Proximal Hamstring Tears: Endoscopic Hamstring Repair.

Proximal hamstring tears are common among athletes, especially in sports involving eccentric lengthening during forced hip flexion and knee extension, such as hurdles or water skiing. Tears are described by timing (acute [<1 month] or chronic) and severity (partial or complete). Complete tears are easily identified with magnetic resonance imaging; however, partial tears may be subtle and potentially missed. The spectrum of pathology associated with acute injuries ranges from minor strains to complete tears or avulsions. Acute tears commonly present as pain and bruising over the posterior thigh along with weakness with active knee flexion and often a sensation of instability of the lower extremity. Chronic injuries typically present with ischial pain associated with repetitive activities, and the spectrum includes chronic tendinopathies, ischial bursitis, partial tears, and nonoperatively treated complete tears. Nonoperative treatment is recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. Further, surgical repair of complete tears with retraction is usually recommended for active patients. Historically, surgical treatment has been limited to open surgical approaches, although endoscopic management of proximal hamstring tears and chronic ischial bursitis is an option. Our endoscopic technique employs the use of two anchors, double loaded with high-strength suture, and may support a faster recovery due to decreased surgical morbidity. It is important to note that some patients may not be candidates for this endoscopic repair as a result of several factors, including prior chronic and retracted tears, as well as those with altered regional tissue planes due to prior surgical repair.

Editorial Commentary: Biomechanical Analyses of the Hip Capture Are Way Too Simple! The Capsule Is Just One Piece of the Puzzle.

The hip capsule is clearly a significant part of the hip and the considerations that we need to take into account when performing hip arthroscopy. Any study that adds some further clarity to this important structure is welcome and appreciated. The inherent problem with all of these articles is the lack of application to the reality of a living, breathing patient whose capsule changes following time zero of the capsular intervention and also whose negative intra-articular pressure is immediately violated and not recreated following any intervention that is undertaken. Hip capsular closure and perhaps even imbrication is indicated in some cases, but in many cases, it is a nonissue.

Sonographic evaluation of anterior inferior iliac spine morphology demonstrates excellent accuracy when compared to false profile view.

PURPOSE: To compare ultrasound examination to false profile radiographs in identification and classification of AIIS morphology. The study hypothesis stated that sonographic imaging of the AIIS correlates well to AIIS morphology seen on false profile radiographs. METHODS: Fifty-three hips in 30 consecutive patients met the inclusion criteria. A single, fellowship trained, orthopedic surgeon performed an ultrasound on all of the patients to evaluate the AIIS morphology. The patients underwent standing false profile radiographs. The US and radiographic images were independently reviewed and classified according to Hetsroni classification of AIIS morphology by two senior, fellowship trained, orthopedic surgeons. Agreement between the two raters was calculated for each imaging modality (inter-rater agreement) as well as the agreement between the rating in each modality by the same rater ("inter-method" agreement). RESULTS:  The agreement between the raters (inter-rater agreement) for morphologic evaluation of the AIIS by means of FP view was 88.8% (p < 0.001) and that by means of US was 81.5%(p < 0.001). The overall accuracy of the US compared to the FP view was 92.3% (48/52) for both rater 1 and 2. CONCLUSION:  This study showed near-perfect agreement in analyzing the morphology of the AIIS in a group of patients with hip pathology. Office sonographic evaluation of the AIIS is reliable and, therefore, may be routinely utilized in the clinic setting avoiding unnecessary radiation exposure to the patient. LEVEL OF EVIDENCE: Level II.

Editorial Commentary: It's Not the Age; It's the Story: Acetabular Labral Repair.

The major factor separating a good from a poor outcome in any study is appropriate indications. We don't operate on x-rays, magnetic resonance images, or computed tomography scans alone; we operate on clinical symptoms. With proper patient selection, we can achieve good outcomes from hip arthroscopic surgery in many older patients. There is no controversy involved in performing hip arthroscopy for an older patient. The key is to prospectively identify the proper candidates.

Reliability of the Tönnis Classification and Its Correlation With Magnetic Resonance Imaging and Intraoperative Chondral Damage.

PURPOSE: To evaluate the reliability of the Tönnis classification in the setting of femoroacetabular impingement (FAI) hips without dysplasia. METHODS: Forty-nine patients with FAI underwent preoperative radiography and magnetic resonance imaging (MRI). Radiographs were evaluated in 2 separate settings by 5 observers and graded according to the Tönnis classification. Interobserver and intraobserver reliability was calculated using the κ coefficient. Intraoperative chondral damage was assessed, and chondral damage to the acetabulum (acetabular labrum articular disruption [ALAD] classification) and to the femur (Outerbridge classification) was graded. The Spearman coefficient was computed to quantify the degree of correlation between the Tönnis grade and MRI-detected chondral damage, as well as intraoperative chondral damage. RESULTS: The average intraobserver reliability of the Tönnis classification was moderate (κ = 0.472), and the interobserver reliability was fair (κ = 0.287). Statistically significant positive correlations were found between the Tönnis classification and the ALAD classification (P = .0087) and between the Tönnis classification and femoral chondral damage detected by MRI (P = .0247). A statistically significant correlation was not found between the Tönnis grade and the intraoperative Outerbridge classification of the femur (P = .4969), between the Tönnis grade and acetabular chondral damage on MRI (P = .4969), or between the Tönnis grade and the ability to detect a chondral flap on MRI (P = .2160). No statistically significant correlation was found between the ALAD classification and the presence or absence of a chondral flap on MRI (P = .3538), between the ALAD classification and MRI-detected chondral damage to the acetabulum (P = .103), or between the Outerbridge classification and the degree of chondral damage observed on MRI of the femur (P = .1922). CONCLUSIONS: The Tönnis classification and MRI have substantial limitations when evaluating nondysplastic hips with FAI for the degree of chondral damage and arthritis. LEVEL OF EVIDENCE: Level III, retrospective comparative study of prospective data.

Endoscopic Proximal Hamstring Repair and Ischial Bursectomy Using Modified Portal Placement and Patient Positioning.

Endoscopic management has become an effective method to repair proximal hamstring injuries. However, due to the complexity of such a procedure, the dissemination of the technique of endoscopic hamstring repair has occurred slowly among orthopaedic surgeons. This Technical Note with a video modifies previously described techniques and provides safer and more simplified endoscopic management of proximal hamstring injuries.

Incorporating Hip Arthroscopy Into A Practice.

Hip arthroscopy is one of the most rapidly growing areas in orthopaedic surgery because of increased awareness of nonarthritic hip pathologies, advanced imaging modalities, and advanced techniques to reproducibly manage nonarthritic hip pathologies within a deep soft-tissue envelope and a constrained joint. In addition, more academic medical centers are providing residents with education on hip arthroscopy, and many hip preservation fellowships and courses are helping increase awareness of nonarthritic hip pathologies. Nonarthritic hip pathologies currently managed via hip arthroscopy include nonrepairable labral lesions, femoroacetabular impingement, hip instability, and hip fractures. Periarticular hip pathologies currently managed via endoscopy include greater trochanteric pain syndrome, tendinopathy and tears of the gluteus medius and minimus, partial and complete hamstring avulsions, and sciatic nerve entrapment. Ischiofemoral impingement may be addressed endoscopically via the deep gluteal space. Orthopaedic surgeons should understand the role and safety of hip arthroscopy in the pediatric population, specifically in the management of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and septic arthritis of the hip. The efficacy of hip arthroscopy is limited, and hip arthroscopy is relatively contraindicated in patients with osteoarthritis and hip dysplasia. Complications can occur and likely are underreported in patients who undergo hip arthroscopy. Orthopaedic surgeons should understand practical issues associated with incorporating hip arthroscopy into a practice, including the difficult learning curve associated with hip arthroscopy and the reluctance of some payors to reimburse procedures performed arthroscopically because hip arthroscopy is a relatively new technology.

Editorial Commentary: Gluteal Pain Syndrome of the Hip: It's Been There All Along!

The diagnosis and management of deep gluteal syndrome of the hip is currently evolving and the lack of prospective studies makes it even more difficult to discern what is the appropriate treatment. The communication between physicians managing this problem needs to improve to coordinate care better and limit the amount of unnecessary studies that these patients typically undergo.

Editorial Commentary: Please Simplify Hip Arthroscopy.

Hip arthroscopy is a challenging technical procedure for which basic science principles have not been thoroughly discerned with respect to the procedures we perform. In this commentary, a plea is made to continue to expand the science behind what we do, but in as simple a fashion as possible such that more surgeons are willing to learn perfect hip arthroscopy.

Hamstring injuries.

There is a continuum of hamstring injuries that can range from musculotendinous strains to avulsion injuries. Although the proximal hamstring complex has a strong bony attachment on the ischial tuberosity, hamstring injuries are common in athletic population and can affect all levels of athletes. Nonoperative treatment is mostly recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. The technique presented on this article allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now has been managed exclusively with much larger open approaches. The procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.

Anterior hip capsuloligamentous reconstruction for recurrent instability after hip arthroscopy.

A variety of complications, including iatrogenic anterior hip instability, have been reported after hip arthroscopy. We present a case of a patient sustaining a postoperative anterior hip dislocation after cam resection for treatment of femoroacetabular impingement. Our patient developed persistent instability and required anterior capsuloligamentous reconstruction with iliotibial autograft. We present a comprehensive review of the literature on postoperative hip instability after hip arthroscopy, including the role of capsulotomy closure, and use of postoperative orthotics and weight-bearing restrictions.

Intra-abdominal fluid extravasation during hip arthroscopy: a survey of the MAHORN group.

PURPOSE: The purpose of this study was to survey experts in the field of hip arthroscopy from the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group to determine the frequency of symptomatic intra-abdominal fluid extravasation (IAFE) after arthroscopic hip procedures, identify potential risk factors, and develop preventative measures and treatment strategies in the event of symptomatic IAFE. METHODS: A survey was sent to all members of the MAHORN group. Surveys collected data on general hip arthroscopy settings, including pump pressure and frequency of different hip arthroscopies performed, as well as details on cases of symptomatic IAFE. Responses to the survey were documented and analyzed. RESULTS: Fifteen hip arthroscopists from the MAHORN group were surveyed. A total of 25,648 hip arthroscopies between 1984 and 2010 were reviewed. Arthroscopic procedures included capsulotomies, labral reattachment after acetabuloplasty, peripheral compartment arthroscopy, and osteoplasty of the femoral head-neck junction. Of the arthroscopists, 7 (47%) had 1 or more cases of IAFE (40 cases reported). The prevalence of IAFE in this study was 0.16% (40 of 25,650). Significant risk factors associated with IAFE were higher arthroscopic fluid pump pressure (P = .004) and concomitant iliopsoas tenotomy (P < .001). In all 40 cases, the condition was successfully treated without long-term sequelae. Treatment options included observation, intravenous furosemide, and Foley catheter placement, as well as 1 case of laparotomy. CONCLUSIONS: Symptomatic IAFE after hip arthroscopy is a rare occurrence, with an approximate prevalence of 0.16%. Prevention of IAFE should include close intraoperative and postoperative monitoring of abdominal distention, core body temperature, and hemodynamic stability. Concomitant iliopsoas tenotomy and high pump pressures may be risk factors leading to symptomatic IAFE. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33).

PURPOSE: The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders. METHODS: This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥ 4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients). RESULTS: Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points. CONCLUSIONS: We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

Endoscopic proximal hamstring repair and ischial bursectomy.

With the significant increase in use of the arthroscope around the hip have come several less invasive techniques to manage pathologies around this joint. This technical note with a video details one such technique that allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now have been managed exclusively with much larger open approaches. This procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.

Differences in physician and patient ratings of items used to assess hip disorders.

BACKGROUND: The purpose of this study was to determine what issues are important to active individuals with hip lesions and to assess whether these issues are different from those that surgeons think are important. HYPOTHESIS: A discrepancy will be noted between what patients and surgeons believe to be important. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This study comprised 150 consecutive patients (73 men, 77 women) from the international practices of 9 orthopaedic surgeons specializing in the management of hip disorders. All participants were seeking treatment for musculoskeletal hip disease. Average patient age was 42 +/- 11 years (range, 18-60). Patients and surgeons rated the importance of 146 potential hip outcome assessment items on a 6-point Likert-type scale. RESULTS: Of the 23 items identified as being important to patients, 16 were in the sports and recreation category. The top 11 items that the clinicians thought were most important were rated significantly lower by patients (P < .0005). Specifically, surgeons rated several items as being important that fell into the symptoms, functional limitations, and occupational issues categories, whereas patients did not. That is, a difference was found between patients and clinicians in how they rated items related to symptoms, functional limitations, and occupation (P < .01). A difference was not found between patients and surgeons in how they rated items related to sports and recreation and social-emotional lifestyle (P > .01). CONCLUSION: The hypothesis of this study was affirmed: a discrepancy was found between what issues patients believe are important and what surgeons perceive as being important to patients. This information may be particularly important when assessing treatment outcomes from a patient's perspective. Clinicians must be careful in presuming that the issues that they are attempting to improve with treatment are issues that are important to patients. These findings also emphasize the importance of discussing appropriate postoperative expectations for those considering surgery.

The 23-point arthroscopic examination of the hip: basic setup, portal placement, and surgical technique.

The 23-point arthroscopic examination of the hip has been used for more than 400 arthroscopic hip procedures. It ensures that all components of the hip are carefully inspected and allows for proper documentation. It is vital that a precise knowledge of hip anatomy and common portal placement is coupled with proper patient selection, sound preoperative planning, and a consistent arthroscopic technique in order to maximize clinical outcomes. The 23-point arthroscopic examination of the hip uses 3 standard portals (anterior, anterolateral, and posterolateral) that provide a systematic method of examination of the key structures of the central and peripheral hip joint. The points are divided up into groups based on the portal through which they are viewed. The 23-point arthroscopic examination of the hip is reproducible, and offers some standardization within the evolving field of hip arthroscopy. It provides a consistent routine for hip arthroscopy that has yet to be published. Using this standardized examination can assist with the diagnostic accuracy of hip arthroscopy.

Advanced techniques in hip arthroscopy.

The indications for hip arthroscopy are expanding as the understanding of hip disease increases. Improved instrumentation and technical skills also have facilitated the ability to treat some hip disorders arthroscopically. Femoroacetabular impingement (FAI) is increasingly recognized as a disorder that can lead to progressive intra-articular chondral and labral injury. Although FAI is usually treated through an open approach, limited-open and all-arthroscopic approaches have been described. Various arthroscopic techniques allow treatment of labral and acetabular rim pathology as well as peripheral compartment femoral head-neck abnormalities. Early outcomes of limited-open and all-arthroscopic treatment of FAI are only beginning to be reported but appear to compare favorably with those of open dislocation procedures. Although labral tears traditionally have been treated with simple débridement, concerns have been raised about the consequences of removing the labrum. Modified portal placement and hip-specific suture anchors are now being used in an effort to repair some labral tears. Snapping hip disorders typically are treated nonsurgically. For persistent symptoms, arthroscopic release is successful, compared with open release, and allows additional evaluation of the hip joint during surgery. Diagnosis and management of traumatic and atraumatic hip instability continue to be challenging. Hip arthroscopy has been shown to be effective in the treatment of hip instability in some patients. The extra-articular peritrochanteric space is receiving increased attention. The arthroscopic anatomy has been well defined, but the treatment of greater trochanteric pain syndrome and arthroscopic repair of abductor tendon tears are only beginning to be reported. Improved techniques and longer-term outcomes studies will further define the optimal role of hip arthroscopy.

Clinical update: MR imaging of the hip.

With the increasing awareness of hip pathologies and their treatment with arthroscopic surgery, an explosion in the knowledge base has occurred. With this expansion has come the need to assess many injuries with magnetic resonance imaging and other modalities. This update will serve to delineate the common injuries that are seen and their imaging assessment.