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Labral calcification may be part of the natural history of untreated femoroacetabular impingement syndrome (FAIS) in certain patients, making it a potential target for intervention with the goal of preserving the hip joint. The purpose of this study was to investigate if calcified labra create the appearance of lateral joint space narrowing and report minimum 2-year patient-reported outcome measures (PROMs) after treating patients with arthroscopic acetabuloplasty and labral reconstruction. Prospectively collected data on patients who underwent primary hip arthroscopy for FAIS and labral tearing from February 2015 to April 2021 were reviewed. Patients treated with primary labral reconstruction for an intraoperatively confirmed diagnosis of labral calcification were included. A sub-analysis was performed for patients with a minimum of 2-year follow-up. Preoperative and postoperative PROMs for the modified Harris hip score, nonarthritic hip score, the International Hip Outcome Tool-12 and visual analog scale for pain were recorded. Forty-six hips (46 patients) were included, with 19 hips in the sub-analysis. There was a significant increase in apparent lateral joint space width (JSW) measured on supine anteroposterior (AP) pelvis radiographs with no significant changes in medial and central JSW and significant decreases in the lateral and anterior center-edge angles and alpha angle. Patients experienced significant increases in PROMs and high rates of achieving psychometric thresholds. Patients presenting with FAIS and calcified labra may have apparent lateral joint space narrowing on pre-operative supine AP pelvis radiographs. These patients have low rates of full-thickness femoral head and acetabular cartilage pathology, this apparent narrowing can be corrected and excellent outcomes and survivorship can be achieved, with primary labral reconstruction., (© The Author(s) 2022. Published by Oxford University Press.)

There is a paucity of literature investigating the effect of lumbopelvic mobility on patient-reported outcome scores (PROs) after primary hip arthroscopy. The purpose of this study was (i) to report minimum 1-year PROs in patients with limited lumbopelvic mobility (LM) who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (ii) to compare clinical results with a propensity-matched control group of patients with normal lumbopelvic mobility (NM). Data were reviewed for surgeries performed between November 2019 and March 2020. Patients were considered eligible if they received a primary hip arthroscopy for FAIS in the setting of LM (seated to standing change in sacral slope ≤ 10°). LM patients were propensity-matched to a control group of patients with normal lumbopelvic motion (seated to standing change in sacral slope > 10°) for comparison. A total of 17 LM and 34 propensity-matched NM patients were included in the study. LM patients showed significant improvement in all outcome measures and achieved the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS) at high rates for modified Harris Hip Score (MCID: 94% and PASS: 82%) and International Hip Outcome Tool-12 (iHOT-12; MCID: 94% and iHOT-12: 76%). When LM patients were compared to a propensity-matched control group of NM patients, they demonstrated similar postoperative PROs and rates of achieving MCID/PASS. LM patients who undergo primary hip arthroscopy may expect favorable short-term PROs at minimum 1-year follow-up. These results were comparable to a control group of NM patients., (© The Author(s) 2021. Published by Oxford University Press.)

The aim of this study was to review and summarize the available biomechanical data on hip capsular reconstruction to guide clinical decision-making. A literature search was completed in December 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify biomechanical cadaver studies on hip capsular reconstruction, hip capsulectomy or hip capsular defect. The investigated parameters included maximum distraction force, capsular state affecting range of motion (ROM), rotation and translation. Four studies met al. the inclusion-exclusion criteria. The median effective force for resisting maximum distraction for the reconstruction state, capsular defect state and the intact state was 171, 111 and 206 N, respectively. The defect capsule force was significantly lower ( P  = 0.00438) than the intact capsule force. The reconstruction state had a higher distraction force than that of the capsular defect, but due to heterogeneity, the overall effect size was not statistically significant. The capsular reconstruction state reduced excess motion and the degree of instability compared to the capsular defect state but restored the hip close to its native capsular state in the cadaveric model. When compared to capsulectomy/defect state, hip capsular reconstruction significantly improved the rotational stability and effective force at maximum distraction and minimized translation. However, no conclusions can be made regarding the most effective protocol due to the high heterogeneity between the four studies. Further biomechanical studies are needed to test various types of grafts under the same protocol., (© The Author(s) 2021. Published by Oxford University Press.)

The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients >40 years of age and by >84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by >80% of respondents for patients ≤40 years of age and > 80% of respondents if the labral size was >3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was <3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making., (© The Author(s) 2021. Published by Oxford University Press.)

The shelf procedure is a treatment of acetabular dysplasia, with the aim of increasing weight-bearing acetabular coverage. Although several shelf techniques have been described, the endoscopic procedure with concomitant hip arthroscopy is a new, less invasive alternative. Outcomes following this procedure are scarce. The purpose of this study was to report short-term patient-reported outcomes (PROs) following concomitant hip arthroscopy and endoscopic modified shelf procedure in the setting of acetabular dysplasia and labral tears. Patients that met extraordinarily selective surgical indications and underwent the abovementioned surgery between February 2016 and October 2019 and had minimum 1-year follow-up were included. There were five females with a mean age of 40.18 ± 5.05 years and follow-up of 21.55 ± 8.68 months. The lateral center-edge angle increased from 15.80° to 23.20° ( P  =   0.003), and vertical center-edge angle increased from 16.60° to 23.60° ( P  <   0.001). The Tönnis angle decreased from 15.40° to 3.74° ( P  <   0.001). The alpha angle decreased from 58.46° to 40.70° ( P  <   0.001). PROs demonstrated significant improvement at latest follow-up (modified Harris Hip Score, P  =   0.042; Non-Arthritic Hip Score, P  <   0.001; Hip Outcome Score-Sports Specific Subscale, P  =   0.035; Visual Analog Scale, P  <   0.001; International Hip Outcome Tool-12, P  =   0.043), and satisfaction was 8.60 ± 0.89. No secondary surgeries were reported. Concomitant hip arthroscopy and endoscopic modified shelf procedure appears to be a safe and effective procedure for patients with acetabular dysplasia and labral tears yielding favorable outcomes and satisfaction at short-term follow-up., (© The Author(s) 2021. Published by Oxford University Press.)

The function and importance of the acetabular labrum in hip biomechanics have been determined. A labral tear is one of the most common findings in the hip preservation field, commonly associated with femoroacetabular impingement (FAI) syndrome. It has been established that the restoration of labral anatomy and function are key factors to improve patient-reported outcome measurements (PROMs) and psychometric tools following arthroscopic hip arthroscopy in the context of FAI syndrome. Labral repair or refixation is currently the gold-standard surgical option when facing labral tears, with clinical mid to long-term data supporting its use. Labral selective debridement has proven to be a valid alternative in selective patients. Acetabular labral reconstruction has risen as an alternative to labral excision or resection when repair is not an option due to labral tissue deficiency. Restoring the labral sealing mechanism is the goal behind the acetabular labral reconstruction. It has been proven that labral reconstruction leads to superior PROMs when compared with resection. This review presents an analysis of the indications, techniques, and outcomes for arthroscopic acetabular labral reconstruction., (© The Author(s) 2021. Published by Oxford University Press.)

The purpose of this study was to analyze the effect of structured physical therapy protocols on patient-reported outcomes (PROs) following hip arthroscopy. A literature search was completed in October 2019 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify articles reporting specific rehabilitation protocols following hip arthroscopy that document PROs. Studies meeting all inclusion and exclusion were reviewed and data were extracted. Six studies were included in analysis. The mean age was 34.7% and 56.6% were males. Five studies described rehabilitation protocols in phases with specific goals and progression criteria. All studies included range of motion (ROM) and weight-bearing (WB) precautions. Return to sport (RTS)/activity varied between 7 and 32 weeks. The studies used variations of 21 different PROs. Significant improvements in baseline and post-operative PROs noted across studies. Rehabilitation protocols following hip arthroscopy typically consist of 4-5 phase programs with set goals and progression criteria. Several commonalities existed between studies on WB, ROM precautions and gait normalization. However, timing and recommendations for RTS/return to work varied between studies and were dependent on the concomitant procedures performed as well as type of patient population. Clinically significant improvement in PROs from baseline noted in majority of the studies reviewed that involved a structured rehabilitation program following arthroscopic management of femoroacetabular impingement. As there is heterogeneity in patient-specific characteristics across the included studies, no determination can be made as to which protocol is most effective and further high-quality comparative studies are needed., Clinical Relevance: Adopting phase-based rehabilitation protocols following arthroscopic femoroacetabular impingement treatment help achieve improved outcomes that are predictable., (© The Author(s) 2020. Published by Oxford University Press.)

Hip preservation surgery is now an established part of orthopedic surgery and sports medicine. This report describes the key findings of the 11th Annual Scientific Meeting of International Society for Hip Arthroscopy-the International Hip Preservation Society-in Madrid, Spain from 16 to 19 October 2019. Lectures, seminars and debates explored the most up-to-date and expert views on a wide variety of subjects, including: diagnostic problems in groin pain, buttock pain and low back pain; surgical techniques in acetabular dysplasia, hip instability, femoroacetabular impingement syndrome, labral repair and reconstruction, cartilage defects, adolescent hips and gluteus medius and hamstring tears; and new ideas about femoral torsion, hip-spine syndrome, hip capsule surgery, impact of particular sports on hip injuries, registries, robotics and training for hip preservation specialists. Surgeons, sports physicians, radiologists and physiotherapists looking after young people with hip problems have an increasingly sophisticated armoury of ideas and techniques with which to help their patients. The concept of hip preservation has developed incredibly fast over the last decade; now it is clear that the best results can only be achieved by a multidisciplinary team working together. The 2020s will be the decade of 'Teamwork in Hip Preservation'., (© The Author(s) 2020. Published by Oxford University Press.)

The rapid growth of hip preservation has left surgeons following trends based on limited, or even anecdotal, evidence in certain circumstances. A consensus as well as high-level research on how best to manage the iliopsoas is lacking. Arthroscopic treatment of the iliopsoas may be an example of how treatment patterns and trends can shift with limited evidence-based medicine. A cross-sectional survey of 16 high-volume hip preservation surgeons was conducted to gather perspectives and opinions on how and why the arthroscopic management of the iliopsoas has evolved. All participants completed the survey in person and anonymously. Of the surveyed surgeons, the mean career hip preservation volume was 1031.25 cases (250 to >3000) with an average annual volume of 162.08 cases (75-400). Of the surveyed surgeons' caseload, 16.1% involved an iliopsoas tenotomy or fractional lengthening mostly commonly (75%) for recalcitrant internal snapping. Labral repair/reconstruction is performed concomitantly 87.5% of the time. Seventy-five percent of surgeons indicated a decrease in frequency of iliopsoas tenotomy over the course of their practice most commonly (56.3%) because of hip flexion weakness; however, 0% of the surgeons could cite literature evidence to support their practices. Perceived poor outcomes in individual practices was the most common (56.3%) source of this complication. Surgeons were less inclined to perform tenotomy on patients with borderline dysplasia (75%) or ligamentous laxity (56.3%)., (© The Author(s) 2020. Published by Oxford University Press.)

The purpose of this study was to determine (i) if failing to achieve a patient-reported outcome (PRO) threshold at 1 year was associated with secondary operations at minimum 2-year follow-up and (ii)what outcome measure and threshold has the highest association with future surgeries. Inclusion criteria for this study were cases of primary hip arthroscopy between July 2014 and April 2017. Included patients had recorded pre-operative and 1-year post-operative modified Harris Hip Score (mHHS) and 12-item international Hip Outcome Tool (iHOT-12) scores. Patients were classified based on their ability to achieve minimal clinical important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) for each PRO and the status of secondary operations at minimum 2-year follow-up. The sensitivity, specificity, accuracy, positive likelihood ratio and negative likelihood ratio for these thresholds were calculated. Of 425 eligible cases, 369 (86.8%) had minimum 2-year follow-up. Of the included patients, 28 underwent secondary operations (7.59%), with 14 undergoing secondary arthroscopies (3.79%) and 14 converting to total hip arthroplasty (3.79%). For mHHS, 267 (72.4%), 173 (46.9%) and 277 (75.1%) hips met MCID, SCB and PASS, respectively. For iHOT-12, 234 (63.4%), 218 (59.1%) and 280 (75.9%) hips met the respective thresholds. The highest specificity, sensitivity and accuracy were identified as for iHOT-12 MCID (0.79), iHOT-12 PASS (0.79) and iHOT-12 MCID (0.77), respectively. Patients not attaining MCID and PASS for mHHS and iHOT-12 at 1-year post-operatively are at increased risk of secondary operation. The most accurate threshold associated with secondary operation (0.77) is not achieving iHOT-12 MCID. Level of evidence: retrospective case series: level IV., (© The Author(s) 2020. Published by Oxford University Press.)

The purpose of this study was to outline factors that contribute to the appearance of hip osteoarthritis (OA). Secondarily, this study aims to describe radiographic factors that are associated with the progression of OA in the arthritic hip. Pubmed/MEDLINE and Embase were searched in November 2018 for radiographic risk factors for hip OA. All articles were eligible if they (i) were written in the English language and (ii) commented on OA as it relates to radiographic description, appearance or progression of OA. Demographic characteristics of the study cohort, definition of OA, baseline OA and factors for prediction or progression of OA were recorded. Nine articles were included in this review. A total of 3268 patients were analyzed across all studies. The mean age was 60.0 years (range 18-91.5). The most common descriptors for OA were dysplasia and cam impingement. Six of the nine articles found acetabular under-coverage to be associated with developing OA. Four articles found cam morphology to be an associated factor. Finally, four articles commented on the factors associated with the progression to more severe grades of OA, reporting exclusively on acetabular under-coverage, whereas only one reported on cam morphology to be associated. This systematic review found acetabular under-coverage followed by cam morphology to be strongly associated with both the development and progression of hip OA. These findings define patients at risk for developing hip OA and emphasize the importance of early awareness of future joint degeneration., (© The Author(s) 2020. Published by Oxford University Press.)

The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination for detection of gluteus medius (GM) tears. A case group of 50 patients undergoing arthroscopy with GM repair was compared with a control group of 50 patients undergoing arthroscopy who had no peritrochanteric symptoms. Both groups were examined clinically, had magnetic resonance imaging studies performed and underwent arthroscopic surgery. Recorded clinical examinations included abnormal gait (Trendelenburg), tenderness to palpation of the greater trochanter, resisted abduction and the test being studied, resisted internal rotation. For all clinical tests, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates were calculated and compared with the arthroscopic and MRI data for the case group, and the MRI data for the control group. The resisted internal rotation test had a sensitivity of 92%, specificity of 85% and diagnostic accuracy of 88% in the detection of GM tears, with a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of Trendelenburg gait, showed inferior rates. Trendelenburg gait had a higher specificity, but much lower sensitivity. The resisted internal rotation test aides in the detection of GM pathology. Due to the good results of the resisted internal rotation test in all the diagnostic parameters, we recommend incorporating it on the physical exam of patients with hip pain., (© The Author(s) 2019. Published by Oxford University Press.)

The 'upper deck' view is an arthroscopic perspective which visualizes the labral-osseous junction without detachment of the chondro-labral junction. The aim of this study was to evaluate the utility of the 'upper deck' view in preventing incomplete acetabuloplasty. Data were prospectively collected from September 2016 to November 2016 for all hip arthroscopies. We recorded the amount and clock-face of residual pincer-lesion acetabular bone resected using the 'upper deck' view. We noted whether this residual pincer-lesion acetabular bone was visible fluoroscopically, as well as the amount and clock-face of the overall acetabuloplasty. During the study period, 87 hip arthroscopies were performed; 50 met the inclusion criteria. Forty-six (92%) patients had residual pincer-lesion acetabular bone after completion of the acetabuloplasty resected from the bird's eye view. In all such cases the residual pincer-lesion acetabular bone was not visible under fluoroscopy and could only be detected using this specific view. The average maximum resection for the acetabuloplasty was 2.1 ± 0.9 and 1.4 ± 0.5 mm (P = 0.16) for resection of residual pincer-lesion acetabular bone. The 'upper deck' view provides the ability to decrease the risk of incomplete acetabuloplasty, due to the high likelihood (92%) of a residual beak of pincer-lesion acetabular bone when this view is not used during rim trimming., (© The Author(s) 2019. Published by Oxford University Press.)

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade >1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m 2 , Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively ( P  =   0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91-17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group., (© The Author(s) 2019. Published by Oxford University Press.)

To survey high-volume hip arthroscopists regarding their current indications for labral reconstruction, graft preference and technique. In May 2018, a cross-sectional based survey was conducted on high-volume hip arthroscopists. A high-volume surgeon was defined as an orthopaedist who had case experience ranging from 50 to 5000 hip arthroscopies performed annually. The survey included their current indications for labral reconstruction, graft preference and technique. Twelve high-volume surgeons successfully completed the questionnaire. The mean arthroscopic procedures performed by the surgeons annually was 188.7 (range 60-350). Four surgeons (33.3%) performed <5 labral reconstruction cases per year, three (25.0%) 5-10 cases per year, two (16.7%) 11-15 cases per year and three (25.0%) over 20 cases per year. Of the 12 surgeons, 11 (91.6%) would reconstruct in certain primary settings and 100% would reconstruct in revision settings. In the primary setting, the main indications for reconstruction were poor quality labral tissue, calcified labrum and hypoplastic labrum. None of the surgeons recommended labral reconstruction for reparable labral tears in primary cases. In primary cases of irreparable labra, 58.3% of the surgeons favoured reconstruction over debridement. In revisions, 100% of the surgeon favoured reconstruction over debridement; 91.7% chose an allograft option versus an autograft alternative. Amongst high-volume arthroscopists, labral reconstruction was considered a valuable technique to restore labral function. Labral reconstruction was more often advocated in revision than in primary settings. Allograft was the preferred choice for reconstruction. Excision of the labral tissue prior to reconstruction was favoured over augmentation. Fewer surgeons performed circumferential reconstruction than segmental reconstruction.

Hip preservation is one of the fastest growing subspecialties in orthopaedic surgery. Surgical training recommendations and guidelines in this field are lacking. To survey high volume hip preservation surgeons regarding their perspectives on the current and future training of surgeons entering their field, a cross-sectional survey of 16 high-volume hip preservation surgeons was conducted to gather perspectives and opinions on the most appropriate education of future hip preservation surgeons. All participants completed the survey in person and anonymously. Of the surveyed surgeons, the mean career hip preservation volume was 1031.25 cases (250 to >3000) with an average annual volume of 162.08 cases (75-400). The average number of hip arthroscopy cases necessary to competently perform joint access is 19, labral repair is 34, acetabuloplasty/femoroplasty are 54, labral reconstruction is 101 and capsular closure/plication is 53. Fifty-six percent of the surgeons believe mid-career surgeons who have never performed hip preservation surgery should not adopt it as part of their practice. The mean optimal number of cases recommended was 128 hip arthroscopies during a dedicated hip preservation fellowship and 67 hip arthroscopies during a sports medicine fellowship. Surgeons with an interest in hip preservation careers, should strongly consider a 12-month dedicated hip preservation fellowship that provides exposure to at least 128 cases, including open and arthroscopic techniques, hip arthroplasty, and research opportunities. Mid-career surgeons should be cautious about adopting hip preservation into their practice if they have not had prior adequate training.