Self-reported Mental Disorders Negatively Influence Surgical Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement.

Background:Femoroacetabular impingement (FAI) is responsible for hip pain and dysfunction, and surgical outcomes depend on multiple factors. The presence of mental disorders negatively influences outcomes of multiple orthopaedic conditions, although the impact on FAI surgery is unclear. Hypothesis:The authors hypothesized that a preoperative self-reported history of mental disorders would negatively influence patient-reported outcome measures after FAI surgery. Study Design:Cohort study; Level of evidence, 3. Methods:A matched-cohort study was performed by reviewing a prospectively collected database of cases of arthroscopic management of FAI with a single surgeon over a 2-year period. Demographics and radiographic parameters were recorded for all patients. Patients completed the Hip Outcome Score-Activity of Daily Living Subscale (HOS-ADL), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS) prior to surgery and 2 years after surgery. Unpaired and paired t tests were used to compare results between and within cohorts at baseline and follow-up. Statistical significance was defined as P < .05. Results:The cohort included 301 patients, with 75 and 226 patients reporting and not reporting a history of mental disorders, respectively. Before treatment, all patient-reported outcome measures were significantly lower among patients reporting a history of mental disorders (P < .01 for HOS-ADL, HOS-SSS, and mHHS). Patients in both groups demonstrated significant improvements (P < .0001) in HOS-ADL, HOS-SSS, and mHHS when preoperative outcome measures were compared with follow-up. Patients with reported mental disorders had significantly lower scores after surgery as compared with patients without mental disorders (P < .0001 for HOS-ADL, HOS-SSS, and mHHS). Conclusion:The presence of a reported mental disorder is associated with lower patient-reported outcomes before and after surgical management of FAI. Statistically significant and clinically relevant improvements were observed for patients who reported mental disorders. The magnitude of these improvements was not as large as that for an age- and sex-matched control group without a self-reported mental disorder

Rehabilitation Following Hip Arthroscopy – A Systematic Review

CONTEXT: Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy.OBJECTIVES: 1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, 2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols; and 3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy.DATA SOURCES: Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.STUDY SELECTION: Level I-IV evidence clinical studies with minimum two-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included. DATA EXTRACTION: All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS).RESULTS: 18 studies were included (2,092 subjects; 52% male, mean age 35.1 +/- 10.6 years, mean follow-up 3.2 +/- 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return-to-sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported.CONCLUSIONS: The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a speci

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

Prevalence of Cam Morphology in Females with Femoroacetabular Impingement

Cam and pincer are two common morphologies responsible for femoroacetabular impingement. Previous literature has reported that cam deformity is predominantly a male morphology, while being significantly less common in females. The purpose of this study was to determine the prevalence of cam morphology in female subjects diagnosed with symptomatic FAI. All females presenting to the senior author’s clinic diagnosed with symptomatic FAI between December 2006 and Cam and pincer are two common morphologies responsible for femoroacetabular impingement. Previous literature has reported that cam deformity is predominantly a male morphology, while being significantly less common in females. Cam morphology is commonly assessed with the alpha angle, measured on radiographs. The purpose of this study was to determine the prevalence of cam morphology utilizing the alpha angle in female subjects diagnosed with symptomatic FAI. All females presenting to the senior author’s clinic diagnosed with symptomatic FAI between December 2006 and January 2013 were retrospectively reviewed. Alpha (α) angles were measured on AP (anteroposterior) and lateral (Dunn 90°, cross-table lateral, and/or frog-leg lateral) plain radiographs by two blinded physicians, and the largest measured angle was used. Using Gosvig et al.’s classification, alpha angle was characterized as (pathologic > 57°), borderline (51-56°), subtle (46-50°), very subtle (43-45°), or normal (≤42°). Three hundred and ninety-one patients (438 hips) were analyzed (age 36.2 ± 12.3 years). Among the hips included, 35.6% were normal, 14.6% pathologic, 15.1% borderline, 14.6% subtle, and 20.1% very subtle. There was no correlation between alpha angle and patient age (R = 0.17) or body mass index (BMI) (R = 0.05). The intraclass correlation coefficient (ICC) for α-angle measurements was 0.84. Sixty-four percent of females in this cohort had an alpha angle > 42°. Subtle cam deformity plays a significant role in the pathoanatomy of female patients with symptomatic FAI. As the majority of revision hip arthroscopies are performed due to incomplete cam correction, hip arthroscopists need to be cognizant of and potentially surgically address these subtle lesions

Labral Reconstruction with Iliotibial Band Autograft and Semitendinosus Allograft Improves Hip Joint Contact Area and Contact Pressure: An In-Vitro Analysis

Objectives: Labral reconstruction using iliotibial band (ITB) autograft and semitendinosus (Semi-T) allograft have recently been described in cases of labral deficiency. The current study seeks to understand the biomechanical effects of an intact labrum, segmental labral resection, and labral reconstruction on joint contact area, contact pressure, and peak force. Methods: Ten fresh-frozen human cadaver hips were analyzed utilizing thin-film piezoresistive load sensors to measure contact area, contact pressure, and peak force 1) with the native intact labrum, 2) after segmental labral resection and 3) after graft labral reconstruction with either ITB autograft or Semi-T allograft. Each specimen was examined at 20° extension and 60° flexion. Statistical analysis was conducted through one-way ANOVA with post-hoc Games-Howell tests. Results: For the ITB group, labral resection significantly decreased contact area (20°: 73.2%±5.38, P=0.0010; 60°: 78.5%±6.93, P=0.0063) and increased contact pressures (20°: 106.7%±4.15, P=0.0387; 60°: 103.9%±1.15, P=0.0428). ITB reconstruction improved contact area (20°: 87.2%±12.3, P=0.0130; 60°: 90.5%±8.81, P=0.0079) and contact pressures (20°: 98.5%±5.71, P=0.0476; 60°: 96.6%±1.13, P=0.0056) from the resected state. Contact pressure at 60° flexion was significantly lower compared to the native labrum (P = 0.0420). For the Semi-T group, labral resection significantly decreased contact area (20°: 68.1±12.57, P=0.0002; 60°: 67.5%±6.70, P=0.0002) and increased contact pressures (20°: 105.3%±3.73, P=0.0304; 60°: 106.8%±4.04, P=0.0231). Semi-T reconstruction improved contact area (20°: 87.9%±7.95, P=0.0087; 60°: 92.9%±13.2, P=0.0014) and contact pressures (20°: 97.1%±3.18, P=0.0017; 60°: 97.4%±4.39, P=0.0027) from the resected state. Comparative analysis demonstrated no statistically significant differences between either graft reconstruction in relation to contact area, contact pressure, or peak forces. (Figure 1). Conclusion: Segmental anterosuperior labral resection results in significantly decreased contact area and increased contact pressures, while labral reconstruction partially restores time-zero acetabular contact areas and pressures as compared to the resected state. Although labral reconstruction improved the measured biomechanical properties as compared to the resected state, some of these properties remained significantly different compared to the native intact labrum

Preparation Methods and Clinical Outcomes of Platelet-Rich Plasma for Intra-articular Hip Disorders: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

Background: Despite its increasing use in the management of musculoskeletal conditions, questions remain regarding the preparation methods of platelet-rich plasma (PRP) and its clinical applications for intra-articular hip disorders, including femoroacetabular impingement syndrome (FAIS), labral pathology, and osteoarthritis (OA). Purpose: To systematically review and assess the preparation methods and clinical outcomes from randomized clinical trials (RCTs) on the use of PRP for intra-articular hip disorders. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in September 2019. The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Ovid Medline, and Embase were queried for studies regarding the use of PRP to treat intra-articular hip disorders. Qualifying articles were English-language RCTs describing the use of PRP for intra-articular hip disorders, either as standalone treatment or surgical augmentation. Two authors independently assessed article eligibility. Data pertaining to patient characteristics, indication for treatment, PRP preparation method, follow-up period, and clinical outcomes were extracted. Study results were qualitatively reported and quantitatively compared using meta-analysis when appropriate. Results: Seven RCTs met inclusion criteria. Four studies described the use of PRP for hip OA and 3 utilized PRP at arthroscopy for FAIS and labral tears. Outcomes after PRP for OA demonstrated improvement in validated patient-reported outcome measures for up to 1 year; however, pooled effect sizes found no statistically significant difference between PRP and hyaluronic acid (HA) regarding pain visual analog scale scores at short-term (≤2 months; P = .27), midterm (4-6 months; P = .85), or long-term (1 year; P = .42) follow-up. When injected at arthroscopy, 1 study reported improved outcomes, 1 reported no difference in outcomes, and 1 reported worse outcomes compared with controls. The meta-analysis demonstrated no statistically significant difference on the modified Harris Hip Score (mHHS) between PRP and control cohorts at a minimum 1-year follow-up. There were considerable deficiencies and heterogeneity in the reporting of PRP preparation methods for both indications. Conclusion: Treatment of OA with PRP demonstrated reductions in pain and improved patient-reported outcomes for up to 1 year. However, there was no statistically significant difference between PRP and HA in pain reduction. Likewise, for FAIS and labral surgery there was no statistically significant difference in mHHS outcomes between patients treated with PRP and controls. Given the limited number of studies and variability in PRP preparations, additional high-quality randomized trials are warranted

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

Clinical and radiological outcome of conservative vs. surgical treatment of atraumatic degenerative rotator cuff rupture: design of a randomized controlled trial

Background: Subacromial impingement syndrome is a frequently observed disorder in orthopedic practice. Lasting symptoms and impairment may occur when a subsequent atraumatic rotator cuff rupture is also present. However, degenerative ruptures of the rotator cuff can also be observed in asymptomatic elderly individuals. Treatment of these symptomatic degenerative ruptures may be conservative or surgical. Acceptable results are reported for both treatment modalities. No evidence-based level-1 studies have been conducted so far to compare these treatment modalities. The objective of this study is to determine whether there is a difference in outcome between surgical reconstruction and conservative treatment of a degenerative atraumatic rotator cuff tendon rupture. Methods/Design: A randomized controlled trial will be conducted. Patients aged between 45 and 75 with a symptomatic atraumatic rotator cuff rupture as diagnosed by MRI will be included. Exclusion criteria are traumatic rotator cuff rupture, frozen shoulder and diabetes mellitus. Patients will be randomized into two groups. Conservative treatment includes physical therapy according to a standardized protocol, NSAIDs and, if indicated, subacromial infiltration with a local anesthetic and corticosteroids. Surgical reconstruction is performed under general anesthesia in combination with an interscalenus plexus block. An acromioplasty with reconstruction of the rotator cuff tendon is performed, as described by Rockwood et al. Measurements take place preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively. The primary outcome measure is the Constant score. Secondary measures include both disease-specific and generic outcome measures, and an economic evaluation. Additionally, one year after inclusion a second MRI will be taken of all patients in order to determine whether extent and localization of the rupture as well as the amount of fatty degeneration are prognostic factors. Discussion: Both surgical as conservative treatment of a symptomatic atraumatic rotator cuff tendon rupture is used in current practice. There is a lack of level-1 studies comparing surgical vs. conservative treatment. This randomized controlled trial has been designed to determine whether the surgical treatment of a degenerative atraumatic rotator cuff tendon rupture may lead to a better functional and radiological outcome than conservative treatment after one year of follow-up

Principles of Hip Arthroscopy

The field of arthroscopy, originating from Denmark in 1912, has rapidly evolved to diagnose and treat a wide range of musculoskeletal pathologies. Although around for sometime, arthroscopy in the field of orthopedics has traditionally focused on the knee, shoulder, or elbow, as arthroscopy of the hip is technically challenging; the deep structures of the hip, including neurovascular bundles, require specialized training and equipment to access. However, with advances in surgical techniques, hip arthroscopy has become increasingly popular given its ability to treat pathologies with previously poor prognoses such as labral tears, hip arthritis and femoroacetabular impingement (FAI). When indicated, hip arthroscopy results in shorter recovery times, low complication rates, and excellent outcomes in quality of life and pain regardless of age, gender or activity level. The purpose of this e-book is to shed light on this expanding field by delving into the common hip pathology femoroacetabular impingement, its clinical relevance, and to explore various surgical techniques and postoperative rehabilitation. It is our hope that this textbook provides valuable knowledge to advance the field of hip arthroscopy, enhance surgical techniques, and ultimately increase the quality of patient care