Citations

Abstract Tunnel convergence in multiligament knee surgery remains a technical challenge. Anterior cruciate ligament (ACL) femoral sockets/tunnels and lateral collateral ligament (LCL) femoral sockets/tunnels during anatomic posterolateral corner (PLC) reconstructions are particularly vulnerable to convergence. This is secondary to the limited amount of bony real estate available on the lateral distal femur. Previous studies have attempted to define a specific angle to direct the LCL tunnel away from the ACL tunnel. However, inconsistency with ACL femoral socket creation and variability in bony architecture can make this strategy unreliable. This surgical technique describes how to minimize the risk of ACL and LCL tunnel convergence during ACL and PLC reconstructions.

Hip arthroscopy is an increasingly common procedure to treat intra‐articular conditions such as labral tears and femoroacetabular impingement. With the increase in frequency of such procedures, so too are revision arthroscopic hip procedures. Capsular repair in the setting of revision hip arthroscopy can be challenging due to the presence of adhesions and scar tissue formation that obscure tissue planes, suboptimal quality of residual capsular tissue, and the presence of capsular tissue defects. This technical note aims to describe the key surgical principles and considerations of revision hip capsular closure.

Introduction In recent years collared femoral stems have been increasingly utilized in total hip arthroplasty (THA) for their ability to improve rotational stability, metaphyseal load transfer, and prevent periprosthetic femoral fracture (PFF). While literature has demonstrated their benefit over collarless stems, the clinical and biomechanical implications of a postoperative collar–calcar gap (CCG) after implantation remain incompletely understood. Objective The purpose of this scoping review was to evaluate existing literature around CCG in primary THA. Methods A PRISMA Scoping Review literature search was conducted across Ovid MEDLINE, Embase, Cochrane CENTRAL, and Scopus databases. Studies were included if they reported CCG incidence, subsidence, remodeling, or biomechanical performance in primary THA. Two independent reviewers screened studies and extracted data, and clinical study quality was assessed using the Newcastle–Ottawa Scale. Results A total of 408 studies were identified and 11 met inclusion criteria. The incidence of postoperative CCG varied from 18.7% to 53.9%. Most gaps demonstrated closure over time (66–76%). Biomechanical and finite element studies showed improved stability, reduced micromotion, and decreased periprosthetic fracture risk when direct collar–calcar contact was achieved. In contrast, stems with persistent gaps demonstrated increased subsidence (up to 19% vs 1.3%) and biomechanical behavior comparable to collarless designs. Conclusion CCG is common following THA. The majority of gaps resolve, however biomechanical evidence demonstrates that the advantages of collared stems depend on calcar contact. Preventing CCG may optimize early implant stability, though surgical technique must balance mechanical engagement with preservation of proximal femoral bone stock.

Background: Chronic hip abductor insufficiency remains a challenging problem to treat and can result in significant disability in some patients. Tendon transfers involving the gluteus maximus (GM) or combined GM with tensor fascia latae (GM+TFL) are common options for surgical reconstruction. The purpose of this systematic review was to compare clinical outcomes, complications, and revisions rates of patients who underwent GM transfer or GM+TFL transfer for irreparable hip abductor tears. Methods: PubMed (MEDLINE), Scopus (EMBASE, MEDLINE, COMPENDEX), and Cochrane databases were used to conduct a systematic review of articles from inception to February 2025. A total of 18 studies were included (11 GM transfer, 7 GM+TFL transfer). Demographics, hip setting (native hip, primary total hip arthroplasty [THA], revision THA), patient-reported outcome measures, presence of Trendelenburg gait, abduction strength, complication rates, and revision rates were analysed. Results: A total of 207 patients (208 hips) underwent GM transfer, while 55 patients (55 hips) underwent GM+TFL transfer. Meta-analyses demonstrated that both techniques yielded significant preoperative to postoperative improvements in modified Harris Hip Scores/Harris Hip Scores and Visual Analogue Scale pain scores ( p < 0.001). In total, 33.9% of patients who underwent GM transfer had a persistent Trendelenburg gait postoperatively, compared to 48.1% of those who underwent GM+TFL transfer. The complication rate was 16.8% (23/137) for patients who underwent GM transfer and 2.7% (1/37) for those who underwent GM+TFL transfer; while revision rates were 5.9% (9/152) and 3.6% (2/55), respectively. Conclusions: Both GM and GM+TFL transfers yielded comparable outcomes in patients with chronic hip abductor insufficiency not amendable to primary repair. The complication rate was substantially higher in patients who underwent GM transfer, whereas revision rates were comparably low for both techniques. In particular, a sizeable proportion of patients continued to exhibit a persistent Trendelenburg gait postoperatively following both surgical techniques, highlighting the complexity of this pathology. PROSPERO registration number: CRD420251002466

Background: Femoroacetabular impingement (FAI) is a common injury experienced by basketball players. Surgical management with arthroscopic labral repair and femoral osteochondroplasty can lead to successful outcomes for athletes whose nonoperative management fails. Recent studies have demonstrated that athletes undergoing hip arthroscopy in the setting of FAI had favorable return-to-sport (RTS) and sport continuation outcomes. Purpose: To evaluate patient-reported outcome measures (PROMs) and RTS rates at minimum 5-year follow-up in basketball players after hip arthroscopy for FAI. Study Design: Case series; Level of evidence, 4. Methods: All active basketball players at the recreational, high school, and collegiate levels who underwent primary hip arthroscopy with labral repair for FAI between August 2009 and December 2019 were identified. Postoperative RTS, revision rates, and surgery satisfaction at final follow-up were evaluated. PROMs were also analyzed as follows: visual analog scale, Tegner Activity Scale, modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, and Hip Outcome Score–Sport. Results: Fifty-three patients (64 hips) were included with a mean ± SD age of 21.2 ± 6.0 years. Most athletes played recreational or high school basketball (85%), while 15% played college basketball. Forty-three patients attempted to return to basketball. Of these patients, 35 (81%) returned to basketball after surgery, with 32 (91%) returning to the same level of play. Patients who returned to basketball had significantly improved outcomes on the modified Harris Hip Score ( P = .006), Hip Outcome Score–Activities of Daily Living ( P = .007), Hip Outcome Score–Sport ( P = .004), Tegner Activity Scale ( P = .010), and visual analog scale with use ( P = .041) as compared with those who did not return. High school athletes had decreased odds of RTS when compared with recreational athletes ( P = .01). There was significant improvement in all PROMs from baseline to minimum 5-year follow-up ( P < .05). Conclusion: At minimum 5-year follow-up, basketball players demonstrated durable improvements in PROMs and an RTS rate of 81% after hip arthroscopy for FAI. The majority of athletes returned to the same level of competition. There were significantly improved PROMs in patients who returned to sport versus those who did not. High school athletes had decreased odds of RTS when compared with recreational athletes. However, body mass index, sex, age, alpha angle, and basketball position did not significantly correlate with RTS outcomes.

Background: Frequent pivoting, rotation, and deep hip flexion place football players at high risk for femoroacetabular impingement (FAI), a leading cause of hip pain in this population. Previous studies have primarily focused on professional National Football League athletes undergoing mixed surgical techniques, including labral debridement. Limited data exist on outcomes in younger, amateur players treated with labral repair. Purpose: To report return to sport (RTS) rates and functional outcomes at a minimum 5-year follow-up in primarily active high school and college football players undergoing primary hip arthroscopy with labral repair for FAI. Study Design: Case series, Level of evidence, 4. Methods: All football players who underwent primary hip arthroscopy with labral repair for FAI between 2010 and 2019 were identified from an institutional database. Collected data included descriptive data, radiographic parameters, surgical details, and reoperations. At a minimum 5-year follow-up, RTS outcomes and patient-reported outcome measures (PROMs), such as the Modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS), were evaluated. Results: A total of 36 hips in 27 male athletes (mean age, 18 years; body mass index, 28.1 kg/m 2 ) were included. The majority of athletes competed at the high school (70%) or collegiate level (26%). Mean preoperative radiographic measurements were as follows: lateral center-edge angle, 31.6°; Tönnis angle, 4.1°; and alpha angle, 61.4°. Femoroplasty and acetabuloplasty were performed in 100% and 86% of cases, respectively. Also, 84% of players returned to football, all at the same or higher level than before surgery. At a mean follow-up of 9.8 years, all PROMs improved significantly from baseline ( P < .002). Outcome scores at follow-up were as follows: mHHS 90.5; HOS-Activities of Daily Living, 94.5; HOS-Sports-Specific Subscale, 91.1; and visual analog scale (VAS) pain with use, 2.3/10; VAS pain at rest, 1.3/10; and surgical satisfaction, 8.5/10. No patients required revision surgery. However, 2 patients (7%) underwent reoperations—including 1 for heterotopic ossification excision and 1 for periacetabular osteotomy. Conclusion: American football players who underwent primary hip arthroscopy with labral repair for FAI achieved excellent long-term outcomes, with high RTS rates at the same or higher levels, and improvements in PROMs and patient satisfaction. Despite favorable outcomes, nonmedical factors, such as graduation, may influence RTS in competitive athletes, particularly at the high school and collegiate levels.

Background: Arthroscopic treatment of excessive acetabular coverage with pincer morphology or coxa profunda can be challenging. In patients with excessive acetabular coverage with nondistractible hips, an outside-in capsuolotomy can be considered to gain safe and efficient intra-articular access to the hip. Indications: The indications for an outside-in capsulotomy include patients with acetabular retroversion, a lateral center-edge angle >40°, coxa profunda or protrusio, or stiff, older male patients who remain hip preservation candidates. Technique Description: The outside-in capsulotomy is performed once it is recognized that traction on the operative extremity will not provide adequate working space for safe intra-articular access. Traction is taken off the operative extremity, and an anterolateral portal is localized to the 12:00 position on the hip joint with the use of fluoroscopy. The camera is then placed in a juxta-capsular location, and a modified anterior portal is created under direct arthroscopic visualization. We then proceed with extracapsular dissection to identify the indirect head of the rectus. An outside-in capsulotomy is then performed parallel to the indirect head of the rectus, approximately 5 mm distal to its insertion on the acetabular rim. Prior to deep completion of the capsulotomy, the hip joint is flexed to 30° to protect the articular cartilage of the femoral head. Once intra-articular access is obtained, traction can be reapplied, and one can proceed with hip arthroscopy in a standard fashion. Results: This technique decreases the traction time needed, given that the capsulotomy is performed without traction applied. Additionally, the amount of force required for hip distraction is decreased once the capsuolotomy has been completed, through usual sectioning of the iliofemoral ligament. The presented technique is both safe and efficacious, with no published difference in complications as compared to standard inside-out access. A published series of patients with severe pincer morphology and lateral overcoverage who undergo hip arthroscopy with outside-in access demonstrates satisfactory postoperative improvements in patient-reported outcome measures. Discussion/Conclusion: The outside-in capsulotomy provides a means for safe access to the hip joint in otherwise limited or nondistractible hips.

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain in young, active athletes. American football players place high demands on the hip due to the sport's requirements for pivoting, cutting, and loading in deep flexion. Although arthroscopic treatment of FAI in professional National Football League (NFL) players has shown favorable outcomes, football-specific outcomes in non-NFL athletes remain limited. Purpose: To report the return-to-sport (RTS) rates and functional outcomes at a minimum 2-year follow-up for active American football players competing at multiple levels after primary hip arthroscopy for FAI. Study Design: Case series; Level of evidence, 4. Methods: An institutional database was queried to identify all active American football players who underwent primary hip arthroscopy with labral repair between 2010 and 2023. Demographic characteristics, radiographic parameters, procedure details, complications, and reoperations were collected. Follow-up was completed at a minimum of 2 years to obtain updated patient-reported outcome measures (PROMs) as well as football-specific data, including current participation and RTS status. PROMs were reported as mean ± standard deviation, and categorical variables, including RTS, were reported as frequencies. Pre- versus postoperative PROMs were compared using t tests or Mann-Whitney U tests to assess outcomes. Results: In total, 49 hips in 38 male football players (age, 18.1 years; range, 14-26 years) were included. Most athletes played at the high school (74%) or college level (21%). A total of 51% played as linemen. Labral repair was performed in all cases. At a mean 7.6 years, mean modified Harris Hip Score was 90 ± 13, Hip Outcome Score–Activities of Daily Living was 95 ± 7, and Hip Outcome Score–Sport was 89 ± 17. Overall mean surgery satisfaction was 8.7 ± 1.7 (out of 10). Significant postoperative improvements were observed in all PROMs ( P ≤ .002). Twelve players (32%) did not attempt RTS due to other nonmedical factors and were excluded from return to sport analysis. A total of 23 (88%) players achieved RTS, and 3 players (12%) did not. Two players (8%) cited other injuries, and 1 player (4%) continued to have hip limitations. Four hips (8%) underwent reoperation at a mean 4.9 years postoperative. Conclusion: Amateur American football players undergoing primary hip arthroscopy for FAI demonstrated excellent patient-reported outcomes and a high RTS rate of 88%, when excluding those who did not return for nonmedical reasons, at a mean 7.6-year follow-up. Notable positional differences were observed across multiple levels of play. Although outcomes were generally favorable, both medical and nonmedical factors could limit return to sport, particularly among high school and college athletes.

Abstract Introduction The utilization of total hip arthroplasty (THA) in skeletally immature patients remains controversial, with an open triradiate cartilage traditionally perceived as a relative contraindication due to concerns of acetabular fixation and component loosening. Early evidence suggests that THA may be a feasible option in this patient population yielding favorable short-term outcomes, however larger series and mid-term data are lacking. This study presents the largest series of THA in patients with open triradiate cartilage to date with mid-term clinical, radiographic, and patient-reported outcomes. Methods A retrospective review of our institutional Total Joint Registry identified 19 patients (22 hips) who underwent THA while having an open triradiate cartilage growth plate between the year 2000 and 2024. Skeletal maturity was assessed utilizing the modified Oxford bone age and all patients had a score of “1” or “2” on the triradiate cartilage stage of maturation. Demographics, surgical characteristics, implant data, radiographic parameters, and clinical outcomes were collected. Functional hip scores were assessed via the Harris Hip Score (HHS). Kaplan-Meier analysis was performed to analyze reoperation rates. Results The average age at surgery was 14 years (SD=1.68), the average BMI was 24 (SD=7.1) and 64% were male. Mean follow-up was 6.05 years (range 1-15). The mean modified Oxford bone age for this cohort was 23 (SD=1.4). The most common indications for THA were avascular necrosis (64%), degenerative joint disease (27%), and neoplasia (9%). Preoperatively, 54.5% of patients utilized gait aids. Postoperatively, all patients reported independent ambulation without assistive devices with an average HHS of 91.65 (SD=11.42). Ninety-six percent of implants were stable at final radiographic follow up. Both reported complications involved acetabular cup loosening, requiring revision of the acetabular component. Conclusion This study presents the largest cohort in the literature of patients who underwent THA with open triradiate cartilage. Our results highlight high patient reported outcomes and low revision rates at mid-term follow up. All patients had excellent implant fixation without radiographic signs of loosening at final radiographic follow up. These results support the use of THA in skeletally immature patients without the need to delay THA for closure of the triradiate cartilage.

Abstract Introduction Periacetabular osteotomy (PAO) is performed in the setting of hip dysplasia to increase acetabular coverage of the femoral head and improve joint biomechanics and longevity. PAO fixation is generally achieved with two or three 4.5 mm screws, as compared to the generally more substantial plate and screw constructs used in the setting of acetabular fractures or pelvic ring injuries. The purpose of this study was to evaluate postoperative changes in hip joint center medialization and lateral acetabular coverage following PAO, understanding that these radiographic measures are generally used to guide intra-operative assessment of correction. Methods A retrospective chart review of 100 consecutive PAOs during 2021-2023 at a single academic institution by four surgeons was performed. Perioperative radiographs and fluoroscopy images were evaluated to measure lateral center edge angle (LCEA), Tönnis angle, and medialization of the hip joint center. The hip joint center was measured at one-third of the diameter of the femoral head from inferior to superior, to the ilioischial line, as previously validated by Fowler and colleagues. Results One hundred PAOs in 87 patients (87% female, mean age: 23.0 years) were included. Average preoperative radiographic parameters were 19.9° for LCEA, 12.5° for Tönnis angle, and 12.6 mm for distance from the femoral head to ilioischial line. Ninety-four cases (94%) used three screws, and 6 cases (6%) used two screws for unstable fragment fixation. On immediate postoperative films, average correction was to 28.3° for LCEA, 4.9° for Tönnis angle, and 1.9 mm of pre- to postoperative femoral head medialization (p≤0.001). Patients were radiographically followed for an average of 13.3 months, with an average time to radiographic union of 7.1 months. During the course of follow-up, LCEA increased to 29.3°, Tönnis angle remained to 5.0° (p=0.47), and medialization increased to 2.7 mm (p≤0.02), suggesting further significant but clinically modest increases in lateral coverage and femoral head medialization. Conclusion While the majority of lateral acetabular coverage and femoral head medialization occurs intra-operatively at the time of PAO, patients undergo modest but statistically significant postoperative increases in lateral coverage and medialization prior to radiographic union.