Prior Hip Surgery Research Articles

Hip Arthroscopy with Labral Preservation and Capsular Plication in Patients with Borderline Hip Dysplasia: Minimum 5-year Patient Reported Outcomes

Objectives:Arthroscopic management of hip pathology in patients with hip dysplasia has been controversial, and historically demonstrated mixed results. Studies on patients with borderline dysplasia, emphasizing the importance of the labrum and capsule as secondary stabilizers, have shown favorable outcomes. We predicted that patients with borderline dysplasia, who are undergoing hip arthroscopy for intrarticular pathology and who have commensurate labral preservation and capsular plication, will have favorable outcomes at mid-term follow up.Methods:Data was prospectively collected for patients < age 40, who underwent hip arthroscopy for intra-articular pathology. Inclusion criteria included lateral center-edge angle (LCEA) between 18° and 25°, concurrent capsular plication and labral preservation, and minimum five-year follow-up. Exclusion criteria were severe dysplasia (LCEA ≤ 18°), Tönnis grade ≥ 2, preexisting childhood hip conditions, or prior hip surgery. Patient-reported outcome scores (PROs) including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-sport specific subscale (HOS-SSS) and Visual Analogue Score for pain (VAS) were collected preoperatively, at 3 months, and annually thereafter. Complications and revisions were recorded.Results:Twenty-five hips (24 patients) met inclusion criteria. Twenty-one hips (19 patients, 84%) were available for follow-up. Mean age was 22.9 years. Mean preoperative LCEA and Tönnis angle were 21.7° and 6.9°, respectively. Mean follow-up was 68.8 months. Mean mHHS increased from 70.3 to 85.9 (p < 0.0001), NAHS from 68.3 to 87.3 (p < 0.0001) and HOS-SSS from 52.1 to 70.8 (p = 0.0002). VAS improved from 5.6 to 1.8 (p < 0.0001). Four hips (19%) required secondary arthroscopic procedures, all of which resulted in improved PROs at latest follow-up. No patient required conversion to arthroplasty.Conclusion:Using strict patient selection, hip arthroscopy with labral preservation and capsular plication can provide a safe, durable means of managing intra-articular pathology in the setting of borderline acetabular dysplasia. For this select group, this procedure may offer a viable alternative to open surgery (PAO).

Radiographic Hip Anatomy Correlates With Range of Motion and Symptoms in National Hockey League Players

Background: Hip disorders in athletes have been increasingly recognized. Purpose: To characterize radiographic hip anatomy for National Hockey League (NHL) players and correlate it with hip range of motion and hip symptoms and/or surgery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Fifty-nine professional hockey players (118 hips) with 1 NHL organization (mean age, 24.2 years; range, 18-36) prospectively underwent history and physician examination by 2 independent orthopaedic surgeons. Current or previous groin and/or hip pain or surgery was noted. Anteroposterior (AP) pelvis and bilateral Dunn lateral radiographs were obtained for all players with assessment of hip morphology by 2 blinded independent orthopaedic surgeons. Results: Good to very good reliability of radiographic assessments was noted (intraclass correlation coefficients = 0.749-0.958). Sixty-four percent of athletes had a positive crossover sign, while 86% and 60% had a positive posterior wall sign and a prominent ischial spine sign, respectively. Twenty-one percent of hips demonstrated dysplastic acetabular features (lateral center edge angle <25°). Eighty-five percent and 89% of hips demonstrated cam-type morphology based on alpha angle (>50° Dunn lateral) and head-neck offset, respectively. Good to very good reliability was noted for ROM assessments (intraclass correlation coefficient >0.69). Mean hip flexion was 107.4º ± 6.7º, and mean hip internal rotation was 26.1º ± 6.6º. Thirty-one percent of hips had a history of hip-related pain and/or surgery. Higher AP, Dunn lateral, and maximal alpha angles correlated with decreased hip internal rotation (P = .004). Greater AP alpha angle correlated with decreased hip extension/abduction (P = .025), and greater Dunn lateral and maximal alpha angle correlated with decreased hip flexion/abduction (P = .001). A positive posterior wall sign correlated with increased straight hip abduction, while other radiographic acetabular parameters were not predictive of range of motion. Only decreased hip external rotation and total arc of motion correlated with an increased risk for current or prior hip symptoms or surgery (P < .001). Conclusion: Hip anatomy in NHL players is characterized by highly prevalent cam-type morphology (>85%) and acetabular retroversion (>60%). In addition, acetabular dysplasia (21%) was relatively common. Greater cam-type morphology correlated with decreased hip range of motion, and a positive crossover sign correlated with increased hip abduction. Decreased hip external rotation and total arc of motion were predictive of hip-related pain and/or surgery.

Predictors and trajectories of chronic postoperative pain following hip preservation surgery.

Factors contributing to chronic postoperative pain (CPOP) are poorly defined in young people and developmental considerations are poorly understood. With over 5 million children undergoing surgery yearly and 25% of adults referred to chronic pain clinics identifying surgery as the antecedent, there is a need to elucidate factors that contribute to CPOP in surgical patients. The present study includes patients undergoing hip preservation surgery at a children’s hospital. The HOOS and SF-12 Health Survey were administered to 614 pre-surgical patients with 421 patients completing follow-up (6-months, 1-year and 2-years post-surgery). Pain, quality of life, and functioning across time were examined for each group within the population. A three trajectory model (low pain, pain improvement and high pain) emerged indicating three categories of treatment responders. Pain trajectory groups did not differ significantly on gender, pre-surgical age, BMI, prior hip surgery, surgical type, joint congruence or Tönnis grade. The groups differed significantly from each other on pre-surgical pain, pain chronicity, quality of life and functioning. Those in the high pain and pain improvement groups endorsed having pre-surgical depression at significantly higher rates and lower pre-surgical quality of life compared to those in the low pain group (P < 0.01). Those in the high pain group reported significantly worse pre-surgical functioning compared to those in the pain improvement (P < 0.0001) and low pain groups (P < 0.0001).The results demonstrate the need for preoperative screening prior to hip preservation surgery, as there may be a subset of patients who are predisposed to chronic pain independent of hip health.

Use of locking plates for fixation of the greater trochanter in patients with hip replacement.

BackgroundFixation of the greater trochanter with total hip replacement is challenging and associated with short- and long-term complications. Locking plate technology has been used for fixation of other bones and may be applied successfully in trochanteric fixation. The purpose of this retrospective study was to analyze the utility of the use of trochanteric locking plates in total hip arthroplasty (THA) patients.MethodsFrom 2004 to 2014, 32 procedures were performed to fix the greater trochanter in patients with trochanteric fracture, osteotomy, or nonunion in the setting of THA. The median age at the time of surgery was 69 years. This was a primary arthroplasty in 8 of the patients, conversion from prior hip surgery in 5, and a revision in 19. The greater trochanter was fixed with locking plate alone in 15 hips and with the addition of a single cerclage cable in 17 hips. Patients were followed clinically and radiographically until healing occurred. The median duration of radiographic follow-up was 41.6 months (range: 10-112 months).ResultsOsseous union occurred in 29 (90.6%) of 32 hips. The median Harris hip score was 94 (range 54-100, standard deviation = 10.4) at latest follow-up. Complications included broken hardware in 5 (15.6%) patients, of which 3 underwent subsequent hardware removal. Two additional patients elected hardware removal due to trochanteric pain.ConclusionsLocking plate technology is a successful method of fixation of the greater trochanter in patients with THA. Postoperative trochanteric pain and reoperation for hardware-related issues remain a challenge.

Histological changes of the acetabular labrum in coxarthrosis: labral degeneration and repair.

The current study was designed to describe types of histological changes within the acetabular labrum in the advanced stages of coxarthrosis, in patients requiring total hip arthroplasty (THA). 77 consecutive patients without systemic disorders or prior hip surgery, scheduled for THA with 3 types of coxarthrosis: avascular necrosis (AVN), idiopathic, and dysplastic coxarthrosis were analysed. Patient's data: age, gender, side of the involvement, duration of the symptoms were recorded, and standard anteroposterior (AP) radiographic views of the pelvis were obtained. During THA procedure the acetabular labrum was harvested and examined histologically and immunohistochemically. The mean chondrocytes number and density were calculated using morphometric techniques. In 77 analysed acetabular labra the following histological changes were found: heterogenic matrix, foci of granular matrix breakdown, pseudocysts, intralabral c alcifications, chondrocyte apoptosis, inflammatory reaction with lymphocytes infiltration and macrophages infiltration and vascular proliferation with 2 stages of maturation: endothelial cell formation and fully formed blood vessels. The average chondrocytes density was 478 cells in 1 mm2 and significantly decreased with age. The acetabular labrum is an important part of the process of degeneration of the hip in osteoarthritis (OA). Vascular formation and cellular infiltration found in the damaged fibrocartilage may represent a labral response to degenerative changes.

Outcomes After Revision Hip Arthroscopic Surgery in Adolescent Patients Compared With a Matched Cohort Undergoing Primary Arthroscopic Surgery

Background: The incidence of hip arthroscopic surgery is increasing in the young athlete. This has also led to increased numbers of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to describe the outcomes after revision hip arthroscopic surgery in patients ≤18 years of age in comparison to a matched cohort of patients undergoing primary hip arthroscopic surgery. Our hypothesis was that patients undergoing revision hip arthroscopic surgery would demonstrate similar outcomes to those patients undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were included in the study if they underwent revision hip arthroscopic surgery by a single surgeon and did not undergo prior open hip surgery. Each patient in the revision hip arthroscopic surgery cohort was matched with 2 patients undergoing primary hip arthroscopic surgery from the same institution. Cohorts were matched by age, sex, and year of surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected. The primary outcome measure was the Hip Outcome Score for activities of daily living scale (HOS-ADL), a self-reported validated outcome instrument, in addition to the HOS for sports scale (HOS-Sport), modified Harris Hip Score (mHHS), and 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS). Results: Forty-two patients were included in the revision group and were matched with 84 patients in the primary group. The mean age in both groups was 16 years (range, 14-18 years). All female patients in the study were ≥14 years of age, and all male patients were ≥16 years of age. In patients undergoing revision, 13 underwent 1 prior surgical procedure, 22 underwent 2 prior surgical procedures, and 7 underwent ≥3 prior surgical procedures. The mean time from last surgery to revision was 18.7 months (range, 4.7-74 months). Eleven patients (26%) had prior femoroacetabular impingement treated, which required osteoplasty or rim trimming at revision. Subsequent hip arthroscopic surgery was reported in 3 of 84 (4%) patients in the primary group and 6 of 42 (14%) patients in the revision group (P = .162). The mean follow-up in the revision group was 43 ± 17 months, and scores significantly improved (HOS-ADL: 59.6 to 77.6; HOS-Sport: 37.6 to 64.8; mHHS: 55.3 to 74.3; SF-12 PCS: 41.0 to 50.4; P < .05). The mean follow-up in the primary group was 45 ± 18 months, and all scores significantly improved (HOS-ADL: 65.8 to 87.4; HOS-Sport: 46.3 to 79.9; mHHS: 57.5 to 84.2; SF-12 PCS: 39.0 to 51.8; P < .05). At follow-up, there were no significant differences between the primary and revision groups for the HOS-ADL values (P = .051) and SF-12 PCS values (P = .846). Patients in the primary group had significantly higher HOS-Sport values (P = .008), mHHS values (P = .008), and patient satisfaction (P = .008). Patients who underwent 1 prior hip arthroscopic procedure had a higher mean postoperative mHHS value (79.5 vs 72, respectively), HOS-ADL value (91.2 vs 73.4, respectively), and HOS-Sport value (76 vs 60, respectively) (P < .05) compared with those who underwent more than 1 prior procedure. Median patient satisfaction was 9.0 (range, 2-10) in the primary group and 8.0 (range, 2-10) in the revision group. Conclusion: In conclusion, young patients who required revision hip arthroscopic surgery showed significant improvement in patient-reported outcome scores; however, final outcome scores in the revision group for sport activity, general health, and satisfaction were lower than those in the primary group. Patients who underwent 1 revision surgical procedure had higher outcome scores than patients who underwent more than 1 revision surgical procedure.

What is the Prevalence of Radiographic Hip Findings Associated With Femoroacetabular Impingement in Asymptomatic Asian Volunteers?

Morphologic features of the proximal femur reminiscent of those seen in patients with femoroacetabular impingement (FAI) have been reported among asymptomatic individuals in Western populations, but whether this is the case in Asian populations is unknown. The purpose of this study was to determine the prevalence of radiographic findings in the proximal femur that are consistent with FAI in asymptomatic Korean volunteers. Two hundred asymptomatic volunteers with no prior hip surgery or childhood hip problems underwent three-view plain radiographs (pelvis AP view, Sugioka view, and 45° Dunn view) of both hips. There were 146 hips from male volunteers and 254 hips from female volunteers in the study. The mean age of all participants was 34.7 years (range, 21-49 years). Cam-type morphologic features were defined as the presence of the following on one or more of the three views: pistol-grip morphologic features, an osseous bump at the femoral head-neck junction, flattening of the femoral head-neck offset, or alpha angle greater than 55°. Pincer-type morphologic features were determined by radiographic signs, including crossover sign, deficient posterior wall sign, or lateral center-edge angle greater than 40°. The prevalence of cam-type morphologic features seen on at least one radiograph was 38% (male, 57%; female, 26%). The prevalence of cam-type features (at least one positive cam-type feature) was 2.0% (male, 6%; female, 0%) on the pelvic AP view, 24% (male, 36%; female, 17%) on the Sugioka view, and 30% (male, 47%; female, 20%) on the 45° Dunn view. The prevalence of pincer-type morphologic features (at least one positive pincer-type feature) was 23% (male, 27%; female, 21%) on the pelvic AP view. The prevalence of FAI-related morphologic features in asymptomatic Asian populations was comparable to the prevalence in Western populations. Considering the high prevalence of radiographic hip findings reminiscent of FAI in asymptomatic Asian populations, it will be important to determine whether FAI-related morphologic features are a cause of hip pain when considering surgery in Asian patients.

Revision Hip Arthroscopy

Background: As the number of hip arthroscopic surgeries being performed increases, so too does the prevalence of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to compare outcomes in patients requiring revision hip arthroscopic surgery to patients undergoing primary hip arthroscopic surgery. The hypothesis was that patients undergoing revisions would demonstrate similar outcomes to those undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Included in the study were patients undergoing revision hip arthroscopic surgery who did not have a history of prior open hip surgery. Each patient in the revision cohort was matched with 2 patients undergoing primary hip arthroscopic surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected, including the Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL), which was the primary outcome variable; modified Harris hip score (mHHS); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); Hip Outcome Score–Sports subscale (HOS-Sports); and the 12-Item Short Form Health Survey (SF12). At follow-up, scores from the Tegner activity scale and patient self-reported satisfaction with surgical outcome were also collected. Results: A total of 246 patients in the revision cohort were matched with 492 patients in the primary cohort. In the revision cohort, 183 patients had 1 prior surgery, 45 had 2 surgeries, and 18 had ≥3 prior surgeries. Subsequent hip arthroscopic surgery was reported in 39 of 492 (8%) patients in the primary cohort and 5 of 246 (2%) patients in the revision cohort (P = .001). Subsequent surgery was reported in 50 of 492 (10%) patients in the primary cohort and 15 of 246 (6%) patients in the revision cohort (P = .07). Both groups saw significant improvement in outcome scores from preoperation to follow-up. The HOS-ADL was lower in the revision cohort preoperatively (65 vs 70) and postoperatively (79 vs 87) (P = .001). This was also seen in the HOS-Sports, WOMAC, and SF12 physical component scores. Patients who had 1 prior hip arthroscopic procedure had higher postoperative mHHS (81 vs 75) compared with patients with >1 hip arthroscopic procedure; however, there was no difference in postoperative mHHS between the single-revision cohort and the primary cohort. In the revision group, patients whose HOS-ADL improved ≥10 points had greater joint space. Patients with greater improvement were more likely to have had a previous labral tear that was not repaired and to require capsular plication at revision. Conclusion: Patients who underwent revision hip arthroscopic surgery had significant improvement in outcome scores but did have lower scores compared with patients with primary hip arthroscopies. Patients with ≥2 revisions had lower outcomes. Improvement in the revision cohort was seen in patients with increased joint space, no prior labral repair, and capsular plication at revision.

Prospective In Vivo Comparison of Damaged and Healthy-Appearing Articular Cartilage Specimens in Patients With Femoroacetabular Impingement: Comparison of T2 Mapping, Histologic Endpoints, and Arthroscopic Grading

To describe T2 mapping values in arthroscopically determined International Cartilage Repair Society (ICRS) grades in damaged and healthy-appearing articular cartilage waste specimens from arthroscopic femoroacetabular impingement (FAI) treatment. Furthermore, we sought to compare ICRS grades of the specimens with biochemical, immunohistochemistry and histologic endpoints and assess correlations with T2 mapping. Twenty-four patients were prospectively enrolled, consecutively, between December 2011 and August 2012. Patients were included if they were aged 18years or older and met criteria that followed the clinical indications for arthroscopy to treat FAI. Patients with prior hip trauma including fracture or dislocation or who have undergone prior hip surgery were excluded. All patients received a preoperative sagittal T2 mapping scan of the hip joint. Cartilage was graded intraoperatively using the ICRS grading system, and graded specimens were collected as cartilage waste for histologic, biochemical, and immunohistochemistry analysis. Forty-four cartilage specimens (22 healthy-appearing, 22 damaged) were analyzed. Median T2 values were significantly higher among damaged specimens (55.7 ± 14.9ms) than healthy-appearing specimens (49.3 ± 12.3ms; P= .043), which was most exaggerated among mild (grade 1 or 2) defects where the damaged specimens (58.1 ± 16.4ms) were significantly higher than their paired healthy-appearing specimens (48.7 ± 15.4ms; P=.026). Severely damaged specimens (grade 3 or 4) had significantly lower cumulative H&E than their paired healthy-appearing counterparts (P= .02) but was not statistically significant among damaged specimens with mild (grade 1 or 2) defects (P= .198). Among healthy-appearing specimens, median T2 and the percentage of collagen fibers oriented parallel were significantly correlated (rho= 0.425, P= .048). This study outlines the potential for T2 mapping to identify early cartilage degeneration in patients undergoing arthroscopy to treat FAI. Findings in ICRS grade 1 and 2 degeneration corresponded to an increase in T2 values. Further biochemical evaluation revealed a significant difference between healthy-appearing cartilage and late degeneration in cumulative H&E as well as significantly lower percentage of collagen fibers oriented parallel and a higher percentage of collagen fibers oriented randomly when considering all grades of cartilage damage. Level II, prospective comparative study.

Ligamentum Teres Tears and Femoroacetabular Impingement: Prevalence and Preoperative Findings

To determine prevalence of ligamentum teres (LT) injuries identified during hip arthroscopy for treatment of femoroacetabular impingement (FAI) and to identify physical examination findings or radiographic characteristics specific to patients with complete LT tears that could possibly assist in a preoperative diagnosis. Between October 2006 and June 2015, prospective data were collected on consecutive hip arthroscopies. Inclusion criterion was primary hip arthroscopy in patients aged 18years or older. All patients in the study were treated for chondrolabral dysfunction associated with FAI. Patients with prior hip surgery were excluded. A total of 2,213 out of 3,158 hip arthroscopies met the inclusion criterion. Of the 2,213 hips, 233 (11%) had a normal LT, 1,947 (88%) had frayed/partially torn, and 33 (1.5%) had a torn LT. A higher prevalence of torn LT was seen in female subjects. Patients with torn LT had lower body mass index (BMI) (22.5 v 24.7; P < .01) than those with hips with normal LT. On radiographs, patients with torn LTs had a lower center edge angle and had increased odds of having a center edge angle less than 25°. Isolated cam or isolated pincer were seen more often in hips with torn LT than in hips with normal LT. Hips with torn LT were 3.1 times more likely to have a chondral defect on the femoral head than were hips with normal LT (95% confidence interval [CI], 1.2-8.7) and were 3.6 times more likely to have capsular laxity diagnosed at hip arthroscopy than were hips with normal LT (95% CI, 1.4-9.4). Among patients with FAI and labral pathology, complete tears of the LT were rare and were more likely to be seen in women and those with lower BMI and low center edge angles at arthroscopy. LT tears were associated with hip laxity and chondral defects of the femoral head. Level IV, prognostic case series.

Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy

To determine factors associated with grade IV cartilage defects in the hip in patients undergoing hip arthroscopy with joint pain. Data from consecutive patients who underwent hip arthroscopy performed by a single surgeon over a period of 4 years were included in this study. The study group included 1,097 patients (491 women and 606 men; mean age, 37 years) who underwent hip arthroscopy for pain, had no prior hip surgery, and were aged 18 years or older. Preoperative radiographs, patient demographic characteristics, and operative details were used to identify risk factors for cartilage defects. Grade IV chondral defects were present in 308 of 1,097 hips (28%). Isolated chondral lesions were more frequently observed on the acetabulum (76%) than on the femoral head (24%). Defects of the acetabulum were more commonly anterosuperior (94.7%) and less commonly posterolateral (5.3%). Patients with less than 2 mm of joint space on preoperative radiographs were 8 times more likely to have a grade IV lesion than those with more than 2 mm. Men were more likely than women to have grade IV lesions (35% v 19%, P= .0001); patients with grade IV lesions were older than those without (42 years v 34 years, P= .0001). Hips with grade IV lesions had significantly higher alpha angles than those without (74° v 70°, P= .0001). Patients with grade IV defects reported a longer duration of symptoms than those without (37 months v 27 months, P= .007). Independent risk factors for the presence of grade IV chondral defects were less than 2 mm of joint space, male gender, increasing age, larger alpha angle, and longer duration of symptoms. Grade IV chondral defects in patients undergoing hip arthroscopy were associated with decreased joint space, increased time from symptom onset to arthroscopy, male gender, and larger alpha angles associated with femoroacetabular impingement. Level IV, prognostic case series.

Characterizing Radiographic Hip Anatomy and Relationship to Hip Range of Motion and Symptoms in National Hockey League (NHL) Players

Objectives:The objective of this study was to characterize the radiographic proximal femoral and acetabular anatomy for professional (NHL) hockey players, and to correlate with objective assessments of hip range-of-motion and current or prior hip symptoms / surgery.Methods:One hundred and eighteen hips in 59 professional hockey players with one NHL organization (mean age 24.2, range 18-36) underwent a history and physician examination by two independent orthopedic surgeons for direct flexion, adduction, abduction in extension and flexion, and internal and external rotation at 90 degrees of flexion. A history of current or previous groin / hip pain or prior hip and/or core muscle surgery was noted. Well-positioned anteroposterior (AP) pelvis and bilateral Dunn lateral radiographs were obtained for all players with measurements performed independently by two-fellowship trained, hip preservation surgeons to assess acetabular and proximal femoral morphology. Statistical analysis was performed with linear regression models, Pearson and Spearman correlations, as well as intra-class correlation coefficients to assess inter-rater reliability, with p<0.05 defined as significant.Results:Good to Very Good reliability of radiographic assessments were revealed (ICC = .749 - .958, p<.01). With regards to acetabular retroversion, 64% of the athletes had a positive-crossover sign (COS), while 86% and 60% had a positive posterior wall (PWS) and prominent ischial spine sign (ISS), respectively. Mean lateral center edge angle (LCEA) was 28.3◦ ± 4.6◦, and mean Tonnis angle 7.0◦ ± 4.1◦. 18% of hips demonstrated borderline dysplasia (LCEA 20◦-25◦) and 3% frank dysplasia (LCEA<20◦). Femoral head asphericity as assessed by AP and lateral alpha angles was 52.2◦ ± 11.2◦ and 61.0◦ ± 10.1◦, respectively. Both the mean AP and lateral head-neck offset ratio was 0.14 ± 0.02. 85% and 89% of hips demonstrated cam-type proximal femoral morphology based on increased alpha angle and reduced head-neck offset respectively. Very good reliability was confirmed for all ROM assessment (ICC > 0.80) with the exception of direct adduction, which demonstrated good reliability (ICC = 0.69). Mean hip flexion was 107.4±6.7, abduction and adduction 37.6±8.7 and 20.5±5.2 respectively, and IR and ER in 90 degrees of flexion 26.1±6.6 and 44.2±8.6 respectively. 31.4% percent of hips had current or prior history of hip related pain / surgery. Higher AP, lateral, and maximal alpha angles all correlated with decreased hip internal rotation (p=0.004). Greater AP alpha angle correlated with decreased hip extension /abduction (p=0.025), and greater lateral and maximal alpha angle correlated with decreased hip flexion / abduction (p=0.001). Acetabular parameters (LCE, COS, ISS, Tonnis angle) did not correlate with hip ROM. Decreased hip ER correlated with an increased risk for current or prior hip related pain / surgery (p < 0.001).Conclusion:Hip anatomy in NHL hockey players is characterized by highly prevalent cam-type morphology (>85%) and acetabular retroversion (> 60%). In addition, dysplasia (21%) was relatively common. Greater cam type morphology (higher alpha angle) correlated with decreased hip IR, Ext / ABD, and Flex / ABD ROM, whereas acetabular parameters did not correlate with hip ROM. Only decreased hip ER was predictive of hip related pain / surgery.

Prior Hip Surgery Leads to Gender Related Increase in Complication Rates after Transcatheter Aortic Valve Implantation

Prior Hip Surgery Leads to Gender Related Increase in Complication Rates after Transcatheter Aortic Valve Implantation

Does Relief from Intra-articular Anesthetic Injection Predict Outcome after Hip Arthroscopy?

Objectives:Intra-articular (IA) anesthetic injection is commonly performed as a diagnostic test in the setting of femoroacetabular impingement (FAI). Currently, there is a paucity of data correlating post-injection pain relief and outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after IA injection predicts clinical and functional outcomes following hip arthroscopy. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery.Methods:The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent IA injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, prospectively documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores.Results:99 hips in 96 patients met our inclusion criteria and included 71 females (74%) and 25 males (26%) with a mean age of 37.5 ± 14.0 years. 26 patients had Tonnis grade 0, 55 had grade 1, and 18 had grade 2 (0 grade 3). Mean pain relief after IA injection was 73.6 ± 36.1 (range 0-100) percent. 26 patients (26%) had ≤50% pain relief while 73 (74%) had >50% pain relief. Outcome scores were obtained at a mean 14.9 months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 79.2 ± 17.3, 82.6 ± 17.3, and 67.4 ± 28.2, respectively. There was no statistical correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. While patients that received >50% pain relief by IA injection were more likely to achieve positive results (MHHS >70) with a likelihood ratio of 1.23 (95% CI 0.92-1.53), this was not significant. Multivariate regression analysis demonstrated no significant predictors of outcome, including age, gender, Tonnis grade, percent relief with IA injection, number of months postoperatively, or type of surgery.Conclusion:In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from IA injection is a poor predictor of short term outcome, even when adjusting for chondral degeneration. While anesthetic injections can be an important diagnostic tool in select patients, correlation of the clinical history, physical examination, and imaging findings are fundamental. In addition, outcome following hip arthroscopy remains multifactorial.

What are the demographic and radiographic characteristics of patients with symptomatic extraarticular femoroacetabular impingement?

Extraarticular femoroacetabular impingement (FAI) can result in symptomatic hip pain, but preoperative demographic, radiographic, and physical examination findings have not been well characterized. The purposes of this study were to (1) define the demographic characteristics of patients with symptomatic extraarticular FAI; and (2) identify relevant radiographic and physical examination findings that are associated with intraoperative locations of extraarticular FAI. For purposes of this study, we defined extraarticular FAI as abnormal contact between the extraarticular regions of the proximal femur (greater trochanter, lesser trochanter, extracapsular femoral neck) and the ilium or ischium. The diagnosis was suspected preoperatively, but it was confirmed at the time of surgery by direct visualization of extraarticular impingement after surgical hip dislocation. A prospective single-center hip preservation registry was used to retrospectively characterize patients presenting between October 2010 and November 2013 with symptomatic hip pain and intraoperative findings of extraarticular FAI (N = 75 patients, 86 hips). Detailed demographic data were recorded. Radiographs, CT, and MRI scans were reviewed for all patients by two of the authors (BFR, ELS). Outcome instruments including modified Harris hip score (mHHS), Hip Outcome Score (HOS), and International Hip Outcome Tool (iHOT-33) were assessed preoperatively. A comparison group of all patients (N = 1690 patients, 1989 hips) undergoing surgery for intraarticular FAI over the study period were included for demographic comparisons. Cases with extraarticular FAI accounted for 4% (75 of 1765 patients) of our cohort over the study time period. Patients with extraarticular FAI were more likely to be younger (mean ± SD, 24 ± 7 years versus 30 ± 11 years; difference [95% confidence interval {CI}], -7 [-9 to -4]; p < 0.001), female (85% versus 49%; odds ratio [95% CI], 6 [3 to 12]; p < 0.001), to have undergone prior hip surgery (44% versus 10%; odds ratio [95% CI], 9 (6 to 15); p < 0.001), and have lower preoperative outcome scores after adjustment for age, sex, and revision status (mHHS 55 ± 15 versus 63 ± 15; adjusted difference [95% CI], -4 (-8 to -1); p = 0.017; HOS ADL 64 ± 19 versus 73 ± 18; adjusted difference [95% CI], -7 (-11 to -3); p = 0.002) than patients undergoing surgery for intraarticular FAI. Within the extraarticular FAI group, preoperative femoral version on CT was different among patients with anterior versus posterior extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 21° [20, 30], respectively; p = 0.005) and anterior versus complex extraarticular impingement (median [first quartile, third quartile], 8° [2, 18] versus 20° [10, 30], respectively; p = 0.007]. Preoperative external rotation in extension was increased in patients with anterior versus complex extraarticular FAI (median [first quartile, third quartile], 70° [55, 75] versus 40° [20, 60]; p < 0.001). Extraarticular FAI is an uncommon source of impingement symptoms. We suspect the diagnosis often is missed, because many of these patients had prior hip surgery before the procedure that diagnosed the extraarticular impingement source. This diagnosis seems more common in younger, female patients. Radiographic and physical examination findings correspond to locations of intraoperative extraarticular impingement. Future studies will need to determine whether surgical treatment of extraarticular impingement pathology improves pain and function in this subset of patients.

Hip arthroscopy outcomes, complications, and traction safety in patients with prior lower-extremity arthroplasty.

Given the potential for injury due to joint-distraction techniques during hip arthroscopy, this study investigated the outcomes and safety of traction during hip arthroscopy in a series of patients with a prior lower-extremity arthroplasty. Nine patients with a prior hip or knee arthroplasty (Group 1) and a matched cohort of nine additional patients with no prior hip surgery (Group 2) who underwent hip arthroscopy with traction between 2011 and 2013 were evaluated. Collected data included traction and operative times, Modified Harris Hip Scores (MHHS), Non-Arthritic Hip Scores (NAHS), and postoperative complications. Both operative (p = 1) and traction (p = 0.11) times were similar in each group. Each group had a significant improvement in MHHS from baseline to final follow-up: from 39 to 73 (p < 0.001) in Group 1 and from 49 to 75 (p = 0.03) in Group 2. Similarly, the NAHS showed significant improvement in each group from baseline to final follow-up: from 41 to 71 (p < 0.001) in Group 1 and from 48 to 74 (p = 0.02) in Group 2. There was no difference between groups in MHHS or NAHS. There was one postoperative complication in Group 1 (a recurrent labral tear) and no complications from an existing arthroplasty or in Group 2. Hip arthroscopy in patients with a lower-extremity arthroplasty yields improved short-term clinical outcomes without increased complications. The use of traction during hip arthroscopy is safe in this population.

Does Relief from Intra-articular Anesthetic Injection Predict Outcome after Hip Arthroscopy?

Objectives:Arthroscopy is being used more frequently as a treatment for intra-articular hip pathology due to femoroacetabular impingement (FAI). Prior to surgery, intra-articular anesthetic injection is commonly performed as a diagnostic test to localize the source of pain. Currently, there is a paucity of data correlating post-injection pain relief and functional outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after preoperative intra-articular anesthetic injection predicts clinical and functional outcomes following hip arthroscopy with minimum one year follow-up. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery.Methods:The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent pre-operative intra-articular anesthetic injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores.Results:57 hips in 55 patients met our inclusion criteria and included 37 females (67%) and 18 males (33%) with a mean age of 42.6 ± 14.7 (range 15-68) years. 8 patients had Tonnis grade 0, 35 had Tonnis grade 1, and 14 had Tonnis grade 2. Mean pain relief after intra-articular injection was 74.4 ± 31.9 (range 0-100) percent. 13 patients (23%) had ≤50% pain relief while 44 (77%) had >50% pain relief. Outcome scores were obtained at a mean 25.5 (range 12- 60) months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 82.1 ± 17.4 (range 42.9-100), 85.0 ± 16.6 (range 39.7-100), and 71.8 ± 28.1 (range 11.1-100) respectively. There was no correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. When adjusting for Tonnis grade there was no correlation between percent relief and any of the outcome scores measured.Conclusion:In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from intra-articular anesthetic injection does not correlate with minimum 1 year clinical and functional outcomes even when adjusting for Tonnis grade. Although pain relief did not predict outcomes in our study, we still believe it is a useful diagnostic tool to localize the source of pain in patients considering hip arthroscopy.

Heel Response to External Pressure

The purpose of the study was to determine whether the interface pressure created when the heel is in contact with the bed surface reduced healthy adults' heel oxygen delivery (transcutaneous oxygen [TcO2]) and raised heel skin temperature. We also determined whether there was a hyperemic response to pressure relief on 3 consecutive days, and compared data from healthy adults to that from hip surgery patients. A 1-group, prospective, repeated-measures design guided data collection and analysis. Eighteen subjects were age (±5 years) and gender-matched with a previous study on hip surgery patients. The mean age of study participants was 57.3 ± 15.75 (mean ± SD) years and half were men (n = 9). Oxygen and temperature sensors were placed on the plantar surface of each foot, close to the heels. Measures were taken when the heels were (1) suspended above the bed surface (preload), (2) on the bed surface for 15 minutes (loading), and (3) again suspended above the bed surface for 15 minutes (unloading).Repeated measures analysis of variance was used to analyze the data. When compared with preload, both loading and unloading on all 3 days resulted in a statistically significant bilateral reduction in heel TcO2 (P < .001) and a bilateral increase in heel skin temperature (P = .001). There was a significant bilateral heel hyperemic response (during the first 3 minutes of immediate heel unloading) on all 3 days. There were significant changes in heel TcO2 (P = .008) and heel skin temperature (P < .001) in both legs when pressure was relieved. The hyperemic response was not apparent in the operative leg in our prior hip surgery group. When comparing one of the legs of the healthy adults with the operative leg of the prior hip surgery patients, heel TcO2 in both groups decreased (P < .001) while heel skin temperature increased during both loading and unloading in all 3 days (P < .001). Heel TcO2 fell while heel skin temperature increased with both the application and removal of external pressure in healthy adults. The fall in TcO2 and the rise in heel skin temperature were also apparent in the operative leg of the hip surgery group. The brief period of hyperemia, measured by abrupt changes in heel TcO2 and heel skin temperature, was present only in healthy subjects. This raises the question of whether heel pressure ulcer development is related to a blunted hyperemic response in subjects with hip surgery. Further studies are needed that explore the effects of varying the duration of pressure on the hyperemic response as a strategy to understand heel pressure ulcer prevention. Since heel TcO2 fell in both groups after a brief pressure application of 15 minutes, nurses should keep heels off-load at all times to ensure adequate heel skin oxygenation.

A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement

Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data. All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS). Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16-59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12-15) months were 80.1 ± 19.9 (0-100), 83.6 ± 19.2 (13.2-100), and 70.3 ± 27.0 (0-100), respectively. This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.

Hip Osteonecrosis: Does Prior Hip Surgery Alter Outcomes Compared to an Initial Primary Total Hip Arthroplasty?

The purpose of this study was to assess the clinical and radiographic outcomes of total hip arthroplasty (THA) in patients who had osteonecrosis to see if prior hip preserving surgery affected outcomes. Implant survivorship, Harris hip scores, and radiographic outcomes were compared between 87 patients (92 hips) who had undergone prior hip preserving procedures and 105 patients (121 hips) who had only undergone THA. Patients were also sub-stratified into low- and high-risk groups for osteonecrosis. At a mean follow-up of 75 months, there were no significant differences in survivorship, clinical, and radiographic outcomes among the cohorts. Higher revision rates were associated with patients who were in the high-risk group. The authors believe that hip joint preserving procedures may not adversely affect the outcomes of later THA in patients with osteonecrosis.