Borderline Hip Dysplasia Research Articles

Borderline Hip Dysplasia - Best Treated with Hip Arthroscopy or Periacetabular Osteotomy?

As the field of hip preservation evolves, the diagnosis of borderline dysplasia (defined as a lateral center edge angle between 18°-25°) has shown itself to be one of the more challenging diagnoses to treat. As the nuances of acetabular coverage have come to light, the question of whether borderline hip dysplasia is best treated with isolated hip arthroscopy, periacetabular osteotomy, or whether a combined procedure is best, is now top of mind. The goal of these procedures is to not only improve patient symptoms, but to correct underlying pathology and ideally slow the development of hip osteoarthritis. The purpose of this review is to summarize the recent literature and clinical findings regarding both isolated hip arthroscopy and periacetabular osteotomy in the surgical management of borderline hip dysplasia. Current research demonstrates improved postoperative clinical outcome scores for both patients who had isolated hip arthroscopy in the setting of borderline hip dysplasia and for those patients who underwent periacetabular osteotomy. Mid-term outcomes for patients in both groups have showed low rates of conversion to total hip arthroplasty. No gold standard in the surgical management of borderline hip arthroscopy exists. Improved clinical outcomes have been seen postoperatively in patients who undergo hip arthroscopy and in patients who undergo periacetabular osteotomy. Successful clinical outcomes seem to rely on treatment of the underlying clinical pathology and are largely based on the appropriate surgical indications and appropriate surgical techniques. Surgical decision making in this patient population should be individualized based on a comprehensive evaluation of the patient.

Comparing outcomes of hip arthroscopy and periacetabular osteotomy for the treatment of borderline hip dysplasia: a systematic review

Abstract Hip arthroscopy (HA) and periacetabular osteotomy (PAO) are common hip preservation procedures pursued in borderline hip dysplasia (BHD), yet there is no consensus on the preferred treatment. This systematic review aims to synthesize the present literature on HA and PAO for the management of BHD. A review of multiple electronic databases was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that reported outcomes of patients with BHD treated by PAO or HA with capsular closure were included. PROs, complications, and rates of subsequent surgery were evaluated. A total of 14 studies met criteria for inclusion. Eight reported outcomes following PAO and seven reported outcomes following HA. One study reported outcomes of both procedures. Both PAO and HA studies demonstrated significant improvement in PROs. Complication rates in PAO patients ranged from 0% to 7.8% compared to 0% in HA patients. Total hip arthroplasty (THO) conversion rates in PAO patients ranged from 0% to 10.5% compared to 0% to 23.7% in HA patients. Hardware removal was performed in 25–51% of PAO patients. PAO conversion following failed HA occurred in 0–6.1% of patients. Rates of other reoperation (excluding hardware removal) in PAO patients ranged from 0% to 22.2% compared to 0% to 7.9% in HA patients. Based on the current evidence, both PAO and HA demonstrate significant improvement in PROs with a low conversion rate to THA, yet additional long-term follow-up studies are required.

Poster 210: Flexible Athletes with Borderline Hip Dysplasia Achieve Successful and Similar Outcomes after Hip Arthroscopy Compared to Flexible Athletes without Borderline Hip Dysplasia

Objectives: To compare minimum 2-year patient-reported outcomes and achievement of clinically significant outcomes in flexibles athletes with and without borderline hip dysplasia (BHD) undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with capsular plication. Methods: Data was prospectively collected for patients undergoing primary hip arthroscopy for FAIS with borderline hip dysplasia (BHD), defined as a lateral center edge angle (LCEA) of 18° to 25°, with primary participation in a sport with high flexibility requirement including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts. These patients were matched 1:2 to flexible athletes with an LCEA >25° controlling for age, sex, body mass index (BMI) and follow up duration. Preoperative and minimum 2-year postoperative patient-reported outcomes included: Hip Outcome Score (HOS) Activities of Daily Living, HOS Sports Scale, International Hip Outcome Score 12, modified Harris Hip Score, and Visual Analog Scale for Pain. Cohort-specific Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) were calculated and compared between groups. Results: Fifty-two flexible athletes with BHD were matched to 104 flexible athletes without BHD. Similar sport participation (45% dance vs. 41%, p=0.874) and level of competition (74% vs. 74% recreational, p=0.877) were observed. Preoperative LCEA (22.2° ± 1.6 vs. 31.5° ± 3.9, p < 0.001) and Tönnis angle (10.9 °± 3.7 vs. 5.8° ± 4.4, p < 0.001) differed significantly between groups. Capsular plication was performed in all cases (100% and 100%, p = 1.000). Both groups achieved significant improvement in all PROs (p ≤ 0.001) with no differences in PROs between groups (p ≥ 0.147). High MCID (95.7%, 94.8%) and PASS (71.7%, 72.2%) achievement for any PRO was observed with no differences between groups (p ≥ 0.222). Conclusions: Flexible athletes with BHD achieve successful and similar outcomes to those without BHD after primary hip arthroscopy for FAIS with capsular plication.

Poster 203: Staged Hip Arthroscopy and Periacetabular Osteotomy Versus Hip Arthroscopy Alone in Patients with Borderline Hip Dysplasia: A Propensity-Matched Study

Objectives: The management of borderline hip dysplasia (BHD) remains an area of interest in the field of hip preservation. The purpose of this study was to (1) evaluate mean 2-year outcomes for patients with BHD treated with staged hip arthroscopy and periacetabular osteotomy (PAO) to those who underwent hip arthroscopy alone, and (2) evaluate rates of complications, hardware removal, reoperations, conversions to total hip arthroplasty (THA), along with conversions to PAO. Methods: Hips with a lateral center-edge angle (LCEA) values 18° ≤ LCEA < 25° that underwent a hip arthroscopy for femoroacetabular impingement syndrome (FAIS) between January 2018 and June 2022 were reviewed. Patients who underwent staged periacetabular osteotomy and hip arthroscopy were identified. Staged hips were propensity-matched 1:4 to other borderline dysplastic hips that underwent hip arthroscopy alone. Matching was performed based on age, sex, and body-mass index (BMI). Patient-reported outcomes (PROs) were collected, including Hip Outcome Score – Activities of Daily Living (HOS-ADL), HOS-Sports Specific (HOS-SS) subscale, 12-item International Hip Outcome Tool (iHOT-12) questionnaire, Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) subscale, and PROMIS-Physical Function (PROMIS-PF) subscale. Cohort-specific minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds were calculated. Postoperative PROs, rates of MCID/PASS achievement, and rates of reoperation and conversion to THA were compared. Results: Twenty-four patients who underwent staged hip arthroscopy and PAO were successfully matched to 96 patients who underwent hip arthroscopy alone. Both groups were similar in terms of age, sex, and BMI. The patients who underwent a PAO had smaller LCEAs and larger Tönnis angles (21.0° vs. 23° and 11.6° vs. 9.1°, respectively). Both groups demonstrated significant improvement in PROs at minimum 1-year postoperatively (p < 0.001, for all). There were no significant differences in postoperative PRO scores between the groups (p ≥ 0.223, for all). There were no significant differences in MCID/PASS achievement (p ≥ 0.224. for all). There were no reoperations or conversion to THA in the staged hip arthroscopy and PAO group. In the hip arthroscopy alone cohort, reoperation rates were 5.2% and conversion to THA occurred in 1% of the patients. There were no significant differences in secondary surgery rates between the groups (p = 1.000). Three patients in the hip arthroscopy alone group ultimately underwent PAO, 1 underwent a proximal femoral osteotomy (PFO), and one underwent a revision hip arthroscopy. These female patients were young and athletic with an LCEA < 20°. Conclusions: Patients undergoing staged PAO and hip arthroplasty and isolated hip arthroplasty for treatment of BHD demonstrate similar clinical improvement. Rates of revision surgery and conversion to THA were similarly low. A small subset of patients who were initially treated arthroscopically ultimately received a PAO. This group was entirely made up of young, athletic female patients. This is encouraging early data and more long-term data is needed to evaluate the differences in survivorship. [Figure: see text]

The role of different acetabular morphologies on patient-reported outcomes following periacetabular osteotomy in borderline hip dysplasia

IntroductionThe treatment option for borderline hip dysplasia (BHD) includes hip arthroscopy and periacetabular osteotomy (PAO). To the present day the controversial discussion remains, which intervention to prefer. Literature reports supporting an educated choice are scare, based on small patient cohorts and do not address the variability of acetabular morphology. Consequently, we intended to report PAO outcomes, from patients diagnosed with BHD, dependent on acetabular morphology, in a large patient cohort and aimed to define risk factors for poor clinical results and patient satisfaction.Materials and methodsA prospective monocentre study was conducted. Patients enrolled underwent PAO for symptomatic BHD (LCEA, 18°–25°). A total of 107 hips were included with 94 complete data sets were available for evaluation with a minimum follow-up of 1 year and a mean follow-up of 2.3 years. The mean age was 31 ± 8.2 years, and 81.3% were female. As the primary outcome measure, we utilized the modified Harris hip score (mHHS) with minimal clinically important change (MCID) of eight to define clinical failure. Results were compared after a comprehensive radiographic assessment distinguishing between lateral deficient vs. anterior/posterolateral deficient acetabular and stable vs. unstable hip joints.ResultsOverall, clinical success was achieved in 91.5% of patients and the mHHS improved significantly (52 vs. 84.7, p < 0.001). Eight hips failed to achieve the MCID and four had radiographic signs of overcorrection. Comparing variable joint morphologies, the rate of clinical success was higher in patients with an anterior/posterolateral deficient acetabular covarage compared to lateral deficient acetabular (95.2% vs. 90.4%). tThe highest rate of clinical failure was recorded in unstable hip joints (85.7% vs. 92.5% in stable hips).ConclusionsThis study demonstrates that PAO is an effective means to treat symptomatic BHD with variable acetabular morphologies, achieving a clinical success in 91.5% of all patients. To maintain a high level of safety and patient satisfaction technical accuracy appears crucial.

Outcome Scores and Survivorship of Patients Undergoing Primary Hip Arthroscopy With Borderline Hip Dysplasia: A Propensity-Matched Study With Minimum 10-Year Follow-up

Background: Patients with borderline hip dysplasia (BHD) and concomitant femoroacetabular impingement syndrome (FAIS) have demonstrated similar outcomes at short- and midterm follow-up compared with equivalent patients without dysplasia. However, comparisons between these groups at long-term follow-up have yet to be investigated. Purpose: To compare long-term clinical outcomes between patients with BHD undergoing primary hip arthroscopy for FAIS versus matched control patients without BHD. Study Design: Cohort study; Level of evidence, 2. Methods: A retrospective cohort study was conducted on patients with BHD (lateral center-edge angle, 18°-25°) who underwent hip arthroscopy for FAIS between January 2012 and February 2013. Patients were propensity matched in a 1:3 ratio by age, sex, and body mass index to control patients without BHD who underwent primary hip arthroscopy. Groups were compared in terms of patient-reported outcomes (PROs) preoperatively and at 10 years postoperatively, including the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), modified Harris Hip Score, 12-item International Hip Outcome Tool, visual analog scale (VAS) for pain and satisfaction. Achievement rates for minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were compared between groups. Kaplan-Meier survivorship curves were assessed between groups. Results: At a mean follow-up of 10.3 ± 0.3 years, 28 patients with BHD (20 women; age, 30.8 ± 10.8 years) were matched to 84 controls who underwent primary hip arthroscopy. Both groups significantly improved from preoperative assessment in all PRO measures at 10 years (P < .001 for all). PRO scores were similar between groups, aside from HOS-SS (BHD, 62.9 ± 31.9 vs controls, 80.1 ± 26.0; P = .030). Rates of MCID achievement were similar between groups for all PROs (HOS-ADL: BHD, 76.2% vs controls, 67.9%, P = .580; HOS-SS: BHD, 63.2% vs controls, 69.4%, P = .773; modified Harris Hip Score: BHD, 76.5% vs controls, 67.9%, P = .561; VAS pain: BHD, 75.0% vs controls, 91.7%, P = .110). Rates of PASS achievement were significantly lower in the BHD group for HOS-ADL (BHD, 39.1% vs controls, 77.4%; P = .002), HOS-SS (BHD, 45.5% vs controls, 84.7%; P = .001), and VAS pain (BHD, 50.0% vs controls, 78.5%; P = .015). No significant difference was found in the rate of subsequent reoperation on the index hip between groups. Kaplan-Meier survival analysis demonstrated comparable survivorship at long-term follow-up (P = .645). Conclusion: After primary hip arthroscopy, patients with BHD in the setting of FAIS had significantly improved PRO scores at 10-year follow-up, comparable with propensity-matched controls without BHD. Rates of MCID achievement were similar between groups, although patients with BHD had lower rates of PASS achievement. Patients with BHD had similar long-term hip arthroscopy survivorship compared with controls, with no significant difference in rates of revision hip arthroscopy or conversion to total hip arthroplasty.

Primary and Revision Hip Arthroscopy in Borderline Hip Dysplasia Shows Comparable Outcomes at a Minimum 5-Year Follow-Up

PurposeTo compare patient-reported outcomes (PROs), achievement of clinically significant outcomes (CSOs), and reoperation-free survivorship between primary and revision hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in propensity-matched borderline hip dysplasia (BHD) patients at minimum 5-year follow-up. MethodsPatients with BHD, characterized by a lateral center-edge angle 18°-25°, who underwent HA for FAIS with capsular repair by a single surgeon between 01/2012-06/2018 with minimum 5-year follow-up were identified. Cases of revision HA were propensity-matched 1:2 to cases of primary HA, controlling for age, sex, and body mass index (BMI). A 1:2 ratio was chosen to maximize the number of included patients. Collected PROs included: Hip Outcome Score-Activities of Daily Living and Sport Subscales, International Hip Outcome Score 12, modified Harris Hip Score, and Visual Analog Scale for Pain. Achievement of minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for any measured PRO were compared between groups along with reoperation-free survivorship using Kaplan-Meier analysis. ResultsThirty-six revision HA hips (34 patients) were propensity-matched to 72 primary HA hips (70 patients). The groups were similar in age (31.5±10.3 years vs. 30.5±11.2,P=0.669), sex (69.4% female vs. 70.8%,P=0.656), and BMI (25.7±4.0 kg/m2 vs. 25.5±3.7,P=0.849). The revision group showed a greater prevalence of prolonged preoperative pain (50.0% vs. 27.8%,P=0.032) compared to the primary group. A significant improvement in all PROs was observed for both groups with comparable PROs preoperatively and at 5-year follow-up between groups (P≥0.086). The revision and primary groups showed comparable MCID (95.0% vs. 95.7%,P=1.000), PASS (80.0% vs. 83.6%,P=0.757), and SCB (62.5% vs. 70.7%,P=0.603) achievement for any PRO. Comparable reoperation-free survivorship was observed (P=0.151). ConclusionPropensity-matched patients with BHD undergoing primary and revision hip arthroscopy for FAIS achieved similar minimum 5-year PROs, CSOs, and reoperation-free survivorship. Level of EvidenceLevel III, Retrospective Comparative Case Series

How useful are indirect radiographic measurements of hip instability in borderline hip dysplasia? An MRI-based comparison to a healthy cohort

PurposeSymptomatic hips with borderline hip dysplasia (BHD) morphology pose a challenge in differentiating stable from unstable hips. The current study aims to compare indirect radiographic signs of instability in a symptomatic BHD population to those in a healthy cohort.MethodsThe study group consisted of patients with a lateral centre–edge angle (LCEA) with values 18° ≤ LCEA < 25° who underwent corrective periacetabular osteotomy (PAO) and reported an improvement in patient-reported outcome measures (PROMs). The comparison group consisted of a healthy cohort of athletes who did not complain of any hip-related symptoms and who had normal values of their hip morphological parameters (LCEA, acetabular index (AI°), alpha angle (α°), femoral version, acetabular version). Indirect signs of instability consisting of the femoro-epiphyseal acetabular roof index (FEAR), iliocapsularis-to-rectus-femoris (IC/RF) ratio and labral dimensions (height-to-length ratio) were assessed in both groups. Partial Pearson correlation, logistic multiple regression analysis and Receiver-Operating Characteristic (ROC) curve analysis were performed to determine correlations, as well as the sensitivity and specificity of these signs to differentiate between healthy hips and BHD.ResultsOn binary logistic multiple regression analysis, the FEAR Index was the only independent predictor to differentiate between BHD and healthy hips (p < 0.001). The IC/RF ratio did not achieve significance. The calculated area under the curve (AUC) was 0.93 (0.87 – 0.99, CI 95%, p < 0.001) for the FEAR Index and 0.81 (0.70 – 0.92, CI 95%, p < 0.001) for the height-length ratio. Using the predefined cut-off values (dysplastic—FEAR Index ≥ 5° or labral height-to-length ratio ≤ 0.5), 27% sensitivity/100% specificity and 20% sensitivity/ 100% specificity, were achieved. ROC analysis provided the following new thresholds: FEAR Index ≥ -5° (73% sensitivity/97% specificity); labral height-to-length ratio ≤ 0.8 (70% sensitivity, 79% specificity).ConclusionIn our cohort, the FEAR index was an independent parameter that could differentiate between borderline dysplastic and asymptomatic hips. The previously published values for both the FEAR index and labral hypertrophy ratio had a poor sensitivity in differentiating symptomatic unstable BHD from healthy hips. The cut-off values of ≥ -5° (FEAR index) and ≤ 0.8 (labral height-to-length ratio) provided acceptable sensitivity and specificity when comparing to morphological healthy hips.

Noninterportal capsulotomy of hip arthroscopy showed improved outcomes in borderline hip dysplasia: A retrospective study with minimum 2-year follow-up.

The present study aimed to evaluate the functional outcomes of hip arthroscopy using a noninterportal capsulotomy technique to address labral tears in patients with borderline hip dysplasia (BHD). Additionally, we also compared these outcomes with those of patients with BHD who underwent the standard repaired interportal capsulotomy (RIPC) arthroscopy. Data from patients with BHD were retrieved from a database of patients who underwent arthroscopic hip surgery with noninterportal capsulotomy or RIPC to treat labral tears between January 2014 and December 2020. Data collected included both pre- and postoperative patient-reported outcomes (PROs). A total of 58 patients (noninterportal capsulotomy, n = 37; RIPC, n = 21) with a mean age of 30.9 ± 5.6 and 28.6 ± 5.5 years, respectively, met the inclusion criteria. All of the patients underwent a minimal 2-year follow-up. The mean lateral centre-edge angle was 23.3 ± 1.2° in the noninterportal capsulotomy group and 23.7 ± 1.0° in the RIPC group, with no significant difference. The PROs improved from the preoperative to the latest follow-up, with a p < 0.001. There were no differences between the groups. Using strict patient selection criteria, hip arthroscopy with noninterportal capsulotomy demonstrated significant pre- to postoperative improvements in patients with BHD and achieved results comparable to those from hip arthroscopy with RIPC. Level III.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

Background: Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD. Purpose: To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups. Results: In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835). Conclusion: Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.

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.

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.

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.

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.

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.

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.

High-Level Athletes With Borderline Hip Dysplasia Achieve Favorable Outcomes and Return to Sport Rates Following Primary Hip Arthroscopy: Minimum 5-Year Outcomes Comparison to a Propensity-Matched Control Group

High-Level Athletes With Borderline Hip Dysplasia Achieve Favorable Outcomes and Return to Sport Rates Following Primary Hip Arthroscopy: Minimum 5-Year Outcomes Comparison to a Propensity-Matched Control Group