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To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques.A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury.Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P.001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively.The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries.IV, systematic review of Level I-IV evidence.

To compare early outcomes of periacetabular osteotomy (PAO) with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement (FAI) and chondrolabral pathology using patient-reported outcomes measurement information system (PROMIS). Consecutive patients scheduled for PAO with concomitant hip arthroscopy (PAO + HA) or isolated hip arthroscopy (HA) between the ages of 15 and 30 years old were prospectively included in the study. Based on power analysis, subjects were recruited until there were 22 subjects in the PAO + HA group. These subjects were then gender matched to the HA group. The PROMIS, with six subscales and two global health measures, were completed during preoperative and 6-month follow-up visits. One-way ANOVA was performed to compare intake information of age, symptom duration, body mass index, and Beighton scores as well as preoperative and 6-month postoperative PROMIS scores between the PAO + HA and HA. 22 consecutive subjects undergoing PAO + HA were all females (average age 20.0 years) and matched to 22 consecutive females (average age 22.6) in the HA group. ANOVA did not find a significant difference between the two groups when comparing intact information, with exception of age (p = 0.04). A significant difference was also not identified (p ≥ 0.05) between the two groups on preoperative or 6-month postoperative PROMIS scores. The largest difference in 6-month postoperative scores between the two groups was 4.4 points on physical function subscale. Outcomes at 6 months were not significantly different when comparing PAO + HA to HA for FAI and chondrolabral pathology in females under 30 years of age. The more extensive surgery with a prolonged protective period associated with PAO do not seem to negatively impact outcomes at 6 months when compared to HA. These finding support the use of PAO + HA, particularly if the patient and/or surgeon were concerned about prolonged disability, metal health issues, and/or higher pain levels that might be associated with the PAO procedure.

Hip-related pain describes femoroacetabular impingement syndrome, acetabular dysplasia, and other hip pain conditions without clear morphological features. Movement strategies in this population, notably sex-related patterns, are poorly understood and may provide insights into why females report more pain and worse function. This study examined the sex-related differences during a drop vertical jump task between those with hip-related pain and healthy controls.Patients with hip-related pain and healthy controls completed five repetitions of a drop jump while their kinematics and kinetics were recorded using a motion capture system and force plates. Hip, knee, and ankle joint angles and external joint moments during landing were used in general estimating equations for comparison of group by sex by limb interactions. Time series data were further investigated using statistical parametric mapping.Females with hip-related pain had 9.1° less hip flexion (P = .041) and 9.2° less knee flexion (P = .024) than healthy females, and 8.3° less knee flexion than male counterparts with hip-related pain (P = .039). Males demonstrated 1.4° less hip flexion on the affected side compared to their uninvolved side (P = .004). Statistical parametric mapping results showed significant differences in knee flexion angle for females with hip-related pain compared to healthy females (P = .042). There were no significant differences in hip, knee, or ankle moments.Females with hip-related pain showed kinematic patterns distinct from healthy controls. Sex may be an important variable of interest in characterizing movement impairments in this population and movement impairments may be an appropriate target for intervention for these patients.

The purpose of this narrative review is to identify the anatomy and relevant blood supply to the femoral head as it pertains to hip arthroscopy and lateral cam morphology. The primary blood supply to the femoral head is the lateral ascending superior retinacular vessels, which are terminal branches of the medial femoral circumflex artery. These vessels penetrate the femoral head at the posterolateral head–neck junction. Surgeons performing posterolateral femoral osteoplasty must respect this vasculature to avoid iatrogenic avascular necrosis (AVN). Avoidance of excessive traction, avoidance of distal posterolateral capsulotomy and avoidance of disruption of the superior retinacular vessels should keep the risk for AVN low. Hip extension, internal rotation and distraction are useful in hip arthroscopy to better visualize lateral/posterolateral cam morphology to facilitate an accurate comprehensive cam correction and avoid vascular disruption.

Purpose To define unique substantial clinical benefit (SCB) values for improvement on the 12-item International Hip Outcome Tool (iHOT-12) based on a preoperative self-rating of function in patients undergoing hip arthroscopy for intra-articular pathology. Methods This was a retrospective review of prospective collected data on patients having hip arthroscopy for labral and chondral pathology and femoroacetabular impingement. On preoperative assessment and 1-year (+/–1 month) follow-up, subjects completed the iHOT-12 and a self-categorical rating of function (“severely abnormal,” “abnormal,” “nearly normal,” or “normal”). Separate receiver operator characteristic analyses were performed for each preoperative categorical self-rating of function to determine unique SCB values for improvement-based changes in self-rating of function. Results Of 1034 eligible patients, 733 (71%) subjects met the inclusion criteria. Subjects consisted of 537 (73%) female and 196 (27%) male subjects with a mean age of 35.3 years (standard deviation 13). At a mean of 352 (standard deviation 21) days postsurgery, changes in iHOT-12 scores of 22, 28, and 27 points were associated with acceptable accuracy in identifying those who had an improved function rating when reporting a “severely abnormal,” abnormal,” and “nearly normal” rating on preoperative assessment, respectively. The accuracy of these SCB values in predicting improvement was different depending on the patient’s preoperative rating of function. The accuracy of the SCB values in predicting improvement in those who had a “nearly normal” rating of function was not as accurate (area under the curve = 0.73) compared with those who had a “severely abnormal” or “abnormal” rating of function on preoperative assessment (area under the curve = 0.89; 0.89). Conclusions This study provides surgeons with unique SCB values for the iHOT-12 based on a preoperative rating function and may allow for a more precise interpretation of score changes. SCB values of 22, 28, and 27 points on the iHOT-12 at 1-year (+/–1 month) follow-up identified those who had an improved function rating, when reporting a “severely abnormal,” abnormal,” and “nearly normal” rating on preoperative assessment, respectively. Level of Evidence III, retrospective comparative study

To report comparative hip arthroscopic outcomes of patients with low (borderline dysplasia), normal, and high (global pincer femoroacetabular impingement [FAI]) lateral acetabular coverage.A retrospective analysis of prospectively collected data from a multicenter registry was performed. Primary hip arthroscopy patients were assigned to 1 of 3 groups based on preoperative lateral center-edge angle: borderline dysplasia (≤25°), normal (25.1°-38.9°), and pincer (≥39°). Repeated-measures analysis of variance compared preoperative with 2-year minimum postoperative International Hip Outcome Tool (iHOT-12) scores. Subsequent analysis of variance determined the effect of acetabular coverage on magnitude of change in scores.Of 437 patients, the only statistical difference between groups was a lower prevalence of acetabuloplasty in the borderline dysplasia group (P = .001). A significant improvement in the preoperative to postoperative iHOT-12 scores for patients with normal acetabular coverage, acetabular undercoverage, and acetabular overcoverage was observed: F(1, 339) = 311.06; P.001, with no statistical differences in preoperative (P = .505) and postoperative (P.488) iHOT-12 scores when comparing the groups based on acetabular coverage. Mean iHOT-12 scores increased from 37.3 preoperatively to 68.7 postoperatively (P.001) in the borderline dysplasia group, from 34.4 to 72 (P.001) in the normal coverage group, and from 35.3 to 69.4 (P.001) in the pincer group. These preoperative scores increased by 31.4, 37.8, and 34.1, respectively, with no effect for acetabular coverage on the magnitude of change from preoperative to postoperative iHOT-12 scores: F(2,339) = 1.18; P = .310. Ten patients (2.3%) underwent conversion arthroplasty, and 19 patients (4.4%) underwent revision arthroscopy with no significant effect of acetabular coverage on the incidence of revision or conversion surgery: χLateral acetabular coverage did not influence outcomes from primary hip arthroscopy when performed in patients with low (borderline dysplasia), normal, and high (global pincer FAI) lateral center-edge angle. Borderline dysplasia and moderate global pincer FAI with no or minimal osteoarthritis do not compromise successful 2-year minimum outcomes or survivorship following primary hip arthroscopy when performed by experienced surgeons.Level III, retrospective therapeutic trial.

Context: Six months is the expected time frame to return to sport (RTS) after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Objective: The primary aims of this study were to (1) report the RTS rate of physically active individuals 6 months after arthroscopic surgery for FAIS and (2) compare the self-reported hip function between those who were able to RTS against those who had not. Design: Cohort study. Setting: The Ohio State University Wexner Medical Center. Patients: A total of 42 physically active individuals scheduled for hip arthroscopy for FAIS. Main Outcome Measures: Self-reported function, including preinjury and current activity levels and ability to participate in sport, were collected on 42 individuals with FAIS prior to surgery and at 6-month follow-up. Participants were allocated into 2 groups based on self-reported RTS status at 6-month follow-up. Separate 2-way analyses of variance were used to test the interaction of groups (those who did/did not RTS). Main effects were reported in the absence of statistically significant interactions (P ≤ .05). Results: Altogether, 28 of 42 participants (66%) returned for 6-month follow-up; 5 of the 14 participants (35.7%) lost to follow-up underwent contralateral hip surgery within the study time frame. At the 6-month follow-up, 16 of the remaining 28 participants (57.1%) reported that they had returned to sport, 5 of whom returned at their prior level of participation. There was no statistically significant interaction of group and time for either hip outcome score subscale (P ≥ .20). Self-reported hip function improved over time, regardless of group (P ≤ .001). Participants in the yRTS group demonstrated higher hip outcome score-sport scores than did the nRTS group, regardless of time (P = .04). Conclusions: Though just over half of participants returned to sport 6 months after hip arthroscopy for FAIS, only 18% returned to their previous level of sports participation. Participants who returned to sport reported better function than those who did not, but self-reported hip function improved over time regardless of group. The most commonly reported reasons for not returning to sport were weakness (69.6%), fear (65.2%), and pain (56.5%).

Purpose To define minimal clinically important difference (MCID) and substantial clinical benefit (SCB) values for the 12-item International Hip Outcome Tool (iHOT-12) in patients undergoing hip arthroscopy for intra-articular pathology. Methods This was a retrospective review of prospectively collected data on patients who underwent hip arthroscopy. On initial assessment and follow-up between 335 and 395 days after surgery, subjects completed the iHOT-12 and a categorical self-rating of function (severely abnormal, abnormal, nearly normal, or normal). One-half the standard deviation (SD) of the change in 1-year iHOT-12 scores was used to calculate the MCID. Receiver operator characteristic analysis was performed to determine SCB values. A change in SCB value was determined based on an improvement in the categorical rating of function. Absolute postoperative SCB scores were calculated to determine scores that would be associated with normal function ratings or with abnormal or severely abnormal function ratings. Results Of 1,034 eligible patients, 733 (71%) met the inclusion criteria. The subjects consisted of 537 female patients (73%) and 196 male patients (27%), with a mean age of 35.3 years (SD, 13 years). At a mean of 352 days (SD, 21 days) after surgery, 536 patients (73%) were in the “improved” group and 197 (27%) were in the “not improved” group. The MCID was 13 points. An SCB change score of 28 points was able to identify patients who improved with high sensitivity (0.79) and specificity (0.72). Scores of 86 points or greater and 56 points or less were the cutoff values found to identify subjects who rated their function as normal and abnormal, respectively, with high sensitivity (0.74 and 0.90, respectively) and specificity (0.82 and 0.86, respectively). Conclusions This study provides information to help interpret iHOT-12 scores for a follow-up period ranging between 335 and 395 days with MCID and SCB values of 13 and 28 points, respectively. In addition, a vpatient who scored 86 points or better was likely to have a normal rating of function, whereas a patient with a score of 56 points or less was likely to have an abnormal rating of function. Level of Evidence Level III, retrospective comparative study.

Purpose To determine the efficacy of mandatory preoperative nicotine cessation on postoperative nicotine use, and to identify independent predictors of nicotine use relapse in subjects undergoing hip preservation surgery or total hip arthroplasty by a single fellowship-trained orthopedic surgeon. Methods Consecutive subjects that underwent hip surgery from November 2014 to December 2017 were reviewed. Subjects who self-reported nicotine use, quit prior to surgery, and completed a minimum one-year follow-up were included. Multiple linear regression models were constructed to determine the effect of independent variables on nicotine use relapse following surgery. Results Sixty subjects were included in the study (mean follow-up 35.1 months (17-57 months), mean age 44.9 years (20-82 years), and 23 (38.3%) males). Twenty-eight subjects (46.7%) remained nicotine-free at final follow-up. The mean number of cigarettes per day decreased from 13.4 preoperatively to 8.4 postoperatively in the subjects who relapsed (P=0.002). The mean time to return to nicotine postoperatively was 2.4 months. The number of preoperative cigarettes per day was the only independent predictor of tobacco use relapse (P=0.005). Conclusion Mandatory preoperative nicotine cessation prior to elective hip surgery demonstrates a 46.7% nicotine-free survivorship at final follow-up with the number of preoperative cigarettes per day found to be the only independent predictor of nicotine use relapse. Level of evidence The level of evidence of this research study is Level III since it is a non-experimental study with a cohort of patients.

Background: While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue. Purpose/Hypothesis: To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o’clock denoted the anterior extent of the tear and 9 o’clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of “hours” spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers. Results: A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o’clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size ( P < .001 for all), using 1 to 1.6 anchors for 1-hour tears, 1.7 to 2.4 anchors for 2-hour tears, 2.1 to 3.2 anchors for 3-hour tears, and 2.2 to 4.1 for 4-hour tears. Conclusion: Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc >2 hours, at least 2 anchor points were fixated.

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.

(1) To determine the prevalence of depression in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome and (2) to determine whether depression has a statistically significant and clinically relevant effect on preoperative and postoperative patient-reported outcome scores.Consecutive subjects undergoing hip arthroscopy for FAI syndrome were retrospectively reviewed. The Beck Depression Inventory-II (BDI-II), Hip Outcome Score (HOS), and 33-item International Hip Outcome Tool (iHOT-33) were administered preoperatively and postoperatively. Clinically relevant differences were defined by the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state. Comparisons between preoperative and postoperative scores were completed. The Spearman correlation coefficient (r) was used to determine the degree of correlation between the BDI-II score, HOS, and iHOT-33 score preoperatively and postoperatively.We analyzed 77 patients (72.7% female patients; mean age, 35.2 ± 12.5 years). Depressive symptoms were reported as minimal (75.3%), mild (11.7%), moderate (6.5%), or severe (6.5%). Patients with minimal or mild depression had a superior HOS Activities of Daily Living (Δ17.3 preoperatively [P.001] and Δ37.8 postoperatively [P.001]), HOS Sport-Specific Subscore (Δ12.8 preoperatively [P = .002] and Δ52.1 postoperatively [P.0001]), and iHOT-33 score (Δ15.4 preoperatively [P.0001] and Δ51.3 postoperatively [P.0001]) compared with patients with moderate or severe depression. There was a weak to moderate negative correlation between the BDI-II score and iHOT-33 score (r = -0.4614, P.0001 preoperatively; r = -0.327, P.0001 at 1 year), HOS Activities of Daily Living (r = -0.531, P.0001 preoperatively), and HOS Sport-Specific Subscore (r = -0.379, P.0017 at 1 year).Most patients undergoing hip arthroscopy for FAI have minimal depressive symptoms with the overall prevalence higher than the general population. Patients with minimal or mild depressive symptoms have statistically and clinically better preoperative and postoperative patient-reported outcomes, are more likely to obtain substantial clinical benefit from surgery, and are more likely to reach a patient acceptable symptom state after surgery than patients with moderate to severe depressive symptoms.Level III, case-control study.

Importance Yoga is a very popular sporting activity across the world. There is limited information on the epidemiology and characteristics of yoga-related injuries. Objective To determine the incidence and prevalence of musculoskeletal injuries sustained in yoga. Evidence review A systematic review was registered with PROSPERO and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Level I–IV evidence studies reporting the incidence and prevalence of musculoskeletal injuries in male and female yoga practitioners were eligible for inclusion. The number and types of injuries were extracted from each study. Duplicate patient populations within separate distinct publications were analysed and reported only once. Injury rates were recorded and calculated on the basis of gender and nature of injury. Incidence was defined as the number of injuries sustained over a specific time duration. Prevalence was defined as the proportion of subjects with an injury at a given point in time. Findings Five studies were analysed that reported injury incidence or prevalence in yoga (7453 subjects). In four of these studies, the type of yoga was not specified, but Mikkonen et al focused solely on Ashtanga Vinyasa practitioners. There were 6544 female (88%) and 909 male (12%) yoga practitioners analysed (49.1±13.6 years of age). The incidence of injury among yoga practitioners was 1.18 injuries per 1000 yoga hours. Only four studies provided prevalence data, displaying 6.6% injury prevalence in 7415 yoga practitioners overall (up to 62% in Ashtanga Vinyasa). Overall, lower extremity injuries comprised 64% of total injuries; specifically the hip, hamstring, knee, ankle, feet and toe. The upper extremity and head and trunk injuries account for 13% and 23%, respectively. Conclusions and relevance There is limited quantity heterogeneous evidence reporting the characteristics of yoga injuries. The overall injury incidence is 1.18 injuries per 1000 yoga hours. The prevalence of injury is poorly characterised. However, the weighted mean prevalence is 7%. The majority of yoga injuries are lower extremity injuries. Level of evidence Level IV, a systematic review of level I–IV studies.

To report observational findings of patients with acetabular dysplasia undergoing hip arthroscopy.We performed a comparative case series of multicenter registry patients from January 2014 to April 2016 meeting the inclusion criteria of isolated hip arthroscopy, a documented lateral center-edge angle (LCEA), and completion of preoperative patient-reported outcome measures. A retrospective analysis compared range of motion, intra-articular pathology, and procedures of patients with dysplasia (LCEA ≤25°) and patients without dysplasia (LCEA25°).Of 1,053 patients meeting the inclusion criteria, 133 (13%) had dysplasia with a mean LCEA of 22.8° (standard deviation, 2.4°) versus 34.6° (standard deviation, 6.3°) for non-dysplasia patients. There were no statistically significant differences in preoperative modified Harris Hip Score, International Hip Outcome Tool-12 score, or visual analog scale score (pain). Cam deformity occurred in 80% of dysplasia patients. There was a significant difference in internal rotation between the dysplasia (21°) and non-dysplasia groups (16°, P.001). Mean internal rotation (33.5°; standard deviation, 15.6°) of the dysplastic subjects without cam morphology was greater than that of the dysplastic patients with cam morphology (18.5°; standard deviation, 11.6°; P.001). Hypertrophic labra were found more commonly in dysplastic (33%) than non-dysplastic hips (11%, P.001). Labral tears in patients with dysplasia were treated by repair (76%), reconstruction (13%), and selective debridement (11%); labral treatments were not significantly different between cohorts. The most common nonlabral procedures included femoroplasty (76%) and synovectomy (73%). There was no significant difference between the dysplasia and non-dysplasia groups regarding capsulotomy types and capsular closure rates (96% and 92%, respectively).Dysplasia, typically of borderline to mild severity, comprises a significant incidence of surgical cases (13%) by surgeons performing high-volume hip arthroscopy. Despite having similar preoperative pain and functional profiles to patients without dysplasia, dysplasia patients may have increased flexed-hip internal rotation. Commonly associated cam morphology significantly decreases internal rotation. Arthroscopic labral repair, femoroplasty, and closure of interportal capsulotomy are the most commonly performed procedures.Level III, therapeutic comparative case series.

Iatrogenic pudendal nerve and groin complications have been reported to occur at rates up to 4.3%. While many of these complications are transient, the hip preservation community is in search of a safe postless distraction technique. Currently available postless distraction tables are expensive, require the surgeon to adopt a different technique, and have a high disposable fee. We present our technique for postless distraction using a standard table and a pink pad positioning device. Using our technique, we have demonstrated safe and cost-effective post-free distraction.

Background: Hip arthroscopy is a rapidly growing surgical approach to treat femoroacetabular impingement (FAI) syndrome with a significant learning curve pertaining to complication risk, reoperation rate, and total hip arthroplasty conversion. Hip arthroscopy is more frequently being taught in residency and fellowship training. The key, or critical, parts of the technique have not yet been defined. Purpose: To identify the key components required to perform arthroscopic treatment of FAI syndrome. Study Design: Consensus statement. Methods: A 3-question survey comprising questions on hip arthroscopy for FAI was sent to a convenience sample of 101 high-volume arthroscopic hip surgeons in the United States. Surgeon career length (years) and maintenance volume (cases per year) were queried. Hip arthroscopy was divided into 10 steps using a Delphi technique to achieve a convergence of expert opinion. A step was considered “key” if it could (1) avoid complications, (2) reduce risk of revision arthroscopy, (3) reduce risk of total hip arthroplasty conversion, or (4) optimize patient-reported outcomes. Based on previous literature, steps with >90% of participants were defined as key. Descriptive and correlation statistics were calculated. Results: A total of 64 surgeons (63% response rate) reported 5.6 ± 2.1 steps as key (median, 6; range, 1-9). Most surgeons (56.3%) had been performing hip arthroscopy for >5 years. Most surgeons (71.9%) had performed >100 hip arthroscopy procedures per year. Labral treatment (97% agreement) and cam correction (91% agreement) were the 2 key steps of hip arthroscopy for FAI. Pincer/subspine correction (86% agreement), dynamic examination before capsular closure (63% agreement), and capsular management/closure (63% agreement) were selected by a majority of respondents but did not meet the study definition of key. There was no significant correlation between surgeon experience and designation of certain steps as key. Conclusion: Based on a Delphi technique and expert opinion survey of high-volume surgeons, labral treatment and cam correction are the 2 key parts of hip arthroscopy for FAI syndrome.

Objectives: Outcomes from hip arthroscopy for dysplasia and global pincer FAI have fallen short of those for patients with normal acetabular coverage, but no study has investigated arthroscopic outcomes across the spectrum of acetabular coverage. Our objective is to report comparative hip arthroscopic outcomes of patients with low (borderline dysplasia), normal, and high (global pincer FAI) lateral acetabular coverage. Methods: A retrospective analysis of prospectively-collected data from a large multi-center registry (seven United States centers) was performed. Primary hip arthroscopy patients were assigned to one of three groups based on preoperative lateral center-edge angle (LCEA): borderline dysplasia (≤25°), normal (26-38°), and pincer FAI (≥39°). Repeated measures ANOVA compared pre-operative to 2-year minimum post-operative iHOT-12 scores. Subsequent ANOVA determined the effect of acetabular coverage on magnitude of change in scores. Results: Of 437 patients, the only statistical difference between groups was lower prevalence of acetabuloplasty in the borderline dysplasia group (p=0.001). A significant improvement in the pre-operative to post-operative iHOT-12 scores for patients with normal acetabular coverage, acetabular undercoverage, and acetabular overcoverage was observed; F(1, 339)=311.06; pConclusion: Lateral acetabular coverage did not influence outcomes from primary hip arthroscopy performed in patients with low (borderline dysplasia), normal, and high (global pincer FAI) LCEA. Borderline dysplasia and moderate global pincer FAI with no or minimal osteoarthritis do not compromise successful 2-year minimum outcomes or survivorship following primary hip arthroscopy when performed by experienced surgeons.

Purpose To define minimal clinically important difference (MCID) and substantial clinical benefit (SCB) values for a pain visual analog scale (VAS) in patients undergoing hip arthroscopy for femoroacetabular impingement or chondrolabral pathology. Methods This was a retrospective review of prospective collected data on patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and follow-up between 335 and 395 days postsurgery, subjects completed a pain VAS and categorical self-rating of function. MCID was calculated using one-half the standard deviation (SD) of the change in 1-year pain VAS values. Receiver operator characteristic analysis was performed to determine SCB values. A change in SCB value was determined based on change in categorical self-rating of function to create “improved” and “not improved” groups. Absolute postoperative SCB scores were calculated to determine scores that would be associated with “normal” or “abnormal” function ratings. Results Of 1,034 eligible patients, 733 (71%) met the inclusion criteria, with 537 (73%) women and 196 (27%) men having a mean age of 35.3 years (SD 13). At a mean of 352 (SD 21) days postsurgery, 536 (73%) were in the improved group and 197 (27%) in the not improved group. MCID was –15.0 mm. A change of –22.7 mm on the pain VAS was able to identify those that improved with high sensitivity (0.74) and specificity (0.63). Values of ≤10.4 mm and ≥29.0 mm were cutoffs identifying subjects that rated their function as normal or abnormal, respectively, with high sensitivity (0.79 and 0.76) and specificity (0.88 and 0.76). Conclusions This study provides surgeons with information to help interpret pain VAS values at a follow-up period ranging from 335 to 395 days with MCID and SCB values of –15.0 mm and –22.7 mm, respectively. Additionally, a patient who assesses a pain level at ≤10.4 mm is likely to have a normal rating of function, whereas a patient who assesses a pain level at ≥29.0 mm is likely to have an abnormal rating of function. Level of Evidence III, retrospective comparative study.

Purpose To determine the patient acceptable symptomatic state (PASS) cutoff score for the 12-item International Hip Outcome Tool (iHOT-12) for patients after hip-preservation surgery. Methods A multicenter hip arthroscopy registry containing deidentified patient data was analyzed to discriminate patients who achieved satisfactory results from patients who did not. Patients eligible for inclusion in the study were between 18 and 75 years of age, consented to undergo elective hip arthroscopy, and completed preoperative patient-reported outcome questionnaires. A receiver operating characteristic analysis was performed to determine the PASS cutoff score for the iHOT-12 at 1 year after surgery based on the sensitivity and specificity of achieving satisfaction with surgery. A visual analog scale rating patient satisfaction 1 year after surgery was documented and compared between subjects who achieved the PASS score for the iHOT-12 and those who did not achieve it through an independent t test with an a priori α set at .05. Results A total of 647 subjects (66% women) aged between 18 and 73 years (mean, 36.5 years; standard deviation [SD], 12.0 years) were included in the study. A cutoff score of 75.2 for the iHOT-12 yielded a sensitivity of 0.91 and specificity of 0.81. Satisfaction averaged 89.5% (SD, 18.0%) for the patients with iHOT-12 scores greater than the PASS cutoff score versus 60.9% (SD, 30.61%) for those who did not achieve the PASS iHOT-12 score. Conclusions The PASS cutoff score of 75.2 for the iHOT-12 establishes a “minimal” target score at which the patient is highly likely to be satisfied with the physical state of his or her hip joint at 1 year after hip arthroscopy. Level of Evidence Level III, case-control study.

To compare preoperative, radiographic, and intraoperative findings between male and female patients undergoing hip arthroscopy.We performed a retrospective review of a multicenter registry of patients undergoing hip arthroscopy between January 2014 and January 2017. Perioperative data from patients who consented to undergo surgery and completed preoperative patient-reported outcome questionnaires were analyzed to determine the effect of sex on preoperative symptoms, patient-reported outcomes, radiographic measures, and surgical procedures.A total of 1,437 patients (902 female and 535 male patients) with a mean age of 34 years were enrolled in the study. Female patients reported greater pain preoperatively on a visual analog scale (55.42 vs 50.40, P = .001) and deficits in functional abilities as per the modified Harris Hip Score (53.40 vs 57.83, P.001) and International Hip Outcome Tool 12 (31.21 vs 38.51, P = .001) than male patients. There was a significant difference in the alpha angle (67.6° in male patients vs 59.5° in female patients, P.001) corresponding with a higher prevalence of cam deformity in male patients (94.6% vs 84.5%, P.001). Male patients had less range of motion in flexion (-5.67°, P.001), internal rotation (-8.23°, P.001), and external rotation (-4.52°, P.001) than female patients. Acetabular chondroplasty was performed in 58% of male patients versus 40.2% of female patients (P.001). Acetabuloplasty was performed in 59.1% of male patients versus 43.9% of female patients (P.001).Male and female patients undergoing hip arthroscopy differ statistically in terms of preoperative hip function, hip morphology, and self-reported functional deficits, as well as the prevalence of surgical procedures. However, they do not differ significantly in terms of symptom localization, duration, or onset. The observed differences in preoperative functional scores between sexes, although statistically significant, may not represent clinically meaningful differences.Level III, retrospective cross-sectional study.

As the field of hip arthroscopy continues to grow rapidly, our understanding of the population of patients undergoing hip arthroscopy has led to improved diagnosis and management of hip joint pathologies. The Multicenter Arthroscopic Study of the Hip (MASH) Study Group conducts multicenter clinical studies in arthroscopic hip preservation surgery. Patients undergoing arthroscopic hip preservation surgery are enrolled in a large prospective longitudinal cohort at 10 separate sites nationwide by 10 fellowship-trained hip arthroscopists. In this study, we collected epidemiologic data on the 1738 patients who enrolled between January 2014 and November 2016. These data include demographics, pathologic entities treated, patient-reported measures of disease, and surgical treatment preferences. Our study results showed that patients who elected hip arthroscopy were younger to middle-aged white females with pain primarily located in the groin region. Most had pain for at least 1 year, and it was commonly exacerbated by sitting and athletic activities. Patients reported clinically significant pain and functional limitation and a decrease in physical and mental health. It was not uncommon for patients to have undergone another, related surgery and nonoperative treatments, including intra-articular injection and/or physical therapy, before surgery. There was a high incidence of abnormal hip morphology suggestive of a cam lesion, but the incidence of arthritic changes on radiographs was relatively low. Labral tear was the most common diagnosis, and most often it was addressed with repair. Many patients underwent femoroplasty, acetabuloplasty, and chondroplasty in addition to labral repair.

Purpose: This study aimed to define the footprint of the direct and reflected heads of the rectus femoris and the relation of the anterior inferior iliac spine (AIIS) to adjacent neurovascular (lateral circumflex femoral artery and femoral nerve), bony (anterior superior iliac spine [ASIS]), and tendinous structures (iliopsoas). Methods: Twelve fresh-frozen cadaveric hip joints from 6 cadavers, average age of 44.5 (9.9) years, were carefully dissected of skin and fascia to expose the muscular, capsular, and bony structures of the anterior hip and pelvis. Using digital calipers, measurements were taken of the footprint of the rectus femoris on the AIIS, superior-lateral acetabulum and hip capsule, and adjacent anatomic structures. Results: The average dimensions of the footprint of the direct head of the rectus femoris were 13.4 mm (1.7) 26.0 mm (4.1), whereas the dimensions of the reflected head footprint were 47.7 mm (4.4) 16.8 mm (2.2). Important anatomic structures, including the femoral nerve, psoas tendon, and lateral circumflex femoral artery, were noted in proximity to the AIIS. The neurovascular structure closest to the AIIS was the femoral nerve (20.8 3.4 mm). Conclusions: The rectus femoris direct and reflected heads originate over a broad area of the anterolateral pelvis and are in close proximity to critical neurovascular structures, and care must be taken to avoid them during hip arthroscopy. Clinical Relevance: A thorough knowledge of the anatomy of the proximal rectus femoris is valuable for any surgical exposure of the anterior hip joint, particularly arthroscopic subspine decompression and open femoroacetabular impingement (FAI) surgery.

Our purpose was to evaluate evidence regarding the effectiveness of open iliopsoas release and lengthening with arthroscopic approaches, which combine iliopsoas release with the treatment of intra-articular pathology as treatments for internal snapping hip syndrome. Searches were performed of 4 databases and 12 reports on the surgical treatment of internal snapping hip were reviewed. The authors tabulated data according to year of study, journal, study type, level of evidence, patient demographics, procedure, and outcomes. We found that surgical treatment of internal snapping hip improves patient symptoms in the majority of patients. Endoscopic release is associated with fewer reported complications compared with open release. All studies of endoscopic treatment of internal snapping hip syndrome also performed intra-articular examination and treatment of intra-articular pathology. The incidence of associated intra-articular pathology was reported in 5 of 6 studies. These results suggest that a painful snapping iliopsoas tendon in many cases may be a result of intra-articular hip pathology rather than an independent entity. Early studies suggest no difference in efficacy or associated complications rate when comparing extracapsular to transcapsular iliopsoas tendon release. Further studies are needed comparing operative to nonoperative treatment and methods of determining patients likely to benefit from operative intervention.

Recovery of strength is critical for return to sport, and is a known predictor of functional outcomes in post-surgical orthopedic populations. Muscle weakness is a known impairment in patients with femoroacetabular impingement syndrome (FAIS) but whether improvements in muscle strength after arthroscopy are associated with improved hip function is unknown.To examine the relationships between changes in hip and thigh muscle strength and self-reported function in athletes undergoing arthroscopy for FAIS.Single cohort descriptive and correlational study.Twenty-eight athletes underwent strength testing and completed the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-S) subscales prior to and six months after surgery. Isokinetic knee extension and flexion strength were measured using a Biodex dynamometer at 60 °/s and 300 °/s. Isometric hip abduction strength was measured using a custom dynamometer. Changes in strength, limb symmetry, and HOS scores were assessed using paired t-tests. Spearman's rank correlations were used to examine relationships between change in involved limb strength and change in HOS scores.Subjects were tested an average of 32 days before and 178 days after surgery. HOS-ADL and HOS-S subscales improved by a mean of 19.0 ± 21.1 and 23.8 ± 31.9, respectively, over time (Improvements in knee extension strength were associated with improvements in self-reported hip function in athletes following arthroscopy for FAIS. Individuals with knee extension strength deficits prior to surgery may benefit from targeted knee extension strengthening during post-operative rehabilitation to improve functional outcomes.Level III (non-randomized controlled cohort study).

A growing interest exists in the diagnosis and treatment of femoroacetabular impingement. Although cam morphology of the proximal femur may conceptually appear to be a relatively simple topographical aberrancy, it is actually positioned amid a complex developmental, kinematic, and biomechanical region of the human body. The authors introduce a new classification scheme and review the historical and anthropological considerations, biomechanics, and genetic factors involved in cam morphology.

Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level I-IV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p < 0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p < 0.001) with reduced risk of complications and re-rupture (p < 0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.

Recent orthopaedic literature has implicated femoroacetabular impingement, the pathologic abutment of structural aberrancies in the proximal femur and acetabular rim, as an important cause of groin pain in young individuals and a potential factor in early idiopathic osteoarthritis. The etiology and risk factors for developing cam-type morphology are still unknown. The osseous anatomy of the proximal femur in humans is the culmination of nearly 400 million years of evolution. Coxa recta and coxa rotunda are the two predominant morphologies in modern animals. While the latter, characterized by a straight head-neck junction, is often present in cursorial creatures, the former, distinguished by high offset at this junction, is exemplified in most humans. Based on the ontology and phylogeny of the proximal femur, coxa rotunda probably developed from a more primitive coxa recta. We believe that cam-type morphology is neither a redevelopment of coxa recta nor a malformation such as slipped capital epiphysis. The aspherical osteocartilaginous bump is associated with an extended physis and has been noted to appear during mid-adolescence. While this protuberance may contribute to future pathology, the authors feel that increased loading of the hip, not impingement activities, during late childhood and early adolescence predispose patients to develop this morphology.

Femoroacetabular impingement (FAI) is a common cause of hip discomfort in young adults. Recently, a better understanding of the pathomechanics and morphologic abnormalities in the hip has implicated FAI as a possible factor in early osteoarthrosis. The clinical presentation, physical examination findings, and radiographic features are discussed in this article.PubMed was searched using words and terms including femoacetabular impingement, hip osteoarthritis, hip arthroscopy, early osteoarthrosis, and hip dislocation. References of relevant studies were searched by hand.All studies directly involving the treatment of FAI were reviewed by 3 authors and selected for further analysis, including expert opinion and review articles.The quality of each study was assessed, and the results were summarized.Conservative measures, including physical therapy, restriction of activities, core strengthening, improvement of sensory-motor, and control and nonsteroidal anti-inflammatories are the mainstays of nonsurgical treatment. However, surgical management is often necessary to allow full return to activity with options including surgical dislocation of the hip, hip arthroscopy, periacetabular and rotational osteotomies, and combined hip arthroscopy with a limited open exposure. Although the literature is replete with short-term evidence to support surgical treatment, there are currently no long-term prospective data or natural history studies examining the implications of FAI and effects of early intervention.

Background: Mental health impairments have been shown to negatively affect preoperative self-reported function in patients with various musculoskeletal disorders, including those with femoroacetabular impingement. Hypothesis: Those with symptoms of depression will have lower self-reported function, more pain, and less satisfaction on initial assessment and at 2-year follow-up than those without symptoms of depression. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who were enrolled in a multicenter hip arthroscopic surgery registry and had 2-year outcome data available were included in the study. Patients completed the 12-item International Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and 12-item Short-Form Health Survey (SF-12) when consenting for surgery. At 2-year follow-up, patients were emailed the iHOT, the VAS, and a rating scale of surgical satisfaction. Initial SF-12 mental component summary (MCS) scores Results: A total of 781 patients achieved the approximate 2-year milestone (mean follow-up, 735 ± 68 days), with 651 (83%) having 2-year outcome data available. There were 434 (67%) female and 217 (33%) male patients, with a mean age of 35.8 ± 13.0 years and a mean body mass index of 25.4 ± 8.8 kg/m2. The most common procedures were femoroplasty (83%), followed by synovectomy (80%), labral repair (76%), acetabuloplasty (58%), acetabular chondroplasty (56%), femoral chondroplasty (23%), and labral reconstruction (19%). The mean initial SF-12 MCS score was 51.5 ± 10.3, with cutoff scores indicating symptoms of depression and severe depression in 181 (28%) and 71 (11%) patients, respectively. Patients with symptoms of depression scored significantly ( P < .05) lower on the initial iHOT-12 and VAS and 2-year follow-up iHOT-12, VAS, and rating scale of surgical satisfaction. Conclusion: A large number of patients who underwent hip arthroscopic surgery presented with symptoms of depression, which negatively affected self-reported function, pain levels, and satisfaction on initial assessment and at 2-year follow-up. Surgeons who perform hip arthroscopic surgery may need to identify the symptoms of depression and be aware of the impact that depression can have on surgical outcomes.

Background The purpose of this study is to compare a locked screw construct to a single iliosacral screw for fixation of a vertically unstable pelvic ring injury in a transforaminal sacral fracture model. Methods Orthopaedic Trauma Association type 61-C1.3a2c5 fractures were created in 10 fresh frozen cadaveric pelvis specimens. Specimens were divided into two groups of five. In both groups, the anterior ring was stabilized with a six-hole 3.5-mm reconstruction plate. In the locked plate (LP) group, the posterior injury was stabilized using a two-hole locking plate with one solid 5.0-mm locking iliosacral screw directed onto the S1 body and a second locking screw directed into the lateral sacral ala. In the iliosacral screw group, the posterior injury was stabilized using a single cannulated 7.3-mm screw. Testing was conducted on a Materials Testing System. Values for displacement and rotation were recorded. Each pelvis was axially loaded with a compressive sine wave from 175 N to 350 N for 10,000 cycles to simulate limited weight bearing, with data recorded at 1,000 cycle increments. Results Two specimens in the iliosacral screw group displaced more than 1 cm during the first 1,000 cycles. These two specimens displayed gross fracture motion in all planes. All five specimens in the LP group completed 10,000 cycles of testing with less than 1 cm of displacement. A vector displacement calculation from the plane displacement data revealed that the LP group had significantly less displacement (median 1.9 mm) than the specimens in the iliosacral group (median 6.7 mm; p = 0.008) after 10,000 cycles. Conclusions A two-hole plate locked head screw construct resulted in less displacement than a single iliosacral screw in a transforaminal sacral fracture model.

To assess the risk of injury to the superficial peroneal nerve, saphenous nerve, and saphenous vein in percutaneous fixation of the distal fibula and tibia.Ten adult cadaver lower extremities were instrumented with precontoured periarticular plates for the distal tibia and fibula. Plates were inserted percutaneously along the medial distal tibia and lateral fibula. Smooth wires were inserted percutaneously into each screw hole. Dissection of the superficial peroneal nerve, saphenous nerve, and saphenous vein was performed along their respective course. The position of the neurovascular structures relative to the smooth wires was recorded.The saphenous nerve and vein had a predictable course along the medial aspect of the ankle. Both structures were injured in every specimen. This occurred consistently at 2.0 to 4.7 cm from the tip of the medial malleolus. The superficial peroneal nerve demonstrated large variance in the exit point from the lateral compartment crural fascia, exiting at an average of 11.6 cm from the tip of the lateral malleolus. Injury occurred in a single specimen at 11.5 cm from this point.The superficial peroneal nerve, saphenous nerve, and saphenous vein are at risk during percutaneous submuscular plating of the distal fibula and tibia. Careful dissection proximally for the fibula and distally for the tibia can minimize the risk of damage to these structures.

Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown.Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair.Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion.A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.

Background: A novel rib fracture repair plating system was developed to provide durable fixation with a shorter length than standard systems and thus facilitate minimally invasive repair. We hypothesized that U-plate fixation would be at least equivalent in durability to standard anterior fixation. Study: Twenty fresh frozen ribs (10 pairs) from two human cadavers were first tested for intact stiffness (force or deformation). A gap of 5 mm was then created in the middle of each rib with a saw. Each rib was reconstructed with either the U-plate (4.6 cm length, Acute Innovations, LLC, Hillsboro, OR) with four screws or a 2.4-mm anterior locking plate (9.5 cm length, Synthes, Paoli, PA) with six screws. The U-plates were placed on one rib and the anterior plates on the contralateral rib of the paired levels. The reconstructed ribs were cycled 50,000 times with a load of ±2N at 1 Hz in a simulation of the repetitive loading of deep breathing. The stiffness of the construct was measured throughout the test. Results: Stiffness decreased from the intact rib to the transected/plated rib for both types of fixation; however, a significant decrease in stiffness was observed only with the anterior repair (p = 0.03). After 50,000 cycles, the U-plated ribs lost 0.12 ± 0.03 N/mm (1.9%) stiffness, whereas the anterior-plated ribs lost 0.72 ± 0.13 N/mm (9.9%) stiffness (p = 0.001). Conclusions: In this simulation of an unstable rib fracture with a small bony gap, U-plate fixation was more durable than standard anterior fixation. The greatly diminished size of the U-plate compared with the standard may facilitate minimally invasive rib fracture repair.

Background: Femoroacetabular impingement (FAI) is a significant cause of disability in young adults. Hip arthroscopic surgery restores bony congruence and improves function in the majority of patients, but recent evidence indicates that women may experience worse pre- and postoperative function than men. Purpose/Hypothesis: The purpose of this study was to identify whether self-reported hip function differed between men and women with symptomatic FAI. The hypothesis was that mean self-reported hip function scores would improve after arthroscopic surgery but that women would report poorer function than men both before and up to 2 years after arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 229 patients (68.4% women; mean [±SD] age, 31.6 ± 10.8 years; mean [±SD] body mass index, 26.8 ± 11.9 kg/m2) underwent hip arthroscopic surgery for unilateral symptomatic FAI. All eligible and consenting patients with radiologically and clinically confirmed FAI completed the International Hip Outcome Tool (iHOT-33) and the Hip Outcome Score activities of daily living subscale (HOS-ADL) before hip arthroscopic surgery and at 3, 6, 12, and 24 months after arthroscopic surgery. A linear mixed model for repeated measures was used to test for differences in self-reported hip function between men and women over the study period ( P ≤ .05). Results: There were no significant time × sex interactions for either the HOS-ADL ( P = .12) or iHOT-33 ( P = .64), but both measures showed significant improvements between the preoperative time point and each of the 4 follow-up points ( P < .0001); however, self-reported hip function did not improve between 6 and 24 months after arthroscopic surgery ( P ≥ .11). Post hoc independent t tests indicated that women reported poorer hip function than did men before surgery ( P ≤ .003) both on the HOS-ADL (mean ± standard error of the mean [SEM], 67.4 ± 1.9 [men] vs 60.5 ± 1.3 [women]) and iHOT-33 (mean ± SEM, 38.0 ± 1.9 [men] vs 30.9 ± 1.3 [women]); scores were not different between sexes at any other time point. Conclusion: These findings indicate improvements in self-reported hip function in patients with FAI, regardless of sex, until 6 months after hip arthroscopic surgery. Although women reported poorer preoperative function than did men, the differences were not significant 2 years after surgery.

Chronic groin pain in athletes represents a major diagnostic and therapeutic challenge in sports medicine. Two recognized causes of inguinal pain in the young adult athlete are core muscle injury/athletic pubalgia (CMI/AP) and femoroacetabular impingement (FAI). CMI/AP and FAI were previously considered to be two distinct entities, however recent studies have suggested both entities to frequently coincide in the athlete with groin pain. This article briefly discusses the role of femoroacetabular impingement in core muscle injury/athletic pubalgia, and the diagnosis and management of this complex disease.

Early radiographic detection of femoroacetabular impingement might prevent initiation and progression of osteoarthritis. The structural abnormality in femoral-induced femoroacetabular impingement (cam type) is frequently asphericity at the anterosuperior head/neck contour. To determine which of six radiographic projections (anteroposterior, Dunn, Dunn/45 degrees flexion, cross-table/15 degrees internal rotation, cross-table/neutral rotation, and cross-table/15 degrees external rotation) best identifies femoral head/neck asphericity, we studied 21 desiccated femurs; 11 with an aspherical femoral head/neck contour and 10 with a spherical femoral head/neck contour. To radiographically quantify femoral head asphericity, we measured the angle where the femoral head/neck leaves sphericity (angle alpha). The aspherical femoral head/neck contours had a greater maximum angle alpha (70 degrees ) compared with the spherical head/neck contours (50 degrees ). The angle alpha varied depending on the radiographic projection: it was greatest in the Dunn view with 45 degrees hip flexion (71 degrees +/- 10 degrees ) and least in the cross-table view in 15 degrees external rotation (51 degrees +/- 7 degrees ). Diagnosis of a pathologic femoral head/neck contour depends on the radiologic projection. The Dunn view in 45 degrees or 90 degrees flexion or a cross-table projection in internal rotation best show femoral head/neck asphericity, whereas anteroposterior or externally rotated cross-table views are likely to miss asphericity. Level of Evidence: Prognostic study, level II-1 (retrospective study).

Objective: The purpose of this study was to report the results of surgical treatment of a subset of intertrochanteric fractures with posteromedial comminution and extension of the fracture line into the femoral neck using a sliding hip screw. Design: Retrospective review. Setting: Level I county trauma center. Patients: Twenty-nine fractures (8%) with this pattern were identified from 381 intertrochanteric hip fractures treated at a single institution over a 10-year period. Nine patients were excluded (2 died, 7 had incomplete radiographic follow-up), leaving 20 patients for assessment. Intervention: All fractures were treated with a sliding hip screw. Main Outcome Measurements: Radiographs at a mean follow-up of 17 months were recorded as demonstrating: 1) fixation failure; 2) fracture union; or 3) fracture nonunion. The tip-apex distance, amount of lag screw collapse, screw position in the femoral head, and adequacy of reduction were determined. Results: Treatment failed according to these radiographic measures in 5 of 20 (25%) fractures. Failures included fracture nonunion (1 case), lag screw cutout (2 cases), and combined nonunion/lag screw cutout (2 cases). All 5 failures had complete collapse of the lag screw, whereas 4 of the 15 successfully treated fractures had complete collapse. The amount of collapse was significantly greater for the treatment failures (mean, 38 mm) than in the successfully treated hips (mean, 20 mm). There was no significant association between treatment success or failure and tip-apex distance, lag screw position, and adequacy of reduction. Conclusion: We conclude that intertrochanteric hip fractures with associated femoral neck fractures should not be managed with a standard sliding hip screw.

This article reports a prospective series of periprosthetic femur fractures in 33 patients treated with a modernized fracture treatment protocol. Some form of operative treatment was selected prospectively based on the categorization of the fracture by the Duncan-Vancouver and Beals-Tower Oregon classification systems. Fractures in which the prosthesis-bone interface was stable were treated with open reduction and internal fixation of the fracture around the stable implant. Unstable prosthesis-bone interfaces required removal of the primary prosthesis and revision to an uncemented long-stem prosthesis after stabilization of the femoral fracture with plates or allograft struts. Complications were minimal over an average follow-up period of 28.3 months; restoration of function was predictable.

Impaired abductor function of the hip resulting from a discontinuous gluteus medius often is encountered in revision hip surgery. If the gluteus medius can be reattached to the proximal femur, functional results are satisfactory. If this is not possible, it would be desirable to restore the continuity of the gluteus medius by bridging the defect with local tissue. An anatomic study was performed in 15 cadavers, and proximal advancement of the vastus lateralis without injury to the neurovascular pedicle was 8 cm (range, 7-10 cm). Clinically, the technique was used in 3 patients. At follow-up, both living patients walked without a cane and both were able to hold the leg abducted against moderate pressure. Proximal advancement of the vastus lateralis can successfully bridge defects of the gluteus medius and partially restores abductor function.

The management of polytrauma patients is clinically challenging and requires a multi-disciplinary team approach. The immediate and definitive operative care of fractures represents the optimal treatment for polytrauma patients with orthopedic injuries. Early orthopedic intervention in long bone fractures and pelvic ring injuries has been shown to decrease pulmonary complications, improve hemodynamic stability, reduce ventilator time, and facilitate early patient mobilization. These factors decrease mortality and improve outcomes for patients with multiple injuries.