Faculty Bibliography

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.

Acetabular rim fractures can accompany patients with femoroacetabular impingement. Frequently, the acetabular rim fracture is excised. However, if the osseous fragment of the acetabular rim fracture is large enough to result in instability, then the acetabular rim fracture should be reduced and secured with internal fixation. The purpose of this technical note was to describe the arthroscopic technique of internal fixation of an acetabular rim fracture.

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.

PURPOSE/OBJECTIVE:To evaluate the association between postoperative cam lesion measured by the "femoroacetabular impingement resection (FAIR) arc" and 2-year patient outcomes following hip arthroscopy. METHODS:A retrospective review of prospectively gathered data from 2013-2017 was performed. All patients who underwent hip arthroscopy for FAI with ≥ 2-year follow-up were included. Cam FAIR arc measurements were made pre and postoperatively on a 45° Dunn view radiograph. The clinical effect of postoperative cam maximal radial distance (MRD) was assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were divided into subgroups based on relationship to the mean and standard deviations for cam MRD. One half standard deviation above the mean was found to be 3.15 mm. RESULTS:=0.004). Subgroup analysis demonstrated that patients in the cam MRD < 3.15 mm group had significantly higher mHHS (89.7 vs 70.0 p<0.001) and NAHS scores (90.5 vs 72.9, p<0.001) than those in the >3.15 mm group. Additionally, more patients in the <3.15 mm group reached the minimal clinically important difference (MCID) (95.2% vs 78.9%, p=0.048) and were above patient acceptable symptomatic state (PASS) (95.2% vs 52.6%, p<0.001) compared to the >3.15 mm group. CONCLUSION/CONCLUSIONS:Patients with a lower postoperative cam MRD relative to the FAIR arc demonstrated significantly improved outcomes as compared to those with higher postoperative MRD at two-year follow-up.

Purpose/UNASSIGNED:The purpose of this study was to systematically review the evidence in the literature to ascertain whether acetabular labral repair (ALR) or debridement (ALD) resulted in superior patient outcomes. Methods/UNASSIGNED:value <.05 was considered to be statistically significant. Results/UNASSIGNED:There were 8 studies included (level of evidence [LOE] I = 1; LOE II = 2; LOE III = 5). The 7 studies compared 364 patients (369 hips) with ALR to 318 patients (329 hips) with ALD, with a mean follow-up time ranging between 32-120 months. Five studies found significantly improved patient reported outcomes with ALR (Harris Hip Score, Merle d'Aubigné, Pain, SF-12). Several studies compared the outcomes after ALR and ALD and found statistical significance in all investigated metrics in favor of ALR. One study found a significant improvement in abduction but no other study found any difference in range of motion. No study found any difference in complication rate, revision rate or conversion to total hip arthroplasty. Although, 2 studies found ALR reduced the rate of osteoarthritic progression. Conclusion/UNASSIGNED:Current literature suggests that acetabular labral repair may result in superior patient reported outcomes. However, there appears to be no significant difference in the rate of progression to total hip arthroplasty at up to 10-year follow-up. Level of Evidence/UNASSIGNED:Level III, systematic review of Level I, II, and III studies.

PURPOSE/OBJECTIVE:To determine if early PRO improvements in the 6 months after surgery are predictive of achieving a patient acceptable symptomatic state (PASS) at 2 years. METHODS:A prospectively collected database was retrospectively reviewed. Inclusion criteria included patients ≥ 18 years of age, Tonnis grade 0 or 1 changes, radiographic imaging consistent with FAI or labral pathology, a primary diagnosis of symptomatic FAI for which they underwent primary hip arthroscopy and had baseline, 6 month and 2 year modified Harris Hip Score (mHHS) scores. Revision cases were excluded. ROC curve analysis was conducted to determine if 6month changes in mHHS was a predictor for achieving PASS at 2 years. RESULTS:There were 173 patients (mean age: 39.8, 61.8% females) included within the study. Patients who do not achieve the minimal clinically important difference (MCID), defined as a change of 8 points in mHHS, by 6 months (n = 21) tended to have significantly lower mHHS scores at 1 year and 2 years compared to those that did (n = 152). Only 52% of patients that did not achieve MCID by 6 months achieved MCID by 2 years (vs. 98% for those that did) and only 24% achieved PASS by 2 years (vs. 88% that did). Using the MCID as a cutoff for improvement in mHHS at 6 months results in a 96% sensitivity but 47% specificity for predicting PASS achievement at 2 years. Using 24 points of improvement in mHHS as a cutoff at 6 months improves sensitivity and specificity to 81% and 80%, respectively. CONCLUSIONS:Early improvement in mHHS scores are associated with 2 year outcomes. Patients who do not achieve MCID within 6 months of surgery have a high rate of not achieving PASS at 2 years.

BACKGROUND/UNASSIGNED:Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy. PURPOSE/UNASSIGNED:To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes. STUDY DESIGN/UNASSIGNED:Systematic review; Level of evidence, 4. METHODS/UNASSIGNED:A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software. RESULTS/UNASSIGNED:Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy. CONCLUSION/UNASSIGNED:The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.