The Impact of Depression on Patient Outcomes in Hip Arthroscopic Surgery.

Background: Mental health impairments have been shown to negatively affect preoperative self-reported function in patients with various musculoskeletal disorders, including those with femoroacetabular impingement. Hypothesis: Those with symptoms of depression will have lower self-reported function, more pain, and less satisfaction on initial assessment and at 2-year follow-up than those without symptoms of depression. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who were enrolled in a multicenter hip arthroscopic surgery registry and had 2-year outcome data available were included in the study. Patients completed the 12-item International Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and 12-item Short-Form Health Survey (SF-12) when consenting for surgery. At 2-year follow-up, patients were emailed the iHOT, the VAS, and a rating scale of surgical satisfaction. Initial SF-12 mental component summary (MCS) scores Results: A total of 781 patients achieved the approximate 2-year milestone (mean follow-up, 735 ± 68 days), with 651 (83%) having 2-year outcome data available. There were 434 (67%) female and 217 (33%) male patients, with a mean age of 35.8 ± 13.0 years and a mean body mass index of 25.4 ± 8.8 kg/m Conclusion: A large number of patients who underwent hip arthroscopic surgery presented with symptoms of depression, which negatively affected self-reported function, pain levels, and satisfaction on initial assessment and at 2-year follow-up. Surgeons who perform hip arthroscopic surgery may need to identify the symptoms of depression and be aware of the impact that depression can have on surgical outcomes

Allocation of Anchors During Labral Repair: A Multicenter Cohort Analysis of Labral Treatment in Hip Arthroscopy.

Background: While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue. Purpose/Hypothesis: To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o’clock denoted the anterior extent of the tear and 9 o’clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of “hours” spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers. Results: A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o’clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size (P Conclusion: Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc \u3e2 hours, at least 2 anchor points were fixated

Outcomes Following Interposition Arthroplasty of the First Metatarsophalangeal Joint for the Treatment of Hallux Rigidus: A Systematic Review

Background: Interposition arthroplasty of the first MTP joint has recently experienced renewed interest as a treatment for hallux rigidus. The purpose of this study was to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint. Methods: PubMed Central, Embase, and the Cochrane Central Register for Controlled Trials (CENTRAL) were searched. Inclusion criteria included length of time to follow-up, number of patients, outcome measure, and use of allogeneic or autogenous soft tissue or a synthetic matrix as interposition. Results: 20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0%) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6% were of a retrospective nature. Progression to further surgery was observed in 3.8% of toes. The most common complication reported was transfer metatarsalgia of 1 or more lesser toes, observed in up to 57.9% of patients in one study. Conclusion: Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic, and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited. Level of Evidence: Level IV, systematic review of Level III-IV studie

Arthroscopic labral reconstruction using fascia lata allograft: shuttle technique and minimum two-year results

The purpose of this study was to describe the shuttle technique of acetabular labral reconstruction using allograft fascia lata and report minimum two-year clinical outcomes in a prospective patient cohort. We present a shuttle technique to introduce and fixate the allograft, by which the need to fix the free end of the graft from inside the joint is avoided. Between October 2010 and March 2014, 693 hip arthroscopic surgeries were performed by the senior author. Of these 693 patients, 34 patients underwent a labral reconstruction procedure using allograft fascia lata and the shuttle technique and met inclusion criteria. Outcome measures were collected at minimum two years postoperatively. 91.2% (31) of reconstruction patients were available for follow-up at minimum two years after surgery with 12.9% (4) of these patients converting to total hip arthroplasty at average time 27.9 months post-surgery. For the remaining reconstruction patients, mean mHHS increased from 64.0 preoperatively to 84.6 postoperatively ( = 0.0015), SF-12 Physical from 38.9 to 49.0 ( = 0.0004), SF-12 Mental from 49.5 to 55.6 ( = 0.0095), iHOT-12 from 36.4 to 68.1 ( = 0.0017), HOS-ADL from 62.6 to 81.6 ( = 0.0032) and HOS-SS from 32.9 to 65.7 ( \u3c 0.0001). Arthroscopic acetabular labral reconstruction using fascia lata allograft and a shuttle technique appears to be an effective procedure for the treatment of labral pathology through minimum two-year follow-up. While it is difficult to discern the direct influence of the labral reconstructive procedure given the treatment of often concomitant intra-articular pathology, this patient cohort has fared similarly to other cohorts of labral reconstruction patients. No major adverse events are reported

A Characterization of Sensory and Motor Neural Dysfunction in Patients Undergoing Hip Arthroscopic Surgery: Traction- and Portal Placement–Related Nerve Injuries

Background: There is a paucity of prospectively collected data as they relate to nerve injuries after hip arthroscopic surgery. Studies describing the relationship of neurological injuries to portal placement and the duration and magnitude of traction force with regular and standardized patient follow-up protocols are limited. Purpose/Hypothesis: The purpose of this study was to characterize nerve deficits in a series of patients undergoing hip arthroscopic surgery as these deficits relate to axial traction and portal placement. It was hypothesized that in patients who presented without nerve deficits after surgery, the magnitudes of traction-related measurements would exceed previous recommendations based on expert opinion (\u3c50 lb). Additionally, it was hypothesized that sensory disturbance would commonly be observed (≥16%) localized to the distal anterolateral thigh related to portal placement. Study Design: Case series; Level of evidence, 4. Methods: A total of 45 patients scheduled to undergo hip arthroscopic surgery between July 2012 and February 2014 were included in this study. Traction force was measured and recorded every 5 minutes during surgery, and patients were assessed by a physical examination for deficits in light touch sensitivity at all lower extremity dermatomes preoperatively and at 3 weeks, 6 weeks, 3 months, and 1 year postoperatively. Patients were also tested for strength deficits and rated on the manual muscle testing grading scale. Patients reported modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living and –Sport subscales (HOS-ADL and HOS-Sport, respectively), Short Form–12 (SF-12) mental and physical component summaries, and international Hip Outcome Tool–12 (iHOT-12) scores preoperatively and at 1 year postoperatively. Results: Thresholds for maximum traction force, mean traction force, duration of traction, and traction impulse were 120 lb, 82 lb, 61 minutes, and 7109 lb·min, respectively, below which no patients presented with sensory or motor dysfunction thought to be related to traction. A minority (17.8%) of patients presented with highly localized, distal anterolateral sensory deficits suggestive of injuries related to portal placement, and 2.2% of patients presented with perineal numbness localized to the distribution of the pudendal nerve. All nerve deficits had resolved by 1-year follow-up. Conclusion: This study suggests that it may be possible to apply more axial traction force for a longer duration than expert opinion has previously suggested, without significant and, in the majority of cases (82.2%), any traction-related short-term complications. Transient traction- and portal placement–related nerve injuries after hip arthroscopic surgery may be more frequent (31.1% in this study) than have been reported historically

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation

BACKGROUND: The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation. PURPOSE/HYPOTHESIS: Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for0.80. RESULTS: A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities. CONCLUSION: Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms

A tiered system using substantial clinical benefit and patient acceptable symptomatic state scores to evaluate 2-year outcomes of hip arthroscopy with the Hip Outcome Score

There is no information to define variations in hip arthroscopy outcomes at 2-year follow-up using the Hip Outcome Score (HOS). To offer a tiered system using HOS absolute substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) scores for 2-year hip arthroscopy outcome assessment. This was a retrospective review of patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and 2 years (±2 months) post-operatively, subjects completed the HOS activity of daily living (ADL) and Sports subscales, categorical self-rating of function and visual analog scale for satisfaction with surgery. Receiver operator characteristic analysis identified absolute SCB and PASS HOS ADL and Sports subscale scores. Subjects consisted of 462 (70%) females and 196 (30%) males with a mean age of 35.3 years [standard deviation (SD) 13] and mean follow-up of 722 days (SD 29). SCB and PASS scores for the HOS ADL and Sports subscales were accurate in identifying those at a \u27nearly normal\u27 and \u27normal\u27 self- report of function and at least 75% and 100% levels of satisfaction (area under the curve \u3e0.70). This study provides tiered SCB and PASS HOS scores to define variations in 2-year (±2 months) outcome after hip arthroscopy. HOS ADL subscale scores of 84 and 94 and Sports subscale scores of 61 and 87 were associated with a \u27nearly normal\u27 and \u27normal\u27 self-report of function, respectively. HOS ADL subscale scores of 86 and 94 and Sports subscale score of 74 and 87 were associated with being at least 75% and 100% satisfied with surgery, respectively. Level of evidence: III, retrospective comparative study

Allocation of Anchors During Labral Repair: A Multicenter Cohort Analysis of Labral Treatment in Hip Arthroscopy

Background: While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue. Purpose/Hypothesis: To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o\u27clock denoted the anterior extent of the tear and 9 o\u27clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of hours spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers. Results: A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o\u27clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size ( \u3c .001 for all), using 1 to 1.6 anchors for 1-hour tears, 1.7 to 2.4 anchors for 2-hour tears, 2.1 to 3.2 anchors for 3-hour tears, and 2.2 to 4.1 for 4-hour tears. Conclusion: Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc \u3e2 hours, at least 2 anchor points were fixated