Hartigan, David E.

Background: The preoperative assessment of cartilage lesions is critical to surgical planning and decision making. The accurate radiographic determination of acetabular cartilage damage has remained elusive for modern imaging modalities, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). While risk factors have been individually described, no multivariable system exists for predicting high-grade cartilage damage. Purpose: To determine the preoperative predictors of grade 3 to 4 acetabular labrum articular disruption (ALAD) lesions. Study Design: Case-control study; Level of evidence, 3. Cohort study (diagnosis); Level of evidence, 1. Methods: Retrievable radiographs were reviewed from primary hip arthroscopic procedures performed at 2 high-volume institutions between December 2007 and April 2017. The predictive value of demographic and radiographic factors for the intraoperative documentation of ALAD grade 3 to 4 damage was analyzed and entered into a multivariable model, and a statistically guided scoring system for the damage risk was created using the Akaike information criterion. The scoring system was then prospectively validated on 167 patients who underwent primary hip arthroscopy between April 2017 and February 2018. Results: A total of 652 primary hip arthroscopic procedures in 614 patients (390 female, 224 male; mean age, 33.2 ± 12.5 years; mean body mass index, 26.9 ± 5.5 kg/m 2 ) from 2007 to 2017 were analyzed. Male sex (odds ratio [OR], 3.11; P < .01), age ≥35 years (OR, 1.96; P < .01), cam morphology (alpha angle >55°) (OR, 2.96; P < .01), and Tönnis grade 1 to 2 (grade 1: OR, 4.14; P < .01, and grade 2: OR, 9.29; P < .01) were univariate risk factors for intraoperatively documented high-grade damage. A multivariable scoring system, the Rapidly Assessed Predictor of Intraoperative Damage (RAPID) score (0-5 points), was generated based on sex, Tönnis grade, and cam morphology. Patients with increasing RAPID scores had an increasing risk of damage, with a 10.5% risk for those with 0 points and an 88.0% risk for those with 5 points ( P < .01). The area under the curve was 0.75 for the study group and 0.76 for the validation group ( P = .94). Conclusion: While preoperative MRI has diagnostic value for hip arthroscopic surgery, the RAPID score provides added benefit as a readily employable, in-clinic system for predicting high-grade cartilage damage. The discriminatory value of the RAPID score compares favorably with previous MRI and MRA studies. This information will help the clinician and patient plan for high-grade damage and identify potential targets for cartilage treatment.

Abstract Transtendinous abductor tendon repair is a technique the authors described previously to diagnose and treat undersurface tears of the abductor tendons. In this surgical technique article, the authors describe a technique for knotless repair of undersurface tears of the abductor tendons that does not require a transtendinous split or suture passage through the abductor tendon. Because there is no suture passage through the abductor tendon or knot tying, the potential advantages include expeditious technique, compression of tendon against bony footprint, anatomic repair, and avoidance of knots facing the undersurface of the iliotibial band, which may lead to bursal irritation. Technique Video video See video under supplementary data.

Background: Iliopsoas fractional lengthening (IFL) continues to be a controversial procedure in hip arthroscopy. Hypothesis: Patients who underwent arthroscopic surgery for femoroacetabular impingement (FAI) and a labral tear either with or without IFL would experience favorable outcomes, and there would be no difference in postoperative patient-reported outcomes (PROs) between the 2 groups at minimum 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Data from July 2009 and April 2015 were retrospectively reviewed. Patients were eligible if they had hip arthroscopy for both FAI and labral tear treatment with IFL and without IFL. IFL was indicated for painful internal snapping. Minimum postoperative follow-up was set to 2 years. The authors calculated the modified Harris Hip Score, International Hip Outcome Tool–12, Hip Outcome Score–Activity of Daily Living Score, Hip Outcome Score–Sports Specific Subscale, Non-Arthritic Hip Score, visual analog scale for pain, patient satisfaction, minimal clinically important difference (MCID), and the percentage of patients who achieved patient acceptable symptomatic state (PASS). Revision surgeries and conversions to total hip arthroplasty (THA) were documented. Results: 351 hips (307 patients) met the necessary inclusion criteria in the IFL cohort, with a mean ± SD follow-up time of 42.5 ± 18.1 months. For the control cohort, 392 hips (354 patients) were included, with a mean ± SD follow-up time of 43.9 ± 19.6 months. Both groups showed significant postoperative improvement in 2-year follow-up PROs. The group with iliopsoas lengthening showed comparable results to the control group with respect to PRO improvement, MCID, PASS, and rates of revision or THA conversion. Conclusion: This comparative cohort study demonstrated that treatment of painful internal snapping syndrome with arthroscopic IFL, in the setting of FAI and a labral tear, is a safe procedure with good short- to mid-term follow-up results and associated improvement in PROs. Patients who underwent IFL showed similar outcomes compared with a control group treated for FAI and labral tear without IFL. In appropriately selected patients, arthroscopic IFL did not adversely affect clinical outcomes compared with patients who did not need IFL.

Objectives: To report the minimum two-year outcomes of trans-tendinous repairs of Partial Thickness Undersurface Tears of the Abductor (PUSTA) tendon using patient reported outcomes (PROs), visual analog scale (VAS), and patient satisfaction scores. Methods: All patients who underwent endoscopic trans-tendinous gluteus medius repair between October 2009 and May 2013 at one institution were prospectively evaluated. Exclusion criteria consisted of less than two-year follow-up, previous hip surgery, inflammatory arthritis, open surgery, full thickness abductor tear, and worker’s compensation patients. All patients had a documented pre-operative physical exam with strength testing (0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PRO scores collected were mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS. Preoperative strength and gait were compared to latest follow-up. Results: There were 25 patients that fit our criteria. Significant improvement in PRO scores were demonstrated for mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS from 54.9-76.2, 50.2-80.6, 30.1-67.3, 51.9-82.4, and 7.1-2.7 respectively (p<0.001). There were 11 patients with objective weakness prior to surgery; seven of these patients moved up at least one strength grade by final follow-up. There were 14 patients who had a Trendelenbrug gait pre-operatively, 12 of them had a normal gait at latest follow-up (p-<0.001). Average patient satisfaction was 7.5. There were no revision surgeries, and no complications noted. Conclusion: PUSTA lesions can be treated successfully with endoscopic trans-tendinous repair preserving the intact attachment of superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to non-operative treatment, as patients demonstrated clinical benefit at greater than 2 years follow up that exceeds substantial clinical benefit and minimally clinical important difference.

Purpose The purpose of this study is to identify radiographic risk factors (RRFs) and radiographic signs of abductor tendon tears. Methods Between April 2008 and October 2015, patients with intraoperative diagnosis of partial‐ or full‐thickness abductor tear noted at the time of open or endoscopic treatment were included in this study. Exclusion criteria included lack of preoperative standard supine pelvic radiograph, lack of preoperative magnetic resonance imaging (MRI), or abductor tear not present at the time of operative intervention. Patients were matched by age ±5 years, gender, and body mass index ±5 with patients with no abductor pathology by clinical exam and MRI. A standardized supine anterior‐posterior pelvis radiograph was performed on all patients. The radiographs were evaluated for RRF (pelvic width, body weight moment arm, abductor moment arm, abductor angle, pelvic height) and signs of abductor tendon pathology (greater trochanteric enthesophyte). Femoral version was measured on MRI when images were available. Statistical analysis was performed and included bivariate and multivariate analyses. Results There were 152 patients with abductor tears identified at the time of surgery out of 2,838 eligible patients matched with 125 patients without abductor tendon pathology. The study institution was unable to perform a 1:1 match because of the advanced age of the abductor tendon group, which led to a greater age in the abductor group ( n = 58) versus the control group ( n = 54; P = .01. In abductor group the average age was 58, and 137 of 152 (90%) patients were female; in the control group the average age was 54, with 111 of 125 (89%) patients being female. Abductor tear patients were treated with surgical repair. The RRFs found with bivariate analysis were an increased pelvic width (14.8 cm for abductor tears vs 14.3 cm for control; P < .001), body weight moment arm (11.1 cm vs 10.9 cm; P < .001), and abductor moment arm (7.8 cm vs 7.6 cm; P < .001); decreased femoral anteversion (7.6° vs 10.6°; P = .045); and enthesophyte presence (41% vs 3%; P < .001). Multivariate regression analysis of all variables showed that teardrop distance and enthesophyte presence were the 2 variables most predictive of abductor tears, and other variables did not significantly increase or decrease the likelihood of tear when these 2 variables were considered. The presence of an enthesophyte on the greater trochanter was notable for an odds ratio of 20.7 of having an abductor tear. Conclusions Patients with abductor tears have a wider pelvis, longer abductor moment arm, and longer body weight moment arm and have greater trochanteric enthesophyte as noted on nearly half of patients with an abductor tear. Presence of an enthesophyte was noted to have an odds ratio of 20.7 and a positive predictive value of 94% for having an abductor tendon tear. The 2 variables predictive of abductor tendon tear when controlling for all variables were enthesophyte presence and teardrop distance, with no other variables significantly increasing or decreasing the likelihood of tear when these 2 variables were considered. Level of Evidence Level III, retrospective comparative study.

Background: Studies assessing dysplasia’s effect on hip arthroscopy are often limited to the short term and unable to account for demographic factors that may vary between dysplastic and nondysplastic populations. Purpose: To determine the midterm failure rate and patient-reported outcomes of arthroscopic labral repair in the setting of dysplasia and make subsequent failure and outcome comparisons with a rigorously matched nondysplastic control group. Study Design: Cohort study; Level of evidence, 3. Methods: Primary arthroscopic labral repair cases at 2 centers from 2008 to 2011 were reviewed. Patients with lateral center edge angle (LCEA) <25° were matched to nondysplastic controls by age, sex, laterality, body mass index (BMI), Tönnis grade, and capsular repair per a 1:2 matching algorithm. Groups were compared with a visual analog scale (VAS) for pain, modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports Specific Subscale (HOS-SSS) to determine predictors of outcome and failure. Results: Forty-eight patients with dysplasia (mean LCEA, 21.6°; range, 13.0°-24.9°; n = 25 with capsular repair) were matched to 96 controls (mean LCEA, 32.1°; range, 25°-52°; n = 50 with capsular repair) and followed for a mean of 5.7 years (range, 5.0-7.7 years). Patients achieved mean VAS improvements of 3.3 points, mHHS of 19.5, and HOS-SSS of 29.0 points ( P < .01) with no significant differences between the dysplasia and control populations ( P > .05). Five-year failure-free survival was 83.3% for patients with dysplasia and 78.1% for controls ( P = .53). No survival or outcomes difference was observed between patients with dysplasia who did or did not have capsular repair ( P ≥ .45) or when comparing LCEA <20° and LCEA 20° to 25° ( P ≥ .60). BMI ≤30 was associated with increased revision surgery risk ( P < .01). Age >35 years ( P < .05) and Tönnis grade 0 radiographs ( P < .01) predicted failure to reach minimal clinically important differences. Conclusion: With careful selection and modern techniques, patients with dysplasia can benefit significantly and durably from arthroscopic labral repair. The dysplastic cohort had outcomes and failure rates similar to those of rigorously matched controls at midterm follow-up. Subanalyses comparing LCEA <20° and LCEA 20° to 25° are presented for completeness; however, this study was not designed to detect differences in dysplastic subpopulations. BMI ≤30 was associated with increased revision risk. Age >35 years and Tönnis grade 0 radiographs predicted failure to achieve minimal clinically important differences.

Purpose The purpose of this study was to evaluate the greater than 2‐year patient‐reported outcomes (PROs) and patient satisfaction of patients who were treated with hip arthroscopy for snapping iliopsoas tendons that were painful with concomitant acetabular dysplasia and who underwent iliopsoas lengthening for symptomatic iliopsoas tendon snapping with concomitant capsular plication and treatment of hip impingement. Secondary measures included observation of the change in the Tönnis grade at greater than 2 years' follow‐up. Methods Between July 2009 and December 2011, data on patients with a lateral center‐edge angle (LCEA) of less than 25° (range, 19°‐24°) who underwent hip arthroscopy with central‐compartment iliopsoas fractional lengthening and capsular plication were prospectively collected and retrospectively reviewed. Interportal capsular repair was performed using between 2 and 5 simple sutures. Patients also underwent procedures to treat hip impingement pathology. All patients had preoperative and minimum 2‐year postoperative PRO measures: modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living subscale, Hip Outcome Score–Sports‐Specific subscale, and Non‐arthritic Hip Score. The visual analog scale score and patient satisfaction with surgery (from 0 to 10) were also collected. Radiographs were analyzed preoperatively and at latest follow‐up to assess progression of the Tönnis grade. Results We analyzed 32 patients who met the inclusion criteria (30 female and 2 male patients; mean age, 25 years). The mean LCEA and anterior center‐edge angle were 21.6° and 25.5°, respectively. Four patients required revision arthroscopy for labral retears. Among the 28 patients who did not undergo revision surgery, the modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living subscale, Hip Outcome Score–Sports‐Specific subscale, and Non‐arthritic Hip Score improved from 68.7 to 83.5, from 64.9 to 86.6, from 71.6 to 86.7, and from 52.6 to 75.8, respectively ( P < .001). The visual analog scale score improved from 5.6 preoperatively to 1.9 at latest follow‐up ( P < .001). The mean patient satisfaction rating was 8.0. There was no radiographic progression of the Tönnis grade at final follow‐up. Conclusions This study showed that patients with an LCEA of less than 25° and associated painful iliopsoas snapping can be treated by addressing concomitant pathology and performing central‐compartment fractional lengthening of the iliopsoas tendon with concomitant capsular plication and have high satisfaction, improvement in PROs, and improved pain scores, without significant progression of osteoarthritis. Level of Evidence Level IV, case series.

Purpose To evaluate a delayed gadolinium‐enhanced magnetic resonance imaging of cartilage (dGEMRIC) index designed to predict focal acetabular articular cartilage damage in patients with femoroacetabular impingement (FAI). Methods The inclusion criteria were patients who underwent dGEMRIC and hip arthroscopy between April 2010 and August 2015 for FAI syndrome. The exclusion criteria were previous hip conditions, a Tönnis grade greater than 1, and a delay between magnetic resonance imaging and surgery greater than 180 days. The cutoff value for full‐thickness chondral damage was set to 350 milliseconds. The coronal anterolateral (CAL) index was designed to evaluate focal articular anterolateral chondral defects. We calculated the binary classification test of the CAL index for full‐thickness chondral damage, with arthroscopy as the gold standard. We calculated the correlation between the CAL index and the arthroscopically defined acetabular labrum articular disruption (ALAD) and Outerbridge grades and tested for differences between no or mild focal chondral damage and moderate or severe focal chondral damage. We repeated this analysis on the sagittal superior index, a combination of the sagittal anterior and posterior indices. Results A total of 195 hips (183 patients) were reviewed. The CAL index showed a sensitivity of 55% (95% confidence interval [CI], 32%‐76%), specificity of 81% (95% CI, 74%‐86%), positive predictive value of 27% (95% CI, 18%‐37%), and negative predictive value of 93% (95% CI, 90%‐96%). The CAL index showed a significant difference between no or mild focal chondral damage and moderate or severe focal chondral damage per both ALAD and Outerbridge groups ( P < .0001). The CAL index was moderately inversely correlated with ALAD and Outerbridge grades (ρ = –0.403, P < .0001). The sagittal superior index was not significantly different between the groups and showed a weak correlation with focal defects. Conclusions The CAL index may play a role in ruling out full‐thickness articular cartilage defects in patients with FAI syndrome. In addition, it may help in differentiating between no or mild focal chondral damage and moderate or severe focal chondral damage. Level of Evidence Level III, case‐control study.

The anterior inferior iliac spine (AIIS) is a newly recognized etiology of extra-articular hip impingement. The purpose of this article is to describe an arthroscopic technique for AIIS decompression causing extra-articular hip impingement. Arthroscopic decompression of subspine impingement is a novel procedure that can be used to successfully relieve hip pain and improve hip function and range of motion cause by AIIS impingement.

Background: Greater trochanter decortication is frequently performed at the time of abductor tendon repair to theoretically increase healing potential. No previous studies have determined the effect that greater trochanter decortication has on the pullout strength of suture anchors. Hypothesis/Purpose: The purpose of this study is to determine whether greater trochanter decortication and bone mineral density affect suture anchor pullout strength in abductor tendon repair. The authors hypothesize that both will have a significant detrimental effect on suture anchor pullout strength. Study Design: Controlled laboratory study. Methods: Nineteen cadaveric proximal femurs with accompanying demographic data and computed tomography scans were skeletonized to expose the greater trochanter. Bone density measurements were acquired by converting Hounsfield units to T-score, based on a standardized volumetric sample in the intertrochanteric region of the femur. The gluteus medius insertion site on the lateral facet of the greater trochanter was evenly divided into 2 regions, anterior-distal and posterior-proximal, and each region was randomly assigned to receive either no decortication or 2 mm of bone decortication. A single biocomposite anchor was implanted in each region and initially tested with cyclic loading for 10 cycles at 0-50 N, 0-100 N, 0-150 N, and 0-200 N, followed by load to failure (LTF) tested at 1 mm/s. For each trial, the number of cycles endured, LTF, mechanism of failure, and stiffness were recorded. Results: Greater trochanters with no decortication and 2 mm of decortication survived a mean ± SD 35.1 ± 6.4 and 28.5 ± 10.6 cycles, respectively ( P < .01). Load to failure for nondecorticated specimens was 206.7 ± 75.0 N versus 152.3 ± 60.2 N for decorticated specimens ( P < .001). In a multivariate analysis, decortication and bone density were determinants in LTF ( P < .05). Conclusion: Decortication and decreased bone mineral density significantly decreased the pullout strength of suture anchors in the lateral facet of the greater trochanter. Clinical Relevance: Bone density should be considered when determining whether to perform greater trochanter decortication in abductor tendon repairs.