Faculty Bibliography

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.

BACKGROUND/UNASSIGNED:Patients with symptomatic femoroacetabular impingement (FAI) typically have anterior groin pain. However, a subset of these patients may have pain located laterally, posteriorly, or in a combination of locations around the hip. PURPOSE/UNASSIGNED:To report and compare outcomes of hip arthroscopy for patients with FAI and atypical hip pain versus classic anterior groin pain. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 2. METHODS/UNASSIGNED:Consecutive patients undergoing hip arthroscopy for FAI between August 2011 and March 2013 were identified. A total of 258 patients were identified as having symptomatic FAI based on clinical, radiographic, and advanced imaging diagnosis of FAI. Exclusion criteria included isolated thigh, knee, or low back pain. We also excluded patients with hip abductor pathology and trochanteric bursitis. Of the 226 patients ultimately included, 159 (70.4%) reported anterior groin pain, while 67 (29.6%) reported isolated lateral or posterior hip pain or a combination of locations. Patients were categorized into 4 groups: isolated anterior groin pain, lateral hip pain, posterior hip pain, and multiple primary hip pain locations (combined). These patients were followed prospectively with a minimum follow-up of 2 years. Patient characteristics, surgical characteristics, modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), revision hip arthroscopy, and conversions to total hip arthroplasty (THA) were recorded. RESULTS/UNASSIGNED:All 226 patients were included at final follow-up. Hip arthroscopy was performed by a single sports medicine fellowship-trained orthopaedic surgeon. Preoperative patient characteristics and baseline functional outcome scores did not significantly differ among groups. All 4 groups showed statistically significant improvements in mHHS and NAHS from baseline to final follow-up of a mean 2.63 years (range, 2.01-3.23 years). Functional outcome scores and rates of revision hip arthroscopy or conversion to THA did not significantly differ between groups. CONCLUSION/UNASSIGNED:Hip arthroscopy can effectively improve patient outcomes in atypical hip pain. A careful history and physical examination should identify this clinically meaningful subset of patients with FAI who can benefit from surgical intervention while identifying patients with concomitant posterior extra-articular hip or spine pathology that should be addressed appropriately.

Background The MRI manifestations of subspine impingement (SSI) other than morphologic features of anterior inferior iliac spine (AIIS) have not been extensively explored and validated. Purpose To determine the MRI findings associated with SSI, including AIIS morphologic features, femoral distal cam, and associated soft-tissue injuries. Materials and Methods This is a retrospective study of symptomatic patients who underwent arthroscopic treatment for femoroacetabular impingement between December 2014 and March 2017, with preoperative MRI within 6 months before surgery. The SSI group included patients with clinical and intraoperative findings of SSI; the remaining patients comprised the non-SSI group. Preoperative MRI findings were independently assessed by two radiologists who were blinded to clinical information. Interreader agreement was assessed, and multivariable logistic regression was also used. Results A total of 62 patients (mean age ± standard deviation, 42.1 years ± 11.9; 38 women) were included. SSI was diagnosed in 20 of the 62 patients (32%) (mean age, 43 years ± 12); 42 patients (68%) did not have SSI (mean age, 41 years ± 10). Reader 1 detected distal cam in 16 of the 20 patients with SSI (80%) and eight of the 42 patients without SSI (19%), and reader 2 detected distal cam in 15 of the 20 patients with SSI (75%) and eight of the 42 patients without SSI (19%) (P < .001 for both). Reader 1 detected signs of impingement on the distal femoral neck (IDFN) in 18 of the 20 patients with SSI (90%) and seven of the 42 patients without SSI (16%), and reader 2 detected signs of IDFN in 13 of the 20 patients with SSI (65%) and nine of the 42 patients without SSI (21%) (P < .001 and P = .001, respectively). Reader 1 detected superior capsular edema in 15 of 20 patients with SSI (75%) and three of 42 patients without SSI (7%), and reader 2 detected superior capsular edema in 17 of 20 patients with SSI (85%) and 22 of 42 patients without SSI (52%) (P < .001 and P = .02, respectively). Distal cam was a predictor of SSI after adjustment for IDFN. Interreader agreement was substantial for distal cam (κ = 0.80) and moderate for IDFN (κ = 0.50). Conclusion Soft-tissue injuries and osseous findings other than morphologic features of the anterior inferior iliac spine were associated with subspine impingement. © RSNA, 2019 See also the editorial by Guermazi in this issue.