Caudal Lumbar Disc Herniations Are More Likely to Require Surgery for Symptom Resolution.

STUDY DESIGN: Retrospective study. OBJECTIVES: We examined the impact that location of a lumbar disc herniation has on the likelihood that a patient will require surgery after at least 6 weeks of nonoperative management. METHODS: Using ICD-10 codes M51.26 and M51.27, we identified patients at a single academic institution from 2015 to 2016 who received a diagnosis of primary lumbar radicular pain, had magnetic resonance imaging confirming a lumbar disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome or progressive motor deficits were excluded. RESULTS: Five hundred patients met inclusion/exclusion criteria. Twenty-nine (5.8%) had L3-L4 herniations, 245 (49.0%) had L4-L5 herniations, and 226 (45.2%) had L5-S1 herniations. Overall, 451 (90.2%) patients did not undergo surgery within 1 year of diagnosis. Nonsurgical patients had an average herniation size occupying 31.2% of the canal, compared with 31.5% in patients who underwent surgery. While herniation size, age, sex, and race failed to demonstrate a statistical association with the likelihood for surgery, location of disc herniation demonstrated a strong association. L3-L4 and L4-L5 herniations had odds ratios of 0.19 and 0.45, respectively, relative to L5-S1 herniations (P = .0047). Patients were more than twice as likely to require a surgery on an L5-S1 herniation in comparison with an L4-L5 herniation (P < .05). L3-L4 herniations rarely required surgery. CONCLUSIONS: Patients with caudal lumbar disc herniations were more likely to require surgery after at least 6 weeks of conservative management than those with disc herniations in the mid-lumbar spine.

Laminoplasty-an underutilized procedure for cervical spondylotic myelopathy.

BACKGROUND CONTENT: Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States. PURPOSE: To determine the percentage of patients with CSM who are radiographically candidates for LP. STUDY DESIGN: Retrospective comparative cohort study. PATIENT SAMPLE: Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019. OUTCOME MEASURES: Candidacy for LP based on radiographic criteria. METHODS: Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated. RESULTS: One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability. CONCLUSIONS: In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM.

Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Nonoperative Treatment.

STUDY DESIGN: Retrospective study. OBJECTIVE: In this study, we examined whether the size of a lumbar disc herniation (LDH) is predictive of the need for surgical intervention within 2 years after obtaining an initial magnetic resonance imaging (MRI) scan. We hypothesized that a fragment that occupied a larger percentage of the spinal canal would not predict which patients failed conservative management. METHODS: Using the ICD-10 code M51.26, we identified patients at a single academic institution, across the 2-year period from 2015 to 2016, who received a diagnosis of primary lumbar radicular pain, had MRI showing a disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome and those with progressive motor neurological deficits were excluded from analysis, as were patients exhibiting "hard" disc herniations. Within the axial view of an MRI, the following measurements were made on AGFA-IMPACS for a given disc herniation: the length of both the canal and the herniated disc along the anterior-posterior axis, the average width of the disc within the canal; the total canal area, and the area of the disc herniation. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach's alpha as a measure of reliability was obtained. RESULTS: A total of 368 patients met the inclusion and exclusion criteria for this study. Of these, 14 (3.8%) had L3-L4 herniations, 185 had L4-L5 herniations (50.3%), and 169 had L5-S1 herniations (45.9%). Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the LDH diagnosis. Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average. A Cronbach's alpha of .992 was observed overall across interobserver measurements. After controlling for age, race, gender, and location of herniation through a logistic regression, it was found that the size of the herniation and the percentage of the canal that was occupied had no predictive value with regard to failure of conservative management, generating an odds ratio for surgery of 1.00. CONCLUSIONS: The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.

Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis.

BACKGROUND CONTEXT: Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered. PURPOSE: We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM. STUDY DESIGN: Retrospective comparative study. PATIENT SAMPLE: Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded. OUTCOME MEASURES: The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs. METHODS: Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables. RESULTS: Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF. CONCLUSIONS: This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.

Post-operative hyperglycemia and its association with surgical site infection after instrumented spinal fusion.

OBJECTIVE: To evaluate the correlation between postoperative hyperglycemia and surgical site infection among patients who underwent primary instrumented spinal fusion surgery. PATIENTS AND METHODS: We collected data on all eligible patients treated at our institution over the course of 2005-2017. We defined serum hyperglycemia using a primary threshold of serum glucose ≥140 mg/dL and used ≥115 mg/dL as a secondary test. We used logistic regression techniques to evaluate unadjusted results for serum hyperglycemia on revision surgeries for infection, followed by sequential adjustment for sociodemographic and procedural characteristics. RESULTS: We included 3664 patients. Surgical site infections occurred in 4%. Post-operative hyperglycemia was significantly associated with a higher rate of revision surgery for infection (p = 0.02). Following adjusted analysis, hyperglycemia remained a statistically significant predictor for revision surgery due to infection (OR 2.19; 95 % CI 1.13, 4.25). Similar results were evident when using the lower threshold of ≥115 mg/dL (OR 2.36; 95 % CI 1.06, 5.23). CONCLUSIONS: This study highlights the importance of measuring serum glucose after spinal fusion and the need for heightened surveillance and/or treatment in those who exhibit postoperative hyperglycemia. In this context, it could be advantageous to use a lower threshold for hyperglycemia (115 mg/dL) in order to trigger interventions for glycemic control.

Characteristics and Trends in Spine Research Over the Last Decade in The Journal of Bone & Joint Surgery from 2008 to 2017.

BACKGROUND: This study reviews and identifies various trends and characteristics of spine research published by The Journal of Bone & Joint Surgery (JBJS) from 2008 through 2017. METHODS: A PubMed search of all studies published in JBJS from 2008 to 2017 was performed using the keyword "spine." A similar search was conducted on the JBJS website. Citations, authorship, academic degrees, country of origin, topic, level of evidence, positive or negative outcome, and patient-reported outcomes were analyzed. RESULTS: A total of 163 articles were selected using exclusion criteria. The most cited article was referenced 513 times per Google Scholar and 318 times per Web of Science. The most popular research topics were related to either the cervical spine (approximately 22% of articles) or scoliosis (approximately 22% of articles). The United States was responsible for 73.0% of the articles in the study, followed by China at 6.1%. Fifty-eight articles used at least one patient-reported outcome measurement (PROM), most commonly the Short Form Questionnaire. CONCLUSIONS: A strong emphasis on international publications and an increase in authorship are evident. Level of evidence (LOE) I or II studies received 2.4 times as many citations on average as LOE III or IV studies. While no evidence of a positive publication bias from JBJS was found, there appears to be a lack of standardization of patient reported outcome measurements in spine research. Finally, spine articles discussing medical protocols or patient management garnered an average of 1.6 times as many citations as spine studies that explored other topics.

Endoscopic Repair of Full-Thickness Gluteus Medius and Minimus Tears-Prospective Study With a Minimum 2-Year Follow-Up.

PURPOSE: To evaluate the short-term outcomes of endoscopic repair of full-thickness gluteus medius and minimus tendon tears with a minimum of 2-year follow-up and add to the paucity of literature on abductor tendon tears. METHODS: All patients who underwent endoscopic abductor tendon repair between December 2013 and August 2017 were prospectively evaluated. The inclusion criteria for this study were primary full-thickness gluteal tendon tears and at least 2-years of follow-up. Clinical outcome data consisted of visual analog scale (VAS) pain score, hip abduction strength, Trendelenburg sign, complications, and patient-reported outcome measures (PROMs): modified Harris Hip Score, Hip Outcome Score, Non-arthritic Hip Scale, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. RESULTS: A total of 15 hips, all full-thickness tears, met inclusion criteria with an average follow-up of 31.2 months, with no patients being excluded. On physical examination, there was a significant improvement in VAS pain score from 5.36 to 2.43 (P = .0243), hip abduction strength with 8 (53.3%) hips improving by at least 1 point (P = .02056), and resolution of Trendelenburg sign in all 15 hips at 2-years (P = .0019). The mean difference for all 6 PROMs was statistically significant, even after Bonferroni adjustment, with the majority of patient improvement exceeding the minimal clinically important difference (MCID) thresholds: modified Harris Hip Score: 86.67%, Hip Outcome Score-ADL: 86.67%, Hip Outcome Score-SSS: 66.67%, Non-arthritic Hip Scale: 93.33%, and International Hip Outcome Tool-33: 80%. Greater Goutallier grade was associated with a greater VAS pain score. There were no complications, including no retears. CONCLUSIONS: In this study of 15 hips with full-thickness gluteal tendon tears managed endoscopically, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average of 31.2 months follow-up, while offering the potential advantages of less tissue violation, ambulatory day surgery, and fewer complications compared with open repair. LEVEL OF EVIDENCE: Level 4, Case Series.

Disk Area Is a More Reliable Measurement Than Anteroposterior Length in the Assessment of Lumbar Disk Herniations: A Validation Study.

STUDY DESIGN: Retrospective study. OBJECTIVE: The goal of this study is to identify and validate the reliability and accuracy of 2 methods used to assess lumbar disk herniations (LDHs): anteroposterior length and cross-sectional area. BACKGROUND: Many clinicians characterize LDHs through the measurement of the anteroposterior length in the axial plane. Radiologists, on the other hand, have utilized software to measure the disk and canal areas to define the injury. In this study, the authors consider the reliability and accuracy of anteroposterior length in comparison with the area. METHODS: Using International Classification of Diseases, 10th Revision (ICD-10) code M51.26, patients at a single academic medical center who received a diagnosis of primary lumbar radicular pain with subsequent magnetic resonance imaging documentation of a single-level disk herniation in 2015 and 2016 were identified. AGFA-IMPACS software was utilized to make the following measurements: anterior-posterior canal length; anterior-posterior disk length; mid-canal width; mid-disk width; total canal area; total disk area. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach alpha as a measure of reliability was obtained. RESULTS: A total of 408 patients met the inclusion and exclusion criteria for this study. Sixteen (3.9%) had L3-L4 herniation, 208 had L4-L5 herniation (51.0%), and 184 had L5-S1 herniation (47.5%). The least reliable interobserver metrics, with respective Cronbach alpha values of 0.381 and 0.659, were the linear measurements of mid-disk width and anterior-posterior canal length. Area measurements of the disk and canal areas generated Cronbach alpha values of 0.707 and 0.863. Intraobserver Cronbach alpha values for all measurements, including all areas and lengths, met or exceeded 0.982. CONCLUSIONS: The cross-sectional area provides a more reliable measurement modality for diskLDHs in comparison to linear measurements. Unlike anteroposterior length, cross-sectional area incorporates the shape of a herniation or canal in its measurement. Thus, it is superior in its characterization LDH particularly in light of its stronger reproducibility. LEVEL OF EVIDENCE: Level III-retrospective study.

DEXA sensitivity analysis in patients with adult spinal deformity.

BACKGROUND: Adult spinal deformity (ASD) is a debilitating condition that commonly requires surgical intervention. However, ASD patients may also present with osteoporosis, predisposing them to surgical complications and failure of instrumentation. As a result, proper detection of low bone mineral density (BMD) is critical in order to ensure proper patient care. Typically dual-energy x-ray absorptiometry (DEXA) scans are performed on the hip and spine. Unfortunately, in ASD patients, the latter is often inaccurate PURPOSE: In this study, we consider the value of obtaining a forearm DEXA scan in addition to a hip scan in patients suffering from ASD and osteoporosis in order to accurately detect low BMD. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Patient data between 2016 and 2018 from a single academic medical center was utilized. Two hundred eighty-six patients met the initial search criteria. OUTCOME MEASURES: No outcomes measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included T-scores across various anatomic locations and diagnoses relating to low bone density (ie, osteopenia and osteoporosis). METHODS: This retrospective study examines patients that underwent DEXA studies between 2016 and 2018 and were previously diagnosed with both osteoporosis and adult spinal deformity. For each patient, age, gender, body mass index, and smoking history were noted, as well as whether there was long-term prednisone use. T-scores from both the forearm and hip were recorded and analyzed. Diagnoses from hip DEXA scans were compared with those obtained from forearm scans to identify which region was more sensitive in detecting low BMD. From this data, the frequency of a missed diagnosis, due to reliance on hip or spine T-scores for detection of low BMD, was extrapolated. No external funding source was received in support of this study. RESULTS: Two hundred eighty-six patients matched the initial search criteria. Only 68% had one T-score value. However, 24.8% of patients had data for both the hip and forearm, whereas 7.1% had data for the forearm, hip, and spine. Among the 85 patients with more than one anatomical site of study, the forearm was more sensitive than the hip in its ability to detect osteopenia or osteoporosis 41.2% of the time. A two-tailed t test showed no statistically significant difference between hip T-scores and forearm T-scores. However, for more than 17% of patients, the forearm allowed clinicians to detect osteoporosis or osteopenia in a setting where using only the hip data would have missed such a diagnosis. CONCLUSIONS: Clinicians need to ensure they survey at least two locations when conducting DEXA studies before precluding a diagnosis of osteopenia or osteoporosis. All ASD patients being evaluated for low bone density should receive DEXA scans that survey at least the hip and the forearm. Misdiagnoses can be costly in the setting of ASD. They occur frequently when only a single hip scan is relied upon to assess BMD.

Translational relevance of the goat as a preclinical model of the human labrum and chondrolabral junction-histological study.

The purpose of this study was to evaluate the histologic features of the caprine labrum, with emphasis on the chondrolabral junction, with the goal of informing the feasibility of the goat as an animal model. The left hip joint of six adolescent Spanish goats (Capra pyrenaica) was harvested and subjected to anatomical and histological assessments. Human acetabular and femoral head samples, collected during total hip arthroplasty, served as comparison samples. The caprine labrum was found to consist of mostly type I collagen with uniform crimp, with an average crimp length of 20.8 µm. Upon histological assessment, acetabular articular chondrocytes were found to express substance-P, especially near or in the chondrolabral junction. And the majority of nonvascular cells expressed α-smooth muscle actin (SMA), with no notable elastin and laminin expression. Human labrum demonstrated similar staining patterns. Overall, the goat hip was found to be homologous to the human hip, demonstrating potential as a useful animal model for future studies. This is the first report of a crimped collagen structure in the labrum. Crimped type I collagen at the chondrolabral junction imparts an extension-recovery property which allows for toleration of stress without permanent deformation, underlying the importance of its preservation during surgery. The high expression of substance-P reflects the degree to which the labrum is innervated. Finally, the expression of α-SMA with contractile characteristics could indicate the potential for chondrocyte (i.e., myochondrocytes) modeling of the extracellular matrix. Statement of Clinical Significance: Establishment of a large animal model and deeper knowledge of the histological composition of the hip joint will enhance our study of the acetabular labrum, including repair techniques. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1070-1080, 2020.

A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management.

BACKGROUND: Magnetic resonance imaging (MRI) is often used to evaluate the integrity of the rotator cuff in patients with suspected full-thickness rotator cuff tears or other cuff tendinopathies. The value of advanced imaging value comes into question when it is used as the initial musculoskeletal imaging test before a trial of conservative therapy in patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy. METHODS: A prospective study of a group of patients suspected to have cuff tendinopathy based on clinical findings was performed. Every patient underwent MRI and was offered an initial trial of conservative management. Patients had an average follow-up of 28.3 ± 5.3 months after imaging to determine whether surgery was performed. RESULTS: A total of 51 patients were included in this study. Of this cohort, 46 (90.2%) patients did not go on to surgical intervention, whereas 5 (9.8%) patients did at an average 68.3 days after imaging. These results suggest that over 90.2% of patients (46 of 51) had premature MRI, posing an unnecessary economic burden of $181,619 in advanced imaging charges. CONCLUSIONS: The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level.

Serum albumin levels predict which patients are at increased risk for complications following surgical management of acute osteoporotic vertebral compression fractures.

BACKGROUND: Osteoporotic vertebral compression fractures (OVCF) account for a substantial portion of the US healthcare financial burden. With a growing elderly population, the number of fractures contributing to sagittal imbalance is expected to increase. For those patients undergoing surgery, preoperative markers, such as albumin, may help to predict the occurrence of postoperative complications. PURPOSE: To evaluate the association between preoperative serum albumin levels and the incidence of postoperative complications, mortality, and 30-day readmissions following surgical intervention for OVCF. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Patient data were obtained from the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSIP) database between the years 2007 and 2014. OUTCOME MEASURES: No outcome measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included various postoperative complications, patient mortality, and 30-day readmission. METHODS: A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database between 2007 and 2014 was performed, identifying 1,979 patients who met inclusion criteria. Patients were subcategorized into three groups based on preoperative nutritional status as defined by albumin levels. Outcome measures for this study included minor postoperative complication(s), major postoperative complication(s), patient mortality, 30-day readmission due to any cause, 30-day readmission related to OVCF, and total length of hospital stay. Analysis of variance was used to evaluate for associations between continuous variables and preoperative albumin levels. Spearman's rank correlation coefficient, chi-square trend, and Kruskal-Wallis analyses were utilized, as appropriate, for categorical variables. A multivariate logistic regression analysis was then conducted to calculate odds ratios with corresponding p values and 95% confidence intervals. RESULTS: Functional status showed a statistically significant decline when correlated with preoperative albumin levels. Sepsis, septic shock, pulmonary embolism, reintubation, prolonged intubation, and major complications in general are statistically more likely to occur in patients with hypoalbuminemia. Among minor complications evaluated in this study, only surgical site complications failed to demonstrate a statistical correlation with nutritional status. No statistically significant associations were identified between postoperative outcomes and age, sex, or BMI. CONCLUSIONS: Preoperative albumin levels were statistically correlated to the likelihood of minor complications, major complications, or mortality.

Improvement in Functional Outcome Scores Despite Persistent Pain With 1 Year of Nonsurgical Management for Acetabular Labral Tears With or Without Femoroacetabular Impingement.

BACKGROUND: Acetabular labral tears are increasingly recognized as a source of hip pain in a younger active population. Given the significant focus on surgical intervention, there has been limited investigation on the nonsurgical management and natural history of such injuries. HYPOTHESIS: Patients undergoing nonsurgical treatment for symptomatic acetabular labral tears experience functional improvement based on patient-reported outcome measures over the course of 1 year. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Seventy-one patients were identified who had acetabular labral injuries confirmed by magnetic resonance imaging or arthrography, received a minimum of 1 year of nonsurgical treatment, and completed baseline functional outcome questionnaires: modified Harris Hip Score (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports, and iHOT-33 (International Hip Outcome Tool-33). Of these, 52 (73.2%) completed the minimum 1-year follow-up questionnaires. Chart review was conducted to obtain demographic information. Statistical significance ( P < .05) was determined by paired t test, independent samples t test, and chi-square test. RESULTS: Twenty-two male and 30 female patients completed 1-year follow-up questionnaires. Mean ± SD follow-up time was 16.2 ± 3.1 months. The cohort had a mean age of 38.9 ± 9.3 years. Baseline radiographs demonstrated minimal arthritis (Tönnis grades 0-2). Mean alpha angle differed significantly between men and women at 52.9°± 8.6° and 46.3°± 8.5°, respectively. At 1-year follow-up, patients experienced a significant improvement in all 4 functional outcome measures (mHHS: 72.6 vs 81.8, HOS-Activities of Daily Living: 78.6 vs 86.4, HOS-Sports: 56.0 vs 71.1, iHOT-33: 47.5 vs 67.9). Patients with and without femoroacetabular impingement demonstrated a significant improvement in the mHHS. However, 48.1% reported no improvement in their pain; 69.2% were limited in their activities; and 40.4% were still considering surgery. Overall, 71.2% were satisfied with nonsurgical treatment. CONCLUSION: Patients with symptomatic labral tears can experience functional improvement after a minimum 1 year of nonsurgical treatment in the presence and absence of femoroacetabular impingement. However, many report residual pain, alteration of their activities, and interest in surgery. This information is important when patients are counseled in the treatment options for this injury. Identifying the population that responds best to nonsurgical management and comparing outcomes with those undergoing surgical management should be the focus of future research. Longer-term follow-up may be necessary to reevaluate pain, function, and return to activities.