Kevin F. Dunne

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.

Microfracture in the Hip Results of a Matched-Cohort Controlled Study With 2-Year Follow-up

Background: Microfracture in hip preservation surgery has demonstrated favorable outcomes, but studies with a higher level of evidence assessing microfracture are warranted. Purpose: To assess 2-year outcomes of patients who underwent hip arthroscopy with full-thickness chondral damage treated with microfracture and compare these outcomes with those of a control group from a similar cohort of patients who did not have full-thickness chondral damage and who were not treated with microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: Between February 2008 and May 2012, prospectively gathered data for patients undergoing microfracture during hip arthroscopy with a 2-year follow-up were reviewed. All patients were assessed pre- and postoperatively at 3 months, 1 year, and 2 years with 4 patient-reported outcome (PRO) instruments. A matched cohort of patients who did not have full-thickness chondral damage and hence did not receive microfracture was selected on a 1:2 ratio. Matching criteria were sex, age within 6 years, workers’ compensation status, concomitant labral treatment, and radiographic parameters. Statistical analyses were performed to compare the change in PROs in both groups. Results: A total of 79 hips were included in the microfracture group and 158 in the control group. There was no significant difference in PRO scores preoperatively between the groups. Both groups demonstrated significant improvement in all postoperative PRO scores at all time points. There was no statistically significant difference in postoperative PRO scores between the microfracture and control groups, except for the visual analog scale (VAS) score at 2 years, which was higher (P = .02) in the microfracture group (mean ± SD, 3.63 ± 2.50) than in the control group (2.82 ± 2.76). Patient satisfaction was 7.2 for the microfracture group and 8.04 for the control group, which was statistically different (P < .05). The mean change in all PRO scores was similar between groups at 3 months and 1 year postoperatively but significantly lower in the microfracture group at 2 years postoperatively. The greatest improvement in both groups was noted at 3 months postoperatively. Conclusion: This study showed that patients undergoing microfracture during hip arthroscopy had equivalent PRO scores compared with the control group at 2 years postoperatively. The change in PRO scores from preoperatively to 2 years postoperatively was significantly lower in the microfracture group compared with the control group. The VAS scores and satisfaction were inferior by 0.81 and 0.84 units, respectively, in the microfracture group compared with the control group, likely due to lack of full-thickness chondral defects in the latter. However, both groups showed significant improvement in all PRO scores after surgery, with no significant difference in final PRO scores.

Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip Clinical Outcomes With a Minimum 2-Year Follow-up

Background: Internal snapping of the hip is caused by the iliopsoas (IP) tendon sliding over the iliopectineal eminence or the femoral head. In many cases that require hip arthroscopic surgery, there is coexistent painful internal snapping. In such cases, fractional lengthening of the IP tendon has been suggested as an adjunctive procedure. Purpose: To examine the outcomes and effectiveness of arthroscopic IP tendon fractional lengthening as a solution to coexistent internal hip snapping in patients undergoing hip arthroscopic surgery for a labral tear and/or femoroacetabular impingement. Study Design: Case series; Level of evidence, 4. Methods: Between June 2010 and June 2011, data were prospectively collected for all patients with internal snapping of the hip who underwent primary arthroscopic IP tendon fractional lengthening, with a minimum 2-year follow-up. All patients were interviewed by telephone with specific questions regarding the resolution or persistence of snapping. Patients were assessed preoperatively and postoperatively using the following patient-reported outcome (PRO) measures: Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Activity of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS). Pain was recorded on a visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. Results: A total of 55 patients were included, with all PROs showing statistically significant improvement postoperatively (NAHS: 57.6 ± 20.6 preoperatively vs 80.2 ± 19.2 at 2 years; HOS-ADL: 60.9 ± 21.4 preoperatively vs 81.8 ± 20.6 at 2 years; HOS-SSS: 43.4 ± 24.6 preoperatively vs 70.0 ± 26.7 at 2 years; and mHHS: 62.3 ± 16.4 preoperatively vs 80.5 ± 18.3 at 2 years) (P < .001 for all). Forty-five patients (81.8%) reported good/excellent satisfaction (≥7). Overall, 45 patients (81.8%) reported resolution of painful snapping. Patients who had resolution of snapping had statistically significant superior outcomes compared with those with persistent snapping using the change in the NAHS value (25.8 ± 16.1 vs 8.0 ± 22.5, respectively; P = .005), change in the HOS-ADL value (23.6 ± 18.0 vs 8.5 ± 15.2, respectively; P = .017), change in the HOS-SSS value (30.7 ± 26.9 vs 8.7 ± 23.6, respectively; P = .021), and change in the mHHS value (23.3 ± 20.1 vs 4.4 ± 9.9, respectively; P = .005). Conclusion: A majority of patients reported resolution of painful snapping and improvement in symptoms. Nonetheless, the rate of persistence of internal snapping at a minimum 2 years postoperatively was higher than that reported in previous studies.

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 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.

Patient reported outcomes for patients who returned to sport compared with those who did not after hip arthroscopy: minimum 2-year follow-up

Previous studies assessed elite athletes’ return to sport (RTS) after hip arthroscopy, but few investigated a cohort including athletes from all levels of sport. This study compared athletes who returned to sport to those who did not, based on four patient-reported outcome (PRO) scores, including the Hip Outcome Score—Sports Specific Subscale (HOS-SSS). Between September 2008 and April 2012, hip arthroscopies were performed on 157 patients (168 hips) who reported playing a sport preoperatively and indicated their level of sports activity post-operatively. Two-year follow-up was available for 148 (94%) amateur and professional athletes with a total of 158 hips. Of these 60 cases (65 hips) did not return to sports (NRTS) and were in the NRTS group. The remaining 88 cases (93 hips) constituted the RTS group. The modified Harris Hip Score, Non-Arthric Hip Score, Hip Outcome-Activities of Daily Living (HOS-ADL), and HOS-SSS were used to assess outcomes. The HOS-SSS was used to assess specific sport-related movement. Both groups demonstrated significant improvement at 2 years post-operatively in visual analog score and four PRO scores (P < 0.001). There was no significant preoperative differences in HOS-SSS scores between groups; however, the RTS group had significantly higher HOS-SSS scores at 1 and 2 years post-surgery. Post-operatively, the RTS group had significantly better ability to jump, land from a jump, stop quickly and perform cutting/lateral movements (P < 0.05). In summary, patients who indicated RTSs demonstrated significantly higher PRO scores and abilities to perform several sport-related movements, compared with patients who did not.

Labral Injury: Radiographic Predictors at the Time of Hip Arthroscopy

PURPOSE The purpose of this study was to investigate the influence of multiple demographic and radiographic findings on the size of labral tears identified at the time of hip arthroscopy. METHODS Data were prospectively collected for patients treated with arthroscopic labral repair or debridement from February 2008 to August 2011. Preoperative radiographic and demographic data were collected for 392 patients during the study period. Exclusion criteria included revision surgery and previous hip conditions. An anteroposterior pelvic view, 45° Dunn view, and false-profile view were used to measure Tönnis grade, neck-shaft angle, alpha angle, lateral center edge angle (LCEA), anterior center edge angle (ACEA), acetabular inclination, and the extent of crossover sign when present. At the time of surgery, labral tear size and location were documented for all patients, using traditional acetabular clock face nomenclature for sizing. A multiple linear regression analysis was then performed to assess the correlation of radiographic and demographic findings with the size of the labral tear. RESULTS Regression analysis displayed statistical significance for sex (P < .0001), age (P < .0001), and alpha angle (P = .005) with labral tear size. For female patients, Tönnis grade (P = .0004) and neck-shaft angle (P = .004) correlated with labral tear size. This model accounted for only 26% of variation in labral tear size. CONCLUSIONS Preoperative risk factors for the extent of labral tear size are male sex, increasing age, and increasing alpha angle. Labral tears were larger in female patients with higher Tönnis grades and lower neck-shaft angles. Measurements of acetabular coverage and version showed no correlation with labral tear size. The majority of labral tear size variation was not accounted for in this model. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Assessment of Intraoperative Intra-articular Morphine and Clonidine Injection in the Acute Postoperative Period After Hip Arthroscopy

Background: Previous authors have suggested that intra-articular morphine and clonidine injections after knee arthroscopy have demonstrated equivocal analgesic effect in comparison with bupivacaine while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine after hip arthroscopy. Purpose: To evaluate the efficacy of intra-articular morphine in combination with clonidine on postoperative pain and narcotic consumption after hip arthroscopy surgery for femoroacetabular impingement. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review was performed on 43 patients that underwent hip arthroscopy for femoroacetabular impingement at a single institution between September 2014 and May 2015. All patients received preoperative celecoxib and acetaminophen, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 μg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the 2 groups. Results: Patients who received intra-articular morphine and clonidine used significantly less opioid analgesic (mEq) in the postanesthesia recovery (median difference, 17 mEq [95% CI, –32 to –2 mEq]; P = .02) compared with the control group. There were no differences in time spent in recovery before hospital discharge or in visual analog pain scores recorded immediately postoperatively and at 1 hour after surgery. Conclusion: Intraoperative intra-articular injection of morphine and clonidine significantly reduced the narcotic requirement during the postsurgical recovery period after hip arthroscopy. The reduction in postsurgical opioids may decrease adverse effects, improve overall pain management, and lead to better quality of recovery and improved patient satisfaction.

Risk Factors for Early Conversion to Total Hip Arthroplasty following Hip Arthroscopy

Objectives: The most common reason for reoperation following arthroscopic hip surgery is conversion to total hip arthroplasty (THA). The purpose of this study was to identify clinical and radiographic risk factors for early conversion to THA. Methods: Data were prospectively collected on all hip arthroscopy patients from January 2009 through December 2011. Inclusion criteria for the study group were patients undergoing hip arthroscopy for a labral tear who eventually converted to THA. Patients were then compared to a control group of patients who underwent hip arthroscopy for a labral tear and did not convert to THA during the same period. Exclusion criteria were patients with previous hip conditions such as Legg-Calves-Perthes, slipped capital femoral epiphysis, pigmented villonodular synovitis, and avascular necrosis. A bivariate analysis of 41 preoperative and intraoperative variables was performed. Results: A total of 792 patients met inclusion and exclusion criteria. A total of 72 (9%) converted to THA. The control group consisted of 720 patients who did not convert to THA. Bivariate analysis demonstrated that the study group had significantly higher means or frequencies than the control group for the following variables: male gender, age at time of surgery, BMI, back pain, previous back surgery, Tönnis grade above 0, acetabular inclination angle, alpha angle, Seldes combined-type labral tear, labral tear size, chondral injury, traction time, labral debridement (versus repair), number of anchors used repair or reconstruction, and capsular release (versus repair). The study group had significantly lower means or frequencies than the control group for the following variables: preoperative patient reported outcome scores, crossover sign, lateral center edge angle, and psoas release. A statistically significant difference in average joint space was not observed. Conclusion: Multiple risk factors are possible preoperative and intraoperative risk factors for conversion to THA following hip arthroscopy. The clinician and patient should be aware of these variables.

Microfracture Of The Hip: A Two-year Follow-up With A Matched-pair Control Group

Objectives: Full thickness chondral defects have been suggested to portend poor prognosis in hip arthroscopy. Although there is a small amount of data suggesting favorable outcomes with microfracture for such cases, no comparative studies have been performed to assess outcomes of full thickness chondral defects treated with microfracture. The purpose of this study is to compare two-year clinical outcomes of patients treated with microfracture to a matched control group that did not have 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. A matched-pair control group of patients who did not undergo a microfracture procedure was selected in a 1:2 ratio. Matching criteria were age within 5 years, sex, surgical procedures, and radiographic findings. All patients were assessed pre- and post-operatively with 4 patient-reported outcome (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 Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. Results: Forty-nine hips were included in the microfracture group and 98 in the control group. There was no significant difference in pre-operative PRO scores between the groups. For the microfracture group, the score improvement from preoperative to 2-year follow-up was 57.5 to 75.4 for mHHS, 53.6 to 71.8 for NAHS, 59.5 to 79.1 for HOS-ADL, and 35.5 to 55.5 for HOS-SSS. For the control group, the score improvement from preoperative to 2-year follow-up was 59.2 to 79.5 for mHHS, 54.4 to 76.2 for NAHS, 60.6 to 80.4 for HOS-ADL, and 38.6 to 64.2 for HOS-SSS. Both groups demonstrated statistically significant postoperative improvement in all scores (p <.05). All post-operative PRO scores, and all improvements in PRO scores, were found to be similar between the study and control groups. Conclusion: Our study demonstrated that patients receiving microfracture during hip arthroscopy did not show a statistically significant difference in PRO scores when compared to a matched-pair control group at two year follow-up. Both groups demonstrated significant improvement in all PRO scores. These results show that microfracture appears to be a viable treatment option for grade IV cartilage damage identified at the time of hip arthroscopy. Furthermore, full thickness chondral defects may not necessarily portend an inferior functional prognosis when treated with microfracture