Background. Hip arthroscopy is a rapidly growing, evolving area within arthroscopic Orthopaedic Surgery, with annual rates increasing as much as 25-fold each year. Despite improvements in equipment and training, it remains a challenging procedure. Rates of revision surgery have been reported as 6.3% to 16.9%. Objectives. The primary objective was to determine the success of joint preservation after hip arthroscopy. The secondary objective was to determine whether patient characteristics or PROM functional score trends could predict revision hip arthroscopy or Total Hip Arthroplasty (THA). Study Design & Methods. We reviewed 1363 hip arthroscopies performed from January 2010 to December 2016 by a single high-volume surgeon at a single institution. Data was prospectively collected and retrospectively reviewed with a minimum 2-year follow-up. Functional outcomes were assessed with the International Hip Outcome Tool (IHOT-33). Hip arthroscopy failures were defined as Total Hip Arthroplasty or revision hip arthroscopy after index hip arthroscopy. Results. There were751 females and 612 males with an average age of 34.63 years (19 – 58 years). There were 199 cases (14.6%) of labrum repairs only, 286 (20.9%) cam and labrum repairs, 319 (23.4%) cam and pincer surgeries and 193 (14.1%) cam only surgeries. All pre-operative IHOT-33 patient-reported outcomes scores (27.42 ± 6.2) improved significantly at the 6 week-, 3 month- and 6-month follow-up visits (p<0.05). The best improvements were seen in symptoms and functional improvements (IHOT-SFL) (p<0.05) while the poorest amelioration of job-related concerns (IHOT-JRC) existed at all time points (p<0.05). There were 223 failures, 131 patients (9.61%) underwent revision hip arthroscopy and 92 required THA (6.75%) at 18.45 months ± 7.34 months. The 2-year survival rate was 89.2%. The THA conversion rate was 8.4% for patients > 50 years old and 3.72% for patients < 50 years old. Age (>50 years) and female sex were associated with increased risk of conversion to THA (p<0.05) while young (<25 years old) and female patients were most likely to undergo hip revision arthroscopy. Surgery involving repair of the labrum only are more likely to result in revision arthroscopy surgery and THA (70.7% at 10.6 years). CAM & pincer surgery have best longevity (90.9% at 10.6 years). Conclusions. Joint preservation and no subsequent surgery at 10.6 years is 83.64%. This study showed that predictors of revision hip arthroscopy or THA included poor pre-morbid functional score, female gender, age > 45, sudden functional score decrease at 3 months follow-up and cases in which only the labrum is surgically repaired

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed

We present a prospective two-year follow-up study of 1038 hip arthroscopies performed at a high volume tertiary referral centre for hip preservation. We feel that this manuscript is both pertinent and timely due to the advances in the field of hip preservation. We used four validated patient-reported outcome (PRO) scores along with the visual analog scale (VAS) and patient satisfaction scores to assess preoperative and postoperative outcomes in all patients undergoing hip arthroscopy. We divided the entire cohort into patients undergoing primary and revision hip arthroscopies. We found a statistically significant improvement from preoperative to two-year postoperative PRO scores in the two subgroups. We also found a significant difference in the PRO scores at three months, one year, and two years postoperatively between the primary and revision subgroups. The revision subgroup had inferior VAS and patient satisfaction compared to the primary subgroup, however these results were not significant. The conversion to total hip arthroplasty/hip resurfacing (THA/HR) was 5.6% and 11.2% in the primary and revision subgroups, respectively. This resulted in a relative risk of 2.0 for conversion to THA/HR in the revision subgroup. We had a complication rate of 5.3 (only 0.5% of which were considered major) which was similar to that reported in the literature for hip arthroscopy. The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopy at a high volume tertiary referral centre for hip preservation with minimum two-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopy. From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopy. Patients were assessed pre- and post-operatively with modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport Specific Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. There were a total of 1155 arthroscopies performed, including 1040 primary arthroscopies (926 patients) and 115 revision arthroscopies (106 patients). Of these, 931 primary arthroscopies (89.5%) in 824 patients (89.0%) and 107 revision arthroscopies (93.0%) in 97 patients (91.5%), were available for follow-up and included in our study. The mean change in patient reported outcome (PRO) scores at two-year follow-up in the primary subgroup was 17.4 for mHHS, 19.7 for HOS-ADL, 23.8 for HOS-SSS, 21.3 for NAHS, and −3.0 for VAS. The mean change in PRO scores at two-year follow-up in the revision subgroup was 13.4, 10.9, 16.1, 15.4, and −2.7, respectively. All scores improved significantly compared to pre-operatively (p<0.001). PRO scores were higher at all time points for the primary subgroup compared to the revision subgroup (p<0.05). Satisfaction was 7.7 and 7.2 for primary and revision subgroups, respectively. Of 931 primary arthroscopies, 52 (5.6%) underwent THA/HR. Of 107 revision arthroscopies, 12 (11.2%) underwent THA/HR. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures. The overall complication rate was 5.3%. Hip arthroscopy showed significant improvement in all PRO, VAS, and satisfaction scores at two years postoperatively. Primary arthroscopy patients showed greater PRO scores and a trend towards greater VAS compared to the revision subgroup. The relative risk of a THA/HR was 2.0 after revision procedures compared to primary procedures

Introduction: The debridement of deep cartilage defects is one of the most frequently used Methods: in arthroscopic surgery. This randomized study was undertaken to compare the effectiveness of simple mechanical debridement and the 52°C-controlled bipolar chondroplasty. Materials and Methods: A total of 60 patients (28 male, 32 female, average age 43.3 years, range 20 to 50 years) who were suffering from a grade III cartilage defect of the medial femoral condyle were included. Exclusion criteria were revision arthroscopy, injury or osteoarthritis (grade II or higher). After randomization, 30 patients underwent simple debridement of the cartilage defects, which was performed with a mechanical shaver (MSD = mechanical shaver debridement). The remaining patients underwent thermal chondroplasty, which was performed with a temperature-controlled bipolar device with a constant thermo-application of 51°C (RFC = Radio-Frequency-based Chondroplasty). The patients were evaluated by the Knee-injury and Osteoarthritis Outcome Score (KOSS) preoperatively and at time of follow-up. Activity levels were measured by the Tegner score (activity level before onset of the symptoms and at time of follow-up). Follow-up was undertaken 4 years after the arthroscopy. Results: No significant differences between the preoperative findings for the two groups were observed. One patient from the MSD group had died, and one female patient in the RFC group was lost to follow-up. A total of 18 patients had undergone revision operations due to persistent knee problems: in the MSD group, there were 8 endoprostheses, 4 osteotomies, and 2 revision arthroscopies; in the RFC group there was 1 one replacement, 2 osteotomies, and 1 revision arthroscopy with subtotal medial meniscectomy. The proportion of revisions was significantly higher in the MSD group (p=0.006). These patients were excluded from the evaluation. The remaining 40 patients from both groups benefited from the operation. The preoperative KOOS was 11.3 points in the MSD group and 15.5 points in the RFC group (p=0.279). Patients from the MSD group had a KOOS of 53.2 at the time of follow-up. In the RFC group the KOOS (71.8) was significantly higher (p< 0.001). Patients from both groups had to accept a decrease in their level of physical activity. However, patients from the RFC group had a significantly improved (p=0.005) Tegner activity score in comparison to the patients from the MSP group. The radiographic and MRI findings in the MSD group were also worse than in RFC patients. Conclusion: RFC is a potential method for the treatment of deep cartilage defects. The 4-year outcome is better than after MSD. Long-term results are still lacking

Introduction. Persistent pain after medial unicompartmental knee arthroplasty (UKA) is a prevailing reason for revision to total knee arthroplasty (TKA). Many of these pathologies can be addressed arthroscopically. The purpose of this study is to examine the outcomes of patients who undergo an arthroscopy for any reason after medial UKA. Methods. A query of our practice registry revealed 58 patients who had undergone medial UKA between October 2003 and June 2015 with subsequent arthroscopy. Mean interval from UKA to arthroscopy was 22 months (range, 1–101 months). Indications for arthroscopy were acute anterior cruciate ligament tear (1), arthrofibrosis (7), synovitis (12), recurrent hemarthrosis (2), lateral compartment degeneration including isolated lateral meniscus tears (11), and loose cement fragments (25). Results. Mean follow-up after arthroscopy was 37 months (range, 1–134 months). Twelve patients have been revised from UKA to TKA. Relative risk of revision after arthroscopy for lateral compartment degeneration was 4.27 (6 of 11; 55%; p=0.002) and for retrieval of loose cement fragments was 0.05 (0 of 25; 0%; p=0.03). Relative risk for revision after arthroscopy for anterior cruciate ligament tear, arthrofibrosis, synovitis, or recurrent hemarthrosis did not meet clinical significance secondary to the low number of patients in these categories. Conclusions. The results of this study suggest that arthroscopic retrieval of cement fragments does not compromise UKA longevity. However, arthroscopy for lateral compartment degradation after UKA predicts a high risk of revision to TKA regardless of its relative radiographic insignificance

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy. Microfracture is a simple and effective technique to treat chondral lesions with proven long term results in the knee. However, there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint. Methods: Patients with acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy. Results: All patients had chondral lesions confined to the antero-superior aspect of the acetabulum with an associated labral tear. None had diffuse osteoarthritis. The average defect measured 180 mm2 (range 50–300). The mean time interval between primary and revision arthroscopy was 12 months. Excluding one failure the overall percent fill of the defects was 95% (range 75 – 100) with good quality cartilage. Discussion: Only one other series has reported on the macroscopic results of microfracture in the hip. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures.

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy and can cause substantial morbidity and functional limitation. Microfracture is a simple and effective technique to treat chondral lesions. Studies have shown good long term results in the knee. However there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint. Methods: Patients aged 18 years or older who had a full thickness acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy for various reasons form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed with no weight bearing allowed for six weeks. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy. Results: All acetabular chondral lesions were identified in the antero-superior quadrant at primary arthroscopy. The average defect after debridement measured 180 mm2 (range 50–300 mm2). 10 patients had chondral lesions confined to the acetabulum. 1 patient had a large femoral head defect in addition, due to Avascular Necrosis. None of the patients had diffuse osteoarthritis. All patients had an associated labral tear. The mean time interval between the primary and revision arthroscopy was 12 months. Excluding 1 failure the overall percent fill of the defects was 95% (range 75 – 100%) with good quality (Grade 1) cartilage. There was one failure with only a 25% fill. In that particular patient a large flap of delaminated cartilage was not resected at primary arthroscopy. Instead microfracture was done under the flap in the hope of encouraging the cartilage to stick to the underlying bone. Unfortunately the cartilage continued to remain delaminated and also hindered the formation of new repair tissue. Conclusion: Only one other series of second look arthroscopy after microfracture has been reported. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients

Aims

Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients.

The outcomes of hip arthroscopy in the treatment of dysplasia are variable. Historically, arthroscopic treatment of severe dysplasia (lateral center-edge angle [LCEA] < 18°) resulted in poor outcomes and iatrogenic instability. However, in milder forms of dysplasia, favorable outcomes have been reported. The purpose of this study was to compare outcomes following hip arthroscopy for femorocetabular impingement (FAI) in borderline dysplastic (BD) patients compared with a control group of non-dysplastic patients. Between March 2009 and July 2012, a BD group (LCEA 18°–25°) of 46 patients (55 hips) was identified. An age and sex-matched control group of 131 patients (152 hips) was also identified (LCEA 25°–40°). Patient-reported outcome scores, including the Modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL), the Sport-specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected pre-operatively, at 1, and 2 years. The mean LCEA was 22.4 ± 2.0° (range, 18.4°–24.9°) in the BD group and 31.0 ± 3.1° (range, 25.4°–38.7°) in the control group (p<0.001). The mean preoperative alpha angle was 66.3 ± 9.9° in the BD group and 61.7 ± 13.0° in the control group (p=0.151). Cam decompression was performed in 98.2% and 99.3% of cases in the BD and control groups. Labral repair was performed in 69.1% and 75.3% of the BD and control groups respectively, with 100% of patients having a complete capsular closure performed in both groups. At a mean follow-up of 31.3 ± 7.6 months (range, 23.1–67.3) in unrevised patients and 21.6 ± 13.3 months (range 4.7–40.6) in revised patients, there was significant improvement (p<0.001) in all patient reported outcome scores in both groups. Multiple regression analysis did not identify any significant differences between groups. Importantly, female sex did not appear to be a predictor for inferior outcomes. Two patients (4.3%) in the BD group and six patients (4.6%) in the control group required revision arthroscopy during the study period. Favorable outcomes can be expected following the treatment of impingement in borderline dysplastics when labral refixation and capsular closure are performed, with comparable outcomes to non-dysplastic patients. Further follow-up in larger cohorts is necessary to prove the durability and safety of hip arthroscopy in this challenging group and to further explore potential gender-related differences in outcome

Objective

Hip arthroscopy in the setting of hip dysplasia is controversial in the orthopaedic community, as the outcome literature has been variable and inconclusive. We hypothesise that outcomes of hip arthroscopy may be diminished in the setting of hip dysplasia, but outcomes may be acceptable in milder or borderline cases of hip dysplasia.

The August 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicular fractures are being fixed – but how?; Propionibacterium acnes: a pain in the shoulder?; Bacteria, armpits and arthroplasty; Living longer, but unhappy: the woes of shoulder arthroplasty in the under 50s; Recurrent dislocations in the adolescent population; Splinting for elbow stiffness; Revision Bankart repair

In this in vitro study of the hip joint we examined which soft tissues act as primary and secondary passive rotational restraints when the hip joint is functionally loaded. A total of nine cadaveric left hips were mounted in a testing rig that allowed the application of forces, torques and rotations in all six degrees of freedom. The hip was rotated throughout a complete range of movement (ROM) and the contributions of the iliofemoral (medial and lateral arms), pubofemoral and ischiofemoral ligaments and the ligamentum teres to rotational restraint was determined by resecting a ligament and measuring the reduced torque required to achieve the same angular position as before resection. The contribution from the acetabular labrum was also measured. Each of the capsular ligaments acted as the primary hip rotation restraint somewhere within the complete ROM, and the ligamentum teres acted as a secondary restraint in high flexion, adduction and external rotation. The iliofemoral lateral arm and the ischiofemoral ligaments were primary restraints in two-thirds of the positions tested. Appreciation of the importance of these structures in preventing excessive hip rotation and subsequent impingement/instability may be relevant for surgeons undertaking both hip joint preserving surgery and hip arthroplasty.

Cite this article: Bone Joint J 2015; 97-B:484–91.

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.