Walsh, John P.

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.

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.

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 clinical outcomes, demographics, and radiographic findings for patients whose hip arthroscopies involved amorphous calcification (AC) excision and to compare them with a control group with no AC and with the general population regarding diabetes mellitus and hypothyroidism. Methods Patients who underwent primary hip arthroscopy involving surgical excision of AC deposit in the anterosuperior labralcapsular recess between October 2008 and July 2014 were reviewed. Demographics, radiographic findings, intraoperative findings, and procedures were reviewed. Minimum follow‐up was 2 years and included visual analog scale for pain, patient satisfaction, and the following patient‐reported outcome scores: modified Harris hip score, hip outcomes score sport‐specific subscale, and nonarthritic hip score. These patients were matched (1:2 ratio) to patients who underwent hip arthroscopy with no AC using the following matching criteria: age at surgery ± 5 years, body mass index ± 5, gender, type of labral treatment, and type of capsular treatment. Results We reviewed 12 cases in 11 female patients. Mean latest follow‐up scores improved from 64.0 to 83.4 ( P = .003) for modified Harris hip score, from 57.6 to 80.6 ( P < .001) for nonarthritic hip score, from 35.4 to 62.7 ( P = .021) for hip outcomes score sport‐specific subscale, and from 6.4 to 2.8 ( P = .016) for visual analog scale. The survivorship rate was 91.7%, with one hip converting to total hip arthroplasty. Mean patient satisfaction was 8.4 ± 2.3. Six hips of the 12 (50%) had clock face localization of the AC. They were all between 11 and 12 with a mean of 12:30. Postoperative radiographic findings showed no subsequent AC in all 12 hips. No complications or revisions were reported. There were no significant differences between the AC group and the control group. Conclusions The treatment of AC as part of hip arthroscopy for labral tear and femoro‐acetabular impingement is safe and has favorable and similar outcomes compared with a control group at minimum 2‐year follow‐up. Female gender may be a risk factor for the development of AC. There is no strong evidence that AC should be debrided. Level of Evidence Level III, case control study.

Purpose To report the minimum 2‐year outcomes of transtendinous repair of partial‐thickness undersurface tears of the abductor tendon using patient‐reported outcomes (PROs), visual analog scale (VAS) scores, and patient satisfaction scores. Methods All patients who underwent endoscopic transtendinous gluteus medius repair between October 2009 and May 2013 at 1 institution were prospectively evaluated. The exclusion criteria consisted of less than 2 years' follow‐up, previous hip surgery, inflammatory arthritis, open surgery, full‐thickness abductor tear, and Workers' Compensation patients. All patients underwent a documented preoperative physical examination with strength testing (scale of 0‐5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively; at 3 months postoperatively; and at 1, 2, 5, and 10 years after surgery. The PRO scores collected were the modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living Subscale, Hip Outcome Score–Sports‐Specific Subscale, Non‐arthritis Hip Score, and VAS score. Preoperative strength and gait were compared with latest follow‐up. Results There were 25 patients who fit our criteria. Significant improvement in PRO scores were shown for the modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living Subscale, Hip Outcome Score–Sports‐Specific Subscale, Non‐arthritis Hip Score, and VAS score from 54.9 to 76.2, from 50.2 to 80.6, from 30.1 to 67.3, from 51.9 to 82.4, and from 7.1 to 2.7, respectively ( P < .001). Before surgery, 11 patients had objective weakness; 7 of these patients moved up at least 1 strength grade by final follow‐up. Preoperatively, 14 patients had a Trendelenburg gait; 12 of them had a normal gait at latest follow‐up ( P < .001). The average patient satisfaction rating was 7.5. There were no revision surgical procedures, and no complications were noted. Conclusions Partial‐thickness undersurface tears of the abductor can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of the superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to nonoperative treatment because patients showed clinical benefit at greater than 2 years' follow‐up that exceeded substantial clinical benefit and the minimal clinically important difference. Level of Evidence Level IV, case series.

Background: Femoral retroversion has been noted as a possible risk factor for poor clinical results after hip arthroscopic surgery. Purpose: To compare the outcomes of the arthroscopic treatment of hip abnormalities in patients with femoral retroversion to patients with femoral anteversion between 10° and 20°. Study Design: Cohort study; Level of evidence, 3. Methods: Between November 2011 and September 2013, 790 hip arthroscopic procedures were performed at a single institution. Of these, 59 hips (7.5%) were located in patients with femoral version ≤0°, calculated using preoperative magnetic resonance imaging. These patients were pair matched, based on body mass index ±5 kg/m 2 , age ±5 years, and Tönnis grade, with 59 patients with femoral anteversion between 10° and 20°. Exclusion criteria included Perthes disease, inflammatory arthritis, slipped capital femoral epiphysis, previous hip surgery, abductor repair, lateral center-edge angle <20°, Tönnis grade >1, and acetabular profunda or protrusio. Patient-reported outcomes (PROs) were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PROs utilized were the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS). The visual analog scale (VAS) was collected to assess the patients’ pain; patient satisfaction scores (0-10) were also collected. Radiographs were collected at the above time intervals as well. Results: Two patients from the control group and 1 patient from the retroverted group required total hip arthroplasty at a mean 19.5 and 26.3 months, respectively. Both groups demonstrated significant improvement from their preoperative state in all PRO and VAS scores ( P < .001). No differences in preoperative, postoperative, or change in PRO and VAS scores between the groups were noted. Conclusion: Patients with femoral retroversion reported similar outcomes compared to patients with normal femoral version when undergoing hip arthroscopic surgery. Both groups had similar improvements from the preoperative state.

Abstract This article presents the authors' technique for evaluation of possible abductor tears with magnetic resonance imaging (MRI). By using T2 fat‐saturated coronal and axial slices of the hip and T1 coronal images of the pelvis, the authors show how to visualize all tears of the abductor tendons and signs of chronic abductor deficiency. After diagnosis has been made, signs that may help the surgeon determine if open or arthroscopic surgery would be best used are reviewed. Finally, the author reviews indications for a gluteus medius repair with concomitant gluteus maximus reconstruction. Technique Video video See video under supplementary data.

Abstract Excessive femoral anteversion may lead to increasing stress placed on the anterior acetabulum and soft tissues, which can predispose to intra‐articular hip pathology. By addressing the excessive femoral anteversion in combination with intra‐articular hip pathology, the results will be durable over time. This technique details how to perform a femoral derotation osteotomy for excessive femoral anteversion after addressing intra‐articular pathology with hip arthroscopy in one surgical intervention. This allows the surgeon to address both the underlying pathoanatomy and the resultant intra‐articular sequelae. Technique Video video See video under supplementary data.