Knotless Tensionable Anchors: Versatility, Tips, and Tricks.

Arthroscopic surgery, including implants and advanced techniques, continues to advance in the field of orthopaedics. The evolution of suture anchors has undergone design changes, passing from first-generation metal anchors, biodegradable materials, different plastic polymers, to all-suture constructs. Knotless technology also has been found to be a more reproducible method and have comparable outcomes with those found using knotted anchors. This Technical Note describes the advantages and different ways this tensionable anchor can be used in arthroscopic procedures. This implant and its understanding will be useful in the sports medicine area by simplifying procedures and making them more reproducible. The aim of the present Technical Note is to detail the simplicity and versatility of the anchor and discuss different scenarios in which this technology can be used to address common hip pathologies.

Long-Term Outcomes of Arthroscopic Labral Treatment of Femoroacetabular Impingement in Adolescents: A Nested Propensity-Matched Analysis.

BACKGROUND: Hip arthroscopy has demonstrated effectiveness as a treatment for femoroacetabular impingement (FAI) in adult patients, with promising long-term outcomes. However, there is a paucity of literature regarding the adolescent population. The purposes of our study were to report on survivorship and patient-reported outcomes (PROs) at a minimum 10-year follow-up in adolescent patients who underwent hip arthroscopy for FAI and labral tears and to compare the survivorship and outcomes of this population with those of a nested, propensity-matched adult control group. METHODS: Data regarding adolescent patients who underwent primary hip arthroscopy between February 2008 and January 2012 were reviewed. Patients with a minimum 10-year follow-up for the modified Harris hip score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were eligible. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, a Tönnis grade of >1, or dysplasia. In the subanalysis, adolescent patients were matched to young adult patients with use of a 1:1 ratio on the basis of sex, body mass index, Tönnis grade, lateral center-edge angle (LCEA), labral treatment, capsular treatment, and additional procedures performed during the surgery. RESULTS: A total of 74 patients (61 female and 13 male; 74 hips) with a mean (and standard deviation) age of 16.7 ± 1.4 years and a minimum follow-up of 10 years were included. The latest follow-up occurred at a mean of 125.4 ± 5.3 months (range, 120.0 to 144.1 months). Significant improvement in all PROs from baseline and 100% survivorship were demonstrated at the 10-year follow-up. In the subanalysis, 58 adolescent hips were propensity-matched to 58 young adult hips. The adolescent group had higher postoperative scores for the HOS-SSS (p = 0.021), NAHS (p = 0.021), and iHOT-12 (p = 0.042) than the young adult group. Patient satisfaction at the latest follow-up was also significantly higher in the adolescent group (p = 0.00061). The rate of survivorship free from conversion to THA was similar between the adolescent and control groups (100% versus 96.6%; p = 0.200). CONCLUSIONS: Adolescents undergoing hip arthroscopy for the treatment of FAI and labral tears demonstrated excellent outcomes and a high rate of survivorship. These outcomes were superior to those seen in a matched adult group. The results of this study indicate that hip arthroscopy in adolescents is a safe procedure that leads to improvement in outcomes at long-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

TEMPORARY REMOVAL: Favorable and Durable Outcomes at 10-Year Follow Up After Endoscopic Gluteus Medius Repair With Concomitant Hip Arthroscopy.

The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Utility of 3D Planning Software in Understanding Residual Proximal Femoral Deformity for Planning of Revision Hip Arthroscopy.

BACKGROUND: During the early evolution of femoroacetabular impingement (FAI) treatment, undercorrection of femoral deformity was a leading cause of hip arthroscopy failures. As the pendulum has swung, overresection of femoral deformity has increased in prevalence as a cause of persistent hip pain after arthroscopy. Computed tomography (CT) scans are increasingly being used in hip arthroscopy for preoperative planning purposes and may allow for improved 3-dimensional (3D) assessment of complex femoral deformities after previous femoroplasty. PURPOSE: To assess whether CT scans provide additional utility over standard radiographs in understanding proximal femoral morphology in patients being evaluated for revision hip arthroscopy after previous femoroplasty in the setting of FAI. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Preoperative CT scans and standard radiographs were obtained in 80 patients who underwent revision hip arthroscopy for FAI. The anteroposterior and Dunn radiographic views were used to assess patients for residual proximal femoral deformity and were compared with the CT scan views using a commercially available software program. Determinations of underresection were made using alpha angle, while overresection was determined according to a previously described technique. Chi-square tests were performed to determine statistical significance between radiographic and CT classifications of overresection, underresection, and concomitant over- and underresection. A kappa value was calculated to determine the agreement between measurements on the radiographs and CT scans. RESULTS: There were 30 patients (37.5%) for whom the CT scans revealed information about femoral morphology that was not detected on the radiographs. The kappa value of agreement was 0.28 between CT and radiographic measurements. Underresected cams were detected in 30 patients (37.5%) on CT scans versus 17 patients (21.3%) on radiographs (P = .024). Overresected cams were detected in 31 patients (38.8%) on CT scans versus 14 patients (17.5%) on radiographs (P = .0049). Concomitant areas of under- and overresection were detected in 12 patients (15.0%) on CT scans versus 3 patients (3.8%) on radiographs (P = .027). CONCLUSION: CT scans with 3D planning software may be more sensitive than traditional radiographic views at detecting aberrant proximal femoral anatomy in the setting of failed FAI surgery. The use of 3D planning software may be considered as an adjunctive tool to better understand complex deformity in the proximal femur for the planning of revision hip arthroscopy.

Fixation of the Proximal Hamstring Tendon Using an All-Suture Tensionable Knotless Technique.

Proximal hamstring injuries are a common sports and recreational injury among the active patient population. Surgical fixation of the tendons of the hamstring muscle complex, as opposed to conservative treatment alone, has shown improved patient outcomes, prompting the evolution of the suture anchors utilized in these repairs. Previous studies investigating the biomechanical properties of hamstring repair anchors have focused on double-row knotless techniques, in which the fixation of the overall construct relies on each individual anchor to maintain fixation. While these constructs have demonstrated biomechanical strength and clinical durability, each suture anchor represents a potential point of failure for the entire construct due to the crossed stitch anchor configuration. To address this limitation, recent tensionable knotless all-suture anchor designs have been implemented with success due to their smaller size and biomechanical strength. The aim of this technical note is, thus, to describe a technique for proximal hamstring repair using a tensionable knotless all-suture anchor construct that has 5 independent mattress sutures and, in doing so, employs the biomechanical strength of knotless fixation but eliminates the potential single point of failure seen with current knotless suture anchor designs.

Survivorship, Outcomes, and Risk Factors for Conversion to Total Hip Arthroplasty After Revision Hip Arthroscopic Surgery in Obese Patients: Results at a Minimum 5-Year Follow-up.

Background: There is a paucity of literature reporting outcomes after revision hip arthroscopic surgery in obese patients. Purpose: To report the minimum 5-year survivorship, patient-reported outcomes (PROs), clinical benefit, and risk factors for conversion to total hip arthroplasty (THA) in obese patients after revision hip arthroscopic surgery. Study Design: Case series; Level of evidence, 4. Methods: Data were prospectively collected and retrospectively reviewed for patients who underwent revision hip arthroscopic surgery by a single surgeon between April 2010 and August 2016. Inclusion criteria were a body mass index ≥30 and baseline and minimum 5-year postoperative values for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1 and hip dysplasia. Survivorship was defined as no conversion to THA. Clinical benefit was measured using the minimal clinically important difference (MCID). Survivors and nonsurvivors underwent further bivariate and regression analyses to determine the predictors of conversion to THA. Results: Included were 24 hips in 24 patients. The mean patient age was 39.3 ± 12.7 years, and the mean follow-up was 83.9 ± 26.5 months. The survivorship rate was 75.0%, and patients demonstrated a significant improvement in all PROs (P < .01). At 5-year follow-up, the MCID for the mHHS, NAHS, HOS-SSS, and VAS was achieved by 70.6%, 94.1%, 92.9%, and 64.7%, respectively, of the patients. Older age, higher grade ligamentum teres tears, and acetabuloplasty were significant on bivariate analysis for conversion to THA, and increased age was identified as a significant variable for conversion to THA on regression analysis (odds ratio, 1.297 [95% CI, 1.045-1.609]; P = .018), with a 29.7% greater risk for every additional year of age at the time of revision. Conclusion: In this study, 25.0% of obese patients who underwent revision hip arthroscopic surgery required conversion to THA. The study patients who did not need conversion to THA had a significant improvement in all PROs, with >90% achieving MCID for one or more outcome measures. Older age was identified as a significant predictor of conversion to THA.

Inflation-Adjusted Medicare Reimbursement for Hip Arthroscopy Fell by 21.1% on Average Between 2011 and 2022.

Purpose: To examine Medicare reimbursement for hip arthroscopy from 2011 to 2022. Methods: The seven most common procedures performed with hip arthroscopy by a single surgeon were gathered. The Physician Fee Schedule Look-Up Tool was utilized to access financial data of the associated Current Procedural Terminology (CPT) codes. The reimbursement data for each CPT were gathered from the Physician Fee Schedule Look-Up Tool. With the consumer price index database and inflation calculator, reimbursement values were adjusted for inflation to 2022 U.S. dollars. Results: Following an adjustment for inflation, it was found that reimbursement rate for hip arthroscopy procedures on average was 21.1% lower between 2011 and 2022. The average reimbursement per CPT code for the included codes was $899.21 in 2022 compared to inflation adjusted $1,141.45 in 2011, a difference of $242.24. Conclusions: From 2011 to 2022, the average inflation-adjusted Medicare reimbursement has steadily declined for the most common hip arthroscopy procedures. As Medicare is one of the largest insurance payers, these results have substantial financial and clinical implications for orthopaedic surgeons, policy makers, and patients. Level of Evidence: Level IV, economic analysis.

Durable Outcomes After Hip Labral Reconstruction at Minimum 5-Year Follow-Up: A Systematic Review.

PURPOSE: To systematically review and report the mid- to long-term patient-reported outcomes (PROs) after hip labral reconstruction. METHODS: A literature search of the PubMed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting mid- to long-term PROs at minimum 5-year follow-up after arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries. RESULTS: Four studies met inclusion criteria, with 182 hips (age range, 27.9-38.7 years) undergoing labral reconstruction in primary and revision hip surgery with minimum 5-year follow-up. There were three Level III studies and one Level IV study, with an average Methodological Index of Non-Randomized Studies score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum. Three studies performed segmental labral reconstructions, whereas another study used a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, iliotibial band autograft, and tensor fascia lata autograft. All studies demonstrated improved PROs from baseline to most recent follow-up, with 4 studies reporting modified Harris Hip Score values that increased from baseline (range, 58.9-66.8) to most recent follow-up (range, 80.1-86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3% and conversion to total hip arthroplasty ranged from 1.6% to 27%. CONCLUSIONS: Improved PROs were observed in all studies at minimum 5-year follow-up, suggesting that labral reconstruction can offer durable results beyond short-term follow-up. Although surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were used across studies, limiting the ability to determine an optimal treatment approach. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Propensity-Matched Patients Undergoing Revision Hip Arthroscopy Older Than the Age of 40 Years Had Greater Risk of Conversion to Total Hip Arthroplasty Compared With Their Primary Counterparts.

PURPOSE: To report patient-reported outcomes (PROs) and survivorship following revision hip arthroscopy in patients aged ≥40 years and to compare these results with a propensity-matched primary hip arthroscopy control group. METHODS: Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between June 2008 and January 2019. Patients were included if they were ≥40 years of age at the time of surgery and had minimum 2-year follow-up for the modified Harris Hip Score, Nonarthritic Hip Score, Visual Analog Scale for pain, and the Hip Outcome Score-Sports Specific Subscale. Patients who had a previous hip condition, or those who lacked minimum 2-year follow-up, were excluded. The revision group was further analyzed by conducting a 1:1 propensity-matched sub-analysis to a primary hip arthroscopy control group based on age, sex, body mass index, and acetabular labrum articular disruption grade. Statistical significance was set at P < .05. RESULTS: Eighty-nine hips (92.7% follow-up) were included, with 66.3% being females. The mean age, body mass index, and follow-up time were 49.4 ± 8.0 years, 26.6 ± 4.1, and 62.7 ± 38.5 months, respectively. Significant improvement in all PROs (P < .001) was reported, and 71.8%, 58 74.4%, and 65.2% achieved the minimal clinically important difference for the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, respectively. Eighty-seven revision hips were successfully propensity-matched to 87 primary hips. Both groups reported similar improvement for all PROs, but the relative risk of conversion to total hip arthroplasty was 2.63 times greater (95% confidence interval 1.20-5.79) for the revision group. CONCLUSIONS: Patients aged ≥40 years who underwent revision hip arthroscopy reported significant improvement in all PROs at a mean follow-up of 62.7 months with favorable rates of achieving the minimal clinically important difference. When compared to the propensity-matched control group, both achieved similar rates of improvement, but the revision group was 2.63 times more likely to convert to total hip arthroplasty. LEVEL OF EVIDENCE: III. case-control study.

Anchor Arthropathy Caused by Cartilage Penetration: An Approach to Revision Hip Arthroscopy With Removal of Problematic Anchors.

Hip arthroscopy has been proven to effectively treat labral tears in the setting of femoroacetabular impingement. Anchors used for this treatment have constantly evolved and improved to ensure safety and minimal invasion. However, acetabular drilling and anchor placement are technically challenging due to the concavity of the acetabular articular surface, limited angles for anchor insertion, and finite bone availability in the anterior and posterior column. Inadequate technique can result in protruding anchors, which may lead to full-thickness articular cartilage damage, manifesting in pain, mechanical symptoms, and impaired function. This Technical Note demonstrates arthroscopic removal of protruding anchors and management of the iatrogenic grade IV cartilage damage. In this description, the technical pearls and pitfalls of acetabular anchor placement to treat labral pathology are presented along with the aforementioned technique.