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Background: A limited joint space (Purpose: To reevaluate the relationship between the radiographic joint space and outcomes after hip arthroscopic surgery and to assess the validity of a joint space of 2 mm as the accepted cutoff for successful hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Patients aged 18 to 50 years who underwent hip arthroscopic surgery for femoroacetabular impingement between January 2008 and December 2016 and had a minimum 2-year follow-up were included. Patients with previous ipsilateral hip surgery, a history of hip fractures, dysplasia (lateral center-edge angle 2) were excluded. The joint space was categorized as diminished (≤2 mm), borderline (>2 to ≤3 mm), or preserved (>3 mm). Minimum 2-year patient-reported outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports-Specific Subscale [HOS-SSS]), revision rates, and rates of conversion to THA were compared between groups. Results: A total of 699 patients (782 hips) with a mean age of 33.8 ± 10.1 years met 2-year inclusion criteria. The mean follow-up time was 4.2 ± 2.1 years. Overall, 51 hips (6.5%) had a diminished joint space, 297 (38.0%) had a borderline joint space, and 434 (55.5%) had a preserved joint space. Patients with a diminished joint space had larger femoral and acetabular defects compared with those with larger joint spaces. All groups had improved patient-reported outcome scores compared with baseline ( P < .001 for all), and there were no differences between the groups in the percentage of patients who reached the minimal clinically important difference or patient acceptable symptom state. There were also no differences between the groups in revision rates ( P = .95). A greater number of hips with a diminished joint space converted to THA (n = 8 [15.7%]) compared with those with a borderline (n = 9 [3.0%]) or preserved (n = 9 [2.1%]) joint space ( P < .001). Considering joint space as a continuous variable, adjusted logistic regression showed that for every millimeter decrease in the joint space, the odds of conversion to THA increased by a factor of 2.5 (odds ratio, 2.5 [95% CI, 1.6-3.8]). Conclusion: This study demonstrated that patients with a diminished joint space were at a higher risk of conversion to THA. Although 2 mm should not serve as a strict cutoff, patients should be counseled based on their preoperative radiographic findings accordingly.

Background: Femoroacetabular impingement (FAI) is often a chronic problem, which can lead to a decrease in mental well-being. Purpose/Hypothesis: The purpose of this study was to determine patient mental health improvement after hip arthroscopy and if this improvement correlated with improved outcomes. It was hypothesized that patients with low mental health (LMH) status would improve after hip arthroscopy for FAI and that their patient-reported outcomes (PROs) would significantly improve after surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent hip arthroscopy with labral repair between 2008 and 2015 were included. The minimum follow-up was 2 years. PROs included the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports (HOS-Sports), and 12-Item Short Form Health Survey (SF-12). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) were determined for HOS-ADL, HOS-Sports, and the mHHS based on previously published studies. Patients who scored Results: In total, 120 (21%) of the 566 patients were in the LMH group and 446 (79%) patients were in the HMH group preoperatively. There was no difference in age or sex between groups. Patients in the LMH group had lower mHHS, HOS-ADL, and HOS-Sports at the mean 4-year follow-up and were less likely to reach PASS for the scores. Postoperatively, 84% (478/566) of the entire group was in the HMH group. A total of 88 (73%) of the LMH group improved to HMH. A multiple linear regression model for change in MCS identified independent predictors of changes in preoperative MCS to be LMH group preoperatively, change in HOS-Sports, and change in mHHS ( r2 = 0.4; P < .001). Conclusion: HMH was achieved in 84% of the patients after hip arthroscopy for FAI. Improvement in MCS was correlated with function and activity, as indicated by a significant correlation with HOS-ADL and HOS-Sports. A small percentage of patients did see a decline in their MCS score. This study showed that patients with LMH scores before hip arthroscopy for FAI can improve to normal/high mental health, and this correlated with higher PROs.

Background: The presence of adhesions is a common source of pain and dysfunction after hip arthroscopic surgery and an indication for revision surgery. The placement of a capsular spacer in the capsulolabral recess after lysis of adhesions has been developed to treat and prevent the recurrence of adhesions. Purpose: To evaluate patient-reported outcomes (PROs) and survivorship at a minimum of 2 years after revision hip arthroscopic surgery with capsular spacer placement for capsular adhesions. Study Design: Case series; Level of evidence, 4. Methods: Between January 2013 and June 2018, a total of 95 patients (99 hips) aged ≥18 years underwent revision hip arthroscopic surgery for the treatment of capsular adhesions with the placement of a capsular spacer. Overall, 53 patients (56 hips) met the inclusion criteria and had a minimum 2-year follow-up, forming the cohort of this study. Exclusion criteria included confounding metabolic bone diseases (eg, Legg-Calve-Perthes disease, Marfan syndrome), labral deficiency, or advanced osteoarthritis (Tönnis grade 2 or 3). Preoperative and postoperative outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sport-Specific Subscale [HOS-SSS], 12-Item Short Form Health Survey [SF-12], and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were collected and compared in addition to the revision rate, conversion to total hip arthroplasty, and patient satisfaction. Results: The mean age of the cohort was 32 ± 11 years, with 32 female hips (57%) and a median number of previous hip arthroscopic procedures of 1 (range, 1-5). The arthroplasty- and revision-free survivorship rate at 2 years was 91%. Overall, 5 patients (6 hips; 11%) underwent revision surgery at a mean of 2.4 ± 1.4 years after capsular spacer placement, with symptomatic capsular defects being the most common finding. There were 4 patients (7%) who converted to total hip arthroplasty. For hips not requiring subsequent surgery (n = 46), there was a significant improvement in outcome scores except for the SF-12 Mental Component Summary, with rates of achieving the minimal clinically important difference of 70%, 70%, and 65% for the mHHS, HOS-ADL, and HOS-SSS, respectively. Conclusion: Capsular spacers, as part of a systematic approach including lysis of adhesions with early and consistent postoperative physical therapy including circumduction exercises, resulted in improved PROs as well as high arthroplasty– and revision-free survivorship (91%) at a minimum 2-year follow-up. Capsular spacers should be considered in revision hip arthroscopic procedures when an adequate labral volume remains but adhesions continue to be a concern.

Avascular necrosis of the femoral head (AVNFH) is a debilitating disease that requires early intervention to prevent subchondral collapse and irreversible damage leading to premature hip replacement. Patients presenting with AVNFH can have concomitant intra-articular pathology, including femoroacetabular impingement (FAI), that contributes to their hip pain and dysfunction. It is important to restore the native hip anatomy in addition to providing revascularization of necrotic areas to reduce pain, improve function, and maximize efforts to preserve the joint. The purpose of this Technical Note is to describe our preferred arthroscopic approach to core decompression through the femoral neck in combination with femoral osteoplasty to address AVNFH and FAI in a single-staged and minimally invasive procedure.

Background: While labral repair has been widely adopted as the first line treatment for labral injury during hip arthroscopy, there is no widespread consensus on the procedural technique, including the number of anchors that should be used to avoid recurrent instability and revision surgery. Purpose: To determine if anchor density can predict patient-reported outcomes after arthroscopic labral repair in the hip. Study Design: Cohort study; Level of evidence, 3. Methods: Patients aged 18 to 50 years who underwent primary hip arthroscopic surgery with labral repair between January 2011 and December 2016 were identified from a prospectively collected database. Exclusion criteria consisted of previous ipsilateral surgery, osteoarthritis (Tönnis grade >1), and severe cartilage defects (Outerbridge grade III/IV) or concomitant labral reconstruction, capsular reconstruction, or microfracture. Minimum 2-year patient-reported outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score [HOS]–Activities of Daily Living [ADL], HOS–Sport Specific Subscale [SSS], 12-Item Short Form Health Survey [SF-12]), rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) for each score, revision surgery rate, and rate of conversion to total hip arthroplasty (THA) were compared based on anchor density (number of anchors per millimeter of labral tear). Results: A total of 634 hips (575 patients) with a mean age of 30.4 ± 9.5 years (range, 18.0-49.9 years) met inclusion criteria. The mean labral tear size was 31 ± 11 mm (range, 2-70 mm) with a median number of anchors used for labral repair of 3 (range, 1-7) and mean anchor density of 0.11 ± 0.08 anchors (range, 0.03-1.33) per millimeter of labral tear. Hips with a minimum 2-year follow-up (451/634 [71.1%]) had significant improvements on the mHHS, HOS-ADL, HOS-SSS, and SF-12 Physical Component Summary ( P < .001 for all). There was no significant correlation detected between anchor density or number of anchors used and postoperative scores (correlation coefficient range, –0.05 to 0.17; P > .05 for all). The rate of revision surgery was 6.4% (28 patients), with 8 hips found to have labral tears and/or deficiency on revision. Additionally, 6 hips (1.3%) had to undergo THA at a mean of 3.6 ± 2.1 years (range, 2.0-5.5 years). Conclusion: Anchor density did not have a correlation with postoperative outcomes, achieving the MCID or PASS, revision hip arthroscopic surgery, complications, or conversion to THA.

Purpose The purpose of this study was to determine whether radiographic parameters, intraoperative findings, patient-reported outcome measures, or intraoperative interventions that were performed differentiate those patients with >2 mm of joint space who convert under two years to total hip arthroplasty (THA) after undergoing hip arthroscopy for femoroacetabular impingement (FAI) when compared to those converting after 2 years. Methods Included in this study were patients who underwent conversion to THA within 2 years of primary hip arthroscopy from a prospectively collected patient registry from 2007 to 2017. Patients who underwent early conversions to arthroplasty were matched 1:1 with patients who converted after 2 years, based upon age and gender. Preoperative outcome scores were collected, including Short Form-12, modified Harris Hip Score, and Hip Outcome Score. Additionally, variables from the preoperative radiographic evaluation, surgical findings, and procedures performed were also compared. Results Forty-nine patients were included in the early conversion group and were matched with 49 patients in the later conversion group. Patients with lateral center edge angles of less than 25° were more likely to be in the early failure group [OR: 3.9; 95% CI: 1.01 to 15]. Patients with unipolar chondral defects on either the femoral (P = .128) or acetabular side (P = .656) were not at increased odds for early conversion compared to later conversion; however, those with bipolar chondral lesions at the time of surgery had increased odds of early conversions [OR: 3.3; 95% CI: 1.4 to 8] (P = .01). Neither surgical treatment nor preoperative patient-reported outcome measures were associated with early conversion. Conclusions In patient with >2 mm of joint space, lateral center edge angles of less than 25° and those with bipolar articular cartilage lesions seen at the time of hip arthroscopy are at increased risk for conversion to total hip arthroplasty within two years. Level of Evidence Level III, retrospective comparison study.

Orthobiologics encompass numerous substances that are naturally found in the human body including platelet-rich plasma (PRP), isolated growth factors, and cell therapy approaches to theoretically optimize and improve the healing of cartilage, fractures, and injured muscles, tendons, and ligaments.PRP is an autologous derivative of whole blood generated by centrifugation and is perhaps the most widely used orthobiologic treatment modality. Despite a vast amount of literature on its use in osteoarthritis as well as in tendon and ligament pathology, clinical efficacy results remain mixed, partly as a result of insufficient reporting of experimental details or exact compositions of PRP formulations used.Mesenchymal stromal cells (MSCs) can be isolated from a variety of tissues, with the most common being bone marrow aspirate concentrate. Similar to PRP, clinical results in orthopaedics with MSCs have been highly variable, with the quality and concentration of MSCs being highly contingent on the site of procurement and the techniques of harvesting and preparation.Advances in novel orthobiologics, therapeutic targets, and customized orthobiologic therapy will undoubtedly continue to burgeon, with some early promising results from studies targeting fibrosis and senescence.

Because of the unique theoretical surgical risks, including osteonecrosis, acute iatrogenic slipped capital femoral epiphysis, and epiphyseal injury, the optimal treatment strategy for femoroacetabular impingement (FAI) in growing adolescents has yet to be established. The aim of this study was to compare the clinical outcomes of primary arthroscopic treatment of FAI in growing adolescents with a matched adult group.Patients with FAI who underwent arthroscopic treatment with a minimum follow-up of 2 years were included. Patients with previous ipsilateral hip surgery, an Outerbridge grade of ≥3, a preoperative Tönnis grade of ≥2, or evidence of dysplasia (lateral center-edge angle of25°) were excluded. Eligible patients who were ≤19 years old and whose proximal femoral physis had not yet closed were matched to adult (20 to 40-year-old) counterparts in a 1:1 ratio by sex, body mass index, and time of surgery. For the adolescents, cam resection was performed with a physeal-sparing approach. Outcome scores, including the modified Harris hip score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and HOS-Sports-Specific Subscale (HOS-SSS), were prospectively collected.Of the 196 eligible adolescents, 157 (80%) were pair-matched to adult controls, with a median postoperative follow-up of 8.9 and 6.6 years, respectively. Fourteen (9%) of the adolescents required revision hip arthroscopy compared with 18 adults (11%) (p = 0.46). No patient in the adolescent group had conversion to a total hip arthroplasty (THA), while 3 in the adult group had a THA (p = 0.25). For adolescents without subsequent hip surgery, the median mHHS improved from 59 preoperatively to 96 postoperatively; the HOS-ADL, from 71 to 98; and the HOS-SSS, from 44 to 94 (p0.001), which were significantly higher postoperative scores than those of the matched adults (p0.05) despite similar or inferior baseline scores. No complications were found during the office visit or at the final follow-up.Hip arthroscopy performed with a physeal-sparing approach for FAI in growing adolescents is safe and effective and yields superior clinical outcomes compared with those in a matched adult group.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Labral augmentation has emerged as an essential procedure to address a deficient or irreparable labrum while preserving native labral tissue and restoring the hip suction seal mechanism. Purpose: To evaluate midterm outcomes of arthroscopic hip labral augmentation for labral insufficiency after previous hip arthroscopy. Study Design: Case series; Level of evidence, 4. Methods: Patients were identified from a prospectively collected database who underwent arthroscopic hip labral augmentation between January 2011 and January 2017 with a minimum 3-year follow-up. Pre- and postoperative patient-reported outcome scores were compared and included the 12-Item Short Form Health Survey physical and mental component summaries, Western Ontario and McMaster Universities Osteoarthritis Index, modified Harris Hip Score (mHHS), and Hip Outcome Score (HOS) (Activities of Daily Living [ADL] and Sport). Postoperative Tegner Activity Scale and patient satisfaction (1-10) scores were also evaluated. The minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) between the preoperative and minimum 3-year follow-up scores were calculated. Results: A total of 88 patients (39 men, 49 women) underwent revision hip arthroscopy with labral augmentation. The average age was 32.8 ± 11 years. Of these, 77 patients (88%) were available for the minimum 3-year follow-up. The survivorship (absence of conversion to total hip arthroplasty) at 3 years and 5 years was 93% at both time points, with a mean survival time of 8.5 years (95% CI, 8.0-8.9). Eleven patients (14%) required revision arthroscopic surgery for continued pain. Revisions occurred at a mean of 2.6 ± 1.4 years after augmentation. The mean follow-up was 5.2 ± 1.2 years (range, 3-9 years). For patients not requiring subsequent surgery (n = 61), all patient-reported outcome measures significantly improved, which included a 20-point increase in HOS-ADL (MCID, 82%; PASS, 72%) and mHHS (MCID, 78%; PASS, 70%). The median postoperative Tegner score was 4 (range, 1-10). The median postoperative patient satisfaction score was 9 out of 10 (range, 1-10). Conclusion: Arthroscopic hip labral augmentation is a successful treatment option for patients with labral insufficiency after previous hip arthroscopy, demonstrating improved patient-reported outcomes and survivorship of 93% at 3 years and 5 years. This technique provides a valuable labral preservation option when addressing hip labral pathology when viable native labral tissue remains.

Background: The role of hip arthroscopy in the treatment of patients with borderline hip dysplasia is controversial and evolving. Purpose: To evaluate outcomes at a minimum 10-year follow-up in patients who underwent hip arthroscopy for femoroacetabular impingement in a hip with borderline dysplasia. Study Design: Case series; Level of evidence, 4. Methods: All hips that underwent labral repair between June 2006 and March 2009 for femoroacetabular impingement with borderline dysplasia were included if they had a lateral center-edge angle of 20° to 25°, had primary hip arthroscopy for the diagnosis of femoroacetabular impingement, and were aged 18 to 70 years. Patients were excluded if they had previous hip surgery, avascular necrosis, or fracture. Kaplan-Meier survivorship was performed, with survivorship defined as avoidance of conversion to total hip arthroplasty (THA). Results: A total of 45 patients met the inclusion criteria, and 38 were contacted at a minimum 10 years postoperatively (84%; mean ± SD, 12 ± 1.3 years). There were 23 women and 15 men with an average age of 41 ± 9.6 years (range, 25-69). Twenty patients were ≥40 years of age. In this patient cohort, survivorship was 87% at 5 years and 79% at 10 years for conversion to THA. Of the 38 patients included, 9 were converted to THA (24%), and 3 required revision hip arthroscopy (7%). Patient age, Tönnis grade, microfracture of cartilage lesions, and Tönnis angle >15° were associated with conversion to THA. No statistically significant differences were found between those who underwent conversion to THA and those who did not regarding lateral center-edge angle, Sharp angle, or alpha angle. Significant improvements were seen at follow-up of 12 years (range, 10-13) for the modified Harris Hip Score (58 to 83; P = .002), Hip Outcome Score–Activities of Daily Living (70 to 87; P = .003), Hip Outcome Score–Sport (47 to 76; P = .004), and Western Ontario and McMaster Universities Osteoarthritis Index (31 to 10; P = .001). At follow-up, >80% maintained the minimal clinically important difference for the Hip Outcome Score (Activities of Daily Living and Sport) with no differences between patients aged Conclusion: Risk factors for conversion to THA after hip arthroscopy in the borderline dysplastic hip included older age, higher Tönnis grades, grade 4 chondral lesions that were microfractures, and Tönnis angle >15°. In those patients who did not convert to THA, improvement in outcome measures was seen at 10 years. Careful patient selection is critical to the success of this procedure.

Background: Within the hip joint, the anatomy of the acetabulum and cotyloid fossa is well established. There is little literature describing the association between the size of the cotyloid fossa relative to the acetabulum and characteristics of patients with femoroacetabular impingement (FAI). Purpose/Hypothesis: The purpose was to calculate the cotyloid fossa coverage percentage in the acetabulum and determine its association with patient characteristics, radiographic parameters, intra-articular findings, and preoperative patient-reported outcomes in patients with FAI. We hypothesized there is an association between the cotyloid fossa coverage percentage of the acetabulum and characteristics of patients with FAI. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were included who underwent standard clinical 3-T magnetic resonance imaging of the hip and primary arthroscopic FAI correction surgery during 2015 and 2016. Exclusion criteria were age 40 years, osteoarthritis, labral reconstruction, previous ipsilateral hip surgery, and hip dysplasia. Measurements of the cotyloid fossa and surrounding lunate cartilage were performed to calculate cotyloid fossa width (CFW) and cotyloid fossa height (CFH) coverage percentages. The relationships between coverage percentages and patient characteristics and intraoperative findings were assessed using independent t tests or Pearson correlations. Results: An overall 146 patients were included. Alpha angle negatively correlated with CFH coverage percentage ( r = −0.19; P = .03) and positively correlated with labral tear size ( r = 0.28; P < .01). CFH coverage percentage was negatively correlated with labral tear size ( r = −0.24; P < .01). Among patients with degenerative tears, CFH was negatively correlated with labral tear size ( r = −0.31; P < .01). However, this association was no longer significant after adjusting for sex (partial r = −0.10; P = .39). Cotyloid fossa coverage was not associated with the condition of the cotyloid fossa synovium (synovitis vs no synovitis). CFW coverage percentage was negatively correlated with the 12-Item Short Form Health Survey (SF-12) physical component summary score ( r = −0.23; P < .01). Conclusion: The CFW and CFH coverage percentages may be associated with alpha angle, labral tear size, and SF-12 physical component summary score in patients with FAI. We may be able to predict the labral condition based on preoperative measurements of CFH and CFW coverage percentages.

Background: Labral augmentation and labral reconstruction have emerged as essential procedures for restoring the anatomic and functional characteristics of the hip joint in patients with a deficient hip labrum or irreparable labral tear. Hypothesis/Purpose: The purpose of this study was to compare allograft and autograft hip labral reconstruction and augmentation. We hypothesized that autografts would entail fewer revision arthroscopic procedures. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were identified who underwent labral reconstruction or labral augmentation using iliotibial band (ITB) allograft or ITB autograft performed by a single surgeon between 2011 and 2017. Patient-reported outcome measures collected before surgery and at minimum 2-year follow-up included the following: Hip Outcome Score Activities of Daily Living and Hip Outcome Score Sports-Specific Subscale and, at follow-up, patient satisfaction (range, 1-10, with 10 being very satisfied). Patients followed a standardized rehabilitation protocol after surgery with relative individualization to address each patient's needs. For continuous variables, comparisons between allografts and autografts were made using Student t tests or Mann-Whitney tests. Categorical comparisons were assessed using chi-square or Fisher exact test. Multiple logistic regression was performed to determine the influence of graft choice on risk of revision or THA. Results: A total of 205 hips met 2-year inclusion criteria. ITB allografts were used for 55 patients (37 augmentations, 18 reconstructions) and ITB autografts for 150 patients (34 augmentations, 116 reconstructions). Females represented a greater proportion of allograft versus autograft patients (71% vs 46%, respectively; P = .001). Overall, autograft patients had larger alpha angles (66.6° vs 59.1°; P = .001) and longer grafts (46 vs 41 mm; P = .03) compared with allograft patients. A total of 13 (23.6%) patients required revision surgery in the allograft group compared with 11 (7.3%) in the autograft group ( P < .001). After controlling for sex, procedure (reconstruction vs augmentation), and previous surgery, the odds of revision were higher for allograft patients (OR, 4.1; 95% CI, 1.5-11.6). No significant differences in conversion to THA were observed between groups (allograft = 9%; autograft = 6%; P = .50), even after adjustment for the above covariates (OR, 2.3; 95% CI, 0.6-7.9). No differences in postoperative patient-reported outcome measures or patient satisfaction were observed between groups. Conclusion: Labral augmentation or reconstruction with autograft has a significantly lower revision rate than labral augmentation or reconstruction with allograft.

To evaluate outcomes of arthroscopic hip remplissage with folded iliotibial band allograft to treat cam over-resection.Patients who underwent arthroscopic iliotibial band hip remplissage from May 2013 to April 2018 were prospectively evaluated. Pre- and postoperative patient-reported outcome scores were compared and included the 12-Item Short Form Survey (SF12) Physical Health Composite Score (PCS), SF12 Mental Health Composite Score (MCS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), and Hip Outcome Score (HOS) (Activities of Daily Living [ADL] and Sport). Postoperative Tegner Activity Scale and patient satisfaction (1-10) were also evaluated.Thirteen patients (2 men, 11 women) with an average age of 39.8 ± 9 years underwent arthroscopic hip remplissage with minimum 2-year and mean 3.1-year follow-up (range, 2.1-4.1 years). One hundred percent follow-up was achieved. The average number of previous surgeries was 1.38 (range, 1-3). One patient underwent total hip arthroplasty 2 years after remplissage. All 12 patients who did not undergo total hip arthroplasty had improved patient-reported outcomes after remplissage (mean scores: SF12 PCS 36 vs 42, P = .02; SF12 MCS 45 vs 51, P = .14; mHHS 45 vs 66, P.001; minimal clinically important difference [MCID] 83%; WOMAC 42 vs 28, P.001; HOS ADL 52 vs 69, P = .003; MCID, 67%; HOS Sport 27 vs 46, P = .015; MCID, 67%). All improvements met statistical significance, besides the SF12 MCS. Median postoperative Tegner score was 2.9. Median postoperative patient satisfaction was 7 out of 10 (range, 5-10).Arthroscopic hip remplissage is a successful salvage treatment option for hip instability caused by previous cam over-resection. Care must be taken during primary surgery not to over-resect the cam as patient-reported outcomes after remplissage are inferior to those undergoing primary hip arthroscopy.Level IV, case series.

Background: The treatment of pincer deformity in hip arthroscopy remains controversial, with some authors advocating that over resection may risk early joint deterioration. The role of acetabular resection depth and postoperative acetabular morphology on postoperative outcomes has yet to be defined. Purpose/Hypothesis: This study measures the influence of acetabular resection depth and postoperative lateral center-edge angle (LCEA) on minimum 5-year patient-reported outcomes (PROs), revision rates, and conversion to total hip arthroplasty using a single surgeon’s prospective database. We hypothesized that patients with acetabular resections >10°, as measured by LCEA, or patients with postoperative LCEA outside the normal range of 25° to 35° would have lower PROs, higher revision rates, and higher conversion to total hip arthroplasty at midterm follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 192 patients who underwent primary hip arthroscopy with acetabuloplasty and labral repair by a single surgeon with a minimum 5-year follow-up met the inclusion criteria. Preoperative and postoperative LCEAs were measured on supine anteroposterior radiographs, and patients were divided into cohorts based on LCEA and acetabular resection depth. Cohorts for postoperative LCEA were 35° (borderline overcoverage). Cohorts for acetabular resection depth were 10° difference from preoperative to postoperative LCEA. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short Form Health Survey, modified Harris Hip Score, Hip Outcome Score, satisfaction scores, revision rates, and conversion to arthroplasty rates. Results: Patients significantly improved in all outcome score measures at final follow-up. There were no statistically significant differences in PRO scores or conversion to total hip arthroplasty between any cohorts in the postoperative LCEA group. There were more revisions in the 25° to 35° cohort than the other cohorts ( P = .02). The 5-10° resection depth cohort demonstrated a higher postoperative WOMAC score ( P = .03), but otherwise no statistically significant differences were seen between resection depth cohorts in the remaining postoperative outcomes scores, revision rates, or conversion to total hip arthroplasty rates. Conclusion: Patients with postoperative LCEA values outside the normal reference range and with large resections perform similar to those with normal postoperative LCEA values and smaller resections at a minimum 5-year follow-up.

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

In the setting of femoroacetabular impingement, the acetabular labrum may be torn or pathologic, and it must be surgically repaired to restore the native suction seal and hip function. However, the current methods of arthroscopic suture passage commonly result in some degree of disruption of the chondrolabral junction, with penetration and shuttling of the repair sutures. Novel instrumentation and surgical techniques have aimed to repair the acetabular labrum with decreased violation of the intrasubstance fibers to provide anatomic eversion/inversion of the labrum to restore the suction seal. In this Technical Note, we describe a method of suture passage through the use of a self-grasping suture-passing device that allows for anatomic labral repair while maintaining the chondrolabral junction as well as minimizing iatrogenic damage the labrum intrasubstance fibers.

Background:The acetabular labrum contains free nerve endings, and an unstable labrum can result in increased femoral head movement during hip motion. This can be caused by chondrolabral junction (CLJ) separation, especially in association with pincer-type femoroacetabular impingement, and may contribute to hip pain.Hypothesis:Rim resection alone has no effect on suction seal biomechanics. Further, separation of the CLJ changes hip suction seal biomechanics when compared with those of the native state, whereas repair and refixation with suture anchors restore these biomechanical parameters.Study Design:Controlled laboratory study.Methods:A total of 12 fresh-frozen human cadaveric hips were used in this study. Hips were mounted in a saline bath on a dynamic tensile testing machine and were distracted at a rate of 0.5 mm/s from neutral position. A total of 3 parameters (force, displacement, and intra-articular pressure) were measured throughout testing. Before testing, hips were randomly allocated to 1 of 2 groups: 1 that included the CLJ separation (CLJ Cut group) and 1 that did not (CLJ Intact group). Hips were tested in the following states: (1) native, (2) rim trimming, (3) separated CLJ (CLJ Cut group only), and (4) labral repair/refixation. For each group a linear mixed-effects model was used to compare biomechanical parameters between states.Results:Rim trimming did not affect any suction seal parameters relative to those of the native state. In the CLJ Cut group, no significant difference in distance to break the suction seal was observed for any states compared with that of the native state. In the CLJ Intact group, the distance to break the suction seal was significantly shorter in the labral refixation state (1.8 mm) than the native state (5.6 mm; P = .002). The maximum distraction force (62.1 ± 54.1 N) and the peak negative pressure (−36.6 ± 24.2 kPa) of the labral repair/refixation state were significantly lower than those of the native state in both groups (93.4 ± 41.7 N, P = .01; –60.7 ± 20.4 kPa, P = .02).Conclusion:Rim trimming did not change the biomechanical properties of the labral suction seal. Labral refixation resulted in a shorter distance to break the labral suction seal. This indicates that labral mobility is reduced by the labral refixation procedure, which could be beneficial in postoperative pain relief and labral healing.Clinical Relevance:The labral refixation reduced labral mobility, which could be beneficial for both pain relief and labral healing to the acetabulum after pincer-type femoroacetabular impingement resection.

Background Labral reconstruction has been shown to result in improved patient-reported outcomes (PROs) at mid-term follow-up in patients with a deficient labrum. The purpose of this study was to determine survivorship and PROs at a minimum 10-year follow-up. Methods A retrospective evaluation of a prospectively collected single-surgeon database included 91 hips (89 patients) that underwent arthroscopic labral reconstruction with iliotibial band autograft between 2006 and 2008. The primary PRO was the Hip Outcome Score (HOS)-activities of daily living (ADL). The modified Harris hip score (mHHS), HOS-sports, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and patient satisfaction (on a scale of 1 to 10) were also collected at a 10-year minimum follow-up. Survivorship analysis curves were evaluated. Results Eighty-two hips were evaluated at a 10-year minimum follow-up. Overall survivorship, with revision hip arthroscopy or total hip arthroplasty (THA) as the end point, was 70% at 5 years and 61% at 10 years, and the mean survival time was 9 years (95% confidence interval = 7.6 to 10 years). For the patients who did not undergo subsequent surgery, on average the mHHS increased from 60 preoperatively to 82 at the 10-year follow-up (p = 0.001), the HOS-ADL improved from 69 to 90 (p = 0.004), the HOS-sports improved from 43 to 76 (p = 0.001), and the median patient satisfaction was 10 of 10. Eighty percent of the patients achieved the minimal clinically important difference (MCID) in the HOS-ADL, and 87% obtained a patient acceptable symptom state (PASS). Conclusions Following arthroscopic labral reconstruction with iliotibial band autograft, 9% of the hips underwent revision arthroscopy and 27% underwent THA. At 10 years, the survival rate, with revision hip arthroscopy or THA as the end point, was 61%; however, for those with >2 mm of joint space, the current indication for labral reconstruction, the 10-year survival rate was 90%. Excellent PROs and patient satisfaction were reported by those who did not require revision or THA. With appropriate patient selection and prevention of postoperative adhesions, labral reconstruction results in excellent outcomes and high patient satisfaction that is sustained at a minimum 10-year follow-up. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Aims Femoroacetabular impingement (FAI) is a potential cause of hip osteoarthritis (OA). The purpose of this study was to investigate the expression profile of matrix metalloproteinases (MMPs) in the labral tissue with FAI pathology. Methods In this study, labral tissues were collected from four FAI patients arthroscopically and from three normal hips of deceased donors. Proteins extracted from the FAI and normal labrums were separately applied for MMP array to screen the expression of seven MMPs and three tissue inhibitors of metalloproteinases (TIMPs). The expression of individual MMPs and TIMPs was quantified by densitometry and compared between the FAI and normal labral groups. The expression of selected MMPs and TIMPs was validated and localized in the labrum with immunohistochemistry. Results On MMP arrays, most of the targeted MMPs and TIMPs were detected in the FAI and normal labral proteins. After data normalization, in comparison with the normal labral proteins, expression of MMP-1 and MMP-2 in the FAI group was increased and expression of TIMP-1 reduced. The histology of the FAI labrum showed disorderly cell distribution and altered composition of thick and thin collagen fibres. The labral cells expressing MMP-1 and MMP-2 were localized and their percentages were increased in the FAI labrum. Immunohistochemistry confirmed that the percentage of TIMP-1 positive cells was reduced in the FAI labrum. Conclusion This study established an expression profile of MMPs and TIMPs in the FAI labrum. The increased expression of MMP-1 and MMP-2 and reduced expression of TIMP-1 in the FAI labrum are indicative of a pathogenic role of FAI in hip OA development. Cite this article: Bone Joint Res. 2020;9(4):173–181.

Purpose To quantify the damage to the soft tissue stabilizers of the hip after a transverse interportal capsulotomy and subspine trimming in hip arthroscopy. Methods Eight human cadaveric hemipelvises underwent hip arthroscopy through a transverse interportal capsulotomy. Arthroscopic subspine trimming performed on all specimens was classified according to an anatomic index. The width of the proximal capsule was measured before and after subspine trimming. The extent of damage to the iliofemoral ligament (IFL) after dissection was recorded. Potential damage to pericapsular structures was assessed by measuring the distance between the capsulotomy and rectus femoris and iliocapsularis muscle with an electronic caliper. Results In all specimens, ≥50% of the width of the IFL was damaged. The subspine trimming was successfully performed in 7 of 8 specimens (87.5%) according to the proposed index. The sizes of the trimmed bone area measured in the anteroposterior and proximal-distal axis were 21.2 ± 7.5 and 13.1 ± 9 mm, respectively (mean ± standard deviation). The width of the proximal capsule at the anterior and posterior corner of the capsulotomy was 19.8 ± 5.2 and 11.8 ± 1.7 mm, respectively. After subspine trimming, the mean width of the anterior and posterior proximal capsular attachments was 6.4 ± 1.4 and 7.0 ± 1.6 mm, respectively. On average, 13.4 mm of anterior capsule was damaged after anterior inferior iliac spine trimming, versus 4.7 mm of the posterior capsule. The distances from the capsulotomy to the rectus femoris direct and reflected head were 6.8 ± 4.9 and 6.3 ± 7.7 mm, respectively, and to the iliocapsularis muscle, 11.5 ± 7.8 mm. Conclusion High rates of damage to the IFL were observed with the interportal capsulotomy. Increased tissue damage at the anterior capsule was observed after subspine trimming. The width of the proximal capsular attachment was ≥5 mm in all specimens. Clinical Relevance Surgeons should be aware of the potential damage to the native capsule and pericapsular structures when using a transverse interportal capsulotomy for the arthroscopic subspine decompression. Level of Evidence IV: cadaveric study, case series.

The purpose of this systematic review was to assess the indications, outcomes, and complications of hip arthroscopy in individuals 50 years of age or older over the past 5 years.The electronic databases PUBMED, MEDLINE, and EMBASE were searched on March 3, 2022, for studies assessing the use of primary hip arthroscopy for patients aged 50 years or older from the past 5 years. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively.Overall, 17 studies were included, consisting of 6,696 patients (37.5%) with a mean age of 61.4 ± 5.0 years and a median follow-up of 24 months (range: 1.4-70.1). Indications for hip arthroscopy in patients aged 50 years or older were unspecified/undefined (93.8%), mixed pathology (i.e., combined femoroacetabular impingement [FAI], labral tear, osteoarthritis, etc.) (2.7%), and FAI (2.6%). Eleven studies demonstrated significant improvement in functional outcome scores from baseline to final follow-up. Of the 6 studies that compared outcomes across multiple age groups, 3 demonstrated significantly worse functional outcomes, and 2 demonstrated significantly higher rates of conversion to THA for older patients compared to younger patients. Lastly, the overall complication rates ranged from 0 to 38.3%. The rate of conversion to THA ranged from 0 to 34.6%, occurring between 6 and 60 months postoperatively.Hip arthroscopy for patients aged 50 years or older yields significant improvements in patient-reported outcomes postoperatively compared to baseline, with a moderate rate of conversion to THA (range: 0 to 34.6%). Clinicians should consider patient history (e.g., imaging, comorbidities, etc.) and values when electing for hip arthroscopy in the older population.IV, systematic review of Level III and IV studies.

Background: The most reliable suture technique for capsular closure after a capsulotomy remains unknown. Purpose: To determine which suture technique best restores native stability after a 5-cm interportal capsulotomy. Study Design: Controlled laboratory study. Methods: Ten human cadaveric hip specimens were tested using a 6-degrees-of-freedom robotic arm in 7 states: intact, capsular laxity, 5-cm capsulotomy, standard suture, shoelace, double shoelace, and Quebec City slider (QCS). Rotational range of motion (ROM) was measured across 9 tests: flexion, extension, abduction, abduction at 45° of flexion, adduction, external rotation, internal rotation, anterior impingement, and log roll. Distraction (ie, femoral head translation [FHT]) was measured across a range of flexion and abduction angles. Results: When compared with the native state, the 5-cm capsulotomy state showed the largest laxity increases on all tests, specifically in external rotation ROM (+13.4°), extension ROM (+11.5°), and distraction FHT (+4.5 mm) ( P < .001 for all). The standard suture technique was not significantly different from the 5-cm capsulotomy on any test and demonstrated significantly more flexion ROM than the double shoelace suture (+1.41°; P = .049) and more extension ROM (+5.51°; P = .014) and external rotation ROM (+6.03°; P = .021) than the QCS. The standard suture also resulted in significantly higher distraction FHT as compared with the shoelace suture (+1.0 mm; P = .005), double shoelace suture (+1.4 mm; P < .001), and QCS (+1.1 mm; P = .003). The shoelace, double shoelace, and QCS techniques significantly reduced hip laxity when compared with the 5-cm capsulotomy state, specifically in external rotation ROM (respectively, –8.1°, –7.8°, and –10.2°), extension ROM (–6.3°, –7.3°, and –8.1°), and distraction FHT (–1.8, –2.2, and –1.9 mm) ( P ≤ .003 for all). These 3 techniques restored native stability (no significant difference from intact) on some but not all tests, and no significant differences were observed among them on any test. Conclusion: Hip capsule closure with the standard suture technique did not prevent postoperative hip instability after a 5-cm capsulotomy, and 3 suture techniques were found to be preferable; however, none perfectly restored native stability at time zero. Clinical Relevance: The shoelace, double shoelace, and QCS suture techniques are recommended when closing the hip capsule.