Predicting Late Follow-up and Understanding Its Consequences in Growth Modulation for Pediatric Lower Limb Deformities.

BACKGROUND: Growth modulation with implants facilitates correction of angular deformities and limb-length discrepancies (LLDs) in children. Close follow-up is necessary when using growth modulation to prevent overcorrection. We examined factors associated with late follow-up and overcorrection rates in patients with late versus timely follow-up. METHODS: This was a retrospective review of growth modulation procedures in children at 1 institution from 2000 through 2014. Procedures were assigned to the following categories on the basis of deformity: ankle valgus, genu valgum, genu varum, knee flexion contractures, and LLDs. Radiographic and clinical parameters were assessed. Late follow-up was defined as delaying a recommended appointment by ≥6 months. Loss to follow-up was defined as failure to return for a recommended postoperative appointment. Associations were evaluated using the following tests: χ, Fisher exact, analysis of variance, Mann-Whitney U, and logistic regression. Statistical significance was set at P<0.05. RESULTS: Of the 112 patients, there were 41 cases of genu valgum, 23 of ankle valgus, 18 each of genu varum and LLD, and 12 of knee flexion contractures. Twenty-two patients had late follow-up. Another 22 patients were lost to follow-up with retained implants. Patients with late follow-up had significantly higher odds of experiencing overcorrection deformities versus patients with timely follow-up (odds ratio, 19.2; 95% confidence interval, 5.2-71.4; P<0.005). The only deformity for which there was a significant difference in final alignment between patients with timely versus late follow-up was genu valgum (P<0.005). Late follow-up was associated with having a primary language other than English (P=0.05) and being obese/overweight (P=0.004). CONCLUSIONS: Late follow-up and loss to follow-up were common, occurring in 39% of patients combined. Late follow-up was associated with overcorrection in guided-growth procedures, as were overweight/obesity and primary language other than English. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Comparable patient-reported outcomes in females with or without joint hypermobility after hip arthroscopy and capsular plication for femoroacetabular impingement syndrome.

Hip arthroscopy is widely utilized to treat femoroacetabular impingement syndrome (FAIS). In order to evaluate the postoperative clinical and functional outcomes at 2-year follow up in patients with and without benign joint hypermobility syndrome following hip arthroscopy with capsular plication for FAIS, consecutive female patients with generalized ligamentous laxity undergoing primary hip arthroscopy with complete T-capsulotomy closure via plication for FAIS were prospectively identified. Patients were matched in a 4:1 ratio based on Beighton-Horan joint mobility index (BHJMI) then classified into no generalized joint laxity (NGJL, Score<4) or generalized joint laxity cohort (GJL, Score=4). Patient and surgical-related factors were analyzed using univariate and paired analysis with statistical significance set at a = 0.05. A total of 125 female patients were included in the study: 25 generalized joint laxity (GJL) patients and 100 matched to age, sex and BMI (NGJL cohort). The results demonstrated that there were no significant differences between demographics, preoperative range of motion, or radiographic analysis on univariate analysis. There was no statistical difference in postoperative range of motion between groups, though both groups demonstrated significant increases in postoperative flexion and postoperative internal rotation following hip arthroscopy. Paired analysis demonstrated no significant difference in HOS-SS, HOS-ADL, mHHS or VAS-pain, while GJL patients reported significantly greater patient satisfaction score at 2-years follow-up (p=0.007). In summary, hip arthroscopy with capsular plication is a highly effective treatment for FAIS in patients with and without generalized joint laxity. In our analysis, patients with and without generalized joint laxity demonstrated statistically similar and significant improvement in outcomes.

Return to Dance and Predictors of Outcome After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

PURPOSE: To investigate the rate of return to dance and factors influencing this primary outcome after hip arthroscopy for the treatment of femoroacetabular impingement syndrome. METHODS: A consecutive series of self-identified dancers with femoroacetabular impingement syndrome was included. To assess for the impact of hypermobility on outcomes, patients were classified as having either generalized joint laxity (GJL) or no GJL based on the Beighton-Horan Joint Mobility Index. A return-to-dance survey, the modified Harris Hip Score, and the Hip Outcome Score (HOS)-Activities of Daily Living and HOS-Sports-Specific subscales were collected preoperatively and postoperatively at 6, 12, 24, and 36 months. The preoperative-to-postoperative outcome score change was compared using the minimal clinically important difference and patient acceptable symptomatic state. Return to dance was evaluated regarding (1) return to any dance activity, (2) return to prior level of dance, and (3) number of hours of dance participation after surgery. Clinical and demographic predictors and return to dance were analyzed using univariate or bivariate analysis where appropriate. RESULTS: The study included 64 consecutive dancers (62 female and 2 male patients) (mean age, 22.3 ± 9.4 years; body mass index, 22.8 ± 4.1) with a mean follow-up period of 23.0 months. Postoperatively, 62 patients (97%) returned to dance at an average of 6.9 ± 2.9 months; 40 patients (62.5%) reported that they returned to a better level of participation, whereas 20 dancers (31%) returned to the same level of participation. Statistically significant increases were observed for the HOS-Activities of Daily Living subscale (60.5 ± 19.5 vs 92.4 ± 11.8, P < .001), HOS-Sports-Specific subscale (40.3 ± 20.3 vs 83.5 ± 19.4, P < .001), and modified Harris Hip Score (57.0 ± 13.6 vs 86.6 ± 13.9, P < .001). There was, however, a significant decrease in the number of hours of dance postoperatively: 11.5 ± 8.2 h/wk preoperatively versus 9.0 ± 7.3 h/wk postoperatively (P = .041). All postoperative hip outcome measures showed statistically significant (P < .001) and clinically relevant improvements. Patient-reported outcomes and return time showed no significant differences between the patient groups with GJL and without GJL (P = .1 and P = .489, respectively). For competitive dancers, a correlation was shown with a shorter time to return to dance (r2 = 0.45, P = .001), but there were no significant differences by skill level in patient-reported outcomes or dance hours. CONCLUSIONS: After hip arthroscopy, 97% of dancers returned to dance at an average of 6.9 months, with most dancers dancing at a level higher than their preoperative status. Dance experience level was the only significant factor influencing return-to-dance outcomes, with competitive dancers showing a faster return to dancing.conclusion LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Assessment of Association Between Spino-Pelvic Parameters and Outcomes Following Gluteus Medius Repair.

PURPOSE: To evaluate postoperative coronal/sagittal spinal plane and spinopelvic parameters in patients undergoing gluteus medius repair and to identify associations between outcomes and the aforementioned spinopelvic variables. METHODS: Patients who underwent gluteus medius/minimus repair by a single surgeon between January 20, 2012, and November 25, 2015, were retrospectively identified from a prospectively collected database. Radiographic measurements included Cobb angle, lumbar lordosis, sagittal vertical axis (SVA), pelvic tilt, sacral slope, and pelvic incidence. Patient-reported outcomes (PROs) were obtained at baseline and a minimum of 22 months after surgery. Bivariate correlation determined effects of spinopelvic measurements on PROs. Scoliosis and nonscoliosis groups were compared using independent samples t-test, and multivariate analysis determined whether the preoperative variables affected outcomes. RESULTS: Thirty-eight (80.9%) of 47 consecutive patients were radiographically evaluated with a scoliosis series. All patients demonstrated significant improvements in all PROs and pain (P < .001 for all), as well as at an average 28.2 ± 7.8 (range, 22-51) months after surgery. There were significant negative relationships between SVA and Hip Outcome Score-Activities of Daily Living (r = -0.405, P = .026) and Hip Outcome Score-Sports Specific (r = -0.492, P = .011) scores. Patients with a positive SVA (>0 cm) had significantly worse patient-reported outcomes than their counterparts with negative (≤0 cm) SVA. Also, patients with positive sagittal plane deformity (SVA >5 cm) had significantly worse HOS-SS than patients without positive sagittal plane deformity (SVA <5 cm) (47.0 ± 35.3, 73.2 ± 24.0; P = .04). Independent sample t-testing for the patients with scoliosis (n = 18) versus no scoliosis (n = 20) demonstrates a significantly worse postoperative International Hip Outcome Tool (short version) score in the patients with scoliosis (77.4 ± 15.1, 53.8 ± 37.1; P = .043). CONCLUSIONS: Patients with scoliosis presented with lower rates of symptom improvement and ability to return to an active lifestyle in patients with hip disorders. In addition, patients with positive sagittal plane deformity experienced lower hip-related sport-specific outcome scores. Although the direct relationship between the spine and the hip in patients after gluteus medius/minimus repair remains unclear, this study shows an association between these postoperative outcomes and spinopelvic parameters. LEVEL OF EVIDENCE: Level IV, case series.

Intra-articular Volume Reduction With Arthroscopic Plication for Capsular Laxity of the Hip: A Cadaveric Comparison of Two Surgical Techniques.

PURPOSE: To compare intracapsular volume reduction between interportal capsular shift and T-capsulotomy plication in a cadaveric model. METHODS: Twelve pair-matched specimens were randomized into T-capsulotomy plication or interportal capsular shift. T-capsulotomy was performed using a 2-cm interportal and 2-cm bisecting, longitudinal limb to the intertrochanteric line. Plication was performed utilizing 5-mm bites on either side of the capsulotomy with arthroscopic knot tying technique standard alternating half hitches. Pair-matched interportal capsular shift specimens underwent 5-cm interportal capsulotomy, and capsular shift was performed utilizing 5 nonabsorbable sutures placed in 45° orientation at 5 mm from the capsulotomy margin. With each specimen in a position of slight flexion and adduction, a spinal needle was used to inject methylene blue-colored saline solution intra-articularly; the volcano method was used to measure capsular volume before and after each respective plication technique. Mean absolute volumes and relative volumetric reduction for each technique were quantified and compared to determine statistical significance. RESULTS: At baseline, there were no statistically significant differences in capsular volume between pair-matched specimens (T-capsulotomy plication, 42.5 ± 5.1 mL; interportal capsular shift, 45.0 ± 88.6 mL; P = .555). After capsulotomy and secondary plication, both the T-capsulotomy (post: mean = 32.5 ± 8.0 mL; P < .001) and interportal capsulotomy groups (post: mean = 29.4 ± 10.0; P < .0001) demonstrated significant decreases in capsular volume, with average reductions of 10.0 ± 3.3 mL and 15.6 ± 3.2 mL, respectively. Although the interportal capsular shift (35.9% ± 11.3%) demonstrated greater volumetric reduction relative to baseline when compared with the T-capsular plication (24.5% ± 10.8%), these results were not significant (P = .104). CONCLUSIONS: Both T-capsular plication and interportal capsular shift produce statistically significant reductions in overall hip capsular volume. Although the interportal capsular shift may generate modestly higher degrees of capsular reduction, the comparative biomechanical repercussions of each technique are not currently known. CLINICAL RELEVANCE: Irrespective of arthroscopic technique, capsular plication with 5-mm bites decreases capsular volume by approximately one-third to one-fourth that of baseline measures.

Preoperative Symptom Duration Is Associated With Outcomes After Hip Arthroscopy.

BACKGROUND: Prolonged disease chronicity has been implicated as a cause of suboptimal clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), possibly due to disease progression, deconditioning, and the development of compensatory pathomechanics. PURPOSE: To evaluate the effect of increasing duration of preoperative symptoms on patient-reported outcomes, reoperation, and clinical failure of hip arthroscopy for FAIS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed to identify all patients undergoing primary hip arthroscopy between January 1, 2012, and July 30, 2014, by a single surgeon, with minimum follow-up of 2 years. Patient demographics, comorbid medical conditions, and preoperative outcome scores were compared between patients with preoperative symptoms lasting less than 2 years and those with symptoms lasting 2 years or longer. Multivariate regressions were used to compare Hip Outcome Score Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport-Specific (HOS-SS), and modified Harris Hip Score (mHHS) between the 2 cohorts at 2 years of follow-up. RESULTS: A total of 624 patients were included, with an average age of 34.0 ± 13.5 years; 235 (37.7%) patients had experienced preoperative symptoms 2 years or longer. Patients with symptoms lasting less than 2 years had statistically significant higher outcome scores than those with symptoms lasting 2 or more years for the HOS-ADL (86.3 ± 16.4 vs 80.3 ± 19.9, respectively), HOS-SS (75.0 ± 25.3 vs 65.1 ± 29.0), and mHHS (79.1 ± 16.6 vs 74.0 ± 18.8), as well as higher satisfaction (82.1 ± 30.7 vs 71.1 ± 31.6) and lower pain scores (2.6 ± 2.3 vs 3.5 ± 2.6). On multivariate analysis, patients with symptoms 2 years or longer had significantly higher visual analog scale-Pain score (ß = 0.6, P = .039) and lower HOS-ADL (ß = -3.4, P = .033), HOS-SS (ß = -6.3, P = .012), and satisfaction (ß = -6.7, P = .028) at 2-year follow-up. Patients with longer duration of symptoms also demonstrated less improvement in HOS-SS (ß = -10.3, P = .001) at 2 years after surgery. Patients with symptoms for 2 years or longer were significantly less likely to achieve a patient acceptable symptomatic state for HOS-ADL (relative risk [RR] = 0.8, P = .024) and HOS-SS (RR = 0.8, P = .032) at 2 years of follow-up. Patients with symptoms 2 years or longer also demonstrated significantly higher rates of revision arthroscopy (RR = 10.1, P = .046). CONCLUSION: Patients with untreated, FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery when compared with those patients with a shorter duration of preoperative symptoms.

Return to Golf After Arthroscopic Management of Femoroacetabular Impingement Syndrome.

PURPOSE: To investigate if patients who reported playing golf before arthroscopic hip surgery for femoroacetabular impingement syndrome were able to return to playing golf postoperatively. METHODS: The study was a retrospective analysis of all consecutive patients undergoing hip arthroscopy for femoroacetabular impingement syndrome between 2012 and 2014. Inclusion criteria required that a patient (1) reported playing golf before the surgery, (2) had a minimum 2-year follow-up, and (3) completed patient-reported outcome measures. An electronic postoperative return to golf questionnaire was completed by patients who reported golf as an activity. To evaluate patients' ability to return to golf after surgery, the following variables were analyzed with paired samples t test and χ-square tests: handedness, holes played, modified-Harris Hip Score, and Hip Outcome Score Activity of Daily Living and Sports-Specific Subscale. RESULTS: A total of 29 patients (22 men; age, 36.0 ± 11.9 years) with a minimum of 24 months of follow-up who self-reported playing golf preoperatively were included in the analysis. Preoperatively, 23 patients (79%) had discontinued golfing owing to activity-related hip complaints. At the final follow-up, all patients had significant improvements in the Hip Outcome Score Activity of Daily Living (preoperatively, 65.9 ± 19.9; postoperatively, 91.5 ± 12.8; P < .0001), the Hip Outcome Score Sports-Specific Subscale (38.2 ± 23.5, 79.7 ± 28.8; P = .0002), and modified-Harris Hip Score (54.8 ± 15.6; 84.2 ± 15.8; P < .0001). Additionally, there was a decrease in pain from 7.34 ± 1.63 to 1.71 ± 2.3 postoperatively (P < .0001), and 97% of patients returned to golf at an average of 7.2 months postoperatively. Postoperatively, 55% of patients (n = 16) noted improved golfing performance, 41% (n = 11) returned to their preinjury level, 1 patient (3%) returned at a lower level owing to non-hip-related problems, and 1 (3%) did not return to golf owing to fear of reinjury. CONCLUSIONS: Arthroscopic treatment of femoroacetabular impingement syndrome in patients who reported playing golf before surgery resulted in significant improvements in hip function and predictably high rates of patient satisfaction, with 97% returning to golfing activity and 55% noting improvement from preinjury sporting performance. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Antegrade Femoral Nail Distal Interlocking Screw Causing Rupture of the Medial Patellofemoral Ligament and Patellar Instability.

Antegrade reamed intramedullary nailing has the advantages of high fracture union and early weight-bearing, making it the gold standard for fixation of diaphyseal femur fractures. However, knowledge of distal femoral anatomy may mitigate the risk of secondary complications. We present a previously unrecognized complication of antegrade femoral nailing in which a 23-year-old man sustained iatrogenic rupture of the medial patellofemoral ligament (MPFL) caused by the distal interlocking screw of the femoral nail. The patient had a history of antegrade intramedullary nailing that was revised for rotational malalignment, after which he began experiencing recurrent episodes of atraumatic bloody joint effusion and swelling of the right knee with associated patellar instability. Plain radiographs and magnetic resonance imaging revealed a large effusion with a prominent intra-articular distal interlocking screw disrupting the MPFL. The patient underwent a right knee arthroscopic-assisted MPFL reconstruction and removal of the distal interlocking screw. Following surgery, the patient experienced resolution of his effusions, no recurrent patellar instability, and was able to return to his activities. This case demonstrates that iatrogenic MPFL injury is a potential complication of antegrade femoral nailing and a previously unrecognized cause of patellar instability. Surgeons should be aware of this potential complication and strive to avoid the MPFL origin when placing their distal interlocking screw.

High Rate of Return to High-Intensity Interval Training After Arthroscopic Management of Femoroacetabular Impingement Syndrome.

BACKGROUND: Since the inception of CrossFit in 2000, the popularity of high-intensity interval training (HIIT) in the United States has risen dramatically. While HIIT is a highly efficient exercise for weight loss and improved conditioning, some literature reports injuries in up to 34% of HIIT participants. We sought to evaluate the functional and sports-specific results of hip arthroscopic surgery in recreational HIIT participants. PURPOSE: To evaluate patients' ability to return to HIIT after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients with FAIS who had identified themselves as participating in HIIT and had undergone hip arthroscopic surgery for the treatment of FAIS by a single fellowship-trained surgeon between 2012 and 2015 were reviewed. Demographic data; preoperative physical examination findings; preoperative imaging results; preoperative patient-reported outcome (PRO) scores including the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain; and postoperative examination and PRO scores at a minimum 2 years after surgery, including a HIIT-specific questionnaire, were assessed for all patients. RESULTS: Thirty-two patients (13 male, 19 female) with a mean age of 34.7 ± 6.9 years (range, 21-49 years) were identified with a minimum 24-month follow-up. Among these, 22 participated in CrossFit, 4 in Shred415, 3 in Orangetheory, and 3 in self-directed cross-training including plyometrics. Preoperatively, 14 patients had discontinued HIIT because of activity-related hip complaints, 17 patients had scaled back involvement in HIIT, and 1 patient maintained her baseline routine. Postoperatively, 28 of 32 patients (88%) returned to HIIT at a mean of 9.8 ± 5.7 months after surgery (range, 3-24 months); 96% returned to HIIT at the same level as or better than before the injury. Fear of reinjury was the most common reason for cessation (3/4). Preinjury and postoperative involvement in HIIT were comparable (5.3 vs 5.1 h/wk, respectively; P = .8). All patients had significant improvements in the HOS-ADL score (69.7 ± 17.3 to 94.2 ± 8.4; P < .001), HOS-SSS score (49.2 ± 21.2 to 83.3 ± 21.4; P < .001), mHHS score (59.9 ± 14.2 to 85.4 ± 11.6; P < .001), and VAS for pain score (7.5 ± 1.8 to 1.1 ± 1.3; P < .001) from preoperatively to postoperatively. CONCLUSION: Arthroscopic treatment of FAIS in recreational HIIT participants resulted in significant improvements in hip function and predictably high rates of patient satisfaction. Postoperatively, 88% of patients returned to HIIT, 44% noted improvement from preinjury HIIT performance, and the mean weekly participation was comparable with before the injury.

The Importance of Comprehensive Cam Correction: Radiographic Parameters Are Predictive of Patient-Reported Outcome Measures at 2 Years After Hip Arthroscopy.

BACKGROUND: The specific influence of preoperative and postoperative radiographic measurements on patient-reported outcome measures after hip arthroscopy for femoroacetabular impingement (FAI) remains unclear. PURPOSE: To investigate the relationship between radiographic measurements and 2-year outcomes after hip arthroscopy for the treatment of FAI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A clinical registry of patients undergoing primary hip arthroscopy for FAI between January 1, 2012, and December 31, 2014, was queried. Outcome measures included the Hip Outcome Score (HOS) Activities of Daily Living (ADL), HOS Sport-Specific Subscale (SSS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction. Preoperative and postoperative radiographic measurements were recorded. Univariate analysis was conducted to identify relationships between all radiographic and demographic variables and outcome scores. A multivariate regression analysis, controlling for demographic factors, was used to identify independent associations between radiographic measurements on plain radiographs and patient-reported outcomes. RESULTS: The authors identified 707 patients who underwent primary hip arthroscopic management for FAI who were included for analysis. Two-year outcome surveys were completed for 78% to 84% of patients. The mean age of the patients was 33.2 ± 12.3 years, and 64.4% of the patients (n = 456) were female. The mean anteroposterior (AP) alpha angle decreased by 34.3° ( P < .0001), false profile alpha angle by 25.2° ( P < .0001), Dunn lateral alpha angle by 28.9° ( P < .0001), lateral center edge angle by 2.6° ( P < .0001), and anterior center edge angle by 3.4° ( P < .0001). The HOS-ADL score increased from 65.7 ± 18.7 preoperatively to 85.9 ± 16.7 postoperatively ( P < .0001), HOS-SSS increased from 43.4 ± 23.1 to 72.6 ± 27.2 ( P < .0001), and mHHS increased from 57.7 ± 14.0 to 79.1 ± 17.2 ( P < .0001). With multivariate analysis, independent predictors of the postoperative HOS-ADL score included the preoperative false profile alpha angle (beta = -0.16, P = .028). Independent predictors of HOS-SSS score were preoperative AP alpha angle (beta = -0.33, P = .032) and preoperative false profile alpha angle (beta = -0.28, P = .041). For the postoperative mHHS score, independent predictors included preoperative AP alpha angle (beta = -0.18, P = .046), preoperative false profile alpha angle (beta = -0.20, P = .014), and postoperative false profile alpha angle (beta = -0.48, P = .035). The preoperative AP alpha angle (beta = 0.28, P = .024) was a significant predictor for the postoperative VAS pain score. The preoperative false profile alpha angle (beta = -0.34, P = .040) was a significant predictor for the postoperative VAS satisfaction score. CONCLUSION: The authors observed that radiographic measurements, specifically the preoperative false profile alpha angle, AP alpha angle, and postoperative false profile alpha angle, are independent predictors of 2-year clinical outcomes. The femoral-side measurements were the strongest independent predictors of outcomes, especially measurements of the anterior and lateral-based CAM lesion.

Self-reported Mental Disorders Negatively Influence Surgical Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is responsible for hip pain and dysfunction, and surgical outcomes depend on multiple factors. The presence of mental disorders negatively influences outcomes of multiple orthopaedic conditions, although the impact on FAI surgery is unclear. HYPOTHESIS: The authors hypothesized that a preoperative self-reported history of mental disorders would negatively influence patient-reported outcome measures after FAI surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A matched-cohort study was performed by reviewing a prospectively collected database of cases of arthroscopic management of FAI with a single surgeon over a 2-year period. Demographics and radiographic parameters were recorded for all patients. Patients completed the Hip Outcome Score-Activity of Daily Living Subscale (HOS-ADL), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS) prior to surgery and 2 years after surgery. Unpaired and paired t tests were used to compare results between and within cohorts at baseline and follow-up. Statistical significance was defined as P < .05. RESULTS: The cohort included 301 patients, with 75 and 226 patients reporting and not reporting a history of mental disorders, respectively. Before treatment, all patient-reported outcome measures were significantly lower among patients reporting a history of mental disorders (P < .01 for HOS-ADL, HOS-SSS, and mHHS). Patients in both groups demonstrated significant improvements (P < .0001) in HOS-ADL, HOS-SSS, and mHHS when preoperative outcome measures were compared with follow-up. Patients with reported mental disorders had significantly lower scores after surgery as compared with patients without mental disorders (P < .0001 for HOS-ADL, HOS-SSS, and mHHS). CONCLUSION: The presence of a reported mental disorder is associated with lower patient-reported outcomes before and after surgical management of FAI. Statistically significant and clinically relevant improvements were observed for patients who reported mental disorders. The magnitude of these improvements was not as large as that for an age- and sex-matched control group without a self-reported mental disorder.

Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males.

PURPOSE: To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. METHODS: Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1 years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. RESULTS: The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4 cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6 cm from the superior aspect and 3.9 ± 0.7 cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4 cm from the superior aspect and 2.7 ± 0.7 cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5 cm from the superior aspect and 2.3 ± 0.8 cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1 cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2 cm lateral to the lateral aspect of the proximal hamstring origin. CONCLUSIONS: The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. CLINICAL RELEVANCE: Knowledge that the pudendal nerve lies 2 to 3 cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal hamstring repair or deep gluteal space endoscopy.

High Rate of Return to Yoga for Athletes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is most commonly diagnosed in patients who perform activities that require repetitive hip flexion and rotational loading. Yoga is an activity growing in popularity that involves these motions. The purpose of this study was to evaluate patients' ability to return to yoga after hip arthroscopy for FAIS. HYPOTHESIS: There would be a high rate of return to yoga after hip arthroscopy. STUDY DESIGN: Retrospective analysis. LEVEL OF EVIDENCE: Level 4. METHODS: Consecutive patients with FAIS who had identified themselves as participating in yoga and had undergone hip arthroscopy for the treatment of FAIS between 2012 and 2015 were reviewed. Demographic data were collected and assessed for all patients, as well as preoperative physical examination, imaging, and patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, and visual analog scale (VAS) for pain. Postoperatively, examination and PRO data were collected at a minimum 1 year after surgery, including a yoga-specific questionnaire. RESULTS: A total of 42 patients (90% female; mean age, 35 ± 9 years; mean body mass index, 23.1 ± 3.2 kg/m2) were included. Thirty patients (71%) had to discontinue their yoga routine preoperatively because of hip-related symptoms at a mean 9.5 ± 8.2 months before surgery. After surgery, 39 patients (93%) were able to return to yoga at a mean 5.3 ± 2.2 months after surgery. Two of the 3 patients who did not return to yoga noted loss of interest as their reason for stopping, while 1 patient was unable to return because of persistent hip pain. Nineteen patients (45%) returned to a higher level of yoga practice, 17 patients (40%) returned to the same level, and 3 patients (7%) returned to a lower level. There was no difference in the number of hours spent practicing yoga per week pre- and postoperatively (2.7 ± 1.9 vs 2.5 ± 1.3 hours; P = 0.44). All patients demonstrated significant improvement in all PROs as well as pain scores after surgery (HOS-ADL, 67.4 ± 18.3 to 93.1 ± 6.9 [ P < 0.001]; HOS-SS, 45.6 ± 24.7 to 81.5 ± 18.8 [ P < 0.001]; mHHS, 62.3 ± 11.3 to 86.8 ± 12.3 [ P < 0.0001]; VAS pain, 6.3 ± 2.2 to 0.90 ± 1.1 [ P < 0.001]). CONCLUSION: Patients participating in yoga return to yoga 93% of the time and at a mean 5.3 ± 2.2 months after hip arthroscopy for FAIS. CLINICAL RELEVANCE: Information regarding surgical outcomes is critical in counseling patients, particularly female athletes, on their expectations with respect to returning to yoga after hip arthroscopy for FAIS.

High Rate of Return to Swimming After Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To evaluate patients' ability to return to swimming after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with capsular closure. METHODS: Consecutive FAIS patients who had undergone hip arthroscopy for the treatment of FAIS by a single fellowship-trained surgeon were reviewed. The inclusion criteria included patients with a diagnosis of FAIS who self-reported being swimming athletes with a minimum clinical follow-up duration of 2 years. For all patients, we assessed demographic data; preoperative physical examination findings, imaging findings, and patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and visual analog scale for pain; and postoperative examination findings and PROs at a minimum of 2 years after surgery, including a swimming-specific questionnaire. RESULTS: The study included 26 patients (62% female patients; average age, 31.3 ± 7.2 years; average body mass index, 24.2 ± 2.7 kg/m2). Preoperatively, 24 patients (92%) were unable to swim at their preinjury level, and swimming was either decreased or discontinued entirely at an average of 6.0 ± 4.0 months before surgery. All 26 patients (100%) returned to swimming at an average of 3.4 ± 1.7 months after surgery, including 14 (54%) who returned at a higher level of performance than their preoperative state, 10 (38%) who returned to the same level, and 2 (7%) who returned at a lower level. The ability to return at a higher level of performance was not associated with age (P = .81), sex (P = .62), or body mass index (P = .16). At an average of 31.2 ± 4.95 months' follow-up, postoperative PRO scores improved significantly from preoperative values (Hip Outcome Score-Activities of Daily Living subscale from 68.5 ± 19.9 to 93.9 ± 5.7, P < .0001; Hip Outcome Score-Sports-Specific subscale from 44.0 ± 21.0 to 85.2 ± 16, P < .0001; and modified Harris Hip Score from 59.5 ± 12.1 to 94 ± 8.6, P < .0001). The average patient satisfaction level was 93% ± 9%. CONCLUSIONS: Recreational and amateur swimmers return to swimming 100% of the time after hip arthroscopy for FAIS, with just over half returning at a higher level, and most of these patients return within 4 months after surgery. This information is critical in counseling patients on their expectations with respect to returning to swimming after hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level IV, case series.

High Rate of Return to Cycling After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is most commonly diagnosed in athletes who sustain repetitive flexion and rotational loading to their hip. The purpose of this study was to evaluate a patient's ability to return to cycling after hip arthroscopy for FAIS. HYPOTHESIS: There is a high rate of return to cycling after hip arthroscopy. STUDY DESIGN: Retrospective analysis. LEVEL OF EVIDENCE: Level 4. METHODS: Consecutive patients who had identified themselves as cyclists and had undergone hip arthroscopy for the treatment of FAIS were reviewed. Pre- and postoperative physical examinations, imaging, and patient-reported outcomes (PROs) scores, including the modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, and visual analog scale for pain, as well as a cycling-specific questionnaire, were assessed for all patients. RESULTS: A total of 58 patients (62% female; mean age, 30.0 ± 7.1 years; mean body mass index, 23.2 ± 2.7 kg/m2) were included. Prior to surgery, patients averaged 30 ± 42 miles per week (range, 2-300 miles). Fifty-five patients (95%) were forced to discontinue cycling at an average of 7.5 ± 6.2 months prior to surgery due to hip pain. Fifty-six patients (97%) returned to cycling at an average of 4.5 ± 2.5 months after surgery, with 33 (59%) returning to a better level of cycling and 23 (41%) to the same cycling level. Postoperatively, there was no difference in the average number of miles patients completed per week compared with preoperative values ( P = 0.08). At a mean follow-up of 31.14 ± 0.71 months (range, 24-48 months), all patients experienced significant improvements in mHHS, HOS-ADL, and HOS-SS PROs (all P < 0.0001), with an overall satisfaction rate of 91% ± 13%. CONCLUSION: Recreational and competitive cyclists return to cycling 97% of the time after hip arthroscopy for FAIS, with most of these patients returning at an average of 4.5 months after surgery. This information is helpful in counseling patients on their expectations with regard to returning to cycling after hip arthroscopy for FAIS. CLINICAL RELEVANCE: Cyclists return to sport 97% of the time at an average of 4.5 months after hip arthroscopy for FAIS.

The Effect of Platelet-Rich Fibrin Matrix at the Time of Gluteus Medius Repair: A Retrospective Comparative Study.

PURPOSE: To evaluate the effect of platelet-rich fibrin matrix (PRFM) on outcomes after surgical repair of gluteus medius tendons. METHODS: This is a retrospective review of prospectively collected data comparing patients who underwent gluteus medius repair with PRFM and patients without PRFM. Preoperative characteristics, intraoperative characteristics, and postoperative outcomes at a minimum of 1 year were recorded. Statistical analysis was performed using a multivariate analysis of variance to test for differences in continuous demographic variables and postoperative-only scores between patient groups, χ2 tests were performed for categorical variables, and a repeated-measures analysis of variance was performed to test for the effects of PRFM. We also assessed for interobserver variation in grading adductor tendon tears. RESULTS: In total, the series of gluteus medius repairs without PRFM included 29 patients (25 women and 4 men, 15 right and 4 left) with a mean age of 63.09 ± 12.0 years. The series of gluteus medius repairs with PRFM included 18 patients (16 women and 2 men, 6 right and 12 left) with a mean age of 60.26 ± 8.8 years. There were no differences in patient preoperative variables or intraoperative characteristics. Although there was a significant effect of surgical intervention on the visual analog scale for pain, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific, and modified Harris Hip Score, the use of PRFM had no significant effect on outcome. Linear models showed a significant positive effect of PRFM on only postoperative Short Form 12 Physical and International Hip Outcome Tool 12 scores. CONCLUSIONS: PRFM augmentation does not appear to have an effect on gluteus medius tendon repair in terms of pain or clinical evidence of retears but may have a role in improving subjective outcomes of overall and hip-specific physical functioning. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Critical Review: Management and Surgical Options for Articular Defects in the Hip.

Patients with articular cartilage lesions of the hip may present with pain and symptoms that may be vague in nature and onset. Therefore, a thorough history and physical examination should be performed for every patient presenting with hip pain and/or disability. The management may be operative or nonoperative. Nonoperative management includes a trial of rest and/or activity modification, along with anti-inflammatory medications, physical therapy, and biologic injections. Operative treatment in the form of arthroscopic techniques continues to decrease morbidity and offer innovative solutions and new applications for microfracture, ACT, and AMIC.

Current Techniques in Treating Femoroacetabular Impingement: Capsular Repair and Plication.

Management of the hip capsule has evolved with increased awareness that capsular closure during hip arthroscopy restores the normal anatomy of the ilio-femoral ligament and therefore restores the biomechanical characteristics of the hip joint. Both anatomical and clinical studies have found that capsular closure or plication after hip arthroscopy restores normal motion and allows patients to return to activity more quickly. Capsular closure is technically challenging and increases operative time, but gross instability and microinstability can be avoided with meticulous closure/plication. In this article, we describe capsular closure of a T-capsulotomy and an extensile interportal capsulotomy.