Faculty Bibliography

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to understand their correct usage and definitions. In this second part of a 2-part review, we describe the history of eponym usage in the radiography of the adult hip; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to adult hip radiography.

Purpose: To describe the clinical and patient-reported outcomes of heterotopic ossification (HO) excision as well as the results of a standardized HO prophylaxis protocol among a group of patients who previously underwent open or arthroscopic hip surgery. Methods: Patients who developed HO after index hip surgery and were subsequently treated with arthroscopic excision of HO and postoperative HO prophylaxis using 2 weeks of indomethacin and radiation were retrospectively identified. All patients were seen by a single surgeon and were treated with the same arthroscopic technique. Patients were also placed on a regimen of 2 weeks of indomethacin 50 mg and radiation therapy with 700 cGy in one fraction on the first postoperative day. Outcomes assessed included recurrence of HO and conversion to total hip arthroplasty by latest follow-up. Other outcomes included Modified Harris Hip Scores and Non-Arthritic Hip Scores, which were collected preoperatively and at 1-year and 2-year follow-up. Results: There were 5 female and 9 male subjects, with an average age of 39 years (range 22-66) and average body mass index of 27.1 (19.1-37.5). Average follow-up time was 46 months (range 4-136). No patients had experienced HO recurrence by latest follow-up. Only 2 patients converted to total hip arthroplasty, one at 6 months and the other at 11 months postexcision. Average outcome scores improved by 2-year follow-up (average Modified Harris Hip Scores 52.8 improved to 86.5, average Non-Arthritic Hip Scores 49.4 improved to 83.8). Conclusions: Minimally invasive arthroscopic excision of HO and postoperative prophylaxis with combined indomethacin and radiation therapy effectively treats and prevents the recurrence of HO. Level of Evidence: Level IV, case series, therapeutic.

BACKGROUND:Magnetic resonance imaging (MRI) is an integral component of the treatment algorithm for proximal hamstring avulsion injuries. OBJECTIVE:The purpose of this study was to survey orthopedic surgeons and musculoskeletal radiologists on the reporting and analysis of proximal hamstring avulsions on MRI. METHODS:Two online surveys were developed to evaluate musculoskeletal radiologists' and orthopedic surgeons' perceptions of MRI-reporting for proximal hamstring avulsion injuries. Each survey was designed to provide information on physicians' best practices with respect to four primary questions (1) ischial tuberosity landmark determination (2) difficulties associated with measuring tendon retraction, (3) important ancillary findings, and (4) perceived clinical impact of measured retraction. Descriptive statistics were calculated for all categorical variables, which were reported as frequencies with percentages. Chi-squared test was utilized to compare rates of responses between surgeons and radiologists. Statistically significant differences were analyzed with post-hoc Fisher's exact tests; p < 0.05 considered statistically significant. RESULTS:218-Musculoskeletal radiologists and 33-orthopedic surgeons responded to their respective surveys. There were statistically significant differences with responses to two of the questions asked in both surveys; (1) in cases of complete hamstring avulsion (avulsion of both the semimembranosus and conjoint tendon), which arrow represents the tendon gap measurement used for planning surgery? p = 0.028; (2) in cases of avulsion of only the conjoint tendon, which arrow represents the tendon gap measurement used for planning surgery? p = 0.013. Post-hoc testing demonstrated that for either partial or complete hamstring avulsions, more surgeons use the conjoint tendon origin to measure tendon retraction than radiologists (p < 0.05 for both). Significantly more radiologists use the semimembranosus origin to measure hamstring retraction for partial or complete hamstring tears (p < 0.05 for both). However, for each of these questions, both radiologists and surgeons most frequently stated that the conjoint tendon landmark should be used for surgical planning. CONCLUSION/CONCLUSIONS:Musculoskeletal radiologists and orthopedists frequently utilize the conjoint tendon origin as an anatomic landmark for measuring complete and partial proximal hamstring avulsion injuries; though, orthopedists are more likely to utilize this landmark. Additionally, the broad surface area of the ischial tuberosity may lead to variability in measurement. CLINICAL IMPACT/CONCLUSIONS:Standard landmarks at the ischial tuberosity and/or detailed descriptions of tendon retractions would improve communication between radiologists and surgeons for proximal hamstring avulsions.

PURPOSE/OBJECTIVE:To determine whether the presence of spine pathology affects clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in the setting of hip-spine syndrome (HSS). METHODS:A systematic review of PUBMED and Cochrane was conducted. Primary research articles evaluating patient-reported outcomes (PRO) after hip arthroscopy for FAIS in the presence of concomitant spine pathology were considered. RESULTS:Literature review identified twelve studies meeting criteria. In 2109 FAIS patients undergoing hip arthroscopy, 591 had concomitant spine pathology. Baseline PROs in the hip-spine (mHHS: 39.8-65.29 versus 56.9-78.8, 8 studies; NAHS: 42.2-51.5 versus 68.2-75.2, 4 studies; HOS-ADL: 45.9-71.1 versus 49.3-89.51, 9 studies; HOS-Sport: 22.8-49.6 versus 50.6-73.1, 3 studies; iHOT-12: 38.0 versus 66.0, 1 study; VAS Pain: 6.43-6.56 versus 1.18-3.60, 3 studies; VAS Satisfaction: 7.18-7.46 range at follow up, 2 studies) and control (mHHS: 39.3-64.9 versus 70.2-92.6, 6 studies; NAHS: 42.8-54.2 versus 74.0-87.1, 4 studies; HOS-ADL: 59.0-76.4 versus 75.4-97.1, 4 studies; HOS-Sport: 38.1-55.1 versus 60.9-93.9, 3 studies; iHOT-12: 43.4 versus 89.8, 1 study; VAS Pain: 6.18-6.22 versus 1.82-3.44, 2 studies; VAS Satisfaction: 7.74-8.22 range at follow up, 2 studies). Minimal clinically important difference threshold rates achieved in the hip-spine (44.1-86.7, 4 studies) cohorts were significantly lower than control (79.4-88.2%; 4 studies) cohorts in 3 studies. Patient acceptable symptomatic state threshold rates achieved in the hip-spine (42-63.5, 3 studies) cohorts were significantly lower than control (58.8-81.0, 3 studies) in 1 study. There was no statistical difference in complication and re-operation rates between cohorts. CONCLUSION/CONCLUSIONS:FAIS patients with concomitant HSS have improved but inferior outcomes after hip arthroscopy compared to patients without HSS.

INTRODUCTION/BACKGROUND:Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS/METHODS:Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS:Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = - 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS:This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate out- comes of hip arthroscopy for femoroacetabular impingement (FAI) in female patients at 5-year follow-up. The working hypothesis for this study was that increased age and body mass index (BMI) would be associated with poor outcomes. METHODS:This study included all female patients 14 years and older who underwent primary hip arthroscopy for FAI with 5-year patient-reported outcome scores. Patients were separated into three age-based cohorts (< 30 years old, 30 to 45 years old, and > 45 years old) for subsequent statistical analysis. This analysis included a comparison of patient demographic information, intraoperative pathology, and functional outcome scores (modified Harris Hip Score [mHHS] and nonarthritic hip score [NAHS]). Statistically significant values were utilized in a regression-based analy- sis to determine predictors of 5-year outcomes in female patients. A p-value of < 0.05 was considered to be statisti- cally significant. RESULTS:Overall, 97 patients met the inclusion criteria, and there was no significant difference in patient demo- graphics (other than age and BMI) or in intraoperative pathologies identified. There were no significant difference across the three groups for mHHS and NAHS at baseline (p > 0.05). At baseline, there were no statistically significant differences between groups for NAHS scores, however < 30-year-old and 30- to 45-year-old cohorts had superior final NAHS scores relative to the > 45-year-old cohort (p = 0.005). At 5-year follow-up, the NAHS scores were significantly better for patients under 30 and 30 to 45 year olds relative to patients over 45 (84.2 ± 15.1 vs. 86.7 ± 11.0 vs. 71.9 ± 26.8, respectively; p = 0.005). Overall, 88 patients (91%) met the minimal clinically important differ- ence (MCID), and 60 patients (62%) achieved the patient acceptable symptomatic state (PASS). Baseline mHHS and BMI were shown to be statistically significant predictors of achieving MCID at 5 years in multivariate analysis (p < 0.001). CONCLUSION/CONCLUSIONS:The results of this study suggest that women generally have good-to-excellent outcomes following hip ar- throscopy, although females older than 45 may have inferior outcomes relative to younger patients, and BMI and baseline mHHS may be utilized to predict long-term improvement.

Pelvic floor dysfunction (PFD) describes a broad spectrum of clinical conditions that affect the viscera and musculature of the pelvic cavity. Though musculoskeletal pathologies have been implicated in various forms of PFD, orthopedic surgeons are not routinely consulted for the management of patients with pelvic symptomatology. Muscle dysfunction in PFD can be broadly classified into hypertonic or hypotonic conditions, each with their own associated symptoms. Pelvic musculoskeletal dysfunction may also present differently between males and female given gender differences in pelvic structure. In addition to the standard orthopedic history, physical examination maneuvers may be able to distinguish hip, spine, and sacroiliac joint dysfunction contributing to PFD. For certain etiologies of PFD, non-operative and/or operative orthopedic intervention may help to alleviate functional symptoms such as urinary incontinence and sexual dysfunction. The available research highlights the importance of a multidisciplinary approach to treating PFD that includes orthopedic expertise, as well as the need for further research to assess the impact of orthopedic intervention on concomitant PFD symptoms, develop appropriate surgical indications, and achieve better outcomes for this patient population.
Copyright

Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.

BACKGROUND/UNASSIGNED:Hip arthroscopy is a procedure commonly performed to correct various hip pathologies such as femoroacetabular impingement and labral tears. These hip pathologies commonly affect young, otherwise healthy patients. The recovery after hip arthroscopy can prevent patients from returning to work and impair performance levels, having significant economic repercussions. To date, there has been no cumulative analysis of the existing literature on return to work after hip arthroscopy. PURPOSE/UNASSIGNED:The purpose of this study was to perform a systematic review of the existing literature regarding return to work after hip arthroscopy and analysis of factors associated with the ability to return to work and time to return to work. STUDY DESIGN/UNASSIGNED:Systematic review and meta-analysis; Level of evidence, 4. METHODS/UNASSIGNED:< .05 was considered statistically significant. RESULTS/UNASSIGNED:Twelve studies with 1124 patients were included. Patients were followed for an average of 17.6 months. Using weighted means, the average rate of return to work was 71.35%, while full return to previous work duties was achieved at a rate of 50.89%. Modification to work duties was required at a rate of 15.48%. On average, the time to return to work was 115 days (range, 17-219 days). Rate of return by patients with workers' compensation status was found to be 85.15% at an average of 132 days (range, 37-211 days). Rate of return to work in workers performing professions reported as strenuous vs light (ie, mostly sedentary) jobs showed a statistically higher return to work in light professions (risk ratio, 0.53; 95% CI, 0.41-0.69). CONCLUSION/UNASSIGNED:After hip arthroscopy, there is a high rate of return to work at an average of 115 days after surgery. However, full return to work was achieved by only half of patients upon final follow-up.

Although hip arthroscopy has been around for decades, recent developments in the understanding of hip pathology and surgical technique have led to the evolution of how labral pathology is addressed. Femoroacetabular impingement (FAI) is the primary condition that hip arthroscopy can treat and is described as the mechanical conflict between the femoral neck and acetabulum due to bony morphology. As a result, the labrum endures increased stress and is subject to disruption of its biomechanical properties, which leads to tearing, destabilization of the chondral-labral junction, and loss of the suction seal effect of the hip joint. This review provides an overview of current practices in the diagnosis and treatment of labral pathology. The 4 "R"s of labrum management are described: resect, repair, reconstruct, and replace.