Kay S. Jones

Diagnostic Accuracy of Clinical Assessment, Magnetic Resonance Imaging, Magnetic Resonance Arthrography, and Intra-articular Injection in Hip Arthroscopy Patients

Background Hip arthroscopy has defined elusive causes of hip pain. Hypothesis/Purpose It is postulated that the reliability of various investigative methods is inconsistent. The purpose of this study is to evaluate the diagnostic accuracy of these methods. Study Design Retrospective review of prospectively collected data. Methods Five parameters were assessed in 40 patients: clinical assessment, high-resolution magnetic resonance imaging, magnetic resonance imaging with gadolinium arthrography, intra-articular bupivacaine injection, and arthroscopy. Using arthroscopy as the definitive diagnosis, the other parameters were evaluated for reliability. Results Hip abnormality was clinically suspected in all cases with 98% accuracy (1 false positive). However, the nature of the abnormality was identified in only 13 cases with 92% accuracy. Magnetic resonance imaging variously demonstrated direct or indirect evidence of abnormality but overall demonstrated a 42% false-negative and a 10% false-positive interpretation. Magnetic resonance arthrography demonstrated an 8% false-negative and 20% false-positive interpretation. Response to the intra-articular injection of anesthetic was 90% accurate (3 false-negative and 1 false-positive responses) for detecting the presence of intra-articular abnormality. Conclusions In this series, clinical assessment accurately determined the existence of intra-articular abnormality but was poor at defining its nature. Magnetic resonance arthrography was much more sensitive than magnetic resonance imaging at detecting various lesions but had twice as many false-positive interpretations. Response to an intra-articular injection of anesthetic was a 90% reliable indicator of intra-articular abnormality.

Arthroscopic Management of Femoroacetabular Impingement: Minimum 2-Year Follow-up

PURPOSE We report the results of arthroscopic management of femoroacetabular impingement with 2-year follow-up. METHODS All patients undergoing hip arthroscopy were prospectively assessed with the modified Harris Hip Score. Arthroscopic correction of femoroacetabular impingement was first performed in 2003. The cohort of this study consists of the first 100 consecutive cases that had achieved 2-year follow-up. RESULTS There was 100% follow-up at 2 years. The mean age was 34 years (range, 13 to 76 years), with 67 male and 33 female patients. There were 63 cam, 18 pincer, and 19 combined lesions. Acetabular articular damage was found in 97 cases, femoral damage was present in 23, and there were 92 labral tears. The median improvement was 21.5 points, with 79 good and excellent results. No patient required revision to total hip arthroplasty, but 6 patients underwent a subsequent arthroscopic procedure. There were 3 complications including a transient neurapraxia of the pudendal nerve and a transient neurapraxia of the lateral femoral cutaneous nerve, which resolved uneventfully, and 1 mild case of heterotopic ossification. CONCLUSIONS We report favorable outcomes for the arthroscopic management of femoroacetabular impingement in our early experience in the first 100 consecutive cases. The high incidence of significant articular damage observed at the time of arthroscopic intervention is concerning.

Hip Arthroscopy in Athletes: 10-Year Follow-Up

Background Arthroscopy is a well-accepted technique in the management of many athletic-related hip disorders, yet little quantitative outcomes data have been reported. Purpose To report the results of hip arthroscopy in a consecutive series of athletes with 10-year follow-up. Study Design Case series; Level of evidence, 4. Methods Since 1993, all patients undergoing hip arthroscopy at our institution have been prospectively assessed with a modified Harris hip score preoperatively and then postoperatively at 1, 3, 6, 12, 24, 60, and 120 months or until a subsequent procedure was performed. The variables studied included age, sex, type of sport, level of sport, diagnosis, duration of symptoms, onset of symptoms, and center edge angle. Fifty-two procedures were performed on 50 patients who had achieved 10-year follow-up. Fifteen patients developed symptoms in the course of athletic activities and their cases represent the substance of this study. Results Follow-up information was available for all 15 patients (11 men and 4 women). The average age was 31.7 years (range, 14–70 years). Type of sport involved included football (3), tennis (3), basketball (2), golf (2), and others (5); with 9 recreational, 4 high school, and 2 intercollegiate athletes. Diagnoses included chondral damage (8), labral tear (7), arthritis (5), avascular necrosis (1), loose body (1), and synovitis (1). The median improvement in the modified Harris hip score was 45 points (from 51 preoperatively to 96, on the 100-point scale), with 13 patients (87%) returning to their sport. All 5 athletes with arthritis eventually underwent total hip arthroplasty at an average of 6 years. There were no complications. Conclusion Arthroscopy to address hip injuries in athletes can result in substantial improvement with durable results. However, arthritis is a prognostic indicator of poor long-term outcomes.

Arthroscopic Surgery for Isolated Capitellar Osteochondritis Dissecans in Adolescent Baseball Players Minimum Three-Year Follow-Up

Background Osteochondritis dissecans of the capitellum of the humerus usually occurs in adolescence and is caused by the valgus forces associated with excessive throwing. Hypothesis Arthroscopic surgery is an appropriate procedure for this condition. Study Design Retrospective cohort study. Methods Arthroscopic surgery was performed on 10 baseball players (average age, 13.8 years) with osteochondritis dissecans whose symptoms had been apparent for an average of 9 months before the operation. Follow-up at an average of 3.9 years included use of a standard rating scale, radiographs, and a questionnaire regarding return to sport. Results There were two grade I, one grade II, two grade IV, and five grade V lesions. Symptoms and objective findings correlated poorly with the grade of the lesion. The postoperative score averaged 195, reflecting excellent results. Radiographically, the primary lesion was still apparent in one patient, secondary degenerative changes were evident in one patient, and, in one patient, the lesion was still evident and degenerative changes had occurred. Only four athletes returned to organized baseball. Conclusions Arthroscopic surgery for symptomatic osteochondritis dissecans of the capitellum in adolescent baseball players can provide excellent rating scores with intermediate follow-up but does not assure return to baseball.

Ultrasound-Guided Hip Injections: A Comparative Study With Fluoroscopy-Guided Injections

PURPOSE The purpose was to assess ultrasound-guided injections through patient satisfaction in a comparative internally controlled study of fluoroscopic versus ultrasound technique and to quantitate the reliability of the ultrasound method. In addition, the reliability of the ultrasound method was quantitated. METHODS This study consisted of the first 50 consecutive patients to undergo ultrasound-guided intra-articular injection of the hip (by a nurse practitioner) and who had previously undergone fluoroscopy-guided intra-articular injections by our centers fellowship-trained musculoskeletal radiologists. The patients rated the ultrasound and fluoroscopic experiences on a scale from 1 to 10 for convenience and pain; in addition, they indicated their preference between the 2 techniques. Success of the injection was documented among a total of 206 consecutive patients who underwent ultrasound-guided injections during the period of the controlled study. RESULTS For convenience, ultrasound injection had a mean rating of 9.8 whereas fluoroscopic injection had a mean rating of 3.1. For pain, ultrasound had a mean rating of 3 and fluoroscopy had a mean rating of 5.6. These differences were statistically significant (P < .01) in favor of ultrasound. For preference, 49 of 50 patients in the control study (98%) stated that they would prefer the ultrasound injection, whereas 1 was uncertain. The injection was successful in 202 of the first 206 patients (98%) to undergo ultrasound injection, whereas 4 patients required a second pass for successful injection. CONCLUSIONS In this study in-office ultrasound-guided injections of the hip were more convenient and less painful than fluoroscopy-guided hospital-based injections and were preferred by patients who have undergone both. Furthermore, the ultrasound-guided injections were performed by a recently trained physician extender in contrast to the fluoroscopic method, which was performed by experienced fellowship-trained musculoskeletal radiologists. The procedure is highly successful in the hands of a properly trained clinician. LEVEL OF EVIDENCE Level II, prospective comparative study.

Two to 10 Years' Follow-up of Arthroscopic Management of Pigmented Villonodular Synovitis in the Hip: A Case Series

PURPOSE The purpose of this study was to evaluate the results of arthroscopic treatment for pigmented villonodular synovitis (PVNS) of the hip. METHODS All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris Hip Score preoperatively and postoperatively at 3, 12, 24, 60, and 120 months. Thirteen patients were identified with histologically confirmed PVNS and minimum 2-year follow-up. These procedures were performed between 2001 and 2008, during which time a total of 1,640 arthroscopic procedures were performed. There was 100% follow-up at a mean of 63 months (range, 24 to 120 months). There were 9 female and 4 male patients with a mean age of 27 years (range, 14 to 46 years). The pattern of involvement was diffuse in 3 patients, nodular in 3, and combined in 7. Concomitant pathology included 7 articular cartilage lesions (3 grade III and 4 grade IV), 6 labral tears, and 4 cases with femoroacetabular impingement. RESULTS The mean improvement in the Harris Hip Score was 27 points (62 points preoperatively and 89 points postoperatively) (SD, 17 points), with a range of 3 to 56 points. The mean improvement based on pattern of disease was as follows: diffuse, 30 points (SD, 23 points); nodular, 25 points (SD, 18 points); and combined, 26 points (SD, 0.70 points). There were no complications, but one patient was converted to a total hip arthroplasty at 6 years postoperatively. CONCLUSIONS In this cohort the results of arthroscopic management of PVNS have been favorable with minimal morbidity. Arthroscopy may be necessary to substantiate the diagnosis, as well as to assess and address other accompanying damage. The procedure must include both the central and peripheral compartments. The secondary damage and prelude to osteoarthritis cannot be reversed and, when severe, make the less invasive nature of the arthroscopic approach especially appealing. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Femoroacetabular Impingement in Adolescent Athletes Outcomes of Arthroscopic Management

Background: Adolescent athletes with symptomatic femoroacetabular impingement (FAI) may respond well to arthroscopic intervention. Purpose: This study reports the outcomes of arthroscopic treatment for symptomatic FAI in adolescents. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 104 consecutive athletes (116 hips) younger than 18 years who underwent arthroscopic correction of symptomatic FAI with a minimum 2-year follow-up. All patients were prospectively assessed with the modified Harris Hip Score (mHHS). Pincer lesions were defined by acetabular overcoverage or retroversion with an accompanying labral injury, and cam lesions were defined by loss of sphericity of the femoral head with associated acetabular articular failure. Results: The average follow-up was 38 months (range, 24-120 months), and the average patient age was 16 years (range, 12-17 years), with 47 male and 57 female patients. There were 67 combined, 33 cam, and 16 pincer lesions. The average improvement on the mHHS was 25 points (average score: 69 preoperatively, 94 postoperatively), with 97% improved and 94% good and excellent results. Athletes returned to their sport after 100 procedures (86%). After 16 procedures, 5 patients were unable to return to sport, 6 chose not to, and 5 had completed their high school athletic careers. There were 2 complications, both transient pudendal nerve neurapraxias, that resolved within 2 weeks. Four patients underwent repeat arthroscopic surgery, and 1 underwent periacetabular osteotomy. Conclusion: This study reports favorable outcomes of arthroscopic treatment of FAI among adolescent athletes. A high proportion improved, although only 87% actually returned to their sport. Return to sport may be influenced by factors other than just the success of the procedures.

Hip arthroscopy in the warrior athlete: 2 to 10 year outcomes

Hip disorders are increasingly recognized among athletic populations. The rigors of military service expose individuals to the same risks as those participating in competitive sports, compounded by potential exposure to violent macrotrauma. This is a retrospective review of prospectively collected data among 62 active duty military personnel (64 hips) with 2–10-year follow-up. Follow-up averaged 47 months (range 24–120 months). The average age was 30 years (range 17–53 years) with 45 males and 17 females; 37 right and 27 left hips. Duration of symptoms prior to arthroscopy averaged 28 months (range 6–168 months). The average improvement was 22 points (pre-op 63; post-op 85) using the 100-point modified Harris hip score and was statistically significant (P <  0.001). Patients were improved after 60 of 64 procedures (94%) and returned to active duty following 52 (80%) and an average of 5 months (range 1 week–15 months). Forty-six (72%) underwent correction of FAI including 27 combined, 17 cam and two pincer lesions. Overall diagnoses and procedures are detailed. One patient underwent repeat arthroscopy and remained improved at 2-year follow-up; none were converted to total hip arthroplasty. There were two minor complications, a transient ulnar nerve neurapraxia and superficial sensory dysesthesias of the foot, both of which resolved within a few days. This is a heterogeneous cohort of pathology, but illustrates that hip disorders may exist among active duty military personnel and may benefit from arthroscopic intervention. A sense of awareness is important for accurate diagnosis and timely treatment.

Revision hip arthroscopy: findings and outcomes

Abstract The purpose of this study is to report on the operative findings and the outcomes of revision hip arthroscopy. All hip arthroscopy cases are prospectively assessed with a modified Harris Hip Score (mHHS) preoperatively and postoperatively. This study consists of 190 consecutive hips (186 patients) who underwent revision arthroscopy with minimum 2-year follow-up. There were 69 males and 117 females with a mean age of 32.7 (14–64). The mean time from index to revision procedure was 24.5 months (3–146). Common diagnoses included labral tears (102) and unaddressed or residual femoroacetabular impingement (FAI) (49 cam, 11 pincer, and 20 combined). In addition to FAI correction, there were 82 labral debridements, 28 repairs/refixations, and 6 excisions of labral calcifications. Ninety-three underwent various amounts of synovectomy and 21 underwent iliopsoas release/debridement. At a mean follow-up of 46.9 months, 84.5% of patients reported symptomatic improvement. Twenty patients underwent subsequent surgery at mean of 51 months (11 repeat arthroscopy and 9 THA). Among 166 patients who had no further surgery, the mHHS had improved 27.1.8 points from a preoperative mean of 54.5 to 81.6. Patients who underwent treatment of FAI demonstrated a mean mHHS improvement of 25.7 points. Complications included two cases of transient pudendal neurapraxia, one case of transient quadriceps weakness, one case of retroperitoneal extravasation, and one case of perioperative myocardial infarction. In conclusion, for properly selected patients with persistent or recurrent symptoms following previous hip arthroscopy, revision surgery can result in favorable outcomes with an acceptably low complication rate.

Endoscopic repair of hip abductor tears: outcomes with two-year follow-up

Abstract Abductor lesions are increasingly recognized as a source of recalcitrant laterally based hip pain and dysfunction. There is a growing body of evidence that many of these may be amenable to endoscopic repair. To report the demographic data and outcomes of endoscopic hip abductor repair. Twelve patients underwent endoscopic abductor repair with 2-year follow-up. These patients were prospectively assessed with modified Harris hip and iHOT scores. The indications for surgery were clinical and MRI findings of symptomatic abductor tears that had failed conservative treatment. All patients underwent concomitant or prior arthroscopy of the joint. Repair was performed with suture anchors using an iliotibial band-sparing endoscopic technique; followed by a 4-month structured rehabilitation protocol. Follow-up was obtained on all patients at 24 months. The average age was 56 years (range 39–77 years). These were all females. All demonstrated improved modified Harris hip scores, averaging 43 points (preop 42; postop 85). Eleven of 12 (92%) demonstrated improved iHOT scores, averaging 52 points (preop 21; postop 73). Ten patients had accompanying intra-articular pathology including 10 labral tears, 7 chondral lesions, 6 synovitis and 1 pincer impingement. There were no complications, and none underwent further surgery. Abductor tears of the hip can be clinically relevant and respond well to endoscopic repair. This tends to be a disorder of older females who present with severe disability, reflected by low preoperative modified Harris hip scores, and demonstrate significant, although incomplete, improvement.