John M. Redmond

Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center.

Background: Hip arthroscopy has gained increasing popularity over the past decade. The need to develop metrics to evaluate success and complications in primary hip arthroscopy is an important goal. Purpose: To evaluate 2-year patient-related outcome (PRO) scores and patient satisfaction scores for a single surgeon at a high-volume referral center for all primary hip arthroscopy procedures performed. Study Design: Case series; Level of evidence, 4. Methods: During the study period between April 2008 and October 2011, data were collected on all patients who underwent primary hip arthroscopy. All patients were assessed pre- and postoperatively with 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), and Hip Outcome Score–Sport-Specific Subscale (HOS-SSS). Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. The number of patients who underwent revision arthroscopy, total hip arthroplasty (THA), or a resurfacing procedure during the study period was also reported. Results: A total of 595 patients were included in the study. The score improvement from preoperative to 2-year follow-up was 61.29 to 82.02 for mHHS, 62.79 to 83.05 for HOS-ADL, 40.96 to 70.07 for HOS-SSS, 57.97 to 80.41 for NAHS, and 5.86 to 2.97 for VAS. All scores were statistically significantly different (P < .0001). Overall patient satisfaction was 7.86 ± 2.3 (range, 1-10). Forty-seven (7.7%) patients underwent revision hip arthroscopy, and 54 (9.1%) patients underwent either THA or the hip resurfacing procedure during the study period. The multivariate regression analysis showed that increased age at time of surgery was a significant risk factor for conversion to THA, revision arthroscopy, and change in NAHS <10 points. Acute injury, acetabuloplasty, iliopsoas release, and patient sex were significant for 2 of these 3 types of failure. Conclusion: Primary hip arthroscopy for all procedures performed in aggregate had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study. More studies must be conducted to determine the definition of a successful outcome. There was a 6.1% minor complication rate, which was consistent with previous studies. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty as well as the potential for revision surgery.

Detecting vascular injury in lower-extremity orthopedic trauma: The role of CT angiography

As a screening tool, CT angiography has excellent sensitivity and specificity combined with fewer complications compared to conventional arteriography.

Arthroscopic Acetabuloplasty and Labral Refixation Without Labral Detachment

Background: Arthroscopic acetabuloplasty was initially described with detachment of the labrum to access the acetabular rim for resection, followed by labral refixation. Recent technical improvements have made it possible to perform acetabuloplasty and labral refixation without labral detachment when the chondrolabral junction is intact. Purpose: To compare outcomes for patients undergoing arthroscopic acetabuloplasty and labral refixation without labral detachment (study group), as well as compare this with a group of patients who underwent acetabuloplasty with labral refixation and labral detachment (control group) with a minimum 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: During the study period, data were prospectively collected on all patients treated with hip arthroscopy. Inclusion criteria for the study group were acetabuloplasty and labral refixation without detachment, performed in cases with an intact chondrolabral junction. Patients were then compared with a control group of patients who had acetabuloplasty with labral detachment and refixation. All patients were assessed pre- and postoperatively using 4 patient-reported outcome (PRO) measures and a visual analog scale (VAS) for pain, as well as monitored for revision surgery. Results: In the study group, the preoperative to postoperative score changed from 64.2 to 86.6 for modified Harris Hip Score (mHHS), 60.5 to 83.8 for Nonarthritic Hip Score (NAHS), 65.3 to 87.3 for Hip Outcome Score–Activity of Daily Living (HOS-ADL), 45 to 75.1 for Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and 5.7 to 2.6 for VAS. In the control group, the preoperative to postoperative score changed from 61.2 to 84.4 for mHHS, 59 to 84 for NAHS, 62.7 to 86.2 for HOS-ADL, 40.1 to 74.1 for HOS-SSS, and 6.3 to 2.8 for VAS. There was no difference between preoperative and postoperative PRO scores. The preoperative VAS score was lower in the study group than in the control group (P = .04). The control group demonstrated larger mean preoperative anterior center edge angles (ACEA) (33.8° vs 29.5°) and mean alpha angles (60.5° vs 53.5°) than the study group (P < .05). There was no statistically significant difference in the change in PRO or VAS scores between groups. Both groups demonstrated significant improvement from preoperative to 2-year follow-up for all 4 PRO scores (P < .05) and decrease in VAS (P < .05). One patient in the study group converted to total hip arthroplasty. Seven patients underwent revision hip arthroscopy in the study group, and 8 patients in the control group underwent revision hip arthroscopy. There was no difference in revision rates between groups. Conclusion: Treatment of pincer- and combined-type impingement with arthroscopic acetabuloplasty and labral refixation without detachment, when possible, resulted in similar patient outcomes compared with acetabuloplasty with labral detachment. We may conclude that in cases where the chondrolabral junction remains intact, acetabuloplasty and labral refixation without detachment is a viable option.

Concomitant Hip Arthroscopy and Periacetabular Osteotomy

PURPOSE To detail our early experience using concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of acetabular dysplasia. METHODS We prospectively collected and retrospectively reviewed the surgical and outcome data of 17 patients who underwent concomitant hip arthroscopy and PAO between October 2010 and July 2013. Preoperative and postoperative range of motion, outcome and pain scores, and radiographic data were collected. Intraoperative arthroscopic findings and postoperative complications were recorded. RESULTS The group consisted of 3 male and 14 female patients with a mean follow-up period of 2.4 years. Three patients had undergone previous surgery on the affected hip. Chondrolabral pathology was identified in all 17 patients. Twelve patients underwent labral repair, and five patients underwent partial labral debridement. No patient was converted to total hip arthroplasty or required revision surgery at short-term follow-up. All 4 patient-reported outcome scores showed statistically significant changes from baseline to latest follow-up (P < .001). An excellent outcome was obtained in 82% of patients (13 of 16). The lateral center-edge angle averaged 11° preoperatively and 29° postoperatively. The acetabular inclination averaged 18° preoperatively and 3° postoperatively. The anterior center-edge angle averaged 7° preoperatively and 27° postoperatively. At most recent radiographic follow-up, 1 patient had progression of arthritic changes but remained asymptomatic. No other patient showed any radiographic evidence of progression of arthritis. Complications included 3 superficial wound infections, 1 pulmonary embolism, and 1 temporary sciatic neurapraxia. CONCLUSIONS Our initial experience with concomitant hip arthroscopy and PAO has been favorable. We noted that all our patients have evidence of chondrolabral damage at the time of PAO when the joint is distracted and evaluated. All patients in this series had intra-articular pathology treated arthroscopically and showed satisfactory mean clinical improvement. Hip arthroscopy with PAO did not appear to introduce complications beyond the PAO alone. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Best Practices During Hip Arthroscopy: Aggregate Recommendations of High-Volume Surgeons

PURPOSE To survey surgeons who perform a high volume of hip arthroscopy procedures regarding their operative technique, type of procedure, and postoperative management. METHODS We conducted a cross-sectional survey of 27 high-volume orthopaedic surgeons specializing in hip arthroscopy to report their preferences and practices related to their operative practice and postoperative rehabilitation protocol. All participants completed the survey in person in an anonymous fashion during a meeting of the American Hip Institute. RESULTS All surgeons perform hip arthroscopy with the patient in the supine position, accessing the central compartment of the hip initially, using intraoperative fluoroscopy. All surgeons perform labral repair (100%), with the majority performing labral reconstructions (77.8%) and gluteus medius repairs (81.5%). There is variability in the type of anchors used during labral repair. Most surgeons perform capsular closure in most cases (88.9%), inject either intra-articular cortisone or platelet-rich plasma at the conclusion of the procedure (59%), and prescribe a postoperative hip brace for some or all patients (59%). There is considerable variability in rehabilitation protocols. All surgeons routinely prescribe postoperative heterotopic ossification prophylaxis to their patients, with most surgeons (88.9%) prescribing a nonsteroidal anti-inflammatory medication for 3 weeks. Forty percent of the respondents use the modified Harris Hip Score as the most important outcome measure. CONCLUSIONS Consistent practices such as use of intraoperative fluoroscopy, heterotopic ossification prophylaxis, and labral repair skills were identified by surveying 27 hip arthroscopy surgeons at high-volume centers. Most of the surgeons performed routine capsular closure unless underlying conditions precluded capsular release or plication. The survey identified higher variability between surgeons regarding postoperative rehabilitation protocols and use of intra-articular pharmacologic injections at the end of the procedure. These data may provide surgeons with a set of aggregate trends that may help guide training, clinical practice, and research in the evolving field of hip arthroscopy.

Does Obesity Affect Outcomes in Hip Arthroscopy? A Matched-Pair Controlled Study With Minimum 2-Year Follow-up

Background: Hip arthroscopy has gained popularity over the past decade, and its indications have broadened as newer techniques have been developed. However, there has been a paucity of literature evaluating the outcomes of hip arthroscopy in obese patients. Purpose: To compare 2-year clinical outcomes of obese patients undergoing primary hip arthroscopy with matched nonobese controls. Study Design: Cohort study; Level of evidence, 3. Methods: From February 2008 to February 2012, data were collected prospectively on all obese patients undergoing primary hip arthroscopy. A matched-pair nonobese control group was selected at a 1:2 ratio. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Activities of Daily Living, and Hip Outcome Score–Sport Specific Subscale. Pain was estimated on the visual analog scale, and satisfaction was measured on a scale from 0 to 10. Results: Sixty-two hips (62 patients) were included in the obese group and 124 hips (124 patients) in the control group. At preoperative baseline, the obese group had significantly lower PRO scores when compared with the control group. Both groups demonstrated statistically significant postoperative improvement in all scores (P < .05). Absolute scores were significantly lower in the obese group for all PRO measures, pre- and postoperatively. However, the improvement (delta) in PRO scores from pre- to postoperative time was not significantly different between groups. The rate of conversion to total hip arthroplasty, the rate of revision, and the complication rate were not significantly different between the 2 groups; however, rates of conversion to total hip arthroplasty and revision tended to be twice as high in the obese patients, but the study was not powered for these 2 outcomes. Conclusion: Overall, obese patients had lower absolute PRO scores preoperatively and at 2-year follow-up. Both obese and nonobese patients demonstrated significant improvement in all PRO scores, and the change in scores were similar between groups. These results indicate that while obese patients may not have similar absolute scores after hip arthroscopy, they may show similar gains in improvement when compared with baseline. Hip arthroscopy appears to be a viable treatment option in the obese patient as long as expectations are adjusted accordingly.

A Matched-Pair Controlled Study of Microfracture of the Hip With Average 2-Year Follow-up: Do Full-Thickness Chondral Defects Portend an Inferior Prognosis in Hip Arthroscopy?

PURPOSE This study compared 2-year clinical outcomes in hip arthroscopy patients treated with microfracture to a matched control group without full-thickness chondral damage. METHODS During the study period between June 2008 and July 2011, data were collected on all patients treated with hip arthroscopy who underwent microfracture. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures. Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. A matched-pair group of patients who did not undergo microfracture was selected in a 1:2 ratio. Matching criteria were age within 5 years, sex, surgical procedures, and radiographic findings. RESULTS Average follow-up for the study was 26.66 months (17.29 to 48.89 months). Forty-nine hips were included in the microfracture group and 98 hips were in entered in the nonmicrofracture group, with no significant difference in PRO scores preoperatively between the groups. Both groups had statistically significant postoperative improvement in all scores, and the average amount of change from preoperative to postoperative scores between the 2 groups was not statistically significantly different for any of the PRO scores. Most importantly, there was no statistically significant difference in postoperative PRO scores between the microfracture and control groups. Patient satisfaction was 6.9 for the microfracture group and 7.84 for the nonmicrofracture group, which was statistically significant (P < .05). When comparing patients who received acetabular microfracture to those who received femoral microfracture, both groups had similar preoperative and postoperative PRO scores, with no significant difference in the magnitude of change (delta) at final follow-up. CONCLUSIONS Our study found that patients undergoing microfracture during hip arthroscopy did not show a statistically significant difference in PRO scores when compared with a matched-pair control group at an average of 2 years of follow-up. Both groups showed significant improvement in all PRO scores. LEVEL OF EVIDENCE Level III, matched case-control study.

Does obesity affect outcomes after hip arthroscopy? A cohort analysis.

BACKGROUND Obesity presents a challenging problem in surgical treatment and has led to poorer postoperative outcomes. The purpose of this study was to evaluate whether hip arthroscopy in the obese patient influences postoperative clinical and patient-reported outcome scores. METHODS From February 2008 to February 2012, data were collected prospectively on all patients undergoing primary hip arthroscopy. A total of 680 patients were included. All patients were assessed preoperatively and postoperatively with four patient-reported outcome measures. Pain was estimated on the visual analog scale. The patient satisfaction score was measured. Three groups were stratified by body mass index. The non-obese group, those with a body mass index of <30 kg/m(2) (mean, 23.61 kg/m(2)), included 562 patients with a mean age of 34.78 years. The class-I obese group, those with a body mass index of ≥30 to 34.9 kg/m(2) (mean, 33.85 kg/m(2)), included ninety-four patients with a mean age of 44.02 years. The class-II obese group, those with a body mass index of ≥35 to 39.9 kg/m(2) (mean, 39.11 kg/m(2)), included twenty-four patients with a mean age of 39.33 years. RESULTS In the non-obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 63.41 to 83.81 points for the modified Harris hip score, 60.86 to 83.62 points for the Non-Arthritic Hip Score, 66.24 to 86.24 points for the Hip Outcome Score Activities of Daily Living, and 44.01 to 73.26 points for the Hip Outcome Score Sport-Specific Subscale. In the class-I obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 54.81 to 75.95 points for the modified Harris hip score, 48.98 to 72.51 points for the Non-Arthritic Hip Score, 53.22 to 72.99 points for the Hip Outcome Score Activities of Daily Living, and 30.56 to 60.75 points for the Hip Outcome Score Sport-Specific Subscale. In the class-II obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 50.81 to 80.01 points for the modified Harris hip score, 42.36 to 72.50 points for the Non-Arthritic Hip Score, 48.11 to 74.73 points for the Hip Outcome Score Activities of Daily Living, and 28.25 to 62.56 points for the Hip Outcome Score Sport-Specific Subscale. Traction time did not vary significantly between groups (p < 0.05). CONCLUSIONS Our study demonstrated that obese patients started with lower absolute scores preoperatively and ended with lower overall absolute postoperative scores. However, obese patients showed substantial benefit from hip arthroscopy and demonstrated a degree of improvement that was similar to that of the control non-obese group.

Does the Femoral Cam Lesion Regrow After Osteoplasty for Femoroacetabular Impingement? Two-Year Follow-up

Background: There are currently no studies that have examined the recurrence of the cam lesion after femoral neck osteoplasty for femoroacetabular impingement. Although patient-reported outcome (PRO) scores at midterm follow-up have shown continued success, the maintenance of a normalized alpha angle has not been shown radiographically. Purpose: To assess the radiographic recurrence of cam deformity at 2-year follow-up after adequate decompression during the index hip arthroscopic procedure and correlate the findings with PRO scores. The hypothesis was that there would be no recurrence or regrowth of the cam deformity at the 2-year postoperative time point after adequate cam decompression during hip arthroscopic surgery. Study Design: Case series; Level of evidence, 4. Methods: Between March 2009 and January 2011, data were prospectively collected on all patients undergoing hip arthroscopic surgery with femoral neck osteoplasty. Minimum follow-up was 2 years, with radiographic images for review. Results: A total of 47 patients met the inclusion criteria. The mean age of the participants at the start of the study was 37.18 years (range, 31.70-47.43 years). There were 28 men (59.57%) and 19 women (40.43%). The mean follow-up duration was 28.32 months (range, 24-41 months). The mean preoperative alpha angle (Dunn view) was 70° (range, 60°-97°), compared with 42.79° (range, 32°-50°) at 2 weeks postoperatively (P < .0001). The mean 2-year alpha angle was 42.72° (range, 32°-54°), which was not significantly different compared with the mean 2-week alpha angle (P = .93). Additionally, the mean femoral offset measurement was 3.7 mm (range, 0-9.9 mm) preoperatively and 7.8 mm (range, 0.3-13.9 mm) 2 weeks postoperatively (P < .0001). The mean 2-year postoperative femoral offset measurement was 8.0 mm (range, 2.4-12.8 mm), which was not significantly different compared with the mean 2-week femoral offset measurement (P = .63). All PRO scores were significantly improved at 3 months compared with preoperative scores and, except for visual analog scale score, continued to show improvement at 2-year follow-up. Conclusion: There was no recurrence of cam deformity at 2 years after femoral neck osteoplasty for femoroacetabular impingement. PRO scores were improved at the 3-month and 2-year postoperative time points.

Accuracy of Component Positioning in 1980 Total Hip Arthroplasties: A Comparative Analysis by Surgical Technique and Mode of Guidance

The purpose of this multi-surgeon study was to assess and compare the accuracy of acetabular component placement, leg length discrepancy (LLD), and global offset difference (GOD) between six different surgical techniques and modes of guidance in total hip arthroplasty (THA). A total of 1980 THAs met inclusion criteria. Robotic- and navigation-guided techniques were more consistent than other techniques in placing the acetabular cup into Lewinneks safe zone (P<0.005 and P<0.05, respectively). Robotic-guided surgery was more consistent than other techniques in placing the acetabular component within Callanans safe zone (P<0.005). No statistically significant differences were found between groups in the frequency of patients with excessive LLD. Clinically significant differences between groups were not found in the frequency of patients with excessive GOD. Level of Evidence: IV.