Faculty Bibliography

PURPOSE/UNASSIGNED:To assess hip symptomatology during the perioperative and peripregnancy periods and postoperative outcomes among reproductive age females undergoing arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) and pregnancy complications in females after hip arthroscopy. METHODS/UNASSIGNED:Females aged 18-44 years who underwent hip arthroscopy for the treatment of FAIS with a single surgeon were included in the study. Postoperatively, patients were surveyed regarding obstetric history, hip symptomology, and post-surgery pregnancy experiences. Subjects were classified as nulligravid (Group 1), pregnant at least once before hip surgery but never again following surgery (Group 2), or pregnant at least once following hip surgery (Group 3). Hip pain intensity was reported on a 10-point Visual Analog Scale (VAS) and hip function was reported using the modified Harris Hip Score (mHHS). Patients self-reported pregnancy outcomes and complications. RESULTS/UNASSIGNED:85 patients were enrolled with a mean age of 32.3 ± 6.5 years at the time of surgery. Mean follow-up time was 51.9 ± 34.5 months. There were 39 subjects in Group 1 (45.9 %), 20 in Group 2 (23.5 %), and 26 in Group 3 (30.6 %). There were no significant inter-group differences in mHHS preoperatively or at final follow-up (p = 0.95). Group 3 subjects reported that both postoperative and post-pregnancy VAS remained significantly lower than the preoperative baseline (p < 0.001). 69.2 % and 73.1 % report worsened hip pain during the third trimester and postpartum, respectively. 57.9 % reported that their hip pain returned to the pre-pregnancy baseline by time of survey completion. CONCLUSION/UNASSIGNED:Females of reproductive age with FAIS can expect clinical improvements relative to their baseline after hip arthroscopy regardless of pregnancy timing relative to surgical intervention. A majority of patients who become pregnant post-arthroscopy experience a peripartum recurrence of their symptoms. Most but not all of these patients return to the level of maximal improvement they had initially experienced postoperatively.

Traditionally, acetabular global overcoverage had been treated by open surgical dislocation of the hip and was a relative contraindication for hip arthroscopy. With advancing arthroscopic techniques, hip arthroscopy can successfully treat acetabular global overcoverage with less morbidity for the patient than an open hip procedure. Successful arthroscopic treatment of this condition is not for the beginner hip arthroscopist. Pitfalls of an arthroscopic technique include difficult entry into the joint and labral insufficiency with the inability to perform a repair and these difficulties should be understood ahead of the procedure. However, with careful, thoughtful technique, arthroscopic treatment of acetabular global overcoverage has successful outcomes and now should be considered the preferred option instead of open surgical dislocation of the hip.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate patient-reported outcomes (PROs) and survivorship in obese patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year follow-up. METHODS:A retrospective review was conducted of patients who underwent arthroscopy for FAIS from 2010-2013. Patients were assessed at baseline, 1 month, 6 months, 1-, 2-, 5-, and 10 years using the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS). Patients were categorized based on BMI into normal, overweight, and obese cohorts. Minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated for both PROs. Improvements from baseline were analyzed and differences between groups were evaluated while controlling for age. Survival to revision surgery was assessed with Kaplan-Meier survival curves. RESULTS:144 patients (65.2% female) with a mean age of 38.8 ± 13.0 years and an average follow-up of 11.6 (range 10.0-13.8) years were included, and categorized into normal weight (59.7%), overweight (26.4%), and obese (13.9%). All groups showed significant improvement in PROs at 10 years compared to baseline (p=0.007). Obese patients had lower postoperative scores (mHHS: 72.8 vs. 90.1, p=0.009; NAHS: 68.4 vs.. 88.6, p=0.003) and improvement in scores from baseline (mHHS: 23.4 vs. 37.7, p=0.013; NAHS: 18.4 vs. 40.0, p=0.004) at 10-year follow-up, as well as lower achievement of mHHS PASS (60.0% vs 87.2%, p=0.015), NAHS PASS (50.0% vs. 89.5%, p<.001) and NAHS MCID (70.0% vs. 93.0%, p=0.008). Obese patients also had a higher rate of conversion to THA (17.4% vs 3.3%, p=0.012). The overall complication rate was 4.2% compared to 10% in the obese group, with obese patients experiencing a superficial infection more frequently (p=0.002). CONCLUSION/CONCLUSIONS:Although obese patients still have significantly improved outcomes compared to baseline, at 10-year follow-up they have inferior outcomes compared to nonobese patients and higher rates of conversion to THA. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

Previous studies suggest a relationship between femoroacetabular impingement (FAI) and femoral neck stress fractures (FNSF), due to pathologic biomechanics in the setting of femoral head abutment (cam morphology) and/or acetabular overcoverage (pincer morphology). The purpose of this study is to evaluate the association between cam or pincer morphology and FNSF, compared to a control group of patients without hip pain. A retrospective review of the electronic medical record at a single institution was queried for patients with FNSF over a 10-year time period from January 2011-2021. These patients were compared to a control group with diagnostic radiographs and a chief complaint that was not hip pain presenting to the institution's emergency department. Hip morphology was evaluated radiographically. A multivariate logistic regression was used to investigate an association between FNSF and cam or pincer morphology. Eighty-three patients with FNSF and a mean age of 38.6 years were compared to 55 healthy controls with a mean age of 35.8 years. Patients in the FNSF group were more often female, white, and had lower BMI. These patients were also more likely to have associated cam morphology (p = 0.010). Binary logistic regression demonstrated a statistically significant independent association between both cam (OR 5.2, p = 0.01) and pincer (OR 4.6, p = 0.022) morphology with FNSF when controlling for demographic variables. Black race and higher BMI were protective factors for FNSF (OR 0.09, OR 0.84, p < 0.01). In summary, radiographic cam morphology, superolateral acetabular overcoverage, female sex, and lower BMI are risk factors for sustaining FNSF, while the black race was found to be protective.

PURPOSE/OBJECTIVE:This study aims to evaluate patient-reported outcomes (PROs) and reoperation rates in patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) over a minimum 10-year follow-up stratified by sex, age, and body mass index (BMI). METHODS:Primary hip arthroscopies performed for FAIS between 2010 and 2013, with a minimum 10-year follow-up, were reviewed. Procedures consisting of microfracture, or labral debridement without repair, were excluded. Ten-year PROs were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were categorized into three groups by age (<30, 30-44, >45 years) and BMI (<25.0, 25.0-29.9, ≥30). Minimum clinically important difference (MCID) was set to half the preoperative standard deviation of the cohort. Reoperation rates and PROs were compared, and regression analysis identified independent predictors of PROs. RESULTS:At minimum 10-year follow-up (mean: 11.6 [10.0-13.9] years), 59.2% follow-up was achieved, representing 154 hips (141 patients). The cohort had a mean age of 38.5 years, BMI of 24.4, and was 68.2% female. At follow-up, 91.6% of the cohort achieved MCID with a 9.7% re-operation rate. In the middle-aged group, males had higher mHHS (mean, 92.8 vs. 85.2, P = 0.015) and NAHS (mean, 91.6 vs. 83.4, P = 0.008) scores compared to females. In the BMI ≥30 group, males had higher mHHS (mean, 83.3 vs. 66.4, P = 0.030) and NAHS scores (mean, 83.0 vs. 58.5, P = 0.035). Only 72.7% of females with BMI ≥30 achieved MCID for mHHS and NAHS, compared to BMI < 25 (96.6% and 94.9%, respectively) and 25-29.9 (87.5% and 83.3%) (mHHS: P = 0.016; NAHS: P = 0.038). Similarly, 78.8% of females aged ≥ 45 achieved MCID for NAHS, compared to 92.9% of those aged < 30 and 97.1% of those 30-44 (P = 0.040). Multivariable regression identified older age (mHHS: P=0.019; NAHS: P=0.042) and higher BMI (mHHS: P=0.007; NAHS: P<0.001) as independently predictive of worse 10-year PROs. CONCLUSION/CONCLUSIONS:Older age and greater BMI independently predicted poorer long-term functional outcomes after hip arthroscopy for FAIS. Female sex, while not independently predictive, may make patients more susceptible to the negative effects of older age and BMI. No significant association was observed for reoperation rates. LEVEL OF EVIDENCE/METHODS:Level IV, retrospective therapeutic case series.

PURPOSE/OBJECTIVE:The aim of this study is to assess agreement between retrospectively and prospectively collected patient-reported outcome measures (PROMs) following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS:Patients undergoing hip arthroscopy from 2021 to 2023 for FAIS completed preoperative PROMs, including the modified Harris Hip Score (mHHS) and the Non-Arthritic Hip Score (NAHS). Post-operatively, patients were surveyed and asked to recall their preoperative hip function. Paired two-sample t tests were used to compare baseline and recalled baseline PROMs and the difference between scores was compared to previously published minimally clinically important difference (MCID) values. Intraclass correlation coefficients (ICCs) were calculated to test the reliability between scores based on a single-rater, two-way mixed-effects model. Multivariable regression, accounting for age, sex and preoperative baseline scores, was used to evaluate the relationship of time elapsed since surgery with recall accuracy. RESULTS:A total of 116 patients (age: 37.6 ± 11.8 years; 61.2% female) were included. The mean time elapsed for recalled data was 13.1 months (range: 1-27 months). Overall, patients' recalled scores were significantly lower than those prospectively collected (mHHS: 52.9 ± 20.1 vs. 61.5 ± 18.5, p < 0.0001; NAHS: 54.7 ± 20.0 vs. 58.8 ± 19.1, p < 0.0001). Frequency distribution found 68.1% of recalled mHHS and 61.2% of NAHS scores to have a greater difference (between baseline and recalled scores) than the MCID. The ICC was moderate for both mHHS (ICC = 0.559, 95% confidence interval [CI] = [0.420-0.672], p < 0.001) and NAHS (ICC = 0.612, 95% CI = [0.484-0.714], p < 0.001). Multivariate regression analysis did not find time elapsed since surgery to be associated with the difference between baseline and recalled mHHS (n.s.) or NAHS (n.s.). CONCLUSION/CONCLUSIONS:There are significant differences between retrospective and prospectively collected PROMs in patients undergoing hip arthroscopy that are not predicted by time to recall. These findings should impact the interpretation of the existing literature, support the routine collection of prospective data and inform patient counsel regarding their perceived post-operative outcomes. LEVEL OF EVIDENCE/METHODS:Level IV.

Acetabular cartilage delamination (ACD) can result in focal chondral defects, increasing contact stresses and contributing to osteoarthritis. This is commonly associated with femoroacetabular impingement, particularly with cam deformities due to shearing of the cam on the acetabulum. Additionally, ACD associated with labral tears or chondrolabral separation, when untreated, can compromise labral repair outcomes. ACD is often missed on preoperative magnetic resonance imaging and magnetic resonance arthrography, which show a sensitivity of <80%. Thus, given the ubiquity of ACD in patients undergoing femoroacetabular impingement surgery, a single-stage treatment option is essential. Acetabular shape, depth, and constraint, coupled with the thinness of acetabular cartilage, make treatment technically difficult, particularly arthroscopically. Treatment generally falls within 3 categories: repair, repair with augmentation, or cell-based cartilage transplantation. Currently, we most commonly employ primary repair and incorporate the cartilage flap into the labral repair. The chondral nail described by Zhu et al. is an intriguing off-the-shelf, single-stage technique that merits further investigation.

BACKGROUND:Three-dimensional MR fingerprinting (3D-MRF) has been increasingly used to assess cartilage degeneration, particularly in the knee joint, by looking into multiple relaxation parameters. A comparable 3D-MRF approach can be adapted to assess cartilage degeneration for the hip joint, with changes to accommodate specific challenges of hip joint imaging. PURPOSE/OBJECTIVE:in clinically feasible scan times. STUDY TYPE/METHODS:Prospective. SUBJECTS/METHODS:Eight healthy subjects, three patients with mild osteoarthritis (OA), and one of the OA patients had femoral acetabular impingement (FAI). A National Institute of Standards and Technology/International Society for Magnetic Resonance in Medicine (NIST/ISMRM) system phantom was also used. FIELD STRENGTH/SEQUENCE/UNASSIGNED:mapping. ASSESSMENT/RESULTS:maps of 3D-MRF sequence were evaluated on a NIST/ISMRM phantom and human subjects. Differences in the parametric maps between OA and healthy subjects were assessed. STATISTICAL TESTS/METHODS:Regression, Bland-Altman, Kruskal-Wallis, and Wilcoxon tests were used to assess for accuracy, repeatability, and subregional variation. The P-value <0.05 indicated statistically significant. RESULTS:) in femoral lateral compartment of the hip joint compared to healthy controls. DATA CONCLUSION/CONCLUSIONS:3D-MRF may be a feasible approach for simultaneous, quantitative mapping of bilateral hip joint cartilage in healthy and mild OA patients. EVIDENCE LEVEL/METHODS:1 TECHNICAL EFFICACY: Stage 1.

INTRODUCTION/BACKGROUND:Bone Marrow Lesions (BMLs) have a strong correlation to patient reported pain, functional limitations, joint deterioration, and rapid progression to total knee arthroplasty. The Subchondroplasty® (SCP) Procedure uses AccuFill®, a calcium phosphate bone substitute material (BSM), to treat bone defects such as microtrabecular fractures and BML. METHODS:This observational, prospective, multicenter, cohort study evaluated the effect of the SCP Procedure at two-year follow-up for 70 patients with knee BML. Under arthroscopic and fluoroscopic guidance, the BML was injected with AccuFill®. Patient reported outcomes, including Visual Analog Scale (VAS) pain, Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and modified Knee Society Score (mKSS) were collected through 24 months postoperatively. Radiographs and magnetic resonance images (MRI) were performed at baseline and up to 24 months post-operatively. Patient selection was not limited based on degree of osteoarthritis (OA) as determined radiologically by Kellgren-Lawrence (K-L) grade. For a subset of subjects, patient reported outcomes were collected up to five years including pain evaluation, patient knee global assessment, and satisfaction with the procedure. RESULTS:Pre-operative radiographs indicated moderate to severe osteoarthritis (K-L grades 2-4) in 65 subjects (92.8%). Significant improvements (p<0.0001) in mean VAS Pain, IKDC, mKSS and KOOS scores were observed compared with baseline. Kaplan-Meier survivorship free from conversion to knee arthroplasty was 76.2% at two years. The subset of subjects followed for five years demonstrated low pain scores and high procedure satisfaction. CONCLUSION/CONCLUSIONS:This study presents statistically significant and clinically meaningful evidence of improvement in clinical outcomes following SCP for BMLs of the knee after two years. The survivorship rate from arthroplasty at two years was 76.2%. SCP for BMLs can relieve pain with a minimally invasive procedure and may delay the need for knee arthroplasty.

Compared with total hip arthroplasty, hip arthroscopy is a relatively new procedure and, as such, hip-spine syndrome in young adults is an emerging topic of research. In the past decade, our understanding of spinopelvic alignment has improved the stability and survivorship of hip replacements in patients with prior lumbar fusions. Obviously, the hip affects the spine and the spine affects the hip. In terms of hip arthroscopy, just as older patients and patients with cartilage damage have inferior outcome, patients with spine pathology are at risk for post-operative worsening spinal symptoms, including sciatica. In addition, back and radicular pain may limit post-operative hip rehabilitation. Yet, other patients show resolution of back symptoms after hip arthroscopy. Today, surgeons indicating hip arthroscopy must first investigate patient sagittal balance which includes pelvis tilt, pelvic incidence and sacral slope. When properly indicated, hip-spine pain patients show greater percentage improvement with no increased failure risk compared to patients with isolated FAIS. Exceptions include patients with concomitant lumbar stenosis or lumbar fusion. rate of revision hip arthroscopy and conversion for total hip replacement is two-fold compared to controls if patients had prior 1-2 level fusion and three-fold if 3 or more levels are fused. Our understanding of hip-spine patients with regard to arthroscopy outcomes continues to develop. In addition to a comprehensive spine exam, the patient's spine surgical history and current spine symptoms must be investigated in order to predit the efficacy of hip arthroscopy. If patients have both hip and spine symptoms, a diagnostic hip injection to determine the prime pain generator is essential. If the hip is the source of pain, patients should be counseled that back symptoms will likely improve after hip arthroscopy but not in all cases. EOS imaging to measure sagittal balance may allow the surgeon to predict if impingement measurements on hip x-rays may be underestimated in the setting of a stiff spine. If the patient has multiple risk factors for poor outcomes such as advancing age, articular cartilage damage, borderline dysplasia, hypermobility, on top of a history of multilevel lumbar fusion or spinal deformity, hip arthroscopy may not be ideal and hip arthroplasty should be considered. Clearly, the spine may not be ignored in patients with FAIS.