Faculty Bibliography

BACKGROUND: Avulsion injuries of the lesser trochanter apophysis are relatively uncommon injuries and there have been no peer-reviewed case series dedicated to the evaluation and treatment of this injury. The purpose of this study is to characterize avulsion injuries of the lesser trochanter apophysis, review treatment protocols, and time to return to sport.  Methods: We reviewed 30 confirmed avulsion fractures of the lesser trochanter. Clinical data were reviewed to evaluate treatment protocols, duration, and time to return to sport. Radiographs were reviewed to confirm lesser trochanter avulsion and fracture displacement. RESULTS:There were 26 males and 4 females, with the average age at the time of injury being 14.2 years. Treatment modalities consisted of protective weight-bearing, discontinuation of the patient's sport in all cases, and formal physical therapy in 18 cases. The average treatment duration was 30.7 days. The mean follow-up time was 102 days. The radiographic assessment demonstrated an average fracture displacement of 5.1 mm. The average return to sport was 11 weeks. CONCLUSION/CONCLUSIONS:This is the first large case series studying avulsion injuries of the lesser trochanter. We have shown that these athletes can be managed non-surgically and can successfully return back to sport within three months.

BACKGROUND/UNASSIGNED:Arthroscopic management of femoroacetabular impingement (FAI) in the setting of borderline hip dysplasia is controversial. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement. PURPOSE/HYPOTHESIS/UNASSIGNED:The purpose was to report outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia compared with a matched cohort with nondysplastic FAI. Addressing a prominent subspinous region and cam/pincer lesion in the borderline dysplastic hip may lead to favorable outcomes comparable with those of patients undergoing arthroscopic management of nondysplastic FAI. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:Patients with symptomatic hip impingement, borderline dysplasia (lateral center-edge angle [LCEA], 18°-24°), and prominent AIIS (BDSI group) whose nonoperative management failed and who subsequently underwent arthroscopic subspinous decompression were retrospectively identified. Three-dimensional computed tomography imaging was used to categorize AIIS morphology into type 1, 2, or 3 (Hetsroni classification). Patient-reported outcome (PRO) scores consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperatively (range, 23-61 months). Exclusion criteria were Tönnis osteoarthritis grade >1 and a history of previous hip procedures. An age-, sex-, and body mass index-matched cohort of patients without dysplasia (LCEA, >25°) who underwent arthroscopic FAI surgery with a minimum 2-year follow-up were selected to serve as the control group. RESULTS/UNASSIGNED:= .04). CONCLUSION/UNASSIGNED:Arthroscopic AIIS decompression in patients with coexisting borderline dysplasia and subspinous impingement is a safe and effective method of treatment that produces outcomes comparable with those of a cohort with nondysplastic FAI.

BACKGROUND:Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols. METHODS:The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting. RESULTS:Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants. CONCLUSION/CONCLUSIONS:We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

Background/UNASSIGNED:"Athletic pubalgia," a term that has gained acceptance over "sports hernia," is more common in men than women; however, it represents a significant source of morbidity for patients of both sexes. Inconsistent terminology surrounding this entity poses a diagnostic challenge and makes studying the populations at risk difficult. Purpose/UNASSIGNED:To review a case series of women with athletic pubalgia by analyzing their presentations, concomitant pathologies, and surgical outcomes. Study Design/UNASSIGNED:Case series; Level of evidence, 4. Methods/UNASSIGNED:Between 2013 and 2016, 197 patients were seen and evaluated for the diagnosis of athletic pubalgia. Eighteen patients seen during this time were women. All patients received "pubalgia protocol" magnetic resonance imaging and subsequent surgical intervention for their pathologies. Outcomes among 17 women were assessed with a patient questionnaire >1 year after surgery. Results/UNASSIGNED:Of the 17 women, 9 had rectus aponeurotic plate injury only, or pure athletic pubalgia; the remaining 8 had athletic pubalgia in combination with ≥1 inguinal, obturator, and femoral hernias. Regarding female patients in both groups, 88.2% reported that the surgery was a success at follow-up. Conclusion/UNASSIGNED:Surgical repair of athletic pubalgia among women is successful in dramatically reducing pain levels in this important subset of patients.

Background/UNASSIGNED:Sports-related groin injuries are common among athletes. However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair. Purpose/UNASSIGNED:To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique. Study Design/UNASSIGNED:Case series; Level of evidence, 4. Methods/UNASSIGNED:Prospective data were collected on patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Patient-reported outcomes (Hip Outcome Score-Activities of Daily Living [HOS-ADL] and Hip Outcome Score-Sport Specific [SS] subscales, modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) were collected preoperatively and at a minimum 2-year follow-up. Results/UNASSIGNED:< .001). Conclusion/UNASSIGNED:Patient-reported outcomes offer an objective measure of hip function and pain control. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport.

Proximal adductor injuries are relatively common groin injuries in athletes. Various tenotomy techniques have been described including open, partial, and percutaneous approaches. Current techniques help most athletes return to sport; however, many develop adductor weakness. Moreover, the procedures lack full visualization of the tendon and do not allow for return to athletes' preinjury level of play. We describe an endoscopic z-lengthening of the proximal adductor tendon with the potential to minimize complications associated with open procedures such as incisional pain and neurovascular injury while affording a more complete tenotomy than current percutaneous techniques. This is a safe and reproducible technique that allows for release of tension as a result of pathologic adductor tendon pathologies.

PURPOSE/OBJECTIVE:Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions. METHODS:A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined. RESULTS:The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis. CONCLUSION/CONCLUSIONS:The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

The purpose of this study is to investigate the outcomes from anchor-induced chondral damage of the hip, both with and without frank chondral penetration. A multicenter retrospective case series was performed of patients with chondral deformation or penetration during initial hip arthroscopic surgery. Intra-operative findings, post-surgical clinical courses, hip outcome scores and descriptions of arthroscopic treatment in cases requiring revision surgery and anchor removal are reported. Five patients (three females) of mean age 32 years (range, 16-41 years) had documented anchor-induced chondral damage with mean 3.5 years (range, 1.5-6.0 years) follow-up. The 1 o'clock position (four cases) and anterior and mid-anterior portals (two cases each) were most commonly implicated. Two cases of anchor-induced acetabular chondral deformation without frank penetration had successful clinical and radiographic outcomes, while one case progressed from deformation to chondral penetration with clinical worsening. Of the cases that underwent revision hip arthroscopy, all three had confirmed exposed hard anchors which were removed. Two patients have had clinical improvement and one patient underwent early total hip arthroplasty. Anchor-induced chondral deformation without frank chondral penetration may be treated with close clinical and radiographic monitoring with a low threshold for revision surgery and anchor removal. Chondral penetration should be treated with immediate removal of offending hard anchor implants. Preventative measures include distal-based portals, small diameter and short anchors, removable hard anchors, soft suture-based anchors, curved drill and anchor insertion instrumentation and attention to safe trajectories while visualizing the acetabular articular surface.

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient co- hort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients under- going hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgi- cal proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.