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Minimum 5-Year Follow-up

Mario Hevesi,* MD, Aaron J. Krych,*y MD, Nick R. Johnson,* BS, John M. Redmond,z MD, David E. Hartigan,§ MD, Bruce A. Levy,* MD, and Benjamin G. Domb,II MD

Investigation performed at Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic, Phoenix, Arizona, USA; Southeast Orthopedic Specialists, Jacksonville, Florida, USA;

and American Hip Institute, Westmont, Illinois, USA

Background: The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown.
Purpose: To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes.
Study Design: Cohort study; Level of evidence, 3.
Methods: Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), To¨ nnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery.
Results: A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent peri- acetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI .30 kg/m2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI :::30 kg/m2 (P \ .01). Patients aged .35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged :::35 years (P = .03). Patients with To¨ nnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score (P = .02) and a 23.0-point worse HOS-SSS score (P \ .01) when compared with patients with To¨ nnis grade 0.
Conclusion: Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with To¨ nnis grade 2 changes preoperatively, BMI .30 kg/m2, and age .35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.
Keywords: hip arthroscopic surgery; midterm; labral repair; clinical outcomes; VAS; mHHS; HOS-SSS

Hip pain and the development of osteoarthritis have been strongly associated with structural abnormalities of the hip joint including chondral injuries, labral tears, and fem- oroacetabular impingement (FAI).4,24,35,42 Traditionally, the treatment of hip disorders required open approaches; however, there has been a contemporary shift to less inva- sive management of these lesions.6  Hip arthroscopic surgery was popularized in the late 2000s, and there has been a dramatic increase in its recent use, as it has been shown to be safe and efficacious in short-term studies.7,28 Initial arthroscopic management of acetabular labral injuries was in the form of debridement, and this has been shown to have modest outcomes at mid-term follow- up, with 20% of hips requiring subsequent surgery and an additional 25% of hips rating function as abnormal or severely  abnormal  at  5  years’  follow-up. Subsequent efforts to preserve the labrum through repair have demon- strated promising short-term outcomes, with significantly greater improvements in the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and HOS–Sports-Specific Subscale (HOS-SSS) when compared with isolated debridement.37 However, longer follow-up is currently underreported. As such, it is largely unknown whether early improvements after labral repair will be durable over time.

Short-term studies have additionally established that body mass index (BMI) and increased patient age are risk factors for decreased patient-reported outcomes postoperatively.27,30,39,53 However, the preoperative Tonnis grade, which had previously been postulated to be a negative predictor of outcomes, has not been shown to have significant postoperative effects in large, matched cohorts.13,14

Therefore, the purpose of this study was to (1) outline the clinical mid-term patient-reported outcomes of arthroscopic hip labral repair at a minimum 5 years of follow-up, (2) determine the applicability of short-term risk factors on mid- to long-term outcomes, and (3) establish novel risk fac- tors as patient groups differentiate over time. Our hypothe- ses were that (1) patients would demonstrate durable improvements in patient-reported outcome scores at mid- term follow-up, (2) previously established short-term risk factors such as increased BMI and patient age would predict worse mid-term outcomes, and (3) an increased preoperative To¨nnis grade would negatively affect mid- to long-term out- comes as patients with varying degrees of pre-existing oste- oarthritis differentiate over time.

METHODS

Study Population and Design

This retrospective clinical and radiographic study included all eligible patients undergoing hip arthroscopic surgery after the failure of nonoperative management at 4 high- volume hip arthroscopic surgery centers (Mayo Clinic, Rochester, Minnesota; Mayo Clinic, Phoenix, Arizona; Southeast Orthopedic Specialists, Jacksonville, Florida; and American Hip Institute, Westmont, Illinois). Patients consented to participate in research after institutional review board approval of the study design (#08-002259). Inclusion criteria consisted of all patients undergoing primary hip arthroscopic  surgery between February 2008 and December 2011 who consented to research participation with labral repair performed at the time of surgery. Exclusion criteria consisted of less than 5 years of clinical follow-up, patients choosing not to participate in outcome surveys, labral debridement, labral reconstruction, and previous hip surgery. Patients with bilateral hip arthroscopic surgery, both simultaneous and staged, were included and noted in our database. Indications for arthroscopic surgery included labral tears, chondral injuries, and FAI that had failed nonoperative management. The prospectively collected institutional databases contained the records of 449 primary hip arthroscopic procedures with labral repair performed during the study period for potential inclusion. Of these, 146 patients were excluded because they had less than 5 years of clinical follow-up, resulting in 303 patients for inclusion in this study.

Surgical Technique

Arthroscopic hip surgery was performed by experienced arthroscopic surgeons (A.J.K., J.M.R., D.E.H., B.A.L., B.G.D.) in an operative setting. Patients were positioned in a modified supine position, and 2 or more portals were employed, including the anterolateral and midanterior portals. Positioning and approaches have been previously described in detail.8,40,54 Diagnostic arthroscopic surgery was performed to directly evaluate the articular and labral status. Correction of cam and pincer lesions was per- formed when present.16,17 All patients underwent labral repair with concurrent debridement as indicated, employing standard techniques.18,23,34 Psoas release was performed in the setting of clinically painful iliopsoas snapping reproduced on physical examination. Capsular repair was performed at the discretion of the operating surgeon, with its use favored  in the setting of young patients participating in high-demand activities, patients demonstrating hip or generalized laxity such as that easily translated under femoral head traction, and those with dysplastic radiographic features.

Rehabilitation Protocol

Patients underwent standard postoperative rehabilitation and pain relief protocols, which were consistent between physicians at the same institution and similar between institutions. Patients were placed on crutches for 2 to 4 weeks with foot-flat partial weightbearing. Passive motion was started at 0 weeks. As crutches were gradually discontinued, patients progressed through institutional rehabilitation protocols, which have been previously outlined in detail for the centers involved.21,50 Jogging exercises began at 3 months, as tolerated, and return to sport was allowed at 5 to 6 months.

Outcome Measures

Demographic data such as age at the time of surgery, BMI, and sex were collected. In addition, preoperative radiographic measures such as Tonnis grade,51 alpha angle,2 and lateral center edge angle (LCEA)41 were noted. Hips with an LCEA \25° were classified as dysplastic. Surgical diagnoses such as the presence of cam and/or pincer lesions, femoral and acetabular chondromalacia as defined by the Outerbridge45 and acetabular labrum articular disruption (ALAD)9 classification systems, and surgical techniques such as ligamentum teres debridement and psoas release were documented using a standardized data form. Subjective preoperative and postoperative outcomes were documented using the visual analog scale (VAS),38 modi- fied Harris Hip Score (mHHS),29 and HOS-SSS.43 The completion rate for each individual outcome scale was 2:89.3%. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery, open hip surgery, and conversion to hip replacement.

Statistical Analysis

Descriptive statistics were used to present demographic data, employing means and SDs, percentages, and medians with interquartile ranges (IQRs), as appropriate. Factors such as BMI, sex, laterality, and intraoperative cartilage grade were examined for their association with outcome measures such as VAS, mHHS, and HOS-SSS using the Spearman rank correlation coefficient for continuous variables, independent sample t tests for differences between nominal values, and analysis of variance for categorical variables such as Tonnis, femoral, and acetabular cartilage grades. After analysis of single-factor predictors, stepwise linear regression was performed employing the Akaike information criterion to identify the optimal set of explanatory variables for postoperative outcome scores.1 The Wilcoxon rank-sum test (Mann-Whitney U test) was used to compare ordinal variables such as preoperative and postoperative VAS, mHHS, and HOS-SSS  scores. Cox proportional hazards regression was performed to determine predictors of postoperative failure.

A priori analysis was used to determine the mean group sample size needed to demonstrate the minimal clinically important difference (MCID) for patient-reported outcome scores at an alpha of 0.05 and power of 0.80. Using the study by Chahal et al,12 in which MCID cutoffs were determined for mHHS and HOS-SSS at 3, 6, and 12 months after hip arthroscopic labral repair for FAI, the most conservative MCID value presented for each outcome measure was selected, resulting in a cutoff of 9.0 points for mHHS and 25.0 points for HOS-SSS. Additionally, based on a study of arthritic hip pain in 211 patients, an MCID of 2.0 points was established for VAS.52 Employing these values and out- come score distributions derived from previous studies on hip arthroscopic labral repair, the mean group sample size needed to demonstrate the MCID was determined to be 48 for mHHS, 12 for HOS-SSS, and 21 for VAS.32 P values\.05 were considered significant. Analyses were conducted in R version 3.4.0 (R Core Team).

RESULTS

Using institutional databases comprising cases of hip arthroscopic surgery performed from February 2008 to December 2011 at 4 institutions, we identified 303 patients with 2:5 year

s of clinical follow-up. The mean age at the time of surgery was 32.0 years, the mean BMI was 24.4 kg/m2, and the mean duration of follow-up was 5.7 years (range, 5.0-7.9 years) (Table 1). In terms of preoperative radiographic measures, Tonnis grade 0 predominated (72.1%), followed by grade 1 (24.2%) and grade 2 (3.7%). The median alpha angle was 56.9° (IQR, 49.0°-67.0°), and the median LCEA was 30.0° (IQR, 26.5°-34.0°). Of note, right-sided surgery (58.1%) was significantly more com- mon than left-sided surgery (41.9%) (P \ .01), and women (66.7%) were represented to a greater proportion than men (33.3%) (P \ .001).

 

Four patients underwent bilateral hip surgery, with both hips included in the dataset with a minimum 5 years of follow-up. Of these, 1 pair of hips underwent surgery simultaneously, and another 3 pairs underwent surgery in a staged manner, with the 2 procedures separated by 4.5 to 24.6 months. An additional 5 patients underwent hip arthroscopic surgery performed in a staged manner, with the second hip performed after December 2011 and thus had less than 5 years of follow-up. In these cases, the first hip was included in the dataset.

Patients underwent hip arthroscopic surgery for a combination of hip dysplasia (n = 50), cam lesions (n = 200), pincer lesions (n = 66), and labral lesions (n = 303) in the setting of varied acetabular and femoral chondromalacia (Table 2). For patients with dysplasia, the mean LCEA was 21.5° (range, 13.0°-24.9°).

Ligamentum teres debridement was performed in 37.6% of the study population, psoas release in 38.3%, and capsular repair in 48.5%. The total failure rate was observed to be 16.2%, with 49 of 303 patients undergoing revision hip surgery during the course of follow-up. Of these, 7 went on to total hip arthroplasty, 2 underwent hip resurfacing, 2 underwent periacetabular osteotomy   alone,   37   underwent   revision   arthroscopic management, and 1 patient  underwent revision  arthroscopic management, followed by periacetabular osteotomy, at a later time. All patients going on to periacetabular osteotomy did so in the setting of hip dysplasia.

 

A multivariable Cox proportional hazards model was constructed to evaluate preoperative and intraoperative findings predictive of subsequent failure and the progres- sion to ipsilateral hip surgery. No significant predictors of failure were noted (Table 3). Dysplasia did not predict subsequent ipsilateral hip surgery, whether defined as an LCEA \25° (P = .56) or an LCEA \20° (P = .60).

VAS, mHHS, and HOS-SSS scores were all observed to significantly improve (P \ .001) between preoperative values and final follow-up at 5.0 to 7.9 years postoperatively (Figure 1). VAS score decreased a mean of 3.5 points after surgery, whereas mHHS and HOS-SSS scores increased by 20.1 and 29.3 points, respectively. Analysis was conducted to explore whether the institution or performing surgeon had an effect on outcome scores. The location and provider were found to be nonsignificant in predicting VAS, mHHS, and HOS-SSS scores at final follow-up (P 2: .11) when accounting for patient age, BMI, and Tonnis grade.

BMI was found to be significantly and negatively corre- lated to final mHHS (P \ .001) and HOS-SSS (P \ .001) scores. It was nonsignificant for predicting VAS scores (P = .33). This pattern was also present for age at the time of surgery, with a significant negative correlation with final mHHS (P = .02) and HOS-SSS (P \ .01) scores and nonsignificance in terms of VAS scores (P = .66).

On average, patients with a BMI .30 kg/m2 had a final mHHS score 9.5 points lower (mean mHHS score, 74.0) than those with a BMI :::30 kg/m2  (mean mHHS score,83.5) (P \ .01) and demonstrated a HOS-SSS score 15.9 points lower (mean HOS-SSS score, 57.0) than those with a BMI :::30 kg/m2 (mean HOS-SSS score, 72.9) (P \ .001) (Figure 2). Patients aged .35 years at the time of surgery had a final mHHS score 4.5 points lower (mean mHHS score, 79.8) than those aged :::35 years (mean mHHS score, 84.3) (P = .03) and similarly demonstrated a HOS-SSS score 6.7 points lower (mean HOS-SSS score, 67.1) than those aged :::35 years (mean HOS-SSS score, 73.8) (P =.03) (Figure 3). Patients with a BMI .30 kg/m2 achieved mean improvements in the VAS of 4.0, the  mHHS  of 19.1, and the HOS-SSS of 29.2 postoperatively, whereas patients aged .35 years had mean improvements of 3.2 in the VAS, 17.5 in the mHHS, and 27.3 in the HOS-SSS. As such, both groups, while statistically inferior in outcomes as compared with patients with a BMI :::30 kg/m2 and age :::35 years, surpassed the MCID for each patient-reported score (2.0, 9.0, and 25.0, respectively).

Additionally, patients with Tonnis grade 2 preoperatively were found to have a 12.5-point worse mHHS score (P = .02) and 23.0-point worse HOS-SSS score

 (P \ .01) at the time of follow-up as compared with patients with Tonnis grade 0 (Figure 4). VAS demonstrated no significant association with the Tonnis grade. No significant differences in the mHHS or HOS-SSS were found when comparing patients with grade 0 and grade 1 radiographs preoperatively. Patients presenting with To¨nnis grade 2 changes achieved final mean improvements in the VAS of 3.7 points (P = .0.01), surpassing the MCID. However, the mean HOS-SSS score decreased nonsignificantly from 72.1 preoperatively to 71.0 postoperatively (P = .84), while the mean HOS-SSS score decreased from 68.8 preoperatively to 49.5 postoperatively (P = .66) in Tonnis grade 2 patients.

The preoperative alpha angle, LCEA, sex, laterality, intra- operative femoral and acetabular cartilage grades, ligamen- tum teres debridement, psoas release, and capsular repair were found to be nonsignificant at predicting VAS, mHHS, and HOS-SSS scores.

After univariate analysis, multifactorial analysis for predictors of each of the 3 patient-reported outcomes was performed using stepwise regression employing the Akaike information criterion. As previously observed in univariate analysis, no significant predictors of the final VAS score were found. It was determined that the optimum model for both the mHHS and HOS-SSS at final follow-up was through the combination of BMI and Tonnis grade. As such, patients with a BMI .30 kg/m2 and Tonnis grade 2 preoperatively were modeled to have the worst outcomes, whereas patients with a BMI :::30 kg/m2 and Tonnis grade  0 to 1 were predicted to experience the most favorable results after arthroscopic labral repair (Table 4). 

 

DISCUSSION
The purpose of this study was to determine the clinical out- comes of arthroscopic hip labral repair at a minimum 5 years of follow-up as well as to determine the risk factors for worse patient outcomes. Our hypothesis was supported in that patients demonstrated durable improvements in VAS, mHHS, and HOS-SSS scores at mid-term follow-up. In addition, we found that increasing Tonnis grade, patient BMI, and age at the time of surgery significantly predicted worse outcomes.

Our finding that patient outcomes demonstrated significant and sustained improvement at 5 years after hip arthro- scopic surgery is an extension of the previous literature that has demonstrated well-established short-term efficacy and favorable outcomes in terms of VAS,13 mHHS,11,20,33 and HOS-SSS scores.20 As longer term outcomes become available for analysis, recent studies have demonstrated mid- term benefits of hip arthroscopic surgery in the setting of FAI and labral tears. However, the sample size for most studies has been relatively small, and we believe that this study is among the largest cohorts with the longest mean follow-up when reviewing the current literature.25,31,44,47,49 As such, we believe that this study supports the durable outcomes previously described at mid-term follow-up while adding statistical power and decreasing the propensity for type 2 errors present in smaller sample sizes.

In terms of the VAS, our findings demonstrated a mean postoperative VAS score within the SD of the overall VAS score observed for 935 hips previously described at 2:2 years of follow-up.13 It is noteworthy that our mean VAS score fell below the point estimates for the Tonnis grade 0, 1, and 2 subgroups reported in the prior study; however, our population was 12.8 years younger at the time of surgery, making direct comparisons between study populations difficult. In terms of our findings associating increasing To¨nnis grade with decreasing outcome scores, it has been previously reported in large matched-cohort studies that  VAS, mHHS, and HOS-SSS scores are not significantly affected by the preoperative  Tonnis grade at 2 years of follow-up.13,14 Our findings are significant in that they suggest that preoperative osteoarthritis evolves over time, causing significant effects in mHHS and HOS-SSS at mid-term fol- low-up, which are not apparent earlier in patients’ clinical courses. This was especially noticeable in mHHS and HOS-SSS scores for patients with Tonnis grade 2 radio- graphs, which decreased nonsignificantly postoperatively, failing to meet the MCID. In comparison, patients with Tonnis grade 0 to 1 changes demonstrated significant postoperative improvements in mHHS and HOS-SSS as well as VAS, which surpassed the MCID. This highlights the importance of large cohorts with extended follow-up as outcomes can differentiate over the course of many years. Future studies should aim to investigate outcome  score  trends over time as well as correlate these outcomes to postoperative radiographic signs of arthritis.

In terms of mHHS, we observed postoperative scores that approximated the findings of Kamath et al,33 who demonstrated a mean mHHS score of 80.4 at 4.8 years in their sample of labral tears managed arthroscopically. When comparing our subgroup of patients aged .35 years to their sample, which had an average age of 42 years, the difference in the observed postoperative mHHS score is 0.6, suggesting relative homogeneity between our outcomes and those found at the university and private hospital included in their study. Similarly, our HOS-SSS scores are similar to values previously presented for both adolescents and recreational athletes at short-term follow-up.20,53

A meta-analysis comprising 107 study populations and 9044 hips at 2:1 year by Levy et al39 demonstrated that increasing patient age negatively predicts mHHS and HOS-SSS scores. Similarly, the study suggested that increasing BMI predicts worse HOS-SSS scores. In terms of age, there has been a significant amount of data associating age-related chondropathy with worse outcomes as well as identifying increasing age as an independent negative predictor of postoperative outcomes and as a risk factor for subsequent conversion to total hip arthroplasty, especially  in those patients over 40 years of age.27,30 However, meta-analyses have focused on stratifying the risk of revision and have been limited by differences in outcome scores collected by various studies as well as by their combination of relatively dissimilar and individually small sample sizes. We believe that this cohort serves as the first single-study sample to describe the association between increased age and worsened mid-term outcomes after hip arthroscopic surgery.

Our finding of increased BMI being associated with worse patient outcome scores has also been described previously in the short-term literature. A recent work correlated increasing BMI and decreased mHHS and HOS-SSS values at 2 years’ follow-up in a population of relatively young recreational and amateur athletes.53 These findings  have  also been described in larger cross-sectional samples, such as the previously mentioned meta-analysis by Levy et al,39 which demonstrated a significant correlation between increasing BMI in 3149 hips and decreasing HOS-SSS and HOS-ADL scores. Finally, a 2-study meta-analysis associated BMI 2:30 kg/m2 with both decreased mHHS and Non-Arthritic Hip Score (NAHS) scores as compared with nonobese controls as well as an increased risk of revision arthroscopic surgery and total hip arthroplasty at 2.5 years of follow-up.3 The current study, however, remains the only study to extend these findings to mid-term follow-up, suggesting that increased BMI and patient age have lasting effects on patient outcomes. It is noteworthy that there is likely a considerable degree of interplay between age, BMI, and osteoarthritis for most patients; however, each  has been established as an independent risk factor for failure after hip arthroscopic surgery.30,39,46 With the exception of the isolated VAS improvements observed in patients presenting with preoperative Tonnis grade 2 radiographs, patients at risk for poorer outcomes because of increased BMI and age achieved significant improvements in VAS, mHHS, and HOS-SSS, reaching the MCID in all 3 scales, albeit to a lower magnitude than their younger and lower BMI counterparts. As such, our findings suggest that while outcomes are com- promised in these patients, hip arthroscopic labral repair may still provide significant relief and improvement in function.

While the 4 institutions and use of 3 outcome scales (VAS, mHHS, and HOS-SSS) are relative strengths of our study, future investigations should aim to include additional arthroscopic surgery centers and outcome measures as the prior literature contains a variety of measurement tools, such as the NAHS,11,19 International Hip Outcome Tool (iHOT-12),22,26 and Functional Activity Assessment,5,48 for which further outcome research is merited. An  associated  limitation  of our study is the inherent difficulty of mid-term to long-term clinical follow-up in a young and healthy patient popu- lation and ensuring that patients fill out multiple time-con- suming scales at each clinical visit. Although we believe that our data performed well at a 2:89.3% completion rate for each scale, future studies should aim to achieve near 100% response rates as relationships may  exist between patient outcomes and patient propensity to complete surveys. Additionally, while Tonnis grade is a reasonable surrogate for degree of joint involvement and chondral damage, further studies may also consider noting the intraoperative surface area of chondral damage in addition to the Outerbridge grade. Our study also contains biases inherent to a retrospective review, namely, selection bias and reliance on accurate and complete record keeping.

In summary, our data suggest that improvements in VAS, mHHS, and HOS-SSS scores outlined in previous studies are durable through mid-term follow-up. Additionally, this study reinforces the association between increased BMI and patient age and worse patient outcomes after hip arthroscopic surgery. Our finding that patients with a higher preoperative Tonnis grade have worse outcomes at mid-term follow-up is novel in that this differentiation was not apparent in previous short-term studies, suggesting that patients grouped by preoperative radiographic arthritis clinically differentiate over the course of extended follow-up. As such, we believe that this study’s  significance lies in its  ability to support  hip arthroscopic surgery in providing sustained relief for labral tears and FAI as well as in providing both univariate and multivariate preoperative measures that can serve as enduring predictors of clinical outcomes for the surgeon selecting and counseling patients for hip arthroscopic surgery.

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Multicenter Analysis of Midterm Clinical Outcomes of Arthroscopic Labral Repair in the Hip

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Minimum 5-Year Follow-up

Mario Hevesi,* MD, Aaron J. Krych,*y MD, Nick R. Johnson,* BS, John M. Redmond,z MD, David E. Hartigan,§ MD, Bruce A. Levy,* MD, and Benjamin G. Domb,II MD

Investigation performed at Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic, Phoenix, Arizona, USA; Southeast Orthopedic Specialists, Jacksonville, Florida, USA;

and American Hip Institute, Westmont, Illinois, USA

Background: The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown.
Purpose: To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes.
Study Design: Cohort study; Level of evidence, 3.
Methods: Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), To¨ nnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery.
Results: A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent peri- acetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI .30 kg/m2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI :::30 kg/m2 (P \ .01). Patients aged .35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged :::35 years (P = .03). Patients with To¨ nnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score (P = .02) and a 23.0-point worse HOS-SSS score (P \ .01) when compared with patients with To¨ nnis grade 0.
Conclusion: Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with To¨ nnis grade 2 changes preoperatively, BMI .30 kg/m2, and age .35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.
Keywords: hip arthroscopic surgery; midterm; labral repair; clinical outcomes; VAS; mHHS; HOS-SSS

Hip pain and the development of osteoarthritis have been strongly associated with structural abnormalities of the hip joint including chondral injuries, labral tears, and fem- oroacetabular impingement (FAI).4,24,35,42 Traditionally, the treatment of hip disorders required open approaches; however, there has been a contemporary shift to less inva- sive management of these lesions.6  Hip arthroscopic surgery was popularized in the late 2000s, and there has been a dramatic increase in its recent use, as it has been shown to be safe and efficacious in short-term studies.7,28 Initial arthroscopic management of acetabular labral injuries was in the form of debridement, and this has been shown to have modest outcomes at mid-term follow- up, with 20% of hips requiring subsequent surgery and an additional 25% of hips rating function as abnormal or severely  abnormal  at  5  years’  follow-up. Subsequent efforts to preserve the labrum through repair have demon- strated promising short-term outcomes, with significantly greater improvements in the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and HOS–Sports-Specific Subscale (HOS-SSS) when compared with isolated debridement.37 However, longer follow-up is currently underreported. As such, it is largely unknown whether early improvements after labral repair will be durable over time.

Short-term studies have additionally established that body mass index (BMI) and increased patient age are risk factors for decreased patient-reported outcomes postoperatively.27,30,39,53 However, the preoperative Tonnis grade, which had previously been postulated to be a negative predictor of outcomes, has not been shown to have significant postoperative effects in large, matched cohorts.13,14

Therefore, the purpose of this study was to (1) outline the clinical mid-term patient-reported outcomes of arthroscopic hip labral repair at a minimum 5 years of follow-up, (2) determine the applicability of short-term risk factors on mid- to long-term outcomes, and (3) establish novel risk fac- tors as patient groups differentiate over time. Our hypothe- ses were that (1) patients would demonstrate durable improvements in patient-reported outcome scores at mid- term follow-up, (2) previously established short-term risk factors such as increased BMI and patient age would predict worse mid-term outcomes, and (3) an increased preoperative To¨nnis grade would negatively affect mid- to long-term out- comes as patients with varying degrees of pre-existing oste- oarthritis differentiate over time.

METHODS

Study Population and Design

This retrospective clinical and radiographic study included all eligible patients undergoing hip arthroscopic surgery after the failure of nonoperative management at 4 high- volume hip arthroscopic surgery centers (Mayo Clinic, Rochester, Minnesota; Mayo Clinic, Phoenix, Arizona; Southeast Orthopedic Specialists, Jacksonville, Florida; and American Hip Institute, Westmont, Illinois). Patients consented to participate in research after institutional review board approval of the study design (#08-002259). Inclusion criteria consisted of all patients undergoing primary hip arthroscopic  surgery between February 2008 and December 2011 who consented to research participation with labral repair performed at the time of surgery. Exclusion criteria consisted of less than 5 years of clinical follow-up, patients choosing not to participate in outcome surveys, labral debridement, labral reconstruction, and previous hip surgery. Patients with bilateral hip arthroscopic surgery, both simultaneous and staged, were included and noted in our database. Indications for arthroscopic surgery included labral tears, chondral injuries, and FAI that had failed nonoperative management. The prospectively collected institutional databases contained the records of 449 primary hip arthroscopic procedures with labral repair performed during the study period for potential inclusion. Of these, 146 patients were excluded because they had less than 5 years of clinical follow-up, resulting in 303 patients for inclusion in this study.

Surgical Technique

Arthroscopic hip surgery was performed by experienced arthroscopic surgeons (A.J.K., J.M.R., D.E.H., B.A.L., B.G.D.) in an operative setting. Patients were positioned in a modified supine position, and 2 or more portals were employed, including the anterolateral and midanterior portals. Positioning and approaches have been previously described in detail.8,40,54 Diagnostic arthroscopic surgery was performed to directly evaluate the articular and labral status. Correction of cam and pincer lesions was per- formed when present.16,17 All patients underwent labral repair with concurrent debridement as indicated, employing standard techniques.18,23,34 Psoas release was performed in the setting of clinically painful iliopsoas snapping reproduced on physical examination. Capsular repair was performed at the discretion of the operating surgeon, with its use favored  in the setting of young patients participating in high-demand activities, patients demonstrating hip or generalized laxity such as that easily translated under femoral head traction, and those with dysplastic radiographic features.

Rehabilitation Protocol

Patients underwent standard postoperative rehabilitation and pain relief protocols, which were consistent between physicians at the same institution and similar between institutions. Patients were placed on crutches for 2 to 4 weeks with foot-flat partial weightbearing. Passive motion was started at 0 weeks. As crutches were gradually discontinued, patients progressed through institutional rehabilitation protocols, which have been previously outlined in detail for the centers involved.21,50 Jogging exercises began at 3 months, as tolerated, and return to sport was allowed at 5 to 6 months.

Outcome Measures

Demographic data such as age at the time of surgery, BMI, and sex were collected. In addition, preoperative radiographic measures such as Tonnis grade,51 alpha angle,2 and lateral center edge angle (LCEA)41 were noted. Hips with an LCEA \25° were classified as dysplastic. Surgical diagnoses such as the presence of cam and/or pincer lesions, femoral and acetabular chondromalacia as defined by the Outerbridge45 and acetabular labrum articular disruption (ALAD)9 classification systems, and surgical techniques such as ligamentum teres debridement and psoas release were documented using a standardized data form. Subjective preoperative and postoperative outcomes were documented using the visual analog scale (VAS),38 modi- fied Harris Hip Score (mHHS),29 and HOS-SSS.43 The completion rate for each individual outcome scale was 2:89.3%. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery, open hip surgery, and conversion to hip replacement.

Statistical Analysis

Descriptive statistics were used to present demographic data, employing means and SDs, percentages, and medians with interquartile ranges (IQRs), as appropriate. Factors such as BMI, sex, laterality, and intraoperative cartilage grade were examined for their association with outcome measures such as VAS, mHHS, and HOS-SSS using the Spearman rank correlation coefficient for continuous variables, independent sample t tests for differences between nominal values, and analysis of variance for categorical variables such as Tonnis, femoral, and acetabular cartilage grades. After analysis of single-factor predictors, stepwise linear regression was performed employing the Akaike information criterion to identify the optimal set of explanatory variables for postoperative outcome scores.1 The Wilcoxon rank-sum test (Mann-Whitney U test) was used to compare ordinal variables such as preoperative and postoperative VAS, mHHS, and HOS-SSS  scores. Cox proportional hazards regression was performed to determine predictors of postoperative failure.

A priori analysis was used to determine the mean group sample size needed to demonstrate the minimal clinically important difference (MCID) for patient-reported outcome scores at an alpha of 0.05 and power of 0.80. Using the study by Chahal et al,12 in which MCID cutoffs were determined for mHHS and HOS-SSS at 3, 6, and 12 months after hip arthroscopic labral repair for FAI, the most conservative MCID value presented for each outcome measure was selected, resulting in a cutoff of 9.0 points for mHHS and 25.0 points for HOS-SSS. Additionally, based on a study of arthritic hip pain in 211 patients, an MCID of 2.0 points was established for VAS.52 Employing these values and out- come score distributions derived from previous studies on hip arthroscopic labral repair, the mean group sample size needed to demonstrate the MCID was determined to be 48 for mHHS, 12 for HOS-SSS, and 21 for VAS.32 P values\.05 were considered significant. Analyses were conducted in R version 3.4.0 (R Core Team).

RESULTS

Using institutional databases comprising cases of hip arthroscopic surgery performed from February 2008 to December 2011 at 4 institutions, we identified 303 patients with 2:5 year

s of clinical follow-up. The mean age at the time of surgery was 32.0 years, the mean BMI was 24.4 kg/m2, and the mean duration of follow-up was 5.7 years (range, 5.0-7.9 years) (Table 1). In terms of preoperative radiographic measures, Tonnis grade 0 predominated (72.1%), followed by grade 1 (24.2%) and grade 2 (3.7%). The median alpha angle was 56.9° (IQR, 49.0°-67.0°), and the median LCEA was 30.0° (IQR, 26.5°-34.0°). Of note, right-sided surgery (58.1%) was significantly more com- mon than left-sided surgery (41.9%) (P \ .01), and women (66.7%) were represented to a greater proportion than men (33.3%) (P \ .001).

 

Four patients underwent bilateral hip surgery, with both hips included in the dataset with a minimum 5 years of follow-up. Of these, 1 pair of hips underwent surgery simultaneously, and another 3 pairs underwent surgery in a staged manner, with the 2 procedures separated by 4.5 to 24.6 months. An additional 5 patients underwent hip arthroscopic surgery performed in a staged manner, with the second hip performed after December 2011 and thus had less than 5 years of follow-up. In these cases, the first hip was included in the dataset.

Patients underwent hip arthroscopic surgery for a combination of hip dysplasia (n = 50), cam lesions (n = 200), pincer lesions (n = 66), and labral lesions (n = 303) in the setting of varied acetabular and femoral chondromalacia (Table 2). For patients with dysplasia, the mean LCEA was 21.5° (range, 13.0°-24.9°).

Ligamentum teres debridement was performed in 37.6% of the study population, psoas release in 38.3%, and capsular repair in 48.5%. The total failure rate was observed to be 16.2%, with 49 of 303 patients undergoing revision hip surgery during the course of follow-up. Of these, 7 went on to total hip arthroplasty, 2 underwent hip resurfacing, 2 underwent periacetabular osteotomy   alone,   37   underwent   revision   arthroscopic management, and 1 patient  underwent revision  arthroscopic management, followed by periacetabular osteotomy, at a later time. All patients going on to periacetabular osteotomy did so in the setting of hip dysplasia.

 

A multivariable Cox proportional hazards model was constructed to evaluate preoperative and intraoperative findings predictive of subsequent failure and the progres- sion to ipsilateral hip surgery. No significant predictors of failure were noted (Table 3). Dysplasia did not predict subsequent ipsilateral hip surgery, whether defined as an LCEA \25° (P = .56) or an LCEA \20° (P = .60).

VAS, mHHS, and HOS-SSS scores were all observed to significantly improve (P \ .001) between preoperative values and final follow-up at 5.0 to 7.9 years postoperatively (Figure 1). VAS score decreased a mean of 3.5 points after surgery, whereas mHHS and HOS-SSS scores increased by 20.1 and 29.3 points, respectively. Analysis was conducted to explore whether the institution or performing surgeon had an effect on outcome scores. The location and provider were found to be nonsignificant in predicting VAS, mHHS, and HOS-SSS scores at final follow-up (P 2: .11) when accounting for patient age, BMI, and Tonnis grade.

BMI was found to be significantly and negatively corre- lated to final mHHS (P \ .001) and HOS-SSS (P \ .001) scores. It was nonsignificant for predicting VAS scores (P = .33). This pattern was also present for age at the time of surgery, with a significant negative correlation with final mHHS (P = .02) and HOS-SSS (P \ .01) scores and nonsignificance in terms of VAS scores (P = .66).

On average, patients with a BMI .30 kg/m2 had a final mHHS score 9.5 points lower (mean mHHS score, 74.0) than those with a BMI :::30 kg/m2  (mean mHHS score,83.5) (P \ .01) and demonstrated a HOS-SSS score 15.9 points lower (mean HOS-SSS score, 57.0) than those with a BMI :::30 kg/m2 (mean HOS-SSS score, 72.9) (P \ .001) (Figure 2). Patients aged .35 years at the time of surgery had a final mHHS score 4.5 points lower (mean mHHS score, 79.8) than those aged :::35 years (mean mHHS score, 84.3) (P = .03) and similarly demonstrated a HOS-SSS score 6.7 points lower (mean HOS-SSS score, 67.1) than those aged :::35 years (mean HOS-SSS score, 73.8) (P =.03) (Figure 3). Patients with a BMI .30 kg/m2 achieved mean improvements in the VAS of 4.0, the  mHHS  of 19.1, and the HOS-SSS of 29.2 postoperatively, whereas patients aged .35 years had mean improvements of 3.2 in the VAS, 17.5 in the mHHS, and 27.3 in the HOS-SSS. As such, both groups, while statistically inferior in outcomes as compared with patients with a BMI :::30 kg/m2 and age :::35 years, surpassed the MCID for each patient-reported score (2.0, 9.0, and 25.0, respectively).

Additionally, patients with Tonnis grade 2 preoperatively were found to have a 12.5-point worse mHHS score (P = .02) and 23.0-point worse HOS-SSS score

 (P \ .01) at the time of follow-up as compared with patients with Tonnis grade 0 (Figure 4). VAS demonstrated no significant association with the Tonnis grade. No significant differences in the mHHS or HOS-SSS were found when comparing patients with grade 0 and grade 1 radiographs preoperatively. Patients presenting with To¨nnis grade 2 changes achieved final mean improvements in the VAS of 3.7 points (P = .0.01), surpassing the MCID. However, the mean HOS-SSS score decreased nonsignificantly from 72.1 preoperatively to 71.0 postoperatively (P = .84), while the mean HOS-SSS score decreased from 68.8 preoperatively to 49.5 postoperatively (P = .66) in Tonnis grade 2 patients.

The preoperative alpha angle, LCEA, sex, laterality, intra- operative femoral and acetabular cartilage grades, ligamen- tum teres debridement, psoas release, and capsular repair were found to be nonsignificant at predicting VAS, mHHS, and HOS-SSS scores.

After univariate analysis, multifactorial analysis for predictors of each of the 3 patient-reported outcomes was performed using stepwise regression employing the Akaike information criterion. As previously observed in univariate analysis, no significant predictors of the final VAS score were found. It was determined that the optimum model for both the mHHS and HOS-SSS at final follow-up was through the combination of BMI and Tonnis grade. As such, patients with a BMI .30 kg/m2 and Tonnis grade 2 preoperatively were modeled to have the worst outcomes, whereas patients with a BMI :::30 kg/m2 and Tonnis grade  0 to 1 were predicted to experience the most favorable results after arthroscopic labral repair (Table 4). 

 

DISCUSSION
The purpose of this study was to determine the clinical out- comes of arthroscopic hip labral repair at a minimum 5 years of follow-up as well as to determine the risk factors for worse patient outcomes. Our hypothesis was supported in that patients demonstrated durable improvements in VAS, mHHS, and HOS-SSS scores at mid-term follow-up. In addition, we found that increasing Tonnis grade, patient BMI, and age at the time of surgery significantly predicted worse outcomes.

Our finding that patient outcomes demonstrated significant and sustained improvement at 5 years after hip arthro- scopic surgery is an extension of the previous literature that has demonstrated well-established short-term efficacy and favorable outcomes in terms of VAS,13 mHHS,11,20,33 and HOS-SSS scores.20 As longer term outcomes become available for analysis, recent studies have demonstrated mid- term benefits of hip arthroscopic surgery in the setting of FAI and labral tears. However, the sample size for most studies has been relatively small, and we believe that this study is among the largest cohorts with the longest mean follow-up when reviewing the current literature.25,31,44,47,49 As such, we believe that this study supports the durable outcomes previously described at mid-term follow-up while adding statistical power and decreasing the propensity for type 2 errors present in smaller sample sizes.

In terms of the VAS, our findings demonstrated a mean postoperative VAS score within the SD of the overall VAS score observed for 935 hips previously described at 2:2 years of follow-up.13 It is noteworthy that our mean VAS score fell below the point estimates for the Tonnis grade 0, 1, and 2 subgroups reported in the prior study; however, our population was 12.8 years younger at the time of surgery, making direct comparisons between study populations difficult. In terms of our findings associating increasing To¨nnis grade with decreasing outcome scores, it has been previously reported in large matched-cohort studies that  VAS, mHHS, and HOS-SSS scores are not significantly affected by the preoperative  Tonnis grade at 2 years of follow-up.13,14 Our findings are significant in that they suggest that preoperative osteoarthritis evolves over time, causing significant effects in mHHS and HOS-SSS at mid-term fol- low-up, which are not apparent earlier in patients’ clinical courses. This was especially noticeable in mHHS and HOS-SSS scores for patients with Tonnis grade 2 radio- graphs, which decreased nonsignificantly postoperatively, failing to meet the MCID. In comparison, patients with Tonnis grade 0 to 1 changes demonstrated significant postoperative improvements in mHHS and HOS-SSS as well as VAS, which surpassed the MCID. This highlights the importance of large cohorts with extended follow-up as outcomes can differentiate over the course of many years. Future studies should aim to investigate outcome  score  trends over time as well as correlate these outcomes to postoperative radiographic signs of arthritis.

In terms of mHHS, we observed postoperative scores that approximated the findings of Kamath et al,33 who demonstrated a mean mHHS score of 80.4 at 4.8 years in their sample of labral tears managed arthroscopically. When comparing our subgroup of patients aged .35 years to their sample, which had an average age of 42 years, the difference in the observed postoperative mHHS score is 0.6, suggesting relative homogeneity between our outcomes and those found at the university and private hospital included in their study. Similarly, our HOS-SSS scores are similar to values previously presented for both adolescents and recreational athletes at short-term follow-up.20,53

A meta-analysis comprising 107 study populations and 9044 hips at 2:1 year by Levy et al39 demonstrated that increasing patient age negatively predicts mHHS and HOS-SSS scores. Similarly, the study suggested that increasing BMI predicts worse HOS-SSS scores. In terms of age, there has been a significant amount of data associating age-related chondropathy with worse outcomes as well as identifying increasing age as an independent negative predictor of postoperative outcomes and as a risk factor for subsequent conversion to total hip arthroplasty, especially  in those patients over 40 years of age.27,30 However, meta-analyses have focused on stratifying the risk of revision and have been limited by differences in outcome scores collected by various studies as well as by their combination of relatively dissimilar and individually small sample sizes. We believe that this cohort serves as the first single-study sample to describe the association between increased age and worsened mid-term outcomes after hip arthroscopic surgery.

Our finding of increased BMI being associated with worse patient outcome scores has also been described previously in the short-term literature. A recent work correlated increasing BMI and decreased mHHS and HOS-SSS values at 2 years’ follow-up in a population of relatively young recreational and amateur athletes.53 These findings  have  also been described in larger cross-sectional samples, such as the previously mentioned meta-analysis by Levy et al,39 which demonstrated a significant correlation between increasing BMI in 3149 hips and decreasing HOS-SSS and HOS-ADL scores. Finally, a 2-study meta-analysis associated BMI 2:30 kg/m2 with both decreased mHHS and Non-Arthritic Hip Score (NAHS) scores as compared with nonobese controls as well as an increased risk of revision arthroscopic surgery and total hip arthroplasty at 2.5 years of follow-up.3 The current study, however, remains the only study to extend these findings to mid-term follow-up, suggesting that increased BMI and patient age have lasting effects on patient outcomes. It is noteworthy that there is likely a considerable degree of interplay between age, BMI, and osteoarthritis for most patients; however, each  has been established as an independent risk factor for failure after hip arthroscopic surgery.30,39,46 With the exception of the isolated VAS improvements observed in patients presenting with preoperative Tonnis grade 2 radiographs, patients at risk for poorer outcomes because of increased BMI and age achieved significant improvements in VAS, mHHS, and HOS-SSS, reaching the MCID in all 3 scales, albeit to a lower magnitude than their younger and lower BMI counterparts. As such, our findings suggest that while outcomes are com- promised in these patients, hip arthroscopic labral repair may still provide significant relief and improvement in function.

While the 4 institutions and use of 3 outcome scales (VAS, mHHS, and HOS-SSS) are relative strengths of our study, future investigations should aim to include additional arthroscopic surgery centers and outcome measures as the prior literature contains a variety of measurement tools, such as the NAHS,11,19 International Hip Outcome Tool (iHOT-12),22,26 and Functional Activity Assessment,5,48 for which further outcome research is merited. An  associated  limitation  of our study is the inherent difficulty of mid-term to long-term clinical follow-up in a young and healthy patient popu- lation and ensuring that patients fill out multiple time-con- suming scales at each clinical visit. Although we believe that our data performed well at a 2:89.3% completion rate for each scale, future studies should aim to achieve near 100% response rates as relationships may  exist between patient outcomes and patient propensity to complete surveys. Additionally, while Tonnis grade is a reasonable surrogate for degree of joint involvement and chondral damage, further studies may also consider noting the intraoperative surface area of chondral damage in addition to the Outerbridge grade. Our study also contains biases inherent to a retrospective review, namely, selection bias and reliance on accurate and complete record keeping.

In summary, our data suggest that improvements in VAS, mHHS, and HOS-SSS scores outlined in previous studies are durable through mid-term follow-up. Additionally, this study reinforces the association between increased BMI and patient age and worse patient outcomes after hip arthroscopic surgery. Our finding that patients with a higher preoperative Tonnis grade have worse outcomes at mid-term follow-up is novel in that this differentiation was not apparent in previous short-term studies, suggesting that patients grouped by preoperative radiographic arthritis clinically differentiate over the course of extended follow-up. As such, we believe that this study’s  significance lies in its  ability to support  hip arthroscopic surgery in providing sustained relief for labral tears and FAI as well as in providing both univariate and multivariate preoperative measures that can serve as enduring predictors of clinical outcomes for the surgeon selecting and counseling patients for hip arthroscopic surgery.

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3 Things You Should Know About Hip Flexor Strains

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A hip flexor strain occurs when your hip flexor muscles become injured through various activities that cause the muscles to overstretch or hyperextend. Such strains can vary in severity, from minor injuries which can be treated at home to severe strains that need medical attention.

Where are your hip flexors located and how can they become injured?

Your hip flexors are the group of muscles that connect your femur in your upper leg to your hips, groin and lower back. This set of muscles works together to help you move around and stabilize yourself.

Through overuse or overstretching, the muscles and tendons that make up your hip flexors can become injured. Because your hip flexors are most engaged when you bring your knees up, activities that involve this motion such as running, dancing and martial arts are most likely to result in hip flexor strain.

What are the typical signs of a hip flexor strain?

Sharp pain in the pelvis or hip area is the most common symptom of a hip flexor strain and usually appears suddenly after the injury has occurred. You may also experience cramping in your upper leg muscles, tenderness or swelling in the area, muscle spasms in your thighs or hips, and overall reduced mobility and strength in your hips and upper legs.

How should you treat a hip flexor strain?

Minor hip flexor strains can typically be treated at home. Resting the muscles and avoiding activities that can aggravate the injury can help encourage healing. To deal with the pain associated with such an injury, you can apply a compression wrap, use ice or heat on the injured area, or take over-the-counter medications such as Tylenol or ibuprofen.

If you continue to experience pain in your hip flexors after 10 days, medical attention may be needed; in severe cases, physical therapy or even surgery may be necessary. Contact the orthopedic doctors at Southeast Orthopedic Specialists to learn more about your treatment options and our orthopedic services.

A Study on Banning Home Plate Collisions Suggests Less Othopedic Injury

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Recently, Major League Baseball revealed plans to put a ban on home plate collisions. According to the results of recent research, banning these collisions may help protect players from serious injuries, some of which require orthopedic surgery.

About the Study

The study was published by two researchers from Wake Forest University in the International Journal of Sports Medicine. This study compared the number of injuries per play for different types of plays. The researchers discovered that an average of seven injuries occurred for every 1,000 tag outs on home plate. For plays involving throws from the outfield to second or third base, the average number of injuries was only 1.5 per 1,000 plays.
Based on this data, researchers determined that plays at home plate raised the risk of injury by more than four times. In these incidents, injuries were slightly more likely for runners than catchers. In all types of plays, the typical injuries sustained were similar in severity. However, the type of injury sustained differed by location. For outfield throws, the most common injury was a fracture. For double play attempts and plays at home plate, dislocations and sprains were most common.

Dangers of Home Plate Collisions

Home plate collisions are more dangerous than other baseball injuries for several reasons. In most cases, these collisions occur with one highly-motivated individual running at full speed toward home plate. This runner collides with a catcher who is fully outfitted in protective armor. This combination creates the ideal circumstances for injuries to occur.

How the Ban Will Help

The proposed ban would require the catcher to stay out of the baseline and touch the runner only with the ball in his glove. If this ban is enacted, it could help to prevent some injuries during baseball games.

Even with the ban in place, injuries are still likely to occur. If you have suffered an injury while playing baseball, getting the right treatment is essential. Please contact Southeast Orthopedic Specialists to make an appointment today.

Is Tennis Elbow An Occupational Risk?

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Recent research shows that certain manual tasks commonly performed on the job may be increasing your risk of tennis elbow, a painful condition that may require surgery. In light of this evidence, it is important for employers and employees to take steps to protect themselves from this condition.

About Tennis Elbow

Tennis elbow, also known as “lateral epicondylitis,” is a disorder that develops in the elbow and causes joint pain. It occurs when the tendons in your elbow sustain damage, usually from repetitive motions that put stress on these tendons over time.

About the Research

The research study in question focused on five specific studies from the United States and France. Through meta-analysis, researchers concluded that there was a significant, positive association between exposure to repetitive activities involving the elbow and/or wrist and the development of tennis elbow. The more an individual was exposed to this activity, the more likely they were to develop this condition.

What Does It Mean for Workers?

This meta-analysis has important implications for workers and employers alike. People who spend their workdays performing repetitive motions with their wrists and/or elbows should be aware of their risk of developing tennis elbow. In addition, people who have already developed tennis elbow should make an effort to reduce or eliminate repetitive motions that affect this part of their body.

Based on the evidence found in this study, employers who require employees to engage in repetitive motions involving the wrist and elbow should also consider changing their protocols and/or providing supportive services to help prevent the development of tennis elbow among their employees. Furthermore, employers should be prepared to make adjustments and adaptations for workers who are already affected by this condition and need to prevent further damage.

If you are experiencing the symptoms of tennis elbow, you need to seek treatment to prevent the condition from getting worse. Please contact Southeast Orthopedic Specialists today to make an appointment.

Rise in Knee Osteoarthritis

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According to new research, the incidence of knee osteoarthritis has doubled over the last 50 years. Based on this information, experts have determined that this condition, which often leads to knee replacement, may be more preventable than once thought.

Research

During this study, researchers examined thousands of skeletons from different periods looking for signs of knee osteoarthritis. They found signs of advanced knee osteoarthritis in approximately 6 percent of skeletons from the pre-industrial period and 18 percent of skeletons from the post-industrial period. Regression analysis showed that the increase could not be blamed on obesity or aging.

Prior to the completion of this research, the medical community believed that osteoarthritis in the knee was becoming more common primarily because of increases in obesity rates, as well as the lengthening of the human lifespan. However, this research determined that the increase in the incidence of knee osteoarthritis could not be explained by these two issues alone. It was also believed that osteoarthritis was unavoidable for many patients, but this evidence indicates that patients may be able to reduce their risk of this condition by changing certain lifestyle factors.

What Does It Mean?

Researchers maintain that aging and obesity still play a significant role in the development of knee arthritis. As an individual ages, the knee joint begins to deteriorate. In addition, because the knee is a weight-bearing joint, being overweight or obese puts considerable strain on the knee. However, other factors are clearly contributing to the condition as well. Some possibilities include a lack of physical activity, inflammation and injuries to the knee.

Further research will be required to determine the exact causes of the increase in knee arthritis. However, in order to reduce the chances of developing osteoarthritis of the knee in the meantime, people are encouraged to maintain a healthy weight, be as active as possible and avoid injuring the knee.

If you have already developed knee osteoarthritis or other knee conditions, you may need treatment. Please contact Southeast Orthopedic Specialists today to learn more.

Smokers Face Higher Risk for Revision after Knee Replacement

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Following a total knee replacement procedure, one of the most significant risks patients face is the need for a revision procedure. Recent studies indicate that one of the most significant risk factors for revision is smoking. For this reason, patients undergoing knee replacement surgery should quit smoking immediately.

About the Study

The study in question covered a total of 436 patients who had undergone total knee replacement surgery. Researchers followed the patients over a period of 13 years and recorded any revisions required in order to identify risk factors. The study determined that, smoking increased the risk of needing a revision by 300 percent.

Among the revisions that did occur, the most common situations leading to a revision were infection, aseptic loosening, stiffness or instability. The study did not investigate the mechanism by which smoking leads to a higher risk of revision. Further research will be necessary to investigate the connection in more depth.

What It Means for Patients

Based on this information, it seems plausible that smoking increases the risk of needing a revision following total knee replacement. For this reason, smokers who know they need a knee replacement should quit smoking as soon as possible. Quitting smoking is also recommended for patients who have already had a knee replacement procedure and hope to limit their chances of eventually needing a revision.

In addition to quitting smoking, there are other steps patients can take to reduce their risk of needing a revision after total knee replacement surgery, such as choosing the right surgeon and following his or her instructions carefully. To learn more about total knee replacement surgery, please contact Southeast Orthopedic Specialists today.

Study Reveals Risk Factor for Women with Rheumatoid Arthritis

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Researchers at the University of Nebraska have recently uncovered a link between menopause and a larger decline in physical functionality in women who have been diagnosed with rheumatoid arthritis.

What the Study Uncovered Regarding Rheumatoid Arthritis and Menopause

In the study published in Rheumatology, University of Nebraska scientists surveyed 8,189 women who had been diagnosed with rheumatoid arthritis prior to entering menopause. The researchers’ aim was to discover if there is a link between menopause and decline in function in women with rheumatoid arthritis.

After controlling for other variables in the study participants’ health backgrounds that could also contribute to functional decline, the University of Nebraska researchers found that the premenopausal women in the study experienced markedly less decline in physical function as compared to postmenopausal women. Furthermore, the study revealed that women who had used hormone replacement therapy, been pregnant and had longer reproductive lives generally experienced less decline in function.

Other Hormonal Factors Can Influence Functional Decline in Those with Rheumatoid Arthritis

The findings of the University of Nebraska study support past studies that have shown that hormonal and reproductive events can influence functional decline in women with rheumatoid arthritis. For example, past research has revealed that pregnancy reduces the symptoms of rheumatoid arthritis, but the postpartum period following pregnancy is associated with increased development of the disease and decline in function.

Researchers were careful to note that the exact reasons why menopause leads to greater loss of physical function in women with rheumatoid arthritis were not made clear by their study, and the lead scientist indicated that further research is necessary to understand the best ways to maintain function following menopause for women with rheumatoid arthritis.

If you are experiencing a decline in your physical function and have been diagnosed with rheumatoid arthritis, the orthopedic doctors at Southeast Orthopedic Specialists may be able to help. Our regenerative medicine practice includes therapies such as stem cell injections that can help restore function.

The Difference Between Aerobic and Anaerobic Training for Sports

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There are two different types of exercise that people can do, whether most of them realize it or not. The two different types of exercise are aerobic and anaerobic. These two types of exercise serve two different purposes and can help people achieve different goals as well.

What is Aerobic Exercise?

Aerobic exercise is what is commonly referred to as cardio. To break that down further, it is exercise that requires the body to use oxygenated blood to work the lung muscles and other muscles in the body. It is something that stimulated the breathing and heart rate. Some examples of aerobic exercises include running, hiking, dancing, kickboxing, swimming, and even using cardio machines. However, any aerobic activity can turn into an anaerobic activity if it is performed at too high of a level or intensity. Aerobic exercise is something that can improve the physical health of a person as well as emotional health. Additionally, it can help prevent or reduce the chance of getting some cancers, diabetes, and even cardiovascular disease.

What is Anaerobic Exercise?

Anaerobic exercise is characterized by exercising without oxygen. It is a type of exercise that makes a person become quickly out of breath. It is a high intensity type of workout where the result is that the body is needing more oxygen than there is available in the body. One of the major differences between this type of exercise and aerobic exercise is that this one relies on the energy sources that are stored in the muscles of the body instead of on the oxygen in the air. Some examples of this type of exercise include sprinting and even lifting heavy weights. The benefit of this type of exercise is that it can be used to increase the strength of the body.

Contact An Orthopedic Today

If you do get injured, especially with an injury to your joints, muscles, or bones, it is important to get the right help to get you back to your training regimen as soon as possible. Contact us today to make an appointment with our orthopedic.

What’s the Difference Between a Slipped Disc and a Herniated Disc?

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The terms “slipped disc” and “herniated disc” are often used interchangeably. This leaves some patients feeling confused. Understanding these terms and what they mean can help you understand your spine and your spine health. If you’re suffering from either of these conditions, knowing how they can affect your spine health can also help you get the treatment you need to heal.

What are Spinal Discs?

The discs in your spine provide cushion between the vertebrae, helping your spine to maintain flexibility. Each disc is comprised of hard cartilage on the outside and a softer center on the inside.

What is a herniated disc?

A herniated disc occurs when the outer edges of the disc begin to crack, causing the soft interior to bulge out. This herniation can cause the disc to protrude from the tough casing that surrounds the spine, leading to pain, numbness and tingling.

What does it mean if a spinal disc has slipped?

Technically, spinal discs can’t slip out of place. However, this term can be used to describe a herniated disc, and is sometimes used to describe a bulging disc.

What is a bulging disc?

As people age, spinal discs start to stiffen and bulge from the spinal column. A bulging disc is one that has flattened slightly, so that the edges of the disc protrude farther than it should. A bulging disc can be painful, but is typically not as painful as a herniated disc. Patients suffering from a bulging disc may also have trouble walking, experience a feeling of heaviness in the legs and may feel tingling.

What can you do if you’re suffering from a herniated or bulging disc?

If you’re suffering from either of these conditions, work with a spine specialist to get treatment. At Southeast Orthopedic Specialists, our orthopedic surgeons provide natural treatment to patients suffering from conditions like a slipped disc. To get started, contact your spine specialist today at (904) 634-0640.

Maintaining a Healthy Spine Through Good Foods

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Maintaining a healthy spine can prevent back pain and uncomfortable chronic conditions. One of the ways that you can maintain a healthy spine is by eating the right foods. Knowing which foods to eat can help you keep up a healthy diet.

Eat Foods High in Calcium

Calcium is one of the most well-known minerals to positively affect bone health. Calcium is best obtained through natural sources, like through the foods you eat. Consuming calcium-rich foods can help prevent osteoporosis and can also help strengthen the bones in the back. For older adults, 1,000 mg of calcium is enough to help keep the back healthy. There are many foods that contain calcium, including:

  • Yogurt
  • Milk
  • Cheese
  • Figs
  • Green beans
  • Carrots
  • Broccoli
  • Almonds

Some adults take in calcium through supplements and vitamins, but taking in calcium through food sources is better.

Lose Weight Through Healthy Foods

Excess weight can put a lot of pressure on the vertebrae, which can eventually lead to back pain and disc degeneration. To control weight gain and maintain a healthy BMI, eat a balanced diet of healthy foods, including:

  • Lean meat (6 ounces daily)
  • Fish (every day or every other day)
  • Olive oil (daily)
  • Nuts (daily)
  • Raw or steamed vegetables (daily)

Limit your intake of trans fats, empty calories, candy, cookies and carbohydrates.

Avoid Nightshade Plants

Nightshade plants (tomatoes and eggplant, for example) are known to contribute to inflammation, which can lead to an increase in pain and discomfort. To avoid problems, cut back your consumption of nightshade plants, then watch to see if your pain goes away. If reducing or eliminating nightshade plants from your diet does nothing to help your pain, then nightshades may not be the source of your problem.

Work With Your Orthopedic Specialists

If you’re struggling to maintain spine health and would like to improve your spine strength and flexibility, contact your orthopedic surgeons at Southeast Orthopedic Specialists. We help patients manage their pain and avoid back discomfort. Contact us today at (904) 634-0640.

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