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Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification

Li, Zachary I; Buldo-Licciardi, Michael; Moore, Michael; Kanakamedala, Ajay; Burke, Christopher J; Samim, Mohammad M; Youm, Thomas
INTRODUCTION/BACKGROUND:Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures. MATERIALS AND METHODS/METHODS:This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores. RESULTS:Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (β = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (β = - 0.75; p = 0.037). CONCLUSIONS:The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.
PMID: 38480556
ISSN: 1434-3916
CID: 5646612

Borderline Hip Dysplasia Is Not Associated With Significant Differences in Hip Survivorship or Patient-Reported Outcomes Following Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Cohort Study

Li, Zachary I; Shankar, Dhruv S; Akpinar, Berkcan; Rynecki, Nicole D; Garra, Sharif; Vasavada, Kinjal D; Lin, Charles C; Youm, Thomas
PURPOSE/OBJECTIVE:To compare hip survivorship and patient-reported outcomes after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients with versus without comorbid borderline hip dysplasia (BHD) at 2-year follow-up. METHODS:A retrospective matched-cohort study was conducted involving patients who underwent primary hip arthroscopy for FAIS with a single surgeon from 2010 to 2019. BHD was defined as lateral center edge angle (LCEA) of 20 to 25°. Subjects with BHD were matched 1:2 to controls without BHD on age, sex, body mass index, and preoperative modified Harris Hip Score (mHHS). Alpha angle, LCEA, Tönnis angle, and acetabular retroversion signs were measured on preoperative and/or postoperative hip radiographs. Patient-reported outcomes were assessed using the mHHS and the Non-Arthritic Hip Score. Hip survivorship, outcome scores, and achievement of the minimum clinically important difference were compared between groups using the Mann-Whitney U test or Fisher exact test, as appropriate. P values <.05 were considered significant. RESULTS:Thirty-one BHD subjects (mean age 36.8 years, 71.0% female) and 62 controls (mean age 38.0 years, 71.0% female) were included. There were no significant intergroup differences in demographics or preoperative radiographic measurements besides LCEA and Tönnis angle (all P > .05). Intraoperatively, subjects with BHD were found to have significantly shorter labral tears (mean 2.6 vs 2.8 clock-face hours, P = .048), but there were no significant intergroup differences in acetabular or femoral cartilage status (all P > .05). Postoperatively, there were no significant intergroup differences in rates of revision arthroscopy (BHD 6.5% vs control 11.3%) or conversion to total hip arthroplasty (BHD 9.7% vs control 1.6%), in 2-year improvement of the mHHS and Non-Arthritic Hip Score, or in minimum clinically important difference achievement rates (all P > .05). CONCLUSIONS:BHD is not associated with a significant difference in hip survivorship or patient-reported outcomes following primary hip arthroscopy for FAIS. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.
PMID: 37716631
ISSN: 1526-3231
CID: 5593362

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes

Shankar, Dhruv S; Bi, Andrew S; Buldo-Licciardi, Michael; Rynecki, Nicole D; Akpinar, Berkcan; Youm, Thomas
PURPOSE/OBJECTIVE:The purpose of our study was to evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS:We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. RESULTS:In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P = .03) and NAHS (P = .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (β = -1.14, P = .02) and NAHS (β = -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR] = 0.82, P = .02) and NAHS MCID (OR = 0.88, P = .04). Older age was predictive of reduced improvement in NAHS (β = -0.31, P = .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR = 3.98, P = .02). CONCLUSIONS:Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative prognostic trial.
PMID: 37394153
ISSN: 1526-3231
CID: 5538932

A Superolateral Cam Lesion Location Increases Odds of Total Hip Arthroplasty 5 Years After Hip Arthroscopy

Buldo-Licciardi, Michael; Shankar, Dhruv S; Akpinar, Berkcan; Montgomery, Samuel R; Vasavada, Kinjal D; Savage-Elliott, Ian; Youm, Thomas
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.
PMID: 37579955
ISSN: 1526-3231
CID: 5667732

Global Acetabular Retroversion Is Not Associated With Differences in Outcomes After Primary Hip Arthroscopy Among Patients With Femoroacetabular Impingement Syndrome: A Matched Cohort Study With Minimum 5-Year Follow-Up

Savage-Elliott, Ian; Shankar, Dhruv S; Li, Zachary I; Moore, Michael; Vasavada, Kinjal D; Akpinar, Berkcan; Youm, Thomas
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.
PMID: 37579957
ISSN: 1526-3231
CID: 5667742

Patient Satisfaction with Postoperative Telemedicine Versus In-Office Visits Following Primary Hip Arthroscopy: A Prospective Observational Study Before and During the COVID-19 Pandemic

Shankar, Dhruv S; Li, Zachary I; Hoberman, Alexander R; Blaeser, Anna M; Gonzalez-Lomas, Guillem; Youm, Thomas
PMID: 37585554
ISSN: 1556-3669
CID: 5635342

The impact of data augmentation and transfer learning on the performance of deep learning models for the segmentation of the hip on 3D magnetic resonance images

Montin, Eros; Deniz, Cem M.; Kijowski, Richard; Youm, Thomas; Lattanzi, Riccardo
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.
SCOPUS:85182365313
ISSN: 2352-9148
CID: 5629782

No difference in prevalence of postoperative iliopsoas tendinitis in patients undergoing arthroscopic hip surgery when using absorbable versus non-absorbable suture for capsular closure

Moore, Michael; Savage-Elliott, Ian; Lehane, Kevin; Li, Zachary I.; Magister, Steven; Hoffmeister, Thomas; Youm, Thomas
Purpose: The volume of arthroscopic hip surgery has increased dramatically in recent years with iliopsoas tendinitis (IPT) being one of the most common complications of this procedure. The purpose of this study is to investigate the prevalence of post-operative IPT in patients who undergo arthroscopic hip surgery with capsular closure using absorbable versus non-absorbable suture. Methods: This is a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023 comparing two cohorts who underwent hip arthroscopy. Patients were divided into those who underwent surgery with capsular closure using absorbable (Vicryl®, Johnson and Johnson, New Brunswick, NJ) suture and those who underwent capsular closure with non-absorbable suture (Suturetape, Arthrex, Naples FL). All patients who underwent primary or revision hip arthroscopy and were at least 2 months post-operation were initially included in the study. Results: Between August 2007 and May 2023 a total of 1513 hip arthroscopy surgeries were performed. Within this cohort, 1421 hips underwent hip arthroscopy with non-absorbable suture and 64 hips underwent surgery with absorbable suture. There was no significant difference between the proportion of IPT in the non-absorbable cohort (2.3%) versus the absorbable cohort (1.6%) (P = 0.669). Conclusion: Capsular closure with Absorbable sutures was non-inferior to capsular closure with non-absorbable sutures with respect to the proportion of post-operative IPT following hip arthroscopy for FAI. Additionally, the proportion of post-operative IPT was found to be significantly higher in patients undergoing revision versus primary hip arthroscopy, regardless of capsular closure suture type. Level of evidence: IV.
SCOPUS:85182454767
ISSN: 1633-8065
CID: 5629682

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage

Kingery, Matthew T; Akpinar, Berkcan; Rynecki, Nicole D; Campbell, Hilary T; Lin, Lawrence J; Youm, Thomas
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.
PMID: 38164680
ISSN: 1552-3365
CID: 5625912

Decreased Hip Labral Width Measured on Preoperative Magnetic Resonance Imaging is Associated with Higher Revision Rate After Primary Arthroscopic Labral Repair for Femoroacetabular Impingement Syndrome at 5-Year Follow-Up

Li, Zachary I; Shankar, Dhruv S; Vasavada, Kinjal D; Akpinar, Berkcan; Lin, Lawrence J; Samim, Mohammad M; Burke, Christopher J; Youm, Thomas
PURPOSE/OBJECTIVE:To examine the associations between hip labral width and patient-reported outcomes, clinical threshold achievement rates, and rate of reoperation among patients with femoroacetabular impingement syndrome (FAIS) who underwent hip arthroscopy and labral repair at minimum 5-year follow-up. METHODS:Patients were identified from a prospective database who underwent primary hip arthroscopy for treatment of labral tears and FAIS. Modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were recorded preoperatively and at 5-year follow-up. Achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) was determined using previously established values. Labral width MRI measurements were performed by two independent readers at standardized "clockface" locations. Patients were stratified into three groups at each position: lower-width (<½ SD below mean), middle-width (within ½ SD of mean), and upper-width (>½ SD above mean). Multivariable regression was used to evaluate associations of labral width with patient-reported outcomes and reoperation rate. RESULTS:Seventy-three patients (age: 41.0±12.0 years; 68.5% female) were included. Inter-rater reliability for labral width measurements was high at all positions (ICC: 0.94-0.96). There were no significant inter-group differences in mHHS/NAHS improvement (p>0.05) or in achievement rates of MCID/SCB/PASS at each clockface position (p>0.05). Eleven patients (15.1%) underwent arthroscopic revision and four patients (5.5%) converted to THA. Multivariable analysis found lower-width groups at 11:30 (OR: 1.75, p=0.02) and 3:00 (OR: 1.59, p=0.04) positions to have increased odds of revision within 5 years, however, labral width was not associated with 5-year improvement in mHHS/NAHS, achievement of MCID/PASS/SCB, or conversion to THA (p>0.05). CONCLUSION/CONCLUSIONS:Hip labral width <½ SD below the mean measured on preoperative MRI at 11:30 and 3:00 clockface positions was associated with increased odds of reoperation after arthroscopic labral repair and treatment of FAIS. Labral width was not associated with 5-year improvement of mHHS, NAHS, achievement of clinical thresholds, or conversion to arthroplasty. LEVEL OF EVIDENCE/METHODS:Level IV, case series.
PMID: 38061686
ISSN: 1526-3231
CID: 5591402