Faculty Bibliography

Primary repair of acetabular labral tears has been the gold standard treatment with excellent short to mid-term results. Autograft and allograft labral reconstruction has been described mostly in the revision labral surgery setting with good short-term results. A recent study has compared primary labral reconstruction to labral repair head-to-head in the same patient. Primary labral reconstruction may be a suitable alternative to labral repair in patients with symptomatic labral pathology. Concerns remain, however, about sacrificing living labral tissue for dead allograft tissue for the long term.

Subchondroplasty is a relatively new procedure developed to treat bone marrow lesions by injecting a calcium phosphate bone substitute into the pathologic, subchondral area of bone under fluoroscopic guidance. The procedure is described as a minimally invasive strategy that provides reliable relief of pain while preserving the native joint with minimal risk of significant complications. No prospective, randomized clinical trials have reported the efficacy of the procedure. Here, we present the case of a 64-year-old healthy male who developed Staphylococcus aureus osteomyelitis following subchondroplasty requiring further surgical intervention and intravenous antibiotic therapy.

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.

BACKGROUND: Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized. METHODS: We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy. RESULTS: We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary. CONCLUSION: Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Objectives: Hip arthroscopy for femoroacetabular impingement (FAI) and related hip pathology is increasing in volume. Variable presentations of hip pain often lead to confusion with lumbar spine pathology however. We sought to define the relationship between the lumbar spine and the hip joint. Our hypothesis is that patients with concurrent lumbar spine pathology will experience inferior outcomes after hip arthroscopy when compared to patients without lumbar spine pathology. Methods: Prospectively-collected data from a single-surgeon database from 2010 to 2014 was used to identify patients who had undergone hip arthroscopy and had documented concurrent lumbar spine pathology. Patients with spine pathology were matched by age, gender, and BMI in a 3:1 fashion to patients without spine pathology. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to scores at two-year follow-up. "Poor outcome" of initial hip arthroscopy was defined as any combination of: requiring a revision procedure, conversion to THA, or mHHS below 70. Results: 167 patients met inclusion criteria: 72.5% were "normal" while 27.5% had spine pathology. Baseline demographics were appropriately matched between cohorts (Table I). Preoperative and two-year mHHS scores were significantly different between cohorts (Figure 1). Both cohorts demonstrated significant within-group improvement at two-year follow-up, however normal patients had greater improvements than those with spine pathology (34.0 vs 31.76, p<0.001). Overall revision/THA conversion rate for entire cohort was 14.97%, with nearly twice as many spine co-pathology patients requiring additional surgery than those in the normal cohort (23.91% vs 11.57%, p=0.045). Patients with spine pathology were significantly more likely to have "poor outcomes" than those without spine pathology (36.96% vs 21.49%, p=0.048). Conclusion: Our results demonstrate that patients undergoing hip arthroscopy with concomitant lumbar spine pathology demonstrate significantly lower total improvement, significantly higher revision/THA conversion rates and significantly higher rates of suboptimal outcomes after hip arthroscopy than patients without spine pathology. (Table Presented) (Figure Presented)

Objectives: The use of hip arthroscopy for the management of hip pathology has increased dramatically in recent years. Despite evidence demonstrating excellent outcomes, there are some patients that may require revision arthroscopy or conversion to total hip arthroplasty (THA). Data regarding risk factors for poor outcomes after hip arthroscopy is limited. The purpose of this study is to evaluate the rates of revision hip arthroscopy and conversion to THA in order to identify risk factors for suboptimal outcomes. Methods: New York State Department of Health Statewide Planning and Research Cooperative Systems database was queried from 2011 through 2014 to identify patients undergoing hip arthroscopy. Patients were longitudinally followed for a minimum of two years to determine the incidence and nature of subsequent hip procedures. Multivariate logistic regression was performed to identify independent risk factors for revision surgery or conversion to THA. Results: We identified 3,957 patients who underwent hip arthroscopy. Mean age of the sample was 35.8 years (SD+/-13.1). After a minimum follow-up of two years, overall failure rate was 9.6%: 3.7% (n=148) had revision hip arthroscopy at an average of 15.8 months, while 5.9% (n=235) converted to THA at 14.7 months. Index surgery performed by surgeons in the lowest volume tertile was an independent risk factor for both revision (p=0.001) and conversion to THA (p<0.001). Females (p<0.001), older patients (p<0.001) and those with a history of obesity (p<0.001) converted to THA at a significantly higher rate than other patients. Young patients (p<0.001) and females (p<0.001) were more likely to undergo revision hip arthroscopy. Conclusion: Hip arthroscopy may be better performed by medium to high volume surgeons. Additionally, patients with identified risk factors for revision or THA conversion should be counseled pre-operatively on potentially adverse outcomes, thus allowing patient-physician engagement during the shared decision-making process

Objectives: Hip arthroscopy has been an increasingly used tool in the treatment of labral tears, chondral defects and ligamentum teres lesions and has demonstrated efficacy in returning patients to function and relieving their pain. Despite this, failures continue to occur. Our understanding of risk factors for failure or poor outcome continues to evolve as larger cohorts of patients are available for study. We sought to identify risk factors for poor outcome in our patient population. Methods: Prospectively collected data for all patients undergoing hip arthroscopy by a single fellowship-trained surgeon was obtained. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline demographic data regarding patient age, gender, BMI was collected. Patients without two year follow-up were excluded. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to mHHS at two-year follow-up. "Poor outcome" of initial hip arthroscopy was defined as any combination of: requiring a revision procedure or conversion to THA or mHHS below 70. Multivariate logistic regression was performed to identify independent risk factors for "poor outcome." Results: 258 patients met inclusion criteria. Mean age (SD) and body mass index (BMI) were 40.4 years (12.7 years) and 25.6 (4.7) respectively. 62.8% (162/258) of the sample was female. Mean preoperative baseline mHHS was 49.6 (12.5) and average mHHS at two year follow-up was 83.6 (15.6), resulting in a mean improvement of 34.1 (p<0.001). Baseline and 2 year differencess in mHHS by demographic be found in Figures 1,2,3. Overall revision/THA conversion rate was 16.7% (43/258), while another 10.5% (27/258) of patients reported outcome scores <70, resulting in 27.31% (70/258) having poor outcomes. Independent risk factors for poor outcome were female gender (OR 1.79; p=0.03), obesity (OR 2.1; p=0.04), and pre-operative mHHS lower than 40 (OR 3.34, p<0.001). Conclusion: Our findings that female gender, obesity and poorer preoperative functional status increase the risk for failure of hip arthroscopy coincide and add to an increasing volume of literature examining risk factors for poor outcome after hip arthroscopy. These factors should be taken into consideration with operative indications as well as in counseling patients

Hip dysplasia, when significant, is effectively treated with periacetabular osteotomy. There have been good results reported with hip arthroscopy when dysplasia is mild. However, when dysplasia is significant, hip arthroscopy with labral repair alone has led to poor results and even rapid decline to end stage arthritis. Staged hip arthroscopy and periacetabular osteotomy would potentially treat the labral lesion and correct the underlying bony abnormality that resulted in the labral pathology. Such a staged treatment plan should help prevent progression to degenerative joint disease. We report a case of a 33-year-old woman who presented with left hip pain and was diagnosed with mild hip dysplasia and a labral tear. She underwent staged hip arthroscopy and labral repair followed by periacetabular osteotomy 2 weeks later. Three and a half months after surgery she developed constant pain and began limping at 5 months. Radiographs showed progression to severe degenerative joint disease. The patient was indicated for total hip arthroplasty.

PURPOSE: To examine clinical outcomes and survivorship in patients aged 60 years or older who underwent hip arthroscopy for management of hip pain. METHODS: Prospectively collected data for patients 60 or older undergoing hip arthroscopy were obtained. All patients were indicated for hip arthroscopy based on standard preoperative examination as well as routine and advanced imaging. Demographic data, diagnosis, and details regarding operative procedures were collected. Baseline preoperative modified Harris Hip Scores (mHHS) and Non-arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at the 2-year follow-up. Survivorship was assessed to determine failure rates, with failure defined as any subsequent ipsilateral revision arthroscopic surgery and/or hip arthroplasty. RESULTS: Forty-two patients met inclusion criteria. Mean age (standard deviation) and body mass index were 65.8 years (4.5 years) and 26.1 (4.7), respectively. Baseline mean mHHS and NAHS for all patients improved from 47.8 (+/-12.5) and 47.3 (+/-13.6) to 75.6 (+/-17.6) and 78.3 (+/-18.6), respectively (P < .001 for both). Five patients (11.9%) met failure criteria and underwent additional surgery at an average of 14.8 (8-30) months. Three underwent conversion to total hip arthroplasty (7.1%), whereas 2 had revision arthroscopy with cam/pincer resection and labral repair for recurrent symptoms (4.7%). One- and 2-year survival rates were 95.2% and 88.9%, respectively. CONCLUSIONS: Our results suggest that in patients 60 or older with Tonnis grade 0 or 1 osteoarthritic changes on initial radiographs-treatment with hip arthroscopy can lead to reliable improvement in early outcomes. As use of hip arthroscopy for treatment of mechanical hip pain increases, additional studies with long-term follow-up are needed. LEVEL OF EVIDENCE: Level IV, therapeutic case series.