Timothy J. Jackson

Arthroscopic Capsular Plication and Labral Preservation in Borderline Hip Dysplasia Two-Year Clinical Outcomes of a Surgical Approach to a Challenging Problem

Background: The role of hip arthroscopy in the treatment of patients with dysplasia is unclear because of the spectrum of dysplasia that exists. Patients with borderline dysplasia are generally not candidates for periacetabular osteotomy because of the invasive nature of the procedure. However, arthroscopy in dysplasia has had mixed results and has the potential to exacerbate instability. Hypothesis: Patients with borderline dysplasia will demonstrate postoperative improvement, high satisfaction rates, and low reoperation rates after a surgical approach that includes arthroscopic labral repair augmented by capsular plication with inferior shift. Study Design: Case series; Level of evidence, 4. Methods: Between April 2008 and November 2010, patients less than 40 years old who underwent hip arthroscopy for symptomatic intra-articular hip disorders, with a lateral center-edge (CE) angle ≥18° and ≤25°, were included in this study. Patients with Tönnis grade 2 or greater, severe hip dysplasia (CE ≤17°), and Legg-Calve-Perthes disease were excluded. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), Hip Outcome Score–Activity of Daily Living (HOS-ADL), and visual analog scale (VAS) for pain were obtained in all patients preoperatively and at 1, 2, and 3 years postoperatively. Revision surgery and complications were recorded for each group. Results: A total of 26 patients met the criteria to be included in the study. Of these, 22 (85%) patients were available for follow-up. The mean (± standard deviation) length of follow-up for this cohort was 27.5 ± 5.5 months (range, 17-39 months) and the average age was 20 years (range, 14-39 years). The mean lateral CE angle was 22.2° (range, 18°-25°) and the mean Tönnis angle was 5.8° (range, 0°-17°). There was significant improvement in all patient-reported outcome scores (mHHS, NAHS, HOS-SSS, and HOS-ADL) (P < .0001). There was a significant improvement in VAS scores from 5.8 to 2.9 (P < .0001). Overall patient satisfaction was 8.4 out of 10. Seventeen patients had good/excellent results (77%). Two patients required revision arthroscopy. Conclusion: Patients with borderline dysplasia have often fallen into a gray area between arthroscopy and periacetabular osteotomy, and viable treatment options have remained scarce. The current study demonstrates favorable results at 2-year follow-up for an arthroscopic approach that includes labral repair augmented by capsular plication with inferior shift.

Arthroscopic Labral Reconstruction Is Superior to Segmental Resection for Irreparable Labral Tears in the Hip A Matched-Pair Controlled Study With Minimum 2-Year Follow-up

Background: The acetabular labrum is an important structure that plays a significant role in proper biomechanical function of the hip joint. When the labrum is significantly deficient, arthroscopic reconstruction could provide a potential solution for the nonfunctional labrum. Purpose: To compare the clinical outcomes of arthroscopic labral reconstruction (RECON) with those of arthroscopic segmental labral resection (RESEC) in patients with femoroacetabular impingement (FAI) of the hip. Study Design: Cohort study; Level of evidence, 3. Methods: Between April 2010 and March 2011, all prospectively gathered data for patients with FAI who underwent arthroscopic acetabular labral reconstruction or segmental resection with a minimum 2-year follow-up were reviewed. Eleven cases in the RECON group were matched to 22 cases in the RESEC group according to the preoperative Non-Arthritic Hip Score (NAHS) and sex. The patient-reported outcome scores (PROs) used included the NAHS, the Hip Outcome Score (HOS), and the modified Harris Hip Score (mHHS). Statistical analyses were performed to compare the change in PROs in both groups. Results: There was no statistically significant difference between groups regarding the preoperative NAHS (P = .697), any of the other preoperative PROs, or demographic and radiographic data. The mean change in the NAHS was 24.8 ± 16.0 in the RECON group and 12.5 ± 16.0 in the RESEC group. The mean change in the HOS–activities of daily living (HOS-ADL) was 21.7 ± 16.5 in the RECON group and 9.5 ± 15.5 in the RESEC group. Comparison of the amount of change between groups showed greater improvement in the NAHS and HOS-ADL for the RECON group (P = .046 and .045, respectively). There was no statistically significant difference in the mean changes in the rest of the PROs, although there were trends in all in favor of the RECON group. All PROs in both groups showed a statistically significant improvement at follow-up compared with preoperative levels. Conclusion: Arthroscopic labral reconstruction is an effective and safe procedure that provides good short-term clinical outcomes in hips with insufficient and nonfunctional labra in the setting of FAI.

Joint-preserving Surgical Options for Management of Chondral Injuries of the Hip

&NA; Management of injuries to the articular cartilage is complex and challenging; it becomes especially problematic in weight‐bearing joints such as the hip. Several causes of articular cartilage damage have been described, including trauma, labral tears, and femoroacetabular impingement, among others. Because articular cartilage has little capacity for healing, nonsurgical management options are limited. Surgical options include total hip arthroplasty, microfracture, articular cartilage repair, autologous chondrocyte implantation, mosaicplasty, and osteochondral allograft transplantation. Advances in hip arthroscopy have broadened the spectrum of tools available for diagnosis and management of chondral damage. However, the literature is still not sufficiently robust to draw firm conclusions regarding best practices for chondral defects. Additional research is needed to expand our knowledge of and develop guidelines for management of chondral injuries of the hip.

Arthroscopic hip surgery with a microfracture procedure of the hip: clinical outcomes with two-year follow-up:

Background Outcome studies assessing a cohort of patients receiving microfracture in the hip have focused on second look arthroscopy and return to sport, which have shown favourable results in the absence of osteoarthritis. Few studies exist focusing on clinical outcomes after microfracture in the hip using patient reported outcome (PRO) scores. The purpose of this study is to evaluate two-year clinical outcomes of a series of patients treated with microfracture during arthroscopic hip surgery using PRO scores. Methods During the study period, all workers’ compensation (WC) and non-WC patients treated with microfracture during arthroscopic hip surgery were included. Four PRO scores, pain scores and satisfaction were used to assess clinical outcomes. Any revision surgeries or conversions to total hip arthroplasty (THA) were noted. Location of microfracture procedure, lesion size and additional variables assessed survivorship. Results Thirty-seven cases met the inclusion/exclusion criteria, of which 30 patients (30/37, 81%) were available for minimum two-year follow-up. Twenty-six patients were classified as survivors. Preoperative scores for patients with WC status were lower than non-WC patients and statistically significant (p<0.5) for three of the PROs. However, changes in all four PRO measurements demonstrated statistically significant improvements from preoperative to two-year follow-up for both compensation groups (p<0.05). The amount of change in PRO scores for both compensation groups was similar and not statistically significant. Two patients required THA and two patients required revision arthroscopy. Conclusion Our study demonstrates statistically significant clinical improvement in PROs after receiving microfracture during arthroscopic hip surgery at minimum two-year follow-up.

Ulnar Collateral Ligament Reconstruction Using Bisuspensory Fixation A Biomechanical Comparison With the Docking Technique

Background: Many ulnar collateral ligament (UCL) reconstruction techniques have been created and biomechanically tested. Single-bundle reconstructions aim to re-create the important anterior bundle of the UCL. To date, no technique has utilized suspensory fixation on the ulnar and humeral sides to create a single-bundle reconstruction. Hypothesis: The bisuspensory technique will restore valgus laxity to its native state, with comparable load-to-failure characteristics to the docking technique. Study Design: Controlled laboratory study. Methods: Six matched pairs of fresh-frozen cadaveric elbows were randomized to undergo UCL reconstruction using either the docking technique or a novel single-bundle bisuspensory technique. Valgus laxity and rotation measurements were quantified using a MicroScribe 3DLX digitizer at various flexion angles for the native ligament, transected ligament, and 1 of the 2 tested reconstructed ligaments. Laxity testing was performed from maximum extension to 120° of flexion. Each reconstruction was then tested to failure, and the method of failure was recorded. Results: Valgus laxity was restored to the intact state at all degrees of elbow flexion for both the docking and bisuspensory techniques. In load-to-failure testing, there was no significant difference with regard to stiffness, ultimate torque, ultimate torque angle, energy absorbed, and applied moment to reach 10° of valgus. Yield torques for the bisuspensory and docking reconstructions were 18.7 ± 7.8 N·m and 18.6 ± 4.4 N·m, respectively (P = .95). The ultimate torque for the bisuspensory technique measured 26.5 ± 9.2 N·m and for the docking technique measured 25.1 ± 7.1 N·m (P = .78). Conclusion: The bisuspensory fixation technique, a reproducible single-bundle reconstruction, was able to restore valgus laxity to the native state, with similar load-to-failure characteristics as the docking technique. Clinical Relevance: This reconstruction technique could be considered in a clinical setting as a primary method of UCL reconstruction or as a backup fixation method should intraoperative complications occur.

Hip Arthroscopy for Labral Tears in Workers’ Compensation A Matched-Pair Controlled Study

Background: Workers’ compensation (WC) status has been related to clinical outcomes; however, no comparative studies have been performed to assess 2-year outcomes between hip arthroscopy patients based on WC status. Purpose: To evaluate 2-year outcomes of patients receiving WC who underwent hip arthroscopy for labral tears and to compare outcomes with those of a matched control group not receiving WC. Study Design: Cohort study; Level of evidence, 3. Methods: During the study period between June 2008 and August 2010, data were collected on all patients treated with hip arthroscopy. Inclusion criteria for the study group were diagnosis of labral tear and WC status. All patients were assessed pre- and postoperatively 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. A matched-pair group of patients not associated with WC was selected in a 1:1 ratio according to age within 3 years, sex, surgical procedures, and radiographic findings. Results: Twenty-one hips were included in each group. Patients with WC status had significantly lower preoperative PRO scores for all measures (P < .001). However, there was no significant difference between VAS pain scores between the groups. Of the WC patients, 86% returned to work at a median 82 days postoperatively. For the WC group, the score improvement from preoperative to 2-year follow-up was 46 to 67.7 for mHHS, 39.3 to 66 for NAHS, 39.7 to 69.5 for HOS-ADL, and 15.3 to 49.8 for HOS-SSS. For the control group, the score improvement from preoperative to 2-year follow-up was 67.9 to 85.8 for mHHS, 62.6 to 84.4 for NAHS, 69.8 to 86.9 for HOS-ADL, and 41.9 to 73.8 for HOS-SSS. Both groups demonstrated statistically significant postoperative improvement in all scores, and the average amount of change of preoperative to postoperative scores between the 2 groups was only significantly different for the HOS-ADL in the control group (P = .043). However, the WC group demonstrated greater improvement in aggregate scores in the HOS-ADL. Pain scores decreased from 7 to 3.9 in the WC group and 5.8 to 3.2 in the control group and were not significantly different between the groups. Patient satisfaction was 6.8 for the WC group and 7.7 for the control group, with no significant difference between groups. Conclusion: Our study demonstrated that WC patients had significantly lower baseline PRO scores when compared with a matched-pair control group. However, both groups demonstrated statistically significant postoperative improvement in all scores. Patients with WC status started and ended with lower absolute scores but benefited from arthroscopic intervention for hip injuries. While patient and physician expectations may be adjusted accordingly, these results may reflect favorably on the use of hip arthroscopy for labral tears in the WC population.

Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia

AbstractHip arthroscopy can be a successful surgery when properly indicated and performed properly. In the setting of dysplasia, arthroscopy of the hip can lead to devastating consequences. This case presents a patient who underwent hip arthroscopy despite having significant hip dysplasia. The surgery failed and was subsequently revised with a concomitant arthroscopic labral repair and periacetabular osteotomy with good results at 2-year follow-up. Level of evidence Case report, Level IV.

Biomechanical Effect of Capsular Shift in the Treatment of Hip Microinstability. Creation and Testing of a Novel Hip Instability Model

Objectives: The objective of the study was to create a cadaveric model of hip capsule laxity and evaluate the biomechanical effects of a capsular shift used to treat hip instability on this model. Methods: Eight fresh frozen cadaveric hips, average age 58.5, were tested with a custom hip jig. To create the hip laxity model, the capsule was stretched in extension under 35Nm of torque for 1 hour in neutral rotation. Specimens went through a series of six testing conditions: intact, vented, stretched, capsulotomy, side to side repair, and capsular shift. Specimens were tested in internal (IR) and external (ER) rotational range of motion under 1.5 Nm of torque at 5 positions: 5° extension, 0°, 15°, 30° and 45° flexion. Maximum extension was measured at 5Nm torque, and femoral distraction under 40N and 80N of force. Following creation of the instability model, capsulotomy was performed just distal to and in line with the labrum from 12 o’clock to 4 o’clock through the entire substance of the iliofemoral ligament. Capsulotomies underwent two repairs, including a 1 cm capsular shift technique and side to side repair using #2 vicryl. Statistical analysis was performed using repeated measures ANOVA with TUKEY post-hoc analysis. Results: Analysis of the “stretched” state showed significantly increased IR at 5° ext, 0° flex, 15° flex, and 30° flex and increased distraction at 40N and 80N as compared to intact (Figure 1)(Table 1). Max extension increased by 6.6° between intact and stretched, however this was not statistically significant. Capsulotomy condition significantly increased ER and IR from intact at all flexion-extension positions. Furthermore, capsulotomy increased distraction at 40N and 80N, as well as max extension, as compared to intact. The repair restored IR back to the stretched state but not to the intact state at 5° ext and 0° flex (19.6° vs 24.5° and 21.8° vs 26.4°, respectively). The capsular shift significantly decreased IR compared to stretched state at 5° ext, 0°, and 15° flex, and at 5° ext and 0° compared to the vented state. Capsular shift restricted IR significantly more than repair at 5° ext, 0° flex, and 15° flex. Capsule shift and repair had similar effects on ER. Distraction distance at 40N and 80N was greater in the repair compared to the shift but this was not statistically significant. The capsular shift decreased distraction as compared to the stretched state but the repair did not. Maximum extension was significantly reduced back to the intact/vented state from the laxity state in the capsular shift but not in the repair. Conclusion: The instability model (stretched) was shown to have significantly greater range of motion, extension, and distraction than the intact condition. The greatest effects of capsular shift are seen with internal rotation, extension, and distraction with minimal effect on external rotation. The biomechanical effects of the capsular shift procedure in hip laxity patients show that its use can safely treat pathologic hip capsular laxity.

Sex-Based Differences in the Clinical Presentation of Patients With Symptomatic Hip Labral Tears

Background: An increasing body of literature describes the clinical presentation and demographics of patients with hip labral tears. The differences in pelvic structure and joint laxity between sexes have been described; however, no study has evaluated differences in the clinical presentation of patients with symptomatic labral tears between sexes. Purpose: To describe the differences between sexes in demographics, clinical history, physical examination, and intraoperative findings in patients with symptomatic labral tears. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected between February 2008 and February 2013 on 1401 patients who had symptomatic labral tears and underwent arthroscopic surgery. Hips with previous pathologic disorders were excluded. Data on demographics and clinical history were gathered, and a physical examination was performed. Preoperative pain was estimated on the visual analog scale (VAS), and 4 hip-specific patient-reported outcomes (PROs) were administered to evaluate functional status. Intraoperative findings were recorded. Results: A total of 654 patients met our inclusion/exclusion criteria, with 320 males and 334 females. The median age for males was 38.3 years (range, 15.0-69.6 years) and for females 40.4 years (range, 13.1-66.8 years). Male patients had a higher incidence of acute injury than females (39.6% vs 27.6%, respectively; P < .05) and a higher incidence of workers’ compensation status (14.1% vs 4.5%, respectively; P < .05). Females had increased range of motion compared with males, which was statistically significant for all range of motion measurements (P < .05). The anterior impingement test was positive in 94.4% of females and 92.9% of males, the flexion/abduction/external rotation test was positive in 59.5% of females and 61.5% of males, and the lateral impingement test was positive in 55.0% of females and 59.2% of males, but there was no statistically significant difference between sexes in any of the tests. Pain with palpation over the greater trochanter was positive in 22.0% of males and 36.9% of females (P < .0001). Females had lower PROs; however, VAS scores were similar. Conclusion: Male and female patients differ in their hip structure, biomechanics, and operative findings of symptomatic labral tears. However, they do not differ substantially in clinical presentation, except that males are more likely to report an acute injury and females are more likely to be evaluated with increased range of motion.

Magnetic Resonance Imaging Findings in the Symptomatic Hips of Younger Retired National Football League Players

Background: American football players have an increased level of risk for hip injuries because of the high level of contact, biomechanical load, and anatomic strain placed on the hip joint. Many injuries are attributed to soft tissue injury rather than intra-articular lesions. However, because of improved imaging and increased knowledge, physicians are attributing unexplained hip pain to intra-articular lesions with increasing frequency. Purpose: To assess the prevalence of pathologic intra-articular hip lesions in a younger, retired National Football League (NFL) player cohort evaluated for persistent hip pain. Study Design: Case series; Level of evidence, 4. Methods: A retrospective chart review was performed of magnetic resonance imaging (MRI) on retired NFL players evaluated at an orthopaedic clinic for persistent hip pain. All MRIs were performed at the same location and reviewed by the same independent radiologist. The study included 62 hips; MRI was used to evaluate 27 hips, and MRI arthrogram was used to evaluate 35 hips. Images were assessed for labral tears, chondral lesions, ligamentum teres (LT) tears, bone cysts, osteophytes, loose bodies, trochanteric bursitis, and alpha angle. Player demographics, including position and seasons played, were recorded. Results: From February 2011 to December 2012, a total of 50 retired players from the NFL (average age, 33 years; range, 27-39 years) received impairment evaluations assessing all symptomatic joints. Thirty-eight (76%) players had hip complaints and underwent a dedicated hip MRI. Twenty-four players (63%) had bilateral hip pain, for a total of 62 hips evaluated. There were 55 (89%) labral tears, 61 (98%) chondral lesions, and 50 (81%) partial or complete LT tears identified on MRI. Additional findings included 3 (5%) hips with osteophytes, 9 (14.5%) with subchondral bone cysts, and 3 (5%) with paralabral cysts. None of the players were found to have trochanteric bursitis or loose bodies. Fifty-eight of 62 alpha angles could be measured, for a mean of 59° (range, 39°-77°). The majority of players were defensive players (63%), while the remainder were offensive players (34%) and 1 special teams player. Position breakdown was as follows: 29% were defensive backs, 16% played the defensive line, 18% were linebackers, 13% were fullbacks, 11% were wide receivers, 5% played the offensive line, and the remaining 8% were kickers, running backs, and quarterbacks. Conclusion: This study demonstrated a high incidence of intra-articular pathologic lesions of the hip in a younger cohort of retired NFL players. The majority of players had bilateral hip pain. The most common finding was chondral lesions, followed by labral tears. Future research is needed to further elucidate incidence and treatment outcomes using prospective studies examining active and retired players with hip-related injuries.