Krych, Aaron J

AbstractPurposeCurrently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2‐year follow‐up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).MethodsThe records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2‐year follow‐up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.ResultsFifty‐nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow‐up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.ConclusionsIsolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.Level of evidenceRetrospective case series, Level IV.

Abstract Purpose Intra‐articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. Methods At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre‐injection, during post‐injection anaesthetic phase, and at 14 days post‐injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. Results Fifty‐four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre‐injection NRS score was 7.0 (range 2.5–10.0), post‐injection anaesthetic phase was 1.0 (range 0.0–5.0), and 14 day post‐injection was 5.0 (range 0.0–10.0). As a group, NRS scores significantly diminished from post‐injection anaesthetic phase to 14 days post‐injection ( p < 0.001). At 14 days post‐injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. Conclusion In patients with symptomatic FAI and labral tear, intra‐articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic‐only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool. Level of evidence Therapeutic case series, Level IV.

Abstract We present our technique for isolated arthroscopic rotator interval closure in the treatment of mild symptomatic glenohumeral instability in the absence of a labral tear. A careful history, physical examination, and imaging help to identify a select subset of atraumatic instability patients who may benefit from this procedure, and diagnostic arthroscopy can provide further evidence. By use of a posterior viewing portal with anterior and anterolateral working portals, the anterior capsuloligamentous complex is mobilized, and the rotator interval is closed with carefully placed sutures to advance the capsule superiorly and provide tension through decreased capsular volume. Technique Video video See video under supplementary data.

Abstract Femoral neck osteoplasty is an integral component for successful treatment of femoroacetabular impingement. Current techniques allow this to be performed arthroscopically, and results are equivalent to those of open procedures when typical anterior and anterosuperior lesions are considered. The arthroscopic procedure is dependent on obtaining adequate visualization through capsular management and proper leg positioning, and it requires fluoroscopy to guide and verify an adequate resection. We present our preferred technique for arthroscopic femoral neck osteoplasty. Technique Video video See video under supplementary data.

Abstract The role of capsular repair in the arthroscopic treatment of femoroacetabular impingement remains poorly defined. Some surgeons rarely repair the capsule, whereas others perform repairs routinely. There is little direct clinical evidence to guide surgeon decision making. When capsular repairs are performed, the procedure requires adequate visualization and careful suture placement either to re‐establish the patient's normal capsular volume or to plicate a redundant capsule in a hip with hyperlaxity preoperatively. We present our preferred technique for arthroscopic capsular repair. Technique Video video See video under supplementary data.

Abstract We present our arthroscopic technique for fixation of an unstable osteochondritis dissecans (OCD) lesion. This technique includes arthroscopic evaluation of cartilage and bone quality of the OCD fragment, hinging open the lesion, debridement of fibrous nonunion tissue, reducing the fragment, and obtaining multi‐point compression screw fixation. This technique avoids the morbidity of an open arthrotomy and should be considered when treating an unstable OCD lesion with adequate bone for fixation. Technique Video video See video under supplementary data.

Context: Articular cartilage injuries are common in patients presenting to surgeons with primary complaints of knee pain or mechanical symptoms. Treatment options include comprehensive nonoperative management, palliative surgery, joint preservation operations, and arthroplasty. Evidence Acquisition: A MEDLINE search on articular cartilage restoration techniques of the knee was conducted to identify outcome studies published from 1993 to 2013. Special emphasis was given to Level 1 and 2 published studies. Study Design: Clinical review. Level of Evidence: Level 3. Results: Current surgical options with documented outcomes in treating chondral injuries in the knee include the following: microfracture, osteochondral autograft transfer, osteochondral allograft transplant, and autologous chondrocyte transplantation. Generally, results are favorable regarding patient satisfaction and return to sport when proper treatment algorithms and surgical techniques are followed, with 52% to 96% of patients demonstrating good to excellent clinical outcomes and 66% to 91% returning to sport at preinjury levels. Conclusion: Clinical, functional, and radiographic outcomes may be improved in the majority of patients with articular cartilage restoration surgery; however, some patients may not fully return to their preinjury activity levels postoperatively. In active and athletic patient populations, biological techniques that restore the articular surface may be options that provide symptom relief and return patients to their prior levels of function.

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

AbstractPurposeThe purpose of this study was to evaluate the utility of multimodal analgesia with fascia iliaca blockade and for acute pain control in patients undergoing hip arthroscopy.MethodsThirty consecutive patients undergoing primary hip arthroscopy were prospectively studied. All patients were treated preoperatively with ultrasound‐guided single injection fascia iliaca blockade and multimodal analgesia. Data collected included post‐operative nausea, numeric rating scale (NRS) pain scores during rest and activity, opioid consumption during the first five days (recorded as tablets of 5 mg hydrocodone/500 mg acetaminophen) and overall patient satisfaction with analgesia.ResultsThis study included 23 female and 7 male patients with a median age of 35 years (range 14–58). No patient required medication for post‐operative nausea. The overall NRS scores were an average of 3.9 on day 0, 3.6 on day 1, 3.4 on day 2, 2.9 on day 3, 3.0 on day 4 and 2.7 on day 5. The average tablets of opioid taken were 1.5 on day 0, 1.2 on day 1, 1.3 on day 2, 1.0 on day 3, 1.1 on day 4 and 0.9 on day 5. Overall, 20 patients rated their post‐operative pain control as very satisfied (67 %), and 10 patients as satisfied (33 %). There were no complications or side effects from the fascia iliaca blockade.ConclusionIn this prospective study, multimodal analgesia with fascia iliaca blockade following hip arthroscopy was safe and effective. The quality of early post‐operative analgesia provided by the fascia iliaca blockade was excellent and resulted in low opioid consumption, high quality of pain relief and high overall patient satisfaction.Level of evidenceProspective case series, Level II.

Abstract Labral repair has become an essential technique in the arthroscopic surgical management of femoroacetabular impingement. Several clinical studies suggest that labral repair results in superior patient outcomes in comparison to labral debridement alone. The repair procedure requires accurate evaluation of labral tissue quality, precise placement of sutures and anchors, and careful re‐tensioning of the labrum. We present our preferred technique for labral repair. Technique Video video See video under supplementary data.