Findings on repaired full-thickness acetabular articular cartilage defects during revision hip arthroscopy allowing a second look.

Full-thickness acetabular articular cartilage defects (FAACD) are found on most hips with femoroacetabular impingement (FAI) with a wave sign in the acetabulum. When not repaired it can produce pain and catching sensation. Multiple arthroscopic techniques for repairing this chondral lesion exist, but only few show the quality of the repair on a second look. The purpose of this study is to evaluate the quality of the repaired cartilage during revision hip arthroscopy (RHA) allowing a second look in patients treated of FAACD. A total of 13 hips with FAACD repaired in the past underwent RHA for ongoing pain. Signs of persistent chondral defects or the ability to elevate the articular cartilage from subchondral bone were evaluated by zones. Those with persistent defects were re-repaired. All patients had FAACD lesions in zones I, II and III diagnosed in the index hip arthroscopy. The most common finding at the RHA was the presence of bone growth or residual impingement. Before FAACD repair, 11 (85%) hips had the wave sign, while 2 (15%) hips had it in RHA. Five (38%) hips had residual delamination in the second look, these patients had residual FAI, were ≥58 years or waited >6 months to be revised. The wave sign was not observed in 85% of the revised hips, indicating the technique was successful in most cases and was not the principal cause of their ongoing pain. This technique achieved the stated goal of stabilizing the articular cartilage seen in the wave sign.

Editorial Commentary: Can We Derive Any Practical Information From a Study of "The Top 50 Most Influential Papers in Hip Arthroscopy," or Are We Tooting Our Own Horns?

Orthopaedic literature on hip arthroscopy has become more robust primarily from the advent and transformation in the treatment of femoroacetabular impingement syndrome from an open surgical dislocation to an ambulatory arthroscopic procedure. Numerous studies have reviewed the frequency of authors and subjects in particular areas of arthroscopy, but until this article, none had been performed on the most influential in hip arthroscopy. The question to be answered is, Do such studies contribute significantly to our knowledge by suggesting future topics to clinicians and training programs?

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

BACKGROUND: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated. PURPOSE AND CLINICAL RELEVANCE: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery. METHODS: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated. RESULTS: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment. CONCLUSION: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Editorial Commentary: What is the Real Story Behind "What Makes Suture Anchor Use Safe in Hip Arthroscopy?"

Reproducibly safe hip suture anchor placement requires clear visualization of the acetabular rim and acetabular articular cartilage and a correct trajectory when the anchor sites and position are selected and when depth stop drilling is done. I favor the lateral decubitus approach over the supine approach and do an extensive capsulotomy for global access to the central and peripheral compartments, thus requiring fewer distraction forces and minimal time spent in the central compartment. My views of the acetabular rim are obtained from the periphery most of the time, and as such, suture anchor drilling and placement are always visualized during simultaneous viewing of both the bony acetabular rim and articular cartilage; thus, the trajectory is targeted with clear visualization of the drill hole from the time of creation to anchor placement. If the drill inadvertently penetrates the articular cartilage, early recognition of a cartilage bulge will allow for backing out and redirection.

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.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

PURPOSE AND HYPOTHESIS: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair. METHODS: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS). RESULTS: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001). CONCLUSION: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission. LEVEL OF EVIDENCE: IV.

Arthroscopic Labrum Reconstruction in the Hip Using the Indirect Head of Rectus Femoris as a Local Graft: Surgical Technique.

The importance of the acetabular labrum has been well documented for the health and function of the hip joint. Labral reconstruction has proven effective but often requires the use of a cadaveric allograft or auto graft from the fascia lata or gracilis. The indirect head of the rectus femoris is in close proximity with the anterior superior acetabulum, which is the most common site of labral tears. Using the indirect head of the rectus femoris as a local graft minimizes surgical invasiveness by mitigating the need to harvest the graft from a different location, in case of an autograft, and by minimizing donor site morbidity and damage to local tissues. The graft is harvested and fixed to the acetabular rim through the same arthroscopic portals. Hip labral reconstruction using the reflected head of the rectus femoris tendon is a minimally invasive surgical procedure that restores stability to the hip joint, is applicable in all patients undergoing hip labral reconstruction, and offers decreased tissue morbidity compared with other grafting techniques.

Hip Arthroscopy: Tales From the Crypt.

Complications after hip arthroscopy vary in frequency and severity, even for experienced surgeons. It is important for surgeons to be aware of some of the more dramatic, often unusual, and always memorable (nightmarish) complications of hip arthroscopy and understand how they are caused, how they can be treated, and how they can be prevented.

The regional microvascular density of the gluteus medius tendon determined by immunohistochemistry with CD31 staining: a cadaveric study.

BACKGROUND AND PURPOSE: There are no studies to date about the vascularisation into the gluteus medius tendon. The purpose of this study was to define the microvessel density of the gluteus medius in 3 zones through a special staining with CD31 and to identify regional differences in microvascular density that may have implications for the healing. METHODS: We obtained 12 complete gluteus medius tendons from cadavers who had been an average age of 30.3 years old (range 18 to 55). All the donors were males with no known history of hip abnormalities.Following a rigorous protocol, each gluteus medius tendon was divided in 3 portions. Each gluteus medius tendon was divided in 3 portions (I: musculotendinous, II: Tendon, III: Tendon-Bone junction). RESULTS: There were regional differences between all anatomic zones in both the transverse section (p<0.001) and the longitudinal section (p = 0.007). Furthermore, a significant difference was found between zones II and I (mean difference -23.45 IC95% -38.77 to -8.13, p<0.001) and between zones II and III (mean difference -26.08 IC95% -41.39 to -10.76, p<0.001) in transverse section. In longitudinal sections, this difference was found as well between zones II and I (mean difference -29.48 IC95% -51.54 to -7.43, p = 0.01), but not between zones II and III (mean difference -10.87 IC95% -32.93 to 11.18, p = 0.67). CONCLUSIONS: The microvessel density was significantly lower in the length of the tendon (central portion) compared to the other 2 regions.

Capsular closure does not affect development of heterotopic ossification after hip arthroscopy.

PURPOSE: The purpose of this study was to evaluate the role of capsular closure after hip arthroscopy in reduction of the incidence of heterotopic ossification (HO). METHODS: One hundred (50 study group, 50 control group) consecutive hip arthroscopy procedures with radiographic follow-up of more than 9 weeks were included in the study. The study group consisted of 50 patients in whom capsular closure with 2 No. 1 polydioxanone (PDS) sutures was performed, and a control group consisted of 50 patients in whom the capsule remained open after capsulotomy. HO was assessed by radiographs using the Brooker classification. Statistical analysis of the data was carried out with the χ-square or Fisher exact test and Student t test, when appropriate, at a significance level of .05. RESULTS: Thirty-six (36%) patients had radiographic evidence of postoperative HO (14 patients in the capsular closure group). No significant difference was found regarding sex, side of operation, age, or HO rate between the study and the control groups (P = .778, P = .123, P = .744, and P = .144, respectively). Furthermore, no significant difference was found in the rate of HO with potential clinical significance (Brooker classification > I) between the control and study groups (P = .764). CONCLUSIONS: Capsular closure did not seem to alter the rate of HO when compared with a control group of patients in whom the capsulotomy was not repaired. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopy of the nondistractable hip: a novel extracapsular approach.

Adequate traction to achieve hip joint distraction is essential for avoiding iatrogenic injury to the joint during hip arthroscopy. An inability to distract the joint is a relative contraindication for hip arthroscopy. This report describes a novel technique involving an extracapsular approach to gain safe access to a hip joint that fails a trial of traction during positioning for hip arthroscopy. The anterolateral portal is established under fluoroscopic guidance. The arthroscope is positioned on the lateral rim of the acetabulum. A shaver, introduced through a modified anterior portal, is used to facilitate capsular exposure. An arthroscopic capsular incision is made proximal to the lateral acetabular rim and extended anteriorly with a radiofrequency probe. Osteoplasty of the anterolateral acetabular rim is carried out with a burr while protecting the labrum. Distraction of the hip is then possible, allowing safe central-compartment access and subsequent chondrolabral procedures.

The incidence of heterotopic ossification in hip arthroscopy.

PURPOSE: The purpose of this study was to assess the incidence of heterotopic ossification (HO) after hip arthroscopy. METHODS: Between July 2010 and July 2011, 83 patients underwent hip arthroscopy for various etiologies. We prospectively reviewed 50 consecutive hip arthroscopy procedures (31 male and 19 female patients; mean age, 36.7 years) with a mean follow-up of 29.56 weeks (range, 9 to 62 weeks) to assess the incidence of HO and its effect on function and clinical outcome. Preoperative and postoperative evaluation included general assessment by visual analog scoring, modified Harris Hip Score, Hip Outcome Score, and preoperative and postoperative radiographs. Heterotopic bone formation was assessed on radiographs at a minimum of 9 weeks from surgery with the Brooker classification. RESULTS: Of the patients, 22 (44%) had radiographic evidence of postoperative HO (15 male patients): 13 (26%) had Brooker stage 1, 5 (10%) had Brooker stage 2, and 4 (8%) had Brooker stage 3. HO appeared as early as 9 weeks after surgery. No significant difference was found in demographic data, surgery-related data, or clinical and functional scores between patients with HO and patients without HO. No factor was found to significantly affect the incidence of HO after logistic regression. No distinct clinical manifestation was associated with the presence of HO. CONCLUSIONS: This study shows that the incidence of HO after hip arthroscopy may be underestimated. We could not find a contributing factor to the formation of HO. Although in most cases the presence of HO will have minimal or no clinical and functional significance, it should be sought at a minimum of 9 weeks postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

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.

Arthroscopic treatment for chondral lesions of the hip.

Arthroscopic treatment of chondral lesions of the hip is challenging. Understanding the etiology is paramount not only in treating hip chondral damage but also in mitigating the cause, using arthroscopic means. This article addresses chondral lesions of the hip caused by either injury or morphologic conflicts such as seen in femoroacetabular impingement. Fractures, aseptic necrosis, and metabolic or immunologic damage are not addressed. Methods using arthroscopic surgery for the treatment of chondral lesions are presented.

The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists.

PURPOSE: The purpose of this study was to systematically evaluate the technique and tests used in the physical examination of the adult hip performed by multiple clinicians who regularly treat patients with hip problems and identify common physical examination patterns. METHODS: The subjects included 5 men and 6 women with a mean age (+/-SD) of 29.8 +/- 9.4 years. They underwent physical examination of the hip by 6 hip specialists with a strong interest in hip-related problems. All examiners were blind to patient radiographs and diagnoses. Patient examinations were video recorded and reviewed. RESULTS: It was determined that 18 tests were most frequently performed (>or=40%) by the examiners, 3 standing, 11 supine, 3 lateral, and 1 prone. Of the most frequently performed tests, 10 were performed more than 50% of the time. The tests performed in the supine position were as follows: flexion range of motion (ROM) (percentage of use, 98%), flexion internal rotation ROM (98%), flexion external rotation ROM (86%), passive supine rotation test (76%), flexion/adduction/internal rotation test (70%), straight leg raise against resistance test (61%), and flexion/abduction/external rotation test (52%). The tests performed in the standing position were the gait test (86%) and the single-leg stance phase test (77%). The 1 test in the prone position was the femoral anteversion test (58%). CONCLUSIONS: There are variations in the testing that hip specialists perform to examine and evaluate their patients, but there is enough commonality to form the basis to recommend a battery of physical examination maneuvers that should be considered for use in evaluating the hip. CLINICAL RELEVANCE: Patients presenting with groin, abdominal, back, and/or hip pain need to have a basic examination to ensure that the hip is not overlooked. A comprehensive physical examination of the hip will benefit the patient and the physician and serve as the foundation for future multicenter clinical studies.

A geographic zone method to describe intra-articular pathology in hip arthroscopy: cadaveric study and preliminary report.

PURPOSE: Our purpose was to develop an alternative method to divide the acetabulum and femoral head into different zones based on anatomic landmarks clearly visible during arthroscopy to facilitate reporting the geographic location of intra-articular injuries. METHODS: Two vertical lines are positioned across the acetabulum aligned with the anterior and posterior limits of the acetabular notch. A horizontal line is positioned aligned with the superior limit of the notch perpendicular to the previous lines. The lines divide the acetabulum into 6 zones. Numbers are assigned to each zone in consecutive order. Zone 1 is the anterior-inferior acetabulum. The numbers progress around the notch until zone 5 is assigned to the posterior-inferior acetabulum. Zone 6 is the acetabular notch. The same method is applied to the femoral head. Six experienced hip arthroscopists were instructed in the zone and clock-face methods and were asked to identify and describe the geographic locations of lesions at the acetabular rim, acetabular cartilage, and femoral head in the same cadaveric specimen. RESULTS: The zone method was more reproducible than the clock-face method in the geographic description of intra-articular injuries on the acetabulum and the femoral head. CONCLUSIONS: Among a group of expert hip arthroscopists, the zone method was more reproducible than the clock-face method. CLINICAL RELEVANCE: The presented method divides the acetabulum into 6 different zones based on the acetabular notch. The zones are the same for right- and left-side hips. The same method is applied for the femoral head allowing, for the first time, a geographic description of pathology.