Background: Optimal treatments of patients with borderline hip dysplasia, defined as LCEA 20°-25°, is controversial. These patients can have symptomatic impingement and/or instability. The optimal treatment of either hip arthroscopy (HA) alone or periacetabular osteotomy (PAO) (with/without hip arthroscopy) has not been established. Purpose: The purpose of this study was to evaluate surgical outcomes of patients with borderline hip dysplasia at a minimum of 2-year follow-up. Methods: A longitudinal cohort was utilized to identify patients with borderline acetabular dysplasia defined via prospective radiographic measurements. Demographics and radiographic measurements were recorded. Patient evaluation, diagnosis and treatment decisions (PAO v HA) were made by one treating surgeon. Outcome were assessed at baseline and a minimum 2 years postoperative. Descriptive and comparative statistics were performed. Failure was defined as reoperation, or failure to reach mHHS MCID (8 points) or PASS (mHHS <74). Results: Total of 113 hips were included at 4.7 years postoperatively (range 2.0-11.2 years). Overall, 76% were female and 42% of hips had PAO (65% combined with hip arthroscopy), while 58% had isolated hip arthroscopy (HA). For PAO group, mHHS improved from 57.9 to 82.8 postoperatively, compared to 62.6 to 84.0 for the HA group. Similarly, HOOS pain (PAO 48.2 to 79.1, HA 61.2 to 82.0) and HOOS Sports (PAO 36.5 to 73.0, HA 47.8 to 74.4) demonstrated similar improvements. Comparing the PAO and HA groups, the change in PRO was significantly greater for the PAO group for HOOS Pain (10.5 ±23.2, p=0.02) and HOOS ADL (9.4 ±20.5, p=0.04) which was primarily due to a lower baseline score (similar final score). No significant difference was detected for other PROs. Reoperations in the PAO group were 2% (1 hip arthroscopy) and 6% for hip arthroscopy group (3 hip arthroscopies, 1 PAO). The failure rate was 17% for PAO and 15% for HA (p=0.86). Discussion: Surgical outcomes at minimum of 2 years in patients with borderline hip dysplasia in selected patients undergoing PAO or hip arthroscopy were good. Significant differences in patient characteristics and radiographic parameters were present between hips indicated for PAO vs. HA emphasizing the need for careful diagnosis and treatment decision-making.
Background: Hips with borderline acetabular dysplasia (lateral center-edge angle, LCEA, between 20° and 25°) are challenging in terms of diagnostic and treatment decision-making. It is accepted that a portion of this population has primarily hip instability-based symptoms consistent with symptomatic acetabular dysplasia, while others have primarily hip impingement-based symptoms consistent with femoroacetabular impingement (FAI). Nevertheless, the diagnostic characteristics that differentiate hip instability and FAI have not been identified. The purpose of this study was to examine a cohort of patients with minor acetabular dysplasia features in order to identify the preoperative clinical characteristics and imaging findings that differentiate patients with hip instability from patients with FAI. Methods: A retrospective cohort study of patients with borderline acetabular dysplasia was performed. Utilizing our institution’s hip preservation database, we identified 143 consecutive hips in 134 patients undergoing hip preservation surgery in the setting of borderline acetabular dysplasia. All patients were identified by prospective radiographic evaluation with an LCEA between 20° and 25°. Inclusion criteria included age 14-40 years and primary surgical treatment. Medical records were reviewed to determine patient demographics, details of clinical presentation, baseline patient-reported outcome scores, physical exam findings, plain radiographic findings, and the operative procedures performed. Statistical analyses were used to compare the clinical features and imaging parameters of the symptomatic acetabular dysplasia and FAI subgroups. Results: Of the 143 hips in the cohort, 39.2% (n = 56) had the diagnosis of symptomatic instability, while 60.8% (n = 87) had the diagnosis of FAI. The cohort included 109 females (76.2%) and 34 males (23.8%). Hips with instability (compared to FAI) had a significantly lower LCEA (21.8° vs. 22.8°; p < 0.001), lower ACEA (23.3° vs. 26.6°; p = 0.002), a higher AI (11.8° vs. 8.5°; p < 0.001), and a lower maximum alpha angle (54.4° vs. 61.1°; p = 0.001). The odds of instability increased 1.7 times for each one-degree decrease in LCEA, 1.4 times for each one-degree decrease in ACEA, and 1.1 times for each one-degree increase in acetabular inclination (all p < 0.003). Sex was strongly associated with the clinical diagnosis, with instability present in 48.6% of females compared to only 8.8% of males (p < 0.001). Patients with instability presented with significantly greater disability, as indicated by the modified Harris hip score, UCLA activity, SF-12 physical function, and HOOS (pain, activities of daily living, sports and recreation, and quality of life) scores (all p = 0.05). The symptomatic acetabular dysplasia subgroup had significantly greater range of motion in terms of internal rotation in flexion (IRF, 22.7° vs. 12.4°, p < 0.001) and total arc of rotational motion (IRF+ERF, 61.2° vs. 47.4°, p < 0.001). Lateral hip pain was present in 42.9% (24/56) of hips in the instability group compared to 25.3% (22/87) of hips in the impingement group (p = 0.03). Conclusions: We found significant differences in the clinical characteristics and radiographic features of the symptomatic acetabular dysplasia and FAI subgroups within the borderline dysplasia cohort. Patients with symptomatic instability tend to have lateral hip pain, greater functional limitations, higher range of motion, and a greater AI, while patients with impingement symptoms tend to have more limited range of motion (especially IRF), a greater ACEA, and a greater alpha angle.
Background: Given the lack of established, externally validated criteria for the diagnosis of unstable hips, the Femoro-Epiphyseal Acetabular Roof (FEAR) index has been proposed as a useful tool for identifying hips with instability in the setting of borderline acetabular dysplasia. Purposes: To (1) determine the external performance of the FEAR index in identifying hips with a clinical diagnosis of instability in the setting of borderline dysplasia and (2) assess the performance of the FEAR index compared with acetabular inclination or physeal scar angle alone. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The authors reviewed 176 patients with borderline acetabular dysplasia (lateral center-edge angle, 20°-25°). A positive FEAR index was defined as ≥5°. An alternative threshold ≥2° was also assessed. Significant instability was determined by the senior surgeon based on the combination of patient and radiographic features; unstable hips were treated with periacetabular osteotomy (with or without hip arthroscopy), and stable hips were treated with isolated hip arthroscopy. Results: Only 18% of borderline hips had a positive FEAR index. The ≥5° positive FEAR index threshold had a sensitivity of 33% (23/70) and specificity of 92% (98/106) in predicting the clinical diagnosis of instability. The ≥2° FEAR index threshold had a sensitivity of 39% (27/70) and specificity of 89% (94/106) in predicting the clinical diagnosis of instability. No alternative threshold for the FEAR index resulted in high levels of sensitivity and specificity. A threshold of –5° was required to reach an adequate sensitivity of 74%. The FEAR index remained a significant predictor of hip instability even after controlling for acetabular inclination (odds ratio, 1.12; P < .001) or physeal scar angle (odds ratio, 1.6; P < .001). Conclusion: In the current study, a positive FEAR index was generally indicative of the presence of clinical instability, but the FEAR index alone remained inadequate to fully define the instability of a given hip, as it demonstrated low sensitivity (only 33%) in the external validation. The FEAR index is best used in the context of other clinical and radiographic features.
Purpose: Recent efforts have been made by the American Society for Surgery of the Hand to encourage female inclusion in expert panels. We hypothesized that female representation on expert panels has increased over the past decade and that a directed intervention by the American Society for Surgery of the Hand would be associated with an increased percentage of submissions with female panelists. Methods: We performed a retrospective analysis of Instructional Course Lecture and Symposium submissions for the 2011 through 2021 American Society for Surgery of the Hand Annual Meetings. Authorship was reviewed, and the gender of the proposed authors was recorded. Additionally, the status of "all-male panel" was attributed to panels with no proposed female authors. Submissions were reviewed and compared with meeting programs to determine the status of accepted or rejected. Longitudinal analysis was performed to determine trends in the gender composition of expert panels. Results: In total, 1,687 submissions were reviewed, including 1,323 Instructional Course Lectures and 364 Symposia. Female authorship constituted 18% of authorship (1,170/6,663), and lead authorship was similarly distributed, with 18% being female (296/1,687). Overall, female representation has increased steadily over the past decade, with females constituting 13% (43/332) and 20% (163/818) of the submitted authors in 2011 and 2020, respectively. Similarly, all-male panels declined from 74% (76/103) to 46% (85/ 185) of panels over the same timeframe. Most strikingly, a sharp increase in gender representation was observed with the directed intervention noted in the 2021 Call for Abstracts, resulting in an increase in female authorship to 26% (295/1,124) and a decline in all-male panels to 29% (70/241). Conclusions: Gender representation among hand surgery expert panels moved toward increased equity over the past decade, which has been aided by directed interventions. Clinical relevance: Career development and trainee decision making are impacted by gender representation; directed and intentional interventions by professional organizations are effective in encouraging greater equity and diversity within the field.
Background Treatment of borderline acetabular dysplasia (BD) is controversial with some patients having primarily instability-based symptoms while others have impingement-based symptoms. The existing literature lacks direct comparisons of different treatment approaches, and generally fails to report other important diagnostic characteristics beyond the lateral center edge angle (LCEA). Purpose The purpose of this study was (1) to identify the most important patient characteristics influencing the diagnosis of instability vs. non-instability, (2) to develop a clinical score (Borderline Hip Instability Score, BHIS) to collectively characterize these factors and (3) to externally validate BHIS in a multicenter cohort BD patients. Methods In Part 1, this study utilized a retrospective cohort study of 186 hips undergoing surgical treatment of BD (LCEA 20°-25°) from a single surgeon experienced in arthroscopic and open techniques. Multivariate analysis determined characteristics associated with presence of instability (treated with PAO +/- hip arthroscopy) or absence of instability (treated with isolated hip arthroscopy) based on clinical diagnosis of the single surgeon. During the study period, 39.8% of the cohort underwent PAO. Multivariate analysis with bootstrapping was performed and results were transformed into a BHIS nomogram (higher score representing more instability). In Part 2, BHIS was externally validated in 114 BD patients enrolled in a multicenter prospective cohort study across 10 surgeons (with varied treatment approaches from arthroscopy to open procedures). Results In Part 1, the most parsimonious, best fit model included 4 variables associated with the diagnosis of instability: acetabular inclination (AI), anterior center edge angle (ACEA), maximum alpha angle, and internal rotation in 90 degrees of flexion (IRF). Sex and LCEA were not significant predictors. Mean BHIS in the population was 50.0 (instability 57.7 ±7.9; non-instability 44.8±7.3, p<0.001). BHIS demonstrated excellent predictive (discriminatory) ability with c-statistic=0.89. In Part 2, BHIS maintained excellent c-statistic=0.92 in external validation. Mean BHIS in the external cohort was 53.9 (instability 66.5±11.5; non-instability 43.0±10.8, p<0.001). Discussion In patients with BD, key factors in diagnosing significant instability treated with PAO were AI, ACEA, maximum alpha angle, and IRF. The BHIS score allowed for differentiation of patients with and without instability in the development and external validation cohort.
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