiting understanding of the role and utility of hip arthroscopy in this patient cohort. Purpose: To provide an up-to-date, evidence-based review of the clinical outcomes of primary hip arthroscopy in patients with frank or borderline hip dysplasia at ≥5-year follow-up and report the failure rate and progression to total hip arthroplasty in this cohort. Study Design: Systematic review; Level of evidence, 4. Methods: A comprehensive literature search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated outcomes of primary hip arthroscopy in patients with lateral center-edge angle (LCEA) <25° at ≥5-year follow-up. Risk of bias assessment was performed using the methodological index for non-randomized studies scoring system. Level of evidence was determined using criteria from the Oxford Centre for Evidence-Based Medicine. Results: Nine studies were included in this review. Patients with LCEA <25° demonstrated satisfactory clinical outcomes, high patient satisfaction, and significant postoperative improvements in patient-reported outcomes (PROs) at follow-up ranging from a ≥5 to 10 years. Studies comparing patients with dysplasia to those without did not demonstrate significant differences in preoperative, postoperative, or delta PROs or in failure, reoperation, or revision rates. There was no overall significant correlation between outcomes and LCEA stratification. Conclusion: Hip arthroscopy in carefully selected patients with LCEA <25° can be successful at mid- to long-term follow-up and may provide clinical outcomes and failure rates comparable with patients with normal LCEA, understanding that this is a singular, 2-dimensional radiographic measure that does not differentiate instability from impingement or combinations thereof, warranting future studies delineating these differences. These findings suggest that hip dysplasia may not be an absolute contraindication for isolated hip arthroscopy and may serve as a viable intervention with consideration of staged future periacetabular osteotomy (PAO). Importantly, this review does not suggest that hip arthroscopy alters the natural history of dysplasia; therefore, patients with dysplasia should be counseled on the potential utility of PAO by appropriate hip preservation specialists.

Patients with Borderline Hip Dysplasia Undergoing Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Demonstrate Lower Outcome Scores but Comparable Survivorship to Non-Dysplastic Controls: A Propensity-Matched Study with Minimum 10-Year Follow-up

Background: Patients with borderline hip dysplasia (BHD) have demonstrated similar outcomes following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) compared to equivalent patients without dysplasia at short- and mid-term follow-up. However, outcomes in these groups have not yet been compared at long-term follow-up. Objectives: To compare long-term clinical outcomes following primary hip arthroscopy for FAIS between patients with BHD and non-dysplastic matched controls. Methods: A retrospective review was conducted of patients who underwent primary hip arthroscopy for FAIS from January 2012 through February 2013. Patients with BHD, defined as a lateral center edge angle (LCEA) between 18° and 25°, were propensity matched in a 1:3 ratio by sex, age, and body mass index (BMI) to non-dysplastic controls. Preoperative and postoperative radiographs were assessed. Patient-reported outcomes (PROs) were collected preoperatively and 10 years postoperatively, and achievement rates of Minimal Clinically Important Difference (MCID) and Patient-Acceptable Symptom State (PASS) were calculated. PRO measures included the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and Visual Analog Scales (VAS) for Pain and Satisfaction. Gross survivorship was assessed using Kaplan-Meier curves. PROs, MCID and PASS achievement rates, and survivorship were compared between groups. Results: Twenty-eight patients with BHD (71.4% female; age: 30.8 ± 10.8 years, BMI: 24.2 ± 3.9 kg/m2) were matched to 84 controls (66.7% female, age: 34.4 ± 10.5 years, BMI: 24.9 ± 5.1 kg/m2; p ≥ 0.135). Mean follow-up was 10.3 ± 0.3 years. There were no significant differences between groups in any demographic characteristics, radiographic measurements, or intraoperative findings (p ≥ 0.096), except pre- and post-operative LCEA and Tönnis angle, which were lower and higher, respectively, among BHD patients (p &lt; 0.001). Both groups demonstrated significant improvement in all PROs between the preoperative and 10-year postoperative time points (p &lt; 0.001 for all). Preoperative, 10-year postoperative, and magnitude of change (delta) in PRO scores were similar between groups for all measures (p ≥ 0.072), except 10-year postoperative HOS-SS (BHD: 62.9 ± 31.9 vs. Controls: 80.1 ± 26.0, p = 0.030) and change in VAS Pain (BHD: -34.2 ± 27.2 vs. Controls: -48.5 ± 26.1, p = 0.047). Rates of MCID achievement were similar between groups for all PRO measures, but rates of PASS achievement were significantly lower among BHD patients for HOS-ADL (BHD: 39.1% vs. Controls: 77.4%, p = 0.002), HOS-SS (BHD: 45.5% vs. Controls: 84.7%, p = 0.001), and VAS Pain (BHD: 50.0% vs. Controls: 78.5%, p = 0.015). There was no difference in reoperation rate between groups (BHD: 14.3% vs. Controls: 17.9%, p = 0.778). Kaplan-Meier survival analysis demonstrated comparable gross survivorship at long-term follow-up (p = 0.645). Conclusions: Patients with BHD undergoing primary hip arthroscopy for FAIS demonstrated significantly lower sports-specific PRO scores than propensity-matched controls at 10-year follow-up, with a trend toward significantly worse scores for measures assessing activities of daily living, pain, and satisfaction. Rates of MCID achievement were similar between groups, but BHD patients demonstrated lower rates of PASS achievement for the majority of PRO measures. However, patients with BHD had similar long-term hip survivorship compared to controls, with no significant differences in rates of revision hip arthroscopy or conversion to total hip arthroplasty.

Decision-making in borderline hip dysplasia and concomitant femoracetabular impingement syndrome: using a discrete choice experiment to explore patient preferences

ABSTRACT Decision-making regarding surgical treatment of patients showing radiographic evidence of femoroacetabular impingement syndrome (FAIS) in the setting of borderline hip dysplasia (BHD) remains a challenge as there is no consensus on treatment in current literature. When medical evidence is unclear, understanding patient preferences becomes particularly important in deciding the optimal treatment for each patient. The purpose of this study was to measure the patient-determined importance of factors surrounding surgical treatment of FAIS in BHD. Patients aged 18–65 with hip pain and BHD (defined as lateral center edge angle 18–25 or Tonnis angle 10–15) morphology were given a discrete-choice experiment (DCE) focusing on attributes that differ between treatment options: Length of Hospital Stay, Major Complication Rate, Chance of Needing Reoperation within 2 Years and Time to Return to Regular Exercise. This DCE was used to calculate treatment preferences, relative attribute importance and preference weights. A total of 101 patients fully completed the DCE. The most important attribute (average importance weight, 95% CI) was Chance of Reoperation (60.16, 56.99–63.34), while the least important was Hospital Stay (6.57, 5.73–7.41). Only 6 Months to Resume Regular Exercise and 2% Chance of Reoperation (P &amp;lt; 0.05) significantly impacted treatment choice. When presented with fixed choice parameters, 50.5% of subjects preferred PAO and arthroscopy while 49.5% opted for arthroscopy alone. When no clear surgical treatment is indicated, patient preferences have an amplified role in patient decision-making. Our results confirm variation in attribute importance within treatments as well as treatment choice, highlighting the importance in understanding patient preferences in decision-making for FAIS in BHD. More patient-specific generalizable outcomes of surgical treatment options are needed in the literature.

Outcomes and Return-to-Sports Rates in Patients With Borderline Hip Dysplasia After Periacetabular Osteotomy: A Case Series With 5-Year Follow-up

Background: The optimal surgical approach in patients with borderline hip dysplasia (BHD) remains controversial. Both hip arthroscopy and periacetabular osteotomy (PAO) are commonly employed in this patient population. Those who participate in sports want to resume and maintain sports activities after surgery, and the ability to do so plays an important role in the choice of a treatment method. To our knowledge, no previous study has assessed return-to-sports rates and activity levels in patients with BHD after PAO. Purpose: To assess return-to-sports rates and postoperative activity levels as measured by the University of California, Los Angeles (UCLA), activity scale as well as patient-reported outcome measures. Also to assess changes in sports activity both qualitatively and quantitatively as well as underlying reasons for these changes. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective analysis of prospectively collected data from 55 hips in 52 patients with BHD who underwent PAO between January 2015 and June 2017. Return-to-sports rates, UCLA activity scores, International Hip Outcome Tool–12 scores, Subjective Hip Value scores, Hip disability and Osteoarthritis Outcome Score subscores, sports practiced, frequency and duration of sports activity, and postoperative changes as well as underlying reasons were recorded. Results: The mean follow-up was 62.8 ± 9.0 months. The return-to-sports rate among preoperatively active patients was 92.5%. Most patients resumed sports activity after 6 months (50%) or after 3 to 6 months (37.5%). The UCLA activity score improved significantly (from 5.2 ± 2.4 to 7.0 ± 1.8; P < .001). The International Hip Outcome Tool-12, Subjective Hip Value, and Hip disability and Osteoarthritis Outcome Score scores also improved significantly (all, P < .001). Changes in sports activity occurred in 34.5% of cases after PAO. Significantly more patients engaged in low-impact sports postoperatively. Participation in high-impact sports did not decrease significantly. Reasons for changes were both hip related and non–hip related. Quantitatively, patients were able to significantly increase both the frequency (P = .007) and duration (P = .007) of sports activity. Conclusion: The return-to-sports rate in patients with BHD after PAO was high at over 92%. Most patients returned to sports after a period of 6 months or 3 to 6 months. Overall, activity levels and hip function improved after PAO. A number of patients adjusted their sports activity after PAO. Although more patients engaged in low-impact sports, participation in high-impact sports was maintained postoperatively. The results of this study may help both patients and orthopaedic surgeons in deciding on the best surgical procedure in the setting of BHD.

Results of Arthroscopic Treatment of Patients With Femoroacetabular Impingement Depending on the Type of Hip Deformity

Background. Femoroacetabular impingement (FAI) is one of the most common causes of pain syndrome and limited mobility in the hip joint among young and middle-aged individuals.&#x0D; The aims of this study: 1) To evaluate the impact of the type of hip joint deformity in patients with FAI on treatment outcomes; 2) To identify the type of hip joint deformity that is optimal for correction using arthroscopy; 3) To determine the impact of the acetabular structure in conditions of borderline dysplasia on the treatment outcome.&#x0D; Methods. A retrospective uncontrolled single-center study was conducted, including 121 patients (135 hip joints), among them 49 (40.5%) women and 72 (59.5%) men. Patients were divided into four groups based on the type of deformity. The first group included 33 (24.4%) joints with cam-type FAI, the second group — 72 (53.4%) joints with mixed-type, the third group — 17 (12.6%) joints with dysplasia (LCEA-O25°) and cam-type deformity of the femoral head-neck junction, and the fourth group — 13 (9.6%) joints with a combination of dysplasia, cam-type deformity, and retroversion of the acetabulum. All patients underwent physical examination and radiographic diagnostics. In patients with borderline dysplasia, the version of the acetabulum was additionally assessed. The iHOT-33 and HOS scales were used to evaluate the preoperative status and postoperative results.&#x0D; Results. The best treatment outcome was achieved in the first group of patients, which was statistically significantly different from the results in the third group. The treatment outcomes in the second group of patients did not show statistically significant differences from the first group according to the HOS questionnaire, but differed according to the iHOT-33 scale. The treatment outcomes in the fourth group of patients were almost indistinguishable on the iHOT-33 scale from the first group and on the HOS scale from the second group. In the third group, a statistically significant result on the HOS-Sport subscale was achieved in only 30% of patients, while in other groups it was not less than 58%. Other scales showed a slight superiority of treatment results in the first and fourth groups compared to the second and third groups. In the first years after surgery, all groups of patients showed a significant improvement in sports activity, but after 2 years, there was a tendency for a decrease in patients in the second and third groups.&#x0D; Conclusion. The highest results of arthroscopic treatment were shown by patients in the first group with isolated cam-type deformity, slightly worse were results by patients in the second group (with mixed-type). In patients with borderline dysplasia, the effectiveness of arthroscopy depended on the structure of the anterior wall of the acetabulum. The worst result was observed in patients with borderline dysplasia and insufficiently developed anterior wall of the acetabulum — in that group of patients, it is worth preferring isolated periacetabular osteotomy or in combination with arthroscopy.

Femoro-Epiphyseal Acetabular Roof Index Values on Anteroposterior Pelvic Radiographs Significantly Increase With Hip Adduction and Decrease With Abduction

PurposeTo investigate the impact of hip adduction and abduction on the femoro-epiphyseal acetabular roof (FEAR) index using conventional anteroposterior pelvic radiographs of patients with borderline hip dysplasia (BHD). MethodsPatients with BHD (lateral center edge angle [LCEA] with values of 18° ≤ LCEA <25°) and who were subject to periacetabular osteotoym were selected from a consecutive retrospective cohort from January 2009 to January 2016. The hip ad-/abduction (adduction handled as negative values) and the FEAR index (lateral opening angles handled as positive values) were measured in the initially standardized acquired pelvic radiographs. Thereafter, using surgical planning software, different degrees of hip adduction and abduction were simulated from 20° of adduction to 30° of abduction, and the FEAR index was measured at each position. Pearson correlation was used to identify a potential correlation between the hip ad-/abduction and the FEAR index. ResultsEighty-nine hips were included. Initial radiographs showed unintentional mean ad-/abduction of –5.3° ± 3.1° (range, –14° to 2°). The mean FEAR index at the initial ad-/abduction angle was –3.6° ± 7.2° (range, –18.0° to 16.0°) and was significantly different from neutral position (0° of ad-/abduction) –9.2° ± 7.0° (range, –27.0° to 10.0°) (P < .001). The FEAR index was negatively correlated to the hip ad-/abduction angle (r = 1, P < .001), with lower values for the FEAR index with the hip in abduction. ConclusionsSignificant differences in FEAR index measurements were observed depending on hip ad-/abduction on pelvic radiographs. A linear change of the FEAR index of 5° per 5° of hip adduction or abduction could be demonstrated, with adduction resulting in increasing and abduction in decreasing values for the FEAR index. Level of EvidenceLevel III, diagnostic study.

A Modified Approach to Measuring Femoro-Epiphyseal Acetabular Roof (FEAR) Index Has Better Intraobserver and Interobserver Reliability Compared With the Original FEAR Index

PurposeTo propose a modified approach to measuring femoro-epiphyseal acetabular roof (FEAR) index while still abiding by its definition and biomechanical basis, and to compare the intra- and inter-observer reliabilities of the original and the modified FEAR index. To propose a classification for medial sourcil edges. MethodsWe retrospectively reviewed a consecutive series of patients treated with periacetabular osteotomy and/or hip arthroscopy at a single institute. Patients with unilateral or bilateral symptomatic borderline hip(s) were included. Hips with remarkable osteoarthritis, deformities, history of previous surgery, or without symptoms were excluded. A modified FEAR index was defined using a best-fit circle to determine the sourcil line and two ancillary lines connecting femoral head and sourcil edges to determine epiphyseal line. Lateral center-edge angle, Sharp’s angle, Tonnis angle on all hips, as well as FEAR index with original and modified approaches were measured. Intra- and inter-observer reliability were calculated as intraclass correlation coefficients (ICC) for FEAR index with both approaches and other alignments. A classification was proposed to categorize medial sourcil edges. ICC for the two approaches across different sourcil groups were also calculated. ResultsAfter reviewing 411 patients, 49 were finally included. Thirty-two patients (40 hips) were identified as having borderline dysplasia defined by an LCEA of 18 to 25 degrees. Intra-observer ICC for the modified method were good to excellent for borderline hips; poor to excellent for DDH; moderate to excellent for normal hips. As for inter-observer reliability, modified approach outperformed original approach with moderate to good inter-observer reliability (DDH group, ICC=0.650; borderline dysplasia group, ICC=0.813; normal hip group, ICC=0.709). The medial sourcil edge were classified to 3 groups upon its morphology. Type II (39.0%) and III (43.9%) sourcils were the dominant patterns. The sourcil classification had substantial intra-observer agreement (observer 4, kappa=0.68; observer 1, kappa=0.799) and moderate inter-observer agreement (kappa=0.465). Modified approach to FEAR index possessed greater inter-observer reliability in all medial sourcil edge patterns. ConclusionThe modified FEAR index has better intra- and inter-observer reliability compared with the original approach in all hip groups and sourcil groups. Type II and III sourcils accounts for the majority to which the modified approach is better. Level of EvidenceLevel II, Development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding)

The role ofiliopsoas fractional lengthening inhip arthroscopy: a systematic review.

Arthroscopic iliopsoas fractional lengthening (IFL) is a surgical option for the treatment of internal snapping hip syndrome (ISHS) after failing conservative management. Systematic review. A search of PubMed central, National Library of Medicine (MEDLINE) and Scopus databases were performed by two individuals from the date of inception to April 2023. Inclusion criteria were ISHS treated with arthroscopy. Sample size, patient-reported outcomes and complications were recorded for 24 selected papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and registered on PROSPERO database for systematic reviews (CRD42023427466). Thirteen retrospective case series, ten retrospective comparative studies, and one randomized control trial from 2005 to 2022 were reported on 1021 patients who received an iliopsoas fractional lengthening. The extracted data included patient satisfaction, visual analogue scale, the modified Harris hip score and additional outcome measures. All 24 papers reported statistically significant improvements in post-operative patient-reported outcome measures after primary hip arthroscopy and iliopsoas fractional lengthening. However, none of the comparative studies found a statistical benefit in performing IFL. Existing studies lack conclusive evidence on the benefits of Iliopsoas Fractional Lengthening (IFL), especially for competitive athletes, individuals with Femoroacetabular Impingement (FAI), and borderline hip dysplasia. Some research suggests IFL may be a safe addition to hip arthroscopy for Internal Snapping Hip Syndrome, but more comprehensive investigations are needed. Future studies should distinguish between concurrent procedures and develop methods to determine if the psoas muscle is the source of pain, instead of solely attributing it to the joint.

Joint instability in patients with borderline developmental dysplasia of the hip

BackgroundThe treatment strategy for developmental dysplasia of the hip is determined based on the lateral center-edge angle. Nonetheless, an evaluation of joint instability may be important in determining the treatment strategy. This study classified the displacement patterns of the femoral head center during hip abduction. MethodsTen patients with borderline developmental dysplasia of the hip, 10 patients with developmental dysplasia of the hip, and 10 patients with normal hips were analyzed. Image matching was performed using X-ray images of hip abduction with a three-dimensional hip model. The displacement of the femoral head center and its trajectory length were measured. A cluster analysis was conducted to classify the displacement pattern of the femoral head center, and trajectory lengths were compared. FindingsDisplacement was classified into three patterns: medialization, hinge abduction, and centering. Patients with borderline developmental hip dysplasia exhibited all three patterns. Almost all patients with developmental dysplasia of the hip showed medialization and hinge abduction, whereas all normal patients had the centering type. The mean trajectory length indices for the medialization and hinge abduction types were significantly longer than those for the centering type (P = 0.01 and P = 0.016, respectively). InterpretationBorderline developmental dysplasia of the hip is a heterogeneous condition characterized by varying hip instability levels. Our findings suggest that uniform evaluation based on the lateral center-edge angle is inappropriate and that joint instability must be evaluated in each patient with borderline developmental dysplasia of the hip.

Borderline Hip Dysplasia Is Not Associated With Significant Differences in Hip Survivorship or Patient-Reported Outcomes Following Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Cohort Study

To compare hip survivorship and patient-reported outcomes after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients with versus without comorbid borderline hip dysplasia (BHD) at 2-year follow-up. A retrospective matched-cohort study was conducted involving patients who underwent primary hip arthroscopy for FAIS with a single surgeon from 2010 to 2019. BHD was defined as lateral center edge angle (LCEA) of 20 to 25°. Subjects with BHD were matched 1:2 to controls without BHD on age, sex, body mass index, and preoperative modified Harris Hip Score (mHHS). Alpha angle, LCEA, Tönnis angle, and acetabular retroversion signs were measured on preoperative and/or postoperative hip radiographs. Patient-reported outcomes were assessed using the mHHS and the Non-Arthritic Hip Score. Hip survivorship, outcome scores, and achievement of the minimum clinically important difference were compared between groups using the Mann-Whitney U test or Fisher exact test, as appropriate. P values <.05 were considered significant. Thirty-one BHD subjects (mean age 36.8 years, 71.0% female) and 62controls (mean age 38.0 years, 71.0% female) were included. There were no significant intergroup differences in demographics or preoperative radiographic measurements besides LCEA and Tönnis angle (all P > .05). Intraoperatively, subjects with BHD were found to have significantly shorter labral tears (mean 2.6 vs 2.8 clock-face hours, P= .048), but there were no significant intergroup differences in acetabular or femoral cartilage status (all P > .05). Postoperatively, there were no significant intergroup differences in rates of revision arthroscopy (BHD 6.5% vs control 11.3%) or conversion to total hip arthroplasty (BHD 9.7% vs control 1.6%), in 2-year improvement of the mHHS and Non-Arthritic Hip Score, or in minimum clinically important difference achievement rates (all P > .05). BHD is notassociated with a significant difference in hip survivorship or patient-reported outcomes following primary hip arthroscopy for FAIS. Level III, retrospective comparative study.

Hip Disorders in Bull Riders: Clinical Observations and Outcomes of Arthroscopy.

Bull riders represent a microcosm of athletes in whom severe consequences of femoroacetabular impingement may challenge the limits of arthroscopic intervention. Observations of this cohort may provide meaningful insight into the treatment of other populations. All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris Hip Score. Sixteen consecutive bull riders (21 hips) with minimum 2-year follow-up are reported. The average age was 26 years, duration of symptoms was 33 months, and follow-up was 57 months. Arc of rotational hip motion averaged 31°. All had femoroacetabular impingement (17 combined and 4 cam impingements). Among the cam impingements, 1 also had dysplasia and 1 also had borderline dysplasia. Radiographic Tönnis grades were as follows: 2 Tönnis 1; 18 Tönnis 2; and 1 Tönnis 3. All had acetabular articular damage (14 Outerbridge grade 4; 6 Outerbridge grade 3; and 1 Outerbridge grade 1). Nine underwent microfracture. Four had accompanying femoral chondral lesions (3 grade 3; 1 grade 4). There were 20 labral tears (14 repaired and 6 debrided). All but 1 (95%) improved after surgery. One bilateral case underwent conversion to resurfacing arthroplasty on one side and revision arthroscopy on the other. The average improvement was 21.3 points. Thirteen (81.25%) returned to bull riding at an average of 7 months. Among the 3 who did not return, each had undergone bilateral procedures. There were no complications. Femoroacetabular impingement can be a significant problem among bull riders. Limited range of motion, grade 4 articular damage, and Tönnis 2 radiographic changes may not preclude successful arthroscopic treatment, but advanced bilateral disease may be too much even for these hardened athletes. [Orthopedics. 2024;47(2):79-82.].

Lateral Center-edge Angle of 18° (Bone-Edge): Threshold for Hip Arthroscopy Treatment in Patients with Borderline Developmental Dysplasia of the Hip?

Hip arthroscopy for the treatment of symptomatic borderline developmental dysplasia of the hip (BDDH) has been controversial. The purpose of this study was to retrospectively analyze minimum 2-year outcomes of BDDH after arthroscopic surgery and explore the criteria and thresholds of the lateral center-edge angle (LCEA) in arthroscopic surgery for BDDH. Data were retrospectively collected from patients aged 18-50 who underwent arthroscopic surgery for BDDH and had an LCEA 18-25° between September 2016 and June 2020. The consistency of interobserver and intraobserver measurements of bone-edge LCEA was analyzed. Patients were divided into two groups based on LCEA (18-20°and 20-25°) and the results of arthroscopy compared between groups. Patient-reported outcome (PRO) scores, consisting of the modified Harris hip score (mHHS), the visual analogue scale (VAS) and the international hip outcome tool-12 (IHOT-12), the minimal clinically important difference (MCID) and patient acceptable symptom status (PASS) were calculated. In 52 patients with ≥2-year follow-up, female patients accounted for 71.2% and the mean age was 30.8 ± 8.4 years (range: 18 to 49 years). There was a high level of agreement when measuring the bone-edge LCEA definition of BDDH (Kappa = 0.921). Interobserver repeatability (ICC = 0.909, 95%CI: 0.847-0.947) and intraobserver repeatability (ICC = 0.944, 95%CI: 0.905-0.968) were excellent for bone-edge LCEA measurements. In addition to LCEA and Tönnis angle, there were no significant differences in α angle, neck stem angle, femoral anteversion angle, medial joint space, Tönnis grade of osteoarthritis, acetabular retroversion (8 sign), Cam deformity and anterior inferior iliac spine (AIIS) morphology between the two groups (p > 0.05). Intraoperative findings and procedures showed no statistical difference between groups (p > 0.05). The mean follow-up time was 44.4 ± 11.0 months (range: 25 to 64 months). Postoperative VAS, mHHS and IHOT-12 scores in the LCEA 18-20° group and the LCEA 20-25° group were significantly improved compared with those before surgery, and there was no statistically significant difference in the percentage of MCID and PASS (mHHS and iHOT-12) between the groups (p > 0.05). Patients in the LCEA 18-20° group and the LCEA 20-25° group achieved favorable outcomes after arthroscopic surgery. LCEA 18° (bone-edge) should be the threshold for hip arthroscopic surgery in BDDH patients without obvious hip instability.

Arthroscopy Confers Favorable Clinical Outcomes in Asian Patients with Borderline Developmental Dysplasia of the Hip.

Hip arthroscopy has recently appeared as a successful therapy in treating borderline developmental dysplasia of the hip (BDDH). This study aimed to describe the minimal 2-year follow-up after hip arthroscopy for patients with BDDH in the Asian population and use the combination of lateral center edge angle (LCEA) and alpha angles to detect the appearance of impingement in the BDDH population. This retrospective investigation was conducted utilizing information from arthroscopically treated BDDH patients in 2018 and 2019. The following patient-reported outcomes were reported: modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, International Hip Outcome Tool 12-component form, and Visual Analog Scale. We also considered the clinical data regarding radiological measurements, intraoperative findings, interventions, complications, and subsequent surgical revisions, in the analysis of combination angles in detecting the occurrence of impingement. Patients with asymptomatic contralateral hips from traumatic hip injury (pelvic fracture) served as the control group. A 2:1 propensity score matching was based on age, sex, and BMI. A receiver operating characteristic curve (ROC) was used to identify the thresholds of combination angles and their accuracies. A total of 77 hips met the inclusion and exclusion requirements. After the follow-up period, most patients showed a considerable improvement in patient-reported outcomes compared to their preoperative values (P < 0.001 for all). The overall rate of complications was 5.2%, whereas the rate of revisions was 3.9%. Increasing preoperative alpha angle age was significantly positively correlated with improving patient-reported outcomes. The combined angle cut-off was determined to be 80.5° (AUC, 0.858; 95% CI: 0.757-0.938; sensitivity (SE), 98.1%; specificity (SP), 74.1%; P < 0.001) for the occurrence of impingement in BDDH population. Good patient-reported outcomes and low revision rates can be expected in the BDDH population with careful selection of patients in Asian populations. A combination angle >80.5° could be a reliable predictive factor of impingement in BDDH populations.

Defining the Borderline Dysplastic Hip: High Variability in Acetabular Coverage and Femoral Morphology on Low-Dose Computed Tomography.

Borderline acetabular dysplasia is commonly radiographically defined as a lateral center-edge angle (LCEA) of 20° to 25°. While the variability of plain radiographic assessment of this population has been reported, an understanding of the variability of 3-dimensional (3D) hip morphology remains to be better defined. To investigate the variability of 3D hip morphology present on low-dose computed tomography (CT) in the setting of symptomatic borderline acetabular dysplasia and to determine if plain radiographic parameters correlate with 3D coverage. Cohort study (diagnosis); Level of evidence, 2. A total of 70 consecutive hips with borderline acetabular dysplasia undergoing hip preservation surgery were included in the current study. Plain radiographic evaluation included LCEA, acetabular inclination, anterior center-edge angle (ACEA), anterior wall index (AWI), posterior wall index (PWI), and alpha angles on anteroposterior, 45° Dunn, and frog-leg views. All patients underwent low-dose pelvic CT for preoperative planning, which allowed detailed characterization of 3D morphology relative to normative data. Acetabular morphology was assessed with radial acetabular coverage (RAC) calculated according to standardized clockface positions from 8:00 (posterior) to 4:00 (anterior). Coverages at 10:00, 12:00, and 2:00 were classified as normal, undercoverage, or overcoverage relative to 1 SD from the mean of normative RAC values. Femoral morphology was assessed with femoral version, alpha angle (measured at 1:00 increments), and maximum alpha angle. Correlation was assessed with the Pearson correlation coefficient (r). Lateral coverage (12:00 RAC) was deficient in 74.1% of hips with borderline dysplasia. Anterior coverage (2:00 RAC) was highly variable, with 17.1% undercoverage, 72.9% normal, and 10.0% overcoverage. Posterior coverage (10:00 RAC) was also highly variable, with 30.0% undercoverage, 62.9% normal, and 7.1% overcoverage. The 3 most common patterns of coverage were isolated lateral undercoverage (31.4%), normal coverage (18.6%), and combined lateral and posterior undercoverage (17.1%). The mean femoral version was 19.7°± 10.6° (range, -4° to 59°), with 47.1% of hips having increased femoral version (>20°). The mean maximum alpha angle was 57.2° (range, 43°-81°), with 48.6% of hips having an alpha angle ≥ 55°. The ACEA and AWI were poorly correlated with radial anterior coverage (r = 0.059 and 0.311, respectively), while the PWI was strongly correlated with radial posterior coverage (r = 0.774). Patients with borderline acetabular dysplasia demonstrate highly variable 3D deformities, including anterior, lateral, and posterior acetabular coverage; femoral version; and alpha angle. Plain radiographic assessments of anterior coverage are poorly correlated with anterior 3D coverage on low-dose CT.

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

To compare minimum 5-year patient-reported outcome measures after hip arthroscopy (HA) and periacetabular osteotomy (PAO) for borderline hip dysplasia. Hips with a lateral center-edge angle (LCEA) between 18° and less than 25° that underwent either PAO or HA were selected from 2 institutions. The exclusion criteria were as follows: LCEA less than 18°, Tönnis osteoarthritis grade greater than 1, prior hip surgical procedures, active inflammatory disease, Workers' Compensation, and concomitant surgery. Patients underwent propensity matching based on age, sex, body mass index, and Tönnis osteoarthritis grade. Patient-reported outcome measures included the modified Harris Hip Score, as well as calculation of the minimal clinically important difference, patient acceptable symptom state, and maximum outcome improvement satisfaction threshold. Preoperative radiographic predictors included comparison of the Femoro-epiphyseal Acetabular Roof index and ligamentum teres lesions. A total of 28 PAO patients underwent propensity matching to 49 HA patients. The 2 groups were similar in terms of mean age, sex, preoperative body mass index, and LCEA. The PAO group had a longer mean follow-up period (95.8 months vs 81.3 months, P= .001). The mean Femoro-epiphyseal Acetabular Roof index was significantly lower preoperatively in the HA group (P < .001). The 2 groups showed similar and significant improvements in the mean modified Harris Hip Score from preoperatively to latest follow-up (P < .001). The relative risk of subsequent surgery in the PAO group was 3.49 (P= .024), mostly attributed to hardware removal (25%). The revision rate was 3.6% in the PAO group and 8.2% in the HA group (P= .65). One patient in the PAO group required revision HA for intra-articular adhesions. Three of the patients requiring revision in the HA group underwent PAO because of persistent pain, and one underwent revision HA alone. Conversion to total hip arthroplasty was required in 1 patient in the HA group and no patients in the PAO group. Both PAO and HA with capsular plication provide borderline hip dysplasia patients with clinically significant improvements and low revision rates at a minimum of 5 years postoperatively. Level III, retrospective, comparative therapeutic trial.

Ligamentum Teres Tears and Increased Combined Anteversion Are Associated With Hip Microinstability in Patients With Borderline Dysplasia

(1) To investigate the differences in the prevalence of ligamentum teres (LT) tears and other radiographic measurements in borderline dysplasia of the hip (BDDH) with/without microinstability and (2) and to evaluate the associations between these imaging findings and the prevalence of microinstability in patients with BDDH. This was a retrospective study of symptomatic patients with BDDH (18° ≤ lateral center-edge angle <25°) treated with arthroscopy in our hospital between January 2016 and December 2021. These patients were divided into the BDDH with microinstability (mBDDH) group and the stable BDDH (nBDDH) group. The radiographic parameters associated with hip joint stability, such as the state of LT, acetabular versions, femoral neck version, Tönnis angle, combined anteversions, and anterior/posterior acetabular coverage, were reviewed and analyzed. There were 54 patients (49 female/5 male, 26.7 ± 6.9 years) in the mBDDH group and 81 patients (74 female/7 male, 27.2 ± 7.7 years) in the nBDDH group. The mBDDH group had greater LT tear (43/54 vs 5/81) and general laxity rates, increased femoral neck version, acetabular version and combined anteversion (52.4 ± 5.9 vs 41.5 ± 7.1 at 3-o'clock level) than the nBDDH group. Binary logistic regression showed that LT tears (odds ratio 6.32, 95% confidence interval 1.38-28.8; P= .02; R2= .458) and combined anteversion at the 3-o'clock level (odds ratio 1.42, 95% confidence interval 1.09-1.84; P < .01; R2= .458) were independent predictors of microinstability in patients with BDDH. The cutoff value of combined anteversion at 3-o'clock level was 49.5°. In addition, LT tear was correlated with increased combined anteversion at 3-o'clock level in patients with BDDH (P < .01, η2= 0.29). LT tears and increased combined anteversion at the 3-o'clock level on the acetabular clockface were associated with hip microinstability in patients with BDDH, suggesting that patients with BDDH and LT tears might have a greater prevalence of anterior microinstability. Level III, case‒control study.

Factors influencing patient-reported outcomes following periacetabular osteotomy and open osteochondroplasty in the setting of borderline hip dysplasia.

This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology. The mean follow-up was 96 months (67 to 139). The SHV, mHHS, WOMAC, and Tegner scores significantly improved (p < 0.001) at last follow-up. According to SHV and mHHS, there were three hips (7%) with poor results (SHV < 70), three (7%) with a fair score (70 to 79), eight (19%) with good results (80 to 89), and 28 (67%) who scored excellent (> 90) at the last follow-up. There were 11 subsequent operations: nine implant removals due to local irritation, one resection of postoperative heterotopic ossification, and one hip arthroscopy for intra-articular adhesions. No hips were converted to total hip arthroplasty at last follow-up. The presence of preoperative labral lesions or LT lesions did not influence any PROMs at last follow-up. From the three hips that had poor PROMs, two have developed severe osteoarthritis (> Tönnis II), presumably due to surgical overcorrection (postoperative AI < -10°). PAO is reliable in treating BHD with favourable mid-term outcomes. Concomitant LT and labral lesions did not negatively influence outcomes in our cohort. Technical accuracy with avoidance of overcorrection is essential in achieving successful outcomes.

Poster 212: Return to Sport Rate of Collegiate Athletes Following Primary Hip Arthroscopy for Femoroacetabular Impingement

Objectives: Athletic participation has been increasingly associated with symptomatic femoroacetabular impingement (FAI). High-intensity and repetitive sporting activities, especially those involving “at-risk” hip positions, can increase the risk for developing FAI. Numerous studies have shown that elite athletes can return to play at the professional level after undergoing hip arthroscopy. However, there is minimal data on return to sport rate and outcomes at the collegiate level. The purpose of this study is to determine the return to sport (RTS) rate of collegiate athletes following hip arthroscopy for treatment of FAI. Methods: Patients who were collegiate athletes and underwent hip arthroscopy surgery for treatment of FAI performed by a single surgeon between January 2010 and May 2020 were included. Patients who were in their final year of eligibility, graduated, retired or had plans to retire from collegiate play prior to surgery, or who had undergone prior ipsilateral hip surgery were excluded. Publicly available data was collected on each patient’s collegiate team and division, RTS status after surgery, and level of play after surgery. Successful RTS was defined as competing in a competition at the collegiate level after surgery. If both hips were operated on during the same season, then RTS was the same for both hips. Comparisons between RTS and no RTS groups were performed with the Mann-Whitney U test for continuous endpoints and Fisher’s exact test or Pearson’s Chi-squared test for categorical or binary endpoints. Results: A total of 181 hips (in 148 unique athletes) met inclusion criteria comprised of 114 male (63%) and 67 female (37%) hips with mean age of 20.5±1.5 (Table 1). Thirty-eight patients had bilateral hip arthroscopy. Patients were collegiate athletes in 19 different sports with football (17% of hips), soccer (15%), ice hockey (14%), and baseball (8%) the most commonly played (Table 2). The majority of patients played at the Division I level (n=140 hips, 79%). There were 19 patients with borderline dysplasia (lateral center-edge angle (LCEA)=20-25 degrees) and 7 patients with dysplastic hips (LCEA &lt;20 degress). Severe cartilage defects (Outbridge III/IV) were found in 41 hips (23%) with 15 hips (8%) undergoing microfracture. Eighty-six percent (155 hips) returned to sport at the collegiate level following hip arthroscopy. Males were significantly less likely to RTS compared to females (82% vs 93%, OR = 2.8, 95% CI [1.003, 7.819], p=0.042). Patients who RTS did have a marginally statistically significantly higher mean pre-operative SF-12 MCS compared to those who did not (55±9 vs 51±9, p=0.050). There was no signficiant association between the RTS and no RTS groups with respect to preoperative alpha angle, minimum joint space, LCEA or dysplasia category, collegiate division, presence or treatment of severe cartilage defect, or pre-operative outcome scores relating primarily to pain or physical function (mHHS, HOS-ADL, HOS-Sport, SF-12 PCS) (p&gt;0.05 for all). Conclusions: There is a high return to sport rate among collegiate athletes following hip arthroscopy for the treatment of FAI. Male athletes and those with lower preoperative SF-12 MCS scores may be at risk for lower likelihood of return to collegiate competition. [Table: see text][Table: see text]

A MODIFIED APPROACH TO MEASURING FEMORO-EPIPHYSEAL ACETABULAR ROOF (FEAR) INDEX: ASSESSING THE INTRAOBSERVER AND INTEROBSERVER RELIABILITY

To propose a modified approach to measuring femoro-epiphyseal acetabular roof (FEAR) index while still abiding by its definition and biomechanical basis, and to compare the reliabilities of the two methods. To propose a classification for medial sourcil edges.We retrospectively reviewed a consecutive series of patients treated with periacetabular osteotomy and/or hip arthroscopy. A modified FEAR index was defined. Lateral center-edge angle, Sharp's angle, Tonnis angle on all hips, as well as FEAR index with original and modified approaches were measured. Intra- and inter-observer reliability were calculated as intraclass correlation coefficients (ICC) for FEAR index with both approaches and other alignments. A classification was proposed to categorize medial sourcil edges. ICC for the two approaches across different sourcil groups were also calculated.After reviewing 411 patients, 49 were finally included. Thirty-two patients (40 hips) were identified as having borderline dysplasia defined by an LCEA of 18 to 25 degrees. Intra-observer ICC for the modified method were good to excellent for borderline hips; poor to excellent for DDH; moderate to excellent for normal hips. As for inter-observer reliability, modified approach outperformed original approach with moderate to good inter-observer reliability (DDH group, ICC=0.636; borderline dysplasia group, ICC=0.813; normal hip group, ICC=0.704). The medial sourcils were classified to 3 groups upon its morphology. Type II(39.0%) and III(43.9%) sourcils were the dominant patterns. The sourcil classification had substantial intra-observer agreement (observer 4, kappa=0.68; observer 1, kappa=0.799) and moderate inter-observer agreement (kappa=0.465). Modified approach to FEAR index possessed greater inter-observer reliability in all medial sourcil patterns.The modified FEAR index has better intra- and inter-observer reliability compared with the original approach. Type II and III sourcils accounts for the majority to which only the modified approach is applicable.