Minimum 2-year Outcomes Research Articles

Paper 08: Outcomes After Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Glenohumeral Instability at a Mean 9 Year Follow-up

Objectives:Arthroscopic treatment with suture anchors of multidirectional instability (MDI) of the shoulder is gaining popularity as compared to an open approach, but no studies with mid to long-term outcomes are reported in the literature. Meanwhile, atraumatic onset MDI is associated with worse outcomes compared to traumatic onset MDI in short-term studies. The objective of this study is to report on survivorship and patient reported outcomes following arthroscopic pancapsular shift (APS) for MDI with minimum five-year follow up, including comparing atraumatic versus traumatic onset MDI.Methods:Patients who underwent APS for MDI and were at a minimum 5 years postoperative from the surgical intervention were included. Baseline pre and perioperative data was prospectively collected as part of an institutional registry and retrospectively reviewed, and patient questionnaires were sent by email to determine long-term outcomes including mechanism of onset of MDI, patient satisfaction, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), American Shoulder and Elbow Surgeons (ASES), Short Form-12 Physical Component Summary (SF-12 PCS), and Single Assessment Numeric Evaluation (SANE) scores. Additional information about recurrent instability, dislocation and reoperation as well as return to sport were collected and Kaplan-Meier survivorship analysis was performed. Preoperative, short-term (1-2 year) and final follow-up patient reported outcomes were compared.Results:49 shoulders in 44 patients (15 male, 29 female) treated between October 2005 and November 2015 were included in the study. Overall, 14/49 (28.6%) of shoulders reported feelings of instability, of which 5 (10.2%) underwent revision surgery at a mean of 1.5 years postoperatively. Kaplan-Meier analysis demonstrated a survivorship rate of 80% at 5 years and 75% at 8 years with failure defined at postoperative feelings of instability. Final analysis was performed on 44 shoulders, of which minimum 5-year outcomes were collected on 36 (82%) with an average follow-up length of 9.0 years (5.1-14.6 years). All patient reported outcome scores as well as subjective improvement outcomes demonstrated statistically significantly improved results at final follow-up (p<0.05). Patient reported outcome measures were persistently statistically significantly improved at short-term and long-term final follow-up. (Figure 1) MDI onset was atraumatic in 27 shoulders and traumatic in 21. There was no difference in subjective or patient reported outcome scores between atraumatic and traumatic onset MDI patients. Rotator interval closure was performed in 19 patients with no effect on postoperative outcomes.Conclusions:Arthroscopic pancapsular shift for the treatment of MDI provides excellent, durable long-term patient reported outcomes that persist from short-term follow-up. Although 28% of patients experience feelings of instability at final follow-up, most of these patients still have high postoperative satisfaction and acceptable patient reported outcomes and do not undergo revision surgery Compared to short-term data, long-term results indicate that atraumatic onset MDI is not associated with worsened postoperative outcomes as compared to traumatic onset MDI.

Effect of Preoperative MRI Coracoid Dimensions on Postoperative Outcomes of Latarjet Treatment for Anterior Shoulder Instability.

Background:Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer.Purpose:To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability.Study Design:Cohort study; Level of evidence, 3.Methods:Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions.Results:Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) (P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) (P ≥ .05 for all).Conclusion:Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made.

Poster 161: Consequence Athletes with Anterior Shoulder Instability: Consider Latarjet

Objectives:The Latarjet procedure has been shown to be effective in treating recurrent shoulder instability, especially in the setting of glenoid bone loss and after failed previous Bankart repair. Several studies have additionally shown a significant reduction in recurrent instability rates when compared to Bankart repair in contact athletes when the Latarjet procedure is performed in a primary setting. We have identified an additional population of patients that provides greater challenges beyond the common athlete including those involved in contact sports. Termed “consequence athletes,” these patients are defined as athletes who perform in high risk, uncontrolled environments for whom an injury is likely to threaten life or livelihood. This population includes elite military forces, law enforcement and federal agents, motocross, elite skiers/snowboarders, whitewater kayak and rafters, and rock climbers. The purpose of this study is to evaluate minimum 2-year outcomes of primary Latarjet procedure in consequence athletes with anterior shoulder instability.Methods:Consequence athletes who underwent open Latarjet by one of the three sports medicine trained senior surgeons between August 2006 and January 2018 were retrospectively reviewed from prospectively collected data. Minimum 24 follow up was obtained on all patients. Those younger than 18 at follow up, history of concomitant or prior remplissage procedure, glenoid reconstruction with allograft, severe glenohumeral arthritis, or hyperlaxity were excluded. Glenoid bone loss (GBL) was evaluated on preoperative MRI and the cohort divided into GBL 0-14% and ≥15%. Patient-reported outcome scores (PROs) were collected and included the American Shoulder and Elbow Surgeons (ASES) score, Single Numeric Assessment Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Short Form–12 (SF-12) Physical Component Summary (PCS), and numeric rating scale (NRS) for pain score (0 - 10, 10 = worst pain). Postoperative patient satisfaction (1 - 10, 10 = very satisfied) was evaluated. Complications and revision surgeries were recorded. Failure was defined as a postoperative dislocation or a revision surgery.Results:Sixty-five consequence athletes were included (54 males, 11 females). The mean age at surgery was 28.5 ± 8.7 years (range 15.8-56.4). The most frequent professions included 17 skiers (26.2%), 17 rock climbers (26.2%), 10 snowboarders (15.4%), 9 white water kayakers/rafters (13.8%), and 8 federal agents/military (12.3%). Primary latarjet was performed in 30 (46.2%) without prior history of soft tissue stabilization procedures. Mean GBL was 13.7%; 27 (41.5%) had 0-14% GBL and 32 (49.2%) had ≥15% GBL. Significant improvement in PROs at minimum 2-year follow was demonstrated for SANE (57.9 ± 24.5 to 91.0 ± 9.5), SF12 PCS (45.5 ± 8.7 to 54.4 ± 7.1), ASES pain (41.5 ± 9.7 to 47.4 ± 5.3), ASES function (31.8 ± 12.6 to 46.2 ± 6.8), ASES total (73.0 ± 19.8 to 93.7 ± 10.0), and quickDASH (27.0 ± 14.0 to 10.0 ± 28.8). Median patient satisfaction was 10. One patient sustained a recurrent dislocation (1.5%), 2 (3%) patients underwent revision surgery. There was no significant correlation between PROs and GBL, number of previous dislocations, or prior soft tissue stabilization procedures.Conclusions:The latarjet procedure a reliable and safe treatment for shoulder instability in the high demand “consequence athlete” population with a post-operative dislocation rate of 1.5% and revision rate of 3%. Significant improvement in PROs was demonstrated for SANE, SF12 PCS, ASES, and DASH with median patient satisfaction score of 10. These findings support treatment of this population with the latarjet procedure, even in the setting of minimal preoperative GBL, where a recurrent instability event could be catastrophic to the individual patient or those working or participating along with them.

Minimum 5-Year Outcomes of Osteochondral Autograft Transplantation with a Concomitant High Tibial Osteotomy for Spontaneous Osteonecrosis of the Knee with a Large Lesion.

The purpose of this study was to evaluate the mid-term clinical outcomes of osteochondral autograft transplantation (OAT) with concomitant high tibial osteotomy (HTO) in spontaneous osteonecrosis of the knee (SONK) with a large lesion. A total of 48 knees of 48 consecutive patients with SONK (lesion size ≥4 cm2, no age criteria) who underwent opening wedge HTO and concomitant OAT were retrospectively investigated, and those who were followed up postoperatively for at least 5 years were included in this case series study. Clinical outcomes were evaluated using knee and function scores of Knee Society Score, radiographic outcomes were evaluated using the anatomical femorotibial angle (FTA), and these outcomes were compared between patients aged ≥70 years and <70 years. Of the 48 cases, a total of 43 cases were available for review at a minimum of 5 years, and 5 cases were excluded from the analysis. Overall, the mean knee score improved from preoperative 48.8 ± 13.3 to postoperative 87.9 ± 8.6 at 1 year (P < 0.05) and 85.0 ± 10.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean function score also improved from preoperative 60.1 ± 10.9 to postoperative 87.3 ± 12.2 at 1 year (P < 0.05) and 84.2 ± 12.4 at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). The mean standing FTA was corrected significantly from 181.1° ± 2.7° preoperatively to 169.7° ± 2.4° at 1 year (P < 0.05) and 169.4° ± 3.1° at final follow-up (P < 0.05 vs. preop., N.S. vs. 1 year). There were no significant differences in clinical and radiographic outcomes between patients aged ≥70 years and <70 years. There were 4 cases of lateral hinge fracture around the osteotomy site and 1 case of delayed union. None of the patients underwent revision surgery during the follow-up period (survival rate of 100%). Mid-term clinical outcomes of patients with SONK who underwent HTO and OAT with a relatively large lesion were good.

Intra-articular Damage and Patient Outcome Comparison Between Athletes and Nonathletes After Hip Arthroscopy

Background: The body of literature comparing hip arthroscopy between athletes and nonathletes is relatively scarce. Analyzing these groups can help to shed light on the severity of intra-articular damage and end-stage osteoarthritis that may result from participation in strenuous activities. Purpose: (1) To compare the intra-articular damage at the time of hip arthroscopy between athletes and nonathletes, and (2) to compare the pre- and postoperative outcomes between the groups. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were considered eligible for analysis if they had received a primary hip arthroscopy between August 2008 and June 2018, were participating in competitive athletics, and had preoperative baseline scores and minimum 2-year follow-up for the following patient-reported outcomes: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale, and visual analog scale. Propensity score matching was used to match eligible patients in a 1:1 ratio to patients who were not participating in any sports greater than a recreational level before surgery. Results: A total of 234 patients were included. There were no significant differences in the severity of labral tears, ligamentum teres tears, or cartilage damage (P > .05). The procedures performed between cohorts were similar (P > .05). The athlete population had higher preoperative means scores for the modified Harris Hip Score and NAHS (each P < .001). Likewise, the athlete population had higher postoperative means scores for the NAHS, Hip Outcome Score–Sports Specific Subscale, and visual analog scale (P = .031, P = .030, and P = .032, respectively). Additionally, the athlete cohort reported higher minimum 2-year outcomes than the nonathlete cohort for the 12-Item Short Form Health Survey (mental component; P = .003) and Veterans RAND 12-Item Health Survey (mental component, P = .032; physical component, P = .005). Conclusion: At the time of hip arthroscopy, athletes demonstrate similar intra-articular damage to their nonathlete counterparts. Given their higher preoperative scores, it is possible that athletes better tolerate the damage to the hip joint. Despite their strenuous activities and potentially higher tolerance to pain, athletes should not necessarily be expected to have greater severity of intra-articular pathology.

Outcomes After Primary Hip Arthroscopy in Athletes Older Than 40 Years Compared With Nonathletes

Background: Master athletes (MAs), or athletes older than 40 years, make up a patient population whose outcomes after primary arthroscopic hip surgery are largely unknown. Purpose: To report minimum 2-year outcomes of MAs after primary hip arthroscopy and compare their results to a propensity-matched nonathlete (NA) control group. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected between February 2008 and April 2019 and retrospectively reviewed for all patients who underwent primary hip arthroscopy. Patients were included if they were older than 40 years and had preoperative data for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, and visual analog scale score for pain. MAs reported participating in organized sports competition within 1 year before surgery and were propensity matched to a control group of patients who did not report participating in organized sports competition (NAs). Patient characteristics, radiographic and intraoperative findings, surgical procedures performed, and patient-reported outcome measures (PROMs) were reported and compared between the groups. The rates of achieving the minimal clinically important difference and maximum outcome improvement satisfaction threshold were recorded. Results: A total of 366 hips were eligible; 328 (89.6%) had adequate follow-up data. 328 patients met inclusion criteria but 88 were not included due to the restrictions of the propensity score match ratio. Of these, 80 hips (76 patients) were classified as MAs (mean age, 48.9 ± 6.2 years) and were propensity matched 1:2 to an NA control group. Groups were comparable for baseline demographic and radiographic parameters, intraoperative findings, and procedures performed. MAs had significantly better baseline and minimum 2-year PROM scores (P < .05), higher satisfaction (P = .01), and higher rates of achieving clinically meaningful improvement across all the outcome tools used (P < .05). MAs, when compared with NAs, had lower rates of secondary arthroscopy (0% vs 7.5%, respectively; P = .001) and conversion to total hip arthroplasty (12.5% vs 26.9%, respectively; P = .011). Conclusion: MAs demonstrated favorable outcomes after primary hip arthroscopy. When compared with a propensity score–matched control group of NA patients, MAs demonstrated better preoperative and postoperative PROMs, higher rates of clinically meaningful improvement, and lower rates of secondary arthroscopy and conversion to total hip arthroplasty. Absolute improvements in PROM scores were similar between the groups.

Comparison of Outcomes Between Nonsmokers and Patients Who Discontinued Smoking 1 Month Before Primary Hip Arthroscopy: A Propensity-Matched Study With Minimum 2-Year Follow-up.

Background:Cigarette smoking has been shown to negatively affect outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The effect of cessation of cigarette smoking before surgery has not been well established.Purposes:(1) To report minimum 2-year patient-reported outcomes (PROs) of former smokers who underwent primary hip arthroscopy for FAIS and (2) to compare these results with those of a propensity-matched control group of nonsmokers.Study Design:Cohort study; Level of evidence, 3.Methods:Data were collected for all patients who underwent primary hip arthroscopy for FAIS between December 2008 and November 2017. Patients were eligible if they indicated that they had previously smoked cigarettes but had quit smoking at least 1 month before surgery and had minimum 2-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. The percentage of hips achieving the minimal clinically important difference (MCID) were recorded. The study group was then propensity matched in a 1:1 ratio by age, sex, and body mass index (BMI) to patients who had never smoked.Results:A total of 83 former-smoking patients (84 hips; age, 45.0 ± 13.5 years) were included at a median follow-up of 38.6 months (interquartile range, 27.5-48.2 months); all patients had stopped smoking at a mean ± standard deviation of 14.3 ± 24.5 months preoperatively. Former smokers demonstrated significant improvement from preoperatively to the minimum 2-year follow-up for all recorded PROs (P < .001 for all) and achieved the MCID for the mHHS, NAHS, and VAS at favorable rates (75.0%-81.6%). Logistic regression analysis did not identify a significant relationship between cessation time and rates of achieving MCID for mHHS, NAHS, or VAS. When compared with 84 never-smokers (84 hips), the former smokers demonstrated similar preoperative scores, postoperative scores, and improvement on all recorded PROs (P > .05 for all). Both groups achieved MCID for mHHS, NAHS, and VAS at similar rates and demonstrated similar rates of revision surgery.Conclusion:Former smokers who underwent primary hip arthroscopy for FAIS demonstrated significant improvement in PROs at minimum 2-year follow-up. When compared with a propensity-matched control group of never-smokers, they achieved similar postoperative PROs and rates of achieving psychometric thresholds.

Basketball Players Undergoing Primary Hip Arthroscopy Exhibit Higher Grades of Acetabular Cartilage Damage but Achieve Favorable Midterm Outcomes and Return to Sports Rates Comparable With a Propensity-Matched Group of Other Cutting Sports Athletes

Background: Favorable short-term outcomes in competitive basketball players have been reported. Midterm outcomes in these athletes and how they compare with athletes in sports with similar demands have not been well established. Purpose: (1) To report minimum 5-year patient-reported outcomes (PROs) and return to sports data in competitive basketball players undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to compare outcomes with a propensity-matched control group of other cutting sports athletes. Study Design: Cohort study, Level of evidence, 3. Methods: Data were prospectively collected and retrospectively reviewed for basketball players who competed at the professional, collegiate, high school, or competitive amateur levels and underwent primary hip arthroscopy for FAIS between May 2009 and March 2016. Patients with preoperative and minimum 5-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Patients were propensity matched to athletes in other cutting sports (soccer, lacrosse, field hockey, and tennis) according to age, sex, body mass index (BMI), and preoperative competition level for comparison. Results: A total of 28 competitive basketball players were included, with a mean follow-up time of 67.1 ± 5.1 months and a mean BMI of 23.7 ± 4; there were 12 (42.9%) female athletes. The cohort was composed of 1 professional, 10 collegiate, 13 high school, and 4 organized amateur athletes. They demonstrated significant improvements in all recorded PROs from baseline to the minimum 5-year follow-up (P < .001) and had high rates of achieving the minimal clinically important difference (MCID) for the mHHS (75%), NAHS (75%), HOS-SSS (67.9%), and VAS for pain (71.4%). Furthermore, 76.5% of basketball players who returned to sports were still competing at a minimum of 5 years postoperatively. When compared with a propensity-matched cohort of other cutting athletes, basketball athletes demonstrated a significantly higher acetabular labrum articular disruption (ALAD) grade (P < .001) and trended toward a higher Outerbridge grade of the acetabular cartilage (P = .067). Despite this, basketball players demonstrated similar preoperative, postoperative, and improvement scores in all recorded PROs. Moreover, both groups exhibited similar rates of achieving psychometric thresholds and rates of continued sports participation at minimum 5-year follow-up. Conclusion: Competitive basketball players undergoing primary hip arthroscopy for FAIS demonstrated significant improvements in all recorded PROs and high rates of continued play at a minimum 5-year follow-up. When compared with a control group of other cutting sports athletes, basketball players exhibited more severe ALAD grades intraoperatively but similar midterm outcomes.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes.

Background:It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.Purpose:To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.Results:Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.Conclusion:Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Vertebral body tethering compared to posterior spinal fusion for skeletally immature adolescent idiopathic scoliosis patients: preliminary results from a matched case–control study

Direct comparisons between vertebral body tethering (VBT) and posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS)are limited. We aimed to evaluate 2-year results of VBT and PSF to report comparative outcomes. 26 prospectively enrolled VBT patients were matched 1:1 by age, gender, Risser sign and major curve magnitude with PSF patients. At a minimum 2-year follow-up, surgical results and radiographic outcomes were reviewed. Operative time, anesthesia time, blood loss, and length of stay were significantly lower in the VBT group (< 0.001, p = 0.003, p < 0.001, p < 0.001, respectively). The major curve at 2years was corrected by 46% in the VBT group vs. 66% in the PSF (p = 0.0004). Success following VBT, defined as no fusion surgery and Cobb angle < 35° at the 2-year follow-up, was seen in 20 VBT patients (77%) (p = 0.0003) and correlated with mean Cobb angle of < 35° on 3-month imaging. 12 VBT patients (46%) showed curve improvement over time, and those patients had significantly lower mean Cobb angle on the 3-month radiograph than non-modulators (23° vs 31°, p = 0.014). At 2years, cord breakage occurred in five patients (19%). By 2years, three VBT patients developed complications (2 pleural effusion and 1 overcorrection needing return to OR). In contrast to PSF, growth continued at T1-T12 (mean 13mm) and over the instrumented levels (mean 10mm) following VBT, compared to no growth over instrumented segments in the fusion cohort (p = 0.011, p = 0.0001). In Sanders stages 3 and 4 patients treated in the USA, Cobb angle < 35° on 3-month imaging was associated with success at the 2-year follow-up. Curve correction was superior in the PSF group with 96% achieving curve correction to < 35° vs. 77% of the VBT patients. Cord breakage was noted in 19% of VBT patients at the 2-year follow-up. Three patients developed complications in both the VBT and PSF cohorts. Level II (prospective study with matched retrospective comparison group).

Outcomes for the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome With Acetabular Retroversion: A 3D Computed Tomography Analysis

Background: Increased attention has been directed toward the acetabular morphology in the management of patients with femoroacetabular impingement syndrome (FAIS). Whether acetabular version influences patient-reported outcomes remains poorly understood. Purpose: To use computed tomography (CT)–based 3-dimensional (3D) bone models to (1) quantify acetabular version in patients with FAIS, (2) compare acetabular version on 3D bone models with current plain radiographic parameters, and (3) explore the relationship between the magnitude of acetabular version and minimum 2-year clinical outcomes after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Three-dimensional models of the pelvis and femur were generated by semiautomated segmentation and aligned to a standard coordinate system. Acetabular version was quantified at the 3-o’clock position, and 3 groups were identified: acetabular retroversion (AR; <15°), normal acetabular version (NV; 15°-25°), and acetabular anteversion (AA; >25°). Patient demographic characteristics, plain radiographic parameters, and clinical outcomes were analyzed, including the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports Subscale, modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. Results: Preoperative CT scans were acquired in 105 consecutive patients before hip arthroscopy for FAIS, of which 84 (80.0%) completed minimum 2-year patient-reported outcomes. The mean ± SD age and body mass index of patients were 33.9 ± 12.6 years and 26.0 ± 5.4, respectively; 70.2% were female. The number of patients and the mean central acetabular version within each group were as follows: AR (n = 12; 11.3°± 2.7°), NV (n = 56; 20.7°± 2.9°), and AA (n = 16; 28.5°± 2.7°). Posterior wall sign was the only plain radiographic parameter that was significantly more observed in the AR group than in the other 2 groups. At minimum 2-year follow-up, significant between-group differences in the mHHS, iHOT-12, and VAS for pain and satisfaction (P < .05) were appreciated, while post hoc analysis with Bonferroni correction (P < .0167) found lower scores on the mHHS, iHOT-12, and VAS for pain and satisfaction in patients with AR as compared with NV. Lower scores on the VAS for satisfaction were reported in patients with AR when compared with AA (P = .006) but not on the mHHS (P = .023), iHOT-12 (P = .032), or VAS for pain (P = .072). Conclusion: Traditional plain radiographic indices to describe AR, including crossover sign and ischial spine sign, were not reliable in defining AR according to 3D models derived from CT scans. Only the posterior wall sign was observed in a higher proportion in the AR group. Patients with AR demonstrated inferior outcomes when compared with patients with NV and AA after hip arthroscopy for FAIS.

Competitive Athletes Who Underwent Hip Arthroscopy With Capsular Repair Showed Greater Improvement in Patient-Reported Outcome Scores Compared With Those Who Did Not Undergo Repair

To compare minimum 2-year postoperative patient-reported outcome (PRO) scores and return to sport between competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome with interportal capsulotomy repair and competitive athletes with an unrepaired interportal capsulotomy. Data on all consecutive competitive athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between February 2012 and December 2018 were collected. Athletes were divided into 2 groups: those who underwent repair and those without repair. Athletes were considered eligible if they participated in sports within 1 year prior to surgery. Patients were eligible if the return-to-sport status and the following preoperative and minimum 2-year postoperative PROs were available: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain. Patients were excluded if they underwent prior hip surgery, had Workers' Compensation, were unwilling to consent, had a Tönnis grade greater than 1, or had a previous hip condition. The percentages of patients achieving the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold were recorded. Athletes who underwent interportal capsulotomy repair were propensity score matched in a ratio of 2:1 to athletes without interportal capsulotomy repair according to age, sex, body mass index, sport level, and acetabular labrum articular disruption grade. Forty-nine athletes (53 hips) without repair with an average follow-up time of 36.5 ± 10.2 months and age of 32.1 ± 13.3 years were matched to 79 athletes (84 hips) with repair with an average follow-up time of 41.3 ± 9.4 months and age of 30.1 ± 12.1 years. Athletes in the repaired group showed significantly greater improvements in the NAHS, HOS-SSS, and VAS score and significantly higher rates of achievement of the MCID for the HOS-SSS compared with athletes in the unrepaired group. Competitive athletes who underwent primary hip arthroscopy with interportal capsulotomy repair showed a significantly greater magnitude of improvement in PRO scores (NAHS, HOS-SSS, and VAS score) and rates of achieving the MCID (HOS-SSS) compared with a propensity score-matched control group of competitive athletes with an unrepaired interportal capsulotomy. Level III, retrospective comparative therapeutic trial.

Effect of Cigarette Smoking on Midterm Outcomes After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome: A Propensity-Matched Controlled Study With Minimum 5-Year Follow-up.

Background:There is limited literature evaluating patient-reported outcomes (PROs) in cigarette smokers undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at midterm follow-up.Purpose:(1) To report minimum 5-year PROs for cigarette-smoking patients who underwent primary hip arthroscopy for FAIS and (2) to compare these results with a propensity-matched control group of never-smoking patients.Study Design:Cohort study; Level of evidence, 3.Methods:Data were collected for all patients who underwent primary hip arthroscopy for FAIS between June 2009 and March 2016. Patients were eligible if they indicated that they smoked cigarettes within 1 month of surgery and had minimum 5-year postoperative outcomes for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sport Specific Subscale (HOS-SSS), and International Hip Outcome Tool–12 (iHOT-12). The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and maximum outcome improvement satisfaction threshold were recorded. The study group was then propensity matched in a 1:2 ratio to patients who had never smoked for comparison.Results:Included were 35 patients (35 hips) with a mean age of 39.4 ± 13.0 years and mean follow-up of 64.6 ± 4.1 months. These patients demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for all recorded PROs (P < .05). When compared with 70 control patients (70 hips), smoking patients demonstrated significantly worse preoperative scores for all PROs (P < .05). Study patients also demonstrated worse minimum 5-year scores for all recorded PROs compared with control patients, which did not reach statistical significance but trended toward significance for HOS-SSS (70.4 vs 81.9; P = .076) and iHOT-12 (74.7 vs 82.2; P = .122). Smoking patients also trended toward lower rates of achieving PASS for the iHOT-12 compared with never-smoking patients (50.0% vs 68.2%; P = .120).Conclusion:Patients who smoked cigarettes and underwent primary hip arthroscopy for FAIS demonstrated significant improvement in PROs at a minimum 5-year follow-up. When compared with a propensity-matched control group of never-smokers, they trended toward lower postoperative HOS-SSS and iHOT-12 scores and lower rates of achieving PASS on the iHOT-12.

Minimum 5-Year Outcomes After Primary Segmental Labral Reconstruction for Irreparable Labral Tears in the Hip With Hamstring Grafts: With a Subanalysis Comparing Autograft Versus Allograft

Background: Comparable short-term outcomes have been obtained using hamstring allografts versus autografts after primary segmental labral reconstruction (SLR). Midterm results have not yet been determined. Purpose: (1) To evaluate minimum 5-year patient-reported outcome (PRO) scores in patients who underwent primary SLR with hamstring grafts in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare the outcomes of hamstring autografts versus allografts in a subanalysis using propensity-matched groups. Study Design: Cohort study; Level of evidence, 3. Methods: Prospectively collected data were retrospectively reviewed for patients who underwent primary hip arthroscopy between September 2010 and November 2015. Patients were included if they underwent SLR using hamstring autografts or allografts and had preoperative and minimum 5-year PROs. The exclusion criteria were previous ipsilateral hip surgery or conditions, dysplasia, or Tönnis grade >1. Patients with autograft SLR were propensity matched 1 to 1 based on age, sex, and body mass index (BMI) to patients who underwent SLR using hamstring allografts. The minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) were calculated. Results: Overall, 48 patients (N = hips 48) were eligible to be included in this study, and 41 patients (n = 41 hips [85.4%]) had a minimum 5-year follow-up reporting significant improvements in all PROs. Within the entire cohort, 9.8% required a secondary arthroscopy, with a mean time of 19 ± 1.8 months, and survivorship was 82.9%. Of the 41 included patients, 15 underwent an SLR with a hamstring autograft and were matched to 15 patients with labral reconstruction using a hamstring allograft. Groups were similar for sex (P > .999), age (P = .775), and BMI (P = .486). The mean follow-up times were 80.8 ± 25.5 and 66.1 ± 8.3 months (P = .223) for the autograft and allograft groups, respectively. Baseline PROs, preoperative radiographic measurements, surgical findings, and intraoperative procedures were similar. The groups achieved significant and comparable improvements for all PROs (P < .0001), satisfaction (P = .187), and the rate of achieving the MCID and the PASS. However, a tendency for higher postoperative PROs favoring allograft reconstruction was found. Conclusion: At a minimum 5-year follow-up, patients who underwent primary arthroscopic SLR in the context of FAIS and irreparable labra, with either autograft or allograft hamstring tendons, reported significant improvements and comparable postoperative scores for all PROs, patient satisfaction, MCID, and PASS.

Minimum 2-Year Outcomes and Return to Sports of Competitive Athletes Who Undergo Subspine Decompression During Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome and Subspine Impingement: A Propensity-Matched Controlled Study

Background: Patient-reported outcomes (PROs) and return to sports (RTS) have not been established in athletes undergoing primary hip arthroscopy and subspine decompression for femoroacetabular impingement syndrome (FAIS) and subspine impingement (SSI). Purpose: (1) To report minimum 2-year PROs and RTS in competitive athletes undergoing primary hip arthroscopy for treatment of FAIS with subspine decompression for treatment of SSI and (2) to compare clinical results with a matched control group of athletes without SSI. Study Design: Cohort study, Level of evidence, 3. Methods: Data were reviewed for professional, collegiate, and high school athletes undergoing primary hip arthroscopy for FAIS with arthroscopic subspine decompression for SSI between February 2011 and October 2018. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sport Specific Subscale, and visual analog scale for pain. Rates of achieving the minimal clinically important difference (MCID) were also calculated. For comparison, athletes in the SSI group were propensity matched according to age at the time of surgery, sex, body mass index, lateral center-edge angle, alpha angle, sport level, acetabular labrum articular disruption grade, and sport type to a control group of athletes without SSI. Results: A total of 30 SSI athletes were included in the study, with a mean plus or minus standard deviation follow-up of 32.1 ± 7.1 months and age of 20.9 ± 5.7 years. The SSI cohort demonstrated significant improvement in all recorded PROs (P < .001), returned to sports at high rates (88.5%), and achieved the MCID for the Hip Outcome Score–Sport Specific Subscale at a high rate (80.0%). Furthermore, these patients had a low rate of undergoing revision surgery (6.7%). When compared with a propensity-matched control group of 59 athletes, the SSI group demonstrated similar rates of RTS, revision, and achieving the MCID for all PROs. Conclusion: Competitive athletes with FAIS and SSI who underwent primary hip arthroscopy and subspine decompression had favorable outcomes and high RTS rates at minimum 2-year follow-up. These results were comparable with those of a control group of athletes without SSI undergoing primary hip arthroscopy.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Workers’ Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score–Matched Study

Background: The workers’ compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce. Purpose: (1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score–matched control group without WC claims. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score–Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI). Results: A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05). Conclusion: Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Athletes Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy Demonstrate Greater Than 80% Return-to-Sport Rate at 2-Year Minimum Follow-Up

To report minimum 2-year follow-up patient-reported outcomes and return-to-sport (RTS) rates in athletes undergoing concomitant hip arthroscopy and periacetabular osteotomy (PAO) to treat acetabular dysplasia and intra-articular pathologies such as cam deformity and labral tears. We reviewed the data of consecutive athletes undergoing concomitant primary hip arthroscopy and PAO for acetabular dysplasia and cam deformity from November 2010 to December 2018. Patients were included in the study if they had the following preoperative and minimum 2-year postoperative scores: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The percentage of patients who achieved the minimal clinically important difference was recorded, in addition to RTS status. A total of 29 athletes (29 hips) were included, with a mean follow-up time of 34.1 ± 7.9 months, mean age of 26.0 ± 8.7 years, and mean body mass index of 23.7 ± 3.4. These athletes showed significant improvements in the mHHS, NAHS, and HOS-SSS from baseline to latest follow-up (P < .001). The minimal clinically important difference was achieved at high rates for the mHHS (82.8%), NAHS (86.2%), and HOS-SSS (79.3%). Athletes who attempted to RTS successfully returned at a rate of 81.8%. Athletes undergoing concomitant hip arthroscopy and PAO showed significant improvements in patient-reported outcomes at minimum 2-year follow-up and had an RTS rate of 81.8%. Level IV, retrospective case series.

Flexible Versus Rigid Reaming Systems for Independent Femoral Tunnel Reaming During ACL Reconstruction: Minimum 2-Year Clinical Outcomes.

Background:Radiographic and cadaveric studies have suggested that anatomic anterior cruciate ligament reconstruction (ACLR) femoral tunnel drilling with the use of a flexible reaming system through an anteromedial portal (AM-FR) may result in a different graft and femoral tunnel position compared with using a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR). No prior studies have directly compared clinical outcomes between the use of these 2 techniques for femoral tunnel creation during ACLR.Purpose:To compare revision rates at a minimum of 2 years postoperatively for patients who underwent ACLR with AM-FR versus AAM-RR. The secondary objectives were to compare functional testing and patient-reported outcomes between the cohorts.Study Design:Cohort study; Level of evidence, 3.Methods:Included were consecutive patients at a single academic institution between 2013 and 2018 who underwent primary ACLR without additional ligamentous reconstruction. Patients were separated into 2 groups based on the type of anatomic femoral tunnel drilling: AM-FR or AAM-RR. Graft failure, determined by revision ACLR, was assessed with a minimum 2 years of postoperative follow-up. The authors also compared patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and functional performance testing performed at 6 months postoperatively.Results:A total of 284 (AAM-RR, 232; AM-FR, 52) patients were included. The mean follow-up time was 3.7 ± 1.5 years, with a minimum 2-year follow-up rate of 90%. There was no significant difference in the rate of revision ACLR between the AAM-RR and AM-FR groups (10.8% vs 9.6%, respectively; P = .806). At 6 months postoperatively, there were no significant between-group differences in peak knee extension strength, peak knee flexion strength, limb symmetry indices, or hop testing, as well as no significant differences in IKDC (AAM-RR, 81.1; AM-FR, 78.9; P = .269) or KOOS (AAM-RR, 89.0; AM-FR, 86.7; P = .104).Conclusion:In this limited study, independent femoral tunnel drilling for ACLR using rigid or flexible reaming systems resulted in comparable rates of revision ACLR at a minimum of 2 years postoperatively, with no significant differences in strength assessments or patient-reported outcomes at 6 months postoperatively.

Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports

Background: Athletes who compete in flexibility sports (FS) place unique demands on their hip joints because of the supraphysiologic range of motion required. Purpose: To compare the pathologic features, outcomes, and return-to-sports (RTS) rates of high-level athletes participating in FS who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear against a propensity score–matched cohort of high-level athletes participating in non–flexibility sports (NFS). Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected and retrospectively reviewed for high-level athletes who underwent primary hip arthroscopy for FAIS from April 2008 to December 2018. Patients who participated in FS such as dancing, gymnastics, martial arts, figure skating, and cheerleading were propensity score matched by body mass index, age at time of surgery, sex, sports competition level, and labral treatment to a cohort of high-level athletes participating in all other sports, such as distance running, soccer, volleyball, and softball. Baseline patient characteristics, intraoperative findings, and surgical procedures were compared. Minimum 2-year patient-reported outcome measures were compared for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sport Specific Subscale, and visual analog scale for pain and satisfaction. Rates of secondary surgery and RTS were compared. Results: A total of 47 patients (50 hips) who participated in FS were included and propensity score matched to 130 patients (150 hips) who participated in NFS. Follow-up time was 37.5 ± 10.4 months (mean ± SD). Most patients (96.0%) were female with a mean age of 19.5 ± 7.3 years. FS athletes had significantly higher rates of femoral head cartilage lesions (Outerbridge ≥2; 12.0% vs 2.0%; P = .008) and ligamentum teres tears (48% vs 26%; P = .003). FS and NFS athletes demonstrated significant clinical improvements after surgery for all patient-reported outcome measures. Of the patients who attempted, 34 (75.6%) participating in FS were able to RTS while 11 (24.4%) were not because of ongoing hip issues. This was not significantly different than the NFS group (P = .073). Conclusion: High-level athletes who participated in FS and were treated for FAIS with hip arthroscopy exhibited higher rates of femoral head cartilage lesions and ligamentum teres tears requiring debridement when compared with a benchmark group of athletes who participated in other sports. Despite this, both groups demonstrated similar improvements in outcome scores and comparable rates of RTS at minimum 2-year follow-up.