Sivashankar Chandrasekaran, MBBS, FRACS Nader Darwish, BS John P Walsh, MA Parth Lodhia, MD, FRCSC Carlos Suarez-Ahedo, MD Benjamin G.

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1 Arthroscopic Treatment of Labral Tears and Instability in Professional Dancers: Patterns of Clinical Presentation and Intraarticular Derangements, Radiological Associations, and Minimum Two-Year Outcomes Sivashankar Chandrasekaran, MBBS, FRACS Nader Darwish, BS John P Walsh, MA Parth Lodhia, MD, FRCSC Carlos Suarez-Ahedo, MD Benjamin G. Domb, MD

2 Disclosures American Orthopedic Foundation a, American Hip Foundation a, AANA Learning Center Committee a, Adventist Hinsdale Hospital c, Hinsdale Hospital Foundation a, Hinsdale Orthopedic Associates e, Hinsdale Orthopedic Imaging e, American Hip Institute e, Arthroscopy Journal a, SCD#3 e, North Shore Surgical Suites e, Munster Specialty Surgery Center e, Amplitude c, Arthrex b,c,d, DJO Global d, Medacta b,c, Orthomerica d, Stryker b,c a boardmember; b research support; c consulting; d royalty; e ownership interest

3 Background Outline The hip region is involved in approximately one in four injuries sustained by dancers, limiting their ability to train and perform. 1 Soft tissue laxity in dancers has been associated with injury to other joints such as the knee and shoulder. 2 The extremes of hip motion required for dancing coupled with ligamentous laxity may lead to labral damage despite osseous anatomy that is not stereotypical of femoroacetabular impingement. Poor outcomes have been reported in hips with those features when soft tissue constraints have not been adequately addressed. Capsular plication in this setting has lead to improved outcomes with hip arthroscopy. 3 1 Reid DC. Prevention of hip and knee injuries in ballet dancers. Sports medicine Nov;6(5): Jacobs CL et al. Musculoskeletal injuries and pain in dancers: a systematic review update. Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science. 2012;16(2): Domb BG, Stake CE, Lindner D, El-Bitar Y, Jackson TJ. Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem. The American journal of sports medicine Nov;41(11):

4 Purpose and Outline Study Design To report on patterns of clinical presentation, intraarticular derangements, radiological associations and minimum two-year outcomes following hip arthroscopy in patients who are professional dancers. This study was a retrospective case series on prospectively collected data on patients who had undergone hip arthroscopy for treatment of painful intra-articular disorders that had failed non-operative management during the study period from April 2008 to April 2013.

5 Methods Outline Patient Selection Inclusion Criteria Patients undergoing hip arthroscopy for labral tears refractory to non-operative management Professional dancers Minimum two-year followup were included in the study Exclusion Criteria Revision surgeries Previous Hip Conditions o AVN o SCFE o Inflammatory arthritis o Hip fractures LCEA <20 o Consideration of PAO + HA Tönnis grade > 1 OA

6 Methods Outline Outcomes PROs o mhhs o NASH o HOS-ADL o HOS-SSS VAS/10 Patient satisfaction/10 Revision Arthroscopy THA o Progression of chondropathy at follow-up was considered the main source of pain. Statistics A paired t-test was used to test for differences in means for numerical data Chi-square analysis was used to detect differences within categorical data Values of p <0.05 were considered statistically significant. Intra-rater reliability of radiographic measurements was determined using Bartko s method for measuring a rater s self-consistency o The intra-class correlation coefficient was found to be greater than 0.89 for all radiological measurements

7 Results -Outline Demographics DEMOGRAPHICS Study Procedures eligible for study 14 Procedures with two year follow-up 14 (100%) Female:Male 14:0 Right:Left 10:4 Age at surgery (years) (mean and range) 16.8 ( ) BMI (kg/cm2) 20.6 ± 2.73 Follow-up time (months) (mean and range) 26.2 ( ) Conversion to arthroplasty 0 Time to arthroplasty (months) (mean and range) NA Revision Arthroscopies 0 Time to Revision Arthroscopies (months) (mean and range) NA Tonnis 0 14 (100%)

Results Findings Clinical examination parameters Study Flexion in degrees (mean and std deviation) 137.4 ± 18.5 Abduction in degrees (mean and std deviation) 44.4 ± 13.

8 Results Findings Clinical examination parameters Study Flexion in degrees (mean and std deviation) ± 18.5 Abduction in degrees (mean and std deviation) 44.4 ± 13.0 Internal rotation in degrees (mean and std deviation) 47.8 ± 14.0 External rotation in degrees (mean and std deviation) 38.9 ± 16.8 Anterior Impingement (%) 14 (100%) Posterior Impingement (%) 11 (76%) Lateral Impingement (%) 9 (64%) Beighton s Score 5.6 ± 2.7 Radiological parameters Study LCEA mean and std dev 21.3 ± 4.69 ACEA mean and std dev 22.7 ± 7.52 Acetabular inclination mean and std dev 6.18 ± 6.29 Cross over sign (%) 8 (57.0%) Coxa Profunda 6 (46%) Alpha angle 58.3 ± 17.3 MRI femoral anteversion 21.3 ± 12.4

99 Grade 0 0 (0%) Grade 1 6 (42.9%) Grade 2 7 (50.0%) Grade 3 0 (0%) Grade 4 1 (7.14%) Procedures Study Labral Treatment Repair 12 (85.

9 Results Intraoperative Diagnoses and Procedures Intra-operative diagnoses Seldes Tear Type Labral tear size (mean ± sd) Acetabular Chondral Lesion (ALAD) Classification Study Population Type 1 8 (57.1%) Type 2 3 (21.4%) Type 1 and 2 3 (21.4%) 1.86 ± 0.99 Grade 0 0 (0%) Grade 1 6 (42.9%) Grade 2 7 (50.0%) Grade 3 0 (0%) Grade 4 1 (7.14%) Procedures Study Labral Treatment Repair 12 (85.7%) Debridement 2(14.3%) Capsular Treatment Repair 14 (100%) Acetabuloplasty 14 (100%) Acetabular Chondroplasty 5 (35.7%) Femoral Osteoplasty 14 (100%) Iliopsoas release 11 (78.6%)

10 Results - PROs Score Dancers Pre Post Change p - Value mhhs 56.8 ± ± ± 30.0 <0.001 HOS-ADLS 54.9 ± ± ± 27.2 <0.001 HOS-SSS 36.4 ± ± ± 29.9 <0.001 NAHS 52.9 ± ± ± 28.1 <0.001 VAS 7.50 ± ± ± 2.55 <0.001 Satisfaction 8.14 ± 2.14

11 Conclusions Strengths of this study: o Multiple PROs o Mean 2 year follow-up Limitations of this study: o Is the benefit sustained for greater than 2 years? The pattern of labral injury in professional dancers is most likely due to instability and soft tissue laxity. Morphological features in this cohort include borderline dysplasia and increased femoral anteversion. An arthroscopic approach that entails, labral preservation, minimal acetabuloplasty and capsular plication are associated with improvements in patient outcomes and pain at minimum two-year follow-up with a mean patient satisfaction of 8.14.

12 Sivashankar Chandrasekaran, MBBS, FRACS, Nader Darwish, BS, John P Walsh, MA, Parth Lodhia, MD, FRCSC, Carlos Suarez-Ahedo, MD, Benjamin G. Domb, MD

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Outcomes of Hip Arthroscopy for Patients with Symptomatic Borderline Dysplasia: A Comparison to a Matched Cohort of Patients with FAI

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