HOS-Sports Subscale Research Articles

A new technique of percutaneous minimally invasive surgery assisted by magnetic resonance neurography.

In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance. A total of 30 patients (60 hips) were included in this study. MRN scans of the pelvis were performed before surgery. The contracture band shape and external rotation angle (ERA) of the proximal femur were also analyzed. Then, the minimally invasive GMC releasing surgery was performed based on the images and measurements, and during the operation, incision lengths, surgery duration, intraoperative bleeding, and complications were recorded; the time of the first postoperative off-bed activity was also recorded. Furthermore, the patients' clinical functions were evaluated by means of Hip Outcome Score (HOS) and Ye et al's objective assessments, respectively. The contracture bands exhibited three typical types of shape - feather-like, striped, and mixed shapes - in MR images. Guided by MRN images, we designed minimally invasive approaches directed to each hip. These approaches resulted in a shortened incision length in each hip (0.3 cm (SD 0.1)), shorter surgery duration (25.3 minutes (SD 5.8)), less intraoperative bleeding (8.0 ml (SD 3.6)), and shorter time between the end of the operation and the patient's first off-bed activity (17.2 hours (SD 2.0)) in each patient. Meanwhile, no serious postoperative complications occurred in all patients. The mean HOS-Sports subscale of patients increased from 71.0 (SD 5.3) to 94.83 (SD 4.24) at six months postoperatively (p < 0.001). The follow-up outcomes from all patients were "good" and "excellent", based on objective assessments. Preoperative MRN analysis can be used to facilitate the determination of the relationship between contracture band and normal tissues. The minimally invasive surgical design via MRN can avoid nerve damage and improve the release effect.

Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair

To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging/arthrography predict 2-year functional outcomes after arthroscopic acetabular labral repair. Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis > 1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on magnetic resonance imaging/arthrography. Primary outcomes were International Hip Outcome Tool and modified Harris Hip Score. Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics. Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of International Hip Outcome Tool scores (weighted difference= 1.60; 95% confidence interval [CI],-5.09, 8.28; P= .64), modified Harris Hip Scores (weighted difference= 0.56; 95% CI,-4.16, 5.28; P= .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference=-11.85; 95% CI,-22.85,-0.84; P= .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P> .99), or conversion to total hip arthroplasty between cohorts (P> .99). These results held across all sensitivity analyses. Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair. Level III, retrospective cohort study.

Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome in Hips With Mild Osteoarthritis (Tönnis Grade 1): A Matched Comparative Cohort Analysis at Minimum 5-Year Follow-up

Background: There is a paucity of information in the literature on midterm outcomes from the arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) with concomitant labral treatment in patients with mild osteoarthritis (OA) using modern surgical techniques. Purpose: To compare outcomes of hip arthroscopy for the treatment of FAIS between patients with mild OA (Tönnis grade 1) and patients without OA (Tönnis grade 0) at minimum 5-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were identified who underwent primary hip arthroscopy for FAIS with routine capsular closure between January 2012 and December 2015. Patients with Tönnis grade 1 were matched 1:3 by age, sex, and body mass index to patients without OA. The Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score, and 12-item International Hip Outcome Tool were collected preoperatively and at 5 years postoperatively and compared between groups using an independent t test. Survivorship rate and percentage achievement of a Patient Acceptable Symptom State (PASS) or minimal clinically important difference (MCID) were compared using a Fisher exact test. Results: A total of 50 patients (54 hips) with Tönnis grade 1 were matched to 162 patients (162 hips) with Tönnis grade 0. The mean ± SD age and body mass index of the Tönnis grade 1 group were 44.5 ± 9.6 years and 28.5 ± 5.5, respectively. Patient-reported outcome (PRO) scores improved significantly for both groups from presurgery to 5 years postoperatively for all PROs (P≤ .03). There were no significant differences in preoperative PROs between the groups. Patients with Tönnis grade 1 had significantly lower postoperative scores on the HOS-ADL (74.7 ± 22.6 vs 83.0 ± 20.1; P = .04) and HOS-SS (58.8 ± 33.7 vs 71.8 ± 29.3; P = .03) than patients with grade 0. Patients with Tönnis grade 1 also had significantly lower rates of achievement of the MCID (57.1% vs 80.2%; P < .01) and PASS (34.1% vs 53.4%; P = .03) for any PRO when compared with patients with Tönnis grade 0. Gross survivorship was significantly lower for Tönnis grade 1 versus grade 0 (77.8% vs 96.9%; P < .001). Conclusion: Patients with Tönnis grade 1 arthritis experienced significant improvement in PROs after hip arthroscopy for the treatment of FAIS. However, they had significantly lower postoperative HOS-ADL and HOS-SS scores with significantly lower rates of achievement on the MCID and PASS, with a significantly lower gross survivorship rate at a minimum 5 years postoperatively in comparison with those with Tönnis grade 0 changes.

Paper 08: Predicting Clinically Significant Outcomes in Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome: Five-Year Results in 453 Patients

Objectives:To determine predictors of clinically significant outcome achievement at a minimum of 5-year follow-up in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement syndrome with routine capsular closure.Methods:Data were collected and analyzed from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS from a single fellowship-trained surgeon between January 2012 and December 2018. Baseline data, preoperative patient reported outcome measures (PROMs) and 5- year PROMs including Hip Outcome Score-Activities of Daily Living, HOS-Sports Subscale, international Hip Outcome Tool 12 questions, modified Harris Hip Score and visual analog scale pain were recorded. The minimal clinically important difference (MCID) was calculated using the distribution method while patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) were determined from literature defined values. Bivariate correlations with any MCID achievement, any PASS achievement, and any SCB achievement as well as a principle components analysis for variable reduction were used to create three separate multivariate binary logistic regressions to identify significant predictors of achieving a clinically significant outcome.Results:453 patients with an average age of 34.3 ± 12.5 and average BMI of 25.5 ± 4.9 and majority female (69.1%) were included in the final analysis. There was a significant improvement in all 5-year functional outcomes when compared to preoperative scores (p<0.001 for all). At a minimum of 5-year follow-up, 82.8% of patients achieved any MCID, 69.8% achieved any PASS, and 58.9% achieved any SCB. A total of 23 patients (5.1%) of the study population underwent revision hip arthroscopy or total hip arthroplasty within the follow-up period. Female sex (Odds Ratio (OR), 2.56 [95% confidence interval (CI), 1.47 to 4.45) was a positive predictor of achieving any MCID while higher Tönnis angle (OR, 0.92 [95% CI, 0.87 to 0.98]), Tönnis grade =1 (OR, 0.34 [95% CI, 0.14 to 0.83]) were negative predictors of achieving any MCID. Higher preoperative HOS-ADL (OR, 1.03 [95% CI, 1.01 to 1.05]) and female sex (OR, 2.01 [95% CI, 1.14 to 3.55]) were positive predictors of PASS. With regards to SCB, running (OR, 2.02 [95% CI, 1.31 to 3.14]) was a positive predictor of achievement while a history of back pain (OR, 0.49 [95% CI, 0.28 to 0.86]) and preoperative chronic pain for greater than 2 years (OR, 0.62 [95% CI, 0.36 to 0.98]), were negative predictors of achievement.Conclusions:At a minimum of 5-year follow-up, 82.8% of patients undergoing primary hip arthroscopy for the treatment of FAIS achieved any MCID, 69.8% achieved any PASS, 58.9% achieved any SCB. Female sex, higher preoperative PROs, and participation in running were positive predictors of achieving a clinically significant outcome while a higher Tönnis angle, Tönnis grade = 1, preoperative chronic pain, and back pain were negative predictors of achieving a clinically significant outcome.

Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up.

Background:The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known.Purpose:To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill.Study Design:Cohort study; Level of evidence, 3.Methods:Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score— Activities of Daily Living subscale (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not.Results:A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) (P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03).Conclusion:Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.

Superior Gluteal Reconstruction Results in Promising Outcomes for Massive Abductor Tendon Tears

PurposeTo evaluate the 1-year outcomes of a small patient series following open gluteus medius/minimus repair with human dermal allograft incorporated into the repair construct using a double-row repair.MethodsData from consecutive patients undergoing a superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy by a single fellowship trained surgeon from January 2018 to May 2019 were collected and analyzed. Baseline demographic data and magnetic resonance imaging were collected preoperatively. Clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Score-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were recorded at 1-year postoperatively.ResultsA total of 8 patients underwent open superior gluteal reconstruction for severe hip abductor deficiency. The mean age and body mass index were 62.6 ± 7.3 years and 29.6 ± 5.3 kg/m2, respectively. The majority of patients were female (N = 7, 87.5%). Three (37.5%) patients had undergone previous endoscopic gluteus medius repair and presented for revision surgery. All patients had full-thickness tears with gluteus medius and gluteus minimus involvement. Patients were evaluated at an average of 11.5 ± 1.7 months from the initial surgical intervention and reported a mean HOS-ADL of 82.9 ± 24.3, HOS-SS of 73.2 ± 37.3, mHHS of 83.6 ± 17.1, iHOT-12 of 63.9 ± 27.4, VAS Pain of 30.0 ± 23.1, and VAS Satisfaction of 87.1 ± 17.0. There was no evidence of retears in this patient cohort as defined by physical examination findings and/or corroborating magnetic resonance imaging.ConclusionsSuperior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy is a technique that demonstrates promising 1-year postoperative outcomes in both primary and revision patients.Level of EvidenceLevel IV, therapeutic case series.

Effect of Capsular Closure After Hip Arthroscopy for Femoroacetabular Impingement Syndrome on Achieving Clinically Meaningful Outcomes: A Meta-analysis of Prospective and Comparative Studies.

Background:Recent literature has demonstrated conflicting evidence as to whether capsular closure after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) results in superior outcomes compared with capsulotomy without repair. Additionally, these studies have not explored the effect of capsular management on clinically significant outcome improvement.Purpose:To perform a meta-analysis of prospective and comparative studies to determine whether capsular management influences the rate of clinically significant outcome improvement after hip arthroscopy for FAIS.Study Design:Systematic review; Level of evidence, 3.Methods:PubMed, OVID/Medline, EMBASE, and Cochrane databases were queried in September 2020 for studies with evidence levels 1 to 3 that directly compared capsular management cohorts and reported rates of achieving the minimal clinically important difference (MCID) at a minimum follow-up of 2 years. Studies of level 4 evidence, those not describing or directly comparing capsular management techniques as well as those not reporting the MCID were excluded. Methodological quality was assessed using the methodological index for nonrandomized studies tool. Mantel-Haenszel fixed-effects models were constructed to quantitatively evaluate the association between capsular management and achievement of the MCID by generating effect estimates in the form of relative risk (RR) with 95% CIs.Results:A total of 6 studies with 1611 patients were included. The overall pooled rate of MCID achievement for the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and HOS Sports Subscale (HOS-SS) were 84.4%, 80.3%, and 82.5%, respectively, at a mean follow-up of 40.8 months (range, 24-87.6 months). Capsular closure was associated with a significantly higher rate of MCID achievement for the mHHS (RR, 1.06; 95% CI, 1.01-1.10; P = .001) and trended toward statistical significance for the HOS-ADL (RR, 1.11; 95% CI, 1.0-1.24; P = .055) and the HOS-SS (RR, 1.09; 95% CI, 0.99-1.21; P = .094).Conclusion:Although capsular closure appeared to result in higher rates of clinically significant outcome improvement in hip function, there was no definitively increased likelihood of achieving clinically significant improvement in relevant hip outcome scores with capsular closure.

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

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

Meaningful Clinical Improvement and Failure Rates 5 years Following Hip Arthroscopy in Adolescents

To define hip-specific survey score thresholds for achieving minimal clinically important difference (MCID) in the adolescent population, and identify rates of clinical success and failure 5-years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Data from consecutive adolescent patients (age≤21) who underwent hip arthroscopy for the treatment of FAIS between January 2012 and April 2014 were collected. Baseline data, clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Tool (iHOT-12), and clinical failure rates were recorded at 5-years postoperatively. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty (THA). Clinical success was defined as achieving MCID on a hip specific outcome measure at five-year follow-up. A total of 67 patients were included in the final analysis, with an age and BMI average of 17.2(SD+2.2) years and 22.1(SD+3.1) kg/m2 respectively. The majority of the patients were female (80.6%) and participated in sports (86.9%). The HOS-ADL, HOS-SS, mHHS, and iHOT-12 threshold scores for achieving MCID were 9.5, 13.5, 9.6, and 15.1 respectively. There was significant difference between preoperative and postoperative score averages across every reported outcome (p<0.001). Sixty patients (89.6%) had maintained clinically successful outcome at a minimum of five years; five patients had clinical failure, with two (2.9%) undergoing conversion to THA and three undergoing revision (4.5%). Both patients undergoing THA conversion had a history of pediatric hip pathology (SCFE and Perthes), and underwent conversion due to significant osteoarthritis. This study demonstrated that a majority (89.6%) of pediatric patients treated for symptomatic FAIS with hip arthroscopy achieved MCID. Furthermore, a small number of patients had clinical failure, with 4.5% requiring revision hip arthroscopy due to continued pain and 2.9% undergoing THA conversion due to complications from pre-existing pediatric hip pathology.

Predictors of Extended Postoperative Opioid Use in Patients Undergoing Hip Arthroscopy For FAIS

To identify predictors of requiring at least one postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement and determine 2-year reported outcomes for those patients. Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Baseline demographics were recorded, along with preoperative opioid use and pre- and 2-year postoperative functional outcomes scores including the Hip Outcome Score-Activity of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified hip Harris score (mHHS), international hip outcome tool (iHOT-12), and visual analog score (VAS) for pain and satisfaction. A correlation analysis was used to identify variables associated with requiring postoperative opioid refill. Statistically significant variables (p>0.05) were included in a final logistic regression model. 775 patients with postoperative opioid use and 2-year follow-up were included in the analysis. 141 (18.2%) patients required at least one postoperative opioid prescription refill. Patients requiring refills had significantly lower HOS-ADL (79.9+-20.3 vs 88.7+-14.9), HOS-SS (64.6+-29.5 vs 78.2+-23.7), mHHS (74.2+-21.1 vs 83.6+-15.9), iHOT-12(63.6+-27.9 vs 74.9+-24.8), and VAS satisfaction (73.4+-30.3 vs 82.2+-24.9), as well as higher pain (26.8+-23.4 vs 17.9+-21.8) with p<0.001 for all outcomes. Predictors of requiring additional postoperative opioids included patients with a history of opioid use prior to surgery (OR: 4.04; 95%CI: 1.99-8.19) and larger preoperative alpha angles (OR:1.04; 95%CI: 1.01-1.07). Sub-analysis by past versus current opioid use at the time of surgery demonstrated that current use was predictive of requiring additional postoperative opioids (OR:3.12; 95%CI: 1.06-9.21; p=0.039), while past opioid use for was not. Patients requiring at least one postoperative opioid refill after undergoing hip arthroscopy for FAIS have lower 2-year functional scores when compared to patients not requiring refills. Additionally, active pre-operative opioid use at the time of surgery, as well as larger preoperative alpha angles are predictors of requiring additional opioids for pain management.

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

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

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Provides Clinically Significant Outcome Benefit at Minimum 5-Year Follow-Up

To report the rates of achieving clinically significant outcomes as defined by the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) in adolescent patients and the rates of clinical failure 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Data from consecutive adolescent patients (defined by the American Academy of Pediatrics as age 11 to 21 years) who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2015 by a single, fellowship-trained surgeon was collected. Baseline data, clinical outcomes including Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris hip score, international Hip Outcome Tool, and clinical failure rates were recorded at 5 years after operative. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Clinically significant outcomes was defined as achieving MCID, PASS, or SCB on at least 1 hip-specific outcome measure. Of the 139 eligible patients, a total of 85 (60.4%) patients (85 hips) were included in the final analysis, with an age and body mass index average of 17.6 ± 2.5 years (range 13-21) and 22.3 ± 3.1 kg/m2, respectively. The majority of the patients were female (80.6%) and participated in sports (76.2%). There was statistically significant difference between preoperative and postoperative score averages across every reported outcome (P < .001). At 5 years, 88.4%, 67.6%, and 64.9% reached at least 1 threshold for achieving MCID, PASS, and SCB, respectively, whereas 89.2% achieved at least one of the meaningful outcome thresholds. Last, 2 patients (2.4%) failed clinically, with both undergoing revision (2.4%) because of continued pain. There were no conversions to total hip arthroplasty. This study demonstrated that a large majority (89.2%) of adolescent patients undergoing primary arthroscopic treatment for symptomatic FAIS achieved meaningful clinically significant outcomes. Furthermore, only 2.4% of patients failed clinically, requiring revision hip arthroscopy because of continued pain. IV, Retrospective Case Series.

Prolonged Postoperative Opioid Use after Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum Two Year Follow-up

Objectives:To identify preoperative predictors for patients requiring at least one postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement and 2) to determine 2-year reported outcomes in those requiring opioid refills.Methods:Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 was analyzed. Baseline demographics were recorded, including preoperative opioid use, as well as pre- and 2-year postoperative functional scores specifically the Hip Outcome Score-Activity of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified hip Harris score (mHHS), international hip outcome tool (iHOT-12), and visual analog score (VAS) for pain and satisfaction were recorded. A correlation analysis was used to identify preoperative demographic and clinical variables associated with requiring postoperative opioid refill. Variables with a statistically significant association (p<0.05) were included in a final logistic regression model.Results:A total of 775 patients with postoperative opioid use and 2-year follow-up were included in the analysis. 141 (18.2%) patients required at least one preoperative opioid prescription refill in addition to the routine opioid total prescription postoperatively to every patient after hip arthroscopy. Patients requiring opioid refills had significantly lower HOS-ADL (79.9+20.3 vs 88.7+14.9), HOS-SS (64.6+29.5 vs 78.2+23.7), mHHS (74.2+21.1 vs 83.6+15.9), iHOT-12(63.6+27.9 vs 74.9+24.8), and VAS satisfaction (73.4+30.3 vs 82.2+24.9) averages, as well as higher pain (26.8+23.4 vs 17.9+21.8) when compared to patients without additional opioid refills with p<0.001 for all outcomes. Logistic regression analysis demonstrated that preoperative predictors of requiring additional postoperative opioids included patients with a history of opioid use prior to surgery (OR: 4.04; 95%CI: 1.99-8.19) and larger preoperative alpha angles (OR:1.04; 95%CI: 1.01-1.07). Sub-analysis by past versus current opioid use at the time of surgery demonstrated that current use was a predictive of requiring additional postoperative opioids (OR:3.12; 95%CI: 1.06-9.21; p=0.039), while past opioid use for was not.Conclusion:Patients requiring at least one postoperative opioid refill after undergoing hip arthroscopy for FAIS have lower 2-year functional scores when compared to patients not requiring refills. Additionally, active pre-operative opioid use at the time of surgery, as well as larger preoperative alpha angles are predictors of requiring additional opioids for pain management.

Patients with a Hypoplastic Labrum Achieve Similar Outcomes After Primary Labral Repair in the Treatment of Femoracetablular Impingement Syndrome Compared to Patients with a Normal Labrum

Objectives:A preoperative or intraoperative finding of an acetabular labrum width of <4mm is often cited as an indication for performing primary labral reconstruction over repair in the surgical correction of Femoracetablular Impingement Syndrome (FAIS). The purpose of this study is to compare patient reported clinical outcomes and rates of reaching Minimum Clinical Important Differences (MCID) and Patient Acceptable Symptomatic State (PASS) between patients with a hypoplastic labrum compared to those with a normal labrum width at a minimum 1 year from arthroscopic treatment of FAIS.Methods:Data from consecutive patients who underwent primary hip arthroscopy between November 2015 and July 2018 for the treatment of FAIS were analyzed. Baseline demographic data, preoperative, and minimum 1 year post-operative clinical outcomes including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool 12 questions (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were recorded. The labrum size was documented by the senior surgeon for all patients using the tip of an arthroscopic probe measuring 4mm. Labrum hypoplasia was defined as a labrum width at the 12 o’clock position of <4mm and normal labrum was defined as labrum width between 4 and 7mm. Patients with hypoplastic labrum were matched 1:1 by age and BMI to patients with normal labrum width. All patients underwent arthroscopic labral repair in addition to impingement resection and capsular repair. The groups were further compared after separating by acetabular coverage, in which a Lateral Center Edge Angle of 18-24.9 was considered borderline dysplastic and 25-40 was considered normal. Rates of achieving MCID calculated using a distribution-based method and PASS calculated using an anchor-based method.Results:A total of 360 patients were included in the study with 180 in each of the normal and hypoplastic groups. There was no significant differences seen in 1-year post operative outcome scores or score improvement between the two groups. When examining only borderline dysplastic patients there were no significant differences in outcomes between normal and hypoplastic labrum patients. In the subset with a normal LCEA only post-operative VAS satisfaction (85.5 ± 19.3 vs 78.2 ± 27.4; p=0.050) was significantly higher in the normal labrum patients compared to hypoplastic labrum. Patients with hypoplastic labrum achieved MCID and PASS at the same rate as patients with normal labrum across all outcome measures.Conclusions:Patients with an intraoperative finding of labral hypoplasia achieve 1-year meaningful clinical outcome at the same rate as those with normal labral width following arthroscopic labral repair. These results bring into question the need for primary labral reconstruction in patients with labral hypoplasia with a normal or borderline dysplastic acetabulum.

The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups. A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1± 25.9, P= .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P= .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P= .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all). Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery. Level III, retrospective case-control study.

The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis

Background: Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively. Purpose: To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score–activities of daily living subscale (HOS-ADL), HOS–sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool–12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent t test. The threshold of every outcome score for achieving MCID was calculated separately for each group and frequencies were compared. Results: A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non–spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all P < .001). There were significant differences in the proportion achieving the threshold for HOS-ADL (60.6% vs 80.0%; P = .004), HOS-SS (57.6% vs 82.1%; P < .001), mHHS (66.7% vs 81.7%; P = .025), and iHOT-12 (54.8% vs 87.6%; P < .001) scores for MCID when comparing the lumbosacral and nonlumbosacral pathology groups. Conclusion: Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

Two-Year Patient-Reported Outcomes for Patients Undergoing Revision Hip Arthroscopy with Capsular Incompetency

To determine clinical outcomes of patients undergoing revision hip arthroscopy for failure to improve with magnetic resonance imaging (MRI) and intraoperative evidence of a capsular incompetency as compared with (1) patients undergoing revision hip arthroscopy without evidence of a capsular incompetency and (2) patients undergoing primary surgery for femoroacetabular impingement syndrome (FAIS) at a minimum follow up of 2 years. Data from consecutive patients undergoing revision hip arthroscopy with MRI/arthrogram-confirmed capsular incompetency between January 2012 and June 2016 were analyzed. All revision patients with capsular incompetency was matched 1:1 by age and body mass index to FAIS revision patients without capsular incompetency and primary FAIS patients. Outcomes included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Subscale (SS), Modified Harris Hip Score (mHHS), pain, and satisfaction. The minimal clinically important difference was calculated for HOS-ADL, HOS-SS, and mHHS. In total, 49 patients (54.4%) of 90 undergoing revision hip arthroscopy had MRI evidence of a capsular incompetency. Most patients were female (79.6%), with a mean age of 30 ± 10.5 years and body mass index of 25.7 ± 5.5. The difference among pre- and postoperative HOS-ADL, HOS-SS, mHHS, and visual analog scale score for pain were all statistically significant (P < .05). Analysis of reported outcomes among matched groups demonstrated statistically significant differences, with the group undergoing primary surgery having the greatest 2-year outcomes. Only 66.7% of patients undergoing revision surgery with capsular incompetency achieved a minimal clinically important difference; however, there was no significant difference when compared with revision patients without capsular incompetency. When compared with patients undergoing primary surgery, the difference in frequency was statistically significant (66.7% vs 91.3%; P < .001). More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. Revision arthroscopy for capsular incompetency results in significantly improved 2-year outcomes. However, patients undergoing revision for capsular incompetency and intact capsule revisionpatients reported significantly lower outcomes compared with primary patients. Level III, Retrospective Comparative Study.

Early Surgical Intervention for Femoroacetabular Impingement Syndrome Provides Clinically Significant Outcome Improvement

Objectives: The purpose of the current study is to assess the outcomes of hip arthroscopy for FAIS according-timing of surgical intervention. Methods: Patients undergoing arthroscopic intervention for FAIS with minimum two year follow-up were included. All patients completed the hip outcome score (HOS)-activities of daily living (ADL), HOS-sports subscale (HOS-SS), modified Harris hip score (mHHS), international hip outcome tool-12 (IHOT-12), and visual analog scales (VAS) for pain and satisfaction. Patients were stratified by time with FAIS symptoms until surgical intervention. We compared 3-6 months of symptoms with other subsequent time frames (6-12 months, 12-24 months, and &gt;24 months). Clinically significant outcome was determined using the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS). Results: A total of 1,094 patients with mean (+ standard deviation) age 32.3+12.4 years and follow-up 30.8+6.7 (range:24-58) months were included. Patients undergoing surgery at 3-6 months of symptoms had no significant differences in outcome compared-those in the 6-12 month group except for the IHOT-12 (p:0.028). Patients with symptom duration of 12-24 months and greater than 24 months had worse outcome across all outcome measures (p&lt;0.0001 for symptoms &gt;24 months). Patients in the 3-6 month symptom group had increased likelihood for achieving MCID on HOS ADL (OR:1.81; 1.20-2.73), and HOS-SS (OR:1.90; 1.11-3.17), as well as PASS on the HOS-ADL (OR:1.85; 1.34-2.56) and HOS-SS (OR:1.58; 1.14-2.18). In multivariate regression analysis, symptom duration was the most predictive of VAS pain (Beta:3.10, 95% Confidence Interval [95%CI]:1.56-4.63; p&lt;0.001) and satisfaction scores (Beta:-4.16, 95%CI:-6.14- -2.18; p&lt;0.001). Conclusion: In patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) is associated with superior outcomes when compared to patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making on behalf of surgeons and patients who are considering delaying intervention. [Table: see text]

Influence of Acetabular Labral Tear Length on Postoperative Clinical Outcomes and Patient Satisfaction following Hip Arthroscopy for Femoroacetabular Impingement Syndrome with Capsular Plication

Objectives: To determine the effect of labral tear length on post-operative outcomes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Methods: Patients undergoing primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified in a prospectively collected database. All patients completed the hip outcome score (HOS)-activities of daily living (ADL), HOS-sports subscale (HOS-SS), modified Harris hip score (mHHS), international hip outcome tool-12 (IHOT-12), and visual analog scales (VAS) for pain and satisfaction. Patients were stratified by labral tear length into small (&lt;2.5 cm) or large (&gt;2.5 cm) labral tear based on the ROC curve analysis. Patient demographics and outcomes were analyzed using parametric and multivariate linear regression analyses to identify predictors of labral tear length. Binary logistic regression analysis was performed to determine whether labral tear length predicted the likelihood of achieving the Minimal Clinically Important Difference (MCID). Results: A total of 747 eligible patients were included in the analysis. Mean age and BMI were 33.5±12.3 years and 25.4±8.6 kg/m2 22, respectively. Mean length of labral tears was 2.7±0.7 cm with 99% occurring in the anterosuperior position. Men had a higher proportion of large tears (&gt;2.5 cm) when compared to women (75% vs 44%; p&lt;0.001). All PROs showed improvement at a minimum of 2-years postoperatively (p&lt;0.05 for all). Independent T-test demonstrated significant differences in two-year outcomes between patients with tears less than and greater than 2.5 cm: HOS-ADL (87.3±16.3 vs. 84.3±18.3, p=0.033), HOS-SS (76.6±23.5 vs. 70.5±27.7, p=0.005), mHHS (82.5±18.0 vs. 78.5±18.2, p=0.009), and satisfaction (83.5±23.4 vs. 77.8±34.9, p=0.026). Multivariate regression analysis demonstrated that labral tear length is an independent predictor of VAS satisfaction, HOS-ADL, -SS, and mHHS. Binary logistic regression analysis demonstrated that patients with small labral tears (&lt;2.5 cm) had a higher likelihood of achieving MCID HOS-SS (OR: 1.61; p-value&lt;0.02) and PASS mHHS (OR:1.56; p-value 0.038) than those with larger tears (more than 2.5 cm). Conclusion: Labral tear length is associated with numerous preoperative factors. These factors were found to be predictive of injury pathology and outcomes following hip arthroscopy for FAIS. Furthermore, patients with smaller tears (&lt; 2.5 cm) had better outcomes and a higher likelihood of achieving a minimal clinically important difference at 2 years follow-up. [Table: see text]

Radiographic Prevalence of Symphysis Pubis Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome

Background: The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis. Purpose: To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities. Study Design: Cohort study; Level of evidence, 3. Methods: Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. Results: 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013). Conclusion: A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.