Search

Background: Individualized risk prediction has become possible with machine learning (ML), which may have important implications in enhancing clinical decision making. We previously developed an ML algorithm to predict propensity for clinically meaningful outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome. External validity of prognostic models is critical to determine generalizability, although it is rarely performed. Purpose: To assess the external validity of an ML algorithm for predicting clinically meaningful improvement after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: An independent hip preservation registry at a tertiary academic medical center was queried for consecutive patients/athletes who underwent hip arthroscopy for femoroacetabular impingement syndrome between 2015 and 2017. By assuming a minimal clinically important difference (MCID) outcome/event proportion of 75% based on the original study, a minimum sample of 132 patients was required. In total, 154 patients were included. Age, body mass index, alpha angle on anteroposterior pelvic radiographs, Tönnis grade and angle, and preoperative Hip Outcome Score–Sports Subscale were used as model inputs to predict the MCID for the Hip Outcome Score–Sports Subscale 2 years postoperatively. Performance was assessed using identical metrics to the internal validation study and included discrimination, calibration, Brier score, and decision curve analysis. Results: The concordance statistic in the validation cohort was 0.80 (95% CI, 0.71 to 0.87), suggesting good to excellent discrimination. The calibration slope was 1.16 (95% CI, 0.74 to 1.61) and the calibration intercept 0.13 (95% CI, –0.26 to 0.53). The Brier score was 0.15 (95% CI, 0.12 to 0.18). The null model Brier score was 0.20. Decision curve analysis revealed favorable net treatment benefit for patients with use of the algorithm as compared with interventional changes made for all and no patients. Conclusion: The performance of this algorithm in an independent patient population in the northeast region of the United States demonstrated superior discrimination and comparable calibration to that of the derivation cohort. The external validation of this algorithm suggests that it is a reliable method to predict propensity for clinically meaningful improvement after hip arthroscopy and is an essential step forward toward introducing initial use in clinical practice. Potential uses include integration into electronic medical records for automated prediction, enhanced shared decision making, and more informed allocation of resources to optimize patient outcomes.

Background: There is a paucity of information in the literature on midterm outcomes from the arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) with concomitant labral treatment in patients with mild osteoarthritis (OA) using modern surgical techniques. Purpose: To compare outcomes of hip arthroscopy for the treatment of FAIS between patients with mild OA (Tönnis grade 1) and patients without OA (Tönnis grade 0) at minimum 5-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were identified who underwent primary hip arthroscopy for FAIS with routine capsular closure between January 2012 and December 2015. Patients with Tönnis grade 1 were matched 1:3 by age, sex, and body mass index to patients without OA. The Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score, and 12-item International Hip Outcome Tool were collected preoperatively and at 5 years postoperatively and compared between groups using an independent t test. Survivorship rate and percentage achievement of a Patient Acceptable Symptom State (PASS) or minimal clinically important difference (MCID) were compared using a Fisher exact test. Results: A total of 50 patients (54 hips) with Tönnis grade 1 were matched to 162 patients (162 hips) with Tönnis grade 0. The mean ± SD age and body mass index of the Tönnis grade 1 group were 44.5 ± 9.6 years and 28.5 ± 5.5, respectively. Patient-reported outcome (PRO) scores improved significantly for both groups from presurgery to 5 years postoperatively for all PROs ( P≤ .03). There were no significant differences in preoperative PROs between the groups. Patients with Tönnis grade 1 had significantly lower postoperative scores on the HOS-ADL (74.7 ± 22.6 vs 83.0 ± 20.1; P = .04) and HOS-SS (58.8 ± 33.7 vs 71.8 ± 29.3; P = .03) than patients with grade 0. Patients with Tönnis grade 1 also had significantly lower rates of achievement of the MCID (57.1% vs 80.2%; P < .01) and PASS (34.1% vs 53.4%; P = .03) for any PRO when compared with patients with Tönnis grade 0. Gross survivorship was significantly lower for Tönnis grade 1 versus grade 0 (77.8% vs 96.9%; P < .001). Conclusion: Patients with Tönnis grade 1 arthritis experienced significant improvement in PROs after hip arthroscopy for the treatment of FAIS. However, they had significantly lower postoperative HOS-ADL and HOS-SS scores with significantly lower rates of achievement on the MCID and PASS, with a significantly lower gross survivorship rate at a minimum 5 years postoperatively in comparison with those with Tönnis grade 0 changes.

Background: Patients with femoroacetabular impingement syndrome (FAIS) may frequently have co-existing sacroiliac joint (SIJ) pain. It is known that patients with lower back pain undergoing total hip arthroplasty (THA) have inferior outcomes; however, it is unclear what the effect of SIJ pain is on outcomes after hip arthroscopy. Purpose: To determine whether patients undergoing hip arthroscopy with SIJ pain either subjectively or on physical examination achieve similar postoperative improvement in patient-reported outcomes (PROs) compared with patients without SIJ pain at 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with a minimum 2-year follow-up who underwent primary hip arthroscopy for FAIS with SIJ pain were matched in a 1:2 ratio to controls without SIJ pain. Baseline demographics, as well as postoperative PROs and rates of achievement of the minimal clinically important difference (MCID) or Patient Acceptable Symptom State (PASS) at 2-year follow-up were compared between the 2 groups. Results: A total of 73 patients (75 hips) with SIJ pain were matched to 150 control patients (150 hips) without SIJ pain. Both groups demonstrated statistically significant improvement in all PROs at 2 years ( P < .05 for all). Patients with SIJ pain had significantly lower postoperative PRO scores for the Hip Outcome Score–Activities of Daily Living (HOS-ADL) (SIJ pain: 80.4 ± 22.4 vs no SIJ pain: 88.0 ± 15.1; P = .006), modified Harris Hip Score (mHHS) (SIJ pain: 73.2 ± 22.8 vs no SIJ pain: 80.0 ± 17.3; P < .001), and International Hip Outcome Tool–12 questionnaire (iHOT-12) (SIJ pain: 61.7 ± 25.9 vs no SIJ pain: 73.7 ± 23.7; P = .008). There were no statistically significant differences in improvement (delta) in PRO scores between the 2 groups ( P > .05 for all). The SIJ pain group had significantly lower achievement of MCID for the HOS-ADL (SIJ pain: 65.2% vs no SIJ pain: 80.5%; P = .044) but not HOS-SS, mHHS, or iHOT-12 ( P > .05 for all). The SIJ pain group had significantly lower achievement of PASS for the mHHS (SIJ pain: 27.5% vs no SIJ pain: 45.3%; P = .030) and iHOT-12 (SIJ pain: 31.0% vs no SIJ pain: 56.0%; P = .010) but not the HOS-ADL and HOS-SS ( P > .05 for both). Only 4.1% of patients with SIJ pain and 2.4% of controls required revision surgery or converted to THA at the time of final follow-up ( P = .69). Conclusion: Patients with FAIS and SIJ pain on history or physical examination experience significant improvement in PROs at 2 years after hip arthroscopy. However, they may be less likely to achieve the MCID or PASS and have significantly lower postoperative PROs compared with a matched cohort of patients without SIJ pain. Overall rates of revision and conversion to THA were similarly low in both groups.

Background: The International Hip Outcome Tool 12-Item Questionnaire (IHOT-12) has been proposed as a more appropriate outcome assessment for hip arthroscopy populations. The extent to which preoperative patient factors predict achieving clinically meaningful outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remains poorly understood. Purpose: To determine the predictive relationship of preoperative imaging, patient-reported outcome measures, and patient demographics with achievement of the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) for the IHOT-12 at a minimum of 2 years postoperatively. Study Design: Case-control study; Level of evidence, 3. Methods: Data were analyzed for consecutive patients who underwent hip arthroscopy for FAIS between 2012 and 2018 and completed the IHOT-12 preoperatively and at a minimum of 2 years postoperatively. Fifteen novel machine learning algorithms were developed using 47 potential demographic, clinical, and radiographic predictors. Model performance was evaluated with discrimination, calibration, decision-curve analysis and the brier score. Results: A total of 859 patients were identified, with 685 (79.7%) achieving the MCID, 535 (62.3%) achieving the PASS, and 498 (58.0%) achieving the SCB. For predicting the MCID, discrimination for the best-performing models ranged from fair to excellent (area under the curve [AUC], 0.69-0.89), although calibration was excellent (calibration intercept and slopes: –0.06 to 0.02 and 0.24 to 0.85, respectively). For predicting the PASS, discrimination for the best-performing models ranged from fair to excellent (AUC, 0.63-0.81), with excellent calibration (calibration intercept and slopes: 0.03-0.18 and 0.52-0.90, respectively). For predicting the SCB, discrimination for the best-performing models ranged from fair to good (AUC, 0.61-0.77), with excellent calibration (calibration intercept and slopes: –0.08 to 0.00 and 0.56 to 1.02, respectively). Thematic predictors for failing to achieve the MCID, PASS, and SCB were presence of back pain, anxiety/depression, chronic symptom duration, preoperative hip injections, and increasing body mass index (BMI). Specifically, thresholds associated with lower likelihood to achieve a clinically meaningful outcome were preoperative Hip Outcome Score–Activities of Daily Living 55.6, preoperative IHOT-12 score ≥48.5, preoperative modified Harris Hip Score ≤51.7, age >41 years, BMI ≥27, and preoperative α angle >76.6°. Conclusion: We developed novel machine learning algorithms that leveraged preoperative demographic, clinical, and imaging-based features to reliably predict clinically meaningful improvement after hip arthroscopy for FAIS. Despite consistent improvements after hip arthroscopy, meaningful improvements are negatively influenced by greater BMI, back pain, chronic symptom duration, preoperative mental health, and use of hip corticosteroid injections.

Background: Dancers possess a large degree of hip range of motion that results from a combination of innate and acquired osseous morphology and permissive soft tissues. Generalized hypermobility in dancers may predispose them to a spectrum of hip instability. The objective of this narrative review is to discuss the anatomical characteristics, pathogenesis, risk factors, clinical signs and symptoms, management, and outcomes of hip instability treatments in dancers. Methods: A retrospective search was performed beginning November 1, 2017, for English language articles regarding hip stability in the dancer. Key words used included but were not limited to: dance(r), ballet, hip, hypermobility, range of motion, instability, microinstability, and laxity. PubMed, Scopus, and MEDLINE databases were used. Results: Forty-three studies were analyzed. Groin pain was found to be the most common presenting symptom of hip instability. A variety of impingement and instability signs may be elicited during physical examination. Hypermobility is frequently observed and is thought to be a necessity for participation in elite levels of ballet. Radiographs and advanced planar imaging (magnetic resonance imaging and computed tomography) should be scrutinized to evaluate for dysplasia, cam, pincer, subspine, and rotational morphologies. Dysplasia (low volume acetabulum), cam morphology, femoral retroversion, and coxa valga are common findings in the ballet dancers' hip. Labral injuries and ligamentum teres tears are common and may potentiate instability in the hip. Management options include education, oral non-opioid medications, activity modification, exercise prescription, and surgery. Reported outcomes of these treatments in ballet are limited. Conclusion: Hip hypermobility is prevalent in the ballet population and is a clear advantage. However, it may increase the risk of instability. It is important to identify the multifactorial osseous and soft tissue etiology of hip or groin pain in dancers. Practitioners should have a high level of suspicion for hip instability in the dancer presenting with hip pain and treat accordingly. There is a significant need for increased quantity and quality of investigation into the outcomes of treatment for hip instability in the dancer.

Background: Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series. Purpose: To clarify the relationship between FI and surgical outcomes for hip abductor tears. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared. Results: A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score ( P > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair ( P > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005). Conclusion: Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.

Background: A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Purpose: To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients. Study Design: Case-control study; Level of evidence, 3. Methods: A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool–12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership. Results: A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers’ compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores. Conclusion: Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers’ compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

Background: Impairments in squat depth have been reported in patients with femoroacetabular impingement syndrome (FAIS). However, little is known about single-leg squat (SLS) performance in these patients, despite this task being commonly used in the rehabilitation and training settings. Purpose/Hypothesis: The aims of this study were (1) to investigate whether patients with FAIS demonstrate differences in SLS performance compared with healthy controls and (2) to determine whether dynamic range of motion (ROM), muscle strength, hip morphologic measures, hip pain, and hip-specific function predict SLS performance in patients with FAIS. We hypothesized that patients with FAIS would demonstrate impaired SLS performance and that impaired hip biomechanics, muscle strength, and hip-specific function would predict squat performance in patients with FAIS. Study Design: Controlled laboratory study. Methods: Three-dimensional (3D) kinematic data were collected at 100 Hz using a 20-camera 3D motion capture system during 3 SLS trials in 34 patients with FAIS and 26 healthy controls. Isometric muscle strength was tested with a stationary handheld dynamometer in all participants. Squat performance was quantified by squat depth (in meters), and the biomechanical variables of dynamic ROM of the pelvis, the hip, the knee, and the ankle in all planes were calculated. In patients with FAIS, femoral and acetabular morphology were measured using radiographic alpha angles and lateral center-edge angles. Hip pain and hip-specific function were measured using the visual analog scale for pain and the Hip Outcome Score Activities of Daily Living subscale, respectively. Two-tailed independent-samples t tests were used to determine between-group differences for squat depth, dynamic ROM variables, and muscle strength. A hierarchical multiple linear regression (MLR) model was used to determine whether biomechanical variables, muscle strength, hip morphology measures, hip pain, and hip-specific function were predictors of squat depth. All statistical analyses were performed using SPSS Version 26. Results: There were no between-group differences in age (FAIS, 30.0 ± 7.0 years vs controls, 27.3 ± 7.0 years; P = .18) or body mass index (FAIS, 23.1 ± 2.8 vs controls, 22.6 ± 3.2; P = .51). Squat depth was less in patients with FAIS compared with healthy controls (FAIS, 0.24 ± 0.4 m vs controls, 0.29 ± 0.05 m; P < .001). In the sagittal plane, patients with FAIS demonstrated less dynamic ROM of the hip (FAIS, 67.8°± 12.4° vs controls, 79.2°± 12.5°; P = .001) and the knee (FAIS, 71.9°± 9.4° vs controls, 78.9°± 13.2°; P = .02) compared with controls. Patients with FAIS also demonstrated a less dynamic coronal plane pelvis ROM (FAIS, 11.3°± 5.0° vs controls, 14.4°± 6.7°; P = .044). Patients with FAIS had reduced hip muscle strength of the hip external rotator (FAIS, 1 ± 0.3 N/kg vs controls, 1.2 ± 0.3 N/kg; P = .034), hip internal rotator (FAIS, 0.8 ± 0.3 N/kg vs controls 1 ± 0.3 N/kg; P = .03), and hip flexor (FAIS, 4 ± 1.1 N/kg vs controls, 4.8 ± 1.2 N/kg; P = .013) muscle groups. The hierarchical MLR revealed that the dynamic ROM of the hip, the knee, and the pelvis, the hip external rotation muscle strength, and the femoral alpha angles were all significant predictors of squat performance, and the final MLR model explained 92.4% of the total variance in squat depth in patients with FAIS. Conclusion: Patients with FAIS demonstrate impaired SLS squat performance compared with healthy controls. This impaired squat performance is predominantly predicted by sagittal plane knee and hip biomechanics and hip external rotator strength, and less by frontal plane pelvic ROM and hip morphology in patients with FAIS. Clinical Relevance: Clinicians should focus treatment on improving dynamic ROM and hip external rotator muscle strength to improve squat performance; however, femoral morphology should also be considered in the treatment paradigm.

Background: There is a paucity of literature evaluating patient outcomes in patients undergoing revision labral repair and labral reconstruction. Purpose: To compare outcomes in patients undergoing revision hip arthroscopy for treatment of labral tears by labral repair or labral reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. An a priori power analysis determined that a total of 62 patients were required. Patients undergoing revision hip arthroscopy for labral tears with completed 2-year outcome scores were included. Patients undergoing primary hip arthroscopy, labral debridement, concomitant gluteal repair, and patients with hip dysplasia (lateral center-edge angle Results: A total of 40 patients underwent revision labral repair and 55 patients underwent labral reconstruction. Patients undergoing revision labral repair were younger (mean age, 30.0 ± 10.7 years vs 34.4 ± 9.7 years; P = .048), had lower rates of labral degeneration (25.0% vs 62.7%; P = .004), and had lower rates of severe complexity of tears (21.1% vs 66.0%; P = .003). However, the labral repair group had higher rates of articular cartilage damage (62.5% vs 33.3%; P = .009). There were no differences in any preoperative or 2-year postoperative PROs. Furthermore, no differences were seen in achievement of MCID or PASS in any PRO. Conclusion: In this multicenter study on revision hip arthroscopy, patients undergoing revision labral repair were younger and had better labral characteristics but greater cartilage damage compared with patients undergoing labral reconstructions. Despite these differences, patients who underwent labral repair reported similar outcomes to those undergoing labral reconstruction.

Background: On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures. Purpose: (1) To determine if the opioid prescription–limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting–adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts. Results: A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = –280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01). Conclusion: Opioid prescription–limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Purpose: To define the anatomical relationship of the major neurovascular structures to the standard endoscopic portals used in endoscopic hamstring repair. A secondary outcome was to determine the safest angle of insertion from each standard portal. Methods: Endoscopic portals were established in the 3 standard locations (lateral, medial, and inferior) and Steinmann pins inserted at various angles. Each hip was dissected and the distance between the pins and the pertinent anatomy measured. Results: The lateral portal placed the sciatic and posterior femoral cutaneous (PFC) nerves at greatest risk: direct injury to the sciatic nerve was seen in 11/30 (37%) of the lateral portals sited. A lateral portal with an approach at 60° was the most dangerous orientation with a mean distance of 0.36 ± 0.49 mm and 4.30 ± 2.69 mm from the sciatic and PFC nerves, respectively ( p < 0.001). The 60° medial portal was the safest of all portals measured, at a mean distance of 67.37 ± 11.06mm (range, 47–78 mm) from the sciatic nerve and 58.90 ± 10.57 mm (range 40–70 mm) from the PFC nerve. Conclusions: While currently described techniques recommend establishing the standard lateral portal first, this study shows that it carries the highest risk of injury if used blind. We recommend that the standard medial endoscopic portal is established first to identify the neurovascular structures and minimise iatrogenic neurovascular injury. The inferior and lateral portals can then be established created under direct vision. The lateral portal should be inserted in a more horizontal orientation to decrease the risk of nerve injury.

Background: Capsule management has emerged as an important topic in the field of hip arthroscopy. The 2 most popular techniques are interportal capsulotomy and T-type capsulotomy, but few studies have compared outcomes between these 2 techniques. Purpose: To compare 2-year (±2 months) patient-reported outcomes (PROs) between patients who underwent interportal versus T-type capsulotomy during arthroscopic labral repair for femoroacetabular impingement syndrome (FAIS). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a large multicenter registry of patients undergoing arthroscopic hip preservation surgery for FAIS was performed. Data from 9 surgeons across 9 sites between January 2014 and February 2018 were included in the study. Baseline demographic data, preoperative PROs, and minimum 2-year postoperative PROs including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score, and International Hip Outcome Tool–12 (iHOT-12) were recorded. Patients were divided into 2 groups based on whether interportal or T-type capsulotomy was performed according to the senior surgeon’s preference and training, and all capsulotomies were then routinely repaired. The 2 groups were matched 1:1 by age, sex, and body mass index (BMI). Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) was compared for the HOS-ADL, HOS-SS, and iHOT-12 between the 2 groups. Results: The final analysis included 658 of 1483 eligible patients with a mean ± SD age of 32.6 ± 11.6 years and BMI of 24.0 ± 3.7; of these, 329 patients were treated via interportal capsulotomy, and 329 patients were treated via T-type capsulotomy. Female patients comprised 66.3% of the study population. Capsulotomy type was not a predictor of 2-year postoperative PROs on multivariate linear regression analysis when adjusted for covariates. Chi-square analysis showed no statistical difference in achievement of MCID, PASS, and SCB between the interportal and T-type groups for HOS-ADL (80.3%, 75.8%, 52.7% and 77.1%, 71.7%, 53.6%, respectively; P > .01 for all), HOS-SS (83.6%, 72.5%, 51.5% and 81.7%, 68.4%, 49.2%, respectively; P > .01 for all), and iHOT-12 (87.5%, 72.0%, 50.5% and 80.0%, 64.7%, 45.6%, respectively; P > .01 for all). Conclusion: Arthroscopic management of FAIS resulted in significant clinical improvement that was independent of capsulotomy type when the capsulotomy included repair.

Background: Femoroacetabular impingement syndrome (FAIS) is an increasingly common diagnosis among working-age adults. Hip arthroscopy provides reliable improvements in pain and may allow patients to return to physical activities. No study to date has evaluated return to work (RTW) among a general population of adults after arthroscopic surgery for FAIS. Purpose: To evaluate (1) patients’ rate of RTW, (2) time required to RTW, and (3) factors correlated with time required to RTW after arthroscopic surgery for symptomatic FAIS. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients aged 25 to 59 years who underwent arthroscopic surgery for FAIS between June 2018 and December 2018 were reviewed. Workers’ compensation cases and patients with Results: A total of 97 patients were selected through inclusion and exclusion criteria. RTW surveys were collected for 79 (81.4%), and 61 were employed preoperatively. Time worked per week was 42.8 ± 12.5 hours (mean ± SD). Patients’ work level was most commonly classified as sedentary (42.6%), followed by moderate (24.6%). All 61 (100%) patients returned to work at a mean 7.3 weeks (range, Conclusion: Patients undergoing arthroscopic treatment for FAIS demonstrated a high rate of RTW at a mean of

Background: There is a paucity of information available to clinicians on outcomes of patients undergoing endoscopic surgery for labral repairs and femoroacetabular impingement syndrome with simultaneous repair of the gluteus medius and/or minimus muscles. Purpose: To determine whether patients with labral tears and concomitant gluteal pathology who undergo simultaneous endoscopic labral and gluteus medius and/or minimus repair experience similar outcomes to patients with isolated labral tears who undergo endoscopic labral repair alone. Study Design: Cohort study; Level of evidence, 3. Methods: A matched retrospective comparative cohort study was performed. Patients who underwent gluteus medius and/or minimus repair with concomitant labral repair between January 2012 and November 2019 were identified. These patients were matched in a 1:3 ratio by sex, age, and body mass index (BMI) to patients who underwent labral repair alone. Preoperative radiographs were assessed. Patient-reported outcomes (PROs) were assessed preoperatively and 2 years postoperatively. PRO measures included the Hip Outcome Score Activities of Daily Living and Sports subscales, modified Harris Hip Score, 12-Item International Hip Outcome Tool, and visual analog scales for pain and satisfaction. Published labral repair minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds were utilized for these measures. Results: A total of 31 patients who underwent gluteus medius and/or minimus repair with concomitant labral repair (27 female, 4 male; age, 50.8 ± 7.3 years; BMI, 27.9 ± 5.2) were matched with 93 patients who underwent labral repair alone (81 female, 12 male; age, 50.9 ± 8.1 years; BMI, 28.5 ± 6.2). There were no significant differences in sex ( P > .99), age ( P = .869), or BMI ( P = .592); preoperative radiographic measurements; or preoperative or 2-year postoperative PRO scores ( P≥ .081). Changes between preoperative and 2-year postoperative PRO scores were significantly different for both groups for all PROs assessed ( P < .001 for all). There were no significant differences in MCID or PASS achievement rates ( P≥ .123), with low PASS achievement rates of 40% to 60% found in both groups. Conclusion: Patients who were treated with endoscopic gluteus medius and/or minimus repair with concomitant labral repair demonstrated comparable outcomes with those who were treated with endoscopic labral repair alone.

Background: Machine learning (ML) has emerged as a method to determine patient-specific risk for prolonged postoperative opioid use after orthopedic procedures. Purpose: We sought to analyze the efficacy and validity of ML algorithms in identifying patients who are at high risk for prolonged opioid use following orthopedic procedures. Methods: PubMed, EMBASE, and Web of Science Core Collection databases were queried for articles published prior to August 2021 for articles applying ML to predict prolonged postoperative opioid use following orthopedic surgeries. Features pertaining to patient demographics, surgical procedures, and ML algorithm performance were analyzed. Results: Ten studies met inclusion criteria: 4 spine, 3 knee, and 3 hip. Studies reported postoperative opioid use over 30 to 365 days and varied in defining prolonged use. Prolonged postsurgical opioid use frequency ranged from 4.3% to 40.9%. C-statistics for spine studies ranged from 0.70 to 0.81; for knee studies, 0.75 to 0.77; and for hip studies, 0.71 to 0.77. Brier scores for spine studies ranged from 0.039 to 0.076; for knee, 0.01 to 0.124; and for hip, 0.052 to 0.21. Seven articles reported calibration intercept (range: –0.02 to 0.16) and calibration slope (range: 0.88 to 1.08). Nine articles included a decision curve analysis. No investigations performed external validation. Thematic predictors of prolonged postoperative opioid use were preoperative opioid, benzodiazepine, or antidepressant use and extremes of age depending on procedure population. Conclusions: This systematic review found that ML algorithms created to predict risk for prolonged postoperative opioid use in orthopedic surgery patients demonstrate good discriminatory performance. The frequency and predictive features of prolonged postoperative opioid use identified were consistent with existing literature, although algorithms remain limited by a lack of external validation and imperfect adherence to predictive modeling guidelines.

Background: Patellar tendon rupture is an injury most often occurring in adults and commonly caused by tensile overload to the extensor mechanism of the knee or direct trauma to the tendon. Early diagnosis and timely surgical repair lead to good functional outcomes and high rates of return to activity. Indications: In patients with impaired knee extensor mechanisms, inability to perform a straight leg raise, or evidence of complete tendon rupture on imaging, surgical tendon repair is indicated. Technical Description: The surgical technique demonstrated here presents a standard patellar tendon repair with transosseous tunnels of a 32-year-old man. Briefly, dissection was performed down to the retinacular layer, and the patellar tendon stump was identified. Any devitalized soft tissue was removed from the inferior pole of the patella and the proximal tendon stump by a rongeur. Two locking Krackow sutures were placed along the medial and lateral aspect of the patellar tendon. Then, a drill bit was used to create 3 transosseous tunnels in the patella and a nitinol basket was used to pass sutures through each tunnel. The retinacular layer was closed by figure-of-eight stiches, followed by layered closure of the subcutaneous layer, and finally, the skin. Results: Early surgical repair of the patellar tendon leads to good functional outcomes and return to sport rates. In a retrospective study of 38 knees, at average of 9.3 years follow-up, 96% of patients reported they were satisfied/very satisfied, with a 100% returning to work. High rates of return to sports have been reported from a retrospective study, with a 94.4% and 83.3% rate of return to sport and rate of return to sport at the same level, respectively. Discussion: In this surgical technique video, we review the common presentation, indications of surgical repair, key steps and technique pearls for a case of a ruptured patellar tendon. Furthermore, we review complications and postoperative rehabilitation guidelines, postoperative clinical outcomes, and return-to-sport rates existing in the literature. Finally, we assess key differences between 2 commonly used surgical techniques, knotless suture anchors versus transosseous tunnels, in patellar tendon repair. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Proximal hamstring ruptures meeting operative criteria may be treated through endoscopic, open, or combined techniques. Open techniques allow for facilitated tendon visualization and mobilization with ease of suture passage. Indications: Proximal hamstring repairs are indicated for complete 3 tendon avulsions; partial avulsions with 2 or more tendons involved with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tears that remain refractory to conservative treatment. Technique Description: Through an incision along the gluteal crease, the tendon stump is identified and mobilized. Anchors are placed in the prepped ischium and sutures are passed through the tendon in a running fashion. The tendon is secured to its origin in a docking technique. Results: Patients undergoing hamstring repair have high satisfaction rates and patient-reported outcome scores. Competitive and elite athletes have demonstrated reliable return-to-sport rates at presurgical levels. Discussion: Open proximal hamstring repairs produce reliable results. The open technique is advantageous for its ease of tendon mobilization, direct visualization, and suture passage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Significant short-term improvements in function and pain after arthroscopic management of femoroacetabular impingement syndrome (FAIS) have been demonstrated regardless of mass index (BMI). No studies have reported the influence of obesity on mid- to long-term outcomes. Purpose: To evaluate the effect of BMI class on 5-year patient outcomes after arthroscopic treatment of FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a prospective database was performed to identify patients who underwent arthroscopic treatment for FAIS. A matched-pair analysis for age and sex was performed in a 1:1:2:3 fashion for morbidly obese (BMI ≥35), obese (BMI = 30-34.9), overweight (BMI = 25-29.9), and normal weight (BMI = 18.5-24.9) patients, respectively. Patient characteristics, imaging, Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Subscale (HOS-SS) scores, modified Harris Hip Score (mHHS), and pain scores were recorded preoperatively, with the same outcome scores recorded at 5 years postoperatively, along with satisfaction scores. Standardized modern hip arthroscopy, with labral repair, acetabuloplasty, femoroplasty, and capsular plication followed by formalized rehabilitation, was performed for all patients. Absolute outcomes along with change in outcomes were assessed between BMI groups. A between-group analysis was also conducted evaluating achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for any outcome score. A multivariable analysis was additionally included to evaluate outcomes adjusting for known confounding variables. Results: A total of 140 patients with mean follow-up of 62.1 ± 6.5 months were identified: 20 morbidly obese, 20 obese, 40 overweight, and 60 normal weight. There were significant improvements for HOS-ADL, HOS-SS, and mHHS scores in the normal (all P < .0001) and overweight groups (all P < .0001), mHHS in the obese group ( P = .0275), and no significant improvement in functional scores in the morbidly obese group ( P > .05). Compared with normal controls, multivariable analysis, adjusting for confounders, showed similar improvement in HOS-ADL for patients in the overweight and obese groups, HOS-SS for patients in the overweight group, and mHHS for patients in the overweight and obese groups (all P > .05). All groups showed significant improvement in pain scores (all P < .01) that were not significantly different between groups in multivariable analysis (all P > .05). Obese BMI was associated with a 54.9-point decrease in 5-year HOS-SS, and morbidly obese BMI was associated with a 27.3, 35.0, and 23.7-point decrease in 5-year HOS-ADL, HOS-SS, and mHHS, respectively (all P < .05). Regarding surgical benefit in comparison with normal weight patients, patients in the overweight and obese groups were as likely to achieve MCID (reciprocal odds ratio [ROR]: 1.5 and 1.2, respectively, both P > .05), but patients in the morbidly obese group were not. All groups were significantly less likely than the normal weight group to achieve PASS (ROR: overweight 5.2, obese 14.1, morbidly obese 13.0; all P < .05) and SCB (ROR: overweight 3.9, obese 7.8, morbidly obese 20.3; all P < .05). Conclusion: There were significant improvements in at least 1 outcome score across all BMI groups with arthroscopic treatment of FAIS. While the normal weight patients demonstrated universal improvement in all patient-reported outcomes and significantly greater likelihood of achieving PASS and SCB, the higher BMI groups still demonstrated significant improvement in function and pain, except for the morbidly obese group. Patients with morbid obesity demonstrated long-term pain improvement, although they did not experience functional improvement.

Background: Previous studies have established a classification of sports based on hip mechanics: cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead. No previous review has compared the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) using this classification. Purpose: To determine whether the rate of return to sport differs among cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead athletes who undergo hip arthroscopy for FAIS. We also aimed to identify differences in patient characteristics, intraoperative procedures performed, and time to return to play among the 6 sport categories. Study Design: Systematic review and meta-analysis. Methods: Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract, and full-text articles using prespecified criteria. Eligible articles were those that reported the rate of return to sport (defined by the number of hips) after hip arthroscopy for FAIS in athletes of all levels. Data collected were patient age, sex, body mass index, type of sport, rate and time to return to sport, and intraoperative procedures performed. A mixed effects model was used for meta-analysis. Results: A total of 29 articles and 1426 hip arthroscopy cases were analyzed with 185 cutting, 258 impingement, 304 contact, 207 endurance, 116 flexibility, and 356 asymmetric/overhead athletes. The mean age was similar among the 6 subgroups ( P = .532), but the proportion of female athletes was significantly higher in flexibility, endurance, and asymmetric/overhead sports as compared with impingement and contact athletes. Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS (94.8%), whereas contact athletes had the lowest rate (88%). The longest mean ± SD time (8.5 ± 1.9 months) to return to sport was reported in cutting sports, while endurance athletes returned faster than the rest (5.4 ± 2.6 months). The difference in rate and time to return to sport, as well as the intraoperative procedure performed, did not reach statistical significance among the 6 subgroups. There was evidence of publication bias and study heterogeneity, and the mean Methodological Index for Non-randomized Studies score was 13 ± 2.6. Conclusion: Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS, while endurance athletes returned the fastest. The difference in rate and time to return to sport and intraoperative procedures performed did not reach statistical significance among the 6 subgroups. These results are limited by the evidence of publication bias and should be interpreted with caution. Laboratory-based studies are necessary to validate the classification of sports based on hip mechanics.

Background: Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited. Purpose: To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m2) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group. Results: The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant ( P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS. Conclusion: The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.

Background: The effect of preoperative hip strength on outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is unclear. The purpose of this study was to determine whether preoperative isometric hip strength is associated with outcome scores at 6 months as well as achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients undergoing hip arthroscopy for FAIS. Hypothesis: Increased preoperative isometric strength will be correlated with short-term postoperative outcomes and will be predictive of achieving higher functional status. Study Design: Case series. Level of Evidence: Level 4. Methods: Data from 92 consecutive patients undergoing primary hip arthroscopy for treatment of FAIS from March through August 2018 were analyzed. All patients included in the analysis had preoperative measures of isometric hip strength on both affected and unaffected limbs, as well as preoperative and 6-month patient-reported outcome (PRO) scores. Analysis was performed to determine correlations between normalized isometric hip strength measurements and PROs and whether strength measurements were predictive of achieving MCID or PASS. Results: A total of 74 (80.4%) patients had 6-month PROs and were included in the final analysis. Hip extension strength on both sides was correlated with all postoperative PROs (all P > 0.05). Abduction strength on both sides was correlated with postoperative Hip Outcome Score–Activities of Daily Living subscale score, achieving MCID on at least 1 score threshold, and reaching the international Hip Outcome Tool-12 threshold score for achieving PASS (all P < 0.05). Regression analysis showed that extension strength on the affected side was the only strength measurement predictor of achieving PASS (1.043; P = 0.049). Conclusion: Preoperative isometric hip extension and abduction strength are correlated with 6-month postoperative PRO scores. Furthermore, hip extension strength is a predictor of achieving clinically meaningful outcomes. Clinical Relevance: This study highlights the possible importance of preoperative optimization of hip function to maximize outcomes in patients undergoing hip arthroscopy for FAIS.

Background: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopaedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically meaningful outcome; however, it is unknown what represents meaningful patient-reported outcome improvement in the medium to long term. Purpose: (1) To define MCID, PASS, and SCB at a minimum 5 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to evaluate the time-dependent nature of MCID, PASS, and SCB. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score including the Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL), Hip Outcome Score–Sport-Specific subscale (HOS-SS), modified Harris Hip Score (mHHS), and International Hip Outcome Tool (iHOT-12) at 1, 2, and 5 years. MCID was calculated by use of a distribution-based method, whereas PASS and SCB were calculated by use of an anchor method. Results: The study included 283 patients with a mean ± SD age of 34.2 ± 11.9 years. The mean changes in 1-year, 2-year, and 5-year scores, respectively, required to achieve MCID were as follows: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4); and iHOT-12 (15.1, 13.9, 15.1). The threshold scores for achieving PASS were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6); and iHOT-12 (69.1, 72.2, 74.3). Last, the threshold scores for achieving SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4); and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB, and PASS at 2-year compared with 1-year follow-up; however, by 5 years, fewer patients had achieved clinically meaningful outcome (minimum 1-, 2-, and 5-year follow-up, respectively: MCID, 82.6%, 87.3%, 79.3%; PASS, 67.6%, 74.9%, 67.5%; SCB, 62.3%, 67.2%, 56.6%). Conclusion: The greatest proportion of patients achieved MCID, PASS, and SCB at 2-year follow-up after arthroscopic treatment of FAIS compared with 1- and 5-year time points. Improvements were maintained out to 5-year follow-up, although the proportion of patients achieving clinical significance was slightly decreased.

Background: Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively. Purpose: To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score–activities of daily living subscale (HOS-ADL), HOS–sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool–12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent t test. The threshold of every outcome score for achieving MCID was calculated separately for each group and frequencies were compared. Results: A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non–spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all P < .001). There were significant differences in the proportion achieving the threshold for HOS-ADL (60.6% vs 80.0%; P = .004), HOS-SS (57.6% vs 82.1%; P < .001), mHHS (66.7% vs 81.7%; P = .025), and iHOT-12 (54.8% vs 87.6%; P < .001) scores for MCID when comparing the lumbosacral and nonlumbosacral pathology groups. Conclusion: Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

Background: Hip arthroscopy has become an important tool for surgical treatment of intra-articular hip pathology. Predictive models for clinically meaningful outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are unknown. Purpose: To apply a machine learning model to determine preoperative variables predictive for achieving the minimal clinically important difference (MCID) at 2 years after hip arthroscopy for FAIS. Study Design: Case-control study; Level of evidence, 3. Methods: Data were analyzed for patients who underwent hip arthroscopy for FAIS by a high-volume fellowship-trained surgeon between January 2012 and July 2016. The MCID cutoffs for the Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sport Specific (HOS-SS), and modified Harris Hip Score (mHHS) were 9.8, 14.4, and 9.14, respectively. Predictive models for achieving the MCID with respect to each were built with the LASSO algorithm (least absolute shrinkage and selection operator) for feature selection, followed by logistic regression on the selected features. Study data were analyzed with PatientIQ, a cloud-based research and analytics platform for health care. Results: Of 1103 patients who met inclusion criteria, 898 (81.4%) had a minimum of 2-year reported outcomes and were entered into the modeling algorithm. A total of 74.0%, 73.5%, and 79.9% met the HOS-ADL, HOS-SS, and mHHS threshold scores for achieving the MCID. Predictors of not achieving the HOS-ADL MCID included anxiety/depression, symptom duration for >2 years before surgery, higher body mass index, high preoperative HOS-ADL score, and preoperative hip injection (all P < .05). Predictors of not achieving the HOS-SS MCID included anxiety/depression, preoperative symptom duration for >2 years, high preoperative HOS-SS score, and preoperative hip injection, while running at least at the recreational level was a predictor of achieving HOS-SS MCID (all P < .05). Predictors of not achieving the mHHS MCID included history of anxiety or depression, high preoperative mHHS score, and hip injections, while being female was predictive of achieving the MCID (all P < .05). Conclusion: This study identified predictive variables for achieving clinically meaningful outcome after hip arthroscopy for FAIS. Patient factors including anxiety/depression, symptom duration >2 years, preoperative intra-articular injection, and high preoperative outcome scores are most consistently predictive of inability to achieve clinically meaningful outcome. These findings have important implications for shared decision-making algorithms and management of preoperative expectations after hip arthroscopy for FAI.

Background: A growing number of studies have examined return to sport in competitive athletes after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); however, few have evaluated the rate of achieving meaningful clinical outcomes in this group. Purpose: To determine if competitive athletes (professional, semiprofessional, or collegiate) have better 2-year patient-reported outcomes and achieve the minimal clinically important difference (MCID) and substantial clinical benefit at higher rates when compared with nonathletes undergoing hip arthroscopy for the treatment of FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: The study was a retrospective analysis of all consecutive patients who identified as either a competitive athlete or a nonathlete and had undergone hip arthroscopy for FAIS by a single fellowship-trained surgeon between January 2012 and April 2017. Patients in the 2 groups were matched 1:2 by age, sex, and body mass index. Baseline and clinical outcomes, including the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports Subscale (HOS-SS), modified Harris Hip Score, and international Hip Outcome Tool-12, were collected preoperatively and at 2 years postoperatively and compared between the groups. The MCID and substantial clinical benefit were calculated for each group separately and compared using chi-square analysis. Results: A total of 59 competitive athletes and 118 nonathletes were included in the final analysis. Most of the competitive athletes were soccer players (23.7%), followed by softball players (10.2%) and runners (10.2%). Postoperative score comparison between competitive athletes and nonathletes demonstrated a statistically significant difference in the HOS-SS (mean ± SD, 84.5 ± 19.0 vs 76.1 ± 23.8; P = .02). Meaningful outcome analysis demonstrated that competitive athletes had a higher rate of achieving the HOS-SS threshold for the MCID (97.4% vs 82.5%; P = .021). There was no other difference in frequency of achieving the threshold for any other meaningful clinical outcome between the groups. Conclusion: Hip arthroscopy for the treatment of FAIS in competitive athletes and nonathletes produced clinically meaningful outcomes in both patient groups. However, competitive athletes achieved the MCID on the HOS-SS at higher rates than nonathletes and had significantly higher scores at 2 years postoperatively on the HOS-SS.

Background: There is a growing trend for hip arthroscopists to treat patients with borderline hip dysplasia (BHD) for femoroacetabular impingement syndrome (FAIS) without addressing the acetabular coverage. However, the literature of outcomes and failure rates for these patients is conflicting. Purpose: (1) To identify whether patients with BHD achieved 2-year similar patient-reported outcome, minimal clinically important difference (MCID), and patient acceptable symptomatic state (PASS) when compared with patients without BHD and (2) to identify predictors for achieving the MCID and PASS among patients with BHD who are undergoing hip arthroscopy for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Data from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2017 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA], 20°-25°) were matched 2:1 by age, sex, and body mass index (BMI) to control patients with normal acetabular coverage (LCEA, >25°-40°). Patient-reported outcome, MCID, and PASS were compared between the groups. Multivariate logistic regression analysis identified significant predictors of achieving the MCID and PASS in the BHD group. Results: The MCID in the BHD group was defined as 9.2, 13.7, 8.5, and 15.2 for the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sport Specific, modified Harris Hip Score, and iHOT-12, respectively. Threshold scores for achieving the PASS in both groups were 87.9, 76.4, 78.1, and 60.0. A total of 112 patients were identified as having BHD (LCEA, 20°-25°) and were matched to 224 controls. Both groups saw statistically significant increases in score averages over the 2-year period; however, the differences between them were not statistically significant ( P > .05 for all). There was no statistical difference in the frequency of the BHD and non-BHD cohorts achieving the MCID on at least 1 threshold score (86.6% vs 85.6%, P = .837) and the PASS (78.6% vs 79.8%, P = .79). There was, however, a statistically significant difference between the rates of patients with and without BHD achieving the PASS on the modified Harris Hip Score threshold (62.5% vs 74.5%, P = .028). The final logistic models demonstrated that lower BMI (odds ratio [OR], 0.872; P = .029), lower preoperative alpha angle (OR, 0.965; P = .014), and female sex (OR, 3.647; P = .03) are independent preoperative predictors of achieving the MCID, while lower preoperative alpha angle (OR, 0.943; P = .018) and self-reported limp (OR, 18.53; P = .007) are independent preoperative predictors of achieving the PASS. Conclusion: Outcome improvements in patients with BHD who are undergoing arthroscopic treatment with capsular closure for FAIS are not significantly different from patients with normal acetabular coverage. Lower BMI, lower alpha angle, absence of limp, and female sex are preoperative predictors of achieving meaningful clinically significant outcome improvements in patients with BHD.

Background: There is literature on the association between chronic preoperative pain and worse outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). However, there are few data on whether there is an optimum window that provides the best midterm surgical outcomes. Purpose: To assess the outcomes of hip arthroscopy for FAIS according to timing of surgical intervention. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing arthroscopic intervention for FAIS with a minimum 2-year follow-up were included. All patients completed the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales for pain and satisfaction. Patients were stratified by preoperative symptom duration. We compared 3 to 6 months of symptoms with other subsequent time frames (>6-12, >12-24, and >24 months). Clinically significant outcome was determined with the minimal clinically important difference and patient acceptable symptomatic state. Results: A total of 1049 patients were included (mean ± SD: age, 32.3 ± 12.4 years; follow-up, 30.8 ± 6.7 months). Patients undergoing surgery at 3 to 6 months of symptoms had no significant differences in outcome when compared with those in the >6- to 12-month group except for the iHOT-12 ( P = .028). Patients with symptom duration of >12 to 24 months and >24 months had worse outcomes across all measures ( P < .001). Surgery within 3 to 6 months of symptoms was predictive for achieving the minimal clinically important difference on the HOS-ADL (odds ratio [OR], 1.81; 95% CI, 1.20-2.73) and HOS-SS (OR, 1.90; 95% CI, 1.11-3.17), as well as the patient acceptable symptomatic state on the HOS-ADL (OR, 1.85; 95% CI, 1.34-2.56) and HOS-SS (OR, 1.58; 95% CI, 1.14-2.18), when compared with the other groups. In multivariate regression analysis, symptom duration was predictive of visual analog scale for pain (β = 3.10; 95% CI, 1.56-4.63; P < .001) and satisfaction (β = −4.16; 95% CI, −6.14 to −2.18; P < .001). Conclusion: Among patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) was associated with superior postoperative outcomes when compared with patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making regarding delay of surgery. These findings should be confirmed in a prospective study.

Background: The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis. Purpose: To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities. Study Design: Cohort study; Level of evidence, 3. Methods: Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. Results: 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013). Conclusion: A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.

Background:The literature on the effects of labral tear on patient-reported outcomes, midterm pain, and overall patient satisfaction is limited.Purpose:To determine the effect of labral tear length on postoperative outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).Study Design:Cohort study; Level of evidence, 3.Methods:Consecutive patients undergoing primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified in a prospectively collected database. All patients completed the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale for pain and satisfaction. Patients were stratified by labral tear length into small (Results:Of the 747 eligible patients, 600 (80.3%) had 2-year reported outcomes and were included in the final analysis. Mean age, body mass index, and tear length were 33.5 ± 12.3 years, 25.4 ± 9.2 kg/m2, and 2.7 ± 0.7 cm, respectively. Men had higher frequency of large tears when compared with women (77% vs 43.7%, P < .001). Independent t test demonstrated significant differences in 2-year outcomes between patients with tears Conclusion:Labral tear length is independently predictive of patient-reported outcomes after hip arthroscopy for FAIS. Furthermore, patients with smaller tears (

Background: Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly expanding field, and preoperative factors predictive of persistent postoperative pain are currently unknown. Purpose: To identify predictors for persistent postoperative pain at the site of surgery after hip arthroscopy for FAIS. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent hip arthroscopy for FAIS and had a minimum 2-year follow-up with patient-reported outcomes (PROs) were included in this study. Patients with previous open hip surgery and diagnoses other than FAIS were excluded. Patients were grouped by visual analog scale scores for pain as limited (Results: The limited pain (n = 514) and persistent pain (n = 174) groups totaled 688 patients (449 females). There was a statistically significant difference in age between groups, with the persistent pain group being older than the low pain group (35.9 ± 12.2 vs 32.4 ± 12.6, respectively; P = .002). Patients with persistent postoperative pain demonstrated significantly lower preoperative PRO scores in the Hip Outcome Score–Activities of Daily Living (57.6 ± 21.2 vs 67.7 ± 16.8), Hip Outcome Score–Sport Specific (35.9 ± 23.9 vs 44.1 ± 22.7), modified Harris Hip Score (51.6 ± 16.2 vs 59.6 ± 12.9), and International Hip Outcome Tool (32.0 ± 16.8 vs 40.0 ± 17.82) but no significant differences in preoperative visual analog scale scores for pain (7.3 ± 1.8 vs 7.2 ± 1.7). Mean postoperative PRO differences between pain groups were all statistically significant. Bivariate logistic regression analysis demonstrated that history of anxiety or depression (odds ratio, 1.8; 95% CI, 1.02-3.32; P = .042), revision hip arthroscopy (odds ratio, 8.6; 95% CI, 1.79-40.88; P = .007), and a low preoperative modified Harris Hip Score (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .30) were predictors of persistent postoperative pain. Conclusion: Independent predictors for persistent postoperative pain include revision hip arthroscopy and mental health history positive for anxiety and depression. Our analysis demonstrated significant improvements in pain and functional PROs in the limited pain and persistent pain groups; however, those with persistent pain demonstrated significantly lower PRO scores.

Background: Hamstring injuries at the musculotendinous junction are relatively common. However, injuries to the proximal hamstring account for just 12% of hamstring injuries. Surgical repair of these injuries including both open and endoscopic techniques are becoming increasingly more common. Indications: Surgical intervention is generally reserved for cases with 2 or more torn tendons and at least 2 centimeters of retraction. Technique Description: The combined open and endoscopic technique utilizes direct posterior and posterolateral portals. After visualizing the posterior femoral cutaneous (PFCN) and sciatic nerves (SN), the proximal hamstring tear is identified, and the shaver is used to remove any surrounding adhesions and aid in clearing any hematoma. The ischial tuberosity is prepared using a shaver, radiofrequency ablation, and a 5.5 mm, round arthroscopic burr. Two, 4.5 mm, doubled-loaded anchors are placed into the ischium. The incision for the open portion of the case is created by incising the skin between the direct posterior and posterolateral portals. A dissection is continued down to the gluteal fascia, and the gluteal fascia is incised in line with the surgical incision. The gluteus maximus is retracted then the hamstring stump is secured with a stay suture and brought outside the surgical incision for inspection. The double-loaded sutures are passed in a running locking technique. The other suture limbs are then passed through the central aspect of the tendon and tensioned to reduce the proximal hamstring onto the prepared tuberosity. Results: Significant postoperative improvements in patient-reported outcomes have been reported for open and endoscopic repairs in isolation, but to date there are no outcomes studies on the combined “Scopen” technique. Postoperative complications may include numbness or neuropraxia, re-rupture, infection, and deep vein thrombosis (DVT). Discussion: The endoscopic portion allows an improved view and preservation of the SN and PFCN, as well as a detailed view of the ischial tuberosity for decortication and anchor placement in comparison with a purely open approach. In comparison with a purely endoscopic approach, this combined approach can be used in patients with retraction >4 cm, and can also be utilized for chronic, retracted tears as well.

Background: At the time of hip arthroscopy, some patients are found to have irreparable labral tears that are not amenable to primary repair. For these patients, treatment with segmental reconstruction is a surgical option to restore labral tissue and biomechanics. Indications: Patients with segmental irreparable hip labral tears that are technically not amenable for primary labral repair should be considered for labral reconstruction with allograft. Technique Description: Standard hip arthroscopic portals are established. An interportal capsulotomy is performed, and acetabular rim trimming is performed to remove the pincer deformity. Visualized segmental labral defects are measured using a piece of suture to allow for measurement of a curved surface and 1.4-mm polyether ether ketone (PEEK) anchors are placed in anticipation of labral fixation. On the back table, the tibialis anterior allograft is prepared for labral reconstruction. We mark a central portion of the graft tissue based on the measured defect size. A 3-0 vicryl suture is used to place a running stitch from one end to the other of the marked portion of the allograft and the marked, prepared graft is sharply divided from the rest of the tissue. Stitches from the anterior and posterior anchors are passed through the graft using a free needle. The graft is then placed through the distal accessory anterolateral portal and positioned into place. The posterolateral and then medial-most anchors are secured and tied using arthroscopic knots, followed by sequential tying of the middle anchors. Any additional arthroscopic procedures, such as cam resection, are performed, and capsular/skin closure is performed using standard methods. Results: Published outcomes support reconstruction of the labrum using allograft, with 2 series consisting of a total of 141 segmental/circumferential reconstructions demonstrating similar outcome scores at 2 years of follow-up as compared to matched cases of primary labral repairs. Discussion/Conclusion: Hip segmental labral reconstruction with tibialis anterior allograft provides a viable surgical option for patients with labral defects precluding primary labral repair. The presented material demonstrates a readily employable technique as well as clear, step-by-step postoperative rehabilitation protocols, and satisfactory published short- and mid-term outcomes literature.

Background: The current clinical standard for the evaluation of cam deformity in femoroacetabular impingement syndrome is based on radiographic measurements, which limit the ability to quantify the complex 3-dimensional (3D) morphology of the proximal femur. Purpose: To compare magnetic resonance imaging (MRI)–based metrics for the quantification of cam resection as derived using a best-fit sphere alpha angle (BFS-AA) method and using 3D preoperative-postoperative surface model subtraction (PP-SMS). Study Design: Descriptive laboratory study. Methods: Seven cadaveric hemipelvises underwent 1.5-T MRI before and after arthroscopic femoral osteochondroplasty, and 3D bone models of the proximal femur were reconstructed from the MRI scans. The alpha angles were measured radially along clockfaces using a BFS-AA method from the literature and plotted as continuous curves for the pre- and postoperative models. The difference between the areas under the curve for the pre- and postoperative models was then introduced in the current study as the BFS-AA–based metric to quantify the cam resection. The cam resection was also quantified using a 3D PP-SMS method, previously described in the literature using the metrics of surface area (FSA), volume (FV), and height (maximum [FHmax] and mean [FHmean]). Bivariate correlation analyses were performed to compare the metrics quantifying the cam resection as derived from the BFS-AA and PP-SMS methods. Results: The mean ± standard deviation maximum pre- and postoperative alpha angle measurements were 59.73° ± 15.38° and 48.02° ± 13.14°, respectively. The mean for each metric quantifying the cam resection with the PP-SMS method was as follows: FSA, 540.9 ± 150.7 mm2; FV, 1019.2 ± 486.2 mm3; FHmax , 3.6 ± 1.0 mm; and FHmean, 1.8 ± 0.5 mm. Bivariate correlations between the BFS-AA–based and PP-SMS–based metrics were strong: FSA ( r = 0.817, P = .012), FV ( r = 0.888, P = .004), FHmax ( r = 0.786, P = .018), and FHmean ( r = 0.679, P = .047). Conclusion: Strong positive correlations were appreciated between the BFS-AA and PP-SMS methods quantifying the cam resection. Clinical Relevance: The utility of the BFS-AA technique is primarily during preoperative planning. The utility of the PP-SMS technique is in the postoperative setting when evaluating the adequacy of resection or in patients with persistent hip pain with suspected residual impingement. In combination, the techniques allow surgeons to develop a planned resection while providing a means to evaluate the depth of resection postoperatively.

Background: The citation rate of a research published article is an indicator of its quality and impact and contributes to the journal’s impact factor. Within the orthopaedic sports medicine literature, predictors of citation rates have not been previously described. Purpose: To identify characteristics of published articles that predict 5-year citation rates of studies in the orthopaedic sports medicine literature. Study Design: Cross-sectional study. Methods: Research articles published in The American Journal of Sports Medicine (AJSM), Arthroscopy: The Journal of Arthroscopic and Related Surgery, and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) from 2012 were analyzed. Extracted characteristics of published articles included journal, author number, origin of study, first author degree, subject of study, study type, sample size, number of references and institutions, conflicts of interest, level of evidence, and 5-year citation rates. Multivariate logistic regression was used to determine predictors of greater than the mean number of citations at 5 years. Results: A total of 825 published articles ( AJSM, n = 313; Arthroscopy, n = 173; KSSTA, n = 339) were included in the final analysis. The mean number of 5-year citations was 23.2 (95% CI, 21.6-24.9; range, 1.0-260.0). AJSM had a significantly greater citation rate (32.4) than Arthroscopy (21.7) and KSSTA (15.2) ( P < .001 for both). Arthroscopy had a greater citation rate than KSSTA ( P = .008). Independent predictors of greater than the mean number of citations at 5 years were published articles in AJSM (odds ratio [OR], 5.17; 95% CI, 2.81-9.52; P < .0001), published articles of North American origin (OR, 1.79; 95% CI, 1.25-2.58; P = .002), and published articles regarding the hip (OR, 2.68; 95% CI, 1.08-6.67; P = .035). Conclusion: Published articles in AJSM, those from North America, and those examining the hip were independent predictors of greater citation rates at 5 years.

BACKGROUND: There is increased emphasis on efficiently administering patient-reported outcome measures (PROMs). The International Hip Outcome Tool-12 (iHOT-12) is a short-form version of the iHOT-33, and relatively little is known about clinically significant outcomes using the iHOT-12. QUESTIONS/PURPOSES: The purpose of this study was to define minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the iHOT-12 and to identify predictors for achieving these psychometric end points in patients undergoing arthroscopic treatment of femoroacetabular impingement (FAI). METHODS: Data was prospectively collected and retrospectively analyzed as part of an institutional hip preservation repository. One hundred and twenty patients were included; mean age and body mass index (BMI) were 38.7 years and 25.9, respectively. A majority of patients were female (67.5%) and white (81.7%) and participated in recreational sports (79.2%). The iHOT-12 was administered pre-operatively and at 1-year follow-up to patients undergoing primary hip arthroscopy for FAI. The following anchor question was also asked at 1-year follow-up: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?” MCID was calculated using a distribution-based method. Receiver-operating characteristic analysis with area under the curve was used to confirm the significance of the PASS threshold. RESULTS: Mean iHOT-12 scores improved from 35.6 at pre-operative assessment to 70.7 at 1-year follow-up. Patients indicating satisfaction with their outcome improved from 37.5 pre-operatively to 79.0 at 1-year follow-up. MCID value for the iHOT-12 was 13.0. The PASS threshold was 63.0, indicating an excellent predictive value that patients scoring above this threshold were likely to have met an acceptable symptom state. Worker’s compensation patients and those with increased BMI were less likely to achieve PASS; lower pre-operative iHOT-12 score was predictive for achieving MCID, and achieving MCID was predictive for achieving PASS. CONCLUSION: This is the first study to define PASS and MCID for the iHOT-12, which measures clinically significant outcome improvement comparably to that of other commonly used hip PROMs. As its use becomes more widespread, the iHOT-12 data-points presented in this study can be used to determine clinically significant improvement of patient-reported outcomes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-018-9646-0) contains supplementary material, which is available to authorized users.

The hip and pelvis have a complex anatomy and are a common source of pain and injury in the athletic population. The clinical examination of the hip requires a systematic approach to differentially diagnose hip problems with overlapping pain referral patterns. Because of the complex anatomy of the hip, the physical examination is a comprehensive evaluation of the 4 main pain generators of the hip from deep to superficial: the osteochondral, capsulolabral, musculotendinous, and neurovascular elements of the hip. The hip examination begins with the standing examination and gait analysis followed by a seated, supine, lateral, and prone examination. A targeted physical examination used in conjunction with a layered understanding of the hip and pelvis can help guide diagnostic testing, distinguish hip-specific diagnoses from similar presenting pathologies, and inform treatment.

Background: Deep gluteal syndrome (DGS) encompasses a spectrum of pathologies causing symptomatic sciatic nerve compression deep to the gluteus maximus muscle. Endoscopic sciatic neurolysis is an option for management of DGS when conservative treatment fails. Indications: Endoscopic sciatic neurolysis is indicated for retro-trochanteric pain, sciatica-like burning in the posterior thigh, and sitting discomfort that is reproducible on physical examination after failing conservative management. Technical Description: The technique presented here introduces a standard endoscopic sciatic neurolysis technique with an accessory posterolateral portal placed distally and in line with the sciatic nerve. Use of a switching stick through an accessory distal posterolateral portal can allow for in-line protection and retraction of the sciatic nerve while it is carefully released from compressive fibrous bands using an arthroscopic shaver. It is important that the accessory portal be placed under direct visualization with caution not to injure the sciatic nerve. An arthroscopic radiofrequency device can be used for hemostasis and further release of fibrous bands. At the end of the procedure, the sciatic nerve should be visualized fully released and freely mobile from the piriformis muscle to the level of the lesser trochanter. Results: In properly selected patients, the procedure is very successful. In a series of 35 cases, the procedure reduced sitting pain (present in 97% of patients preoperative, 17% of patients postoperative), reduced narcotic use, improved visual analog scale (VAS) pain scores, and improved modified Harris hip scores without major complications. Discussion: Although rare following hip arthroscopy, postoperative scarring and fibrous bands are a common cause of DGS which can be effectively treated by endoscopic sciatic nerve decompression. Results of endoscopic sciatic neurolysis have thus far been encouraging with improvements in patient reported outcome scores and high rates of satisfaction. However, complications do occur and can result in neurologic deficits. Nevertheless, with careful patient selection and meticulous sciatic nerve dissection, endoscopic sciatic neurolysis for DGS is a safe and effective technique for decompression of fibrous bands and adhesions that can lead to sciatic neuralgia.

Objectives: A preoperative or intraoperative finding of an acetabular labrum width of Methods: Data from consecutive patients who underwent primary hip arthroscopy between November 2015 and July 2018 for the treatment of FAIS were analyzed. Baseline demographic data, preoperative, and minimum 1 year post-operative clinical outcomes including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool 12 questions (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were recorded. The labrum size was documented by the senior surgeon for all patients using the tip of an arthroscopic probe measuring 4mm. Labrum hypoplasia was defined as a labrum width at the 12 o’clock position of Results: A total of 360 patients were included in the study with 180 in each of the normal and hypoplastic groups. There was no significant differences seen in 1-year post operative outcome scores or score improvement between the two groups. When examining only borderline dysplastic patients there were no significant differences in outcomes between normal and hypoplastic labrum patients. In the subset with a normal LCEA only post-operative VAS satisfaction (85.5 ± 19.3 vs 78.2 ± 27.4; p=0.050) was significantly higher in the normal labrum patients compared to hypoplastic labrum. Patients with hypoplastic labrum achieved MCID and PASS at the same rate as patients with normal labrum across all outcome measures. Conclusions: Patients with an intraoperative finding of labral hypoplasia achieve 1-year meaningful clinical outcome at the same rate as those with normal labral width following arthroscopic labral repair. These results bring into question the need for primary labral reconstruction in patients with labral hypoplasia with a normal or borderline dysplastic acetabulum.

Objectives: Non-modifiable factors including age and sex have been shown to effect outcomes following hip arthroscopy in patients with femoroacetabular impingement syndrome (FAIS) at short-term follow-up. However, their effect on achieving long-term meaningful outcomes has not been evaluated. As such, the purpose of this study is to compare clinical outcomes, including achieving meaningful clinical important difference (MCID) and the patient acceptable symptomatic state (PASS) at 5-years, by age and sex. Methods: 150 patients undergoing hip arthroscopy for femoroacetabular impingement by a single fellowship trained surgeon were prospectively analyzed, with 25 patients in each of the following groups: female patients younger than 30 years of age, female patients 30 to 45 years of age, female patients older than 45 years of age, male patients younger than 30 years of age, male patients 30 to 45 years of age, and male patients older than 45 years of age. Pre and postoperative functional scores were collected including the Hip Outcome Score Activities of Daily Living Subscale (HOS-ADL), Hip Outcome Score Sport-Specific Subscale (HOS-Sport), the modified Harris hip score (mHHS), and visual analog scale (VAS) satisfaction and pain at 5-year follow-up. MCID and PASS was calculated for each functional measure and compared by gender and age category. Results: At 5-year follow-up, all groups demonstrated statistically significant improvement in the functional outcome score averages and pain (p0.05).Analysis of achieving MCID and PASS demonstrated that females had a higher rate of reaching the HOS-SS and mHHS threshold for achieving MCID as compared to their male counterparts (48.3% vs 58%%; p=0.008 and 54% vs 75.4%; p=0.012, respectively). Furthermore, patients 0.05 for both). Conclusions: Non-modifiable factors, including age and sex, influence the rate of achieving meaningful clinical outcomes at 5-year follow up. Female patients are more likely to reach the HOS-SS and mHHS threshold for achieving MCID, while those

Paste abstract here and remove the remaining text. *For structured abstracts, begin each section under a separate, bolded subheading. Suggested subheadings are below Objectives: The iliopsoas is a major hip flexor that provides anterior hip stability. Recent studies report significant compromise to these important functions with iliopsoas tenotomy. The purpose of this study is to report the prevalence, associated findings, rendered procedures, and outcomes of hips with iliopsoas involvement undergoing hip arthroscopy for FAI and/or chondrolabral pathology. The hypothesis is that there is a decrease in the incidence of tenotomy compared with historic controls and that tenotomy compromises patient-reported outcomes. Methods: Level of evidence 3 controlled study with prospectively-collected multicenter database from 7 centers. Enrolled patients that underwent isolated hip arthroscopy that reached 2-year minimum follow-up with iHOT-12 were assigned to Iliopsoas group defined as pre-operative diagnosis of iliopsoas tendonitis, internal snapping symptoms, intra-operative anteroinferior labral pathology (below 3 O’clock location) and/or preoperative psoas injection or the control group. The prevalence of iliopsoas pathology, radiographic and intra-operative findings, and rendered procedures between groups were compared using Chi square analysis. Minimum 2-year outcomes of Iliopsoas group versus control group were compared using analysis of variance (a priori alpha set at 0.05). Subanalysis within the Iliopsoas group was performed of patients with versus without tenotomy. Results: There were 97 study group subjects and 1053 control group subjects. There was no statistical difference in demographics between the groups (p>0.05) nor was there a difference in length of preoperative symptom duration (p=0.51). There were no significant differences in the incidence of cam impingement, pincer impingement or dysplasia between cohorts, nor were there significant differences between radiographic measures. There was a similar incidence of femoroplasty, acetabuloplasty, chondroplasty, microfracture, and synovectomy (p>0.05) regardless of iliopsoas involvement. There was not a significant effect on the surgical treatment of the labrum based on psoas involvement (p>0.16). Labral repair was performed in 55% of patients with iliopsoas involvement and 62% of patients without iliopsoas involvement. Although there was not a significant difference in capsular closure between cohorts (96% vs 93%, p=0.121), the overwhelming majority of patients with psoas involvement received capsular repair (87%) or plication (9%). Pre-operative iHOT-12 scores were similar 34 (SD: 18) for the iliopsoas group and 35 (SD 18) for the control group groups (p=0.51). Post-operative iHOT-12 scores improved to 72 for both the groups. The iliopsoas group achieved MCID, SCB, and PASS scores established for the iHOT-12 of 83%, 62%, and 58% which were similar to the control group. Ten subjects (10%) in the iliopsoas group received iliopsoas tenotomy. Subjects with tenotomy had lower 2-year post-op iHOT-12 scores compared to the non-tenotomy subgroup (55 vs 72, respectively; p=0.03) . This corresponded with lower achievement of MCID scores (60% vs 86%; p=0.03) and SCB scores (30% vs 70%, p=0.01) of patients with tenotomy compared to those without tenotomy. Conclusion: Iliopsoas tenotomy is rarely performed relative to its prevalence in patients undergoing hip arthroscopy by high volume surgeons for FAI and/or chondrolabral pathology. Surgical outcomes are not worsened with iliopsoas involvement but are worsened with tenotomy.

Objectives: Minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically significant outcome, however, it is unknown what represents meaningful patient reported outcome improvement in the medium to long-term. The purpose of the present study was to define MCID, PASS and SCB at a minimum five years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Secondarily, we sought to evaluate the time dependent nature of MCID, PASS and SCB. Methods: Patients undergoing hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score at 1-, 2-, and 5- years. MCID was calculated using a distribution-based method while PASS and SCB were calculated using an anchor method. Results: Two hundred and eighty-three patients were included with an average age of 34.2+11.9 years. The one year, two year and five-year MCID scores were as follows respectively: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4) and iHOT-12 (15.1, 13.9, 15.1). PASS scores were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6) and iHOT-12 (69.1, 72.2, 74.3). SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4) and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB and PASS at two-year follow-up than at one-year follow-up. However, 79.3% of the patients achieved MCID by 5 years. Conclusion: The greatest proportion of patients achieve clinically significant outcome improvement at two-year follow-up after arthroscopic treatment of FAIS. Improvements are maintained out to five-year follow-up although there is a slight decrease in the proportion of patients achieving clinical significance. Table 1. Frequency of patients achieving any MCID, PASS, or SCB threshold at 1,2, and 5-years 1-year 2-year 5-year p-value Any MCID 233 (82.6%) 247 (87.3%) 224 (79.3%) 0.035 Any PASS 191 (67.6%) 211 (74.9%) 191 (67.5%) 0.114 Any SCB 176 (62.3%) 190 (67.2%) 160 (56.6%) 0.034

Objectives: An integral component of hip stability is the negative pressure gradient created by the labral suction seal. No prior studies have quantitatively compared the integrity of the suction seal under normal, pathologic, and surgical conditions. The purpose of this study was to evaluate the biomechanical properties of the labral suction seal in the following four scenarios: intact labrum, labral tear, labral augmentation, and labral reconstruction. Methods: Eight fresh-frozen hemi-pelvises without osteoarthritis and with an intact labrum were dissected to the level of labrum and mounted for biomechanical testing. Each specimen was evaluated sequentially under four testing conditions: intact labrum, labral tear, labral augmentation, and labral reconstruction. Following testing of the intact labrum, the specimens were manipulated to create a labral tear from 12- to 3-o’clock. Labral augmentation was then performed with bone anchors and iliotibial band graft after debridement of only the peripheral half of the labral tear. Labral reconstruction was performed last with bone anchors and iliotibial band graft after removing the entire labral tear. In each condition the specimens were placed in the test machine to undergo pure distraction of the joint. First, the femur was compressed with 250 N of force and then distracted at 10 mm/s with force and displacement continuously recorded until the suction seal was disrupted. In each specimen, the tests were repeated for a total of three tests in each of the four conditions, and the average peak force was calculated. Data was normalized to the intact peak force for each specimen to account for gender and size differences. Statistical testing was performed via a repeated measures ANOVA with a post hoc Bonferroni correction for pairwise analysis. Results: Peak loads occurred early in displacement. The average peak force values (mean ± standard deviation) were as follows: intact (137.2 ± 40.7), labral tear (126.3 ± 43.5), labral augmentation (94.7 ± 59.7), labral reconstruction (78.9 ± 51.2). The average normalized peak force values relative to the intact condition were as follows: labral tear (91.1 ± 8.5), augmentation (66.1 ± 27.6), and reconstruction (55.6 ± 25.7). There was no statistically significant difference in peak force relative to the intact labrum for the labral tear (p = 0.34). Relative to the labral tear, there was no significant difference in peak force for the augmentation (p = 0.12), but there was a significant decrease in peak force for the reconstruction (p = 0.03). Conclusion: This model provides a new means of quantitatively evaluating the labral suction seal under various normal, pathologic, and surgical conditions. The results show that relative to the labral tear condition, labral augmentation may recreate the labral suction seal better than labral reconstruction. Clinically, these findings suggest augmentation may improve hip stability over labral reconstruction. [Figure: see text]

Objectives: To identify preoperative predictors for patients requiring at least one postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement and 2) to determine 2-year reported outcomes in those requiring opioid refills. Methods: Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 was analyzed. Baseline demographics were recorded, including preoperative opioid use, as well as pre- and 2-year postoperative functional scores specifically the Hip Outcome Score-Activity of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified hip Harris score (mHHS), international hip outcome tool (iHOT-12), and visual analog score (VAS) for pain and satisfaction were recorded. A correlation analysis was used to identify preoperative demographic and clinical variables associated with requiring postoperative opioid refill. Variables with a statistically significant association (pResults: A total of 775 patients with postoperative opioid use and 2-year follow-up were included in the analysis. 141 (18.2%) patients required at least one preoperative opioid prescription refill in addition to the routine opioid total prescription postoperatively to every patient after hip arthroscopy. Patients requiring opioid refills had significantly lower HOS-ADL (79.9+20.3 vs 88.7+14.9), HOS-SS (64.6+29.5 vs 78.2+23.7), mHHS (74.2+21.1 vs 83.6+15.9), iHOT-12(63.6+27.9 vs 74.9+24.8), and VAS satisfaction (73.4+30.3 vs 82.2+24.9) averages, as well as higher pain (26.8+23.4 vs 17.9+21.8) when compared to patients without additional opioid refills with pConclusion: Patients requiring at least one postoperative opioid refill after undergoing hip arthroscopy for FAIS have lower 2-year functional scores when compared to patients not requiring refills. Additionally, active pre-operative opioid use at the time of surgery, as well as larger preoperative alpha angles are predictors of requiring additional opioids for pain management.

Background: Ischiofemoral impingement is a rare but increasingly recognized as a source of hip pain. Its etiology is often multifactorial and can be due to congenital, iatrogenic, or extra-articular pathology. Prior literature has described lesser trochanter osteoplasty and iliopsoas release for the treatment of ischiofemoral impingement, but postoperative hip flexor weakness has been noted with this technique. We present a novel technique for the treatment of ischiofemoral impingement, with resection of the ischial tuberosity. Indications: Patients with ischiofemoral impingement that remain symptomatic despite nonsurgical management, or patients with persistent gait abnormalities, are considered for surgery. Technique Description: In the prone position, direct posterior and posterolateral arthroscopic portals are created in the gluteal fold. The posterior femoral cutaneous and sciatic nerve are identified. Fluoroscopy is used to identify the region of impingement on the ischial tuberosity and the overlying hamstring tendon is elevated off the tuberosity. An arthroscopic burr is used to resect the tuberosity. Fluoroscopy is utilized to confirm adequate resection. This is combined with a dynamic examination under direct arthroscopic visualization with the hip in an extended, adducted, and externally rotated position. To repair the hamstring tendon, 2 double-loaded anchors are placed into the ischium, the sutures of which are used to repair the hamstring tendons using a horizontal mattress configuration. Patients undergo a stepwise postoperative physical therapy protocol, followed by a functional testing profile prior to return to competitive sport. Results: Significant improvements in patient-reported outcomes have been reported following treatment of ischiofemoral impingement, with some studies reporting Hip Outcome Score—Activities of Daily Living (HOS-ADL) >90 at 2 years postoperatively. Athletes have been able to return to sport at a mean 5.6 months after surgery. Large studies have yet to report on outcomes compared with nonsurgical or open techniques. Discussion/Conclusion: Recent advancements in endoscopic techniques have allowed for adequate visualization and release of ischiofemoral impingement. We present our endoscopic technique of ischial tuberoplasty, which, compared to lesser trochanter osteoplasty and iliopsoas release, may reduce the incidence of postoperative hip flexor weakness.

Background: Interportal and T-capsulotomies are popular techniques for exposing femoroacetabular impingement deformities. The difference between techniques with regard to the force required to distract the hip is currently unknown. Purpose: To quantify how increasing interportal capsulotomy size, conversion to T-capsulotomy, and subsequent repair affect the force required to distract the hip. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric hip specimens were dissected and fixed in a materials testing system, such that pure axial distraction of the iliofemoral ligament could be achieved. The primary outcome measure was the load required to distract the hip to a distance of 6 mm at a rate of 0.5 mm/s. Each hip was tested in the intact state and then sequentially under varying capsulotomy conditions: 2-cm interportal, 4-cm interportal, half-T (4-cm interportal and 2-cm T-capsulotomy), and full-T (4-cm interportal and 4-cm T-capsulotomy). After serial testing, isolated T-limb repair and then subsequent complete repair were performed. Repaired specimens underwent distraction testing as previously stated to assess the ability to restore hip stability to the native profile. Distraction force as well as the relative distraction force (percentage normalized to the intact capsule) were compared between all capsulotomy and repair conditions. Results: Increasing interportal capsulotomy size from 2 to 4 cm resulted in significantly less force required to distract the hip ( P < .001). The largest relative decrease in force was seen between the intact state (274.6 ± 71.2 N; 100%) and 2-cm interportal (209.7 ± 73.2 N; 76.4% ± 15.6%; P = .0008). There was no significant mean difference in distraction force when 4-cm interportal (160.4 ± 79.8 N) was converted to half-T (140.7 ± 73.5 N; P = .270) and then full-T (112.0 ± 70.2 N; P = .204). When compared with the intact state, isolated T-limb repair partially restored stability (177.3 ± 86.3 N; 63.5% ± 19.8%; P < .0001), while complete repair exceeded native values (331.7 ± 103.7 N; 122.7% ± 15.1%; P = .0008). Conclusion: The conversion of interportal capsulotomy to T-capsulotomy did not significantly affect the force required to distract the hip in a cadaveric model. However, larger interportal capsulotomies resulted in significant stepwise decreases in distraction force. When performing interportal or T-capsulotomy, the iliofemoral ligament strength is significantly decreased, but complete capsular repair demonstrated the ability to restore joint stability to the native, intact hip. Clinical Relevance: Increasing interportal capsulotomy size decreases the force required to distract the hip. In an effort to maximize visualization and minimize the magnitude of iliofemoral ligament fibers cut, many surgeons have moved from extended interportal capsulotomy to T-capsulotomy. Interportal and T-capsulotomies result in equivalent hip distraction, partial capsular repair marginally improves hip stability, and only complete repair has the ability to restore the hip to its native biomechanical profile.

Background: Pelvic incidence (PI) is an important variable in assessing spinopelvic balance that is associated with hip pathology. A lateral radiograph of the pelvis can be used to measure PI, but this view is not routinely performed in the clinical setting during evaluation of hip pain. The false-profile (FP) radiographic view of the hip is commonly obtained to measure acetabular coverage. Purpose: To evaluate the tolerance of PI measurements to pelvic rotation and assess the feasibility of using an FP radiograph to obtain an accurate measurement of PI. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A mathematical model was developed to predict the change in PI with rotation. Fluoroscopic images were obtained of 6 reconstructed cadaveric adult pelvis and femur specimens at varying degrees of rotation, including a perfect lateral and FP image. PI was measured with the midpoint between the centers of the femoral heads as a reference point. The findings were confirmed clinically by retrospectively reviewing FP radiographs and computed tomography (CT) scans of 40 clinical patients. PI was measured on FP radiographs and CT scans by 2 independent reviewers. Results: With dry cadaveric pelvis specimens, the discrepancy in PI measured between fluoroscopic FP and lateral views was 1.6° (95% CI, 0.7°-2.4°). There was excellent agreement between CT and FP radiographs with regard to measurement of PI (intraclass correlation coefficient = 0.92; 95% CI, 0.78-0.98). Mean discrepancy in PI measured between the 40 clinical FP radiographs and CT scans was 2.8° (range, 0.1°-9.1°). Conclusion: Increased rotation from a lateral view results in greater error in measuring PI, although relatively nominally with a 2.8° error with the 25° of rotation in clinical true FP views. These data demonstrate that FP radiographs can be used to measure PI with reasonable accuracy.

Background: The specific influence of preoperative and postoperative radiographic measurements on patient-reported outcome measures after hip arthroscopy for femoroacetabular impingement (FAI) remains unclear. Purpose: To investigate the relationship between radiographic measurements and 2-year outcomes after hip arthroscopy for the treatment of FAI. Study Design: Case series; Level of evidence, 4. Methods: A clinical registry of patients undergoing primary hip arthroscopy for FAI between January 1, 2012, and December 31, 2014, was queried. Outcome measures included the Hip Outcome Score (HOS) Activities of Daily Living (ADL), HOS Sport-Specific Subscale (SSS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction. Preoperative and postoperative radiographic measurements were recorded. Univariate analysis was conducted to identify relationships between all radiographic and demographic variables and outcome scores. A multivariate regression analysis, controlling for demographic factors, was used to identify independent associations between radiographic measurements on plain radiographs and patient-reported outcomes. Results: The authors identified 707 patients who underwent primary hip arthroscopic management for FAI who were included for analysis. Two-year outcome surveys were completed for 78% to 84% of patients. The mean age of the patients was 33.2 ± 12.3 years, and 64.4% of the patients (n = 456) were female. The mean anteroposterior (AP) alpha angle decreased by 34.3° ( P < .0001), false profile alpha angle by 25.2° ( P < .0001), Dunn lateral alpha angle by 28.9° ( P < .0001), lateral center edge angle by 2.6° ( P < .0001), and anterior center edge angle by 3.4° ( P < .0001). The HOS-ADL score increased from 65.7 ± 18.7 preoperatively to 85.9 ± 16.7 postoperatively ( P < .0001), HOS-SSS increased from 43.4 ± 23.1 to 72.6 ± 27.2 ( P < .0001), and mHHS increased from 57.7 ± 14.0 to 79.1 ± 17.2 ( P < .0001). With multivariate analysis, independent predictors of the postoperative HOS-ADL score included the preoperative false profile alpha angle (beta = −0.16, P = .028). Independent predictors of HOS-SSS score were preoperative AP alpha angle (beta = −0.33, P = .032) and preoperative false profile alpha angle (beta = –0.28, P = .041). For the postoperative mHHS score, independent predictors included preoperative AP alpha angle (beta = −0.18, P = .046), preoperative false profile alpha angle (beta = −0.20, P = .014), and postoperative false profile alpha angle (beta = –0.48, P = .035). The preoperative AP alpha angle (beta = 0.28, P = .024) was a significant predictor for the postoperative VAS pain score. The preoperative false profile alpha angle (beta = −0.34, P = .040) was a significant predictor for the postoperative VAS satisfaction score. Conclusion: The authors observed that radiographic measurements, specifically the preoperative false profile alpha angle, AP alpha angle, and postoperative false profile alpha angle, are independent predictors of 2-year clinical outcomes. The femoral-side measurements were the strongest independent predictors of outcomes, especially measurements of the anterior and lateral-based CAM lesion.

Background: Femoroacetabular impingement syndrome (FAIS) is most commonly diagnosed in patients who perform activities that require repetitive hip flexion and rotational loading. Yoga is an activity growing in popularity that involves these motions. The purpose of this study was to evaluate patients’ ability to return to yoga after hip arthroscopy for FAIS. Hypothesis: There would be a high rate of return to yoga after hip arthroscopy. Study Design: Retrospective analysis. Level of Evidence: Level 4. Methods: Consecutive patients with FAIS who had identified themselves as participating in yoga and had undergone hip arthroscopy for the treatment of FAIS between 2012 and 2015 were reviewed. Demographic data were collected and assessed for all patients, as well as preoperative physical examination, imaging, and patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, and visual analog scale (VAS) for pain. Postoperatively, examination and PRO data were collected at a minimum 1 year after surgery, including a yoga-specific questionnaire. Results: A total of 42 patients (90% female; mean age, 35 ± 9 years; mean body mass index, 23.1 ± 3.2 kg/m2) were included. Thirty patients (71%) had to discontinue their yoga routine preoperatively because of hip-related symptoms at a mean 9.5 ± 8.2 months before surgery. After surgery, 39 patients (93%) were able to return to yoga at a mean 5.3 ± 2.2 months after surgery. Two of the 3 patients who did not return to yoga noted loss of interest as their reason for stopping, while 1 patient was unable to return because of persistent hip pain. Nineteen patients (45%) returned to a higher level of yoga practice, 17 patients (40%) returned to the same level, and 3 patients (7%) returned to a lower level. There was no difference in the number of hours spent practicing yoga per week pre- and postoperatively (2.7 ± 1.9 vs 2.5 ± 1.3 hours; P = 0.44). All patients demonstrated significant improvement in all PROs as well as pain scores after surgery (HOS-ADL, 67.4 ± 18.3 to 93.1 ± 6.9 [ P < 0.001]; HOS-SS, 45.6 ± 24.7 to 81.5 ± 18.8 [ P < 0.001]; mHHS, 62.3 ± 11.3 to 86.8 ± 12.3 [ P < 0.0001]; VAS pain, 6.3 ± 2.2 to 0.90 ± 1.1 [ P < 0.001]). Conclusion: Patients participating in yoga return to yoga 93% of the time and at a mean 5.3 ± 2.2 months after hip arthroscopy for FAIS. Clinical Relevance: Information regarding surgical outcomes is critical in counseling patients, particularly female athletes, on their expectations with respect to returning to yoga after hip arthroscopy for FAIS.

Background: The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known. Purpose: To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill. Study Design: Cohort study; Level of evidence, 3. Methods: Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score— Activities of Daily Living subscale (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not. Results: A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) ( P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03). Conclusion: Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.