Utilization Of Hip Arthroscopy Research Articles

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

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

The Effect of Pelvic Incidence on Outcomes Following Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears

Objectives: Left untreated, femoroacetabular impingement (FAI) poses an elevated risk for the early progression of degenerative joint disease. As a result, the utilization of hip arthroscopy has increased to counteract the maladaptive effects of FAI, as femoroacetabular osteoplasties have been shown to reconcile deleterious loading patterns caused by CAM and pincer lesions. However, variations in the sagittal alignment of the lumbosacral spine also pose an elevated risk for the early progression of degenerative joint disease. While femoroacetabular osteoplasties improve degenerative loading patterns caused by CAM and pincer lesions, variations in the sagittal alignment of the lumbosacral spine may continue to generate deleterious effects on the labrum, chondrolabral junction, and articular cartilage following hip arthroscopy for acetabular labral tears and FAI. Thus, the purpose of this study was to evaluate the impact of pelvic incidence (PI) on patient-reported outcomes measures (PROMs) and rates of achieving clinically meaningful outcomes following primary hip arthroscopy for acetabular labral tears and FAI. Methods: A retrospective review of a prospectively collected, single-surgeon database was performed to identify patients ≥18 years of age who underwent primary hip arthroscopy for the treatment of labral tears secondary to FAI with a minimum of 12 months of follow-up. Patients with a history of ipsilateral hip or spine surgery, absence of preoperative lumbar spine imaging, radiographic evidence of hip dysplasia or advanced hip osteoarthritis, and contraindicated spinal pathologies were excluded. PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were measured on 2-D supine lumbar images, and patients were stratified into low PI (PI &lt; 45°), moderate PI (45° ≤ PI ≤ 60°), and high PI (PI &gt; 60°) cohorts. PROMs, VAS Pain, and frequencies of achieving clinically meaningful outcomes were compared between groups. PROMs and frequencies of achieving clinically meaningful outcomes were compared between cohorts using one-way analysis of variance tests and Fisher’s exact tests, respectively. Additionally, a sensitivity analysis using a linear mixed-effects model with time as a continuous variable was carried out to evaluate the weighted differences in PROM averages between cohorts. Results: A total of 74 patients undergoing primary hip arthroscopy for FAI and acetabular labral tears met eligibility criteria and were subsequently stratified into low ( n=28), moderate ( n=31), and high ( n=15) PI cohorts. The mean ± SD length of follow-up was 25.16 ± 2.91 months, and no significant differences were observed between cohorts in patient demographics. However, as expected, patients in the high PI cohort displayed significantly larger mean values for PT ( P=0.001), SS ( P&lt;0.001), acetabular version ( P&lt;.001), and acetabular inclination ( P=0.049). Moreover, despite no differences in preoperative outcome scores between cohorts, the high PI cohort displayed significantly inferior scores for all PROMs and VAS pain across 6-, 12, and 24-month follow-ups. This finding also extended to our sensitivity analysis, with the high PI cohort displaying significantly lower weighted averages in scores across all PROMs relative to the moderate PI cohort ( P≤.001 for all). Additionally, the high PI cohort demonstrated significantly lower rates of clinically meaningful outcome achievement and overall patient satisfaction at 12- and 24-month follow-ups compared to the moderate and/or low PI cohorts. No significant differences were found between cohorts in terms of revision hip arthroscopy, subsequent spine surgery, or conversion to THA. Conclusions: Following hip arthroscopy to address acetabular labral tears, patients with a high PI exhibit significantly inferior PROMs relative to those with moderate and low PI. Thus, despite addressing FAI deformities, variations in lumbosacral alignment may continue to impact patient outcomes. Although the current study design limits our ability to infer causality, the significantly greater acetabular version and inclination values observed in the high PI cohort lead us to speculate that the sagittal imbalance in the setting of a high PI places increased mechanical stress on the anterior-superior acetabulum, which portends poor outcomes following hip arthroscopy. Overall, our findings highlight the critical importance of analyzing pelvic alignment in order to prognosticate outcomes following hip arthroscopy for acetabular labral tears in the setting of FAI.

Capsular Repair, Labral Repair, and Femoroplasty are Increasingly Performed for the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome

PurposeThe purpose of our study was to provide an updated assessment of hip arthroscopy utilization using an institutional database that is specific to the treatment of femoroacetabular impingement syndrome (FAIS). MethodsAll patients undergoing hip arthroscopy for the treatment of FAIS were retrospectively identified between the years 2014 and 2022 via Current Procedural Terminology (CPT) coding in a multi-institutional, single health-system database. A longitudinal analysis was performed to identify trends in the utilization of arthroscopic techniques including capsular and labral treatment, osteoplasty, and traction set-up. ResultsDuring the study, a total of 789 arthroscopic hip procedures in 733 patients were analyzed (56 staged bilateral). Between 2016 and 2022, the number of hip arthroscopies performed each year increased by 1490% (R2 =0.87, p=0.001). Capsular repair (R2=0.92, p<0.001), labral repair (R2=0.75, p=0.002), and femoroplasty (R2=0.70, p=0.004) were performed in an increasing proportion of cases over our study period while labral debridement (R2=-0.84, p<0.001) became less utilized. Postless traction systems were employed in 84% (663/789) of hip arthroscopies overall, were used in at least 70% of hip arthroscopies each year, and did not undergo any significant changes in utilization (R2=0.02, p=0.73). ConclusionCapsular repair, labral repair, and femoroplasty were increasingly performed for the arthroscopic treatment of FAIS while the use of labral debridement decreased significantly over our study period. Postless traction systems were utilized in the majority of cases each year. Clinical RelevanceAs comparative literature continues to define the safety and efficacy of hip arthroscopy, understanding how novel techniques or procedures are incorporated in clinical practice is important.

Safety of a Novel Capsular Closure Device in Hip Arthroscopy for Femoroacetabular Impingement

Abstract Introduction: The utilization of hip arthroscopy for the management of femoroacetabular impingement has increased. Capsular closure has been shown to maintain biomechanical stability postoperatively compared to unrepaired capsules. The novel Cap-Fix device (Smith and Nephew, Watford, UK) was developed to aid in capsular closure both by improving the placement of suture and decreasing the number of steps required for capsulotomy. This study aimed to evaluate the safety of the Cap-Fix device for use in capsulotomy and capsular repair following hip arthroscopy. Materials and Methods: A retrospective review of 30 patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement (FAI) with capsular repair using the Cap-Fix 45° or 70° Suture Passer was performed. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) measures were used to evaluate patient-reported outcomes at the baseline and the follow-up intervals. Outcomes of interest included complications and patient-reported outcomes at 2-week, 6-week, and 3-month follow-up. Results: All patients completed 2- and 6-week follow-up, and 28 (93.3%) completed 3-month follow-up. Two patients experienced complications; one with pain requiring glucocorticoid injection at 6 weeks postoperatively, and another with a 12-mm capsular defect found on 3-month postoperative magnetic resonance imaging requiring repeat arthroscopic debridement, revision labral repair, and capsular plication. By 3 months postoperatively, statistically significant improvement in HOOS JR but not PROMIS-PF scores was seen. Conclusion: The Cap-Fix device appears to be safe for use in capsulotomy and subsequent capsular repair during hip arthroscopy for FAI.

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States.

Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Descriptive epidemiology study. The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.

Poster 362: Identifying Racial Disparity in Utilization and Outcomes of Hip Arthroscopy using Machine Learning

Objectives: Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has been increasingly used in the past thirty years with interventions resulting in improved hip function and ultimate delay of hip arthroplasty in a minimally invasive manner. Unfortunately, previous investigations have observed decreased rates of access, utilization of, and outcomes following orthopedic interventions such as hip arthroplasty in underrepresented patients. The purpose of this study is to examine racial differences in procedural rates, outcomes, and complications in patients undergoing hip arthroscopy. Methods: The State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) of New York were queried for patients undergoing hip arthroscopy from 2011 to 2017. The primary outcomes investigated were utilization over time, total charges billed per encounter, 90-day emergency department visits, and revision hip arthroscopy. Patients were stratified into White and non-White race, and intergroup differences were evaluated with descriptive statistics. Subgroup analysis was performed with linear mixed-effects models to identify significant interactions between race and individual variables that contributed to any differences in the outcomes of interest. Temporal trends in utilization of hip arthroscopy and concomitant procedures between the two groups were analyzed with Poisson regression modeling. Finally, targeted maximum likelihood estimation (TMLE) was performed to provide nonparametric estimates of the specific differences in the outcomes studied using machine learning ensembles while controlling for patient risk factors. Results: A total of 9,745 patients underwent hip arthroscopy during the study period, with 1,081 patients of non-White race (11.9%). Results of Poisson regression demonstrated an annual increase of 1.11 in the incidence rate of hip arthroscopy among White patients, compared to 1.03 for non-White patients (p&lt;0.001), with this disparity projected to increase by 2040. Based on TMLE utilizing an ensemble of machine learning models, non-White patients were significantly more likely to incur higher costs (OR: 1.30, 95% CI: 1.24-1.37, p&lt;0.001) and visit the emergency department within 90-days (OR: 1.09, 95% CI: 1.01, 1.18, p=0.05), but had negligible differences in reoperation rates at 90 days to 2 years (OR: 1.13, 95% CI: 0.78-1.63, p=0.53). Subgroup analysis identified higher likelihood for 90-day emergency department admissions among non-White patients compared to White patients, which were significantly compounded by Medicare insurance (OR: 2.95, 95% CI 1.46-5.95, p=0.002), median income in the lowest quartile (OR: 1.84, 95% CI: 1.2-2.61, p=0.012), and residence in low-income neighborhoods (OR: 2.05, 95% CI: 1.31-3.2, p=0.006). Subgroup analysis for charges billed and reoperation did not identify significant findings. Conclusions: Hip arthroscopy remains an increasingly utilized surgical technique for the treatment of a myriad of hip disorders. Unfortunately, racial disparities exist and are worsening over time. Irrespective of insurance status, non-white patients undergo hip arthroscopy at a lower rate, incur higher costs, and more frequently experience unexpected returns to the emergency department. Improved initiatives to improve the disparity in access to and outcomes following hip arthroscopy must be addressed to further its utility for all patients.

Poster 216: Comparison of Joint Space Narrowing to the Contralateral Side During Hip Arthroscopy: Predictor of Conversion to THA?

Objectives: Reduced joint space at the time of joint-preserving hip arthroscopy has been shown to be correlated with rates of eventual conversion to total hip arthroplasty (THA). With an increasingly aging population and increased utilization of hip arthroscopy, it is important to identify factors that may predict early failure and the eventual need for arthroplasty. For some patients, hip arthroscopy may provide symptomatic relief for years, while others garner limited benefit and require conversion THA soon after their index surgery. This study sought to determine if quantitative differences in joint space width (JSW) between the operative and non-operative hip predicted the likelihood of conversion to THA at the time of hip arthroscopy. Methods: After obtaining institutional review board approval, a retrospective review identified 105 patients treated for labral tears with arthroscopic hip surgery by a single-surgeon with a minimum of 5- year follow-up. Patients were stratified into cohorts based on whether they received a subsequent THA. Preoperative, anteroposterior pelvic radiographs were obtained for each patient and semi-automated, quantitative JSW measurements were performed at 3 predefined fixed locations per hip (10, 30, and 50 degrees with respect to a polar coordinate system; Figure 1). All measurements were obtained by an independent assessor blinded to other radiographic or clinical information, with high reliability (intra- class correlations &gt; 0.8), as previously described in literature. Differences in JSW at each prefixed angle were calculated by subtracting the width (millimeters) of each patient’s operative hip from the measurements obtained from their non-operative hip. Categorical variables were analyzed using chi- square test or Fisher exact test, as appropriate. After assessing for normality with Shapiro-Wilk tests, continuous variables were compared using Student t-tests or Mann-Whitney U tests to determine baseline differences between patients that converted to THA and those that did not. Logistic regression was run for JSW at each prefixed angle, followed by adjusted, multivariable logistic regression to determine independent predictors of conversion to THA. Results: Mean [standard deviation (SD)] follow-up was 8.81 [2.68] years, identifying 16 (15.2%) patients that converted to THA and 89 (84.8%) that did not. When comparing baseline demographic and intraoperative characteristics between cohorts, THA patients were found to have higher mean [SD] age 41.8 [13.4; p=0.003], BMI 29.3 [4.2; p&lt;0.001], Tönnis grade (p&lt;0.001), Outerbridge grade (p=0.002) and higher percentage of males (p=0.014; Tables 1&amp;2). THA patients were found to have a significantly greater difference in JSW at 30° compared to those that did not require subsequent hip arthroplasty (0.566 ± 0.883mm versus 0.038 ± 0.499mm, p=0.035). Differences in JSW between cohorts were not significant at the 10° (p=0.104) or 50° (p=0.096) locations. When adjusting for significantly different covariates, the difference in JSW at 30° was correlated with an increased likelihood of conversion to THA (Adjusted Odds Ratio [AOR]: 4.00; 95% Confidence Interval [CI]: 1.06 to 15.13; p =0.041). Finally, adjusted analysis controlling for differences in JSW at all predefined angles found that narrowing at 30° was significantly associated with increased odds of conversion ([AOR]: 3.88; [CI]: 1.06 to 14.22; p=0.041), while 10° (p=0.630) and 50° (p=0.995) were not. Conclusions: To best educate patients on the risk of THA following hip arthroscopy, identifying objective predictors of early failure is imperative during preoperative evaluation. This study identified that differences in JSW at 30° between the operative and non-operative hip were significantly associated with increased risk of conversion after controlling for demographic and intraoperative factors. Analysis was limited by predetermined locations for JSW and future studies may identify stronger correlations by incorporating additional measurements within the acetabular sourcil. Quantitative differences in JSW comparing the operative hip to the contralateral side predicts patients progressing to THA at the time of hip arthroscopy. [Table: see text] [Table: see text]

Hip arthroscopy utilization and reoperation rates in Ontario: a population-based analysis comparing different age cohorts.

Background:Older age (> 40 yr) and osteoarthritis are negative prognostic variables for hip arthroscopy, but their impact has not been quantified from a population standpoint. The purpose of this study was to perform a population-based analysis of hip arthroscopy utilization and associated 2- and 5-year reoperation rates and complications in different age cohorts.Methods:Administrative databases from Ontario, Canada, were retrospectively reviewed to identify patients aged 18–60 years who underwent hip arthroscopy between 2006 and 2016. Patients were stratified into 2 cohorts: 18–39 and 40–60 years of age. Patients were followed for 2 and 5 years to capture the occurrence of subsequent surgery (repeat arthroscopy or total hip arthroplasty) and postoperative complications.Results:A total of 1906 patients underwent hip arthroscopy, 818 (42.9%) of whom were aged 40–60 years. In the entire cohort, revision surgery occurred in 6.5% and 15.1% of cases at 2 and 5 years, respectively. Revision surgery rates were significantly higher among patients aged 40–60 years at 2 (10.8% v. 3.2%, p < 0.001) and 5 years (22.7% v. 8.2%, p < 0.001) than among those aged 18–39 years. Revision rates were higher among patients aged 50–60 years than among those aged 40–49 years at 2 years (14.3% v. 9.1%, p = 0.027). Complication rates did not differ between cohorts. Regression analysis revealed higher 2- and 5-year odds of secondary surgery in patients aged 40–49 years (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.70–4.22; OR 2.82, 95% CI 1.87–4.25; p < 0.001), patients aged 50–60 years (OR 4.39, 95% CI 2.67–7.22; OR 3.44, 95% CI 2.11–5.62; p < 0.001) and those with osteoarthritis (OR 2.41, 95% CI 1.39–4.20; p = 0.002; OR 1.76, 95% CI 1.00–3.09; p = 0.049).Conclusion:Revision surgery rates following hip arthroscopy are significantly higher among older patients and those with concomitant osteoarthritis. Although the data have limitations, they provide useful information to guide surgical decision-making.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age.

Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use. A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage. Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use. Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use. Level III.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction.

Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

History of hip arthroscopy

Hip arthroscopy is a minimally invasive therapeutic and diagnostic procedure appropriate for an evolving list of conditions. It is routinely used for the treatment of intra- and extra-articular pathology of the hip joint. The development of endoscopy paved the way for the development of arthroscopy. Hip arthroscopy was first described in 1931 by Michael Burman, and its widespread adoption was only achieved some 60 years later during the 1990s. Dr. Watanabe, from Japan, has been credited with the development of modern arthroscopy for his work in developing a practical arthroscope and advancement of both explorative arthroscopy and surgical arthroscopic techniques. More recently, the use of distraction proved as a significant step in the utility of hip arthroscopy and paved the way for future innovations in the procedure. The authors provide a brief overview of the history hip arthroscopy, relevant developments which have paved the way for this procedure and the current state of arthroscopy as a diagnostic and therapeutic procedure.

All About the Ligamentum Teres: From Biomechanical Role to Surgical Reconstruction.

Intriguing anatomists and surgeons for centuries, the exact function and biomechanical significance of the ligamentum teres (LT) remains incompletely understood. The LT, also described as the ligamentum femoris capitis, is an intra-articular extrasynovial ligament extending from the cotyloid fossa of the acetabulum to the fovea on the femoral head. Some studies have described it as a vestigial structure in the adult hip. More recent biomechanical studies, however, along with histological and anatomical studies, have suggested the LT to have an important function in proprioception, nociception, and as a secondary stabilizer of the hip joint. The advent and increased utilization of hip arthroscopy to treat hip pathology over the past two decades has ignited a renewed interest in the role of the LT, as well as techniques and indications for management of pathology. In the constellation of intra-articular pain generators of the hip, LT injuries have historically been difficult to diagnose through physical examination or advanced imaging. Numerous classification systems have been proposed based on arthroscopic appearance, and for most cases, conservative management is adequate. In patients undergoing hip arthroscopy, LT débridement usually suffices, although in cases of persistent pain and severe instability, reconstruction of the ligament may be indicated. Multiple methods for reconstruction have been described, with the greatest variation in the method of acetabular fixation of the graft. Future research should focus on clarifying the role of the LT, appropriate surgical indications for reconstruction, and optimization of graft fixation within the acetabulum.

The utility of hip arthroscopy for patients with painful borderline hip dysplasia.

We measured the width of the acetabular labra in, and the clinical outcomes of, patients with borderline hip dysplasia (HD) who underwent arthroscopy. A total of 1436 patients who underwent hip arthroscopy to treat symptomatic, acetabular labral tears were enrolled. From this cohort, we extracted a borderline HD group (162 cases). Lateral labral widths were evaluated using preoperative magnetic resonance imaging scans. Clinical data including the modified Harris hip score (mHHS), non-arthritic hip score (NAHS), hip outcome score-activity of daily living (HOS-ADL) score, visual analog scale (VAS) pain score, and Tönnis grade were collected. In addition, patient satisfaction with arthroscopy outcomes was rated. All complications and reoperations were noted. The mean follow-up time was 87.4 months. The lateral labral width was 7.64 mm in those with normal hips and 7.73 mm in borderline HD patients, respectively (p = 0.870). The Tönnis grade progressed mildly from 0.46 to 0.76 (p = 0.227). At the last follow-up, clinical outcome scores (mHHS, NAHS, and HOS-ADL scores) and the VAS score were improved (p < 0.001). The mean patient satisfaction was scored at 8.2. The reoperation rate was higher in those who underwent labral debridement (25.6%) than labral repair (4.1%). The lateral labral width did not differ significantly between the borderline HD group and the nondysplastic control group. Arthroscopy relieved the symptoms of painful borderline HD and did not accelerate osteoarthritis. Therefore, if such patients do not respond to conservative treatment, hip arthroscopy can be considered for further treatment.

Who Is Performing Hip Arthroscopy?: An Analysis of the American Board of Orthopaedic Surgery Part-II Database.

Hip arthroscopy utilization has increased dramatically over the last decade. However, the lack of a formal training curriculum raises concern that inconsistent technical performance may be an issue for early-career hip arthroscopists. The purpose of the present study was to investigate hip arthroscopy utilization by early-career orthopaedic surgeons while focusing on fellowship training status to better guide future development of a hip arthroscopy training curriculum. The American Board of Orthopaedic Surgery (ABOS) Part-II database was used to identify candidates who had performed ≥1 hip arthroscopy procedures between 2006 and 2015. Procedures were categorized using Common Procedural Terminology (CPT) codes, and candidates were categorized by fellowship training experience. Trends in hip arthroscopy utilization were evaluated using univariate and regression analyses while stratifying by fellowship training experience. Overall, 9.2% (643) of 6,987 ABOS candidates had performed ≥1 hip arthroscopy procedures. Over the study period, both the proportion of candidates performing hip arthroscopy and the proportion of hip arthroscopy procedures performed (relative to all procedures performed, of any type) increased (p < 0.001). Candidates performing hip arthroscopy most frequently reported sports medicine fellowship training (74.5%; 479 of 643). Also, among the candidates who performed hip arthroscopy, the proportion who had sports medicine fellowship training increased over the study period (p = 0.001). The majority of candidates performing hip arthroscopy (67.2%; 432 of 643) performed ≤5 hip arthroscopy procedures, while a small number of high-volume hip arthroscopists (6.5%; 42 of 643) performed 34.6% (1,403 of 4,054) of all hip arthroscopy procedures. The increase in hip arthroscopy utilization in this cohort appears to have been driven primarily by the increased number of candidates performing hip arthroscopy and less by an increasing number of hip arthroscopy procedures being performed by individual candidates. The majority of candidates performing hip arthroscopy were sports-medicine-fellowship trained. This information is valuable for both trainees and educators interested in improving education and defining a curriculum for future hip arthroscopy training.

Should We Be Concerned About Who Is Performing Hip Arthroscopy?: Commentary on an article by Kyle R. Duchman, MD, et al.: "Who Is Performing Hip Arthroscopy? An Analysis of the American Board of Orthopaedic Surgery Part-II Database".

Commentary The utilization of hip arthroscopy surgery has increased by 365% in the United States in recent years, with the majority of cases performed in patients 20 to 39 years of age1. The increased rate can most likely be attributed to increased awareness of the procedure, diagnostic improvements, technical advances that make hip arthroscopy easier to perform, a broadening of indications to treat conditions that were previously treated with open procedures (e.g., femoroacetabular impingement [FAI]), and an increase in the number of fellowship programs offering hip arthroscopy training1,2. Duchman et al. used the American Board of Orthopaedic Surgery (ABOS) Part-II database to design their study, with the primary aim of providing an update on hip arthroscopy utilization by ABOS Part-II candidates and the secondary aim of describing the fellowship training experiences of candidates performing hip arthroscopy. This study is an extension of work done by Colvin et al., who had used the same database2. The study by Duchman et al. demonstrated that utilization of hip arthroscopy by ABOS Part-II candidates has continued to rise at a significant rate: from 5.3% in 2006 to 10.3% in 2015. This increase was attributed to more candidates performing hip arthroscopy and less so to an increasing number of hip arthroscopy procedures being performed by individual candidates. Duchman et al. found that the procedure was most common among candidates who had received any sports medicine training, as they accounted for 74.5% of all candidates who performed the procedure. High-volume hip arthroscopists (candidates who performed ≥20 procedures) accounted for 6.5% of all candidates who performed hip arthroscopy, and the most common fellowship training among these high-volume candidates was also sports medicine. This information is important to educators as a call to create a hip-preservation curriculum for sports medicine trainees that is commensurate with improved clinical and radiographic outcomes. Careful patient selection with definition of proper indications is important to avoid the overuse of hip arthroscopy. A candidate’s training period is the most important time for learning such information. Gupta et al.3 and Harris et al.4 reviewed complications that can arise from hip arthroscopy, including neurapraxia, heterotopic ossification, iatrogenic cartilage scuffing, labral penetration, abdominal fluid extravasation, instrument breakage, and reoperations (revision hip arthroscopy for residual FAI or conversion to total hip arthroplasty). The rates of major and minor complications were 0.58% and 4.1%, respectively, and the reoperation rate was 6.3%. The learning curve for hip arthroscopy was directly related to the rates of reoperations and minor complications. The authors concluded that technique-related complications can be minimized by surgeon experience3,4. Avoiding these complications is important to enable patients to return to their normal life and sports activities. Defining the learning curve for hip arthroscopy is especially important as we know from the article by Duchman et al. that more and more sports-medicine-trained candidates are performing the procedure. Colvin et al. found that fellows are exposed to <20 hip arthroscopy cases in their fellowship training program2. The number of cases needed to achieve proficiency during the training period needs to be defined. The Accreditation Council for Graduate Medical Education (ACGME) has established minimum procedure volumes for shoulder and knee arthroscopy in residency programs but not for arthroscopy in other joints5. However, we are seeing a rise in hip arthroscopy elsewhere in the literature: Gil et al. found a 588.9% increase in hip arthroscopy procedures performed by residents during their training period5. Future Directions It would be helpful if we could evaluate outcomes (clinical scores, complications, revision hip arthroscopy procedures, and conversion procedures) of patients who were treated with hip arthroscopy by ABOS Part-II candidates. Outcomes could then be compared among candidates on the basis of the numbers of hip arthroscopy procedures that they performed during their fellowship training. This could help educators both outline a hip arthroscopy curriculum and set target goals for the numbers of cases that candidates need to perform to achieve proficiency. The numbers of hip arthroscopy procedures performed during the training period can be calculated on the basis of self-reporting and by incorporating the ACGME training case log database, which lists procedures logged during residency and fellowship. Combining the data from the ACGME training log with data from the ABOS Part-II database may provide greater clarity in defining the learning curve for early-career surgeons and creating a curriculum for hip arthroscopy in sports medicine programs.

Hip arthroscopy utilization and associated complications: a population-based analysis.

The purpose of this study is to review the trends in hip arthroscopy using data from a statewide database, focusing on utilization rates, patient demographics and complication rates. The Statewide Planning and Research Cooperative System (SPARCS) database for New York State was queried for cases of hip arthroscopy from 1998 to 2012. Patient demographics and procedural details were collected. Patients were subsequently reviewed for complications and readmissions within 30 and 90 days. In total, 12 194 hip arthroscopy procedures were performed by 295 surgeons in 137 centers between 1998 and 2012. There was a 95-fold increase in the annual frequency of hip arthroscopy procedures between 1998 (n = 24) and 2012 (n = 2296). Thirty-day complication rates were 0.2% (n = 19), whereas the 90-day complication rate was 0.3% (n = 30). The all-cause 30-day readmission rate was 0.5% (n = 66), whereas the 90-day rate was 1.6% (n = 200). The number of surgeons performing hip arthroscopy increased 7-fold over the observation period. However, only 14.9% (n = 44) of surgeons performed more than 30 procedures annually. Lower volume surgeons (<102 cases/year) demonstrated significantly higher 90-day readmission rates, compared with higher volume surgeons (>163 cases/year, P < 0.0060); however, complication rates and readmission rates did not differ based on surgeon volume. Our findings confirm our hypothesis, demonstrating a significant increase in utilization of hip arthroscopy in the State of New York. We did not identify an associated increase in annual complication rates as hypothesized with increasing utilization, although there was an association of higher readmission rates among lower volume surgeons. Further study is needed to define rates of failure requiring revision hip arthroscopy or conversion to arthroplasty, and to clarify the relationship between complication rates and surgeon volume and case complexity. Level of Evidence: III, retrospective cohort series.

Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013

BackgroundThe utilization of hip arthroscopy continues to increase in the United States. The purpose of this study was to examine trends in hip arthroscopy procedures and outcomes. MethodsWe performed a retrospective cohort study using Optum Labs Data Warehouse administrative claims data. The cohort comprised 10,042 privately insured enrollees aged 18-64 years who underwent a hip arthroscopy procedure between 2005 and 2013. Utilization trends were examined using age-specific, sex-specific, and calendar-year-specific hip arthroscopy rates. Outcomes were examined using the survival analysis methods and included subsequent hip arthroscopy and total hip arthroplasty (THA). ResultsHip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. The overall 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In the subset of patients in whom laterality of the subsequent procedure could be determined, about half of the subsequent hip arthroscopy procedures (46%) and almost all of the THA procedures (94%) were on the same side. Decreasing age was significantly associated with the risk of subsequent arthroscopy (P < .01), whereas increasing age was significantly associated with the subsequent risk of THA (P < .01). The 5-year cumulative incidence of THA reached as high as 35% among individuals aged 55-64 years. ConclusionThe utilization of hip arthroscopy procedures increased dramatically over the last decade in the 18-64-year-old privately insured population, with the largest increase in younger age-groups. Future studies are warranted to understand the determinants of the large increase in utilization of hip arthroscopy and outcomes.

Survivorship of Primary Hip Arthroscopy in New York State - A Population-Based Study

Objectives:Hip arthroscopy utilization has significantly increased over the past decade, with annual rates increasing as much as 300-600% in that time period. While large sample data demonstrates significant improvement in clinical outcomes out to two years post-operatively, with low rates of associated post-operative complications, there is little information on the long-term survival of primary hip arthroscopy procedures. The purpose of this study is to report on the rates of revision hip arthroscopy and conversion to resurfacing or total hip arthroplasty (THA) following hip arthroscopy in the State of New York. We will also report on prognostic variables that may contribute to the need for repeat surgery.Methods:The Statewide Planning and Research Cooperative System (SPARCS) database, a census of all hospital admissions and ambulatory surgery in New York State, was used to identify cases of outpatient primary hip arthroscopy. Demographic information was collected for these patients. After case identification, unique identifiers were utilized to identify those patients that underwent revision hip arthroscopy or subsequent ipsilateral hip resurfacing or THA. The risks of each of these outcomes were modeled with use of age, sex, socio-economic status, hospital and surgeon volume as potential risk factors. Patients were also tracked for 30-day and 90-day complications requiring re-admission.Results:We identified 8,267 hip arthroscopy cases from 1998-2012 performed by 295 surgeons in 137 different surgical centers. Demographics revealed that 46.1% of patients were male, with 80.2% carrying private insurance. Annual hip arthroscopy rates increased 88-fold over the observation period, with a 750% increase over the last 10 years. Revision surgery (scope or arthroplasty) was required in 1,087 cases (13.1%) at a mean of 622 ± 603 days. More specifically, revision hip arthroscopy was required in 310 cases (3.8%) at a mean of 649 ± 586 days after the index procedure, while conversion to either resurfacing or THA was required in 796 (9.7%) cases at an average of 616 ± 616 days. The 30-day complication rate, excluding revision surgery, was 0.2%, while the 90-day complication rate was 0.3%. Thirty-day all-cause re-admission rate was 0.7%. Regression analysis revealed that age > 50 y.o. was associated with increased risk of re-operation (Hazard Ratio[HR] 2.30; CI 2.02-2.62), while males carried a slightly lower risk of re-operation (HR 0.88, CI 0.78 -1.0). Additionally, increased surgical volume, for both surgeon and center (≥75th percentile of annual cases), resulted in a lower risk of re-operation (HR 0.64; CI 0.53-0.77; HR 0.61; CI 0.51-0.73).Conclusion:Hip arthroscopy represents a viable treatment option for femoroacetabular impingement, with low rates of revision surgery and conversion to hip arthroplasty. Age less than 50 and higher surgeon and center surgical volume were associated with lower risk of re-operation.

Classification and Diagnostic Criteria of Femoroacetabular Impingement Are Essential for Clinical Outcome Evaluation: Commentary on an article by Rachel M. Frank, MD, et al., "Outcomes for Hip Arthroscopy According to Sex and Age: A Comparative Matched-Group Analysis".

The utilization of hip arthroscopy as a treatment option for nonarthritic hip disorders, particularly femoroacetabular impingement, has grown exponentially over the past decade. Many clinical studies have confirmed that arthroscopic treatment of femoroacetabular impingement results in great improvement in hip functional outcomes. However, as Frank et al. state in their article, there are no data currently available that compare outcomes on the basis of age and sex alone. For this reason, this study was designed as a Level-II prospective cohort study to divide a total of 150 patients with femoroacetabular impingement into 6 groups: female patients younger than 30 years of age, female patients 30 to 45 years of age, female patients older than 45 years of age, male patients younger than 30 years of age, male patients 30 to 45 years of age, and male patients older than 45 years of age. Using the Hip Outcome Score Activities of Daily Living …

Limited Retinacular Vessel Damage Does Not Compromise Femoral Head Perfusion During Hip Arthroscopy - Can the Vascular Safe Zone be Extended?

Objectives:The utilization of hip arthroscopy for FAI is on the rise. Hip arthroscopy has been shown to be safe to the blood supply of the femoral head when performing femoral osteochondroplasty. There are no reports of avascular necrosis of the femoral head after hip arthroscopy from cohort studies. Arthroscopic safe zones have been identified, based on femoral head vascularity studies, that extend from the lateral synovial fold anterior to 12 o clock to the medial synovial fold at 6 o clock. However, advances in technique have allowed for treatment of more extensile posterolateral cam deformities with both arthroscopic and open approaches, and may therefore place a portion of the retinacular vessels at risk for injury. The purpose of this study was to quantify the effect of an extended arthroscopic femoroplasty on femoral head vascularity. We hypothesized that limited retinacular vessel damage by extending a cam resection posterior to 12 o clock would not cause a significant reduction in femoral head perfusion.Methods:Ten fresh-frozen cadaveric specimens with an intact pelvis and bilateral femurs were used. The mean patient age was 66 years (range, 64-69). Each pelvis was randomized to either the Standard Resection (SR) or Wide Resection (WR) group. In the SR group, bone was resected with a motorized burr from the lateral synovial fold at 12 o clock to the medial synovial fold, at a depth of 10mm. In the WR group, bone was resected as in the SR group but was then extended posterolaterally to 11 o clock, damaging the intervening vessels. For each pelvis, one hip was the experimental side and the contralateral hip served as a matched control. Arteriotomy was performed and the medial femoral circumflex artery origin was cannulated. After unilateral arthroscopic resection, all specimens underwent a gadolinium-enhanced MRI with a validated, quantitative protocol. A CT scan was then performed to confirm the zones of osseous resection. Contrast enhancement on MRI was quantified in four quadrants of the femoral head using custom analysis software. Statistical analysis was performed using a two-sided unpaired t-test to assess differences in femoral head perfusion between the specimens in both groups.Results:MRI quantification revealed that the perfusion of the entire femoral head was reduced by a mean of 5.0 ± 3.9% compared to the matched control side in the SR group. In contrast, femoral head perfusion was reduced by a mean of 11.1 ± 16.1% compared to the matched control side in the WR group. The reduction in femoral head perfusion between the SR and WR groups was not statistically significant (p = 0.49). There were no significant differences between groups (p > 0.32). Postoperative CT scans confirmed that all osseous resections in the SR group were within the 12 to 6 o clock arc and all osseous resections in the WR group extended posteriorly beyond 12 o clock but not posterior to 11 o clock.Conclusion:Posterolateral retinacular vessel damage not extending past 11 o clock results in 11% reduction in femoral head perfusion when performing arthroscopic femoral osteochondroplasty. This drop in perfusion is not significantly different to the reduction in perfusion observed when performing osseous resection within previously recognized vascular safe zones. These findings lend support to the use of hip arthroscopy to address extensile cam deformities, but must also be interpreted with caution as further encroachment on the retinacular vessels may result in a dangerous drop in perfusion.