Background: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population. Purpose/Hypothesis: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores. Results: The patients’ mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score ( P = .795), visual analog scale for pain score ( P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score ( P = .699), 12-item International Hip Outcome Tool score ( P = .582), and patient satisfaction ( P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups ( P < .001). Conclusion: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

Objectives: The treatment of femoroacetabular impingement (FAI) has evolved over the last two decades, transitioning from an open hip dislocation to a more minimally invasive arthroscopic approach as the gold standard for treatment. The non-surgical management of FAI has evolved as well, and a key mainstay of the treatment paradigm for FAI has become physical therapy, both in the preoperative and postoperative periods. Previous research has demonstrated the importance of physical therapy in reducing pain and improving function in patients with FAI. As FAI treatment has changed, the delivery of patient physical therapy and rehabilitation has similarly changed, specifically with the introduction of home exercise programs that are patient-driven methods of postoperative rehabilitation. While other areas of orthopaedic surgery, such as shoulder and knee arthroplasty, have demonstrated similar results when comparing formal physical therapy programs with home-based programs, a comparable study has yet to be conducted specifically in the hip arthroscopy patient population. Given this lack of investigation, the purpose of this study was to compare the short-term outcomes of a formal physical therapy program or a home exercise program (HEP) in FAI patients treated with hip arthroscopy. Our hypothesis was that individuals in both groups would report similar outcomes at short- term follow up and would be significantly improved from their preoperative baselines. Methods: Patients undergoing hip arthroscopy for the treatment of FAI at a single center from October 2020 to October 2021 were prospectively enrolled. Inclusion criteria were 1) completion of a preoperative survey, 2) age greater than 18 years at time of surgery, and 3) lack of previous hip surgery. Patients were allowed to self-select to a formal physical therapy (FPT) program, which consisted of a traditional physical therapy course, or a home exercise program (HEP). Patients were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. Included in the survey was a single assessment numeric evaluation (SANE), visual analogue scale (VAS) pain scores, the International Hip Outcome Tool-12 (iHOT-12), the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and patient satisfaction of physical therapy and their overall care. Demographic characteristics were collected from the electronic medical record. Statistical analysis was conducted using descriptive statistics, unpaired and paired t-tests, and Chi Square and Fisher’s Exact tests for categorical variable comparisons. A p-value of < 0.05 was used to indicate statistical significance. Results: A total of 147 patients were included in this study, with 61 in the FPT group and 86 in the HEP group. There were no significant differences regarding patient sex (p = 0.675) and body mass index (p = 0.188), though the HEP group was slightly older than the FPT group (33.6 ± 9.5 years vs 30.1 ± 11.4 years; p = 0.048). At 12 months postoperative, no significant differences were reported between the FPT and HEP groups regarding hip function rated as a percent of normal (p = 0.576), VAS pain scores at rest (p = 0.262) or during activities of daily living (p = 0.214) or during sport (p = 0.066), PROMIS PF scores (p = 0.426), and iHOT-12 scores (p = 0.421). Furthermore, no differences were reported in patient satisfaction (p > 0.05). Outcome scores at 12 months postoperative were significantly improved from the preoperative baseline across all measures in both groups (p > 0.05). Conclusions: For patients undergoing hip arthroscopy for the treatment of FAI, formal physical therapy and home exercise programs are similarly efficacious in terms of patient-reported outcomes of hip function, with both rehabilitation options resulting in significant patient improvement at short term follow-up from their preoperative baseline.

Purpose:To evaluate short- to mid-term-outcomes, including instability rates, following medial patellofemoral ligament (MPFL) reconstruction in skeletally immature versus mature pediatric patients.Methods:Patients younger than age 18 with recurrent patellar instability who underwent primary allograft MPFL reconstruction by a single surgeon from 2013 to 2019 were identified. Skeletally immature patients underwent all-epiphyseal drilling and mature patients underwent metaphyseal drilling at the Schöttle's point. Patients 1 year from surgery were contacted to complete questionnaires, which included the International Knee Documentation Committee score. Further data included chart and imaging review. Significance was determined by P < .05.Results:Of 118 eligible patients, 88 completed questionnaires. There were 67 skeletally mature and 21 skeletally immature patients. The mature group was older (15 vs 13 years, P < .001), predominantly female (67 vs 43%, P = .046), and heavier (24.7 vs 18.9, P < .001). Trochlear dysplasia (P = .594), concomitant procedures (P = .336), graft choice (P = .274), and follow-up length (P = .107) did not differ, although mature patients more often underwent suture tape augmentation (68 vs 13%, P < .001). Immature patients had greater rates of ipsilateral injury (35 vs 16%, P = .043); redislocation rate did not differ (9 vs 3%, P = .225). Mature patients were more likely to respond "definitely yes or probably yes" when asked if they would undergo the same care if needed (96 vs 76%, P = .007). At minimum 2-year follow-up, subsequent ipsilateral injury rates did not differ, although willingness to undergo the same care remained significant (95 vs 69%, P = .010). In a multivariable elimination logistic regression model, skeletal maturity was the only variable associated with subsequent ipsilateral injury (P = .049).Conclusions:Pediatric patients undergoing MPFL reconstruction have good and comparable outcomes regardless of skeletal maturity. However, younger age and lack of tape augmentation in skeletally immature patients may predispose them to subsequent injury.Level of Evidence:III, case-control study.

Purpose:To evaluate mid-term outcomes after medial patellofemoral ligament (MPFL) reconstruction with and without tape augmentation in the skeletally mature adolescent population.Methods:All patients under age 18 with recurrent patellar instability treated with surgery at a single institution by a single surgeon from January 2013 through June 2017 were identified by current procedural terminology codes. Inclusion criteria were (1) primary MPFL reconstruction, (2) minimum 3 years' follow-up, (3) skeletal maturity. Exclusion criteria were (1) bilateral MPFL reconstruction using different techniques on each knee, (2) prior surgery for patellar instability. Chart and imaging review was completed. Patients were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form.Results:Fifty-one of 92 eligible patients completed questionnaires. Two patients were excluded. Twenty patients underwent 23 non-augmented MPFL reconstructions; 29 patients underwent 33 augmented MPFL reconstructions. Group demographics were similar. At 4.9 ± 1.2 years follow-up, mean IKDC scores were 77.4 and 79.4 in the nonaugmentation and augmentation groups, respectively. Significantly fewer patients in the augmentation group experienced further injury to their ipsilateral knee compared to the non-augmentation group (6% vs 30%, P = .019). Fewer knees in the augmentation group developed recurrent subjective instability or dislocation after initial surgery requiring surgical correction compared to knees in the nonaugmentation group, although this difference was not significant (6% vs 17%, P = 0.181). Overall patient-reported outcomes were similar between the 2 groups.Conclusions:There were no significant differences in patient-reported outcomes after MPFL reconstruction with or without tape augmentation. Tape augmentation significantly decreased the risk of subsequent ipsilateral knee injuries, although it did not show a significant difference in recurrent dislocations.Level of Evidence:IV, therapeutic case series.

Objectives: Patellar instability requiring medial patellofemoral ligament reconstruction (MPFL) in the pediatric population poses a challenge in that the isometric point of femoral fixation (Schottle’s point) is in close proximity to the distal physis. As a result, various alternative fixation techniques have been described to avoid physeal damage, however the consequences of this are unclear. Continued growth and altered graft mechanics in the growing child are areas of concern. The objective of the current study was to evaluate short to midterm outcomes, including redislocation rates, following MPFL reconstruction in skeletally immature versus mature pediatric patients. Methods: Patients under age 18 with recurrent patellar instability that underwent primary MPFL reconstruction by a single surgeon from 2013 to 2019 were identified using current procedural terminology (CPT) codes. Patients who were a minimum of 1 year from surgery were contacted to complete questionnaires. Questions pertained to knee pain and function, including International Knee Documentation Committee (IKDC) score, as well as further injury or surgery. Further data included chart and imaging review. Based on radiographic appearance of the distal physis, patients were placed into either the skeletally mature or immature cohort for comparison. Statistical analysis included chi-square, fisher’s exact, and Mann-Whitney U tests. Significance was determined by p-value <0.05. Results: There were 103 primary MPFL reconstructions in 94 patients: 70 skeletally mature and 24 immature. As expected, the skeletally mature group was older (15.5 vs. 13.1 years). Skeletally immature patients had a higher incidence of trochlear dysplasia (88 vs. 63%, p=0.04). No other baseline differences were identified. Average follow-up was similar at 4.1 years for the mature group and 3.5 years in the immature. Skeletally immature patients were more likely to sustain a subsequent dislocation or any ipsilateral knee injury (15 vs. 3%, p=0.03; 35 vs. 16%, p=0.04 respectively). Skeletally immature patients underwent more revision instability procedures, which trended towards but did not reach significance (23 vs. 9%, p=0.06). No significant difference was observed in IKDC score (80 each), perceived percent of normal for that knee (85% each), frequency of instability events, current sport participation (42 vs. 31%), sport avoidance (46 vs. 35%), or subjective stiffness (38 vs. 41%). Visual analog scale pain scores for skeletally immature compared to mature patients were not different at rest, with activities of daily living, or with sport (0.9 vs. 0.8, 1.5 vs. 1.7, 2.5 vs. 3 respectively). Significantly fewer patients in the skeletally immature group were satisfied (79 vs. 97%, p<0.05) and would undergo the surgery again (68 vs. 100%, p<0.05). Conclusions: In pediatric patients undergoing MPFL reconstruction, both skeletally immature and mature patients have good and comparable outcomes. However, those that are skeletally immature are more likely to have a subsequent ipsilateral injury or dislocation. These patients are also less likely to be satisfied with their results. Of note, there was a higher incidence of trochlear dysplasia in skeletally immature patients which may predispose them to subsequent injury.

PURPOSE:To evaluate short- to mid-term outcomes after arthroscopic operative fixation of tibial spine fractures in pediatric patients, to determine the incidence of further ipsilateral and contralateral knee injuries, and to describe associated meniscal pathology and intraoperative findings at the time of tibial spine repair.METHODS:All patients under age 18 with a tibial spine fracture treated arthroscopically at 1 institution by 2 surgeons from 2008 through 2019 were identified by Current Procedural Terminology codes. Patients at least 1 year from their date of surgery were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form. Questions pertained to knee function, pain, and further injury or surgery on either knee. Patient charts, preoperative imaging, and operative reports were reviewed to determine demographic information, tibial spine fracture type, concomitant injuries, and intraoperative details.RESULTS:Sixty-six of 97 eligible patients (68%) completed questionnaires. Average age at initial surgery was 10.7 years (range, 4-17). Mean follow-up was 5.8 years (range, 1.0-11.9). Average IKDC score at follow-up was 91.4 (range, 62.1-100). Patients reported their knee as 92% of "normal" (range, 40-100). Thirty-five (53%) currently participate in sport; 6 (9%) remain limited because of instability and residual pain. Regarding pain on a visual analog scale, 94%, 95%, and 83% of patients reported less than a 3 at rest, with daily activity, and with sport, respectively. Seven patients (11%) had subsequent ACL rupture. Six patients (9%) underwent ACL reconstruction 3.1 years (range, 0.9-7) after initial repair. Fourteen patients (21%) required at least 1 additional procedure. Regarding the contralateral knee, there were no ACL or tibial spine injuries. Sixty-one (92%) patients were both satisfied and would definitely undergo the procedure again.CONCLUSIONS:Although many pediatric patients demonstrate excellent results after tibial spine repair at mean 5.8 years follow-up, 10.6% sustained an ipsilateral ACL rupture, and 21% required an additional procedure. No patient had a contralateral tibial spine or ACL injury. This is helpful when counseling patients regarding injury risk when returning to activity after tibial spine repair.LEVEL OF EVIDENCE:Level IV, therapeutic case series.

CASEA 12-year-old girl sustained a right-sided tibial spine fracture while jumping on a trampoline. Postoperative course was complicated initially by arthrofibrosis requiring manipulation under anesthesia and subsequent leg length discrepancy attributed to posttraumatic overgrowth necessitating femoral epiphysiodesis. Ten years after initial injury, she reported her knee to be 63% of normal and an International Knee Documentation Committee score of 63.2. Symptomatic overgrowth requiring epiphysiodesis after tibial spine repair has not been previously reported to our knowledge.CONCLUSIONTibial spine fixation, although previously associated with growth arrest because of physeal damage, may also result in symptomatic limb overgrowth.

A 15-year-old boy presented with left-sided hip pain and imaging consistent with the diagnosis of femoroacetabular impingement. Following hip arthroscopy, which included an osteochondroplasty, labral repair, and capsular repair, the patient's anterior hip pain improved. However, his deep aching hip pain persisted until an ischial osteoid osteoma was identified and treated with radiofrequency ablation. At 3 years follow-up, the patient reports high satisfaction and minimal pain. We present this case to illustrate the importance of considering all potential causes of persistent hip pain following hip arthroscopy, including benign bone tumors which may be difficult to visualize on plain radiographs.

Case: A 13-year-old boy sustained an acute, grade III medial collateral ligament (MCL) distal periosteal avulsion injury while playing noncontact football. Treatment consisted of diagnostic knee arthroscopy with open physeal-sparing MCL repair. At approximately 1-year follow-up, new development of genu valgum in the operative extremity was noted. After 8 months of nonoperative treatment with deformity progression, the patient underwent correction with proximal medial tibial hemiepiphysiodesis. Conclusion: Although Cozen's phenomenon commonly occurs after a proximal metaphyseal tibial fracture in children aged 2 to 7 years, it can occur as a rare complication of MCL injury/repair and remains a possible outcome in skeletally immature patients.

Purpose: To investigate the individual and combined contributions of acetabular and femoral morphology to hip range of motion (ROM) in patients with femoroacetabular impingement syndrome (FAIS) by use of computed tomography measurements and hip ROM evaluated on physical examination. Methods: A retrospective chart and radiographic analysis of patients presenting with hip pain suggestive of FAIS was performed. The femoral neck -shaft angle, femoral version, magnitude and clock -face location of the alpha angle, midcoronal center -edge angle (CEA), midsagittal CEA, acetabular version, and McKibbin index were measured on computed tomography scans. Univariate and multivariate linear regression analyses determined which measurements correlated with hip ROM, including hip flexion as well as hip internal and external rotation with the hip in 90 ? of flexion. Results: Two hundred hips that met the inclusion and exclusion criteria during the eligibility period were included in the analysis. The mean age was 31.9 ?10.0 years, there were 145 female patients (72%), and the mean body mass index was 25.2 ? 5.0. Multivariate linear regression analysis showed that the midsagittal CEA was the only measurement correlating with flexion (q = .031) whereas the femoral neck -shaft angle and McKibbin index were the only significant variables that correlated with external rotation (q = .031 and q < .001, respectively). Finally, the McKibbin index and maximum alpha angle were the only variables that correlated with internal rotation (q < .001 and q = .034, respectively). Conclusions: Multivariate analysis showed that combined acetabular and femoral version significantly correlated with internal and external rotation whereas femoral version in isolation did not. Increased cam morphology remained a significant contributor to reduced internal rotation but did not affect hip flexion. These data suggest that hip ROM is affected by both femoral pathomorphology and acetabular path- omorphology and that careful evaluation of both should be conducted prior to corrective osteoplasty or osteotomy. Level of Evidence: Level IV, retrospective case series.

Objectives: Prior studies have suggested femoral version may outweigh the effect of cam impingement on hip internal rotation; however, the effects of acetabular morphology were considered. This study investigates the influences of acetabular and femoral morphology on hip range of motion (ROM) in patients with femoroacetabular impingement syndrome (FAIS). Methods: With IRB approval, a retrospective chart review and radiographic analysis was performed of patients presenting with hip pain to the clinic of a single surgeon. Patients were included in the study if their hip pain was thought to be intra-articular in origin, had full physical exam documentation (including bilateral hip evaluations and measurements of passive hip ROM), Tönnis grade ≤ 1, and had full imaging including: AP pelvis, 45⁰ Dunn lateral, and false profile radiographs and a CT scan with 3-D reconstructions of the affected hip. Patients were excluded if they had prior hip surgery, prior hip trauma or other underlying hip pathology. Femoral head/neck angle, femoral version, size and clock-face location of the maximum femoral alpha angle, mid-coronal center edge angle (CEA), mid-sagittal CEA, acetabular version at the 1, 2 and 3 o’clock positions and the McKibbin index were measured on CT scan. Univariable and multivariable logistic regression analyses were performed to determine which measurements correlated with hip ROM. Results: 200 hips from 200 patients were included in the final analysis. Mean age was 31.9 ±10 years, 145 (72%) patients were female, and mean BMI of the cohort was 25.2 ± 5. Univariable logistic regression analysis found femoral head/neck angle, mid-sagittal CEA, acetabular version at 1 and 2 o’clock, and McKibbin Index all significantly correlated with hip flexion (all q’s > 0.05 after adjusting for false discovery rate). Femoral head-neck angle, femoral version, and McKibbin index all significantly correlated with external rotation. Femoral neck version, mid-sagittal CEA, acetabular version at all three clock positions, McKibbin index, max femoral alpha angle, and alpha position all significantly correlated with internal rotation. In the multivariate logistic regression analysis mid-sagittal CEA was the only measurement correlating with flexion, femoral head/neck angle and McKibbin index were the only significant variables correlating with external rotation, and McKibbin index and maximum femoral alpha angle were the only variables correlating with internal rotation. The results of the logistic regressions are summarized in Figure 1. Conclusion: Our univariate data supported previous data that suggested femoral version significantly correlated with hip internal rotation. However, multivariate analysis including acetabular version demonstrated that combined acetabular and femoral version significantly correlated with internal and external rotation while femoral version in isolation did not. In contrast to prior studies, an increased cam deformity, as defined by max femoral alpha angle, remained a significant contributor to reduced internal rotation but did not affect hip flexion. Rather, the increased mid-sagittal CEA remained the sole significant contributor to reduced hip flexion in the multivariable analysis. These data suggest that hip ROM is affected in a bipolar fashion and careful multiplanar evaluation of the femoral and acetabular pathomorpohlogy should be conducted prior to attempting to increase hip ROM with corrective osteoplasty or osteotomy. [Figure: see text]

Purpose: The purpose of this study was to evaluate the trends and report on the demographics of patients undergoing hip arthroscopy in the United States. Methods: Patients who underwent hip arthroscopy from 2004 to 2009 were identified by searching Current Procedural Terminology codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopaedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 10,000 patients searched in the database. Results: In total, 3,447 cases of hip arthroscopy were identified between 2004 and 2009. The incidence of procedures increased significantly over the study period, from 1.20 cases per 10,000 patients in 2004 to 5.58 in 2009 (P < .001). Hip arthroscopy was performed most commonly in patients aged 20 to 39 years (P < .05), with an incidence of 4.45 cases in each age group. In contrast to other common arthroscopic procedures searched, no gender differences were observed, with a male-to-female ratio of 0.89 (P = .18). The greatest incidence of hip arthroscopy was observed in the Western region with an incidence of 5.24 cases identified compared with 2.94, 2.70, and 2.56 in the Northeast, Midwest, and South, respectively (P < .001). Conclusions: A 365% increase in the rate of hip arthroscopy was observed in the examined cohort of patients between 2004 and 2009. The majority of cases were performed in patients aged 20 to 39 years, with no difference in gender. The Western region of the United States was found to have a higher incidence of hip arthroscopy compared with the Midwest, South, and Northeast. Level of Evidence: Level IV, cross-sectional study.