Domb, Benjamin G.

Purpose To report minimum 2‐year follow‐up patient‐reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient‐acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery. Methods Prospectively collected data from two high‐volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2‐year follow‐up for the modified Harris Hip Score (mHHS), Non‐Arthritic Hip Score (NAHS), Hip Outcome Score‐Sports Specific Subscale (HOS‐SSS), International Hip Outcome Tool‐12 (iHOT‐12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge‐angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted. Results A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow‐up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported ( P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS‐SSS, and iHOT‐12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery ( P = .03). Conclusion The results of this multi‐center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2‐year follow‐up. Level of Evidence IV, retrospective multicenter study.

Abstract The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients &gt;40 years of age and by &gt;84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by &gt;80% of respondents for patients ≤40 years of age and &gt; 80% of respondents if the labral size was &gt;3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was &lt;3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.

Background: Hip arthroscopy is rapidly advancing and increasingly commonly performed. The most common surgery after arthroscopy is total hip arthroplasty (THA), which unfortunately occurs within 2 years of arthroscopy in up to 10% of patients. Predictive models for conversion to THA, such as that proposed by Redmond et al, have potentially substantial value in perioperative counseling and decreasing early arthroscopy failures; however, these models need to be externally validated to demonstrate broad applicability. Purpose: To utilize an independent, prospectively collected database to externally validate a previously published risk calculator by determining its accuracy in predicting conversion of hip arthroscopy to THA at a minimum 2-year follow-up. Study Design: Cohort study (diagnosis); Level of evidence, 1. Methods: Hip arthroscopies performed at a single center between November 2015 and March 2017 were reviewed. Patients were assessed pre- and intraoperatively for components of the THA risk score studied—namely, age, modified Harris Hip Score, lateral center-edge angle, revision procedure, femoral version, and femoral and acetabular Outerbridge scores—and followed for a minimum of 2 years. Conversion to THA was determined along with the risk score’s receiver operating characteristic (ROC) curve and Brier score calibration characteristics. Results: A total of 187 patients (43 men, 144 women, mean age, 36.0 ± 12.4 years) underwent hip arthroscopy and were followed for a mean of 2.9 ± 0.85 years (range, 2.0-5.5 years), with 13 patients (7%) converting to THA at a mean of 1.6 ± 0.9 years. Patients who converted to THA had a mean predicted arthroplasty risk of 22.6% ± 12.0%, compared with patients who remained arthroplasty-free with a predicted risk of 4.6% ± 5.3% ( P < .01). The Brier score for the calculator was 0.04 ( P = .53), which was not statistically different from ideal calibration, and the calculator demonstrated a satisfactory area under the curve of 0.894 ( P < .001). Conclusion: This external validation study supported our hypothesis in that the THA risk score described by Redmond et al was found to accurately predict which patients undergoing hip arthroscopy were at risk for converting to subsequent arthroplasty, with satisfactory discriminatory, ROC curve, and Brier score calibration characteristics. These findings are important in that they provide surgeons with validated tools to identify the patients at greatest risk for failure after hip arthroscopy and assist in perioperative counseling and decision making.

Background: The preponderance of literature on the repair of proximal hamstring tendon tears focuses on the acute phase (<4 weeks). As such, there is a paucity of data reporting on the outcomes of chronic proximal hamstring tears. Purpose: To report minimum 2-year postoperative patient-reported outcome (PRO) scores, visual analog scale (VAS) for pain, and patient satisfaction from patients who underwent open or endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. Study Design: Case series study; Level of evidence, 4. Methods: Between April 2002 and May 2017, prospectively collected data from 3 tertiary care institutions were retrospectively reviewed for patients who underwent open and endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. Patients were included only if they had a chronic proximal hamstring tear (defined as ≥4 weeks from symptom onset to surgery). Patients were excluded if they had a tear treated <4 weeks after injury, underwent hamstring reconstruction, or claimed workers’ compensation. Patients who reported minimum 2-year follow-up for VAS, patient satisfaction, and the following PROs had their outcomes analyzed: the modified Hip Harris Score, Non-arthritic Hip Score, iHOT-12 (International Hip Outcome Tool), and Hip Outcome Score–Sports Specific Subscale. Results: Fifty patients (34 females and 16 males) were included in this study. There were 19 endoscopic repairs and 31 open repairs. Within the cohort, 52.0% had a full-thickness tendon tear on magnetic resonance imaging, and 48.0% had a partial tear. Average follow-up time was 58.07 ± 37.27 months (mean ± SD; range, 24-220 months). The mean age and body mass index of the group were 46.13 ± 13 years and 25.43 ± 5.14. The average time from injury to surgery was 66.73 weeks (range, 5.14-215.14 weeks). Average postoperative PROs were as follows: modified Hip Harris Score, 91.94 ± 9.96; Non-arthritic Hip Score, 91.33 ± 9.99; iHOT-12, 87.17 ± 17.54; Hip Outcome Score–Sports Specific Subscale, 87.15 ± 18.10; and VAS, 1.16 ± 1.92. Patient satisfaction was 8.22 ± 1.20. Conclusion: Patients who underwent open and endoscopic repairs for chronic partial- and full-thickness proximal hamstring tendon tears reported high PROs and satisfaction at a minimum 2-year follow-up with low rates of complications.

Background: Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes. Purpose: To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia. Study Design: Case-control study; Level of evidence, 3. Methods: Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05. Results: A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group ( P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle >10°, 84% required secondary operation. Conclusion: Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle >10°, 84% required a secondary operation.

Purpose To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy. Methods We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient‐reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2‐year postoperative follow‐up and lateral center‐edge angles between 25° and 40°. Results The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision ( P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score ( R 2 = 0.05780), modified Harris Hip Score ( R 2 = 0.19826), or Nonarthritic Hip Score ( R 2 = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score ( P = .0287) and Nonarthritic Hip Score ( P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state. Conclusions Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient‐perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty. Level of Evidence Level IV, retrospective case series.

Objectives: Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high grade acetabular cartilage lesions should be treated with debridement or microfracture. In addition, patients treated with microfracture are subject to extended partial weight-bearing rehabilitation in order to mitigate risk of subchondral plate fracture and protect fibrocartilage tissue formation. The purpose of this study was to determine the mid-term patient-reported outcomes and failure rate and patient-reported outcomes of Grade 3 and 4 acetabulum labrum articular disruption (ALAD) lesions managed with microfracture or debridement. Methods: Primary arthroscopic labral repair cases at two centers from November 2008 to April 2016 were reviewed in patients aged < 55 years with unipolar ALAD Grade 3 and 4 pathology. Patients undergoing microfracture and debridement were compared using visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score - Sports Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure. Results: 127 hips in 123 patients (47 M, 76 F, mean age 34.7 ± 11.1) undergoing debridement (n = 95) or microfracture (n = 32) were followed for a mean of 4.9 years (range 2.0 - 8.5). Patients undergoing debridement achieved 3.5 point mean improvements in VAS (p < 0.01), 20.9 point improvements in mHHS (p < 0.01), and 25.5 point improvements in HOS-SSS (p < 0.01), which was statistically similar to that observed in microfracture patients (p ≥ 0.19). Five-year survival free of revision surgery was 83.0% in the debridement group and 85.6% in the microfracture group (p = 0.85). Cartilage treatment technique was found not to be predictive of revision risk during both univariate (p = 0.84) and multivariate (p = 0.84) analysis. Conclusion: Patients undergoing debridement of high grade unipolar acetabular cartilage lesions demonstrate similar patient reported outcome scores and revision rates compared to patients undergoing microfracture. These outcomes support debridement of acetabular lesions in order to optimize recovery while maintaining established positive outcomes following hip arthroscopy. [Table: see text]

Background: Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high-grade acetabular cartilage lesions should be treated with debridement/abrasion or microfracture. In addition, patients treated with microfracture are subject to extended protected weightbearing rehabilitation to mitigate risk of subchondral plate fracture and to protect fibrocartilage tissue formation. Purpose: To determine the midterm patient-reported outcomes and failure rate of patients with grade 3 and 4 acetabular labrum articular disruption (ALAD) lesions managed with debridement/abrasion or microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: Primary arthroscopic labral repair cases at 2 centers from November 2008 to April 2016 were reviewed for patients aged <55 years with unipolar ALAD grade 3 and 4 chondrolabral acetabular delamination. Patients undergoing microfracture and debridement/abrasion were compared using the visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure. Results: A total of 113 hips in 110 patients (66 males, 44 females; mean age, 34.5 ± 1.1 years) undergoing debridement/abrasion (n = 82) or microfracture (n = 31) were followed for a mean of 4.9 years (range, 2.0-8.5 years). Lesion size was not statistically different between the debridement/abrasion (1.3 ± 1.0 cm 2 ) and microfracture cohorts (1.4 ± 1.0 cm 2 ) ( P = .47). Patients undergoing debridement/abrasion achieved 3.6-point mean improvements in VAS ( P < .01), 21.2-point improvements in mHHS ( P < .01), and 25.4-point improvements in HOS-SSS ( P < .01), which were not significantly different from those observed in microfracture patients ( P≥ .20). The 5-year rate of survival free of revision surgery was 84.0% in the debridement/abrasion group and 85.6% in the microfracture group ( P = .78). The cartilage treatment technique was found not to be predictive of revision risk during both univariate (hazard ratio [HR], 1.01; P = .98) and multivariate (HR, 0.93; P = .90) analysis accounting for patient age, lesion grade, and acetabular coverage. Conclusion: Patients undergoing debridement/abrasion of high-grade unipolar acetabular cartilage lesions demonstrate similar outcome scores and revision rates compared with those of patients undergoing microfracture. These outcomes support the consideration of preferential debridement/abrasion at the discretion of the treating surgeon to optimize recovery while maintaining established positive outcomes after hip arthroscopy.

Purpose To elucidate the effect, if any, of acetabular chondral defect size on surgical outcomes after arthroscopic microfracture was performed with concomitant treatment for labral tears and femoroacetabular impingement (FAI) syndrome. Methods The study period was between February 2008 and November 2014. Data were collected on patients who underwent hip arthroscopy. The inclusion criteria were acetabular microfracture; concomitant treatment for labral tears and FAI syndrome; and preoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, and visual analog scale. Exclusion criteria were Workers' Compensation, preoperative Tönnis grade >1, or previous ipsilateral hip surgeries or conditions. Patients were grouped based on smaller chondral defects (SCDs) or larger chondral defects (LCDs), then matched 1:1 by age at surgery ±10 years, sex, body mass index ±5, labral treatment, capsular treatment, acetabuloplasty, and femoroplasty. Outcomes, secondary arthroscopies, and conversions to total hip arthroplasty (THA) were documented. Results Of 131 eligible cases, 107 (81.7%) had minimum 2‐year follow‐up. Before matching, the conversion rate to THA was higher for LCDs (24.6%) than for SCDs (12.0%). Thirty‐five patients were matched for each group. Mean follow‐up time was 47.9 months (range, 24.0, 84.1) for the matched LCD group and 46.1 months (range, 24.0, 88.1) for the matched SCD group. Ligamentum teres debridement ( P = .03) was performed more frequently in the LCD group. No other differences were found regarding demographics, intraoperative findings, procedures, traction time, preoperative scores, or follow‐up scores. Both groups demonstrated significant improvements in all scores. Rates of revision or conversion to THA were similar between groups. The relative risk for conversion to THA was 2.33 for patients with defects ≥300 mm 2 compared with patients with defects ≤250 mm 2 ( P = .13). Deep vein thrombosis occurred in 3 (5.3%) patients with LCDs. Conclusions Matched patients with either SCDs or LCDs undergoing arthroscopic acetabular microfracture with concomitant treatment for labral tears and FAI syndrome demonstrated similar improvements at minimum 2‐year follow‐up. Patients with chondral defects approaching 300 mm 2 or greater may have a higher propensity toward conversion to THA. Level of Evidence Level III, retrospective comparative therapeutic trial.

Purpose To determine the degree of correlation of radiographic measurements, degree of correlation of intraoperative pathology, and difference in outcomes between sides of patients requiring staged bilateral hip arthroscopy. Methods Two high‐volume hip preservation centers retrospectively reviewed hip preservation databases for staged bilateral hip arthroscopies conducted between 2008 and 2015. Patients were separated into those who presented with bilateral hip pain and those that presented with unilateral pain and developed contralateral pain >2 years later. Patients were analyzed for radiographic correlation (alpha angle, lateral center edge angle, anterior center edge angle, magnetic resonance imaging alpha angle, Tönnis grade) and correlation of intraoperative pathology (acetabular labrum articular disruption grade, Outerbridge grade/location, Villar class ligamentum teres tears, labral tear location, symmetry of Seldes tear types, and the differences between operative procedures). Patient‐reported outcomes were analyzed (modified Harris Hip Score, Non‐Arthritic Hip Score, International Hip Outcome Tool‐12, hip outcome score‐sport specific subscale, visual analog scale, patient satisfaction). Correlative tests included Pearson and Spearman; univariate and multivariate analysis for differences included χ‐square test and Student t tests for ordinal and continuous variables respectively. Results A total of 133 of 2,705 patients (4.6%) underwent bilateral hip arthroscopy. Radiographic alpha angle, magnetic resonance imaging alpha angle, lateral center edge angle, and anterior center edge angle demonstrated strong correlation (Pearson's coefficients 0.651, 0.648, 0.644, 0.667, respectively, P < .0001). Tönnis grade was weakly correlated (Pearson's coefficient 0.286, P = .001). Intraoperative pathology was moderately correlated (Pearson's coefficients for acetabular Outerbridge location, 0.300, P = .0170; acetabular labrum articular disruption, 0.490, P < .0001; acetabular Outerbridge; 0.530; P < .0001; femoral head Outerbridge, 0.459, P < .0001; Villar class, 0.393, P < .0001; and labral tear location, 0.468, P < .0001). Labral tear Seldes type was compared with Bowker's symmetry test and there was no significant difference between sides. There were no significant differences in surgical interventions performed between sides. Patients with bilateral hip arthroscopies significantly improved in all measured patient‐reported outcomes and had a high patient satisfaction after both procedures. Final patient‐reported outcomes and change in patient‐reported outcomes were not different between procedures; follow up ranged from 3 months to 8 years. Conclusions This study demonstrated an incidence of 4.6% of patients who require bilateral hip arthroscopy. These patients can expect significant improvement after surgical intervention. Patients that had 1 side done gained similar improvement when the contralateral side was performed. Preoperative radiographic, intraoperative pathology, and procedures performed were similar between hips. Level of Evidence Level III, retrospective cohort study.