Kang, Louis S

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain in female athletes. There are limited data on midterm outcomes for female athletes undergoing hip arthroscopic surgery. Purpose: To evaluate return-to-sport rates and clinical outcomes in female athletes with FAI after primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of a single institution’s database was performed to identify female athletes who underwent primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty from July 2011 to October 2019 with a minimum 5-year follow-up. Preoperative radiographs were evaluated for the lateral center-edge angle, Tonnis angle, Tonnis grade, and alpha angle. Patient-reported outcome measure (PROM) scores, including those for the modified Harris Hip Score, Hip Outcome Score, Tegner Activity Scale, and visual analog scale for pain, as well as patient satisfaction with surgery were analyzed postoperatively. Results: A total of 63 hips (27 left, 36 right) in 56 female patients (mean age, 21.6 ± 8.0 years; mean body mass index, 24.7 ± 4.8 kg/m 2 ) were included and followed for a mean of 8.4 ± 2.1 years (range, 5.0-13.2 years). Preoperatively, patients participated in basketball (n = 18), dance (n = 21), hockey (n = 8), and soccer (n = 12). Of the 56 patients, 41 attempted to return to sport. There were 28 (68%) female athletes who successfully returned to their preoperative sport. Of the total cohort, 21 (38%) patients cited non–hip-related factors for discontinuing their sport. All postoperative PROM scores improved significantly compared with preoperatively ( P ≤ .002) for patients with available preoperative data. Those who returned to sport had significantly improved Hip Outcome Score values compared with those who did not return to sport ( P ≤ .010). Conclusion: Female athletes who underwent primary hip arthroscopic surgery for FAI had significant improvements in PROM scores and moderate return-to-sport rates at a minimum 5-year follow-up. Most athletes discontinued sports because of non–hip-related factors, although hip-related issues were also cited. Our analysis highlights the need for thorough perioperative counseling and establishing appropriate patient expectations for female athletes before hip arthroscopic surgery.

Abstract The acetabular labrum is a fibrocartilaginous structure that deepens the acetabular socket and helps maintain a suction seal. In patients with hip dysplasia, a distinct labral tear pattern called an inside‐out labral tear is often seen. This tear pattern is particularly challenging to correct via conventional techniques since the labrum can potentially remain everted and insufficiently restore the native hip labral suction seal after repair. An inverted hip labral repair technique is performed for this pathology at our institution and focuses on achieving optimal labral orientation to enhance the suction seal and joint stability, particularly in dysplastic hips. This Technical Note aims to describe the key surgical principles and clinical considerations of inverted hip labral repair. Technique Video video See video under supplementary data.

Objectives: To evaluate return-to-sport (RTS) rates and patient reported outcome measures (PROMs) following hip arthroscopy for femoroacetabular impingement (FAI) in active football players with a minimum of 5-years follow-up. Methods: All active football players who underwent hip arthroscopy for FAI from 2010-2019 were identified. Preoperative radiographic measures including lateral center edge angle, Tönnis angle, alpha angle, and acetabular depth were obtained. Patients were evaluated for post-operative RTS and revision surgery data at final follow-up. Modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), HOS Activities of Daily Living (HOS-ADL), HOS Sports Specific Subscale (HOS-Sports), Tegner Activity Scores, Visual Analogue Scale (VAS) for pain, and surgery satisfaction were collected at a minimum 5-year follow-up. Descriptive and comparative statistical analysis was performed using R software (version 4.4.1). Results: Sixty-six hips from 53 male patients were included. The mean age was 20.4 ± 6.4 years and mean BMI was 27.3 ± 6.6 kg/m² (Table 1). Mean follow-up was 8.7 ± 2.8 years. The majority (60%) were high school players and 19% were college players. Figure 1 displays the most commonly affected positions which included wide receiver (32%), defensive lineman (26%), and tight end or offensive lineman (16%). There were 11 bilateral cases and 2 revisions. The mean lateral center edge angle was 31.6º ± 6.4, the mean Tönnis angle was 5.0º ± 5, and the mean alpha angle was 63.2º ± 12.7. There was significant improvement in all PROMs from baseline to a minimum 5-year follow-up (p<0.04). Fifty-four percent of athletes returned to football postoperatively and the average overall surgery satisfaction rating was 8.1/10. Among those who didn’t return, 14% cited hip-related reasons, while 67% cited non-hip related reasons such as priorities changing or graduating (Figure 2). Athletes who returned to football had significantly higher mean HOS-ADL (p=0.049), HOS-Sport (p=0.042), and Tegner level before surgery (p=0.023) compared to those who did not return (Table 2). Conclusions: Football players undergoing hip arthroscopy for FAI demonstrate significant improvements in outcome scores at a minimum 5-year follow-up with a moderate return-to-sport rate. Athletes who are able to return to football report higher patient reported outcomes compared to those who do not. Player position may also influence incidence and outcomes. Although football players demonstrate significant improvements following hip arthroscopy, the moderate RTS rates highlights the demanding nature of the sport and need for improved perioperative counseling.

Objectives: Periacetabular osteotomy (PAO) is utilized for the treatment of hip dysplasia, with a growing trend towards hip arthroscopy at the time of PAO or in a planned, staged manner prior to PAO in order to address intra-articular pathology such as labral tears. For patients with persistent or new pain following isolated PAO, a subset undergo unplanned, primary hip arthroscopy. To date, there is a paucity of available evidence regarding the risk factors for and outcomes of unplanned hip arthroscopy for persistent or new pain after PAO. The purpose of this study was to determine demographic and radiographic characteristics of patients undergoing hip arthroscopy for persistent pain after PAO and also to compare radiographic parameters, surgical characteristics, and postoperative PROMs between patients that underwent hip arthroscopy following PAO and a demographically similar group of controls without acetabular dysplasia that underwent primary hip arthroscopy. Methods: An institutional database of 3014 hip arthroscopies performed between 1988 and 2022 was reviewed for patients having undergone unplanned (i.e. non-staged) first-time hip arthroscopy after PAO. These patients were propensity-matched on a 1:2 ratio with demographically similar, non-dysplastic patients undergoing primary hip arthroscopy with labral repair. All patients were contacted at final-follow-up to collect outcomes including subsequent procedures, progression to THA, and patient-reported outcome measures (PROMs), including modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT), Tegner Activity Scores, Visual Analogue Scale (VAS) for pain, and surgery satisfaction. Demographics, radiographic characteristics, and postoperative outcomes were compared. All statistical analysis and Kaplan-Meier survival curve analysis was performed using R software (version 4.4.1). Results: We identified 22 hips in 21 patients (17 female, 4 male; age: 24.6 ± 8.5 years; BMI: 29.3 ± 7.4 kg/m²) who underwent first-time arthroscopy after ipsilateral PAO and were followed for a mean of 7.2 ± 2.8 years (Table 1). The median post-PAO LCEA was 28° (IQR: 24.6 – 31.7) and the mean Tönnis angle was 4.2° ± 5.9. The median time from the date of PAO to date of subsequent hip arthroscopy was 1.6 years (IQR: 1.1 - 3.4). Compared to the control group, there was a significantly lower rate of femoral osteochondroplasty (50% vs, 86%, p < 0.01), as well as trends towards lower rate of labral repair (77% vs. 95% p = 0.11), and higher rate of capsular repair (64% vs. 75%, p = 0.34). No differences were found between the PAO and control groups in any of the postoperative PROMs (Table 2). Among the PAO patients, 3 (20%) progressed to total hip arthroplasty (THA) compared to 1 (9%) in the control group (p=0.62). Conclusions: Hip arthroscopy after prior PAO was associated with postoperative improvements in pain and moderate rates of conversion to THA. When patients undergoing hip arthroscopy following PAO were compared to a demographically similar matched cohort of nondysplastic hips who underwent primary hip arthroscopy without a prior PAO, similar postoperative outcome scores were observed. This data provides valuable counselling information for clinicians discussing hip arthroscopy in the setting of patients with persistent pain following PAO.

Background: Treatment decisions in patients with anterior cruciate ligament (ACL) injuries are influenced by multiple factors, such as the desire to return to sports or symptomatic instability. Identifying the differential treatment effect of ACL reconstruction (ACLR) compared with nonoperative management on a patient-specific level can inform surgical decision-making. Hypothesis: Unsupervised machine learning can identify distinct patient subgroups based on outcome achievement after ACL injury, and ACLR will exert a protective effect on the development of posttraumatic osteoarthritis (PTOA) over nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: A longitudinal populational registry identified patients with ACL injuries from 1990 to 2016 with a minimum 7.5-year follow-up. An unsupervised random forest algorithm was utilized to develop and validate patient subgroups. Treatment effects of ACLR on outcomes were analyzed using a machine learning causal inference estimator. Patient subgroup membership was incorporated into a multivariable logistic regression to identify factors predictive of optimal outcomes. Results: A total of 923 patients (785 primary ACLR, 138 nonoperative) were included. The random forest algorithm arrived at an optimal partition of 2 subgroups, with 653 patients in the optimal outcome subgroup (368 male [56.4%]; mean age, 26.0 ± 10.2 years; mean body mass index [BMI], 26.5 ± 4.30) and 270 patients in the suboptimal outcome subgroup (152 male [56.3%]; mean age, 35.0 ± 10.1 years; mean BMI, 30.5 ± 5.54). The latter group demonstrated significantly increased rates of secondary meniscal injury, development of symptomatic PTOA, and progression to total knee arthroplasty (TKA) at the final follow-up (all P < .01). In the optimal outcome subgroup, ACLR had significantly protective treatment effects on the risk of secondary meniscal injury (average treatment effect [ATE], 61%), contralateral ACL injury (ATE, 8%), symptomatic PTOA (ATE, 16%), and progression to TKA (ATE, 6%) (all P < .01). Conversely, in the suboptimal outcome subgroup, ACLR only protected against symptomatic PTOA (ATE, 11%) and progression to TKA (ATE, 8%) (both P < .01). Conclusion: Two clinically meaningful subgroups were identified from retrospectively collected data and found to experience differential treatment responses after ACL injuries. ACLR decreased the rate of development of PTOA and TKA in both subgroups but was not as effective in preventing secondary meniscal injuries or contralateral ACL injuries in patients who were older, heavier, or had concomitant medial meniscus injuries.

Abstract Arthrofibrosis of the knee is a difficult‐to‐manage complication after meniscoligamentous knee injuries, traumatic injuries with articular extension, and surgeries to treat these conditions. Treatment protocols for the management of postoperative arthrofibrosis exhaust nonoperative therapies before proceeding to the operating room for lysis of adhesions (LOA). Although LOA restores range of motion in most cases, a recurrence of arthrofibrosis is possible when postoperative therapy protocols are not strictly followed. Limited treatment options exist in the setting of recalcitrant arthrofibrosis. Revision arthroscopic LOA may be performed in this scenario. This revision procedure places neurovascular anatomy in the posterior compartment at risk. Performing a posterior capsule release in the arthroscopic management of recalcitrant arthrofibrosis is challenging but important to optimize recovery of range of motion. This Technical Note and accompanying video present a stepwise approach to LOA that demonstrates a safe method for performing an arthroscopic posterior capsule release in these challenging cases. Technique Video video See video under supplementary data.

Abstract Hip chondral defects often are encountered at the time of hip arthroscopy and can result in substantial pain and dysfunction. With the evolution of cell‐based techniques, there is growing interest in single‐stage, arthroscopic treatment of such chondral lesions. Arthroscopic orthobiologic delivery remains technically challenging, given the constrained and concave nature of the acetabulum and the need to perform instrumentation taking into account nearby structures such as the articular surface, hip capsule, and labrum. In this Technical Note, we describe our preferred method for arthroscopic delivery of orthobiologics at the time of single‐stage cartilage repair, which allows for needle‐based transcapsular, translabral access of hip chondral defects for both the acetabulum and femoral head. Technique Video video See video under supplementary data.

Abstract Periprosthetic fractures of the lesser trochanter may migrate proximally and result in anterior mechanical irritation and impingement with hip flexion refractory to comprehensive conservative management. In such cases, patients may benefit from arthroscopic resection of the displaced lesser trochanteric fragment. We present a minimally invasive, arthroscopic approach with initial access through an air bursogram. This technique can be performed percutaneously, with standard access cannulas, without the need for additional disposable instrumentation or large cannulas. In such a way, reproducible arthroscopic instrumentation can be provided for safe and efficient fragment removal while remaining cognizant of the nearby medial neurovascular bundle. Technique Video video See video under supplementary data.

Abstract Meniscal root tears have been shown to significantly impact tibiofemoral mechanics and contribute to accelerated development of osteoarthritis. A common finding in conjunction with a meniscal root tear is extrusion of the meniscus. Meniscal extrusion is an independent risk factor for tibiofemoral cartilage loss and the progression of osteoarthritis. Meniscus centralization was first introduced to directly address extrusion alongside root repair techniques. To date, reported techniques for meniscus centralization generally involve anchoring the meniscus directly to the tibia in some fashion, which can limit the normal anatomic motion of the meniscus. We present a technique for meniscus centralization that aims to maintain natural meniscal motion by utilizing the meniscotibial ligaments. Technique Video video See video under supplementary data.