Objectives: Hip arthroscopy has been an increasingly used tool in the treatment of labral tears, chondral defects and ligamentum teres lesions and has demonstrated efficacy in returning patients to function and relieving their pain. Despite this, failures continue to occur. Our understanding of risk factors for failure or poor outcome continues to evolve as larger cohorts of patients are available for study. We sought to identify risk factors for poor outcome in our patient population. Methods: Prospectively collected data for all patients undergoing hip arthroscopy by a single fellowship-trained surgeon was obtained. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline demographic data regarding patient age, gender, BMI was collected. Patients without two year follow-up were excluded. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to mHHS at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure or conversion to THA or mHHS below 70. Multivariate logistic regression was performed to identify independent risk factors for “poor outcome.” Results: 258 patients met inclusion criteria. Mean age (SD) and body mass index (BMI) were 40.4 years (12.7 years) and 25.6 (4.7) respectively. 62.8% (162/258) of the sample was female. Mean preoperative baseline mHHS was 49.6 (12.5) and average mHHS at two year follow-up was 83.6 (15.6), resulting in a mean improvement of 34.1 (p<0.001). Baseline and 2 year differencess in mHHS by demographic be found in Figures 1,2,3,. Overall revision/THA conversion rate was 16.7% (43/258), while another 10.5% (27/258) of patients reported outcome scores <70, resulting in 27.31% (70/258) having poor outcomes. Independent risk factors for poor outcome were female gender (OR 1.79; p=0.03), obesity (OR 2.1; p=0.04), and pre-operative mHHS lower than 40 (OR 3.34, p<0.001). Conclusion: Our findings that female gender, obesity and poorer preoperative functional status increase the risk for failure of hip arthroscopy coincide and add to an increasing volume of literature examining risk factors for poor outcome after hip arthroscopy. These factors should be taken into consideration with operative indications as well as in counseling patients.
Patients with symptomatic femoroacetabular impingement (FAI) typically have anterior groin pain. However, a subset of these patients may have pain located laterally, posteriorly, or in a combination of locations around the hip.To report and compare outcomes of hip arthroscopy for patients with FAI and atypical hip pain versus classic anterior groin pain.Cohort study; Level of evidence, 2.Consecutive patients undergoing hip arthroscopy for FAI between August 2011 and March 2013 were identified. A total of 258 patients were identified as having symptomatic FAI based on clinical, radiographic, and advanced imaging diagnosis of FAI. Exclusion criteria included isolated thigh, knee, or low back pain. We also excluded patients with hip abductor pathology and trochanteric bursitis. Of the 226 patients ultimately included, 159 (70.4%) reported anterior groin pain, while 67 (29.6%) reported isolated lateral or posterior hip pain or a combination of locations. Patients were categorized into 4 groups: isolated anterior groin pain, lateral hip pain, posterior hip pain, and multiple primary hip pain locations (combined). These patients were followed prospectively with a minimum follow-up of 2 years. Patient characteristics, surgical characteristics, modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), revision hip arthroscopy, and conversions to total hip arthroplasty (THA) were recorded.All 226 patients were included at final follow-up. Hip arthroscopy was performed by a single sports medicine fellowship-trained orthopaedic surgeon. Preoperative patient characteristics and baseline functional outcome scores did not significantly differ among groups. All 4 groups showed statistically significant improvements in mHHS and NAHS from baseline to final follow-up of a mean 2.63 years (range, 2.01-3.23 years). Functional outcome scores and rates of revision hip arthroscopy or conversion to THA did not significantly differ between groups.Hip arthroscopy can effectively improve patient outcomes in atypical hip pain. A careful history and physical examination should identify this clinically meaningful subset of patients with FAI who can benefit from surgical intervention while identifying patients with concomitant posterior extra-articular hip or spine pathology that should be addressed appropriately.
Elbow injuries in athletes who perform overhead throwing motions often present diagnostic challenges because of the undue stresses and often chronic, repetitive patterns of injury. Accurate and efficient assessment of the injured elbow is essential to maximize functional recovery and expedite return to play. Radiographic evaluation should be tailored to the specific injury suspected and requires a thorough understanding of normal anatomic relationships as well as familiarity with common injuries affecting these athletes.
To the editor, We thank Dr. Wyland and appreciate his interest in our study. We would like to respond to the concerns raised in his letter to the editor [2]. We agree with Dr. Wyland that reporting the outcome in five separate subscales (symptoms; pain; function, daily living; function, sports and recreational activities; quality of life), enhances interpretation. However, as stated by Roos and colleagues [7], even though it makes it impossible to closely monitor the stages of rehabilitation, the calculation of a total KOOS score can show an improvement. Due to the fact that our objective was to report the general patient-relevant outcome at a minimum of 6 months postoperatively (and not to optimize rehabilitation), we decided to report a single score in this initial retrospective case series. Dr. Wyland noted that “the grading system described by Mitsou et al. and previously by Tegner actually evaluated the success of ACL reconstruction, not knee osteoarthritis treatments.” Due to lack of a specific patient-reported outcome score for treatment evaluation of subchondral bone marrow edema lesions, we decided to use the Tegner-Lysholm Score which, as correctly stated by Dr. Wyland, was initially developed and validated for ACL injuries. The rationale behind our decision lies in the fact that in up to 80% of ACL-ruptured knees, bone marrow edema lesions are present [3, 4]. We also feel that the critique by Bengsston and colleagues [1] on the sensitivity of the Tegner Lysholm Score regarding ACL injuries and other lower extremity conditions corroborates as opposed to discredits our choice. The grading of the score allows a more critical analysis of the outcome [1]. Dr. Wyland also correctly noted that “… there was no discussion of surgical revisions in evaluating clinical failure or surgeon learning curve, which one would expect to influence failure rates.” Within the confines of manuscript length, we reported the followup data that was available for this retrospective study; none of the patients had revisions. However, three patients were lost to followup. Also, the minimum followup to be included in this study was only 6 months (and the median was only 1 year). Even at short followup, 10 of the 22 patients had either fair or poor patient-reported outcome scores. The point by Dr. Wyland regarding the surgeon learning curve had also been raised by a peer review referee. We agree that, especially for novel techniques, the learning curve should be addressed. However, as stated in the operative technique section, the 22 reported surgeries were performed by four of our fellowship-trained surgeons, and based on the current literature, the number of procedures performed by each of the four surgeons is not large enough to adequately power meaningful statistical analyses regarding learning curves. We agree with Dr. Wyland that surgeon learning curve may influence failure rate, but for such an investigation, a larger case series is needed. Dr. Wyland believed our suggestion of a negative relationship between postoperative outcomes and severity of osteoarthritis was an overstatement given the lack of K-L Grade 4 patients, the relatively weak R2 value presented, and the small sample size. However, the lack of K-L Grade 4 patients in this retrospective case series is due to our general indication for this procedure as we deemed the most advanced grade of osteoarthritis to be a contraindication, as there is little reason to think that treating marrow edema below a bare joint surface would provide durable pain relief or regrow cartilage. In light of other studies [5, 6] which have shown that the prevalence of symptomatic bone marrow edema lesions rises with increasing Kellgren-Lawrence Grade, we were not surprised by the negative correlation between K-L Grade and outcome scores. Our small sample size has been discussed as a limitation and we believe further studies with a larger number of study subjects would corroborate our finding. Therefore, we encourage Dr. Wyland and other orthopaedic surgeons to report their data on this novel percutaneous calcium phosphate injection technique in the orthopaedic literature. Dr. Wyland also mentioned in his letter that “… the raw data presented show that 20 of 22 patients (91%) in this small cohort study actually demonstrated improvement from baseline in one or both scores. The magnitude of mean improvement was clinically significant while the improvement in mean scores from the cohorts’ baseline was statistically significant. The authors suggested the concomitantly performed arthroscopies likely contributed to the observed improvements, discounting the probable effect of the CaP injection.” We agree with Dr. Wyland, and also mentioned in our results that we observed a statistically significant improvement in the outcome scores. However, we believe the outcomes graded according to the Tegner Lysholm Knee Scoring Scale represents more accurately the dissatisfaction of our patient population; it is not the mean score of the population that best describes the results here (as might be the situation in many small case series), but rather the proportion of patients doing well and the proportion doing poorly. In terms of this group, only 12 of 22 patients had good or excellent knee scores, while 10 of 22 had fair or poor scores, and three others were lost to followup before the 6-month minimum. The short followup, study design (a retrospective case series), and loss to followup all suggest that our results were a best-case scenario for this approach, and the fact that nearly half scored “fair” or “poor” on the Tegner scoring system, supported our conclusions, which we stand by. In our opinion, as stated in the discussion, the low rate of clinical success might be due to the high proportion of patients treated who had osteochondral and meniscal pathologies. To capture the true benefit of calcium phosphate injections, we believe patients with minimal osteochondral and meniscal damage need to be investigated.
Previous studies have demonstrated increased glenohumeral translations with simulated type II superior labral anterior posterior lesions, which may explain the sensation of instability in the overhead-throwing athlete. It is unknown whether this amount of increased translation alters glenohumeral kinematics.To determine whether type II superior labral anterior posterior lesions significantly alter glenohumeral kinematics as defined by path of glenohumeral articulation in a simulated cadaveric model of the throwing shoulder.Controlled laboratory study.Six cadaveric shoulders were tested for glenohumeral rotational range of motion and translation using a custom shoulder testing system and the Microscribe 3DLX. The path of glenohumeral articulation was measured by calculating the humeral head center with respect to the glenoid articular surface at maximal internal rotation, 30 degrees, 60 degrees, 90 degrees, and maximal external rotation. Data were recorded for vented intact shoulders, shoulders with arthroscopically created type II superior labral anterior posterior lesions, and shoulders with arthroscopically repaired superior labral anterior posterior lesions.A subtle but significant increase in external rotation (2.7 degrees) was seen after creating a type II lesion. Small increases in glenohumeral translation were found in the anterior (0.9 mm) and inferior (0.9 mm) directions with application of a 15-N force in the superior labral anterior posterior group. Increases in glenohumeral rotation and translation were restored to the intact state after repair of the lesion. No significant differences were found in the path of glenohumeral articulation for the superior labral anterior posterior condition compared with the intact shoulder.The small amounts of increased external rotation and translation found with arthroscopically created type II superior labral anterior posterior lesions do not significantly affect glenohumeral kinematics in this passive motion model as quantified by the path of glenohumeral articulation.Findings suggest that in the absence of pain or mechanical symptoms, type II superior labral anterior posterior lesions that do not significantly involve the superior and middle glenohumeral ligaments may not need surgical repair.
The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy.Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded.We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure.In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.
Objectives: Women of reproductive age are among the most frequent recipients of hip arthroscopic procedures in the U.S., and anecdotal evidence suggests that some female patients consider pregnancy a factor in their decision to undergo, delay, or avoid such surgeries. In addition, anatomical changes during pregnancy may exacerbate existing hip pathologies such as femoroacetabular impingement (FAI) and labral tears, potentially leading to greater pain and risk of complications during gestation, labor, and delivery. However, the impact of hip pain and arthroscopy on pregnancy-related decision-making and outcomes is poorly understood. The aims of this study were to determine (1) how pregnancy planning affected patients’ decisions to pursue hip arthroscopy, (2) whether undergoing hip arthroscopy affected hip pain before and after pregnancy, and (3) whether hip arthroscopy was associated with any pregnancy-related complications. Methods: We retrospectively studied female patients aged 18-45 years who underwent hip arthroscopy for the treatment of FAI and/or labral tears at our center from 2010-2021. Subjects were identified using a prospectively-collected single-surgeon database. Eligible subjects were administered an electronic survey that assessed obstetrical history, concerns about how their hip pain and/or the process of undergoing hip arthroscopy could affect future pregnancies, location and intensity of hip pain at various time points (before surgery, after surgery, during pregnancy), and complications experienced during pregnancy. Hip pain intensity was reported on a 10-point Visual Analog Scale (VAS). Subjects also completed the modified Harris Hip Score (mHHS). Continuous variables were compared within groups with Wilcoxon signed rank test and between groups with Kruskal-Wallis test. Fisher’s exact test was used to compare categorical variables between groups. P-values < 0.05 were considered significant. Results: A total of 86 patients completed the survey. Mean age at time of surgery was 32.3 ± 6.4 years (range 18 - 45), mean BMI was 24.5 ± 4.7 (range 18.7 – 39.8), and mean follow-up time was 52.0 ± 34.3 months (range 6 – 146). 47 patients (54.7%) had been pregnant at least once. Half of the cohort reported moderate or high concern that their hip pain would worsen during a future pregnancy, while a slight majority felt that hip surgery would not raise their risk of complications during pregnancy (56.0%) or impair hip function after pregnancy (51.2%). 27 patients (31.4%) had become pregnant after hip surgery at an average of 6.3 ± 1.4 months (range 2 – 8) postoperative, of whom 13 (48.2%) cited hip pain as a factor in getting surgery before pregnancy and 9 (33.3%) reported delaying a planned pregnancy to undergo surgery. Patients who became pregnant after surgery experienced a significant increase in VAS hip pain during pregnancy (p = 0.02), most commonly during the third trimester, though pain resolved after pregnancy in most (19 of 27, 70.4%). Five patients (5 of 27, 18.5%) experienced a miscarriage and the most common complication reported was vaginal/perineal tear (13 of 27, 48.1%). Of the 39 nulligravid patients, 28 (71.2%) were considering a future pregnancy and 32 (84.2%) did not consider hip pain to be a factor in their nulligravid status. There was no significant difference in mHHS at latest follow-up between nulligravid patients, patients who had not been pregnant since hip surgery, and patients who got pregnant after hip surgery (mean 79.6 vs 80.0 vs 79.6, p = 0.94). Conclusions: Most female hip arthroscopy patients were not concerned that their surgery would have a negative impact on their pregnancy outcomes or hip function after pregnancy. Within the hip arthroscopy population, although hip pain was exacerbated during pregnancy, most patients experienced a resolution of pain following delivery. Pregnancy-related complications did not occur more frequently in the hip arthroscopy cohort compared to the wider U.S. population. Patient-reported hip outcomes were comparable between nulligravid women and those who had only been pregnant prior to surgery.
