Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis

Efficacy of preemptive analgesia versus postoperative analgesia of celecoxib on postoperative pain, patients' global assessment and hip function recovery in femoroacetabular impingement patients underwent hip arthroscopy surgery

We aimed to investigate the efficacy of preemptive analgesia of celecoxib on postoperative pain, patients' global assessment (PGA) and hip function recovery compared to postoperative analgesia of celecoxib in femoroacetabular impingement (FAI) patients who underwent hip arthroscopy surgery (HAS). The 100 FAI patients underwent HAS were randomly allocated to preemptive analgesia group (N = 50) or postoperative analgesia group (N = 50) as a 1:1 ratio for 3 months. Pain visual analog scale (VAS) score, PGA score, rescue-use pethidine consumption and Harris hip score were assessed. Compared to postoperative analgesia group, pain VAS score decreased on day 1 (P = 0.036), day 2 (P = 0.046) and day 3 (P = 0.046), while was similar prior to operation (P = 0.587), on day 7 (P = 0.398), at month 1 (P = 0.461) and month 3 (P = 0.805) in preemptive analgesia group. Besides, rescue-use pethidine consumption was decreased in preemptive analgesia group than postoperative analgesia group within 3 days (P = 0.016) and within 7 days (P = 0.033) post-operation. For PGA score, it reduced on day 2 (P = 0.030) and day 3 (P = 0.048), while was similar prior to operation (P = 0.699), on day 1 (P = 0.699), day 7 (P = 0.224), at month 1 (P = 0.640) and month 3 (P = 0.400) in preemptive analgesia group than postoperative analgesia group. For Harris hip score, it was similar prior to operation (P = 0.372), on day 7 (P = 0.366), at month 1 (P = 0.466) and month 3 (P = 0.658) between the two groups. In conclusion, preemptive analgesia of celecoxib decreases short-term postoperative pain and PGA, but without effect on long-term hip function recovery than postoperative analgesia of celecoxib in FAI patients who underwent HAS.

Editorial Commentary: Consider the Sacroiliac Joint: Imaging a Source of Pain Can Feel Compelling. Orthopaedists Would Do Well to Remain Skeptical

With regard to the association of sacroiliac (SI) pain and hip arthroscopy outcomes, it is vital to understand that imaging the SI joint may be unreliable. A recent systematic review on diagnostic accuracy for SI joint pain concluded that more reliable criteria are strongly positive responses to diagnostic injection and a physical examination in which 3 or more provocative maneuvers are positive. SI joint degenerative changes can be found in a majority of asymptotic patients and might be considered normal finding until proven otherwise. When it comes to the spine and pelvis, radiologic changes should be interpreted by caution by both hip surgeons and spine surgeons.

Demographic and Radiographic Factors Associated With Intra-articular Hip Cartilage Injury: A Cross-sectional Study of 1511 Hip Arthroscopy Procedures

BACKGROUND

Moderate to severe (grade 3-4) hip joint cartilage injury seems to impair function in patients with femoroacetabular impingement syndrome.

PURPOSE

To investigate whether demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were identified in the Danish Hip Arthroscopy Registry. The outcome variables were acetabular cartilage injury (modified Beck grade 0-2 vs 3-4) and femoral head cartilage injury (International Cartilage Repair Society grade 0-2 vs 3-4). Logistic regressions assessed the association with the following: age (<30 vs 30-50 years); sex; sport activity level (Hip Sports Activity Scale); alpha angle (AA) assessed as normal (AA <55°), cam (55°≤ AA <78°), or severe cam (AA ≥78°); lateral center-edge angle (LCEA) assessed as normal (25°≤ LCEA ≤ 39°), pincer (LCEA >39°), or borderline dysplasia (LCEA <25°); joint space width (JSW) assessed as normal (JSW >4.0 mm), mild reduction (3.1 mm ≤ JSW ≤ 4.0 mm), or severe reduction (2.1 mm ≤ JSW ≤ 3.0 mm).

RESULTS

A total of 1511 patients were included (mean ± SD age: 34.9 ± 9.8 years). Male sex (odds ratio [OR], 4.42), higher age (OR, 1.70), increased AA (cam: OR, 2.23; severe cam: OR, 4.82), and reduced JSW (mild: OR, 2.04; severe: OR, 3.19) were associated (P < .05) with Beck grade 3-4. Higher age (OR, 1.92), increased Hip Sports Activity Scale (OR, 1.13), borderline dysplasia (OR, 3.08), and reduced JSW (mild: OR, 2.63; severe: OR, 3.04) were associated (P < .05) with International Cartilage Repair Society grade 3-4.

CONCLUSION

Several demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. Most notably, increased cam severity and borderline dysplasia substantially increased the risk of grade 3-4 acetabular and femoral head cartilage injury, respectively, indicating that specific deformity may drive specific cartilage injury patterns in the hip joint.

Return to Duty After Mini-Open Arthroscopic-Assisted Treatment of Femoroacetabular Impingement in an Active Military Population

Purpose

To report the return-to-duty rate and surgical outcomes in a military population after mini-open arthroscopic-assisted surgery for femoroacetabular impingement (FAI) in an effort to affirm its efficacy.

Methods

A retrospective review of consecutive active-duty patients receiving mini-open arthroscopic-assisted surgery for FAI between 2007 and 2011 was performed. Patients younger than 18 years, non–active-duty patients, and patients with prior hip surgery were excluded. Demographic, radiographic, and duty-status data were collected. The primary outcome measure was a return to duty. Outcome scores were obtained in a proportion of the cohort, including the modified Harris Hip Score, Single Assessment Numeric Evaluation score, Western Ontario and McMaster Universities Osteoarthritis Index score, patient satisfaction score, and Veterans RAND 12 (VR-12) score. All patients had achieved a minimum of 1 year of follow-up at the time of assessment. All P values for significance were set at .05 or lower.

Results

Of 182 patients (average age, 30.4 years), 156 (86%) were available for follow-up with return-to-duty data at an average of 2.8 years (range, 1-6 years). Of the patients, 78% returned to full duty (53%) or returned to duty with restrictions (25%). Outcome scores were available for 101 of 182 patients (55%) with duty rates similar to the total cohort (81% who returned to duty: 58% with no restrictions and 23% with restrictions). Return to duty correlated with improved outcomes compared with those who were medically discharged with respect to the modified Harris Hip Score (68.2 vs 54.5, P < .03), Single Assessment Numeric Evaluation score (48.2 vs 25.3, P < .02), and VR-12 physical (39.7 vs 33.2, P < .05) and VR-12 mental (54.5 vs 43.4, P < .005) scores.

Conclusions

Mini-open arthroscopic-assisted surgery for FAI is successful in returning most service members to duty at short-term follow-up. Return correlates with improved outcome scores, although previously reported minimally clinical important difference and patient acceptable symptomatic state threshold values were not uniformly achieved.

Level of Evidence

Level IV, retrospective case series.

Primary labral reconstruction in patients with femoroacetabular impingement, irreparable labral tears and severe acetabular chondral defects decreases the risk of conversion to total hip arthroplasty: a pair-matched study

In the presence of severe acetabular cartilage defects, the benefits of labral reconstruction (RECON) versus labral resection (RESEC) have not been determined. Prospectively collected data between October 2008 and December 2016 were retrospectively reviewed. Inclusion criteria were hip arthroscopy, acetabular Outerbridge grade III/IV, irreparable labral tears that underwent RECON or RESEC, and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, International Hip Outcome Tool, Patient Satisfaction and Visual Analogue Scale for pain. Exclusion criteria included Tönnis grade >1, previous hip conditions or previous ipsilateral hip surgeries. A 1:1 matched-pair analysis was performed based on age ±5 years, sex, body mass index ±5 kg/m², Tönnis grade, acetabular microfracture, femoral Outerbridge grade (0 or I compared with II, III or IV). Relative risk (RR) and conversion rate to total hip arthroplasty (THA) were calculated. A total of 38 RECON hips were successfully matched. Both groups demonstrated significant improvements in patient-reported outcomes (PROs). THA conversion was 5.3% and 21.1% for the RECON and RESEC groups, respectively (P = 0.04). RECON was four times less likely to require THA conversion than the RESEC group (RR=4.0; 95% CI 0.91-17.63). In the setting of primary arthroscopic management of femoroacetabular impingement, irreparable labral tears and acetabular chondral lesions of Outerbridge III/IV, patients that underwent RECON and RESEC experienced significant improvement in PROs at minimum 2-year follow-up, and these functional scores were comparable when groups were matched. However, RR and rate to THA conversion were significantly higher in the RESEC group.

Editorial Commentary: The Gain in Pain After Hip Arthroscopic Surgery: What Is Clinically Relevant, and Is Pain Related to Function in Patients With Femoroacetabular Impingement Syndrome?

Hip arthroscopic surgery improves patient-reported outcomes in patients with femoroacetabular impingement syndrome and/or hip chondropathy. The minimal clinically important change on a pain visual analog scale has now been calculated in this patient group, and the pain level 1 year after surgery has been related to function. Next step: identifying what causes pain and decreased function 1 year after surgery.

Minimal Clinically Important Difference and Substantial Clinical Benefit Values for a Pain Visual Analog Scale After Hip Arthroscopy

PURPOSE

To define minimal clinically important difference (MCID) and substantial clinical benefit (SCB) values for a pain visual analog scale (VAS) in patients undergoing hip arthroscopy for femoroacetabular impingement or chondrolabral pathology.

METHODS

This was a retrospective review of prospective collected data on patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and follow-up between 335 and 395 days postsurgery, subjects completed a pain VAS and categorical self-rating of function. MCID was calculated using one-half the standard deviation (SD) of the change in 1-year pain VAS values. Receiver operator characteristic analysis was performed to determine SCB values. A change in SCB value was determined based on change in categorical self-rating of function to create "improved" and "not improved" groups. Absolute postoperative SCB scores were calculated to determine scores that would be associated with "normal" or "abnormal" function ratings.

RESULTS

Of 1,034 eligible patients, 733 (71%) met the inclusion criteria, with 537 (73%) women and 196 (27%) men having a mean age of 35.3 years (SD 13). At a mean of 352 (SD 21) days postsurgery, 536 (73%) were in the improved group and 197 (27%) in the not improved group. MCID was -15.0 mm. A change of -22.7 mm on the pain VAS was able to identify those that improved with high sensitivity (0.74) and specificity (0.63). Values of ≤10.4 mm and ≥29.0 mm were cutoffs identifying subjects that rated their function as normal or abnormal, respectively, with high sensitivity (0.79 and 0.76) and specificity (0.88 and 0.76).

CONCLUSIONS

This study provides surgeons with information to help interpret pain VAS values at a follow-up period ranging from 335 to 395 days with MCID and SCB values of -15.0 mm and -22.7 mm, respectively. Additionally, a patient who assesses a pain level at ≤10.4 mm is likely to have a normal rating of function, whereas a patient who assesses a pain level at ≥29.0 mm is likely to have an abnormal rating of function.

LEVEL OF EVIDENCE

III, retrospective comparative study.

High relative reliability and responsiveness of the forgotten joint score-12 in patients with femoroacetabular impingement undergoing hip arthroscopic treatment. A prospective survey-based study

The forgotten joint score-12 (FJS-12) may be an advantageous questionnaire in young patients with high hip function and a low level of pain. We investigated the reliability and the responsiveness of the FJS-12 in patients with femoroacetabular impingement undergoing hip arthroscopic treatment. Fifty patients were included in the reliability study and 34 patients were included in the responsiveness study. Test-retest reliability was assessed with intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC). Responsiveness was assessed from testing correlations between the FJS-12 and the Copenhagen Hip and Groin Outcome Score (HAGOS) of the change score, effect size (ES) and standardized response mean (SRM). Floor and ceiling effect were defined as present if the number of patients obtaining the maximum (100) and minimum score (0) exceeded 15%. The relative reliability was high (ICC = 0.9, 95% CI: 0.8-0.9) and the absolute reliability was low (SEM = 11, MDC_individual = 32, MDC_group = 4.5). The responsiveness was high, and the change score was highly correlated with the subscale 'pain' from the HAGOS and moderately correlated with the subscale 'ADL'. Furthermore, the FJS-12 exceeded or equalled the HAGOS subscales in ES and SRM. Below 15% of the patients scored the maximum or minimum score. The FJS-12 has high reliability, high responsiveness to change and shows no floor or ceiling effect.

Hip Function 6 to 10 Months After Arthroscopic Surgery: A Cross-sectional Comparison of Subjective and Objective Hip Function, Including Performance-Based Measures, in Patients Versus Controls

Background:

Little is known about hip-related function, mobility, and performance in patients after hip arthroscopic surgery (HA) during the time that return to sports can be expected.

Purpose:

To evaluate measures of subjective and objective hip function 6 to 10 months after HA in patients compared with healthy controls and to compare objective function in the HA group between the operated and nonoperated hips.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 33 patients who had undergone HA (mean, 8.1 ± 2.6 months postoperatively) and 33 healthy participants matched on sex, age, and activity level were compared regarding subjective hip function (Copenhagen Hip and Groin Outcome Score [HAGOS]) and objective function including hip range of motion (ROM; flexion, internal rotation, and external rotation), isometric hip muscle strength (adduction, abduction, flexion, internal rotation, and external rotation), and performance-based measures: the Y Balance Test (YBT), medial and lateral triple-hop test, and Illinois agility test. Group differences were analyzed using independent-samples t tests. Paired-samples t tests were used for a comparison of the operated and nonoperated hips. Standard effect sizes (Cohen d) were provided for all outcomes.

Results:

The HA group reported worse subjective hip function than the control group (HAGOS subscores: d = –0.7 to –2.1; P ≤ .004). Objective measures of hip ROM (d = –0.5 to –1.1; P ≤ .048), hip flexion strength (d = –0.5; P = .043), and posteromedial reach of the YBT (d = –0.5; P = .043) were also reduced in the HA group, although there were no significant differences between groups regarding the remaining objective measures (d = –0.1 to –0.4; P ≥ .102 to .534). The only significant difference between the operated and nonoperated hips in the HA group was reduced passive hip flexion (d = –0.4; P = .045).

Conclusion:

Patients who had undergone HA demonstrated reduced subjective hip function compared with controls 6 to 10 months after surgery, when return to sports can be expected. While most objective strength and performance test results were comparable between the HA and control groups at 6 to 10 months after surgery, the HA group presented with impairments related to hip mobility and hip flexion strength. No consistent pattern of impairments was found in operated hips compared with nonoperated hips.

The association between specific sports activities and sport performance following hip arthroscopy for femoroacetabular impingement syndrome: A secondary analysis of a cross-sectional cohort study including 184 athletes

The main purpose of this secondary analysis was to compare the proportion of athletes with moderate-to-extreme difficulties in eight specific sport activities in athletes with optimal versus impaired sport performance after a hip arthroscopy for femoroacetabular impingement syndrome. Subjects were identified in a nationwide registry and invited to answer a return to sport and performance questionnaire, and the Copenhagen Hip and Groin Outcome Score Sport subscale investigating difficulties in eight specific sports activities (HAGOS sport items) as; none, mild, moderate, severe or extreme. Subjects were divided into two groups based on sport performance (optimal or impaired). The proportion of athletes with none-to-mild versus moderate-to-extreme difficulties in the eight specific sport activities was compared between groups. The association between difficulties in sport activities and sport performance were investigated using logistic regression analysis. One hundred and eighty-four athletes (31 athletes with optimal and 153 athletes with impaired sport performance) were included at a mean follow-up of 33.1 ± 16.3 months. Up to six athletes (<20%) with optimal sport performance had moderate-to-extreme difficulties in sport activities. Contrary, 43–108 athletes (28.1–70.6%) with impaired performance had moderate-to-extreme difficulties in sport activities. Furthermore, moderate-to-extreme difficulties in HAGOS sport items: ‘running as fast as you can’ and ‘kicking, skating etc.’ increased the odds (14.7 and 6.1 times, respectively) of having impaired sport performance. Many athletes with impaired sport performance reported moderate-to-extreme difficulties in sport activities, specifically moderate-to-extreme difficulties in ‘running as fast as you can’ and ‘kicking, skating etc.’ were associated with patients having impaired sport performance.

Do Female Athletes Return to Sports After Hip Preservation Surgery for Femoroacetabular Impingement Syndrome?: A Comparative Analysis

Background

Female patients undergoing surgery for femoroacetabular impingement syndrome (FAIS) often experience inferior clinical outcomes and higher failure rates when compared with male patients. The influence of athletic status on hip arthroscopic outcomes in female patients, however, is unclear.

Purpose

To compare patient-reported outcomes (PROs) of athletic and nonathletic female patients undergoing hip arthroscopic surgery for FAIS, and to determine the return-to-sports rate in the athlete group.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two-year PROs were assessed in female patients who had undergone hip arthroscopic surgery for FAIS by a single surgeon. Patients who self-identified as athletes were compared with nonathletes. Preoperative and postoperative PRO scores including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport-Specific (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction were analyzed and compared between athletes and nonathletes. Subanalysis was performed based on patient age and body mass index (BMI).

Results

A total of 330 female patients undergoing hip arthroscopic surgery for FAIS were identified. Of these, 221 patients identified as athletes (mean age, 29.1 ± 11.1 years; mean BMI, 23.0 ± 3.5 kg/m²) and 109 as nonathletes (mean age, 39.3 ± 11.4 years; mean BMI, 27.8 ± 5.8 kg/m²). Both groups demonstrated improvements in HOS-ADL, HOS-SS, mHHS, VAS for pain, and VAS for satisfaction scores (P < .001 for all). Athletes had significantly higher postoperative PRO scores compared with nonathletes (P < .001 for all). A 1:1 matched-pair subanalysis of 97 athletes and 97 nonathletes controlling for age and BMI indicated that these relationships held independently of potential demographic confounders (P < .001 for all). The number of patients meeting the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the HOS-ADL, HOS-SS, and mHHS was significantly higher in athletes aged ≤25 years versus those aged >25 years and for athletes versus nonathletes (P < .05 for all). Further, 189 of 194 athletes returned to sports at a mean of 6.0 ± 3.9 months postoperatively, with 93.7% reporting returning to the same or higher level of competition.

Conclusion

Among female patients undergoing hip arthroscopic surgery for FAIS, patients considered athletes achieved superior clinical outcomes compared with patients considered nonathletes. In addition, younger female athletes had higher rates of achieving the MCID and PASS for all PRO measures.

Predictors of Persistent Postoperative Pain at Minimum 2 Years After Arthroscopic Treatment of Femoroacetabular Impingement

BACKGROUND

Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly expanding field, and preoperative factors predictive of persistent postoperative pain are currently unknown.

PURPOSE

To identify predictors for persistent postoperative pain at the site of surgery after hip arthroscopy for FAIS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent hip arthroscopy for FAIS and had a minimum 2-year follow-up with patient-reported outcomes (PROs) were included in this study. Patients with previous open hip surgery and diagnoses other than FAIS were excluded. Patients were grouped by visual analog scale scores for pain as limited (<30) and persistent (≥30). Patient factors and outcomes were analyzed with univariate and correlation analyses to build a logistic regression model to identify predictors of persistent postoperative pain.

RESULTS

The limited pain (n = 514) and persistent pain (n = 174) groups totaled 688 patients (449 females). There was a statistically significant difference in age between groups, with the persistent pain group being older than the low pain group (35.9 ± 12.2 vs 32.4 ± 12.6, respectively; P = .002). Patients with persistent postoperative pain demonstrated significantly lower preoperative PRO scores in the Hip Outcome Score-Activities of Daily Living (57.6 ± 21.2 vs 67.7 ± 16.8), Hip Outcome Score-Sport Specific (35.9 ± 23.9 vs 44.1 ± 22.7), modified Harris Hip Score (51.6 ± 16.2 vs 59.6 ± 12.9), and International Hip Outcome Tool (32.0 ± 16.8 vs 40.0 ± 17.82) but no significant differences in preoperative visual analog scale scores for pain (7.3 ± 1.8 vs 7.2 ± 1.7). Mean postoperative PRO differences between pain groups were all statistically significant. Bivariate logistic regression analysis demonstrated that history of anxiety or depression (odds ratio, 1.8; 95% CI, 1.02-3.32; P = .042), revision hip arthroscopy (odds ratio, 8.6; 95% CI, 1.79-40.88; P = .007), and a low preoperative modified Harris Hip Score (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .30) were predictors of persistent postoperative pain.

CONCLUSION

Independent predictors for persistent postoperative pain include revision hip arthroscopy and mental health history positive for anxiety and depression. Our analysis demonstrated significant improvements in pain and functional PROs in the limited pain and persistent pain groups; however, those with persistent pain demonstrated significantly lower PRO scores.

Is hip muscle strength normalised in patients with femoroacetabular impingement syndrome one year after surgery?: Results from the HAFAI cohort

OBJECTIVES

Little is known about hip function after hip arthroscopic surgery in patients with femoroacetabular impingement syndrome. Hence, the aim of the study was (1) to investigate changes in hip muscle strength from before to one year after hip arthroscopic surgery, (2) to compare patients with a reference group.

DESIGN

Cohort study with a cross-sectional comparison.

METHODS

Before and after hip arthroscopic surgery, patients underwent hip muscle strength testing of their hip flexors and extensors during concentric, isometric and eccentric contraction in an isokinetic dynamometer. Reference persons with no hip problems underwent tests at a single time point. Participants completed completed the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire and physical capacity (stair climbing loaded and unloaded, stepping loaded and unloaded and jumping) tests.

RESULTS

After surgery, hip flexion strength improved during all tests (6-13%, p<0.01) and concentric hip extension strength improved (4%, p=0.002). Hip flexion and extension strength was lower for patients than for reference persons (9-13%, p<0.05) one year after surgery. Higher hip extension strength after surgery was associated with better patient reported outcomes. Patients, who were unable to complete at minimum one test of physical capacity, demonstrated significantly weaker hip muscle strength. Compared with their healthy counterparts, female patients were more impaired than male patients.

CONCLUSIONS

One year after surgery, patients improved their maximal hip muscle strength. When compared to reference persons, maximal hip muscle strength was still impaired.

Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions

Objectives

We aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy.

Methods

Data from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery.

Results

1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (p<0.001) proportionally for all comorbidities after surgery. Relative to baseline, cases of mental health disorders rose 84%, chronic pain diagnoses increased 166%, substance abuse disorders rose 57%, cardiovascular disorders rose by 71%, metabolic syndrome cases rose 85.9%, systemic arthropathy rose 132% and sleep disorders rose 111%.

Conclusions

Major (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery.

Level of evidence

Prognostic, level III.

[Application of arthroscopic surgery combined with direct anterior approach in hip diseases]

Objective

To evaluate the short-term effectiveness of arthroscopic surgery combined with direct anterior approach for hip diseases.

Methods

A retrospective study was performed on 23 cases with hip diseases (23 hips), who were treated with the arthroscopic surgery combined with direct anterior approach, between January 2015 and December 2016. There were 9 males and 14 females, aged from 27 to 49 years (mean, 38.6 years). There were 11 cases of posterior dislocation of the hip associated with femoral head fracture (Pipkin typeⅠ) and 7 cases of femoral neck fracture (Garden type Ⅳ). And the interval between injury and operation was 2-8 days (mean, 4.3 days). Five cases were osteonecrosis of femoral head at precollapse stage which were rated as stageⅡA according to Association Research Circulation Osseous (ARCO) classification system. The disease duration was 3-8 months (mean, 5.9 months). The preoperative Harris hip score, Oxford Hip Score (OHS), Postel score, and visual analogue scale (VAS) were 57.3±8.2, 11.2±3.6, 3.2±1.5, and 7.2±1.3, respectively.

Results

All the wounds healed primarily. Lateral femoral nerve injury occurred in 3 cases. All patients were followed up 8-19 months (mean, 15.6 months). Bone union achieved in all patients after 14-19 weeks (mean, 15.8 weeks) and no secondary osteoarthritis or heterotopic ossification occurred. At last follow-up, the Harris hip score (92.5±5.3), OHS (36.5±5.9), and Postel score (14.2±2.6) were significantly higher than preoperative scores ( t=45.274, P=0.000; t=36.586, P=0.000; t=32.486, P=0.000), and VAS score (1.8±0.9) was significantly lower than preoperative score ( t=21.314, P=0.000).

Conclusion

Arthroscopic surgery combined with direct anterior approach for hip diseases can effectively relieve pain, improve hip function, and obtain the satisfactory short-term effectiveness.

Return to Sport and Performance After Hip Arthroscopy for Femoroacetabular Impingement in 18- to 30-Year-Old Athletes: A Cross-sectional Cohort Study of 189 Athletes

BACKGROUND

A recent systematic review found that 87% of athletes return to sport after hip surgery for femoroacetabular impingement syndrome. However, the proportion of athletes returning to preinjury sport at their preinjury level of sport is less clear.

PURPOSE

The main purpose of this study was to determine the rate of athletes returning to preinjury sport at preinjury level including their associated sports performance after hip arthroscopy for femoroacetabular impingement syndrome. Furthermore, self-reported hip and groin function was investigated.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Eligible subjects were identified in the Danish Hip Arthroscopy Registry. A self-reported return to sport questionnaire was used to collect data after hip arthroscopy. If athletes reported they were engaged in preinjury sport at their preinjury level, the associated sports performance and participation were assessed as either (1) optimal sports performance including full sports participation; (2) impaired sports performance, but full sports participation; or (3) impaired sports performance including restricted sports participation. Self-reported hip and groin function was assessed for all athletes by use of the Copenhagen Hip and Groin Outcome Score.

RESULTS

The study included 189 athletes (mean ± SD age at follow-up, 26.9 ± 3.4 years) at a mean ± SD follow-up of 33.1 ± 16.3 months after surgery. At follow-up, 108 athletes (57.1%) were playing preinjury sport at preinjury level, whereas the remaining 81 athletes (42.9%) failed to return to preinjury sport at preinjury level. Of the 108 athletes engaged in their preinjury sport at preinjury level at follow-up, 32 athletes (29.6%) reported optimal sports performance including full sports participation, corresponding to 16.9% of the study sample. Better self-reported hip and groin function was observed in athletes who were engaged in preinjury sport at preinjury level compared with athletes who were not.

CONCLUSION

Fifty-seven percent of athletes returned to preinjury sport at their preinjury level. This is considerably lower than a previously reported return to sport rate of 87% and may reflect that the present study used a clear and strict definition of return to sport. Of note, only one-third of athletes who returned to preinjury sport at preinjury level reported their sports performance to be optimal, corresponding to 16.9% of the study sample. Better self-reported hip and groin function was observed in athletes who were playing preinjury sport at preinjury level compared with athletes who were not.

Patient-Reported Outcomes Within the First Year After Hip Arthroscopy and Rehabilitation for Femoroacetabular Impingement and/or Labral Injury: The Difference Between Getting Better and Getting Back to Normal

BACKGROUND

The Copenhagen Hip and Groin Outcome Score (HAGOS) was recently found valid, reliable, and responsive for patients undergoing hip arthroscopy. However, it is currently unknown to what degree patients undergoing hip arthroscopy improve and/or normalize their HAGOS result within the first year after surgery.

PURPOSE

First, to use HAGOS to evaluate clinical outcomes at 3, 6, and 12 months after hip arthroscopy for femoroacetabular impingement (FAI) and/or labral injury and compare the HAGOS results with the modified Harris Hip Score (mHHS). Second, to explore how many patients would (a) improve to a degree of minimal clinical importance (MIC) and (b) obtain scores within the reference intervals of healthy controls.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From September 2011 to March 2014, 97 consecutive patients [56 females (mean age, 38 years; range, 17-60 years) and 41 males (mean age, 37 years; range, 19-59 years)] underwent first-time hip arthroscopy for FAI and/or labral injury. Standardized postoperative rehabilitation instructions were provided. HAGOS (0-100 points) and mHHS (0-100 points) values were obtained preoperatively and again postoperatively at 3, 6, and 12 months. Furthermore, 158 healthy controls, matched on age and sex, were included to obtain HAGOS and mHHS reference values for comparison. Minimal important change was determined by using the 0.5 SD of the baseline values for HAGOS and mHHS.

RESULTS

Improvements for all HAGOS subscales and mHHS results were seen at 3 months ( P < .001). Further improvements were seen only for HAGOS Sport and Recreation (Sport/Rec) and Participation in Physical Activities (PA) subscales between 3 and 12 months ( P < .05) but not for HAGOS Pain, Symptoms, Activities of Daily Living (ADL), or Hip-Related Quality of Life (QOL) subscales or the mHHS. Furthermore, on HAGOS Sport/Rec, PA, and QOL subscales, patients reached scores of only 54 to 70 points 1 year after surgery. At the individual level, up to 70% of the patients experienced minimal important improvements during the first year after surgery, but only up to 38% and 36% of patients reached a score within the reference interval of HAGOS and mHHS, respectively.

CONCLUSION

Statistically and clinically relevant improvements in HAGOS and mHHS results after hip arthroscopy and rehabilitation can be seen at 3 months and up to 1 year. However, specific HAGOS subscales suggest that a patient's ability to function and participate in sport and physical activity is still markedly reduced 1 year after surgery. Furthermore, the majority of patients undergoing hip arthroscopy cannot expect to reach the level of the healthy population on self-reported pain and function within the first year after surgery.

A Systematic Summary of Systematic Reviews on the Topic of Hip Arthroscopic Surgery

BACKGROUND

There is a rapidly growing body of literature on the topic of hip arthroscopic surgery.

PURPOSE

To provide an overall summary of systematic reviews published on the indications, complications, techniques, outcomes, and information related to hip arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all hip arthroscopic surgery-related systematic reviews published between January 2000 and May 2018 was performed using PubMed, MEDLINE, and the Cochrane Library. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 837 articles were found, of which 85 met the inclusion criteria. Included articles were summarized and divided into 6 major categories based on the subject of the review: femoroacetabular impingement (FAI), non-FAI indications, surgical technique, outcomes, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on hip arthroscopic surgery can provide surgeons with a single source for the most current synopsis of the available literature. As the prevalence of orthopaedic surgeons performing hip arthroscopic surgery increases, updated evidence-based guidelines must likewise be advanced and understood to ensure optimal patient management.

Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial

Synopsis The number of hip arthroscopies for the management of femoroacetabular impingement syndrome and other hip intra-articular conditions has grown exponentially in the last decade. Postoperative rehabilitation is part of the treatment algorithm, although there is a lack of high-quality studies on the efficacy of both surgery and postoperative rehabilitation programs. It is known that impairments can be present up to 2 years after hip arthroscopy, with individuals exhibiting reduced function and quality of life when compared to those of similar age, highlighting a need to improve postoperative care. Postoperative rehabilitation programs aim to improve hip function; however, the description of interventions as well as criteria for progression are lacking in the literature. The aim of this clinical commentary was to present a targeted clinical rehabilitation approach for individuals undergoing hip arthroscopy. J Orthop Sports Phys Ther 2018;48(4):336-342. doi:10.2519/jospt.2018.8002.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Femoral Version Abnormalities Significantly Outweigh Effect of Cam Impingement on Hip Internal Rotation

BACKGROUND

The purpose of this study was to investigate the effects of femoral version, cam-type femoroacetabular impingement (FAI), and the combination of the 2 on the passive hip range of motion (ROM).

METHODS

We prospectively analyzed a consecutive cohort of 220 patients (440 hips) who presented with unilateral or bilateral hip pain. The passive hip ROM was measured bilaterally with the patient in prone, supine, and lateral positions. Femoral version was measured and the presence of cam-type deformity was determined on preoperative computed tomography (CT) scans. Diagnostic findings of cam-type FAI included an alpha angle of >50° on CT radial sequences of the head-neck junction and a femoral head-neck offset ratio of <0.18 on both radiographs and CT.

RESULTS

Multivariate linear regression analysis confirmed that femoral version, as compared with the presence of a cam lesion, was a stronger independent predictor of internal rotation ROM. Conversely, the presence of a cam lesion resulted in a significant decrease in the passive hip flexion ROM (p < 0.001) with no additional effects due to the degree of femoral version. The passive hip internal rotation ROM in neutral flexion/extension and with the hip in 90° of flexion were maximized in patients with femoral anteversion and decreased significantly with each incremental decrease in femoral version (p < 0.001).

CONCLUSIONS

Abnormalities in femoral version significantly outweigh the effect of cam-type impingement on the passive hip internal rotation ROM. In contrast, the presence of a cam lesion significantly decreases the hip flexion ROM, irrespective of the degree of femoral version. These findings help to inform surgical decision-making for patients with cam-type FAI or femoral version abnormalities.

CLINICAL RELEVANCE

It is common clinical practice to ascribe loss of hip internal rotation to the presence of a cam lesion and to assume that arthroscopic femoral osteoplasty will substantially improve internal rotation postoperatively. Our study shows that the cam lesion is more intimately tied to hip flexion than to hip internal rotation. This result directly impacts the clinical assessment of a patient presenting with radiographic findings of FAI.

Similar views on rehabilitation following hip arthroscopy among physiotherapists and surgeons in Scandinavia: a specialized care survey

PURPOSE

The rising number of hip arthroscopies (HA) is leading to increasing numbers of patients requiring post-surgical rehabilitation; however, evidence regarding post-operative rehabilitation is currently limited. The purpose of the study was to describe and compare current rehabilitation strategies and views among surgeons and physiotherapists in Scandinavia.

METHODS

Scandinavian surgeons and physiotherapists experienced with HA and post-surgical rehabilitation were asked to complete an online survey. Ninety clinicians (28 surgeons, 62 physiotherapists) responded.

RESULTS

Both professions mostly rated physiotherapy as very or extremely important in the rehabilitation process. The majority advocated criteria-based or combined criteria- and time-based progression. Expected rehabilitation timelines were reported with large intra-professional variation but general inter-professional agreement. However, compared with physiotherapists surgeons expected fewer weeks on crutches and faster return to competitive sport. Surgeons more often reported use of evidence-based self-reported outcomes while physiotherapists more often evaluated readiness for return to play.

CONCLUSIONS

Among surgeons and physiotherapists, physiotherapy is considered very important following HA. Generally, very similar views were held between professions. Surgeons expected reduced time on crutches and to return to competitive sports than physiotherapists. Surgeons also used evidence-based self-reported outcomes to a higher degree than physiotherapists. Being the first study to provide an overview on currently applied rehabilitation strategies following HA, results of this study may guide much needed, future research on the rehabilitation process following HA.

LEVEL OF EVIDENCE

IV.