Faculty Bibliography

PURPOSE:To compare hip survivorship and patient-reported outcome measures (PROMs) after primary hip arthroscopy at 5-year follow-up between patients with femoroacetabular impingement syndrome (FAIS) with radiographic signs of global acetabular retroversion and those without. METHODS:A retrospective matched-cohort study was conducted using a single-surgeon hip arthroscopy database. Patients were included if they underwent primary hip arthroscopy for treatment of FAIS, had preoperative hip x-rays, and had a minimum 5-year follow-up. Global retroversion was defined as the presence of ischial spine sign, posterior wall sign, and crossover sign on anteroposterior view. Patients with FAIS with global retroversion were matched 1:1 on age, sex, and body mass index to FAIS controls. The modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were administered preoperatively and at follow-up. Hip survivorship and PROMs were compared between the 2 groups using the paired t test, Wilcoxon signed rank test, and/or Cochran-Mantel-Haenszel test as appropriate. P values <.05 were considered significant. RESULTS:Thirty-eight patients with global retroversion (mean age 40.6 ± 10.8 years, 60.5% female) were matched to 38 controls (mean age 41.3 ± 13.6 years, 60.5% female). Reoperation rates were the same in both groups (5.3%). On average, both groups reported significant pre- to postoperative improvement in mHHS (P < .001) and NAHS (P < .001), and there was no significant intergroup differences in the change in mHHS (P = .86) or NAHS (P = .90). Achievement rates for the patient acceptable symptom state on the mHHS were higher among males compared to females (P = .04) in both the global retroversion group (93.3% vs 73.9%) and the control group (93.3% vs 73.9%). CONCLUSIONS:Patients with FAIS with and without global acetabular retroversion had no significant difference in outcomes after primary hip arthroscopy at a minimum 5-year minimum follow-up. LEVEL OF EVIDENCE:Level III, retrospective comparative prognostic trial.

PURPOSE:To determine if radiographic cam location is associated with hip survivorship and postoperative patient-reported outcomes (PROs) at 5-year follow-up. METHODS:We conducted a review of prospectively collected data of patients with cam lesions who underwent hip arthroscopy for femoroacetabular impingement syndrome. Cam lesions were categorized into 3 locations: superolateral, anterolateral, or anterior. Conversion to total hip arthroplasty (THA), revision rates, and reoperation rates were assessed. Patient-reported outcome measures, including modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS), were collected preoperatively and at 5-year follow-up. RESULTS:Of the 156-patients, 125 met the final criteria (80.1%). Mean age was 41.1 ± 12.7 years. Seventy-one patients (56.8%) had superolateral cam lesions, 41 (32.8%) had anterolateral lesions, and 13 (10.4%) had anterior lesions. Revision rates within 5 years were 7.7% for anterior, 24.4% for anterolateral, and 14.1% for superolateral lesions; conversions to THAs were 15.4% for anterior), 7.3% for anterolateral, and 8.5% for superolateral. Reoperations were 23.1% for anterior, 29.3% for anterolateral, and 21.1% for superolateral. The superolateral cohort was younger than the anterior and anterolateral cohorts (anterior, 46.6 ± 12.2 years; anterolateral, 44.7 ± 12.2 years; superolateral, 38.1 ± 12.3 years; P = .006). Multivariable analysis showed the anterolateral group was significantly predictive of lower odds of undergoing THA compared to the superolateral group (odds ratio, 0.01; 95% CI, <0.01-0.72; P = .03). There were no differences in the 5-year improvement in mHHS (anterior, 32.4; anterolateral, 36.8; superolateral, 33.0; P = .29) or NAHS (anterior, 34.8; anterolateral, 39.0; superolateral, 37.3; P = .65). CONCLUSIONS:A superolateral cam lesion increases the odds of conversion to THA within 5 years of hip arthroscopy compared to those with anterolateral lesions on multivariable analysis. Those with superolateral lesions were significantly younger compared to those with anterior or anterolateral lesions. Cam lesion location did not affect improvement in PROs at 5-year follow-up. LEVEL OF EVIDENCE:Level III, retrospective comparative prognostic trial.

BACKGROUND/UNASSIGNED:Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS). PURPOSE/UNASSIGNED:To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups. RESULTS/UNASSIGNED:< .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score. CONCLUSION/UNASSIGNED:There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.

Different pathologies of the hip are characterized by the abnormal shape of the bony structures of the joint, namely the femur and the acetabulum. Three-dimensional (3D) models of the hip can be used for diagnosis, biomechanical simulation, and planning of surgical treatments. These models can be generated by building 3D surfaces of the joint's structures segmented on magnetic resonance (MR) images. Deep learning can avoid time-consuming manual segmentations, but its performance depends on the amount and quality of the available training data. Data augmentation and transfer learning are two approaches used when there is only a limited number of datasets. In particular, data augmentation can be used to artificially increase the size and diversity of the training datasets, whereas transfer learning can be used to build the desired model on top of a model previously trained with similar data. This study investigates the effect of data augmentation and transfer learning on the performance of deep learning for the automatic segmentation of the femur and acetabulum on 3D MR images of patients diagnosed with femoroacetabular impingement. Transfer learning was applied starting from a model trained for the segmentation of the bony structures of the shoulder joint, which bears some resemblance to the hip joint. Our results suggest that data augmentation is more effective than transfer learning, yielding a Dice similarity coefficient compared to ground-truth manual segmentations of 0.84 and 0.89 for the acetabulum and femur, respectively, whereas the Dice coefficient was 0.78 and 0.88 for the model based on transfer learning. The Accuracy for the two anatomical regions was 0.95 and 0.97 when using data augmentation, and 0.87 and 0.96 when using transfer learning. Data augmentation can improve the performance of deep learning models by increasing the diversity of the training dataset and making the models more robust to noise and variations in image quality. The proposed segmentation model could be combined with radiomic analysis for the automatic evaluation of hip pathologies.

The purpose of this study was to determine if there is a difference in hip survivorship rates and patient-reported outcomes (PROs) at a 5-year follow-up after arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) between patients with versus without systemic inflammatory diseases (SIDs). A retrospective single-surgeon matched cohort study of FAIS patients who underwent hip arthroscopy and had a minimum of a 5-year follow-up was conducted. Subjects with SIDs were matched at a ratio of 2:3 of age and body mass index (BMI) with respect to controls without SIDs. Subjects completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) prior to surgery and at a 2-year and 5-year follow-up. Survival distributions for time to reoperation and to total hip arthroplasty (THA) were compared between groups using the log-rank test. Fifteen subjects with SIDs (mean age 41.5 years) were matched with twenty-five controls (41.8 years). There were no significant differences in reoperation rates (SIDs 27% vs. controls 20%, p = 0.71) or THA conversion rates (SIDs 7% vs. controls 12%, p = 1.00) at the 5-year follow-up, nor were there differences in survival distributions for reoperations (p = 0.72) or THAs (p = 0.55). There were no significant differences in postoperative mHHS (SIDs 79.3 vs. controls 88.5, p = 0.09) or NAHS (SIDs 82.7 vs. controls 89.3, p = 0.77) by the 5-year follow-up. At the 5-year follow-up, FAIS patients with comorbid SIDs experienced a significant clinical improvement from hip arthroscopy that is comparable to that of FAIS patients without SIDs.

PURPOSE/OBJECTIVE:Thisstudy sought to assessthe prognostic effect of preoperative symptom severity on hip arthroscopy outcomes for femoroacetabular impingement syndrome (FAI). METHODS:Patients undergoing hip arthroscopy between September 2012 and July 2014 for FAI with a minimum of 5-year clinical outcomes were compiled. Patient reported outcomes (PROs) including modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were collected. High and low preoperative function (PF) subgroups were created using baseline population median mHHS (43.3) as a threshold with PROs below the median score indicating low preoperative function and vice versa for scores above the median. Kaplan-Meier analysis, Cox proportional modeling, analysis of variance (ANOVA), and linear regressions were used for analysis. RESULTS:One hundred five of 131 eligible patients(80.2% inclusion; age: 42.6 ± 1.4 years; body mass index: 25.3 ± 0.4 kg/m2 ) met the study criteria. The 5-year survival-torevision rate (85% versus 61%, p = 0.013) and survivalto-arthroplasty rate (95% vs. 82%, p = 0.022) were greater in the high versus low PF group. ANOVA demonstrated the high versus low PF group had higher baseline (mHHS: 52.7 ± 1.4 vs. 36.1 ± 1.1, p < 0.001; NAHS: 57.4 ± 1.6 vs. 39.3 ± 1.2, p < 0.001) and 1-year (mHHS: 91.9 ± 1.8 vs. 79.5 ± 2.7, p < 0.001; NAHS: 91.7 ± 1.6 vs. 80.8 ± 2.5, p < 0.001) outcomes. High versus low PF achieved higher Minimal Clinically Important Difference (77% vs. 57%, p = 0.026) at 5-years. High versus low PF achieved higher Patient Acceptable Symptomatic State rates at 1 year (79% vs. 47%, p < 0.001) and 5 years (66% vs. 45%, p = 0.032). Linear regression demonstrated body mass index (mHHS: p = 0.002; NAHS: p = 0.005), pincer resection (mHHS: p = 0.046), and preoperative symptom severity (mHHS: p = 0.001; NAHS: p = 0.002) to be predictors of 5-year change in PROs. CONCLUSION/CONCLUSIONS:Preoperative symptom severity is a reliable prognostic indicator of clinical survival rates and PROs after hip arthroscopy for FAI. Subjects with high PF are likely to have increased longevity of the index procedure while maintaining excellent PASS and MCID rates mid-term as opposed to those with low PF.

PURPOSE/OBJECTIVE:To prospectively evaluate the effectiveness of the transmuscular quadratus lumborum block (TQLB) with pericapsular injection (PCI) versus PCI alone in patients undergoing hip arthroscopy for treatment of femoroacetabular impingement (FAI) in terms of perioperative pain control, as well as postoperative function in the postoperative anesthesia unit (PACU) setting. METHODS:Patients undergoing hip arthroscopy for FAI were prospectively randomized to receive 30 mL of 0.5% bupivacaine in a TQLB (n = 52) with PCI versus PCI alone (n = 51). The PCI included 20 mL of 0.25% bupivacaine given by the surgeon. All analyzed patients received general anesthesia. The primary outcome was postoperative pain scores assessed via the numerical rating scale (NRS) at 30 minutes postoperatively and immediately prior to discharge. Secondary outcomes were opioid utilization, expressed as morphine milligram equivalents (MMEs), PACU recovery time, quadriceps strength (assessed after completion of PACU phase 1 criteria), and adverse events (nausea/vomiting). RESULTS:Average age, body mass index, and preoperative pain assessment were not significantly different between groups. There were no differences in NRS pain scores preoperatively, 30 minutes postoperatively, or immediately prior to discharge between groups (P > .05). Intraoperative opioid consumption was significantly lower in the TQLB group (MME: 16.8 ± 7.9) compared to controls (MME 20.6 ± 8.0; P = .009). However, there was no difference in the total opioid consumption (P > .05). There was no significant difference in total PACU length of stay (minutes) between the treatment (133.0 ± 48) and control groups (123.5 ± 47; P > .05). Quadriceps weakness was not significantly different between groups (P = .2). There was no difference in the number of patients that experienced nausea or vomiting between the TQLB group and control group (13% vs 16%; P = .99). Neither group had any reported serious adverse events. CONCLUSIONS:TQLB and PCI do not improve postoperative pain scores or total opioid consumption compared to PCI alone. TQLB may decrease the amount of intraoperative opiate usage. LEVEL OF EVIDENCE/METHODS:Level I, randomized controlled trial.

PURPOSE/OBJECTIVE:The aims of the study were to (1) classify surgical centers in New York State (NYS) by volume of hip arthroscopies performed, (2) calculate rates of readmissions and complications by center volume, and (3) identify socioeconomic predictive factors for readmissions and complications following hip arthroscopy. METHODS:Patients who underwent hip arthroscopy at NYS health care facilities from 2010-2020 were retrospectively identified using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Hip arthroscopic procedures were identified using the following Current Procedural Terminology (CPT) codes. Surgical center volumes were classified into three categories: low (<85th percentile), medium (85th-95th percentile), and high (>95th percentile). Incidence of readmissions and complications within 90 days was abstracted from SPARCS. Neighborhood socioeconomic status was quantified using the U.S. Area Deprivation Index (ADI). Multivariable logistic regression was used to determine whether center volume and other socioeconomic variables were independent predictors of outcomes. RESULTS:50,252 hip arthroscopy patients were identified in SPARCS from 2010-2020. Of these patients, 13,861 (27.6%) underwent surgery at low-volume centers, 11,757 (23.4%) at medium-volume centers, and 24,634 (49.0%) at high-volume centers. Minorities, publicly-insured patients, and patients from lower socioeconomic status neighborhoods made up a larger proportion of cases seen by low-volume centers versus high-volume centers (p<0.001). Patients in the low-volume group experienced significantly higher 90-day rates of readmissions (p<0.001) and all-cause complications (p<0.001) than the other groups. Furthermore, high-volume centers were independently associated with lower odds of readmission (OR=0.57, p<0.001) and all-cause complications (OR=0.73, p<0.001) versus low-volume centers. CONCLUSION/CONCLUSIONS:Low-volume surgical centers are associated with increased readmission and complication rates following hip arthroscopy, independent of other socioeconomic factors such as age, sex, race, insurance status, and neighborhood socioeconomic status.

PURPOSE/OBJECTIVE:Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS. METHODS:A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model. RESULTS:Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03). CONCLUSION/CONCLUSIONS:Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts. LEVEL OF EVIDENCE/METHODS:III.