Endoscopic Rectus Abdominis and Prepubic Aponeurosis Repairs for Treatment of Athletic Pubalgia.

Review of the English orthopaedic literature reveals no prior report of endoscopic repair of rectus abdominis tears and/or prepubic aponeurosis detachment. This technical report describes endoscopic reattachment of an avulsed prepubic aponeurosis and endoscopic repair of a vertical rectus abdominis tear immediately after endoscopic pubic symphysectomy for coexistent recalcitrant osteitis pubis as a single-stage outpatient surgery. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.

Poorer Arthroscopic Outcomes of Mild Dysplasia With Cam Femoroacetabular Impingement Versus Mixed Femoroacetabular Impingement in Absence of Capsular Repair.

PURPOSE: To compare outcomes of mild dysplasia with cam femoroacetabular impingement (FAI) vs mixed FAI with hip arthroscopy without capsular repair. METHODS: A retrospective review of a 2009 to 2010 multicenter prospective outcome study was performed comparing a cohort with mild dysplasia and cam femoroacetabular impingement (cohort D) to a cohort with mixed FAI (cohort M). Outcome measures included Nonarthritic Hip Score (NAHS) and satisfaction with minimum 2-year follow-up. RESULTS: Of 150 patients/159 hips enrolled in the initial prospective outcome study, 10 patients/10 hips had acetabular dysplasia and 8 patients met the inclusion criteria. Cohort D had 8 patients (5 female) of mean age 49.6 years with mean lateral center-edge angle (LCEA) of 19° (range, 16°-24°) demonstrating a mean change in NAHS of +20.00 at 3 months (P = .25), +14.33 at 12 months (P = .03), and -0.75 at 24 months (P = .74). Mean satisfaction was 2.88 out of 5. Cohort M had 69 patients (32 female) of mean age 38.6 years with a mean LCEA of 33° (range, 25°-38°) demonstrating a mean change in NAHS of +12.09 at 3 months (P < .0001), +20.39 at 12 months (P < .0001), and +21.99 at 24 months (P < .0001). Mean satisfaction was 3.58 out of 5. Cohort D demonstrated significantly less improvement in NAHS (P = .002) and a difference of -31.06 points compared to cohort M at minimum 2-year follow-up. Dysplasia was the only statistically significant predictor of poorer outcomes. CONCLUSION: The common combination of mild dysplasia and cam FAI has poorer outcomes than mixed FAI following arthroscopic surgery without capsular repair.

Simultaneous Bilateral Hip Arthroscopy.

Many patients are afflicted with painful conditions affecting both hips, most commonly femoroacetabular impingement. Some patients prefer the advantage of undergoing a single surgical procedure and anesthetic followed by a single postoperative rehabilitation program. We present a Technical Note on single-stage bilateral hip arthroscopy. This Technical Note reports on key steps enabling safe and efficient performance of bilateral arthroscopic acetabuloplasty, labral refixation, femoroplasty, and dynamic testing while limiting traction times and facilitating rapid transition to the second hip arthroscopic surgery. Enabling factors include supine positioning with bilateral mobile leg spars, rapid surgical and hip traction times, and postoperative rehabilitation with immediate weight bearing as tolerated. A rationale for deciding which hip should undergo arthroscopy first is also offered. Concurrent bilateral hip arthroscopy is a viable option for select patients and experienced surgical teams, enabling potentially expedited recovery and return to work or sport with inherent cost savings.

Endoscopic Pubic Symphysectomy for Athletic Osteitis Pubis.

Osteitis pubis is a common form of athletic pubalgia associated with femoroacetabular impingement. Endoscopic pubic symphysectomy was developed as a less invasive option than open surgical curettage for recalcitrant osteitis pubis. This technical note demonstrates the use of the anterior and suprapubic portals in the supine lithotomy position for endoscopic burr resection of pubic symphyseal fibrocartilage and hyaline endplates. Key steps include use of the suprapubic portal for burr resection of the posteroinferior symphysis and preservation of the posterior and arcuate ligaments. Endoscopic pubic symphysectomy is a minimally invasive bone-conserving surgery that retains stability and may be useful in the treatment of recalcitrant osteitis pubis or osteoarthritis. It nicely complements arthroscopic surgery for femoroacetabular impingement and may find broader application in this group of co-affected athletes.

Multicenter Outcomes of Endoscopic Pubic Symphysectomy for Osteitis Pubis Associated With Femoroacetabular Impingement.

PURPOSE: To investigate outcomes of athletic patients treated with concurrent femoroacetabular impingement (FAI) and osteitis pubis (OP) surgery including endoscopic pubic symphysectomy. METHODS: We performed a multicenter retrospective case series of 7 consecutive adult patients (4 men) with a mean age of 33 years with symptomatic FAI and OP who underwent arthroscopic surgery for the former and endoscopic pubic symphysectomy for the latter with a mean follow-up period of 2.9 years (range, 2.0 to 5.0 years). The visual analog scale (VAS) score, the Non-Arthritic Hip Score (NAHS), and patient satisfaction were measured. Complications and revision surgical procedures were reported, and preoperative and postoperative radiographs were assessed. RESULTS: The mean preoperative VAS score of 6.7 (range, 4 to 8) improved to a mean postoperative VAS score of 1.5 (range, 0 to 7) (P = .03). The mean preoperative NAHS of 50.2 points (range, 21 to 78 points) improved to a mean postoperative NAHS of 84.7 points (range, 41 to 99 points) (P = .03). The mean patient satisfaction rating was 8.3 (range, 3 to 10). Two male patients had postoperative scrotal swelling that resolved spontaneously. There were no other complications. Preoperative and postoperative radiographs showed no anterior or posterior pelvic ring instability. One patient underwent pubic symphyseal arthrodesis because of continued pain. CONCLUSIONS: Endoscopic pubic symphysectomy is a minimally invasive treatment for athletic OP with encouraging early outcomes that may be performed concurrently with surgery for FAI in co-afflicted patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Anchor-induced chondral damage in the hip.

The purpose of this study is to investigate the outcomes from anchor-induced chondral damage of the hip, both with and without frank chondral penetration. A multicenter retrospective case series was performed of patients with chondral deformation or penetration during initial hip arthroscopic surgery. Intra-operative findings, post-surgical clinical courses, hip outcome scores and descriptions of arthroscopic treatment in cases requiring revision surgery and anchor removal are reported. Five patients (three females) of mean age 32 years (range, 16-41 years) had documented anchor-induced chondral damage with mean 3.5 years (range, 1.5-6.0 years) follow-up. The 1 o'clock position (four cases) and anterior and mid-anterior portals (two cases each) were most commonly implicated. Two cases of anchor-induced acetabular chondral deformation without frank penetration had successful clinical and radiographic outcomes, while one case progressed from deformation to chondral penetration with clinical worsening. Of the cases that underwent revision hip arthroscopy, all three had confirmed exposed hard anchors which were removed. Two patients have had clinical improvement and one patient underwent early total hip arthroplasty. Anchor-induced chondral deformation without frank chondral penetration may be treated with close clinical and radiographic monitoring with a low threshold for revision surgery and anchor removal. Chondral penetration should be treated with immediate removal of offending hard anchor implants. Preventative measures include distal-based portals, small diameter and short anchors, removable hard anchors, soft suture-based anchors, curved drill and anchor insertion instrumentation and attention to safe trajectories while visualizing the acetabular articular surface.

Endoscopic hip osteotomies: less invasive approaches to peri-acetabular, proximal femoral and pubic symphyseal procedures.

Beyond the recent expansion of extra-articular hip arthroscopy into the peri-trochanteric and subgluteal space, this instructional course lecture introduces three innovative procedures: endoscopy-assisted periacetabular osteotomy, closed derotational proximal femoral osteotomy and endoscopic pubic symphysectomy. Supportive rationale, evolving indications, key surgical techniques and emerging outcomes are presented for these innovative less invasive procedures.