Faculty Bibliography

OBJECTIVE:There is a high prevalence of femoroacetabular impingement (FAI) amongst elite men's ice hockey players, yet little is known about the hips of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic cam-type FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the cam deformity and both menarchal age and hip range-of-motion (ROM). METHODS:Data were collected for NWHL players during pre-participation physicals. Alpha angles were measured on 45° Dunn radiographs, with alpha angles >55° defined as cam-positive. Pearson correlation coefficients (ρ) were performed to analyze the relationship between alpha angle and both ROM measurements and menarchal age, with statistical significance set at p<0.05. RESULTS:Twenty-six athletes were included. Twenty-four (92%) had alpha angles >55°; 20 players (77%) had bilateral cam deformity. Average menarchal age was 13.8 ±1.7 years. There was a significant association between age of menarche and alpha angle (ρ=0.36, p<0.02). There was no significant association between alpha angle and hip ROM, (p>0.05). CONCLUSION/CONCLUSIONS:Elite women's ice hockey players have a higher prevalence of cam-type morphology than the general population. The positive association between alpha angle and menarchal age lends additional support to the etiological hypothesis of the cam lesion resulting from activity-related stress at the proximal femoral physis during skeletal development. Professional women's ice hockey players have a high risk of developing cam-type morphology, although each player's menarchal age may mediate her individual risk for cam development.

PURPOSE/OBJECTIVE:To determine the mHHS and NAHS at 2 year follow up in patients that underwent staged bilateral hip arthroscopy versus age, sex, and Body Mass Index (BMI) matched patients that underwent unilateral hip arthroscopy. METHODS:Patients that underwent staged bilateral primary hip arthroscopy between January 2007 to December 2017 for the indication of Femoroacetabular Impingement (FAI) with a minimum 2 year follow-up were identified. The control group was comprised of patients that underwent a unilateral hip arthroscopy for FAI. The modified Harris Hip Score (mHHS) and the Non-Arthritic Hip Score (NAHS) were analyzed. RESULTS:Forty-two patients (84 hips) in the bilateral group were matched with 84 patients (84 hips) in the unilateral group. Both groups had significantly improved mHHS and NAHS when comparing preoperative scores to postoperative scores (bilateral group mHHS: 45.5 ± 15.1 to 81.7 ± 17.6, p <0.0001, bilateral group NAHS: 49.5 ± 13.8 to 83.6 ± 20.0, p <0.0001, unilateral group mHHS 48.5 ± 13.8 to 83.6 ± 15.9, p <0.0001, unilateral group NAHS 48.8 ± 12.0 to 85.0 ± 16.6, p <0.0001). The patient acceptable symptomatic state (PASS) was achieved in 57 hips (68%) in the bilateral group vs 62 hips (74%) in the unilateral group, p =0.4. Patients with bilateral hip arthroscopy that had < 17 months between index procedure and contralateral hip arthroscopy had significantly better mHHS and NAHS (85.5 ± 18.4 vs 75.71 ± 14.4, p = 0.013 for mHHS and 88.1 ± 17.1 vs 76.2 ± 22.4, p = 0.0074 for NAHS). CONCLUSIONS:Bilateral hip arthroscopy for the indication of FAI has improved mHHS and NAHS at 2 years of follow up compared to baseline. There was no difference in 2 year mHHS and NAHS in patients that underwent bilateral hip arthroscopy and unilateral hip arthroscopy. Patients in the bilateral hip arthroscopy group that had the contralateral surgery longer than 17 months from index procedure had lower 2 year follow up mHHS and NAHS scores than those that underwent the second surgery within 17 months of the index procedure.

BACKGROUND/UNASSIGNED:The practice of hip arthroscopy is increasing in popularity, which has highlighted the importance of identifying risk factors that predict hip arthroscopy outcomes. The literature suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip arthroplasty; however, the effect of lumbar spine disease on hip arthroscopy outcomes has not been fully investigated. At present, there is a paucity of literature investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip arthroscopy. PURPOSE/UNASSIGNED:To evaluate the outcomes of hip arthroscopy in patients with concomitant lumbar spine disease compared with those without a history of lumbar spine disease. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:test. RESULTS/UNASSIGNED:= .44). CONCLUSION/UNASSIGNED:Patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease.

PURPOSE/OBJECTIVE:This report examines 4-year patient reported outcomes and procedural survivorship in patients who underwent microfracture during hip arthroscopy compared to a matched group of non-microfracture patients as well as the risk factors for procedural failure following microfracture of articular lesions in the hip. METHODS:Data for 38 consecutive patients undergoing arthroscopic microfracture was retrospectively analyzed. Propensity score matching identified a matched group of hip arthroscopy patients who had Outerbridge grade 3 or grade 4 chondral lesions but did not undergo microfracture. Preoperative modified Harris Hip Scores (mHHS) and NonArthritic Hip Scores (NAHS) were compared to those at 2- and 4-year follow-up. Postoperative rates of ipsilateral revision arthroscopic surgery or hip arthroplasty were assessed. RESULTS:Thirty-three (86.8%) of the 38 microfracture patients were available for 4-year follow-up. Forty-six patients were matched with the microfracture group. Scores including mHHS and NAHS increased postoperatively for both groups (p < 0.05), though there were no significant differences between groups (p > 0.05). Overall reoperations rates were 24.2% and 21.7% (p = 0.873) for the microfracture and non-microfracture groups, respectively. Hip arthroplasty rates were higher among microfracture patients (18.2% vs. 2.2%, p = 0.038), wherein Tonnis grade ≥ 2, cartilage lesions ≥ 400 mm2 , and femoral-sided lesions were associated with failure. CONCLUSIONS:Patients who underwent microfracture treatment of chondral lesions fared no better than a matched group of patients who did not receive microfracture treatment. Risk of reoperation is high for both groups and microfracture patients are more likely to require conversion to total hip arthroplasty or hip resurfacing.

PURPOSE/OBJECTIVE:To evaluate post-operative outcomes and pre-operative risk factors for patients with underlying systemic inflammatory disorders (SID) after hip arthroscopy. METHODS:A retrospective analysis of patients that had undergone hip arthroscopy, with a history of systemic inflammatory disease. This included patients with a diagnosis of lupus, positive ANA, rheumatoid arthritis, psoriatic arthritis, sarcoidosis, inflammatory bowel disease, Reiter Syndrome, mixed connective tissue disease (MCTD). These cases were 1:2 matched to a control group of patients with no history of systemic inflammatory disease based on age and sex. An a-priori power analysis was conducted and A 1:2 case-control ratio was selected in order to increase study power. Inclusion criteria included all skeletally-mature patients with hip pain refractory to non-operative management who underwent hip arthroscopy for labral tears and femoroacetabular impingement (FAI). Skeletally immature patients, those with Tonnis grades of 2 or more (less than 2mm of joint space), hip dysplasia, patients undergoing revision hip arthroscopy, and patients whose pain failed to improve after intra-articular injection were excluded. The primary outcome was rate of revision hip arthroscopy or total hip arthroplasty 24 months after surgery. Secondary outcomes included two patient-reported outcome (PRO) scores, modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS). RESULTS:Twenty patients (21 hip arthroscopy procedures) and 42 controls were included. There was no significant difference in proportion of patients who met failure criteria (28.6% vs 16.7%,p=0.271) or two-year survivorship (76.2% vs 83.3%, p=0.496) between the SID and control groups, respectively. Both groups had a significant improvement in modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS) at 24-months compared to baseline, however, there was no significant difference in mHHS (p=0.28) or NAHS (p=0.22) at 24-months between the two groups. CONCLUSION/CONCLUSIONS:Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared to patients with no history of inflammatory disease. LEVEL OF EVIDENCE/METHODS:This is a retrospective comparative study, Level of Evidence III.

We present a 24-year-old male who developed an infected hematoma that resulted in sciatic nerve injury after he underwent an endoscopic sciatic nerve decompression. He underwent urgent hematoma evacuation and cultures speciated as Salmonella. At 4 months' follow-up, the patient's nerve had improved motor and sensory function. This case highlights the importance of obtaining appropriate hemostasis at the end of an endoscopic sciatic nerve decompression.

PURPOSE/OBJECTIVE:To determine if magnetic resonance angiography (MRA) and/or magnetic resonance imaging (MRI) could accurately determine the width of the labrum. METHODS:Consecutively enrolled patients between the ages of 18 and 65 indicated for hip arthroscopy for femoroacetabular impingement were included between December 2017 and June 2018. Inclusion criteria for preoperative MRIs included: MRI availability in picture archiving and communication system; performance on a 1.5T or 3T MRI or 3T MRA; and adequate quality and lack of labrum ossification. Intraoperative labral width measurements were taken at standardized locations using an established acetabular "clockface" paradigm. Measurement was performed using a calibrated probe. The labral width was defined as the distance from the labrum extended laterally from the acetabular rim. MRI measurements were taken by 2 blinded musculoskeletal fellowship-trained radiologists at the same positions. Measurements were made at the 11:30 o'clock position (indirect rectus) on coronal proton density (PD) sequence, at 3 o'clock position (psoas-U) on axial oblique PD sequence, and at 1:30 (a point halfway between the 2) on sagittal fat-suppressed PD. The surgeons were blinded to the radiologists' measurements and vice versa. Intraoperative and radiographic labral width measurements were compared using an intraclass correlation coefficients (ICC), absolute agreement, and 2-way random effects model. The 2 radiologists' measurements were compared for interrater reliability using the same ICC model. RESULTS:Fifty-one patients were included (30 females, 26 right hips). Average labrum width at the 3:00, 11:30, and 1:30 o'clock positions by arthroscopic measurement were 5.8 mm (range; standard deviation, 2-8; ±1.4), 6.3 mm (2-10; ±1.5) and 6.0 mm (2-9; ±1.5), and by MRI were 6.3 mm (2-10; ±1.5), 6.7 mm (3-10; ±1.4), and 6.1 mm (2-9; ±1.6), respectively. When including all MRI modalities, ICC agreement between intraoperative assessment, and radiologist assessment at the 3:00 o'clock, 11:30, and point halfway between was 0.82 (P < .001), 0.78 (P < .001), 0.84 (P < .001), respectively. Radiologist interrater ICC agreement at the same points was 0.88 (P < .001), 0.93 (P < .001), and 0.88 (P < .001). CONCLUSIONS:Strong agreement was found between radiologic and arthroscopic measurement of labrum width when using MRI, suggesting MRI is an accurate way to measure labral width. There was not a significant difference between different MRI modalities. Accurately measuring labral width preoperatively with MRI may aid in surgical decision making. LEVEL OF EVIDENCE/METHODS:Level II, diagnostic study.

BACKGROUND/UNASSIGNED:Iliopsoas tendinitis is a known source of extra-articular hip pain and it has been shown to be a common cause of continued hip pain following total hip arthroplasty. While iliopsoas tendinitis after hip arthroscopy is a well-known phenomenon amongst hip arthroscopists, its presentation, course, and treatment has yet to be elucidated. METHODS/UNASSIGNED:An IRB-approved chart review was performed of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between March 2015 and July 2017. No cases of dysplasia were included. All patients had combined cam/pincer impingement as well as labral pathology. Tendinitis patients were identified. Patient demographics, surgical data, time to onset/diagnosis of iliopsoas tendinitis, treatment (oral anti-inflammatories, corticosteroid injection, physical therapy), and resolution of symptoms were recorded. These cases were age- and sex-matched to a control group that did not develop postoperative iliopsoas tendinitis for comparison. Patient outcomes were measured with the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) recorded from the preoperative and 1-year postoperative visits. RESULTS/UNASSIGNED: = 0.09) scores at their 1-year postoperative visits. CONCLUSIONS/UNASSIGNED:Iliopsoas tendinitis is a common source of pain following arthroscopic hip surgery and can be effectively diagnosed and treated with ultrasound-guided injection. Therefore, surgeons performing arthroscopic procedures of the hip must remain aware of and include it in their differential when encountering patients with hip flexion pain after surgery. Research should be continued to further evaluate the long-term outcomes and return to sport rates of these patients.

PURPOSE/OBJECTIVE:To determine whether patients who reported a discrete traumatic event precipitating the onset of femoroacetabular impingement syndrome (FAIS) reported similar patient-reported outcomes for the modified Harris Hip Score (mHHS) and the Non-Arthritic Hip Score (NAHS) following hip arthroscopy as patients with atraumatic hip pain associated with FAIS alone. METHODS:A retrospective comparative therapeutic investigation of a prospectively collected database of cases performed by a single surgeon from 2010 to 2015 identified a group of patients who developed FAIS after a discrete traumatic event. This group was compared 1:2 with a body mass index and age-matched group of primary hip arthroscopies with atraumatic hip pain attributed to FAIS. Preoperative mHHS and NAHS were obtained and compared with those at 2-year follow-up. Clinical failure at 2 years was defined as any further ipsilateral hip surgery including revision arthroscopy and conversion to arthroplasty. RESULTS:In the traumatic etiology group, the mean mHHS and NAHS improved from 49.6 to 82.7 (P < .001) and from 46.9 to 84.0 (P < .001), respectively. The mean mHHS and NAHS in the atraumatic group improved from 51.5 to 85.82 (P < .001) and from 49.3 to 85.2 (P < .001), respectively. Survivorship at 2 years was 81.1% for traumatic etiology and 88.3% for atraumatic etiology; adjusted proportional hazards regression analysis demonstrated a difference in survivorship that was not statistically significant between the traumatic and atraumatic cohorts (hazard ratio 1.8, 95% confidence interval 0.8-4.0). CONCLUSIONS:The findings of this study demonstrate that patients presenting with FAIS and history of a traumatic hip injury can expect to experience similar good outcomes at 2 years following primary hip arthroscopy as compared with patients with atraumatic FAIS. LEVEL OF EVIDENCE/METHODS:Level III (Therapeutic) retrospective comparative study.

PURPOSE/OBJECTIVE:To determine when patients reach critical thresholds of clinical improvement after hip arthroscopy for femoroacetabular impingement (FAI) using previously defined cutoffs for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) and to identify risk factors for prolonged recovery. METHODS:Consecutive patients with a diagnosis of FAI who underwent unilateral hip arthroscopy between January 2010 and January 2015 with at least 2 years of clinical follow-up were studied. The modified Harris Hip Score was collected prospectively at 6 consecutive time points. The number of patients reaching the MCID and PASS at each time point was determined. RESULTS:During the study period, 340 consecutive hip arthroscopies were performed in 316 patients with a mean final follow-up period of 50 months (range, 29-84 months). The mean modified Harris Hip Score and percentage of patients reaching the MCID and PASS increased at each time point. At 2 years, 271 patients (93%) surpassed the MCID and 212 patients (73%) achieved the PASS. Female sex, age of 40 years or older, and body mass index of 30 or greater were associated with lower rates of achieving the MCID and PASS at set time points. Patients undergoing labral repair had superior PASS rates at 3 months and beyond than patients undergoing labral debridement alone. Patients who did not achieve the PASS by 3 months were more likely to require reoperation. CONCLUSIONS:Hip arthroscopy for FAI results in increased patient-reported outcome measures at interval follow-up. Most patients reach critical thresholds of minimal and satisfactory clinical improvement. Patients who are female, older, or obese or who undergo labral debridement alone are less likely to reach these milestones at major time intervals. Patients who do not reach the PASS by 3 months are more likely to require reoperation. LEVEL OF EVIDENCE/METHODS:Level IV, therapeutic case series.