Association of Postless Distraction in Hip Arthroscopy With Decreased Postoperative Groin Numbness.

BACKGROUND: Patients undergoing hip arthroscopy performed with perineal post distraction may experience postoperative nerve and soft tissue complications related to the perineal post. PURPOSE: To compare rates of postoperative numbness in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with postless distraction and perineal post distraction methods. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of prospectively collected data was performed on patients who underwent hip arthroscopy for FAIS, with postless distraction and perineal post distraction methods. Medical records were reviewed for patient characteristics, radiographic data, and operative data. Traction force data were collected on all patients prospectively using a previously validated method. Data on postoperative numbness (presence/absence and regionality) were collected prospectively at routine postoperative follow-ups (6-week and 3-month postoperative clinic visits). RESULTS: Overall, 195 patients were included, with 94 patients (mean age, 30.4 years) in the postless distraction cohort and 101 patients (mean age, 31.9 years) in the post distraction cohort. The overall numbness rates were 29 of 94 (30.9%) in the postless distraction group and 45 of 101 (44.6%) in the post distraction group (P = .068). Rates of postoperative groin numbness were 1 of 94 (1.1%) in the postless distraction group and 19 of 101 (18.8%) in the post distraction group (P < .001). Multivariate analysis for postoperative groin numbness demonstrated post distraction (odds ratio [OR], 16.5; P = .022) and traction time (OR, 1.7; P = .020) to be statistically significant variables. In subgroup analysis of the post distraction group, traction time (P = .015), but not holding (P = .508) or maximum traction force (P = .665), reached statistical significance in patients who developed postoperative groin numbness. CONCLUSION: Postless distraction hip arthroscopy demonstrated a statistically significantly lower rate of groin numbness rates in comparison with a traditional perineal post distraction method. In the post distraction group, traction time was significantly higher in patients who developed postoperative groin numbness than in those who did not.

Postless Hip Distraction Systems Decrease the Amount of Traction Force Needed to Obtain Adequate Hip Distraction Versus a Conventional Post Hip Distractor.

PURPOSE: To directly compare hip distraction distance and traction force data for hip arthroscopy performed using a post-basedsystem versus a postless system. METHODS: Adult patients undergoing primary hip arthroscopy for femoroacetabular impingement were prospectively enrolled. Before March 26, 2019, arthroscopy was performed using a post-based system. After this date, the senior author converted to using a postless system. Intraoperative traction force and fluoroscopic distraction distance were measured to calculate hip stiffness coefficients at holding traction (k-hold) and maximal traction (k-max). We used multivariable regression analysis to determine whether postless arthroscopy was predictive of lower stiffness coefficients when controlling for other relevant patient-specific factors. RESULTS: Hip arthroscopy was performed with a post-based system in 105 patients and with a postless system in 51. Mean holding traction force (67.5 ± 14.0 kilograms-force [kgf] vs 55.8 ± 15.3 kgf) and mean maximum traction force (96.0 ± 16.6 kgf vs 69.9 ± 14.1 kgf) were significantly lower in the postless group. On multivariable analysis, postless traction was an independent predictor of decreased k-hold (ß = -31.4; 95% confidence interval, -61.2 to -1.6) and decreased k-max (ß = -90.4; 95% confidence interval, -127.8 to -53.1). Male sex, Beighton score of 0, and poor hamstring flexibility were also predictors of increased k-hold and k-max in the multivariable model. CONCLUSIONS: Postless traction systems decrease the amount of traction force required for adequate hip distraction for both maximal and holding traction forces when compared with post-based systems. Postless traction systems may help further reduce distraction-type neurologic injuries and pain after hip arthroscopy by lowering the traction force required to safely distract the hip. LEVEL OF EVIDENCE: Level III, prospective cohort-historical control comparative study.

Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy.

Background: Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy. Purpose/Hypothesis: The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use. Study Design: Case-control study; Level of evidence 3. Methods: The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes. Results: Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003). Conclusion: Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.

The Blackburne-Peel Index for Determining Patellar Height Is Affected by Tibial Slope.

PURPOSE: To establish a quantitative relationship between the Blackburne-Peel index and posterior tibial slope in both skeletally mature and skeletally immature individuals and to evaluate the rate at which variation in tibial slope influences changes in patellar height categorization as normal, patella alta, and patella baja. METHODS: A consecutive series of lateral knee radiographs were retrospectively reviewed. Radiographs were excluded for rotation, inadequate visible proximal tibia length, and obstructive hardware/pathology. Modified tibial slopes of 0°, 5°, 10°, and 15° were projected anteriorly from the medial tibial plateau as described by Blackburne-Peel. The Blackburne-Peel index was determined at each modified tibial slope interval. Caton-Deschamps and Insall-Salvati indices also were measured for comparison. The rate of Blackburne-Peel index change with increase in posterior tibial slope was quantitatively analyzed. RESULTS: Fifty skeletally mature and 50 skeletally immature radiographs were included. In the skeletally mature, Blackburne-Peel indices decreased on average by 0.037, 0.044, and 0.049 as posterior tibial slope increased from 0-5°, 5-10°, and 10-15°, respectively. In the skeletally immature, Blackburne-Peel indices decreased on average by 0.045, 0.053, and 0.059 as posterior tibial slope increased from 0-5°, 5-10°, and 10-15°, respectively. Overall, 29 individuals with 0° of tibial slope were categorized as patella alta by the Blackburne-Peel index, and only 16 (55%) remained categorized as patella alta after increasing their posterior tibial slope to 15°. CONCLUSIONS: This study quantitatively demonstrates the relationship between posterior tibial slope and the Blackburne-Peel index. As expected, as posterior tibial slope increases, the Blackburne-Peel index decreases. While the change in the Blackburne-Peel index per 5° change in tibial slope appears to be small, nearly half (45%) of individuals categorized as patella alta with 0° of tibial slope were categorized as normal when their posterior tibial slope was systematically increased from 0° to 15°. When evaluating patellar height, it is important to understand how tibial slope affects the Blackburne-Peel Index measurement. CLINICAL RELEVANCE: As posterior tibial slope increases, the numerator of the Blackburne-Peel ratio decreases, and vice versa. This relationship can lead to incorrect assessment of patellar height. Objectively placing individuals into patella alta and baja categories may influence patient care and decision making.

Femoral Neck Shaft Angle and Management of Proximal Femur Fractures: Is the Contralateral Femur a Reliable Template?

OBJECTIVES: To (1) assess interrater reliability of a novel technique for measurement of neck shaft angle (NSA); (2) use pelvic anteroposterior (AP) radiographs of unaffected hips to assess variability of NSA; and (3) evaluate the side-to-side variability of NSA to determine reliability of using the contralateral hip as a template. DESIGN: Retrospective cohort study. SETTING: Academic Level 1 regional trauma center. PATIENTS/PARTICIPANTS: Four hundred six femora (203 patients) with standing AP pelvis radiographs were selected. Exclusions included lack of acceptable imaging, congenital abnormalities, or prior hip surgery. INTERVENTION: An AP pelvis radiograph in the standing position. MAIN OUTCOME MEASUREMENTS: Bilateral NSA measurements obtained in a blinded fashion between 2 reviewers. Pearson coefficients and coefficient of determination assessed correlations and variability between left and right NSA. Concordance correlation coefficients assessed the interrater reliability between measurements performed by the 2 reviewers. RESULTS: Two hundred three patients (406 femora) were assessed. Male patients had a lower overall NSA mean of 131.56 degrees ± 4.74 than females with 133.61 degrees ± 5.17. There was no significant difference in NSA side-to-side in females (P = 0.18), 0.3 degrees [95% confidence interval (-0.15 to 0.75)], or males (P = 0.68), 0.19 degrees [95% confidence interval (-0.74 to 1.12)]. There was a strong linear relationship between left and right femora (r2 = 0.70). Forty-one percent of patients fell within the 131-135 degrees range bilaterally. Eighty-eight percent of patients had <5 degrees difference in NSA bilaterally and 0% had >10 degrees difference. CONCLUSIONS: There is no significant variability between bilateral femora in males and females. Use of this measurement method and contralateral NSA for proximal femur fracture planning is supported.

Joint Venting Prior to Hip Distraction Minimizes Traction Forces During Hip Arthroscopy.

PURPOSE: This study evaluates the effect of venting on distraction of the hip during arthroscopy on a post-free traction table for fixed traction forces ranging from 0 to 100 pounds (lbs). METHODS: Patients underwent surgery by the senior author (S.K.A.) between November 2018 and July 2019. Inclusion criteria were primary hip arthroscopy requiring central compartment access. Patients were positioned in 10-15° Trendelenburg on a post-free traction table. Prior to instrumentation, fluoroscopic images of the operated hip joint were taken at 25-lb intervals from 0 to 100 lbs of axial traction. Traction was released for 15 minutes. Venting with 20 mL of air was performed and fluoroscopic images were repeated at all traction intervals. Joint displacement was measured at all intervals. An unvented control group underwent the same axial traction protocol for comparison. RESULTS: Sixty-one consecutive patients underwent study protocol. Fifty-eight hips in 57 patients were included. Thirty-two (55.2%) were female; mean age was 31 ± 13 years and mean body mass index was 25.7 ± 6.2. Paired samples analysis demonstrated mean differences in distraction distance prior to and after venting of 0.27, 2.60, 4.09, 4.54, and 2.31 mm at 0, 25, 50, 75, and 100 lbs of traction, which were significant (P < .001) at all traction intervals. Significantly more vented hips distracted at least 10 mm at 25-100 lbs traction (P ≤ .001). An unvented control group showed no significant differences between the first and second traction application. CONCLUSIONS: Venting prior to applying traction on a post-free traction table increases the distraction distance achieved for a given traction force at multiple levels of traction in comparison to the pre-vented state. Our results suggest venting the hip joint prior to the application of traction may serve to reduce the maximal amount of traction required to safely instrument the hip arthroscopically. LEVEL OF EVIDENCE: IV, case series.

A 2-Week Course of Naproxen for Heterotopic Ossification Prophylaxis Is Effective Following Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To evaluate the effectiveness of 2 weeks of naproxen prophylaxis for heterotopic ossification (HO) after primary hip arthroscopy for femoroacetabular impingement (FAI). METHODS: All consecutive hip arthroscopy cases by a single surgeon from January 1, 2015, to December 31, 2016, were retrospectively reviewed. Cases were included if they met the following criteria: (1) Primary hip arthroscopy, including femoral neck osteoplasty, for FAI; (2) naproxen prophylaxis for 2 weeks' duration; and (3) radiographic follow-up at a minimum of 3 months postoperatively. Radiographic imaging for each patient was evaluated for the presence of HO, and independent radiology reports were used to confirm patients with HO. Maximal size of HO was measured and classified according to the Brooker criteria. Demographic and operative variables of the patients included in this study who received naproxen prophylaxis for 2 weeks were formally compared with a cohort of patients who received naproxen prophylaxis for 3 weeks in a previous randomized controlled trial. RESULTS: A total of 185 patients who received naproxen prophylaxis for 2 weeks were included in the study, 5 of whom developed HO (3%). A total of 48 patients who received naproxen prophylaxis for 3 weeks were included for comparison, 2 of whom developed HO (4%). There was no significant difference in the rate of HO formation between 2 weeks and 3 weeks of naproxen prophylaxis (P = .597). All 7 cases of HO were classified as Brooker class 1. CONCLUSIONS: The observed rate of postoperative heterotopic ossification after 2 weeks of naproxen prophylaxis in this study was equivalent to that observed after 3 weeks' prophylaxis in a previously published study. Two weeks of naproxen prophylaxis may be a sufficient treatment course for the prevention of heterotopic ossification after primary hip arthroscopy for FAI. LEVEL OF EVIDENCE: Level III - Retrospective Comparative Study.

A Narrow Posterior Joint Space on a False Profile Radiograph Does Not Correlate With Posterior Joint Cartilage Degeneration in Hip Preservation Patients.

PURPOSE: To evaluate whether a narrow posterior joint space (<2 mm) correlated with posterior joint cartilage degeneration in the hip preservation patient population. METHODS: A retrospective chart review of 155 consecutive hip arthroscopy cases by a single surgeon (SKA) from March 2012 to February 2013 was performed. Patients were included in the study if they had an adequate perioperative false profile radiograph and clear intraoperative arthroscopic images of the posterior hip joint. The narrowest posterior joint space (NPJS) width and the directly posterior, posterosuperior, superior, and anterosuperior joint space widths were measured on the false profile radiograph. Femoral and acetabular cartilage of the posterior hip joint were graded according to the International Cartilage Repair Society (ICRS) classification system using arthroscopic images obtained at the time of surgery. The cartilage grades of patients with <2 mm NPJS were compared with cartilage grades of patients with ≥2 mm NPJS. RESULTS: There was no difference in cartilage grading between patients with <2 mm NPJS (19 patients) and those with ≥2 mm NPJS (81 patients) (P = .905). The mean age of patients with NPJS ≥2 mm and <2 mm was 34.0 (median 31.2; interquartile range [IQR] 23.7, 42.9) and 38.7 (median 43.0; IQR 26.1, 50.9) respectively, and was not statistically different (P = .183). No correlation between cartilage grade and NPJS measurement was found (P = .374). CONCLUSION: In this predominantly cam-type femoroacetabular impingement patient cohort, our findings indicate there is no correlation between a <2 mm posterior hip joint narrowing seen on false profile radiographs and posterior hip cartilage degeneration confirmed with arthroscopy. Although posterior arthritis can be visualized on a false profile radiograph, a posterior joint space measurement <2 mm should not be interpreted as isolated posterior joint wear and should not be considered a hip arthroscopy contraindication. LEVEL OF EVIDENCE: Level IV, case series.

Leg dominance as a risk factor for femoroacetabular impingement syndrome.

One etiological factor of femoroacetabular impingement syndrome (FAIS) is high impact athletics involving deep hip flexion, axial loading and jumping during skeletal development. Previous work has established that there is physiologic asymmetry of the lower limbs regarding function, with the dominant limb being primarily responsible for propulsion and kicking while the non-dominant limb is responsible for stability and planting. The authors hypothesize that the dominant limb will be more likely to undergo hip arthroscopy for symptomatic FAIS. Four hundred and sixty-nine patients at a single surgical center who underwent primary or revision hip arthroscopy for cam-type FAIS were identified. Patients were asked to identify their dominant lower extremity, defined as the lower extremity preferred for kicking. Sixty patients who indicated bilateral leg dominance were excluded. It was assumed that with no association between limb dominance and the need for surgery, the dominant side would have surgery 50% of the time. Enrichment for surgery in the dominant limb was tested for using a one-sample test of proportions, determining whether the rate differed from 50%. The enrichment for surgery on the dominant side was 57% (95% confidence interval 52-62%) which was significantly different from the rate expected by chance (50%), P = 0.003. No other significant differences were noted between groups. Limb dominance appears to be an etiological factor in the development of cam-type FAIS. Patients are more likely to undergo arthroscopic treatment of FAIS on their dominant lower extremity, although the non-dominant lower extremity frequently develops FAIS as well.

The Bipolar Hip: How Acetabular and Femoral Pathomorphology Affects Hip Motion in Femoral Acetabular Impingement Syndrome.

PURPOSE: To investigate the individual and combined contributions of acetabular and femoral morphology to hip range of motion (ROM) in patients with femoroacetabular impingement syndrome (FAIS) by use of computed tomography measurements and hip ROM evaluated on physical examination. METHODS: A retrospective chart and radiographic analysis of patients presenting with hip pain suggestive of FAIS was performed. The femoral neck-shaft angle, femoral version, magnitude and clock-face location of the alpha angle, midcoronal center-edge angle (CEA), midsagittal CEA, acetabular version, and McKibbin index were measured on computed tomography scans. Univariate and multivariate linear regression analyses determined which measurements correlated with hip ROM, including hip flexion as well as hip internal and external rotation with the hip in 90° of flexion. RESULTS: Two hundred hips that met the inclusion and exclusion criteria during the eligibility period were included in the analysis. The mean age was 31.9 ±10.0 years, there were 145 female patients (72%), and the mean body mass index was 25.2 ± 5.0. Multivariate linear regression analysis showed that the midsagittal CEA was the only measurement correlating with flexion (q = .031) whereas the femoral neck-shaft angle and McKibbin index were the only significant variables that correlated with external rotation (q = .031 and q < .001, respectively). Finally, the McKibbin index and maximum alpha angle were the only variables that correlated with internal rotation (q < .001 and q = .034, respectively). CONCLUSIONS: Multivariate analysis showed that combined acetabular and femoral version significantly correlated with internal and external rotation whereas femoral version in isolation did not. Increased cam morphology remained a significant contributor to reduced internal rotation but did not affect hip flexion. These data suggest that hip ROM is affected by both femoral pathomorphology and acetabular pathomorphology and that careful evaluation of both should be conducted prior to corrective osteoplasty or osteotomy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The effects of venting and capsulotomy on traction force and hip distraction in hip arthroscopy.

This study evaluated the effects of venting and capsulotomy on the ratio of normalized distraction distance to traction force, correlating this trend with patient demographic factors. A ratio was chosen to capture the total effect of each intervention on the hip joint. During primary hip arthroscopy, continuous traction force was recorded, and fluoroscopic images were acquired to measure joint distraction before and after the application of traction, venting and interportal capsulotomy. Distraction-traction force ratios were compared using a one-sided paired t-test. A linear regression model was used to determine the relationship between age, sex and body mass index and pre- and post-intervention distraction-traction force ratios. Seventy-two adult patients and 73 hips were included. There was an increase in hip distraction with a decrease in traction force post-venting and capsulotomy (both P's <0.001). Mean normalized distraction distance increased 1.5% of femoral head size after venting and an additional 2.2% of femoral head size after capsulotomy. Mean traction force decreased 2.2% (14.7 N) after venting and 2.3% (15.3 N) after capsulotomy. Female sex significantly correlated with larger differences in both pre- and post-venting capsulotomy ratios. Venting and capsulotomy both independently improve the ratio of normalized distraction distance to traction force when performed in vivo. However, the effect sizes of each intervention are small and of questionable clinical significance. Specifically, when adequate distraction for safe surgical hip access cannot be obtained despite application of significant traction force, venting and capsulotomy after the application of traction may not afford substantial improvement.

Traumatic Pediatric Quadriceps Rupture After Medial Patellofemoral Ligament Reconstruction: A Case Report.

CASE: A healthy 14-year-old boy, who presented with recurrent patellar instability, underwent medial patellofemoral ligament (MPFL) reconstruction. Four weeks following this operation, the patient slipped and fell while wearing his knee brace and was found to have sustained a quadriceps tendon rupture. CONCLUSIONS: We present a case of a rare, previously undescribed complication following an MPFL reconstruction in a young athlete. The etiology of this particular injury pattern may be due to a disruption of the vascular supply to the superior pole of the patella. Orthopaedic surgeons performing these reconstructions should be aware of this unusual complication.

Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy.

PURPOSE: To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness. METHODS: Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness. RESULTS: A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3 minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2 days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P = .04). Neither traction time nor force were associated with generalized numbness (P = .85 and P = .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P = .001 and P = .005, respectively). CONCLUSIONS: Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1 hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade. LEVEL OF EVIDENCE: IV, case series.

Knee Extension Does Not Reliably Reduce Acute Type II Tibial Spine Fractures: MRI Evaluation of Displacement During Extension Versus Resting Flexion.

BACKGROUND: Type II tibial spine avulsion (TSA) fractures have traditionally been managed by first attempting to achieve closed reduction with extension and immobilization, with surgical indications reserved for those who fail to reduce within 3 mm. However, the frequency with which appropriate reduction can be achieved is largely unknown. PURPOSE: To evaluate changes in displacement of type II TSA fractures by comparing magnetic resonance imaging (MRI) scans obtained with the knee in flexion and in extension. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Ten patients with type II TSA fractures were identified. Fracture displacement was measured using 3 images for each patient: (1) initial lateral view radiography, (2) sagittal-plane MRI of the knee in resting flexion, and (3) sagittal-plane MRI of the knee in passive extension. Maximum displacement of the bony fragment was measured in the 2 MRI studies for all patients, and the corresponding change in displacement was calculated. Displacement in flexion was compared with displacement in extension using a paired-sample t test. Statistical significance was set at P < .05. RESULTS: The displacement distance of the bony fragment was reduced by a mean of 0.97 mm on MRI when the knee was in extension compared with flexion in patients with type II TSA fractures (P = .02). Mean displacement with extension was 6.14 mm, with no fractures reduced below 4 mm. The largest reduction observed was 2.80 mm. The displacement distance increased in 2 knees with extension. The intermeniscal ligament (IML) was entrapped in 4 of 10 patients; however, the amount of reduction achieved did not differ based on the presence of IML entrapment (P = .85). CONCLUSION: While the amount of tibial spine displacement warranting surgical treatment can be debated, the study findings suggest that knee extension is not reliable in obtaining adequate closed reduction for type II TSA fractures. Management decisions may need to be based on the initial displacement distance of the fracture, with a lower threshold for operative treatment than previously recognized.

Understanding Preoperative Demographics and Risk Factors for Early Revision Surgery in Patients Undergoing Hip Arthroscopic Surgery: A Large Database Study.

BACKGROUND: Hip arthroscopic surgery has become an increasingly common surgical technique to diagnose and treat various hip abnormalities. While increased efficacy has been reported, debate remains regarding appropriate surgical indications. Multiple factors including patient demographics, surgical procedure, and underlying disease have been associated with poor surgical outcomes. Preoperative diagnostic and treatment interventions including physical therapy and injections may affect surgical indications and outcomes. PURPOSE: To identify patient characteristics and preoperative factors associated with an increased risk of early revision surgery and/or extended postoperative medical care after index hip arthroscopic surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Utah's All Payer Claims Database, a state-mandated registry containing data from all payers, including private insurance, Medicare Advantage, and Medicaid, was queried to identify patients who underwent hip arthroscopic surgery during a 3-year period (January 1, 2013, to December 31, 2015). Demographics, comorbidities, nonoperative care modalities, pain medications, and revision procedures were collected using claims data at 6 months preoperatively and 12 months postoperatively. RESULTS: A total of 1283 patients who underwent primary hip arthroscopic surgery were analyzed, of whom 57.6% (n = 739) were female. Within 1 year of index surgery, 7.8% and 2.1% of patients underwent revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA), respectively. Patients older than 60 years and male patients were more likely to undergo revision arthroscopic surgery (odds ratio [OR], 0.89; P < .001 and OR, 1.59; P = .04, respectively) and convert to THA (OR, 1.03; P = .01 and OR, 2.25; P = .05, respectively). Preoperative opioid use was significantly associated with increased odds of revision surgery (OR, 1.64; P = .05) and THA (OR, 2.70; P = .03). No significant relationship existed between preoperative physical therapy or intra-articular hip injections and revision hip arthroscopic surgery (OR, 1.20; P = .45 and OR, 1.18; P = .52, respectively) or conversion to THA (OR, 0.89; P = .79 and OR, 0.71; P = .46, respectively). CONCLUSION: This study showed that predictable patient factors can effectively guide preoperative decision making and may improve prognosis. Certain patient pools require optimization preoperatively, and a subset of patients appears to require additional surgical indications.

Arthroscopic Reduction and Fixation of a Lesser Trochanter Avulsion Nonunion.

Identifying and treating avulsion fractures of the pelvis and proximal femur in adolescent athletes has become increasingly more important as the rate of competitive sports participation has grown. The majority of these fractures can be treated conservatively, with most returning to full activity. Surgical treatment of these injuries has been traditionally indicated for >2 cm displacement, painful nonunion, symptomatic exostosis formation, or persistent pain and symptoms. Lesser trochanter avulsion injuries are extremely rare and literature outlining their surgical treatment lacking. We present our method of arthroscopic reduction and fixation of lesser trochanter avulsion nonunions.

Extracapsular local infiltration analgesia in hip arthroscopy patients: a randomized, prospective study.

Hip arthroscopy patients can experience significant post-operative pain. Many strategies to combat this pain have been explored including nerve blocks, which can be costly. An alternative option for pain management is local infiltration analgesia (LIA) which has been studied in hip and knee arthroplasty, but its ability to decrease pain in the setting of hip arthroscopy remains uncertain. A prospective randomized controlled trial of 74 patients who underwent hip arthroscopy at a single medical center was performed. Thirty-seven patients received a 20-ml extracapsular injection of 0.25% bupivacaine-epinephrine under direct arthroscopic visualization after capsular closure while 37 from the control group received no injection. Primary outcome measures were both maximum and discharge numeric rating scale (NRS) pain scores while in the post-anesthesia care unit (PACU). The LIA group had a statistically significant decrease in the maximum PACU NRS score (6.16 versus 7.35, P = 0.009), however this did not reach the level of minimal clinically important difference of 1.5. There was an insignificant difference in discharge PACU pain scores. This is the first randomized controlled trial studying extracapsular LIA in hip arthroscopy. While LIA offers an uncomplicated and low-cost approach to post-operative pain management, this specific technique did not reduce pain to a clinically significant level.

Patient-Specific Parameters Associated With Traction in Primary and Revision Hip Arthroscopic Surgery.

BACKGROUND: Distraction of the hip joint is a necessary step during hip arthroscopic surgery. The force of traction needed to distract the hip is not routinely measured, and little is known about which patient factors may influence this force. PURPOSE: To quantify the force of traction required for adequate distraction of the hip during arthroscopic surgery and explore the relationship between hip joint stiffness and patient-specific demographics, flexibility, and anatomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 101 patients (61 female) undergoing primary hip arthroscopic surgery were prospectively enrolled. A load cell attached to the traction boot continuously measured traction force. Fluoroscopic images were obtained before and after traction to measure joint displacement. The stiffness coefficient was calculated as the force of traction divided by joint displacement. Relationships between the stiffness coefficient and patient demographics and clinical parameters were investigated using a univariable regression model. The regression analysis was repeated separately by patient sex. Variables significant at P < .05 were included in a multivariable regression model. RESULTS: The instantaneous peak force averaged 80 ± 18 kilogram-force (kgf), after which the force required to maintain distraction decreased to 57 ± 13 kgf. In univariable regression analysis, patient sex, alpha angle, hamstring flexibility, and Beighton hypermobility score were each correlated to stiffness. However, patient sex was the only significant variable in the multivariable regression model. Intrasex analysis demonstrated that increased hamstring flexibility correlated with decreased final holding stiffness in male patients and that higher Beighton scores correlated with decreased maximal stiffness in female patients. CONCLUSION: Male patients undergoing primary arthroscopic surgery have greater stiffness to hip distraction during arthroscopic surgery compared with female patients. In male patients, stiffness increased with decreasing hamstring flexibility. In female patients, increased Beighton scores corresponded to decreased stiffness. The presence of a labral tear was not correlated with stiffness to distraction. These data may be used to identify patients in whom a specific focus on capsular repair and/or plication may be warranted.

Revisiting the Anteroinferior Iliac Spine: Is the Subspine Pathologic? A Clinical and Radiographic Evaluation.

BACKGROUND: Subspine impingement is a recognized source of extraarticular hip impingement. Although CT-based classification systems have been described, to our knowledge, no study has evaluated the morphology of the anteroinferior iliac spine (AIIS) with plain radiographs nor to our knowledge has any study compared its appearance between plain radiographs and CT scan and correlated AIIS morphology with physical findings. Previous work has suggested a correlation of AIIS morphology and hip ROM but this has not been clinically validated. Furthermore, if plain radiographs can be found to adequately screen for AIIS morphology, CT could be selectively used, limiting radiation exposure. QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the prevalence of AIIS subtypes in a cohort of patients with symptomatic femoroacetabular impingement; (2) to compare AP pelvis and false profile radiographs with three-dimensional (3-D) CT classification; and (3) to correlate the preoperative hip physical examination with AIIS subtypes. METHODS: A retrospective study of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome was performed. Between February 2013 and November 2016, 601 patients underwent hip arthroscopy. To be included here, each patient had to have undergone a primary hip arthroscopy for the diagnosis of femoroacetabular impingement syndrome. Each patient needed to have an interpretable set of plain radiographs consisting of weightbearing AP pelvis and false profile radiographs as well as full documentation of physical findings in the medical record. Patients who additionally had a CT scan with 3-D reconstructions were included as well. During the period in question, it was the preference of the treating surgeon whether a preoperative CT scan was obtained. A total of 145 of 601 (24%) patients were included in the analysis; of this cohort, 54% (78 of 145) had a CT scan and 63% (92 of 145) were women with a mean age of 31 ± 10 years. The AIIS was classified first on patients in whom the 3-D CT scan was available based on a previously published 3-D CT classification. The AIIS was then classified by two orthopaedic surgeons (TGM, MRK) on AP and false profile radiographs based on the position of its inferior margin to a line at the lateral aspect of the acetabular sourcil normal to vertical. Type I was above, Type II at the level, and Type III below this line. There was fair interrater agreement for AP pelvis (κ = 0.382; 95% confidence interval [CI], 0.239-0.525), false profile (κ = 0.372; 95% CI, 0.229-0.515), and 3-D CT (κ = 0.325; 95% CI, 0.156-0.494). There was moderate to almost perfect intraobserver repeatability for AP pelvis (κ = 0.516; 95% CI, 0.284-0.748), false profile (κ = 0.915; 95% CI, 0.766-1.000), and 3-D CT (κ = 0.915; 95% CI, 0.766-1.000). The plane radiographs were then compared with the 3-D CT scan classification and accuracy, defined as the proportion of correct classification out of total classifications. Preoperative hip flexion, internal rotation, external rotation, flexion adduction, internal rotation, subspine, and Stinchfield physical examination tests were compared with classification of the AIIS on 3-D CT. Finally, preoperative hip flexion, internal rotation, and external rotation were compared with preoperative lateral center-edge angle and alpha angle. RESULTS: The prevalence of AIIS was 56% (44 of 78) Type I, 39% (30 of 78) Type II, and 5% (four of 78) Type III determined from the 3-D CT classification. For the plain radiographic classification, the distribution of AIIS morphology was 64% (93 of 145) Type I, 32% (46 of 145) Type II, and 4% (six of 145) Type III on AP pelvis and 49% (71 of 145) Type I, 48% (70 of 145) Type II, and 3% (four of 145) Type III on false profile radiographs. False profile radiographs were more accurate than AP pelvis radiographs for classification when compared against the gold standard of 3-D CT at 98% (95% CI, 96-100) versus 80% (95% CI, 75-85). The false profile radiograph had better sensitivity for Type II (97% versus 47%, p < 0.001) and specificity for Types I and II AIIS (97% versus 53%, p < 0.001; 98% versus 90%, p = 0.046) morphology compared with AP pelvis radiographs. There was no correlation between AIIS type as determined by 3-D CT scan and hip flexion (rs = -0.115, p = 0.377), internal rotation (rs = 0.070, p = 0.548), flexion adduction internal rotation (U = 72.00, p = 0.270), Stinchfield (U = 290.50, p = 0.755), or subspine tests (U = 319.00, p = 0.519). External rotation was weakly correlated (rs = 0.253, p = 0.028) with AIIS subtype. Alpha angle was negatively correlated with hip flexion (r = -0.387, p = 0.002) and external rotation (r = -0.238, p = 0.043) and not correlated with internal rotation (r = -0.068, p = 0.568). CONCLUSIONS: The findings in this study suggest the false profile radiograph is superior to an AP radiograph of the pelvis in evaluating AIIS morphology. Neither preoperative hip internal rotation nor impingement tests correlate with AIIS type as previously suggested questioning the utility of the AIIS classification system in identifying pathologic AIIS anatomy. LEVEL OF EVIDENCE: Level III, diagnostic study.

Is the Lesser Trochanter Profile a Reliable Means of Restoring Anatomic Rotation After Femur Fracture Fixation?

BACKGROUND: Restoring normal femoral rotation is an important consideration when managing femur fractures. Femoral malrotation after fixation is common and several preventive techniques have been described. Use of the lesser trochanter profile is a simple method to prevent malrotation, because the profile changes with femoral rotation, but the accuracy of this method is unclear. QUESTIONS/PURPOSES: The purposes of this study were (1) to report the rotational profiles of uninjured femora in an adult population; and (2) to determine if the lesser trochanter profile was associated with variability in femoral rotation. METHODS: One hundred fifty-five consecutive patients (72% female and 28% male) with a mean age of 32 years (range, 12-56 years) with a CT scanogram were retrospectively evaluated. Patients were included if CT scanograms had adequate cuts of the proximal and distal femur. Patients were excluded if they had prior hip/femur surgery or anatomic abnormalities of the proximal femur. CT scanogram measurements of femoral rotation were compared with the lesser trochanter profile (distance from the tip of the lesser trochanter to the medial cortex of the femur) measured on weightbearing AP radiographs. These measurements were made by a single fellowship-trained orthopaedic surgeon and repeated for intraobserver reliability testing. Presence of rotational differences based on sex and laterality was assessed and correlation of the difference in lesser trochanter profile to the difference in femoral rotation was determined using a coefficient of determination (r). RESULTS: The mean femoral rotation was 10.9° (SD ± 8.8°) of anteversion. Mean right femoral rotation was 11.0° (SD ± 8.9°) and mean left femoral rotation was 10.7° (SD ± 8.7°) with a mean difference of 0.3° (95% confidence interval [CI], -1.7° to 2.3°; p = 0.76). Males had a mean rotation of 9.4°(SD ± 7.7°) and females had a mean rotation of 11.5° (SD ± 9.1°) with a mean difference of 2.1° (95% CI, -0.1° to 4.3°; p = 0.06). Mean lesser trochanter profile was 6.6 mm (SD ± 4.0 mm). Mean right lesser trochanter profile was 6.6 mm (SD ± 3.9 mm) and mean left lesser trochanter profile was 6.5 mm (SD ± 4.0 mm) with a mean difference of 0.1 mm (-0.8 mm to 1.0 mm, p = 0.86). The lesser trochanter profile varied between the sexes; males had a mean of 8.3 mm (SD ± 3.4), and females had a mean of 5.9 mm (SD ± 4.0). The mean difference between sexes was 2.5 mm (1.5-3.4 mm; p < 0.001). The magnitude of the lesser trochanter profile measurement and degree of femoral rotation were positively correlated such that increasing measures of the lesser trochanter profile were associated with increasing amounts of femoral anteversion. The lesser trochanter profile was associated with femoral version in a linear regression model (r = 0.64; p < 0.001). Thus, 64% of the difference in femoral rotation can be explained by the difference in the lesser trochanter profile. Intraobserver reliability for both the femoral version and lesser trochanter profile was noted to be excellent with intraclass correlation coefficients of 0.94 and 0.95, respectively. CONCLUSIONS: This study helps define the normal femoral rotation profile among adults without femoral injury or bone deformity and demonstrated no rotational differences between sexes. The lesser trochanter profile was found to be positively associated with femoral rotation. Increasing and decreasing lesser trochanter profile measurements are associated with increasing and decreasing amounts of femoral rotation, respectively. CLINICAL RELEVANCE: The lesser trochanter profile can determine the position of the femur in both anteversion and retroversion, supporting its use as a method to restore preinjury femoral rotation after fracture fixation. Although some variability in the rotation between sides may exist, matching the lesser trochanter profile between injured and uninjured femora can help reestablish native rotation.