Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State After Endoscopic Gluteus Medius or Minimus Repair With or Without Labral Treatment and Routine Capsular Closure at Minimum 5-Year Follow-up

Abstract

Background:

There is a paucity of information in the literature on midterm outcomes of endoscopic gluteus medius and/or minimus repair with concomitant labral treatment using only modern surgical techniques.

Purpose:

To define the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) at a minimum of 5 years postoperatively for patients undergoing endoscopic hip abductor repair with routine capsular closure.

Study Design:

Case series; Level of evidence, 4.

Methods:

Consecutive patients who underwent primary endoscopic repair of gluteus medius and/or minimus tears between January 2012 and December 2015 by the senior author were eligible for inclusion. Patient-reported outcome scores were assessed preoperatively and at 5 years postoperatively: Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The MCID was uniquely calculated using the distribution method, and the PASS was determined via the anchor-based method utilizing receiver operating characteristic curves and Youden index.

Results:

A total of 46 patients were included in the study. The majority were female (87.0%), with a mean ± standard deviation age of 59.1 ± 8.9 years and body mass index of 27.3 ± 6.9. Significant postoperative improvements (P < .001) in each of the 5 patient-reported outcomes were observed at 5 years postoperatively. The MCID threshold values were calculated as follows: HOS-ADL, 11.5; HOS-SS, 15.1; mHHS, 13.3; iHOT-12, 11.8; and VAS, 15.8. The PASS thresholds were calculated as follows: HOS-ADL, 75.7; HOS-SS, 79.7; mHHS, 81.2; and iHOT-12, 60.8. A majority of patients achieved a clinically significant outcome, with 96.2% of patients reaching a threshold score for the MCID or PASS for at least 1 patient-reported outcome.

Conclusion:

Endoscopic hip abductor repair with concomitant arthroscopic labral treatment has a high rate of achievement of clinically significant outcomes and survivorship at a minimum 5-year follow-up. We defined the MCID for the HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcome scores to be 11.5, 15.1, 13.3, 11.8, and 15.8, respectively. The PASS threshold scores for the HOS-ADL, HOS-SS, mHHS and iHOT-12 scores of 75.7, 79.7, 81.2, and 60.8, respectively. Future researchers and clinicians can use the MCID and PASS values established in this study to better evaluate mid-term outcomes of patients undergoing hip abductor repair.

Keywords

hip arthroscopy general sports trauma muscle injuries groin pain

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain seen more commonly in middle-aged women and represents a range of disease causes, such as bursitis, tendinopathy, and tearing of the gluteus medius and minimus.^10,36 GTPS is believed to arise from altered limb mechanics and abnormal force vectors across the hip.^36,41 The syndrome typically presents with lateral hip pain in the region of the greater trochanter and may radiate posteriorly to the buttock or over the anterior thigh to the knee.^23,36,42 Historically, many patients presenting with GTPS were diagnosed with trochanteric bursitis but are now increasingly recognized to have hip abductor tendinopathy.³⁹

Hip abductor tendinopathy can result from acute traumatic events or chronic degenerative changes, which can result in a broad spectrum of tendinopathy from interstitial partial-thickness tears to retracted full-thickness tears.^8,19,21,44 The hip abductors are often referred to as the “rotator cuff of the hip” given their similarities in anatomy and function.^2-4,16 Patients typically have lateral hip pain worsened by weightbearing and sleeping on the affected side, a Trendelenburg gait, and hip abduction weakness.^1,4 Magnetic resonance imaging (MRI) has demonstrated excellent interobserver reliability for the diagnosis of hip abductor tendinopathy and is now commonly used by clinicians in cases of lateral hip pain and dysfunction recalcitrant to nonoperative management.^6,14,19,25

Operative intervention, including endoscopic and open techniques, has become increasingly used for patients whose nonoperative treatments have failed.^{9,17,31,38,45} Several studies have demonstrated excellent short- to medium-term outcomes^5,7,14,26 with high rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) at 2 years postoperatively.^20,29,31,46 Despite this, few studies have assessed patient-reported outcomes (PROs) at 5 years postoperatively. Perets et al³⁵ noted significant improvement in PROs at 5 years in patients who underwent endoscopic gluteus medius and/or minimus repairs with no increase in complications from 2 to 5 years postoperatively. Meghpara et al³⁰ likewise showed favorable outcomes at 5 years with comparable rates of achievement of the MCID and PASS between patients who underwent endoscopic gluteus medius and/or minimus repair with labral treatment and patients who underwent labral treatment alone. However, no studies to date have defined an MCID threshold score at 5 years for the 12-item International Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, or Hip Outcome Score–Activities of Daily Living (HOS-ADL). Therefore, the purpose of this study was to define the MCID and PASS at a minimum of 5 years postoperatively for patients undergoing endoscopic hip abductor repair with routine capsular closure. We hypothesized that all patients would demonstrate statistically significant improvement in PRO scores at 5 years.

Methods

Patient Selection

After approval was obtained from the local institutional review board, patients were retrospectively selected from a prospectively maintained single-institution database. Consecutive patients who underwent primary endoscopic hip abductor repair with or without concomitant labral treatment by the senior author (S.J.N.) between January 2012 and December 2015 were eligible for inclusion. Patients were required to have completed at least 1 PRO at a minimum 5 years postoperatively to be eligible for inclusion. Thirteen patients who underwent open primary hip abductor repair and 2 patients who underwent revision hip abductor repair were excluded from the study (Figure 1). Patients with a history of pediatric hip diseases (ie, slipped capital femoral epiphysis, Legg-Calve-Perthes disease, or congenital hip dislocation) were also excluded from the study.

All patients had findings consistent with hip abductor tears, including lateral hip pain, tenderness to palpation over the greater trochanter, and weakness with resisted hip abduction. Findings of gluteus medius and/or minimus tears were confirmed on preoperative MRI. Patients were indicated for surgery if any of these findings were present and persisted after a failed trial of nonoperative treatment, such as nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and trochanteric injections.

Data Collection and Analysis

Patient demographic data (eg, age, sex, and body mass index [BMI]) were prospectively collected in a secure repository. Additional preoperative characteristics were obtained: smoking status, physical activity status, workers’ compensation status, history of low back pain, and psychiatric history. Preoperative radiographic measurements were recorded, such as alpha angle, lateral center-edge angle, anterior center-edge angle, Tönnis angle, and Tönnis grade. Intraoperative findings and procedures were recorded, including whether tears were partial or full thickness or involved the gluteus medius, gluteus minimus, or both. The Shapiro-Wilk test for normality was used to determine whether continuous variables were normally distributed. Normally distributed continuous variables were reported as mean and standard deviation; variables that were not normally distributed were reported as median and interquartile range. Categorical variables were reported as percentage of the total study population.

Defining Clinically Significant Outcomes

PROs included the HOS-ADL and HOS–Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), iHOT-12, and VAS for pain. Data were collected preoperatively and at 5 years postoperatively using secure electronic data collection platforms (OBERD, PatientIQ).

Clinically significant outcomes were defined by the achievement of or failure to achieve an MCID and PASS. The MCID is analogous to the minimal amount of improvement between pre- and postoperative PRO scores corresponding to a minimal amount of clinical improvement in function. The MCID has been defined as the smallest difference in score in the domain of interest that patients perceive as beneficial and that would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient’s management.^15,37 The PASS is defined as threshold score above which a patient has reached a satisfactory symptom state.¹⁸

For the current study, the MCID for patients who underwent endoscopic repair of hip abductor tears was calculated using the distribution method by taking one-half the standard deviation of the difference between pre- and postoperative (5 years) PRO scores. To determine the threshold score for a PASS, patients were asked the following yes/no question at the 5-year postoperative time point: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?” The answer to this question was coded as a binary outcome, and the PASS threshold for each PRO was calculated using receiver operating characteristic curve analysis. The Youden index was used to maximize the sensitivity and specificity of the threshold score. The area under the curve (AUC) was analyzed to determine the overall performance of the binary classifier. Consistent with previous psychometric studies in the orthopaedic literature, a minimum AUC of 0.7 was considered acceptable discriminative ability, and an AUC of 0.5 was equivocal to chance.^12,27,34 Incomplete or missing PRO surveys were excluded from analysis.

Survivorship

Cases of failure were those in which the patient required an additional hip arthroscopy or related procedure. At the time of most recent follow-up, all patients were asked whether they underwent additional surgery or had a total hip replacement on the operative hip.

A Kaplan-Meier survivorship curve was created to estimate total study population survival over time using SPSS statistics (Version 27; IBM). Additional information was collected retrospectively, such as persistent postoperative pain requiring corticosteroid injection for pain management.

Surgical Technique

All patients underwent general endotracheal anesthesia. Patients were positioned supine on a standard hip arthroscopy table with an attached hip distraction system, including a perineal post and well-padded boots, as described by Levy et al²² (Advanced Supine Hip Positioning System; Smith & Nephew). The operative leg was prepared and draped in a standard surgical fashion. Preoperative antibiotics were administered. An anterolateral portal was established first under fluoroscopic guidance by penetrating the capsule at the 12-o’clock position. Needle localization was then used to establish a modified or midanterior portal under direct visualization with an outside-in technique penetrating the capsule at the 2-o’clock position. An interportal capsulotomy connecting the anterior and anterolateral portals was performed using an arthroscopic scalpel, leaving a cuff of tissue for capsular repair or plication at the conclusion of the case. Limited capsulectomy and synovectomy were performed as appropriate for each case.

In cases with concomitant labral tear, the labrum was repaired in a standard fashion based on previously published techniques.³³ Pincer deformity at this stage was likewise addressed using standard techniques previously published in orthopaedic literature.^11,13,43 Traction was released within 45 minutes of traction time. With the hip in 20° of flexion, the arthroscope was passed into the extra-articular space to identify the interval between the gluteus minimus and underlying capsule. With the arthroscope in the anterior portal, a Wissinger rod was placed in a direct anterolateral accessory portal. A 5.0-mm cannula was placed over the Wissinger rod, and an arthroscopic scalpel was passed through the cannula to perform the vertical portion of the T capsulotomy to visualize the peripheral compartment. The transverse portion of the T capsulotomy extended from the intertrochanteric line to the zona orbicularis. The borders of the iliocapsularis and gluteus minimus muscles and tendons were identified. In the event of a cam-type deformity, impingement was corrected again using standard arthroscopic techniques.^11,13,43 After any necessary osteochondroplasty, capsular redundancy must be plicated to prevent joint instability. No. 2 ultra-high molecular weight polyethylene sutures were used to close the vertical portion of the iliofemoral ligament. Once the vertical portion was plicated, the interportal capsulotomy was plicated.

With the camera in the midanterior portal, the arthroscopic shaver was passed through the anterolateral portal to perform a trochanteric bursectomy. The muscular and tendinous aspects of the gluteus medius and minimus were identified. Any mucoid degeneration of the tendons was removed. The gluteus medius tendon was incised in line with its fibers. The gluteus medius tendon footprint was prepared using an ablator to form the bed and subsequently a bur was used to decorticate it. A single-row suture anchor technique as described by Levy et al²² was used for most repairs; specifically, a single 5.5-mm triple-loaded suture anchor was placed 1 cm proximal and posterior to the posterolateral corner of the greater trochanter footprint (Biosteon; Stryker). In cases with a gluteus minimus tear, a second suture anchor was placed in the gluteus minimus footprint using spinal needle localization as indicated. For large tears with significant retraction or diffuse fatty degeneration requiring extensive debridement, a double-row suture anchor technique as described by Levy et al was utilized: a suture bridge was created by using the proximal row sutures and feeding the posterior sutures through an additional knotless anchor placed in line with the most posterior proximal anchor (SwiveLock; Arthrex). This process was repeated using the anterior sutures and anterior knotless anchor. Once excellent fixation of the gluteus medius and/or minimus tendon back to the anatomic footprint was performed, the hip was abducted and flexed to ensure appropriate suture ties and fixation. To close, 2-0 Vicryl sutures (Ethicon) were used to close deep subcutaneous tissue, followed by 2-0 Prolene and a sterile dressing.

Rehabilitation Protocol

A previously described standard 3-phase postoperative rehabilitation protocol was utilized.^34,40 During the initial postoperative period (0-6 weeks), phase 1 recovery consisted of full-time bracing to limit abduction, allowing only gentle passive range of motion and partial weightbearing with walker or crutches. At 6 to 12 weeks, phase 2 consisted of progression to full weightbearing with initiation of hip-strengthening exercises while discontinuing the brace. Last, at 12 weeks, phase 3 concluded with ambulation without assistance and a gradual return to general activity as tolerated.

Results

Study Population

A total of 52 patients underwent endoscopic hip abductor repair by the senior author between January 2012 and December 2015 and were eligible for inclusion. Minimum 5-year postoperative PRO scores were available for 46 patients in the final analysis (88.5% compliance rate). A majority of patients were female (87.0%) with a mean ± SD age of 59.1 ± 8.9 years and BMI of 27.3 ± 6.9 (Table 1). More than one-third of the study population (37.0%) self-reported being physically active in sports or recreational activity. One-fifth of the patients (21.7%) were current or former smokers. Two patients (4.3%) were receiving workers’ compensation at the time of surgery or recovery. Additionally, a history of back pain (23.9%) or psychiatric history (21.7%) was relatively common among the population. The average follow-up time was 67.6 months.

Table 1

Preoperative Patient and Radiographic Characteristics (n = 46)^a

Age, y	59.1 ± 8.9
Sex: female, %	87.0
Body mass index	27.3 ± 6.9
Smoker (former/current)	10 (21.7)
Physically active/sports	17 (37.0)
Workers’ compensation	2 (4.3)
History of back pain	11 (23.9)
Psychiatric history	10 (21.7)
Angle, deg
Alpha (Dunn)	53.3 ± 12.2
Lateral center edge	30.4 ± 6.5
Tönnis grade
0	43 (93.5)
1	3 (6.5)
Tönnis angle	3.4 ± 7.23

Values are presented as mean ± SD or No. (%) unless noted otherwise.

Intraoperative Findings and Procedures

A majority of cases were isolated gluteus medius repairs (78.3%), whereas 15.2% were isolated gluteus minimus repairs and 6.5% were combined repairs. Five full-thickness tears were repaired endoscopically, and the remaining repairs were for partial-thickness tears. Concomitant labral treatment occurred in 36 (78.3%) cases: 14 (38.9%) were labral repair attributed to frank labral tearing, and 22 (61.1%) were isolated labral debridement attributed to degenerative fraying of the labrum. All labral repairs included labral debridement. Of the 14 labral tears, 8 (57.1%) were most likely due to femoroacetabular impingement confirmed intraoperatively: 7 (87.5%) cases of combined impingement and 1 (12.5%) of isolated pincer-type impingement. The remaining labral tears (n = 6; 42.9%) were most likely because of age-related degenerative changes. Other common procedures were trochanteric bursectomy, synovectomy, excision of calcific tendinitis, femoral osteochondroplasty, acetabular rim trimming, iliotibial band lengthening, and platelet-rich plasma application (Table 2). Femoroacetabular impingement was confirmed intraoperatively in 8 patients. Of the total study population, there were 5 (10.9%) cases of combined impingement, 1 (2.2%) case of isolated cam impingement, and 2 (4.3%) cases of isolated pincer impingement.

Table 2

Intraoperative Findings and Procedures

Findings and Procedures	% or No. (%)
Hip abductor repair
Gluteus medius only	78.3
Gluteus minimus only	15.2
Gluteus medius and minimus	6.5
Partial-thickness tear	89.1
Full-thickness tear	10.9
Labral treatment
Debridement	36 (78.3)
Repair	14 (30.4)
Femoroacetabular impingement
Cam	7 (15.2)
Pincer	8 (17.4)
Combined	7 (15.2)
Trochanteric bursectomy	100.0
Acetabular rim trimming	17.4
Femoral osteochondroplasty	15.2
Synovectomy	15.2
Platelet-rich plasma	6.5
Iliotibial band lengthening	4.4
Excision of calcific tendinitis	2.2

Postoperative Outcomes

Each of the 5 PRO scores improved significantly from presurgery to 5 years postoperatively (P < .001 for all) (Figure 2). Five-year MCID threshold scores were calculated as follows: HOS-ADL, 11.5; HOS-SS, 15.1; mHHS, 13.3; iHOT-12, 11.8; and VAS for pain, 15.8 (Table 3). A majority of patients reached the MCID at 5 years for each of the 5 PROs: 92.3%, 84.2%, 81.5%, 83.3%, and 66.7%, respectively. Five-year PASS threshold scores (AUC) were also calculated: HOS-ADL, 75.7 (0.799); HOS-SS, 79.7 (0.819); mHHS, 81.2 (0.730); iHOT-12, 60.8 (0.829); and VAS for pain, 15.5 (0.229). A majority of patients likewise met the PASS at 5 years for each of the 5 PROs: 70.3%, 57.6%, 56.5%, 65.8%, and 56.8%. In total, 96.2% of patients reached a clinically significant outcome, with 92.1% and 74.4% achieving an MCID and a PASS, respectively, for at least 1 PRO. In addition, 68.4% of patients achieved both the MCID and PASS for at least 1 PRO. A full breakdown of the availability of each PRO outcome measure can be found in Appendix Table A1 (available in the online version of this article).

Table 3

Threshold Scores and Achievement of the MCID and PASS for Each PRO^a

PRO	MCID	Achievement, %	PASS	AUC	Achievement, %
HOS-ADL	11.5	92.3	75.7	0.799	70.3
HOS-SS	15.1	84.2	79.7	0.819	57.6
mHHS	13.3	81.5	81.2	0.730	56.5
iHOT-12	11.8	83.3	60.8	0.829	65.8
VAS for pain	15.8	66.7	15.5	0.229	56.8
Any PRO		92.1			74.4

AUC, area under the curve; HOS-ADL, Hip Outcome Score–Activities of Daily Living; HOS-SS, Hip Outcome Score–Sport Specific; iHOT-12, 12-item International Hip Outcome Tool; MCID, minimal clinically important difference; mHHS, modified Harris Hip Score; PASS, Patient Acceptable Symptom State; PRO, patient-reported outcome; VAS, visual analog scale.

Survival Analysis

Total survivorship free of any reoperation or retear at postoperative 5 years was 89.1% for the study population (Figure 3). Survival free of gluteus medius or minimus retear or revision hip abductor repair was 93.5%. One patient required revision surgery with gluteus maximus transfer 35.1 months postoperatively because of a partial-thickness retear, with significant muscular atrophy of the gluteus medius and minimus confirmed on MRI. Additionally, 2 patients experienced retearing at a mean 57.7 months, but at the time of this writing had not had revision repair surgery. The first patient demonstrated retearing with a full-thickness gluteus medius and minimus tear with Goutallier-Fuchs grade 3 fatty atrophy and trochanteric bursitis on MRI. MRI of the second patient revealed postsurgical changes consistent with retearing of the gluteus medius and minimus. Survival free of conversion to total hip arthroplasty was similarly 93.5%. Three patients converted to total hip arthroplasty at an average of 46.9 months after surgery. Of the remaining patients who did not require revision surgery or conversion to total hip arthroplasty, 23.9% developed GTPS of the contralateral hip. Additionally, nearly one-fifth (19.6%) developed recurrent symptoms of GTPS requiring corticosteroid injections for pain management an average of 24.7 months postoperatively.

Discussion

The purpose of our study was to define the MCID and PASS at a minimum 5 years postoperatively for patients undergoing endoscopic gluteus medius and/or minimus repair. Our hypothesis was confirmed: endoscopic hip abductor repair results in a high rate of achievement of clinically significant outcomes and survivorship at a minimum 5-year follow-up. In addition, we defined the MCID and PASS for the HOS-ADL, HOS-SS, mHHS, and iHOT-12 outcome scores and the MCID for the VAS outcome score. We found statistically significant improvements in all PRO outcome scores 5 years after surgery. Our results are clinically significant in that 92.1% and 74.4% of patients were able to achieve at least 1 threshold score to meet the MCID or PASS for at least 1 PRO, respectively. Additionally, 96.2% were able to attain a clinically significant outcome by achieving at least 1 threshold score for the MCID or PASS.

Clinically significant improvements after endoscopic repair of gluteus medius and minimus tears at a minimum 2-year follow-up have been well documented in the literature.^4,7,31,34 Endoscopic repair has also been proved to be effective as open repair. A recent systematic review of 22 studies revealed that endoscopic and open gluteal tendon repairs resulted in PRO improvements and functional improvements.²⁴ Retear rates were similar between open and endoscopic repairs, with endoscopic repairs demonstrating lower complication rates.²⁴ In an evaluation of 15 patients with full-thickness gluteus medius tears undergoing endoscopic repair, Nazal et al³¹ noted significant improvement in the HOS-ADL, HOS-SS, mHHS, Nonarthritic Hip Score, and 33-item International Hip Outcome Tool at an average follow-up of 31.2 months.

Midterm outcomes of endoscopic hip abductor repair with concomitant arthroscopic labral treatment are not well described in the literature. Our findings are consistent with those of Meghpara et al,³⁰ who demonstrated significant improvement in the mHHS, HOS-SS, and iHOT-12 scores at a minimum follow-up of 5 years. Meghpara et al³⁰ defined MCID thresholds unique to endoscopic gluteus medius repair with concomitant labral treatment for the mHHS (8.2), Nonarthritic Hip Score (8.8), and HOS-SS (12.9) as well as PASS thresholds for the mHHS (74), HOS-SS (65), and iHOT-12 (63). Our study defined higher MCID and PASS thresholds for the mHHS (13.3 and 81.2) and HOS-SS (15.1 and 79.7). However, similar rates of achievement were noted between the study populations. Additionally, our study defined clinically significant outcomes for additional PRO measures, including the HOS-ADL and VAS scores, as well as the MCID for the iHOT-12.

This study represents the largest patient series to date of endoscopic hip abductor repairs with concomitant labral treatment. We defined the MCID for the HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcome scores as 11.5, 15.1, 13.3, 11.8, and 15.8, respectively. The PASS threshold scores for the HOS-ADL, HOS-SS, mHHS. and iHOT-12 were 75.7, 79.7, 81.2, and 60.8. The values represent clinically significant outcomes in patients undergoing endoscopic hip abductor repair with concomitant labral treatment and may serve as a reference for future studies. We found that a large portion of patients attained statistically (100%) and clinically (96.2%) significant outcomes, demonstrating the efficacy of the combined procedure. Additionally, our overall survivorship rate of 89.1% was comparable with the 92.9% rate reported by Perets et al.³⁵

We chose the distribution method with standard deviation as the measure of variability to define the MCID for 2 reasons: (1) the large portion of the study population with pre- and postoperative scores available (76.9%) and (2) the lack of adequate response from a 15-point global rating scale on changes in the domains of interest needed for anchor-based approaches. It is important to note that previous authors have expressed concern regarding the ability of the distribution method to assess what is clinically important to individual patients without specific anchor questions.²⁸ However, Norman et al³² demonstrated that the MCID, whether defined by a distribution or anchor-based approach, often emerges as approximately one-half of a standard deviation. The distribution method may even be a preferred means of reporting the MCID owing to its greater applicability across a broad range of clinical scenarios and its ease of comparison among studies during meta-analyses.⁴⁷

Limitations

Our study is not without certain important limitations. First, although this study represents the largest study population of endoscopic hip abductor repairs with concomitant labral treatment and a minimum 5-year follow-up published to date, our cohort is limited by its sample size. A larger study population would allow for more advanced statistical methods to determine predictors of achievement of the MCID or PASS. Second, our study population consisted of consecutive hip abductor tears repaired endoscopically by a single high-volume, fellowship-trained hip arthroscopic surgeon (S.J.N.) at a major academic medical center, which may limit our ability to provide generalizable conclusions to lower-volume or non–hip-specialized practices. Third, the study population consisted largely of middle-aged to elderly adults with a majority being female and having an overweight BMI. Yet, the study population is reflective of a typical hip abductor repair population with a strong female predominance and tendency to present in the sixth decade of life.²⁰ However, it is worth noting that despite more than one-third of patients indicating a physically active status, the HOS-SS may not be as applicable to the study population investigated as compared with the populations upon which it is historically based. Additionally, it is important to note that a complete set of PROs was not available for all patients, and the degree to which missing PRO scores may have affected the MCID and PASS thresholds is unknown. Last, a lack of postoperative imaging for all patients may lead to an underestimation of the true rate of retearing or postsurgical complications.

Conclusion

Endoscopic hip abductor repair with concomitant arthroscopic labral treatment has a high rate of achievement of clinically significant outcomes and survivorship at a minimum 5-year follow-up. We defined the MCID for the HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcome scores as 11.5, 15.1, 13.3, 11.8, and 15.8, respectively. The PASS threshold scores for the HOS-ADL, HOS-SS, mHHS, and iHOT-12 scores were respectively 75.7, 79.7, 81.2, and 60.8. Of the study population, 92.1% and 74.4% were able to attain at least 1 threshold score to meet the MCID or PASS, respectively, for at least 1 PRO.

Supplemental Material

sj-pdf-1-ajs-10.1177_03635465221105469 – Supplemental material for Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State After Endoscopic Gluteus Medius or Minimus Repair With or Without Labral Treatment and Routine Capsular Closure at Minimum 5-Year Follow-up

Supplemental material, sj-pdf-1-ajs-10.1177_03635465221105469 for Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State After Endoscopic Gluteus Medius or Minimus Repair With or Without Labral Treatment and Routine Capsular Closure at Minimum 5-Year Follow-up by Morgan W. Rice, Lakshmanan Sivasundaram, Mario Hevesi, Robert B. Browning, Thomas D. Alter, Katlynn Paul and Shane J. Nho in The American Journal of Sports Medicine

Footnotes

Submitted November 1, 2021; accepted April 1, 2022.

Presented at the annual meeting of the AOSSM, Colorado Springs, Colorado, July 2022.

One or more of the authors has declared the following potential conflict of interest or source of funding: L.S. has received support for education from Rock Medical Orthopedics. M.H. has received hospitality payments from DePuy Synthes Sales. R.B.B. has received support for education from Medwest Associates. S.J.N. has received nonfinancial support from Allosource, Arthrex Inc, Athletico, DJ Orthopedics, Linvatec, Miomed, and Smith & Nephew; consulting fees and royalties from Stryker; and personal fees from Springer and Ossur. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iD

Thomas D. Alter

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