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The purpose of this study was to perform a cross-sectional analysis of diversity among academic shoulder and elbow surgeons in the United States.US shoulder and elbow surgeons who participated in shoulder and elbow fellowship and/or orthopedic surgery resident education as of November 2018 were included. Demographic data (age, gender, race), practice setting, years in practice, academic rank, and leadership roles were collected through publicly available databases and professional profiles. Descriptive statistics were performed and findings were compared between different racial and gender groups. Statistical significance was set at P.05.A total of 186 orthopedic shoulder and elbow surgeons were identified as participating in shoulder and elbow fellowship and/or orthopedic surgery residency education. Overall, 83.9% were white, 14.5% were Asian, 1.1% were Hispanic, 0.5% were an other race, and 0% were African American. In addition, 94.6% of surgeons were male, whereas 5.4% were female. Further, 64.5% of all surgeons had been in practice for10 years, and 39.2% worked in an urban setting. Less than half (40.3%) of the surgeons practicing primarily at academic institutions held a professor rank. White surgeons had a significantly greater time in practice vs. nonwhite surgeons (mean 18.8 vs. 12.6 years, P.01) and were more likely to hold a professor rank (44.0% vs. 21.7%, P = .04).Racial and gender diversity among US shoulder and elbow surgeons who participate in fellowship and residency education is lacking. Hispanic, African American, and female surgeons are underrepresented. Efforts should be made to identify the reasons for these deficiencies and address them to further advance the field of orthopedic shoulder and elbow surgery.

The purpose of this study was to compare the cross-sectional area (CSA) of joint visualization between extended interportal and T-capsulotomies. Twenty fresh-frozen cadaveric hips were dissected to their capsuloligamentous complexes and fixed in a custom apparatus in neutral hip position. Ten hips underwent sequential interportal capsulotomies at lengths of 2, 4, 6, and 8 cm. Ten hips underwent sequential T-capsulotomies starting from a 4 cm interportal capsulotomy, creating a 2 cm T-capsulotomy (Half-T), and finally a 4 cm T-capsulotomy (Full-T). Following each sequential capsule change in both groups, a high-resolution digital photograph was taken to measure the visualized intra-articular cross-sectional area (CSA). Independent t-test was used to compare CSA interportal and T-capsulotomy groups. Analysis demonstrated a statistically significant increase in CSA visualization with each sequential increase in interportal capsulotomy length up to 6 cm (2cm: 0.6 ± 0.2 cm2; 4cm: 2.1 ± 0.5 cm2 (p

Background: Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement. Purpose: To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID. Results: There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m2), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients ( P = .01) and athletic patients ( P = .003) were more likely to attain the PASS. Conclusion: The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

Patients with bilateral femoroacetabular impingement syndrome treated with either staged or simultaneous hip arthroscopy have similar postoperative outcomes compared with patients undergoing unilateral procedures. A longer duration between surgeries is associated with inferior outcomes; however, the reasons underlying this trend are unclear. Identifying prognostic variables that are associated with contralateral symptom onset and disease progression are important goals for future investigation.

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: Hip arthroscopy in the setting of dysplasia and borderline dysplasia is controversial. Dysplasia severity is most often defined by the lateral center edge angle (LCEA) but can also be evaluated radiographically by the acetabular inclination (AI). Purpose/Hypothesis: The purpose was to determine the effect of AI on outcomes after isolated hip arthroscopy for femoroacetabular impingement (FAI). We hypothesized that patients with dysplasia would have higher rates of arthroplasty as well as inferior clinical and functional outcomes compared with patients who did not have dysplasia. Study Design: Cohort study; Level of evidence, 3. Methods: A hip arthroscopy registry was reviewed for participants undergoing arthroscopic correction of FAI from February 28, 2008, to June 10, 2013. Participants required a clinical diagnosis and isolated arthroscopic correction of FAI with preoperative imaging and intraoperative cartilage status recorded. AI dysplasia was defined as an AI greater than 10°, LCEA dysplasia as LCEA less than 18°, and borderline LCEA dysplasia as LCEA 18° to 25°. Patients without an acetabular deformity (LCEA 25°-40°; AI Results: This study included 419 patients: 9 (2%) with LCEA dysplasia, 42 (10%) with AI dysplasia, and 51 (12%) with borderline dysplasia. The AI but not LCEA was significantly correlated with lower outcome scores on the modified Harris Hip Score ( r = 0.13; P = .01), Non-Arthritic Hip Score ( r = 0.10; P = .04), and Hip Outcome Score–Sports Subscale ( r = 0.11; P = .04). A total of 58 patients (14%) underwent arthroplasty at 31 ± 20 months postoperatively. Patients with LCEA dysplasia had an arthroplasty rate of 56% (odds ratio, 8.4), whereas patients with AI dysplasia had an arthroplasty rate of 31% (odds ratio, 3.3), which was significantly greater than the rate for the nondysplastic cohort (13.5%; P < .0001). Patients with borderline LCEA dysplasia did not have increased rates of arthroplasty. A multivariate analysis found increasing age, increasing AI, Tönnis grade higher than 1, and femoral Outerbridge grade higher than 2 to be most predictive of conversion to arthroplasty. Conclusion: We found that an elevated AI, along with increasing age, Tönnis grade, and femoral Outerbridge grade significantly predict early conversion to arthroplasty after isolated hip arthroscopy. We recommend using the AI, in addition to the LCEA, in evaluating hip dysplasia before hip arthroscopy.

Background: There has been increasing interest in defining clinically meaningful outcomes in patient reported outcomes following orthopaedic surgery. Little is known about the factors associated with clinically meaningful outcomes after hip arthroscopy for femoroacetabular impingement. Study Design: Case-control study; Level of evidence, 3. Purpose: To report on a large, prospectively collected consecutive series of patients who underwent comprehensive arthroscopic treatment of femoroacetabular impingement (FAI) and capsular management with greater than 2-year follow-up. The objectives were to determine (1) what percentage of patients achieve clinically significant outcomes after hip arthroscopic surgery for FAI as determined by the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) and (2) what factors are associated with achieving the MCID and PASS. Methods: Data from an institutional repository of consecutive patients undergoing primary hip arthroscopic surgery with routine capsular closure for FAI that had failed nonsurgical management between January 2012 and January 2014 were prospectively collected and analyzed. Of 474 patients during the enrollment period, 386 (81.4%) patients were available for a minimum 2-year follow-up. Demographics, radiographic measurements, intraoperative characteristics, and patient-reported outcome scores were collected. The primary outcome measure was achieving published thresholds for the MCID and PASS for the Hip Outcome Score (HOS)–Activities of Daily Living (ADL) in patients with FAI. The HOS–Sport-Specific Subscale (SSS), complications, and reoperations were secondary outcome measures. Multivariate regression analyses were conducted to identify factors associated with achieving the MCID and PASS. Results: At a minimum of 2-year follow-up, the patients had statistically significant improvements in all patient-reported outcomes (HOS-ADL, HOS-SSS, and modified Harris Hip Score [mHHS]; P < .001 for all), with a 1.2% rate of revision hip arthroscopic surgery and 1.7% rate of conversion to total hip arthroplasty. The MCID was achieved by 78.8% of patients for the HOS-ADL, and the PASS was achieved by 62.5% for the HOS-ADL. Younger age ( P = .008), Tönnis grade 0 ( P = .022), and lower preoperative HOS-ADL score ( P < .001) were associated with successfully achieving the MCID for the HOS-ADL. Younger age ( P < .001), larger medial joint space width ( P = .028), and higher preoperative HOS-ADL score ( P < .001) were associated with achieving the PASS for the HOS-ADL. Younger age ( P < .001), lower body mass index ( P = .006), non–workers’ compensation status ( P = .020), and lower preoperative HOS-SSS score ( P < .001) were associated with achieving the MCID for the HOS-SSS. Younger age ( P = .001), Tönnis grade 0 ( P = .014), running ( P = .008), and higher preoperative HOS-SSS score ( P < .001) were associated with achieving the PASS for the HOS-SSS. Overall, 49.4% of patients achieved all 4 clinically significant outcomes: both the MCID and PASS for the HOS-ADL and HOS-SSS. Conclusion: The majority of patients undergoing hip arthroscopic surgery with routine capsular closure for FAI experienced clinically significant outcomes that met the MCID or PASS criteria, with low rates of revision and conversion to total hip arthroplasty. Factors associated with these successful outcomes on multivariate analyses included younger age with a normal joint space. Patients with lower preoperative HOS scores were more likely to achieve the MCID, whereas patients with higher preoperative HOS scores were more likely to achieve the PASS.

Background: The literature contains conflicting reports regarding whether outcomes of hip arthroscopic surgery for patients with borderline dysplasia are inferior to outcomes in patients with normal acetabular coverage. Purpose: To assess differences in the outcomes of hip arthroscopic surgery for femoroacetabular impingement (FAI) in groups of patients with borderline dysplasia and normal coverage. Study Design: Cohort study; Level of evidence, 3. Methods: A registry of consecutive patients who had undergone primary hip arthroscopic surgery with capsular plication for FAI between January 2012 and January 2014 were divided based on the preoperative lateral center-edge angle (LCEA) into 2 distinct groups: (1) borderline dysplasia (LCEA 18°-25°) and (2) normal acetabular coverage (LCEA 25.1°-40°). There were 36 patients in the borderline dysplastic group and 312 patients in the normal coverage group. The primary outcome measure was the Hip Outcome Score–Activities of Daily Living (HOS-ADL) at a minimum of 2 years postoperatively. Secondary outcome measures included the HOS-Sports and modified Harris Hip Score (mHHS). Results: The mean preoperative LCEA differed significantly between groups (23.4° ± 1.5° for borderline dysplastic, 32.5° ± 3.8° for normal coverage; P < .001). The borderline dysplastic group had a higher percentage of female patients than the normal coverage group (27/36 [75%] vs 177/312 [57%], respectively; P = .048). There were no differences in other preoperative demographics and radiographic parameters. At a minimum 2 years after hip arthroscopic surgery (mean follow-up, 2.6 ± 0.6 years), both groups demonstrated significant improvements in all patient-reported outcome scores ( P < .001 in all cases). There were no significant differences between the borderline dysplastic and normal coverage groups in final outcome scores, score improvements, or percentage of patients experiencing clinically significant improvements. One patient in the borderline dysplastic group (3%) underwent revision hip arthroscopic surgery, and none underwent total hip arthroplasty during the follow-up period. There were no differences between the borderline dysplastic and normal coverage groups with regard to subsequent surgery. Female patients in the borderline dysplastic group had greater improvements in the mean HOS-ADL (25.9 ± 16.3 vs 10.8 ± 18.5, respectively; P = .05) and mHHS (27.9 ± 12.9 vs 8.1 ± 19.0, respectively; P = .005) compared with male patients in the borderline dysplastic group, but male and female patients did not differ in outcomes for the normal coverage group. Conclusion: Patients who underwent hip arthroscopic surgery for FAI with capsular plication experienced significant clinical improvements with low rates of subsequent surgery, regardless of whether their acetabulum had borderline dysplasia or normal coverage.

Background: Femoroacetabular impingement (FAI) most commonly manifests as anterior groin pain. Patients occasionally have posterior pain but otherwise have clinical and radiographic evidence of FAI. Purpose: To compare outcomes of hip arthroscopy for FAI in patients with atypical posterior pain versus a matched group with the typical anterior pain presentation. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing primary hip arthroscopy for FAI were identified from a clinical repository between January 2012 and 2014. Of 503 patients during the study period, 31 (6.2%) had posterior hip or buttock pain reproduced with flexion, adduction, and internal rotation (FADDIR) and were classified as “atypical,” while those with anterior hip or groin pain were classified as “typical.” Atypical patients were matched in a 1:2 cohort to the typical group based on sex, age, and body mass index (BMI). Postoperative patient-reported outcomes included visual analog scale (VAS) for pain, modified Harris Hip Score (mHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales. Results: Of the 31 atypical patients, 28 (90.3%) were available for a minimum 2-year follow-up (mean ± SD, 2.6 ± 0.6 years). These patients were matched with 56 typical patients. No differences were noted between typical and atypical cohorts in preoperative demographic or radiographic parameters. Postoperatively, both groups demonstrated significant improvements in mHHS (atypical 60.1 ± 12.4 to 78.8 ± 12.9; typical 60.0 ± 12.3 to 76.9 ± 13.6; P < .001), HOS-ADL (atypical 68.5 ± 17.0 to 88.6 ± 11.0; typical 69.2 ± 17.1 to 86.8 ± 14.7; P < .001), and HOS-SS (atypical 42.0 ± 25.5 to 71.0 ± 26.2; typical 44.4 ± 24.9 to 71.3 ± 27.3; P < .001). No differences were found in 2-year score improvements between the atypical and typical cohorts (mHHS 18.7 ± 13.4 vs 16.9 ± 13.1, P = .48; HOS-ADL 20.1 ± 16.8 vs 17.6 ± 14.6, P = .19; HOS-SS 29.0 ± 30.2 vs 26.9 ± 27.3, P = .93). Also, no significant differences were found in VAS pain improvement (5.0 ± 3.2 vs 5.6 ± 2.8, P = .56) or postoperative satisfaction (79.5 ± 5.5 vs 77.5 ± 4.1, P = .78). Conclusion: Atypical posterior hip pain is an uncommon presentation of FAI. Patients demonstrate similar significant improvements after hip arthroscopy in outcome scores, postoperative pain, and satisfaction compared with patients who have classic anterior groin pain.

Purpose The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy. Methods All patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) with routine capsular closure between January 1, 2012, and December 31, 2015, were eligible. Only patients with unilateral surgery and a postoperative magnetic resonance imaging (MRI; ordered for persistent symptoms) were included. Four independent reviewers evaluated each hip capsule for thickness and the absence or presence of defects. Results During the study, 1,463 patients had hip arthroscopy for FAI with routine capsular closure, and 53 (3.6%) underwent a postoperative MRI. Fourteen of the 53 were excluded owing to revision status or additional procedures. The final study population included 39 patients (23 female patients and 16 male patients), with an average patient age of 31.7 ± 11.4 years and an average body mass index of 23.3 ± 2.9. There were 3 (7.5%) capsular defects, and the intraclass correlation coefficient (ICC) was 0.82. The operative hip capsule was significantly thicker in the zone of capsulotomy, and subsequent repair as compared with the unaffected, contralateral hip capsule (5.0 ± 1.2 mm vs 4.6 ± 1.4 mm; P = .02), ICC 0.83. Additionally, males had thicker hip capsules as compared with their female counterparts, on the operative side (5.4 ± 1.1 mm vs 4.5 ± 1.2 mm; P = .02) and the nonoperative side (4.8 ± 1.6 mm vs 4.1 ± 0.9 mm; P = .08). Conclusions In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1 year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect. Level of Evidence Level IV, prognostic case series.

Background: Femoroacetabular impingement (FAI) is most commonly diagnosed in athletes who sustain repetitive flexion loading to their hips. No studies to date have focused solely on patients’ return-to-running ability after hip arthroscopy. Purpose: To evaluate patients’ ability to return to running after hip arthroscopy for FAI and capsular plication. Study Design: Case series; Level of evidence, 4. Methods: Clinical data were retrospectively retrieved for 51 consecutive patients with FAI (22 men, 29 women) who had undergone hip arthroscopy for the treatment of FAI and identified themselves as recreational or competitive runners on intake forms. Two-year outcome measures included the modified Harris Hip Score (mHHS) and the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales. A postoperative return-to-running survey was used to obtain running-specific information. Results: Patient age and body mass index (BMI) were a mean (±SD) of 26.3 ± 7.8 years and 23.7 ± 3.3 kg/m2, respectively. Before surgery, patients had refrained from running because of pain for a mean of 8.1 ± 5.7 months. After surgery, 48 patients (94%) returned to running at a mean of 8.5 ± 4.2 months. Patients who had discontinued running for more than 8 months before surgery had a longer return-to-running time than did those who had stopped for less than 8 months (10.6 ± 4.2 vs 7.6 ± 4.1 months; P = .01). After 2 years, mean preoperative distance had decreased significantly ( P < .01) from 9.5 ± 6.5 miles per week when healthy to 6.4 ± 5.8 miles postoperatively. Despite decreased mileage, all 2-year outcomes scores improved significantly ( P < .001). Conclusion: Recreational and competitive runners with FAI returned to running 94% of the time at a mean of 8.5 months after hip arthroscopy. However, runners should be counseled before their surgery that they may run fewer miles than when they were pain free. Additionally, patients with a higher BMI and/or longer preoperative lull may have a longer recovery time.

Purpose To determine whether the hip arthroscopy literature to date has shown outcomes consistent with published patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) estimates. Methods All clinical investigations of hip arthroscopy using modified Harris Hip Score (mHHS) and/or Hip Outcome Score (HOS) outcomes with at least 1 year of follow-up were reviewed. Ninety-one studies (9,746 hips) were included for review. Eighty-one studies (9,317 hips) contained only primary hip arthroscopies and were the primary focus of this review. The remaining studies (429 hips) did not exclude patients with prior surgical history and were thus considered separately. Mean mHHS, HOS-ADL (Activities of Daily Living) and HOS-SS (Sports-Specific) scores were compared with previously published PASS and MCID values. Results After 31 ± 20 months, 5.8% of study populations required revision arthroscopy and 5.5% total hip arthroplasty. A total of 88%, 25%, and 30% of study populations met PASS for mHHS, HOS-ADL, and HOS-SS, respectively, and 97%, 90%, and 93% met MCID. On bivariate analysis, increasing age was associated with significantly worse postoperative mHHS ( P R 2 = 0.14), HOS-SS ( P = .05, R 2 = 0.12), and rates of reoperation ( P = .02, R 2 = 0.08). Increasing body mass index was associated with significantly worse HOS-ADL ( P = .02, R 2 = 0.35) and HOS-SS ( P = .03, R 2 = 0.30). Conclusions In this meta-analysis of 81 studies of primary hip arthroscopy, we have found that more than 90% of study populations meet MCID standards for the most commonly used patient-reported outcomes measures in hip arthroscopy literature, mHHS and HOS. Eighty-eight percent meet PASS standards for the mHHS, but PASS standards are far more difficult to achieve for HOS-ADL (25%) and HOS-SS (30%) subscales. Differences in psychometric properties of the mHHS and HOS likely account for the discrepancies in PASS. Level of Evidence Level IV, systematic review of Level I to IV studies.

Hip arthroscopy has experienced unprecedented growth in recent years and remains an area of booming technology and interest in orthopedic surgery. As understanding of the pathologic state of femoroacetabular impingement (FAI) has grown, imaging modalities have increased. Careful consideration of all bony and soft tissue structures in concert with physical examination findings in nonarthritic patients is necessary before any surgical intervention. This article summarizes the authors' approach to imaging in patients suspected of FAI, which facilitates careful patient selection and preoperative planning.

In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.

Abductor tendon tears typically develop insidiously in middle-aged women and can lead to debilitating lateral hip pain and a Trendelenburg limp. The gluteus medius tendon is most commonly torn and may show fatty degeneration over time, similar to the rotator cuff muscles of the shoulder. Endoscopic repair offers a therapeutic alternative to traditional open techniques. This article describes the workup, examination, and endoscopic repair of a full-thickness gluteus medius tear presenting as lateral hip pain and weakness. The surgical repair for this case used a single-row suture anchor technique. In addition, the indications and technique for a double-row repair will be discussed.

Antegrade reamed intramedullary nailing has the advantages of high fracture union and early weight-bearing, making it the gold standard for fixation of diaphyseal femur fractures. However, knowledge of distal femoral anatomy may mitigate the risk of secondary complications. We present a previously unrecognized complication of antegrade femoral nailing in which a 23-year-old man sustained iatrogenic rupture of the medial patellofemoral ligament (MPFL) caused by the distal interlocking screw of the femoral nail. The patient had a history of antegrade intramedullary nailing that was revised for rotational malalignment, after which he began experiencing recurrent episodes of atraumatic bloody joint effusion and swelling of the right knee with associated patellar instability. Plain radiographs and magnetic resonance imaging revealed a large effusion with a prominent intra-articular distal interlocking screw disrupting the MPFL. The patient underwent a right knee arthroscopic-assisted MPFL reconstruction and removal of the distal interlocking screw. Following surgery, the patient experienced resolution of his effusions, no recurrent patellar instability, and was able to return to his activities. This case demonstrates that iatrogenic MPFL injury is a potential complication of antegrade femoral nailing and a previously unrecognized cause of patellar instability. Surgeons should be aware of this potential complication and strive to avoid the MPFL origin when placing their distal interlocking screw.

Background: Femoroacetabular impingement (FAI) is responsible for hip pain and dysfunction, and surgical outcomes depend on multiple factors. The presence of mental disorders negatively influences outcomes of multiple orthopaedic conditions, although the impact on FAI surgery is unclear. Hypothesis: The authors hypothesized that a preoperative self-reported history of mental disorders would negatively influence patient-reported outcome measures after FAI surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A matched-cohort study was performed by reviewing a prospectively collected database of cases of arthroscopic management of FAI with a single surgeon over a 2-year period. Demographics and radiographic parameters were recorded for all patients. Patients completed the Hip Outcome Score–Activity of Daily Living Subscale (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS) prior to surgery and 2 years after surgery. Unpaired and paired t tests were used to compare results between and within cohorts at baseline and follow-up. Statistical significance was defined as P < .05. Results: The cohort included 301 patients, with 75 and 226 patients reporting and not reporting a history of mental disorders, respectively. Before treatment, all patient-reported outcome measures were significantly lower among patients reporting a history of mental disorders ( P < .01 for HOS-ADL, HOS-SSS, and mHHS). Patients in both groups demonstrated significant improvements ( P < .0001) in HOS-ADL, HOS-SSS, and mHHS when preoperative outcome measures were compared with follow-up. Patients with reported mental disorders had significantly lower scores after surgery as compared with patients without mental disorders ( P < .0001 for HOS-ADL, HOS-SSS, and mHHS). Conclusion: The presence of a reported mental disorder is associated with lower patient-reported outcomes before and after surgical management of FAI. Statistically significant and clinically relevant improvements were observed for patients who reported mental disorders. The magnitude of these improvements was not as large as that for an age- and sex-matched control group without a self-reported mental disorder.

The objective of this study was to determine if adolescent and young adult patients undergoing hip arthroscopy for symptomatic femoroacetabular impingement (FAI) experience clinically meaningful improvements in functional outcome scores. A consecutive series of patients under age 18 who underwent primary hip arthroscopy for symptomatic FAI was identified using our institution’s hip registry. Demographics, preoperative radiographic measurements, and preoperative and postoperative patient-reported outcome scores [Hip Outcome Score (HOS), Activity of Daily Living (ADL), and Sports-Specific Subscale (SS), and modified Harris Hip Score (MHHS)] were collected. Percentage of patients achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) were determined using published cutoffs for HOS and MHHS in FAI patients. Forty-three patients met study inclusion criteria, and 37 patients (86%) were available at a minimum follow-up of 2 years. Mean age was 17.0±1.4 years, 70% were female, and 8.1% had an open proximal femoral physis. All competitive high school and college athletes were able to return to sport. Patients experienced significant improvements following hip arthroscopy in HOS-ADL, HOS-SS, and MHHS scores (all P

To quantify how increasing interportal capsulotomy size affects the force required to distract the hip and to biomechanically compare simple side-to-side suture repair to acetabular-based suture anchors as capsular repair techniques.Twelve fresh-frozen cadaveric hip specimens were dissected to the capsuloligamentous complex of the hip joint and fixed in a material testing system, such that a pure axial distraction of the iliofemoral ligament could be achieved. After each hip in was tested an intact state, sequential distraction was tested with 2, 4, 6, and 8 cm capsulotomies. Specimens were assigned randomly to be repaired with either 4 side-to-side suture repair (n = 6) or 2 double-loaded all-suture anchors (n = 6). The distraction force as well as the relative distraction force percentage normalized to the intact capsule were compared between suture repair and suture anchor repair groups.Increasing the size of the capsulotomy resulted in less force required to distract the hip to 6 mm. The force decreased as the capsulotomy was extended with statistical significance in distraction force seen between the intact state and the 4 cm (P = .003), 6 cm (P.001), and 8 cm (P ≤ .001) capsulotomy but not for the intact state compared to the 2 cm capsulotomy (P = .28). Statistical significance in relative distraction force was seen for each of the capsulotomy conditions (P.001 for all conditions compared with the intact state). The side-to-side suture repair construct (104.3% of intact force) required greater force to distraction to 6 mm compared with the suture anchor repair (87.1% of intact force) (P = .008).An interportal capsulotomy significantly affected the force required to distract the hip in a cadaveric model, with the larger the size of capsulotomy resulting in less force required to distract the hip. When we performed an interportal capsulotomy, the iliofemoral ligament strength was altered significantly but capsular repair with either side-to-side sutures or suture anchor-based repair was able to restore the capsular strength to a native intact hip. We found, however, that the side-to-side suture repair was better able to restore the distraction force compared with suture anchor repair.Capsular management during hip arthroscopy remains a debated topic, with multiple techniques involving both capsulotomy and capsular closure published in the literature. This study provides insight into capsular stability against axial stress under capsulotomy and capsular repair conditions.

To compare the return-to-play rates, patient-reported outcome (PRO) scores, and satisfaction between high-level amateur athletes and recreational athletes and to evaluate for differences in ability to return to sport in these groups based on patient-related and sport-related characteristics.Clinical data were retrieved for 66 (26 male/40 female) consecutive athletes undergoing hip arthroscopy for femoroacetabular impingement. Athletes were classified as high-level amateur or recreational. Athletes were also divided into 6 distinct sporting categories based on the physical demands on the hip. Preoperative and 2-year PROs including a sport-specific questionnaire, modified Harris Hip Score (MHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales were collected.Of the 66 patients, 49 were recreational and 17 were high-level amateur athletes (10 high school and 7 collegiate). High-level athletes were significantly younger than recreational athletes (18.4 ± 2.3 years vs 29.7 ± 6.8 years; P.001). After 2 years, all PROs had improved significantly, with no differences between the 2 athletic groups. There was a high overall rate of return for both recreational and high-level amateur athletes (94% vs 88%; P = .60). Increasing preoperative withdrawal time from sport prior to surgery was associated with decreased HOS-SS (r = 0.33; P = .04) and MHHS scores (r = 0.02; P = .02). Overall, athletes who had withdrawn from sport for greater than 8 months before surgery returned to sport significantly more slowly (P = .01). Increasing body mass index (BMI) was associated with lower improvements in HOS (r = 0.26; P = .04) and MHHS scores (r = 0.38; P.01).Recreational athletes, despite being significantly older than their high-level counterparts, return to play at a similar high rate and with comparable PROs. Increasing preoperative cessation time from sport significantly prolongs return to sport. Additionally, increasing preoperative cessation from sport and higher preoperative BMI were associated with decreased improvements in PROs.Level III, retrospective comparative study.

Hip arthroscopy has become an increasingly utilized surgical technique for the treatment of the young, active patients with hip pain. The clinical outcomes of hip arthroscopy in this patient population have been largely successful; however, there is increasing interest in the contribution of hip capsule in postoperative clinical and functional outcomes. The structure and function of the normal hip capsule will be reviewed. Capsular contributions to hip stability will be discussed in the setting of hip arthroscopy with an emphasis on diagnosis-based considerations. Lastly, clinical outcomes following hip arthroscopy will be discussed as they relate to capsular management.