Citations

Objective The incidence of hip osteoarthritis (OA) is increasing with the aging population, leading to interest in intra-articular orthobiologic injections to alleviate symptoms and potentially slow disease progression. This systematic review aims to evaluate the clinical outcomes associated with six orthobiologic therapies for hip OA: hyaluronic acid (HA), platelet-rich plasma (PRP), autologous cells therapy (ACT), microfragmented adipose tissue (MFAT), and bone marrow aspirate (BMA) and its concentration (BMAC). Methods We conducted a literature search according to the PRISMA guidelines. Studies were included in our review if they used at least one of the four orthobiologic therapies and reported on the clinical outcome using patient reported outcome measures (PROMs). Since there is a large variability among clinical outcomes, we focused on the three most utilized PROMs (VAS, WOMAC, and HHS) and the latest follow-up time point. Results Of the 716 studies reviewed, thirty-six studies (n=36) fit inclusion criteria. There were 21 studies examining HA, 11 on PRP, 3 for MFAT, 2 for ACT, and 3 on BMA/BMAC. Eight studies were randomized controlled trials and 28 were cohort studies. The mean age of the patient population ranged from 45 ± 17.0 to 74 ± 8.0. The baseline grade of osteoarthritis ranged from 1-4 but was most reported as moderate (2-3). Overall, there was an improvement in PROMs at the latest follow-up after receiving orthobiologic interventions. Discussion Orthobiologic injections have shown promise for improving PROMs in patients with hip OA. Future studies should evaluate long-term efficacy and include randomized trials to establish efficacy.

Purpose Hip arthroscopy is a minimally invasive procedure which has been increasingly used among athletes for several hip joint related pathologies as it allows for a faster recovery. However, objective return to sport criteria have not been described previously among this population. Objective To systematically review the literature to evaluate and describe the objective return-to-sport (RTS) criteria to release patients back to sport following hip arthroscopy. Methods We conducted a comprehensive literature search according to the PRISMA guidelines. Studies were included in the review if patients underwent a hip arthroscopy procedure and the study described criteria for their patients to RTS. Two independent reviewers selected studies for inclusion and extracted study characteristics and objective RTS criteria. Results Of the 306 that were a part of our original search, 6 studies fit our inclusion criteria. There were 250 athletes (average age: 26.1) and 263 hips which underwent hip arthroscopy surgery. Of these athletes, the cohort was on average 46.5% female and an average of 91.2% of athletes returned to sport about 6 months following surgery. The primary sports these athletes participated in were soccer, swimming, skiing/snowboarding, and hockey. The objective RTS measures that were generally described included sport specific tests, range-of-motion, hip strength, and performance-based criteria. Conclusion There are minimal studies who described objective RTS criteria to release patients back to sport following hip arthroscopy procedures. Sports specific tests, hip strength, and performance-based criteria were mentioned as objective criteria to release patients back to sport.

Abstract The all‐inside anterior cruciate ligament reconstruction technique has gained popularity because of its ability to preserve bone stock, accommodate shorter graft lengths, and reduce postoperative pain. Traditionally, this technique uses metallic cortical suspensory buttons for graft fixation, which are reliable but may cause soft‐tissue irritation and hardware prominence. A recent modification to traditional all‐inside suspensory fixation uses all‐suture cortical buttons, eliminating the need for metallic or screw‐based implants while maintaining secure fixation. This Technical Note describes an all‐inside anterior cruciate ligament reconstruction technique that uses an all–soft tissue quadriceps tendon autograft, secured with only suture‐based buttons (no metal, no plastic) on both the femoral and tibial sides. Technique Video video See video under supplementary data.

Background: Chronic hamstring tears can result in challenging surgical repairs. Allografts may be used to augment the repair; however, there is limited clinical evidence supporting their use. Purposes: To (1) evaluate clinical outcomes of patients who underwent proximal hamstring repair with allograft augmentation or interposition and (2) compare them to matched controls who underwent primary hamstring repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 117 patients who underwent proximal hamstring repair were included, consisting of 19 allograft augmentations, 20 allograft interpositions, and 78 primary repairs. Allograft cohorts were propensity-matched with those who underwent primary repair in a 1 to 2 ratio. Clinical outcomes were obtained at the final follow-up. Data were extracted using continuous variables, with normality reported as mean values ± standard deviation, and non-normality reported as median values with interquartile ranges (IQR). Results: The median follow-up of the augmentation cohort was 1.9 [IQR, 0.8-3.9] years, while it was 3.2 [IQR, 1.6-5.1] years ( P = .182) for the primary repair cohort. The mean follow-up for the interposition cohort was 3.5 ± 2.4 years, while it was 4.2 ± 2.5 years for the primary repair cohort ( P = .227). Forty-two percent of the augmentation cohort had undergone previous surgery, compared with 5% of the interposition cohort. The time from injury to surgery for the augmentation and primary repair cohorts was 6.4 and 1.3 months, respectively ( P < .001). For the interposition and primary repair cohorts, the durations were 17.8 and 1 months, respectively ( P < .001). Clinical outcomes, including the Tegner Activity Scale (3 vs 3), pain with activity (47.4% vs 23.7%), and muscle spasms (36.8% vs 26.3%), did not show significant differences between the augmentation and primary repair cohorts. The augmentation cohort had a significantly worse Lower Extremity Functional Scale (LEFS) score (64 vs 75; P < .001) and were more likely to experience pain with sitting (52.6% vs 21.1%; P = .034) than the primary repair cohort. There was no significant difference in clinical outcomes between the interposition and primary repair cohorts (LEFS: 69 vs 75.5, Tegner Activity Scale: 4 vs 4; pain with sitting: 26.3% vs 27.5%; pain with activity: 42.1% vs 30%; muscle spasms: 26.3% vs 30%). Revision rates were similar between cohorts ( P ≥ .255). Conclusion: Proximal hamstring repair for chronic tears with allograft augmentation or interposition is a reproducible procedure that results in satisfactory, yet poorer clinical outcomes compared with patients who underwent primary hamstring repair. These procedures should be considered in symptomatic patients with chronic tears that are not amenable to primary repair.

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.

Background: Arthrofibrosis is seen in 1.7% to 38% of patients after anterior cruciate ligament reconstruction (ACLR) and has been associated with worse postoperative patient-reported outcomes. There are limited data regarding the optimal time to intervene in cases of arthrofibrosis after ACLR. Purpose: To assess if timing of arthrofibrosis treatment after ACLR affects final knee range of motion (ROM) and to help establish guidelines with regard to timing of intervention for arthrofibrosis after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Databases were retrospectively screened at 2 high-volume practices for patients who underwent lysis of adhesions (LOA; Current Procedural Terminology [CPT] 29884 and 29875) with or without manipulation under anesthesia (CPT 27570) after ACLR (CPT 29888). Clinical ROM assessments were collected at multiple time points. Patients were grouped into cohorts based on timing of LOA. Comparative analysis was performed to assess for relationships between ROM and timing of intervention. Results: Seventy-nine patients underwent LOA after ACLR: 25 patients who had a time from ACLR to LOA <3 months, 23 patients between 3 and 6 months, and 31 patients >6 months. Earlier LOA was associated with greater total loss of motion before LOA. The final total arc of motion was 132.7°, 133.7°, and 131.8° for patients who had a time from ACLR to LOA <3 months, between 3 and 6 months, and >6 months, respectively. There were no significant differences among groups in final flexion ( P = .8), extension ( P = .746), or total arc of motion ( P = .781). Linear regression modeling did not identify time from ACLR to LOA as a predictive variable ( P = .982) in final ROM. Conclusion: This study failed to demonstrate a linear relationship between the timing of LOA and final ROM. Regardless of the time to intervention, ROM improved significantly; however, patients with more severe arthrofibrosis underwent LOA at earlier time points.

Background: Optimized surgical fixation and meniscal stabilization during rehabilitation increase healing success. However, the latest generation of all-inside devices has not yet been biomechanically compared with inside-out suture tape (IO-ST) repair. Hypothesis: (1) The contact area of a suture anchor (SA) would compensate for a meniscal defect better than polyether ether ketone anchors (PA); (2) adjustable tensioning for all-inside meniscal repair fixation would result in higher initial load than IO-ST repair; and (3) stiffer constructs would decrease secondary displacement. Study Design: Controlled laboratory study. Methods: This study investigates human menisci (N = 39) via microscopic imaging and a biomechanical testing protocol. For the imaging protocol, needles of an all-inside SA or PA device and an IO-ST device were inserted after staining to measure the iatrogenic defect created by the needle insertion (n = 20) and the length, width, and meniscus contact area of deployed all-inside anchors (n = 6). For biomechanical testing, menisci with longitudinal bucket handle tears were prepared, and single stitches were repaired (each n = 9). After suture tensioning (50 N) and fixation, initial load, initial stiffness, and relief displacement were measured. Constructs underwent cyclic loading between 2 and 20 N, with 10,000 cycles (0.75 Hz), and stiffness and displacement were measured. Ultimate stiffness and load-to-failure were analyzed at 3.15 mm/sec. Results: All-inside needles created greater iatrogenic meniscal defects ( P < .001) than IO-ST repair. While PAs were longer ( P < .001), SAs were wider with a greater meniscal contact area (both P < .001). IO-ST repair resulted in the lowest initial load ( P < .001) and relief displacement ( P < .001), whereas SA repair resulted in a higher initial load ( P < .007) and stiffness ( P < .023) than PA repair. The overall stiffer SA fixation ( P < 001) significantly reduced cyclic displacement compared with other repairs ( P < .044). The PA group failed due to an anchor fracture at a significantly lower load (84.3 ± 10.7 N; P < .001) than the IO-ST (136.4 ± 10.5 N) and the SA repair (122.1 ± 17.5 N), with a suture-based failure mode. The ultimate stiffness of SA constructs was higher ( P < .045) than that of other repairs. Conclusion: While all-inside devices showed improved primary stability, the IO-ST construct demonstrated the highest load-to-failure. In a human cadaveric model, meniscal repair with a more compact and conforming SA was stiffer and reduced cyclic displacement compared with PA and IO-ST repair. Clinical Relevance: All-inside SA repair improved primary stability. Future clinical series will define the overall significance of healing rates.

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.