Survivorship and Outcomes 10 Years Following Hip Arthroscopy for Femoroacetabular Impingement: Labral Debridement Compared with Labral Repair

An Increased Allograft Width for Circumferential Labral Reconstruction Better Restores Distractive Stability of the Hip: A Cadaveric Biomechanical Analysis

BACKGROUND

Questions remain about whether circumferential labral reconstruction (CLR) using an iliotibial band (ITB) allograft can effectively restore the labral suction seal of the hip.

HYPOTHESES

(1) CLR with an ITB allograft >6.5 mm would restore distractive stability force to that of the intact labrum. (2) CLR with an ITB allograft >6.5 mm would achieve significantly superior distractive stability force compared with CLR with an ITB allograft <6.5 mm.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 6 fresh-frozen pelves with attached femurs (n = 12 matched hemipelves) from male donors were procured and dissected free of all soft tissue, including the hip capsule but preserving the native labrum, transverse acetabular ligament, and ligamentum teres. Potted hemipelves were placed in a saline bath and securely fixed to the frame of a hydraulic testing system. A 500-N compressive load was applied, followed by femoral distraction at a rate of 5.0 mm/s until the suction seal ruptured. Force and femoral displacement were continually recorded. Force versus displacement curves were plotted, the maximum force was recorded, and the amount of femoral distraction to rupture the suction seal was determined. After intact testing, the labrum was excised, and specimens were retested using the same protocol. CLR was subsequently performed twice in a randomized fashion using (1) an ITB allograft with a width >6.5 mm (7.5-9.0 mm) and (2) an ITB allograft with a width <6.5 mm (4.5-6.0 mm). Specimens were retested after each CLR procedure. Force (in Newtons) and femoral distraction (in millimeters) required to rupture the suction seal were measured and compared between the 4 testing states (intact, deficient, CLR <6.5 mm, and CLR >6.5 mm) using repeated-measures analysis of variance.

RESULTS

On average, intact specimens required 148.4 ± 33.1 N of force to rupture the hip suction seal, which significantly decreased to 44.3 N in the deficient state (P < .001). CLR with ITB allografts <6.5 mm did not improve the maximum force (63 ± 62 N) from the deficient state (P = .42) and remained significantly lower than the intact state (P < .01). CLR with ITB allografts >6.5 mm recorded significantly greater force to rupture the suction seal (135.8 ± 44.6 N) compared with both the deficient and CLR <6.5 mm states (P < .01), with a mean force comparable with the intact labrum (P = .59). The amount of femoral distraction to rupture the suction seal demonstrated similar findings.

CONCLUSION

In a cadaveric model, CLR using ITB allografts >6.5 mm restored the distractive force and distance to the suction seal rupture to values comparable with hips with an intact labrum. CLR using ITB allografts >6.5 mm outperformed CLR with ITB allografts <6.5 mm, demonstrated by a significantly higher force to rupture the suction seal and increased distraction before the rupture.

CLINICAL RELEVANCE

The results of this cadaveric investigation suggest that using wider labral allografts during CLR will provide the distractive force required to rupture the suction seal and immediate postoperative stability of the hip, although further studies are required to determine if these results translate to improved clinical outcomes.

Healing of joint capsule after hip arthroscopy using interportal capsulotomy and capsular closure influences clinical outcomes

Background

Hip arthroscopy for treatment of femoroacetabular impingement (FAI) has developed rapidly and has been shown to significantly decrease pain and improve hip function. However, the relationship between hip capsule characteristics and healing after arthroscopic surgery and changes in patient-reported outcomes scores (PROs) for postoperative pain, function, and symptoms is still uncertain.

Methods

We retrospectively evaluated consecutive patients who were diagnosed with FAI and underwent hip arthroscopy for treatment in our hospital between May 2018 and November 2020. All patients had preoperative MRI and postoperative MRI at least 6 months after arthroscopy. Hip capsular thickness was measured at the proximal, middle, and distal site of the capsule. PROs and PROs at final follow-up were obtained, including visual analog scale (VAS) for pain and modified Harris Hip Score (mHHS).

Results

A total of 194 patients were included in this study. The mean MRI follow-up time was 14.3 (range, 6–37) months, and the mean clinical follow-up time was 26.1 (range, 12–43) months. Postoperative capsular thickness or net change were not correlated with postoperative PROs and VAS (P > .05). Capsular defect was observed in 17 (8.8%) patients. Patients with capsular defect had a relatively higher BMI (P < .05). Patients with capsular defect had a significant lower mHHS and higher VAS compared with patients with continuous capsule (P < .05). Ninety-one percentage of patients with continuous capsule surpassed minimal clinically important difference (MCID) and 80.8% achieved PASS, but only 58.8% of patients with capsular defect surpassed MCID and 47.1% achieved patient acceptable symptom state (PASS).

Conclusions

Postoperative capsular thickness may not have influence on the clinical outcomes of hip arthroscopy for treatment of FAI. Some capsule of patients who underwent arthroscopic interportal capsulotomy and repair could not heal. Postoperative capsular continuity had a great impact on the clinical outcomes of hip arthroscopy for FAI. Patients with higher BMI may be more likely to have capsule failure to heal.

Ultrasound Can Determine Joint Distraction During Hip Arthroscopy but Fluoroscopic-Guided Portal Placement Is Superior

Purpose

To compare joint distraction measured on ultrasound (US) with joint space width (JSW) measured on fluoroscopy in hip arthroscopy and to determine whether ultrasound guidance is as safe and effective as fluoroscopy, the current gold standard, for establishing arthroscopic portals.

Methods

Cadaveric whole-body specimens were positioned supine and subjected to 60 lbs. of unilateral axial traction using a distal femoral Steinman pin. Joint distraction was measured via JSW on fluoroscopic and ultrasound images. A single, fellowship-trained orthopaedic surgeon established anterolateral arthroscopy portals via ultrasound or fluoroscopic guidance in a randomized sequence. Total procedure time, number of times the spinal needle pierced the capsule, and iatrogenic chondral or labral injury were recorded.

Results

Twelve full-body specimens (20 hips) underwent distraction, and 17 hips underwent portal placement with fluoroscopic (n = 8) or ultrasound (n = 9) guidance. JSW measured on ultrasound was significantly less laterally (13.0 vs 9.2 mm, P < .001), apically (16.7 vs 9.2 mm, P < .001), and medially (17.9 vs 9.2 mm, P < .001). Successful portal entry was achieved in every specimen. Average procedure time was 133 ± 51 seconds for the fluoroscopy group and 371 ± 260 seconds for the ultrasound group (P = .026). Fluoroscopic guidance required significantly less needle insertion attempts at 1.13 compared with 3.33 attempts for ultrasound (P = .022). Labral damage was greater in the ultrasound group at 66.67% compared with 12.50% for fluoroscopy (P = .0497).

Conclusions

Joint distraction measured on ultrasound can be used to subjectively determine if the joint is adequately distracted in hip arthroscopy. Ultrasound-guided portal placement was associated with more needle insertion attempts, iatrogenic injury of the labrum, and overall procedure time in comparison to fluoroscopic guidance.

Clinical Relevance

Fluoroscopy is the gold standard to confirm adequate joint distraction, aid in establishing arthroscopy portals, and evaluate resection of the femoral head during hip arthroscopy but exposes the patient to ionizing radiation, requires additional operators in the operating room, and involves the need for a heavy lead shield. Alternatives to fluoroscopy are needed, but ultrasound has not proven superior in our cadaveric model.

Do the outcomes of hip arthroscopy for femoroacetabular impingement change over time?

BACKGROUND

The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up.

HYPOTHESIS

We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up.

PATIENTS AND METHODS

Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis.

RESULTS

Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25-37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75-91.25) and 85.8 (IQR 66.7-96.7) respectively (p<0.001). Medium-term survivorship was 91.2%. Survivorship following labral repair was 94.2%, and 81.3% following labral debridement (p=0.09).

DISCUSSION

Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up.

LEVEL OF EVIDENCE

IV, Case series.

Variations in postoperative electrolyte concentrations and influential factors in hip arthroscopy

BACKGROUND

Different from arthroscopy in other joints, more perfusion is required for a better access to perform surgical procedures in hip arthroscopic operations. The significant fluid perfused may lead to complications of partial tissue injury and electrolyte imbalance. However, there were few studies on the change of serum electrolyte after hip arthroscopy and the influential factors were still unknown.

METHODS

We evaluated consecutive patients who underwent hip arthroscopy in our hospital between October 2021 and February 2022. Age, sex, and BMI matched patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction at the same time were also included as the control group. Preoperative and postoperative serum electrolyte of sodium (Na +), potassium (K +), chloride (Cl-), magnesium (Mg2 +), and carbon dioxide capacity (CO2CP) were analyzed. The correlations between influential factors like perfusion volume, operating time, BMI and hip circumference, and changes in serum electrolyte were also analyzed.

RESULTS

A total of 79 patients were involved in this study, including 49 patients who underwent hip arthroscopy and 30 patients who underwent knee arthroscopy. For hip arthroscopy, decrease of potassium levels was observed in 40.8% of the patients, and postoperative hypokalemia was found in 10.2% patients. There were significant variations in postoperative sodium, magnesium, chloride and carbon dioxide capacity in hip arthroscopy (p < 0.05). No correlations were found between each of the electrolyte concentrations and influential factors like perfusion volume, operating time, BMI, sex and hip circumference. The significant variations were found in chloride and carbon dioxide capacity in knee arthroscopy (p < 0.05).

CONCLUSIONS

Hip arthroscopy would significantly influence postoperative serum electrolyte, and hypokalemia could be a postoperative complication. The correlation between serum electrolyte and fluid perfusion volume is remained to be investigated. We therefor advocate that performing a systematic care of preoperative and postoperative serum electrolyte analysis as perioperative management is necessary.

Outcomes and Survivorship at a Median of 8.9 Years Following Hip Arthroscopy in Adolescents with Femoroacetabular Impingement: A Matched Comparative Study with Adults

BACKGROUND

Because of the unique theoretical surgical risks, including osteonecrosis, acute iatrogenic slipped capital femoral epiphysis, and epiphyseal injury, the optimal treatment strategy for femoroacetabular impingement (FAI) in growing adolescents has yet to be established. The aim of this study was to compare the clinical outcomes of primary arthroscopic treatment of FAI in growing adolescents with a matched adult group.

METHODS

Patients with FAI who underwent arthroscopic treatment with a minimum follow-up of 2 years were included. Patients with previous ipsilateral hip surgery, an Outerbridge grade of ≥3, a preoperative Tönnis grade of ≥2, or evidence of dysplasia (lateral center-edge angle of <25°) were excluded. Eligible patients who were ≤19 years old and whose proximal femoral physis had not yet closed were matched to adult (20 to 40-year-old) counterparts in a 1:1 ratio by sex, body mass index, and time of surgery. For the adolescents, cam resection was performed with a physeal-sparing approach. Outcome scores, including the modified Harris hip score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and HOS-Sports-Specific Subscale (HOS-SSS), were prospectively collected.

RESULTS

Of the 196 eligible adolescents, 157 (80%) were pair-matched to adult controls, with a median postoperative follow-up of 8.9 and 6.6 years, respectively. Fourteen (9%) of the adolescents required revision hip arthroscopy compared with 18 adults (11%) (p = 0.46). No patient in the adolescent group had conversion to a total hip arthroplasty (THA), while 3 in the adult group had a THA (p = 0.25). For adolescents without subsequent hip surgery, the median mHHS improved from 59 preoperatively to 96 postoperatively; the HOS-ADL, from 71 to 98; and the HOS-SSS, from 44 to 94 (p < 0.001), which were significantly higher postoperative scores than those of the matched adults (p < 0.05) despite similar or inferior baseline scores. No complications were found during the office visit or at the final follow-up.

CONCLUSIONS

Hip arthroscopy performed with a physeal-sparing approach for FAI in growing adolescents is safe and effective and yields superior clinical outcomes compared with those in a matched adult group.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Return to Work After Primary Hip Arthroscopy: A Systematic Review and Meta-analysis

BACKGROUND

Hip arthroscopy is a procedure commonly performed to correct various hip pathologies such as femoroacetabular impingement and labral tears. These hip pathologies commonly affect young, otherwise healthy patients. The recovery after hip arthroscopy can prevent patients from returning to work and impair performance levels, having significant economic repercussions. To date, there has been no cumulative analysis of the existing literature on return to work after hip arthroscopy.

PURPOSE

The purpose of this study was to perform a systematic review of the existing literature regarding return to work after hip arthroscopy and analysis of factors associated with the ability to return to work and time to return to work.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature search of the MEDLINE, EMBASE, and Cochrane Library databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies assessing functional outcomes and return to work, including return to military duty, after hip arthroscopy were included. Patients' ability to return to work, as well as time to return, was compared between selected studies. Where available, workers' compensation status as well as type of work was compared. All statistical analysis was performed using SPSS, Version 22. P < .05 was considered statistically significant.

RESULTS

Twelve studies with 1124 patients were included. Patients were followed for an average of 17.6 months. Using weighted means, the average rate of return to work was 71.35%, while full return to previous work duties was achieved at a rate of 50.89%. Modification to work duties was required at a rate of 15.48%. On average, the time to return to work was 115 days (range, 17-219 days). Rate of return by patients with workers' compensation status was found to be 85.15% at an average of 132 days (range, 37-211 days). Rate of return to work in workers performing professions reported as strenuous vs light (ie, mostly sedentary) jobs showed a statistically higher return to work in light professions (risk ratio, 0.53; 95% CI, 0.41-0.69).

CONCLUSION

After hip arthroscopy, there is a high rate of return to work at an average of 115 days after surgery. However, full return to work was achieved by only half of patients upon final follow-up.

Midterm Outcomes After Hip Labral Augmentation in Revision Hip Arthroscopy

BACKGROUND

Labral augmentation has emerged as an essential procedure to address a deficient or irreparable labrum while preserving native labral tissue and restoring the hip suction seal mechanism.

PURPOSE

To evaluate midterm outcomes of arthroscopic hip labral augmentation for labral insufficiency after previous hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were identified from a prospectively collected database who underwent arthroscopic hip labral augmentation between January 2011 and January 2017 with a minimum 3-year follow-up. Pre- and postoperative patient-reported outcome scores were compared and included the 12-Item Short Form Health Survey physical and mental component summaries, Western Ontario and McMaster Universities Osteoarthritis Index, modified Harris Hip Score (mHHS), and Hip Outcome Score (HOS) (Activities of Daily Living [ADL] and Sport). Postoperative Tegner Activity Scale and patient satisfaction (1-10) scores were also evaluated. The minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) between the preoperative and minimum 3-year follow-up scores were calculated.

RESULTS

A total of 88 patients (39 men, 49 women) underwent revision hip arthroscopy with labral augmentation. The average age was 32.8 ± 11 years. Of these, 77 patients (88%) were available for the minimum 3-year follow-up. The survivorship (absence of conversion to total hip arthroplasty) at 3 years and 5 years was 93% at both time points, with a mean survival time of 8.5 years (95% CI, 8.0-8.9). Eleven patients (14%) required revision arthroscopic surgery for continued pain. Revisions occurred at a mean of 2.6 ± 1.4 years after augmentation. The mean follow-up was 5.2 ± 1.2 years (range, 3-9 years). For patients not requiring subsequent surgery (n = 61), all patient-reported outcome measures significantly improved, which included a 20-point increase in HOS-ADL (MCID, 82%; PASS, 72%) and mHHS (MCID, 78%; PASS, 70%). The median postoperative Tegner score was 4 (range, 1-10). The median postoperative patient satisfaction score was 9 out of 10 (range, 1-10).

CONCLUSION

Arthroscopic hip labral augmentation is a successful treatment option for patients with labral insufficiency after previous hip arthroscopy, demonstrating improved patient-reported outcomes and survivorship of 93% at 3 years and 5 years. This technique provides a valuable labral preservation option when addressing hip labral pathology when viable native labral tissue remains.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study

BACKGROUND

The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce.

PURPOSE

(1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score-Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI).

RESULTS

A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05).

CONCLUSION

Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Comparison of Acetabular Labral Reconstruction With 7-mm Tibialis Anterior Allograft and 5-mm Iliotibial Band Autograft at Minimum 2-Year Follow-up

BACKGROUND

Labral reconstruction has been described as a treatment option for irreparable labral tear. Labral graft size ranges from 5 to 7 mm² for reconstruction. A thicker labral graft could support mechanical stability and protect cartilage better. No study has compared the effect of graft thickness on clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare patient-reported outcomes between hips reconstructed with an autologous iliotibial band (AUITB; 5 mm²) graft and with an allogenic tibialis anterior (ALTA; 7 mm²) tendon graft. Our hypothesis was that hips reconstructed with a thicker allograft (7 mm²) would have better clinical outcomes than those with a smaller autograft (5 mm²).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 42 patients (aged 21 to 54 years) underwent arthroscopic hip segmental labral reconstruction during the study period of January 2016 to November 2018. Twenty patients had reconstruction with AUITB grafts (5 mm²) and 22 with ALTA grafts (7 mm²). Both groups had minimum 2 year follow-up. Patients were evaluated with patient-related outcome scores: modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific. Pain evaluation was performed using a visual analog scale.

RESULTS

There were significant differences in all studied variables when comparing pre- and postoperative scores. Yet, there were no differences in terms of patient-related outcome scores between the groups postoperatively. Postoperative visual analog scale scores averaged 2.1 for the AUITB group vs 1.9 for the ALTA group (P = .89); modified Harris Hip Score, 82.7 vs 83.3 (P = .77); Nonarthritic Hip Score, 81.1 vs 82.2 (P = .81); and Hip Outcome Score-Sports Specific, 81.6 vs 82.5 (P = .67).

CONCLUSION

No differences were found in terms of clinical outcomes between the 7-mm² ALTA graft and the 5-mm² AUITB graft. Both graft types and thicknesses might be considered comparable choices for primary reconstruction. Although a thicker-graft labral reconstruction seemed to have more ability to cover joint surface, clinical results did not show any superiority of a thicker graft whether it is autologous or allogenic.

Does labral treatment technique influence the outcome of FAI surgery? A matched-pair study of labral reconstruction versus repair and debridement with a follow-up of 10 years

The aim of this study was to analyze the long-term clinical outcomes of labral reconstruction in patients undergoing femoro-acetabular impingement (FAI) surgery and compare them with labral repair and debridement. This is a single-center, single-surgeon, retrospective match-paired study from a prospectively collected hip preservation database. All patients underwent a hip surgical dislocation for FAI surgery. Eight patients underwent labral reconstruction with the ligamentum teres and were matched on sex, age and body mass index with 24 labral repair and 24 labral debridement (1:3). Failure was defined as conversion to total hip replacement (THR) and patient-reported outcome measures (PROMs) were collected. Mean follow-up was 9.8 years ±2.6 (5.2–13.9). There was a significant improvement in postoperative PROMs in the three groups regarding the WOMAC total, WOMAC function, HOOS-QoL, HOOS-ADL and HOOS-SRA (P < 0.05). There was no statistical difference between the three groups regarding postoperative PROMs and change in PROMs (P > 0.05). A total of 10 hips underwent joint replacement surgery at a mean time of 7.9 ± 3.5 years (2.4–12). There was no statistically significant difference between the three groups regarding the conversion rate to THR (P = 0.64) or time between surgery and conversion to THR (P = 0.15). Compared to a match-pair group of labral repair and debridement, labral reconstruction with ligamentum teres provides similar survival with conversion to a THR as an endpoint, as well as similar improvement in PROMs. Labral treatment can be safely adapted at the nature of the labral lesion with a treatment ‘à la carte’.

Satisfaction, functional outcomes and predictors in hip arthroscopy: a cohort study

INTRODUCTION

Hip arthroscopy is not always successful, leading to high rates of total hip arthroplasty (THA) after arthroscopy. The aim of this study was to identify risk factors for THA, revision arthroscopy and low patient satisfaction and to compare outcomes of the different procedures of primary hip arthroscopy.

METHODS

A total of 91 primary hip arthroscopy procedures in 90 patients (66% female) were analysed. Data were gathered from patient files and a questionnaire was sent to patients including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), the EuroQol 5-dimension and questions about return to sports, satisfaction and pain before and after surgery. Using regression analyses, predictive factors for the outcomes were identified.

RESULTS

After a mean of 1.6 years, 4 patients (4%) underwent revision arthroscopy and 10 (11%) a THA. Of the responders (62%), 66% of the patients was satisfied to very satisfied about the surgery. Mean mHHS score was 75.3 (SE 1.9) and the mean WOMAC score was 81.0 (SE 2.8). Return to sports rate was 58%. A higher age was a significant predictor for lower satisfaction (p = 0.008) and a longer duration of symptoms was a significant predictor for worse mHHS outcome scores (p = 0.005).

CONCLUSION

A higher age is a predictor for a lower satisfaction and a longer duration of symptoms before surgery has a negative influence on functional outcome. No risk factors for THA or revision arthroscopy were found and there were no significant differences in outcome measurements between the performed surgeries.

How Does Chondrolabral Damage and Labral Repair Influence the Mechanics of the Hip in the Setting of Cam Morphology? A Finite-Element Modeling Study

BACKGROUND

Individuals with cam morphology are prone to chondrolabral injuries that may progress to osteoarthritis. The mechanical factors responsible for the initiation and progression of chondrolabral injuries in these individuals are not well understood. Additionally, although labral repair is commonly performed during surgical correction of cam morphology, the isolated mechanical effect of labral repair on the labrum and surrounding cartilage is unknown.

QUESTION/PURPOSES

Using a volunteer-specific finite-element analysis, we asked: (1) How does cam morphology create a deleterious mechanical environment for articular cartilage (as evaluated by shear stress, tensile strain, contact pressure, and fluid pressure) that could increase the risk of cartilage damage compared with a radiographically normal hip? (2) How does chondrolabral damage, specifically delamination, delamination with rupture of the chondrolabral junction, and the presence of a chondral defect, alter the mechanical environment around the damage? (3) How does labral repair affect the mechanical environment in the context of the aforementioned chondrolabral damage scenarios?

METHODS

The mechanical conditions of a representative hip with normal bony morphology (characterized by an alpha angle of 37°) and one with cam morphology (characterized by an alpha angle of 78°) were evaluated using finite-element models that included volunteer-specific anatomy and kinematics. The bone, cartilage, and labrum geometry for the hip models were collected from two volunteers matched by age (25 years with cam morphology and 23 years with normal morphology), BMI (both 24 kg/m2), and sex (both male). Volunteer-specific kinematics for gait were used to drive the finite-element models in combination with joint reaction forces. Constitutive material models were assigned to the cartilage and labrum, which simulate a physiologically realistic material response, including the time-dependent response from fluid flow through the cartilage, and spatially varied response from collagen fibril reinforcement. For the cam hip, three models were created to represent chondrolabral damage conditions: (1) "delamination," with the acetabular cartilage separated from the bone in one region; (2) "delamination with chondrolabral junction (CLJ) rupture," which includes separation of the cartilage from the labrum tissue; and (3) a full-thickness chondral defect, referred to throughout as "defect," where the acetabular cartilage has degraded so there is a void. Each of the three conditions was modeled with a labral tear and with the labrum repaired. The size and location of the damage conditions simulated in the cartilage and labrum were attained from reported clinical prevalence of the location of these injuries. For each damage condition, the contact area, contact pressure, tensile strain, shear stress, and fluid pressure were predicted during gait and compared.

RESULTS

The cartilage in the hip with cam morphology experienced higher stresses and strains than the normal hip. The peak level of tensile strain (25%) and shear stress (11 MPa) experienced by the cam hip may exceed stable conditions and initiate damage or degradation. The cam hip with simulated damage experienced more evenly distributed contact pressure than the intact cam hip, as well as decreased tensile strain, shear stress, and fluid pressure. The peak levels of tensile strain (15% to 16%) and shear stress (2.5 to 2.7 MPa) for cam hips with simulated damage may be at stable magnitudes. Labral repair only marginally affected the overall stress and strain within the cartilage, but it increased local tensile strain in the cartilage near the chondrolabral junction in the hip with delamination and increased the peak tensile strain and shear stress on the labrum.

CONCLUSION

This finite-element modeling pilot study suggests that cam morphology may predispose hip articular cartilage to injury because of high shear stress; however, the presence of simulated damage distributed the loading more evenly and the magnitude of stress and strain decreased throughout the cartilage. The locations of the peak values also shifted posteriorly. Additionally, in hips with cam morphology, isolated labral repair in the hip with a delamination injury increased localized strain in the cartilage near the chondrolabral junction.

CLINICAL RELEVANCE

In a hip with cam morphology, labral repair alone may not protect the cartilage from damage because of mechanical overload during the low-flexion, weightbearing positions experienced during gait. The predicted findings of redistribution of stress and strain from damage in the cam hip may, in some cases, relieve disposition to damage progression. Additional studies should include volunteers with varied acetabular morphology, such as borderline dysplasia with cam morphology or pincer deformity, to analyze the effect on the conclusions presented in the current study. Further, future studies should evaluate the combined effects of osteochondroplasty and chondrolabral treatment.

Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.

PURPOSE

To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.

RESULTS

Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

CONCLUSION

Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports

BACKGROUND

Athletes who compete in flexibility sports (FS) place unique demands on their hip joints because of the supraphysiologic range of motion required.

PURPOSE

To compare the pathologic features, outcomes, and return-to-sports (RTS) rates of high-level athletes participating in FS who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear against a propensity score-matched cohort of high-level athletes participating in non-flexibility sports (NFS).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high-level athletes who underwent primary hip arthroscopy for FAIS from April 2008 to December 2018. Patients who participated in FS such as dancing, gymnastics, martial arts, figure skating, and cheerleading were propensity score matched by body mass index, age at time of surgery, sex, sports competition level, and labral treatment to a cohort of high-level athletes participating in all other sports, such as distance running, soccer, volleyball, and softball. Baseline patient characteristics, intraoperative findings, and surgical procedures were compared. Minimum 2-year patient-reported outcome measures were compared for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain and satisfaction. Rates of secondary surgery and RTS were compared.

RESULTS

A total of 47 patients (50 hips) who participated in FS were included and propensity score matched to 130 patients (150 hips) who participated in NFS. Follow-up time was 37.5 ± 10.4 months (mean ± SD). Most patients (96.0%) were female with a mean age of 19.5 ± 7.3 years. FS athletes had significantly higher rates of femoral head cartilage lesions (Outerbridge ≥2; 12.0% vs 2.0%; P = .008) and ligamentum teres tears (48% vs 26%; P = .003). FS and NFS athletes demonstrated significant clinical improvements after surgery for all patient-reported outcome measures. Of the patients who attempted, 34 (75.6%) participating in FS were able to RTS while 11 (24.4%) were not because of ongoing hip issues. This was not significantly different than the NFS group (P = .073).

CONCLUSION

High-level athletes who participated in FS and were treated for FAIS with hip arthroscopy exhibited higher rates of femoral head cartilage lesions and ligamentum teres tears requiring debridement when compared with a benchmark group of athletes who participated in other sports. Despite this, both groups demonstrated similar improvements in outcome scores and comparable rates of RTS at minimum 2-year follow-up.

Arthroscopic Debridement Versus Refixation of the Acetabular Labrum Associated With Femoroacetabular Impingement: Updated Mean 7-Year Follow-up

BACKGROUND

Short- and midterm follow-up studies suggest that arthroscopic labral refixation/preservation leads to superior outcomes compared with labral excision/debridement.

PURPOSE

To update the previous early (16 months) and midterm (mean, 42 months) follow-up of this cohort, which reported better patient-reported outcome measures and lower failure rates in the repair/refixation group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors identified patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. A consecutive group of patients within the labral debridement group thought to be repairable with the authors' current arthroscopic techniques were compared with a group of consecutive patients who underwent labral repair/refixation. In 46 hips, the labrum was focally excised/debrided consistent with pincer- or combined pincer- and cam-type impingement; in 54 hips, the labrum was repaired/refixed. Subjective outcomes were measured with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) for pain preoperatively and postoperatively.

RESULTS

The mean age was 34.0 years in the debridement group and 28.3 years in the repair/refixation group, with a mean follow-up of 7.3 years (range, 2-13.6 years). At the mean follow-up of 7.3 years, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The mHHS (P = .008), SF-12 score (P = .012), and VAS pain score (P = .002) were all significantly better for the repair/refixation group compared with the debridement group. Although most recent outcomes for both groups fell slightly at the mean follow-up of 7.3 years in comparison with the 16-month and 3.5-year follow-ups, these differences were not significant. However, the failure rate in the debridement group did get significantly worse (P = .014). Good to excellent results were 47.7% in the debridement group and 86.3% in the refixation group (P < .001), and failure rates were 30.4% (debridement) and 13% (refixation) (P = .033). There were 4 revisions in the debridement group and 3 revisions in the refixation group.

CONCLUSION

Longer term, >7-year follow-up comparing focal labral excision/debridement with repair/refixation revealed better patient-reported outcomes and lower failure rates in the labral repair/refixation cohort. Additionally, despite an absolute decrease in patient-related outcome scoring and number of good/excellent results in both groups compared with the 3.5-year report, there was a significantly greater increase in failure rates over time for the excision/debridement group with better maintenance of good to excellent results in the repair/refixation group.

Ten-Year Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement and Borderline Dysplasia

BACKGROUND

The role of hip arthroscopy in the treatment of patients with borderline hip dysplasia is controversial and evolving.

PURPOSE

To evaluate outcomes at a minimum 10-year follow-up in patients who underwent hip arthroscopy for femoroacetabular impingement in a hip with borderline dysplasia.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All hips that underwent labral repair between June 2006 and March 2009 for femoroacetabular impingement with borderline dysplasia were included if they had a lateral center-edge angle of 20° to 25°, had primary hip arthroscopy for the diagnosis of femoroacetabular impingement, and were aged 18 to 70 years. Patients were excluded if they had previous hip surgery, avascular necrosis, or fracture. Kaplan-Meier survivorship was performed, with survivorship defined as avoidance of conversion to total hip arthroplasty (THA).

RESULTS

A total of 45 patients met the inclusion criteria, and 38 were contacted at a minimum 10 years postoperatively (84%; mean ± SD, 12 ± 1.3 years). There were 23 women and 15 men with an average age of 41 ± 9.6 years (range, 25-69). Twenty patients were ≥40 years of age. In this patient cohort, survivorship was 87% at 5 years and 79% at 10 years for conversion to THA. Of the 38 patients included, 9 were converted to THA (24%), and 3 required revision hip arthroscopy (7%). Patient age, Tönnis grade, microfracture of cartilage lesions, and Tönnis angle >15° were associated with conversion to THA. No statistically significant differences were found between those who underwent conversion to THA and those who did not regarding lateral center-edge angle, Sharp angle, or alpha angle. Significant improvements were seen at follow-up of 12 years (range, 10-13) for the modified Harris Hip Score (58 to 83; P = .002), Hip Outcome Score-Activities of Daily Living (70 to 87; P = .003), Hip Outcome Score-Sport (47 to 76; P = .004), and Western Ontario and McMaster Universities Osteoarthritis Index (31 to 10; P = .001). At follow-up, >80% maintained the minimal clinically important difference for the Hip Outcome Score (Activities of Daily Living and Sport) with no differences between patients aged <40 and ≥40 years.

CONCLUSION

Risk factors for conversion to THA after hip arthroscopy in the borderline dysplastic hip included older age, higher Tönnis grades, grade 4 chondral lesions that were microfractures, and Tönnis angle >15°. In those patients who did not convert to THA, improvement in outcome measures was seen at 10 years. Careful patient selection is critical to the success of this procedure.

Arthroscopic acetabular labrum suture

It is essential to be aware of the anatomy and biomechanics of the acetabular labrum in order to understand why it should be conserved. Vascularization comes from the capsule and also from the bone. The joint side contains numerous nerve endings, which explains why labral lesions are painful. It is involved in joint stabilization by maintaining a negative pressure inside the joint able to resist distraction. It acts as a seal. There are two main suture techniques: trans- and peri-labral. Translabral suture is better suited to a wide and solid labrum free of degenerative lesions. Both techniques should be known, and may be associated. Results are comparable. It is essential to manage the underlying pathology responsible for the labral lesion. Joint degeneration is associated with poor prognosis. It needs to be recognized and discussed with the patient, to avoid unrealistic expectations.

Comparable Minimum 2-Year Patient-Reported Outcome Scores Between Circumferential and Segmental Labral Reconstruction for the Management of Irreparable Labral Tear and Femoroacetabular Impingement Syndrome in the Primary Setting: A Propensity-Matched Study

PURPOSE

To compare minimum 2-year follow-up patient-reported outcome scores (PROs) in patients who underwent primary acetabular circumferential and segmental labral reconstruction for irreparable labral tears and femoroacetabular impingement syndrome (FAIS).

METHODS

Data were reviewed from August 2010 to December 2017. Patients with primary labral reconstruction and minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Circumferential and segmental reconstruction were selected in each case based on the extent of the labral pathology. Exclusion criteria were previous ipsilateral hip surgery/conditions, dysplasia, or Tönnis grade >1. Patients were propensity matched 1:1 based on age, sex, and body mass index. Secondary surgeries were reported. The P value was set at <.05.

RESULTS

In total, 144 hips were eligible, and 17 hips were lost to follow-up, leaving 127 hips (88.2%) for analysis. Eighty hips underwent a segmental reconstruction, and 47 hips underwent a circumferential reconstruction. Forty-seven hips with circumferential reconstruction were matched to 47 hips with segmental reconstruction. The average follow-up and age for the segmental and circumferential groups were 29.0 ± 7.8 and 27.9 ± 7.0 months (P = .732) and 43.1 ± 9.4 and 44.7 ± 10.2 years (P = .442) respectively. The segmental and circumferential groups were 48.9% and 51.1% female, respectively. The groups achieved significant and comparable improvement for all PROs and rates of secondary surgeries. No differences were found for achieving the minimal clinically important difference (MCID) and the patient acceptable symptomatic state (PASS). The MCIDs for the segmental and circumferential groups were 76.7% and 77.8% for the mHHS, 64.9% and 77.8% for the HOS-SSS, 71.1% and 68.9% for the VAS, and 68.9% and 73.9% for the NAHS, respectively. The PASSs for the segmental and circumferential groups were 78.3% and 73.3% for the mHHS, 55.3% and 55.0% for the HOS-SSS, and 75.6% and 71.1% for the International Hip Outcome Tool 12, respectively.

CONCLUSIONS

At minimum 2-year follow-up, patients who underwent primary hip arthroscopy for either circumferential or segmental labral reconstruction for irreparable labra and FAIS reported significant improvement and similar postoperative scores for all PROs, with no difference in psychometric outcomes and rate of secondary surgeries. A customized approach, using the extent of the irreparable labral tear, seems to be an appropriate strategy.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

High prevalence of acetabular rim osteophytes after hip arthroscopy for treatment of FAI

Background

Few studies mentioned acetabular rim osteophytes (ARO) after arthroscopy for femoroacetabular impingement (FAI) in follow-up after primary hip arthroscopy. We found that many patients had postoperative ARO, which may lead to recurrent or secondary pincer-type deformity after primary hip arthroscopy for FAI and postoperative ARO sometimes even led to revision surgery. It is necessary to carry out related research on ARO.

Methods

We respectively evaluated consecutive cases who underwent hip arthroscopy in our hospital between January 2008 and January 2020. Radiographic examination was obtained for all patients preoperatively and postoperatively. Another CT scan was performed at least 6 months after surgery at final follow-up. Preoperative patient-reported outcomes (PROs) and PROs at final follow-up were obtained, including visual analog scale (VAS) for pain and modified Harris Hip Score (mHHS). The volume of ARO was calculated using mimics 21.0 software. According to the material of anchors and whether the anchors were used, patients were divided into absorbable group, non-absorbable group and no anchor group.

Results

A total of 71 patients were finally included in this study. Patients with postoperative ARO had higher VAS at final follow-up (P<0.05). Patients without postoperative ARO had higher mean mHHS at final follow-up (P = 0.08) and higher percentage of passing minimal clinical important difference. The percentage and volume of postoperative ARO was significantly higher in patients who underwent acetabuloplasty and labral repair (P<0.05). The percentage and volume of postoperative ARO in absorbable group were significantly higher than the other groups (P<0.05).

Conclusion

There is a high percentage of ARO after hip arthroscopy for treatment of FAI and patients who have undergone labral repair and acetabuloplasty are more likely to have postoperative ARO. Using of absorbable anchors may increase the possibility and volume of postoperative ARO. Postoperative ARO may predict a worse clinical outcome.

The Erector Spinae Plane Block in the Setting of Hip Arthroscopy: A Prospective Randomized Controlled Clinical Trial

PURPOSE

To investigate whether the use of an erector spinae plane block (ESPB) would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine the amount of additional opioids and postoperative nausea and vomiting (PONV).

METHODS

From October 2019 to October 2020, 68 patients undergoing arthroscopic therapy for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided ESPB preoperatively with 30 mL of 0.375% ropivacaine and standard postoperative oral medication. The second group received a sham block preoperatively with 30 mL of 0.9% saline and standard postoperative oral medication. The primary endpoint was pain scores (numeric pain score out of 10) during the first 24 hours postoperatively. Secondary outcomes were opioid consumption during the first 24 hours (converted to morphine equivalents) and the incidence of PONV. Demographic and clinical characteristics were recorded for all patients. Categorial data were compared with chi-squared and Fisher's exact tests. Continuous data were compared with 2-sided t tests and Wilcoxon rank-sum tests.

RESULTS

Sixty-eight subjects consented and were successfully randomized. Reported postoperative pain was significantly lower in the ESPB group than in the control group during the first 24 hours. The opioid amount (P = .865) and postoperative nausea (P = .642) did not differ significantly between groups. No associated complications such as falls, hematomas, or muscular weakness occurred in either group.

CONCLUSION

This study demonstrates that ESPB significantly decreases pain in the first 24 hours after arthroscopic therapy for FAIS. However, there was no evidence of lower opioid consumption compared with the control group. Overall, a low and comparable rate of PONV was present. Therefore, the ESPB seems to complement a multimodal approach to perioperative pain management in hip arthroscopy.

LEVEL OF EVIDENCE

1, randomized controlled trial.

Survivorship Rate and Clinical Outcomes 10 Years After Arthroscopic Correction of Symptomatic Femoroacetabular Impingement

BACKGROUND

Femoroacetabular impingement (FAI) is a common mechanical hip condition, prevalent in both the athletic and the general population. Surgical intervention is an effective treatment option that improves both symptoms and function in short- to medium-term follow-up. Few studies within the literature have reported the longer-term success of arthroscopic surgery.

PURPOSE

The aim of this study was to quantify the 10-year survivorship and clinical outcome for patients treated arthroscopically for symptomatic FAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients from our hip registry (n = 119) completed patient-reported outcome measures (PROMs) including the modified Harris Hip Score (mHHS), University of California Los Angeles (UCLA) activity scale, 36-Item Short Form Health Survey (SF-36), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at a minimum of 10 years after arthroscopy (range, 10-12 years). Results were compared with baseline scores using the Wilcoxon signed rank test. The associations among several prognostic factors, which included age, sex, Tönnis grade, and labral treatment, and subsequent conversion to total hip replacement (THR) or repeat hip arthroscopy (RHA) were analyzed using the chi-square analysis. Relationships between range of motion and radiological findings with clinical outcome were also examined using Pearson correlation analysis. Minimal clinically important difference (MCID) was calculated using a distribution method (0.5 standard deviation of the change score), and substantial clinical benefit (SCB) was determined using an anchor method. Finally, receiver operating characteristic curves with subsequent Youden index were used to determine cutoffs for PROMs, which equated to a Patient Acceptable Symptom State (PASS).

RESULTS

A total of 8.4% of cases required conversion to THR, and 5.9% required RHA. Statistically significant improvements in mHHS, SF-36, and WOMAC scores, with high satisfaction (90%), were observed 10 years after surgery. No significant change was seen in activity level (UCLA score) despite patients being 10 years older. A high percentage of patients achieved MCID for mHHS (88%), SF-36 (84%), and WOMAC (60%). The majority of patients also achieved PASS (62% for mHHS, 85% for UCLA, 78% for SF-36, and 84% for WOMAC) and SCB (74% for mHHS, 58% for UCLA, 52% for SF-36, and 56% for WOMAC).

CONCLUSION

Arthroscopic intervention is a safe and viable treatment option for patients with symptomatic FAI, and patients can expect long-term improvements and high satisfaction. Results indicated a high satisfaction (90%) and survivorship rate (91.6%), with excellent clinical outcome, 10 years after the initial procedure.

Cotyloid Fossa Coverage Percentages May Be Associated With Alpha Angle, Labral Tear, and Clinical Outcomes in Patients With Femoroacetabular Impingement

BACKGROUND

Within the hip joint, the anatomy of the acetabulum and cotyloid fossa is well established. There is little literature describing the association between the size of the cotyloid fossa relative to the acetabulum and characteristics of patients with femoroacetabular impingement (FAI).

PURPOSE/HYPOTHESIS

The purpose was to calculate the cotyloid fossa coverage percentage in the acetabulum and determine its association with patient characteristics, radiographic parameters, intra-articular findings, and preoperative patient-reported outcomes in patients with FAI. We hypothesized there is an association between the cotyloid fossa coverage percentage of the acetabulum and characteristics of patients with FAI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were included who underwent standard clinical 3-T magnetic resonance imaging of the hip and primary arthroscopic FAI correction surgery during 2015 and 2016. Exclusion criteria were age <18 or >40 years, osteoarthritis, labral reconstruction, previous ipsilateral hip surgery, and hip dysplasia. Measurements of the cotyloid fossa and surrounding lunate cartilage were performed to calculate cotyloid fossa width (CFW) and cotyloid fossa height (CFH) coverage percentages. The relationships between coverage percentages and patient characteristics and intraoperative findings were assessed using independent t tests or Pearson correlations.

RESULTS

An overall 146 patients were included. Alpha angle negatively correlated with CFH coverage percentage (r = -0.19; P = .03) and positively correlated with labral tear size (r = 0.28; P < .01). CFH coverage percentage was negatively correlated with labral tear size (r = -0.24; P < .01). Among patients with degenerative tears, CFH was negatively correlated with labral tear size (r = -0.31; P < .01). However, this association was no longer significant after adjusting for sex (partial r = -0.10; P = .39). Cotyloid fossa coverage was not associated with the condition of the cotyloid fossa synovium (synovitis vs no synovitis). CFW coverage percentage was negatively correlated with the 12-Item Short Form Health Survey (SF-12) physical component summary score (r = -0.23; P < .01).

CONCLUSION

The CFW and CFH coverage percentages may be associated with alpha angle, labral tear size, and SF-12 physical component summary score in patients with FAI. We may be able to predict the labral condition based on preoperative measurements of CFH and CFW coverage percentages.

Treatment of Full-Thickness Acetabular Chondral Flaps During Hip Arthroscopy: Bone Marrow Aspirate Concentrate Versus Microfracture

Background:

The optimal treatment strategy for patients with full-thickness chondral flaps undergoing hip arthroscopy is controversial.

Purpose:

To compare functional outcomes of patients who underwent bone marrow aspirate concentrate (BMAC) application with those of patients who underwent microfracture.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This was a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by 1 surgeon between June 2014 and April 2020. The inclusion criteria for this study were age ≥18 years, preoperative radiographs of the pelvis, arthroscopic acetabular labral repair, exposed subchondral bone with overlying chondral flap seen at the time of hip arthroscopy, microfracture or BMAC to address this lesion, and completed patient-reported outcome measures (PROMs) (International Hip Outcome Tool–33 [iHOT-33], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports Subscale [HOS-Sport], modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) at enrollment and 12-month follow-up. Clinical outcomes were assessed using PROM scores.

Results:

A total of 81 hips with full-thickness chondral flaps were included in this study: 50 treated with BMAC and 31 treated with microfracture. There were no significant differences between groups in age, sex, body mass index, tear size, radiographic osteoarthritis, or radiographic femoroacetabular impingement. In the BMAC cohort, all PROM scores improved significantly from preoperatively to follow-up: 41.7 to 75.6 for iHOT-33, 67.6 to 91.0 for HOS-ADL, 41.5 to 72.3 for HOS-Sport, 59.4 to 87.2 for mHHS, and 6.2 to 2.2 for VAS pain (P < .001 for all). In the microfracture cohort, the score improvements were 48.0 to 65.1 for iHOT-33 (P = .001), 80.5 to 83.3 for HOS-ADL (P = .275), 59.2 to 62.4 for HOS-Sport (P = .568), 70.4 to 78.3 for mHHS (P = .028), and 4.9 to 3.6 for VAS pain (P = .036). Regarding clinically meaningful outcomes, 77.6% of the BMAC group and 50.0% of the microfracture group met the minimal clinically important difference for iHOT-33 at the 12-month follow-up (P = .013).

Conclusion:

Patients with full-thickness chondral flaps at the time of hip arthroscopy experienced greater improvements in functional outcome scores at the 12-month follow-up when treated with BMAC as opposed to microfracture.

Favorable Outcomes of Revision Hip Arthroscopy Irrespective of Whether Index Surgery was Performed by the Same Surgeon or a Different Surgeon

The purpose of this study was to compare minimum 2-year patient-reported outcomes (PROMs) after revision hip arthroscopy between two different patient cohorts who had undergone primary hip arthroscopy with the same surgeon (SS) and a different surgeon (DS). We hypothesized no difference in clinical outcomes between the groups despite differences in intraoperative findings based on the surgical decision making in a revision setting at a high-volume center.

Three-Dimensional Measures of Bony Resection During Femoral Osteochondroplasty Are Related to Alpha Angle Measures: A Cadaveric Study

Purpose

Methods

Results

Conclusions

Clinical Relevance

Improved Functional Outcome Scores Associated with Greater Reduction in Cam Height Using the Femoroacetabular Impingement Resection Arc During Hip Arthroscopy

PURPOSE

We sought to evaluate the association between postoperative cam lesion measured by the femoroacetabular impingement resection (FAIR) arc and show 2-year patient outcomes following hip arthroscopy.

METHODS

A retrospective review of prospectively gathered data from 2013-2017 was performed. All patients who underwent hip arthroscopy for femoroacetabular impingement resection (FAI) with ≥2-year follow-up were included. Cam FAIR arc measurements were made preoperatively and postoperatively on a 45° Dunn view radiograph. The clinical effect of postoperative cam maximal radial distance (MRD) was assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were divided into subgroups based on relationship to the mean and standard deviations for cam MRD. One half standard deviation above the mean was found to be 3.15 mm.

RESULTS

Sixty-one hips in 59 consecutive patients (age 38.1 ± 13.1; body mass index [BMI]: 25.5 ± 4.3; 36 females) were included. Mean preoperative and postoperative cam maximal radial distances (MRD) were 4.5 ± 1.7 mm and 2.3 ± 1.7 mm (P < .001), respectively. The interclass correlation coefficient was excellent (>.9) for all measurements. There were no differences in age, sex, BMI or preoperative mHHS/NAHS between <3.15 mm and >3.15 mm cam MRD groups (P > .05). Using linear regression, cam MRD was found to be significantly associated with 2-year outcomes for both mHHS (R² = .21, P < .001) and NAHS (R² = .004). Subgroup analysis demonstrated that patients in the cam MRD < 3.15 mm group had significantly higher mHHS (89.7 vs 70.0, P < .001) and NAHS scores (90.5 vs 72.9, P < .001) than those in the >3.15 mm group. Additionally, more patients in the <3.15 mm group reached the minimal clinically important difference (95.2% vs 78.9%, P = .048) and were above patient acceptable symptomatic state (95.2% vs 52.6%, P < .001) compared to the >3.15 mm group.

CONCLUSION

Patients with a lower postoperative cam MRD relative to the FAIR arc demonstrated significantly improved outcomes as compared to those with higher postoperative MRD at two-year follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

One Bony Morphology, Two Pathologic Entities: Sex-Based Differences in Patients With Borderline Hip Dysplasia Undergoing Hip Arthroscopy

BACKGROUND

Sex-based differences have been largely uncharacterized for patients with borderline hip dysplasia (BHD) undergoing hip arthroscopy.

PURPOSE

To evaluate for sex-based differences in clinical and pathologic characteristics as well as surgical outcomes in patients with BHD undergoing hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2011 and December 2018, data were prospectively collected on all patients with BHD undergoing primary hip arthroscopy. Patients were included if they had preoperative and minimum 2-year postoperative scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain. Patients with previous ipsilateral hip conditions or surgery, Tönnis grade >1, lateral center-edge angle <18° or >25°, or workers' compensation status were excluded. Patients were then divided by sex and propensity score matched in a 1:1 ratio for body mass index, age, and Tönnis grade. The rates of patients who achieved the minimal clinically important difference were recorded for the mHHS and NAHS. The rates of achieving the patient acceptable symptomatic state for the mHHS were calculated.

RESULTS

A total of 344 hips met the inclusion criteria, and 317 hips (92%) had adequate follow-up. Propensity score matching created cohorts of 109 male and 109 female patients. Male patients had significantly higher preoperative average alpha angles (69.79° vs 58.17°, P < .001), more often requiring a femoroplasty (97.2% vs 83.5%, P < .001), and had higher rates of complex labral tearing (50.5% vs 33.0%, P < .001). Male patients also had higher rates of grade 3 and 4 acetabular labral articular disruption (62.4% vs 19.3%, P < .001) and higher rates of grade 3 and 4 acetabular cartilage injury (59.6% vs 20.2%, P < .001) requiring a microfracture more frequently (32.1% vs 7.3%, P < .001). Female patients more typically had painful internal snapping requiring iliopsoas fractional lengthening (60.6% vs 32.1%, P < .001). Female patients also underwent capsular plication more regularly to address hip instability (79.8% vs 45.9%, P < .001). Male and female patients showed significant improvements in all outcome scores after surgery (P < .001). Female patients achieved the minimal clinically important difference for the NAHS at higher rates (85.3% vs 71.6%, P = .020).

CONCLUSION

Female and male patients with BHD who underwent hip arthroscopy achieved favorable outcomes but had notably dissimilar pathology. Hence, although they share similar acetabular bony morphology, male and female patients with BHD may represent 2 very different pathologic entities.

Preoperative Dynamic Hip Examination Under Fluoroscopic Guidance Enhances the Understanding of Femoroacetabular Impingement Pathology and Treatment Planning

Purpose

To review the relative accuracy of preoperative magnetic resonance imaging (MRI) and fluoroscopically guided examination-under-sedation (EUS) findings and to explore the validity of the anterior acetabular sector angle (AASA) as a radiologic MRI-based marker of anterior acetabular coverage in pincer-type impingement.

Methods

A cohort of 150 consecutive patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) in 2018 to 2019 was reviewed. The inclusion criteria were pure FAI unilateral symptomatic pathology and the availability of complete data sets (MRI, EUS, and intraoperative records). Preoperative MRI and EUS findings were compared with gold-standard intraoperative arthroscopic findings, specifically evaluating the alpha angle in the presence of cam lesions, AASA in the presence of pincer lesions, as well as soft-tissue lesions. An alpha angle greater than 50° and an AASA greater than 65° were deemed pathologic.

Results

The patient cohort included 78 women and 72 men with an average age of 38 years (range, 18-53 years). Intraoperatively, pincer lesions were present in 20% of patients; cam lesions, 26%; and mixed impingement, 54%. MRI versus EUS correctly identified pincer lesions in 36% versus 89% of cases and identified cam lesions in 44% versus 77% of cases. MRI findings characterizing labral tears and articular cartilage pathology were accurate in 80% and 10% of cases, respectively. Although there was no difference in the AASA between pure pincer- and mixed-type impingements (62° and 63°, respectively; P = .62), there was a statistically significant difference in reported AASA values between pure cam-type impingement and impingement involving the presence of pincer lesions (57° and 63°, respectively; P = .03). Furthermore, 31% of patients with intraoperatively identified pincer lesions had an AASA of 60° to 65°.

Conclusions

Fluoroscopic EUS is accurate in characterizing FAI pathology. In addition, MRI is useful to diagnose or rule out non-FAI pathology, ascertain labral pathology, and outline hip alignment. These methods of preoperative planning are complementary.

Level of Evidence

Level IV, therapeutic case series.

Labral Tear Management in Patients Aged 40 Years and Older Undergoing Primary Hip Arthroscopy: A Propensity-Matched Case-Control Study With Minimum 2-Year Follow-up

BACKGROUND

Previous literature has suggested that primary acetabular labral reconstruction leads to lower secondary surgery rates than does labral repair for patients aged ≥40 years.

PURPOSE

To report minimum 2-year patient-reported outcome (PRO) scores, survivorship, and secondary surgeries in patients aged ≥40 years who underwent primary hip arthroscopy with labral reconstruction compared with a propensity-matched primary labral repair group.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent a primary hip arthroscopy for femoroacetabular impingement syndrome between January 2014 and June 2018. Patients aged ≥40 years who underwent a labral reconstruction or a labral repair and had preoperative and minimum 2-year PROs for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS) for pain were included. Patients with previous ipsilateral hip conditions and surgery, Tönnis grade >1, hip dysplasia, or workers' compensation status were excluded. Patients in the reconstruction group were propensity matched 1:2 to patients in the repair group based on age, sex, and body mass index. Secondary surgeries and achievement of the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and maximum outcome improvement (MOI) were recorded.

RESULTS

A total of 53 and 106 hips were included in the labral reconstruction and repair groups, respectively. The average follow-up time was 37.6 months. The average ages for the reconstruction and repair groups were 48.01 ± 5.4 years and 48.61 ± 6.0 years, respectively. Both groups achieved significant improvements in all PROs at a minimum of 2 years, with similar achievements of MCID, PASS, and MOI, and comparable secondary surgery rates.

CONCLUSION

Patients aged ≥40 years who received primary labral repair and primary labral reconstruction achieved similar significant improvements in all PROs, VAS pain, and patient satisfaction at the minimum 2-year follow-up, with comparable rates of secondary surgeries and achieving MCID, PASS, and MOI. Based on these findings, labral repair remains the gold standard treatment for viable labrum in this population group, while reconstruction is a useful alternative for irreparable labrum.

Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure

Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair.

In search of labral restoration function with hip arthroscopy: outcomes of hip labral reconstruction versus labral repair: a systematic review

PURPOSE

To perform a systematic review comparing patient-reported outcomes (PROs) in patients who underwent hip arthroscopy with labral repair versus labral reconstruction in the setting of femoroacetabular impingement syndrome (FAIS) and labral tears.

METHODS

A systematic review of the PubMed, Embase, and Cochrane databases was performed in May 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Articles were included in the analysis if they compared PROs between a labral repair and labral reconstruction cohort. For all PROs, the standardised mean difference (SMD) was calculated to compare the effect size of labral repair and labral reconstruction.

RESULTS

10 comparative studies, with 582 reconstruction cases and 631 repair cases, were included in this analysis. The mean age for the reconstruction and the repair groups ranged from 27.0 years to 52.6 years and 27.5 years to 47.0 years, respectively. The mean follow-up for the reconstruction and the repair groups ranged from 24.0 months to 66.0 months and 24.0 months to 71.0 months, respectively. The modified Harris Hip Scores (mHHS) was favourable in 8 reconstruction studies (range 80.4-95.0) and 9 repair studies (range 84.1-93.0). Average NAHS scores for the repair and reconstruction cohorts ranged from 77.9-88.6 and 73.9-92.4, respectively. Additionally, the effect sizes regarding NAHS and mHHS scores were large (SMD > 0.8) in both the reconstruction and repair groups for the majority of studies. Finally, reconstruction patients underwent a subsequent total hip arthroplasty (THA) at a slightly higher rate.

CONCLUSIONS

In the setting of FAIS and labral tears, patients who underwent hip arthroscopy may expect significant improvement in PROs at short-term follow-up with either labral repair or labral reconstruction. Although, not statistically significant, the repair group trended towards higher scores and exhibited a lower risk of conversion to THA.

Isolated Acetabuloplasty for Femoroacetabular Impingement: Favorable Patient-Reported Outcomes and Sustained Survivorship at Minimum 5-Year Follow-Up

PURPOSE

To evaluate minimum 5-year outcomes and conversion rate to total hip arthroplasty (THA) for the treatment of femoroacetabular impingement (FAI) syndrome with an isolated acetabular osteoplasty.

METHODS

Patients undergoing hip arthroscopy with an isolated acetabular osteoplasty from March 2009 to June 2014 for FAI syndrome with pincer and/or cam morphology and a labral tear were identified. Those who underwent femoroplasty or prior ipsilateral hip surgery or who had previous hip conditions, ipsilateral hip dysplasia, or a Tönnis grade higher than 2 were excluded. Patient-reported outcomes (PROs) collected included Patient-Reported Outcomes Measurement Information System (PROMIS) scores specific to physical functioning and pain interference, modified Harris Hip Score, International Hip Outcome Tool 12, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, and Numeric Pain Rating Scale. Patients were also queried about secondary surgical procedures and conversion to THA.

RESULTS

We identified 86 patients at minimum 5-year follow-up (average, 7.4 years). The average patient age was 39.8 ± 12.3 years, 70.9% of patients were female, and 7% of patients had Tönnis grade 2. The mean PRO scores were 52.0 ± 8.9 for the PROMIS physical functioning score, 39.6 ± 7.5 for the PROMIS pain interference score, 78.7 ± 12.0 for the modified Harris Hip Score, 73.3 ± 23.1 for the International Hip Outcome Tool 12 score, 89.9 ± 12.0 for the Hip Outcome Score-Activities of Daily Living, and 81.4 ± 21.0 for the Hip Outcome Score-Sport-Specific Subscale. Of the patients, 72.1% achieved the patient acceptable symptomatic state (PASS) according to previously established PASS scores for FAI syndrome treated with hip arthroscopy at minimum 5-year follow-up. The overall rate of revision arthroscopy was 3.5%, and the rate of conversion to THA was 5.8%.

CONCLUSIONS

An isolated acetabular osteoplasty can provide sustained clinical benefits for the treatment of FAI syndrome with labral tears, with good to excellent PROs and PASS rates and a low rate of conversion to THA at minimum 5-year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Femoroplasty May Not Be Necessary in All Patients With Hip Femoroacetabular Impingement, But Cam Lesions Should Not Be Ignored in Patients With Significant Femoral Head-Neck Offset

Our knowledge of appropriate arthroscopic management of femoroacetabular impingement (FAI) continues to evolve. However, few studies exist evaluating mid- to long-term surgical outcomes to guide optimal treatment. The recent focus has been on the importance of cam femoroplasty in addition to labral treatment; however, studies have shown that correction of the alpha angle to normal does not correlate with patient outcomes. Furthermore, in cases of mixed impingement, an optimal degree of acetabuloplasty as measured by the lateral center-edge angle has not been determined. Few studies have evaluated isolated pincer decompression with omission of cam treatment. In select patients with small or negligible cam lesions who do not have acetabular dysplasia, a small, isolated acetabular rim resection of 1 to 3 mm may provide adequate FAI decompression as well as reduce surgical time and complications. Nonetheless, individualized FAI treatment is necessary that includes a comprehensive 180° femoroplasty in patients with sizable cam lesions to prevent future labral and chondral damage. An intraoperative dynamic examination is important to determine sufficient resolution of FAI. Predictive modeling may play an increasingly important role to ensure appropriate bony resection and to optimize long-term patient outcomes.

Repair versus Debridement for Acetabular Labral Tears-A Systematic Review

Purpose

The purpose of this study was to systematically review the evidence in the literature to ascertain whether acetabular labral repair (ALR) or debridement (ALD) resulted in superior patient outcomes.

Methods

The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed studies comparing ALR and ALD published in English with full text available were included. Patients undergoing both open and arthroscopic surgery in randomized controlled trials, prospective cohort studies, retrospective cohort studies, and case-control studies were included. Studies were quantified for methodological quality using the MINORS criteria. Clinical outcomes were compared, with qualitative analysis, and quantitative analyses were performed using GraphPad Prism version 7. A P value <.05 was considered to be statistically significant.

Results

There were 8 studies included (level of evidence [LOE] I = 1; LOE II = 2; LOE III = 5). The 7 studies compared 364 patients (369 hips) with ALR to 318 patients (329 hips) with ALD, with a mean follow-up time ranging between 32-120 months. Five studies found significantly improved patient reported outcomes with ALR (Harris Hip Score, Merle d'Aubigné, Pain, SF-12). Several studies compared the outcomes after ALR and ALD and found statistical significance in all investigated metrics in favor of ALR. One study found a significant improvement in abduction but no other study found any difference in range of motion. No study found any difference in complication rate, revision rate or conversion to total hip arthroplasty. Although, 2 studies found ALR reduced the rate of osteoarthritic progression.

Conclusion

Current literature suggests that acetabular labral repair may result in superior patient reported outcomes. However, there appears to be no significant difference in the rate of progression to total hip arthroplasty at up to 10-year follow-up.

Level of Evidence

Level III, systematic review of Level I, II, and III studies.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome Results in 2 Recovery Patterns Based on Preoperative Pain and on Arthritis: Improvers and Non-improvers

Purpose

To analyze whether subgroups of patients could be distinguished with different functional recovery trajectories after hip arthroscopy for femoroacetabular impingement (FAI) syndrome and to identify differences between those subgroups using data from our prospective cohort registration.

Methods

We retrospectively reviewed the prospectively registered data of patients who had undergone hip arthroscopy for FAI syndrome in our clinic from 2015 through 2018. Latent class growth modeling and growth mixture modeling were used to identify and classify groups of patients according to the trajectory of functional recovery using the Hip Outcome Score–Activities of Daily Life (HOS-ADL). We used univariable analysis and descriptive statistics to explore whether differences in group membership could be identified.

Results

A total of 100 patients were analyzed. Growth mixture modeling identified 2 main types of recovery pattern after surgery: patients in whom the HOS-ADL improved significantly after surgery to 90, whom we called the “improvers” (with fast initial improvement within 3 months that is maintained during follow-up), and patients who did not significantly benefit from surgery (with only mild improvement in the HOS-ADL at 3 months and no further change during follow-up), whom we called the “non-improvers.” Univariable analysis and comparison of differences between subgroups showed higher preoperative visual analog scale scores for pain and more intraoperative arthrosis of the femoral head for the non-improvers.

Conclusions

We identified 2 main types of recovery pattern after arthroscopic treatment of FAI syndrome: improvers and non-improvers. Both groups recover in a different manner postoperatively. Preoperative pain and intraoperative arthrosis of the femoral head differed in the non-improvers compared with the improvers.

Level of evidence

Level III, retrospective cohort study.

Good Outcome Scores and Low Conversion Rate to THA 10 Years After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of symptomatic femoroacetabular impingement (FAI) has promising short-term to mid-term results. In addition to treating acute pain or impaired function, the goal of hip-preserving surgery is to achieve a lasting improvement of hip function and to prevent the development of osteoarthritis. Long-term results are necessary to evaluate the effectiveness of surgical treatment and to further improve results by identifying factors associated with conversion to THA.

QUESTIONS/PURPOSES

(1) How do the Merle d'Aubigné-Postel scores change from before surgery to follow-up of at least 10 years in patients undergoing hip arthroscopy for the treatment of FAI? (2) What is the cumulative 10-year survival rate of hips with the endpoints of conversion to THA or a Merle d'Aubigné-Postel score less than 15? (3) Which factors are associated with conversion to THA?

METHODS

Between 2003 and 2008, we treated 63 patients (65 hips) for symptomatic FAI with hip arthroscopy at our institution. During that period, the indications for using arthroscopy were correction of anterior cam morphology and anterolateral rim trimming with debridement or reattachment of the labrum. We excluded patients who were younger than 16 years and those who had previous trauma or surgery of the hip. Based on that, 60 patients (62 hips) were eligible. A further 17% (10 of 60) of patients were excluded because the treatment was purely symptomatic without treatment of cam- and/or pincer-type morphology. Of the 50 patients (52 hips) included in the study, 2% (1) of patients were lost before the minimum study follow-up of 10 years, leaving 49 patients (51 hips) for analysis. The median (range) follow-up was 11 years (10 to 17). The median age at surgery was 33 years (16 to 63). Ninety percent (45 of 50) of patients were women. Of the 52 hips, 75% (39 of 52) underwent cam resection (femoral offset correction), 8% (4 of 52) underwent acetabular rim trimming, and 17% (9 of 52) had both procedures. Additionally, in 35% (18 of 52) of hips the labrum was debrided, in 31% (16 of 52) it was resected, and in 10% (5 of 52) of hips the labrum was reattached. The primary clinical outcome measurements were conversion to THA and the Merle d'Aubigné-Postel score. Kaplan-Meier survivorship and Cox regression analyses were performed with endpoints being conversion to THA or Merle d'Aubigné-Postel score less than 15 points.

RESULTS

The clinical result at 10 years of follow-up was good. The median improvement of the Merle d'Aubigné-Postel score was 3 points (interquartile range 2 to 4), to a median score at last follow-up of 17 points (range 10 to 18). The cumulative 10-year survival rate was 92% (95% CI 85% to 99%) with the endpoints of conversion to THA or Merle d'Aubigné-Postel score less than 15. Factors associated with conversion to THA were each year of advancing age at the time of surgery (hazard ratio 1.1 [95% CI 1.0 to 1.3]; p = 0.01) and preoperative Tönnis Grade 1 compared with Tönnis Grade 0 (no sign of arthritis; HR 17 [95% CI 1.8 to 166]; p = 0.01).

CONCLUSION

In this series, more than 90% of patients retained their native hips and reported good patient-reported outcome scores at least 10 years after arthroscopic treatment of symptomatic FAI. Younger patients fared better in this series, as did hips without signs of osteoarthritis. Future studies with prospective comparisons of treatment groups are needed to determine how best to treat complex impingement morphologies.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Prognostic Factors for Conversion to Arthroplasty after Hip Arthroscopy. Review of the Literature

Arthroscopic techniques in the treatment of femoroacetabular impingement have experienced an exponential increase over recent years for both diagnosis and treatment. The main risks with treatment are poor clinical outcomes and the conversion to prosthesis. Better knowledge and understanding of the various risk factors leading to prosthesis will improve patient selection for arthroscopic treatments rendering better results. The published papers that have been selected are related to series of hip arthroscopies with risk factors that lead to total hip arthroplasty (THA), in the PubMed database, without a time limit, number of patients, or follow-up time. We selected over 302 papers, 19 papers that show risk factors for conversion to THA. The main risk factors found were femoral chondropathy grade III/IV (relative risk 58.1-12 times increased), acetabular (20-2.96 times), an articular space <2 mm (39-4.26 times), age (14.6-1.06 times), Tönnis 2 in radiographic studies (7.73-3.1 times), obesity (5.6-2.3 times), and osteoarthritis (4.6-2.4 times). There are several risk factors which in an isolated way, highly increase the risk of THA. Some of them have a clear relationship (chondropathy, reduced joint space, Tönnis 2, and osteoarthritis). Based on the review we observed that the elements that are most associated with a conversion to THA after a hip arthroscopy are a high degree of femoral and acetabular chondropathy, a reduced joint space below 2 mm, older age, Tönnis 2, obesity, and hip osteoarthritis.

Restoration of Labral Function in Primary Hip Arthroscopy From Labral Repair to Labral Reconstruction

The function and importance of the labrum in hip biomechanics has been established. A labral tear is the most common pathology in patients undergoing hip arthroscopy, and adequate management is critical for favorable outcomes. Although labral debridement was initially performed for arthroscopic labral tear management, there has been a shift toward labral restoration techniques. Currently, restoration with labral repair remains the gold standard for labral tear treatment, particularly in the primary setting. When compared to labral debridement, the literature has shown that labral repair has more favorable outcomes. Irreparable labral tears, although unusual in the primary setting, present a challenge. Labral reconstruction and augmentation are recent advancements in this scenario of hip arthroscopy that can help restore labral function. Two alternatives of labral reconstruction have been described: segmental and circumferential. Clinical data for segmental labral reconstruction has reported good outcomes at short-, mid-, and long-term follow-up. Similarly, arthroscopic circumferential reconstruction has shown good to excellent results at short-term follow-up. As the name suggests, only a segment of the labrum is reconstructed during segmental reconstruction. In a circumferential reconstruction, the entire labrum is taken down from the most anterior to the most posterior aspect of the transverse acetabular ligament and is reconstructed using an auto or allograft. A benefit of circumferential labral reconstruction is the removal of the entire damaged labral tissue, a potential source of pain. However, there is no clear evidence that demonstrates the superiority of one method over the other. Labral graft reinforcement via tissue augmentation or labral augmentation is an interesting option because it preserves the native chondrolabral junction. Labral augmentation can also be used for hypoplastic labrum that intraoperatively demonstrates a deficient suction-seal.

Return to Sports and Minimum 2-Year Outcomes of Primary Arthroscopic Hip Labral Reconstruction for Irreparable Tears in High-Level Athletes With a Propensity-Matched Benchmarking Against a Labral Repair Control Group

BACKGROUND

Labral reconstruction has shown promise for the treatment of irreparable labral tears in high-level athletes. The literature is scarce regarding outcomes and timing of return to sports (RTS) in these patients.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores and RTS characteristics for high-level athletes undergoing primary labral reconstruction for irreparable labral tears and (2) to compare clinical results with a matched control group of athletes undergoing labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high school, college, and professional athletes who underwent a primary arthroscopic labral reconstruction between January 2010 and June 2018. Minimum 2-year PROs were compared for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS), as well as the visual analog scale (VAS) pain score, patient satisfaction, and RTS. The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for the mHHS (PASS, >74 points; MCID, >8 points) and HOS-SSS (PASS, >75 points; MCID, >6 points) were also recorded. These patients were propensity score matched in a 1:3 ratio to other high-level athletes undergoing labral repair.

RESULTS

A total of 17 high-level athletes with primary arthroscopic labral reconstruction were included with a median follow-up time of 37.1 months (95% CI, 37.2-60.3 months). They demonstrated significant improvement from preoperatively to the latest follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). Further, patients achieved PASS/MCID for mHHS at high rates (PASS, 84.2%; MCID, 68.4%). Athletes were able to return to sport-specific training at a median of 3.33 months (95% CI, 3.07-4.71 months) and RTS at a median of 6.2 months (95% CI, 5.08-11.98 months). Fourteen (82.4%) of reconstructions and 29 (82.8%) of repairs either returned to sport or decided not to do so for reasons unrelated to the hip. PROs, RTS rate, and PASS/MCID rates were similar between the labral reconstruction group and a control labral repair group (P > .05).

CONCLUSION

Primary arthroscopic labral reconstruction for irreparable labral tears was associated with significant improvement in PROs and high rates of RTS in high-level athletes. These results were comparable with those of a control group of athletes undergoing labral repair.

Outcomes following surgical management of femoroacetabular impingement: a systematic review and meta-analysis of different surgical techniques

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures.

The lateral joint space width is essential for the outcome after arthroscopically assisted mini-open arthrotomy for treatment of a femoroacetabular impingement: an analysis of prognostic factors for the success of this hip-preserving technique

PURPOSE

The purpose of this study was to analyze predicting factors for a conversion to a total hip replacement (THR) after mini-open arthrotomy for treatment of femoroacetabular impingement (FAI).

METHODS

Between 2011 and 2016, we identified 32 patients, who were treated for FAI with a mini-open arthrotomy and received after mean time of 2.1 ± 1.4 years a THR. These patients were compared to 47 cases who did not receive a THR (mean follow-up: 4.3 ± 0.7 years) to explore pre- and intra-operative factors associated with a conversion to THR. The results were presented in separated Kaplan-Meier curves with log rank test for significance and hazard ratios.

RESULTS

A lateral joint space width of > 4 mm showed a higher THR-free survival rate compared to < 4 mm (p = 0.001); analogously one-sided (acetabular/femoral) 3-4° cartilage damage had a comparable THR-free survival rate than 1-2° kissing lesions (p = 0.001). Furthermore, an intact labrum without treatment and good cartilage status, a refixed labrum after rim resection in case of a pincer type FAI, or a refixed teared labrum were associated with a longer THR-free time than an untreated labrum accompanied by a poor cartilage status or an ossified labrum (p = 0.002). The strongest independent factor for a conversion to THR was femoral cartilage damage grade 1 and higher (p = 0.046). However, the rate of available patients was 53.0%.

CONCLUSION

The success of a joint-preserving mini-open arthrotomy seems to be dependent on the status of the radiological joint space width and the intra-operative cartilage status of the lateral edge.

Parameters affecting baseline hip function in patients with cam-derived femoroacetabular impingement syndrome: data analysis from the German Cartilage Registry

BACKGROUND

Using the database of the German Cartilage Registry (KnorpelRegister DGOU), this study aims to present patient- and joint-related baseline data in a large cohort of patients with cam-derived femoroacetabular impingement syndrome (FAI) and to detect symptom-determining factors.

MATERIALS AND METHODS

Requiring cam morphology as the primary pathology, 362 patients were found to be eligible for inclusion in the study. The assessment of preoperative baseline data was performed using the patient-reported outcome measure-International Hip Outcome Tool (iHOT-33). Descriptive statistics were performed to present baseline data. Univariate and multiple regression with post hoc testing were used to identify patient- and joint-related factors that might affect the preoperative iHOT-33 and its subscores, respectively.

RESULTS

The study collective's mean age was 36.71 ± 10.89 years, with 246 (68%) of them being male. The preoperative mean iHOT-33 total was 46.31 ± 20.33 with the subsection "sports and recreational activities" presenting the strongest decline (26.49 ± 20.68). The parameters "age," "sex," "body mass index" (BMI), and the confirmation of "previous surgery on the affected hip" were identified to statistically affect the preoperative iHOT-33. In fact, a significantly lower mean baseline score was found in patients aged > 40 years (p < 0.001), female sex (p < 0.001), BMI ≥ 25 kg/m² (p = 0.002) and in patients with previous surgery on the affected hip (p = 0.022). In contrast, the parameters defect grade and size, labral tears, and symptom duration delivered no significant results.

CONCLUSIONS

A distinct reduction in the baseline iHOT-33, with mean total scores being more than halved, was revealed. The parameters "age > 40 years," "female sex," "BMI ≥ 25," and confirmation of "previous surgery on the affected hip" were detected as significantly associated with decreased preoperative iHOT-33 scores. These results help to identify symptom-defining baseline characteristics of cam-derived FAI syndrome.

TRIAL REGISTRATION

The German Cartilage Registry is conducted in accordance with the Declaration of Helsinki and registered at germanctr.de (DRKS00005617). Registered 3 January 2014-retrospectively registered. The registration of data was approved by the local ethics committees of every participating institution. Primary approval was given by the ethics committee at the University of Freiburg (No. 105/13). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005617.

Magnetic Resonance Imaging Predictors of Chondral Lesions in Patients With Femoroacetabular Impingement: An Analysis of 545 Cases

PURPOSE

A large prospective cohort was used (1) to evaluate the overall ability of magnetic resonance imaging (MRI) to detect Outerbridge grade III and IV cartilage defects found during surgery and (2) to identify the specific MRI findings most associated with these cartilage defects so that the practicing hip arthroscopist can better predict cartilage injury before surgery.

METHODS

All patients undergoing hip arthroscopy between February 2015 and May 2017 at 1 institution were enrolled in a prospective cohort. Intra-articular findings were documented at the time of surgery. MRI reports were retrospectively reviewed for radiologist-reported articular cartilage, osseous, or synovial abnormalities. Sensitivity and specificity of MRI findings were calculated; multivariate logistic regression analysis determined which findings were associated with high-grade chondral damage at the time of arthroscopy and used to create an online risk calculator, https://orthop.washington.edu/hiprisk/.

RESULTS

Of 598 patients who underwent hip arthroscopy, 550 had MRI reports available for review (92%). Grade III and IV cartilage injuries were reported on arthroscopy in 70 patients (13%) of average age 33 ± 13 years. On univariate analyses, individual MRI findings were not sensitive in detection of articular cartilage injury (mean 22%; range, 1.4%-46%), but positive findings were highly specific (mean 90%,; range, 76%-99%). Multivariate analysis revealed that older age (odds ratio [OR] 1.09 [1.06-1.11], P < .001) and osseous findings such as subchondral cyst or edema (OR 4.77 [2.51-9.05], P < .001) were most predictive of grade III and IV defects (P < .001).

CONCLUSION

MRI was a specific but not sensitive tool in diagnosing articular cartilage injury. Surgeons should be aware that osseous findings such as cysts or edema are highly predictive of full-thickness cartilage loss in FAI.

LEVEL OF EVIDENCE

Level III, development of diagnostic criteria (consecutive patients with consistently applied reference standard, no blinding).

Minimum 5-Year Outcomes for Revision Hip Arthroscopy With a Prospective Subanalysis Against a Propensity-Matched Control Primary Group

BACKGROUND

There is a paucity of midterm outcome data on hip revision arthroscopic surgery.

PURPOSE

(1) To report minimum 5-year patient-reported outcome measurement scores (PROMSs) in patients who underwent revision hip arthroscopy, (2) to compare minimum 5-year PROMSs with a propensity-matched control group that underwent primary hip arthroscopy, and (3) to compare the rate of achieving the minimal clinically important difference (MCID) at minimum 5-year follow-up between the revision group and the propensity-matched control primary group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected between June 2008 and April 2014. Patients were included who underwent revision hip arthroscopy with preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patients with Tönnis grade >1 or with hip conditions such as avascular necrosis, Legg-Calve-Perthes disease, Ehlers-Danlos syndrome, and pigmented villonodular synovitis were excluded. A subanalysis was performed against a propensity-matched control group that underwent primary surgery. Groups were propensity matched in a 1:2 ratio for sex, age, body mass index, and follow-up time.

RESULTS

A total of 127 revision arthroscopies (113 patients) were included, and the mean ± SD follow-up time was 72.8 ± 23.3 months. The revision group was 74.0% female, and the average age and body mass index were 34.9 ± 12.4 years and 24.8 ± 4.2, respectively. The revision group demonstrated improvement for all PROMSs and reached the MCID for the mHHS (66.1%), HOS-SSS (68.4%), NAHS (66.9%), and VAS (80.0%). All revision cases were propensity matched to 254 primary arthroscopy cases. PROMSs in the revision group were lower than those of the control group before and after surgery. Delta values were similar between groups for all PROMSs. There were no differences in rates of achieving the MCID. The relative risk of arthroplasty conversion was 2.6 (95% CI, 1.5-4.6) for the revision group as compared with the primary group.

CONCLUSION

Significant improvement in all PROMSs, including the VAS, and high patient satisfaction at minimum 5-year follow-up were reported after revision hip arthroscopy. A high proportion of patients in the revision cohort reached the MCID for the mHHS, HOS-SSS, NAHS, and VAS, with similar rates and magnitudes of improvement relative to the control group. As expected, these data indicate that patients undergoing primary hip arthroscopy have higher PROMSs before and after surgery and lower rates of conversion to arthroplasty.

Concomitant Lumbar Spinal Stenosis Negatively Affects Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

The purpose of this study was to assess the prognostic effect of lumbar spinal stenosis on clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAI).

METHODS

Patients undergoing hip arthroscopy between September 2009 and December 2015 for FAI with concomitant lumbar spinal stenosis (central/neuroforaminal) and a 2-year follow-up were identified (hip-spine). A 1:1 case-matching query using preoperative modified Harris Hip Score (mHHS) within 3 points, body mass index (BMI) within 3 points, age within 5 years, and sex identified a control cohort without spinal pathology. Follow-up patient-reported outcomes (PROs) and clinical failure rates to revision procedure were compared using analysis of variance (ANOVA) and Kaplan-Meier survival analysis.

RESULTS

Twenty-six patients met criteria of the hip-spine group (age: 45.9 ± 12.2 years; BMI: 27.3 ± 5.0 kg/m², baseline mHHS: 44.17 ± 2.76) vs the control group (age: 46.2 ± 12.4 years, P = .94; BMI: 26.7 ± 4.1 kg/m², P = .61; baseline mHHS: 44.27 ± 2.82, P = .98). ANOVA analysis demonstrated that all PROs improved from baseline to 2-year outcomes (P < .001). The hip-spine vs control group had lower 1-year (mHHS: 65.97 ± 5.64 vs 85.04 ± 3.09, P = .006; nonarthritic hip score (NAHS): 70.26 ± 5.71 vs 87.89 ± 2.65, P = .010) and 2-year (mHHS: 69.72 ± 4.92 vs 84.71 ± 2.56, P = .007; NAHS: 72.23 ± 5.18 vs 87.14 ± 2.23, P = .008) outcomes. While there was no difference in patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) rates at 1-year follow-up, the hip-spine group demonstrated lower PASS (42% vs 81%, P = .004) and MCID (58% vs 88%, P = .027) rates at 2 years. Although susceptible to type II error, there was no difference in clinical failure rates to revision procedure (P = .13).

CONCLUSIONS

While net PROs from baseline improve after hip arthroscopy for FAI, the presence of concomitant lumbar spinal stenosis negatively affects postoperative PROs. FAI patients with spinal stenosis should be counseled accordingly.

LEVEL OF EVIDENCE

Level III, case-control study.

Arthroscopic Circumferential Acetabular Labral Reconstruction for Irreparable Labra in the Revision Setting: Patient-Reported Outcome Scores and Rate of Achieving the Minimal Clinically Important Difference at a Minimum 2-Year Follow-up

BACKGROUND

There is a paucity in the literature reporting patient-reported outcome (PRO) scores and the minimal clinically important difference (MCID) after revision hip arthroscopic surgery with circumferential labral reconstruction.

PURPOSE

To report minimum 2-year PRO scores and the rate of achieving the MCID in patients who underwent revision hip arthroscopic surgery with circumferential labral reconstruction in the setting of irreparable labral tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were retrospectively reviewed for all patients who underwent revision hip arthroscopic surgery between February 2016 and November 2017. Patients were included if they had undergone circumferential labral reconstruction and had preoperative and postoperative scores for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), 12-Item Short Form Health Survey physical and mental components (SF-12 P and SF-12 M, respectively), Veterans RAND 12-Item Health Survey physical and mental components (VR-12 P and VR-12 M, respectively), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, fractures, hip dysplasia, or revision labral treatment different from circumferential labral reconstruction. The MCID was calculated. Secondary surgical procedures were documented.

RESULTS

A total of 26 hips (26 patients; 61.5% female) were included. The mean age and body mass index were 33.2 ± 10.4 years and 25.5 ± 4.9, respectively. Significant improvements were reported for the mHHS (17.0 ± 19.5; P = .0002), NAHS (17.9 ± 16.7; P < .0001), HOS-SSS (21.7 ± 23.1; P = .0005), VAS (-2.2 ± 3.0; P = .006), iHOT-12 (25.8 ± 32.5; P = .0007), SF-12 P (8.5 ± 11.2; P = .001), and VR-12 P (8.9 ± 11.6; P = .001). Rates of meeting the MCID for the mHHS, NAHS, HOS-SSS, iHOT-12, and VAS were 76.9%, 80.0%, 65.0%, 62.5%, and 69.2%, respectively. No case of re-revision arthroscopic surgery was documented, but 1 case of conversion to total hip arthroplasty was documented at 38.6 months.

CONCLUSION

In the setting of revision hip arthroscopic surgery and irreparable labral tears, circumferential labral reconstruction resulted in significant improvements in all PRO and VAS scores at a minimum 2-year follow-up with a high rate of achieving the MCID.

Osteoarthrosis, Advanced Age, and Female Sex Are Risk Factors for Inferior Outcomes After Hip Arthroscopy and Labral Debridement for Femoroacetabular Impingement Syndrome: Case Series With Minimum 10-Year Follow-Up

PURPOSE

(1) To determine the cumulative survivorship using the endpoint of total hip arthroplasty (THA) correlated with osteoarthrosis (Tönnis grade ≤ 1 vs Tönnis grade > 1) at a minimum 10-year follow-up and (2) to identify risk factors for THA conversion.

METHODS

This study examined 112 patients who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) between 2007 and 2009. The inclusion criterion was primary hip arthroscopy to treat FAIS with corresponding chondrolabral pathologies. The exclusion criteria were secondary hip pathologies, revision hip arthroscopy, or dysplasia. The mean follow-up period was 11 years. Cumulative survival was estimated by Kaplan-Meier analysis using the endpoint of THA. Risk factors for THA conversion were identified using a multivariate Cox proportional hazards model.

RESULTS

Forty patients underwent THA. The cumulative survivorship rate at 11 years was 86% for patients with a Tönnis grade of 1 or less and 46% for those with a Tönnis grade greater than 1. Osteoarthrosis, advanced age, and female sex were associated with lower hip survival rates. In particular, the risk of THA conversion was 24% higher for patients with an advanced age at the time of surgery, 97% higher for female patients, and 133% higher for hips with a Tönnis grade greater than 1.

CONCLUSIONS

The survivorship rate at a mean 11-year follow-up after arthroscopic FAIS therapy was 86.3% in the group with a Tönnis grade of 1 or less and 46.4% in the group with a Tönnis grade greater than 1. The presence of osteoarthrosis, advanced age, and female sex adversely affected the outcome.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.